Time in Therapeutic Range for Dialysis Patients on Warfarin: Determination and the Effect of Dietary Intervention.

This study aimed to identify the time in therapeutic range (TTR) for dialysis patients on warfarin, and improve TTR with dietary review and intervention of interacting foods. We identified 151 patients undergoing hemodialysis in two units who were being treated with warfarin from January 1, 2010, through February 1, 2018, who were included in the overall TTR study. Of these, 15 patients were available to undergo the dietary intervention. International normalized ratio values were collected retrospectively for all eligible hemodialysis patients, and TTR was calculated for each period in which the patient was on hemodialysis. Patients who were available and agreed to the intervention underwent targeted dietician review of interacting foods, and their TTR post-treatment was calculated. The median (interquartile range [IQR]) TTR was 44 (IQR, 29 to 53) % among the 151 patients. Among the 15 patients who underwent the intervention, median (IQR) TTR was 52 (IQR, 32 to 56) pre-intervention and 51 (IQR, 38 to 69) post-intervention (P=0.53). TTR for dialysis patients is low in this overall cohort despite patients being seen at an integrated health care system. Focused improvement projects such as dietary review of interacting foods may help increase a patient's TTR.

Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population.

The purpose of this study was to estimate the extent of potential antidepressant overprescribing in a geographically defined U.S. population, and to determine the indications and factors that account for it. We conducted a cohort study of new antidepressant prescriptions for elderly residents of Olmsted County, Minnesota, 2005-2012, using the Rochester Epidemiology Project medical records-linkage system. Indications for antidepressants were abstracted from health records for all cohort members. Potential antidepressant overprescribing was defined based on regulatory approval, the level of evidence identified from a standardized drug information database, and multidisciplinary expert review. Predictors of potential antidepressant overprescribing were investigated using logistic regression models, stratified by general antidepressant indication (general medical indication, specific psychiatric diagnosis, and non-specific psychiatric symptoms). Potential antidepressant overprescribing occurred in 24% of 3199 incident antidepressant prescriptions during the study period, and involved primarily newer antidepressants that were prescribed for non-specific psychiatric symptoms and subthreshold diagnoses. Potential antidepressant overprescribing was associated with nursing home residence, having a higher number of comorbid medical conditions and outpatient prescribers, taking more concomitant medications, having greater use of urgent or acute care services in the year preceding the index antidepressant prescription, and being prescribed antidepressants via telephone, e-mail, or patient portal. In conclusion, potential antidepressant overprescribing occurred in elderly persons and involved mainly newer antidepressants used for non-specific psychiatric symptoms and subthreshold diagnoses, and was associated with indicators of higher clinical complexity or severity and with prescribing without face-to-face patient contact.

Impact of Pharmacist-Provided Medication Therapy Management on Healthcare Quality and Utilization in Recently Discharged Elderly Patients.

BACKGROUND: The optimization of medication use during care transitions represents an opportunity to improve overall health-related outcomes. The utilization of clinical pharmacists during care transitions has demonstrated benefit, although the optimal method of integration during the care transition process remains unclear. OBJECTIVE: To evaluate the impact of pharmacist-provided telephonic medication therapy management (MTM) on care quality in a care transitions program (CTP) for high-risk older adults. METHODS: This prospective, randomized, controlled study was conducted from December 8, 2011, through October 25, 2012, in a primary care work group at a tertiary care academic medical center in the midwestern United States. High-risk elderly (aged ≥60 years) patients were randomized to a pharmacist-provided MTM program via telephone or to usual care within an existing outpatient CTP. The primary outcome was the quality of medication prescribing and utilization based on the Screening Tool to Alert Doctors to the Right Treatment (START) and the Screening Tool of Older Persons' Prescriptions (STOPP) scores. The secondary outcomes were medication utilization using a modified version of the Medication Appropriateness Index, hospital resource utilization within 30 days of discharge, and drug therapy problems. RESULTS: Of 222 eligible high-risk patients, 25 were included in the study and were randomized to the pharmacist MTM intervention (N = 13) or to usual care (N = 12). No significant differences were found between the 2 groups in medications meeting the STOPP or START criteria. At 30-day follow-up, no significant differences were found between the 2 cohorts in medication utilization quality indicators or in hospital utilization. At 30-day follow-up, 3 (13.6%) patients had an emergency department visit or a hospital readmission since discharge. In all, 22 patients completed the study. Medication underuse was common, with 20 START criteria absent medications evident for all 25 patients at baseline, representing 15 (60%) patients with ≥1 missing medications. Overall, 55 drug therapy problems were identified at baseline, 24 (43.6%) of which remained unresolved at 30-day follow-up. CONCLUSION: The use of a pharmacist-provided MTM program did not achieve a significant difference compared with usual care in an existing CTP; however, the findings demonstrated frequent utilization of inappropriate medications as well as medication underuse, and many drug therapy problems remained unresolved. The small size of the study may have limited the ability to detect a difference between the intervention and usual care groups.

Correlation of point-of-care International Normalized Ratio to laboratory International Normalized Ratio in hemodialysis patients taking warfarin.

BACKGROUND AND OBJECTIVES: To determine whether point-of-care (POC) International Normalized Ratio (INR) test results correlate with plasma INR measures in intermittent hemodialysis (IHD) patients on warfarin. Anemia is thought to reduce the accuracy of POC INR assay results. Whether POC INR testing could be implemented for hemodialysis patients on chronic warfarin, who are often anemic despite hematopoietic therapy, has not been established. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Thirty-seven chronic hemodialysis patients on warfarin contributed sets of three consecutive blood samples for INR comparison immediately before hemodialysis: one finger stick, two from hemodialysis access (arteriovenous graft, fistula, or catheter). POC INR testing was performed using CoaguChek S device. Anemia was defined as hematocrit < 32%. RESULTS: Pairwise comparison and correlation of 258 INR results showed high correlation for POC versus laboratory INR (r = 0.94; P < 0.001). Of these, 16 (6%) differed by >0.6 INR units, four (1.6%) differed by >0.8 INR units, and one differed by >1.0 INR units. Resulting pairwise correlation analyses between samples were: for anemic patients (0.96; P < 0.001), nonanemic patients (0.93; P < 0.001), and for those obtained from arteriovenous grafts (0.94; P < 0.001). POC INR samples from dialysis catheters correlated poorly with laboratory INR results. CONCLUSIONS: POC INR correlates well with plasma INR measures in IHD patients requiring chronic warfarin, and anemia did not influence this reliability. Blood sampling from finger stick or arteriovenous graft or fistula showed excellent correlation with laboratory INR, whereas sampling from dialysis catheters was unsatisfactory, likely from heparin contamination.

Inappropriate medication use in the elderly.

Medications are commonly used in the elderly population. Because of a variety of treatments now available, many disease states now have very effective treatment. As a result, our elderly patients often take multiple medications. Due to various changes that occur, the elderly are at increased risk of adverse drug effects and drug toxicity potentially resulting in serious complications. Some medications have a greater potential to cause harm and these should be made aware to those who prescribe to elderly patients. Some of these medications should not be used if at all possible, while others, if used, need to be used with great caution, watching carefully for signs of problems. This article describes a variety of medications which have an increased potential for causing harm in elderly patients and gives alternatives of safer medications consideration.

Intracerebral hemorrhage associated with use of an imported medication.

INTRODUCTION: The importation of medications is strongly discouraged in the United States. However, with the cost of prescription medications on the rise, an increasing number of patients are seeking alternative ways of obtaining drugs. Although medication errors involving imported drugs have been described in the literature, there is little available information on the prevalence of such problems. CASE SUMMARY: A 74-year-old woman who had been taking warfarin therapy for >2 years presented to the emergency department with new-onset headache. She was found to have a small subdural hematoma on computed tomography and a prothrombin time >120 seconds. Warfarin was stopped and anticoagulation was corrected with fresh frozen plasma. At follow-up testing, the international normalized ratio (INR) continued to be >2 despite vitamin K therapy and the patient's insistence that she had discontinued warfarin. Further evaluation by a hematologist detected warfarin in the blood. Subsequent inspection of her medications revealed unmarked white tablets labeled "phenytoin" that had been dispensed by a pharmacy in another country. The INR normalized after these tablets were discarded and a new prescription for phenytoin was started. DISCUSSION: Application of the Naranjo scale to this case suggested a high likelihood of an adverse drug reaction (ADR). Potential causes of the ADR included the placement of warfarin in a bottle mislabeled "phenytoin" and contamination of phenytoin with warfarin. CONCLUSIONS: Obtaining medications from pharmacies in or by mail order from other countries means that patients miss the opportunity to ask questions and receive counseling from a pharmacist. Physicians and pharmacists should inspect patients' medications to ensure product legitimacy and confirm that the indications, dispensing, and labeling are accurate.

Inappropriate medications for elderly patients.

The use of medications is common in elderly persons, and this population has the highest risk of medication-related problems. Elderly persons are more susceptible to the effects of various medications for a number of reasons. It is well known that polypharmacy is one of the most serious problems in caring for elderly persons; however, many of these patients continue to receive medications that have an increased risk of causing harm. In 1991, an important article was published about inappropriate medication use in the elderly population. This article raised awareness of the problem and presented explicit criteria for determining which medications were inappropriate for elderly patients residing in long-term care facilities. This list of drugs is still used for evaluating medications taken by elderly persons and for determining whether satisfactory prescribing practices are being used. We reviewed the medications described as inappropriate for elderly persons and searched the scientific literature to determine whether evidence exists to defend or refute the labeling of particular drugs. At times, evidence was difficult to find, and many of the original studies were dated. For most medications listed as inappropriate, we found evidence to support these designations.