Comparing Drug Shortages Experienced by Institutions With National Metrics

Drug shortages have increasingly posed challenges to providers, pharmacists, and patients for more than 20 years. Regardless of the underlying causes, for which there does not appear to be a solution in sight, healthcare providers and patients must deal with the consequences. There is often conflicting and confusing information published that confuses everyone. This article describes the reasons for conflicting information from different sources.

Tramadol and Opioid Prescription Rates in Chronic Kidney Disease Patients Before and After the 2016 Centers for Disease Control and Prevention Opioid Guideline

Objectives. The objectives of this study were (1) to assess the impact of the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (GPOCP) on tramadol and opioid prescription rates in patients with chronic kidney disease (CKD), (2) to identify if tramadol was being properly dosed based on kidney function, and (3) to identify the number of clinically relevant drug-drug interactions related to tramadol. Design. Retrospective cohort study. Setting and Participants. Patients with a diagnosis of CKD stage IV or V or end-stage renal disease (ESRD) with a hospital discharge were identified. Participants were distributed into a pre-GPOCP cohort (January to December 2015) and post-GPOCP cohort (January 2017 to May 31, 2018) based on their hospital discharge date. Participants were then further divided into three categories: those who were discharged with a new prescription for tramadol, those who were discharged with a prescription for another opioid product, or those who were discharged with no new opioid or tramadol prescription. Outcome Measures. The primary outcome was incidence of new outpatient tramadol and opioid hospital discharge prescriptions. The secondary outcomes were the number of correctly dosed tramadol discharge prescriptions based on kidney function and incidence of clinically significant drug-drug interactions with tramadol. Results. New tramadol and opioid prescription rates upon hospital discharge for CKD stage IV and V and ESRD patients decreased from 76 (2.5%) to 54 (1.1%) and from 145 (4.7%) to 119 (2.5%), respectively (P < .001). Among the patients discharged with a new tramadol prescription, 113 (86.9%) patients did not have any clinically significant drug-drug interactions, and 94 (72.3%) patients were dosed correctly based on kidney function. Conclusion. The incidence of new outpatient tramadol and opioid prescriptions at discharge was significantly lower after the CDC GPOCP publication than before the publication.

Leja et al reply

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Antimicrobial Stewardship by Transitions of Care Pharmacists at Hospital Discharge

Objectives: This study assessed the impact transitions of care (TOC) pharmacists have on optimizing antimicrobial use for patients at high risk for mortality at hospital discharge. In addition, this study aimed to summarize and categorize the types of interventions made. Methods: This was a retrospective descriptive study that included adult patients 18 years of age or older who were at high risk for readmission and mortality. Participants were selected if they had a hospital discharge date between January 2017 and June 2018, but were excluded if they were discharged to a facility where medications were managed by healthcare employees or if they were hospice eligible. TOC pharmacists identified eligible participants and reviewed their discharge medication lists to optimize pharmacological therapy, contacting the discharging prescriber if therapy changes were identified. The therapy recommendations made by TOC pharmacists were documented in an internal database for further analysis. Results: A total of 1100 patients were analyzed by TOC pharmacists during the studied timeframe and a total of 2066 interventions were made. With respect to study objectives, 298 (14.4%) of the interventions made by TOC pharmacists involved antimicrobial recommendations, affecting 255 (23.2%) patients. Recommendations involving dosing (89, 29.9%), treatment duration (74, 24.8%), and drug interactions (41, 13.8%) were the most frequent types of interventions made. Sixty-six (25.9%) patients received multiple interventions and 240 (80.5%) recommendations were accepted by the provider. Conclusion: An opportunity exists to optimize antimicrobial therapy surrounding the time of hospital discharge.

Transportation of a commercial premixed intravenous insulin product through a pneumatic tube system

PURPOSE

Delivery of insulin products via pneumatic tubes is often avoided in health systems, as agitation may cause insulin proteins to destabilize, resulting in loss of function through denaturation, aggregation, or other processes. The actual loss of potency due to delivery via pneumatic tubes has not been reported for new, ready-to-use insulin products.

METHODS

Samples were drawn from 7 commercial intravenous (IV) bags containing a 100 units/100 mL premixed solution of regular insulin in sodium chloride injection (Myxredlin, Baxter). The bags were then exposed to 7 unique long-distance pneumatic tube routes. The post-transportation bags were visually inspected for evidence of foaming. Samples were drawn from the post-transportation bags and insulin concentrations were analyzed via an enzyme immunoassay and compared to pretransportation concentrations.

RESULTS

All seven post-transportation insulin samples were within 10% of their respective pretransportation sample. No foaming was observed in any of the Myxredlin bags after transportation through the pneumatic tube system.

CONCLUSION

Transporting 100 unit/100 mL Myxredlin i.v. bags through a pneumatic tube system does not result in a clinically significant loss of potency. Therefore, delivery of this drug product via a pneumatic tube system to patient care areas can be considered in daily practice.

Updating formulations for compounded oral liquid medications in a university health system

PURPOSE

The development of a compounded oral liquid medication formulary and subsequent implementation of revised standard formulations in a university health system are described.

METHODS

A standard assessment form was developed to direct evaluation of published literature and current compounding resources for all oral liquid formulations prepared by health-system pharmacies. Specific variables reviewed included concentration, components, beyond-use dating, and storage recommendations. After their review and approval, revised formulations were typed into distinct templates that incorporated additional safety features. An online departmental repository was developed to house the revised formulations.

RESULTS

Modifications were made to 136 (78%) of the 175 compounded formulations reviewed. Changes in storage conditions and extension of beyond-use dating were the most common revisions in 77 (44%) and 42 (24%) of compounds, respectively. In addition, strawberry syrup was removed as a component of 38 (22%) formulations, reducing exposure of pediatric patients to red dye. Presentations were given at several forums to inform pharmacy staff of the goals of the project and details regarding implementation. In addition, e-mail communications were sent to share the online location of the updated formulations and compounding sheets. Nursing, medical, and pharmacy staff were notified of concentration changes through the pharmacy newsletter and e-mail.

CONCLUSION

A comprehensive review resulted in updates to over 75% of oral liquid medications prepared by pharmacies in a university health system. Revised formulations were made available through an online repository, ensuring consistency of compounding procedures with respect to concentrations, components, and storage requirements.

MixMD Probeview: Robust Binding Site Prediction from Cosolvent Simulations

Mixed-solvent molecular dynamics (MixMD) is a cosolvent simulation technique for identifying binding hotspots and specific favorable interactions on a protein's surface. MixMD studies have the ability to identify these biologically relevant sites by examining the occupancy of the cosolvent over the course of the simulation. However, previous MixMD analysis required a great deal of manual inspection to identify relevant sites. To address this limitation, we have developed MixMD Probeview as a plugin for the freely available, open-source version of the molecular visualization program PyMOL. MixMD Probeview incorporates two analysis procedures: (1) identifying and ranking whole binding sites and (2) identifying and ranking local maxima for each probe type. These functionalities were validated using four common benchmark proteins, including two with both active and allosteric sites. In addition, three different cosolvent procedures were compared to examine the impact of including more than one cosolvent in the simulations. For all systems tested, MixMD Probeview successfully identified known active and allosteric sites based on the total occupancy of neutral probe molecules. As an easy-to-use PyMOL plugin, we expect that MixMD Probeview will facilitate identification and analysis of binding sites from cosolvent simulations performed on a wide range of systems.