Trending Topics in Health-System Pharmacy
What medications are related to the most visits to the ED?
Adverse effects of medications result in numerous visits to urgent care centers and emergency departments (EDs) each year. To assess the scope of acute medication harms from both therapeutic and nontherapeutic medication use in the United States, researchers from CDC studied nationally representative public health surveillance based on patient visits to 60 EDs from 2017 through 2019.
Based on 96,925 cases, there were an estimated 6.1 ED visits related to adverse events per 1,000 people annually with 38.6% resulting in hospitalization. The rate of ED visits for medication harms were higher for patients aged 65 years or older than for those younger than 65 years. Overall, an estimated 69.1% of ED visits for medication harms involved therapeutic medication use, but among patients younger than 45 years an estimated 52.5% involved nontherapeutic use.
The study, published in the October 5, 2021, issue of JAMA, showed that the most frequent medication types associated with ED visits for people aged 45 to 64 years were therapeutic use of anticoagulants and diabetes medications. In adults aged 25 to 44 years, these were nontherapuetic use of benzodiazepines. For children younger than 5 years old, unsupervised medication exposures and therapeutic use of antibiotics resulted in the most ED visits. The proportions of ED visits for medication harms involving therapeutic use were lowest for barbiturates, benzodiazepines, nonopioid analgesics, and antihistamines.
These data reinforce the need for patient counseling for all medication use.
A new way to fight Lyme disease
Current treatment for Lyme disease, which is caused by the spirochete Borrelia burgdorferi, involves broad spectrum antibiotics that can damage the microbiome by affecting non-target bacteria. By screening soil microorganisms, a group led by Kim Lewis at Northeastern University’s Antimi-crobial Discovery Center identified a compound that is highly selective against spirochetes, including B. burgdorferi.
The study, published in the October 14, 2021, issue of Cell, showed that this active compound turned out to be hygromycin A, a known antimicrobial produced by Streptomyces hygroscopicus. Hygromycin A was effective in clearing B. burgdorferi infection in mice and was less disruptive to the fecal microbiome than clinically relevant antibiotics. The authors conclude that this selective antibiotic holds the promise of providing more effective treatment for Lyme disease and could be used to eradicate it in the environment.
The case for a short course of antimicrobial therapy for patients with uncomplicated Pseudomonas aeruginosa bloodstream infection
Most patients with uncomplicated P. aeruginosa bacteremia are prescribed at least 14 days of antibiotic therapy, but a recent study by Bae and colleagues published September 30, 2021, in the Journal of Antimicrobial Chemotherapy has shown that many patients do well with a shorter course of antibiotics. Researchers at the University of Ulsan College of Medicine (Seoul, South Korea) compared the primary outcome (a composite of the rate of recurrent
P. aeruginosa infection and mortality within 30 days after discontinuing antimicrobial therapy) for patients admitted to a tertiary-care hospital from April 2010 to April 2020. Of the 290 patients in the study,
97 (33%) underwent short-course therapy (median of 9 days) and 193 (67%) underwent prolonged-course therapy (median of 15 days). No significant difference was found in the risk of infection recurrence or 30-day mortality between the prolonged-course and short-course groups. In addition, the prolonged-course therapy did not significantly reduce the risk of recurrence of P. aeruginosa infection within 180 days compared to short-course therapy.
Despite the limitations of the study due to the low number of patients, the authors conclude that short-course antimicrobial therapy could be as effective as prolonged-course therapy for uncomplicated
P. aeruginosa bacteremia.
How does apixaban compare with warfarin in preventing thrombosis in patients with TAPS?
Because patients with thrombotic antiphospholipid syndrome (TAPS) are at high risk for recurrent thrombosis, indefinite anticoagulation is recommended. A vitamin K antagonist such as warfarin has generally been the preferred treatment for TAPS patients; however, given the dietary restrictions, possible drug interactions, and the need for frequent dose adjustment and associated blood draws, apixaban—which does not require dose monitoring—has been suggested as an alternative medication for these patients.
In a study published online in Blood Advances on October 18, 2021, Woller and colleagues compared the incidence of stroke in TAPS patients given either apixaban or warfarin.
The multicenter prospective randomized open-label blinded endpoint study assigned patients to apixaban or warfarin for 12 months. Apixaban was first given at 2.5 mg twice daily, but increased to 5 mg twice daily after the 25th patient was randomized based on recommendations from the data safety monitoring board. After the 30th patient was randomized, patients who had experienced prior arterial thrombosis were excluded.
The results of the study indicated that strokes occurred in 6 of 23 patients treated with apixaban, compared with 0 of 25 patients treated with warfarin. Although conclusions are inconclusive due to protocol modifications and low patient counts, the authors suggest that apixaban should not be routinely substituted for warfarin to prevent recurrent thrombosis (and especially strokes) among patients with TAPS.
Are NSAIDs as effective as opioids for pain relief in osteoarthritis?
Knee and hip osteoarthritis is common, especially among older patients, and is often treated with opioids although several studies have suggested that NSAIDs could be as effective in managing pain. A recent systematic review and network meta-analysis of randomized trials in BMJ, published on October 12, 2021, showed that oral NSAIDs are effective for reducing pain and improving function in patients with osteoarthritis.
A worldwide group of researchers led by Bruno da Costa analyzed data from over 100,000 patients in 192 randomized trials that evaluated NSAIDs, opioids, or acetaminophen to treat osteoarthritis. Their results indicated that 3 NSAIDs (diclofenac, rofecoxib, and etoricoxib) were most likely to reduce pain among these patients; however, only diclofenac is FDA-approved for use in the United States. Topical diclofenac was particularly effective for knee osteoarthritis, but no data were available for this medication in patients with hip osteoarthritis. In addition, the analysis showed that opioids and acetaminophen were unlikely to provide the necessary pain reduction.
The study authors conclude that topical diclofenac (70–81 mg/day) should be considered as first-line pharmacological treatment for knee osteoarthritis, and that the clinical benefit of opioid treatment, regardless of preparation or dose, does not outweigh the potential harm to patients.