American Journal of Health-System Pharmacy最新文献

Purpose: Antimicrobial stewardship programs have been widely implemented with positive results in the inpatient healthcare delivery model. However, data supporting these interventions is limited in other care settings.

Summary: Formulary restrictions and conducting prospective audit and feedback (PAF) are mainstays of antimicrobial stewardship. A PAF program targeted specifically at fluoroquinolone use was implemented in the Federal Bureau of Prisons (FBOP), in addition to exclusionary formulary restrictions on ciprofloxacin and levofloxacin. After implementation of these interventions, overall fluoroquinolone orders per 1,000 adults in custody (AICs) were reduced by 46.4% (P < 0.0001). The majority of PAF interventions addressed situations in which an antibiotic was unnecessary or a fluoroquinolone was not the recommended first-line agent. Over the same time period, nonformulary approval rates for ciprofloxacin and levofloxacin averaged 62%.

Conclusion: The interventions from this program provide data supporting the effectiveness of formulary changes and PAF for antimicrobial stewardship in a nontraditional care setting.

Purpose: The purpose of this study was to assess the incidence of sodium-glucose cotransporter 2 (SGLT2) inhibitor initiation in hospitalized patients with heart failure and determine what potential factors may influence use.

Methods: A single-center, retrospective cohort analysis was conducted of hospitalized patients with heart failure. The primary outcome was the incidence of SGLT2 inhibitor initiation. Secondary outcomes included the rates of use of other guideline-directed medical therapy, identification of factors associated with initiation of SGLT2 inhibitors, and reasons why SGLT2 inhibitors were not initiated.

Results: A total of 503 patients were included. The overall incidence of SGLT2 inhibitor initiation was 18% across all heart failure types, with 30% incidence in heart failure with reduced ejection fraction, 2.2% incidence in heart failure with mildly reduced ejection fraction (HFmrEF), and 5.7% incidence in heart failure with preserved ejection fraction (HFpEF). Logistic regression analysis showed that older age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-0.99; P = 0.009) and the presence of HFpEF (OR, 0.37; 95% CI, 0.17-0.77; P = 0.007) or HFmrEF (OR, 0.22; 95% CI, 0.05-0.69; P = 0.02) were negatively associated with SGLT2 inhibitor initiation. Presence of an angiotensin-converting enzyme inhibitor, angiotensin 2 receptor blocker, or angiotensin receptor/neprilysin inhibitor (OR, 2.14; 95% CI, 1.16-4.05; P = 0.017) or a β-blocker (OR, 3.78; 95% CI, 1.62-10.37; P = 0.004) was positively associated with the addition of an SGLT2 inhibitor, as was a cardiology consult (OR, 8.29; 95% CI, 2.36-52.83; P = 0.005). Providers rarely documented the reason for not prescribing an SGLT2 inhibitor, but the most commonly cited reasons were deferral to the outpatient setting (5.6%) and concern for renal function (4.6%).

Conclusion: Use of SGLT2 inhibitors remains low despite recommendations advocating for their use in heart failure, with these agents specifically underutilized in HFpEF and HFmrEF at this institution.

Purpose: The study objective was to analyze the use of health equity (HE)- and social determinants of health (SDOH)-related language within pharmacy residency websites and recruitment materials.

Methods: Using the ASHP residency directory of 2022, a randomly selected sample of postgraduate year 1 (PGY1) and PGY1/PGY2 programs from each state were analyzed. After search terms were selected from HE/SDOH resources, each program's residency-specific webpages (RSWs) and institution-specific webpages (ISWs) were searched and given a score based on the frequency of identified terms. The primary outcome was the number of programs with at least one identified instance of HE/SDOH terms. Additional outcomes included the frequency of HE/SDOH terms on ISWs or RSWs and program score distribution. Outcomes were also evaluated among programs in medically underserved areas (MUAs).

Results: Three hundred eighteen programs were included, of which 205 (64%) included HE/SDOH language within RSWs, ISWs, or both. Of these 205 programs, 126 programs (61%) included language only on ISWs. The number of programs that only had one instance of HE/SDOH terms on either category of webpages, or had a score of 1, was 128 programs (40.2% of the total of 318 programs). Of the 111 programs in MUAs (35%), 66 (59.5%) included HE/SDOH language within the ISWs.

Conclusion: Most evaluated programs, including those in MUAs, lacked language specifically identifying their focus and work around HE/SDOH within their residency promotional materials.

Purpose: Cabotegravir/rilpivirine (CAB/RPV) is the first long-acting antiretroviral therapy for patients with human immunodeficiency virus (HIV). It is administered via intramuscular injection into the gluteal muscle, requiring precise technique. We report the case of a patient living with HIV who developed resistance to CAB despite on-time administration of all doses.

Summary: A 34-year-old man with a body mass index (BMI) of 38.42 kg/m2 who received therapy with CAB/RPV 600 mg/900 mg intramuscularly every other month for 15 months presented to the clinic for routine HIV care. An HIV viral load obtained just before the visit demonstrated a significant elevation in his viral load, which was previously undetectable. Further testing demonstrated the development of a G118R resistance-associated mutation in the virus with a class-wide effect on integrase inhibitors. Upon review, it was determined that the patient had received all doses of his medication with a 1.5-inch needle rather than the recommended 2-inch needle based on his BMI. He was subsequently switched to darunavir/cobicistat/emtricitabine/tenofovir alafenamide and quickly achieved viral suppression.

Conclusion: This case demonstrates the potential for patients living with HIV to develop resistance to CAB/RPV despite on-time administration of the medication. Proper administration and timing of antiretroviral therapy for these patients is essential to ensure efficacy and safety in the management of HIV but does not completely prevent development of resistance.

Purpose: The goals of this paper are to (1) provide evidence and expert consensus to support a unified approach to estimating kidney filtration in adults with stable kidney function using race-free estimated glomerular filtration rate (eGFR) in place of Cockcroft-Gault estimated creatinine clearance (C-G eCrCL) for medical and medication-related decisions, and (2) demonstrate how adjusting eGFR results for an individual's body surface area (BSA) when it is higher or lower than 1.73 m2 will improve results for medication-related decisions.

Summary: C-G eCrCL is predominantly used by US pharmacists to determine eGFR for the purposes of medication-related decisions, even though more accurate eGFR equations exist. Several driving factors make it the ideal time to shift clinical practice from using C-G eCrCL to eGFR. These factors include the following: (1) 2024 Food and Drug Administration (FDA) guidance for industry recommends eGFR over C-G eCrCL to evaluate the impact on pharmacokinetics in patients with impaired kidney function; (2) a joint National Kidney Foundation (NKF) and American Society of Nephrology task force recommends 3 race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFR equations for medical and medication-related decision-making; (3) the almost ubiquitous use of standardized serum creatinine assay methods in US clinical laboratories; and (4) increasing availability and use of serum cystatin C for eGFR assessment. This publication guides practitioners through the rationale for using race-free eGFR equations for medication-related decisions and how to implement this practice change.

Conclusion: The NKF Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions suggests that health systems, health settings, clinical laboratories, electronic health record systems, compendia and data vendors, and healthcare practitioners involved with medication-related decision-making transition away from C-G eCrCL and towards the race-free eGFR equations for more accurate assessment of kidney filtration and consistency in medication and medical decision-making across the US.

Purpose: The purpose of this review is to highlight the role of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonists (GLP-1/GIP RAs) in managing cardiovascular-kidney-metabolic (CKM) syndrome, focusing on their cardiovascular (CV) and kidney-protective effects beyond glycemic control.

Summary: In multiple randomized controlled trials, GLP-1 RAs were demonstrated to confer significant benefits in reducing CV events and preserving kidney function in patients with preexisting atherosclerotic cardiovascular disease (ASCVD) and those at high CV risk. Current guidelines, including those from the Kidney Disease: Improving Global Outcomes (KDIGO) initiative and the American Diabetes Association (ADA), underscore the therapeutic potential of these agents for managing chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), and metabolic syndrome. Additionally, emerging data suggests their utility beyond T2DM. This review summarizes the evidence supporting these guidelines, along with newer findings not yet fully integrated into clinical practice. It also examines the role of pharmacists and multidisciplinary teams, safety considerations, and practical strategies for managing common adverse effects.

Conclusion: The integration of GLP-1 RAs and dual GLP-1/GIP RAs into clinical practice offers substantial benefits for patients, both with and without diabetes. Pharmacists play a pivotal role in recommending evidence-based treatments for those at high CV and kidney risk, educating patients, addressing social determinants of health, and bridging gaps across multidisciplinary care teams.