Colette B. Raymond

Sodium thiosulfate, bisphosphonates, and cinacalcet for treatment of calciphylaxis

PURPOSE The use of sodium thiosulfate, bisphosphonates, and cinacalcet for the treatment of calciphylaxis in adults with chronic kidney disease (CKD) is discussed. SUMMARY Calciphylaxis, generally characterized by extraosseous calcification of soft tissues, typically occurs in patients with stage 4 or 5 CKD. Very little data are available regarding the treatment of calciphylaxis. The role of elevated calcium and phosphate concentrations and hyperparathyroidism as risk factors for calciphylaxis has led clinicians to explore therapies that modify these factors, including sodium thiosulfate, bisphosphonates, and cinacalcet. Sodium thiosulfate has been shown to produce clinical improvement of calciphylaxis lesions. Bisphosphonates have been shown to be effective in animal models of calciphylaxis, and the mechanism of action is believed to be due to inhibition of macrophages and local proinflammatory cytokines and binding to calcified vascular smooth muscle cells to inhibit further arterial calcification. Cinacalcet, a calcimimetic agent that increases the sensitivity of the calcium-sensing receptor on the parathyroid gland to calcium, is believed to decrease serum parathyroid hormone levels and stabilize calcium and phosphate concentrations. Cinacalcet has been associated with improved pain control and ulcer healing. Cases describing the use of combination therapy with cinacalcet and sodium thiosulfate for the treatment of calciphylaxis have been published, but the positive effect on wound healing is difficult to attribute to a single drug. CONCLUSION Evidence for the treatment of calciphylaxis with pharmacotherapeutic interventions is limited to case reports. Further research is necessary to fully describe the optimal use of sodium thiosulfate, bisphosphonates, and cinacalcet for the treatment of calciphylaxis, including their pharmacokinetics in adults with CKD, optimal dosing strategies, and duration of therapy.

Development and evaluation of a workplace-based preceptor training course for pharmacy practitioners.

Background: There has been limited research about preceptor training programs that include coaching, experiential practice or development of preceptor coaching capacity. We describe the development and evaluation of a workplace preceptor training course for pharmacists and pharmacy technicians within a large regional health authority. Methods: The instructional format was self-study readings and interactive seminars followed by structured practical experience plus feedback from a preceptor coach. During the structured practical experience, each participant served as a preceptor for a student or new staff member. Course evaluations and qualitative interviews were used to evaluate utility and perceived value among participants. Interview transcripts were analyzed using qualitative description and themes were aggregated; illustrative quotes are presented. Results: Since 2006, a total of 40 pharmacists and technicians have participated in the course and interviews were conducted with 14 of these participants. Aspects of the course that interview participants found to be particularly useful included receiving feedback from a coach, implementing a lesson plan and identifying and using different learning and teaching styles. Some participants described changes in attitudes or behaviours toward new employees or students, the use of new learning styles and changes in focus and approach to being a preceptor. Discussion: This unique course could be applied in other workplaces where pharmacy staff members help to deliver experiential education programs. The delivery format was appropriate for a mixed group of pharmacist and technician participants. Conclusion: A preceptor training course of readings, seminars and structured practical experience with feedback from a coach resulted in satisfaction with learning experiences and evidence of attitudinal and behavioural change up to 3 years after the course.Can Pharm J 2012;145:231–236.

Erythropoietin-Alpha Dosage Requirements in a Provincial Hemodialysis Population: Effect of Switching from Subcutaneous to Intravenous Administration

Background: The purpose of this initiative was to compare erythropoietin-α doses in hemodialysis patients who changed from subcutaneous to intravenous administration. The Manitoba Renal Program switched routes due to concern about erythropoietin-associated pure red cell aplasia. Methods: We compared the erythropoie tin-α dosage requirements during subcutaneous administration (3 months pre-switch) and intravenous administration (months 4–6 post-switch). We also compared: hemoglobin, transferrin saturation (Tsat%), ferritin, and percent of patients receiving intravenous iron. The same erythropoietin-α regimen was initially used when patients were switched. Results: Of the 628 patients receiving erythropoietin-α, the data were complete for 400. The dose increased 26% (mean ± SD, 10,425 ± 7,330 vs. 13,125 ± 8,638 IU/week; p < 0.0001), despite similar hemoglobin, (mean ± SD, 11.5 ± 1.1g/dl (114.9 ± 11.2 g/l) vs. 11.3 ± 1.0 g/dl (113.5 ± 10.4 g/l); p = 0.0450) and iron parameters (Tsat 30.9%, ferritin 464 ng/ml (µg/l) vs. Tsat 28.7%, ferritin 538 ng/ml (µg/l)). For the subgroup of 84 patients who maintained target hemoglobin (10–11 g/dl or 110–120 g/l) for both periods, the dose increased 26% (mean ± SD, 8,393 ± 6,242 vs. 10,589 ± 7,049 IU/week; p < 0.0001) without a change in hemoglobin, (mean ± SD, 11.5 ± 0.3 g/dl (115.2 ± 3.0 g/l) vs. 11.5 ± 0.3 g/dl (114.9 ± 3.3 g/l); p = 0.5789). When stratified by subcutaneous dose, patients with the lowest dose (<5,000 IU/week) demonstrated the greatest increase (89%), and those with the highest dose (>20,000 IU/week) experienced no increase (–3%). Conclusion: Overall, erythropoietin-α doses increased by 26% when patients were converted from subcutaneous to intravenous administration.

Reliability and validity of a survey to evaluate attitudes and behaviours of pharmacy staff toward near misses.

The purpose of this study was to describe attitudes and behaviours of pharmacy staff toward near misses through a survey and interviews. Themes of an acknowledgment of pharmacy process changes resulting from near miss reporting, feelings of personal responsibility, minimizing the importance of reporting near misses, and a need for further education were evident in both the survey and qualitative discussions. This survey is useful to inform educational efforts and to encourage near miss reporting.

Multihospital collaborative orientation program for new pharmacy employees.

From 1998 to 2005, nine hospital pharmacies in Winnipeg, Manitoba, Canada, had annual pharmacist vacancy rates ranging from 3.4% to 67%. Despite the implementation of very successful recruitment initiatives citywide from 2002 to 2004, most pharmacies had difficulty retaining new pharmacist recruits

Evaluation of a medication order writing standards policy in a regional health authority.

Background: The Winnipeg Regional Health Authority (WRHA) implemented a medication order writing standards (MOWS) policy (including banned abbreviations) to improve patient safety. Widespread educational campaigns and direct prescriber feedback were implemented. Methods: We audited orders within the WRHA from 2005 to 2009 and surveyed all WRHA staff in 2011 about the policy and suggestions for improving education and compliance. Results: Overall, orders containing banned abbreviations, acronyms or symbols numbered 2261/8565 (26.4%) preimplementation. After WRHA-wide didactic education, the proportion declined to 1358/5461 (24.9%) (p = 0.043) and then, with targeted prescriber feedback, to 1186/6198 (19.1%) (p < 0.0001). A survey of 723 employees showed frequent violations of the MOWS, despite widespread knowledge of the policy. Respondents supported ongoing efforts to enforce the policy within the WRHA. Nonprescribers were significantly more likely than prescribers to agree with statements regarding enhancing compliance by defining prescriber/transcriber responsibilities and placing sanctions on noncompliant prescribers. Discussion: Education, raising general awareness and targeted feedback to prescribers alone are insufficient to ensure compliance with MOWS policies. WRHA staff supported ongoing communication, improved tools such as compliant preprinted orders and reporting and feedback about medication incidents. A surprising number of respondents supported placing sanctions on noncompliant prescribers. Conclusion: Serial audits and targeted interventions such as direct prescriber feedback improve prescription quality in inpatient hospital settings. Education plus direct prescriber feedback had a greater impact than education alone on improving compliance with a MOWS policy. Future efforts at the WRHA to improve compliance will require an expanded focus on incentives, resources and development of action plans that involve all affected staff, not just prescribers. Plans include continued advertising, MOWS summaries in all charts, all-staff education, reminders and exploration of sustainable interventions for targeted feedback for prescribers.

Cost Analysis of an Intravenous to Subcutaneous Epoetin α Conversion

Background/Aims: A cost analysis of a conversion from intravenous (IV) to subcutaneous (SC) epoetin α in patients receiving chronic in-center hemodialysis (HD). Methods: This retrospective analysis compared epoetin α drug costs during a 6-month period of IV usage (July to December 2010, period 1) to a 6-month period of SC usage (July to December 2011, period 2) in four large in-center HD units. Data were collected from quarterly counts of HD patients receiving epoetin α and monthly inventory billing records. Results: 622 HD patients who received IV epoetin α (period 1) were compared to 609 HD patients who received SC epoetin α (period 2). A 12.6% decrease in dose was observed. The average weekly cost of epoetin α was USD 173.02 per patient during the IV period versus USD 151.20 per patient during the SC period. This equated to a yearly cost savings of USD 1,135 per patient with SC epoetin α. Conclusion: The switch from IV to SC epoetin α was successfully implemented in all four centers and realized significant cost savings.

Prior Learning Assessments in a Professional Workplace for Practising Pharmacists and Technicians

Background: A prior learning assessment (PLA) is a summative statement of an individuals learning acquired through education and experience. We developed PLA surveys for 3 groups of pharmacy staff: experienced pharmacists with supervisory or clinical roles; pharmacists entering a pharmacy practice residency program; and experienced pharmacy technicians. Methods: Each PLA survey was developed based on a literature review and desirable learning outcomes for a regional pharmacy program. PLAs consisted of numerous potential learning needs, including possible job roles, competencies, essential skills and areas of practice expertise in 11 domains. Pharmacy staff scored past exposure, perceived ability (prior experience) and interest for each potential learning need. Learning needs were calculated as interest score minus ability score. Results: 23 of 38 (61%) experienced pharmacists, all 24 (100%) pharmacy residents and all 17 (100%) pharmacy technicians invited to complete the PLA responded. For each of the 11 domains, Cronbachs alpha scores were greater than 0.69. For experienced pharmacists, the highest learning needs occurred in technical domains (drug distribution and computer/informatics), with low needs in practice management and patient care. For pharmacy residents, the highest learning needs occurred in patient care domains. Pharmacy technician learning needs were greatest in human resources and drug distribution. Conclusion: We developed PLA surveys for experienced pharmacists, pharmacy residents and pharmacy technicians that demonstrate internal consistency reliability. Regulatory bodies, education providers, employers, managers and individual pharmacy personnel can use PLA to identify learning needs either prior to a practice change or as part of continuing professional development planning.