Use of Sodium-Glucose Cotransporter-2 Inhibitor for Diabetes Management in Patients Following Kidney Transplantation.

Objective: To evaluate data sources pertaining to the safety and efficacy of sodium-glucose cotransporter-2 (SGLT2) inhibitor use for diabetes management in patients following kidney transplantation. Data Sources: A literature search was conducted through PubMed (1966-January 2023), EMBASE (1973-January 2023), and clinicaltrials.gov databases using the search terms kidney transplantation, diabetes mellitus, and SGLT2 inhibitor or empagliflozin, dapagliflozin, and canagliflozin. Study Selection and Data Extraction: Studies evaluating human kidney transplant recipients (KTR) receiving SGLT2 inhibitors treatment and published in the English language were included. Eight case series or retrospective analyses, 4 prospective observational studies, and 1 randomized controlled trial were identified. Data Synthesis: Available literature provides evidence that the addition of SGLT2 inhibitors may provide modest benefits on glycemic control, body weight, and serum uric acid levels in certain KTR. Various studies and case reports found that incidence of urinary tract infections was low, but still present. Overall, there are limited data on mortality and graft survival; however, one study reported a benefit of SGLT2 inhibitor use in KTR relative to these outcomes. Conclusions: The current literature evaluated demonstrates that there may be benefit to the addition of SGLT2 inhibitors for diabetes management in select KTR. However, the limited evidence within a large diverse population and extended duration of treatment makes it difficult to definitively identify the true efficacy and safety of SGLT2 inhibitor use in this population.

Corticosteroids in Community-Acquired Pneumonia: A Review of Current Literature.

Objective: To review the evidence and recommendations for the use of adjunctive corticosteroid therapy in community-acquired pneumonia (CAP). Data Sources: A literature search was conducted using PubMed (1993 to November 2020) using the search terms corticosteroids AND community-acquired pneumonia. Study Selection and Data Extraction: Pertinent randomized controlled trials, systematic reviews, and meta-analyses assessing the efficacy and safety of adjunctive corticosteroids in patients with pneumonia were evaluated for inclusion. Data Synthesis: Studies suggest that corticosteroids reduce time to clinical stability and length of hospital stay, but data regarding other important clinical outcomes, such as mortality, are limited. The greatest margin of benefit appears to be in patients with severe CAP. Evidence consistently demonstrates hyperglycemia as the most common adverse effect of corticosteroid therapy in CAP. Safety concerns regarding the potential impact of corticosteroids on the rate of CAP-related rehospitalizations require further investigation. Relevance to Patient Care and Clinical Practice: This review summarizes literature evaluating the efficacy and safety of adjunctive corticosteroids in patients with CAP. It also includes a discussion on current guideline recommendations, patient selection, corticosteroid regimens, adverse effect considerations, limitations, and future directions in this area of research. Conclusions: Studies reviewed suggest that corticosteroids are relatively beneficial and safe in patients with CAP, with the greatest benefit in severe CAP. Currently, the routine use of corticosteroids is not recommended by clinical practice guidelines with the exception of CAP and refractory septic shock. Further research is needed to better define the ideal role of corticosteroids in CAP.

Implementation of a Discharge Education Program to Improve Transitions of Care for Patients at High Risk of Medication Errors.

Background: Transitions of care (TOC) points are those where patient outcomes can be affected, especially patients at high risk for medication errors. Pharmacist-led postdischarge telephone counseling positively affects patient outcomes, though challenges exist relating to successful patient contact. Objective: The objective of this study was to develop and evaluate a discharge education service bridging the inpatient and outpatient setting to increase successful patient contact points during the TOC process from hospital to home. Methods: This prospective, single-centered observational study examined the impact of a discharge medication education program on successful telephone follow-up contact. The primary outcome was the percentage of high-risk patients educated at hospital discharge who were successfully reached via follow-up telephone contact within 2 business days of discharge. Secondary end points included hospital readmission rates and patient survey responses. Results: A total of 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation. When asked if they understood the medication component of their care and if they found the TOC service to be satisfactory, 100% and 96% of patients strongly agreed or agreed with these statements, respectively, and none disagreed. Conclusion and Relevance: This service demonstrates how pharmacists can interact with a high-risk population and increase contact points to optimize care at crucial health care transition points.

Effect of a Rivaroxaban Patient Assistance Kit (R-PAK) for Patients Discharged With Rivaroxaban: A Randomized Controlled Trial.

Background: The combination of poor health literacy and a complex dosing regimen/transition for rivaroxaban in venous thromboembolism (VTE) treatment may increase the likelihood of negative clinical outcomes secondary to nonadherence. Objective: The aim was to determine if a Rivaroxaban Patient Assistance Kit (R-PAK) given at hospital discharge increases proper dose transition and overall patient adherence. Methods: This prospective, randomized, controlled trial was conducted at an 859-bed academic medical center. Patients were randomized into 2 groups. In the treatment group, patients received the R-PAK with counseling at discharge, whereas patients in the control group received discharge counseling alone. In addition, patients were contacted after 21 days of therapy to assess dose transition, adherence, satisfaction, and safety. The primary outcome was percentage of patients who properly transitioned to rivaroxaban once daily on day 22. Results: Twenty-five patients were enrolled; 12 received an R-PAK, whereas 13 comprised the control group. No difference in the baseline assessment of health literacy status was noted (P = 1.00). Proper transition to daily administration on day 22 was no different between the groups (P = .891). Adherence was reported in 99.8% of R-PAK patients and 97.65% of control patients (P = .074). Side effects were rarely reported. Conclusions: The use of an R-PAK for the treatment of VTE was not associated with an improvement in transition to daily administration; however, both groups had high rates of overall adherence. Pharmacist counseling/education was provided in both groups and is an important component to include in any patient discharge, especially for medications with dose transitions.

Efficacy of Oral Vancomycin in Preventing Recurrent Clostridium difficile Infection in Patients Treated With Systemic Antimicrobial Agents.

We compared rates of recurrent Clostridium difficile infection in patients receiving or not receiving oral vancomycin prophylaxis with systemic antimicrobial therapy. The incidence of C. difficile infection was significantly lower in patients receiving prophylaxis (4.2% vs 26.6% in those without prophylaxis; odds ratio, 0.12; 95% confidence interval, .04-.4; P < .001).

Identification of Factors Impacting Recurrent Clostridium difficile Infection and Development of a Risk Evaluation Tool.

PURPOSE: Recurrent Clostridium difficile infection (RCDI) is a growing concern, yet limited data exists to clarify which patients are at highest risk.  Identification of these patients may better inform decisions of those who may benefit from prophylactic intervention. The purpose of this study was to determine which factors are associated with the recurrence of Clostridium difficile infection (CDI) and to develop a risk stratification tool.  Methods. Patients readmitted within 10 weeks of positive C. difficile polymerase chain reaction (PCR) with symptoms were included in this retrospective case control study.  The primary outcome was analyzed via univariate regression analyses of the independent factors including age, gender, number of CDI episodes, administration of acid blocking agents, antibiotics or chemotherapy, Charlson Comorbidity Index, gastrointestinal conditions, and exposure to healthcare facilities.  Results. Recurrent CDI was identified in 44 of 220 included patients.  In the univariate analysis, factors associated with development of RCDI included antibiotic exposure (OR 2.51, 95% CI 1.14-5.54; p 0.02) and inflammatory bowel disease (OR 5.77, 95% CI 1.24-26.79; p 0.03).  An evaluation tool was created from a well-fit model.  Additional factors included in the tool were chosen based on evaluation of findings from existing literature.  Conclusions. Antibiotic therapy and inflammatory bowel disease were found to be associated with RCDI.  Although a statistically significant association with RCDI was not found for other factors, this is likely related to small sample size.  The creation of an evaluation tool using specific patient factors can help determine the risk of RCDI, while future studies may validate this tool. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

Impact of a Training Program on Pharmacists' Comfort With Pediatric Pharmacy Concepts and Basic Pediatric Knowledge.

Objective: To determine the impact of a training program on pharmacists' comfort with pediatric pharmacy concepts and basic pediatric knowledge. Methods: All pharmacists at our institution were invited to participate in the study. Consenting participants completed a baseline survey of 15 questions on basic knowledge in 5 pediatric topic areas (pharmacokinetics/pharmacodynamics, weight-based dosing, anticoagulation, renal dosing, and common antibiotics) as well as 8 statements rating self-reported comfort with pediatric pharmacy. Following the pretraining survey, a training program combining self-study of handouts on the 5 topics with optional attendance at live education sessions was completed. Participants then completed a posttraining survey of the 5 topics including repeat comfort assessment. The primary outcome was change in self-assigned scores on the comfort-based assessment before and after training. Results: Fifty-two pharmacists consented to participate. Participants reported significant improvement in 6 of 8 comfort questions after training (p < .001). Those without prior pediatric experience had lower comfort ratings at baseline and showed significant improvement after training for 5 of the 8 questions (p < .001). Significant improvement in the proportion of correct answers on the knowledge assessment occurred after training, regardless of prior experience (61% vs 89%, p < .001). Conclusions: Self-study training with optional live education resulted in significant improvement in most self-reported comfort scores for pharmacists, particularly those without recent pediatric pharmacy experience. Pharmacists, regardless of experience, improved basic pediatric knowledge scores after training.

Conception of a Personalized Medication Adherence Discharge Kit for Rivaroxaban.

Purpose: Due to a lack of necessary monitoring with rivaroxaban, patients have fewer opportunities for education, adherence reinforcement, and follow-up. If rivaroxaban is taken incorrectly, patients are at increased risk for adverse events. The objective was to create personalized rivaroxaban patient adherence kits (R-PAKs) to enhance successful transition from 15 mg twice daily to 20 mg once daily on day 22 of venous thromboembolism (VTE) treatment. Summary: A review of rivaroxaban drug information and existing medication adherence tools was completed to increase understanding of ways to improve adherence. Clinical pharmacists identified several concerns the R-PAK should address, including patient understanding of correct dose, administration timing, serious adverse effects, and importance of compliance, along with loss to follow-up by a health care provider. In the pilot phase, 100 R-PAKs were created. Each kit includes an educational handout describing adverse effects, administration, and monitoring; a reminder card with dosing information, date to transition, and emergency contact information; and a personalized 28-day pill organizer containing customized dividers to correlate with the first 21 days of treatment. Color-coded stickers denote the first day of starting twice-daily therapy upon discharge and the day of transition to once-daily dosing. The items were distributed in tote bags at discharge along with pharmacist education. Conclusion: The R-PAKs are being used at a community teaching hospital for patients newly diagnosed with VTE who are discharged on rivaroxaban. The concept of a personalized medication box could be modified for any medication that requires high compliance or dose transitions.

Evaluation of education on the appropriate use of vitamin k in warfarin reversal in adult inpatients.

PURPOSE: Vitamin K (phytonadione) is a commonly used first-line reversal agent for vitamin K antagonist (VKA) therapy in patients presenting with a supratherapeutic international normalized ratio (INR) with or without significant bleeding or in patients with a therapeutic INR in need of surgery. The purpose of this study was to determine the impact of education on the appropriate use of vitamin K for VKA reversal. METHODS: Data were collected on patients admitted to a community teaching hospital during February 2010 (pre-education group). These data were analyzed to determine the most common guideline deviations in vitamin K use. Following this analysis, pharmacist education took place in the form of in-service presentations; a protocol, including a guideline-based dosing table, was developed to assist pharmacists in evaluating vitamin K therapy. Data were then collected on patients admitted during February 2011 (post-education group). RESULTS: Forty patients and 47 vitamin K administrations were included in the pre-education group, and 34 patients and 49 vitamin K administrations were included in the post-education group. The number of patients with appropriate vitamin K administrations improved after pharmacist education (25% pre-education vs 55.8% post-education; P = .01). Whereas 27.6% of individual vitamin K administrations were appropriate in the pre-education group, this increased to 63.2% in the post-education group (P = .04). CONCLUSION: Education techniques on the appropriate use of vitamin K for VKA reversal significantly improved compliance with standards of care for proper use of vitamin K. Additional education sessions are necessary to further increase compliance with standards of care and subsequently optimize patient care.

Impact of Vitamin K Administration on Elevated International Normalized Ratio in Chronic Liver Disease.

Limited studies assess the efficacy of vitamin K administration in patients with chronic liver disease (CLD). However, vitamin K is commonly used to treat elevations in international normalized ratio (INR) in these patients with the intended benefit of reducing bleeding risk. This retrospective, single-center cohort study aimed to evaluate the impact of vitamin K administration on INR in patients with CLD. Hospitalized patients ≥ 18 years of age with a diagnosis of CLD or cirrhosis and received vitamin K were included. The primary outcome was the absolute change in INR from baseline to 24 to 48 h after vitamin K administration. Secondary endpoints included subgroup analyses of the primary outcome by route of administration and single versus multidose administration, and incidence of in-hospital venous thromboembolism (VTE) or major bleeding. A total of eighty-five patients, primarily with Child-Pugh class C (76.5%), were included. Route of vitamin K administration included oral (PO) (72%) and intravenous (IV) (26%) with a mean daily dose of 8.5 ± 2.3 mg. The absolute change in INR was -0.07 ± -0.35 following vitamin K administration. There was no difference in absolute INR change between single versus multiple dose administration (-0.16 ± -0.35 and -0.03 ± -0.35; P= .13) or between PO versus IV administration (-0.06 ± -0.23 and -0.18 ± -0.48; P = .11). The incidences of in-hospital VTE and major bleeding were 2.4% and 3.5%, respectively. The administration of vitamin K in hospitalized patients with CLD resulted in minimal INR change, suggesting this intervention may not have the intended benefit of reducing bleeding risk.

Evaluation of a Pharmacist-Driven Protocol for the Treatment of Opioid-Induced Constipation.

BACKGROUND: Opioid-induced constipation (OIC) treatment guidelines recommend over-the-counter laxatives as first-line therapy, followed by treatment with a peripherally-acting mu-opioid receptor antagonist (PAMORA) in refractory patients. OBJECTIVE: To evaluate the ability of a pharmacist-driven OIC protocol to promote increased scheduled laxative use prior to escalation to PAMORA therapy. METHODS: This retrospective, single-center cohort study evaluated patients 2 years pre- and post-protocol implementation. The primary outcome was the difference in the percentage of patients receiving 2 scheduled laxatives for ≥ 2 days prior to PAMORA therapy pre- and post-protocol. Secondary outcomes included difference in time to first bowel movement after PAMORA initiation, difference in total number of laxative/PAMORA doses administered, and difference in overall estimated total cost. Data was analyzed using chi-squared tests and Student's t tests. RESULTS: Three-hundred patients were included (150 patients in the pre and post-protocol groups). In the pre-protocol group, 53 patients (35%) received 2 scheduled laxatives for 2 days prior to naloxegol/methylnaltrexone compared to 96 patients (64%) in the postprotocol group (p < 0.0001). One-thousand twenty-one scheduled laxative doses were given pre-protocol versus 1625 doses post-protocol. Average time to first bowel movement was similar between groups (17.7 hours vs 16.0 hours p = 0.441). Estimated total cost of OIC reversal therapy decreased from $20,896.95 to $13,405.47. CONCLUSION: A pharmacist-driven OIC protocol is associated with an increase in the use of scheduled laxatives prior to PAMORA administration and decreased overall estimated total cost. A larger, prospective study is necessary to assess if this promotes more efficacious OIC.

Evaluation of Appropriate Sodium Polystyrene Sulfonate Use With a Hyperkalemia Order Set: A Pilot Study.

BACKGROUND: No consensus guidelines exist to assist practitioners in the management of hyperkalemia. Sodium polystyrene sulfonate (SPS) is a common treatment option for hyperkalemia. To aid health-care professionals, a hyperkalemia order set was created at a 979-bed community teaching hospital. OBJECTIVE: The objective of this study was to determine whether use of a hyperkalemia order set is associated with appropriate use of SPS. METHODS: Orders for SPS were evaluated for appropriateness in this retrospective cohort of adult patients. Data were collected from December 1, 2015, to December 31, 2016. All orders for SPS not from an order set were randomly matched to those from the order set in a 2:1 fashion. Appropriate use was defined as potassium level >5.5 mEq/L and no contraindications to use. The primary outcome was the absolute difference in the proportion of patients with appropriate SPS use in the order set group compared to the nonorder set group. RESULTS: A total of 120 patients were analyzed, 40 in the order set group and 80 in the nonorder set group. Baseline characteristics were similar between the groups. Appropriate use occurred in 97.5% of order set patients compared to 60% in the nonorder set group (P < .001). Use of the order set was associated with a greater reduction in serum potassium, quicker follow-up potassium level, and lower incidence of gastrointestinal adverse effects. CONCLUSIONS: The use of a hyperkalemia order set is associated with appropriate use of SPS. Requiring the use of the hyperkalemia order set for administration of SPS may enhance patient care and safety.

The Evolving Role of Long-Term Pharmacotherapy for Opioid-Induced Constipation in Patients Being Treated for Noncancer Pain.

Nationally, the prescription of opioids for acute and chronic pain is increasing. As opioid use continues to expand and become of increased concern for health-care practitioners, so do the adverse effects and long-term management of those effects. Opioid-induced constipation (OIC) presents a unique challenge because tolerance does not develop to this particular adverse effect, making chronic pain management a delicate balance between relieving pain and preventing long-term adverse effects such as constipation and dependence. Several agents have been developed for the treatment of OIC in patients with chronic noncancer pain on the basis of short-term studies of 12 weeks or less. However, chronic pain management often extends beyond this 12-week boundary, resulting in health-care professionals questioning the safety and efficacy of continued treatment with OIC agents. This review evaluates available literature on long-term treatment of OIC in patients with chronic noncancer pain with lubiprostone, naloxegol, and methylnaltrexone as well as preliminary results of the recently completed naldemedine long-term trial, COMPOSE-3.

An individualized approach to residency preparation for fourth professional year pharmacy students.

INTRODUCTION: The objective of this study was to evaluate the impact of an individualized residency preparation program and faculty mentorship on student preparedness for pursuing residency training and their ability to successfully match with a postgraduate year one (PGY1) residency position. METHODS: This prospective cohort enrolled fourth professional year pharmacy students from August 2016 to March 2017. Students participated in a faculty-designed residency preparation program, were assigned faculty mentors, and were provided with several residency preparation resources. The primary outcome was change in the median overall perceived level of preparedness, as measured by pre- and post-residency preparation program surveys. A key secondary end point was the correlation between obtaining a PGY1 residency position and the number of residency preparation sessions attended. RESULTS: Fifty-two students participated in the residency preparation program. The median overall perceived level of preparedness increased following the preparation program. Of the 52 students participating, 37 attended over half of the program sessions. Twenty-one of the 37 (56.8%) students participating in more than half of the sessions matched with a PGY1 program compared to three out of 15 (20%) students participating in fewer than half the sessions. Additionally, students reported value in mock interviews, faculty mentorship, and institution-specific residency preparation guidance delivered via a workbook. CONCLUSIONS: Participation in an individualized residency preparation program with faculty mentorship and institution-specific guidance improves the perceived level of preparedness for students pursuing residency training. High attendance at sessions, along with other factors, may contribute to a higher rate of success.

A structured mentoring program to develop junior faculty into successful co-coordinators of a large multi-instructor pathophysiology course.

BACKGROUND AND PURPOSE: To develop and implement a system for junior clinical faculty to become successful course coordinators with the use of a mentoring program and ensure that student performance and satisfaction are maintained at a high level. EDUCATIONAL ACTIVITY AND SETTING: For five years, first-time faculty discussion group leaders in a required large (>225 students) multi-instructor pathophysiology course opted into a structured mentoring program for course coordination in the subsequent year. Program categories included course material development, exam and quiz management, discussion group management, and communication among students, faculty, and staff. FINDINGS: Mentors' previous coordination experience ranged from a few years to over a decade. Faculty participants included three second-year faculty. Each participant successfully undertook a full co-coordinator role the following year. Subsequently, each then became a lead mentor the following year for new participants. Exam quality/reliability statistics were sustained at a high level, course evaluations and student performance improved throughout the program, and all mentor/mentee reflections demonstrated a positive and impactful experience. DISCUSSION AND SUMMARY: Course coordination can be a small percentage of clinical faculty workload, yet is a significant time commitment. Pharmacy resident certificate or new faculty academy programs often do not include course coordination, which is a vital, higher level function/role. Structured mentoring early in professional career of junior faculty aids in the assumption of pedagogical leadership roles, while also developing mentoring skills of mid-level faculty.

Comparison of hospital length of stay in patients treated with non-vitamin K oral anticoagulants or parenteral agents plus warfarin for venous thromboembolism.

OBJECTIVES: Existing research comparing hospital length of stay for patients treated with non-vitamin K oral anticoagulants or parenteral bridging to warfarin has been conducted primarily with the agent rivaroxaban. The objective of this study was to compare hospital length of stay between patients initiated on the non-vitamin K oral anticoagulants, apixaban or rivaroxaban, and patients initiated on parenteral anticoagulation agents plus warfarin for the treatment of venous thromboembolism. METHODS: A retrospective cohort study was conducted at an 859-bed, not-for-profit, teaching hospital. Adult patients admitted for a primary diagnosis of venous thromboembolism between 1 November 2012 and 31 August 2015 and treated with apixaban or rivaroxaban or a parenteral anticoagulant plus warfarin were included in the study. Eligible patients were identified using International Classification of Diseases, Ninth Revision codes for a primary diagnosis of acute thromboses and emboli and medication administration record data. Individuals using anticoagulation therapy prior to admission, released from the emergency department, or treated with thrombectomy or fibrinolytic therapy were excluded. RESULTS: A total of 152 patients were included in this study. Patient characteristics, including renal function, were similar between study arms. Venous thromboembolism treatment with apixaban or rivaroxaban compared to a parenteral anticoagulant plus warfarin was associated with a reduced hospital length of stay (2.63 vs 5.33 days; p < 0.05) and decreased total hospital cost adjusted to 2015 dollars (US$21,694 vs US$38,851; p = 0.013). CONCLUSION: These results suggest that treatment with a non-vitamin K anticoagulant may significantly reduce hospital length of stay and total hospital cost compared to a parenteral anticoagulant plus warfarin for patients admitted for venous thromboembolism.

Thrombolytic Therapy in Wake-Up Stroke Patients.

OBJECTIVE: The aim of the study is to review existing and ongoing trial data on wake-up stroke (WUS) patients for thrombolytic therapy. METHODS: A literature search was conducted in PubMed (conception-October 2016) using the terms wake-up stroke, acute ischemic stroke, wake-up thrombolysis, computed tomography imaging in wake-up stroke, and magnetic resonance imaging in wake-up stroke. Ongoing trials were found using the ClinicalTrials.gov website. RESULTS: The search yielded 61 articles in PubMed and 7 ongoing trials. After removing duplicate/irrelevant articles, 33 articles and relevant references were reviewed; of these, 6 articles and 3 ongoing trials were included. Two retrospective studies evaluating the characteristics between WUS and known-onset stroke were identified; the only significant difference between groups was the ability to receive treatment with tissue plasminogen activator (tPA). One study suggested that perfusion brain imaging may be useful to identify patients that may benefit from tPA. In addition, 3 studies have evaluated WUS treatment; all used different methods to identify potential patients. Two of 3 studies showed that treatment with tPA is associated with better outcomes when controlling for baseline National Institutes of Health Stroke Scale. No difference in safety outcomes was seen between groups for all 3 studies. CONCLUSIONS: Available data suggest promising strategies to identify WUS patients who may benefit from thrombolysis. Once on-going trials are complete, there may be sufficient information to redefine tPA eligibility for previously excluded patients.

The 2016 ACCP Pharmacotherapy Didactic Curriculum Toolkit.

The 2016 American College of Clinical Pharmacy (ACCP) Educational Affairs Committee was charged with updating and contemporizing ACCP's 2009 Pharmacotherapy Didactic Curriculum Toolkit. The toolkit has been designed to guide schools and colleges of pharmacy in developing, maintaining, and modifying their curricula. The 2016 committee reviewed the recent medical literature and other documents to identify disease states that are responsive to drug therapy. Diseases and content topics were organized by organ system, when feasible, and grouped into tiers as defined by practice competency. Tier 1 topics should be taught in a manner that prepares all students to provide collaborative, patient-centered care upon graduation and licensure. Tier 2 topics are generally taught in the professional curriculum, but students may require additional knowledge or skills after graduation (e.g., residency training) to achieve competency in providing direct patient care. Tier 3 topics may not be taught in the professional curriculum; thus, graduates will be required to obtain the necessary knowledge and skills on their own to provide direct patient care, if required in their practice. The 2016 toolkit contains 276 diseases and content topics, of which 87 (32%) are categorized as tier 1, 133 (48%) as tier 2, and 56 (20%) as tier 3. The large number of tier 1 topics will require schools and colleges to use creative pedagogical strategies to achieve the necessary practice competencies. Almost half of the topics (48%) are tier 2, highlighting the importance of postgraduate residency training or equivalent practice experience to competently care for patients with these disorders. The Pharmacotherapy Didactic Curriculum Toolkit will continue to be updated to provide guidance to faculty at schools and colleges of pharmacy as these academic pharmacy institutions regularly evaluate and modify their curricula to keep abreast of scientific advances and associated practice changes. Access the current Pharmacotherapy Didactic Curriculum Toolkit at http://www.accp.com/docs/positions/misc/Toolkit_final.pdf.

Evaluation of N-acetylcysteine for the prevention of contrast-induced nephropathy.

BACKGROUND: Contrast-induced nephropathy (CIN) remains a leading cause of acute renal failure in hospitalized patients. N-Acetylcysteine has been studied previously for the prevention of CIN, resulting in mixed findings. OBJECTIVE: The objective of this study was to determine the impact of N-acetylcysteine on the development of CIN in order to guide its use at community, teaching hospitals. METHODS: Patients admitted between January 1 and December 31, 2011, receiving intravenous radiocontrast dye were included if they were compliant with two or more of the following conditions: baseline serum creatinine >1.2 mg/dL or estimated creatinine clearance <50 mL/min, age ≥75 years, diabetes mellitus, heart failure, or hypertension. The primary outcome was the difference in the proportion of patients in each group (N-acetylcysteine or no N-acetylcysteine) who developed CIN, which was defined as a ≥0.5 mg/dL increase in serum creatinine or a ≥25% increase in serum creatinine within 12-96 hours post-exposure to contrast. RESULTS: A total of 302 patients were included, 151 who received N-acetylcysteine and 151 who did not receive N-acetylcysteine. Patients who received N-acetylcysteine had significantly worse renal function at baseline than those who did not receive N-acetylcysteine (mean pre-contrast serum creatinine, 1.41 vs. 0.95 mg/dL, p<0.0001). A lower proportion of patients developing CIN was observed between those who received N-acetylcysteine and those who did not receive N-acetylcysteine (10.2% vs. 21.8%, p=0.0428). CONCLUSIONS: The use of N-acetylcysteine was likely associated with a reduced incidence of CIN in patients at risk for CIN development. Based on these results, hospitals may benefit from the development of a protocol to guide the appropriate use of N-acetylcysteine.

Evaluation of a Pharmacy-Managed Pharmacokinetic Dosing Program.

PURPOSE: The objective of this study was to determine the impact of a pharmacy-managed pharmacokinetic dosing program on appropriate dosing of famotidine, enoxaparin, and ketorolac. METHODS: A large community teaching hospital implemented a pharmacy-managed pharmacokinetic dosing program for famotidine, enoxaparin, and ketorolac. Subjects were included if they received famotidine and had a creatinine clearance (CrCl) of <50 mL/min; received therapeutic enoxaparin and had a CrCl of <30 mL/min; or received ketorolac and had a CrCl <30 mL/min, age > 65 years or weight <50 kg. RESULTS: One hundred and forty-six patients were included in the preimplementation group (famotidine [n = 50], enoxaparin [n = 46], and ketorolac [n = 50]) and 143 patients were included in the postimplementation group (famotidine [n = 50], enoxaparin [n = 43], and ketorolac [n = 50]). In all, 66% of patients were dosed appropriately in the preimplementation group (famotidine 28%, enoxaparin 85%, and ketorolac 86%) compared to 94% in the postimplementation group (famotidine 92%, enoxaparin 95%, and ketorolac 94%), P < .001. CONCLUSION: Implementation of a pharmacy-managed pharmacokinetic dosing program significantly improved appropriate dosing of famotidine, enoxaparin, and ketorolac. These findings could justify expansion of pharmacist autonomy through institution-approved, pharmacy-managed programs for other medications to improve appropriate dosing. Analyses specifically evaluating patient-oriented or financial outcomes may provide additional support for expansion.