A review of interprofessional training wards: Enhancing student learning and patient outcomes.

Background: In an interprofessional training ward (ITW), students from different health professions collaboratively perform patient care with the goal of improving patient care. In the past two decades, ITWs have been established world-wide and studies have investigated their benefits. We aimed to compare ITWs with respect to their logistics, interprofessional learning outcomes and patient outcomes. Methods: We explored PubMed, CINAHL, Web of Science and EMBASE (1990-June 2017) and included articles focusing on interprofessional, in-patient training wards with student teams of medical and other health professions students. Two independent reviewers screened studies for eligibility and extracted data. Results: Thirty-seven articles from twelve different institutions with ITWs were included. ITWs world-wide are organized similarly with groups of 2-12 students (i.e. medical, nursing, physiotherapy, occupational therapy, and pharmacy) being involved in patient care, usually for a period of two weeks. However, the type of clinical ward and the way supervisors are trained differ. Conclusions: ITWs show promising results in short-term student learning outcomes and patient satisfaction rates. Future ITW studies should measure students' long-term interprofessional competencies using standardized tools. Furthermore, a research focus on the impact of ITWs on patient satisfaction and relevant patient care outcomes is important.

Metabolism and drug interactions of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors in transplant patients: are the statins mechanistically similar?

3-Hydroxy-3-methylglutaryl coenzyme A reductase (EC 1.1.1.88) inhibitors are the most effective drugs to lower cholesterol in transplant patients. However, immunosuppressants and several other drugs used after organ transplantation are cytochrome P4503A (CYP3A, EC 1.14.14.1) substrates. Pharmacokinetic interaction with some of the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, specifically lovastatin and simvastatin, leads to an increased incidence of muscle skeletal toxicity in transplant patients. It is our objective to review the role of drug metabolism and drug interactions of lovastatin, simvastatin, pravastatin, fluvastatin, atorvastatin, and cerivastatin. In the treatment of transplant patients, from a drug interaction perspective, pravastatin, which is not significantly metabolized by CYP enzymes, and fluvastatin, presumably a CYP2C9 substrate, compare favorably with the other statins for which the major metabolic pathways are catalyzed by CYP3A.

Tacrolimus oral bioavailability doubles with coadministration of ketoconazole.

OBJECTIVE: To quantitate the effect of ketoconazole, an azole antifungal agent and potent inhibitor of CYP3A4 and P-glycoprotein, on the bioavailability of tacrolimus, a substrate of the CYP3A system and of P-glycoprotein. SUBJECTS AND METHODS: The pharmacokinetics of tacrolimus were studied in six healthy volunteers (two women and four men) in a four-dose study after each received single doses of tacrolimus alone (0.1 mg/kg orally and 0.025 mg/kg intravenously) and with coadministered ketoconazole (200 mg orally at bedtime for 12 days). The dose of tacrolimus was reduced during the ketoconazole phase (0.04 mg/kg orally; 0.01 mg/kg intravenously). Ketoconazole and tacrolimus doses were separated by approximately 10 hours. Whole blood tacrolimus concentrations were determined by enzyme-linked immunosorbent assay. Estimated pharmacokinetic parameters in whole blood (mean +/- SD) before and with ketoconazole were calculated with noncompartmental techniques. RESULTS: Coadministration of ketoconazole did not consistently affect tacrolimus clearance (55.6 +/- 16.7 ml/hr/kg versus 42.5 +/- 7.6 ml/hr/kg), and steady-state volume of distribution was unchanged (0.99 +/- 0.26 L/kg versus 0.93 +/- 0.25 L/kg). However, a significant increase in tacrolimus bioavailability (14% +/- 5% versus 30% +/- 8%; p < 0.01) was observed with coadministered ketoconazole. Hepatic bioavailability was unchanged by the presence of ketoconazole (96% +/- 1% versus 97% +/- 1%). CONCLUSIONS: Because ketoconazole did not alter hepatic bioavailability and because 10 hours separated administration times of the drugs, it appears that the marked increase in tacrolimus bioavailability can be explained by ketoconazole having a local inhibitory effect on tacrolimus gut metabolism or on intestinal P-glycoprotein activity.

The pharmacokinetics and metabolic disposition of tacrolimus: a comparison across ethnic groups.

OBJECTIVE: Our objective was to compare the intravenous and oral pharmacokinetics of tacrolimus among subjects of three different ethnic backgrounds, African American, white, and Latin American. METHODS: Ten African American, 12 white, and 12 Latin American subjects received intravenous and oral tacrolimus in an open-label, two-period, parallel group study. All of the subjects received intravenous tacrolimus (0.015 mg/kg) as a constant infusion over 4 hours and oral tacrolimus capsules (5 mg) as single doses in randomized order. Concentrations of tacrolimus and its metabolites were measured in whole blood with the use of a validated HPLC-mass spectrometry assay. RESULTS: There were no significant differences in pharmacokinetic parameters among the three study groups after intravenous administration of the drugs. After oral administration, the tacrolimus maximum concentration was significantly lower (P < .01) in the African American subjects (20.8 microg/L) than in the white subjects (37.8 microg/L) and Latin American subjects (33.0 microg/L). Absolute bioavailability was significantly lower (P = .01) in the African American subjects (11.9%) and in the Latin American subjects (14.4%) than in the white subjects (18.8%). After the oral dose, the area under the plasma concentration-time curve was lower in the African American subjects (179 microg/L x h, geometric mean) than in the white (293 microg/L x h) and Latin American subjects (239 microg/L x h, differences not statistically significant). Maximum concentration (P < .02) and area under the plasma concentration-time curve (not statistically significant) of the main tacrolimus metabolite 13-O-desmethyl tacrolimus was lower in the African American subjects than in the white and Latin American subjects. CONCLUSIONS: Significant differences in tacrolimus pharmacokinetics exist among the three different ethnic groups. Our results indicate that this may result from differences in intestinal CYP3A or P-glycoprotein activities.

Pharmacokinetic/pharmacodynamic analysis of adjuvant pegylated interferon α-2b in patients with resected high-risk melanoma.

PURPOSE: High-dose pegylated interferon α-2b (peginterferon α-2b) significantly decreased disease recurrence in patients with resected stage III melanoma in a clinical study. We investigated the pharmacokinetics (PK) and safety of high-dose peginterferon α-2b in patients with high-risk melanoma. METHODS: For PK analysis, 32 patients received peginterferon α-2b 6 µg/(kg week) subcutaneously for 8 weeks (induction) then 3 µg/(kg week) for 4 weeks (maintenance). PK profiles were determined at weeks 1, 8, and 12. Exposure-response relationships between peginterferon α-2b and absolute neutrophil count (ANC) and alanine aminotransferase (ALT) level were also studied. RESULTS: Peginterferon α-2b was well-absorbed following SC administration, with a median T (max) of 24 h. Mean half-life estimates ranged from 43 to 51 h. The accumulation factor was 1.69 after induction therapy. PK parameters showed moderate interpatient variability. PK profiles were described by a one-compartmental model with first-order absorption and first-order elimination. Toxicity was profiled and was acceptable; observed side effects were similar to those previously described. Dose reduction produced proportional decreases in exposure and predictable effects on ANC in an Imax model; however, a PK/pharmacodynamic (PK/PD) relationship between peginterferon α-2b and ALT could not be established with high precision. CONCLUSIONS: Peginterferon α-2b was well-absorbed and sustained exposure to peginterferon α-2b was achieved with the doses tested. These data confirm and extend previous PK observations of peginterferon α-2b in melanoma and solid tumors. Our PK/PD model of exposure and ANC effect provides useful information for prediction of peginterferon α-2b-related hematologic toxicity.

Tamoxifen in liver disease: potential exacerbation of hepatic dysfunction.

Tamoxifen, a non-steroidal anti-estrogen, has been used successfully for a decade as post-operative adjuvant therapy for breast cancer. Tamoxifen is generally well tolerated with few side effects, especially at the typical dose of 10 mg twice daily. However, hepatic effects have been reported after tamoxifen administration and are usually found to be cholestatic in nature. Although previous reports concentrate on tamoxifen as a probable cause of drug-induced hepatotoxicity, very little attention has been focused on the use of tamoxifen in patients with pre-existing liver dysfunction and the possible need for dose adjustment. We present the case of a 48-year-old woman with an acute exacerbation of her pre-existing liver dysfunction and subsequent elevations of tamoxifen blood levels after approximately one year of tamoxifen therapy for adjuvant treatment of breast cancer. Tamoxifen dosing was adjusted based on serum levels.