EXPRESS: Survival and Drug Persistence in Patients Receiving Inhaled Treprostinil at Doses Greater than 54 Mcg (9 Breaths) 4 Times Daily

Treprostinil is a prostacyclin analogue approved for the treatment of pulmonary arterial hypertension (PAH). Commercial data sets indicate that approximately 20-25% of patients are prescribed a higher dose than the maximum recommended dosage of 9 breaths per treatment session (bps) (54 Ï g), four times a day (QID) and numerous studies have demonstrated the safety of doses >9 bps QID. This phase 4, retrospective analysis of specialty pharmacy records assessed the effects of inhaled treprostinil at doses >9 bps QID. Patients receiving inhaled treprostinil between September 2009 and June 2018 were included, and a random sampling of 5,000 patients were selected for further analysis. Subjects were grouped based on the highest dose reached for ≥2 months within a rolling 6-month window and were followed for up to three years. Of the total of 5,000 patients analyzed, 28.5% received >9 bps QID. Survival rates were significantly higher in the >9 bps QID dosing group for years one, two, and three (P < 0.001). The time to transition to parenteral therapy was significantly longer for those at doses >9 bps (17.5 months) compared to doses ≤9 bps (9.5 moths; P < 0.0001). Drug persistence was also significantly higher for those taking >9 bps at years 1, 2, and 3 (P < 0.0001). Patients receiving inhaled treprostinil at doses >9 bps QID had a higher rate of survival and drug persistence over a three-year period, suggesting that higher doses may provide clinically relevant benefits while remaining tolerable.

Clozapine & constipation: an audit of bowel habit monitoring and laxative prescribing in inpatients on clozapine

AimsTo establish how often bowel habits are monitored in inpatients on clozapineTo determine how many of these patients are prescribed laxatives and whether these are utilisedBackgroundIt's estimated that 30-60% of patients will suffer from constipation whilst on clozapine; this can lead to ileus, intestinal obstruction and bowel ischaemia, all of which can be fatal. Constipation is much more common than clozapine-induced blood dyscrasias, and has a higher mortality rate. Despite this, there is no strict universal framework for bowel habit monitoring equivalent to the compulsory FBC monitoring. Local trust guidance indicates that bowel habits should be monitored regularly, at least at any point of blood sampling. However, monitoring processes across the trust were noted to be variable, as were laxative prescribing practices.MethodThe data sample of current inpatients on clozapine across the trust was identified from pharmacy records. The patient's Rio notes from the preceding 3 months were searched for predetermined terms relating to bowel habits and constipation, and the notes were then analysed for assessment of bowel habit. The number of FBCs collected during this 3 month period was then used to produce comparison with the audit standard. The data on laxative prescribing were collected from current medication lists on EPMA.ResultA data sample of 31 current inpatients was identified. The audit found that only 54.8% (17) of patients had their bowel habits monitored at least with every FBC taken. There was significant variability between different wards, with the best performing ward having 100% adherence to the audit standard, and the worst performing having 0%. In terms of laxative prescribing, it was found that 87.1% (27) of patients had at least 1 regular or 1 PRN laxative prescribed. Regular laxatives were prescribed for 61.2% (19) of patients, whereas only PRN laxatives were prescribed in 25.8% (8) of patients. Of those prescribed only PRN laxatives, only 50% (4) ever utilised this medication.ConclusionBowel habits are not consistently monitored across the trust in inpatients on clozapine, leaving room for potentially life-threatening side effects to be missed. Additionally, regular laxative prescribing is not standard throughout the trust, which could further add to the potential for significant constipation-related morbidity to occur. A standard method of monitoring bowel habits throughout the trust, as well as a trust laxative prescribing policy, could be a way of remedying this issue and preventing harmful outcomes for our patients on clozapine.

P063 SystmOne clinical reporting to identify high-risk rheumatology patients for shielding

Background/Aims At the start of the COVID-19 pandemic, shielding guidance was issued by Public Health England with a risk stratification guide developed by the BSR to assist with patient identification. At BTHFT we benefited with all GP practices in the region using TPP SystmOne (S1) for medical records. We describe how we used S1 to help identify high risk patients under our care. Methods We did not appreciate the full extent we could use S1 to identify patients in our initial shielding identification process. As such, we reviewed notes of patients on biologic prescriptions and SC MTX from Homecare prescription lists. To capture patients on high dose prednisolone, we identified patients with a recent diagnosis of GCA and patients with recent prescriptions of &gt; 20mg prednisolone through pharmacy records. On recognising the ability of S1 to identify patients that had glucocorticoid exposure through primary care and/or on cDMARDS we used S1 reporting mechanisms to identify these patients. Clinical record sharing enabled BTHFT’s rheumatology department to access S1 for all patients under their care. S1’s clinical reporting function was used to search for patients within at least one of the following cohorts before being combined in a single cohort of ‘at risk’ patients (heart, lung or kidney disease, ≥70 years, diabetes or hypertension [including pulmonary artery hypertension]). Reports were created for patients on any DMARD issued within primary care within the previous 12 weeks. High dose steroid use was more challenging to demonstrate, but a report was devised to include all patients with an issued prescription for prednisolone 5mg tablets within the preceding 8 weeks (for any reason). An additional report was created for patients with a rheumatological diagnosis co-existing with an interstitial lung disease. Using S1's report joining function, the different drugs and ‘at risk’ cohorts were combined to provide an accurate list of patients with features increasing their vulnerability to COVID-19. This list was easily modifiable and searches were re-run to update lists once inclusion on the shielding list was updated. Results Patients meeting the criteria for shielding were then advised in writing including signposting to BTHFT’s rheumatology website and helpline for further information if required. By searching for all prednisolone prescriptions, this would have included patients given prednisolone for other reasons. 5mg tablet strength ensured patients on low dose were excluded, but we recognise some patients were likely over-recruited into this cohort. Conclusion We can update our searching methods to easily include patients on biologics and SC MTX by some additional bulk coding in preparation for future shielding specifications thereby bypassing the need to review individual notes for patients. We were able to achieve an accurate shielding list in a relatively short space of time to reduce patient risk. Disclosure D. Kirby: None. K. Nadesalingam: None.

Infection with antiretroviral-susceptible HIV in an individual adherent to pre-exposure prophylaxis: strategies for treatment initiation

HIV pre-exposure prophylaxis (PrEP) is effective at preventing sexual acquisition of HIV, and failures in clinical trials are largely attributable to medication nonadherence. We report here a case of infection with a fully susceptible strain of HIV in an individual adherent to PrEP as demonstrated by pharmacy records and intracellular tenofovir diphosphate levels. At diagnosis, the viral load was 90 copies/mL precluding initial genotype testing due to low copy number. While PrEP failure is rare, this case underscores the importance of regular HIV testing for patient on PrEP and prompts discussion regarding the approach to treatment following failure where an initial genotype is not yet available or not possible due to low viral load. Few other case reports of PrEP failure exist in the literature and approaches to treatment varied widely. We suggest the initial viral copy number may guide next steps and discuss the risks and benefits of stopping PrEP, escalating therapy with integrase inhibitors or boosted protease inhibitors, or switching to non-nucleoside antiretroviral treatment regimens.

Impact of CancelRx on Discontinuation of Controlled Substance Prescriptions

ObjectiveTo assess how controlled substance medication discontinuations were communicated over timeData SourcesSecondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation.Study DesignThe study utilized an interrupted time series analysis (ITSA) to capture the proportion of controlled substance medications that were cancelled in the clinic’s electronic health record and also cancelled in the pharmacy’s dispensing software. The ITSA plotted the proportion of successful cancellation messages over time, particularly after the health system’s implementation of CancelRx, a novel technology.Data Collection/ExtractionData were extracted from the EHR and pharmacy records for patients aged 18+ who had a controlled substance discontinued by a health system provider. Information collected included patient demographics, drug information (name, dose), and dates discontinued in the clinic and pharmacy records.Principal FindingsAfter CancelRx implementation there was a significant increase in the proportion of discontinued controlled substance medications that were communicated to the pharmacy.ConclusionsThis study demonstrates the role that technology can play in promoting controlled substance policy and medication safety.

An Evaluation of Acyclovir Prescribing Patterns in a Public Hospital in AlKharj

Aim: This study aimed to analyze acyclovir prescription patterns in a public hospital in AlKharj. Methodology: Cross-sectional study, via hospital pharmacy services that included collecting data on acyclovir utilization from de-identified pharmacy records in maternity and children hospital in Alkharj from 1 Jan 2018 until 31 Aug 2020. Results: A total of 1059 prescriptions contained acyclovir were dispensed between 1 Jan 2018 till 31 Aug 2020. In the present study, acyclovir was prescribed mainly as an intravenous (45.89%) or oral (34.09%) treatment. It is prescribed mainly as a vial (45.89%) followed by suspension (31.63%). Inpatient Ward prescribed 52.60% of the prescriptions and emergency department prescribed 25.87% of the prescriptions. Conclusion: It can be concluded that acyclovir was prescribed commonly in the hospital and that it’s using should be monitored to ensure that it is prescribed and dispensed appropriately.

Enteral baclofen withdrawal managed with intravenous dexmedetomidine: A case report

Purpose Acute enteral baclofen withdrawal can be clinically severe if not identified and managed appropriately. Treatment of baclofen withdrawal includes supportive care and reinitiation of baclofen. There are limited pharmacotherapeutic interventions available to manage symptoms of acute enteral baclofen withdrawal, especially in nonintubated patients. Summary We describe a 61-year-old Caucasian male with a past medical history of chronic back pain and spinal stenosis who was admitted to the medical intensive care unit with confusion, insomnia, agitation, delirium, and auditory and visual hallucinations. For control of agitation, the patient was administered 10 mg of i.v. haloperidol, 1 mg of i.v. lorazepam, and 14 mg of i.v. midazolam, with minimal improvement noted; therefore, dexmedetomidine was initiated, which led to clinical resolution of his symptoms. Upon further investigation it was determined that the patient was taking approximately 10 baclofen 20-mg tablets a day. According to his pharmacy records, he had filled prescriptions for a total of 738 baclofen tablets in the previous 12 weeks. The patient’s presentation and sudden discontinuation of high-dose baclofen led to a diagnosis of baclofen withdrawal. Baclofen was subsequently restarted, and dexmedetomidine was weaned over 36 hours. Conclusion Dexmedetomidine controlled this patient’s agitation and delirium without suppressing his respiratory drive and should be considered for management of acute enteral baclofen withdrawal.