Houston Methodist Department of Pharmacy Annual Research Report 2021-2022

HOUSTON METHODIST POSTGRADUATE PHARMACY RESIDENCY & FELLOWSHIP CLASS

Houston Methodist Department of Pharmacy

The Department of Pharmacy at Houston Methodist collaborates with the health care team to provide innovative, personalized, cost-effective pharmaceutical care in a culture dedicated to quality and safety.

The pharmacy department’s vision is to be recognized as a global leader of pharmaceutical care in the health care setting. To that end, we strive to:

• Continuously improve the quality and safety of patient care and the medication management process.

• Cultivate an environment of collaboration and teamwork.

• Provide high-quality training and education to our technicians, student interns, residents and pharmacists.

• Maximize the use of automation and information technology.

• Maximize cost efficiencies and resource utilization.

TABLE OF CONTENTS

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Letter from Daniel L. Metzen, PharmD, MBA

System Director of Pharmacy Services, Houston Methodist

Letter from Alex C. Varkey, PharmD, MS, FAPhA

Director of Pharmacy Services, Houston Methodist Hospital 4

Letter from Jill C. Krisl, PharmD, BCPS, BCTXP

Chair of Pharmacy Research Committee 5 Pharmacy Research Committee Members

8–30 2021-2022 Houston Methodist Hospital Pharmacy Postgraduate Trainees

8 PGY1 Pharmacy Residency

Emily Allen, PharmD

Alyssa Chaplain, PharmD

Eric Rubido, PharmD Mariah Sigala, PharmD Evan Steere, PharmD Eileen Sullivan, PharmD

14 PGY1 International Graduates Pharmacy Residency Tania Baigi, PharmD Donna Barakeh, PharmD

16 PGY1 Pharmacy Residency – Sugar Land Shireen Rasheed, PharmD Cylene Talabucon, PharmD

6–7 Pharmacy Research Funding 34 System Pharmacy Research Bibliography

18 PGY1/PGY2 HealthSystem Pharmacy Administration Residency

Alfred Awuah, PharmD Nathan Jones, PharmD Alan Luu, PharmD Niha Zafar, PharmD

22 PGY1/PGY2 Pharmacy Informatics Residency Wenfei Wei, PharmD

23 PGY2 Critical Care Pharmacy Residency Caitlin Labay, PharmD Nina Srour, PharmD

25 PGY2 Infectious Diseases Pharmacy Residency Melissa O’Neal, PharmD

26 PGY2 Internal Medicine Pharmacy Residency Corey Dinunno, PharmD

27 PGY2 Oncology Pharmacy Residency Karen Abboud, PharmD Breanna Hinman, PharmD

29 PGY2 Solid Organ Transplant Pharmacy Residency Richard Lincoln, PharmD Allison Yun, PharmD

31 Clinical Pharmacy Fellowship in Outcomes Research Bader Alghamdi, PharmD Phuong Duong, PharmD Navjot Kaur, PharmD

LETTER FROM THE SYSTEM DIRECTOR OF PHARMACY SERVICES

My first impression when reading this report is as it is every year: “Wow, amazing work and amazing accomplishments.” I am honored to have the opportunity to work alongside such a highly talented team of pharmacy clinicians. Demonstrated on these pages is a dedication to unparalleled excellence in patient care, a prominent characteristic amongst the pharmacy team. Thank you to all who contributed to the endeavors in this annual report and congratulations to a successful year!

Daniel L. Metzen, PharmD, MBA System Director of Pharmacy Services, Houston Methodist

LETTER FROM THE DIRECTOR OF PHARMACY SERVICES

On behalf of the Houston Methodist Hospital Pharmacy Management Team, I want to extend my sincere appreciation to all our graduating residents and fellows. Our residents and fellows fully invest in their respective opportunities to grow both personally and professionally, and in the process, make a lasting impact on HMH Pharmacy’s effort to optimize patient outcomes. The last few academic years have been especially challenging given our need to respond to the global COVID-19 pandemic, and as usual, HMH Pharmacy responded with unparalleled efforts in patient care and in facilitating cutting-edge research. We administered well over 1 million doses of COVID-19 vaccinations and have emerged as a national leader in the provision of monoclonal antibody treatments.

Our system efforts continue to be lauded by state and national leaders and have been highlighted in several highly reputable publications, including the New England Journal of Medicine (NEJM), as well as national and international conferences. This past academic year, several of our outstanding pharmacists and leaders at HMH have been awarded significant grant funding to advance research in a variety of areas including infectious diseases, opioid stewardship, solid organ transplant, telehealth, and pharmacy education – totaling more than $395,000. Our team has contributed 23 new publications to the literature across several specialties.

As has been the case for more than 30 years, a catalyst for our department-initiated research success has resided in our pharmacy training programs, and we continue to be grateful for the hard work and dedication of our pharmacy learners, preceptors/practitioners, and staff. Each of our achievements took considerable commitment and an immense amount of work. Our successes in research and scholarship are a true testament to HMH pharmacy’s commitment to working alongside other health care disciplines in advancing patient care. I continue to be impressed with the quality of pharmacy’s efforts in growth and innovation, and I have our residents, fellows and their preceptors to thank for much of that. We remain in position to develop and share innovative practices in part because of our Pharmacy Research Committee, a group dedicated to ensuring excellence in the quality and feasibility of research conducted by HM pharmacy.

As we move ahead to the 2022-2023 residency year, we will continue with laser focus on what we do every day. That includes enhancing our medication distribution, clinical services, and regulatory/quality compliance efforts to provide an environment of unparalleled safety, quality, service, and innovation for our patients. Our patients always deserve our best – and it is the reason we all work so hard to develop safe and effective processes and practices from which our patients will benefit. Thanks for all that you have done and continue to do for patients.

Alex C. Varkey, PharmD, MS, FAPhA

Director of Pharmacy Services , Houston Methodist Hospital

LETTER FROM THE PHARMACY RESEARCH COMMITTEE CHAIR

Welcome to our Department of Pharmacy’s seventh edition of the Annual Research Report. This report serves to showcase the dedication to research and patient care of the pharmacy department across the Houston Methodist hospital system.

Over the course of 2021-2022, members of our pharmacy department have led research collaborations within internal medicine, infectious diseases, transplant, critical care, anticoagulation, and oncology patient populations, as well as research in informatics and pharmacy management. The pharmacy department continues to strive toward the advancement of pharmacy practice and patient care throughout Houston Methodist.

The mission of the Pharmacy Research Committee is to ensure excellence in the quality of research conducted and the research training provided by the Department of Pharmacy at Houston Methodist. The PRC has continued to optimize established programs including project proposal development, project approval, resident project alignment, support, education, visibility, and building a more robust research infrastructure and partnership with the Research institute. Clinician and preceptor education remained a focal point for 2021-2022, continuing to facilitate the research process from the early stages of an idea to project completion. Additionally, during this year we brought a greater emphasis to research endeavors across the entire Houston Methodist system.

The PRC continues to evolve to meet the needs of the department. We now are 10 members, plus three pharmacy research fellows assisting with our support lead. Members of the PRC represent pharmacy across the system hospitals and clinical specialties. Our Department of Pharmacy preceptors, residents, and staff remain committed to high quality and innovative patient care, education, research, leadership and advocacy. As always, our goals are grounded in our mission to be unparalleled. I would like to sincerely thank all members of the Pharmacy Research Committee for the continued dedication and hard work; the work of this group is truly vital to our success.

Jill C. Krisl, PharmD, BCPS, BCTXP Chair, Pharmacy Research Committee

PHARMACY RESEARCH COMMITTEE MEMBERS

Bader Alghamdi, PharmD Member - Fellow

Elsie Rizk, PharmD Project Support Lead

Phuong Duong, PharmD Member - Fellow

Chelsea Lopez, PharmD, BCCCP Project Development

Punit Shah, PharmD, BCPS, BCIDP Education

Navjot Kaur, PharmD Member - Fellow

Hayley Brazeale, PharmD, BCPS Project Approval Co-Lead

Godsfavor Umoru, PharmD, BCOP Project Alignment

David R. Putney, PharmD, MPH, BCPS - AQ Cardiology Project Alignment Lead

Engie Attia, PharmD, BCPS Project Development Lead

Mobolaji Adeola, PharmD, BCPS Project Approval Lead

Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM Education Lead

PHARMACY RESEARCH FUNDING

Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM , and Elsie Rizk, PharmD, were awarded a $156,900 grant from Grifols Biologicals, LLC to conduct a prospective, observational, multicenter study to evaluate the safety of human rabies immune globulin when administered to pediatric patients per standard of care for rabies postexposure prophylaxis in the emergency department. The study will collect safety data using surveys and medical record chart review and will be supported by the Houston Methodist Clinical Pharmacy Fellowship in Outcomes Research.

Niaz Deyhim, PharmD, MS, BCPS, and a Houston Methodist systemwide team of collaborating pharmacists (Kayleigh Emerson, PharmD; Joke Fasoranti, PharmD; Anne Nguyen, PharmD; and Ian Dunne, PharmD) were awarded a $5,000 grant from the ASHP Foundation to describe the implementation and study the impact of a hospital-system Doctor of Pharmacy Longitudinal Advanced Pharmacy Practice Experience (LAPPE) program.

PHARMACY RESEARCH FUNDING

Elsie Rizk, PharmD, received $103,796 as a subaward from Texas Targeted Opioid Response, a public health initiative operated by the Texas Health and Human Services Commission through federal funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) grant award number 1H79TI083288 (under direction of J. Douglas Thornton, PharmD, PhD, at the University of Houston). This subaward supports the development and implementation of clinical decision support in the electronic health record to reduce discharge opioid prescriptions that exceed guideline recommendations following high-volume surgical procedures.

In addition, Elsie was awarded a $125,970 grant from Grifols Biologicals, LLC to conduct a retrospective study to describe current practice of IgG monitoring, hypogammaglobulinemia (HGG) diagnosis and incidence, current use patterns of intravenous immune globulin (IVIG), different IVIG treatment approaches used for HGG, and possible risk factors for HGG in lung transplant recipients. The study is supported by the Houston Methodist Clinical Pharmacy Fellowship in Outcomes Research.

Ian Dunne, PharmD, BCPS; Sandy Spurlock, PharmD; Heidi Matus, MD, FACP; and Bhargavi Patham, MD, PhD, were awarded a grant for $3,500 from Texas A&M University College of Medicine to conduct research regarding the impact of interprofessional telehealthcare for high-risk, low-resource adults.

Retrospective Study on the Efficacy and Tolerability of Dose Modification of PD-1 and PD-L1 Inhibitors in Hospital-Based Outpatient Cancer Clinics: Continued Review

Emily Allen, PharmD; Erika N. Brown, PharmD, BCOP; Rodrigo De La Torre, PharmD; Asha Murthy, MD

PURPOSE

Programmed cell death (PD-1) is a transmembrane receptor protein expressed on T cells, B cells, and NK cells that interacts with its ligand, PD-L1. Anti-PD-1 and anti-PD-L1 medications inhibit that PD-1 and PD-L1 interaction and have been shown to be effective in treating several forms of advanced cancers. Since the approval of these agents, standard dosing protocols have been utilized. However, a small population of patients in the community setting have received dose modified PD-1 and PD-L1 inhibitors secondary to adverse events. The purpose of this retrospective study is to assess the efficacy and tolerability of dose modified PD-1 and PD-L1 inhibitors compared to standard dosing.

METHODS

This retrospective observational study includes data collected from 221 patients initiated on a PD-1 or PD-L1 inhibitor between September 1, 2017 and September 31, 2019 in the outpatient community setting of the Houston Methodist Hospital System. Patients were 18 years or older, received outpatient immunotherapy, and had a diagnosis of an FDA-labeled indication for immunotherapy. The primary endpoints included incidence of adverse effects (defined by the common terminology criteria for adverse events) and time to progression.

RESULTS

of the 221 patients that received PD-1 and PD-L1 inhibitors, 200 patients have been reviewed. Patients received either nivolumab (n=81), pembrolizumab (n=93), atezolizumab (n=21) or durvalumab (n=26). Patients observed to have a dose modification included: nivolumab (n=40, 49%), pembrolizumab (n=24, 26%), and durvalumab (n=9, 35%). The most common side effects that lead to immunotherapy dose modification were pneumonitis (16%, n=21), musculoskeletal pain (15%, n=20), and diarrhea (14%, n=19). There was a median time to progression of 204 days for patients with an immunotherapy time delay, and for patients with an immunotherapy dose reduction; median time to progression was 299 days. Overall, approximately 40% of the patients included in the study had either a dose modification or delay in treatment with continued response to treatment.

CONCLUSION

Further large studies are needed to assess dose modifications of immunotherapy on both clinical outcomes and adverse events.

Emily Allen, PharmD

Emily earned her PharmD from The University of Texas at Austin in 2021. Following completion of her PGY1, Emily will continue her residency training as a PGY2 Oncology Resident at Houston Methodist Hospital.

Primary project preceptor: Erika N. Brown, PharmD, BCOP

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference, and HOPA 2022 Annual Conference.

PGY1 PHARMACY RESIDENCY

Evaluation of Voriconazole Dosing for Prevention of Aspergillus in Lung Transplant Recipients

Alyssa Chaplain, PharmD; Brett J. Pierce, PharmD, BCPS; Christine Pham, PharmD; Aaron Hutchins, PharmD; Will L. Musick, PharmD, BCIDP; Duc T. Nguyen, MD; Edward A. Graviss, PhD; Simon W. Yau, MD; Ahmad Goodarzi, MD; Jihad G. Youssef, MD; Howard J. Huang, MD

PURPOSE

Aspergillus (ASP) infections are a known complication seen in lung transplant (LT) recipients and are associated with an increased risk in mortality. Guidance published by the American Society of Transplantation suggests the use of universal prophylaxis or preemptive therapy for these patients. However, there is currently no consensus regarding the ideal anti-fungal agent or prophylaxis strategy due to limited randomized control trials. In addition, voriconazole (VCZ) prophylaxis dosing recommendations have not been fully established. We sought to evaluate the efficacy of VCZ 200 mg twice a day (BID) for three months post LT in preventing ASP.

METHODS

A single-center, retrospective review was conducted on LT recipients who were initiated on VCZ 200 mg BID for three months between 2016 - 2020. Patients were excluded if transplanted for cystic fibrosis, received an azole other than VCZ, received an alternative VCZ dose, had prophylaxis started >14 days post-transplant, or death occurred within 30 days of transplant. The primary endpoint was defined as the incidence of (+) ASP cultures after receiving at least five days of VCZ. Secondary endpoints included classification of ASP infection, patient specific-characteristics associated with ASP infection, weight-based dose of VCZ, and time to ASP clearance.

RESULTS

Three hundred twenty patients were transplanted during this time, 143 patients met inclusion criteria, and 12 patients (7.7%) experienced a breakthrough (+) ASP culture. Of patients who developed a (+) culture, 1 (0.65%) had a proven invasive infection, 9 (5.8%) had a probable invasive infection, and 2 (1.3%) were classified as colonized based off the ISHLT consensus definitions. Most (+) ASP culture patients were designated as Lung Diagnosis Group D (restrictive). The median weight-base dose of VCZ at the time of the positive ASP culture was 2.6 mg/kg twice daily for both cohorts. More rapid clearance in days, median (IQR), was seen in patients who switched agents, 13.0 (11.0, 35.0), compared to the patients who were continued on the same VCZ dose, 57.5 (34.0, 117.0), or increased VCZ dose, 150 (98, 203), p=0.12.

CONCLUSION

Patients who received 200 mg BID of VCZ for three months resulted in a low percentage of breakthrough (+) ASP cultures with only one patient developing a proven invasive ASP infection. This retrospective chart review suggests VCZ 200 mg BID is effective at preventing ASP in LT recipients.

Alyssa Chaplain, PharmD

Alyssa earned her PharmD degree from the University of Houston College of Pharmacy in 2021. Following the completion of her PGY1 Residency, Alyssa will continue her postgraduate training as a PGY2 Solid Organ Transplant Pharmacy Resident at Houston Methodist Hospital.

Primary project preceptor: Brett J. Pierce, PharmD, BCPS

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference, and 2022 American Transplant Congress.

PGY1 PHARMACY RESIDENCY

Descriptive Analysis of Direct Oral Anticoagulants in Heart and Lung Transplant

Eric Rubido, PharmD; Megan Cooper, PharmD; Kevin Donahue, PharmD, BCPS; Jill Krisl, PharmD, BCPS, BCTXP

PURPOSE

Direct oral anticoagulants (DOACs) are widely utilized following cardiothoracic transplantation due to complications such as atrial fibrillation and venous thromboembolism. Given the lack of published evidence describing the use of DOACs in the cardiothoracic transplant population, we aim to describe the prescribing patterns of DOACs in relation to DDIs, renal dysfunction, and periprocedural management, as well as explore the use of DOAC-specific anti-xa monitoring.

METHODS

This was a single-center, retrospective, descriptive analysis of adult cardiothoracic transplant recipients initiated on ≥3 consecutive days of DOAC therapy between May 2016 and July 2021. Patients were excluded if DOAC therapy was initiated prior to transplant or at an outside institution. The primary endpoint for this analysis was the percentage of patients dosed per package labeling. Secondary endpoints included DOAC prescribing in the context of drugdrug interactions, renal dysfunction, and periprocedural management, thromboembolism and major bleeding at 6 and 12 month, 90-day readmission due to bleeding or thrombosis, and need for DOAC-reversal.

RESULTS

A total of 125 patients were included in this analysis with a median age of 62 years. At initiation, 61.6% of patients were dosed according to package labeling. The most common reason for non-labeled dosing was concomitant azole antifungal therapy. DOAC therapy was held for 82 procedures with no reported thrombotic events and 1 major bleed in the setting of AKI. Deviation from package labeling, concomitant azole antifungal therapy, and hemodialysisdependence were not associated with increased risk of thromboembolism or major bleeding. DOAC-specific anti-xa guided dosing was associated with a reduced risk of major bleeding (0% vs. 8.9%, P = 0.05).

CONCLUSION

Deviation from package labeling is common following cardiothoracic transplantation with azole antifungal therapy as the leading cause. Additionally, DOAC therapy appears safe and effective in the setting of upcoming procedures, with further studies necessary to establish an optimal anticoagulation strategy. Furthermore, DOACspecific anti-xa monitoring has been associated with a reduction in the risk for major bleeding when used to guide long-term dosing.

Eric Rubido, PharmD

Eric earned his PharmD from the University of Florida College of Pharmacy in 2021. Following completion of his PGY1 residency, Eric will complete a PGY2 in Solid Organ Transplant at Houston Methodist Hospital.

Primary project preceptor: Jill Krisl, PharmD, BCPS, BCTXP

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

PGY1 PHARMACY RESIDENCY

Comparison of Sedation and Analgesia Requirements in Patients with SARS-CoV-2 versus Non-SARS-CoV-2 Acute Respiratory Distress Syndrome on Veno-venous ECMO

Mariah I. Sigala, PharmD; Diane Dreucean, PharmD, BCCCP; Jesse E. Harris, PharmD, BCCCP; Kevin R. Donahue, PharmD, BCPS; Fariedeh Bostan, PharmD; Prakruthi Voore, MD; Jose Francisco Saille Cuevas, MD; Celia Morton, PharmD, BCCCP

PURPOSE

increased sedation and analgesia requirements have been described in patients with acute respiratory distress syndrome (ARDS) on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. However, there is a paucity of data comparing sedation requirements in patients on VV ECMO for ARDS secondary to SARS-CoV-2 vs other etiologies of ARDS. The objective of this study is to compare sedation and analgesia requirements in adult patients with SARS-CoV-2 ARDS versus other etiologies of ARDS requiring VV-ECMO support.

METHODS

We performed a retrospective cohort study of adult patients receiving sedation and analgesia on VV-ECMO support for ARDS. Patients were excluded if cannulated at an outside hospital for greater than 24 hours, expired within 48 hours of ECMO cannulation, or received neuromuscular blocking agents for greater than 7 consecutive days following ECMO cannulation.

RESULTS

We evaluated 108 patients on VV-ECMO support, including 44 with non-SARS-CoV-2 ARDS and 64 with SARS-CoV-2 ARDS. The median daily dexmedetomidine requirements were significantly higher in the SARS-CoV-2 cohort (16.7 vs. 13.4 mcg/kg/day, p=0.03), while the median propofol daily requirements were significantly higher in the non-SARS-CoV-2 cohort (40.3 vs. 53.5 mg/kg/day, p <0.01). There was no difference in daily requirements of opioids, benzodiazepines, and ketamine between groups. Use of adjunct agents to facilitate weaning was significantly higher in the SARS-CoV-2 cohort (78.1% vs. 43.2%, p<0.01).

CONCLUSION

We found that patients with ARDS on VV-ECMO support require multiple analgesic and sedative agents with concomitant use of adjunct agents to facilitate analgesia and sedation weaning in both SARS-CoV-2 and nonSARS-CoV-2 ARDS cohorts. To circumvent these challenges, ECMO centers should consider implementation of ECMO-specific analgosedation protocols to optimize patient outcomes.

PGY1 PHARMACY RESIDENCY

Mariah Sigala, PharmD

Mariah Sigala earned both her BSA in Biochemistry and PharmD from The University of Texas at Austin in 2021. Following completion of PGY1, Mariah will continue her postgraduate training as a PGY2 Critical Care Pharmacy Resident at Houston Methodist Hospital.

Primary project preceptor: Celia Morton, PharmD, BCCCP

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

Impact of Hypoalbuminemia on Ceftriaxone Treatment Failure in Patients with Enterobacterales Bacteremia

Evan L. Steere, PharmD, MS; Taryn A. Eubank, PharmD, BCIDP; Megan H. Cooper, PharmD; Sage B. Greenlee, PharmD; Ty C. Drake, PharmD, BCIDP

PURPOSE

Ceftriaxone is a frequently used antibiotic among hospitalized patients in the United States due to convenient dosing and robust Gram-negative activity. However, patients with hypoalbuminemia may experience a greater degree of drug clearance and suboptimal exposure due to its high protein binding affinity. The aim of this study was to assess the impact of hypoalbuminemia on clinical outcomes among hospitalized patients treated with ceftriaxone for Enterobacterales bacteremia

METHODS

We performed a retrospective cohort study to assess the impact of hypoalbuminemia (plasma albumin ≤ 2.5 g/dL) on treatment failure among hospitalized adults with monomicrobial Enterobacterales bacteremia that received at least 72 hours of CRO therapy. Secondary outcomes included hospital length of stay, total duration of antibiotic therapy, and time to infection resolution. Propensity score matching was performed based on the probability of hypoalbuminemia.

RESULTS

A total of 448 patients met study criteria and 260 patients were included in the propensity score matched analysis. The majority of patients developed bacteremia from a urinary source (71.5%), and Escherichia coli was the most common pathogen identified (72.3%). Compared to patients with normoalbuminemia, those with hypoalbuminemia experienced numerically higher rates of treatment failure although this difference did not reach statistical significance (12.3% vs. 7.7%, P = 0.21). Among the subgroup of patients receiving care in the intensive care unit, the impact of hypoalbuminemia on treatment failure was more pronounced (24.4% vs. 7.3%, P = 0.07).

CONCLUSION

Hypoalbuminemia may increase the risk of CRO treatment failure in patients with Enterobacterales bacteremia especially in those that are critically ill.

Evan L. Steere, PharmD

Evan earned his PharmD from the University of Kansas in 2021. Following the completion of his PGY1 residency, Evan will continue his postgraduate training as a PGY2 Infectious Diseases Pharmacy Resident at Houston Methodist Hospital.

Primary project preceptor: Ty Drake, PharmD, BCIDP

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

PGY1 PHARMACY RESIDENCY

Comparison of the Efficacy and Safety of Sodium Polystyrene Sulfonate and Sodium Zirconium Cyclosilicate for the Treatment of Hyperkalemia in Hospitalized Patients

Eileen Sullivan, PharmD; Melanie Ruegger, PharmD, BCPS; Ian Dunne, PharmD, BCPS; Neil Sutaria, MD; William Towers, PharmD, BCPS

PURPOSE

Hyperkalemia is a common electrolyte abnormality that has been associated with life-threatening arrhythmias and increased mortality. Due to the ability to exchange potassium for other electrolytes in the gastrointestinal tract, potassium binders are a mainstay of treatment in the acute care setting. The purpose of this study was to compare the efficacy and safety of two commonly utilized potassium binders ¬sodium polystyrene sulfonate (SPS) and sodium zirconium cyclosilicate (SZC) - for the treatment of hyperkalemia in hospitalized patients.

METHODS

This retrospective cohort study included 3,903 patients with a potassium level greater than 5 mEq/L who received either SPS or SZC for the treatment of hyperkalemia between May 2018 and August 2021. Patients who received dialysis prior to SPS/SZC administration or a repeat potassium level and those who received other potassium lowering medications for treating hyperkalemia were excluded.

RESULTS

The mean reduction in serum potassium 4-24 hours after potassium binder administration was 0.96 mEq/L with SPS and 0.78 mEq/L with SZC. The mean total dose of SPS and SZC leading to these reductions was 25 g SPS and 10 g SZC respectively. The rate of hyperkalemia resolution within 24 hours was higher in patients who received SPS (74.9%) compared with SZC (68.8%). Overall, other electrolyte derangements were rare, but there was a greater incidence of hypomagnesemia with SPS. No events of intestinal necrosis were noted in this study.

CONCLUSION

Both SPS and SZC effectively lowered potassium within 24 hours of administration in hospitalized patients and demonstrated favorable safety profiles. While a statistically greater reduction in potassium was seen with SPS compared to SZC, most patients receiving SZC received only a single 10 g dose. Further dosing comparisons between both agents are needed to optimize the potassium lowering effects for the treatment of acute hyperkalemia.

PGY1 PHARMACY RESIDENCY

Eileen Sullivan, PharmD

Eileen earned her BS in Biochemistry and PharmD from the University of Texas at Austin in 2021. Following completion of her PGY1, Eileen will be completing a PGY2 in Internal Medicine at Houston Methodist.

Primary project preceptor: Melanie Ruegger, PharmD, BCPS

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

Impact of Pharmacy Liaison Service and Institutional Specialty Pharmacy on the Time to Medications Delivery for Patients Newly Started on Oral Oncolytics: a Before and After Study

PURPOSE

Oral oncolytic offers several benefits compared to intravenous chemotherapy. However, it also creates a unique set of challenges including toxicity identification/management, financial barriers, and complications of drug distribution model through specialty pharmacy. There are pros and cons to institutional-based versus non-institutional-based specialty pharmacies. with the increase in oral oncolytics in diverse cancers and differences in clinical practice across institutions, the purpose of this study was to investigate the impact of institution-based specialty pharmacy and pharmacy liaison service on oral oncolytic availability and addressing barriers to optimal patient outcomes.

METHODS

A single center, retrospective chart review was conducted on patients that were prescribed oral oncolytic and received services from Houston Methodist Hospital’s specialty pharmacy and pharmacy liaisons from January 2021 to August 2021. The data were, subsequently, compared to when these services were not available (January 2017-August 2017). The primary endpoint aimed to assess the impact of pharmacy liaison service and institutional specialty pharmacy on the acquisition time of oral oncolytic agents. The secondary endpoints include the financial barriers identified by pharmacy liaisons, the drug-related toxicities identified by the specialty pharmacy, and the number of hospitalizations due to oral oncolytic toxicity.

RESULTS

During the study timeframe, 102 patients filled new-start oral oncolytics through the specialty pharmacy. The median time to oral oncolytic availability (defined as time interval between when prescription was written to when patient received medication, in days) was 4 days, compared to 8 days prior to specialty pharmacy implementation. Among these 102 patients, the pharmacy liaisons achieved 67 approved prior authorizations, with the remaining 35 patients not requiring prior authorizations after initial investigation by the pharmacy liaisons. Financial assistance was provided to 34 patients for a total amount of approximately $50,051.84. The percentage of treatment-related adverse effects (TRAE) per patient identified by specialty pharmacy was approximately 18% higher compared to the pre-specialty pharmacy phase. Management of TRAE involved supportive care, dose reduction, and/ or chemotherapy discontinuation. Severe TRAE resulting in hospitalization or non-routine clinic visit occurred in 16% of patients compared to 19% reported before the establishment of specialty pharmacy.

CONCLUSION

As the use of oral chemotherapy agents continues to increase, data from this study highlight how specialty pharmacy and pharmacy liaison services benefit oncology patients. By providing patients with financial assistance, education and effective management of adverse effects, specialty pharmacies can increase adherence and improve treatment outcomes.

Tania Baigi, PharmD

Primary

Presented

Tania earned her PharmD from MCPHS University in 2021. She is completing her PGY1 pharmacy residency at Houston Methodist Hospital. Following completion of her PGY1, Tania will seek a clinical pharmacist position in the future.

project preceptor: Veronica Ajewole, PharmD, BCOP

at 2022 Midwest Pharmacy Residents Conference.

PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES

Tania Baigi, PharmD; Ashka Patel, PharmD, BCOP; Cynthia El Rahi, PharmD, BCOP; Javon Artis, PharmD, MS; Veronica Ajewole, PharmD, BCOP

Evaluation of Risk Factors for Supratherapeutic Anti-Xa Levels in Hospitalized Patients without Severe Renal Impairment Receiving Treatment-Dose Enoxaparin

PURPOSE

The standard dose of enoxaparin for therapeutic anticoagulation is 1 mg/kg every 12 hours in patients with a CrCl > 30 mL/minute. At Houston Methodist Hospital (HMH), we anecdotally observed supratherapeutic antifactor Xa (anti-Xa) levels in patients with CrCl well above this cutoff. These patients often had independently elevated BUN levels and many were COVID-19 positive. Outside of pregnancy, obesity, and renal impairment, literature describing the association between BUN or other factors that may increase the risk of supratherapeutic anti-Xa levels is sparse. The purpose of this study was to determine risk factors for supratherapeutic anti-Xa levels to inform empiric enoxaparin dosing strategies.

METHODS

This retrospective study included adult patients admitted within the HMH System between June 1, 2016 and December 1, 2021 that received enoxaparin at a dose of 0.91 to 1.09 mg/kg every 12 hours and had an anti-Xa level drawn 3 to 7 hours after at least 3 doses. Patients were excluded if they had a CrCl < 30 mL/min or received a factor Xa inhibitor within 7 days prior to the initial anti-Xa level. The primary outcome was the correlation between BUN and anti-Xa levels. Secondary outcomes included the association between other patient characteristics and supratherapeutic anti-Xa levels, as well as the incidence of major bleeding and breakthrough thrombosis in patients with supratherapeutic initial anti-Xa levels versus those with therapeutic or subtherapeutic levels.

RESULTS

A total of 732 patients met inclusion criteria. A small correlation was found between BUN and anti-Xa levels, with a Pearson correlation coefficient of 0.25 (p<0.001). Multivariable logistic regression analyses revealed that female gender, rising BMI, lower CrCl, and concomitant corticosteroid administration were associated with an increased risk of supratherapeutic anti-Xa levels (p<0.05). The association of BUN with supratherapeutic levels was not statistically significant (p=0.265). There were no significant differences in the incidence of major bleeding or breakthrough thrombosis in patients with supratherapeutic anti-Xa levels as compared to those with therapeutic or subtherapeutic levels.

CONCLUSION

Elevated BUN was not significantly associated with supratherapeutic anti-Xa levels when evaluated in a multivariable regression model. Patient characteristics that retained a statistically significant association included female gender, BMI, CrCl, and concomitant corticosteroid administration. In this study, we identified patientspecific factors that may increase the risk of developing supratherapeutic anti-Xa levels in patients with normal renal function and may be important to consider when empirically dosing therapeutic enoxaparin.

PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES

Donna Barakeh, PharmD

Donna earned her PharmD degree from the Lebanese American University in 2020. Following completion of her PGY1, Donna will continue her postgraduate training as a PGY2 Critical Care Pharmacy Resident at Houston Methodist Hospital.

Primary project preceptor: Mahmoud Sabawi, PharmD, BCCCP

Presented at 2022 Midwest Pharmacy Residents Conference.

Donna Barakeh, PharmD; Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM; Elsie Rizk, PharmD; Hangil Seo, BCPS, BCCCP; Mahmoud Sabawi, PharmD, BCCCP

Evaluation of a Pharmacy-Initiated Fall Consult

PURPOSE

To assess whether a pharmacy-initiated consult based on the Hester Davis Scale, a nursing driven assessment tool to identify patients at high risk for falls, increased pharmacy interventions in hospitalized patients.

METHODS

This was an IRB approved, single-center, randomized study that enrolled patients ≥ 70 years old with a HDS ≥ 18, and those who had a fall within the past month or during current admission between January to July 2021. Clinical pharmacists performed an evaluation of all medications that increased risk of falls and made recommendations in the intervention group. The primary outcome was the number of accepted pharmacy recommendations to modify medication that increase risk of falls. Secondary outcomes included length of stay (LOS), inpatient falls, and mortality.

RESULTS

The study included 561 patients, 291 patients in the control group and 270 patients in the intervention group. There was an increase in pharmacist recommendations in the intervention group compared to the control group (20% vs 11%; p=0.021). Opioids and cardiovascular agents were the most common categories with accepted interventions.

CONCLUSION

The results of this study suggest a benefit in pharmacistfocused review to optimize pharmacotherapy regimens in patients at high risk of falls. Future studies should aim to assess the association between pharmacist interventions with reduction in falls.

Shireen Rasheed, PharmD

Primary

Shireen earned her PharmD from Texas A&M Irma Lerma Rangel College of Pharmacy in 2021. Following completion of her PGY1 residency, Shireen will be completing a PGY2 ambulatory care residency at JPS Hospital in Fort Worth, Texas.

project preceptor: Meghan Thibeaux, PharmD, BCPS

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

Shireen Rasheed, PharmD; Meghan Thibeaux, PharmD, BCPS; Brittany Yalamanchili, PharmD, BCPS; Punit Shah, PharmD, BCIDP; Kathryn Agarwal, MD

PGY1 PHARMACY RESIDENCY – HOUSTON METHODIST SUGAR LAND

Evaluation of Nasal MRSA PCR-Driven De-Escalation of AntiMethicillin-Resistant Staphylococcus Aureus Antibiotics for Pneumonia: A Multi-Center Retrospective Cohort Study

Cylene Ann Talabucon, PharmD; Punit J. Shah, PharmD, BCPS, BCIDP; Sapana Desai, PharmD, BCPS; Chiamaka Ike, PharmD, BCPS, BCCP, BCCCP; Christine Huls, PharmD, BCPS; Rebecca Kessinger, PharmD, BCCCP; Hoang Huynh, PharmD, MBA, BCPS; Judy Ikwuagwu, PharmD, BCPS, BCIDP

PURPOSE

Methicillin-resistant Staphylococcus aureus (MRSA) is a pathogen of concern in hospital-acquired pneumonia (HAP) and has been infrequently implicated in community-acquired pneumonia (CAP). The administration and monitoring of anti-MRSA antibiotics (vancomycin, linezolid, ceftaroline) for pneumonia are associated with significant healthcare costs and increased risk of adverse events. As MRSA is a natural colonizer of the nares, the nasal MRSA PCR has been identified as a tool to guide antimicrobial therapy in patients with suspected pneumonia. It has a high negative predictive value for ruling out MRSA pneumonia in both CAP (98.4%) and HAP (97.7%) and may be utilized as an antimicrobial stewardship tool for de-escalating anti-MRSA antimicrobials prescribed for pneumonia.

METHODS

The primary objective was to assess change in perceived just culture after distribution of the medication safety newsletter, which was measured by change in percentage of negative responses (PNR) to the just culture assessment tool (JCAT) pre- and post- intervention.

RESULTS

Utilizing the MRSA PCR reduced the mean duration of therapy of empiric MRSA therapy for respiratory tract infections by 1.3 days (3.9 days for the no MRSA PCR group versus 2.6 days for the MRSA PCR group; P = 0.0001; 95% CI: 0.94 to 1.71). This was driven by two thirds (63%) of our pharmacists were able to successfully intervene through de-escalating or discontinuing antibiotics. Being admitted into the ICU increased duration of therapy (P < 0.0001; 95% CI: 0.40 to 1.08) versus utilizing the MRSA PCR decreased duration of therapy (P < 0.0001; 95% CI: -1.77 to 1-.01).

CONCLUSION

in conclusion, our retrospective chart review found that using the nasal MRSA PCR resulted in significant reduction in duration of therapy of vancomycin, linezolid, and ceftaroline. These findings support the role of pharmacists and nasal MRSA PCR testing in antimicrobial stewardship to encourage de-escalation of therapy for patients with respiratory tract infections.

Cylene Ann G. Talabucon, PharmD

Cylene

Primary project preceptor: Punit J. Shah, PharmD, BCPS, BCIDP

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

PGY1 PHARMACY RESIDENCY – HOUSTON METHODIST SUGAR LAND

completed her PharmD from Belmont University College of Pharmacy in 2021. She completed her PGY1 residency at Houston Methodist Sugar Land Hospital. Following completion of her PGY1, Cylene will be seeking a clinical pharmacist position in the future.

Development and Evaluation of an Outpatient Pharmacy Infusion Productivity Model

PURPOSE

Evolving pharmacy practices have challenged historic workload efficiencies. Inadequate staffing may lead to delays in therapy and concerns for the safety of patient care. The primary objective was to identify and quantify key performance indicators (KPIs) that capture all valuable clinical and operational activities performed by staff pharmacists, pharmacy technicians, and compounding robot within outpatient pharmacy infusion areas.

METHODS

This was a retrospective review of all outpatient infusion preparations compounded at Houston Methodist Hospital between July 2020 to August 2021. Data were extracted from the electronic health record and intravenous (IV) workflow management system to examine workflows between various staff and technology implemented during the selected time frame. A relative value unit (RVU) unit of service was calculated, as a weighted value to express relative values of other activities and to conform workload into a standard unit. In this instance, 1 RVU is equivalent to 1 hour of labor. This is to incorporate cognitive clinical review and compounding activities that more accurately represent complexity-weighted verifications and complexityweighted doses dispensed.

RESULTS

A total of 12,481 hazardous preparations and 10,250 non-hazardous preparations were manually compounded during the period. The median total processing time for hazardous products was 26 minutes (0.43 RVUs) and was 15 minutes (0.25 RVUs) for non-hazardous products. For all preparations, the median time for pharmacist first verification was 9 minutes (0.2 RVUs), second verification was 4 minutes (0.07 RVUs), and sort was 13 minutes (0.22 RVUs). Additionally, the median time for technician preparation was 10 minutes (0.17 RVUs).

CONCLUSION

The number of hazardous preparations outweighed nonhazardous preparations in both quantity and complexity. This data supports a staffing model that can be predicted on median order processing times for hazardous and nonhazardous preparations, as well as ancillary functions in an outpatient pharmacy infusion satellite.

PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION AND LEADERSHIP RESIDENCY

Alfred Awuah, PharmD

Alfred earned his Bachelor of Science in biological science from Georgia State University and his Doctor of Pharmacy from the University of Georgia. Following completion of the PGY1 year, Alfred will continue his residency training in the combined program as a PGY2 Health-System Pharmacy Administration and Leadership resident.

Primary project preceptor: Adam Smith, PharmD, MS, BCPS

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

Alfred Awuah, PharmD; Adam Smith, PharmD, MS, BCPS; David Putney, PharmD, MPH, BCPS

Assessment of an Integrated Clinical Surveillance Alert System

Nathan Jones, PharmD, MS; Matthew A. Wanat, PharmD, BCPS, BCCCP, FCCM; David Putney, PharmD, MPH, BCPS; Engie Attia, PharmD, BCPS; Mobolaji Adeola, PharmD, BCPS; Mabel Truong, PharmD, BCPS; Alex C. Varkey, PharmD, MS, FAPhA

PURPOSE

Utilization of traditional clinical decision support for pharmacotherapy orders at time of computerized provider order entry (CPOE) and pharmacist order verification is widely utilized in the hospital pharmacy setting. Many electronic health records (EHR) systems lack more advanced, automated clinical surveillance capabilities or alerts to assess ongoing monitoring requirements of medications. Standalone clinical surveillance software services are available that provide this more advanced monitoring assistance but come with similar challenges for pharmacist use including alert fatigue and non-integration in the EHR. This assessment will describe the changes in alert acknowledgement and intervention rate after integration of a clinical surveillance alert system with an electronic health record.

METHODS

This is a 60-day pre-post quasi-experimental study to assess an EHR integrated clinical surveillance alerting system. Eight alerts were added to an integrated alert system and included in the analysis depending on pharmacist utility, clinical value, and frequency, based on baseline alert data. The primary outcome assessed was alert acknowledgement rate by clinical pharmacists, secondary outcomes include time to alert acknowledgement and alertdriven pharmacist intervention rate.

RESULTS

A total of 176 interventions in the pre-intervention period and 230 alerts in the post-intervention period were included. Alerts acknowledgement rate increased from 19.9% to 42.2% (95% CI 0.20 - 0.54. p<0.05), time to acknowledgement was reduced from 20.9 hours to 9.7 hours (p=0.051), and pharmacist intervention rate increased from 18.1% to 20.0% with an absolute increase of 8 interventions, (p=0.89).

CONCLUSION

The use of clinical surveillance alerting systems can identify meaningful pharmacy-led therapy interventions in a pharmacy consult service model. Integration of such systems into the EHR improved alert utilization and in our study was associated with a higher rate of pharmacist mediated therapy intervention identified by an alert.

Nathan Jones, PharmD, MS

Nathan earned his PharmD from the University of Kansas School of Pharmacy in 2020, and MS from the University of Houston College of Pharmacy in 2022. Following completion of his residency, Nathan has accepted a manager position at Children’s Mercy in Kansas City, Missouri.

Primary project preceptor: David Putney, PharmD, MPH, BCPS

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Alcalde Southwest Leadership Conference.

PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION AND LEADERSHIP RESIDENCY

Impact of a

Computerized

Physician Order Entry Intervention on Potentially Inappropriate Medications Use and Delirium in Older

Adult Patients

Alan Luu, PharmD; Kathryn Agarwal, MD; Nghi (Andy) Bui, PharmD; Mobolaji Adeola, PharmD, BCPS; Amaris Fuentes, PharmD, BCCCP; Sunny Bhakta, PharmD, MS, BCP

PURPOSE

The Beers Criteria are guidelines that provide recommendations on the usage of potentially inappropriate medications (PIM) in older adults. Our institution began implementation of active clinical decision support (CDS) alerting in the computerized provider order entry (CPOE) in 2018 to six medications. After the 2019 Beers criteria revision, the initiative was expanded in 2020 to 17 medications. A passive-CDS approach to establish a geriatric ordering context within the electronic health record (EHR) and CPOE system focused on provision of appropriate dosages, frequency defaults and medication selection in older adults. This study aims to evaluate the impact of CDS geriatric context changes implemented within our health-system on medication usage patterns.

METHODS

This is a retrospective descriptive study comparing institutional EHR data between January to September 2019 (pre-implementation) and January to September 2020 (post-implementation). Data included all doses of 17 intervened medications ordered during this time in patients age 65 or older. The primary endpoint is the percentage of PIMs with an ordered dose and frequency beyond the context parameters. Secondary outcomes include total daily dose and average dose per patient, listed by each medication intervened.

RESULTS

A total of 62,738 hospital admissions were included (32,969 pre-implementation and 29,769 postimplementations). Diphenhydramine showed a change from 2.9% pre-implementation to 3.4% post-implementation (P<0.001) in doses ordered. Lorazepam showed a change from 30.8% pre-implementation to 30.9% postimplementation (P<0.018). Alprazolam, amitriptyline and chlorpromazine showed an increase in inappropriate dose. Amitriptyline, cyclobenzaprine and imipramine showed an increase in inappropriate frequency. Chlorpromazine, cyclobenzaprine, diazepam, diphenhydramine, haloperidol, hydroxyzine, lorazepam, meclizine, metoclopramide, methocarbamol and promethazine showed statistically significant reductions in AD and TDD. Chlorpromazine and diazepam showed the greatest reduction in inappropriate AD by 32% and TDD by 30% respectively.

CONCLUSION

Utilization of a passive CDS process for implementation of the geriatric context demonstrated beneficial changes to our primary and secondary endpoints. This tool has allowed our institution to align ISMP’s recommendations for designing safe and effective processes for CPOE in our geriatric cohort. Moving forward, this passive CDS model utilized in our geriatric cohort will continue to be expanded on with additional medications and other select populations.

PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION AND LEADERSHIP RESIDENCY

Alan Luu, PharmD

Alan earned his PharmD from the University of Houston College of Pharmacy in 2021. Following completion of his PGY1, Alan will continue postgraduate training as a PGY2 pharmacy resident in the health-system pharmacy administration and leadership program at Houston Methodist Hospital.

Primary project preceptor: Nghi (Andy) Bui, PharmD

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

Impact of Unit-Based Pharmacy Technicians at a Tertiary Academic Medical Center

Niha Zafar, PharmD, MS; Engie Attia, PharmD, BCPS; David Putney, PharmD, MPH; Amanda Beck, PharmD, MS; Alex Varkey, PharmD, MS; Kevin Garey, PharmD, MS

PURPOSE

This study aimed to evaluate the impact of a unit-based pharmacy technician service on the quality of patient care provided within a tertiary academic medical center, defined by its effect on clinical pharmacist efficacy, the discharge process, and operational efficiency.

METHODS

A quasi-experimental, single-center pilot study was conducted to evaluate the integration of two unit-based pharmacy technicians on four acute care cardiology and neurology floors. Their specific primary functions included completing medication histories, performing insurance coverage verification, screening for high-cost medications and prior authorizations, and facilitating utilization of the bedside medication delivery program. The primary endpoint was a composite of clinical pharmacist efficacy, defined as the documented number of advanced clinical interventions (aside from pharmacy consult-related interventions), prior authorizations, discharge counseling, and discharge process support. Secondary endpoints included various operational and outcomes metrics, such as medication re-dispense rates, medication message rates, length of stay, length of stay index, 30-day readmission rates, and patient satisfaction scores. Patients were included only with a discharge disposition to home in the pre-intervention period from October 2020 to January 2021 and the post-intervention period from October 2021 to January 2022.

RESULTS

of the 2076 patients who met inclusion criteria in the postintervention period, approximately 35.5% had an intervention performed by a unit-based pharmacy technician during hospitalization. The composite rate of clinical pharmacist interventions per number of patients discharged significantly increased from 31% in the pre-intervention period to 38% in the post-intervention period (95% CI, -12.86 to -2.03, p<0.01). There was also a significant increase in the rate of prior authorizations completed from 2% to 7% (95% CI, -6.65 to -2.98, p<0.01). A nonsignificant increase was noted in the number of discharge counseling from 9% to 10% (95% CI, -5.06 to 2.38, p=0.47), other discharge support interventions from 3% to 4% (95% CI, -1.77 to 0.37), and non-consult interventions from 17% to 18% (95% CI, -3.91 to 2.83) performed between the pre- and post-intervention periods. A statistically significant reduction in the 30-day readmission rate from 9.7% to 7.3% was observed (95% CI, 0.43 to 4.29, p=0.02). There was no significant difference in length of stay, length of stay index, or satisfaction scores for patients who were seen by unit-based pharmacy technicians.

CONCLUSION

Unit-based pharmacy technicians contributed to improving clinical pharmacist efficacy, decreasing 30-day readmission rates, and decreasing the rate of missing doses through various patient care support and operational tasks in this study. Additional studies are needed to identify the most optimal workflow and productivity metrics for unit-based pharmacy technicians to achieve desired goals in a targeted area of focus.

HEALTH-SYSTEM PHARMACY ADMINISTRATION AND LEADERSHIP RESIDENCY

Niha Zafar, PharmD, MS

Niha completed her undergraduate coursework and earned her PharmD from the University of Houston College of Pharmacy in 2020. She also concurrently completed her MS in Pharmacy Leadership and Administration from the University of Houston over the course of the residency program. Following completion of her PGY2 residency, Niha will assume the role of Pharmacy Administrative Specialist at Houston Methodist Hospital.

Primary project preceptor: Engie Attia, PharmD, BCPS

Presented

PGY1/PGY2

at 2021 Virtual Vizient Pharmacy Network and 2022 Alcalde Southwest Leadership Conference.

Electronic Health Record Tools for Improving Patient Access to Prescriptions After Hospital Discharge

Wenfei Wei, PharmD; Rafael Felippi, PharmD, BCPS; Ghalib Abbasi, PharmD, MS, MBA; Theresa Pinn, R2; Kelly St. Rose; Isha Rana, PharmD

PURPOSE

Assess the impact of electronic health record (EHR) interventions on patient access to post-hospital discharge prescriptions.

METHODS

Five interventions were implemented in the EHR to improve patient access to prescriptions after discharge from hospital: electronic prior authorization (EPA), alternative medication suggestions, order sets, mail order pharmacy alerts, and medication interchange instructions. Patient responses from discharges during six months before the first intervention implementation and six months after the last intervention implementation were documented in the EHR and a transition-in-care platform. Primary endpoint was the proportion of discharges with patient-reported issues that would have been prevented by the studied interventions out of number of discharges with at least one prescription.

RESULTS

Discharges with patient-reported issues that would have been prevented by the studied interventions out of 1,000 discharges with prescriptions decreased from 1.68 to 1.07 (P < 0.001).

CONCLUSION

interventions in the EHR reduce barriers faced by patients to picking up prescriptions post-discharge from hospital, potentially leading to improved patient satisfaction and improved health outcomes. Important factors to consider for EHR intervention implementation are workflow development and intrusiveness of clinical decision support. Similar implementations to the five studied interventions should be made to continuously improve patients’ access to prescriptions after discharge from hospital.

Wenfei Wei, PharmD

Wenfei earned her PharmD from Texas A&M University College of Pharmacy in 2020. She is currently completing the second year of her 2-year Pharmacy informatics Residency at Houston Methodist Hospital. Following completion of her PGY2 residency, Wenfei will remain at Houston Methodist in a Pharmacy informatics Specialist role.

Primary project preceptor: Isha Rana, PharmD

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

PGY1/PGY2 PHARMACY INFORMATICS RESIDENCY

Anti-Xa Guided Direct Oral Anticoagulant Reversal with Four-Factor Prothrombin Complex Concentrate

Caitlin E. Labay, PharmD; Celia Morton, PharmD; Annette Lista, PharmD; JD Fields, MS; Christina Cisar, BS; Suraj Sulhan, MD; Kevin R. Donahue, PharmD

PURPOSE

Major bleeding in patients taking direct oral anticoagulants (DOACs) is associated with significant cost and increased mortality. DOAC reversal with four-factor prothrombin complex concentrate (4F-PCC) has a hemostatic failure rate of 20%. While use of DOAC anti-Xa levels to guide dosing of 4F-PCC is a theoretical strategy to optimize outcomes, data is lacking.

METHODS

This was a single-center, retrospective study that compared patients with and without rivaroxaban or apixaban DOAC antiXa levels prior to reversal with 4F-PCC. The primary outcome was total cumulative dose of 4F-PCC administered.

RESULTS

A total of 199 patients were included. Fifty-two had a DOAC anti-Xa levels. The most common indication for reversal was major bleeding (90.4% level group vs. 85.7% no-level group). Median cumulative dose of 4F-PCC was not different between groups (39.3 units/kg [IQR 26.450.2] level group vs. 35.6 units/kg [IQR 24.3-49] no-level group; p = 0.3). DOAC anti-Xa levels did not correlate with hemostatic efficacy, however among patients who received DOAC anti-Xa monitoring, the dose of 4F-PCC trended higher in those who achieved hemostasis compared to those who did not both for patients on apixaban (40.2 units/kg effective hemostasis vs. 36.0 units/kg ineffective hemostasis) and rivaroxaban (46.4 units/kg 4F-PCC effective hemostasis vs. 22.2 units/kg ineffective hemostasis).

CONCLUSION

No significant difference was observed in total 4F-PCC dose or clinical outcomes when utilizing DOAC specific anti-Xa levels. Furthermore, DOAC anti-Xa level monitoring did not impede patient care and may result in trends toward more effective hemostasis.

PGY2 CRITICAL CARE PHARMACY RESIDENCY

Caitlin Labay, PharmD

Caitlin received her Doctor of Pharmacy degree from The University of Texas at Austin and completed her PGY1 training at Houston Methodist Hospital. Following the completion of her PGY2 in Critical Care, Caitlin assume the role of a critical care clinical pharmacist at Methodist Hospital in San Antonio, TX.

Primary project preceptor: Kevin Donahue, PharmD

Presented at 2021 Virtual Vizient Pharmacy Network and TMC Critical Care Research Forum.

Vancomycin Dosing in High-Intensity Continuous Renal Replacement Therapy: A Retrospective Cohort Study

Nina Srour, PharmD; Chelsea Lopez, PharmD, BCCCP; Luma Succar, PharmD, BCCCP; Peter Nguyen, MD

PURPOSE

An inverse relationship exists between vancomycin serum concentrations and CRRT doses, reflected through the dialysate flow rate (DFR). There remains a lack of evidence to guide initial vancomycin dosing in the setting of high CRRT doses (i.e. DFR >30 mL/kg/h). Improved understanding of the influence of CRRT doses on vancomycin AUC/MIC has the potential to enhance antibiotic dosing and therefore efficacy. The goal of this study is to evaluate current vancomycin dosing strategies and achievement of pharmacokinetic targets in patients on high dose CRRT.

METHODS

This was a single center, retrospective cohort study of adult critically ill patients admitted to Houston Methodist between May 2019 – October 2021 and received vancomycin therapy while on high dose CRRT. High dose CRRT was defined by a DFR that was both ≥3 L/hr and >30 mL/kg/ hr. Depending on the initial vancomycin dosing strategy, patients were stratified into either the traditional (≤15 mg/ kg/day) or enhanced (>15 mg/kg/day) dosing group. The primary outcome was the difference in the rate of AUC:MIC goal (≥ 400 mg*hr/L) attainment between the two groups.

RESULTS

A total of 125 patients were included in the final analysis. The primary endpoint occurred in 74% and 54% of patients in the enhanced and traditional dosing groups, respectively (p=0.029). Therapeutic vancomycin trough levels (10–20 µg/mL) were more commonly achieved in the enhanced dosing group (66.7% vs 45%, p=0.013). As DFR rose, increasingly higher doses of vancomycin, up to 27 mg/kg/ day, were required to achieve the therapeutic targets.

CONCLUSION

This is the first study to evaluate the influence of variable CRRT doses on vancomycin AUC/MIC. Our findings suggest that vancomycin doses ≥ 15 mg/kg/day are needed to achieve early therapeutic targets in patients on high dose CRRT.

Nina Srour, PharmD

Nina graduated with her Doctorate of Pharmacy degree from the University of Colorado at Denver. She completed her PGY1 Pharmacy Residency at Houston Methodist Hospital. Following completion of her PGY2 residency, Nina has accepted a position as a pediatric critical care pharmacist at Seattle Children’s Hospital.

Primary project preceptor: Chelsea Lopez, PharmD, BCCCP

Presented at 2021 Virtual Vizient Pharmacy Network and TMC Critical Care Research Forum.

PGY2 CRITICAL CARE PHARMACY RESIDENCY

Extended Duration Vancomycin (EDV) Versus Standard of Care for initial Clostridioides Difficile Episode in Solid Organ Transplant (SOT) Recipients

PURPOSE

C. difficile infection (CDI) occurs up to 5-times more frequently among solid organ transplant (SOT) recipients compared to the general population and is associated with significant graft loss and mortality. Current treatment recommendations come primarily from studies in immunocompetent individuals, there remains a lack of evidence specifically in SOT patients. The objective of this review is to evaluate the use of extended duration vancomycin (EDV) as a primary treatment for index CDI to reduce recurrent CDI in SOT patients.

METHODS

This was a retrospective chart review of all SOT recipients across the Houston Methodist system from February 15, 2018 to June 30, 2021 who were diagnosed with, and treated for, index C. difficile episode. Diagnosis of C. difficile included a positive PCR test and documentation of diarrhea preceding the test. EDV was defined as at least 21 days of oral vancomycin; non-EDV was defined as no more than 20 days of either oral vancomycin or fidaxomicin. The primary endpoint was recurrence at 30 days from end of treatment. The secondary endpoints were recurrence at 90 days from end of treatment, incidence of recurrence, and overall time to recurrence.

RESULTS

Overall 103 patients were included; 47 and 56 patients in the EDV and non-EDV cohorts, respectively. Median duration of treatment was 25 days in the EDV group and 14 days in the non-EDV group. The primary endpoint was significantly lower in the EDV cohort (2.1 vs 12.5%, p=0.050). Ninety-day recurrence was similar between groups (17.0% vs 19.6%). The overall recurrence rate was 32.0% and similar between groups. Median time to recurrence was numerically longer in the EDV cohort (81.5 days vs 49 days).

CONCLUSION

Solid organ transplant patients have a myriad of risk factors that predispose them to C. difficile infection and recurrence. in order to reduce CDI in this population, it is imperative to reduce or mitigate risk factors wherever possible. Best available treatment for CDI in these patients has not yet been fully elucidated. Vancomycin remains a mainstay of therapy for these patients and extended-duration vancomycin may present a viable initial option to reduce recurrence. Further studies comparing primary treatments and durations in SOT recipients are needed to validate these findings.

Melissa O’Neal, PharmD

Melissa earned her PharmD from the University of South Carolina College of Pharmacy in 2020. She completed her PGY1 residency at Houston Methodist Hospital. Following completion of her PGY2 residency, Melissa has accepted an ID Specialist position at Tampa General Hospital.

Primary project preceptor: William L. Musick, PharmD, BCIDP

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

Melissa P. O’Neal, PharmD; William L. Musick, PharmD, BCIDP; Kevin Grimes, MD, MPH, FIDSA

PGY2 INFECTIOUS DISEASES PHARMACY RESIDENCY

Direct Oral to Parenteral Anticoagulants: Role of Factor Xa inhibitor-Specific Anti-Xa Concentrations

Corey V. Dinunno, PharmD; Chelsea N. Lopez, PharmD, BCCCP; Luma Succar, PharmD, BCCCP; Duc T. Nguyen, MD, PhD; Edward A. Graviss, PhD, MPH; Eric Salazar, MD, PhD; Kevin R. Donahue, PharmD, BCPS

PURPOSE

increasing use of oral factor Xa inhibitors (FXaI) has led to increased interest in the clinical utility of laboratory monitoring to enhance safety and efficacy. Particularly, use of oral FXaI anti-Xa concentrations has gained traction and has been advocated for several indications, but limited studies have explored its role in guiding inpatient transitions from oral to parenteral anticoagulants. Therefore, additional data on such approaches are warranted to help balance bleed and thrombotic risks in the higher acuity inpatient setting. This study sought to compare two strategies for oral-to-parenteral anticoagulant transitions: FXaI anti-Xaguided versus standard of care (i.e., per-package insert).

METHODS

Hospitalized patients converted from an oral FXaI (apixaban or rivaroxaban) to therapeutic parenteral anticoagulation with or without FXaI anti-Xa concentration guidance were reviewed. The primary outcome of major bleeding, according to international Society on Thrombosis and Hemostasis criteria, was compared between groups. Cox proportional hazard modeling was used to evaluate patient characteristics associated with the major bleeding events.

RESULTS

A total of 845 patients met inclusion criteria. Major bleeding was significantly lower in the concentration-guided vs. the non-concentration-guided group (4.8% vs. 11.7%; p<0.001). There were no differences between the groups in thromboembolic complications (2.4% vs. 2.7%; p=0.73) despite a significantly longer time from last oral FXaI dose to parenteral anticoagulant initiation in the concentrationguided group (27.9 hours vs. 15.1 hours; p<0.001).

CONCLUSION

This analysis suggests using FXaI anti-Xa concentrations to guide transition from oral to parenteral anticoagulants may be beneficial in reducing major bleeds in select patient populations.

Corey Dinunno, PharmD

Corey earned his PharmD from the University of Connecticut College of Pharmacy in 2020. He completed his PGY1 residency at Houston Methodist Hospital. Following completion of his PGY2 residency, Corey has accepted a position as an Acute Care Clinical Pharmacy Specialist at Houston Methodist Hospital.

Primary project preceptor: Chelsea N. Lopez, PharmD, BCCCP

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.

PGY2 INTERNAL MEDICINE PHARMACY RESIDENCY

Cardio-Oncologic Interventions for Cardiotoxicity Associated with Oral Chemotherapy

Karen Abboud, PharmD, BCPS; Godsfavour Umoru, PharmD; Barry Trachtenberg, MD; Veronica Ajewole, PharmD, BCOP

PURPOSE

Chemotherapy-induced cardiotoxicity has a wide variety of presentations including arrhythmia, cardiomyopathy, and myocardial infarction. The true prevalence and incidence of cardiotoxicity with oral chemotherapy medications is underreported, and data related to the management of patients who develop cardiotoxicity on these agents is limited. As oral targeted cancer treatments are expected to exponentially increase, continued investigations to determine the best monitoring and treatment strategies are crucial. The purpose of this study was to characterize the cardiooncologic interventions performed in a cohort of patients who experienced cardiotoxicity on oral chemotherapy.

METHODS

This was a retrospective, cohort study of patients admitted to the hospital system between June 2016 and July 31, 2021, who had at least one medical record order of oral chemotherapy agents considered to have cardiotoxic potential based on supporting literature or reported cases in the FDA Event Reporting System (FAERS) Pharmacovigilance Database, and had an ICD10 code for arrythmias, heart failure, cardiomyopathy, myocardial infarction, pericardial disease, and venous and/or arterial thrombosis after starting oral chemotherapy. The primary endpoint was to describe cardio-oncologic and medication-related interventions (reducing the dose, holding treatment, discontinuing treatment, or initiating cardioprotective medications). Secondary endpoints included the correlation between

cardiovascular risk factors and observed incidence of cardiotoxicity and the relationship between onset of cardiotoxicity and treatment duration.

RESULTS

A total of 67 patients were included. The majority (97%) had pre-existing cardiovascular disease (CVD) or a risk factor for CVD. The three most common classes of oral chemotherapy were aromatase inhibitors (36%), BCR-ABL inhibitors (16%), and VEGFR inhibitors (13%). New-onset or worsening heart failure (n=31), which occurred after a median of 148 days (IQR 43-476 days) and arrhythmias (n=30), which occurred after a median of 95.5 days (IQR 20.75-361 days), were the most common cardiotoxic events. Pharmacological treatment of the cardiotoxicity (n=44) and treatment interruption (n=18) were the most frequent interventions.

CONCLUSION

Pre-existing CVD or CV risk factors appear to predispose patients to cardiotoxicity. Real-world practice reveals that treatment is continued in most cases with temporary interruption and initiation of pharmacologic treatment. A multidisciplinary, patient-centered approach to treatment that includes temporary interruption of treatment during workup of the cardiotoxicity, discussion of risks/benefits of treatment continuation, and initiation of guideline-directed treatment is recommended until high-quality, drug-specific data for monitoring and treatment is available.

Karen Abboud, PharmD, BCPS

Primary project preceptor: Veronica Ajewole, PharmD, BCOP

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and HOPA’s 18th Annual Conference 2022.

Karen earned her PharmD from the Lebanese American University in 2019. She completed her PGY1 residency at Houston Methodist Hospital in 2020. Following completion of her PGY2, Karen will be staying on as a pharmacy clinical specialist in oncology at Houston Methodist Hospital.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Evaluation of Extended Duration Letermovir in Hematopoietic Stem Cell Transplant Recipients

James Cox, PharmD, BCOP; Godsfavour Umoru, PharmD; Will Musick, PharmD, BCIDP; Rammurti Kamble, MD

PURPOSE

Recipients of allogeneic hematopoietic cell transplants (HSCT) are highly susceptible to post‐transplant viral infections due to delayed immune reconstitution and long-term immunosuppression. Despite the use of prophylactic therapy, cytomegalovirus (CMV) remains the most common clinically significant infection in this patient population. It is not known if the patients that receive extended duration CMV prophylaxis with letermovir have less CMV reactivation and infection compared to those who do not. This study aimed to evaluate the efficacy of letermovir prophylaxis when continued for greater than 100 days post allogeneic stem cell transplant in CMV seropositive patients.

METHODS

A single-center retrospective chart review was conducted on all allogeneic HSCT recipients from November 2017 to July 2021. Patients were eligible for inclusion if they were at least 18 years of age, received an allogeneic HSCT, CMV seropositive, and initiated letermovir between days 0-28 post-transplant. The primary endpoint of this study is to compare rates of CMV reactivation in patients that stopped letermovir prophylaxis at day 100 days post-transplant versus those who continued letermovir prophylaxis.

RESULTS

A total of 87 patients met eligibility criteria for inclusion. The median duration of letermovir was 78 days and 132 days in the standard and extended duration groups respectively. There were more CMV reactivations in the standard duration group versus the extended duration group, 28% versus 19% respectively. CMV pneumonitis was observed in one of the patients in the standard duration group. All-cause mortality at day 200 posttransplant was similar between the two groups.

CONCLUSION

Extended duration letermovir prophylaxis was associated with less CMV reactivation compared to the standard duration group.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Breanna Hinman, PharmD

Breanna earned her PharmD from the University of Houston College of Pharmacy in 2020. She completed her PGY1 Pharmacy Residency at Houston Methodist Hospital in June 2021. Following completion of her oncology PGY2, Breanna has accepted a position as a Bone Marrow Transplant pharmacist at Houston Methodist Hospital.

Primary project preceptor: James Cox, PharmD, BCOP

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and Hematology/Oncology Pharmacy Association (HOPA) Annual Conference.

Utility of Cytomegalovirus-Specific T-Cell Immunity Panel to Predict Cytomegalovirus infections in Lung Transplant Recipients

Richard W. Lincoln, PharmD; Brett J. Pierce, PharmD, BCPS; Christine Pham, PharmD; Simon Yau, MD; Ahmad Goodarzi, MD; Jihad G. Youssef, MD; Howard Huang, MD

PURPOSE

Lung transplant recipients (LTR’s) remain at the highest risk of CMV infection and disease in the solid organ transplant population. The use of cytomegalovirus T-cell immunity panels (CMV-TCIP) have been evaluated for use in the solid organ transplant population but given the limited data of CMV-TCIP in LTRs, we sought to describe our center’s experience with CMV TCIP in LTR.

METHODS

We reviewed all CMV TCIP results from LTRs drawn between 1/2019 – 6/2021. LTRs were excluded if they received a multi-organ transplant or re-transplantation. TCIP results were excluded if there was an assay control error or if no CMV PCR was checked after assay collection. Our primary outcome was the rate of CMV infection any point after TCIP collection. Secondary endpoints included CD4% and CD8%, characteristics of LTR’s who developed CMV infection, assessment of serial CMV TCIP monitoring, and characteristics of LTRs who did not show immunity.

RESULTS

A total of 191 CMV TCIPs from 156 LTRs were evaluated. Median time from transplant to CMV-TCIP was 687 (3891508) days. One hundred and twenty assays (62.8%) demonstrated immunity (both CD4% and CD8% >0.2%), with median CMV CD4% = 0.63% and CD8% = 1.42%. Twenty LTRs experienced a CMV infection after a TCIP was checked, 17/20 developed CMV after CMV TCIP was positive for immunity. CMV infection developed a median 121 of days after TCIP and 30% were off prophylaxis. Median CMV CD4% and CD8% in those who developed infection post-positive TCIP were 2.01% and 1.46%, respectively. ROC-AUC curve for CD4 and CD8 were 0.5663 and 0.5624 respectively. Twenty-nine patients had two or more CMV-TCIP drawn. Median time between repeat CMV-TCIP was 168 (122-298) days. The median change in CD4% and CD8% was -0.01 and 0.01 respectively.

CONCLUSION

These results suggest that T-cell specific CMV immunity monitoring in lung transplantation may not be an absolute indicator of CMV immunity. There were marginal changes in TCIP with repeat testing. Prospective trials are needed to assess the utility of serial TCIP monitoring.

PGY2 SOLID ORGAN TRANSPLANT RESIDENCY

Richard “Woody” Lincoln, PharmD

Woody earned his PharmD from the University of Cincinnati College of Pharmacy in 2020. He completed his PGY1 residency at The University of Cincinnati Medical Center. Following completion of his PGY2 residency, Woody has accepted a position as an Advanced Heart Failure and Heart Transplant Pharmacist at Banner University Medical Center – Phoenix.

Primary project preceptor: Brett J. Pierce, PharmD, BCOP Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and 2022 American Transplant Congress in Boston, MA. This poster received an ATC Poster of Distinction Ribbon.

Plasmapheresis and Rituximab for Prevention of Focal Segmental Glomerulosclerosis Recurrence Post-Kidney Transplantation

Allison N. Yun, PharmD; Alex Rogers, PharmD, BCPS; Jill C. Krisl, PharmD, BCTXP; Anna Kagan, MD; Horacio E. Adrogue, MD; Abdul J. Khan, MD; Pascale Khairallah, MD; Stephanie G. Yi, MD; Mark J. Hobeika, MD; Robert R. McMillan, MD; Hemangshu Podder, MD; Ahmed O. Gaber, MD; Richard J. Knight, MD

PURPOSE

Primary focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation (KT) in 30-50% of recipients with a median time of 1.5 months post-KT. Recurrence is associated with early graft loss in 60% of cases. The aim of this study is to assess the efficacy of pre-emptive therapeutic plasma exchange (TPE) and rituximab for the prevention of FSGS recurrence post-KT.

METHODS

This single-center, retrospective study included patients receiving KT for primary FSGS between May 2016 and August 2021. Living-donor KT recipients received three sessions of TPE prior to scheduled transplant. Recipients of both living and deceased donor KT received 3 postoperative sessions of TPE followed by one dose of 375 mg/m2 rituximab with or without intravenous immune globulin (IVIG) 0.5 g/kg. Recipients underwent protocol biopsy at one month to screen for FSGS recurrence. The primary endpoint was a composite for disease recurrence including proteinuria (≥1 g/day) or/and biopsy-proven FSGS within one month.

RESULTS

54 patients received KT for FSGS during the study period using the TPE/rituximab protocol. 5 patients (9%) experienced FSGS recurrence within one month of transplant. A total of 10 (23%) of 44 patients with followup were found to have disease recurrence within a year, with median (IQR) time to recurrence of 37 days (27-66). White race and history of hypertension were independent risk factors for recurrence, whereas African American race and diabetes were associated with a reduced risk of recurrence. 31 patients (57%) also received IVIG prior to discharge due to concerns for hypogammaglobulinemia. There were 18 documented infections in 13 patients (24%) within 3 months of transplant. Patients who received IVIG had significantly fewer cases of infection (3 cases: 1 viral and 2 COVID-19) compared to patients who did not receive IVIG (15 cases: 4 bacterial, 9 viral, 1 fungal, and 1 COVID-19), p<0.001. At one year, 9 patients (19%) had biopsy-proven rejection (5 acute cellular rejection, 1 antibody-mediated rejection, and 3 mixed rejection). There were no instances of graft loss or mortality observed at one year.

CONCLUSION

The utilization of plasma exchange and rituximab may prevent early disease recurrence of FSGS without significant rates of infection, graft loss, or mortality.

PGY2 SOLID ORGAN TRANSPLANT RESIDENCY

Allison Nara Yun, PharmD

Allison earned her PharmD from Northeastern University in Boston, Massachusetts in 2020. She completed her PGY1 Acute Care residency at Massachusetts General Hospital. After her completion of her PGY2 Solid Organ Transplant residency, Allison will stay on at Houston Methodist Hospital as an Abdominal Transplant Clinical Specialist.

Primary project preceptor: Alex Rogers, PharmD, BCPS

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and 2022 American Transplant Congress.

Hyperkalemia as a Potential Therapeutic Target to Prevent Delayed Graft Function Among Kidney Transplant Recipients

Joshua T. Swan, PharmD, MPH; Elsie Rizk, PharmD; Phuong Y Duong, PharmD; Bader M. Alghamdi, PharmD; Linda W. Moore, PhD; Alex W. Rogers, PharmD; Pascale Khairallah, MD; George M. Nassar, MD; Amy D. Waterman, PhD; William Irish, PhD; A. Osama Gaber, MD

PURPOSE

Up to 20% of kidney transplant (KT) recipients require hemodialysis within 7 daysfollowing transplant, which is referred to as delayed graft function (DGF). This study aimed to evaluate the role of hyperkalemia as the indication for initiating hemodialysis by considering all concurrent hemodialysis indications (hyperkalemia, uremic symptoms, acidemia, and edema) and the rationale documented by providers who ordered hemodialysis.

METHODS

This single-center, single-cohort, retrospective study included all KT recipients who received in-hospital hemodialysis within 7 days following a deceased or living donor kidney transplant at Houston Methodist Hospital from January 2018 to December 2019. Patients who had multiorgan transplant were excluded. Investigators abstracted information on hemodialysis indications from all electronic health record progress notes documented starting 24 hours before placement of the first hemodialysis order up to 12 hours after the end of the first hemodialysis session. The indication for the first hemodialysis was categorized as follows: (#1) exclusively for hyperkalemia, (#2) predominately for hyperkalemia, (#3) multiple indications including hyperkalemia, or (#4) not indicated for hyperkalemia. The primary endpoint was the proportion of patients with hyperkalemia (categories #1 or #2) as the indication for the first hemodialysis session.

RESULTS

A total of 45 KT recipients with DGF were included. The first session of hemodialysis was adjudicated as (#1) exclusively for hyperkalemia in 0% (n=0), (#2) predominately for hyperkalemia in 67% (n=30), (#3) multiple indications including hyperkalemia in 13% (n=6), or (#4) not indicated for hyperkalemia in 20% (n=9). Hyperkalemia was the indication for hemodialysis (categories #1 or #2) in 67% (95% CI, 51% to 80%) of KT recipients. During the 24-hour period prior to ordering the first hemodialysis, the maximum potassium value had an average of 6.0 ± 0.9 mEq/L. Majority of patients (60%) received up to 2 hemodialysis sessions within 7 days of KT.

CONCLUSION

Study findings suggest that hyperkalemia is a potential clinically meaningful DGF phenotype, which could provide a therapeutic target to reduce the incidence of DGF. This finding needs to be confirmed at other transplant centers.

CLINICAL PHARMACY FELLOWSHIP IN OUTCOMES RESEARCH

Phuong Duong, PharmD

Phuong earned her PharmD from MCPHS University – Boston in 2019. She completed her PGY1 residency at Cooley Dickinson Hospital in Northampton, Massachusetts. Phuong will continue postgraduate training at Houston Methodist Hospital as a second year Clinical Pharmacy Fellow.

Primary project preceptor: Joshua T. Swan, PharmD, MPH; and Elsie Rizk, PharmD

Specification, Validation and Adherence of Quality Indicators to Optimize the Safe Use of Nonsteroidal Anti-inflammatory Drugs for Knee Osteoarthritis Pain in the Primary Care Setting

Joshua T. Swan, PharmD, MPH; Elsie Rizk, PharmD; Phuong Y Duong, PharmD; Bader M. Alghamdi, PharmD; Navjot Kaur, MS, PharmD; Sudha Nagaraj, MD; Anthony E. Brown, MD, MPH; Eleazar Flores, MD; Nathan Spence, PharmD; Sharla Tajchman, PharmD

PURPOSE

A multi-disciplinary expert panel at Houston Methodist recently established expert consensus on 15 prioritized, valid, and feasible quality indicators (QIs) that can be used to track quality initiatives for osteoarthritis (OA) pain management in the primary care setting. The objective of this study was to evaluate adherence to two QIs to optimize the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) when used for OA chronic pain management.

METHODS

This retrospective study included patients who had primary care clinic visits for knee OA at Houston Methodist in 2019. We evaluated adherence to 2 QIs with highest priority: add proton pump inhibitors (PPI) to NSAIDs for patients with gastrointestinal (GI) risk (QI #1 NSAID-PPI) and avoid oral NSAIDs in chronic kidney disease (CKD) stage G4 or G5 (QI #2 NSAID-CKD).

Operational definitions were developed for both QIs based on the literature review and feasibility assessment from existing data elements in the electronic health record. Adherence to QIs was evaluated in 2 cohorts: simple random sample of 60 patients (validation cohort) and all patients not otherwise included in the validation cohort (expanded cohort).

RESULTS

A total of 395 patients with at least one primary care visit for knee OA were included. Among 60 patients in the validation cohort, analysis of data extracts was validated against chart review for QI #1 NSAID-PPI (100% sensitivity and 91% specificity) and QI #2 NSAIDCKD (100% accuracy). Analysis of data extracts for 335 patients in the expanded cohort showed that 44% used NSAIDs, 27% used PPIs, 73% had elevated GI risk, and only 2% had CKD stage 4 or 5. Twenty-one percent used NSAIDs and had elevated GI risk but were not using PPIs. Therefore, adherence to QI #1 NSAID-PPI was 79% (95% CI, 74% to 83%). No patients with CKD stage 4 or 5 used NSAIDs. Therefore, adherence to QI #2 NSAIDCKD was 100%.

CONCLUSION

A substantial proportion of knee OA patients with GI risk did not receive PPI with NSAID therapy during primary care visits. These findings suggest an opportunity to improve safe NSAID prescribing through electronic health record clinical decision support.

Navjot Kaur, PharmD, MS

Navjot earned her MS in Pharmaceutical Sciences from Punjabi University, india in 2014 and her PharmD from the NOVA Southeastern University in 2021. Navjot will continue postgraduate training at Houston Methodist Hospital as a second year Clinical Pharmacy Fellow.

Primary project preceptor: Joshua T. Swan, PharmD, MPH; and Elsie Rizk, PharmD

CLINICAL PHARMACY FELLOWSHIP IN OUTCOMES RESEARCH

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HOUSTON METHODIST houstonmethodist.org/pharmacy