Scary hospital practices

[mustang sally]

So I am working now in a hospital that is, um, kind of backwoodsy. All of the pharmacists that I work with are older and have years of hospital experience working in similarly sized hospitals, whereas I have none. Some of the things they do here really freak me out. However, whenever I make a suggestion or politely disagree with something they stare at me like I'm an alien with two heads.

For instance, the computer calculates the eGFR of each patient and so they use that to renally dose adjust meds. The other day I mentioned that the MDRD is not the same thing as CrCl and we should really be using CrCl to dose adjust. The other pharmacist on duty at the time said that almost without fail, eGFR and CrCl are the same. Which clearly they were not the same in this instance. I could just see what the other pharmacist was thinking in his head, "this b*tch isn't even fully trained in order entry yet and she is telling me how to dose adjust antibiotics."

There are many other examples of shady things they do here but I will spare you the gory details. And I realize there are many shades of gray in how people do things in pharmacy, but I was taught over and over in school that you use CrCl to dose meds. I don't know what the point of this post is, other than that I don't have any other contemporaries here to bounce ideas off of. Sometimes I feel like I have fallen into a pharmacy black hole that I didn't even know existed. What do you guys think, is this common hospital practice to use the eGFR? Because I have never seen it done before.

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[Ackj]

So I am working now in a hospital that is, um, kind of backwoodsy. All of the pharmacists that I work with are older and have years of hospital experience working in similarly sized hospitals, whereas I have none. Some of the things they do here really freak me out. However, whenever I make a suggestion or politely disagree with something they stare at me like I'm an alien with two heads.

For instance, the computer calculates the eGFR of each patient and so they use that to renally dose adjust meds. The other day I mentioned that the MDRD is not the same thing as CrCl and we should really be using CrCl to dose adjust. The other pharmacist on duty at the time said that almost without fail, eGFR and CrCl are the same. Which clearly they were not the same in this instance. I could just see what the other pharmacist was thinking in his head, "this b*tch isn't even fully trained in order entry yet and she is telling me how to dose adjust antibiotics."

There are many other examples of shady things they do here but I will spare you the gory details. And I realize there are many shades of gray in how people do things in pharmacy, but I was taught over and over in school that you use CrCl to dose meds. I don't know what the point of this post is, other than that I don't have any other contemporaries here to bounce ideas off of. Sometimes I feel like I have fallen into a pharmacy black hole that I didn't even know existed. What do you guys think, is this common hospital practice to use the eGFR? Because I have never seen it done before.

CrCl is what's used to dose meds. MDRD is used to stage renal function, and is not validated for dosing. That said, they are both estimates with limitations. eGFR is often reported by the lab, so I can see someone using that rather than going through the (ridiculously quick and simple) calculation. The hospitals I've been in have had globalrph open on the second screen at all times, and pharmacists just plugged the numbers in there for any abx dosing.

Speaking of backwoods, the hospital I'm in right now doesn't have an IV room, we just have a glovebox. Other than that we're fairly up to date.

 

[njac]

Our order entry software calculates a CrCl using C-G (and rounding the SCr to 1 in elderly *eye roll*, and using ABW in the obese); are you sure yours is using MDRD?

I'd take this up with your clinical coordinator and/or the IT pharmacist, or whoever is responsible for that aspect.

 

[mustang sally]

It is definitely MDRD. And that is just one example.

But anyway, njac, you bring up a good point. How does everyone calculate CrCl? In some classes we were taught to never use less than one for the Cr, but in some hospitals I rotated through I believe they didn't use less than 0.6 unless the patient was over 65, then they didn't use less than 0.8 (or something like that).

 

[Ackj]

It is definitely MDRD. And that is just one example.

But anyway, njac, you bring up a good point. How does everyone calculate CrCl? In some classes we were taught to never use less than one for the Cr, but in some hospitals I rotated through I believe they didn't use less than 0.6 unless the patient was over 65, then they didn't use less than 0.8 (or something like that).

I've discussed this point with a few different preceptors, and none of them really have a hard and fast cuttoff or rule. Patient's age and lean body mass definitely come into play when determining whether to round or not. I've also been advised to run the numbers both ways and compare them to see how big of a difference it is. If not rounding is 33ml/min, but rounding gives you 20 ml/min, you will most likely use a "less than 30" dose.

 

[owlegrad]

We only round to 1 if the pt is >65yo with SCr<1. I think it is a little odd that it is not customary to use the procedure done to make the dosing guidelines to begin with (which I think is to not round at all, though I could be mistaken), but what do I know?

 

[psychoandy]

I don't really consider this "shady". it would be more shocking if you said that people are started on heparin drips without ptt checks or hold parameters, or everyone gets LMWH without looking at SCr/CrCl. MDRD and eGFR and est CrCl are all technically different. And i'm sure all of us could discuss IBW vs ABW vs dosing weight in addition to that. If this worries you a lot you can use the globalrph CrCl multicalc and use that for dosing and f whatever all the other RPhs do. Hell most of the time I can ballpark a decent CrCl just by looking at SCr...this will come with time.

WRT renal dosing things like abx, if I came across a circumstance where eGFR was 40 and calc'd est CrCl was 26 or something, obviously I would dose reduce. Stick to your guns and do what you think is right, but be humble and take other factors into consideration as well. The zealotry of a newly minted PharmD regarding the estimated CrCl can be kind of scary (and i say this as a recent grad).

That being said, I haven't seen it drastically differ unless there are specific pt factors that would complicate any of these factors (such as old age, morbid obesity, amputation, para/quadriplegia, muscle mass, etc).

tl;dr: use whatever calculation you'd like, just keep in mind pt specific factors that could impact this.

 

[xiphoid2010]

I round up Cr to 1 for the elderly. A the muscle mass decreases with age, the Cr production decrease, so going with SrCr will often result in overly high Vanc and AG dosing. I just had a pt who is 80+, SrCr of 0.3, wt ~80 kg, around 5'6'. GlobalRPh asked me to give vanc 1.25 q12. LOL, Yet I can see some fresh grad might fall for it. I ordered 1.25 gram q24h and it was right on. Know the physiology and use your head/common sense.

P.S MDRD overall tend to over estimate renal function. From a pharmacy director point of view: (1) drug studies use CrCl. So eGFR isn't not equivalent or the standard.... but also because (2) lower CrCl results in a larger dose reduction, which helps pharmacy expenditure. So why let my budget go over because staff pharmacists are too lazy to do a quick number crunch?

 

[njac]

New study in pharmacotherapy says rounding SCr isn't necessary.

One of the best residency projects I've ever seen.

Someone should JC it for us.

 

[njac]

So do your kidneys just magically disintegrate the night of your 65th birthday!? What about your 72y/o grandma who ran a marathon last month and her SCr is 0.6. What about the bed bound 30y/o quadriplegic with a SCr of 0.3?

I have the advantage of working in the ED, so I can lay my eyes on every patient I'm dosing. I know details like, oh that SCr is from *before* they coded, etc.

I also think we need to remember *why* we are renally dosing meds. Are they nephrotoxic or going to accumulate? What would be the effects of this?? With a septic patient I'm more than willing to round up the first couple days of therapy, say if the CrCl is ~45, I'm not going to hesitate to schedule their levaquin q24h.

 

[gotdrugs]

New study in pharmacotherapy says rounding SCr isn't necessary.

Yep, it confirms the papers/studies that had been published in the 1990's that demonstrated that rounding isn't necessary.

Yet many pharmacists still do it.

 

[gotdrugs]

So do your kidneys just magically disintegrate the night of your 65th birthday!?

Actually we need to reconsider that number........they do magically disintegrate when you cash your first SS check.

 

[gotdrugs]

but also because (2) lower CrCl results in a larger dose reduction, which helps pharmacy expenditure.

It's comments like this that make me cringe when people who don't have enough experience are put in positions of power.

 

[xiphoid2010]

It's comments like this that make me cringe when people who don't have enough experience are put in positions of power.

Well, let's see. Drugs are supposed to be dosed on CrCl. eGFR dosing is wrong to begin with, and eGFR telling you to give Lovenox 1mg/kg BID when it should be based onCrCl dosed Q24h. Pharmacist just overdosed the patient and doubled the drug cost, yeah I have a problem with that.

 

[xiphoid2010]

So do your kidneys just magically disintegrate the night of your 65th birthday!? What about your 72y/o grandma who ran a marathon last month and her SCr is 0.6. What about the bed bound 30y/o quadriplegic with a SCr of 0.3?

I have the advantage of working in the ED, so I can lay my eyes on every patient I'm dosing. I know details like, oh that SCr is from *before* they coded, etc.

I also think we need to remember *why* we are renally dosing meds. Are they nephrotoxic or going to accumulate? What would be the effects of this?? With a septic patient I'm more than willing to round up the first couple days of therapy, say if the CrCl is ~45, I'm not going to hesitate to schedule their levaquin q24h.

There is no hard rules for rounding or not, some of it is just a hunch based on experience for the lack of a better explanation. But blindly chugging Co into globalrph and dose away is not the way to do it. Muscle mass loss is a gradual and patient dependent process. And like you alluded to, need to factor in severity of the disease state. In septic patients you need a weight based vanc or AG loading dose any way.

 

[gotdrugs]

Well, let's see. Drugs are supposed to be dosed on CrCl. eGFR dosing is wrong to begin with, and eGFR telling you to give Lovenox 1mg/kg BID when it should be based onCrCl dosed Q24h. Pharmacist just overdosed the patient and doubled the drug cost, yeah I have a problem with that.

The problem is that your original statement doesn't take into account the patient. It's very narrow-minded.

Like when you wanted to switch people's anticoagulants back and forth just to save a few dollars in drug expenditures without looking at collateral damage or the overall state of care to the patient.

 

[xiphoid2010]

The problem is that your original statement doesn't take into account the patient. It's very narrow-minded.

Like when you wanted to switch people's anticoagulants back and forth just to save a few dollars in drug expenditures without looking at collateral damage or the overall state of care to the patient.

Correct dosing is in the interest of the patients.

And you didn't fully understand why I was thinking about switching to pradaxa. It does not save money, I was thinking it would make better patient care as it avoid supra and subtherapeutic INRs.

 

[njac]

And then they come into my ER bleeding and we have no way to stop it other than PCC. Fabulous.

 

[gotdrugs]

Correct dosing is in the interest of the patients.

And you didn't fully understand why I was thinking about switching to pradaxa. It does not save money, I was thinking it would make better patient care as it avoid supra and subtherapeutic INRs.

You should have quit while you were ahead, now I cringe even more if you thought that was your rationale.

 

[All4MyDaughter]

You should have quit while you were ahead, now I cringe even more if you thought that was your rationale.

I think it's selective recall anyway. If I remember correctly, the discussion was as much about the daily cost of Pradaxa vs. the daily cost of INR monitoring as it was about supra/sub INRs. At any rate, I agree that the relentless focus on cost is potentially wrongheaded.

 

[xiphoid2010]

I think it's selective recall anyway. If I remember correctly, the discussion was as much about the daily cost of Pradaxa vs. the daily cost of INR monitoring as it was about supra/sub INRs. At any rate, I agree that the relentless focus on cost is potentially wrongheaded.

The cost of pradaxa is the same as daily INR. It doesn't save money, in fact it would increase pharmacy cost. So money is not a significant factor. but a consistent anticogulation is better for patient care.

 

[xiphoid2010]

You should have quit while you were ahead, now I cringe even more if you thought that was your rationale.

What ever, you try to say I care only about money when I was actually going to use more expensive drugs to try to achieve better anticoag. But hey think whatever you want.

 

[HouTX]

What ever, you try to say I care only about money when I was actually going to use more expensive drugs to try to achieve better anticoag. But hey think whatever you want.

i think it shifted to your clinical expertise

 

[Daiphon]

And then they come into my ER bleeding and we have no way to stop it other than PCC. Fabulous.

Fabulous is not the F-word I would use.

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[xiphoid2010]

And then they come into my ER bleeding and we have no way to stop it other than PCC. Fabulous.

The bleeding risk is a subject of concern, but if I recall both of the oral agents have lower ICH risks compared to warfarin. The debate is going on whether it's better to have a lower risk of bleeding or have a reversal agent.

But yes, it is a concern without a clear cut answer, and which is why neither paradaxa and xarelto are officially formulary agents at our hospital, but both are kept in stock. While warfarin is still the most used by farm, I have noticed that docs here have been prescribing xarelto more frequently.

 

[njac]

It's not the bleeding risk I worry so much about, that's a risk we have to deal with. What I worry about is reversal. Also, without a direct value to correlate the degree of anticoagulation with dabigatran (since we don't do ECT) it's hard to know how much to correct for, etc.

 

[njac]

Fabulous is not the F-word I would use.

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Right?

 

[KARM12]

MDRD should never be used to adjust drug doses. All dosing studies are based on CG.

There are plenty of studies that say SCr rounding isn't generally necessary. 65yo is way too young to round up.

 

[xiphoid2010]

It's not the bleeding risk I worry so much about, that's a risk we have to deal with. What I worry about is reversal. Also, without a direct value to correlate the degree of anticoagulation with dabigatran (since we don't do ECT) it's hard to know how much to correct for, etc.

The last I looked, there wasn't any good data to show which is better, less bleeding vs. more bleeding but has reversal agent. What we do have is the mortality data for comparison which include death from bleeding, the newer oral agents are no worse than warfarin despite the fact that warfarin has reversal agents. If I recall correctly from some of the JC, several study actually showed the newer agents has lowe mortality.

I agree a reversal agent would be great, and no doubt the company that invents it will be rich. But the biggest impact might be more of peace of mind. But I agree until it is discovered, many physicians would still prefer to use the "devil we know".

At my place, pradaxa use is rare while xarelto use in comparison is pretty common now. I think the stink with pradaxa GI bleed in the news played a big part. Meanwhile xarelto has received approval for a.fib and has a shorter half life, which might have contributed to the increased use.

 

[mustang sally]

Speaking of bleeding...what about doctors who routinely give a large dose of warfarin to bump up INR quickly and prescribe vitamin K to reverse it? Is this a common practice?! I think I recall a thread about that earlier in the spring, maybe time to go search for it...

 

[xiphoid2010]

Speaking of bleeding...what about doctors who routinely give a large dose of warfarin to bump up INR quickly and prescribe vitamin K to reverse it? Is this a common practice?! I think I recall a thread about that earlier in the spring, maybe time to go search for it...

The new Chest guideline recommend warfarin loading dose of 10mg daily x 2 days. That scares me.

 

[spacecowgirl]

The new Chest guideline recommend warfarin loading dose of 10mg daily x 2 days. That scares me.

I know. this has rocked my world. All those years of having the fear of loading warfarin instilled - it's hard to undo that.