Pharmacist Prescribing at Inpatient Discharge in Alberta.

Background: Pharmacists in the province of Alberta may apply for additional prescribing authorization (APA), which allows them to independently prescribe medications. Currently, no literature exists about pharmacist prescribing for inpatients at the time of discharge. Objectives: The primary objective was to report the proportion of patients for whom inpatient pharmacists with APA prescribed at discharge across Alberta, Canada. Secondary objectives were to describe discharge interventions other than prescribing that were provided, enablers of and barriers to discharge prescribing, and differences in discharge prescribing by facility or population type, clinical area, and health care charting system. Methods: A descriptive, cross-sectional web-based survey of inpatient pharmacists with APA across Alberta was conducted over a 6-week period in early 2022. Results: A total of 104 respondents met the inclusion criteria. Under half (45/102, 44.1%) of the participants reported prescribing at discharge. Those that reported prescribing at discharge did so for only a median 14.5% of their patients. The most common enabler of discharge prescribing was a supportive care team, and the most common barrier was the presence of other prescribers. Pharmacists who did not report prescribing at discharge selected "discomfort with being responsible for the prescription" and "fear of professional liability" as barriers more often than those who did report discharge prescribing (51.0% [26/51] vs 33.3% [13/39] and 43.1% [22/51] vs 25.6% [10/39], respectively). The proportion of pharmacists who reported prescribing at discharge was greater with increasing population/facility size (30% [6/20] of pharmacists in settings that served small populations vs 50% [29/58] of those in settings that served large populations). Conclusions: Inpatient pharmacists who use APA at discharge reported prescribing for only a minority of patients, and discharge prescribing practices varied widely across the province. Future areas of research include how pharmacists can overcome barriers to prescribing at discharge.

Contexte: Les pharmaciens de la province de l'Alberta peuvent demander une autorisation supplémentaire de prescrire des médicaments de manière indépendante. À l'heure actuelle, aucune documentation n'existe sur la prescription de médicaments destinés aux patients hospitalisés au moment de leur congé par les pharmaciens. Objectifs: L'objectif principal visait à rendre compte de la proportion de patients à qui les pharmaciens en milieu hospitalier titulaires d'une autorisation supplémentaire de prescrire prescrivaient des médicaments au moment du congé en Alberta, au Canada. Les objectifs secondaires visaient quant à eux à décrire : les interventions au moment du congé, autres que la prescription; les obstacles et les facilitateurs de la prescription au moment du congé; et les différences en matière de prescription au moment du congé par type d'établissement ou de population, domaine clinique et système de dossiers de soins de santé. Méthode: Une enquête en ligne descriptive et transversale a été menée auprès de pharmaciens en milieu hospitalier titulaires d'une autorisation supplémentaire de prescrire en Alberta, sur un intervalle de 6 semaines au début de 2022. Résultats: Au total, 104 répondants satisfaisaient aux critères d'inclusion. Moins de la moitié (45/102, 44,1 %) des participants ont déclaré prescrire au moment du congé. Ceux-ci le faisaient pour seulement une médiane de 14,5 % de leurs patients. Le facteur le plus courant favorisant la prescription au moment du congé était une équipe de soins de soutien; l'obstacle le plus courant était la présence d'autres prescripteurs. Les pharmaciens ayant déclaré ne pas prescrire au moment du congé ont plus fréquemment indiqué comme obstacle le fait d'être « mal à l'aise à l'idée d'être responsable de la prescription ¼ et la « crainte de la responsabilité professionnelle ¼ que les pharmaciens ayant indiqué prescrire au moment du congé (51,0 % [26/51] contre 33,3 % [13/39] et 43,1 % [22/51] contre 25,6 % [10/39], respectivement). La proportion de pharmaciens ayant déclaré prescrire au moment du congé était plus élevée lorsque la taille de la population/de l'établissement était plus importante (30% [6/20] des pharmaciens dans des milieux desservant de petites populations contre 50 % [29/58] de ceux dans des milieux desservant de grandes populations). Conclusions: Les pharmaciens en milieu hospitalier titulaires d'une autorisation supplémentaire de prescrire ont déclaré prescrire pour seulement une minorité de patients au moment du congé, et les pratiques en la matière variaient largement dans la province. Les futurs domaines de recherche comprennent la manière dont les pharmaciens peuvent surmonter les obstacles les empêchant de prescrire au moment du congé.

The MedSafer Study-Electronic Decision Support for Deprescribing in Hospitalized Older Adults: A Cluster Randomized Clinical Trial.

IMPORTANCE: Scalable deprescribing interventions may reduce polypharmacy and the use of potentially inappropriate medications (PIMs); however, few studies have been large enough to evaluate the impact that deprescribing may have on adverse drug events (ADEs). OBJECTIVE: To evaluate the effect of an electronic deprescribing decision support tool on ADEs after hospital discharge among older adults with polypharmacy. DESIGN, SETTING, AND PARTICIPANTS: This was a cluster randomized clinical trial of older (≥65 years) hospitalized patients with an expected survival of more than 3 months who were admitted to 1 of 11 acute care hospitals in Canada from August 22, 2017, to January 13, 2020. At admission, participants were taking 5 or more medications per day. Data analyses were performed from January 3, 2021, to September 23, 2021. INTERVENTIONS: Personalized reports of deprescribing opportunities generated by MedSafer software to address usual home medications and measures of prognosis and frailty. Deprescribing reports provided to the treating team were compared with usual care (medication reconciliation). MAIN OUTCOMES AND MEASURES: The primary outcome was a reduction of ADEs within the first 30 days postdischarge (including adverse drug withdrawal events) captured through structured telephone surveys and adjudicated blinded to intervention status. Secondary outcomes were the proportion of patients with 1 or more PIMs deprescribed at discharge and the proportion of patients with an adverse drug withdrawal event (ADWE). RESULTS: A total of 5698 participants (median [range] age, 78 [72-85] years; 2858 [50.2%] women; race and ethnicity data were not collected) were enrolled in 3 clusters and were adjudicated for the primary outcome (control, 3204; intervention, 2494). Despite cluster randomization, there were group imbalances, eg, the participants in the intervention arm were older and had more PIMS prescribed at baseline. After hospital discharge, 4989 (87.6%) participants completed an ADE interview. There was no significant difference in ADEs within 30 days of discharge (138 [5.0%] of 2742 control vs 111 [4.9%] of 2247 intervention participants; adjusted risk difference [aRD] -0.8%; 95% CI, -2.9% to 1.3%). Deprescribing increased from 795 (29.8%) of 2667 control to 1249 (55.4%) of 2256 intervention participants [aRD, 22.2%; 95% CI, 16.9% to 27.4%]. There was no difference in ADWEs between groups. Several post hoc sensitivity analyses, including the use of a nonparametric test to address the low cluster number, group imbalances, and potential biases, did not alter study conclusions. CONCLUSIONS AND RELEVANCE: This cluster randomized clinical trial showed that providing deprescribing clinical decision support during acute hospitalization had no demonstrable impact on ADEs, although the intervention was safe and led to improvements in deprescribing. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03272607.

Practice patterns surrounding referral to a specialty venous thromboembolism (VTE) clinic: a retrospective review.

This study audited prescribing practices for patients with acute venous thromboembolism (VTE) prior to and after being seen in an outpatient VTE clinic. This retrospective chart review conducted between June 2018 through May 2019 included patients with confirmed acute VTE, seen for an initial appointment. Exclusion criteria were patients with additional indications for anticoagulation, lack of information to determine primary outcome and active cancer. To assess practices, the time taken to be seen in clinic, anticoagulant therapies (prior to/following clinic) used and concordance of anticoagulant use with product monographs were assessed. Of the 325 (40.6%) patients included, the median age was 57.7 years, most were referred with pulmonary embolism (PE) (54.5%) and the majority of referrals came through the emergency department (45.2%). The median time to be seen in clinic was 13 days, with no differences in time between type of VTE or proximity of clot. Prior to being seen in VTE clinic, most were prescribed direct oral anticoagulants (DOACs) (81.9%), with a small portion receiving low molecular weight heparin (LMWH) (12.9%) and warfarin (5.2%). Most received anticoagulants concordant with product monographs (87.7%), with more discordance with warfarin (52.9%) and LMWH (14.3%) compared to DOACs (9.4%) (P < 0.001). At the initial VTE clinic visit, 70 (21.5%) patients had therapy changes, with most being from LMWH/warfarin to a DOAC (47.1%). Our data reflects high uptake of DOACs for acute VTE treatment with most prescribed in accordance with product monographs.

Clinical Pharmacokinetics and Pharmacodynamics of Anti-Tubercular Drugs in Pregnancy.

The objectives of this qualitative review were to critically evaluate and summarize the currently available data on the use of anti-tuberculosis (TB) drugs during pregnancy, with a focus on treatment outcomes, safety, and pharmacokinetics. This qualitative, narrative review was based on literature searches in Medline, Pubmed, Embase, and Google Scholar (from their inception to 13 August 2020). Our search identified 22 papers related to treatment outcomes and 14 papers related to pharmacokinetic exposures and fetal distributions. While it is challenging to study this patient population, current evidence supports treatment of drug-susceptible TB, multidrug-resistant TB and latent TB infections. However, decisions regarding initiating, continuing, or discontinuing anti-tubercular medications while pregnant should be individualized and discussed with a specialist. Similarly, the pharmacokinetic data of anti-TB agents were mainly derived from small scale, observational studies many of which lacked high quality controls. Based on these data, it does not appear that pregnancy has an extensive impact on the pharmacokinetics of the majority of first-line and second-line agents, although caution (discussed in the review) should be exercised in data interpretation. Fetal drug exposure can also be significant and should be considered when selecting an anti-TB agent for longer term treatment. Overall, it is generally difficult to predict pregnancy-associated pharmacokinetic changes based only on drug's physiochemical characteristics.

Clinical Pharmacokinetics and Pharmacodynamics of Delafloxacin.

Delafloxacin has recently received approval by the US Food and Drug Administration for the treatment of acute bacterial skin and skin structure infections. This article provides a balanced and comprehensive systematic critique of the literature in order to provide an up-to-date summary of its clinical pharmacology. Oral delafloxacin is rapidly absorbed and exhibits comparable exposure characteristics (300 mg intravenous versus 450 mg oral) between the two formulations, allowing easy transition from intravenous to oral therapy. The bioavailability is high (60-70%) and absorption is not affected by food intake, although further studies are required under clinically relevant conditions. Delafloxacin is primarily excreted renally (thus requiring renal dose adjustment in the setting of renal dysfunction), but also undergoes metabolism by uridine diphosphate-glucuronosyltransferase enzymes in the formation of a conjugated metabolite. Few drug-drug interaction studies have been identified, although more systematic characterizations in vitro and in vivo are warranted. Delafloxacin is a concentration-dependent bactericidal agent that has in vitro susceptibility for gram-positive (notably potent activity against methicillin-resistant Staphylococcus aureus), gram-negative, and anaerobic organisms. In addition to acute bacterial skin and skin structure infections, the clinical utility of delafloxacin has also been studied in community-acquired pneumonia, acute exacerbation of chronic bronchitis, and gonorrhea, with potentially promising findings. Given its mild side effect profile, including an apparent lack of association with clinically important QTc prolongation, delafloxacin is generally well tolerated.

Medication Discrepancies Associated With a Medication Reconciliation Program and Clinical Outcomes After Hospital Discharge.

STUDY OBJECTIVE: To identify the frequency of unintended medication discrepancies 30 days postdischarge from medicine wards with interprofessional medication reconciliation processes and clinical import. METHODS: Prospective cohort study of adults discharged between October 2013 and November 2014 from two teaching hospitals in Edmonton, Canada. The Best Possible Medication Discharge Plan (BPMDP) was prepared for all patients. Patients were called 30 days postdischarge to determine the medication discrepancy rate from the BPMDP and whether this was intentional or unintentional; three clinicians used standardized criteria to determine if the discrepancy was inconsequential. Electronic health records and patient contact were used to ascertain death, hospital readmissions, and emergency department (ED) visits at 90 days. RESULTS: Of 433 patients (mean age 64 yrs, 52% female, median discharge prescriptions 6 [interquartile range 4-9]), 168 (38.8%) had at least one unintentional medication discrepancy at 30 days (325 total discrepancies; median one [interquartile range 1-2 discrepancies per patient]). Patients with unintentional medication discrepancies were older (65.9 vs 61.9 yrs, p=0.03) with more discharge medications (7 vs 6, p=0.03). Most unintentional discrepancies (91.1%) were judged inconsequential. The presence of an unintentional medication discrepancy was not associated with 90-day readmission or death (42/167 [25.1%] vs 64/263 [24.3%], adjusted odds ratio 0.96 [95% confidence interval 0.60-1.54]) or ED visits (69 [41.3%] vs 101 [38.4%], adjusted odds ratio 1.11 [95% confidence interval 0.74-1.67]. CONCLUSION: Despite the presence of an interprofessional medication reconciliation process, over one-third of patients had a medication discrepancy within 30 days of discharge, although most were inconsequential and there was no association between unintended medication discrepancies and risk of readmission, ED visit, or death 3 months after discharge.

Continuous versus intermittent infusions of antibiotics for the treatment of severe acute infections.

BACKGROUND: Intravenous broad-spectrum antibiotics are indicated for the treatment of severe infections. However, the emergence of infections caused by multi-drug resistant organisms in conjunction with a lack of novel antibiotics has prompted the investigation of alternative dosing strategies to improve clinical efficacy and tolerability. To optimise pharmacokinetic and pharmacodynamic antibiotic parameters, continuous antibiotic infusions have been compared to traditional intermittent antibiotic infusions. OBJECTIVES: To compare the clinical efficacy and safety of continuous intravenous administration of concentration-dependent and time-dependent antibiotics to traditional intermittent intravenous administration in adults with severe acute bacterial infections. SEARCH METHODS: The following electronic databases were searched in September 2012: The Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S). The reference lists of all relevant material, the Internet and the trials registry www.clinicaltrials.gov for completed and ongoing trials were also searched. SELECTION CRITERIA: Randomized controlled trials in adults with a bacterial infection requiring intravenous antibiotic therapy comparing continuous versus intermittent infusions of antibiotics were included. Both time-dependent and concentration-dependent antibiotics were considered. DATA COLLECTION AND ANALYSIS: Three independent authors performed data extraction for the included studies. All data was cross-checked and disagreements resolved by consensus. An intention to treat analysis was conducted using a random-effects model. MAIN RESULTS: Twenty-nine studies met inclusion criteria with a combined total of over 1,600 patients. The majority of included studies were judged to be at unclear or high risk of bias with regard to randomisation sequence generation, allocation concealment, blinding, management of incomplete outcome data, selective outcome reporting, and other potential threats to validity. No studies were judged to be at low risk of bias for all methodological quality items assessed. There were no differences in all-cause mortality (n=1241, RR 0.89, 95% CI 0.67 - 1.20, p=0.45), infection recurrence (n=398, RR 1.22, 95% CI 0.35 - 4.19, p=0.76), clinical cure (n=975, RR 1.00, 95% CI 0.93 - 1.08, p=0.98), and superinfection post-therapy (n=813, RR 1.08, 95% CI 0.60 - 1.94, p=0.79). There were no differences in safety outcomes including adverse events (n=575, RR 1.02, 95% CI 0.94 - 1.12, p=0.63), serious adverse events (n=871, RR 1.36, 95% CI 0.80 - 2.30, p=0.26), and withdrawal due to adverse events (n=871, RR 2.03, 95% CI 0.52 - 7.95, p=0.31). A difference was observed in the subgroup analyses of clinical cure in septic versus non-septic patients, where intermittent antibiotic infusions were favoured for clinical cure in septic patients. However, this effect was not consistent between random-effects and fixed-effects analyses. No differences were found in sensitivity analyses conducted. AUTHORS' CONCLUSIONS: There were no differences in mortality, infection recurrence, clinical cure, superinfection post-therapy, and safety outcomes when comparing continuous infusions of intravenous antibiotics to traditional intermittent infusions of antibiotics. However, the wide confidence intervals suggest that beneficial or harmful effects cannot be ruled out for all outcomes. Therefore, the current evidence is insufficient to recommend the widespread adoption of continuous infusion antibiotics in the place of intermittent infusions of antibiotics. Further large prospective randomised trials, with consistent and complete reporting of clinical outcome measures, conducted with concurrent pharmacokinetic and pharmacodynamic studies in special populations are required to determine whether adoption of continuous antibiotic infusions is warranted in specific circumstances.

Dosing and monitoring of methadone in pregnancy: literature review.

BACKGROUND: The pharmacokinetics of methadone is altered during pregnancy, but the most appropriate dosing and monitoring regimen has yet to be identified. OBJECTIVE: To review dosing and monitoring of methadone therapy in pregnancy. METHODS: A literature search was performed in several databases (PubMed, MEDLINE, Embase, International Pharmaceutical Abstracts, and the Cochrane Database of Systematic Reviews) from inception to May 2012. The search terms were "methadone", "pregnancy", "pharmacokinetic", "clearance", "metabolism", "therapeutic drug monitoring", and "methadone dosing". Additional papers were identified by searching the bibliographies of primary and review articles. All English-language primary articles related to methadone pharmacokinetics in pregnancy were included. Articles not related to maternal outcomes were excluded. RESULTS: The literature search yielded 1 case report and 10 studies discussing use of methadone by pregnant women. Methadone pharmacokinetics in pregnancy has been studied in 3 pharmacokinetic trials, and split dosing of methadone in pregnant women has been described in 1 case report and 3 dosing trials. Only 4 trials evaluated monitoring of methadone concentration in pregnancy. The studies included in this review confirm that methadone pharmacokinetics is altered in pregnancy and is potentially correlated with increases in maternal withdrawal symptoms. Insufficient evidence is available to warrant routine monitoring of serum methadone concentrations in pregnant women with opioid dependence. CONCLUSIONS: Few studies of methadone pharmacokinetics and therapeutic drug monitoring are available for pregnant women with opioid dependence. Although it is known that methadone pharmacokinetics is altered in pregnancy, there is insufficient evidence to guide dosage adjustments and serum concentration monitoring. Until further studies are available, regular follow-up of maternal withdrawal symptoms and empiric dosage adjustments throughout pregnancy are still recommended.

Frequency of intensive statin therapy in patients with acute coronary syndrome admitted to a tertiary care center.

Intensive statin therapy (IST) has been shown to decrease cardiovascular events in patients with acute coronary syndrome (ACS). Numerous studies have described statin use for secondary prevention; however, few data have highlighted IST use after ACS. The objective of the present study was to describe IST use in an ACS population before hospitalization, on discharge, and during early follow-up after discharge. A retrospective chart review was conducted of randomly selected patients admitted to a tertiary care center from November 1, 2007 to October 31, 2008. Eligible patients included adults admitted to cardiology with a most responsible diagnosis of ACS (International Classification of Diseases code 20-25). The exclusion criteria included transfer to another hospital or cardiovascular surgery ward and in-hospital death. Phase 1 included an inpatient chart review. Phase 2 was a follow-up cardiologist clinic letter review that included only patients who started IST in-hospital. Of 234 charts reviewed, 111 (47%) patients met the inclusion criteria (mean age 65 ± 11.7 years, 76% men). Most patients (93%) were discharged with a statin. However, although 72% of the study population were eligible for IST, only 52% had IST during hospitalization. Of the patients who started IST with clinic letters available (n = 31), 68% continued IST (mean interval to follow-up 85 days, range 33 to 208). In conclusion, although statin use is good, IST use after ACS is suboptimal. Additionally, newly initiated IST demonstrates poor persistence after discharge.

Pseudohyperphosphatemia associated with high-dose liposomal and lipid complex amphotericin B when tested with Synchron LX 20 (Beckman/Coulter) phosphorous assay.

Although case reports of hyperphosphatemia have been previously described in patients receiving liposomal amphotericin B, this has not been reported in patients receiving the lipid complex formulation. We report a case of hyperphosphatemia that persisted despite switching from liposomal to lipid complex amphotericin B in a child with invasive zygomycosis. This case suggests that in the context of acute renal dysfunction, hyperphosphatemia may also be observed with lipid complex amphotericin B. This case highlights the importance of differentiating between pseudohyperphosphatemia and hyperphosphatemia to prevent complications.