American College of Clinical Pharmacy/ European Society of Clinical ...

ABSTRACTS

American College of Clinical Pharmacy/ European Society of Clinical Pharmacy International Congress on Clinical Pharmacy

ACCP Pharmacotherapy Preparatory Course Pediatric Pharmacy Advocacy Group International Pediatric Pharmacy and Clinical Pharmacology Symposium April 24–28 • 2009 Orlando • Florida Abstracts and Index of Authors Are Available Online at www.pharmacotherapy.org

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2009 ACCP/ESCP International Congress on Clinical Pharmacy April 24–28, 2009 Orlando, Florida, USA ORIGINAL RESEARCH ADR/Drug Interactions 1. Use of oral and intravenous N-acetylcysteine for prevention of contrast-induced nephropathy in a Singapore hospital. Candice Yong, B.Sc.Pharm.(Hons), Ian Wee, M.Pharm.(Clin Pharm.), Michelle See, B.Sc.Pharm.(Hons); Department of Pharmacy, Changi General Hospital, Singapore, Republic of Singapore. OBJECTIVES: Given the varying regimens used in practice and the lack of clear guidelines, this study aimed to review the appropriateness of use of N-acetylcysteine (NAC) for prevention of contrast-induced nephropathy (CIN) in an acute care hospital in Singapore, and provide recommendations for its use. METHODS: This was a prospective observational study conducted over a 4-month period. Patients who received NAC and underwent a procedure requiring radiocontrast media (e.g., cardiac catheterization, computed tomography) were included. Patients were categorized into four dosing regimens: 600 mg or 1200 mg twice-daily for patients on oral NAC; low-dose (600 mg/1200 mg twice daily) or high-dose (up to 200 mg/kg) for patients on intravenous (IV) NAC. Serum creatinine (SCr) levels and estimated creatinine clearance were used as indicators of renal function. The primary outcome measure was incidence of CIN (>25% increase in SCr from baseline) at 48 hours post-procedure. RESULTS: Thirty-four patients on oral NAC and 13 patients on IV NAC were included. At 48 hours post-procedure, SCr levels were available for 21/34 (61.8%) and 11/13 (84.6%) of the patients on oral and IV NAC respectively. Three (18.8%) patients on oral 600 mg twice daily developed CIN versus one patient (20.0%) for oral 1200 mg twice daily (p>0.05). None of the patients who received low-dose IV NAC developed CIN, whereas two (50.0%) high-dose IV NAC recipients experienced CIN (p=0.039). CONCLUSIONS: The use of NAC for prevention of CIN is recommended in at-risk patients undergoing procedures that require contrast. Oral NAC should be administered at 600 mg twice daily for 2–4 days (at least on the day before and the day of the procedure). Alternatively, an IV dosing of 600–1200 mg twice daily may be considered. High-dose IV NAC should only be used for patients undergoing emergency procedures. Patient’s renal function should be monitored at least once during the first 48–72 hours post-procedure.

Adult Medicine 2. Financial impact of venous thromboembolism prophylaxis strategy on costs associated with heparin induced thrombocytopenia: A Monte Carlo simulation. Eli N. Deal, Pharm.D., James M. Hollands, Pharm.D., Angela R. Wills, Pharm.D., Lee P. Skrupky, Pharm.D., Scott T. Micek, Pharm.D.; Barnes Jewish Hospital, Saint Louis, Missouri, USA. OBJECTIVES: To determine the financial impact of switching from lowmolecular weight heparin (LMWH) to low-dose unfractionated heparin (LDUH) for venous thromboembolism (VTE) prophylaxis in patients for whom similar efficacy and bleeding rates have been described (nopreference population). METHODS: A Monte Carlo simulation model was created based on VTE prophylaxis practices at a large, tertiary teaching hospital to estimate yearly costs within 95%. Medication expenditures related to VTE prophylaxis and overall net expenditures were explored when use of LDUH was maximized (24% to 46%) and LMWH was reduced (25% to 5%) in the no-preference population, while tolerating an increase in LMWH (31% to 41%) use in other populations in whom LMWH use is preferred. The overall impact of this approach on expenditures was also analyzed using literature-based estimates of heparin-induced thrombocytopenia (HIT) and associated costs in this population. RESULTS: Decreasing LMWH use in the no-preference population

resulted in a decrease in drug expenditure for VTE prophylaxis of $581,021 (95% confidence interval [CI] $332,696–$791,577; 95% chance of decreased costs). Using this model with contemporary estimates of HIT incidence and costs, the LDUH switch would result in net increased expenditures of $1,564,175 (95% CI −$65,381 -$847,016; 1.7% chance of net savings). Decreased drug expenditures for VTE prophylaxis from a LMWH to LDUH switch in the no-preference population would be offset if 30 cases of HIT (95% CI 16–40) per year were treated or if LDUH-induced HIT incidence in this population was >0.12%. CONCLUSIONS: LMWH use in no-preference populations is the driver for pharmacy expenditures for VTE prophylaxis. Use of LMWH in this population demonstrates cost benefits when contemporary estimates of HIT incidence and costs are utilized in this analysis as the factors related to HIT are the drivers for the overall net costs. Future studies should focus on delineating HIT incidence in this patient population.

Ambulatory Care 3. Cardiometabolic risk factor knowledge of participants in a worksite health screening. Amy M. Franks, Pharm.D., T. Scott Warmack, Pharm.D., Donna S. West, Ph.D.; University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas, USA. OBJECTIVES: Despite the widespread prevalence of diseases such as coronary disease and diabetes, there is a disparity in layperson knowledge regarding cardiometabolic risk factors. The objective of this study was to describe worksite health screening participants’ knowledge of cardiometabolic risk factors. This information provides important insight into the lay public’s knowledge of risk factors and may impact educational methods for relaying information during health screening programs. METHODS: The study employed a cross-sectional survey of employees of a public school system who presented to a worksite health screening. Participants were asked to complete a written questionnaire to assess their knowledge of cardiometabolic risk factors by identifying risk factors from a list of conditions. Descriptive statistics were used to analyze the data obtained. RESULTS: One-hundred-five participants (85% female; mean age 44.5 ± 10.4 years) completed the questionnaire. The most frequently identified cardiometabolic risk factors were: overweight (95% of respondents), obesity (92%), high blood pressure (92%), high cholesterol (90%), lack of exercise (85%), sedentary lifestyle (82%), large or “thick” waist (70%), diabetes (65%), and high triglycerides (58%). Less frequently identified risk factors were: high blood sugar without diabetes (48%), pre-diabetes (41%), metabolic syndrome (29%), impaired fasting glucose (23%), and low high density lipoprotein (HDL) cholesterol (20%). CONCLUSIONS: Worksite screening participants in this study frequently identified many traditional cardiometabolic risk factors, including overweight, obesity, hypertension, and hypercholesterolemia. Participants less frequently identified risk factors such as pre-diabetes, metabolic syndrome, impaired fasting glucose, and low HDL cholesterol. Practitioners should continue to reinforce education regarding traditional risk factors but also focus on improving recognition and knowledge of other high risk-conferring conditions. 4. Comparison of safety outcomes in three models of anticoagulation management. Kelly M. Rudd, Pharm.D., BCPS; Bassett Healthcare, Cooperstown, New York, USA. OBJECTIVES: Both pharmacy and medical literature suggest that specialized anticoagulation clinics improve the efficacy of therapy management. However, no direct comparisons exist to determine if pharmacist-managed clinics improve the quality of care over existing models. This study was designed to produce a head-to-head comparison of three anticoagulation management models: (1) usual care by physicians and/or mid-level providers; (2) a specialty clinic staffed by nurses operating a simple protocol with physician support; and (3) a specialty clinic staffed by a pharmacist and a nurse, operating on the clinical judgment of a pharmacist in a collaborative practice arrangement. METHODS: The three models were compared using the number of hospitalization and emergency department (ER) visits directly related to anticoagulation therapy. One year’s results of international normalized

INTERNATIONAL CONGRESS ABSTRACTS ACCP/ESCP ratios (INR) from chronically anticoagulated Internal Medicine patients were queried in each group. Anticoagulation indication, INR goal, baseline characteristics, admission diagnosis, and duration of admission were extracted from the medical record. If the INR goal was not documented, a range was assigned as appropriate from the American College of Chest Physicians CHEST anticoagulation guidelines. RESULTS: Baseline characteristics were similar between the study groups. The Pharmacist and Nurse Clinic (n=6243) yielded the lowest rates of both hospitalization and ER visits. The number of hospitalizations was reduced by 56% versus the Nurse and Protocol (n=3618), and 61% versus Usual Care (n=3142) (p 34 weeks

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GA and 34 weeks GA improved the drug’s pharmacokinetics and possibly pharmacodynamics, was simple, and did not increase the incidence of adverse effects. Presented at the 2008 Pediatric Academic Society and Asian Society for Pediatric Research Joint Meeting, May 2008. 368. Free wersus total cortisol levels in treatment of adrenal insufficiency in the newborn. Varsha Bhatt-Mehta, M.S., (CRDSA), Pharm.D., FCCP, John D Barks, M.D.; University of Michigan, Ann Arbor, Michigan, USA. OBJECTIVES: Determine the relationship between total and free cortisol levels in newborn infants with relative adrenal insufficiency. METHODS:A non-interventional study of residual plasma from blood collected for routine laboratory tests of infants receiving intravenous Hydrocortisone (HC) for treatment of pressor resistant hypotension due to presumed adrenal insufficiency. Residual plasma for free cortisol (FC) concentrations at baseline prior to IVHC administration per a predesigned dosing protocol was collected from the clinical laboratory and frozen at -80°C until analysis (LC-MS). Demographic data and baseline total cortisol level values measured routinely to guide HC treatment, analyzed by the clinical pathology laboratory using radioimmunoassay methods (RIA), were collected from the patient’s medical record. RESULTS: 36 pairs of Total vs. Free baseline HC were available for analysis. The Mean (± SD) GA, PNA, BW and treatment WT were 29.1 ± 5.7 weeks, 1.78 ± 3.36 weeks, 1.49 ± 1.27 kg and 1.65 ± 1.25 kg , respectively. The correlation between free and total cortisol levels was strong (r2=0.8) for concentrations ≤10 ng/mL. However this correlation became much weaker at higher concentrations. CONCLUSIONS: Cortisol is highly protein bound and may provide variable total serum cortisol values in premature and term infants secondary to fluctuating protein concentration as a result of prematurity, malnutrition and critical illness. Free cortisol values are a more reliable indicator of adrenal insufficiency but not easily measured routinely. The results of this study suggest good correlation between free and total cortisol levels at low cortisol values. However, total cortisol levels under stress conditions or during HC treatment are much higher and do not correlate well with free cortisol levels. Routine RIA methods may not reflect true cortisol levels under stress or during treatment of relative adrenal insufficiency. . 369E. Use of olanzapine for emergency management in the agitated pediatric patient. Brenda E. Darling, Pharm.D.,1 Mercedes Uribe, M.D.,2 Maria Stephan, M.D.3; (1)Children’s Medical Center, Dallas, Texas, USA; (2)UT Southwestern Medical Center, Dallas, Texas, USA; (3)UT Southwestern Medical Center, Dallas, Texas, USA OBJECTIVES: Treatment of agitation (AG), posing a safety risk to the patient (pt) and caregiver, is problematic in pediatrics. Benzodiazepines are the mainstay of treatment in most emergency pts. Olanzapine (OL), is an alternative used in AG adult psych patients. This use is considered off-label in children. We present the first study describing the use of OL in pediatric pts presenting with AG, violence or psychosis to the emergency department (ED). METHODS: A 3-year retrospective study of pts