Comparing safety of Acute Kidney Injury with Two Different Medication Combinations

In this study, Peyko and colleagues compare the efficacy of two different medication combinations for Acute Kidney Injury. The two medications combinations in this study are Piperacillin-Tazobactam with Vancomycin and Vancomycin with either Cefepime or Meropenem. These drugs are often used in combination for infections, so their comparative safety is important.

The design for the trial was a prospective, open-label cohort study that lasted 3 months and included 125 patients. Patients in the study were treated for their respective infections and dosed accordingly. By the end of the study, it was found that 7.7% of patients that were receiving vancomycin with either cefepime or meropenem had Acute Kidney Injuries. This is compared to the 37.3% of patients that had Acute Kidney Injuries after receiving the piperacillin-tazobactam and vancomycin treatment for their infection.

Do you think the piperacillin-tazobactam and vancomycin treatment might be worth it if it proves to be more effective?

Peyko V, Smalley S, Cohen H.Prospective Comparison of Acute Kidney Injury During Treatment With the Combination of Piperacillin-Tazobactam and Vancomycin Versus the Combination of Cefepime or Meropenem and Vancomycin. J. Pharm. Pract. doi: 10.1177/0897190016628960

High-dose perioperative atorvastatin and acute kidney injury following cardiac surgery

Atorvastatin is a commonly prescribed medication for hyperlipidemia. It has also been recently found in a study that preoperative statin treatment could decrease the risk of acute kidney injury in patients recovering from cardiac surgery. Acute kidney injury (AKI) affects up to 30% of cardiac surgery patients, and patients who suffer from this complication increase their risk of death by as much as five-fold. This study looked at the efficacy of perioperative statin treatment in prevent AKI occurrences in cardiac surgery patients. The study included cardiac surgery patients who had never received statin treatment before and patients already on statin therapy. The statin-naïve patients were given 40 mg of atorvastatin that morning of and daily after surgery, and patients on statin therapy took regular dosage up to surgery and 80 mg after surgery, or they received a placebo. The study found that perioperative dosing of atorvastatin in patients already on statin did not reduce AKI risk and may even increase AKI risk in statin-naïve patients and in patients with CKD compared to the placebo treatment. These results did not support statin initiation to prevent AKI post-cardiac surgery.

I think it is really interesting to investigate new indications for already well-established medications. In terms of the drug development process, it is much easier and more cost-effective to find new indications for an already approved drug than it is to come up with an entirely new compound. It is also interesting that a previous study had found that statin treatment could possibly decrease the risk of AKI, while this study found that it did not or even could potentially increase the risk of AKI incidence in certain patients. This shows that many different studies’ results must be taken into account before using any of them to support any claims, find proper treatments techniques, or provide patient counseling.

Billings FT, Hendricks PA, Schildcrout JS et al. High-dose perioperative atorvastatin and acute kidney injury following cardiac surgery. JAMA. 2016; 315:877-888.

High dose perioperative atorvastatin and acute kidney injury following cardiac surgery

In a double blind, placebo-controlled, randomized design, researchers conducted a trial involving cardiac surgery patients, acute kidney injury, and post operative statin treatment. Patients were either dispensed 80 mg of atorvastatin the day before the surgery, 40 mg of atorvastatin the morning of the surgery, and 40 mg of atorvastatin daily following the surgery, or given the same amount of placebo.

Acute kidney injury was defined as a rise in 0.3 mg/dL or higher of serum creatinine concentrations with two days after the surgery. Using this definition, the researchers concluded that high-dose statin treatment did not end up decreasing the risk of acute kidney injury as compared to the placebo. The same results were shown in both statin naïve patients as well as patients who were already taking statins.

These results are important because in up to 30 percent of patients who had undergone cardiac surgery, acute kidney injury becomes a complication. From these results, more precautions can be taken to prevent this rather common complication. Other drugs may be used in place of high dosage atorvastatin. This relates to our future as student pharmacists because we now know to be even more careful in selecting certain medications for postoperative surgery.

Billings FT, Hendricks PA, Schildcrout JS, et al. High dose perioperative atorvastatin and acute kidney injury following cardiac surgery. JAMA. doi:10.1001/jama.2016.0548 (published February 23, 2016). 

Keeping the Kidneys Safe: The Pharmacists’ Role in NSAID Avoidance

While non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are very easy to purchase (in grocery stores and gas stations), they are one of the most common medications improperly prescribed, especially to older adults. If these are used at a high dose regularly and combined with the wrong medications, it can lead to acute kidney injury (AKI). NSAIDs inhibit the cyclooxygenase enzyme, preventing prostaglandin production. Prostaglandins help to autoregulate the dilation of arterioles in the kidney, controlling the amount of blood filtered. If AKI goes untreated long enough, self-prescribing NSAIDs can even lead to chronic kidney disease (CKD). Luckily, there are strategies that pharmacists can use to prevent patients from overusing NSAIDs at home and prevent these adverse effects.

Pharmacists can use bright stickers or post-it notes on the prescriptions of those who need medication counseling due to a high risk for AKI or CKD (patients with hypertension or diabetes). This will help the staff to remember to discuss the patient’s personal pain management system during consultations, blood pressure screenings, or when handing out the prescription. If the patient is in a rush, a handout could also be placed in with the prescription or on a pamphlet table so that the information is still available. They can also help to counsel on when to use ice or heat on a musculoskeletal issue, rather than taking an NSAID to relieve pain. This gives the patient other ways to manage their pain without taking an NSAID too frequently.

Acetaminophen could also be recommended as a pain reliever for those who are at high risk for AKI or CKD, as it is metabolized in the liver more than the kidney and is rarely seen to damage the kidney. However, this will then require that the pharmacist counsel on the maximum daily dose for acetaminophen in combination with other acetaminophen-containing medications the patient may have. This would be an optimal alternative if the patient is insistent on taking a pill for their pain, as long as the proper counseling regarding acetaminophen can be delivered.

I felt that this article had a lot of good options for educating patients with increased risk for kidney injuries against NSAID use. The repetition of seeing a helpful handout with the patient’s prescription would demonstrate the importance of the issue. The handout could serve as an additional reminder each time the patient has their prescription filled to steer clear of NSAIDs and use another pain-relieving method. This article also ties in nicely with what we are currently learning in anatomy and physiology and helped my understanding of kidney damage via non-steroidal anti-inflammatory drugs.

Pai, Amy B. “Keeping kidneys safe: The pharmacists’ role in NSAID avoidance in high-risk patients.” Journal of the American Pharmacists Association. 55.1 (2015) e15-e25. Web. 14 February 2016.