Journal of Pharmacy Practice

Clinicians must always maintain a heightened suspicion for the development of venous thromboembolism (VTE) in the cancer patient population. VTE is common in this population and often results in morbidity and mortality. The pathophysiology is complex and likely multifactorial. Risk factors for VTE include patient-associated, cancer-associated, and treatment-associated factors as well as biomarkers. Low-molecular-weight heparin (LMWH) is a cornerstone for VTE prophylaxis and treatment. Studies have shown that LMWH may decrease VTE recurrence and impart a survival benefit. Organizational guidelines are available to assist the clinician in choosing appropriate anticoagulant agents, dosing, and duration of prophylaxis and treatment. Pharmacists serve an important role for the safe and effective management of anticoagulation in this complex patient population. In addition, pharmacists can be important providers of patient education about VTE and anticoagulation.

Updates in recent clinical guidelines have led to a change in the management of perioperative anticoagulation for patients on oral anticoagulant therapy. No standardized bridging consensus exists in the literature. The necessity for bridging therapy is determined based on careful consideration of the thrombosis risk versus the bleeding risk of the procedure. Risk stratification will aid the decision to bridge or not to bridge. Patients are bridged with agents with appropriate kinetics to allow for their elimination prior to the time of the procedure in order to decrease the risk of hemorrhage during invasive procedures. This intent of this article is to discuss perioperative bridging therapy and provide a practical guide for the clinician.

Clinical practice guidelines currently suggest extended anticoagulation therapy for primary and secondary prevention of venous thromboembolism (VTE). The optimal duration of anticoagulation has been an active area of clinical investigation for patients undergoing orthopedic surgeries and those diagnosed with a first episode of unprovoked VTE. Practice guidelines, VTE incidence, clinical predictors/mediators, and clinical trial evidence is reviewed to help pharmacists and other health care providers make an informed, patient-specific decision on the optimal duration of anticoagulation therapy. Extended anticoagulation up to 5 weeks following orthopedic surgery for primary VTE prevention and indefinitely following a first episode of unprovoked VTE for secondary VTE prevention should be considered only if the risk of bleeding is not high and the cost and burden of anticoagulation is acceptable to the patient. The optimal duration of anticoagulation therapy for primary or secondary prevention of VTE should include the health care provider and patient making a decision based on evaluation of individual benefits, risks, and preferences.

There are currently over 1 million patients admitted to hospitals in the United States with the diagnosis of non-ST-segment elevation acute coronary syndrome (NSTE ACS). Due to the significant morbidity and mortality associated with NSTE ACS, appropriate use of the numerous medications employed is critical in ensuring optimal outcomes. Because atherosclerotic plaque rupture and thrombus formation are the central pathophysiologic process in patients with NSTE ACS, it is important to utilize effective and safe combinations of antiplatelet and anticoagulant drug therapy. There are a number of different anticoagulant agents available for use in patients with NSTE ACS, but it is essential to have an in-depth knowledge of the setting in which these agents have been investigated, what current consensus guidelines recommend, as well as an appreciation for the treatment approach and philosophy of the institution for management of patients with NSTE ACS. In this review manuscript, the reader will find an evaluation of the current guidelines concerning the use of anticoagulant therapy in patients with NSTE ACS, as well as a detailed examination of the literature with critical analysis on issues that should be considered when deciding on the appropriate implementation of anticoagulant therapy in protocols for NSTE ACS patients.

Patients with ST-segment elevation myocardial infarction (STEMI) require immediate reperfusion therapy in order to salvage ischemic myocardial tissue and reduce mortality. Reperfusion therapy can be provided mechanically with primary percutaneous coronary intervention (PCI), or pharmacologically with fibrinolysis. Regardless of the reperfusion strategy selected, the appropriate use of anticoagulant therapy is critical to its success. There have been a number of clinical trials evaluating the different anticoagulants in patients with STEMI, as well as recent updates to the guidelines for management of patients with STEMI and on the use of PCI. When making clinical decisions on the use of anticoagulant therapy in the management of patients with STEMI, it is important to not only understand the contents of these consensus guidelines but to also have an appreciation of the details of the clinical trials that have evaluated the different anticoagulants. In this review, the reader will find an evaluation of the current guidelines concerning the use of anticoagulant therapy in patients with STEMI as well as a detailed examination of the literature with critical analysis on issues that should be considered when deciding on the appropriate implementation of anticoagulant therapy in patients with STEMI undergoing either mechanical or pharmacologic reperfusion.

Pharmacists need to apply outcomes from studies to reduce risk and improve patient care. Interpretation of outcomes is based on a variety of assessment tools, such as P values and confidence intervals (CIs). P values determine statistical significance of data, while CIs suggest the degree of clinical application. Many health care providers might not have the skill set required to carefully examine and interpret statistical results and then are required to assume that the researchers of the study correctly interpreted and presented the statistical results. The reluctance to examine statistical data often reflects a misconception that concepts such as P values and CIs are difficult to understand, while in reality, both can be interpreted once basic definitions and applications are understood. Measures of association such as number needed to treat can serve as effective tools for quantifying important parameters that ultimately affect patient care. A basic understanding of how to interpret and apply P values and CIs enhances one’s ability to effectively assess the validity of results from the literature. An informed reader, armed with tools for critical analysis, is in the best position to evaluate studies and thereby discern which information is applicable to a specific patient care decision.

Linezolid is an oxazolidinone antibiotic that has been associated with myelosuppression, including leukopenia and thrombocytopenia. Few studies have assessed the use of linezolid in bone marrow transplantation (BMT) patients. The authors evaluated patients who were admitted to the BMT service at their institution from 2001 to 2002 and had undergone ≥3 days of linezolid therapy. These patients (cases) were matched with BMT patients who had not undergone linezolid therapy (controls). Forty-nine patients were evaluated; 25 cases and 24 controls. The authors found no significant differences in the duration of neutropenia or thrombocytopenia, but there was a trend toward a difference in time to engraftment (P = .16). More bleeding episodes were seen and more platelet transfusions were needed in cases than in controls (16% vs 8%; P = .35 and 54.5 ± 55.0 units vs 19.9 ± 20.0 units, respectively). Patients who had undergone linezolid therapy for >10 days (n = 10) had longer thrombocytopenia (102.2 ± 98.0 vs 62.0 ± 61.0 days; P = .27) and time to engraftment (20.5 ± 20.0 vs 10.7 ± 2.0 days; P = .16) and required more platelet transfusions (83.6 ± 76.0 vs 35.1 ± 23.0 units). None of these observations reached statistical significance. The authors conclude that linezolid therapy can be used safely in BMT patients for up to 10 days. However, when therapy is needed for >10 days, monitoring of platelet counts, bleeding time, and time to engraftment are recommended.

Skin cancer is particularly prevalent in Arizona, with incidence rates ranking number 2 worldwide. This study assessed pharmacists’ knowledge of skin cancer and factors that impacted skin cancer prevention patient counseling. Participants were recruited using a listserv of pharmacists that were members of the Arizona Pharmacy Alliance (AzPA) or preceptors of the University of Arizona College of Pharmacy. Subjects completed an online questionnaire consisting of knowledge-based questions, questions about patient counseling preferences, and subject demographics. The mean correct score on the Skin Cancer and Sun Exposure Knowledge Indicator was 5.8 ± 1.9. Pharmacists living in Arizona for longer duration were more likely to know the minimum recommended sunscreen sun protection factor (SPF) for adults when outdoors (P = .003) and factors associated with malignant melanoma prognosis/survival (P = .004) but were less likely to know the definition of ABCD acronym (P = .027). Having a family or friend diagnosed with any form of skin cancer or precancerous skin condition led to more pharmacists knowing the risk factors for developing melanoma (P = .046) and knowing how often to apply water resistant sunscreen (P = .035). In conclusion, the length of pharmacy practice in Arizona and having a family member or close friend affected by skin cancer significantly impacted a pharmacists’ knowledge of skin cancer.

Purpose: To report a probable association of Stevens-Johnson Syndrome (SJS) with furosemide and suspected cross-sensitivity with lincomycin and silver sulfadiazine cream. Summary: A 28-year-old Hispanic male was admitted for SJS, with a prolonged hospital course and unclear etiology throughout the majority of the stay. Patient’s medications prior to development of SJS symptoms were stable for 3 months and with the exception of furosemide, all were continued throughout the hospitalization while the SJS resolved. During hospitalization, the patient was unintentionally rechallenged with furosemide, after which the rash reappeared and then worsened further with use of silver sulfadiazine cream. At this point in the hospitalization, the prolonged course of the rash prior to admission and the administration of lincomycin 3 days prior to admission were revealed. This suggests the SJS was initially caused by furosemide, a nonaromatic sulfonamide diuretic, with slow progression prior to hospital admission over approximately 7 weeks, followed by an acute worsening caused by lincomycin, a sulfide antibiotic. Conclusion: Use of the Naranjo ADR Probability Scale indicates a probable relationship between SJS and furosemide in this patient. Clinicians should be aware of this rare potential adverse effect, even months after the initiation of therapy.

Experiential programs need input and feedback from the practice community in order to keep the student learning outcomes optimized. A proactive combined effort between practice and academia makes sense and assists the students in transition from school to practice. Understanding some basic accreditation concepts can help the practicing pharmacist align student learning experiences with the expected outcomes. This article highlights some basic accreditation concepts from the Accreditation Council on Pharmacy Education’s 2007 standards that apply to experiential training in the pharmacy profession.