Trending Topics in Health-System Pharmacy
APhA Staff
Text messaging can support use of naloxone after ED discharge
Can text messaging capture patient-reported naloxone acquisition and carrying after an ED encounter? That’s the question asked by Agarwal and colleagues at the University of Pennsylvania Perelman School of Medicine in a study published on March 24, 2022, in JAMA Network Open.
The cohort study collected self-reported patient behaviors involving naloxone after ED discharge in a large, urban academic health system in Philadelphia. Adult patients who were prescribed or dispensed naloxone and who had a mobile phone number listed in the electronic health record (and who had provided informed consent after ED discharge) received an automated text message–based survey. Data were coallected from October 10, 2020, to March 19, 2021.
Of 205 eligible patients, 41 patients with a mean age of ~40 years completed the survey. Half of the patients were women, and 15 patients had a personal history of being given naloxone after an overdose. Almost 90% of respondents reported acquiring naloxone or a naloxone prescription from the ED, and nearly 66% planned to continue carrying naloxone, including most patients who were not carrying the drug before their ED visits.
The authors suggest that this patient-centered automated system offers an opportunity to augment and support ED-based naloxone distribution efforts and guide opioid overdose education. ■
Tranexamic acid may decrease bleeding during noncardiac surgery
Perioperative bleeding is a common complication for patients undergoing noncardiac surgery and is associated with increased morbidity and mortality. A global group of researchers, the POISE-3 Investigators, led by P.J. Devereaux at the Population Health Research Institute (Hamilton, Ontario) conducted a randomized, controlled trial to evaluate the effects of tranexamic acid compared in patients undergoing noncardiac surgery and found that the incidence of the composite bleeding outcome was significantly lower with tranexamic acid than with placebo.
The study, published online in the New England Journal of Medicine on April 2, 2022, involved 9,535 patients randomly assigned to receive a 1-g I.V. bolus of tranexamic acid or placebo at the start and end of surgery. The primary efficacy outcome was life-threatening bleeding, major bleeding, or bleeding into a critical organ (composite bleeding outcome) at 30 days, and the primary safety outcome was myocardial injury after noncardiac surgery, nonhemorrhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism (composite cardiovascular outcome) at 30 days.
The study results showed that a composite bleeding outcome event occurred in 9.1% of patients in the tranexamic acid group and in 11.7% of patients in the placebo group, while a composite cardiovascular outcome event occurred in 14.2% of patients in the tranexamic acid group and in 13.9% of patients in the placebo group. Although the difference in composite cardiovascular complications between the tranexamic acid group and the placebo group was small, the noninferiority of tranexamic acid was not established.
The study authors conclude that given the global blood shortage and that surgical bleeding accounts for up to 40% of all transfusion, the results of their trial show the potential for large public health and clinical benefits if tranexamic acid becomes standard practice in noncardiac surgery. ■
Maintain statin therapy for COVID-19 patients
Statins, commonly used to lower cholesterol levels, are also known to have anti-inflammatory and immunomodulatory properties, which has led to its repurposing for treatment of some infectious diseases, including COVID-19. A recent study, published on February 14, 2022 in the Journal of Hospital Medicine, indicated that discontinuing atorvastatin therapy is associated with worse outcomes for COVID-19 patients
Researchers at HCA Healthcare (Nashville, TN) used data from almost 150,000 hospitalized COVID-19 patients to determine the effect of discontinuation of previous atorvastatin therapy in patients hospitalized for COVID-19 on the risk of mortality and ventilation. Patients were classified as receiving home plus in-hospital atorvastatin (continuation of therapy), home with no in-hospital atorvastatin (discontinuation of therapy), or no atorvastatin use at home or in the hospital. Logistic regression was used to assess the association between atorvastatin administration and either mortality or use of mechanical ventilation.
Continuous use of atorvastatin (at home and in hospital) was associated with a 35% reduction in the odds of mortality compared to patients who received atorvastatin at home but not in the hospital. Similarly, the odds of ventilation were lower with continuous atorvastatin therapy.
The authors suggest that providers should consider maintaining existing statin therapy for patients with known or suspected previous use and that additional study will be needed to determine the potential benefit of statin treatment among COVID-19 patients with no history of previous use. ■
Clinical pharmacists add value to stroke teams
Current stroke guidelines recommend that treatment with tissue plasminogen activator (tPA) should be initiated as quickly as possible to provide maximum therapeutic benefit. A recent study by McSwain, Chughtai, and Harrison at Holy Cross Hospital (Silver Spring, MD) shows that pharmacist participation in stroke teams in the ED reduces door-to-needle (DTN) times and increases the likelihood of a patient receiving tPA in less than 60 minutes.
The study, a retrospective, single-center cohort study at a community teaching hospital and certified primary stroke center from January 1, 2014, to December 31, 2018, was published on March 16, 2022, in the Journal of the American College of Clinical Pharmacy. It compared the average DTN time with a pharmacist present at the stroke team activation with the average DTN time with no pharmacist present. Data was collected on the proportion of patients in each group meeting a DTN time of less than 60 minutes and less than 45 minutes.
Pharmacist involvement resulted in a reduction in the average DTN time from 78 minutes to 66 minutes. The DTN goal of less than 60 minutes was met in 60% of cases with a pharmacist present compared with 35% without a pharmacist present, while the DTN time of less than 45 minutes was met in 18% of cases with a pharmacist present versus 20% without a pharmacist present.
The authors conclude that pharmacists possess multiple skills, including knowledge of dosing, reconstitution, and improved access to medication that may positively impact DTN times for patients with acute ischemic stroke and suggest that pharmacists should be consistently included in stroke teams. ■
Methenamine hippurate vs. antibiotic prophylaxis for prevention of recurrent UTIs
Standard treatment for prevention of recurrent UTIs involves daily use of low-dose prophylactic antibiotics, increasing the risk of antibiotic resistance, particularly in older patients, as well as antibiotic-associated complications, including Clostridium difficile infection. According to a study published on March 9, 2022, in the BMJ, the use of methenamine hippurate could be an appropriate alternative for people with a history of recurrent episodes of UTIs, informed by patient preferences and antibiotic stewardship initiatives.
Harding and colleagues at the U.K.’s National Health Service conducted a multicenter, open label, randomized trial to compare the efficacy of the two treatments. Adult women with recurrent UTIs were randomly assigned to receive either antibiotic prophylaxis (50 mg or 100 mg nitrofurantoin, 100 mg trimethoprim, or 250 mg cephalexin given orally once daily or 1 g oral dose of methenamine hippurate twice daily) for 12 months. Treatment allocation was not masked and crossover between arms was allowed.
Incidence of antibiotic-treated UTIs during the 12-month treatment period was 0.89 episodes per person year in the antibiotics group and 1.38 in the methenamine hippurate group, confirming noninferiority. Adverse reactions were reported by 24% of patients in the antibiotic group and 28% of patients in the methenamine group. ■