Trending Topics in Health-System Pharmacy
Updated recommendations for managing gout
The American College of Rheumatology has developed new guidelines and recommendations to provide direction for clinicians and patients in making decisions on the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.
Published online simultaneously on May 10 in Arthritis Care & Research and Arthritis & Rheumatology, the new guidelines contain 42 recommendations, including 16 strong recommendations based on a group consensus process.
Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares. Allopurinol is the preferred first‐line ULT, including for those with moderate‐to‐severe chronic kidney disease (CKD).
The group recommends using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD ) or febuxostat (<40 mg/day) and a treat‐to‐target management strategy with ULT dose titration guided by serial serum urate measurements, with a target of <6 mg/dl. When initiating ULT, concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months was strongly recommended.
For management of gout flares, colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.
Telemedicine increases at large medical centers
The COVID-19 pandemic has driven rapid expansion of telemedicine use for both urgent and nonurgent care visits in many practices. A recent study published in the Journal of the American Medical Informatics Association provides data on the feasibility and impact of video-enabled telemedicine use and its impact on health care delivery at NYU Langone Health.
Langone, at the epicenter of the COVID-19 outbreak in the United States, saw urgent care telemedicine visits increase from 102 to 802 daily between March 2 and April 14 after a system-wide expansion of virtual care staff in response to COVID-19.
Of all virtual visits postexpansion, 56.2% and 17.6% of urgent and nonurgent visits, respectively, were COVID-19–related. Telemedicine usage was highest by patients aged 20 to 44 years, particularly for urgent care.
The authors concluded that “the impact of telemedicine on COVID-19 response is matched by a likely enduring impact of COVID-19 on telemedicine, and through it on healthcare delivery in general, with a new reality of a broad population of Americans and their providers who are getting a crash course in using telemedicine tools, experiencing their capabilities, and establishing comfort and expectations of their widespread availability.”
ED pharmacists reduce delivery time for anticoagulants
Emergency departments (EDs) are universally hectic. When a patient presents with a life-threatening bleed, a delay in administration of a life-saving medication could cause that patient to experience morbidity (or mortality) that could have been prevented if the time from presentation to drug administration were reduced.
A retrospective cohort study published in a recent issue of the Journal of Emergency Medicine quantified the value of having a pharmacist in the ED.
Patients who presented to the ED with a life-threatening bleed (intracranial hemorrhage was the most common), were currently taking anticoagulants prior to presentation (warfarin was the most common), and were in need of anticoagulant reversal with four-factor prothrombin complex concentrate (4F-PCC) were included if the 4F-PCC was administered within the ED.
A total of 116 patients were included in two groups: The first group consisted of 50 patients with a pharmacist available during the shift during 4F-PCC administration; the second group of 66 patients did not have a pharmacist available during their 4F-PCC need.
The two cohorts consisted of patients who presented to the Loyola University Medical Center ED between 2014 and 2018. The medical center does not staff a pharmacist in the ED 24 hours per day, so the patients in the pharmacist group were simply present in the ED during times when a pharmacist was staffed. For patients who had a pharmacist available, the median time of 4F-PCC was reduced by 140 minutes compared with patients who did not have a pharmacist available. In addition, patients who received 4F-PCC earlier had a shorter ICU stay and overall hospital stay.
Further studies may be needed to evaluate the impact of 24-hour pharmacist staffing within the ED with these measures compared with non-24-hour pharmacist staffing. This could ensure that it is the presence of the pharmacist, and not other staffing changes in the department, that is responsible for differences between procurement/administration times of certain medications.
Preventing VTE in hospitalized patients with cancer
Hospitalized patients with cancer are at an increased risk of developing venous thromboembolism (VTE), and asymptomatic VTE is common among high-risk hospitalized patients with cancer receiving fixed-dose enoxaparin.
Routine pharmacologic thromboprophylaxis in these patients is based on extrapolation of results from noncancer cohorts. To compare the effectiveness of fixed-dose with weight-adjusted enoxaparin in cancer patients, researchers from Beth Israel Deaconess Medical Center, the Cleveland Clinic, and the Dana-Farber Cancer Institute conducted a randomized, double-blinded, Phase II trial in hospitalized patients with active cancer at high risk of developing VTE based on Padua risk score. The study was published in the May 26 issue of Blood Advances.
Researchers randomly assigned a total of 50 patients to either fixed-dose enoxaparin (40 mg daily) or weight-adjusted enoxaparin (1 mg/kg daily) during hospitalization. There were no major hemorrhages or symptomatic VTE in either arm.
In the group randomly assigned to fixed-dose enoxaparin who subsequently underwent surveillance ultrasound, the cumulative incidence of DVT was 22%.
This Phase II trial confirms a high incidence of asymptomatic VTE among high-risk hospitalized patients with cancer and suggests that weight-adjusted thromboprophylaxis is feasible and well tolerated in these patients.
CDC provides information on transmission of COVID-19 to health care workers
Health care personnel are at heightened risk of acquiring COVID-19 infection, but limited information exists about transmission in health care settings. CDC recently found that among 121 health care workers who had unprotected contact with a patient with unrecognized COVID-19, 43 became symptomatic and 3 had positive test results for SARS-CoV-2.
Exposure while performing physical examinations or during nebulizer treatments were more common among health care personnel with COVID-19.
These data, published in Morbidity and Mortality Weekly Report, are subject to at least three limitations, according to the authors. First, exposures among health care personnel were self-reported and are subject to recall bias. Second, the low number of cases limits the ability to detect statistically significant differences in exposures and does not allow for multivariable analyses to adjust for potential confounding.
Finally, additional infections might have occurred among asymptomatic exposed health care workers who were not tested, or among thoase who were tested as a result of timing and limitations of nasopharyngeal and oropharyngeal specimen testing. Serologic testing was not performed.
Based on this information, CDC recommends that health care facilities continue to follow CDC, state, and local infection control and personal protective equipment guidance. Early recognition and prompt isolation, including source control, for patients with possible infection can help minimize unprotected and high-risk health care personnel exposures.