Leslie Briars

Early discontinuation of steroids is safe and effective in pediatric kidney transplant recipients.

Abstract:  In pediatric kidney transplantation, steroid induced growth retardation and cushingoid features are of particular concern. In children, gradual steroid withdrawal late after kidney transplantation increases the risk of rejection. In this pilot study, we investigated the outcome of pediatric renal transplantation with an early steroid withdrawal protocol. This is a retrospective case‐control study of pediatric renal transplants with age‐matched historical control. Groups were comparable in terms of HLA matching, donor type and graft ischemia time. In the steroid withdrawal group (SWG, n = 13), induction therapy included mycophenolate mofetil (MMF) and a 5‐day course of steroids with Thymoglobulin in 11 and basiliximab in two other patients. In the steroid group (SG, n = 13), in addition to steroids, four patients were given basiliximab, eight were given Thymoglobulin, and one OKT3. Maintenance therapy included tacrolimus (SWG n = 11, SG n = 3) or cyclosporine (SWG n = 2, SG n = 10). Azathioprine was given to all the patients in the SG, except the last two patients of this series who were prescribed MMF. MMF was given to all in the SWG. Patient and graft survival rates were 100% in both groups. In the SWG, no acute rejection episode was detected. In the steroid group, three patients (25%) presented with an acute rejection episode. All but one patient in either group showed immediate graft function. Patients in the steroid‐withdrawal group exhibited a significantly higher creatinine clearance at 6 and 12 months post‐transplant (95.8 ± 23.3 vs. 71.3 ± 21.9, p = 0.03; and 91.3 ± 21.6 vs. 69.6 ± 28.6, p = 0.04). In the SWG delta BMI was significantly lower and delta height Z score was significantly higher, and we observed significantly less hyperlipidemia, body disfigurement, and need for anti‐hypertensive medication. Early steroid withdrawal in pediatric renal transplant recipients is efficacious and safe and does not increase risk of rejection, preserving optimal growth and renal function, and reducing cardiovascular risk factors.

Identification of medication non‐adherence factors in adolescent transplant patients: The patient's viewpoint

Abstract:  Studies report a clear association between medication non‐adherence and an unfavorable transplant outcome. The adolescent population, in particular, has difficulty adhering to post‐transplant medication regimens. The purpose of this study is to identify, categorize and understand the opinions of adolescent transplant patients regarding why they may not take their medications as prescribed. From January to August 2005, nine adolescent kidney transplant patients at an urban medical center were surveyed and asked to rank‐order 33 statements regarding their opinions on why adolescents may not take their medications as prescribed. Q‐methodology, a powerful tool in subjective study, was used to identify and categorize the viewpoints of adolescents on this subject. Three factors emerged and were labeled to reflect their distinct viewpoints: (1) Medication Issues (e.g. taste, size, frequency, schedule), (2) Troubled Adolescent (e.g. poor home life, depression, overwhelming situation), and (3) Deliberate Non‐Adherer (e.g. attention‐seeker, infallible attitude). By understanding these different viewpoints and the factors that contribute to them, it may be easier to identify which management approach to non‐adherence works best in specific subgroups of patients.

A Review of Pharmacological Management of Attention-Deficit/Hyperactivity Disorder.

Attention-deficit/hyperactivity disorder (ADHD) is a common psychological diagnosis in children. This disorder impacts children and adolescents in all areas of life, including academic performance, extracurricular activities, and social interactions. ADHD can continue into adulthood where unemployment and substance abuse has been described. Although behavioral therapy is recommended for all patients with ADHD, medication management typically is initiated soon after diagnosis. Psychostimulants remain the primary medication of choice. This review focuses on the clinical use of psychostimulant medication in children and adolescents. The pharmacodynamic and pharmacokinetic differences between the newest long-acting formulations as well as commonly encountered adverse drug reactions, with suggested management strategies, will be highlighted. Non-stimulant therapy with atomoxetine or alpha2-adrenergic agonists is also reviewed. These agents may be warranted for patients who cannot tolerate psychostimulant therapy or have a comorbid condition. Finally, the 8-year multimodal treatment study results are also discussed.

Approach to the Pediatric Prescription in a Community Pharmacy

Pediatric patients are more susceptible to medication errors for a variety of reasons including physical and social differences and the necessity for patient-specific dosing. As such, community pharmacists may feel uncomfortable in verifying or dispensing a prescription for a pediatric patient. However, the use of a systematic approach to the pediatric prescription can provide confidence to pharmacists and minimize the possibility of a medication error. The objective of this article is to provide the community pharmacist with an overview of the potential areas of medication errors in a prescription for a pediatric patient. Additionally, the article guides the community pharmacist through a pediatric prescription, highlighting common areas of medication errors.

Risk of serious bacterial infection associated with tumour necrosis factor-alpha inhibitors in children with juvenile idiopathic arthritis

Objectives TNF-α inhibitors (TNFIs) have a black box warning for increased risk of serious infection that was based on evidence from studies of adults. Evidence of the association is lacking for children. We aimed to examine the risk of infection posed by TNFIs compared with DMARDs in children with JIA. Methods We conducted a cohort study using the 2009-13 Truven MarketScan Commercial Claims and Encounters database. Children <16 years old with JIA who initiated monotherapy with TNFIs or DMARDs were identified and followed for occurrence of serious bacterial infection requiring hospitalization. Cox proportional hazard models were used to estimate hazard ratios for infection associated with TNFIs compared with DMARDs, adjusting for potential confounders with high-dimensional propensity scores and time-varying CS use. Results We identified 2013 DMARD initiators and 482 TNFI initiators with a mean follow-up of 255 and 307 days, respectively. We identified 18 and 11 patients with a serious infection in the DMARD and TNFI groups, resulting in crude rates of 1.28 (95% CI 0.76-2.02) and 2.72 (95%CI 1.36-4.86) per 100 person-years, respectively. In adjusted models, TNFIs were associated with an increased risk of serious bacterial infection compared with DMARDs (adjusted hazard ratio 2.72, 95% CI: 1.08, 6.86). Conclusion Use of TNFIs poses a higher risk of serious infection compared with DMARDs in children with JIA. Our analysis confirms the US Food and Drug Administration warning about TNFI-associated infection in children with JIA.

Use of Tumor Necrosis Factor-Alpha Inhibitors in Children and Young Adults With Juvenile Idiopathic Arthritis or Rheumatoid Arthritis.

To characterize the use of tumor necrosis factor‐α inhibitors (TNFIs) in children with juvenile idiopathic arthritis (JIA) and young adults with rheumatoid arthritis (RA).

Top-down Versus Step-up Prescribing Strategies for Tumor Necrosis Factor Alpha Inhibitors in Children and Young Adults with Inflammatory Bowel Disease

Background:Early initiation of tumor necrosis factor-alpha inhibitor (TNFI) therapy for children and young adults with inflammatory bowel disease (IBD) is not well described. Methods:We conducted a retrospective cohort study of children and young adults (⩽24 yr) newly diagnosed with IBD using health insurance claims from 2009 to 2013. The conventional “step-up” approach was defined as TNFI initiation >30 days after first IBD medication prescription, whereas the “top-down” approach was defined as new TNFI prescription within 30 days of first IBD medication prescription. Switching rates, time to initiation, discontinuation, and adherence to TNFIs were compared between the 2 strategies. Results:A total of 11,962 IBD patients were identified. Among 3300 TNFI users, 1298 (39.3%) were treated with the top-down approach, whereas 2002 (60.7%) were treated with the step-up approach. Top-down approach use increased from 31.4% to 49.8% during the 5-year period, and under this approach, most patients were treated with TNFIs alone. Time to TNFI initiation was shorter for patients diagnosed in more recent years. Patients treated with the top-down strategy had lower rates of corticosteroid use (32.5% versus 94.2%) compared with step-up treatment but presented a higher rate of TNFI discontinuation. The 2 strategies both exhibited high adherence (mean proportion of days covered: 83.7%–95.4%). Conclusions:Early TNFI initiation increased over time for children and young adults with IBD and was related to lower rates of corticosteroid use compared with the conventional approach. However, the higher rate of TNFI discontinuation under the top-down approach requires further examination.

Encouraging pharmacist intervention and standardization of labeling and dispensing of oral liquid medications

OBJECTIVES To initiate a call to action for community pharmacists and key-pharmacy stakeholders in the standardization of oral-liquid dosage forms. DATA SOURCES Not applicable. SUMMARY Unintentional overdose of medication due to administration error results in thousands of pediatric hospitalizations yearly. A lack of prescription and dosage device standardization pertaining to oral-liquid medications continue to be a public health hazard. Multiple professional organizations have publicly endorsed the standardization of oral liquid dosage forms. Universal adoption will not be achieved until key-pharmacy stakeholders encourage their pharmacists to use best practices when verifying and preparing prescription medication. Specifically, these practices should include immediate conversion of prescriptions containing non-metric volumes into metric volumes, providing appropriate sized oral dosing syringes for all oral liquid prescriptions, writing dosing directions in the safest format, and counseling patients and caretakers of proper medication administration. CONCLUSION Community pharmacists are uniquely positioned to lead the universal adoption of these best practices to ensure proper oral-liquid dosing administration for all patients.

The Latest Update on Over-the-Counter Cough and Cold Product Use in Children

The use of over-the-counter (OTC) cough and cold products in children has become a hot topic in the news in the past year due to the potential risk associated with using these products in children. The most recent recommendations were announced in October 2008 from The Consumer Healthcare Products Association (CHPA) which stated that OTC cough and cold medications should not be used in children less than 4 years old.(1) Because of this, parents and healthcare professionals have many questions and concerns. This article will review the current data supporting the recent recommendations and provide strategies and suggestions for educating parents and caregivers when a child has complaints of cough and cold symptoms.

Considerations for Providing Ambulatory Pharmacy Services for Pediatric Patients

Pediatric clinical pharmacists are an integral part of the health care team. By practicing in an ambulatory care clinic, they can reduce the risk of medication errors, improve health outcomes, and enhance patient care. Unfortunately, because of limited data, misconceptions surrounding the role of pharmacists, and reimbursement challenges, there may be difficulty in establishing or expanding pediatric clinical pharmacy services to an ambulatory care setting. The purpose of this paper is to provide an overview of considerations for establishing or expanding pharmacy services in a pediatric ambulatory care clinic. The primer will discuss general and pediatric-specific pharmacy practice information, as well as potential barriers, and recommendations for identifying a practice site, creating a business plan, and integrating these services into a clinic setting.