1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

17
1,2,3 for AUC Implementing the 2020 Vancomycin Dosing Guidelines Angharad Ratliff, PharmD Greg Michaud, PharmD Katie Presser, PharmD Nick Smith, PharmD

Transcript of 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Page 1: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

1,2,3 for AUC Implementing the 2020

Vancomycin Dosing Guidelines Angharad Ratliff, PharmD

Greg Michaud, PharmD

Katie Presser, PharmD

Nick Smith, PharmD

Page 2: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Objectives

• Discuss the rationale for implementing AUC dosing with vancomycin

• Identify successful practices for transitioning from trough-based to AUC-based vancomycin dosing protocols

• Discuss common barriers and identify potential solutions for implementation

Page 3: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Overview

• Background – Why AUC dosing?

• How do I do this? Calculation tools

• When do I do this? Indications, MRSA vs non-MRSA infections, Special Populations, OPAT

• Who else is involved?

• Lab

• Nursing

• Pharmacy education

Page 4: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...
Page 5: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Introducing the Panelists

• Angharad – Alaska Regional Hospital

• Greg – MatSu Regional Medical Center

• Katie – Alaska Native Medical Center

• Nick – Providence Alaska Medical Center

Page 6: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Background: Why AUC?

2009 Guidelines

• AUC/MIC ≥ 400

• Trough of 15-20 mg/L as a surrogate

• Actual body weight for determining dosage

• Loading doses for severe infections

• Knowledge Gaps:

• Pediatrics

• Morbidly obese patients

• Renal failure

• Prolonged or continuous infusion

• Safety data for dosages > 3 g/day

• Safety and efficacy of targeted troughs 15-20mg/L

2020 Guidelines

• AUC/MIC 400-600

• AUC/MIC < 400 – encourages emergence of resistance

• Assume MIC of 1

• Vancomycin-associated AKI –

• Increased with AUC > 650

• Vancomycin monitoring

• Patients at high risk for nephrotoxicity

• Patients with unstable renal function

• Patients receiving prolonged courses of therapy ( > 3-5 days)

• Frequent or daily monitoring for unstable patients

• Weekly monitoring for stable patients

Page 7: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Methods of Calculating AUC

• Bayesian calculators

• Well-developed vancomycin population PK model + individual patient’s observed drug concentration

• Does not require steady state conditions

• Allows for trough-only sampling in select populations

• Limited information in special populations – obese, critically ill, pediatric, patients with unstable renal function

• First order PK analytic equations

• 2 steady state serum concentrations

• Lacks adaptive ability of Bayesian calculations

Page 8: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

AUC Calculators

• Prov Excel calculator

• Precise PK

• Vancopk.com

• InsightRx

• Integration into EMR

• Turner, et al. Pharmacotherapy 2018

• Review of APK, BestDose, DoseMe, InsightRx, PrecisePK

• Considerations: integration into EMR, $$$, training required, adaptability

Page 9: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

AUC Dosing Based Upon Indication?

• Guidelines – serious MRSA infections only

• Serious infections = bacteremia, sepsis, infective endocarditis, pneumonia, osteomyelitis, meningitis

• Easier implementation across the board?

• Increased workload on nursing/lab/pharmacy

• Methods to decrease workload?

• Which indications?

• Differentiating MRSA from non-MRSA infections

Page 10: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Special Patient Populations

• Obesity

• Increased risk of vancomycin-induced nephrotoxicity

• Vd increase not reliably associated with weight increase

• Loading dose (20-25mg/kg) recommended in patients with serious infections

• 3gm dose cap

• Max daily vancomycin doses of 4.5 gm/day

• 2 level analysis

Page 11: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Special Patient Populations

• Renal Failure

• Intermittent HD: pre-dialysis HD levels between 15-20mg/L achieves AUC 400-600

• Loading doses based upon actual body weight and if dose is to be administered intradialytically or post-dialysis

• Benefits of administering dose in dialysis vs. after dialysis

• Continuous renal replacement therapy (CRRT)

• Loading dose of 20-25 mg/kg actual body weight

• Initial maintenance dose: 7.5 – 10mg/kg q12h

• Serum concentration monitoring with 2 levels within 24 hours

• Dose based upon levels?

Page 12: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...
Page 13: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Long-term Therapy/Transition to Outpatient

• Surrogate trough monitoring

• When to use trough-only?

• Continuous infusion?

Page 14: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Nursing Considerations

• Nurses can be your make or break for AUC dosing

• Explaining the “WHY” is essential

• Plans for nursing education

• Concerns from nursing

Page 15: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Pharmacist Education

• Gaps in education

• Competency assessments

• On-hire

• On-going

• One-on-one meetings vs. group training sessions

Page 16: 1,2,3 for AUC Implementing the 2020 Vancomycin Dosing ...

Lab Considerations

• Labeling concerns:

• Education on moving from single level to 2 level analysis

• Terminology for lab orders: peak/trough, 2 randoms, AUC 1/AUC2

• Make sure you are looking at critical levels

• MIC concerns:

• CLSI allows for variability +/- 1 dilution

• E test method consistently higher MICs

• True rates of MIC of 2 much lower than previously reported