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Purpose: The goals of this paper are to (1) provide evidence and expert consensus to support a unified approach to estimating kidney filtration in adults with stable kidney function using race-free estimated glomerular filtration rate (eGFR) in place of Cockcroft-Gault estimated creatinine clearance (C-G eCrCL) for medical and medication-related decisions, and (2) demonstrate how adjusting eGFR results for an individual's body surface area (BSA) when it is higher or lower than 1.73 m2 will improve results for medication-related decisions., Summary: C-G eCrCL is predominantly used by US pharmacists to determine eGFR for the purposes of medication-related decisions, even though more accurate eGFR equations exist. Several driving factors make it the ideal time to shift clinical practice from using C-G eCrCL to eGFR. These factors include the following: (1) 2024 Food and Drug Administration (FDA) guidance for industry recommends eGFR over C-G eCrCL to evaluate the impact on pharmacokinetics in patients with impaired kidney function; (2) a joint National Kidney Foundation (NKF) and American Society of Nephrology task force recommends 3 race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFR equations for medical and medication-related decision-making; (3) the almost ubiquitous use of standardized serum creatinine assay methods in US clinical laboratories; and (4) increasing availability and use of serum cystatin C for eGFR assessment. This publication guides practitioners through the rationale for using race-free eGFR equations for medication-related decisions and how to implement this practice change., Conclusion: The NKF Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions suggests that health systems, health settings, clinical laboratories, electronic health record systems, compendia and data vendors, and healthcare practitioners involved with medication-related decision-making transition away from C-G eCrCL and towards the race-free eGFR equations for more accurate assessment of kidney filtration and consistency in medication and medical decision-making across the US., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: Patients have a poor understanding of outcomes related to total knee replacement (TKR) surgery, with most patients underestimating the potential benefits and overestimating the risk of complications. In this study, we sought to compare the impacts of descriptive information alone or in combination with an icon array, experience condition (images), or spinner on participants' preference for TKR., Methods: A total of 648 members of an online arthritis network were randomized to 1 of 4 outcome presentation formats: numeric only, numeric with an icon array, numeric with a set of 50 images, or numeric with a functional spinner. Preferences for TKR were measured before and immediately after viewing the outcome information using an 11-point numeric rating scale. Knowledge was assessed by asking participants to report the frequency of each outcome., Results: Participants randomized to the icon array, images, and spinner had stronger preferences for TKR (after controlling for baseline preferences) compared to those viewing the numeric only format (P < 0.05 for all mean differences). Knowledge scores were highest in participants randomized to the icon array; however, knowledge did not mediate the association between format and change in preference for TKR., Conclusion: Decision support at the point-of-care is being increasingly recognized as a vital component of care. Our findings suggest that adding graphic information to descriptive statistics strengthens preferences for TKR. Although experience formats using images may be too complex to use in clinical practice, icon arrays and spinners may be a viable and easily adaptable decision aid to support communication of probabilistic information., (© 2018, American College of Rheumatology.)

As the older adult population in the United States increases and diversifies, understanding and reducing risks for hospitalization and institutionalization can reduce burdens for this vulnerable population. Using evidence-based assessment tools to understand medical, psychosocial, pharmacologic, and functional status can aid an interprofessional team to best evaluate older adults at risk. By providing culturally competent care for a diversifying older adult demographic, attention to social determinants can improve health equity for this population. This article describes in a case study exemplar, how one such interprofessional collaborative practice program, Geriatric Outreach and Training with Care (GOT Care!) provides a comprehensive assessment for high-risk older adults, identifies and documents these risks, and shares recommendations and rationale with the primary care provider toward risk reduction and improvement of outcomes.

Arsenic trioxide has been established for use in both relapsed and front-line treatment of acute promyelocytic leukemia. Dose adjustments are recommended to be considered in severe renal impairment although dosage reduction guidelines are not provided. In addition, toxicities of arsenic are significant. The use of arsenic trioxide has not been well studied in dialysis patients and there is a paucity of data in the literature to support the use in such a situation. We describe an 81-year-old relapsed acute promyelocytic leukemia hemodialysis-dependent patient with a pre-existing cardiac condition who was treated with 10 mg arsenic trioxide three times weekly after dialysis. These findings provide support along with the marginal amount of currently published data for an arsenic trioxide dosing regimen in hemodialysis patients., (© The Author(s) 2015.)

We often administer dialyzable medications after dialysis to ensure that adequate concentrations are maintained in the body until the next session. In the case of aminoglycosides, we may have the opportunity to dose more aggressively predialysis, and then use the clearance of the drug by dialysis to limit toxicities. Predialysis aminoglycoside dosing is intriguing, although studies evaluating the safety and efficacy of this approach are necessary before it can be used routinely., (© 2016 Wiley Periodicals, Inc.)

Objective: To evaluate the impact of a pharmacist-led, motivational interviewing on antibiotic adherence following discharge in older adults with pneumonia., Setting: Inpatient medical wards in a large tertiary academic medical center., Practice Description: Older adults diagnosed with pneumonia were enrolled from December 1, 2013, to August 1, 2014, at Yale-New Haven Hospital., Practice Innovation: Motivational interviewing-a patient-centered method of communication-has gained recognition as a tool that can aid pharmacists in addressing negative health behaviors (e.g., medication adherence, health screenings, substance abuse during counseling sessions). However, the potential role of motivational interviewing in older adults to improve medication adherence during transitions of care is not clear. In this study, in addition to standard discharge care, older adults hospitalized with pneumonia who were randomized to the intervention group received enhanced care: pharmacist-led motivational interviewing., Main Outcome Measurements: Evaluation of adherence to prescribed antibiotic regimens and patient satisfaction with the motivational interviewing, enhanced-care session., Results: Ultimately, 87% of patients in the intervention group (n = 16) compared with 64% of patients in the control group (n = 14) were adherent to their antibiotic regimens. Patient satisfaction with the motivational interviewing intervention was high., Conclusion: Pharmacist-led motivational interviewing sessions have the potential to positively influence antibiotic adherence rates and patient satisfaction.

Objective: To identify risk factors for systemic exposure to vancomycin (VAN) following administration of oral vancomycin (POV) for the treatment of Clostridium difficile infection (CDI)., Design: Prospective, observational, single-center case series., Setting: Academic medical center., Patients: Hospitalized patients with suspected or confirmed CDI who received POV for at least 5 days., Intervention: Random VAN serum levels were obtained on days 5, 10, and weekly thereafter in patients treated for ≥ 5 days with POV without concomitant intravenous VAN., Measurements and Results: Of 117 random VAN serum levels from 85 patients, 58 patients (68.2%) had one or more detectable (≥ 0.05 μg/ml) levels and 15 (17.6%) of 85 patients had one or more levels > 2.5 μg/ml. Risk factors for detectable VAN exposure following administration of POV included POV dosages > 500 mg/day (odds ratio [OR] 35.83, 95% confidence interval [CI] 7.56-169.8), the presence of severe CDI (OR 4.11, 95% CI 2.76-10.83, p=0.028), intensive care unit (ICU) admission (OR 3.80, 95% CI 1.02-14.21, p=0.032), and the administration of POV ≥ 10 days (OR 6.71, 95% CI 1.81-24.83, p=0.0025). Risk factors for exposure to serum VAN concentrations > 2.5 μg/ml included the presence of gastrointestinal (GI) pathology (OR 5.22, 95% CI 3.45-18.3, p=0.031), ICU admission (OR 3.21, 95% CI 1.40-10.28, p=0.022), the use of VAN retention enemas (OR 4.73, 95% CI 2.42-20.39, p=0.036), and having a creatinine clearance ≤ 50 ml/minute or undergoing hemodialysis or continuous renal replacement therapy (OR 4.03, 95% CI 1.26-12.84, p=0.039)., Conclusions: Serum VAN levels were detected in 58 (68.2%) of 85 patients receiving POV for CDI. Risk factors for systemic exposure to VAN following administration of POV included ICU admission; VAN dosages > 500 mg/day; administration ≥ 10 days or as retention enemas; and the presence of severe CDI, renal dysfunction, or inflammatory conditions of the GI tract. Unique to our study, we identified ICU admission and the concomitant use of VAN retention enemas to be significant risk factors for systemic exposure to VAN., (© 2015 Pharmacotherapy Publications, Inc.)