Improving inpatient warfarin therapy safety using a pharmacist-managed protocol

Optimizing drug therapy for older adults: shifting away from problematic polypharmacy

INTRODUCTION

The accelerated discovery and production of pharmaceutical products has resulted in many positive outcomes. However, this progress has also contributed to problematic polypharmacy, one of the rapidly growing threats to public health in this century. Problematic polypharmacy results in adverse patient outcomes and imposes increased strain and financial burden on healthcare systems.

AREAS COVERED

A review was conducted on the current body of evidence concerning factors contributing to and consequences of problematic polypharmacy. Recent trials investigating interventions that target polypharmacy and emerging solutions, including incorporation of artificial intelligence, are also examined in this article.

EXPERT OPINION

To shift away from problematic polypharmacy, a multifaceted interdisciplinary approach is necessary. Any potentially successful strategy must be adapted to suit various healthcare settings and must utilize all available resources, including artificial intelligence.

Impact of Clinical Pharmacist Running Anticoagulation Clinic in Saudi Arabia

Despite the effectiveness of warfarin in extended anticoagulation, its narrow therapeutic index requires frequent dose adjustments and careful patient monitoring. Thus, we aimed to evaluate the outcomes of clinical pharmacists' intervention in warfarin therapy management in terms of International Normalized Ratio (INR) control, reduction of bleeding, and hospitalization in a tertiary care hospital. An observational retrospective cohort study was conducted on 96 patients taking warfarin therapy in a clinical pharmacist-led anticoagulation clinic. We observed that 39.6% of patients required dose adjustments at their first and second visits. However, dose adjustments during the third, fourth, and fifth weeks were required at 31.1%, 20.8%, and 4.2%, respectively, to achieve INR levels. We also observed that 36.46% of the patients attained the target INR at baseline, which was increased over the first week to the fifth week to 57.29%, 61.46%, 61.46%, 68.75%, and 85.42%, respectively. No one reported the ADR between the third and fifth weeks. Based on our findings, the study strongly suggests that pharmacists' interventions can improve the health-related quality of life of patients undergoing warfarin therapy. Thus, competent pharmacy personnel must be a priority in both usual patient care and critical care among primary care networks.

Advances in Pharmacy Practice: A Look towards the Future

This review looks at the factors that may influence practice in the future. Transformation could occur at 3 levels. Firstly, the traditional profession of the pharmacist as a dispenser of medicines is expanding. Secondly, the pharmacist’s activities are progressing into new healthcare fields. Thirdly, other changes are stimulated by global developments. This review may be helpful for pharmacy and healthcare leaders looking at the future configuration and aims of their pharmacy services.

Evaluation of a Standardized Tacrolimus Therapeutic Drug Monitoring Protocol in Stable Kidney Transplant Recipients

INTRODUCTION

Transplant nurse coordinators have assisted in accurately adjusting tacrolimus doses under a collaborative practice agreement for kidney transplant recipients in the early post-operative period. This study evaluated the efficiency of a standardized tacrolimus therapeutic drug monitoring (TDM) protocol in stable outpatient recipients.

DESIGN

We conducted a single-center, retrospective study of adult patients who received a kidney transplant at least 3 years ago and were taking immediate-release tacrolimus. Before September 2019, transplant coordinators consulted transplant providers for management of all tacrolimus trough levels (Pre-Arm). Under the standardized protocol, coordinators directly responded to out-of-range tacrolimus trough levels (Post-Arm). The primary outcome was the time to intervention for out-of-range levels. Secondary outcomes included adverse events, time in therapeutic range, coefficient of variation (CV), and protocol compliance.

RESULTS

Of 1712 levels (from 174 patients), 259 levels (15.1%) were out-of-range. The overall time to intervention was 13.2 hours shorter (95% CI: -26.4 to -0.1 hours; P = 0.048) in the Post-Arm. There was no rejection, graft loss, or death during the study period. The time in therapeutic range was 89.3% (17.6%) vs 89% (19.4%; P = 0.816) and CV was 19.7% (15.8%) vs 18.4 (10.7%; P = 0.358) in the Pre-Arm and Post-Arm, respectively. Within the Post-Arm, the protocol required coordinators to independently intervene on 96 out-of-range levels (65.8%), which were accurately addressed 57.5% of the time.

CONCLUSION

Implementation of a standardized TDM protocol improved efficiency without compromising major clinical outcomes or intrapatient variability (IPV) of tacrolimus levels for stable kidney recipients in the outpatient setting.

Implementation, utilization, and evaluation of a pharmacist-driven romiplostim dosing service for patients with immune thrombocytopenia at a multisite cancer centre

Introduction

Romiplostim is a thrombopoietin receptor agonist approved for the treatment of patients with chronic immune thrombocytopenia who have had an insufficient response to corticosteroids, immune globulin, or splenectomy. Dose adjustments of romiplostim are based on platelet counts and follow a dosing schema that requires frequent monitoring. As a quality improvement initiative to increase clinical efficiency and promote clinical pharmacy services at our institution, we developed a collaborative practice agreement and implemented a novel pharmacist-driven romiplostim dosing protocol.

Methods

A retrospective chart review was conducted to evaluate the acceptance, utilization, and impact of the pharmacist-driven romiplostim dosing service. The primary outcome of our analysis was the adoption rate by providers of the romiplostim pharmacist dosing service. Secondary endpoints were focused on patients newly initiating romiplostim on the dosing service and included platelet responses and number of dose adjustments by a pharmacist

Results

A total of 54 patients received romiplostim in our analysis: 25 patients who had already been receiving romiplostim and 29 patients who newly initiated romiplostim during the study period. Of the 29 patients newly initiating romiplostim, 27 (93%) had their dosing managed by a pharmacist Twenty-one patients (84%) and 18 patients (75%) achieved an initial and durable response with romiplostim, respectively. Pharmacists made a median of 3 dose adjustments to romiplostim per patient.

Conclusion

The implementation of a pharmacist-driven romiplostim dosing service led to a significant adoption and utilization by physicians at our health system.

The Impact of Pharmacist-Managed Service on Warfarin Therapy in Patients after Mechanical Valve Replacement

OBJECTIVE

To evaluate the impact of pharmacist interventions on international normalized ratio (INR) control during the warfarin initiation phase after mechanical valve replacement.

METHODS

This was a retrospective cohort study conducted in a cardiovascular surgery ward in a tertiary hospital from August 1, 2015, to July 31, 2019. Patients aged ≥20 years who were admitted for mechanical valve replacement were enrolled in this study and further classified into conventional and pharmacist-managed warfarin therapy (PMWT) groups. All participants were prospectively followed up until the first outpatient appointment after valve replacement. The effectiveness outcomes were time in therapeutic range (TTR), time to therapeutic INR, number of patients with therapeutic INR at discharge and at first outpatient appointment, and length of hospital stay. The safety outcome was the number of patients with any supratherapeutic INR during the hospital stay. Multivariate logistic regression analyses were also used to determine the predictors of a therapeutic INR at discharge or with any supratherapeutic INR during admission.

RESULTS

A total of 39 and 33 patients were enrolled in the conventional and PMWT groups, respectively. At discharge, 18 patients (46.2%) in the conventional group and 24 patients (72.7%) in the PMWT group had achieved the therapeutic INR (P=0.023). Compared to the conventional group, fewer patients in the PMWT group had supratherapeutic INR during hospital stay (35.9% vs. 9.0%, P=0.008). No significant differences were found in TTR, time to therapeutic INR, number of patients with therapeutic INR at return appointment, and length of stay between the study groups. In the multivariate regression analyses, PMWT predicted achieving therapeutic INR at discharge (odds ratio (OR) and 95% confidence interval (CI), 3.14 [1.08-9.14]) and was inversely associated with supratherapeutic INRs during admission (OR = 0.21 [0.05-0.82]).

CONCLUSIONS

Among patients admitted for mechanical valve replacement, the implementation of PMWT was associated with optimal therapeutic INR at discharge and no supratherapeutic INR during admission. Therefore, pharmacist participation is essential for improving the quality of warfarin therapy.

Impact of a Pharmacist Intervention in the Emergency Department on the Appropriateness of Direct Oral Anticoagulants Prescribed in Venous Thromboembolism Patients

BACKGROUND

It is now widely accepted to manage low risk acute venous thromboembolism (VTE) in the outpatient setting with direct oral anticoagulants (DOACs). Although DOACs are straightforward to dose, they are high risk medications and not immune to medication errors. There is limited evidence that pharmacists' intervention has an impact on DOAC discharge medication errors in the ED.

OBJECTIVE

To determine if pharmacist involvement reduced the rate of DOAC discharge medication errors in low risk VTE patients.

METHODS

This retrospective cohort study evaluated a clinical pharmacy service implemented prior to the study. Included patients were evaluated in 2 groups: the cohort with pharmacist involvement and the cohort without pharmacist involvement. The primary outcome was the rate of anticoagulation medication errors.

RESULTS

A total of 58 patients were evaluated. Of these patients, 14 had a pharmacist directly involved with their care in the ED while 44 patients did not. The rate of medication errors was lower when a pharmacist was involved, 7.1% (n = 1), compared to when a pharmacist was not involved, 36.4% (n = 16), (p = 0.046). All patients in the pharmacist involvement group received anticoagulation counseling prior to discharge compared to only 56.8% of patients in the non-pharmacist involvement group (p = 0.002).

CONCLUSION

Our protocol for pharmacist involvement at the time of VTE diagnosis during an ED admission showed a reduced rate of anticoagulation medication errors when a pharmacist was involved. This benefit could potentially translate into improved outcomes such as readmission rates, patient safety outcomes, and hospitalizations.

[Pharmacist-led anticoagulation monitoring can significantly improve the effectiveness and safety of warfarin for patients during hospitalization]

OBJECTIVE

To investigate the role of pharmacist-led anticoagulation monitoring service for warfarin anticoagulation therapy in patients during hospitalization.

METHODS

We retrospectively analyzed the data of 421 patients receiving warfarin anticoagulation therapy during hospitalization between April, 2016 and December, 2017. Of these patients, 316 received daily pharmacist-led anticoagulation monitoring service including checking the patients' International Normalized Ratio (INR) and other pertinent laboratory test results and reviewing medication changes and the patients' clinical status (monitoring group); the other 105 patients receiving warfarin anticoagulation therapy without pharmaceutical care served as the control group. The data including compliance rate of anticoagulant indicators, incidence and rate of prompt management of INR alert, thrombosis and bleeding events during hospitalization were analyzed among these patients.

RESULTS

Compared with the control patients, the patients in the monitoring group showed a significantly higher percentage time within target INR range [(73.20±9.46)% vs (46.32±17.11)%, P < 0.001] and a higher qualified rate of INR before discharge (98.42% vs 60.95%, P < 0.001) as well as a higher proper INR-monitoring frequency (97.15% vs 66.67%, P < 0.001). The patients in the monitoring group showed a significantly lower incidence of INR alert than the control patients (8.23% vs 20.00%, P < 0.001) with also a much higher rate of prompt management (96.15% vs 33.33%). The two groups had similar incidences of clinical events except that the control group reported a higher incidence of minor bleeding episodes (9.52% vs 2.53%, P=0.005).

CONCLUSIONS

Pharmacist-led anticoagulation monitoring service can significantly improve the effectiveness and safety of warfarin anticoagulation therapy for patients during hospitalization.

The Impact of Implementing an Advance Practice Pharmacist-Led Anticoagulation Clinic Within a Correctional Facility

Maintaining warfarin in the therapeutic range is clinically challenging and can be made more complex in the correctional health setting. The care of an inmate population is complicated by its episodic and often brief nature in addition to the frequent lack of consistent care prior to incarceration. As part of a process improvement effort, a descriptive study was conducted on a unique pharmacist-led anticoagulation clinic that was initiated in the Los Angeles County jail. The advanced practice pharmacist (APP) used a Collaborative Practice Agreement and had access to a physician supervisor when necessary. The patients who arrived to the jail on warfarin had their doses adjusted by the APP according to their respective international normalized ratio (INR). The primary endpoints were percentage of INR readings within therapeutic range (RR) and time in therapeutic range (TTR). Secondary endpoints included bleeding and thrombotic events. A total of 141 patients were followed by the anticoagulation clinic over the initial 8-month period from September 2017 to April 2018. Indications for warfarin included deep vein thrombosis or pulmonary embolus (67%), mechanical valve (17%), atrial fibrillation (8%), and other (8%). The average RR was 74.1% in the 8 months following APP management, which met the definition of good control (>65%). The TTR was 67% which met the definition of good control (>65%). No bleeding or thrombotic events that required hospitalization occurred. Implementation of an APP-led anticoagulation clinic in a correctional health setting resulted in good INR control as defined in community standards.