Medication Dose Adjustment Research Articles

Impact of an Oncology Clinical Pharmacist Specialist in an Outpatient Multiple Myeloma Clinic

IntroductionImprovements in cancer treatment and supportive care, as well as the approval of oral chemotherapy medications over the past decade, have resulted in an increasing number of cancer patients being treated in outpatient settings. Transitioning cancer treatments to the outpatient setting places greater emphasis on proper medication counseling and optimal management of adverse effects. We therefore evaluated the clinical and financial impact of an oncology clinical pharmacist specialist in an interdisciplinary multiple myeloma clinic by using a validated scoring tool. MethodsThe oncology clinical pharmacist specialist was available for consult by the multiple myeloma clinic staff. The pharmacist may be consulted for any medication-related inquiry. On the basis of the consult, the pharmacist categorized interventions into 12 predefined intervention categories. ResultsImplementation of a clinical pharmacy specialist into a multiple myeloma clinic over 39 clinic days resulted in 241 patient consults and 474 interventions made by the pharmacist. The most frequent interventions made by the pharmacist were medication teaching (n = 97), dose adjustments (n = 82), and medication reconciliation (n = 63). The value of interventions made by the pharmacist during the study period was $189,441, with a predicted annual value of $757,764. ConclusionThe addition of an oncology pharmacist to an outpatient multiple myeloma clinic can improve clinical and financial outcomes.

SAT-331 HEMATOLOGICAL ABNORMALITIES IN FIRST THREE MONTHS POST RENAL TRANSPLANTATION: A SINGLE CENTRE STUDY FROM NORTH EAST INDIA

Renal transplantation(RT) in renal failure improves patients' quality of life. 20%–63% of RT recipients will experience at least one episode of leukopenia. RT recipients show the lowest platelet count within the first 3 months after transplantation. It is in this period that patients receive induction therapy and higher doses of conventional immunosuppressive drugs to prevent or treat acute rejection. Cytopenia may result due to drug toxicity, drug interactions, viral infections, or immune-mediated reactions. Several drugs may cause cytopenia within the 1st month after RT. Discontinuation or substitution of offending drugs will be helpful in treating thrombocytopenia. Leukopenia in transplanted patients increases the risk of infection. In drug induced cytopenia, the most effective measure is dose reduction or discontinuation of precipitant drug; however, this strategy may increase the risk of acute rejection. Objective: This study assessed incidence, etiology and severity of various forms of hematological abnormalities within the first three months after kidney transplantation. This retrospective study was conducted on kidney transplant recipients from Guahati Medical College and Hospital, Assam for 5 years from Jan'13 to Dec'18. Demographic, clinical, and laboratory data of patients within the first three months after transplantation were collected and reviewed. Strategies like medication dose adjustment, cytomegalovirus infection or G-CSF administration for management of drug-induced leukopenia and thrombocytopenia were also reviewed. Inclusion criteria: All kidney transplant recipients. Exclusion criteria: Patients without voluntary written consent, known haematological disease and thrombocytopenia due to ABMR. 44 kidney transplant recipients (37 males and 7 females) with mean age of 33.4 ±14.4 years old who met the inclusion criteria were enrolled in this study. The most common causes of renal failure among these patients were CGN(38.1% of cases), DM (33.5% of cases), chronic tubulointestitial disease (20.4%) and hypertension (8%). Of these 44 patients, 7 (15.93%) received rATG, 5 (11%) IL2R as induction therapy. All patient received IS agents consisting of CSA/Tacrolimus, MMF and steroid. There wasno significant difference between these groups regarding demographic and clinical data. Sulfamethoxazole and trimethoprim and VGV were routinely given to all recipients as prophylaxis. Of 44 patients, 5(11.3%), 16(36.3%) and 7(15.9%) patients experienced leucopenia, thrombocytopenia and pancytopenia respectively. Leucopenia occurred more commonly among patients with thymoglobulin-containing regimen. Pancytopenia was observed in patients who received rATG, MMF, VGV and TMP-SMX. 5 patients received basiliximab as induction agent and did not develop cytopenia. The total administered dose of rATG in patients with leukopenia showed no significant difference in comparison to patients without leucopenia. Hematological abnormalities are not an uncommon feature amongst kidney transplant recipients. Choice of appropriate induction therapy, immunosupressive agent and prophylactic agents can minimize the hematological abnormalities in kidney transplant recipients.

Culturally based pre-Ramadan education increased benefits and reduced hazards of Ramadan fasting for type 2 diabetic patients.

In the current study, we aimed at evaluating the effect of a culturally-based pre-Ramadan education program (PREP) on glycemic control, weight, adherence to post-sunset physical activity, perception of hypoglycemia, and anti-diabetic medication dose adjustment during Ramadan fasting in type 2 diabetics. A total of 1008 type 2 Diabetes patients were offered a culturally-based PREP in addition to the standard of care, two months before Ramadan. A retrospective interview one month after Ramadan compared the fasting experience of PREP attendees (470 patients) with those who merely received standard of care (538 patients) (Non-PREP). Ramadan fasting improved glycemic control with a correlation between HbA1c percent reduction and the number of fasting days (r = -0.290, p = 0.007). More HbA1c and weight percent reduction were observed in PREP attendees compared to the Non-PREP group (-14.8% ± 9.3 vs. -5.4% ± 5.4; p < 0.001; and - 1.96% ± 5.4 vs. -0.39% ± 2.8; p < 0.001, respectively). More commitment to night prayers in the PREP attendees compared to the Non-PREP group, (85.5% prayed >20 nights vs 28.4%; p < 0.001) with more HbA1c and weight percent reduction in the those who performed the prayers more than 20 nights compared to those who performed no prayers (-11.69% ± 8.8 vs -6.28% ± 6.4, p < 0.001; and - 2.76% ±5.1 vs 1.35% ±1.8, p < 0.001, respectively). More perception of true hypoglycemia was associated with PREP attendance (p0.046), insulin treatment (p0.000), and reduction of antidiabetic medication dosage (p0.004). Repeated lowering of antidiabetic medications doses with sequential downsizing of meals' portions, and appetite was reported. Ramadan fasting was beneficial for people with type 2 diabetes with reduction of HbA1c in correlation with the number of fasting days. Contrasting PREP with Non-PREP participants discovered better HbA1c and weight reduction in the former group even with equal number of fasting days. PREP participants performed more Taraweeh night prayers. The more the prayer nights the more decline of HbA1c and weight was observed. PREP improved perception and response to hypoglycemia with low-dosing of antidiabetic medications, especially insulin.

The Impact of Clinical Pharmacists in Hematopoietic Stem Cell Transplant (HSCT) Outpatient Clinic at an Academic Medical Center

<h3>Background</h3> Pharmacists are increasingly identified as vital members of the HSCT multidisciplinary team. At our institution, pharmacists recently established roles providing clinical pharmacy services in the outpatient setting focused on performing interventions during the pre-HSCT clinic visit. <h3>Objectives</h3> The primary objective was to evaluate the number of medication discrepancies identified during pre-HSCT clinic visits performed by pharmacists, defined as addition, removal, or dose adjustment of current medications. Secondary objectives were to evaluate the number of interventions made by pharmacists for drug interactions, chemotherapy dose adjustments, and other medication recommendations for all patients prior to HSCT. <h3>Methods</h3> A retrospective review of all patients admitted for HSCT from August 2018 to 2019 was performed. Patients are seen by their HSCT provider about 1 week prior to HSCT. At this visit, oncology trained pharmacists specializing in HSCT meet with the patient and provide services such as medication reconciliation, screening for drug interactions, screening for pertinent medication allergies/ intolerances and identifying alternatives, assessing medication adherence, evaluating need for chemotherapy dose adjustments, and identifying barriers to medication access. Patients that are unable to be seen by the pharmacist receive extensive chart review prior to admission to identify medication interventions. <h3>Results</h3> HSCT pharmacists performed 150 pre-HSCT clinic visits for 88 (59%) autologous, 46 (31%) allogeneic, and 16 (11%) Chimeric Antigen Receptor Therapy (CAR- T) recipients. A total of 511 medication discrepancies were identified in 128 (85%) patients seen (Figure 1). In addition to the 150 patients seen, 88 patient charts were reviewed by a pharmacist. A total of 66 significant drug interactions requiring intervention were identified in 52 (22%) patients and 30 chemotherapy dose adjustments were implemented in 29 (12%) patients. Other medication recommendations were made to the provider for 109 (46%) patients. Examples of these interventions include stopping oral chemotherapy prior to HSCT, modifying supportive care medications to reflect patient preference and prior response, modifying hydration due to cardiac history, coordinating steroid tapers before haploidentical HSCT or CAR-T, adjusting prophylactic antimicrobials due to allergies or to meet institutional standards, coordinating refills, and developing a plan for non-formulary medications. <h3>Conclusions</h3> Pharmacists play a crucial role in providing safe and effective care to HSCT patients, and their involvement in the multidisciplinary team can lead to significant clinical interventions. Future directions include expansion of the role of HSCT pharmacists through Pharmacy Consult Agreements, focusing on HSCT patients post-transplant and within a Survivorship Clinic.

COMDORA-SBN recommendations for patients with rare kidney diseases in relation to the Covid-19 pandemic.

ABSTRACTDuring the Covid-19 pandemic, the issue is how to maintain adequate care for people with other diseases. In this document, the SBN Rare Diseases Committee (COMDORA) gives some guidelines on the care of patients with rare kidney diseases. These patients should follow the recommendations for the general population, bearing in mind that, as they have chronic kidney disease, they are included in the risk group for more serious outcomes if they develop Covid-19. Non-essential decision-making procedures should be postponed. In stable cases under appropriate treatment, we must choose to contact our patients remotely, using teleconsultations and home exam collections (if possible). In the presence of a symptom or sign of decompensation of the underlying disease, or infection with Sars-cov-2, advise the patient to seek medical assistance. The patient should not be waiting to get worse. Changes to the prescription should only be made on a scientific basis. Dosage suspension or change is not recommended, even in cases in which the patient needs to go to a center to receive his medication; in this case, the infusion center must follow the recommendations of the Ministry of Health. If the patient develops Covid-19 and uses any drugs, check the need for dose adjustment of the routine medications. Avoid the use of antimetabolics and anti-CD20 in patients with Covid-19, as they reduce viral clearance and predispose to bacterial infections. Contact between the patient and the medical team is essential; changes are recommended only with specialized medical guidance.

Psychotropic Treatment During Pregnancy: Research Synthesis and Clinical Care Principles.

Background: Psychiatric illnesses are common in women of childbearing age. The perinatal period is a particularly high-risk time for depression, bipolar, and anxiety disorders. Methods: The scope of the public health problem of perinatal mental disorders is discussed followed by an examination of the specific research methods utilized for the study of birth and developmental outcomes associated with maternal mental illness and its treatment. The evidence on exposure to common psychotropics during pregnancy and breastfeeding is reviewed. Results: Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitor medications are not associated with higher rates of birth defects or long-term changes in mental development after adjustment for confounding factors associated with underlying psychiatric illness. Lithium exposure is associated with an increased risk for fetal cardiac malformations, but this risk is lower than previously thought (absolute risk of Ebstein's anomaly 6/1,000). Antipsychotics, other than risperidone and potentially paliperidone, have not been associated with an increase in birth defects; olanzapine and quetiapine have been linked with an elevated risk of gestational diabetes. Due to the dramatic physiological changes of pregnancy and enhanced hepatic metabolism, drug doses may need to be adjusted during pregnancy to sustain efficacy. Untreated maternal psychiatric illness also carries substantial risks for the mother, fetus, infant, and family. Conclusions: The goal of perinatal mental health treatment is to optimally provide pharmacotherapy to mitigate the somatic and psychosocial burdens of maternal psychiatric disorders. Regular symptom monitoring during pregnancy and postpartum and medication dose adjustments to sustain efficacy constitutes good practice.

A Qualitative Exploration of Gaps and Challenges in Knowledge and Practices of Electroconvulsive Therapy by Key Personnel in Public and Private Mental Health Units in Kenya.

Background: Evidence-based research for electroconvulsive therapy (ECT) practice in Kenya is scarce. This has seemingly stifled knowledge with regard to ECT practice among key personnel in the country. Research shows that evidence-based guidelines not only harmonize clinical practice in a certain region but also improve health outcomes and quality of clinical decisions made by key personnel. This study aimed at assessing knowledge and administration of ECT by key personnel in psychiatric units in Kenya. Method: This is a qualitative study targeting multiple stakeholders in mental health facilities. The study was undertaken in three counties: Nairobi, Nakuru and Eldoret. Snowballing sampling method was used to interview 33 targeted respondents who work in ECT departments or actively interacted with the procedure in both private and public facilities. Researcher-designed respondent profile questionnaire and interview guides focusing on knowledge, practice and barriers in delivery of ECT were used as tools. Data collected were transcribed from the audio recordings. Thematic and content analyses of these semi-structured interviews were carried out based on the patterns that were noted across the data collected. The interviews were read by the research team and re-read to highlight the core ideas. Findings were presented in form of themes, which were illustrated along with representative verbatim quotations. Results: Overall, the key personnel were knowledgeable about ECT in different stages of the procedure, but we noticed methodological incongruence in their practice with regard to the pre-ECT preparation, stimulus dose calculation adequacy of seizure and in the procedure for dose adjustment of psychotropic medication before and after ECT sessions. The identified barriers to the uptake of evidence-based practice were lack of infrastructure, inadequate funding, lack of adequate training and negative perception by patients, relatives and even some participants. Conclusion: Though key personnel in this study showed that they had knowledge on ECT administration, lack of standard guidelines on ECT practice led to lack of standardized training on the procedure hence the methodological incongruence. Inadequate infrastructure, knowledge and negative perception towards the procedure seemed to interfere with uptake of ECT as an intervention. Recommendations: The study makes the following recommendations: adoption of a guideline by psychiatrists, intense training on ECT, specialized training for nurses in ECT and dose calculation for psychiatrists and registrars. Funding should be made available for new ECT machines. Lastly, education and awareness creation should be done about ECT to help deal with negative perception towards the intervention.

Impact of a pharmacy‐cardiology collaborative management program during initiation of antiarrhythmic drugs

AbstractObjectiveAntiarrhythmic drugs (AADs) are commonly used for management of atrial fibrillation and other cardiac arrhythmias. However, the use of AADs in clinical practice is challenging due to the risk of serious adverse drug events associated with these medications. Adherence to recommended monitoring parameters may improve safety in these agents. The primary objective of this study was to determine the effectiveness of a pharmacy‐cardiology collaborative approach to AAD management.MethodsThis retrospective cohort study was conducted to assess AAD management with a pharmacy‐cardiology collaborative program compared with usual care in a United States Department of Veterans Affairs (VA) medical center.ResultsNinety patients were included for evaluation; 40 in the preintervention group and 50 in the postintervention group. Complete recommended baseline monitoring parameters were obtained for 29 patients (72.5%) in the preintervention group and 47 patients (94%) in the postintervention group (P &lt; .01). There were significantly more clinical interventions (P &lt; .01) in the postintervention group, including AAD dose adjustment or discontinuation, interacting medication dose adjustment or discontinuation, electrolyte supplementation, monitoring ordered, and total interventions.ConclusionThe study results demonstrate a statistically significant improvement in adherence to recommended baseline monitoring parameters with a greater number of clinical interventions when a pharmacy‐cardiology collaborative AAD management program was involved compared with usual care. The increased interventions and improved adherence to monitoring parameters may allow for safer use of these agents.

SUN-131 Improving the Glycemic Control of Women Veterans with Poorly Controlled Diabetes with a Telephone Encounter

Introduction: Despite having a broad range of services available at the Veterans Affairs Healthcare System (VAHS), veterans struggle to control their chronic diseases. At the Miami VAHS, 30% of veterans have diabetes, and of those, 30% are poorly controlled. Women represent a growing number of veterans at the Miami VAHS who face many of the challenges posed by having a diabetes diagnosis. Objective: To improve HbA1c measurements in women veterans (WV) with poorly controlled diabetes following a phone encounter with an endocrinologist addressing diabetes management. Method: This was a prospective intervention study of WV with HbA1c levels ≥ 9%. An endocrinologist attempted up to three telephone calls to reach WV. The phone intervention involved a chart review of co-morbidities to establish a HbA1c target, and management included lifestyle modification counseling, insulin dose adjustment, introduction and/or discontinuation of diabetes medications, and a plan for follow-up. During the following 3-4 months, results of follow-up HbA1c were collected regardless of having had an initial telephone encounter. WV who did not have follow-up HbA1c were excluded from the study. The remaining WV were further divided into 1) those that answered the phone and participated in the assessment (intervention group) and 2) those who did not answer the phone to have an initial encounter (control group). Other variables included BMI, eGFR, type of diabetes, diabetes medication, presence of hypertension, dyslipidemia, coronary artery disease (CAD), smoking, and psychiatric illness. Results: Of 77 WV who were called, 36 WV were assessed by the endocrinologist; 41 did not answer the phone and were regarded as the control. 8 WV from the intervention group and 16 WV from the control group did not have a follow-up HbA1c, and were excluded. 28 intervention and 25 control WV were included in the final analysis. In the intervention group: mean age 55.0 ± 10.3 years, BMI 29.8 ± 5.5, eGFR 57.9 ± 4.5, 86% type 2 diabetes, 61% on basal bolus insulin therapy, 68% HTN, 93% dyslipidemia, 71% smokers, 4% CAD, and 68% psychiatric diagnosis. In the control group: mean age 55.6 ± 9.9 years, BMI 32.5 ± 6.1, eGFR 58.9 ± 4.5, 96% type 2 diabetes, 44% on basal bolus insulin therapy, 80% HTN, 84% dyslipidemia, 16% smokers, 4% CAD, and 68% psychiatric diagnosis. Mean baseline HbA1c was 10.9 ± 1.5 for the intervention and 10.8 ± 1.8 for the control group. After 3-4 months, mean HbA1c was 9.9 ± 2.3 in the intervention group, and 10.6 ± 1.7 in the control group. HbA1c decrease in the intervention group was statistically significant (p = 0.03). Conclusion: This preliminary study demonstrates that a telephone intervention from a diabetes specialist has a positive impact on decreasing HbA1c in WV with poorly controlled diabetes. Findings from this study suggest that this approach should be considered in management of other chronic diseases.

Alternating Thyroid Status Between Thyrotoxicosis and Hypothyroidism in a Patient with Varying Antithyroid Antibodies

Autoimmune pathologies are a growing aspect of medicine. Knowledge about atypical cases is essential. This report will describe a case of unusual, alternating fluctuations in thyroid function. We report a case of thyrotoxicosis alternating with hypothyroidism in a 44-year-old, African-American woman and detail the clinical course and management. The patient presented in a mildly thyrotoxic state with features of thyroiditis that resolved soon thereafter. Subsequently, the course shifted toward a hypothyroid state with a thyroid-stimulating hormone (TSH) level of 24.53 μIU/ml (normal range is 0.45 to 4.5 μIU/ml; measured September 5, 2013) and free thyroxine (FT4) of 0.35 ng/dL (normal range is 0.5 to 1.40 ng/dL; measured September 5, 2013). It ensued with alternating hypothyroid and hyperthyroid trajectories for several cycles. Clinical management was adjusted to negotiate each progression. During certain intervals, levothyroxine was increased. At other visits, it was decreased. Periods without medication were observed as well. Furthermore, methimazole and metoprolol were utilized when required. Reversal of the condition occurred repeatedly. The entire course is tracked with over 30 instances of thyroid function measures that included hypothyroid, euthyroid (TSH at 1.54 μIU/mL, FT4 at 1.16 ng/dL) and thyrotoxic states (TSH at <0.005 μIU/mL, FT4 at 2.67 ng/dL). Various antibody titers were elevated including thyroid-stimulating immunoglobulin, thyroid peroxidase antibody, and TSH receptor antibody. Close monitoring of TSH and FT4 allowed for appropriate medication dose adjustment. This case highlights the unusual phenomenon of fluctuating thyroid function with autoimmune involvement of thyroid-stimulating immunoglobulin and TSH receptor antibodies. Close follow up aided responsive clinical management throughout the fluctuating clinical course.

Clinical Associations, Treatment, and Outcomes of Renal-Limited Thrombotic Microangiopathy

BackgroundThrombotic microangiopathy (TMA) is a clinicopathologic diagnosis that can be characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia and end-organ damage. Though most patients will present with the hematologic abnormalities of MAHA and thrombocytopenia, there are some that never demonstrate those features and only present with acute renal injury. Here we describe the clinical presentation, laboratory assessment, management, and outcomes of patients with renal-limited TMA (rTMA).MethodsAfter IRB approval, the electronic medical record was searched from 2008-March 2017 for patients managed at our institution with a clinical diagnosis of rTMA supported by renal biopsy. Inclusion criteria were as follows: 1) Presence of TMA on renal biopsy, 2) Absence of MAHA 3) No history of renal transplant prior to diagnosis of TMA. Clinical notes were reviewed to document the physician-determined cause of TMA. If no cause was listed, cause of TMA was based off of labs and clinical observation.ResultsThirty-five patients (18 female) met clinical criteria for a diagnosis of rTMA. Median age at time of biopsy was 59 years (range 9 to 87). Creatinine at time of biopsy was 2.4 mg/dL (range 0.55 to 6.4). Evidence of chronic TMA was noted on 17 specimens and an additional 3 had findings of chronic and acute TMA.Ten patients had ADAMTS13 activity performed and all were >10% with negative inhibitor screen (median 66%(26-100)). 24 patients (68.6%) had complement serology assessed. Three patients (12.5%) had low C3 while C4 was normal in 19 patients (79%). One patient in our cohort had complement mutational testing performed with no evidence of a pathogenic variant.Most common etiology of rTMA was medications (28.5%) and underlying rheumatologic disorder (20%)(Table 1). In 6 patients (17%), an identifiable cause was not elucidated.Management of TMA was dependent on underlying etiology of rTMA. Discontinuation or dose adjustment of TMA-causative medications was recommended in 4 patients and 25% of patients had normalization of Cr. Four patients received therapeutic plasma exchange (TPE) for median 5 (2-5) days. Causes of rTMA for those receiving TPE were gemcitabine, bevacizumab, unspecified connective tissue disease, and rTMA due to an unknown cause. 50% of patients were noted to have improvement in Cr with TPE. Antihypertensive medications were used for rTMA secondary to uncontrolled hypertension (n=4) and scleroderma (n=4). 11 patients (31%) were observed or treatment for causative underlying etiology was pursued, while 7 patients were treated with glucocorticoids. Of 6 patients, with no identifiable underlying cause, 4 were treated with observation, 1 was treated with GC, and one was treated with TPEFourteen patients (38.9%) required dialysis; 6 of these patients were able to discontinue dialysis less than two months after initiation. Three patients (8.3%) with rTMA, respectively due to tacrolimus toxicity, longstanding hypertension, and systemic lupus erythematosus, received a renal transplant, and one additional pt (2.8%) with rTMA due to scleroderma remained on the renal transplant waiting list at time of death.In a median follow-up time of 8.73 months (range 0 to 47.9), 16 patients (44.4%) died. Median time from diagnosis of TMA to death was 12.1 months (range 1.47 to 58.2). No deaths were directly attributable to underlying TMA.ConclusionRenal-limited TMA is a pathologic diagnosis that in our cohort was most likely to medications or underlying rheumatologic conditions. rTMA was managed by treating the underlying disorder or removing the causative medication. Though cause of rTMA was evident in the majority of patients, 17% had no identifiable precipitating factor predisposing to rTMA. Larger studies are required to delineate optimal management and surveillance strategies for these patients. DisclosuresNo relevant conflicts of interest to declare.

392. Analysis of GDm-health data: New insights into gestational diabetes management

Aim Little evidence guides the optimal monitoring and management of blood glucose (BG) in women with gestational diabetes mellitus (GDM). Guidelines are based on population-based thresholds and care is not tailored to the needs of the mother and her baby. We aim to explore the utility of data analytics for identifying novel outcome predictors in women with GDM based on trends in capillary BG, demographic, clinical and pharmacological data, as captured from a digital BG management system (GDm-health). Method We developed a smartphone-assisted BG monitoring system which aims to improve the care of women with GDM. We describe the initial analysis of data from women receiving their care using GDm-health at two NHS Trusts between 2014 and 2018. Patient demographic and contextual data including age, booking weight, height, screening criteria for GDM and results, medication use and timing of initiation, qualitative data on diet and lifestyle, HbA1c and maternal and neonatal outcomes will be analysed and corelated with BG data. Results Of 1661 women with diabetes in pregnancy, 1446 had GDM. Analysis was performed on data from 876 women with GDM who had completed a pregnancy. We collected 112,997 readings; (mean 203, SD 181). 36,164 readings were tagged to breakfast, 31,115 to lunch, and 40,316 to evening meal. 5402 were untagged. 267 of women required pharmacological treatment during their pregnancy with detailed information of dose and timing treatment. Conclusion Using large data sets to link BG data with demographic data, therapeutic data, and data on maternal and neonatal outcome will enable new insights to refine targets for BG management during pregnancy; automate decision making around medication commencement and dose adjustment; identify those at most at risk of post-partum hyperglycaemia and identify potential digital biomarkers as predictors of maternal and neonatal outcomes.

A Predictive Model to Identify Skilled Nursing Facility Residents for Pharmacist Intervention.

Objective Develop a predictive model to identify patients in a skilled nursing facility (SNF) who require a clinical pharmacist intervention. Design Retrospective, cross-sectional. Setting Nine freestanding SNFs within an integrated health care delivery system. Patients Patients who received a clinical pharmacist medication review between January 1, 2016, and April 30, 2017. Identified patients (n = 2,594) were randomly assigned to derivation and validation cohorts. Interventions Multivariable logistic regression modeling was performed to identify factors predictive of patients who required an intervention (i.e., medication dose adjustment, initiation, or discontinuation). Patient-specific factors (e.g., demographics, medication dispensings, diagnoses) were collected from administrative databases. A parsimonious model based on clinical judgment and statistical assessment was developed in the derivation cohort and assessed for fit in the validation cohort. Main Outcome Measures Model to predict patients requiring clinical pharmacist intervention. Secondary outcome was a comparison of factors between patients who did and did not receive a clinical pharmacist intervention. Results Ninety-five factors were assessed. The derivation (n = 1,299) model comprised 22 factors (area under the curve [AUC] = 0.79, 95% confidence interval [CI] 0.74-0.84). A clopidogrel dispensing (odds ratio [OR] = 2.42, 95% CI 1.19-4.91), fall (OR = 2.47, 95% CI 1.59-3.83), or diagnosis for vertebral fracture (OR = 2.33, 95% CI 1.34-4.05) in the 180 days prior to clinical pharmacist medication review were predictive of requiring an intervention. The model fit the validation cohort (n = 1,295) well, AUC = 0.79 (95% CI 0.74-0.84). Conclusion Administrative data predicted patients in a SNF who required clinical pharmacist intervention. Application of this model in real-time could result in clinical pharmacist time-savings and improved pharmacy services through more directed patient care.

Some Cautionary Tales About Ideal Body Weight Dosing of Anesthetic Medications: It Is Not All That Ideal!

Studies utilizing ideal body weight (IBW) dosing of perioperative medications are being increasingly published (1–3). One major reason for the increasing interest in weight-based medication dose adjustment is the relentless surge in obesity prevalence across every age spectrum in the United States (US) and many Western Countries (4). Current estimates are that about 12 million (approximately 16.9%) children in the US are obese, defined as age and gender-specific body mass index (BMI) ≥95th percentile using the year 2000 Centers for Disease Control and Prevention (CDC) growth charts (5). A predictable result of the secular trend in childhood obesity prevalence is that an increasing proportion of patients undergoing non-bariatric surgery are overweight, obese or severely obese (6). Since weight-based dosing is used for virtually every medication in children (7), the potential for dosing errors in obese patients is enormous. Because many anesthetic drugs are administered intravenously, overdose of these drugs could cause significant side effects, especially in children with lower internal reserves to buffer dosing errors. Conversely, under-dose of anesthetic medications could cause insufficient anesthesia, pain, suffering during, and long after surgery. The overarching question that perioperative clinicians ask on a fairly regular basis is: should actual body weight be used to select perioperative drug doses in obese individuals? The relative dearth of standardized dosing recommendations in obese individuals (children and adults) and a near absence of clear guidelines regarding optimal dosing of anesthetic medications for obese patients is a critical source of concern (7).

Type 2 Diabetes Mellitus and Renal Impairment in Real-World with Large Outpatient Electronic Medical Records—Antihyperglycemic Medication Dose Adjustment

Objective: To estimate the level of inappropriate dosing of DPP-4 inhibitors, and to assess the level of emergency room visits, hypoglycemia, and mortality according to inappropriate dosing of DPP-4 inhibitors in type 2 diabetes (T2DM) patients with renal impairment(RI). Research Design and Methods: Retrospective database analysis using the National Health Insurance Service Database and the General Health Examination Database in Korea. Patients aged ≥ 40 years with evidence of T2DM (ICD-9-CM codes from E10.x-E14.x) January 1, 2009 to December 31, 2015. Renal impairment defined with estimated with the Modification of Diet in Renal Disease [MDRD] GFR equation. To estimate the level of inappropriate dosing of DPP-4 inhibitors in RI was according to daily prescribed dose. And The incidence of emergency room visits, hypoglycemia, and mortality were assessed using the hazard ratios (HRs) estimated with logistic regression model. Results: In our study, we analysis 161,760 patients with T2DM and RI. Among them DPP-4 inhibitors were prescribed to 44232 patients (27.3%). DPP-4 inhibitor prescribed 21.44% in GFR&amp;lt;30 and 32.28% in 30≤GFR&amp;lt;50. In observation period, percentages of inappropriate dosing of DPP-4 inhibitors in T2DM with RI was 31.9%. The age and sex adjusted HR with 95% confidence interval (CI) for appropriate dosing of DPP-4 inhibitors compared with inappropriate dosing of DPP-4 inhibitors was 0.871(0.842,0.9) for emergency room visits, 0.819(0.748,0.898) for sever hypoglycemia, and 0.775(0.717,0.839) for mortality. Conclusions: Renal impairment is common but often undetected in patients with T2DM. In Korea, one of three patients with T2DM and RI received inappropriate doses, and they were associated with high risk of emergency room visits and sever hypoglycemia, and higher mortality. Further analyses to understand the clinical and economic consequences of these findings are needed. Disclosure S. Hong: None. C. Park: None.

Profile of Medication Variations and Dose Adjustment to Diabetes Mellitus Patients’ Response in PKU Muhammadiyah Hospital dan Panti Rapih Hospital period October – December 2014

Background: Diabetes mellitus patients may have a different response to similar medication. Therefore, individualized treatment and monitoring of the therapy is needed to ensure the patients’ response. Alternative medication or dose adjustment should be considered in order to achieve the therapeutic goal. Objective: The aim of this study was to find out patients’ response to medication variation or dose adjustment. Methods: This study used descriptive design in PKU Muhammadiyah Hospital and Panti Rapih hospital period October-December 2014. Participants are all patients who got pharmacological therapy for treatment of diabetes mellitus type 2, including oral antidiabetics and/ insulin and met the inclusion criteria. The response of therapy was checked 2 times, during check-in and check-out. Results: Analysis of response variation showed that individualized response existed, in which positive response occurred in 10 patients and the other had a negative response. The changes were dose adjustment and medication alteration or medication addition. From 6 patients who needed medication adjusment, 5 patients had a positive response, and others had a negative response. Whereas from 6 patients whose dosage or medication was not changed, 5 of them had a positive response while one had a negative response. Conclusion: Individualized treatment is needed to achieve a therapeutic goal. Individualized treatment can be done through dose adjustment and medication alteration, or medications addition.

Awareness and Knowledge Among Internal Medicine Resident Trainees for Dose Adjustment of Analgesics and Neuropsychotropic Medications in CKD

Errors in drug dosing lead to poor patient outcomes and are common in patients with chronic kidney disease (CKD). Because the majority of patients with CKD are being treated by physicians specializing in internal medicine, we studied the awareness and knowledge that internal medicine resident trainees (IMRTs) have regarding the correct dosage of commonly used analgesic and neuropsychotropic medications for patients with CKD. We surveyed 353 IMRTs about their awareness of whether a medication needs dose adjustment in patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate. There were high percentages for lack of awareness and knowledge. For analgesics, this lack of awareness/knowledge was highest for acetaminophen (awareness 83.0%, knowledge 90.9%). For neuropsychotropics, this was highest for paroxetine (awareness 74.5%, knowledge 91.5%). Analyses for postgraduate year (PGY) -1 trainees and PGY-2 trainees for analgesics showed higher odds for lack of awareness for tramadol (PGY-1 odds ratio [OR] 2.37, 95% confidence interval [CI] 1.2-4.62, P < 0.05; PGY-2 OR 2.34, 95% CI 1.16-4.72, P < 0.05) and for lack of knowledge for meperedine (PGY-1 OR 4.01, 95% CI 1.81-8.89, P < 0.05; PGY-2 OR 3.30, 95% CI 1.44-7.59, P < 0.05). Nephrology residency rotation for the neuropsychotropic medication of gabapentin showed lower odds for both lack of awareness (OR 0.56, 95% CI 0.32-0.97, P < 0.05) and knowledge (OR 0.52, 95% CI 0.27-0.997, P < 0.05). Awareness and knowledge are poor among IMRTs for dose adjustments of analgesics and neuropsychotropic medication classes in patients with CKD. There should be a renewed focus during IMRTs' residency on additional nephrology exposure and formal didactic educational training to help them better manage complex treatment regimens to prevent medication dosing errors.

Commentary on “Awareness and Knowledge Among Internal Medicine Resident Trainees for Dose Adjustment of Analgesics and Neuropsychotropic Medications in CKD”

OBJECTIVES Errors in drug dosing lead to poor patient outcomes and are common in patients with chronic kidney disease (CKD). Because the majority of patients with CKD are being treated by physicians specializing in internal medicine, we studied the awareness and knowledge that internal medicine resident trainees (IMRTs) have regarding the correct dosage of commonly used analgesic and neuropsychotropic medications for patients with CKD. METHODS We surveyed 353 IMRTs about their awareness of whether a medication needs dose adjustment in patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate. RESULTS There were high percentages for lack of awareness and knowledge. For analgesics, this lack of awareness/knowledge was highest for acetaminophen (awareness 83.0%, knowledge 90.9%). For neuropsychotropics, this was highest for paroxetine (awareness 74.5%, knowledge 91.5%). Analyses for postgraduate year (PGY) -1 trainees and PGY-2 trainees for analgesics showed higher odds for lack of awareness for tramadol (PGY-1 odds ratio [OR] 2.37, 95% confidence interval [CI] 1.2-4.62, P < 0.05; PGY-2 OR 2.34, 95% CI 1.16-4.72, P < 0.05) and for lack of knowledge for meperedine (PGY-1 OR 4.01, 95% CI 1.81-8.89, P < 0.05; PGY-2 OR 3.30, 95% CI 1.44-7.59, P < 0.05). Nephrology residency rotation for the neuropsychotropic medication of gabapentin showed lower odds for both lack of awareness (OR 0.56, 95% CI 0.32-0.97, P < 0.05) and knowledge (OR 0.52, 95% CI 0.27-0.997, P < 0.05). CONCLUSIONS Awareness and knowledge are poor among IMRTs for dose adjustments of analgesics and neuropsychotropic medication classes in patients with CKD. There should be a renewed focus during IMRTs' residency on additional nephrology exposure and formal didactic educational training to help them better manage complex treatment regimens to prevent medication dosing errors.

A Pilot Analysis of the Association Between Types of Monitored Anesthesia Care Drugs and Outcomes in Transfemoral Aortic Valve Replacement Performed Without General Anesthesia

The types of agents used for monitored anesthesia care (MAC) and their possible differential effects on outcomes have received less study despite increased use over general anesthesia (GA) in transfemoral aortic valve replacements (TAVRs). In this pilot analysis of patients undergoing TAVR using MAC, the authors described the anesthetic agents used and sought to investigate the possible association of anesthetic agent choice with outcomes and the extent to which total weight and time-adjusted doses of anesthetics declined with increasing 10-year age increments. Retrospective observational study. Tertiary teaching hospital. Ninety-three participants scheduled to undergo TAVR, with a primary plan of conscious sedation between November 2014 and June 2016, were included. None. Types of MAC were divided into 4 primary groups, but 2 groups were focused: propofol (n = 39) and dexmedetomidine plus propofol (n = 34). Conversion to GA occurred in 6 participants (6.45%) and was not associated with the type of sedation received. The authors also compared patients who received dexmedetomidine with those who did not in accordance with their a priori analytic plan. There were no associations between the use of dexmedetomidine and postoperative delirium or intensive care unit/hospital length of stay. No significant trends in medication dose adjustments were seen across increasing 10-year age increments. A wide breadth of MAC medications is in use among TAVR patients and does not support differences in outcomes. Despite recommendations to reduce anesthetic drug dosing in the elderly, no significant trends in dose reduction with increasing age were noted.

Cobicistat Versus Ritonavir: Similar Pharmacokinetic Enhancers But Some Important Differences

To describe properties of cobicistat and ritonavir; compare boosting data with atazanavir, darunavir, and elvitegravir; and summarize antiretroviral and comedication interaction studies, with a focus on similarities and differences between ritonavir and cobicistat. Considerations when switching from one booster to another are discussed. A literature search of MEDLINE was performed (1985 to April 2017) using the following search terms: cobicistat, ritonavir, pharmacokinetic, drug interactions, booster, pharmacokinetic enhancer, HIV, antiretrovirals. Abstracts from conferences, article bibliographies, and product monographs were reviewed. Relevant English-language studies or those conducted in humans were considered. Similar exposures of elvitegravir, darunavir, and atazanavir are achieved when combined with cobicistat or ritonavir. Cobicistat may not be as potent a CYP3A4 inhibitor as ritonavir in the presence of a concomitant inducer. Ritonavir induces CYP1A2, 2B6, 2C9, 2C19, and uridine 5'-diphospho-glucuronosyltransferase, whereas cobicistat does not. Therefore, recommendations for cobicistat with comedications that are extrapolated from studies using ritonavir may not be valid. Pharmacokinetic properties of the boosted antiretroviral can also affect interaction outcome with comedications. Problems can arise when switching patients from ritonavir to cobicistat regimens, particularly with medications that have a narrow therapeutic index such as warfarin. When assessing and managing potential interactions with ritonavir- or cobicistat-based regimens, clinicians need to be aware of important differences and distinctions between these agents. This is especially important for patients with multiple comorbidities and concomitant medications. Additional monitoring or medication dose adjustments may be needed when switching from one booster to another.