Medication Utilization Evaluation of Dabigatran and Rivaroxaban within a Large, Multicenter Health System.

Objective. The objective of this medication utilization evaluation (MUE) was to determine the appropriateness of dabigatran and rivaroxaban while also reviewing outcomes for safety and effectiveness within a large, multi-center health system. Methods. A retrospective chart review was performed using the system’s electronic medical record. A data inquiry was requested and generated for dabigatran usage from July 28, 2011 through July 28, 2012 and for rivaroxaban from March 1, 2012 to July 31, 2012 at eight health system hospitals. All patients receiving at least one dose were eligible for inclusion in the MUE. Results. For dabigatran, 78 of 390 unique patient encounters were analyzed (20%). All 62 rivaroxaban encounters were included in the analysis. Dabigatran was used for appropriate indications in 94% of encounters and 82% for rivaroxaban. Based on indication and renal function, 87% of dabigatran patients and 92% of rivaroxaban patients received correct dosing. For patients transitioning to or from another anticoagulant, appropriate transitions occurred in 44% of dabigatran transitions and 48% of rivaroxaban transitions. At discharge, 83% of dabigatran and 86% of rivaroxaban therapy was continued. There were no reported strokes or systemic embolism with dabigatran, but one reported deep vein thrombosis occurred during hospitalization with rivaroxaban therapy. Documented bleeds in 5% of dabigatran and 3% of rivaroxaban patients. Patient education was documented for 37% of dabigatran and 26% of rivaroxaban patients receiving therapeutic anticoagulation. Conclusion. This MUE revealed the appropriate use of dabigatran and rivaroxaban therapy with few safety outcomes within a large, multi-center health system

Determining an Initial Dosing Recommendation for Vancomycin in Obese Patients

Background: Studies have shown that obese patients have altered vancomycin pharmacokinetic parameters such as larger volumes of distribution (Vd), lower levels of free drug, and increased creatinine clearance. However, limited data exists regarding specific vancomycin dosing recommendations in obese patients. Study Objective: The primary objective of this study is to determine vancomycin pharmacokinetic parameters (Vd, k, T1/2) in the obese patient population and formulate initial dosing recommendations for vancomycin in this patient population. Methods: This is a retrospective observational study which includes patients with a BMI ≥ 30kg/m2, who received vancomycin between October 1, 2012 and March 30, 2014 at Eskenazi Health, and who had a least one set of steady-state vancomycin peak and trough serum concentrations obtained. Reasons for exclusion include \u3c 18 years of age, pregnancy, incarceration, cystic fibrosis, burn injury, hemodialysis, continuous renal replacement therapy, patients at risk for acute kidney injury, and acute kidney injury. The primary outcome for this study is to determine vancomycin pharmacokinetic parameters to develop initial dosing recommendations for vancomycin in the obese patient population. Secondary outcomes include determining the percentage of patients who meet goal serum trough concentrations, have trough concentrations \u3c10mcg/mL or \u3e20mcg/mL, and number of patients requiring dose adjustments. Data regarding clinical outcomes and adverse effects is also evaluated. Significance: Limited data exists to guide vancomycin dosing in the obese patient population. This study may benefit overall patient care, within this population, in regards to the dosing and monitoring of vancomycin therapy

Transition From Intravenous to Subcutaneous Insulin in Critically Ill Adults

BACKGROUND: Glycemic control decreases morbidity and mortality in critically ill patients. However, limited guidance exists regarding the transition from intravenous (IV) to subcutaneous insulin therapy. A validated protocol for transition is necessary since glycemic variability, hyperglycemia, and hypoglycemia adversely impact patient outcomes. METHOD: The objective was to determine the safest and most effective method to transition critically ill adults from IV to subcutaneous insulin. This single-center, retrospective, observational study included adults admitted to the burn, medical, or surgical/trauma intensive care units from January 1, 2011, to September 30, 2014. A computer-based program provided a reflection of the patient's total daily IV insulin requirements. This information was then utilized to stratify patients into groups according to their initial dose of subcutaneous insulin as a percentage of the prior 24-hour IV requirements (group stratification: 0-49%, 50-59%, 60-69%, 70-79%, ≥80%). The primary endpoint was the percentage of blood glucose (BG) concentrations within target range (70-150 mg/dL) 48 hours following transition. RESULTS: One hundred patients with 1394 BG concentrations were included. The 50-59% group achieved the highest rate of BG concentrations in goal range (68%) (P < .001). The 0-49% group, which was the transition method utilized most often, resulted in the lowest rate of goal achievement (46%). CONCLUSIONS: This retrospective study suggests critically ill adults may be safely transitioned to 50-59% of their 24-hour IV insulin requirements. A dosing protocol will be implemented to transition to 50-70% subcutaneous insulin. Follow-up data will be reviewed to assess the protocol's safety and efficacy