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APhA Staff
Polypharmacy may raise BP
Use of medications that raise BP may lead to poor BP control, according to a study from Beth Israel Deaconess Medical Center (Boston) published in the January 2022 issue of JAMA Internal Medicine. The researchers examined data from the National Health and Nutrition Examination Survey to characterize the use of medications that may raise BP among those with hypertension.
The study population, culled from 5 survey cycles (2009–2018) and included more than 27,000 adults, of which 11% identified as Black, 15% as Hispanic, and 65% as non-Hispanic white. Of these individuals, 49% had hypertension and 35% had uncontrolled hypertension. Prescription medication use was obtained from home interviews. Antihypertensives and medications that may cause elevated BP were identified from the 2017 ACC and AHA guidelines.
In total, 15% of the participants reported using medication that may cause elevated BP, including 19% of those with hypertension. The most commonly used medications were antidepressants, NSAIDs, steroids, and estrogens. The use of these medications was associated with increased odds of uncontrolled hypertension among individuals not taking antihypertensives and greater use of antihypertensives among both patients with controlled and uncontrolled hypertension. Study limitations include reliance on patient self-reporting of medication use, lack of reporting on medication dose and duration, and omission of over-the-counter medications, leading to underestimation of NSAIDs and decongestant use.
The authors note that many medications known to raise BP have therapeutic alternatives, such as acetaminophen in place of NSAIDs and progestin-only or nonhormonal contraceptives in place of ethinyl estradiol-containing contraceptives. They encourage clinicians caring for pa-tients with hypertension to routinely screen for medications that may cause elevated BP and consider deprescribing, replacing them with safer therapeutic alternatives, and minimizing the dose and duration of use when alternatives are not available.
Low thiamine supplementation in patients with AUD
Although thiamine supplementation is recommended for patients with alcohol use disorder (AUD), not all critically ill patients with AUD are given thiamine supplementation. Researchers at Beth Israel Deaconess Medical Center (Boston) performed a retrospective observational study to investigate thiamine supplementation incidence in patients with AUD and various critical illnesses among adult patients with AUD who were admitted to the ICU with alcohol withdrawal, septic shock, traumatic brain injury (TBI), or diabetic ketoacidosis (DKA) between 2010 and 2017. The study included 14,998 patients with AUD. Mean age was 52.2 years, 77% of participants were male, and in-hospital mortality was 9%. Overall, 7,689 patients (51%) received thiamine supplementation.
According to the study, published online December 7, 2021, in the Annals of Internal Medicine, the incidence of thiamine supplementation was 59% for alcohol withdrawal, 26% for septic shock, 41% for TBI, and 24% for DKA. Most of those receiving thiamine (52%) received it within 12 hours of presentation in the ED. Specific dosing and duration were not completely captured.
The authors conclude that because almost half of all patients with AUD did not receive the recommended thiamine supplementation, these data highlight the opportunity to improve treatment of critically ill patients with AUD.
Cefazolin could be safely integrated into penicillin allergy protocol
Patients who report a penicillin allergy are often given alternative antibiotic treatment, including as a prophylactic during joint replacement surgery. A new study published in the December 15, 2021, issue of The Journal of Bone and Joint Surgery suggests that a protocol-driven penicillin allergy screening program could increase the use of cefazolin without the need for additional testing.
Researchers from Thomas Jefferson University (Philadelphia) used a questionnaire-based screening protocol for all patients scheduled for primary joint replacement that categorized patients as low or high risk. The low-risk cohort received cefazolin, while the high-risk cohort received noncephalosporin antibiotics. Patients were monitored prospectively, and data on antibiotic usage and adverse outcomes were documented. The protocol group of over 2,000 patients was propensity score matched 1:1 with a control group that included patients who underwent similar surgery in the same institution prior to implementation of the protocol. The primary end point was the efficacy of the protocol in reducing unnecessary use of noncephalosporin antibiotics for prophylaxis, with secondary outcomes of the rate of surgical site infections and allergic reactions to the administered antibiotic.
The number of patients who received non-cephalosporin antibiotics was significantly lower in the protocol group (5.7% compared with 15.2% in the control group) with no difference in the rate of total allergic reactions (0.8% vs. 0.7%, respectively). Of the 239 low-risk patients in the protocol group, only 3 experienced a mild cutaneous reaction following cefazolin administration. There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups.
Eltrombopag immunosuppression could be effective for severe aplastic anemia
Eltrombopag (Promacta), an oral thrombopoietin-receptor agonist, has been shown to have efficacy in patients with aplastic anemia resistant to immunosuppressive therapy. In a study published in the New England Journal of Medicine on January 6, 2022, researchers from the Severe Aplastic Anemia Working Party of the European Society for Blood and Marrow Transplantation report the results of a phase 3, prospective, investigator-led, multicenter, open-label, randomized trial comparing horse antithymocyte globulin (ATG) plus cyclosporine with or without eltrombopag as first-line therapy in patients with severe or very severe aplastic anemia. The primary end point was a hematologic complete response at 3 months.
Results of the study showed that 10% of patients in the ATG plus cyclosporine group had a complete response at 3 months compared with 22% of patients in the group with added eltrombopag. At 6 months, the overall response rate was 41% in patients in the ATG plus cyclosporine group A and 68% for patients who received ATG plus cyclosporine with eltrombopag. The median times to the first response were 8.8 months and 3.0 months, respectively, and the incidence of severe adverse events was similar in the two groups.
The authors concluded that the addition of eltrombopag to standard immunosuppressive therapy improved the rate, rapidity, and strength of hematologic response among previously untreated patients with severe aplastic anemia, without additional toxic effects. They note that further study is needed to understand the mechanism of action.
Post-discharge thromboprophylaxis for high-risk patients with COVID-19
Patients who were hospitalized with COVID-19 are at risk for thrombotic events after discharge. In an open-label, multicenter, randomized trial in Brazil, patients hospitalized with COVID-19 at increased risk for venous thromboembolism were randomly assigned (1:1) to receive, at hospital discharge, 10 mg/day of rivaroxaban or no anticoagulant medication for 35 days.
The study, published in The Lancet on December 15, 2021, showed that symptomatic and asymptomatic venous and arterial thromboembolism, including cardiovascular death, occurred in 3% of the patients treated with rivaroxaban and 9% of the patients who received no anticoagulation. No major bleeding occurred in either study group.
The authors concluded that extended prophylactic-dose rivaroxaban at hospital discharge should be considered as a strategy to improve clinical outcomes in patients with creatinine clearance of more than 30 mL/min who were hospitalized with COVID-19.