Marilyn N. Bulloch

Provision of clinical pharmacist services for individuals with chronic hepatitis C viral infection: Joint opinion of the GI/liver/nutrition and infectious diseases practice and research networks of the American College of Clinical Pharmacy

The objective of this opinion paper was to identify and describe potential clinical pharmacists’ services for the prevention and management of patients infected with the hepatitis C virus (HCV). The goals of this paper are to guide the establishment and development of pharmacy services for patients infected with HCV and to highlight HCV research and educational opportunities. Recommendations were based on the following: a review of published data on clinical pharmacist involvement in the treatment and management of HCV‐infected patients; a consensus of clinical pharmacists who provide direct patient care to HCV‐infected patients and practice in different pharmacy models, including community‐based and academic settings; and a review of published guidelines and literature focusing on the treatment and management of HCV infections. The recommendations provided in this opinion paper define the areas of clinical pharmacist involvement and clinical pharmacy practice in the treatment and management of patients with HCV. Clinical pharmacists can promote preventive measures and education about reducing HCV transmission, improve medication adherence, assist in monitoring clinical and adverse effects, recommend treatment strategies to minimize adverse effects and drug interactions, and facilitate medication acquisition and logistics that positively improve patient outcomes and reduce the health care system costs.

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.

Approximately 16–31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol‐related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom‐triggered treatment of AWS with γ‐aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first‐line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD‐resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD‐resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD‐resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.

Fentanyl pectin nasal spray: a novel intranasal delivery method for the treatment of breakthrough cancer pain

Fentanyl pectin nasal spray is a novel intranasal formulation for the management of breakthrough cancer pain in patients taking and tolerant to opioids for persistent cancer pain. The pectin-based delivery modulates the product’s transmucosal absorption. Nasal delivery allows fentanyl pectin nasal spray to achieve a greater maximum plasma concentration than oral transmucosal fentanyl products and at a much faster rate. Compared with intranasal fentanyl compounded with aqueous solutions, the pectin-based system decreases the maximum plasma concentration and prolongs exposure to more closely match the time course of a typical breakthrough cancer pain episode. Throughout all phases of clinical studies, it was shown to be safe and effective in doses between 100 and 800 µg per breakthrough pain episode. Fentanyl pectin nasal spray is the only proprietary intranasal fentanyl formulation in the USA and one of two in Europe. Owing to the medication’s delivery system, the pharmacokinetics and subsequent dosing are unique to this product and should not be interchanged with any other proprietary or compounded fentanyl product.

Clindamycin-induced hypersensitivity reaction

AbstractDrug-induced anaphylaxis is an unpredictable adverse reaction. Although it may occur with any medication, antibiotics induce more cases of anaphylaxis than any other medication class with most cases being induced by β-lactam antibiotics. Clindamycin is an antibiotic with good gram-positive and anaerobe coverage which is often used in patients with β-lactam allergies. We report the case of a 46-year-old female who experienced anaphylaxis after a dose of intravenous (IV) clindamycin. Following treatment with methylprednisolone, epinephrine, diphenhydramine, and albuterol, the patient stabilized. The patient’s score on the Naranjo’s algorithm was 8 (probable); a score of 9 (definite) limited only by absence of drug re-challenge. To our knowledge, this is the first report of a clindamycin-induced anaphylaxis where the patient was not exposed to any other agent that may have triggered the response, the first case in the United States, and only the third documented case in the literature. Clinicians should be aware of the potential for drug-induced anaphylaxis in all medications.

Ulipristal acetate: a new emergency contraceptive

Ulipristal acetate (UPA) is a newly developed emergency contraceptive currently available in the USA and Europe. It is approved as a 30 mg one-time dose taken within 120 h (5 days) of unprotected intercourse or failed contraception. This selective progesterone receptor modulator appears to be more effective than the levonorgestrel-containing emergency contraceptive, which must be taken within 72 h of unprotected intercourse. According to pharmacodynamic trials, UPA delays follicular maturation and ovulation. In addition, UPA may modulate the endometrium. Both Phase III clinical trials found that UPA does not lose efficacy within the 120-h dosing interval. Throughout all phases of clinical studies, UPA was shown to be well tolerated with only minimal adverse drug reactions, all of which are similar to competitor therapies.

Tolvaptan: a vasopressin antagonist for the management of euvolemic and hypervolemic hyponatremia

Tolvaptan is a new vasopressin antagonist developed for the treatment of hypervolemic or euvolemic hyponatremia. It has greater affinity for the V2 receptor than native vasopressin or any other vasopressin antagonist. Blockade of the V2 receptor induces solute-free water excretion without affecting normal electrolyte excretion. The pharmacokinetics and pharmacodynamics of tolvaptan are suitable for once-daily dosing. Throughout all phases of clinical studies, it was shown to be safe for short- and long-term use. Tolvaptan effectively increases serum sodium levels in patients with heart failure, cirrhosis and syndrome of inappropriate secretion of antidiuretic hormone. In patients hospitalized owing to heart failure, tolvaptan decreased bodyweight, increased urine output and improved dyspnea compared with placebo. However, tolvaptan has not proven to be beneficial for the long-term management of heart failure. Currently, tolvaptan is the only oral agent in its class available in the USA and Europe.

Impact of the Joint Commission Pneumonia Core Measure on Antibiotic Use and Selection for Community-Acquired Pneumonia in the Emergency Room:

Background Prior to 2012, The Joint Commission (TJC) pneumonia core measure (PN-5) required antibiotic administration for suspected community-acquired pneumonia (CAP) within 6 hours of arrival to the emergency room (ER). In 2012, TJC issued PN-6 requiring antibiotic administration within 24 hours of presentation. Though PN-6 was anticipated to reduce overuse and inappropriate antibiotic use and improve appropriate antibiotic selection, the impact of PN-5 and PN-6 on optimizing care for CAP in the ER remains unknown. Objective To investigate the impact of TJC pneumonia core measures on antibiotic use in the ER for suspected CAP. Methods In this single-center study, medical records of patients 18 years old and older diagnosed with CAP in the ER during 2011 (PN-5) and 2012 (PN-6) and admitted for 1 day or longer were reviewed. Exclusion criteria included criteria for health care–associated pneumonia. Comparisons between groups were performed using descriptive statistics and contingency table analysis with chi-square or Fisher exact tests for categorical variables and t tests for continuous variables. Statistical analyses were performed using Microsoft Excel 2010 and SAS version 9.4. Results Antibiotic use was comparable between PN-5 and PN-6. Approximately half of patients in each group received an appropriate empiric CAP regimen (52% vs 54%; P = .807). Among inappropriate regimens, the most common reason was use of a beta-lactam alone (69% vs 83%; P = .26). More patients had an ultimate diagnosis of CAP with PN-6 (78% vs 86%; P = .3). Conclusion Changes in pneumonia core measure requirements did not have a significant impact on appropriate antibiotic use in the ER.

1186: Clindamycin-induced hypersensitivity reaction

Introduction: Anaphylaxis is a rare, unpredictable reaction with sudden onset and can be fatal. It can occur with any drug, but is most commonly associated with β-lactam antibiotics. Though clindamycin has been associated with severe dermatologic and gastrointestinal effects, immediate hypersensitiv