Impact of Vitamin K Administration on Elevated International Normalized Ratio in Chronic Liver Disease.

Limited studies assess the efficacy of vitamin K administration in patients with chronic liver disease (CLD). However, vitamin K is commonly used to treat elevations in international normalized ratio (INR) in these patients with the intended benefit of reducing bleeding risk. This retrospective, single-center cohort study aimed to evaluate the impact of vitamin K administration on INR in patients with CLD. Hospitalized patients ≥ 18 years of age with a diagnosis of CLD or cirrhosis and received vitamin K were included. The primary outcome was the absolute change in INR from baseline to 24 to 48 h after vitamin K administration. Secondary endpoints included subgroup analyses of the primary outcome by route of administration and single versus multidose administration, and incidence of in-hospital venous thromboembolism (VTE) or major bleeding. A total of eighty-five patients, primarily with Child-Pugh class C (76.5%), were included. Route of vitamin K administration included oral (PO) (72%) and intravenous (IV) (26%) with a mean daily dose of 8.5 ± 2.3 mg. The absolute change in INR was -0.07 ± -0.35 following vitamin K administration. There was no difference in absolute INR change between single versus multiple dose administration (-0.16 ± -0.35 and -0.03 ± -0.35; P= .13) or between PO versus IV administration (-0.06 ± -0.23 and -0.18 ± -0.48; P = .11). The incidences of in-hospital VTE and major bleeding were 2.4% and 3.5%, respectively. The administration of vitamin K in hospitalized patients with CLD resulted in minimal INR change, suggesting this intervention may not have the intended benefit of reducing bleeding risk.

Evaluation of a Pharmacist-Driven Protocol for the Treatment of Opioid-Induced Constipation.

BACKGROUND: Opioid-induced constipation (OIC) treatment guidelines recommend over-the-counter laxatives as first-line therapy, followed by treatment with a peripherally-acting mu-opioid receptor antagonist (PAMORA) in refractory patients. OBJECTIVE: To evaluate the ability of a pharmacist-driven OIC protocol to promote increased scheduled laxative use prior to escalation to PAMORA therapy. METHODS: This retrospective, single-center cohort study evaluated patients 2 years pre- and post-protocol implementation. The primary outcome was the difference in the percentage of patients receiving 2 scheduled laxatives for ≥ 2 days prior to PAMORA therapy pre- and post-protocol. Secondary outcomes included difference in time to first bowel movement after PAMORA initiation, difference in total number of laxative/PAMORA doses administered, and difference in overall estimated total cost. Data was analyzed using chi-squared tests and Student's t tests. RESULTS: Three-hundred patients were included (150 patients in the pre and post-protocol groups). In the pre-protocol group, 53 patients (35%) received 2 scheduled laxatives for 2 days prior to naloxegol/methylnaltrexone compared to 96 patients (64%) in the postprotocol group (p < 0.0001). One-thousand twenty-one scheduled laxative doses were given pre-protocol versus 1625 doses post-protocol. Average time to first bowel movement was similar between groups (17.7 hours vs 16.0 hours p = 0.441). Estimated total cost of OIC reversal therapy decreased from $20,896.95 to $13,405.47. CONCLUSION: A pharmacist-driven OIC protocol is associated with an increase in the use of scheduled laxatives prior to PAMORA administration and decreased overall estimated total cost. A larger, prospective study is necessary to assess if this promotes more efficacious OIC.

Rimegepant: acute treatment for migraine headaches.

Migraine headache treatment is quickly evolving. There have been three new acute migraine treatment options (i.e., lasmiditan, rimegepant, ubrogepant) and four new preventive migraine treatment options (i.e., erenumab, fremanezumab, galcanezumab, eptinezumab) released in the past 3 years. The new migraine treatments are focusing on pathways within the newly, better understood neurovascular hypothesis that further describes the pathophysiology of migraine headaches in more detail than before. The discovery of vasoactive peptides, such as calcitonin gene-related peptide, has led to the development of many of these migraine agents. Rimegepant is one of these newly approved agents for acute migraine treatment in adults with or without aura. Rimegepant has been found to decrease pain and symptoms associated with migraine attacks and is generally well-tolerated.

Implementation of a Discharge Education Program to Improve Transitions of Care for Patients at High Risk of Medication Errors.

Background: Transitions of care (TOC) points are those where patient outcomes can be affected, especially patients at high risk for medication errors. Pharmacist-led postdischarge telephone counseling positively affects patient outcomes, though challenges exist relating to successful patient contact. Objective: The objective of this study was to develop and evaluate a discharge education service bridging the inpatient and outpatient setting to increase successful patient contact points during the TOC process from hospital to home. Methods: This prospective, single-centered observational study examined the impact of a discharge medication education program on successful telephone follow-up contact. The primary outcome was the percentage of high-risk patients educated at hospital discharge who were successfully reached via follow-up telephone contact within 2 business days of discharge. Secondary end points included hospital readmission rates and patient survey responses. Results: A total of 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation. When asked if they understood the medication component of their care and if they found the TOC service to be satisfactory, 100% and 96% of patients strongly agreed or agreed with these statements, respectively, and none disagreed. Conclusion and Relevance: This service demonstrates how pharmacists can interact with a high-risk population and increase contact points to optimize care at crucial health care transition points.

Evaluation of the Impact of an Inpatient Hyperglycemia Protocol on Glycemic Control.

PURPOSE: Inpatient hyperglycemia is associated with poor outcomes. Existing research assessing inpatient hyperglycemia protocols has shown improvements in average blood glucose levels with inconsistent results regarding rates of hypoglycemia and hyperglycemia. The objective of this study was to evaluate the impact of an inpatient hyperglycemia protocol on glycemic control. METHODS: This retrospective cohort study at a large, community teaching hospital included adult patients in non-critical care units requiring insulin administration for glycemic control. The intervention examined was utilization of an inpatient hyperglycemia protocol, comprised of a computerized physician order entry order set and provider education at the time of implementation. Two cohorts, a pre-protocol implementation group and a post-protocol implementation group, were compared. The primary outcome was the incidence of blood glucose values within 70-180 mg/dL over a 72-hour period between groups. Key secondary outcomes included the incidence of hypoglycemia (less than 70 mg/dL), severe hyperglycemia (above 300 mg/dL), total insulin use, and hospital length of stay. RESULTS: The primary outcome was significantly improved following protocol implementation (54.2% vs. 58.4%, p = 0.001). Compared to the pre-protocol group, the post-protocol group had lower incidence of hypoglycemia (3.1% vs. 1.2%, p < 0.001), severe hyperglycemia (9.9% vs. 6.7%, p < 0.001), less total insulin use (1.1 units/kg vs. 0.6 units/kg, p < 0.001), and shorter length of stay (5.1 days vs. 3.7 days, p < 0.001). CONCLUSIONS: The implementation of an inpatient hyperglycemia protocol was associated with improved glycemic control, decreased incidence of both hypoglycemia and severe hyperglycemia, and less total insulin use.

A structured mentoring program to develop junior faculty into successful co-coordinators of a large multi-instructor pathophysiology course.

BACKGROUND AND PURPOSE: To develop and implement a system for junior clinical faculty to become successful course coordinators with the use of a mentoring program and ensure that student performance and satisfaction are maintained at a high level. EDUCATIONAL ACTIVITY AND SETTING: For five years, first-time faculty discussion group leaders in a required large (>225 students) multi-instructor pathophysiology course opted into a structured mentoring program for course coordination in the subsequent year. Program categories included course material development, exam and quiz management, discussion group management, and communication among students, faculty, and staff. FINDINGS: Mentors' previous coordination experience ranged from a few years to over a decade. Faculty participants included three second-year faculty. Each participant successfully undertook a full co-coordinator role the following year. Subsequently, each then became a lead mentor the following year for new participants. Exam quality/reliability statistics were sustained at a high level, course evaluations and student performance improved throughout the program, and all mentor/mentee reflections demonstrated a positive and impactful experience. DISCUSSION AND SUMMARY: Course coordination can be a small percentage of clinical faculty workload, yet is a significant time commitment. Pharmacy resident certificate or new faculty academy programs often do not include course coordination, which is a vital, higher level function/role. Structured mentoring early in professional career of junior faculty aids in the assumption of pedagogical leadership roles, while also developing mentoring skills of mid-level faculty.

Comparison of hospital length of stay in patients treated with non-vitamin K oral anticoagulants or parenteral agents plus warfarin for venous thromboembolism.

OBJECTIVES: Existing research comparing hospital length of stay for patients treated with non-vitamin K oral anticoagulants or parenteral bridging to warfarin has been conducted primarily with the agent rivaroxaban. The objective of this study was to compare hospital length of stay between patients initiated on the non-vitamin K oral anticoagulants, apixaban or rivaroxaban, and patients initiated on parenteral anticoagulation agents plus warfarin for the treatment of venous thromboembolism. METHODS: A retrospective cohort study was conducted at an 859-bed, not-for-profit, teaching hospital. Adult patients admitted for a primary diagnosis of venous thromboembolism between 1 November 2012 and 31 August 2015 and treated with apixaban or rivaroxaban or a parenteral anticoagulant plus warfarin were included in the study. Eligible patients were identified using International Classification of Diseases, Ninth Revision codes for a primary diagnosis of acute thromboses and emboli and medication administration record data. Individuals using anticoagulation therapy prior to admission, released from the emergency department, or treated with thrombectomy or fibrinolytic therapy were excluded. RESULTS: A total of 152 patients were included in this study. Patient characteristics, including renal function, were similar between study arms. Venous thromboembolism treatment with apixaban or rivaroxaban compared to a parenteral anticoagulant plus warfarin was associated with a reduced hospital length of stay (2.63 vs 5.33 days; p < 0.05) and decreased total hospital cost adjusted to 2015 dollars (US$21,694 vs US$38,851; p = 0.013). CONCLUSION: These results suggest that treatment with a non-vitamin K anticoagulant may significantly reduce hospital length of stay and total hospital cost compared to a parenteral anticoagulant plus warfarin for patients admitted for venous thromboembolism.

Identification of Factors Impacting Recurrent Clostridium difficile Infection and Development of a Risk Evaluation Tool.

PURPOSE: Recurrent Clostridium difficile infection (RCDI) is a growing concern, yet limited data exists to clarify which patients are at highest risk.  Identification of these patients may better inform decisions of those who may benefit from prophylactic intervention. The purpose of this study was to determine which factors are associated with the recurrence of Clostridium difficile infection (CDI) and to develop a risk stratification tool.  Methods. Patients readmitted within 10 weeks of positive C. difficile polymerase chain reaction (PCR) with symptoms were included in this retrospective case control study.  The primary outcome was analyzed via univariate regression analyses of the independent factors including age, gender, number of CDI episodes, administration of acid blocking agents, antibiotics or chemotherapy, Charlson Comorbidity Index, gastrointestinal conditions, and exposure to healthcare facilities.  Results. Recurrent CDI was identified in 44 of 220 included patients.  In the univariate analysis, factors associated with development of RCDI included antibiotic exposure (OR 2.51, 95% CI 1.14-5.54; p 0.02) and inflammatory bowel disease (OR 5.77, 95% CI 1.24-26.79; p 0.03).  An evaluation tool was created from a well-fit model.  Additional factors included in the tool were chosen based on evaluation of findings from existing literature.  Conclusions. Antibiotic therapy and inflammatory bowel disease were found to be associated with RCDI.  Although a statistically significant association with RCDI was not found for other factors, this is likely related to small sample size.  The creation of an evaluation tool using specific patient factors can help determine the risk of RCDI, while future studies may validate this tool. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

Efficacy of Oral Vancomycin in Preventing Recurrent Clostridium difficile Infection in Patients Treated With Systemic Antimicrobial Agents.

We compared rates of recurrent Clostridium difficile infection in patients receiving or not receiving oral vancomycin prophylaxis with systemic antimicrobial therapy. The incidence of C. difficile infection was significantly lower in patients receiving prophylaxis (4.2% vs 26.6% in those without prophylaxis; odds ratio, 0.12; 95% confidence interval, .04-.4; P < .001).

Clinical implications of statin therapy in patients undergoing hemodialysis.

PURPOSE: The clinical implications regarding the use of statins in patients with end-stage renal disease (ESRD) undergoing hemodialysis are explored. SUMMARY: The majority of the evidence reviewed from randomized controlled trials and recent meta-analyses suggest that there is minimal to no benefit of statin therapy for reducing the risk of coronary heart disease (CHD), including cardiovascular events and mortality, for statin-naive patients undergoing hemodialysis. The Kidney Disease Outcomes Quality Initiative (KDOQI) 2003 dyslipidemia guidelines recommended that patients with ESRD receive a statin to reach a goal low-density-lipoprotein (LDL) cholesterol concentration of <100 mg/dL; however, there was no distinction between nondialysis and dialysis patients, and newer evidence has since been published. Although KDOQI released 2012 guidelines that recommended against the initiation of statins in dialysis patients due to the lack of evidence to support benefit, the guidelines were specific for diabetic dialysis patients. Clinicians should use their clinical judgment and weigh the risks and benefits from the available evidence when deciding whether to initiate statins in hemodialysis patients. A statin may be warranted for secondary prevention of cardiovascular events or in younger hemodialysis patients who have a longer life expectancy. CONCLUSION: The available literature does not support the initiation of statins in hemodialysis patients who were not receiving statin therapy before requiring hemodialysis. At this time, there are no conclusive data to support discontinuation of statins in ESRD patients on hemodialysis receiving statins for either primary or secondary prevention of CHD.