Successful Opioid Minimization Following Kidney Transplant: A Quality Improvement Initiative.

Opioid use after kidney transplant has been associated with an increased risk of death and graft loss. Several transplant centers have reported reductions in opioid use using multimodal analgesia and education. This study evaluated the impact of an opioid minimization protocol on inpatient opioid use and opioid prescribing on discharge. This was a single-center, retrospective study of adult kidney recipients transplanted from October 2021 to July 2022. Patients on chronic opioids prior to transplant were excluded. The protocol included an intra-operative ultrasound-guided lateral transversus abdominis plane (TAP) block combined with scheduled non-opioid analgesics and tramadol as needed. Acetaminophen 1000 mg and gabapentin 300 mg were given 1 hour prior to the procedure and continued three times daily after transplant. The gabapentin dose was reduced for patients with renal impairment. Additional analgesics including opioids could be added for uncontrolled pain. We hypothesized the protocol would decrease total inpatient morphine milligram equivalents (MMEs) and opioid prescribing on discharge. Fifty-nine post-protocol patients were compared to 52 pre-protocol patients. After the protocol, there was a significant decrease in total inpatient MMEs per day administered and no patient-controlled analgesia (PCA) devices were required. In alignment with the protocol, there was a significant increase in the use of TAP blocks, acetaminophen, gabapentin, and lidocaine patches. While opioid use was lowest in post-protocol patients who received TAP blocks, significant reductions in MMEs per day were still seen in those post-protocol who did not receive TAP blocks. Opioid prescribing at the time of discharge decreased significantly after protocol. No difference was seen in patient-reported pain scores, return to operating room, readmission within 30 days, or length of stay. The use of scheduled acetaminophen and gabapentin with or without a TAP block allowed the elimination of PCA devices and led to significant minimizations in both inpatient opioid use and opioid prescribing on discharge.

Hepatitis C viral clearance with coadministration of crushed sofosbuvir/velpatasvir and high-dose pantoprazole after liver transplantation.

PURPOSE: Direct-acting antivirals (DAAs) allow for successful transplantation of livers from hepatitis C nucleic acid test (NAT)-positive donors to negative recipients. However, limited data exist to support crushing DAAs in patients with multiple absorption concerns or significant drug interactions. SUMMARY: Crushed sofosbuvir/velpatasvir has been successfully used in nontransplant patients with dysphagia, but data in transplant patients with absorption concerns are limited. A 31-year-old hepatitis C-negative female underwent liver transplantation from a hepatitis C NAT-positive donor. Her postoperative course was complicated by a mucormycosis infection, gastrointestinal bleed, and necrotizing pancreatitis requiring treatment with liposomal amphotericin B and pantoprazole 80 mg twice daily. Surgical interventions included an above-the-knee amputation and ileostomy. Hepatitis C treatment was initially delayed because of concern for reduced absorption with crushed DAA administration through the nasogastric (NG) tube, high ileostomy output, gastrointestinal bleed, pancreatitis, and a known drug interaction with pantoprazole. One month after transplantation, the patient's bilirubin level remained elevated and hepatitis C treatment was initiated with sofosbuvir/velpatasvir. Crushed sofosbuvir/velpatasvir was mixed with 30 mL of water and administered through the NG tube daily. Hepatitis C viral loads were obtained weekly during treatment to monitor efficacy. Although the patient died before evaluation of sustained virological response at 12 weeks, hepatitis C viral clearance was observed within 4 weeks of initiating treatment. CONCLUSION: A liver transplant patient exhibited viral clearance of hepatitis C following administration of crushed sofosbuvir/velpatasvir in the setting of multiple absorption concerns.

Access to direct-acting antivirals for hepatitis C-negative transplant recipients receiving organs from hepatitis C-viremic donors.

PURPOSE: A barrier to using organs from hepatitis C virus (HCV)-viremic donors is the high cost of direct-acting antivirals (DAAs) and concerns about access for recipients after transplantation. The purpose of this study was to evaluate access, cost, and timing for HCV DAAs following transplantation. METHODS: This was a single-center, retrospective study of HCV-negative adult transplant recipients from June 2017 to December 2019 who received grafts from HCV-viremic and/or HCV-seropositive individuals and became HCV viremic after transplantation. RESULTS: Between June 2017 and December 2019, there were 60 HCV-negative transplant recipients who became viremic after receiving grafts from HCV-viremic or HCV-seropositive donors. Thirty-eight patients met the inclusion criteria (n = 25 with liver transplants, n = 6 with lung transplants, n = 4 with simultaneous liver and kidney transplants, and n = 3 with kidney transplants). Of these patients, 23 had commercial insurance, 13 had Medicare, and 2 had Medicaid. All patients ultimately received insurance coverage for treatment; however, 36 (95%) required prior authorization and 9 (24%) required appeals to obtain insurance coverage. The median time from DAA prescription to insurance approval was 6 days. The median time from transplantation to start of treatment was 29 days (range, 0-84 days). Patients with Medicaid insurance had a significantly longer time to insurance approval (31.5 vs 6 days, P = 0.007). The average out-of-pocket cost to patients was less than $10 a month after patient assistance. All patients who completed treatment and 12-week follow-up after treatment achieved a sustained virologic response (n = 36). CONCLUSION: In this study, all HCV-negative recipients who developed HCV following transplantation had access to DAA therapy, with the majority starting treatment in the first month after transplantation.

Perioperative methadone prescribing and association with respiratory depression.

OBJECTIVE: Over 80 percent of surgery patients experience acute post-operative pain and less than half feel their pain is adequately controlled. Patients receiving chronic opioids, including methadone, are at the highest risk of inadequate pain control. Guidelines do not provide specific recommendations for analgesia management in this population. The purpose of this study was to evaluate the association between post-operative methadone use and respiratory depression. DESIGN: This study was a single center, retrospective, cohort study of adult patients. SETTING: Patients included were admitted to a single academic medical center from July 2016 to September 2018. PARTICIPANTS: Medical records of adult inpatients with an operative procedure who received perioperative methadone were reviewed. MAIN OUTCOME MEASURES: Preoperative methadone use was evaluated for all patients. Post-operative methadone dosing was compared to preoperative methadone dosing. Post-operative respiratory depression was evaluated. Logistic regression was performed to identify risk factors for respiratory depression. RESULTS: Two hundred ninety-eight patients were included in the study. Patients were divided into groups based on pre-operative methadone use. Over 90 percent of patients were on preoperative methadone. There were no significant differences in baseline characteristics between groups. In the initial seven post-operative days, 14.8 percent of patients had documented respiratory depression. Respiratory depression was more common among patients who were newly initiated on methadone post-operatively. Factors associated with respiratory depression included male sex, increased age, and new post-operative methadone initiation. CONCLUSIONS: Most patients who were administered post-operative methadone were on preoperative methadone. New post-operative methadone initiation was a risk factor for respiratory depression.