Commencement of warfarin therapy in children following the Fontan procedure
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Fontan Procedure
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Sensitivity and specificity of dosing alerts for dosing errors among hospitalized pediatric patients
To determine the sensitivity and specificity of a dosing alert system for dosing errors and to compare the sensitivity of a proprietary system with and without institutional customization at a pediatric hospital.A retrospective analysis of medication orders, orders causing dosing alerts, reported adverse drug events, and dosing errors during July, 2011 was conducted. Dosing errors with and without alerts were identified and the sensitivity of the system with and without customization was compared.There were 47,181 inpatient pediatric orders during the studied period; 257 dosing errors were identified (0.54%). The sensitivity of the system for identifying dosing errors was 54.1% (95% CI 47.8% to 60.3%) if customization had not occurred and increased to 60.3% (CI 54.0% to 66.3%) with customization (p=0.02). The sensitivity of the system for underdoses was 49.6% without customization and 60.3% with customization (p=0.01). Specificity of the customized system for dosing errors was 96.2% (CI 96.0% to 96.3%) with a positive predictive value of 8.0% (CI 6.8% to 9.3). All dosing errors had an alert over-ridden by the prescriber and 40.6% of dosing errors with alerts were administered to the patient. The lack of indication-specific dose ranges was the most common reason why an alert did not occur for a dosing error.Advances in dosing alert systems should aim to improve the sensitivity and positive predictive value of the system for dosing errors.The dosing alert system had a low sensitivity and positive predictive value for dosing errors, but might have prevented dosing errors from reaching patients. Customization increased the sensitivity of the system for dosing errors.
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Studies have reported high prevalence of inappropriate dosing in patients with renal impairment, which was significantly reduced with pharmacists' interventions. The objective of this study was to assess the proportions of renal drug dosing errors following the implementation of pharmacists-led renal drug dosing adjustment program. This was a quasi-experimental study conducted at the King Abdul Aziz Medical City, a tertiary teaching hospital, Jeddah, Saudi Arabia. The study comprised of 3 phases. The pre-phase and post-phase evaluated drug orders for dosing appropriateness. During the intervention phase, a renal drug dosing adjustment program was implemented, which included educational sessions on dosing in renal insufficiency and a renal drug dosing guidance. The primary outcome was to assess the change in the proportions of dosing errors following the intervention. In the pre-phase, inappropriate dosing was noted in 20.1% (70/348) of orders that required dosing adjustment. Among the total dosing errors, 44.2% (31/70) were further corrected, and pharmacists have documented intervention in 48.3% (15/31) of the corrected orders. In the post-phase, inappropriate dosing was noted in 21.9% (76/346) of orders that required dosing adjustment. Among the total dosing errors, 39.4% (30/76) were further corrected, and pharmacists have documented intervention in 66.6% (20/30) of the corrected orders. There was no statistically significant difference in inappropriate drug dosing between pre-phase and post-phase with a P = 0.56. The intervention was not associated with significant reduction in renal dosing errors, although pharmacist involvement in the corrected orders orders increased after the implementation of the intervention. This may indicate the need to integrate renal dosing guidance into the hospital prescribing system to optimize drug dosing in renal patients.
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Phosphate binders (PBs) account for a large proportion of the daily pill burden in hemodialysis patients. However, patients do not take them all at once but at several dosing timings.We analyzed the dosing timings of all 322 types of oral drugs prescribed to 533 hemodialysis patients.The median daily dosing frequency for all drugs was 6 (4-7) times/day/patient. Patients prescribed PBs had a markedly higher daily dosing frequency than those not taking PBs (7 [5-8] times/day/patient vs. 4 [3-5] times/day/patient, respectively [p < 0.001]). In addition, the ratio of the number of PB pills to other drugs varied greatly at each dosing timing. Furthermore, it was simulated that the daily dosing frequency could be reduced by approximately two times/day/patient by combining the dosing timings of PBs.Changing PB dosing timings can reduce the daily dosing frequency, which may lead to improved medication adherence.
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Background: Warfarin-related bleeding occurred most commonly during the first three months of therapy, possibly due to an initiating overdose of warfarin. Previous small study reported that 3-mg initiating dose of warfarin appeared to be safe in Thai patients. Objective: To compare the performance of simplified warfarin dosing formula and 3-mg initiating dose to predict actual warfarin dose that achieved therapeutic range of target international normalized ratio (INR). Materials and Methods: The present study was a retrospective study including 640 patients who had been receiving warfarin with target INR of 2.0 to 3.0. The actual warfarin dose was defined as warfarin dose that resulted in INR of 2.0 to 3.0 for at least two consecutive follow-ups after initiation. The simplified warfarin dosing formula was 3.2 – (0.03×age(years)) + (0.02×body weight(kg)) (10% dose reduction if presence of heart failure (HF) and/or stroke). The optimal dosage was defined as difference from actual dose as being within 20%. Results: Mean age was 65±13 years. The mean actual dose of warfarin was 2.8±1.2 mg. The warfarin dosing formula resulted in optimal dosing in 41% and overdosing in 21% of cases, whereas 3-mg initiating dose resulted in optimal dosing in 39% and overdosing in 43% of patients. In patients with HF and/or stroke, using formula resulted in overdosing in 23% of cases, whereas 3-mg initiating dose led to overdosing in 53% of patients. Conclusion: A simplified warfarin dosing formula appeared to be safer than 3-mg initiating dose. Overdosing after using warfarin formula was less prevalent than using 3-mg initiating dose particularly in patients with HF and/or stroke. Keywords: Warfarin, Algorithms, Atrial fibrillation, Anticoagulant Received 15 May 2019 | Revised 4 Jul 2019 | Accepted 11 Jul 2019
Maintenance dose
Stroke
Therapeutic index
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Abstract Dosing antibiotics in critically ill patients to achieve therapeutic concentrations is a significant challenge. The presence of septic shock and prescription of continuous renal replacement therapy introduces further complexities for the clinician. Unfortunately, this is a dilemma encountered daily by intensivists. Although small pharmacokinetic studies are emerging to provide data to help address this problem, the variability in results from these studies is profound. As such, effective antibiotic dosing guidelines for critically ill patients who have septic shock and who receive continuous renal replacement therapy are not available. Dosing flowcharts and therapeutic drug monitoring represent the best available options for clinicians to optimize antibiotic dosing.
Renal replacement therapy
Therapeutic Drug Monitoring
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Abstract Background For decades, vitamin K antagonists and specifically warfarin, have been the sole agents used orally to manage thromboembolic conditions, including stroke and venous thromboembolism (VTE). Several factors lead to warfarin dose variability, including genetic and non-genetic factors which made warfarin management challenging especially at the initiation phase. To overcome the challenges with warfarin dosing at initiation, strategies other than conventional or fixed dosing were introduced and explored. Aim In this narrative review, we aim to discuss and critique the different dosing strategies for warfarin at initiation with more focus on genotype-guided warfarin dosing and the most recent supporting evidence for and against its use. Method Medline database was searched from 1965 to July 2021. Articles addressing different warfarin dosing methods were screened for inclusion. Results A number of methods exist for warfarin initiation. Studies comparing different dosing methods for initiation yielded conflicting outcomes due to differences in study design, population studied, comparator, and outcomes measured. Conclusions Looking at the big picture, the use of genetic dosing for warfarin initiation can lead to better outcomes. Whether these better outcomes are clinically or economically beneficial remains controversial.
Narrative review
VKORC1
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Nivolumab has received regulatory approval to be given by weight-based or flat dosing every two weeks or by flat dosing every four weeks. However, flat dosing would lead to unnecessarily high doses for patients with lower body weight, increasing the drug usage and probability of toxicity. We review the rationale of using a four-weekly hybrid dosing strategy using weight-based and flat-dosing regimens adopted by some jurisdictions.
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Abstract Background: Warfarin, a key anticoagulant medication, has a narrow therapeutic window and individual difference. Many warfarin dosing algorithms have been developed and been proved to have clinical benefits. However, the utilization of algorithms by medical professionals in China was unknown. We conducted an online survey to investigate the use and requirements of warfarin dosing algorithms among Chinese medical professionals. Method: A questionnaire survey was conducted via WeChat to investigate the utilization of warfarin dosing algorithms by medical professionals in seven regions of China. The content of questionnaire was included general characteristics of participants, condition of anticoagulant therapy, utilization of warfarin dosing algorithms and demand for function of an assistant warfarin dosing system we proposed.Results: A total of 399 participants completed the survey. Although most medical professionals use warfarin for anticoagulant therapy, some of them (15.04%) were not familiar with warfarin’s individual difference. As high as 32.97% of clinicians ruled out genotypes when using warfarin. The vast majority of anticoagulant medical professionals believed warfarin dosing algorithms can have clinical benefits, but only 20.80% of them usually use algorithms for anticoagulant therapy. Conclusion: Warfarin dosing algorithms have high evaluation while not good utilization among Chinese anticoagulant medical professionals. If warfarin dosing algorithms and assistant tools aimed to Chinese population were developed, to some extent can improve anticoagulant therapy in China.
Anticoagulant Therapy
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