Impact of Patient-Specific Aminoglycoside Monitoring for Treatment of Pediatric Cystic Fibrosis Pulmonary Exacerbations.

OBJECTIVE: Aminoglycosides are frequently used for empiric and definitive treatment of cystic fibrosis (CF) pulmonary exacerbations. Various methods have been described for aminoglycoside therapeutic drug monitoring. The objective of this study is to evaluate the effect of patient-specific pharmacokinetic calculations for aminoglycosides used to treat CF pulmonary exacerbations. METHODS: Ambidirectional cohort study of patients admitted to a children's hospital from June 1, 2018, through February 28, 2019, and June 1, 2019, through February 8, 2021. The primary outcome was the occurrence of dosing changes after analysis of initial serum concentrations in either group. Secondary outcomes included occurrence of nephrotoxicity, duration of antibiotics, and length of stay. RESULTS: Twenty-four patients (75%) in the intervention group versus zero in the control group required dosing adjustments after initial analysis of serum concentrations were completed (p < 0.001). There was not a statistically significant between-group difference for duration of antibiotics in days (median, 14 vs 13.5; Z, 1.07; p = 0.29) or length of stay (median, 11 vs 11; Z, -0.31; p = 0.76). There was also not a statistically significant between-group difference in forced expiratory volume in one second (FEV1) change from admission to discharge (11.4% vs 13.9%; t, 0.61; Degrees of Freedom, 39; p = 0.55). Two patients (6.25%) in the intervention group experienced nephrotoxicity compared with zero patients in the control group (risk difference, 6.25%; 95% CI, -2.14 to 14.64; number needed to harm, 16). CONCLUSIONS: Patient-specific pharmacokinetic monitoring led to significantly more dosing changes and was associated with similar patient outcomes as trough-only monitoring. Further studies are needed to identify methods to optimize aminoglycoside dosing and monitoring for these patients with the goal of reducing toxicities while maximizing efficacy.

Comprehensive and Collaborative Pharmacist Transitions of Care Service for Underserved Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: Mortality risk from chronic obstructive pulmonary disease (COPD) increases significantly in the first year after a 30-day hospital readmission. OBJECTIVE: To evaluate a comprehensive and collaborative pharmacist transitions of care service for patients hospitalized with COPD compared to usual care. METHODS: In this within-site, retrospective study, discharge counseling, medication reconciliation, medication access assistance, therapy changes, and post-discharge long-term follow-up were provided to underserved adult patients with a primary care provider at the study clinic and admitted to the affiliated hospital with a primary diagnosis of COPD exacerbation. Primary outcome was a 180-day composite of COPD-related hospitalizations and emergency department (ED) visits. Secondary outcomes were 30-, 60-, 90-, and 180-day events, costs, pharmacist interventions, time to follow-up, and pneumonia. RESULTS: Sixty-five patients were identified with a total of 101 index admissions. The mean age was 62.5 years, approximately 55.3% were female, and 67.7% were black or African American. The primary composite was significantly lower in the pharmacist intervention group compared to usual care (mean difference 0.82, P=0.0364, 95% confidence interval [CI] 0.05-1.60), driven by lower 30-day hospitalizations in the intervention group (mean difference 0.15, P=0.0099, 95% CI 0.04-0.27). Cost associated with COPD-related hospitalizations was significantly lower in the pharmacist intervention group compared to usual care ($173,808, P = 0.0330) as well as before intervention ($79,662, P=0.0233). There was no significant difference in time to follow-up or pneumonia. CONCLUSIONS: A comprehensive, collaborative pharmacist transitions of care service significantly reduced 30-day COPD-related hospital readmissions, ED re-visits, and associated costs in an underserved population.

Pharmacist Perception of a Mobile Application Audience Response System for Remote Pharmacy Continuing Education Participants.

INTRODUCTION: Interactive audience response during continuing education (CE) in pharmacy practice increases audience involvement. However, remote-site participants may not have access to interactive technology. This study explores the perceptions of a mobile application audience response system (ARS) by remote pharmacy CE participants. Secondarily, we evaluatedinterest in continued use of ARS, as well as willingness to use as an assessment tool for CE effectiveness. METHODS: Pharmacists participating in CE sessions remotely within a health system were provided a unique ARS session code to enter into a free mobile application. Participants then responded to ARS presentation questions. An online survey link was e-mailed to all potential remote participants inquiring about perceptions of ARS use. RESULTS: Of the 52 potential remote users, 28 (53.8%) responded to the survey. The top 3 positive responses included the availability of free software (71.4%), anonymity (57.1%), and ease of use (53.6%). Top 2 barriers included slowing the process down (14.3%) and requiring the use of application software (14.3%). DISCUSSION: Interactive software during pharmacy CE lectures for participants at remote locations within a health system was well accepted. ARS should be considered and further studied for CE lectures at institutions with remote participants.

A Student-Led Elective Provides Quality Improvement Feedback for a Required Compounding Course.

Objective. To implement an advanced elective compounding course where pharmacy students conduct investigations to improve compounding-related issues that were subsequently evaluated in a required compounding course. Methods. The elective compounding course required students to engage in self-directed learning, critical thinking, creation and evaluation of laboratory data, and self- and group reflection. Students researched and developed "solutions" to compounded preparation problems, and their solutions were tested in the next iteration of a required compounding course. For example, students in the elective course identified sources of potency variability in a ketoprofen Pluronic organogel (PLO) emulsion preparation. The students identified six variables and executed an investigative action plan. They considered all data collected and proposed a method to reduce potency variation. The recommended solution was implemented in the next offering of a required compounding course and the potency variability results were compared to the previous required course's results. Results. The mean ketoprofen PLO emulsion potency achieved in the required course prior to implementing the elective course recommendation was 129% (SD 21%), n=158. After the recommended change from elective course was implemented, the mean potency was 118% (SD 21%), n=131. Conclusion. The teaching methods and activities conducted in the elective course provided students with a deeper level of learning and understanding of compounding science, while providing practical experience in scientific research methodology. The course also provided a cyclic quality improvement feedback mechanism for the required course.

A comprehensive review of chronic heart failure pharmacotherapy treatment approaches in African Americans.

BACKGROUND: Our aim was to review the published literature evaluating treatment approaches for chronic heart failure (HF), notably as it relates to African American patients. METHOD: We undertook a comprehensive database search (1986-2017) of PubMed, EMBASE, and Ovid/MEDLINE utilizing terms 'African American', 'black', 'chronic heart failure', 'heart failure', 'medication', 'chronic therapy', and 'clinical trials'. Additional notable studies were obtained from ClinicalTrials.gov . Studies published in English that examine treatment modalities of chronic HF in African American and non-African American patients were included. RESULTS: Examples of current gaps worthy of investigation include whether to maximize thiazides and calcium-channel blockers prior to adding renin-angiotensin system (RAS) inhibitors or beta blockers in HF with preserved ejection fraction; whether hydralazine/isosorbide dinitrate (ISDN) should be initiated during earlier HF stages; whether to prioritize hydralazine/ISDN over other agents such as RAS inhibitors; varying response of African Americans to different agents within drug classes; and the role of mineralocorticoid receptor antagonists. CONCLUSION: Further studies are needed in order for consensus guidelines to clarify how best to treat this population.

Pharmacy Student Monitoring of Direct Oral Anticoagulants.

BACKGROUND: Best practice recommendations are lacking. Thus far, literature has described pharmacist-led DOAC monitoring. OBJECTIVE: The purpose of this study is to describe a DOAC monitoring program involving pharmacy students. METHODS: This was an observational analysis of a quality improvement initiative. A clinical pharmacist preceptor identified clinic patients taking DOACs by running a report using the electronic medical record. Pharmacy students conducted chart reviews, called pharmacies for 6-month refill histories, and interviewed and educated patients. Findings were communicated to the care team and interventions were performed as applicable with the preceptor. RESULTS: Of 90 patients included, the mean age was 63 years, 54% were female, and 65.6% were black or African American. Rivaroxaban and apixaban were used most commonly. Sixty-two percent of DOACs were prescribed for atrial fibrillation/flutter, while 32.2% for venous thromboembolism. The mean MPR was 77.1%, with 27.7% of patients having an MPR ≤60%. Of the 136 student-led interventions, 25.2% involved medication access, 24.4% adherence education, 20.7% processing refills, 14.8% laboratory monitoring recommendations, 8.9% switching or recommending switching to another anticoagulant, and 4.4% stopping a nonsteroidal anti-inflammatory drug or aspirin. CONCLUSION: Pharmacy students can help to ensure medication safety and effective use of DOACs.