Journal of Pharmacy Practice

Several basal insulins have recently come to market including follow-on insulin glargine (Basaglar®). Currently, there is no real-world data published on the implications of conversion to Basaglar on dosing or glycemic control.

To identify differences in basal insulin dosing requirements, hemoglobin A1c (HbA1c), and incidence of hypoglycemia or weight gain when converting a patient to Basaglar from another basal insulin.

Single-center, retrospective chart review at an academic medical center. All patients prescribed Basaglar between December 15, 2016, and August 31, 2017 were included for review if converted from another basal insulin.

Difference in basal insulin requirements in both units/d and units/kilogram (kg)/d after conversion to Basaglar.

Change in HbA1c and weight.

Mean basal insulin dose was 38.4 ± 26.3 units/d pre-conversion and 40.5 ± 29.8 units/d post-conversion (P = .031). Results were significant for patients with type 2 diabetes mellitus (T2DM; pre-conversion basal dose 34.6 ± 24.3 units/d; post-conversion basal dose 37.6± 29.0 units/d; P = .009). Weight-based dosing changed from 0.37 ± 0.25 units/kg/d pre-conversion to 0.39 ± 0.29 units/kg/d post-conversion (P = .056) and was significant for patients with T2DM (P = .040). A nonsignificant decrease in HbA1c was seen (−0.14% ± 1.24%; P = .142). There was no difference seen in weight (111.6 ± 46.3 kg vs 111.7 ± 46.9 kg; P = .662).

Patients with diabetes require similar basal insulin doses upon conversion to Basaglar. Clinicians should monitor blood glucose closely during basal insulin transition.

Currently, no consensus approach exists for optimal venous thromboembolism (VTE) prophylaxis in obese (BMI ≥30 kg/m²) patients. Time to development of in-hospital VTE is not well studied.

This study evaluates time to in-hospital VTE in obese patients.

A single-center, retrospective study evaluated obese patients that developed an in-hospital VTE. Patients were categorized into 3 BMI groups: 30 to 34.9 (group 1), 35 to 39.9 (group 2), and ≥40 (group 3) kg/m². The primary end point compared time to VTE between the groups.

A total of 246 patients were included, and time to VTE was similar between the groups, 8 (group 1) versus 8 (group 2) versus 9 days (group 3); P = .38. Secondary outcomes showed time to VTE was shorter in acute care versus ICU patients (7.5 vs 10 days; P = .01), nonsurgical versus surgical patients (6 vs 9 days; P = .004), and no prophylaxis versus mechanical plus pharmacologic prophylaxis (4.5 vs 9 days; P < .001).

BMI category did not significantly impact time to in-hospital VTE. This study provides insight into the timing of in-hospital VTE in obese patients. The differences in prophylactic strategies highlight the importance of optimized prophylaxis.

The optimal choice of induction immunosuppression for elderly kidney transplant recipients remains unclear. Although alemtuzumab has been associated with escalating risk of death and graft loss in this population, this risk has not been adequately explored. The purpose of this study was to compare the safety and efficacy of alemtuzumab with basiliximab induction in this population.

This is a retrospective matched cohort study of kidney transplant recipients aged ≥65 years. Patients who received alemtuzumab induction were matched (1:2) to a basiliximab control. The primary outcome was allograft survival. The incidence of acute rejection, infection, and all-cause mortality was measured.

Fifty-one and 102 patients were included in the alemtuzumab and basiliximab groups, respectively. Baseline demographics were similar between groups, except for more living donor transplant recipients in the alemtuzumab group (26/51 [51%] vs 31/102 [30.4%], P = .02). Acute cellular rejection occurred more frequently within the first year in the basiliximab group (P = .02). There was no difference in rates of infection within the first year. Graft and patient survival rates were similar over the follow-up period. Patients receiving basiliximab had a higher glomerular filtration rate at 2 years posttransplant (59 mL/min/1.73 m² vs 49 mL/min/1.73 m², P = .03).

Alemtuzumab induction is associated with similar outcomes to basiliximab in elderly kidney transplant recipients.

Intra- and postprocedural thrombosis are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization. The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuro-endovascular patients is inferred from the cardiology literature without large clinical trials to support it in neuro-endovascular patients.

We conducted an electronic survey to identify practice variations surrounding the use of oral antiplatelets in patients undergoing endovascular neuro-interventional procedures across neuro-endovascular centers in the United States.

An electronic survey was distributed via the Web. Any practicing neuro-intensive care unit (ICU), neuro-interventional or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to this survey between June and October 2017.

A total of 33 responses were collected during the survey period. A response rate of 16% was calculated after taking into account all comprehensive stroke centers in the United States. Aspirin and clopidogrel was the standard-of-care antiplatelet regimen utilized in the majority of institutions (82%). Alternatively, 4 institutions used monotherapy (aspirin [n = 2], clopidogrel [n = 1], either aspirin or clopidogrel [n = 1]) and 2 institutions reported practitioner-dependent practices. Just under half of the centers reported ticagrelor as the primary alternative in clopidogrel nonresponders (48%).

Dual antiplatelet therapy with aspirin and clopidogrel appears to be standard of care in this setting based on our survey. About half of responding institutions use ticagrelor in cases where clopidogrel resistance is suspected. Large society-wide patient registries are needed to provide data for future safety and efficacy studies.

Guidelines support statin therapy post-stroke or transient ischemic attack (TIA); however, previously reported utilization rates are suboptimal.

This study investigates the incidence of statin usage in patients with a documented stroke or TIA while identifying predictors of statin use.

A retrospective, cross-sectional study utilizing data from the National Ambulatory Medical Care Survey.

A total of 2963 unweighted visits were included in the analysis, representing a total of 52 645 000 office visits when weighted. Statin therapy was initiated or continued in 35.7% (95% confidence interval [CI]: 32.4-39.0%) of office visits. Upon multivariate analysis, positive predictors of statin therapy included a diagnosis of hyperlipidemia (odds ratio [OR]: 3.60; 95% CI: 2.40-5.41), angiotensin-converting enzyme inhibitor (ACE-I) therapy (OR: 2.52; 95% CI: 1.69-3.76), aspirin therapy (OR: 2.02; 95% CI: 1.40-2.93), and clopidogrel therapy (OR: 2.60; 95% CI: 1.69-4.02). Negative predictors of statin therapy included office visits with neurologists when compared to visits with primary care practitioners (OR: 0.55; 95% CI: 0.33-0.90) and office visits in rural areas when compared to office visits in urban areas (OR: 0.64; 95% CI: 0.41-0.99).

Various factors impact statin therapy use with overall utilization being suboptimal, highlighting an opportunity for medication optimization.

Few published studies have examined the relationship between pharmacy location and retention in care or clinical outcome in people living with HIV (PLWH).

The study purpose was to determine whether using an on-site/in-clinic pharmacy to obtain antiretroviral therapy increased retention in care and virologic suppression rates.

PLWH attending a Ryan White outpatient clinic in an academic center were matched based on age and insurance. Rates of retention in care ( ≥2 medical visits/calendar year) were assessed between patients using a pharmacy on-site in the clinic versus patients use off-site pharmacy options. Virologic suppression [viral load(VL)<200 copies/mL], completing ≥2 VL, and CD4 count were compared between pharmacy types.

137 on-site pharmacy patients and 274 off-site pharmacy patients met inclusion and matching criteria. 91.2% of on-site pharmacy users attended ≥2 clinic visits compared to 83.2% of off-site pharmacy users (P = .0275) and were approximately twice as likely to complete ≥2 clinic visits (odds ratio: 2.032; 1.071-3.857). A similar proportion of the on-site pharmacy group achieved virologic suppression compared to the off-site pharmacy group (92.7% vs 89.1%; P = .239, respectively).

On-site pharmacies may provide an opportunity to positively impact retention in care and clinical outcomes for PLWH.

Pharmacist prescribing of contraception is becoming increasingly available in selected states. The objective of this study was to assess US community pharmacists’ perspectives on expanding access, barriers, and facilitators since states have begun pharmacist scope of practice expansions for prescribing contraception.

A survey study of US community pharmacists’ support for expanded access models, pharmacist prescribing practices and interest, and importance of safety, cost, and professional practice issues for prescribing was conducted.

Pharmacists are generally supportive of pharmacist prescribing and behind-the-counter models for hormonal contraception and generally opposed to over-the-counter access. A majority (65%) are interested in prescribing hormonal contraception. The top motivation for prescribing contraception is enjoying individual patient contact (94%). Safety concerns (eg, patients not obtaining health screenings) remained most important for pharmacist implementation, followed by cost (eg, lack of payment or reimbursement for pharmacists’ services), and professional practice (eg, pharmacist time constraints and liability) issues.

This study provides an updated understanding of attitudes toward models of expanded access to hormonal contraception, interest in prescribing, and barriers and facilitators to this service among community pharmacists. Many barriers such as time and reimbursement remain unchanged. This information can inform policy and implementation efforts.

Limited literature exists evaluating the ability of a pharmacist to quickly and effectively initiate and manage dose titrations of guideline-directed medication therapy (GDMT) in an outpatient setting.

This pilot study aimed to investigate the impact of pharmacist-managed, outpatient heart failure management on patients’ heart failure outcomes, and health-care–related costs. Retrospective chart review performed on patients referred to pharmacist practicing under collaborative practice agreement. End points included time to achieve individualized target doses of GDMT; beta-blocker dose tolerance; and the clinic’s impact on left ventricular ejection fraction (LVEF), hospital admission, and emergency department encounter rates. Descriptive statistics were used to report nominal data. Wilcoxon signed-rank test was used to evaluate continuous variables.

Thirty-six patients completed full titration utilizing an average of 4.9 visits over 12.7 weeks. Seventy-eight percent (n = 28) achieved full beta-blocker titration. Seventy-six percent of patients had LVEF >35% after titration versus 43% at baseline. A significant reduction in all-cause hospital admissions was seen during both 13-week and 12-month comparison periods (P < .05). We estimated >US$50 000 annual revenue generation from 0.2 full-time equivalent pharmacist.

Although hypothesis generating, our results support the idea that pharmacist-managed medication titration clinics are effective at completing titration, improving LVEF, and generating revenue.

Clinical pharmacy continues to rapidly evolve as does the need to incorporate unique learning opportunities in pharmacy residency training (eg, transitions of care).

To describe the impact of incorporating pharmacy residents into a pharmacist-managed emergency department culture review service (CRS).

This retrospective study included 500 cultures with positive results evaluated by a pharmacy resident during weekend staffing shifts for patients discharged from the emergency department or urgent care center (UCC). The primary outcome of this study was the number of interventions performed by pharmacy residents.

Of the 500 cultures evaluated, 275 (55%) required action by the pharmacy residents, resulting in 233 interventions. Modification of antimicrobial therapy occurred 70 times. When surveyed, a majority of residents strongly agreed that the CRS had a positive impact. Based on evaluations, residents achieved mastery of pertinent residency performance objectives.

Incorporation of pharmacy residents into a pharmacist-managed emergency department CRS promotes safe and effective medication use to patients discharged from an emergency department or UCC while providing residents additional experience in designing a therapeutic regimen, providing education to patients, and communicating with health-care teams to manage medication therapy.

To assess the stability of insulin detemir at controlled room temperature (RT) at 25°C in different packaging systems over 7 days.

The degradation characteristics of insulin detemir were determined based on the assay results in different packaging systems (pinhole glass vial, closed glass vial, glass syringe, and plastic syringe) at RT using a reverse-phase high-performance liquid chromatography (HPLC) assay method for insulin injection. Each packaging system was compared to insulin detemir stored in the original packaged closed glass vial at 2°C to 8°C.

Insulin detemir stored in a closed glass vial and a glass syringe showed minor degradation at the end of day 7 (98.96% ± 1.49% and 99.78% ± 0.10%, respectively). Insulin detemir stored in plastic syringe decreased to 94.90% ± 2.50% by day 3 and to 93.52% ± 0.29% by day 7. Storage in pin-hole glass vial showed an increase in the assay (152.13% ± 0.12%) by day 7.

Stability studies in different packaging systems demonstrated that insulin detemir remained stable for at least 7 days in a closed glass vial or glass syringe, but for only 3 days in a plastic syringe at RT. This study will allow pharmacists in the hospital setting to deliver patient-specific insulin doses into an insulin syringe with confidence in the stability.

Dipeptidyl peptidase-4 inhibitors (DPP-4i) plus basal insulin is noninferior to insulin monotherapy for glycemic control in medical–surgical patients, but data in postoperative cardiac surgery patients are sparse.

To compare glucose control in postoperative cardiac surgery patients with prediabetes or diabetes receiving a DPP-4i plus insulin versus other antihyperglycemic regimens.

We retrospectively identified patients with prediabetes or diabetes who underwent cardiac surgery at our hospital between May 2016 and June 2017. Included patients were stratified into cohorts: (1) DPP-4i plus insulin and (2) other antihyperglycemic regimens. Blood glucose levels were collected on postoperative days 2 to 7. Uncontrolled glucose (≥2 measurements <80 or >180 mg/dL in 1 day), hyperglycemia (>2 measurements ≥180 mg/dL in 1 day), and hypoglycemia (any measurement <70 mg/dL) were compared between cohorts using logistic regression adjusted for home antihyperglycemics.

We included 135 cardiac surgery patients, of which 65 received DPP-4i plus insulin. Eighty-two patients received antihyperglycemics at home. Uncontrolled glucose occurred in 61 (45.2%) patients; while hyperglycemia and hypoglycemia occurred in 50 (37.0%) and 24 (17.8%) patients, respectively. There was no difference in the adjusted odds of uncontrolled glucose (odds ratio [OR] = 1.43; 95% confidence interval [CI] = 0.65-3.11), hyperglycemia (OR = 1.20; 95% CI = 0.52-2.78), or hypoglycemia (OR = 0.69; 95% CI = 0.27-1.75) for those receiving DPP-4i plus insulin versus other regimens.

Glucose control was no different among postoperative cardiac surgery patients receiving a DPP-4i plus insulin versus other regimens. DPP-4i use was not associated with hypoglycemia.

To evaluate the clinical impact of a comprehensive medication management (CMM) service in a Brazilian primary health-care setting.

A quasi-experimental study has been carried out between July 2014 and November 2016 with patients who received the service in the primary care setting of a Brazilian city (n = 1057). Factors associated with drug therapy problems (DTP) detection in the initial assessment were evaluated by performing univariate and multivariate analyzes. To evaluate the impact of the CMM service, a linear regression model was constructed from the difference between the initial and final values of the clinical and laboratory parameters adjusted by multiple variables.

A total of 1642 DTPs was identified, the most prevalent one being “nonadherence” (31.9%) and the “need for additional drug therapy” (22.9%). The use of 5 or more medications and the presence of 3 or more diseases were positively associated with the identification of 3 or more DTPs during the initial assessment. Even after multiple adjustments, a statistically significant reduction has been observed in the values of glycated hemoglobin, systolic blood pressure, low-density cholesterol, and total cholesterol.

The CMM service contributed to the resolution of DTP and showed positive clinical impact in primary health care in the studied setting.

Evidence suggests the standard vancomycin trough goal of 15 to 20 mg/L for serious Staphylococcus aureus infections is associated with acute kidney injury, whereas appropriate monitoring of 24-hour area under the curve (AUC) may decrease nephrotoxicity. As a result, institutions have transitioned to AUC monitoring, the predictive pharmacokinetic/pharmacodynamic parameter of vancomycin to improve safety outcomes. However, this method may require increased pharmacist time and effort. Pharmacist perception of the practice change is largely unknown and warrants investigation.

An electronic survey was disseminated via e-mail to pharmacists 5 months post-AUC implementation. Items of interest were focused on pharmacist perception, including quantity of patients monitored using AUC, justification of the practice change, differences in efficacy and safety, and changes in monitoring time requirements.

The pharmacist survey was distributed to 196 pharmacists and 84 responded (43% response rate). Eighty-one pharmacists had monitored patients using AUC methods. Sixty-nine percent of these respondents perceived the change to result in increased or slightly increased patient safety, 27% described no difference, and 4% stated safety was decreased or slightly decreased. Forty-two percent perceived the transition to result in increased or slightly increased efficacy, while 48% noted no difference and 10% responded that efficacy was decreased or slightly decreased. Pharmacists stated the creation of an institutional calculator decreased the time required to calculate AUC.

After the change to AUC monitoring, pharmacists perceived improvements in safety outcomes while efficacy was at least similar if not increased.

Rural hospitals are isolated without adequate funding needed to provide for clinical services offered at larger health systems. The purpose of this study is to determine the clinical pharmacy services available and desired by rural hospitals in North Carolina.

This prospective, cross-sectional, survey was distributed to a cohort of rural pharmacy directors and managers at rural hospitals across North Carolina. Data collected pertained to characteristics of the hospital and pharmacy, pharmacy director, clinical services, and responder impressions on their ability to maintain or enhance clinical services. Responses were summarized utilizing descriptive statistics and free-responses were coded for similar themes.

Seventeen respondents (32.6%) completed the survey. Clinical activities varied, as did characteristics of the hospitals and staff. Improved patient care is the primary reason why hospital pharmacies expand their clinical participation (46.7%). Pharmacy directors believed growth of clinical activities was a long-term goal while reporting regulations, staff, and finances as barriers to growth.

Clinical pharmacy services vary in NC rural hospitals. Directors exhibit a willingness to expand clinical responsibilities. Rural hospital pharmacy directors desire pharmacists to be active clinically in patient care, but face barriers in reaching that goal.

Sedative-hypnotics, including benzodiazepines (BZDs) and benzodiazepine receptor agonists (BZD-RA), are considered potentially inappropriate medications (PIMs) in older adults. Academic detailing, an educational outreach delivered by trained clinicians to other clinicians to encourage evidence-based care, can promote deprescribing of PIMs.

To evaluate the impact of academic detailing on sedative-hypnotic prescribing to older veterans.

A retrospective analysis was performed to evaluate the impact of academic detailing on BZD and BZD-RA prescribing to veterans aged 75 years and older. Prescribing trends for primary care and mental health prescribers in the Veterans Health Administration (VA) Southeast Network were calculated for the 18 months before and after an initial academic detailing session for each prescriber. Pre–post interrupted time series analyses (ITSAs) were conducted, and period prevalence was calculated as the number of prescriptions per 1000 older veterans.

A total of 155 prescribers were followed for 36 months. BZD prevalence declined by 23% (69.08-53.33 per 1000 population; P < .001) and by 15% for BZD-RA (18.07-15.38 per 1000 population; P < .001). New starts on BZD declined by 54% (2.36-1.09 per 1000 population; P < .001) and new starts on BZD-RA declined by 53% (1.02-0.48 per 1000 population; P < .001). Alternative medications for insomnia increased by 23% (39.98-49.27 per 1000 population; P < .001). Findings from the ITSA confirmed those of the pre–post analysis with sustained effects in the postintervention period.

Academic detailing was associated with reduced sedative-hypnotic prescribing in the primary care and mental health setting.

To summarize findings of pharmacist involvement with Medicare Annual Wellness Visits (AWV), including the number of pharmacist interventions, patient/provider satisfaction, and billing models.

A literature search was conducted using PubMed, ScienceDirect College Edition Journals Collection-Health and Life Sciences, Cochrane Library, CINAHL, Medline, and Academic Search Complete, including dates between January 01, 2011, and November 05, 2018.

Search was limited to full-text, peer-reviewed articles, published in English which were relevant based on identification of a pharmacist’s role in AWV. Search terms included “Medicare annual wellness visits” and “Pharmacists.”

A data extraction tool was used to collect study authors, year published, study design, description of intervention, objectives, primary outcome measures, model of care, clinic setting, location, results, number of patients, and overall effect.

Of the 139 returned citations, 11 met inclusion criteria. Of the practice settings, 7 (72.72%) utilized a collaborative practice agreement for conducting AWV. Six (54.54%) of the studies measured financial outcomes, 3 (27.27%) measured satisfaction of students/patients/physicians, 2 (18.18%) measured clinical outcomes, and finally 4 (36.36%) measured number and types of interventions. Review revealed that 6 (54.54%) articles had more medication-related interventions than nonmedication-related interventions. Studies evaluating finances as it relates to AWVs had various findings including 38% return on investment, higher reimbursement for pharmacist-led visits, and an increase in revenue.

In a variety of outpatient health centers, AWV were conducted by pharmacists, had a positive impact on patient care, and had high satisfaction rates between patients and physicians.

A case report of multiple episodes of priapism associated with the use of 4 different psychotropic medications.

A 34-year-old African American male with treatment-refractory schizoaffective disorder suffered priapism on 6 separate occasions. His medical history is relatively unremarkable, with the exception of possible undiagnosed thalassemia. All incidences were potentially attributable to psychotropic medications, with chlorpromazine, risperidone, trazodone, and quetiapine being the most likely culprits. The onset of priapism ranged from hours after a single injection of chlorpromazine, to years after multiple injections of risperidone, with nothing to indicate a medication dose or duration relationship to priapism. While on clozapine, fluphenazine, haloperidol, lurasidone, and olanzapine at varying times, the patient did not appear to develop priapism. The commonality of high-affinity alpha-1 antagonism with these psychotropics may be to blame. No pharmacokinetic or pharmacodynamic interactions were noted, which would have produced elevations in the levels of these psychotropics, nor was the patient on any phosphodiesterase type 5 (PDE-5) inhibitors or antihypertensives known to cause priapism. Depending on the offending agent, the Naranjo et al’s Adverse-Reaction Probability Scale scores ranged from 5 to 8 (probable).

A man suffered from multiple episodes of priapism attributed to psychotropic medications. This is not the first case to describe this effect, but will give clinicians a timeline of events and medications that did and did not appear to elicit priapism in a patient with treatment-refractory schizoaffective disorder. Knowledge of which psychotropic medications may be more likely to induce priapism is crucial to preventing long-term penile damage.

Efavirenz (Sustiva®) is used for the treatment of human immunodeficiency virus (HIV) type 1 infection. Hepatoxicity is a known potential adverse drug event with efavirenz; however, to our knowledge, vanishing bile duct syndrome (VBDS), a type of liver injury, has not been reported with this therapy.

We report the case of a 48-year-old male with HIV and VBDS secondary to antiretroviral therapy. The patient was started on efavirenz, emtricitabine, and tenofovir disoproxil fumarate (Atripla®). Four weeks later, the patient presented with complaints of poor appetite, nausea with emesis, dark urine, and malaise. Labs obtained supported the diagnosis of acute hepatitis, and a liver biopsy confirmed a diagnosis of VBDS. The Naranjo adverse drug reaction probability scale showed that it was probable (score of 7) that the VBDS was related to drug therapy. Efavirenz was assessed to be the most likely cause of VBDS, end-stage liver disease, and the eventual need for liver transplantation.

To our knowledge, this is the first reported case of probable efavirenz-induced VBDS in a patient living with HIV. Recognition and awareness of this adverse drug reaction by clinicians for quick diagnosis, discontinuation of therapy, and management are important in patients receiving this regimen.

Achieving therapeutic levels of phenytoin is critical to its efficacy and safety. Free serum levels represent pharmacologically active phenytoin due to the high protein binding of the drug. Predicting free serum levels in patients with left ventricular support devices can be challenging, as the pharmacokinetics (PK) can be significantly altered, and equations to correct total levels have not been validated in this population. The aim of this case series was to describe serum phenytoin concentrations in critically ill patients requiring left ventricular support devices.

A retrospective chart review was performed including patients who received phenytoin therapy and had at least 1 set of simultaneously measured free and total serum phenytoin levels during left ventricular support with a mechanical device. Corrected total phenytoin levels were calculated using Sheiner-Tozer equations.

Three patients were included in this case series. Patients 1 and 2 required venoarterial extracorporeal membrane oxygenation (ECMO) during phenytoin therapy, and patient 3 had a durable left ventricular assist device (LVAD). Measured phenytoin levels ranged from 4.1 to 11.4 µg/mL, and calculated corrected levels were 6.8 to 18.4. Measured free phenytoin levels ranged from 1.2 to 3.6 µg/mL, which correlated with free fractions of 15.8% to 37.9%.

This case series demonstrates a higher percentage of free phenytoin compared to the total serum level than would be predicted and an inability to rely on corrected total phenytoin level to predict whether it is within therapeutic range. Monitoring of free serum phenytoin concentrations should be strongly considered in critically ill patients requiring LVAD or ECMO support.

Argatroban, a synthetic, parenteral, nonheparin anticoagulant, is a direct thrombin inhibitor indicated for the prophylaxis or treatment of venous thromboembolism (VTE) in patients with heparin-induced thrombocytopenia with thrombosis (HITT) and for use during percutaneous coronary intervention (PCI) in patients who have or are at risk for developing HITT. Although heparin resistance occurs in approximately 0.5% to 5% of heparin-treated patients and is well documented in the literature, argatroban resistance is limited to a single case report. The objective of this case is to describe a case in which argatroban resistance was suspected in a patient with critical limb ischemia.

This is a case report of a single patient.

A 68-year-old female admitted for critical limb ischemia requiring vascular intervention was treated for presumed HITT with argatroban. A therapeutic activated partial thromboplastin time (aPTT) was not attained (31 seconds) despite multiple uptitrations of the dose to 2.8 μg/kg/min (adjusted based on the institutional protocol and with consideration of organ dysfunction). A coagulopathy workup revealed a high level of factor VIII (265%).

This case supports early assessment of factor VIII levels and the consideration of argatroban resistance and in patients who have a subtherapeutic aPTT, despite multiple increases in dose with an elevated factor VIII level. Early identification should prompt the use of an alternative anticoagulant to ensure efficacy.

Klebsiella pneumoniae has gained recognition for its association with invasive liver abscess syndrome (ILAS). ILAS is associated with a hypervirulent strain of K pneumoniae and can impact immunocompetent as well as immunocompromised patients.

A 42-year-old Hispanic male with no significant past medical history was admitted with complaints of subjective fevers and worsening fatigue. The patient was found to have multiple septic pulmonary emboli, a prostate abscess, a seminal vesicle abscess, bilateral frontoparietal and left temporal infarcts thought to be due to septic emboli, pyelonephritis, endophthalmitis, and hepatic abscesses. Cultures grew K pneumoniae that was determined to be the hypervirulent strain associated with ILAS. The patient was treated for a total of 71 days, including ceftriaxone and multiple intravitreal injections with ceftazidime.

Notably, this case report details a disease state new to Colorado. Pharmacists are able to assist in the care of ILAS with antibiotic selection, considering sites of infection and encouraging appropriate consultation of specialized care teams.