In this episode I’ll:

1. Discuss an article about modification of guideline-directed medical therapy in HF.

2. Answer the drug information question “Can linezolid be used to inhibit bacterial toxin production in necrotizing fasciitis?”

3. Share a resource for full-text journal access.

Article

Guideline-Directed Medical Therapy and Survival Following Hospitalization in Patients with Heart Failure

Lead author: Richard H Tran

Published in Pharmacotherapy February 2018

Background

What happens when guideline-directed medical therapy (GDMT) is modified in a hospitalized patient with heart failure (HF)? That is what the authors of this study investigated. Modification, for purposes of this study, included initiation or discontinuation of any guideline directed therapy.

Methods

Over 5000 hospitalizations were analyzed from the community surveillance arm of the Atherosclerosis Risk in Communities Study. Predictors of guideline-directed medical therapy modification and survival were assessed.

Results

The mean age of patients in the study was 75 years old, 53% were female, 69% were Caucasian, and 81% were admitted for acute decompensated HF (ADHF). About 1/3 of patients had HF with reduced EF (HFrEF), 1/4 had HF with preserved EF (HFpEF), and the remainder were missing EF values.

Modification of GDMT occurred in up to 23% of hospitalizations. Significant predictors of GDMT initiation included ADHF and HFrEF; discontinuation of medications was observed with select comorbidities such as ACEI/ARB discontinuation for acute renal insufficiency.

In HF with reduced EF, initiation of any GDMT was associated with statistically significant reduced 1-year all-cause mortality (adjusted hazard ratio: 0.41) as was initiation of ACEI/ARB, BB, and digoxin. Discontinuation of any therapy versus maintaining GDMT was associated with greater mortality (HR: 1.30; 95% CI: 1.02-1.66).

Similar trends were observed in HF with preserved EF.

Conclusion

The authors concluded:

Our study suggests that GDMT initiation is associated with increased survival and discontinuation of therapy is associated with reduced survival in hospitalized patients with HF. Future studies should be conducted to confirm the impact of GDMT therapy modification in this population.

Discussion

This study clearly identifies a target for hospital pharmacists who want to improve survival outcomes in patients with heart failure. Focusing on both initiation of and preventing discontinuation of guideline-directed medical therapy for HF will lead to improved patient outcomes.

The number of patients who experienced discontinuation of a GDMT was almost double the number that had GDMT initiated. A pharmacist that is able to identify HF patients who had a part of their therapy held due to an acute event such as hyperkalemia or acute renal failure may be able to ensure that patient has their therapy reinstated before discharge when the patient has stabilized.

Drug information question

Q: Can linezolid be used to inhibit bacterial toxin production in necrotizing fasciitis?

A: Yes.

Clindamycin is usually thought of as the antibiotic to use in necrotizing fasciitis to reduce toxin production. But linezolid and clindamycin both bind to the 50S subunit of bacterial ribosomes to inhibit protein synthesis. Linezolid is a particularly interesting choice in infections with group A strep as the drug has both streptococcal bactericidal activity and antitoxin effects. Additionally, necrotizing fasciitis may be caused by MRSA, which would also be covered by linezolid.

Resource

The resource for this episode is the Medical Library in the Hospital Pharmacy Academy. Members of the Hospital Pharmacy Academy get full-text access to all current and back issues for the journals Pharmacotherapy and Academic Emergency Medicine. In addition to full-text access, members are kept up to date on the Medical Literature with weekly hand-curated literature digests.

To get immediate access to the Medical Library, and to learn about the other benefits included in your membership, go to pharmacyjoe.com/academy.

Institutional group memberships for the Hospital Pharmacy Academy are also available. Send an email to joe@pharmacyjoe.com if you are interested in an institutional membership.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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