Spotlight

 

Do you have a case study, book review, clinical pearl or professional experience, etc. to share? We publish members' articles in our News Brief and on this web site.

Clinical Pearl: Considerations for the use of common agents in older adults living with HIV/AIDS

submitted by Katarzyna Sasiela, PharmD Candidate 2018 UConn


Optimizing the Practice Advancement Initiative PAI at the State Level


Webinar Slide Deck


PAI link to the ASHP  webinar recording.

https://www.youtube.com/watch?v=dIeHtOXNaa8&feature=youtu.be

 

2017 Catch the Wave Conference Poster Abstracts

Natural Product Extraction: Vitamin K1 from Kale Utilizing Kitchen Appliances

Presenter: Catherine Bobea, PharmD; University of Saint Joseph School of Pharmacy

Comments and questions: cbobeo@usj.edu

Long-acting anticoagulant rodenticides (LAAR) are second generation anticoagulants not intended for human consumption but rather for use as a pest control mechanism. LAAR poisoning has been documented extensively over the last 25 years and although there are clinical management strategies available to reverse the adverse effects of toxicity, treatment is limited due to increased cost of therapy.

The mechanism of action of LAAR poisoning occurs due to the high affinity of these agents for inhibiting Vitamin K epoxide reductase (VKOR), an enzyme that reduces vitamin K epoxide into Vitamin K1 (VK), which is an electron carrier involved in the oxidation-reduction cycle responsible for formation of vitamin K-dependent coagulation factors. Therefore, inhibition of VKOR prevents formation of VK leading patients to present with VK deficiency along with coagulopathies.

Clinical management of LAAR toxicity requires high doses of VK and long-term therapy due to rebound coagulopathy after initial treatment. Health insurance plans are unwilling to cover outpatient treatment as they consider VK a supplement, which can be obtained from other sources such as over-the-counter products or foods. Inability to obtain coverage for VK therapy, results in costs of about $5,600 per week, placing a financial burden on patients that may lead them to discontinue therapeutic management.

We explored the feasibility of an innovative approach for the development of a natural product extraction protocol that will be patient-friendly, cost-efficient and practical for long-term VK supplementation in LAAR rodenticide toxicity.

An emulsion of kale and a large volume of water was prepared to remove chlorophyll content using a store-bought emulsion blender. Filtration was conducted using unbleached muslin, which efficiently retained plant matter and filtered water. The remaining plant materials were washed with hexanes, an organic solvent not intended for human consumption, which served as a control for analytical purposes and resulted in a concentrated extract. Due to the lipophilicity of VK (logP 9.3), a High-Performance Liquid Chromatography (HPLC) system was employed for quantitative analysis of our samples, which facilitated separation of less lipophilic compounds with polar solvents flowing through a non-polar C-18 reverse phase column.

Initial HPLC analysis revealed that we can extract 15.5 mcg/g of VK from kale and that the primary component is VK. Additionally, recovery of the internal standard is within the range of 80-85%. Based on these preliminary results, we can conclude that this may be a feasible route to making a concentrated vitamin K1 extract.

 

Insulin Infusion Protocol: Are we following the rules? An evaluation of insulin protocol compliance.

Presenter: Hector Garcia Jr., PharmD Candidate 2018; University of Saint Joseph School of Pharmacy

Comments and questions: jgarcia@usj.edu or text to 646-251-1397

Purpose: Insulin is a high-risk medication that can pose significant risk to patients if administered incorrectly or inappropriately. The utilization of protocols and order sets embedded into electronic health records are methods used to help mitigate these risks. At a community teaching hospital, one of these protocols is the medical and surgical insulin infusion protocol. The goal of this project is to assess the adherence to the medical and surgical insulin infusion protocol and the appropriateness of actions taken and use the information to identify potential quality improvement actions.

Methods: A retrospective chart review of patients receiving insulin infusions under a medical/surgical insulin infusion protocol was completed. Charts were evaluated for adherence to the insulin infusion protocol, including initial bolus doses, initial infusion rate, per protocol as needed boluses and infusion titrations. Blood glucose values were also collected to evaluate protocol adherence. Patients were excluded if they were receiving the critical care insulin infusion protocol, if they had diabetic ketoacidosis or hyperglycemic hyperosmolar state, if they were receiving the immediately post-operative cardiac insulin infusion protocol. The primary outcome was total number of charts with a protocol deviation. Secondary outcomes include frequency of protocol deviation by dose type (initial bolus, initial infusion rate, as needed bolus, infusion titration), whether the administered doses/adjusted infusion rates were higher or lower than intended and dose omissions.

Results: A total of 34 patients were evaluated from May 30, 2017 to July 16, 2017. Collectively, there were a total of 197 insulin infusion rate adjustments and 51 bolus doses administered, (which includes initial boluses, as needed boluses, and new orders placed). Of those 51 doses, 10 were initial boluses and 41 were during the titration/maintenance period. It was found that all 41 of the titration/maintenance boluses were placed as new orders. It is concluded that most administrations deviated from the protocol. Furthermore, it was found that patients were receiving a higher insulin infusion rate than the protocol called for.

Conclusion: Overall, there was low compliance to the insulin infusion protocol. These deviations have the potential to increase the risk for adverse events including significant hypoglycemia. The results of this project will be shared with nursing leadership with a goal of improved education and compliance. We are also making updates to our order sets (currently in progress) to improve clarity and guidance for nursing staff when administering this high-risk medication.

 

Designing a pharmacist-led medication education discharge program in the neonatal intensive care unit (NICU)

Presenter: Yamilia Garcia-Colon, PharmD Candidate; University of Saint Joseph School of Pharmacy

Comments and questions: ygarciacolon@usj.edu or text to 787-453-1437

Purpose: Family involvement in pediatric care is a vital component of Connecticut Children’s Medical Center’s Mission. Caretakers of neonates that are being discharged often feel inadequately prepared to care for their infants at home. A pharmacist-led discharge counseling program was designed to increase patient safety and clarify medication information for caretakers of neonatal patients to provide confidence upon transitioning from the hospital to home.

Methods: Currently, there is no pharmacist-led discharge counseling program in place at Connecticut Children’s. This program will first be implemented in the NICU and later expanded to the rest of the medical center. The program will be led by two clinical pharmacists with advanced NICU and patient education training. Nurses and pharmacists will collaborate to schedule counseling sessions 24 hours prior to patient discharge. Home medications will be ordered, reviewed and filled before the scheduled session, then brought to the floor to be incorporated into the medication counseling. Additionally, families will be given color coded home medication information guides that include the name of each medication, dosage, frequency, and route of administration. Guardians will be asked to use the teach back method to demonstrate their understanding of the information provided. Pharmacists and pharmacy students will be available for counseling Monday-Friday. Nursing will be responsible for these services at times when designated pharmacists and students are unavailable.

Results: A pharmacist-led discharge counseling program has been designed with the goals of increasing medication safety and facilitating family involvement in pediatric care. Upon implementation of this program, measures of effectiveness and satisfaction will be recorded in order to assess its success. These measures include the number of changes made to medications, total number of patient counseling sessions provided, number of sessions completed when pharmacists were unavailable, duration of counseling sessions, and number of prescriptions included per counseling session. Both guardian and nursing satisfaction surveys will be evaluated to assess the impact of this program on the hospital staff as well as the community.

Conclusion: Integration of a pharmacist-led discharge counseling program into patient care services at Connecticut Children’s Medical Center provides this institution with a new means to embrace family involvement in neonatal care.

 

Evaluation of suboptimal prescription refill adherence in accordance with Centers for Medicare and Medicaid Services medication adherence measures

Seul Ki Kim, PharmD Candidate; University of CT School of Pharmacy

Comments and questions: seul.kim@uconn.edu

Purpose: Approximately half of patients with chronic illnesses do not take their medications as prescribed, leading to increased costs, morbidity, and death. Centers for Medicare and Medicaid Services (CMS) has established Part D star rating medication adherence measures to increase the number of beneficiaries taking their diabetes, hypertension, and cholesterol medications as prescribed. The purpose of this study is to evaluate reasons for suboptimal prescription refill adherence from pharmacy claims data provided by a large payer.

Methods: This quality improvement study was conducted at a clinically integrated provider network in June 2017. Patients suboptimally adherent to their prescription refills [based on proportion of days covered (PDC) under 80%] for diabetes, hypertension, and cholesterol medications were identified via claims data provided by a large payer. Outreach telephone calls were made to determine medication adherence barriers and any potential medication changes, which were documented in the payer’s population health management portal. Patients with financial and transportation barriers were encouraged to switch to a tier 1 or 2 medication to become eligible for $0 copay through mail order. Patients with clinical issues were encouraged to speak to their providers about switching to an alternative medication if needed. Forgetful patients were encouraged to change to 90 day prescriptions, request for auto refill service, and utilize a pillbox and alarm reminder.

Results: Outreach calls for 35 patients were successfully made regarding prescriptions with PDC<80%. Of the 35 patients, 10 were suboptimally adherent to refills due to residence at a facility. Other barriers to adherence included transportation to their provider’s office for refill requests (n = 1), financial issues (n = 3, including one patient on tier 3 medication), and medication side effect (n = 6). Of the 6 patients with side effects, 1 was discontinued by the provider, 3 were switched to another medication, and 2 were self-discontinued. There were 6 patients who cited forgetfulness as the barrier. The remaining 9 patients had unknown cause for adherence barrier.

Conclusion: Medication nonadherence is a common and costly multidimensional healthcare problem. Outreach calls identified the reason for suboptimal prescription refill adherence or gap in therapy in regards to CMS measures for chronic illnesses. The most common reason for PDC < 80% was long term facility residence at a facility, followed by side effects and forgetfulness. Determining the root cause of suboptimal adherence, offering suggestions, and motivating patients play a crucial role in empowering them to adhere to their medications.

 

Assessment of outcomes in kidney transplant recipients based on a Aransplant center’s induction guideline using alemtuzumab, rabbit anti-thymocyte immune globulin (rATG), and basiliximab

Presenter: Hillary A. Kuzaro, PharmD Candidate; University of Saint Joseph School of Pharmacy

Comments and Questions: hkuzero@usj.edu

Purpose: Induction therapy is a critical component of transplantation used to reduce the rate of acute rejection and extend graft survival. Transplant centers do not use available induction agents similarly, but all transplant centers have a guideline or protocol for induction agent selection.

Alemtuzumab was incorporated into the kidney transplant guideline at Yale New Haven Hospital (YNHH) in January 2015. The objective of this study is to evaluate the efficacy and safety of the current induction guideline used in kidney transplant recipients at Yale New Haven Hospital.

Methods: This was a retrospective, single-center, chart review of 166 patients who received a kidney transplant with alemtuzumab, rATG or basiliximab induction between January 2015 and August 2016. Exclusions include patients less than 18-years-old and those with incomplete medical records. The primary outcome was percent of patients with biopsy-confirmed acute rejection (BCAR). Secondary efficacy and safety outcomes were evaluated. Data was collected at through 30-months post-transplant. Descriptive statistics were used to analyze baseline demographics and results.

Results: Out of 166 kidney transplants, 87 (52.4 percent) received alemtuzumab, 65 (39.2 percent) received rATG, and 14 (8.4 percent) received basiliximab. The percent of BCAR was not significantly different between the alemtuzumab, rATG, and basiliximab groups, 11.5 percent, 23.1 percent, and 14.3 percent respectively (p equals 0.16). Of the 166 patients, two expired, one in the alemtuzumab group and one in the rATG group. DSA formation did not differ significantly between groups. Differences in post-transplant rates of urinary tract infection and pneumonia were not significant. The basiliximab group demonstrated significantly less CMV viremia compared to rATG (p equals 0.047). The alemtuzumab group exhibited significantly less BK viral load detection one month post-transplant than rATG (p equals 0.007) and basiliximab (p equals 0.03). Readmission within 30 days did not differ between groups.

Conclusions: There was no significant difference in BCAR between alemtuzumab, rATG, and basiliximab. Kidney transplant recipients who received alemtuzumab had significantly less incidence of detectable BK viral load at one month. Basiliximab patients demonstrated significantly less CMV viremia compared to rATG. Alemtuzumab induction showed lower average ALC at each time point without increased infection. These results suggest that alemtuzumab is comparable in safety and efficacy to rATG and basiliximab for kidney transplant induction when analyzing BCAR, infection, readmission within 30 days, and DSA formation in our transplant center’s kidney transplant population. More research is necessary to evaluate long- term outcomes in this group of patients.

 

Alteplase: opportunities for cost Avoidance and Process efficiencies.

Presenter: Victoria Lucero, PharmD Candidate; University of Saint Joseph School of Pharmacy

Comments and Questions: vlucero@usj.edu

Purpose: Alteplase (ACTIVASE®) is a high cost medication indicated for acute ischemic stroke (AIS), pulmonary embolism (PE), and ST-elevation myocardial infarction (STEMI). Unused reconstituted alteplase prescribed for a labeled indication may be eligible for replacement through the manufacturer’s spoilage replacement program. We aimed to create a student-led process for ensuring all alteplase orders for AIS, PE, and STEMI are reviewed to facilitate identification and submission of eligible un-administered reconstituted doses.

Methods: A standardized process was created and implemented for a student audit of alteplase to facilitate identification of un-administered reconstituted doses. Data including the intended use, reason for un-administered drug, number and size of replacement vials was collected for submitted claims from April 2017 through September 2017. The process included generating a report within the computerized provider order entry (CPOE) system to identify all alteplase orders for AIS, PE, and STEMI within the previous seven days. If alteplase was not administered or if it was unclear from the electronic medication administration record, the student utilized a standardized written template within the CPOE system to communicate with the responsible pharmacist. The student conveyed the indication and reason for un-administered drug. If this information was not apparent from the electronic medical record, the pharmacist was prompted to follow up with the medical team to ensure documentation. The pharmacist then communicated with the purchasing team who was responsible for submitting the product replacement claim to the manufacturer.

Results: There were 85 total orders entered for alteplase for one of its three labeled indications during the six-month time period reviewed. There were 70 orders for AIS, 14 orders for PE, and one order for STEMI. A total of 21 reconstituted vials (12 for stroke, 8 for PE, and 1 for STEMI) were unused and eligible for replacement product. The majority of these doses were admixed using a 100 mg vial, except for six doses intended for PE which were admixed using 50 mg vials. Each 50mg/50mL alteplase vial has an average wholesale price (AWP) of $5,126 and each 100mg/100mL vial has an AWP of $10,253 resulting in a total cost avoidance of approximately $184,500.

Conclusion: This project presents a standardized method to increase process efficiencies for an audit of alteplase for AIS, PE, and STEMI to facilitate identification of un-administered reconstituted doses and ensure there are no missed opportunities for cost avoidance. Additionally, standardizing this process will allow us to recognize potential strategies to avoid reconstituting unnecessary doses furthering efficiency improvements.

 

Erythema Nodosum, a Painful Skin Reaction, Caused by Omeprazole?: A Case Report

Presenter: Sarah McLarty, PharmD Candidiate; University of Saint Joseph School of Pharmacy

Comments and Questions: skmclarty@gmail.com

This case report demonstrates an adverse reaction, erythema nodosum, uncommonly seen in patients who are taking omeprazole. Erythema nodosum is a type of panniculitis which affects fat in the skin. It is characterized by tender erythematous subcutaneous nodules which are located on the anterior surface of the legs.1

A 68 year old male presents in April 2016 with a chief complaint of painful erythematous swelling on legs, ankle, and feet. The rash initially started in 2012 on the right medial foot, which the patient described as a “sunburn and rough like alligator skin” and moved to other parts of his foot and leg.

It was initially empirically treated with cephalexin providing no improvement. The initial rash dissipated after several weeks and did not reoccur until three years later. Since the reoccurrence, the rash had intermittently reappeared, for which the only treatment received was a cortisol injection with minimal improvement.

A skin biopsy diagnosed erythema nodosum in 2017, a commonly idiopathic disorder, but has been shown to be caused by infection, medications, and rarely malignancy.1 The patient reports no joint pain and tested negative for rheumatoid arthritis. The patient did not show any signs of infection or malignancy. Omeprazole 20mg twice daily was initially started in 2011 for peptic ulcer disease. Since 2011, the patient reports taking one to two capsules per day for his gastric reflux disease. The omeprazole was discontinued in 2017; however, the patient had to restart the medication after experiencing gastric reflux symptoms. Shortly after restarting the omeprazole, the rash reappeared.

After diagnosis, working with patient’s primary care physician and dermatology, the omeprazole was discontinued and added to his allergy list. Upon discontinuation of omeprazole, the rash subsided and has not returned since discontinuation.

This case study suggests that omeprazole is associated with causing erythema nodosum. Although this case report is one incidence, omeprazole has been reported in tertiary sources to cause erythema nodosum. Case reports currently only describe patients who experienced erythema nodosum shortly after starting omeprazole.2 This case study describes a patient which was on omeprazole for a prolonged period of time and continued to experience rashes until omeprazole was discontinued. Due to the lack of evidence, further research is needed to prove omeprazole directly causes erythema nodosum.

1. Schwartz R, Nervi S. Erythema Nodosum: A Sign of Systemic Disease. American Family Physicians. 2007; 75(5), 695-700. http://www.aafp.org/afp/2007/0301/p695.html#afp20070301p695-b19. Accessed August 23, 2017.

2. Ricci R, Deering K. Erythema nodosum caused by omeprazole. Cutis. 1996; 57(6), 434. https://www.ncbi.nlm.nih.gov/pubmed/?term=Ricci+RM%2C+Deering+KC.+Erythema

 

Antidote standardization across a health care system

Primary Presenter: Bich Ngoc Tran, PharmD Candidate, 2018 UConn School of Pharmacy

Comments and questions: bich.tran@uconn.edu; call or text to (203) 917-9943

Purpose: Antidotes are essential in the management of critical toxidromes. Approximately 200,000 cases of utilization of antidotes occur annually. A lack of inventory and storage standardization has led to practice variation between institutions. Missing or delaying administration of antidotes may result in increased mortality and morbidity. Following the most recent and comprehensive expert consensus guidelines for inventory practices of antidotes, we sought to evaluate our institution’s antidote inventory and storage to align with best practices.

Methods: The study assessed the antidote inventory and storage location data within the Yale New Haven Health System (YNHHS) in comparison to the most recent guidelines. Utilization data of antidotes were also evaluated. Recommendations for optimal inventory and storage locations were made based on the most recent expert guidelines, presence of toxin risk factors within the community, and previous antidote utilization data.

Results: Opportunities were identified to stock antidotes utilized in the treatment of common toxicities, or those that must be administered within 60 minutes if local risk factors exist. If multiple antidotes are available for a single toxin, recommendations were made for stocking one of the suitable products. In the event that the antidote had a low frequency of use based on previous utilization data and can be administered after 60 minutes from presentation, at least one affiliated hospital was identified to stock that antidote. A special transport process for obtaining that similar antidote was identified if no hospitals within the system could stock that product. Antidotes that should be administered immediately were recommended to be placed in automated dispensing cabinets in every emergency department unless an expedited delivery system was in place. Other antidotes may be stored in a centralized pharmacy location. Minimum inventory quantities were determined based on the doses for treating one 100kg patient and the anticipated use of that antidote estimated from hospital previous antidote utilization data. Greater antidote quantities were assigned to toxicities with higher incidence rates.

Conclusions: Utilizing the newly standardized antidote inventory management system for the Yale New Haven Health System resulted in recommendations that align with the most current expert consensus guidelines. Implementation of these recommendations will likely improve clinical outcomes and associated costs.

 

Utilization of procalcitonin to improve antimicrobial stewardship in pneumonia

Presenter: Kristela Vulaj, PharmD Candidate 2018, University of Saint Joseph School of Pharmacy

Comments and Questions: kvulaj@usj.edu

Purpose: Pneumonia is a common lower respiratory tract infection affecting 1 million people each year in the United States. Biomarkers are useful in determining the severity and prognosis of pneumonia. Procalcitonin (PCT) is a commonly used biomarker that aids in the diagnosis of sepsis and is useful in guiding antibiotic therapy. The benefits of using PCT have been published but there is poor compliance of PCT prescribing. The purpose of this study was to determine if increased utilization of PCT impacts antibiotic length of therapy (LOT).

Methods: A retrospective single centered pre- and post-intervention study on patients who presented to Saint Francis Hospital and Medical center (SFHMC) between December 2015 to March 2016 (pre-implementation cohort) and December 2016 to March 2017 (post-implementation cohort). The study was approved by the Institutional Review Board. Patients were included in this analysis if they were 18 years or older and were diagnosed with pneumonia. Exclusion criteria comprised of patients with pneumonia secondary to a COPD exacerbation, hospital-acquired pneumonia, or evidence of another systemic infection; requiring transfer to the intensive care unit; or presence of life-threatening medical comorbidities leading to possible imminent death. The primary endpoint compared the rate of PCT utilization pre- and post-implementation of the quality improvement project. Secondary endpoints included antibiotic LOT, documentation of PCT as part of the rationale for discontinuing antibiotics, length of hospital stay, antibiotic adverse reactions, and percentage of 30-day hospital readmissions related to pneumonia.

Results: There was a significant increase of PCT levels order from the pre-implementation cohort to the post-implementation cohort, 59.6 percent of patients (59/99) to 75.5 percent of patients (111/147), respectively (P equals 0.011). This was associated with a decrease in antibiotic LOT from 6.82 plus-minus 3.88 to 5.77 plus-minus 3.43 (P equals 0.028). There was no difference in antibiotic adverse events, length of stay, or 30-day readmission rate. There was a decreased trend in antibiotic-associated diarrhea in the post- implementation cohort (P equals 0.124).

Conclusion: Increased utilization of PCT in patients with pneumonia was associated with a decreased antibiotic LOT by at least one day. The reduction in duration of antibiotics was not associated with an increased risk of 30-day readmission rate attributed to undertreated pneumonia.

 

Integration of the Practice Advancement Initiative to Enhance Inpatient pharmacy operations

Presenter: Russell Sage, RPh; YNHHS/Bridgeport Hospital

Comments and Questions: drsage@bpthosp.org

Purpose: The American Society of Health-System Pharmacists (ASHP) has developed goals for the advancement of pharmacy practice through the Practice Advancement Initiative (PAI). Through the implementation of this initiative, technicians can perform more advanced roles, pharmacists can dedicate more time to patient care, and pharmacy operations can be enhanced. In an effort to create more efficient inpatient pharmacy operations, it is necessary to identify opportunities for improvement and modification.

Methods: In an effort to establish goals for optimization of operations in the health-system, a PAI Operations Committee was established. Goals were limited to the scope of system operations, as a separate committee handles clinical PAI. Specific goals established by this committee include: transitioning technicians into more advanced roles previously performed by pharmacists, standardization of technician career ladders within the health-system, establishing a minimum requirement of Pharmacy Technician Certification Board (PTCB) certification for technicians, and developing standardized job descriptions across the health-system. Each initiative was handled by the respective operations manager for each individual hospital and reported back to the committee.

Results:

Goal

Outcome

Transition Medication Request Messages to Technicians

Completed

Transition Triaging of Phone Calls to Technicians

Completed

Transition Unit Inspections to Technicians

Completed

Technician Career Ladder Standardization and Implementation

Completed

6 technicians promoted using new career ladder

PTCB Certification

Required by 5/1/18

 

If we want actual # here, need weighted percentages or just % of all techs in system

Standardization of Technician Job Descriptions

In Progress

Conclusions: Implementation of these strategies will standardize the knowledge of pharmacy technicians, specifically through the PTCB certification requirement. Furthermore, as technicians complete tasks previously completed by pharmacists, the technician’s role will advance and the pharmacist can focus more directly on patient care.

 

Catatonic effects: The potential interplay of Elevated valproic acid level in a patient on concomitant antipsychotics

Presenter: Melissa Wright, PharmD Candidate 2018; University of CT School of Pharmacy

Comments and Questions: melissa.wright@uconn.edu, or voice or text to 845-392-7259

Case Report: Catatonia is a complex clinical syndrome consisting of altered mental status, often due to an underlying medical condition or treatment course. The use of valproic acid as a possible treatment for patients with catatonia has been controversial. This case describes a patient who presented with catatonic-features while receiving a combination of valproic acid, loxapine, and cariprazine.

A 61 year-old woman with a past psychiatric history significant for depression, anxiety, bipolar disorder, and obsessive compulsive disorder presented to the emergency department with acute worsening mental status. She was lethargic, nonverbal and unable to respond to commands at admission. Prior to admission medications included loxapine 50mg twice daily, divalproex 1500mg nightly, and cariprazine 3mg nightly. Upon admission, this patient’s valproic acid level was measured at 111mcg/ml with an elevated ammonia level at 86µmol/L. Initial assessment of the patient included the potential interplay between a toxic ammonia level, likely due to valproic acid, and catatonic symptoms. For suspected catatonia, patient was initiated on lorazepam 1mg IV every four hours on hospital day 2 which was titrated up to 2mg IV every six hours without response. For elevated ammonia level, the patient was given levocarnitine 3,000mg IV every 8 hours for 3 days beginning on day 4 (50mg/kg every 8 hours with a maximum of 3,000mg per dose). During this time the patient’s ammonia level dropped to 23µmol/L and she became alert and oriented with slow speech and improvement in mental status.

Altered mental status and catatonic features in this patient is likely due to a combination of outpatient psychiatric medications which has been supported in the literature. Through complex neuroreceptor interactions, the elevated valproic acid level likely contributed to catatonic signs and symptoms. Based on this case description of valproic acid potentially leading to catatonic effects, caution should be used when considering valproic acid as a treatment option for catatonia.

 

Analysis of the Utilization of Intravenous Acetaminophen at Veterans Affairs Connecticut Healthcare System (VACT)

Presenter: Brenda Yik, PharmD Candidate 2018; University of CT School of Pharmacy

Comments and Questions: brenda.yik@uconn.edu or text to 203-824-0971

Purpose: The purpose of this medication use evaluation (MUE) is to evaluate the appropriateness of intravenous (IV) acetaminophen use at VACT and to determine the cost of usage compared to other acetaminophen formulations.

Methods: This MUE is a single centered, retrospective chart review of ≥18 year of age patients who were prescribed and/or received at least 1 dose of IV acetaminophen from August 1, 2017 to September 1, 2017. Data was collected from patients’ electronic medical records: age, sex, weight, type of surgical procedures if applicable, number of IV acetaminophen doses, nothing by mouth (NPO) feeding status, and liver function test results. Primary cost outcomes were determined by comparing the costs associated with inappropriate doses of IV acetaminophen to the potential costs if the patients had been treated with another dosage form.

Results: A total of 93 doses of IV acetaminophen were administered to 98 patients during the 1 month study period. Patients had a median age of 63 (range: 22–96) years, and most were male. The majority of patients (56.1%) were prescribed IV acetaminophen appropriately. 43 (43.9%) patients were prescribed IV acetaminophen inappropriately, where 30 patients did not have a NPO feeding status and 39 patients did not undergo a surgical procedure. Based on the results, IV acetaminophen is most commonly used for postoperative pain management, with a total of 60 (61.2%) patients being prescribed doses.

Each single-use vial of IV acetaminophen was acquired at a cost of $12.17. The total acquisition cost of IV acetaminophen therapy over the 1 month study period was $1,131.81. Forty-four doses (47.3%) of IV acetaminophen were administered to patients who did not meet the institutional guideline’s inclusion criteria. The 44 doses came at a cost of $535.48 during the study period, resulting in an annual cost of over $6,400. Compared to IV acetaminophen, the tablet, rectal suppository, and unit dose cup formulations cost significantly less, with a cost savings of more than $11 per dose.

Conclusion: IV acetaminophen is frequently being prescribed for indications that do not meet the national criteria for use at the VACT. This analysis supports the need to increase the availability of VACT’s guidelines to improve safe and fiscally responsible prescribing practices at this site.