Pharmacy of the Eastern Vaud Hospitals

Prescribing medication is a routine part of an emergency physician's clinical practice. However, it carries significant risks that must not be overlooked. Many of the pathologies seen in the emergency department require patients to fast or make oral administration impossible. In such cases, it is critical to evaluate which medications should be continued or stopped, as inappropriate management can lead to clinical deterioration or serious adverse effects. Similarly, every new prescription introduces the potential for drug interactions with the patient's existing treatment regimen, while discontinuing a medication can also destabilize previously well-managed interactions. This underscores the importance of thorough medication reconciliation.

ObjectivesAutomated dispensing cabinets (ADCs) offer improved medication safety, greater efficiency and return on investment. However, integrating ADCs into medication dispensing processes can be challenging in complex hospital environments. This study aimed to draft suggestions to help hospitals adopt ADCs.MethodsTwo-day visits were organised in seven European hospitals operating ADCs. Investigators used an observational grid, a questionnaire and interviews, each divided into the themes of medication processes before and after the introduction of ADCs, the major steps followed and the resources involved, ergonomics and staff perceptions.ResultsADCs were integrated into four global hospital medication dispensing systems (packs of drugs are distributed from the central pharmacy to wards for dispensing) and three nominative systems—that is, patient-specific ones (drug doses prescribed for individuals are distributed from the central pharmacy to wards with ADC as supplementary stock). A general ADC project implementation timeline was shaped: main drivers of automation to initiate the project, visit of other sites, pilot test (with IT integration and staff training), and evaluation phase (satisfaction, safety, efficiency) to justify a possible expansion. Users (7 pharmacists, 21 nurses, 7 data engineers) identified facilitators (such as a dedicated project manager, a pilot phase, an intuitive device), barriers and any improvements needed (training for incoming staff, reorganisation of ward workflow, dynamic inventories).ConclusionsDespite their diverse pharmacy organisations, each hospital raised similar challenges and reported analogous major steps in project implementation. Although integration processes are complex, ADCs rapidly provide users with benefits. By following the practical advice and recommendations from these hospitals, new adopters might reduce the risks of failed ADC projects and accelerate their integration.

Therapeutic drug monitoring (TDM) of conventional cytotoxic chemotherapies is strongly supported yet poorly implemented in daily practice in hospitals. Analytical methods for the quantification of cytotoxic drugs are instead widely presented in the scientific literature, while the use of these therapeutics is expected to keep going for longer. There are two main issues hindering the implementation of TDM: turnaround time, which is incompatible with the dosage profiles of these drugs, and exposure surrogate marker, namely total area under the curve (AUC). Therefore, this perspective article aims to define the adjustment needed from current to efficient TDM practice for cytotoxics, namely point-of-care (POC) TDM. For real-time dose adjustment, which is required for chemotherapies, such POC TDM is only achievable with analytical methods that match the sensitivity and selectivity of current methods, such as chromatography, as well as model-informed precision dosing platforms to assist the oncologist with dose fine-tuning based on quantification results and targeted intervals.

Objetivo: Señalar la importancia de realizar tamiz neonatal de forma universal de Fenilcetonuria. Material y Método: Revisión de Historia Clínica y literatura. Resultado: (Caso Clínico) Recién nacido de sexo femenino, dado de alta como recién nacido sana, con resultado de tamiz neonatal para Fenilcetonuria de 7,789 mg/dl de Fenilalanina en sangre (Valor Normal < 3 mg/dl), valor de segunda muestra: 27,210 mg/dl, paciente es transferida al Hospital Edgardo Rebagliati Martins- Lima-Perú. Se trató con formula libre de Fenilalanina y rica en tirosina. Conclusión. La FCU puede ser diagnosticada tempranamente por tamiz neonatal, realizado de rutina en ESSALUD; sin embargo, existen niños a los que no se les práctica, por lo que es muy importante reconocer la enfermedad para diagnosticarla previo al daño neurológico, así como incorporar el programa de tamizaje neonatal en toda entidad de salud. Palabras clave. Fenilcetonuria, tamizaje neonatal, tirosina (DeCS). DOI: http://dx.doi.org/10.17268/rmt.2020.v15i04.09

In recent years, there has been a growing interest in using baclofen for the management of alcohol use disorder. This off-label indication usually involves high doses of the medication. We report a case of severe baclofen overdose in a 66-year-old man. The patient was found severely agitated, and he presented with delirium and auditory hallucinations. At hospital admission, his daily dose was 180 mg baclofen. He was admitted to the intensive care unit for sedation and supportive care. When sedation was withdrawn, the patient presented with a normal neurological status. In this clinical context, baclofen intoxication was suspected. This was confirmed by measuring blood baclofen levels. This intoxication was probably mediated by a combination of risk factors including a high daily dose of baclofen and acute renal failure, conducive to drug accumulation.

Erlotinib is currently marketed at fixed standard dosage against pancreatic cancer and non-small-cell lung carcinoma. However, erlotinib pharmacokinetics (PK) is characterized by significant variability that may affect efficacy and tolerability. The aim of this review is to assess evidence that would justify therapeutic drug monitoring (TDM) and provide key information for the interpretation of erlotinib plasma concentrations. Literature was systematically reviewed to evaluate the standard criteria defining the potential clinical usefulness of TDM. Assessment was focused on the existence of unpredictable and wide PK variability and of consistent PK-pharmacodynamic relationships. PK parameters actually show marked variability (apparent clearance estimated to 4.85 ± 4.71 L/h, elimination half-life to 21.86 ± 28.35 hours, and apparent volume of distribution to 208 ± 133 L). Many covariates influence these parameters (CYP3A4 inducers or inhibitors, food, age, liver impairment), but most sources of variability still have to be identified. Some studies have demonstrated a relationship between exposure to erlotinib and clinical outcomes or skin toxicity. Erlotinib activity and target concentrations furthermore depend on tumor characteristics (eg, mutations on epidermal growth factor receptor and on K-ras). These results are in favor of TDM in addition to treatment adjustment for tumor biomarkers, but prospective clinical trials validating its clinical benefits are lacking. This review provides all the relevant information available to assist clinical interpretation of erlotinib plasma measurements. PK percentile curves and consideration to covariates yield information on whether a concentration measured is expected, whereas half maximal inhibitory concentration values determined in vitro provide preliminary insights on target concentration values to reach. Eventually, dosage adaptation might be considered in patients with intolerable toxicity because of excessive plasma levels or conversely nonresponse imputable to insufficient exposure.