Direct oral anticoagulant (DOAC) medications have improved safety, efficacy, and laboratory monitoring requirements compared to warfarin. However, available data are limited on the frequency and clinical outcomes of pharmacist-driven warfarin-to-DOAC switches. We aimed to quantify the frequencies and rationale of warfarin-to-DOAC switches in an underserved population. We also assessed clinical outcomes and compliance with recommended laboratory monitoring after switches. This retrospective cohort study included adult (age 18 years or older) patients on warfarin who were assessed by a clinical pharmacist for switch appropriateness to a DOAC. Study data were collected via manual chart review and included demographics, comorbid illnesses, switch status, the rationale for or against switching, incidence of thromboses and bleeds within 6 months of the switch assessment, and the time to the first complete blood count and renal and hepatic function tests after the switch. Statistical analysis utilized descriptive statistics, including the mean and SD, median and interquartile range, and frequencies and percentages. Among 189 eligible patients, 108 (57%) were switched from warfarin to a DOAC. The primary rationales for switching were less monitoring (64%) and labile international normalized ratio (32%). The main reason against switching was DOAC inappropriateness (53%), such as in morbid obesity (14%). Patient preference was commonly cited in both groups (54% and 36%, respectively). The overall incidence of thrombotic events (9%) and bleeds (15%) after switch assessment was low. Laboratory monitoring after switches was consistent with current recommendations. No increase in harm was observed 6 months after switch assessment when pharmacists at a family medicine clinic switched underserved patients from warfarin to DOACs.

Vancomycin area under the concentration-time curve (AUC) can be calculated using steady-state serum peak and trough concentrations; however, compared to traditional trough-only monitoring, this approach requires an additional blood sample. Recently published data demonstrated vancomycin AUC estimations using trough-only data with a volume of distribution (Vd) model incorporating age and actual body weight were reasonably accurate and precise in a veteran population. This study sought to extend these methods to a Mayo Clinic adult population. A retrospective, observational cohort of adult patients with documented steady-state vancomycin peak and trough concentrations was evaluated. Vancomycin AUCs were estimated using trough-only data, and 4 Vd models were assessed for accuracy and precision. Estimated AUCs were compared to AUCs calculated using 1-compartment intermittent infusion equations and steady-state peak and trough ("peak-trough") data. The study population (N = 95) was 46% female, with a median age of 59 years and a median weight of 97 kg. Using the VancoPK equation Vd = 0.29 (age in y) + 0.33 (actual weight in kg) + 11, the mean peak-trough and estimated trough-only AUC were 533 and 534, respectively, with a correlation of 0.936. The root mean square error was 47.7, meaning about 95% of AUCs were within 95 mg · h/L of peak-trough AUCs. Accuracy and precision of Vancomycin AUC estimations using trough-only data and the described Vd model were demonstrated in a Mayo Clinic cohort. Targeting an estimated AUC of 500 mg · h/L using the VancoPK model would likely result in an actual AUC within 400 to 600 mg · h/L.

Myasthenia gravis (MG) is not commonly covered in pharmacy school curricula. However, many medications that have been reported to cause exacerbations of MG are among the top 200 most prescribed drugs. The purpose of this therapeutic update is to provide pharmacists with a general understanding of the pathophysiology and treatment of MG and describe common medications with the potential to cause new onset or acute worsening of this disease. MG is an autoimmune disorder in which patients develop autoantibodies to a component of the neuromuscular junction, most frequently the acetylcholine receptor, resulting in impairment of skeletal muscle contraction. Although MG is not highly prevalent, there are up to 60,000 individuals with MG in the US, making it a disease that many pharmacists will likely encounter at least once in their career. Immunosuppressant medications and acetylcholinesterase inhibitors are the mainstays of treatment, although there is limited evidence as to which agents are most efficacious. Medications that activate the immune system, such as immune checkpoint inhibitors, may cause new onset of disease, while those with actions on the neuromuscular junction, such as macrolides and fluoroquinolones, can cause acute worsening of disease. MG, although not frequently covered in pharmacy school curricula, is a disease state for which it is not uncommon for pharmacists to provide care. Treatment tends to be patient specific, and evidence is often weak. Many medications that cause new onset or worsening of MG are among the most prescribed. Key classes of medications to use with caution include macrolides, fluoroquinolones, β-blockers, and magnesium.

Journal Article Oteseconazole Get access American Journal of Health-System Pharmacy, Volume 79, Issue 23, 1 December 2022, Pages 2083–2085, https://doi.org/10.1093/ajhp/zxac247 Published: 29 September 2022 Article history Corrected and typeset: 29 September 2022 Published: 29 September 2022

Journal Article Corrected proof Ganaxolone Get access American Journal of Health-System Pharmacy, zxac219, https://doi.org/10.1093/ajhp/zxac219 Published: 13 September 2022 Article history Corrected and typeset: 13 September 2022 Published: 13 September 2022

The pharmacology, microbiology, pharmacokinetics, pharmacodynamics, efficacy, safety, and role of ibrexafungerp in the treatment of fungal infections are reviewed. Ibrexafungerp is the first triterpenoid antifungal. Similarly to echinocandins, it inhibits the synthesis of 1,3-β-d-glucan. However, it binds to a different site on the enzyme than echinocandins, resulting in limited cross-resistance. Ibrexafungerp exerts concentration-dependent fungicidal activity against Candida species and retains in vitro activity against most fluconazole-resistant strains. It is also active against Aspergillus species. Ibrexafungerp has been shown to be safe and effective in the treatment of vulvovaginal candidiasis caused by Candida albicans in phase 2 and phase 3 clinical trials. It is approved for vulvovaginal candidiasis in adult and postmenarchal pediatric females and is given as two 150-mg tablets orally, administered 12 hours apart. Ibrexafungerp is contraindicated in pregnancy. The most commonly reported adverse reactions were diarrhea, nausea, abdominal pain, dizziness, and vomiting. Ibrexafungerp should be avoided with strong or moderate CYP3A inducers, and the dose should be reduced with strong CYP3A inhibitors. Ibrexafungerp may be useful for patients who are not able to receive fluconazole or prefer oral therapy for the treatment of vulvovaginal candidiasis. However, it is more expensive than the 150-mg tablet of generic fluconazole, which is the current standard of care for vulvovaginal candidiasis. Clinical trials are ongoing for recurrent and complicated vulvovaginal candidiasis as well as invasive candidiasis and pulmonary aspergillosis. Ibrexafungerp is an alternative to fluconazole for the treatment of vulvovaginal candidiasis in nonpregnant females. It has the potential to be useful for recurrent and complicated vulvovaginal candidiasis as well as certain invasive fungal infections.

The purpose of this study was to investigate the effects of the smartphone-based meditation app Ten Percent Happier on stress, mindfulness, well-being, and resilience in pharmacy students. Pharmacy students in a professional year of study were recruited to participate. Students were instructed to meditate using the Ten Percent Happier app for at least 5 days a week for 4 weeks. Students could use the app at their discretion for weeks 5 to 12. Baseline, week 4, and week 12 responses were collected from the following instruments: the Perceived Stress Scale, the Five-Facet Mindfulness Questionnaire-15, the Flourishing Scale, and the Brief Resilience Scale. Eighty-nine pharmacy students volunteered for the study. Sixty (67%) enrolled by completing the baseline survey. Of these, 28 (47%) completed the week 4 survey and 22 (37%) completed the week 12 survey. Participants experienced a reduction in perceived stress (P = 0.0005) and increases in resilience (P < 0.0001) and well-being (P = 0.0006). Increases in mindfulness were seen in 4 of the 5 subscales of the Five-Facet Mindfulness Questionnaire-15 (P ≤ 0.05). These benefits were noted at week 4 and maintained at week 12. Pharmacy students who practiced mindful meditation through the Ten Percent Happier app for an average of 5 days a week for 4 weeks experienced reduced stress and improved mindfulness, well-being, and resilience. Benefits experienced during the intervention were maintained at the 8-week follow-up, despite app usage decreasing to an average of 4 days a week.

To describe the implementation and validation of a novel patient profile review tool in the electronic medical record (EMR) at an academic medical center. Pharmacy leaders at The Ohio State University Wexner Medical Center aspired to develop a data-driven approach to clinical pharmacy services. The initial phase of this vision highlighted a need to define the clinical activities of a pharmacist and leverage use of the EMR to seamlessly capture data. A comprehensive list of clinical activities was developed and analyzed to determine which activities were currently uncaptured. Patient profile review was prioritized and determined to be variable among staff and undefined. A profile review tool was developed and implemented across the medical center while requiring minimal additional documentation through the EMR. Phase II determined what user audit trail data in the EMR were automatically recorded based on performing various levels of pharmacist-recorded profile review and validated the consistency in utilization of this tool. The information gathered as a result of this study identified interactions within the patient chart that matched profile reviews that were not captured during manual documentation. The department of pharmacy will utilize the data generated from this tool to better make decisions and build a comprehensive clinical productivity model. The implementation of a pharmacist patient profile review tool built within the EMR successfully defined, stratified, validated time spent on, and captured a clinical activity.

Escape rooms are effective educational tools for engaging learners and may serve as a strategy for medication safety training to increase perceived learned safety measures and knowledge retention. Escape rooms are lifelike environments in which participants work together to solve a succession of puzzles to escape a locked room in the allotted time. Novel medication safety training modules such as a pharmacy escape room allow medical errors to be simulated in a team-based, controlled environment focusing on system improvement to establish a culture of safety. This project was conducted to improve medication safety knowledge using a novel pharmacy escape room training module piloted within a large, integrated pharmacy department. Several pilot groups of 2 or more pharmacy employees took part in a virtual medication safety escape room as part of a training module at Advocate Aurora Health between January and March 2021. Participants included pharmacists and pharmacy technicians employed at Aurora St. Luke's Medical Center, Aurora Sinai Medical Center, and Pharmacy Integrated Clinical Services. Assessments were administered before and after completion of the escape room module to evaluate medication safety knowledge and perceived learned safety measures by comparing scores. A total of 101 employees participated in the pharmacy escape room, with an average escape time of 42 minutes. Overall assessment scores before completion of the escape room module ranged from 20% to 86.6%, while those afterwards ranged from 33.3% to 93.3%. Participant feedback was positive, with reports that the novel escape room training module was more engaging and interactive than the alternative online self-paced learning modules. Virtual escape rooms can be used as a novel medication safety training module to increase medication safety knowledge and allow medical errors to be simulated in a controlled environment. Incorporating high-reliability tools and tactics into development of the escape room can promote safe medication practices and reinforce principles of high-reliability organizations.

To describe the implementation and operationalization of a β-lactam (BL) therapeutic drug monitoring (TDM) program at a large academic center. BLs are the most used class of antibiotics. Suboptimal antibiotic exposure is a significant concern in hospitalized patients, particularly in those with altered pharmacokinetics. BL-TDM provides clinicians the opportunity to optimize drug concentrations to ensure maximal therapeutic efficacy while minimizing toxicity. However, BL-TDM has not been widely adopted due to the lack of access to assays. The University of Florida Shands Hospital developed a BL-TDM program in 2015. This is a consultative service primarily run by pharmacists and is conducted in all patient care areas. An analysis was performed on the first BL-TDM encounter for 1,438 patients. BL-TDM was most frequently performed for cefepime (61%, n = 882), piperacillin (15%, n = 218), and meropenem (11%, n = 151). BL-TDM was performed a median of 3 days (interquartile range, 1-5 days) from BL initiation. Among patients with available minimum inhibitory concentration (MIC) values and trough concentrations, the pharmacokinetic/pharmacodynamic (PK/PD) target of 100% fT>MIC was attained in 308 patients (88%). BL-TDM resulted in a dosage adjustment in 25% (n = 361) of patients. Implementation of a BL-TDM program requires the concerted efforts of physicians, pharmacists, nursing staff, phlebotomists, and personnel in the analytical laboratory. Standard antibiotic dosing failed to achieve optimal PK/PD targets in all patients; utilizing BL-TDM, dose adjustments were made in 1 of every 4 patients.