Longing for mercy, requesting death: pharmaceutical care and pharmaceutically assisted death.
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Ethics, Pharmacy↗
Biomedical subjects
K L Kier
Publications and source records attributed to K L Kier.
Potential interaction between clarithromycin and warfarin.
OBJECTIVE: To report a possible drug interaction between clarithromycin and warfarin in a patient with chronic atrial fibrillation. CASE SUMMARY: A patient with chronic atrial fibrillation was placed on warfarin therapy. International normalized ratios (INRs) ranged from 1.61 to 3.99 while the dosage was being adjusted during the first 5 months of warfarin therapy. The dosage was titrated to 20 mg/wk; laboratory tests obtained 2 weeks after this dosage was started indicated an INR of 2.1. The same dosage was continued. Clarithromycin 500 mg bid was started for an acute exacerbation of bronchitis 10 days after the last INR was obtained and was continued for 14 days of therapy. An INR obtained 3 days after completion of the clarithromycin therapy was 16.8. The warfarin was withheld and vitamin K 20 mg im was administered. The INR obtained the next day was 1.52. The warfarin was restarted and the dosage was titrated to between 22.5 and 25 mg/wk, with INRs ranging from 0.85 to 3.14. DISCUSSION: Many factors influence the metabolism of warfarin, including disease states, medications, age, and diet. Data collected in this case suggested clarithromycin may have contributed to the increase in the effect of warfarin. Inhibition of the cytochrome P450 oxidizing system appears to be the reason for the increase. Numerous drugs and disease states affect the rate at which this system metabolizes drugs. CONCLUSIONS: The potential interaction between clarithromycin and warfarin warrants prudent monitoring of the INR during concurrent administration of these drugs. Warfarin dosages may need to be reduced during concurrent clarithromycin therapy to prevent bleeding complications. Further controlled clinical trials are needed to substantiate the interaction between clarithromycin and warfarin.
Aged↗
Thrombocytopenia in intensive care patients: a comprehensive analysis of risk factors in 314 patients.
OBJECTIVE: To define the incidence and severity of thrombocytopenia in a mixed medical-surgical population of critically ill patients and to examine factors that may be related to the development of thrombocytopenia. DESIGN: Retrospective chart review of 314 critically ill patients requiring at least 3 days of critical care. SETTING: A 17-bed combined medical-surgical intensive care unit (ICU) in a 560-bed tertiary care community hospital. PATIENTS: Medical and surgical patients admitted to the ICU. INTERVENTIONS: All medical records over the duration of the ICU stay were reviewed. All scheduled medications, including dosage and start/stop dates, were recorded. All platelet counts, placement of pulmonary artery catheters, liver function test results, and admission serum creatinine concentrations were collected. MEASUREMENT AND MAIN RESULTS: Thrombocytopenia (platelet count less than 200 x 10(9)/L) was observed frequently, but rarely reached a severe stage (7 patients). No single diagnostic category was significantly associated with thrombocytopenia alone, although the combination of sepsis syndrome/septic shock and respiratory failure was strongly correlated (p < 0.0001) with thrombocytopenia. Liver function abnormalities were correlated strongly with thrombocytopenia, and the majority of patients (5 of 7) with severe thrombocytopenia (less than 20 x 10(9)/L) were found to have concurrent severe alterations in liver function test results. Pulmonary artery catheter placement and heparin exposure were associated strongly with thrombocytopenia (p < 0.0001). Drug therapies that were correlated with thrombocytopenia included heparin and vancomycin (p < 0.05). Hemodynamic instability was correlated strongly with the presence and severity of thrombocytopenia. In a stepwise linear regression model, the admission platelet count accounted for the largest proportion of the variance (43%), followed by hemodynamic instability (8%) and the requirement for inotropic agents (2%). CONCLUSIONS: Thrombocytopenia in the critically ill occurs frequently, rarely reaches severely depressed concentrations, and primarily represents a manifestation of disease processes initiated prior to admission. Hemodynamic instability and/or heparin exposure appear to be the strongest identifiable correlates with thrombocytopenia. Although these may cause infrequent isolated cases, other specific drug causes of thrombocytopenia are not responsible for the majority of cases of thrombocytopenia in the critically ill.
Creatinine↗
Drug-usage evaluation: traditional versus outcome-based approaches.
The use of outcome assessment with DUE can provide more detailed information on the impact of drug therapy on the overall health status of the patient, rather than just the narrow view of the drug-prescribing process within the institution. These studies may justify additional pharmacists to help in the selection of drugs and their potential to affect overall quality patient care. In addition, the Joint Commission is recommending that measurement of health outcomes is important in QA. The Joint Commission has stated in their Agenda for Change program "that patient outcomes are influenced by all activities of a health care program." The Joint Commission plans to develop standards that "describe in functional terms what the key jobs are that need to be done to produce good patient outcomes." The major problem with adding outcome measures in the assessment of DUE programs is the evolutionary nature of the available technology to measure these patient outcomes. Incorporation of outcome measures into DUE programs can provide measures of the impact of drug therapy on the patients' HQOL. This HQOL is potentially a better reflection of patient outcomes and the assessment of quality of care.
Drug Utilization↗