Outcomes associated with apixaban vs warfarin in patients with renal dysfunction.

Apixaban in patients with impaired renal function is supported by limited data. Landmark clinical trials evaluating apixaban in patients with atrial fibrillation and/or acute venous thromboembolism excluded patients with creatinine clearance (CrCl) <25 mL/min. This multicenter, retrospective chart review was conducted to evaluate the safety and effectiveness of apixaban compared with warfarin in patients with CrCl <25 mL/min. Included patients were newly initiated on apixaban or warfarin for at least 45 days with a CrCl <25 mL/min. Patients were evaluated for thrombosis and bleeding outcomes 6 months following initiation of anticoagulation. The primary outcome was the time to first bleeding or thrombosis event. A total of 128 patients met inclusion criteria in the apixaban group and 733 patients in the warfarin group. Time to first bleeding or thrombosis event was significantly different between the apixaban and warfarin groups. Cox proportional hazards model was conducted to control for potential confounding factors for the primary outcome. After controlling for atrial fibrillation and coronary artery bypass grafting, risk of thrombotic and bleeding events was lower in the apixaban group (hazard ratio, 0.47; 95% confidence interval, 0.25-0.92). There was not a statistical difference between time to thrombosis (83 days vs 54 days, P = .648), rate of thrombosis (5.5% vs 10.3%, P = .08), time to bleeding (46 days vs 54 days, P = .886), or rate of bleeding (5.5% vs 10.9%, P = .06). The severity of bleeding and thrombotic events was not different between groups. Apixaban may serve as a reasonable alternative compared with warfarin in patients with severe renal dysfunction.

Therapeutic Enoxaparin in the Morbidly Obese Patient: A Case Report and Review of the Literature.

Enoxaparin is a low molecular weight heparin commonly used in the treatment of venous thromboembolisms (VTEs); however, evidence on optimal empiric dosing recommendations are lacking in patients with morbid obesity. Utilization of an absolute dose cap, anti-Xa monitoring, and reduced empiric dosing are among the techniques used in this population. We describe a case of a morbidly obese man (body-mass index, BMI: 68.2 kg/m2, total body weight: 236 kg) who required therapeutic enoxaparin for suspected pulmonary embolism (PE) and critical limb ischemia as a bridge therapy during warfarin initiation. An initial empiric dose of 200 mg Q12 hours (0.85 mg/kg) resulted in an anti-Xa level of 1.01 IU/mL following the fifth dose, and no dose modification was deemed necessary. He experienced no adverse effects from treatment. This report adds to a growing body of evidence illustrating the need for reduced empiric weight-based doses of enoxaparin in the morbidly obese population and raises the question of whether dose capping is an appropriate practice in the clinical setting of morbidly obese patients with acute VTE.

As-needed intravenous antihypertensive therapy and blood pressure control.

BACKGROUND: Hospitalized patients with elevated blood pressure (BP) in most cases should be treated with intensification of oral regimens, but are often given intravenous (IV) antihypertensives. OBJECTIVE: To determine frequency of prescribing and administering episodic IV antihypertensives and outcomes. DESIGN: Retrospective review. SETTING: Urban academic hospital. PATIENTS: Non-critically ill, hospitalized patients with an IV antihypertensive order for enalaprilat, labetalol, hydralazine, or metoprolol. MEASUREMENTS: We analyzed BP thresholds for ordering and administering IV antihypertensives, the types and frequencies of IV antihypertensives administered, and the effect of IV antihypertensive use on short-term BP and adverse outcomes. The BP change during hospitalization was contrasted in those receiving IV antihypertensives between those who did and did not receive subsequent intensification of chronic oral antihypertensive regimens. RESULTS: Two hundred forty-six patients had an episodic IV antihypertensive order. One hundred seventy-two patients received 458 doses, with 48% receiving a single dose. Over 98% of episodic IV antihypertensive doses were administered for systolic blood pressure (SBP) <200 mm Hg and 84.5% for SBP <180 mm Hg. Within 6 hours of administration, there was a statistically significant decline in average SBP and diastolic BP in patients receiving IV hydralazine and labetolol. After administration of IV antihypertensives, the oral inpatient medication regimen was adjusted in 52% of patients; these patients had a greater reduction in SBP from admission to discharge than patients with no change to their oral regimens. A total of 32.6% of patients receiving treatment experienced a BP reduction of more than 25% within 6 hours. CONCLUSIONS: IV antihypertensive drugs are ordered and administered in patients with asymptomatic, uncontrolled BP for levels unassociated with substantive immediate cardiovascular risk, which may cause adverse effects.

Implementation of an inpatient anticoagulation teaching service: expanding the role of pharmacy students and residents in patient education.

PURPOSE: The implementation of and early experience with an anticoagulation teaching service managed by pharmacy students and residents are described. SUMMARY: A structured anticoagulation teaching program was established to improve the provision of education services to inpatients scheduled for discharge home on anticoagulant therapy (consistent with the Joint Commission's National Patient Safety Goal 03.05.01). The program served patients at three affiliated institutions and was designed to supplement pharmacists' usual anticoagulation education activities. After completing supervised training in anticoagulation education and documentation procedures, pharmacy students and residents on rotation at the facilities staffed the service three days per week for five hours per day. In the first five months of operation, the teaching service significantly increased the rate of anticoagulation patient education (to 59.2%, compared with 39.1% during a specified five-month preimplementation period; p < 0.0001). Among patients educated through the teaching service, 60-day readmission rates for both anticoagulation-related and nonanticoagulation-related problems were lower than readmission rates among patients not receiving the structured education services. CONCLUSION: Implementing an anticoagulation teaching service provided by pharmacy students and residents significantly increased the rate of patient education and lowered readmission rates.