Harold J. Manley

Drug record discrepancies in an outpatient electronic medical record: frequency, type, and potential impact on patient care at a hemodialysis center.

Background. Patients who require hemodialysis take many drugs. Electronic drug records may be discrepant with what patients are actually taking. Record discrepancies are a potential source of drug‐related problems. We sought to determine the extent to which drug record discrepancies occur in a hemodialysis population.

Medication-related problem type and appearance rate in ambulatory hemodialysis patients

BackgroundHemodialysis (HD) patients are at risk for medication-related problems (MRP). The MRP number, type, and appearance rate over time in ambulatory HD patients has not been investigated.MethodsRandomly selected HD patients were enrolled to receive monthly pharmaceutical care visits. At each visit, MRP were identified through review of the patient chart, electronic medical record, patient interview, and communications with other healthcare disciplines. All MRP were categorized by type and medication class. MRP appearance rate was determined as the number of MRP identified per month/number of months in study. The number of MRP per patient-drug exposures were determined using: {[(number of patients) × (mean number of medications)]/(number of months of study)} /number of MRP identified. Results were expressed as mean ± standard deviation or percentages.ResultsPatients were 62.6 ± 15.9 years old, had 6.4 ± 2.0 comorbid conditions, were taking 12.5 ± 4.2 medications, and 15.7 ± 7.2 doses per day at baseline. Medication-dosing problems (33.5%), adverse drug reactions (20.7%), and an indication that was not currently being treated (13.5%) were the most common MRP. 5,373 medication orders were reviewed and a MRP was identified every 15.2 medication exposures. Overall MRP appearance rate was 0.68 ± 0.46 per patient per month.ConclusionMRP continue to occur at a high rate in ambulatory HD patients. Healthcare providers taking care of HD patients should be aware of this problem and efforts to avoid or resolve MRP should be undertaken at all HD clinics.

Determination of iron sucrose (Venofer) or iron dextran (DexFerrum) removal by hemodialysis: an in-vitro study

BackgroundIntravenous iron is typically administered during the hemodialysis (HD) procedure. HD patients may be prescribed high-flux (HF) or high-efficiency (HE) dialysis membranes. The extent of iron sucrose and iron dextran removal by HD using HF or HE membranes and by ultrafiltration rate (UFR) is unknown.MethodsTwo in vitro HD systems were designed and constructed to determine the dialyzabiltiy of iron from a simulated blood system (SBS) containing 100 mg iron sucrose or iron dextran (system A) or 1000 mg iron sucrose (system B). Both in vitro systems utilized a 6-L closed-loop SBS system that was subject to 4 different HD conditions conducted over 4 hours: HE membrane + 0 ml/hr UFR; HE membrane + 500 ml/hr UFR; HF membrane + 0 ml/hr UFR; HF membrane + 500 ml/hr UFR. Blood flow and dialysate flow rates were 500 ml/min and 800 ml/min, respectively. The dialysate compartment was a 192-L open system for system A and a 6-L closed-loop system for system B. Samples from the SBS and dialysate compartments were taken at various time points and iron elimination rate and HD clearance was determined. Iron removal from the SBS > 15% was considered clinically significant.ResultsThe greatest percentage removal from the SBS was 13.5% and -0.03% utilizing system A and B, respectively. Iron sucrose and iron dextran dialysate concentration was below the lower limits of assay (< 2 ppm) for system A. Dialysate recovery of iron was negligible: 0 – 5.4 mg system A and 5.47 – 23.59 mg for system B. Dialyzer type or UFR did not affect iron removal.ConclusionHF or HE dialysis membranes do not remove clinically significant amounts of iron sucrose or dextran formulations over a 4-hour HD session. This effect remained constant even controlling for UFR up to 500 ml/hour. Therefore, iron sucrose and iron dextran are not dialyzed by HE or HF dialysis membranes irrespective of UFR.

Thiazolidinedione safety and efficacy in ambulatory patients receiving hemodialysis.

Study Objectives. To determine whether thiazolidinediones cause significant changes in intravascular volume, anemia, or chronic heart failure; to determine which thiazolidinedione, rosiglitazone or pioglitazone, has a greater propensity to cause these adverse effects; and to evaluate thiazolidinedione efficacy in patients with diabetes mellitus and end‐stage renal disease who require hemodialysis.

Darbepoetin-α: A Review of the Literature

Anemia is a chronic condition that affects many patients with chronic kidney disease (CKD). These patients often require recombinant human erythropoietin (rHuEPO) to stimulate bone marrow to produce red blood cells. The agent often has to be administered 2–3 times/week for maximum efficacy. A new product, darbepoetin‐α, is a hyperglycosylated erythropoiesis‐stimulating protein that has a longer terminal half‐life than rHuEPO (25.3 vs 8.5 hrs), which allows for less frequent dosing. At an equivalent dosage as rHuEPO, darbepoetin‐α maintains hemoglobin values within target range and has a similar adverse effect profile. It is safe and effective for treatment of anemia of CKD. Pharmacoeconomic and quality‐of‐life studies are warranted to determine the compounds overall benefit.

Subcutaneous enoxaparin for outpatient anticoagulation therapy in a patient with an aortic valve replacement

Low‐molecular‐weight heparins have been administered for a variety of clinical conditions. A patient with a mechanical aortic valve replacement patient underwent elective transurethral prostatectomy. Anticoagulation was managed with unfractionated heparin immediately preoperatively and postoperatively. Warfarin was begun on postoperative day 1. The patient had a prolonged hospitalization due to subtherapeutic international normalized ratios (INR) despite warfarin administration. Because he intended to leave the hospital against medical advice before therapeutic INR was achieved, enoxaparin 1 mg/kg subcutaneously every 12 hours was prescribed to provide anticoagulation, facilitating discharge and improving the patients quality of life. Enoxaparin was associated with an approximate saving of

Automated Peritoneal Dialysis Symposium: Treatment of Peritonitis in APD: Pharmacokinetic Principles

4500 over warfarin. The only adverse event reported was bruising at the injection site.

Effectiveness of an Amiodarone Protocol and Management Clinic in Improving Adherence to Amiodarone Monitoring Guidelines

Clinicians treating peritoneal dialysis (PD)‐associated peritonitis should be aware that continuous ambulatory PD (CAPD) and automated PD (APD) have different effects on the pharmacokinetics of antibiotics. Results from various APD and comparative CAPD pharmacokinetic studies are reviewed. In APD patients, antibiotic half‐lives were shorter during the cycler exchanges. Antibiotic peritoneal clearance was greater in patients treated with APD than those treated with CAPD regimens. Antibiotic clearance depends upon residual renal function and dialysate flow rate. To ensure that maximal antibiotic bioavailability occurs with intermittent intraperitoneal (IP) dosing, it is recommended that the antibiotic‐containing dialysate must dwell at least 4 hours to ensure an adequate antibiotic depot in the body. Knowledge of antibiotic disposition in PD patients will assist clinicians in appropriate IP antibiotic dose selection and prevention of dose‐related adverse effects.

Antibiotic Prescribing Evaluation in an Outpatient Hemodialysis Clinic

Objective: To determine whether adherence to suggested monitoring parameters improved as a result of the development and implementation of an amiodarone protocol and management clinic. Adverse effects from amiodarone therapy were also evaluated to ascertain whether the Amiodarone Management Clinic (AMC) better identified adverse events as a result of improved monitoring. Methods: A retrospective review of charts of patients with an active amiodarone prescription was conducted. Patients were identified as enrolled in the AMC (intervention) or as receiving standard medical care (control) by nonpharmacist practitioners. Compliance with recommended monitoring parameters, including the presence of interacting medications and associated drug concentration or international normalized ratio (INR), was assessed for all patients and then compared between groups. Type and frequency of adverse effects were determined for both groups. Results: Two hundred twenty-five charts were reviewed; 154 and 71 patients were assigned to the intervention and control groups, respectively. One hundred one (66%) patients in the intervention group were considered compliant with thyroid function monitoring compared with 26 patients (37%) in the control group (p < 0.0001). One hundred six (69%) and 27 (38%) patients in the intervention and control groups, respectively, were deemed compliant with liver function monitoring (p < 0.0001). Intervention patients taking warfarin were more likely to have blood drawn for INR assessment; however, there was no difference in values between groups. Seventy-six patients had a documented adverse effect from amiodarone, 68 of whom were from the intervention group (p < 0.0001). Conclusions: Many patients receiving amiodarone are not managed according to published guidelines. Implementation of a pharmacist-managed protocol and clinic significantly improved compliance with 2 of the 3 parameters needing continuous monitoring. Although more adverse effects were documented for intervention patients, it is unclear whether the AMC actually improved the event detection rate.

Erythropoietin for Prevention and Treatment of Anemia in the Intensive Care Unit

Background Empiric vancomycin treatment is frequently used in hemodialysis (HD) patients because of ease of administration when methicillin-resistant Staphylococcus aureus (MRSA) infection is suspected. Differing rates of MRSA indicate that empiric antibiotic treatment should be based on a center-specific antibiogram. Objective To develop a center-specific antibiogram, evaluate antibiotic prescribing patterns, and determine areas of improvement in infection treatment. Methods The antibiogram was constructed from culture and susceptibility (C&S) data from January through December 1999. Evaluation of prescribing habits was based on 3 criteria: (1) Hospital Infection Control Practices Advisory Committee and Centers for Disease Control and Prevention guidelines; (2) vancomycin for 1 dose followed by appropriate antibiotic based on C&S results; and (3) C&S obtained with more than 1 dose of antibiotic. Results HD was provided to 161 patients during the study period. Antibiotics were empirically prescribed 104 times in 62 different patients. Cultures were obtained 122 times, and 67 different isolates were identified. Gram-positive organisms and gram-negative organisms accounted for 77.6% and 22.4% of isolates, respectively. Gram-positive organisms were identified as Staphylococcus spp. (53.8%); 17.9% of the staphylococcal isolates were MRSA strains. No isolates of vancomycin-resistant enterococcus were identified. Based on the antibiogram, empiric antibiotic therapy within our center should be 1 dose each of vancomycin and an aminoglycoside. Empiric vancomycin was used 71 times. When criterion I is used, 12 prescriptions (16.9%) were considered appropriate. When criterion II and adjustment for MRSA reported for our center were used, 46 (64.8%) vancomycin prescriptions were considered appropriate. Forty-one patients had more than 1 dose of antibiotic therapy, and 18 (43.9%) of those patients did not have C&S data obtained as prescribed by criterion III. Areas of prescribing improvement include obtaining a C&S in all suspected infections prior to empiric therapy and a more aggressive antibiotic switch based on C&S results. Conclusions Antibiograms can be used to determine appropriate empric antibiotic therapy and identify areas of improvement.