Cohort study on immune checkpoint inhibitor-associated acute kidney injury: Incidence, risk factors, and management strategies.

INTRODUCTION: Case studies and retrospective chart reviews of health system data have demonstrated an increased risk of nephrotoxicity in patients receiving immune checkpoint inhibitors compared to clinical trials. This study investigated the frequency, causes, and risk factors for acute kidney injury in a real-world, rural setting. METHODS: This was a retrospective cohort study of patients who received at least one dose of a checkpoint inhibitor at a rural health system from May 2013 to February 2020 and who received at least one dose of a checkpoint inhibitor. Electronic and manual chart review helped to determine the incidence of, risk factors for, and renal outcomes and management strategies of checkpoint inhibitor-related acute kidney injury. Multivariable Fine and Gray subdistribution hazard models were used to assess the impact of patient characteristics on the incidence of sustained acute kidney injury and checkpoint inhibitor-induced acute kidney injury. RESULTS: After exclusion criteria, 906 patients who received at least one dose of a checkpoint inhibitor at Marshfield Clinic Health System during the study period were included. The incidence of acute kidney injury of any duration and due to any cause was 36.1%, while sustained acute kidney injury occurred in 28.7% of patients. Checkpoint inhibitor-related acute kidney injury was thought to have occurred in 2.7% of patients. Baseline estimated glomerular filtration rate < 60 was the sole predictor of checkpoint inhibitors-related acute kidney injury. Most patients with suspected checkpoint inhibitor-related acute kidney injury were managed with corticosteroids, and 62.5% experienced complete renal recovery. CONCLUSIONS: Ours is the first retrospective cohort study to test whether baseline Eastern Cooperative Oncology Group score and checkpoint inhibitor place in therapy were associated with checkpoint inhibitor-related acute kidney injury, and neither of these data points were found to be predictive. Even after expanding the parameters and methodologies of our study as compared to other retrospective cohort studies, we found only three baseline characteristics to be predictive of sustained acute kidney injury: Baseline eGFR, loop diuretic, and spironolactone use. For checkpoint inhibitor-related baseline, eGFR alone was predictive.

Prospective cohort study of opioid use after total knee arthroplasty in a single center.

OBJECTIVES: Fewer opioids prescribed for postoperative pain may help reduce the number of surplus opioids available in the community and decrease the risk of opioid dependence. Published data on patients' opioid use after total knee arthroplasty (TKA) are limited. METHODS: This was a prospective study designed to characterize opioid use after TKA. Patients who have undergone TKA and met inclusion criteria were recruited to complete a survey after orthopedic surgeon follow-up appointments approximately 2 and 6 weeks postoperatively. Questions included satisfaction with pain management strategies, type and quantity of medication prescribed, and quantity of leftover medication. Additional data on opioid use and baseline characteristics were determined through chart review. RESULTS: A total of 60 patients completed surveys after TKA. All patients spent at least 1 night in the hospital or skilled nursing facility with an average length of stay of 1.2 days and an average consumption of 5.2 tablets of oxycodone 5 mg equivalents. After discharge, the mean number of oxycodone 5 mg tablet equivalents prescribed in the initial prescription was 38.6, with an average of 72.6 prescribed over 6 weeks. Patients reported an average of 15.7 unused oxycodone 5 mg tablet equivalents. CONCLUSION: These results could help guide the development of TKA-specific opioid prescribing guidelines and confirm that patients are generally prescribed more opioids than they consume.

Warnings for drug-drug interactions in consumer medication information provided by community pharmacies.

OBJECTIVES: In 2006, the U.S. Food and Drug Administration (FDA) issued a draft guidance for pharmacies to provide consumer medication information (CMI) to patients receiving prescription medications. The objective of this study was to evaluate CMI leaflets provided by community pharmacies for accuracy and completeness regarding drug-drug interactions (DDIs). METHODS: CMI leaflets were obtained for 3 commonly prescribed medications (azithromycin, ciprofloxacin, and simvastatin) from 14 community pharmacies that are part of 6 chain organizations that operate in southern Arizona. Three to 4 salient interacting medications for each leaflet medication were identified with the use of 2 well recognized drug compendia. The content of the DDI information in the leaflets was evaluated for completeness. The font size and reading level of each leaflet were assessed as well. RESULTS: The CMI provided by 14 pharmacies appeared to be produced by 2 information vendors, Wolters Kluwer and First Databank. This was evident based on the identical wording and attribution (e.g., copyright statements) on the leaflets. The CMI from First Databank mentioned 5 of the 11 previously identified interactions with the target medications, although 1 chain in this group chose not to print the DDI section at all and as a result scored 0. The CMI developed by Wolters Kluwer mentioned only 2 of the 11 identified DDIs. The average reading grade level for First Databank leaflets was 10.6 (SD 2.87), and the reading level for the CMI from Wolters Kluwer was 5.0 (SD 1.02). The font sizes varied from 8 to 12 points; FDA recommends that the information be printed in 12-point size or larger. CONCLUSION: Community pharmacies appear to be distributing CMI leaflets with limited warnings about serious and well known DDIs. The results of this study suggest that consumers are not being informed through the CMI about important known DDIs.

Assessing automated product selection success rates in transmissions between electronic prescribing and community pharmacy platforms.

OBJECTIVE: Wrong drug product errors occurring in community pharmacies often originate at the transcription stage. Electronic prescribing and automated product selection are strategies to reduce product selection errors. However, it is unclear how often automated product selection succeeds in outpatient pharmacy platforms. MATERIALS AND METHODS: The intake of over 800 e-prescriptions was observed at baseline and after intervention to assess the rate of automated product selection success. A dispensing accuracy audit was performed at baseline and postintervention to determine whether enhanced automated product selection would result in greater accuracy; data for both analyses were compared by 2x2 Chi square tests. In addition, an anonymous survey was sent to a convenience sample of 60 area community pharmacy managers. RESULTS: At baseline, 79.8% of 888 e-prescriptions achieved automated product selection. After the intervention period, 84.5% of 903 e-prescriptions achieved automated product selection (P = .008). Analysis of dispensing accuracy audits detected a slight but not statistically significant improvement in accuracy rate (99.3% versus 98.9%, P = .359). Fourteen surveys were returned, revealing that other community pharmacies experience similar automated product selection failure rates. DISCUSSION: Our results suggest that manual product selection by pharmacy personnel is required for a higher than anticipated proportion of e-prescriptions received and filled by community pharmacies, which may pose risks to both medication safety and efficiency. CONCLUSION: The question of how to increase automated product selection rates and enhance interoperability between prescriber and community pharmacy platforms warrants further investigation.