Role of a Pharmacist in Postdischarge Care for Patients With Kidney Disease: A Scoping Review.

OBJECTIVE: The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease. DATA SOURCES: PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist's role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible. STUDY SELECTION AND DATA EXTRACTION: Six unique interventions were described in 10 studies meeting inclusion criteria. DATA SYNTHESIS: Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease. CONCLUSIONS: The pharmacist's role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis.

Modifying the risk of recurrent preterm birth: influence of trimester-specific changes in smoking behaviors.

BACKGROUND: Women with at least 1 prior occurrence of premature birth often have demographic and medical risk factors that are not modifiable. However, smoking cessation could be a targeted intervention in which a woman with a history of premature birth may be able to reduce her future risk of recurrence. OBJECTIVE: This study aims to assess how trimester-specific smoking patterns influence the risk of recurrent premature birth. STUDY DESIGN: This was a population-based retrospective cohort study of singleton nonanomalous live births in Ohio, 2006-2012 using vital statistics birth records. This analysis was limited to women with at least 1 prior premature birth. Rates of birth <37 weeks were compared among nonsmokers, women who smoked in the 3 months prior to pregnancy and quit in the first vs quit in the second vs quit in the third trimester. Multivariate logistic regression analyses assessed the association between smoking cessation at various time points in pregnancy and recurrent premature birth while adjusting for maternal race, education, Medicaid enrollment, and marital status. RESULTS: We analyzed the outcomes of 36,432 women with a prior premature birth who subsequently delivered at 20-42 weeks. One third of women with a prior premature birth smoked during pregnancy. Of smokers, 16% quit early in the first trimester, 7% quit in the second, 5% quit in the third trimester, and 72% smoked throughout pregnancy. The rate of recurrent premature birth in nonsmokers was high 28% in this cohort. Smoking in pregnancy with cessation in the first or second trimester was not significantly associated with an increase in recurrent premature birth rates (first trimester, 29% adjusted odds ratio, 0.97 [95% confidence interval, 0.9-1.1], and second trimester, 31% adjusted odds ratio, 1.10 [95% confidence interval, 0.9-1.3], respectively). However, quitting late in pregnancy (third trimester) was associated with a high rate (43%) of delivery <37 weeks, adjusted odds ratio, 1.81 (95% confidence interval, 1.48-2.21). Continued smoking throughout pregnancy was also associated with an increased recurrent premature birth (32%), adjusted odds ratio, 1.14 (95% confidence interval, 1.07-1.22), despite adjustment for concomitant premature birth risk factors. CONCLUSION: Smoking cessation in pregnancy and its relationship to preterm birth has been studied extensively, and it is widely accepted that smoking in pregnancy increases preterm birth rates. However, this study provides novel information quantifying the risk of recurrent preterm birth and stratifies the increased risk of recurrent preterm birth by trimester-specific smoking behavior. Although women with even 1 prior premature birth are at an inherently high risk of recurrence, women who stopped smoking early in the first 2 trimesters experienced similar preterm birth rates compared with nonsmokers. However, delayed smoking cessation or smoking throughout pregnancy significantly increased recurrent premature birth risk. Smoking cessation is a potential modifiable risk factor for recurrent preterm birth in high-risk pregnancies. This study highlights the importance of early pregnancy smoking cessation in those at especially high risk, women with a prior preterm birth.

Monitoring of Urate-Lowering Therapy Among US Veterans Following the 2012 American College of Rheumatology Guidelines for Management of Gout.

BACKGROUND: With the prevalence of and hospitalizations for gout increasing, optimizing care for patients with gout is imperative. The 2012 American College of Rheumatology gout guidelines emphasize that timely monitoring is key to achieving serum urate (SUA) goals. Few studies have examined this metric following the 2012 update, and to our knowledge, none have examined a veteran population. OBJECTIVE: To evaluate adherence to urate-lowering therapy (ULT) monitoring guidelines in a veteran population. METHODS: This is a single-center, multisite, retrospective chart review of US veterans receiving ULT for gout within the VA (Veterans Affairs) Tennessee Valley Healthcare System from January 1, 2013, to June 30, 2015. The primary end point was percentage of patients with a SUA within 6 months of initial xanthine oxidase inhibitor prescription. Secondary end points included percentage of patients with SUA <6 mg/dL and percentage of patients with uptitration following SUA above goal. RESULTS: A total of 601 patients met inclusion criteria for the study; after application of exclusion criteria, 505 were analyzed. Of these, 295 patients (58%) did not have a SUA drawn within 6 months, and 162 patients (32%) reached the end of the study period without SUA measured. Of 226 patients with SUA above goal on initial check, 64 (28%) had timely dose adjustment, whereas 143 patients (63%) had no adjustment. A total of 161 patients (32%) had a SUA at goal within the study period. CONCLUSIONS: Rates of ULT monitoring at a major VA medical center were suboptimal, and improved adherence to guideline recommendations is needed.

Effect of Body Weight on Dose of Vitamin K Antagonists.

OBJECTIVES: Numerous factors are well documented to affect the response to vitamin K antagonists (VKA), including dietary vitamin K, other drugs, age, pharmacogenetics, and disease states. Body weight is perhaps not as well known as a variable affecting VKA dose. Our aim was to review the literature regarding body weight and VKA dose requirements. METHODS: We reviewed the English-language literature via PubMed and Scopus using the search terms VKA, warfarin, acenocoumarol, phenprocoumon, fluindione, AND body weight. RESULTS: Among 32 studies conducted since the widespread use of the international normalized ratio, 29 found a correlation with body weight or body surface area and VKA dose requirement. Warfarin was evaluated in 27 studies and acenocoumarol, phenprocoumon, or fluindione were assessed in 5 investigations. CONCLUSIONS: Because of varying study methodologies, further study is warranted. Based on current evidence, clinicians should include body weight, along with other established variables when dosing VKA. Most important, obese and morbidly obese patients may require a 30% to 50% increase with the initial dosing of VKA.

Comparing dosing of basal insulin analogues detemir and glargine: is it really unit-per-unit and dose-per-dose?

OBJECTIVE: To review the available evidence regarding dosing conversion between glargine and detemir in an effort to assist clinicians in performing dosing conversion. DATA SOURCES: A MEDLINE literature search was performed using the search terms glargine and detemir for articles published through August 2013. STUDY SELECTION AND DATA EXTRACTION: All English-language clinical trials were reviewed for inclusion of dosing and/or pharmacokinetic data. DATA SYNTHESIS: A total of 7 large (n ≥ 258) randomized controlled trials (RCTs) comparing glargine and detemir in patients with type 1 and 2 diabetes had dosing equivalency data available. In these 7 RCTs, on average, a 38% higher detemir dose was required (range = 8.0%-77.2%) to achieve glucose control comparable to that achieved with glargine. A 24-hour isoglycemic clamp study conducted in 11 patients with type 1 diabetes demonstrated that the duration of action of detemir is dose dependent, with increasing doses of detemir resulting in increased duration of action of detemir. Pharmacokinetic studies conducted in patients with type 2 diabetes are conflicting, although the majority of evidence suggests that glargine provides a longer duration of glycemic control as compared with detemir. CONCLUSIONS: When performing conversion between glargine and detemir, prescribers should be aware that higher doses of detemir as compared with glargine may be necessary to achieve the same glycemic control. Additionally, twice-daily injections of detemir should be considered in clinical situations in which glucose control appears to decline after 12 hours, especially with doses ≤0.4 units/kg/d in patients with type 1 diabetes.

Incorrect use of peak flow meters: are you observing your patients?

BACKGROUND: Monitoring peak expiratory flow (PEF) values is one option as part of asthma action plans per national guidelines. PEF assessment is also recommended in emergency department and hospitalized patients. Incorrect use of peak flow meters (PFM) has obvious implications for appropriate decisions by patients and clinicians. METHODS: We searched the English literature via PubMed and SCOPUS using the following search terms: PEF maneuver; incorrect use of PFM. When pertinent articles were found, we assessed publications cited in those papers. All studies related to incorrect use of PFM in patients with asthma were included. RESULTS: Nine studies have reported errors in performing the PEF maneuver, including three pediatric and six adult studies. Errors were found at most steps of the maneuver, and inability to perform all steps correctly was common in these investigations. Examples of errors included failure to inhale fully or give maximum effort on exhalation, accelerating air with the tongue and buccal musculature, and performing only one attempt versus three. Gender differences in correct use of PFM are suggested by three adult studies. One study described falsifying PEF values by manipulating the PFM indicator, and another investigation assessed the PEF maneuver in two positions in bed versus the correct posture of standing. CONCLUSION: Many pediatric and adult patients do not use PFM correctly. Clinicians should regularly observe patients use PFM to detect errors and help ensure correct use and accurate PEF measurements.

Comparison of initial warfarin response in obese patients versus non-obese patients.

Achieving therapeutic anticoagulation with warfarin is complicated by substantial inter-patient and intra-patient variability with numerous factors known to influence dose requirements. Obesity is one factor for which there remains no study to date investigating its initial effect on warfarin response assessed by INR, stratified by BMI category in hospitalized patients. To compare initial warfarin response between obese and non-obese patients by evaluating average daily dose (ADD), time required to attain therapeutic INR, and mean discharge dose (MDD), stratified by BMI category. A retrospective review was conducted to evaluate initial warfarin response in hospitalized patients of different BMI categories initiated on warfarin with ≥4 consecutive days of therapy and managed by pharmacy dosing service. 211 patients were included (10 underweight, 45 normal weight, 48 overweight, 71 obese, 37 morbidly obese). Across BMI categories, the percentage of patients attaining therapeutic INR prior to discharge differed (p = 0.0004) with 71.1 % of normal weight therapeutic compared to 42.3 % of obese and 38 % of morbidly obese. Within BMI categories, when comparing ADD between patients therapeutic and subtherapeutic at discharge, no differences were observed, except among overweight patients (5.6 ± 0.3 vs. 7 ± 0.4 mg, p = 0.0143). Compared to normal weight, obese and morbidly obese required a significantly longer median time to achieve therapeutic INR (8 and 10 days vs. 6 days) and a higher ADD (6.6 ± 0.3 and 7.6 ± 0.5 vs. 5 ± 0.3 mg) and MDD (6.7 ± 0.5 and 6.7 ± 0.7 vs. 4.4 ± 0.5 mg). Compared to normal weight, obese and morbidly obese patients had a decreased initial response to warfarin.

Cardioselective beta-blocker treatment of hypertension in patients with asthma: when do benefits outweigh risks?

BACKGROUND: Benefits outweigh risks of cardioselective beta-blocker therapy in patients with nonsevere asthma and a history of heart failure or myocardial infarction (MI). This review summarizes the risks versus benefits of using cardioselective beta-blockers in the treatment of hypertension in patients with asthma. METHODS: We searched the English literature from 1976 to 2011 via PubMed, EMBASE, and SCOPUS using the following search terms: "beta-blocker treatment of hypertension" AND "asthma"; "cardioselective beta-blockers" AND "asthma." When pertinent articles were found, we assessed relevant articles cited in those papers. All studies related to cardioselective beta-blocker use in patients with asthma and hypertension were included. RESULTS: Seven studies with patient populations ranging from 10 to 17 patients evaluated cardioselective beta-blockers in patients with asthma and hypertension. Atenolol and/or immediate-release metoprolol were evaluated in these studies. The duration of beta-blocker therapy in four studies was 1-8 weeks; two studies were single dose and one investigation lasted 8 months. Metoprolol and atenolol were generally well tolerated except at higher doses such as metoprolol >100 mg daily. CONCLUSION: In the absence of concomitant cardiovascular disease, routine use of beta-blockers for the treatment of hypertension in patients with asthma should be avoided.

Inadequate documentation of asthma management in hospitalized adult patients.

Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.

Examining the Impact of Antimicrobial Fluoroquinolones on Human DNA Topoisomerase IIα and IIß.

Fluoroquinolones are a class of widely prescribed antibiotics with a broad range of activity against Gram-positive, Gram-negative, and some atypical microbes. Unfortunately, these drugs are associated with significant adverse events including neuropathy, tendinopathy, cardiac rhythm abnormalities, and mental health side effects. The mechanism by which fluoroquinolones cause many of these toxicities is unknown. The antibacterial mechanism of action involves disruption of the catalytic mechanism of type-II topoisomerases in bacteria, namely topoisomerase IV and DNA gyrase. Fluoroquinolones inhibit the ability of the enzymes to ligate cleaved DNA and result in single- and double-stranded DNA breaks. Thus, there is an interest in investigating whether human topoisomerase II is involved in mediating the adverse events associated with quinolones. Previous studies demonstrate some response of human topoisomerase IIα and IIß to high levels of ciprofloxacin. However, it is not clear whether the concentration of ciprofloxacin utilized in those studies corresponds to concentrations that would be routinely achievable in patients. Therefore, this study set out to examine three clinically relevant fluoroquinolones along with two older agents to determine whether these compounds display activity against topoisomerase IIα and IIß at drug concentrations that more closely approximate typical patient plasma values. On the basis of our evidence, none of the quinolones studied were able to poison DNA cleavage by either human enzyme. Ciprofloxacin, desethylene-ciprofloxacin, and the recently removed from market gemifloxacin were able to inhibit topoisomerase II-mediated DNA relaxation at concentrations of 200-300 µM. On the basis of these data, we propose that human topoisomerase II is not likely to be the main cause of these adverse events and that additional targets need to be identified to clarify the mechanisms underlying quinolone toxicities.

Effect of diseases on response to vitamin K antagonists.

INTRODUCTION: The purpose of this review article is to summarize the literature on diseases that are documented to have an effect on response to warfarin and other VKAs. METHODS: We searched the English literature from 1946 to September 2015 via PubMed, EMBASE, and Scopus for the effect of diseases on response vitamin K antagonists including warfarin, acenocoumarol, phenprocoumon, and fluindione. DISCUSSION: Among many factors modifying response to VKAs, several disease states are clinically relevant. Liver disease, hyperthyroidism, and CKD are well documented to increase response to VKAs. Decompensated heart failure, fever, and diarrhea may also elevate response to VKAs, but more study is needed. Hypothyroidism is associated with decreased effect of VKAs, and obese patients will likely require higher initial doses of VKAs. CONCLUSION: In order to minimize risks with VKAs while ensuring efficacy, clinicians must be aware of the effect of disease states when prescribing these oral anticoagulants.

Peak expiratory flow in bed? A comparison of 3 positions.

BACKGROUND: Current guidelines for the correct peak expiratory flow (PEF) maneuver include standing. In the hospital setting, PEF values are often ordered to assess response to asthma therapy for exacerbations. We have observed that the PEF is sometimes performed with the patient in bed. METHODS: Healthy adults performed the PEF maneuver in random order, standing, lying back at an ~45° angle on pillows, and sitting, slumped forward ~10° with legs extended. PEF was recorded for 3 attempts in each of the 3 positions. RESULTS: We enrolled 94 subjects (39 male, 55 female, mean age 24 y) in 2011. Mean PEF in the standing position (669 ± 42 L/min) was significantly higher than in the lying back (621 ± 42 L/min) (P < .001) and sitting (615 ± 42 L/min) positions in males (P < .001), and, similarly, in females, standing produced a significantly higher mean PEF (462 ± 42 L/min) than the lying back (422 ± 42 L/min) (P < .001) and sitting (447 ± 42 L/min) positions (P < .05). CONCLUSIONS: Clinicians should ensure that PEF is obtained with patients out of bed and in the standing position.

Are we failing to document adequate smoking histories? A brief review 1999-2009.

BACKGROUND: Documenting a detailed smoking history is of obvious importance. Failure to adequately document the smoking history may result in the misdiagnosis and management of asthma, and may be associated with a deficiency of care in patients with cardiovascular disease and several other common diseases. SCOPE: The purpose of this article is to review the evidence over the past decade that demonstrates inadequate documentation of smoking history. A literature search of English language journals from 1999 to 2009 was completed using several databases, including PubMed, MEDLINE, EMBASE, and SCOPUS. FINDINGS: Fourteen studies demonstrated inadequate documentation of smoking histories by primary care clinicians, specialists, residents, and medical students. Failure to document smoking histories was observed in patients with conditions such as heart failure, coronary artery disease, and asthma. Electronic decision support systems and simple medical record reminders were effective in improving the documentation of smoking histories. CONCLUSIONS: Failure to adequately document the smoking history appears to be common. Strategies such as electronic decision support systems are needed to correct this problem in order for patients to receive optimal therapy for their appropriate diagnoses.