Showing papers in "The Journal of pharmacy technology in 1991"

Use of clinical pharmacists to prevent medication errors in children.

Abstract: Tenfold medication errors (misplacement of the decimal point) are serious iatrogenic problems that are well known to healthcare practitioners. Such incidences are more likely to occur in pediatric practice because misplacing a decimal point as a result of erroneously calculating a dose from stock solution still yields a \"reasonable\" volume of fluid. For drugs that have a narrow margin of safety (e.g., digoxin, theo­ phylline, neostigmine), a tenfold dosage increase may result in serious morbidity or mortality. A variety of strategies have been suggested to im­ prove physicians' and nurses' ability to avoid tenfold medication errors. These include independent checking of calculations, development of tables that convert dos­ ages into volumes of stock solutions, and routine testing of calculation competency for staff acuTiinistering drugs. However, there is no evidence of fewer serious acci­ dents in recent years. Most efforts to prevent tenfold medication errors have focused on the role of the ward staff. The ability of clinical pharmacists to prevent such catastrophes has not been explored. There is evidence that clinical phar­ macists make fewer calculation errors than nurses when a clinically relevant test is administered. Moreover, in many hospitals, clinical pharmacists have become an in­ tegral part of the ward staff. We describe the effective­ ness of clinical pharmacists in preventing a substantial number of potentially fatal prescribing incidences in The Hospital for Sick Children.

Impact of a clinical pharmacist on antibiotic prescribing. A multicenter trial.

Abstract: Within the past two decades, hospital pharmacists have become increasingly involved in providing consultation to physicians for drug management. Antibiotic use has become a complex and rapidly expanding discipline, complicated by the introduction of multiple new antimicrobial agents, each with unique features, and the pressures of prospective payment schemes. This study demonstrated that a team including a pharmacist had a positive impact on medical residents' utilization of antibiotics.

Guidelines for Compounding Oral Medications for Pediatric Patients

Abstract: In our society, oral dosing is the most acceptable route for delivery of medications. Pharmaceutical companies spend millions of dollars each year to develop drugs that will be safe and effective when tak­ en orally. These drugs typically go through extensive testing in healthy, young adults before reaching the marketplace. Children, however, are not merely small adults. Oral formulations for adults are manufactured in dosage forms and concentrations that are not suitable for neo­ nates, infants, and children. In general, children under the age of five have difficulty swallowing solid oral dosage forms and require medication in liquid forms. Children may be regarded as \"therapeutic orphans\" in that many medications that could benefit ill children are not available in suitable dosage forms. Many existing drugs are unstable in an aqueous ve­ hicle, hence an extended shelf life is not possible. Con­ sidering the amount of time that a product stays in the distribution system from the time of manufacture to the time of administration, a stability of less than two years is economically unreasonable. In the case of many an-

King Khalid University Hospital Drug and Poison Information Service. A descriptive report and comparison with the University of Minnesota Drug Information Center.

Abstract: During the first four years of its existence, the Drug and Poison Information Service at King Khalid University Hospital established itself as an integral part of the clinical pharmacy program and was appreciated by the medical staff. In terms of references and request categories it was similar to the UMDIS. Differences result from dissimilar formularies and a large number of physician inquiries, as opposed to the large number of consumer inquiries received at the UMDIS.

Improving job satisfaction and enlarging the role of technicians.

Abstract: The process used in preparing this administrative report provided the means of documenting departmental support of technician task expansion, cost benefits, increased availability of professional time, and the need for a dynamic department. Some of the benefits to St. Luke's Regional Medical Center and its Pharmacy Department were an increase in technician job satisfaction, improved quality of patient care attributable to the increased scope of pharmacy service, and up to 8554 hours per year of professional time available for more clinically oriented responsibilities. If technician turnover were decreased by half, technician pricing errors eliminated, and technicians assumed the identified technical tasks, potential monetary benefits could be as much as +116,900 per year. The departmental cost of implementing these recommendations would be an additional 4.16 technician FTEs, and the professional time for training, supervising, and coordinating technicians and functions. These recommendations were well received by pharmacy administration, and the committee was asked to develop a list of priorities and an implementation plan for administrative approval.

Liability and new drug studies. Informed consent and clinical trials at the National Institutes of Health.

Abstract: The liability risk in carrying out clinical trials can be severely affected if the informed consent process is poorly carried out. A poorly informed patient could prematurely drop out of a costly study. Worse yet, if the patient discovers that information is withheld, the patient could sue the sponsor, physician investigator, or IRB and hold them liable, though this is unlikely for investigational drug studies. These costs can be avoided by making sure the clinical trial is properly carried out according to strict federal regulations. It is also critical that clinicians keep the research participant informed on an ongoing basis. The chain of command is vital: The monitor informs the sponsor, the sponsor in turn informs the investigator, and the investigator in turn informs the patient of any new treatment information that may affect his willingness to stay in the trial. Finally, wherever the clinical trial is conducted, it should conform with the ethical principles outlined in the Declaration of Helsinki or with the latest regulations of that country--whichever guidelines provide the greater protection for the patient.

Issues in contemporary drug delivery. Part IV. Insulin therapy.

Abstract: Continuous insulin infusions are a valuable way of managing highly selected patients, although patients and healthcare practitioners must be aware of the limits and the increased risks involved with this type of technology. Maximum benefit from the CSII technology is achieved when the patient is part of a complete healthcare team accessible on a daily basis to respond to the changing nature of the underlying diabetes. Intranasal and pulmonary delivery of insulin, in contrast, represent a minor technology that will potentially add convenience to some diabetic management plans and possibly provide a new treatment approach for noninsulin-dependent diabetic patients.

Pancytopenia Associated with the Interaction of Allopurinol and Azathioprine

Abstract: Allopurinol has been used for prevention of uric acid nephropathy in patients with malignant diseases and in the management of asymp­ tomatic hyperuricemia in patients with renal dysfunc­ tion. Because hyperuricemia is a common complication of cyclosporine therapy, allopurinol may be indicated in many cyclosporine-treated renal transplant recipi­ ents. 1 However, azathioprine is often combined with cyclosporine plus steroids in an effort to enhance im­ munosuppression and allow for a reduction in cyclo­ sporine dosage and its consequent toxicities. We de­ scribe a potentially fatal pancytopenia resulting from the interaction between aUopurinol and azathioprine in a kidney transplant patient. A 60-kg, 42-year-old man who had undergone two kidney transplants had renal dysfunction resulting from chronic rejection. No history of gout, neplruroUthiasis, or drug abuse was recorded. He was treated with predni­ sone 0.5 mg/kg qod, azathioprine 0.8 mg/kg/d, and cy­ closporine 4.2 m g / k g / d for three years. Cyclosporine dosage was adjusted with plasma concentration moni­ toring and was within the acceptable range (200-400 pg/dL). During this time, his blood analysis showed:

Sucralfate in Prevention of NSAID-Induced Gastric Mucosal Damage

Abstract: The association between peptic ulceration and nonsteroidal antiinflammatory drugs (NSAIDs) remains unclear despite a number of published studies.' Some researchers have concluded that a con­ siderable degree of correlation exists, whereas others have determined that there is no significant risk of de­ veloping peptic ulceration with NSAID use.\" These studies used hospitalization or death as endpoint mea­ surements. Risk of clinically relevant ulceration with NSAID treatment is estimated to be two to three percent per pa­ tient-year. This estimate was garnered from premarket­ ing surveillance of patients receiving NSAID therapy and represents the most probable estimate of gastroin­ testinal (GI) adverse effects secondary to these agents. Unfortunately, these data are largely unpublished and not accessible for thorough evaluation. Acute injury in­ duced by NSAIDs is reported to be more common in the stomach than in the duodenum. However, ulcer complications associated with NSAIDs are reported with nearly equal frequency in both sites. 2 3 Peptic ulcer and its associated complications are not uncommon in the general population. Study method­ ologies designed to examine NSAID-induced ulcers are often fraught with obstacles in identifying risk factors associated with NSAID use versus risk factors for ulcers in general (i.e., smoking, 9 rheumatoid arthritis, 0 alco­ hol consumption, 1 1 ulcer history 1 ). Furthermore, the predictive value of identifying these risk factors in pa-

Ketoconazole in Vaginal Candidiasis

Abstract: Vaginal candidiasis (VC) is a problem that fre­ quently occurs in women. It is not only a medi­ cal problem but also a psychological and emo­ tional one, especially if women have persistent infec­ tions and recurrences. Candidiasis comprises 20-30 percent of cases of vaginal infections. Candida albicans, a dimorphic yeast that can be isolated from the gas­ trointestinal tract, is the usual cause of the disease. Women of all ages are at risk for VC, but pregnant or diabetic women are most commonly infected. In addi­ tion, obesity, general debilitation, increased use of drugs (e.g., antibiotics, corticosteroids, contraceptives), and changes in sexual behavior (several partners) are pre­ disposing factors. ' 4 , 5 The manifestations of VC include the presence of vulvar and vaginal itching; swelling; dysuria; dyspareunia; a thick, white vaginal discharge; and a bright red vagina with patches of white, curd-like plaques. Treatment has relied heavily on the use of vaginal creams, tablets, and suppositories. These preparations are effective in relieving symptoms but incapable of curing the infection or preventing recurrences. With lo­ cal treatment of the infection, vaginal candidiasis per­ haps recurs because topical measures do not abolish rectal carriage of the yeast. There is thus a need for an effective systemic oral agent for the treatment of VC. Bisschop et al. conducted a 28-day pilot study and a 28-day dose-response study. The pilot study was de­ signed to determine the oral effectiveness of ketocona­ zole in VC by treating 12 patients with ketoconazole 200-mg tablets tid. The dose-response study, with 51

Study of antipsychotic drug use in long-term care facilities.

Abstract: We chose to conduct this study because neuroleptic use has not been well defined in nursing homes. To our knowledge, it represents the only attempt at implementing the AIMS procedure in a group of nursing homes. We have provided evidence for what appears to be reasonably typical use of antipsychotic medication in skilled and intermediate care facilities. Senility and dementia were the most common diagnoses noted for neuroleptic recipients. Inservice education had little, if any, impact on antipsychotic drug use. Efforts to reduce the incidence of inappropriate use of neuroleptics should be aimed at physicians. We do feel that nursing and administrative staff are now more aware than previously of the dangers of indiscriminate use of these drugs. We feel that, because of our efforts, nursing staffs are better able to detect the presence of TD in their geriatric residents. If our sample of patients is representative of the entire population of institutionalized elderly, the overall rate of neuroleptic-induced TD may be lower than once thought. Similarly, the use of regularly scheduled neuroleptics in this population may be lower.

Dispensing and the technician: Part II.

Abstract: Should pharmacists continue to be responsible for performing the physical and mechanical tasks in­ volved in dispensing? Despite the maturing of clinical practice in the hospital over the last 30 years, pharmacists in the retail setting continue to spend most of their time either dispensing or involved in other non­ clinical practices. What will bring about a more rapid change in the way the community pharmacist practices, and the pub­ lic's perception of what services the pharmacist pro­ vides? As much as I disdain the thought, I believe the only thing that will hasten change will be more signifi­ cant lawsuits against pharmacists that are upheld in the

Variability of Serum Theophylline Concentrations in Outpatient Asthmatic Children

Abstract: Theophylline has been used for years to produce bronchodilation in the treatment of asthma. Al­ though it is probably no longer the first drug of choice for the treatment of acute or chronic asthma, mil­ lions of patients continue to take theophylline on a reg­ ular basis. As pointed out by Kelly and Murphy, stud­ ies of theophylline \"provided much of the foundation for the routine clinical use of therapeutic drug monitor­ ing and the practice of clinical pharmacy.\" The dose-response curve for theophylline is logarith­ mic; definite pharmacologic response is apparent at a serum theophylline concentration (STC) of 27.8 μιτιοΙ/L. However, numerous studies have shown that an STC between 55.5 and 111 umol/L is significantly beneficial in the treatment of asthma with minimal adverse ef­ fects. 3 6 Present dosing regimens have been shown to attain this range safely. Milavetz et al. d e t e i T n i n e d that after a m e d i a n in ter ­ val of nine months, meophylline concentrations in over one-third of 503 children were no longer in the thera-

New Publication: Preventing and Controlling Drug AbusePreventing and Controlling Drug Abuse Published by the World Health Organization, Geneva, 1990. ISBN 92-4-156134-3. Paperbound, ix + 130 pp., approximately $18.75.

Abstract: τ ο THE EDITOR: Captopril is com­ monly used to treat hypertension in infants and children. The initial dose of Captopril in these patients may range from 0.05 to 0.15 mg/kg, depending on age. Com­ mercially available tablets contain­ ing 12.5, 25, 50, and 100 mg of Captopril cannot easily be used to provide such low doses. Liquid formulations cannot be stored for more than a day, because of captophi's poor stability in liquid dosage forms. Pesko suggested that Captopril tablets can be crushed and mixed with lactose; doses can then be dispensed in powder papers. 1 At one time, we also prepared Capto­ pril powder papers. Our current practice, however, is to package Captopril (0.05 mg/200 mg and 0.75 mg/200 mg in lactose) 2 in 15mL brown glass bottles with alu­ minum seals (Wheaton). These containers are frequently used for unit-dose packaging of extempo­ raneous liquid formulations. We prefer our approach because each unit-dose container can be labeled in accordance with stan­ dard practice. It is less time-con­ suming to fill glass containers than to prepare powder papers, and the nurses can use these containers to mix the Captopril with an appropriate vehicle to pre­ pare the final product for adminis­ tration.

Protriptyline for Treatment of Obstructive Sleep Apnea

Abstract: Approximately two to five million Americans suffer from obstructive sleep apnea (OSA), a condition that results in obnoxious snoring, daytime hypersomnolence, and problems of the cardio­ vascular and pulmonary systems. 1 Therapeutically, OSA remains a challenge despite the development of various treatment modalities. Different surgical proce­ dures have been successfully used, albeit without uni­ form predictability. Until recently, tracheostomy was the standard form of therapy for severe OSA and pro­ vided predictable success; however, tracheostomy is laden with long-term complications and inflicts a psy­ chosocial burden on the patient. , 3 Continuous positive airway pressure (CPAP) has almost totally replaced tra­ cheostomy as the treatment of choice for extreme cases of OSA. 1 Nevertheless, CPAP is associated with ad­ verse effects such as dryness of the nose and throat and the risk of barotrauma. Pharmacologic therapy has been unsuccessful with drugs such as acetazolamide, progesterone, and the­ ophylline. However, the reported effectiveness of tri­ cyclic antidepressants has led to an examination of the role of the nonsedating agent, protriptyline hydrochlo­ ride for the treatment of OSA. 5 An antiapneal mechanism of protriptyline in humans has not been conclusively determined. However, in

Estimating Drug Shelf Life at Various Storage Temperatures

Abstract: Consider the following situation. The manufac­ turer's recommendation for a vial of an antibi­ otic after reconstitution is three days when stored at a refrigeration temperature of 5 °C. The vial is inad­ vertently kept at room temperature (25 °C) for four hours. What is the estimated new shelf life of the drug? This article deals with the effect of storage tempera­ ture on the shelf life of drug products. A simplified method is presented to calculate predicted effects of storage temperature on a product's shelf life or expira­ tion date. A drug product can lose its pharmaceutical quality in a number of ways. The two most important are physi­ cal instability and chemical degradation. Examples of physical instability are changes in the dissolution rate of a tablet or the separation of an emulsion because of creaming or cracking. Even though the labeled strength of these products may not change, physical changes be­ come responsible for the expiration of the product. Even a change in potency can be caused by a physical process. An example of this is nitroglycerin. Here, the loss of potency can result from sublimation of the drug from an open or not tightly closed container. Although temperature may well affect the rate of physical pro­ cesses, the equations presented in this article apply only to classic chemical degradation of the active ingredient that results in loss of potency of the drug product.

Failure of Captopril Therapy for Diabetic Proteinuria

Abstract: Captopril was the first angiotensinconverting enzyme inhibitor to be marketed in the U.S. Captopril was the first angiotensin-converting en­ zyme (ACE) inhibitor to be marketed in the U.S. over a decade ago. Captopril is generally safe and effective for the treatment of hypertension and con­ gestive heart failure. One of its adverse effects, protein­ uria (>1 g/ d), is seen in approximately 0.7 percent of patients taking Captopril, and nephrotic syndrome oc­ curs in about 20 percent of these cases. 1 Interestingly, Captopril has been shown to reduce proteinuria in pa­ tients with renovascular hypertension and diabetic nephropathy. 2 1 4 It has been demonstrated that the renin-angiotensin system plays a critical role in regulat­ ing the glomerular filtration rate. In diabetic nephropa­ thy, there may be reduced renal plasma flow. 3 5 ' 1 5 These findings suggest that angiotensin Π is important for reg­ ulating glomerular filtration rate in diabetic nephropa­ thy. In addition, angiotensin II has been shown to in­ duce proteinuria. 1 6 The case presented here is of a 58-year-old black woman who, despite six months of treatment with Captopril for proteinuria, experienced no annproteinuric effects.

Rational Analgesic Use for Acute and Chronic Pain

Abstract: Pain is a common human experience that touches the lives of everyone. Pain is difficult to define and must be viewed as a complex subjective phe­ nomenon. Despite an increased understanding of pain and improved treatment techniques, we still lack a uni­ versally accepted system of pain measurement. We have come to realize that optimal pain management re­ quires an individualized and often a multimodal and multidisciplinary approach. Pain can be classified as both acute and chronic. Acute pain represents the body's way of signaling that something is wrong. Signs and symptoms such as in­ creased sweating and heart rate and muscle tension are similar to those commonly observed with acute anxiety. One can rationalize that acute pain is part of the healing process and that it will get better with time. Pain fol­ lowing abdominal surgery is an example. Chronic pain, however, cannot be rationalized as part of the healing process. It has no beginning or end; it may be considered a disease in and of itself. Chronic pain can make the person feel helpless and hopeless and occupy all of one's attention. The person ultimately will become isolated from his surroundings and experi­ ence severe depression. Cancer pain is a classic example of chronic pain. Many cancer patients fear dying in pain although only 50 percent of these patients actually will experience severe pain. Unfortunately, approximately 20 percent of cancer patients will have persistent pain during the terminal stages of their disease. The appro-

Auxiliary label use by pharmacists in South Carolina.

Abstract: This study shows the variability in auxiliary labeling recommendations among reference sources as well as the variability in auxiliary label selection by pharmacists. Pharmacists' responses matched the Pharmex, USP DI, and Facts and Comparisons recommendations 6.1, 2.4, and 0.9 percent of the time, respectively. Pharmacists' use of auxiliary labels was correlated to professional setting, computer software, and years of pharmacy practice, but the interaction of these variables was not determined by our study. Finally, pharmacists are not satisfied with current auxiliary reference sources, including computer software programs.

Nosocomial Pneumonia in Intensive Care Patients Secondary to Stress Ulcer Prophylaxis

Abstract: The use of prophylactic therapy in critically ill pa­ tients to prevent potentially fatal gastroduodenal bleeding is common in intensive care units (ICTJs). This bleeding is ascribed to mucosal lesions that occur secondary to mucosal ischemia in the presence of a low gastric pH, even though hypersecretion of acid usually is not observed. 1 ' 2 The use of antacids and histamine 2 (H2)-antagonists to raise the gastric pH to at least 4 is thought to prevent stress ulcer formation and bleed­ ing.\" The agents most commonly used for stress ulcer prophylaxis include antacids and the H 2-antagonists Cimetidine and ranitidine.' Antacids directly alkalinize the stomach contents, whereas the H2-antagonists indi­ rectly alkalinize stomach contents by blocking stomach acid secretion in response to histamine, muscarinic ago­ nists, and gastrin. Stomach contents usually are sterile or have low counts of microorganisms owing to a nor­ mally acidic pH—a hostile environment that discour­ ages microbial growth. When stomach contents are alkalinized by enteral feedings or drugs such as antacids or H2-antagonists, microbial overgrowth may occur. Critically ill patients are usually supine for long periods of time; this lack of posture changes may inhibit normal bacterial clearance mechanisms such as effective swal-

Drug-Induced Syndrome of Inappropriate Secretion of Antidiuretic Hormone:

Abstract: Antidiuretic hormone (ADH, vasopressin) is an octapeptide normally secreted by the neurohy­ pophysis (posterior pituitary) in response to in­ creased plasma osmolality. Two specific receptors exist for circulating ADH, located in the vascular smooth muscle and the collecting duct of the renal tubule. Stim­ ulation of vascular smooth muscle receptors causes ar­ teriolar vasoconstriction with a concomitant increase in arterial pressure. Stimulation of receptors in the renal collecting tubule results in increased water permeability in the collecting ducts and alteration of plasma osmolal­ ity. Normally, ADH secretion occurs in response to an increase in plasma osmolality. Increased plasma osmo­ lality promotes free water reabsorption, which results in an inhibition of diuresis and formation of more con­ centrated urine. In the event of low or decreased plas­ ma osmolality, ADH secretion is inhibited. This results in diuresis and formation of dilute urine secondary to inhibition of free water reabsorption in the renal tubule. Thus, plasma osmolality is maintained within a rela­ tively narrow range of approximately 270-290 mmol/kg by the release of ADH and the thirst response.-