Clinical News

Pharmacists could argue for days over what has been the most significant therapeutic advancement in the past 150 years. Some might consider antibiotics to have had the biggest impact in preventing the spread of bacterial infections, while others could argue that vaccines have had a similar effect.

Today's hospital pharmacists have evolved to such a point that many pioneering pharmacists like Charles Rice and Harvey A. K. Whitney might not recognize their own profession.

A frail 75-year-old man, T.W., has been admitted to your hospital. He has a fever of 102°F, along with bloody diarrhea and abdominal pain. Prior to his admission, T.W.'s medications included the following: valsartan (Diovan, Novartis ) 80 mg daily, metoprolol 25 mg daily, aspirin 81 mg daily, simvastatin 40 mg daily, warfarin 3 mg on Monday, Wednesday, Friday and 2 mg on Tuesday, Thursday, Saturday, and Sunday. (T.W. suffered a myocardial infarction six months ago.) His last INR was 4.0. Because he had been hospitalized 14 days prior for S. pneumoniae pneumonia that was treated with ceftriaxone, the admitting physician suspected a C. difficile infection, which was subsequently confirmed by the lab. The physician has now ordered metronidazole 500 mg three times daily for T.W., and your computer flags that as a significant drug interaction. What do you recommend to the physician?

The notion of a fully integrated electronic healthcare record across the entire health system is no longer pie-in-the-sky thinking. In reality, however, few hospitals have attained that level of technology penetration. But for those that have, the benefits are immense.

The basic principle of health-care treatment-"First, do no harm"-should apply also to the proper disposal of hazardous pharmaceutical waste. A new product, EcoRex, from Vestara in Irvine, Calif., is designed to achieve that end, using customized software to reduce the potential harm of such waste.

Switching community-acquired pneumonia patients as quickly as possible from intravenous to oral antibiotics reduces hospital stays and improves the quality of care, according to many studies. One recent study suggests that even patients with severe CAP may be safely moved to oral antibiotics early in their stay. Health-system pharmacists should be aggressive in promoting that switch, say several clinical pharmacists.

A 75-year-old man, D.P., is seen regularly in your hospital clinic for severe chronic obstructive pulmonary disease (COPD) as a result of a 50-year pack-a-day habit (FEV<50% predicted). He quit smoking last year but still admits to being a heavy drinker. His current medications include fluticasone/ salmeterol 250/50 mcg (Advair, GlaxoSmithKline) one puff twice daily and albuterol inhaler when needed. He has had several COPD exacerbations within the past year, necessitating oral steroid therapy. He was just diagnosed with osteoporosis: recent X-rays show two vertebral fractures. His physician is contemplating osteoporosis therapy. What do you recommend?

The National Comprehensive Cancer Network (NCCN) recently updated its guidelines for the prevention of emesis in patients receiving chemotherapy or radiation. The new guidelines serve as an update to the 2006 guidelines and are consensus based, with explicit review of the scientific evidence by a multidisciplinary panel of expert physicians and pharmacists.

Practitioners will now have access to consensus standards for the treatment of venous thromboembolism (VTE). The National Quality Forum (NQF) has announced publication of a new report, National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism: Policy, Preferred Practices, and Initial Performance Measures.

Less than a year after it first began to receive applications, interest in the Pharmacy Compounding Accreditation Board's (PCAB) seal of approval appears to be growing. "We now have 100 pharmacies going through the process," said Ken Baker, the board's executive director. "We are looking to reach 300 by the end of 2008. Interest among compounding pharmacies has been extremely high."

Treating heart attacks and agents affecting risk factors for heart disease were among the hot topics explored at the American Heart Association's 2006 annual meeting held recently in Chicago. Also, a program on increasing adherence to pharmacotherapy among the elderly was of interest to attendees.

A 24-year-old woman, R.S., who is two months' pregnant, presents to your ER with a severe migraine that has lasted >48 hours. She reports having several migraines a week since she became pregnant, but until now has successfully "slept them off" in a quiet, dark room. Prior to her pregnancy, R.S. had used zolmitriptan nasal spray (Zomig, AstraZeneca) to abort migraines. She was also using amitriptyline 100 mg daily for prophylaxis. The neurologist on call is debating how to treat R.S. He requests a pharmacist consult. What do you recommend and why?

Treating heart attacks and agents affecting risk factors for heart disease were among the hot topics explored at the American Heart Association's 2006 annual meeting held recently in Chicago. Also, a program on increasing adherence to pharmacotherapy among the elderly was of interest to attendees.

With what may turn out to be a nationwide model, hospitals in San Diego have joined forces in an effort to reduce the number of adverse drug events (ADEs) associated with intravenous medication administration.

Wal-Mart offers generics for $4.00. The Deficit Reduction Act cuts billions of dollars from pharmacies' Medicaid reimbursement for generic drugs. There's no doubt about it, generic margins are under siege today.

The Food & Drug Administration continues to warn pharmacies that compounded medications are new drugs under FDA jurisdiction. The FDA is insistent, despite a U.S. District Court ruling in August 2006 that called into question the federal agency's authority to regulate compounded medications. In at least eight instances covering a range of compounded medications, the FDA has warned pharmacies that the compounded drugs either posed danger to patients or too closely resembled FDA-approved products.

With traumatic brain injury (TBI), the first question we often ask is, Will the patient recover? Beyond concerns about cognitive function and disability, little is generally known about the milestones and setbacks patients encounter while recovering from a TBI.

The Food & Drug Administration has approved ondansetron injection, USP (TEVA-SICOR Pharmaceuticals). The pro- product, AP-rated and equivalent to GlaxoSmithKline's Zofran, is the first generic 5-hydroxytryptamine-3 (5-HT-3) receptor antagonist to receive FDA approval. It is indicated for the prevention of chemotherapy-induced nausea and vomiting (CINV) and the prevention of postoperative nausea and vomiting (PONV).

A recent study by researchers at the Mayo Clinic College of Medicine has raised questions about the safety of administering nicotine replacement therapy (NRT) to smokers in the intensive care unit (ICU). Until now, use of NRT was not thought to be associated with serious adverse events. In fact, the Agency for Healthcare Research & Quality (AHRQ) recommends smoking cessation treatment for hospitalized patients.

Consultant pharmacists are busy preparing to implement the Centers for Medicare & Medicaid Services' newly revised survey guidance for Pharmacy Services and Unnecessary Medications (F-Tags 329, 425, 428 and 431) in Appendix PP of the State Operations Manual (SOM). CMS released the revised guidelines on Sept. 15, with the changes scheduled to become effective on Dec. 18. They represent the first substantive changes in these sections in nearly seven years.

According to the U.S. Census Bureau, every 31 seconds a limited-English speaker enters the United States. For the approximately 48 million residents who speak a language other than English at home, that language barrier looms large when they visit an emergency room or are admitted to a hospital.

When three infants died in September after receiving an adult dose of heparin at an Indianapolis hospital, patient safety experts pointed to the absence of bedside bar-coding-a technology they claim could have prevented the tragedy.

Disposing of hazardous pharmaceutical waste is nothing new for hospitals. However, the task has become more challenging in recent years due in part to a greater variety of toxic drugs that are being discarded.

A recent study by researchers at the Mayo Clinic College of Medicine has raised questions about the safety of administering nicotine replacement therapy (NRT) to smokers in the intensive care unit (ICU). Until now, use of NRT was not thought to be associated with serious adverse events. In fact, the Agency for Healthcare Research & Quality (AHRQ) recommends smoking cessation treatment for hospitalized patients.

As propofol utilization increases, so do the safety risks of fast-acting anesthesia. Readily adaptable oversight procedures for propofol management by clinical pharmacists have led to the awarding of medication safety awards to two hospitals by the Delaware Valley Healthcare Council in Philadelphia (DVHC).

Recognizing that health systems are failing to success-fully manage inpatient diabetes, the Joint Commission on Accreditation of Healthcare Organizations and the American Diabetes Association (ADA) joined forces recently to implement the inpatient diabetes certification of distinction program.

The American Association for Respiratory Care (AARC) recently launched a free Web-based tutorial to educate those with asthma and chronic obstructive pulmonary disease (COPD) about the proper use of their inhaled medications.

Ortho-McNeil Neurologics (OMN) has launched a campaign to warn pharmacists about prescribing and dispensing errors. The campaign centers around two OMN drugs, topiramate (Topamax) and galantamine (Razadyne and Razadyne ER).

A 59-year-old Caucasian woman, D.P., is seen regularly in your hospital's diabetes clinic. Daily medications include glipizide ER (Glucotrol XL, Pfizer) 10 mg, pioglitazone (Actos, Takeda) 45 mg, metformin ER (Glucophage XR, Bristol-Myers Squibb) 500 mg, citalopram 40 mg, ezetimibe/simvastatin (Vytorin 10/80, Merck/Schering-Plough), aspirin 81 mg, lisinopril 40 mg. Glycemic control appears good (A1c=7.0), but she has gained >40 lb. in four years (BMI=33). Despite a Jenny Craig diet (1,200 calorie/day) for six months, plus three weekly sessions with a personal trainer, she has lost only 2 lb. D.P. saw a blog claiming pioglitazone causes weight gain-she believes that is her problem. Her physician asks your opinion. What do you say?

Recent news reports linking methadone with a number of casualties, including that of the actress Anna Nicole Smith's son, have fostered the idea that the substance is a "killer" or dangerous drug of abuse. This is a bit paradoxical since methadone has been successfully used in heroin detoxification programs for decades.