Preemptive warfarin dose reduction after initiation of sulfamethoxazole-trimethoprim or metronidazole.

To evaluate the utility of a preemptive warfarin dose reduction at the time of initiation of either sulfamethoxazole-trimethoprim or metronidazole, a retrospective chart review of patients who received an outpatient prescription for warfarin and either sulfamethoxazole-trimethoprim and/or metronidazole from July 1, 2011 to July 1, 2015 was conducted. Clinical outcomes compared Veterans who had a warfarin dose reduction and those who did not within 120 h (5 days) of antibiotic initiation. The primary outcome compared the pre-and post-antibiotic International Normalized Ratio (INR) of patients in the intervention group (warfarin dose reduction) with those in the control group (no intervention). Secondary outcomes assessed incidence of thromboembolic and major bleeding events within 30 days of antibiotic completion. Fifty patients were assessed. Forty-nine patients had at least one follow-up appointment; 126 follow-up visits were evaluated. There was a statistically significant difference for the change in therapeutic INR at the first follow-up appointment (p = 0.029) for those patients in the control group. On average, the patients in the intervention group required fewer follow-up visits (p = 0.019). There were no statistically significant differences for the overall rate of therapeutic INR values between groups, as well as no instances of a thromboembolic or major bleeding events during the follow-up period. Clinically significant differences were observed for patients who received a preemptive warfarin dose reduction upon initiation of sulfamethoxazole-trimethoprim or metronidazole. Patients in the intervention group required fewer follow-up appointments and were more likely maintain a therapeutic INR within the 30 days following the antibiotic course. Results of this study will be presented the at Pharmacy and Therapeutics committee in an effort to seek approval for policy development to initiate a local preemptive warfarin dose adjustment as a standard of practice.

A Case of Severe Iron Deficiency Anemia Associated with Long-Term Proton Pump Inhibitor Use.

The use of proton pump inhibitors (PPIs) in the treatment of gastrointestinal diseases has evolved over recent years. Initially intended for short-term use, PPIs are increasingly being used, often inappropriately, as long-term maintenance medications. The mechanism of action of PPIs is suppression of gastric basal and stimulated acid secretion by inhibiting the parietal cell H+/K+ ATP pump with a resultant increase in gastric pH and hypo- or achlorhydria. Although short-term use is related to few adverse effects, long-term use is associated with numerous complications. We present the case of a 58-year-old man with severe iron deficiency anemia due to malabsorption suspected to be caused by long-term PPI use. An extensive medical work up failed to reveal any definitive source of bleeding. An iron malabsorption test confirmed that iron was not being absorbed from the gastrointestinal tract. The Naranjo Adverse Drug Reaction Probability Scale and the Horn and Hansten Drug Interaction Probability Scale are suggestive of an association between long-term PPI use and the observed iron deficiency anemia. However, the patient's death and lack of an autopsy prevented confirmatory follow-up data from being obtained to connect long-term PPI use as the culprit. Although there are currently no recommendations regarding screening for iron deficiency and/or anemia in patients on long-term PPI therapy, physicians should be aware of this potential side effect and consider monitoring in high-risk patients.

Internal Medicine Residents' Perceptions of Pharmacist Involvement in Medical Rounds.

BACKGROUND: Current physicians note the positive effects of clinical pharmacists on rounds, yet minimal evidence exists regarding medical residents' view of pharmacists in this setting. Knowing their perceptions of clinical pharmacists on acute care rounds will allow pharmacists to optimize their roles and improve their interprofessional interactions. OBJECTIVE: To assess internal medicine residents' perceptions of pharmacists on rounds, evaluate which recommendations they prefer to receive, and examine their past experiences with pharmacists on rounds. METHODS: Internal medicine residents were invited to complete an online survey containing 7 items regarding past experiences with pharmacists on rounds (5-point Likert-type scale; 1=Strongly Disagree, 5=Strongly Agree), 3 items about preferred recommendations (ranking questions), and 6 items regarding perceptions of pharmacy practice (5-point Likert-type scale; 1=Strongly Disagree, 5=Strongly Agree). Data were analyzed using frequencies. RESULTS: 27 residents participated (33.75% response rate). A majority strongly agreed that they always want a pharmacist to be a part of their rounding team (Mean ± SD = 4.93 ± 0.26). They prefer receiving recommendations from the pharmacist in-person before, during, or after rounds and appreciate recommendations on topics such as anticoagulants, antimicrobial stewardship, and renal dose adjustments. Residents did not express a strong knowledge of pharmacists' education and training processes (Mean ± SD = 3.77 ± 1.05), which may have led to their lack of agreement that pharmacists are equipped to be mid-level practitioners (Mean ± SD = 3.00 ± 1.30). CONCLUSIONS: Internal medicine residents had positive experiences with rounding pharmacists and desire their involvement on rounds. Pharmacists should make recommendations to residents in-person and educate them on their education and training to allow for further advocacy for pharmacist services.