Tomasz Z. Jodlowski, Pharm.D., BCPS (AQ-ID) Clinical Pharmacy Specialist, Infectious Diseases VA North Texas HCS

Transcription

1 Tomasz Z. Jodlowski, Pharm.D., BCPS (AQ-ID) Clinical Pharmacy Specialist, Infectious Diseases VA North Texas HCS 02/06/2018

2 Independent contractor. IPRO. IPRO Antibiotic Stewardship Project. August 2017-Present

3 Explain the causes and consequences of medication errors Identify common and severe medication errors in patients on antiretroviral therapy Discuss strategies for minimizing/preventing antiretroviral medication errors Describe the appropriate management of selected medication errors using case based approach

4 Landmark Institute of Medicine (IOM) report estimated up to 98,000 Americans die in hospitals annually as a result of medical errors The actual numbers are most likely much High cost associated with errors This includes medication errors

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6 Updates- Many new formulations and medications i.e. Ritonavir: Darunavir: Kaletra capsules to tablets Complicated regimens Many confusing names and abbreviations (i.e. AZT) Dosing Higher drug-drug interaction potential Lack of information

7 Intelence (?) /Isentress Take 1 tablet PO BID

8 ISMP s list of confused drug names includes: Keppra Kaletra Lamotrigine Lamivudine Denavir Indinavir Retrovir Ritonavir Saquniavir Sinequan Other potential errors: Isentress Intelence Nelfinavir Nevirapine and more.. Not unique to HIV meds! (VA info)

9 Li EH, Foisy MM. Ann Pharmacother 2014;48:

10 Inpatient Purdy BD et al (86 pts) Errors in 5.8% of admissions to the hospital Rastegar DA et al (206 pts) HIV medication errors in 26% of patients admitted Pastakia SD et al (68 pts) At least one error on initial review in 72% of patients 84% if account for initial review and throughout hospitalization Li EH, Foisy MM. Ann Pharmacother 2014;48:

11 Methods: Time period: March October 2010 Approximately 1,500 medical records reviewed Twice-weekly prospective audit Results: 428 potential errors found 57.5% of recommendations accepted (246/428) Since then: October March recommendations on potential ART medication errors 70% acceptance rate (213/306) Overall trend: Annual decrease in interventions, acceptance

12 Renal adjustment Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for use of antiviral agents in HIV-1 infected adults and adolescents. Department of Health and Human Services. Available at Accessed 01/28/2018 Hepatic adjustment

13 Adjustments due to drug interactions

14 Consequences of inappropriate dosing: Too low: Resistance Virologic failure Limit future options Too high: Toxicity Intolerance Refusal of treatment?

15 Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for use of antiviral agents in HIV-1 infected adults and adolescents. Department of Health and Human Services. Available at Accessed 01/28/2018

16 Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for use of antiviral agents in HIV-1 infected adults and adolescents. Department of Health and Human Services. Available at Accessed 01/28/2018

17 + dexlansoprazole omplera_pi.ashx (Last accessed 01/28/2018)

18 To boost or not to boost? That is the question Usual: (100mg- 400mg per day) Depends on Protease inhibitor- Check Package insert However: Atazanavir (+/-), Fosamprenavir (+/-), Indinavir (+/-) Nelfinavir- No Kaletra (Lopinavir/ritonavir)- co-formulated * NEW: Evotaz and Prozcobix (co-formulated with COBI)

19 > 20 agents approved by the FDA NRTIs/NNRTIs/PIs/Entry inhibitors/integrase inhibitors Combination therapy is recommended Some pills contain multiple medications, some do not Some medications should not be combined together Example:

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21 Given with DRV (QD) or ATV CrCl>70mL/min (with TDF)

22 Interactions according to the ingredients Take with food

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24 Genvoya, Odefsey, Descovy TAF TDF

25 Formulary interventions Specialty pharmacies Education of staff Pharmacy, nursing, prescribers Technology Counsel & educate patients Prospective audit with feedback Medication history & evaluation Medication reconciliation/cdtm

26 Additions/ deletions Limitations: Cost/ Generics / Periodic evaluations Lack of co-formulated products Limitation: Cost Non-formulary drug-drug interaction issues Restrictions Limitation: Might lead to delayed access to ART

27 Computerized Physician Order Entry (CPOE) Eliminate abbreviations (AZT), Brand/Generic names etc. References (Online vs. book) Time lag / Accessibility Automated Dispensing Machines Bar Coding Computerized medical administration record E-Prescribing Electronic Medical Record Clinical Decision Support Software

28 Use of pre-printed order forms Medication reconciliation by a pharmacist Corrigan MA et al. Ann Pharmacother 2010;44:222 Communication between providers, pharmacists and patients

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30 Cornerstone of the IDSA antimicrobial stewardship guidelines Typically involves Pharmacy/Medicine Ideally ID/HIV trained personnel Resource & time intensive Inpatient audit is ideal Zucker J et al. Pharmacotherapy 2016;36:245

31 Room for improvement Physicians/Providers Pharmacists Many resources available (next) Credentialing for pharmacists approved

32 AETC National Coordinating Resource Center US Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents.

33 General Micromedex (version 2.0) Lexi-Comp Epocrates Clinical Pharmacology Medscape drug reference Facts and Comparison 4.0 Disease Specific University of Liverpool ( HIV In Site (UCSF) ( Toronto HIV Clinic (

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40 Errors happen; Stay vigilant! If it looks wrong or unsure, investigate Keep up-to-date with your knowledge Organizations will help Empower your patients Communicate Patient Provider Use technology Pharmacist

41 Lets make sure that our heads are in the right place AND THINK BIG!