Enhanced renal clearance impacts levetiracetam concentrations in patients with traumatic brain injury with and without augmented renal clearance.

BACKGROUND: The purpose of this study was to examine the impact of ARC on levetiracetam concentrations during the first week following acute TBI. The hypothesis was levetiracetam concentrations are significantly lower in TBI patients with augmented renal clearance (ARC) compared to those with normal renal clearance. METHODS: This is a prospective cohort pharmacokinetic study of adults with moderate to severe TBI treated with levetiracetam during the first week after injury. Serial blood collections were performed daily for analysis of levetiracetam, cystatin C, and 12-hr creatinine clearance (CrCl) determinations. Patients were divided into two cohorts: with (CrCl ≥130 ml/min/1.73 m2) and without ARC. RESULTS: Twenty-two patients with moderate to severe TBI were included. The population consisted primarily of young male patients with severe TBI (mean age 40 years old, 68% male, median admission GCS 4). Each received levetiracetam 1000 mg IV every 12 h for the study period. ARC was present in 77.3% of patients, with significantly lower levetiracetam concentrations in ARC patients and below the conservative therapeutic range (< 6mcg/mL) for all study days. In patients without ARC, the serum concentrations were also below the expected range on all but two study days (Days 4 and 5). Four of the 22 (18.2%) patients exhibited seizure activity during the study period (two of these patients exhibited ARC). Cystatin C concentrations were significantly lower in patients with ARC, though the mean for all patients was within the typical normal range. CONCLUSIONS: ARC has a high prevalence in patients with moderate to severe TBI. Levetiracetam concentrations after standard dosing were low in all TBI patients, but significantly lower in patients with ARC. This study highlights the need to consider personalized drug dosing in TBI patients irrespective of the presence of ARC. CLINICAL TRIAL REGISTRATION: This study was registered at cliicaltrials.gov (NCT02437838) Registered on 08/05/2015, https://clinicaltrials.gov/ct2/show/NCT02437838 .

Assessing Cognitive Apprenticeship Impact on Clinical Reasoning in Third-Year Student Pharmacists.

OBJECTIVE: The objective of this study was to evaluate the impact of implementing a cognitive apprenticeship theory (CAT) model into a Doctor of Pharmacy course in improving clinical reasoning skills of third-year student pharmacists over time and preparing them for Advanced Pharmacy Practice Experiences (APPEs). METHODS: This was a single center, nonrandomized, observational before-and-after study from January 2022 through May 2022. Third-year student pharmacists enrolled in the Critical Care Integrated Drugs and Disease pharmacotherapy course at the University of Kentucky College of Pharmacy were administered a well-established and nationally recognized clinical patient case assessment on weeks 1 and 15 of the course. Students were asked to prioritize patient problems and provide recommendations for therapy, goals, and monitoring. Responses were then scored using a predefined case key. In addition, student pharmacists were asked to self-evaluate their confidence in APPE readiness on a 5-point Likert scale. RESULTS: Of the 136 student pharmacists enrolled in the course, 92 (68%) student pharmacists completed both week 1 and week 15 clinical cases and self-assessment surveys, provided informed consent, and were included. Cumulative clinical case scores were significantly increased from week 1 to week 15 (34.8 vs 39.7). In addition, significant improvement was seen in overall problem prioritization, overall recommendations, and self-perceived preparedness for APPE rotations. CONCLUSION: The use of a CAT model into a 15-week pharmacotherapy course improved comprehensive scores of clinical reasoning assessment in third-year student pharmacists and was associated with increased self-perceived confidence and readiness for APPEs.

The risks of polypharmacy following spinal cord injury.

OBJECTIVE: The purpose of this study was to examine the overall prevalence of polypharmacy within the spinal cord injury (SCI) population, the level of polypharmacy with respect to seven classes of high-risk drugs commonly used to treat secondary conditions in the SCI population, and the overall risks for drug-related problems (DRP) related to polypharmacy. DESIGN: A retrospective case-control design. SETTING: A commercially available claims dataset that included patient cases from 4800 hospitals in the USA between 2007 and 2009. PARTICIPANTS: Individuals with tetraplegia, paraplegia, and those with SCI but not specified as either tetraplegia or paraplegia as well as a control population of randomly selected, age- and sex-matched individuals without a diagnosis of SCI. OUTCOME MEASURES: The overall prevalence of polypharmacy, the prevalence of commonly prescribed high-risk medications, and the prevalence of reported DRPs. RESULTS: Overall, the patients in the SCI population were prescribed significantly more medications than their control counterparts. There was a higher rate of individuals being prescribed medications from multiple high-risk classes (e.g. analgesic-narcotics, anticonvulsant, antidepressant, and skeletal muscle relaxer), as well as multiple medications within each class (e.g. multiple analgesic-narcotics). The SCI group had a higher incidence of DRPs. CONCLUSION: Our results are some of the first to demonstrate the extent of polypharmacy in individuals with SCI, including commonly prescribed high-risk medications, leading to a higher rate of DPRs. The higher rate of polypharmacy and DRPs can impact rehabilitation goals and community integration following neurologic injury.