End stage renal disease is a common disability that requires kidney transplantation. The ability of a healthcare team to complete this transplantation can return patients to a much more satisfactory quality of life. Although, treatment and care after transplantation can be very complex. Administration of immunosuppressive drugs is very important following transplantation and the slightest deviation from the proper dosing regimen can increase the chances of rejection. The article states that there is a growing need for proper communication between the interdisciplinary team, which would include pharmacists, especially solid organ transplant specialists. This communication is essential to reduce the risk of rejection. As future pharmacists we need to be at the forefront to help create guidelines and protocols for such procedures. We need to establish ourselves as a crucial member of the healthcare team, proving positive outcomes for the patients and hospital units we serve. Adherence following treatment is also a huge issue for patients that have unsuccessful transplants. As the pharmacist how can we best address this issue using our motivational interviewing techniques?
De Pasquale C, Veroux M, Indelicato L, et al. Psychopathological aspects of kidney transplantation: Efficacy of a multidisciplinary team. World J Transplant. 2014;4(4):267-75.
Stroke care is an emergency situation that can be challenging to deal with. Providing a patient with IV thrombolysis for a misdiagnosed stroke or stroke mimic can cause actual thrombolysis. This of course will increase the risks of adverse events following drug administration. The study here looked at the population of stroke patients versus the population of stroke mimic patients. In terms of patient population it was determined that there is a distinct difference between the two. The stroke mimic cohort had a younger mean age of 59.9 years while the stroke cohort mean age was 73.7 years. All clinical diagnoses of the cohorts were confirmed by expert consensus after imaging review and various other factors. The study concluded that even though there are striking similarities in clinical presentation of the two events the stroke mimic cohort consists of a different population. This cohort was also associated with fewer adverse effects.
This article goes to show that staying up to date on the current literature is essential for healthcare providers. While there is increasing education and information available regarding stroke it is important to avoid misdiagnosing a patient. Physiological factors and other patient history information should always be taken into consideration when making the decision to give a patient a certain drug based on diagnosis. It’s important to consider all options while still providing care in a timely manner. Other than completing this assignment for class that allows us to look at the most recent literature, what are some other strategies to staying relevant in the field?
Prasanthi S, Dipender G, Gheed M, et al. A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics. J Stroke Cerebrovasc Dis. 2015.
Silent Myocardial Infarction (SMI) is really a heart attack that can happen at any age and at any time without any real warning signs. This article looked at a case report for a 35 year old male that passed unexpectedly. Upon further evaluation of the autopsy report, SMI proved to be the cause of death for this particular individual. The most common risk factors for SMI include smoking history, family history of heart disease, age, high cholesterol, high blood pressure, diabetes, and being overweight. Although it is found that SMI does occur in “2-4% of young adult asymptomatic men.” Cases like this one seem to be heavily underreported due to the asymptomatic aspect of the disease. The most important piece of conclusion from this case study mentioned that this case should be seen as a valuable reminder of SMI for clinicians and pathologists. Education is key in preventing SMIs and other well-known chronic conditions. It is possible that this patient ignored chest pain days prior to the incident. It’s possible that previous education on cardiovascular events might have led this patient to seek medical attention. As healthcare providers how can we best educate our patients on different disease states? We have a health fair in the near future that will include a wide range of information. What is the best method for teaching the most valuable information in order to save lives? Preventative medicine is essential thanks to our increased knowledge of many chronic disease states and should not be ignored.
Aghdam M, Vodovnik A, Sund B. Sudden death associated with silent myocardial infarction in a 35-year-old man: a case report. J Med Case Rep. 2016; 10:46.
This article interested me right from the start because the title involved anticoagulation. Anticoagulation is a huge part of pharmacy and its management is essential for those with a history of cardiac events. Newer oral anticoagulation drugs or non-Vitamin K oral antagonists (NOAC) directly inhibit factor Xa. These drugs have simpler dosing regimens and do not require frequent INR values for monitoring. Their downside though, is the lack of reversal agents. Although, this issue was partially solved by the FDA with the approval of a monoclonal antibody product that has the capability to reverse the effects of a common NOAC: dabigatran. A clinical pharmacist at the University of Utah College of Pharmacy thinks it’s important to note that even without a reversal agent, patients that suffer from bleeding episodes as a result of anticoagulation therapy are better off on these newer agents rather than something more traditional like warfarin. The coordination of care as well as the fact that INR monitoring is not necessary is another positive to NOACs. What are your thoughts? Should we begin to make the transition from warfarin to newer drugs as the first line therapy for patients in need of anticoagulation? What about switching patients that are already receiving warfarin? Are there potential risks to changing drug therapy in this sense? My thoughts include keeping patients on the medications that they’ve been the most compliant or successful with. If a patient doesn’t mind having their INR levels checked and they haven’t had any trouble with warfarin I think it would make the most sense to keep the patient on this medication.
Kearon C, Akl E, Ornelas J. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016; 149(2):315-52.
This article focused on abuse-deterrent formulations or ADFs of various drug products. Opioid pain relievers are highly abused, with the highest percent of abuse found in pain clinics (8 to 16%). Abusers are known to tamper with the original drug product through various means that include crushing the tablet, administering rectally, combining with alcohol, smoking, and more. The FDA hopes that by regulating the design or both pre and post-marketing studies they will be able to encourage ADFs. Ways in which to make a drug in an abuse-deterrent form is by rendering the drug inactive when tampered with. The product could also be formulated with physiochemical barriers to abuse. Various post-marketing studies will determine whether the completed product actually results in meaningful abuse reductions. Current ADF products include oxycodone with Intac technology, which requires an excessive amount of force to crush or break the tablet. Also, when this formulation comes into contact with water, it transforms into a consistency that can not be drawn into a syringe.
While these formulations have proven to decrease abuse rates in patients seeking pain management, the cost burden might affect the availability for patients at risk of abuse. Most of these products are only available as brand name products, as generic opioids are not in ADF form. In our Drug Development class we have learned a lot about the drug development process when it comes to brand versus generic formulation. How long will it take for these formulations to become available? What barriers might patients face to obtain these products and what are some possible solutions? The article brings up a good point of offering savings cards or coupons for these products. Would this encourage ADFs over regularly formulated opioid pain relievers?
Nguyen V, Raffa RB, Taylor R. The role of abuse-deterrent formulations in countering opioid misuse and abuse. J Clin Pharm Ther. 2015; 40:629-34.
Polypharmacy is a huge topic in the healthcare field. Many patients today have the belief that we are all over-medicated and for this reason some patients feel as if they can not trust certain healthcare professionals. This article takes into consideration the idea of polypharmacy and the physicians’ inability to locate and interpret the wealth of drug information that exists. It’s a huge challenge to take so many different studies or clinical trials and compile this information into clinically relevant guidelines. The article states that a physician may spend a mean time of 29 hours per week reading relevant journal articles. Drug Information Centers or DICs have now been established that are staffed by pharmacists and other drug specialists to aid in the answering of drug-related questions. These centers take the patients’ comorbidities, organ function, and other specific patient characteristics into consideration when providing information to healthcare providers.
I think Drug Information Centers are a great tool for physician use. It is absolutely imperative that each member of the healthcare team understands the implications of the amount of drugs available on the market today versus a few decades ago. While clinical guidelines do exist, drug therapy should remain as a case-by-case basis where the healthcare professional takes individual’s characteristics into consideration when selecting appropriate treatment. How do you think the pharmacist can better assert themselves as the “drug expert” of the healthcare team? We need to act as a liaison between the patient and doctor, but this isn’t always an easy or recognized role.
Reppe L, Spigset O, Schjott J. Drug Information Services Today: current role and future perspectives in rational drug therapy. Elsevier B.V. 2015.
This article looked at the administration of acetaminophen for 700 Intensive Care Unit patients exhibiting fever along with other symptoms. A placebo or acetaminophen was given and the effectiveness of the acetaminophen was measure by the number of ICU-free days. They were given 1 gram of acetaminophen or placebo every 6 hours by IV until fever reduction or ICU discharge occurred. The results of the study concluded that the administration of acetaminophen did not affect the number of ICU-free days. While acetaminophen does have a modest clinical effect it did not reduce the number of ICU-free days to a significant amount.
What interested me about this article in particular was the chosen dose and frequency of the drug. The patients were given a gram of the medication every 6 hours, which could total 4 grams per day. This dose happens to be at the maximum daily-recommended dose for acetaminophen. Even though acetaminophen has such a wide therapeutic index, I would expect many of the patients to experience liver toxicity given that they were receiving 4 grams per day. It turns out that 8.1% of the participants had to discontinue the study due to liver toxicity. Do you think acetaminophen should really be used in the care of critically ill patients for fever reduction if 8.1% of those in this study had to discontinue? With such a wide therapeutic window, as discussed in Principles of Drug Action, is this really worth it considering there was not a significant impact on ICU-free days compared to the placebo group? Are there any alternatives for fever reduction in these situations?
Young P, Saxena M, Bellomo R et al. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. N Engl J Med. 2015; 373: 2215-24.
Although this article is from 2009, I thought it would be an interesting read considering it was one of the most viewed articles listed on the American Journal of Health Systems Pharmacists’ website. The article explores vancomycin monitoring in hospitalized patients to treat gram-positive infections, typically MRSA. It was found that earlier formulations of vancomycin might have been the reason for some serious adverse effects including nephrotoxicity and ototoxicity (toxicity to the ear). These formulations possibly contained impurities. The study found that the AUC, or area under the curve, is the most useful pharmacokinetic parameter to monitor vancomycin administration. Various other methods of monitoring are recommended when obtaining vancomycin serum concentration is not possible, but more clinical data would be necessary.
The article mentioned a lack of clinical data hindering the results of this study. It was stated that due to vancomycin being a generic formulation that very few newer clinical trials had actually been conducted. It was also noted that pediatric monitoring was beyond the scope of the article. Now that we are learning a lot about the drug development process it was interesting to read about a case where this process actually hindered further research for companies.
While a lot of the pharmacokinetic terms were familiar thanks to the Principles of Drug Action course material, it was definitely a newer concept to learn that vancomycin metabolism differed significantly for diabetic patients. Drug dosing, especially with a drug like vancomycin with such a narrow therapeutic index, should be done strategically. A patient’s medical history needs to be carefully reviewed when deciding how to dose a patient, which should be a very individualized process.
Rybak M, Lomaestro B, Rotschafer JC et al. Therapeutic monitoring of vancomycin in adult patients: A consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases. Am J Health-Syst Pharm. 2009; 66:887-98.