Hospital Pharmacy

Adenosine is a potent endogenous mediator of vasodilation. Compounded sterile solutions of adenosine are used in cardiac catheterization lab to perform stress tests on the heart. These tests are used to determine the fractional flow reserve (FFR) and are commonly used in the management and diagnosis of cardiovascular conditions. The purpose of this study was to assess the physical and chemical stability of 2 mg/mL adenosine in 0.9% Sodium Chloride Injection, USP in polyvinyl chloride [PVC]) and polyolefin infusion bags stored at room temperature (20°C-25°C) and under refrigeration (2°C-8°C). The compounding and analytical methods used in this study were very similar to those described in the prior publications from the authors’ laboratory. To ensure a uniform starting concentration of all stability samples, a batch of 2 mg/mL adenosine solution was prepared and then packaged into empty PVC and polyolefin infusion bags. These stability samples were prepared in triplicate for each bag type and storage temperature (a total of 12 samples). The infusion bag samples were assessed for stability immediately after preparation and after 1 day, 3 days, 7 days, and 14 days. At each time point, the infusion bags were first visually inspected against a light background for color change, clarity, and particulates. Aliquots were drawn from each sample at each time point for pH analysis and high-performance liquid chromatography (HPLC) analysis. Over 14 days of storage at room temperature or refrigeration, no considerable change in visual appearance or pH was observed in any bags. All samples retained 90% to 110% of the initial drug concentration. No significant degradation peaks were observed in the HPLC chromatograms.

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.

Acute decompensated heart failure is a sudden worsening of heart failure symptoms, typically resulting in peripheral edema and dyspnea as a result of pulmonary congestion. Acute decompensated heart failure is responsible for over 1 million hospitalizations every year. Current pharmacologic therapy is limited in its options. Despite an improved survival rate, statistic still suggests that about 50% of patients die within 5 years of diagnosis. New pharmacologic agents aim to improve efficacy by targeting previously unexplored physiological pathways.

The Prescription Drug User Fee Act (PDUFA) was originally enacted into law in 1992. PDUFA provides the Food and Drug Administration (FDA) with needed revenue in the form of various fees paid by drug and biologic manufacturers. The FDA utilizes this revenue to streamline the review and approval process for medications. Since the enactment of PDUFA, the median approval time for priority new drug applications and biologics license applications has reduced significantly. The FDA views PDUFA as a successful program that provides a consistent revenue stream to the agency, improves access to medications for patients, and allows industry to have a more predictable product review timeline. However, critics of PDUFA cite concerns including the potential for a lack of FDA independence and medication safety issues involving drugs approved after the existence of PDUFA.

Purpose: The purpose of this article is to share experiences after the development of a health-system pharmacy administration residency with a MS degree and express the need for additional programs in nonacademic medical center health-system settings. Summary: Experiences with the development and implementation of a health-system pharmacy administration residency at a large community teaching hospital are described. Resident candidates benefit from collaborations with other health-systems through master’s degree programs and visibility to leaders at your health-system. Programs benefit from building a pipeline of future pharmacy administrators and by leveraging the skills of residents to contribute to projects and department-wide initiatives. Tools to assist in the implementation of a new pharmacy administration program are also described and include rotation and preceptor development, marketing and recruiting, financial evaluation, and steps to prepare for accreditation. Conclusion: Health-system pharmacy administration residents provide the opportunity to build a pipeline of high-quality leaders, provide high-level project involvement, and produce a positive return on investment (ROI) for health-systems. These programs should be explored in academic and nonacademic-based health-systems.

Background: Pharmacy residents’ knowledge of biostatistics is a self-identified deficit. Objective: To describe statistical training practices across postgraduate year 1 (PGY1) pharmacy residency programs and correlate training practices with residency program directors’ (RPDs) confidence in their residents’ statistical abilities. Methods: A 13-item survey was sent to PGY1 RPDs and included questions regarding respondents’ institution, program characteristics, type and amount of statistical training offered and desired, as well as performance of statistics, resident project publication rates, and RPDs’ confidence in residents’ statistical abilities. Results: Of the 1054 RPDs invited to participate in the survey, 202 (19.7%) surveys were completed. Nearly 25% of PGY1 pharmacy residency programs in this sample offered no statistical training to their residents. The most common types of training were study design considerations/selecting statistical tests (64.9%), descriptive statistics (59.9%), and database development/data manipulation (46.6%). The majority (60.9%) of RPDs had low confidence in their residents’ abilities to perform their own statistical analysis. After adjusting for significant covariates, residents receiving complex statistical training (odds ratio [OR]: 6.76; 95% confidence interval [CI]: 2.7-24.9) and a publication rate >50% (OR: 5.63; 95% CI: 1.61-19.69) were associated with higher RPD confidence in residents’ abilities to perform statistical analyses. Conclusion: The sample of programs in this survey indicates that statistical training for many residents may be limited, and many RPDs are not confident in their residents’ abilities to perform statistical analysis of research projects. Statistical training and opportunities to enhance research skills may be an area for future growth in pharmacy residency training programs.

Background: The monitoring of hypertension treatment can provide insight into the rational drug use pattern. The objective of this study was to examine the antihypertensive medication use among South Indian adults with hypertension in compliance with the hypertension treatment guidelines (Seventh Joint National Committee [JNC 7] and JNC 8). Methods and Results: A total of 550 hypertensive people aged >25 years were included in this retrospective cross-sectional study. The order of drugs prescribed in the year 2012 was beta blockers (BB) > calcium channel blockers (CCB) > CCB + BB > angiotensin receptor blockers (ARB) > angiotensin-converting enzyme inhibitors (ACEI) > thiazide diuretics, whereas in the year 2014, the order has changed drastically, namely, ACEI > CCB > ARB > BB > thiazide diuretics (P < .001). Most notably, there was a large increase in the use of monotherapy (from 56.9% to 82.5%, P < .001). The usage of BB has simply moved from the first position to the last position in concordance with JNC 8 guidelines, whereas use of thiazide diuretics was found to be the least preferred drug in the 2012 prescriptions, thus deviating from JNC 7 guidelines. The use of generic names (28.3% vs 11.3%) and National List of Essential Medicines (NLEM) compliance (79.3% vs 60.9%) were significantly more in the calendar year 2012 than in the calendar year 2014 (P < .001). Conclusions: Antihypertensive medication use has gone through wide variations among south Indian adults with hypertension. Combination therapy regimens must be adopted as per the guidelines for achievement of blood pressure goals.

Purpose:The role of health-system pharmacists continues to expand, and this area of pharmacy practice increasingly requires augmented baseline training. It is unclear how Post Graduate Year 1 (PGY-1) pharmacy residencies may be changing to meet these needs.The objectives of our survey were to describe PGY-1 pharmacy residency program design among academic medical centers, characterize program changes enacted over 5-year period, and describe career paths among PGY-1 pharmacy residency graduates. Methods: A 32-item questionnaire was developed independently, which was reviewed and validated by 4 residency program directors. The survey was uploaded to an online survey tool and sent electronically to residency program directors of 109 Vizient academic medical centers with PGY-1 pharmacy residency programs. Residency program directors were identified from a list of Vizient-participating hospitals. The survey was re-sent at 2-week intervals on 4 occasions to improve response rates. SPSS version 23.0 was used to analyze the data. Results: Overall, 49 (45%) of hospitals responded to the survey. Survey responses showed statistically significant increases over the 5-year survey period in the following areas: the number of PGY-1 resident positions offered (P = .001), percent of time spent on teaching experiences (P = .001), and percentage of PGY-1 residents pursuing PGY-2 or fellowship training (P = .026). Conclusion: We found that PGY-1 pharmacy residency programs at Vizient academic medical centers have undergone limited changes over the 5-year survey period and substantial variation exists between program designs. The most common change to program design was an increase in the percentage of time residents spend on teaching experiences. There was an increase in residents pursuing PGY-2 or fellowship training, which may suggest a shift toward increased specialization in clinical pharmacy practice or may reflect changes in the availability of job opportunities.

Background: Glycemic control in burn patients is critical for reducing infection and mortality. Objective: This study was conducted to assess the incidence and outcomes of hypoglycemia during continuous insulin infusions (CII). Methods: This institutional review board–approved study was a retrospective, single burn center, electronic chart review. Patients admitted between January 1, 2013, and October 31, 2014, who received a CII were included. Patients with incomplete data or who received <24 hours of CII were excluded. Results: Thirty-eight patients met inclusion criteria; 6 were excluded. The average patient was a 52-year-old Caucasian male with a 33% total body surface area burn and an acute physiology and chronic health evaluation (APACHE) II score of 20.Hypoglycemia was present for 87 of 6540 hours of CII therapy (1.1%). Two-thirds experienced a serum glucose <70 mg/dL and half <60 mg/dL. The most commonly assessed reasons for the hypoglycemic episodes were protocol violations (47%) and glucose variability (30%). After multivariable logistic regression, only history of diabetes remained a statistically significant risk factor with an odds ratio of 15.4 (95% confidence interval: 2.5-95.1). Four different CII protocols were prescribed. All protocols had a high glucose variability, as assessed by hours / day within goal range (13.1 ± 2.5, 14.1 ± 3.1, 14.3 ± 2.4, 9.8; P = .282). Conclusion: The amount of different protocols likely contributed to protocol violations and glucose variability. Our data demonstrate the need to create and consolidate usage to a single protocol in attempts to improve glycemic control.

Purpose: The purpose of this study was to determine the physical compatibility of micafungin with commonly used concentrations of sodium bicarbonate hydration fluids administered via a Y-site connected to a central venous catheter (Y-site/CVC). Methods: Micafungin sodium (evaluated concentration of 1.5 mg/mL) was combined in a 3:1 (vehicle:drug) ratio with the following commonly used hydration vehicles: 40 mEq/L sodium bicarbonate in 5% dextrose in water with ¼ normal saline (40SB-D5W-1/4NS), 75 mEq/L sodium bicarbonate in D5W (75SB-D5W), and 154 mEq/L sodium bicarbonate in D5W (154SB-D5W). A 3:1 ratio was used based on the flow rates (typically 125 mL/m²/h for bicarbonate-containing vehicles and 50 mL/h for micafungin) of the corresponding solutions in a clinical setting. Visual observations recorded to determine physical compatibility included visual inspection against different backgrounds (unaided, black, and white). Other physical observations were as follows: odor, evolution of gas, pH, and turbidity immediately recorded after mixing and at specified time points up to 2 hours. Evaluations at each time point were compared against baseline observation values at Time 0. Results: All combinations tested were found to be compatible up to 2 hours. Time points beyond 2 hours cannot be safely verified as compatible. Conclusion: Micafungin may be administered safely using a Y-site/CVC delivery system with all the vehicles tested in this study.