bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of an Algorithm for Intravenous Pantoprazole: Impact on Prescription Compliance in Quebec University Hospitals
Authors: Blouin Julie , Désaulniers Pierre-Louis , Tremblay Lydjie , Poitras Pierre , Dragomir Alice , Perreault Sylvie
Published: September 2013

Background:

Intravenous pantoprazole is used at Centre Hospitalier de l'Université de Montréal (CHUM) for the adjuvant treatment of nonvariceal upper gastrointestinal bleeding (UGB) and for inhibiting acid secretion among patients unable to tolerate oral intake (NPO). Since it was added to the CHUM formulary, the use of intravenous pantoprazole has steadily increased, and at times it has been used without endoscopic documentation of a nonvariceal UGB or even when the patient could have received a proton pump inhibitor orally.

Objective:

To assess the impact of an algorithm for intravenous pantoprazole on prescription compliance.

Methods:

Using a pre–post intervention specification, the use of pantoprazole was audited on a retrospective (January 1, 2002, to April 30, 2002) and prospective (January 1, 2003, to April 30, 2003) basis. We reviewed the medical records of all patients having received intravenous pantoprazole during these periods, assessing the compliance of prescriptions as specified by the algorithm. Cost of therapy and the step-down regimen were also reviewed.

Results:

In total, 150 patients were identified in the retrospective phase and 109patients in the prospective phase. The subjects were organized into 2 groups: UGB and NPO. In the UGB group, rates of compliance with indication, dose, and duration of treatment in the retrospective phase were 8.8%, 76.5%, and 58.8%, respectively; the corresponding rates for the prospective phase were 26.5% (p < 0.01), 80.9% (p = 0.53), and 69.1% (p = 0.78), respectively. The total rates of compliance (including indication, dose, and duration) were 4.4% in the retrospective phase and 11.8% in the prospective phase (p = 0.12). In the NPO group, the rate of compliance at the initiation of pantoprazole was 42.7% in the retrospective phase and 36.6% in the prospective phase (p = 0.51). The cost of noncompliance with the indication in the UGB group was estimated at $12 270 CDN (in the retrospective phase) and $7829 (in the prospective phase). In the NPO group, the cost figures were $8048 (retrospective phase) and $5929 (prospective phase).

Conclusions:

This study demonstrates that intravenous pantoprazole is being used in a suboptimal manner in our institution. Despite explicit criteria for use, in the prospective phase, we observed only 11.8% total compliance in the UGB group and 36.6% compliance at the initiation of pantoprazole in the NPO group. Even though these results were not statistically significant, in the prospective phase, we saw improvement in most compliance rates.
Association of Cardiac Drugs with Depression after Acute Coronary Syndrome
Authors: Corser William , Hanak Michael , Stommel Manfred , Olomu Ade , Yang Zhou , Dunn Susan , Holmes-Rovner Margaret
Published: September 2013

Background:

Depressive adverse effects of major cardiac medications in patients with cardiovascular disease have been suggested.

Objective:

To investigate the influence of the use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and/or β-blockers on subsequent depressive symptoms in patients hospitalized for acute coronary syndrome.

Methods:

A sample of 521 patients was followed for 8 months during 1,340 observations. Data were collected from structured telephone interviews and medical record chart reviews. Pooled time series generalized estimating equations regression models were used to evaluate depressive symptom scores, controlling for major clinical and sociodemographic patient characteristics.

Results:

No significant independent or interactive effects were found linking the use of these medications to subsequent depressive symptoms, despite changes in depressive symptoms over time. Factors that did affect subsequent depression included sociodemographic (eg, increased age, less education) and clinical characteristics (eg, higher composite comorbidity, prior history of depression and/or first myocardial infarction, higher postdischarge pain levels).

Conclusions:

Our results suggest that potential depressive adverse effects should not be considered a contraindication to the use of recommended cardiac medications. Observed increases in depressive symptoms after an acute cardiac injury will more likely be attributed to other patient characteristics independent of the use of major drug therapy prescribed to prevent further acute cardiac events.
Pattern of Medication Use and Errors in a Tertiary Care Children's Hospital Intensive Care Unit
Authors: Burny Ilyas , Lieh-Lai Mary W , Gaynor Ken N , Thomas Ronald L , Sarnaik Ashok P
Published: September 2013

Background:

Children are at increased risk for medication errors because of weight-based dosing and the need for diluting stock solutions, both of which may lead to calculation errors. Medication errors are reported in 0.15% to almost 6% of medication orders for children. Critically ill children may be at the greatest risk because of hemodynamic and respiratory instability, drug–drug interactions, disease-related abnormalities in drug clearance and volume of distribution, and renal or hepatic insufficiency.

Objective:

To describe the pattern of medication use in a tertiary care children's hospital intensive care unit (ICU), to determine the status of FDA labeling for the drugs used in the same ICU, and to determine the rate and types of medication errors reported in our ICU and whether the errors were related to factors such as length of ICU stay and the number of medications received.

Methods:

This prospective, observational study was conducted over a 6 month period in the 20 bed medical–surgical ICU of a free-standing children's hospital. Data collected included all medications prescribed, total number of admissions, patient's age, length of ICU stay, the number of drugs prescribed per patient, and the number of medication errors reported through a computerized database named Dr. Quality. Medication errors were categorized according to the National Coordinating Council for Medication Errors Reporting and Prevention Medication Errors Categories. In addition, the status of pediatric labeling for each drug was determined.

Results:

Six hundred thirty-nine patients were admitted to the ICU during the study period. The average length of stay was 4 days. Two hundred seven (32%) patients stayed for one day, while the longest stay was 62 days (1 patient). The total number of prescriptions ordered and dispensed during the study period was 8,025. Each patient received an average of 13 medications (49 drugs were given to one patient). The 3 most commonly prescribed medication groups in the ICU were analgesics/sedatives, antimicrobials, and gastrointestinal preparations. Five hundred fifty-seven (87%) patients received one or more analgesic or sedative drug. Eighty-one percent received at least one antimicrobial. Of the 8,025 medication orders, 17 (0.21%) medication errors were reported. One hundred different medications were dispensed during the study period, with only 33% labeled for use in children 0–18 years. The effects of ICU length of stay and number of medications prescribed per patient on the occurrence of medication errors could not be determined due to the small sample size.

Conclusions:

Patients in this ICU received a significant number of medications, of which only 33% were labeled for use in children. The rate of medication errors was 0.21%.
Therapeutic Interventions for the Treatment and Control of Influenza
Authors: Patel Gourang P , Crank Christopher W , Black Stephanie
Published: September 2013

Objective:

To review antiviral management of influenza and discuss recent developments in antiviral resistance.

Data Sources:

Literature retrieval was accessed through MEDLINE/PubMed (1977–February 2007) using the terms influenza, resistance, adamantanes, and neuraminidase inhibitors, treatment, and prevention. In addition, reference citations from identified publications were reviewed.

Study Selection and Data Extraction:

All articles in English identified from the data sources were evaluated.

Data Synthesis:

Infection with influenza is associated with 36,000 deaths and more than 200,000 hospitalizations in the US each year and results in a large economic burden on society. We reviewed 7 trials describing management of influenza; the results showed that 92% of influenza cases demonstrated adamantane resistance in 2005. Selection of treatment for influenza with a neuraminidase inhibitor should be based on patient preference, past medical history, and managed care restrictions since one agent has not demonstrated superiority. Early initiation of treatment, within 12 hours of symptom onset (compared with 48 h), has resulted in illness being shortened by more than 3 days. Conclusions shown in the trials reviewed here regarding the consequences of increasing incidence of influenza A resistance include: viral surveillance cultures are important, influenza has a significant global impact, and inappropriate use of antiinfective agents results in local and global resistance.

Conclusions:

Therapeutic options for the management of influenza include the neuraminidase inhibitors, zanamavir and oseltamivir. Unfortunately, new classes of antiviral drugs for influenza will not be forthcoming in the near future. Adamantane resistance is now commonly demonstrated in influenza. At this time, efforts should be made to minimize patient risk for infection.
Evaluation of a Standardized Sliding Scale Insulin Preprinted Order
Authors: Wilbur Kerry , Yu Christine
Published: September 2013

Background:

Poor glycemic control is associated with negative outcomes in hospitalized patients with diabetes, both during and beyond their hospital stay. Despite its limitations, adjunct sliding scale insulin (SSI) is often prescribed to manage glucose levels, but the regimens are subject to wide variability and may contribute to medication error.

Objective:

To evaluate diabetic patients' glycemic control and staff acceptability following development and implementation of an SSI preprinted order (PPO).

Methods:

A retrospective chart review of diabetic patients admitted to the adult internal medicine service at a major Canadian teaching hospital was conducted. A convenience sample of patients who received SSI before (n = 60) and after (n = 60) PPO implementation was evaluated for episodes and management of hypo- and hyperglycemia. A survey also was conducted to determine staff perspectives regarding SSI PPO use.

Results:

Thirty-five SSI regimens were identified among the 60 patients in the pre-PPO group. Although no significant difference in the incidence of hypoglycemia was found between groups, more hyperglycemia episodes occurred in the post-PPO group. Glycemic control was poor regardless of the SSI prescribing strategy employed; only half of the measurements in either group were within a 72–198 mg/dL target range. One-third of medical students reported receiving no prior teaching for devising an SSI regimen. Both medical and nursing staff reported increased clarity and ease in administering SSI with use of a PPO. Half of the respondents believed that the potential for medication error was diminished.

Conclusions:

A PPO decreased variability in SSI prescribing but did not improve glycemic control in diabetic patients admitted to internal medicine. Revisions to our documents have been made to address hyperglycemia events and appropriate SSI use to further promote patient safety through standardized prescribing.
Consumers' Risk Perceptions of Prescription and Over-the-Counter Medications
Authors: Droege Marcus , Maniscalco Maria , Daniel Karen L , Baldwin H John
Published: September 2013

Background:

Flawed judgments about medication risks potentially jeopardize efforts to protect the public. It has been shown that positive risk/benefit perceptions by patients and providers lead to better patient outcomes, higher acceptance of drug therapy, and higher adherence rates.

Objective:

To explore consumers' level of familiarity with 10 best-selling over-the-counter (OTC) and prescription drug products, correlate familiarity with risk perceptions regarding those agents, and ascertain common sources of information regarding the medications studied.

Methods:

A cross-sectional study was conducted in the major metropolitan tri-county area of south Florida using a facilitator-administered survey instrument. Data collection involved asking consumers about the extent to which they agreed with statements related to risk perceptions, familiarity, and sources of information for 10 best-selling medications. Participants were recruited from a convenience sample of 1,035 south Florida residents.

Results:

When ranking the drugs by familiarity, 972 respondents reported a higher level of familiarity with OTC than prescription medications. Overall, prescription agents were perceived to be riskier than OTC products (p < 0.01); however, individual respondents tended to perceive the listed drugs as either risky or not regardless of their OTC or prescription status. Direct-to-consumer advertisements were mentioned most frequently as information sources.

Conclusions:

As shown in this study, marketing status, provider interaction, and effects of an undefined health risk are variables that contribute to consumers' decision-making regarding the medication use process.
Leukopenia Associated with Paroxetine Use
Authors: Trewet CoraLynn B , Galioto Nicholas J , Payne Thomas J
Published: September 2013

Objective:

To report a case of leukopenia associated with paroxetine treatment.

Case Summary:

A 44-year-old white female with a history of anemia secondary to heavy menses, anxiety, depression, and current tobacco dependence presented with general symptoms of fatigue and blurred vision. The patient's medications at the time of the initial visit were ferrous sulfate 325 mg twice a day and paroxetine 20 mg/day. Three years prior to the initiation of paroxetine, the patient's documented white blood cell (WBC) count was 7.4 × 103/ μL with normal differential and hemoglobin was 10.5 g/dL; on presentation, laboratory test results were WBC count 1.3 × 103/ μL, red blood cell count 1.78 × 106/ μL, hemoglobin 4.5 g/dL, hematocrit 15.1%, and platelets 248 × 103/ μL. Three months after discontinuation of paroxetine, the patient's WBC count was 4.4 × 103/ μL.

Discussion:

Paroxetine and other antidepressants have not been known to cause adverse hematologic effects that can be seen with other antipsychotics, namely, clozapine. The use of the Naranjo probability scale indicated a probable relationship between leukopenia and paroxetine therapy in this patient. Based on a MEDLINE search (February 12, 2007), there are limited data on leukopenia as an adverse event of paroxetine. We found this to be a unique case of leukopenia suspected to be secondary to extended use of low-dose paroxetine.

Conclusions:

Although leukopenia caused by paroxetine and other medications with serotonergic effects appears to be uncommon, physicians and pharmacists should be aware of this rare but potentially serious adverse event.
Robustness of Palm Kernel Oil Blend in Suppository Preparation Using Acetaminophen as a Model Drug
Authors: Noordin Mohamed Ibrahim , Chung LY
Published: September 2013

Background:

Theobroma oil suppository base has good characteristics for the delivery of most drugs, but its polymorphism renders it a difficult medium with which to work. Preparation of suppositories using theobroma oil must be carried out at a temperature below 36 °C to avoid formation of metastable polymorphs. Substitutes for theobroma oil are therefore desirable.

Objective:

To compare the characteristics of theobroma oil- and palm kernel oil blend (PKOB)-based suppositories, each produced by 2 different techniques of preparation.

Methods:

Theobroma oil and PKOB (consisting of hydrogenated palm kernel oil and hydrogenated palm kernel stearin in an 8:2 ratio, with 5% stearic acid and 5% glyceryl monostearate) were used as a base. Suppositories were prepared by 2 different techniques, with acetaminophen used as the model drug. The standard technique used a water bath to melt the base preparation at 36 °C before incorporation of acetaminophen, while the second technique involved melting the base in an oven at 60 °C. The 2 types of suppositories produced by these techniques were then tested physically for appearance, hardness, liquefaction time, and melting characteristics using differential scanning calorimetry.

Results:

Satisfactory theobroma oil–based suppositories were produced by the water bath technique at 36 °C, but the oven technique at 60 °C failed to produce a good product. On the other hand, both techniques produced satisfactory PKOB-based suppositories that were similar in both physical and thermal characteristics.

Conclusions:

PKOB constituted with the above-mentioned ingredients can be exposed to a wider range of temperatures without risk of polymorphism.
High Initial Dosing of Olanzapine for Stabilization of Acute Agitation: A Retrospective Case Series
Authors: Brooks John O , Karnik Niranjan , Hoblyn Jennifer
Published: September 2013

Background:

There are several possible dosing strategies for the use of atypical antipsychotics for acute agitation, such as the rapid initial dose escalation protocol (olanzapine) or starting at the maximum recommended dose (aripiprazole). There can be challenges to dose escalation as compared with “loading” patients with an atypical antipsychotic.

Objective:

To describe an effective loading dose protocol for olanzapine used to enhance control of acute psychotic and manic symptoms.

Methods:

A retrospective case series was constructed from the records of inpatients treated on an acute psychiatry unit. Records from 8 patients who were diagnosed with bipolar disorder or schizophrenia and who received an initial dose of olanzapine 40 mg for 2 days, 30 mg for 2 days, and 20 mg for 2 days were retrieved and examined. Scores on the Brief Psychiatric Rating Scale (BPRS) and the Young Mania Rating Scale (YMRS) were assigned retrospectively on the basis of chart review.

Results:

The dosing regimen was associated with average reductions of 9.2 points per day on the BPRS and 9.1 points per day on the YMRS over the first 4 days of treatment. None of the patients in this series experienced serious adverse events, and the only adverse effect observed was mild sedation.

Conclusions:

High initial dose olanzapine, used in a scheduled loading dose regimen, was associated with rapid reduction of psychotic and manic symptoms. Our conclusions are limited by the small sample size, the lack of random assignment, and the retrospective approach. The results of this series suggest the need for additional studies of the efficacy and safety of this olanzapine loading dose protocol.
Ceftobiprole: A Novel Broad-Spectrum Antiinfective
Authors: Dixon Tripp , Eiland Edward H
Published: September 2013

Objective:

To review the efficacy, safety, pharmacology, pharmacokinetics, pharmacodynamics, and in vitro microbiology susceptibilities of ceftobiprole, a new broad-spectrum cephalosporin.

Data Sources:

A PubMed and Internet search (2000–September 2007) was conducted, using the key words ceftobiprole, Ro 63–9141, BAL5788, and BAL9141. Cochrane Library and International Pharmaceutical Abstracts (2000–September 2007) were accessed and reference citations from publications identified were reviewed.

Study Selection and Data Extraction:

All English-language articles identified from the data sources were reviewed. Phase 3 studies were included in the evaluation.

Data Synthesis:

Two multinational, double-blind, pivotal Phase 3 studies involving more than 1,600 patients have shown ceftobiprole to have in vitro activity against penicillin-resistant Streptococcus pneumoniae, Pseudomonas spp., and methicillin-resistant Staphylococcus aureus (MRSA). In addition, the cure rates associated with ceftobiprole for complicated skin and skin structure infections (cSSSI) were comparable with those of a single drug or a 2-drug comparator combination. Adverse effects included nausea, vomiting, taste disturbance, headache, and diarrhea.

Conclusions:

Ceftobiprole is an essential addition to the antimicrobial armamentarium for use against MRSA and/or multidrug-resistant gram-negative infections. Ceftobiprole is approved for the treatment of cSSSI, including diabetic foot infections; however, studies related to the treatment of hospital-acquired and community-acquired pneumonia requiring hospitalization are ongoing. The safety profile is consistent with that of the cephalosporin class of antibiotics. Ceftobiprole will serve as empiric or definitive antimicrobial therapy for resistant gram-negative and gram-positive pathogens. The challenge will be to maintain judicious use through antibiotic stewardship programs and deescalation strategies.
Phlegmasia Cerulea Dolens in a Patient with Heparin-Induced Thrombocytopenia
Authors: Wetz R Colin , Stroup Jeffrey S , Roberts Montgomery L
Published: September 2013

Objective:

To report a case of the venous obstructive condition known as phlegmasia cerulea dolens (PCD) in the presence of heparin-induced thrombocytopenia (HIT).

Case Summary:

A 50-year-old white female presented to the emergency department with a 2-day history of a bluish discoloration of her toes and hands accompanied by chest pain and shortness of breath. The evident edema, tenderness on palpation, and cyanosis of the extremities were suggestive of PCD. She had been hospitalized approximately one month previously due to a fibular fracture and again within the past 2 weeks for intractable abdominal pain and nausea. During her current hospital stay, she was diagnosed with multiple venous thromboembolisms (VTEs); at the time of admission, an unfractionated heparin (UFH) drip was initiated to treat her VTEs. Due to a decreased platelet count on admission, a platelet factor 4 (PF4) antibody assay was performed and found to be positive. After discontinuation of UFH, her platelet count slowly returned to normal range.

Discussion:

The pathogenesis of HIT is due to formation of antibodies against the complex of heparin and PF4. HIT is characterized by a reduction in the platelet count approximately 4–14 days after the initiation of heparin therapy plus a paradoxical prothrombotic state. The typical diagnostic clues are a drop in platelet count of 50% from baseline with the initiation of heparin and a positive assay for heparin-PF4-immunoglobulin G. This condition may result in PCD, which presents as the triad of pain, edema, and cyanosis. This condition often results in venous or arterial thrombus formation. The treatment for PCD includes immediate discontinuation of heparin products and anticoagulation with a direct thrombin inhibitor.

Conclusions:

Thromboembolic complications such as PCD are often observed as a presenting feature of HIT. To avoid these potentially limb- and life-threatening complications, clinicians must be vigilant in their monitoring of platelets and clinical signs and symptoms of HIT while patients are on heparin therapy.
Hospital Pharmacist Familiarity with Patient Discharge Medication Costs
Authors: Wilbur Kerry
Published: September 2013

Background:

Drug therapy poses a financial burden for many individuals. Cost-related medication nonadherence is ultimately associated with increased healthcare resource utilization and poor patient outcomes. Physicians are often unaware of the costs associated with their prescribed therapy, but little is documented regarding familiarity of hospital pharmacists with out-of-pocket medication expenses borne by patients in the community setting.

Objective:

To evaluate how familiar hospital pharmacists are with prescribed medication costs for discharged patients.

Methods:

Hospital pharmacists within a specific healthcare organization were invited to participate in an online survey. Ten brief patient case scenarios and associated discharge therapeutic regimens were outlined and respondents were asked to identify the costs that discharged patients would incur when having the prescriptions filled. The total number and proportion of estimates either above or below the actual medication cost as determined from community pharmacies were calculated.

Results:

Thirty-one pharmacists completed the survey. For the therapeutic regimens described, 47% of medication costs were underestimated, 33% were overestimated, and 20% were correctly estimated (within 10% of the actual value). Incorrect estimates were evident across all therapeutic classes and medical indications presented in the survey. The greatest mean absolute cost differences were underestimation of a linezolid treatment course for skin and soft tissue infection ($384.18 below the mean absolute cost) and overestimation of monthly bisoprolol heart failure therapy ($22.42).

Conclusions:

Hospital pharmacists are often unfamiliar with what discharged patients must pay for drug therapy.
Pharmacy Technology Clubs: A Great Way to Enhance Your Students' Educational Experience
Authors: Davis Karen D
Published: September 2013

Background:

Past experience of starting and continuing a pharmacy technology club has shown that the students who participated have been able to surpass the normal boundaries of technician training and accomplish many extra activities, including community service and awareness, which were done in addition to the competencies required in an ASHP-accredited program.

Objective:

To discuss the role that a pharmacy technology club can play in enhancing and improving students' experience in a technician training program.

Methods:

The information presented was collected from past experiences of a successful organization and include ways to start such a club, the benefits a club can provide, and the actual results from an existing club.

Results:

The Pharmacy Technology Club at Southeastern Technical College in Vidalia, GA, was established 2 years ago and has provided 3 classes of technicians with an enhanced training experience by providing additional viable skills for the field, job opportunities before graduation, and the opportunity to take and pass the Pharmacy Technician Certification Board examination.

Conclusions:

The standard curriculum for technician training programs used across the country is very successful in training technicians for entry-level employment in pharmacy through didactic, experiential, and laboratory experiences. An organized club can provide students with additional skills that will aid in communication, cultural diversity, leadership qualities, and better work ethics. This will give students who complete such a program the additional understanding of how important their role in patient care is today and enable them to adapt to continuous changes in the field.
Role of the Pharmacist on a Multidisciplinary Psychiatry Team: Impact on Medication Adherence in a Community Setting
Authors: Carvalhana Virginia , Flak Edred
Published: September 2013

Objective:

To report the effect of pharmacist involvement in a multidisciplinary psychiatry team managing high-risk patients in the community.

Case Summary:

We report 3 cases of professional collaboration that highlight the role of the pharmacist as a member of the multidisciplinary psychiatry team in the successful management of high-risk patients. Regular communication between pharmacists and psychiatrists, as well as delivery of specialized pharmacy services such as dispensing of medications in controlled supply, witnessed medication consumption, and adherence monitoring, resulted in decreased use of emergency services, decreased incidents of overdose, and increased adherence to medication.

Discussion:

The management of psychiatric patients poses a significant challenge to healthcare providers. Poor adherence to drug therapy is often a significant barrier to treatment success and can lead to clinical and economic burdens. Professional collaboration between psychiatrists and pharmacists can aid in successful management of psychiatric patients at risk of relapse or deterioration in the community setting secondary to nonadherence and/or possible overdose. The pharmacist is often an unrecognized or underutilized member of the multidisciplinary team. The recent focus on expanding the pharmacist's scope of practice supports the involvement of pharmacists as integral members of interdisciplinary and collaborative care models.

Conclusions:

Interprofessional collaboration and implementation of specialized pharmacy services can increase patient adherence to medication regimens, reduce the potential for overdose, and aid in the successful management of psychiatric patients in the community setting. Although we have highlighted a small number of cases, future research is required to assess the effectiveness of such interventions on a larger scale.
Review of Serum Voriconazole Concentrations and Correlations with Adverse Events and Efficacy
Authors: Latran Michael J
Published: September 2013

Objective:

To review the available evidence regarding the monitoring of serum voriconazole concentrations in terms of efficacy and safety.

Data Sources:

A literature search of MEDLINE was conducted (1950–February 2009), with combinations of the following search terms: voriconazole, therapeutic drug monitoring, voriconazole serum concentrations, voriconazole levels, trough, and adverse events.

Data Collection:

All studies and case reports that evaluated serum voriconazole concentrations in adults were reviewed and considered for inclusion. Citations in identified articles were searched for additional information.

Data Synthesis:

Ten studies and case reports that evaluated serum voriconazole concentrations in terms of efficacy and safety in adults were identified and included in this review. Results from efficacy studies show an association between low serum voriconazole concentrations and disease progression. One study found that a lack of response occurred more often in patients with a serum voriconazole trough of 1 μg/mL or less (p = 0.02). Another study found that patients were more likely to fail voriconazole therapy for invasive fungal infections when serum concentrations were less than or equal to 2 μg/mL. In terms of safety, 6 studies showed an association between elevated serum voriconazole concentrations and adverse events.

Conclusions:

Available data suggest that serum voriconazole concentrations of 1 μg/mL or less are associated with therapeutic failures, whereas serum voriconazole concentrations of 6 μg/mL or more are associated with adverse events. Studies show that monitoring serum voriconazole concentrations may decrease the incidence of adverse events while increasing efficacy.
Measuring Persistence to Oral Hypoglycemic Agents in Type 2 Diabetic Veterans
Authors: Kim Nancy , Agostini Joseph , Justice Amy
Published: September 2013

Background:

Medication adherence is essential for diabetes control but difficult to measure. Persistence, the continuous refill of medications, is one measurement that could be integrated into practice, but concordance among definitions of persistence is unclear.

Objective:

To compare persistence patterns in the use of oral hypoglycemic agents by diabetic veterans in the first year of treatment, using 2 separate refill metrics.

Methods:

Eligible veterans were 18 years or older and had filled at least one prescription for any nondiabetes drug during the 6 months preceding study entry. Study entry was the date that patients first filled a prescription for oral hypoglycemic agents between January 1, 2000, and December 31, 2002. Persistence was defined as (1) total days (days' supply/study period) and (2) continuous fill (days' supply/refill interval).

Results:

Inclusion criteria were met by 110,554 veterans. They had a median age of 63 years, 97% were male, and most had multiple comorbidities. Most patients received only one oral hypoglycemic agent. When total days was used, median persistence at 1 year was 83%, with 45% of subjects demonstrating poor persistence (<80%). When continuous fill was used, median persistence was 0.99, and 24% had poor persistence. Both metrics decreased over time. Continuous fill produced higher persistence estimates and a substantial proportion of overpersistence (>24% of patients). The 2 measures had a kappa agreement statistic of 0.56 (95% CI 0.55 to 0.57).

Conclusions:

Although both metrics showed similar trajectories over time, more conservative estimates, ease of calculation, and transparency favor total days over continuous fill. Continuous fill revealed substantial overpersistence, which should be considered separately from good persistence. Explicit definitions of persistence are necessary to enhance comparisons among refill studies and provide context for clinical applications.
Ask-Advise-Refer Increases Referrals to a Smoking Cessation Group Clinic
Authors: Philbrick Ann M , Farris Karen B , Faber Ashley J , Anderson Erin A , Carmody Brenda R , Mascardo Lisa A , Jacobsen Ryan B , Reist Jeffery C , Newkirk Erin N , McDanel Deanna L
Published: September 2013

Background:

The Department of Pharmaceutical Care at the University of Iowa Hospitals and Clinics sponsors a pharmacist-managed smoking cessation group clinic. Ask-Advise-Refer is a method to refer patients to smoking cessation programs, but few data are available to support its use by pharmacists in an academic medical center outpatient pharmacy.

Objective:

To quantify the number of individuals asked about tobacco use, advised to quit smoking, referred, and enrolled in the pharmacist-managed smoking cessation group clinic through the hospital's 2 ambulatory care pharmacies.

Methods:

The Ask-Advise-Refer program was implemented and evaluated prospectively in both ambulatory care pharmacies. Patients over 18 years old who received their own prescriptions were asked about tobacco use. Pharmacists advised tobacco users to quit and surveyed their interest in quitting within the next 30 days. A pharmacist contacted interested patients by phone to provide them with more information to enroll them in the smoking cessation group clinic. A documentation form followed the prescription through the filling process. Forms used for data collection were gathered daily and information on tobacco use was entered into the dispensing system weekly. Forms also provided numerical counts for evaluating the program.

Results:

Of the 3,267 patients asked about smoking status, 889 of them used tobacco. Of those, 53.8% were interested in quitting in the next 30 days; 30% of these patients wanted the pharmacist to contact them. Of the patients who were contacted, 22 agreed to enroll in the clinic, and 10 attended the clinic.

Conclusions:

By implementing an Ask-Advise-Refer brief smoking cessation intervention at an academic medical center outpatient pharmacy, referrals and participation were increased in the pharmacist-managed smoking cessation group clinic.
Amiodarone-Induced Cutaneous Leukocytoclastic Vasculitis after Cardiac Surgery
Authors: Kaushik Prashant , Hefty Matthew , Soule Matthew R
Published: September 2013

Objective:

To remind physicians and pharmacists of the potential of amiodarone to cause leukocytoclastic vasculitis (LCV) as a potentially serious acute adverse drug reaction, and that the cornerstone of treatment for LCV is identification and removal of the etiologic agent (usually a drug such as amiodarone).

Case Summary:

A 70-year-old white male who underwent aortic valve replacement developed cutaneous LCV (without serious systemic involvement) 2 days after treatment with amiodarone 800 mg/day was initiated. Amiodarone was discontinued and the rash almost completely resolved within 48 hours. Amiodarone 400 mg/day was restarted 13 days later and arthralgias and palpable purpuric lesions reappeared in the same distribution, but much more extensively, within 2 days. Amiodarone was discontinued and, once again, arthralgias and skin lesions resolved within 1 week.

Discussion:

Photosensitivity and the development of blue/grey skin pigmentation are the most commonly and classically recognized cutaneous adverse drug reactions (ADRs) of long-term use of amiodarone. LCV, the most common small-vessel necrotizing vasculitis as an acute ADR to amiodarone, is rare, but needs to be considered in day-to-day clinical practice. The Naranjo probability scale suggested a highly probable association between LCV and the use of amiodarone in our patient.

Conclusions:

To the best of our knowledge, this is the first case report of LCV occurring in a post–cardiac surgery setting with the use of amiodarone. Cardiothoracic surgeons, cardiologists, other treating physicians and pharmacists should be aware of this rare but potentially serious adverse event related to amiodarone.
Electronic Communications by Pharmacy Employees: Legal Issues and Practical Concerns
Authors: Van Dusen Virgil R , Whatley Nathan L
Published: September 2013

Employers have justifiable legal concerns about on-the-job computer usage by employees. Monitoring of employee computer usage by employers is a method to address these concerns. Federal laws, such as the Electronic Communications Privacy Act, and state laws provide some guidelines on the appropriate monitoring of employee computer usage. Consent to inspect computer usage by an employee may provide additional protection for employers against employee complaints of invasion of privacy. Off-duty employee electronic activity may be addressed by employer-created policies regarding social networking and/or through training programs. No cases have been reported that impose liability on employers for searching employees' computers or email.
Pharmacy Automation and Workflow Implications: A Case Study
Authors: Silverstein Steven
Published: September 2013

Background:

Inpatient pharmacy automation is becoming an increasingly important component of the medication distribution process across the country. The use of pharmacy automation is perceived as a tool for increasing patient safety and pharmacy department efficiency. Adjusting pharmacy workflow requirements and staffing redefinitions is essential when implementing pharmacy automation.

Objective:

To evaluate the results of an acute care, community, teaching hospital's experience as the inpatient pharmacy implements a robot, medication carousel, and barcode packager, and shifts its medication distribution model from a cartless to cart fill method.

Data on robot efficiency, changing pharmacy technician roles, and pharmacist time were collected over 2 years. The medication distribution process and pharmacy technician roles had to be adjusted multiple times to increase workflow efficiency. The initial shift to a cart fill distribution model, with first doses dispensed from the robot, resulted in robot efficiency of approximately 71%. When the distribution model was shifted to hybrid cart fill and cartless model, with first doses dispensed from automated dispensing cabinets, the robot efficiency improved to between 85% and 90%.

Conclusions:

Pharmacy automation requires proper workflow adjustments to realize the potential increased efficiency of this technology. Additionally, optimizing the medication distribution model to maximize the efficiency of staffing workflow has a significant impact on automation efficiency.
Plerixafor for Stem Cell Mobilization Prior to Autologous Stem Cell Transplant in Non-Hodgkin's Lymphoma and Multiple Myeloma
Authors: Moorman Meredith T , Baxley Allison , Borders Emily B
Published: September 2013

Objective:

To review the pharmacology, pharmacokinetics, dosage, administration, clinical efficacy, safety, and place in therapy of plerixafor, a CXCR4 receptor antagonist used to mobilize stem cells prior to hematopoietic stem cell transplantation.

Data Sources:

Articles were identified by searching MEDLINE (1950-August 2009) and the American Society of Hematology abstract database using the key terms plerixafor, AMD3100, hematopoietic stem cell transplant, mobilization, multiple myeloma, and non-Hodgkin's lymphoma. Additional articles were obtained by using the reference sections of articles found during the literature search.

Study Selection and Data Extraction:

All articles identified from the literature search were reviewed for relevant information. Appropriate information was included in this review. The search was restricted to available English-language articles, including those on both preclinical and clinical trials.

Data Synthesis:

Plerixafor is a CXCR4 receptor antagonist approved by the FDA to assist in the mobilization of hematopoietic stem cells in patients with non-Hodgkin's lymphoma or multiple myeloma undergoing autologous stem cell transplant. Plerixafor is used in combination with granulocyte colony-stimulating factor. Plerixafor has been compared with placebo in both Phase 2 and Phase 3 clinical trials and has been shown to allow for a greater collection of hematopoietic stem cells in fewer apheresis sessions. Plerixafor demonstrated good tolerability in clinical trials.

Conclusions:

Plerixafor has demonstrated efficacy and tolerability when used for stem cell mobilization in patients with non-Hodgkin's lymphoma and multiple myeloma. Further studies are warranted to determine the safety and efficacy of plerixafor in patients with malignancies other than non-Hodgkin's lymphoma or multiple myeloma who are undergoing stem cell transplant and to determine its potential use in healthy stem cell donors.
Milnacipran: A New Treatment for Fibromyalgia Syndrome
Authors: Hale Katherine S
Published: September 2013

Objective:

To review the pharmacology, efficacy, and tolerability of milnacipran, a dual serotonin-norepinephrine reuptake inhibitor (SNRI), in the treatment of symptoms of fibromyalgia syndrome and associated fibromyalgia pain.

Data Sources:

English-language articles were obtained via searches of MEDLINE (1950-January 2010), EMBASE (1980-January 2010), and International Pharmaceutical Abstracts (1970-January 2010), using the key words milnacipran, fibromyalgia, serotonin-norepinephrine reuptake inhibitors, F 2207, and pain management. Bibliographies of selected articles were used to identify additional sources.

Study Selection and Data Extraction:

Available published articles reporting the results of human studies of milnacipran were reviewed for inclusion in this article. Additional information regarding pharmacology, adverse events, contraindications, and precautions was obtained from the manufacturer's prescribing information.

Data Synthesis:

Milnacipran is a dual SNRI approved for the treatment of fibromyalgia symptoms and pain. Milnacipran is well absorbed upon oral administration, has limited first-pass elimination, has a short halflife, and is not metabolized by the cytochrome P450 enzyme group. Phase 3 clinical trials evaluating the efficacy of milnacipran demonstrated a 10–20% higher composite response rate compared with placebo in the treatment of fibromyalgia symptoms and associated pain when milnacipran was given in doses of 100–200 mg/day. Significant improvements in physical functioning, fatigue, cognition, and mental health were also noted. Milnacipran appears to have fewer anticholinergic, sedative, and cardiovascular adverse effects compared with other pharmacologic treatments of fibromyalgia. Nausea was the most commonly reported adverse event.

Conclusions:

Milnacipran is an effective treatment for the symptoms of fibromyalgia syndrome and associated pain. Additional studies are needed to assess comparative effectiveness with that of other pharmacologic treatments of fibromyalgia syndrome, long-term efficacy, and safety.
Iloperidone—A Second-Generation Antipsychotic for the Treatment of Acute Schizophrenia
Authors: Hale Katherine S
Published: September 2013

Objective:

To review the pharmacology, efficacy, and tolerability of iloperidone, a second-generation antipsychotic, in the treatment of acute schizophrenia in adults.

Data Sources:

English-language articles were obtained via MEDLINE (1966-March 2010) and International Pharmaceutical Abstracts (1970-March 2010) searches using the key words iloperidone, acute schizophrenia, atypical antipsychotics, second-generation antipsychotics, HP 873, P88–8991, P95–12113, and Fanapt. Bibliographies of selected articles were used to identify additional sources.

Study Selection and Data Extraction:

Available published articles reporting the results of human studies of iloperidone were reviewed for inclusion in this article. Additional information regarding pharmacology, adverse events, contraindications, and precautions was obtained from the manufacturer's prescribing information.

Data Synthesis:

Iloperidone is a second-generation antipsychotic approved for the treatment of acute schizophrenia in adults. Iloperidone is well absorbed upon oral administration, highly protein bound, and metabolized primarily by CYP3A4 and 2D6. Phase 3 clinical trials evaluating the efficacy of iloperidone demonstrated significantly higher response rates with iloperidone compared with placebo in the treatment of positive, negative, and cognitive symptoms associated with acute schizophrenia when the drug was given in doses up to 24 mg daily. Dizziness, dry mouth, and nausea were the most commonly reported adverse events and appear to be dose related. Additional adverse events occurring in 5% or more of patients include orthostatic hypotension, somnolence, tachycardia, fatigue, nasal congestion, and weight increase. Iloperidone should be titrated slowly over a 7-day interval to avoid the potential for orthostatic hypotension. Product labeling includes a black box warning against the use of iloperidone in dementia-related psychosis and precautions regarding QT interval prolongation.

Conclusions:

Iloperidone is an effective treatment for the symptoms of acute schizophrenia in adults. Additional studies are needed to assess comparative effectiveness with other pharmacologic treatments of schizophrenia, long-term efficacy, and long-term safety.
Pharmacotherapy Using Cardiovascular Agents: Focus on the Top 200 Drugs
Authors: Schnepp Adam R , Nykamp Diane
Published: September 2013

Objective:

To summarize pharmacologic agents available to treat cardiovascular diseases, including heart failure, hypertension, and hyperlipidemia.

Data Sources:

Drugs used in the management of cardiovascular disease were identified from a list of the top 200 drugs of 2008 by number of prescriptions dispensed. Relevant articles were obtained via a MEDLINE search (2000-March 2010) using the key words pharmacy technician, hypertension, heart failure, hyperlipidemia, β-blocker, ACE inhibitor, angiotensin receptor blocker, diuretic, calcium-channel blocker, clonidine, HMG-CoA reductase inhibitor, ezetimibe, fenofibrate, niacin, clopidogrel, warfarin, isosorbide mononitrate, and digoxin. In addition, evidence-based practice guidelines, monographs, package inserts, and other secondary sources were reviewed.

Study Selection and Data Extraction:

Relevant information regarding dosages, trade/generic names, pharmacology, and adverse effects associated with common agents to treat cardiovascular disease was included.

Data Synthesis:

Despite falling mortality rates, cardiovascular disease continues to be the leading cause of death in the US and is a significant cause of morbidity. Pharmacy technicians should be familiar with the basic pharmacology of the most commonly prescribed medications. Selected agents used to treat heart failure and hypertension from the following classes of drugs were reviewed: β-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), diuretics, calcium-channel blockers, and a centrally acting agent. Additionally, common drugs used to treat hyperlipidemia, including hydroxymethylglutaryl coenzyme A reductase inhibitors, cholesterol absorption inhibitors, fibric acids, and niacin, were reviewed. Antiplatelet agents, selected vasodilators, warfarin, and digoxin were also reviewed.

Conclusions:

Drug therapy is the key to successful management of cardiovascular disease. Health-care providers, including knowledgeable pharmacy technicians, can assist patients in the proper use of agents in the treatment of cardiovascular diseases.