Inpatient Insights
APhA Staff
Addiction medication initiation in hospitalized patients may decrease readmission
Patients with SUD are frequently readmitted after hospitalization. However, hospitalization can represent an opportunity for treatment initiation, including medications for alcohol use disorder and OUD through the use of addiction consult teams.
Researchers at Harvard Medical School and Massachusetts General Hospital examined the association between addition consultation and medication receipt during admission or prescription at discharge with 30-day hospital readmission through a retrospective analysis of adult hospitalizations from 2019 to 2023 at an academic medical center with a robust addiction consult team.
The study, published online on January 3, 2025, in the Journal of General Internal Medicine, involved over 10,000 patients with SUD. Addiction consultation was associated with higher rates of medication receipt during admission (84% vs. 49% for patients with OUD and 33.4% vs. 6.0% for alcohol use disorder).
For patients with OUD, discharge prescription rates doubled among those seen by the consult team, while for those with alcohol use disorder, discharge prescription rates increased several-fold among those seen by the consult team. Addiction consultation was associated with reduced risk of readmission for both groups.
The authors concluded that addiction consult teams may be an effective strategy to increase evidence-based medication treatment rates, which in turn may reduce readmission. They note that while these teams require a financial investment at start-up, they are of clinical benefit to patients, especially the vulnerable population of hospitalized patients with medical complexity and an increased risk of drug-related mortality after discharge. ■
Does early vs. late norepinephrine administration impact the prognosis of septic shock?
Vasopressor administration to treat septic shock is crucial, but the optimal timing for such treatment remains controversial. A recent systematic review and meta-analysis from Korean researchers, published in the December 2024 issue of CHEST, included studies of adults with sepsis and categorized patients into an early and late norepinephrine group according to specific time points or differences in norepinephrine use protocols. The primary outcome was overall mortality, and the secondary outcomes included length of stay in the ICU, days free from ventilator use, days free from renal replacement therapy, days free from vasopressor use, adverse events, and total fluid volume.
Searches were conducted in PubMed, EMBASE, the Cochrane Library, and KMbase, and 12 studies (four randomized controlled trials and eight observational studies comprising 7,281 patients) were included in the study databases. Subgroup analysis was performed in the two randomized controlled trials without a restrictive fluid strategy.
The researchers concluded that overall mortality did not differ significantly between early and late norepinephrine administration for septic shock. However, early norepinephrine administration appeared to reduce pulmonary edema incidence, and mortality improvement was observed in studies without fluid restriction interventions, favoring early norepinephrine use. ■
Does as-needed BP medication increase the risk of adverse outcomes?
Asymptomatic BP elevations in the hospital are commonly treated with as-needed BP medications, including recurring as-needed and one-time administration. Veterans represent a population at risk of ischemic events from rapid lowering of BP, but the impact of as-needed BP medication use in this population is unknown.
A nationwide group of researchers from universities and Veterans Administration hospitals conducted a retrospective cohort study using target trial emulation and propensity score matching that included adult veterans who were hospitalized for 3 or more days in Veterans Administration hospitals between October 1, 2015, and September 30, 2020. Participants must have been hospitalized on a non–intensive care unit medical or surgical floor, must not have undergone surgery, and must have received at least one scheduled BP medication in the first 24 hours of admission. Participants also must have had at least one systolic BP reading of more than 140 mm Hg during hospitalization. The primary outcome was time to first acute kidney injury (AKI) occurrence during hospitalization.
The study, published in the January 1, 2025, issue of JAMA Internal Medicine, included 133,500 patients, of whom approximately 28,500 patients (21%) received BP medication as needed. Data analysis showed that as-needed BP medication use was associated with an increased risk of AKI compared with nonuse. Subgroup analyses showed higher AKI risk with I.V. as-needed BP medication use compared with oral or combined oral and I.V. routes.
The authors concluded that their data suggest sufficient uncertainty of the utility of as-needed BP medication use for asymptomatic BP elevation in hospitalized patients to justify a prospective trial to determine risks and benefits of this type of BP medication use. ■
Balanced solution vs. normal saline in patients with predicted severe acute pancreatitis
I.V. fluid therapy is recommended in the early management of acute pancreatitis, and isotonic crystalloids are recommended for initial fluid therapy. However, recent evidence indicates that Lactate Ringer’s, a balanced multielectrolyte solution, may be preferred over normal saline based on improved inflammatory markers and evidence that normal saline may cause an excess chloride load. In a study published in the January 2025 issue of Annals of Surgery, the Chinese Acute Pancreatitis Clinical Trials Group conducted a multicenter, stepped-wedge, cluster-randomized trial to compare the effect of balanced multielectrolyte solutions versus normal saline as I.V. fluid on chloride levels and clinical outcomes in patients with predicted severe acute pancreatitis.
The study enrolled 259 patients from 11 sites with predicted severe acute pancreatitis admitted within 72 hours of the advent of symptoms. The study sites were randomly assigned to staggered start dates for a one-way crossover from the normal saline phase to the balanced multielectrolyte solution (Sterofundin ISO) phase. The primary endpoint was the serum chloride concentration on trial day 3.
Results showed that on trial day 3, the mean chloride level was significantly lower in patients who received the balanced multielectrolyte solution. Patients who received the balanced multielectrolyte solution also had less systemic inflammatory response syndrome, more organ failure-free days, and spent less time in the ICU and hospital by trial day 30. The authors concluded that using balanced multielectrolyte solution rather than normal saline resulted in improved serum chloride levels, which were associated with multiple clinical benefits. ■