Possible role for acetylcysteine as a treatment for acute liver failure secondary to antitubercular medication use.

PURPOSE: Drug-induced liver injury (DILI) that progresses to acute liver failure (ALF) has a high mortality rate, and therapeutic options are limited. Acetylcysteine has a labeled indication for use as an antidote for acetaminophen toxicity and has also been used with limited success in treatment of non-acetaminophen-induced liver injury, with small clinical trials indicating an increase in transplant-free survival. Recommendations for management of non-acetaminophen-induced DILI include withdrawal of the offending agent and supportive care. Treatment guidelines generally discourage a rechallenge with an offending medication, except in cases where there are no other therapeutic options for management of a serious disease, such as active tuberculosis (TB). SUMMARY: This case report describes the reversal of ALF due to DILI in a patient receiving antitubercular agents for active TB. After withdrawal of initially prescribed antitubercular agents, the patient was switched to a less hepatotoxic anti-TB regimen and intravenous acetylcysteine pending results of antimicrobial susceptibility testing. After stabilization of the patient's liver enzyme levels, intravenous acetylcysteine was discontinued and oral acetylcysteine was continued for 5 days without an increase in hepatic enzyme levels or clinical deterioration. After 5 days, oral acetylcysteine was discontinued due to patient-reported nausea and vomiting. CONCLUSION: Given the limited number of therapeutic interventions shown to be beneficial in ALF and data suggesting a protective effect against DILI with initiation of acetylcysteine at the start of treatment with anti-TB medications, acetylcysteine can be considered for patients with anti-TB - associated DILI.

Longitudinal Outcomes of an Elective Academic and Administrative Advanced Pharmacy Practice Experience.

Objective. To evaluate the impact of an academic and administrative advanced pharmacy practice experience (APPE) on participants' career choice and long-term retention of teaching knowledge. Methods. Participants in an academic and administrative APPE from 2009 to 2016 completed a questionnaire about the experience and a 20-item knowledge test covering the five APPE modules. In addition, a retrospective review of graduates from the same timeframe was conducted to determine their faculty and preceptor status. Results. Of the 17 APPE participants, 16 completed the study and 100% reported that the experience helped them understand what it means to be a faculty member and an effective preceptor. The study participants completed the APPE knowledge test over the five modules. Participants passed four of the five module tests, including that for the instructional design module. A greater proportion of participants (75%) obtained faculty positions than did graduates who had not completed the APPE (9%). Seventy-one percent of students became active preceptors compared to 53% of students who did not complete the academic and administrative APPE, but this difference was not significant as the study was not powered to detect a difference. Conclusion. A longitudinal analysis of an academic and administrative APPE found that 75% of participants pursued a faculty position and retained their knowledge over time. A majority of the APPE participants (71%) and nonparticipants (53%) obtained a preceptor license. The outcomes support continued offering of the academic and administrative APPE to fourth-year pharmacy (P4) students. Requiring all P4 students to complete the APPE could help make them "preceptor ready."