A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity

Introduction

Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year.

Methods

The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department.

Results

Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months.

Conclusions

Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.

Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches

OBJECTIVE

The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation.

DATA SOURCES

A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation.

STUDY SELECTION AND DATA EXTRACTION

Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded.

DATA SYNTHESIS

After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV.

CONCLUSIONS

Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.

Low-dose intravenous immunoglobulin (IVIg) in different immune-mediated conditions

IVIg has been used for a long time as a replacement therapy for primary and secondary immunodeficiencies. Beside this supplementary role, when used at higher doses (i.e., 2 g/kg/monthly) it exerts an immunomodulatory role able to control multiple autoimmune and systemic inflammatory diseases. Several mechanisms of action have been described and hypothesized, nonetheless a synergistic action on the different component of the immune response seems to be crucial. The other side of the coin are the costs which showed an increase during the years due to the production of highly purified preparations which limit side reactions. This renders the product not easily accessible especially for low-income countries. Moreover, it is based on plasma donations that experienced a significant shrinkage after the COVID-19 pandemic and the consequences are still impactful. Due to the above-mentioned problems different authors tried to find out if a lower dosage of IVIg (< 2 g/kg/monthly) might exert an immunoregulatory role. In this review we aimed to summarize the current literature about a possible beneficial effect of a lower dosage of IVIg in multiple conditions that would help to treat a vast majority of patients. Even though in some cases (e.g., Kawasaki disease and immune thrombocytopenia) results are promising, for other conditions more research is needed.

Impact of guided weight-based medication dosing in pediatric patients with obesity

BACKGROUND

Obesity is a common disease state within pediatrics, with 19.7% of children in the United States classified as obese. Medication dosing in this population is a challenge not commonly examined in clinical drug trials. Dosing based on total body weight may not always be appropriate; therefore, ideal body weight (IBW) and adjusted body weight (AdjBW) may provide more effective dosing.

OBJECTIVE

The goal was to implement a dosing protocol for pediatric patients with obesity to improve adherence. The primary endpoint was to evaluate adherence to evidence-based dosing recommendations and the secondary endpoints included cost saving analysis for immune globulin and accurate charting of IBW and AdjBW.

METHODS

This was a single center, quality improvement project composed of pre- and post-implementation groups. An IBW and AdjBW calculator were implemented in our electronic health record, as customized enhancements, along with specific weight ordering options. A literature search of pharmacokinetic and pharmacodynamic dosing recommendations based on IBW and AdjBW was conducted. For both groups, patients were included if they were 3-18 years old, had a body mass index greater than or equal to the 95th percentile, and if they received a specified medication.

RESULTS

A total of 618 patients were identified with 24 and 56 patients included for the pre- and post-implementation groups. There were no statistically significant differences in baseline characteristics of the comparator groups. The usage of correct body weight increased from 1.2% to 24.2% after implementation and education (P < 0.001). Cost savings was analyzed for immune globulin with the potential for a net savings of $9423 ± 3626.92.

CONCLUSION

Dosing medications for our pediatric patients with obesity improved with the implementation of calculated dosing weights in the electronic health record, provision of an evidence-based dosing chart, and education of providers.

Immunoglobulin replacement in hematological malignancies: a focus on evidence, alternatives, dosing strategy, and cessation rule

Acquired hypogammaglobulinemia or secondary immunodeficiency (SID) occurs commonly in hematological malignancies with increasing incidence and complexity in the era of modern therapies. Despite current practice of immunoglobulin replacement (IgRT) in SID, the evidence is lacking, especially for newer treatments. We discuss the current evidence for IgRT in various disease groups including issues, such as actual or ideal body weight (IBW)-based dosing, length of treatment, antibiotic prophylaxis, and vaccination. Incidence of SID with newer treatment is lacking. While there is a trend toward decreased respiratory infections and hospitalizations with IgRT, this is not consistent across all disease course or treatment groups. Dosing and indications for cessation of IgRT are also inadequately characterized. Further randomized controlled trials (RCTs) and observational studies are required to assess the optimal indications, timing, and duration of IgRT to improve the efficacy, safety, and cost-effectiveness. Assessment of alternative and adjunctive therapies, such as vaccination and antibiotic prophylaxis could also improve the outcomes and costs.

Dealing With Immunoglobulin Shortages: A Rationalization Plan From Evidence-Based and Data Collection

Background

The demand and consumption of immunoglobulins (IgGs) are growing, and there are many difficulties in obtaining supplies. The aim of the study was to analyze the evolution of IgG consumption and cost over a decade, describe the measures implemented for clinical management in the context of regional public health system, and evaluate the initial impact of these measures.

Methods

We performed a retrospective longitudinal study including patients of all public health systems in Catalonia. First, we analyzed data on consumption and cost of IgGs during a period between 1 January, 2010 and 31 December 2021. Second, we analyzed the impact of a set of regional measures in terms of annual consumption and cost of IgGs. Regional measures were based on rational evidence-based measures and computer registries. We compared the data of year before applying intervention measures (1 January and 31 December 2020) with data of year after applying clinical management interventions (1 January and 31 December 2021). In addition, detailed information on clinical indications of IgG use between 1 January and 31 December 2021 was collected.

Results

Overall, in terms of population, the consumption of IgGs (g/1,000 inhabitants) increased from 40.4 in 2010 to 94.6 in 2021. The mean cost per patient increased from €10,930 in 2010 to €15,595 in 2021. After implementing the measures, the mean annual estimated consumption per patient in 2021 was statistically lower than the mean annual estimated consumption per patient in 2020 (mean difference −47 g, 95% CI −62.28 g, −31.72 g, p = 0.03). The mean annual estimated cost per patient in 2021 was also lower than the mean annual estimated cost per patient in 2020 (the mean difference was –€1,492, 95% CI –€2,132.12, –€851.88; p = 0.027). In 2021, according to evidence-based classification, 75.66% treatments were prescribed for a demonstrated therapeutic evidence-based indication, 12.17% for a developed therapeutic evidence-based indication, 4.66% for non-evidence-based therapeutic role indication, and 8.1% could not be classified because of lack of information.

Conclusion

The annual consumption and cost of IgGs have grown steadily over the last decade in our regional public health system. After implementing a set of regional measures, the annual consumption of IgGs per patient and annual cost per patient decreased. However, the decrease has occurred in the context of the coronavirus disease 2019 (COVID-19) pandemic, which may have influenced their clinical use. Managing the use of IgGs through a rational plan with strategies including evidence-based and data collection may be useful in a shortage situation with growing demand. Registries play a key role in collection of systematic data to analyze, synthesize, and obtain valuable information for decision support. The action developed needs close monitoring in order to verify its effectiveness.

The Trilogy of SARS-CoV-2 in Pediatrics (Part 2): Multisystem Inflammatory Syndrome in Children

Multisystem Inflammatory Syndrome in Children (MIS-C) was first recognized as a novel illness in 2020 with manifestations similar to other hyperinflammatory syndromes, such as Kawasaki disease or macrophage activation syndrome. Severity varies from a self-limited febrile illness to shock requiring inotropes and mechanical ventilation. Gastrointestinal symptoms and persistent fevers are the most common clinical symptoms, with the addition of cardiac manifestations inclusive of ventricular dysfunction and coronary artery aneurysms. With no controlled trials or comparative effectiveness studies evaluating treatment of MIS-C to date, current treatment with immunomodulatory agents has mainly been derived from previous experience treating Kawasaki disease. This article provides a comprehensive review summarizing published data for the evaluation and management of MIS-C, with a focus on pharmacotherapy treatment considerations.

Intravenous Immune Globulin (IVIG) for Treatment of Autoimmune Heparin-Induced Thrombocytopenia: A Systematic Review

OBJECTIVE

To evaluate intravenous immune globulin (IVIG) for autoimmune heparin-induced thrombocytopenia (aHIT), including platelet recovery, IVIG dose, dosing weight, IVIG product used, and complications reported.

DATA SOURCES

PubMed and EMBASE were searched from inception through June 21, 2020. Search terms included heparin-induced thrombocytopenia, HIT, intravenous immune globulin, IVIG, autoimmune HIT, aHIT, and immune globulin.

STUDY SELECTION AND DATA EXTRACTION

Patients administered IVIG for HIT and diagnosed by immunoassay (optical density ≥2) or positive activation assay were included.

DATA SYNTHESIS

Twenty-four cases were reviewed; 92% had persistent aHIT. Time to IVIG administration post-nonheparin anticoagulant initiation was 9 days (median). Most common IVIG cumulative dose was 2 g/kg (dosed as 1 g/kg/d for 2 consecutive days); 75% had a favorable platelet increase (≥50 × 10⁹/L) within 5 days of initial IVIG dosing.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

aHIT is characterized by critically low platelets, thrombosis, and a persistent delay in platelet recovery despite treatment with a nonheparin anticoagulant. An immunoassay and subsequent confirmatory activation assay (at low, high, and 0 IU/mL unfractionated heparin levels) is recommended to confirm diagnosis. Patients nonresponsive to nonheparin anticoagulants within 5 days of initiation should be evaluated for IVIG treatment (2 g/kg cumulative dose). More data are needed to clarify appropriate IVIG dosing weight, although based on current published literature, it is recommended to use actual body weight.

CONCLUSIONS

Data reported support use of IVIG as adjunctive therapy for patients with aHIT. Judicious IVIG use based on key clinical and laboratory findings is critical.

Hemolysis From Intravenous Immunoglobulin in Obese Patients With Kawasaki Disease

Objective: We assessed the risk of IVIG-associated hemolytic anemia in patients with acute Kawasaki disease (KD) and evaluated the risk of weight-based dosing in our obese patients. Methods: IVIG-associated hemolytic anemia was assessed in acute KD patients treated with IVIG at Rady Children's Hospital-San Diego. Patients in whom hemolytic anemia was suspected had a decrease in z-score of their hemoglobin (zHgb) at least two standard deviations below the cohort's mean change in zHgb from baseline to 2 weeks post-IVIG treatment. These patients were further evaluated for spherocytosis, blood type, need for transfusion, red cell distribution width, reticulocytosis, and direct Coombs test. Body mass index was calculated. Results: Of the 30 IVIG-resistant KD patients who received a second dose of IVIG, 2 (6.7%) developed hemolytic anemia after a total of 4 g/kg of IVIG dosed on actual body weight, or a mean of 4.6 g/kg of IVIG based on lean body mass. Compared to 496 non-obese KD patients who received a single dose of IVIG with no cases of hemolytic anemia, two (5.6%) of 36 obese KD patients developed hemolytic anemia after a single dose of IVIG (2 g/kg) dosed on actual body weight, or a mean of 2.7 g/kg IVIG based on lean body mass. Conclusions: In addition to following patients carefully for hemolytic anemia after a second dose of IVIG, physicians should consider IVIG dosing based on lean body mass for obese patients.