Abstract: SA-PO296
Outpatient Drug Dosing for Patients with CKD: Is It Time to Include Pharmacists?
Session Information
- Trainee Case Reports - VI
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1700 Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
Authors
- Kharadjian, Talar, University of Wisconsin Health & Clinics, Madison, Wisconsin, United States
- Pietruszka, Marie, University of Wisconsin Health & Clinics, Madison, Wisconsin, United States
- Singh, Tripti, University of Wisconsin Health & Clinics, Madison, Wisconsin, United States
Introduction
Neurotoxicity due to inappropriate valacyclovir dosing in patients with chronic kidney disease (CKD) is a recognized adverse effect. Electronic databases such as Lexicomp provide pharmacists and physicians with standard dose reductions for renal clearance. Our cases demonstrate the inadequacy of our current systems, which unfortunately failed to avert these preventable outcomes.
Case Description
Case 1
51-year-old male with end-stage renal disease (ESRD) on hemodialysis (HD) was seen in primary care clinic for shingles. Due to ongoing renal transplant workup, he was given valacyclovir 1g three times daily (immunocompromised dosing). Two days later, he presented to the emergency department (ED) with confusion and visual hallucinations. A pharmacist reviewed the dose and recommended switching to acyclovir 800mg five times daily based on clinical indication rather than renal dosing. He later returned to the ED with worsening symptoms. His pre-dialysis acyclovir level was 12mg/L, improved to 3.5mg/L after 3 hours of HD. He had daily HD for 3 days and discharged on valacyclovir 500mg daily for 7 days.
Case 2
53-year-old male with HIV and ESRD on HD developed shingles treated with valacyclovir 1g three times daily (HIV dosing). He became somnolent, agitated and confused. He was admitted for neurotoxicity due to inappropriate valacyclovir dosing, treated with urgent HD for 3 hours. Symptoms improved over 24 hours and he discharged on valacyclovir 500mg daily for 7 days.
Discussion
Our cases demonstrate the limitations of our current electronic medical record, which does not alert prescribers to data present in the chart at the time of medication order entry, namely glomerular filtration rate (GFR) and diagnosis of CKD. Such alerts can reduce the risk of inappropriate renal dosing. We also propose that community pharmacists be granted access to the medical record to properly verify dosing in the outpatient context as it occurs on inpatient wards. This would provide added safety to a currently disjointed prescriber-pharmacist interface in the outpatient setting. Another solution would be an identifying bracelet for patients with GFR<30 mL/min per 1.73m2, similar to community Do Not Resuscitate (DNR) bracelets, which would also foster greater public and provider awareness regarding the vulnerability of this patient population to such medical errors.