Impact of a Clinical Pharmacy Specialist in an Emergency Department for Seniors

Elderly patients (seniors) have different needs in the emergency department than most other patients. A senior is someone that is over the age of 65. For example, it is common for a senior to have many chronic conditions, as well as whatever they came into the emergency room for. The hectic environment of the emergency room is often harmful to seniors, so hospitals and developing specialized emergency departments for geriatric patients across the country.

A retrospective analysis was conducted at Kaiser Permanente Colorado members aged 65 years or older who went to EMBRACE (Emergency Medicine Bridging Acute Care for the Elderly) emergency department during this study. Patients were divided into according to whether they were treated by a clinical pharmacy specialist at EMBRACE, were not treated by a clinical pharmacy specialist at EMBRACE, or not treated at EMBRACE. They measured the 30-day rate of an emergency department return visit from these participants.

A total of 4,103 patients were incorporated into the study. 154 of the patients had a medication-related problem identified by the pharmacist. The group that received medication review from the clinical pharmacy specialist did not show a significant reduction in 30-day return visits. Why do you think these were the results? How could pharmacists help geriatric patients with their medication related problems outside of the emergency room?

Shaw PB, Delate T, Lyman A, et al. Impact of a Clinical Pharmacy Specialist in an Emergency Department for Seniors. Ann Emerg Med. 2016:67(2); 177-188. https://www.clinicalkey.com/#!/content/journal/1-s2.0-S0196064415005284

Effects of Prenatal Acetaminophen Exposure and Risk of Attention Deficit/Hyperactivity Disorder in Children

Acetaminophen has always been one of the most commonly used medications during pregnancy. It is reported that 65%-70% of women use acetaminophen at least once during their pregnancy due to the safety associated with it. In 2015, the FDA stated that there is a possible risk of ADHD developing in children who were exposed to acetaminophen prenatally.

After reviewing several previous studies, it was found that no certain relationship can be identified between prenatal exposure to acetaminophen and the development of ADHD. This is partly caused by the fact that diagnosing methods of ADHD have also changed. There are new medications now that are extended release to treat ADHD. These factors affect the number of children being reported to have ADHD, typically increasing it. It is not clear if there is actually an increase in the number of children with ADHD or if it is just being correctly diagnosed now.

The article explains that pharmacists should continue to recommend the lowest effective dose of acetaminophen. They should also make an effort to educate other health care providers and the expecting mothers of the importance of using acetaminophen properly. Other than these suggestions, what else could pharmacists due to prevent any additional side effects of common medications to pregnant women?

Hoover RM, Hayes AG, Erramouspe J. Association Between Prenatal Acetaminophen Exposure and Future Risk of Attention Deficit/Hyperactivity Disorder in Children. Ann Pharmacother. 2015: 49(12); 1357-1361. http://aop.sagepub.com/content/49/12/1357.full.pdf

Use of Cranberry Products for UTI Prevention in Pediatric Patients

A common infection in the pediatric population is a Urinary Tract Infection (UTI). A UTI can occur due to obstruction of urine flow or urinary stasis. The pathogen that causes most UTIs is called Escherichia coli in adults. In children, however, the most common cause of UTIs is Pseudomonas. Low-dose antibiotics were given for prophylaxis in the past to children who showed obstructive disease or recurrent UTIs. Now, it is realized that this leads to antibiotic resistance and other interventions need to be explored.

Healthcare professionals initially believed that cranberry would be an effective prevention of UTIs because it would cause the urinary tract system to be more acidic, but it is not known for sure that the urine pH changes. Now, cranberry is thought to stop the attachment of bacteria to the uroepithelial cells and also that it inhibits the formation of biofilm bacteria. Cranberry use has been studied in the prevention of recurrent UTIs in women, so now researchers are studying the possible benefits in children.

Eight clinical trials were reviewed and their results showed that cranberry is a safe and effective option that could prevent recurrent UTIs in pediatric  patients. This is especially true for otherwise healthy patients. A dose of 2-5 mL/kg/day proved to have the most benefit in the pediatric population. Should clinicians promote the use of cranberry supplements  for the prophylaxis of UTIs  to parents with children or should they only address that if the child develops a UTI first?

Durham SH, Stamm PL, Eiland LS. Cranberry Products for the Prophylaxis of Urinary Tract Infections in Pediatric Patients. Ann Pharmacother. 2015: 49(12); 1349-1356. http://aop.sagepub.com/content/49/12/1349.full.pdf

The Use of Anticoagulation in Patients with Cirrhosis

In the past, people believed that patients diagnosed with cirrhosis were “autoanticoagulated,” so the need for drug intervention was not necessary. It is common for cirrhotic patients to have an elevated INR due to the effects that cirrhosis has on the body. However, it is now understood that patients with cirrhosis are actually at higher risk for bleeding when compared to patients without cirrhosis. Because the incidence of cirrhosis is increasing in our population, it is critical that clinicians understand the effects of cirrhosis and understand when anticoagulation is and is not needed in each individual patient.

Many articles that involved anticoagulation in cirrhotic patients were analyzed and reviewed in this study. It was confirmed that cirrhotic patients are also at a high risk for bleeding and thrombosis, despite previous beliefs. An important element describing why cirrhotic patients are at risk for bleeding and thrombosis is hemostatic instability. In non-cirrhotic patients, procoagulant and anti-coagulant levels are much higher than necessary to maintain hemostasis. In cirrhotic patients, however, procoagulant and anticoagulant levels are significantly decreased.

INR levels are higher in cirrhotic patients with the absence of anticoagulants. This effect is due to the impaired synthesis of most of the body’s coagulation factors because of decreased liver function. Some clinicians believe that INR should not be used as an indicator in cirrhotic patients.

All of these factors make monitoring therapeutic drugs difficult to interpret and optimize. It has been found that low molecular weight heparin is the best treatment for the prevention and treatment of bleeding and thrombosis in patients who have cirrhosis. These patients should be monitored closely for signs and symptoms of bleeding while on these medications. How could pharmacists in the inpatient and outpatient setting help monitor/provide suggestions in this situation?

Ha NB, Regal RE. Anticoagulation in Patients with Cirrhosis: Caught Between a Rock-Liver and a Hard Place. Ann Pharmacother. 2016: n. pag. http://aop.sagepub.com/content/early/2016/02/08/1060028016631760.full.pdf+html

Erythropoietin-Stimulating Agents Effect on Health-Related Quality of Life in Anemia of Chronic Kidney Disease

Chronic kidney disease (CKD) is a health epidemic globally; it is becoming more and more common. It is common for people with CKD to also have Anemia. The treatment for the combination of the two is erythropoietin-stimulating agents (ESAs), which lowers the need for blood transfusions. Many health professionals believe that the treatment of anemia in patients with CKD influences the quality of life for the patients involved. It is believed that younger patients could potentially benefit from higher hemoglobin targets. However, higher targets may be harmful to older individuals due to cardiovascular risk factors. This study analyzes the benefits of achieving higher hemoglobin targets with ESA’s and how that effects the health-related quality of life.

They analyzed several previously conducted studies to determine if there has been a significant effect on the quality of life of these patients. They measured the follow-up scores of the health-related quality of life between 2 different time points during the hemoglobin studies. They ended up reviewing 17 studies that met their criteria; these studies included patients with CKD who were receiving dialysis and not receiving dialysis and the different levels of ESAs.

This study found that there were no statistically significant differences between lower and higher hemoglobin targets for health-related quality of life measurements. It shows that the use of ESAs to improve quality of life is not appropriate for all patients. This is a way to personalize medicine, but looking at each patient individually and assessing whether or not they would benefit from higher ESA levels and more hemoglobin targets. What are some other ways personalizing medication is being implemented into health care?

Collister, David. “The Effect of Erythropoietin-Stimulating Agents on Health-Related Quality of Life in Anemia of Chronic Kidney Disease.” Ann Intern Med 2016: n. pag. http://annals.org/article.aspx?articleid=2491918

Problems and Advice Regarding Appropriate Antibiotic Use for Acute Respiratory Tract Infections in Adults

The most common reason for antibiotic prescription in adults is acute respiratory tract infection (ARTI) and they are often inappropriately prescribed to these patients. This article examines the best practices for antibiotic use and prescription in otherwise health adults showing signs of ARTI.

ARTI includes pharyngitis, uncomplicated bronchitis, and the common cold. The common cold is the most common reason for outpatient physicians to prescribe antibiotics. Antibiotics are prescribed more than 100 million times per year. The innaccurate use of these antibiotics is contributing to antibiotic resistance, which is a very urgent health threat. Antibiotics are responsible for the largest number of adverse effects related to medication use. This article provides evidence for the appropriate prescribing of antibiotics for adults with ARTI to prevent these issues from arising.

This study showed the best guidelines for antibiotic prescription among physicians who see patients for ARTI. Clinicians should not test patients or prescribe antibiotics for patients with bronchitis unless the clinician also suspects pneumonia. It is, in fact, appropriate for clinicians to prescribe antibiotics if streptococcal pharyngitis has been confirmed. Finally, antibiotics should not be prescribed for patients who have a common cold. By following these guidelines, antibiotic overprescribing can be reduced to make for a healthier population. How do you think pharmacists could aid in reducing antibiotic overprescription?

Harris, Aaron M. “Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults.” Ann Intern Med. 2016: M15-1840. http://annals.org/article.aspx?articleid=2481815

 

 

 

New Interventions Being Used to Reverse the Effects of Anticoagulants

Today, oral anticoagulants are being used more frequently in clinical practice, with warfarin being the most common one. Other anticoagulants being used are dabigatran, rivaroxaban, and apixaban. These medications serve a very important purpose, but sometimes their effects need to be reversed if an emergency surgery is needed or if serious bleeding is occurring. Reversing the effects can be done pharmacologically and this journal article explores the most effective options.

One way that the effects of warfarin can be reduced is by using phytonadione (exogenous vitamin K) in combination with fresh frozen plasma, prothrombin complex concentrate, or recombinant factor VIIa. To choose the appropriate intervention, the clinician will analyze the International Normalized Ration (INR), amount of bleeding, or the urgency of the surgery. This article shows that the clotting factor is more effective that the fresh frozen plasma.

It was concluded that Phytonadione and clotting factor concentrates have a significant role in the reversal of the effects of warfarin, but not as great of an effect on the reversal of other anticoagulants such as dabigatran, rivaroxaban, and apixaban. Based on the information presented about the importance of understanding how to reverse drug effects, how can pharmacists play a role in effectively deciding what therapy should be used and how can pharmacists make the decision effectively and safely?

Kalus, J. S. “Pharmacologic Interventions for Reversing the Effects of Oral Anticoagulants.” Am J Health-Syst Pharm. 2013: 70.10; S12-21. http://www.ajhp.org/content/70/10_Supplement_1/S12.full.pdf+htm