Jennifer E. Stark

Pantoprazole-Induced Thrombocytopenia

Objective: To report 2 cases of thrombocytopenia associated with pantoprazole treatment and discuss existing reports on this drug-induced adverse event. Case Summaries: This paper describes the course of thrombocytopenia associated with pantoprazole 40 mg in 2 hospitalized patients. In both cases, thrombocytopenia appeared after the initiation of pantoprazole and rapidly improved after discontinuation of pantoprazole, although complete resolution of thrombocytopenia occurred in only one patient prior to discharge from the hospital. Discussion: The mechanism of drug-induced thrombocytopenia is often poorly understood, and proton-pump inhibitors are generally not strongly suspected as a cause of thrombocytopenia. However, an objective causality assessment using the Naranjo probability scale revealed a probable relationship between thrombocytopenia and pantoprazole in both of the cases. It is unknown whether this is a class effect. Conclusions: Although drug-induced thrombocytopenia with pantoprazole appears to be rare, it represents a potentially severe adverse effect. This supports the judicious prescribing of pantoprazole and possibly other proton-pump inhibitors.

Olanzapine-associated neuroleptic malignant syndrome.

Neuroleptic malignant syndrome (NMS) is a rare but potentially serious complication of neuroleptic drugs. It may vary in both presenting characteristics and severity. Several different criteria for diagnosis exist, and each differs from the others slightly. We describe a 66‐year‐old woman with chronic paranoid schizophrenia who was prescribed olanzapine along with several other psychiatric drugs and an antihypertensive drug. The patient displayed several characteristics of NMS during therapy with olanzapine, including fever, elevated creatine kinase level, leukocytosis, and mild muscle rigidity. When olanzapine was held, the signs and symptoms improved and then returned with rechallenge of olanzapine. For this reason, olanzapine was considered strongly associated with this patients apparent NMS episode. The patients β‐blocker therapy may have masked additional signs of NMS. In addition, the patient tolerated other neuroleptics that were started in the hospital after the suspected NMS episode. The variation among different diagnostic criteria makes this syndrome a challenging diagnosis at times, in particular when atypical antipsychotics are suspected as the causative agent.

Evaluating the impact of a pre-rotation workshop on student preparation for clinical advanced pharmacy practice experiences

Objectives This pilot study was designed to evaluate the impact of a pre-rotation workshop (PRW) on pharmacy students’ clinical skills and preparation for clinical Advanced Pharmacy Practice Experiences (APPE) involving direct patient care. Methods Randomized controlled trial of an educational intervention with Institutional Review Board approval. PRW activities designed to simulate rotation activities around five competencies, patient charts, medication histories, SOAP notes, patient presentations, and professionalism. Endpoints were evaluated using clinical rotation preceptors’ evaluation of performance and students’ performance on objective structured clinical exams (OSCE). Results Eight fourth-year students and eight GPA matched controls (20% of the total class) were selected to voluntarily participate. The PRW demonstrated a positive impact on students’ clinical skills and preparation for rotations by improving OSCE performance. However, no significant differences were found between groups when comparing preceptor evaluations of skills on rotations. These results are limited by the small sample size, potential OSCE “test-wiseness” effects, lack of OSCE evaluator blinding to study groups, potential case specificity effects due to the limited number of cases used on the OSCE and possible lack of sensitivity of the rotation evaluation tool to capture true differences among the experimental and control group participants. Conclusion The PRW was successful at advancing students’ clinical skills and preparation for rotations and may be considered as a tool to help bridge didactic to clinical experiences in the Pharm.D. curriculum.

Pharmacotherapy for Heart Failure with Left Ventricular Dysfunction: Beyond Angiotensin‐Converting Enzyme Inhibitors and β‐Blockers

Angiotensin‐converting enzyme (ACE) inhibitors and β‐blockers make up the cornerstone of therapy for patients with heart failure involving left ventricular dysfunction. These drug classes have been proven to decrease morbidity and mortality in patients with heart failure. Unfortunately, many patients remain symptomatic and experience disease progression despite taking both an ACE inhibitor and a β‐blocker. Others may be unable to tolerate one or both of these agents. In recent years, several other drug classes have been shown to provide additional morbidity and mortality benefits in patients with heart failure. These include angiotensin II receptor blockers (ARBs), aldosterone antagonists, and the combination of isosorbide dinitrate plus hydralazine. To select the most appropriate drug therapy for patients with heart failure, clinicians should consider results from clinical trials in specific patient populations, adverse‐event profiles, tolerability, cost, and dosing regimens.

Stevens-Johnson Syndrome Associated With Furosemide: A Case Report

Purpose: To report a probable association of Stevens-Johnson Syndrome (SJS) with furosemide and suspected cross-sensitivity with lincomycin and silver sulfadiazine cream. Summary: A 28-year-old Hispanic male was admitted for SJS, with a prolonged hospital course and unclear etiology throughout the majority of the stay. Patient’s medications prior to development of SJS symptoms were stable for 3 months and with the exception of furosemide, all were continued throughout the hospitalization while the SJS resolved. During hospitalization, the patient was unintentionally rechallenged with furosemide, after which the rash reappeared and then worsened further with use of silver sulfadiazine cream. At this point in the hospitalization, the prolonged course of the rash prior to admission and the administration of lincomycin 3 days prior to admission were revealed. This suggests the SJS was initially caused by furosemide, a nonaromatic sulfonamide diuretic, with slow progression prior to hospital admission over approximately 7 weeks, followed by an acute worsening caused by lincomycin, a sulfide antibiotic. Conclusion: Use of the Naranjo ADR Probability Scale indicates a probable relationship between SJS and furosemide in this patient. Clinicians should be aware of this rare potential adverse effect, even months after the initiation of therapy.

A Pharmacist-Initiated Method to Improve Venous Thromboembolic Prophylaxis Rates in Medically Ill Patients

Venous thromboembolism (VTE) is among the most preventable causes of hospital death; however, there is a significant underuse of VTE prophylaxis. The purpose of this study was to determine the impact of a pharmacist-initiated screening method on VTE prophylaxis rates. Clinical pharmacists practicing in an internal medicine teaching service at an academic medical center conducted a 6-month pilot project. Consecutive patients admitted to the service were screened for VTE and bleeding risk factors. Pharmacists made recommendations to the physicians in person, provided monthly educational presentations, and monitored patients daily until discharge to confirm continued appropriateness of recommendations. Of the 444 patients who were screened, 107 were identified to be candidates for VTE prophylaxis, and 21 of these patients also had bleeding risk factors. Appropriate use was significantly better after the screening intervention (37% before vs 85% after; P < .05). Moreover, inappropriate use in patients with bleeding risk factors was avoided by the screening intervention (29% before vs 0% after; P < .05). Clear improvements in VTE prophylaxis rates were observed. This pharmacist-initiated screening method presents unique opportunities for pharmacists.

Treatment of Chronic Hepatitis C Virus Infection With Crushed Ledipasvir/Sofosbuvir Administered via a Percutaneous Endoscopic Gastrostomy Tube

Introduction: Ledipasvir/sofosbuvir (Harvoni®) is a fixed-dose tablet indicated for the treatment of chronic hepatitis C virus (HCV) infection. There are currently no data available on the safety and efficacy of crushed ledipasvir/sofosbuvir tablets. Case Summary: This report describes the first documented case of successful treatment of chronic HCV infection in a patient crushing ledipasvir/sofosbuvir for administration via a percutaneous endoscopic gastrostomy (PEG) tube. The patient was treatment experienced and had evidence of compensated cirrhosis. Treatment duration was 24 weeks, and HCV RNA was undetectable 12 weeks after completion of treatment (SVR12) which is the accepted measure of a clinical cure. Discussion: Issues may arise during or prior to starting HCV treatment that necessitate crushing tablets. Stopping or interrupting HCV treatment could lead to development of resistance or treatment failure. Conclusion: This is the first published case in which crushed ledipasvir/sofosbuvir administered via a PEG tube is documented as a safe and effective option for treatment of chronic HCV infection.

Identifying Missed Opportunities for the Pneumococcal Conjugate Vaccine (PCV13)

Background: The recommendation for the pneumococcal conjugate vaccine (PCV13) in adults 65 years and older is recent, and the dosing schedule of PCV13 and the pneumococcal polysaccharide vaccine (PPSV23) can be complex in this population. Objective: The authors assessed the rate of PCV13 immunization in patients 65 years of age and older and identified barriers that contributed to missed opportunities for PCV13. Methods: This retrospective review evaluated outpatient Veterans age 65 years or older who did not receive PCV13 at a scheduled primary care appointment despite an electronic reminder. Investigators recorded any documented reason for the patient not receiving PCV13. Results: The rate of PCV13 immunizations administered during the primary care visit study period was 37% (89 of 239 PCV13 eligible patients). Of the 150 patients identified who did not receive PCV13, 92% were not offered the vaccine, 6.7% declined vaccination, and 0.7% reported an allergy to vaccination. Electronic immunization records revealed that 48 of the 150 patients who did not receive PCV13 at their clinic appointment did receive PCV13 later the same year. Most patients received PCV13 in influenza vaccine season on the same day as receiving the influenza vaccine. Conclusion: The main barrier identified was not offering the vaccination during primary care visits. Pneumococcal vaccine administration was delayed until the influenza vaccine season in a significant portion of patients. This unexpected finding represents a target for education: ensuring health care professionals are reminded that PCV13 is not a seasonal vaccine like the influenza vaccine, but should be offered throughout the year.