Doug Brunk

DENVER – Before a new protocol was implemented, antimicrobial dosing in patients receiving continuous renal replacement therapy varied and was adherent to evidence-based recommendations in about one-quarter of antimicrobial orders, results from a single-center study showed.

"For any kind of renal replacement therapy, there is always an uncertainty as to how much residual antibiotic is being removed, how much residual renal function the patient has, and how much of the antibiotic is actually staying within the patient for them to achieve therapeutic levels of the drug to combat their infection," Jamie Wagner, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"With renal replacement therapy, everything is dependent on the filter, the flow rate, and how much residual renal function the patient has. We set out to try to determine how well the interdisciplinary teams were adhering with dosing recommendations, defined as use of evidence-based dose for each CRRT [continuous renal replacement therapy] modality employed for the entire duration of antibiotics used during CRRT."

Dr. Wagner, an infectious diseases pharmacy fellow at the 802-bed Henry Ford Hospital, Detroit, and her associates evaluated 246 antimicrobial orders placed for 43 patients from November 2008 to May 2012. Patients were included in the analysis if they had an order placed for a beta-lactam, vancomycin, tobramycin, gentamicin, or daptomycin; if they received the drug in the ICU; and if they were on CRRT at the time the drug was administered. Patients receiving intermittent hemodialysis or peritoneal dialysis were excluded from the study.

Using medical records, the researchers evaluated demographics, CRRT modality, dates of changes in CRRT, and antibiotic dosing information. Each antibiotic order was evaluated for adherence to evidence-based dosing recommendation, which was the primary outcome of interest.

In August 2011, the Henry Ford Health System implemented an institutional guideline for antibiotic dosing in CRRT, which contained a summary of evidence-based dosing recommendations for the most common antimicrobial agents used in the ICU.

Of the 43 patients, 14 met study inclusion criteria before implementation of the guideline (group A), while the remaining 29 met inclusion criteria after implementation of the guideline (group B). The mean ages of patients in both groups were similar (55 years in group A vs. 59 years in group B), as were other variables.

Dr. Wagner reported that no differences were observed in antibiotic use between pre- and postguideline antibiotic orders. The three most commonly prescribed agents were vancomycin (32%), cefepime (21%), and aminoglycosides (15%). Following implementation of the guideline, overall adherence with evidence-based dosing recommendations improved from 24% to 49% between groups A and B, a difference which reached significance (P less than .001).

Four CRRT modalities changed significantly between groups A and B: continuous venovenous hemofiltration (CVVH) for 8-12 hours (24% vs. 0%, respectively); sustained, low-efficiency, daily diafiltration (SLEDD) for 8-12 hours with an F8 filter (29% vs. 6%); SLEDD for 8-12 hours with an F250 filter (14% vs. 1%); and SLEDD for 24 hours (11% vs. 75%).

Changes between modalities occurred in 13% of all orders assessed. Variables found to be associated with nonadherent orders were change of CRRT mode that resulted in a new recommended dose (7%), SLEDD for 8-12 hours (15%), and the use of any aminoglycoside (15%).

"Communication is key between all patient care providers on a daily basis," Dr. Wagner concluded. "At Henry Ford Hospital, providers must submit a new order for CRRT every single day for patients requiring antibiotic dosing. There needs to be communication about this between all providers involved in that patient’s care."

She acknowledged certain limitations of the study, including increased use of 24-hour SLEDD during the postguideline period, strict definition for adherence to the guideline, and the inability to systematically evaluate clinical response or residual function.

"Understanding factors associated with nonadherent orders can provide a starting point for clinicians to improve the antimicrobial use process in CRRT," she said.

Dr. Wagner said that she had no relevant conflicts of interest to disclose.

dbrunk@frontlinemedcom.com

DENVER – Before a new protocol was implemented, antimicrobial dosing in patients receiving continuous renal replacement therapy varied and was adherent to evidence-based recommendations in about one-quarter of antimicrobial orders, results from a single-center study showed.

"For any kind of renal replacement therapy, there is always an uncertainty as to how much residual antibiotic is being removed, how much residual renal function the patient has, and how much of the antibiotic is actually staying within the patient for them to achieve therapeutic levels of the drug to combat their infection," Jamie Wagner, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"With renal replacement therapy, everything is dependent on the filter, the flow rate, and how much residual renal function the patient has. We set out to try to determine how well the interdisciplinary teams were adhering with dosing recommendations, defined as use of evidence-based dose for each CRRT [continuous renal replacement therapy] modality employed for the entire duration of antibiotics used during CRRT."

Dr. Wagner, an infectious diseases pharmacy fellow at the 802-bed Henry Ford Hospital, Detroit, and her associates evaluated 246 antimicrobial orders placed for 43 patients from November 2008 to May 2012. Patients were included in the analysis if they had an order placed for a beta-lactam, vancomycin, tobramycin, gentamicin, or daptomycin; if they received the drug in the ICU; and if they were on CRRT at the time the drug was administered. Patients receiving intermittent hemodialysis or peritoneal dialysis were excluded from the study.

Using medical records, the researchers evaluated demographics, CRRT modality, dates of changes in CRRT, and antibiotic dosing information. Each antibiotic order was evaluated for adherence to evidence-based dosing recommendation, which was the primary outcome of interest.

In August 2011, the Henry Ford Health System implemented an institutional guideline for antibiotic dosing in CRRT, which contained a summary of evidence-based dosing recommendations for the most common antimicrobial agents used in the ICU.

Of the 43 patients, 14 met study inclusion criteria before implementation of the guideline (group A), while the remaining 29 met inclusion criteria after implementation of the guideline (group B). The mean ages of patients in both groups were similar (55 years in group A vs. 59 years in group B), as were other variables.

Dr. Wagner reported that no differences were observed in antibiotic use between pre- and postguideline antibiotic orders. The three most commonly prescribed agents were vancomycin (32%), cefepime (21%), and aminoglycosides (15%). Following implementation of the guideline, overall adherence with evidence-based dosing recommendations improved from 24% to 49% between groups A and B, a difference which reached significance (P less than .001).

Four CRRT modalities changed significantly between groups A and B: continuous venovenous hemofiltration (CVVH) for 8-12 hours (24% vs. 0%, respectively); sustained, low-efficiency, daily diafiltration (SLEDD) for 8-12 hours with an F8 filter (29% vs. 6%); SLEDD for 8-12 hours with an F250 filter (14% vs. 1%); and SLEDD for 24 hours (11% vs. 75%).

Changes between modalities occurred in 13% of all orders assessed. Variables found to be associated with nonadherent orders were change of CRRT mode that resulted in a new recommended dose (7%), SLEDD for 8-12 hours (15%), and the use of any aminoglycoside (15%).

"Communication is key between all patient care providers on a daily basis," Dr. Wagner concluded. "At Henry Ford Hospital, providers must submit a new order for CRRT every single day for patients requiring antibiotic dosing. There needs to be communication about this between all providers involved in that patient’s care."

She acknowledged certain limitations of the study, including increased use of 24-hour SLEDD during the postguideline period, strict definition for adherence to the guideline, and the inability to systematically evaluate clinical response or residual function.

"Understanding factors associated with nonadherent orders can provide a starting point for clinicians to improve the antimicrobial use process in CRRT," she said.

Dr. Wagner said that she had no relevant conflicts of interest to disclose.

dbrunk@frontlinemedcom.com

DENVER – Before a new protocol was implemented, antimicrobial dosing in patients receiving continuous renal replacement therapy varied and was adherent to evidence-based recommendations in about one-quarter of antimicrobial orders, results from a single-center study showed.

"For any kind of renal replacement therapy, there is always an uncertainty as to how much residual antibiotic is being removed, how much residual renal function the patient has, and how much of the antibiotic is actually staying within the patient for them to achieve therapeutic levels of the drug to combat their infection," Jamie Wagner, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"With renal replacement therapy, everything is dependent on the filter, the flow rate, and how much residual renal function the patient has. We set out to try to determine how well the interdisciplinary teams were adhering with dosing recommendations, defined as use of evidence-based dose for each CRRT [continuous renal replacement therapy] modality employed for the entire duration of antibiotics used during CRRT."

Dr. Wagner, an infectious diseases pharmacy fellow at the 802-bed Henry Ford Hospital, Detroit, and her associates evaluated 246 antimicrobial orders placed for 43 patients from November 2008 to May 2012. Patients were included in the analysis if they had an order placed for a beta-lactam, vancomycin, tobramycin, gentamicin, or daptomycin; if they received the drug in the ICU; and if they were on CRRT at the time the drug was administered. Patients receiving intermittent hemodialysis or peritoneal dialysis were excluded from the study.

Using medical records, the researchers evaluated demographics, CRRT modality, dates of changes in CRRT, and antibiotic dosing information. Each antibiotic order was evaluated for adherence to evidence-based dosing recommendation, which was the primary outcome of interest.

In August 2011, the Henry Ford Health System implemented an institutional guideline for antibiotic dosing in CRRT, which contained a summary of evidence-based dosing recommendations for the most common antimicrobial agents used in the ICU.

Of the 43 patients, 14 met study inclusion criteria before implementation of the guideline (group A), while the remaining 29 met inclusion criteria after implementation of the guideline (group B). The mean ages of patients in both groups were similar (55 years in group A vs. 59 years in group B), as were other variables.

Dr. Wagner reported that no differences were observed in antibiotic use between pre- and postguideline antibiotic orders. The three most commonly prescribed agents were vancomycin (32%), cefepime (21%), and aminoglycosides (15%). Following implementation of the guideline, overall adherence with evidence-based dosing recommendations improved from 24% to 49% between groups A and B, a difference which reached significance (P less than .001).

Four CRRT modalities changed significantly between groups A and B: continuous venovenous hemofiltration (CVVH) for 8-12 hours (24% vs. 0%, respectively); sustained, low-efficiency, daily diafiltration (SLEDD) for 8-12 hours with an F8 filter (29% vs. 6%); SLEDD for 8-12 hours with an F250 filter (14% vs. 1%); and SLEDD for 24 hours (11% vs. 75%).

Changes between modalities occurred in 13% of all orders assessed. Variables found to be associated with nonadherent orders were change of CRRT mode that resulted in a new recommended dose (7%), SLEDD for 8-12 hours (15%), and the use of any aminoglycoside (15%).

"Communication is key between all patient care providers on a daily basis," Dr. Wagner concluded. "At Henry Ford Hospital, providers must submit a new order for CRRT every single day for patients requiring antibiotic dosing. There needs to be communication about this between all providers involved in that patient’s care."

She acknowledged certain limitations of the study, including increased use of 24-hour SLEDD during the postguideline period, strict definition for adherence to the guideline, and the inability to systematically evaluate clinical response or residual function.

"Understanding factors associated with nonadherent orders can provide a starting point for clinicians to improve the antimicrobial use process in CRRT," she said.

Dr. Wagner said that she had no relevant conflicts of interest to disclose.

dbrunk@frontlinemedcom.com

A strategy to maintain hydroxychloroquine blood levels above 1,000 ng/mL in adult patients with systemic lupus erythematosus did not reduce the number of SLE flares during a 7-month follow-up period, results from a French study demonstrated.

"This study confirms the pharmacokinetic/pharmacodynamic relation for hydroxychloroquine (HCQ) in patients with SLE," investigators led by Prof. Nathalie Costedoat-Chalumeau reported in the November 2013 issue of Annals of the Rheumatic Diseases.

"Our results do not justify recommending a therapeutic adaptation of HCQ dose. However, we suggest that [HCQ] be measured to detect non-adherence, especially in patients with active disease, and to help patients with poor adherence reach [HCQ levels greater than or equal to] 1,000 ng/mL."

The purpose of the trial, known at the PLUS Study, was to determine the potential benefits of individualizing HCQ dosing schedules to reach a target of 1,000 ng/mL or greater and thereby decrease rates of SLE flare. It was carried out in 573 patients with SLE at 37 centers in France from June 2007 through August 2010.

Of the 573 patients, researchers randomized 171 to one of two treatment groups: 84 to no daily dose change (group A), and 87 to increased HCQ dose to achieve the target of 1,000 g/mL or greater (group B). The primary endpoint was the number of patients with flares during 7 months of follow-up (Ann. Rheum. Dis. 2013;72:1786-92).

At the time of randomization, the mean age of patients was 40 years, 87% were female, and their average HCQ dose was 400 mg/day. At 7 months of follow-up, the proportion of SLE flare rates was similar between the two groups (25% in group A vs. 27.6% in group B; P = .7). In a subset analysis of 57 patients from group A whose HCQ values were below 1,000 ng/mL after randomization and 39 patients from group B who maintained the therapeutic target dose of 1,000 ng/mL or higher after randomization, patients in group B tended to fewer flares compared with their counterparts in group A (20.5% vs. 35.1%, respectively; P = .12).

One reason that HCQ dosing above 1,000 ng/mL did not reduce the rate of SLE flares during the study period "may be that higher doses do not have an added therapeutic effect," the researchers speculated. "However, several factors may provide an alternative explanation of why our study did not provide its primary hypothesis." For one, the maintenance of HCQ above 1,000 ng/mL during the 7 months of follow up "was difficult to achieve." This could be explained by two factors, they continued. "The first is the pharmacokinetic variations of HCQ, but this explanation is unlikely because HCQ has a long terminal half-life and these patients were thought to be in a steady state. The second potential explanation might be adherence problems, even though known or suspected non-adherence was a major criterion for exclusion in our study. We found 10 patients with [HCQ] sufficiently low at inclusion to constitute an objective marker of lack of compliance."

The researchers acknowledged certain limitations of the study, including the potential for being underpowered (171 patients studied though the calculated sample size called for 200), and that the trend toward lower SLE flares in patients with higher HCQ "must be interpreted cautiously, since this analysis was not performed according to randomization group. The result might also be explained by better adherence to other medications, especially steroids."

The study was funded by a grant from the French PHRC 2005 Ministère de la Santé. Sanofi provided the HCQ and placebo tablets.

dbrunk@frontlinemedcom.com

A strategy to maintain hydroxychloroquine blood levels above 1,000 ng/mL in adult patients with systemic lupus erythematosus did not reduce the number of SLE flares during a 7-month follow-up period, results from a French study demonstrated.

"This study confirms the pharmacokinetic/pharmacodynamic relation for hydroxychloroquine (HCQ) in patients with SLE," investigators led by Prof. Nathalie Costedoat-Chalumeau reported in the November 2013 issue of Annals of the Rheumatic Diseases.

"Our results do not justify recommending a therapeutic adaptation of HCQ dose. However, we suggest that [HCQ] be measured to detect non-adherence, especially in patients with active disease, and to help patients with poor adherence reach [HCQ levels greater than or equal to] 1,000 ng/mL."

The purpose of the trial, known at the PLUS Study, was to determine the potential benefits of individualizing HCQ dosing schedules to reach a target of 1,000 ng/mL or greater and thereby decrease rates of SLE flare. It was carried out in 573 patients with SLE at 37 centers in France from June 2007 through August 2010.

Of the 573 patients, researchers randomized 171 to one of two treatment groups: 84 to no daily dose change (group A), and 87 to increased HCQ dose to achieve the target of 1,000 g/mL or greater (group B). The primary endpoint was the number of patients with flares during 7 months of follow-up (Ann. Rheum. Dis. 2013;72:1786-92).

At the time of randomization, the mean age of patients was 40 years, 87% were female, and their average HCQ dose was 400 mg/day. At 7 months of follow-up, the proportion of SLE flare rates was similar between the two groups (25% in group A vs. 27.6% in group B; P = .7). In a subset analysis of 57 patients from group A whose HCQ values were below 1,000 ng/mL after randomization and 39 patients from group B who maintained the therapeutic target dose of 1,000 ng/mL or higher after randomization, patients in group B tended to fewer flares compared with their counterparts in group A (20.5% vs. 35.1%, respectively; P = .12).

One reason that HCQ dosing above 1,000 ng/mL did not reduce the rate of SLE flares during the study period "may be that higher doses do not have an added therapeutic effect," the researchers speculated. "However, several factors may provide an alternative explanation of why our study did not provide its primary hypothesis." For one, the maintenance of HCQ above 1,000 ng/mL during the 7 months of follow up "was difficult to achieve." This could be explained by two factors, they continued. "The first is the pharmacokinetic variations of HCQ, but this explanation is unlikely because HCQ has a long terminal half-life and these patients were thought to be in a steady state. The second potential explanation might be adherence problems, even though known or suspected non-adherence was a major criterion for exclusion in our study. We found 10 patients with [HCQ] sufficiently low at inclusion to constitute an objective marker of lack of compliance."

The researchers acknowledged certain limitations of the study, including the potential for being underpowered (171 patients studied though the calculated sample size called for 200), and that the trend toward lower SLE flares in patients with higher HCQ "must be interpreted cautiously, since this analysis was not performed according to randomization group. The result might also be explained by better adherence to other medications, especially steroids."

The study was funded by a grant from the French PHRC 2005 Ministère de la Santé. Sanofi provided the HCQ and placebo tablets.

dbrunk@frontlinemedcom.com

A strategy to maintain hydroxychloroquine blood levels above 1,000 ng/mL in adult patients with systemic lupus erythematosus did not reduce the number of SLE flares during a 7-month follow-up period, results from a French study demonstrated.

"This study confirms the pharmacokinetic/pharmacodynamic relation for hydroxychloroquine (HCQ) in patients with SLE," investigators led by Prof. Nathalie Costedoat-Chalumeau reported in the November 2013 issue of Annals of the Rheumatic Diseases.

"Our results do not justify recommending a therapeutic adaptation of HCQ dose. However, we suggest that [HCQ] be measured to detect non-adherence, especially in patients with active disease, and to help patients with poor adherence reach [HCQ levels greater than or equal to] 1,000 ng/mL."

The purpose of the trial, known at the PLUS Study, was to determine the potential benefits of individualizing HCQ dosing schedules to reach a target of 1,000 ng/mL or greater and thereby decrease rates of SLE flare. It was carried out in 573 patients with SLE at 37 centers in France from June 2007 through August 2010.

Of the 573 patients, researchers randomized 171 to one of two treatment groups: 84 to no daily dose change (group A), and 87 to increased HCQ dose to achieve the target of 1,000 g/mL or greater (group B). The primary endpoint was the number of patients with flares during 7 months of follow-up (Ann. Rheum. Dis. 2013;72:1786-92).

At the time of randomization, the mean age of patients was 40 years, 87% were female, and their average HCQ dose was 400 mg/day. At 7 months of follow-up, the proportion of SLE flare rates was similar between the two groups (25% in group A vs. 27.6% in group B; P = .7). In a subset analysis of 57 patients from group A whose HCQ values were below 1,000 ng/mL after randomization and 39 patients from group B who maintained the therapeutic target dose of 1,000 ng/mL or higher after randomization, patients in group B tended to fewer flares compared with their counterparts in group A (20.5% vs. 35.1%, respectively; P = .12).

One reason that HCQ dosing above 1,000 ng/mL did not reduce the rate of SLE flares during the study period "may be that higher doses do not have an added therapeutic effect," the researchers speculated. "However, several factors may provide an alternative explanation of why our study did not provide its primary hypothesis." For one, the maintenance of HCQ above 1,000 ng/mL during the 7 months of follow up "was difficult to achieve." This could be explained by two factors, they continued. "The first is the pharmacokinetic variations of HCQ, but this explanation is unlikely because HCQ has a long terminal half-life and these patients were thought to be in a steady state. The second potential explanation might be adherence problems, even though known or suspected non-adherence was a major criterion for exclusion in our study. We found 10 patients with [HCQ] sufficiently low at inclusion to constitute an objective marker of lack of compliance."

The researchers acknowledged certain limitations of the study, including the potential for being underpowered (171 patients studied though the calculated sample size called for 200), and that the trend toward lower SLE flares in patients with higher HCQ "must be interpreted cautiously, since this analysis was not performed according to randomization group. The result might also be explained by better adherence to other medications, especially steroids."

The study was funded by a grant from the French PHRC 2005 Ministère de la Santé. Sanofi provided the HCQ and placebo tablets.

dbrunk@frontlinemedcom.com

SAN DIEGO – Pain management in critically ill patients is vital because most of them experience pain during their ICU stay, both at rest and during activity, Chris Pasero, R.N., said at the University of California, San Diego Critical Care Summer Session.

Research has demonstrated that 13- to 18-year-old patients in the ICU rate wound care as the most painful, but all other patient populations rate simple turning as the most painful procedure in the ICU, said Ms. Pasero, a pain management educator and clinical consultant based in El Dorado Hills, Calif. "It’s no surprise that patients in the ICU remember their pain, and they identify it as a major source of stress and anxiety," she said. "Pain is often undertreated, and I think it’s because we have so many barriers in the ICU."

Barriers to effective pain management in critically ill patients include comorbidities and coadministered drugs that affect the pharmacodynamics and pharmacokinetics of analgesics. Conflicting goals of care also factor into play. "When we are managing pain, many of the drugs we use sedate," said Ms. Pasero, who cofounded the American Society for Pain Management Nursing. "That may conflict with what you’re trying to accomplish, such as the need to control pain in the presence of respiratory compromise. One of the biggest problems is that many of your patients are unable to report their own pain and a failure to properly assess patients for pain. Our failure to properly assess those who are challenging to assess is a major cause of their unrelieved pain and unnecessary suffering."

She described a framework for assessment known as the Hierarchy of Pain Measures. This includes obtaining a self-report of pain, behaviors, physiologic measures, and the presence of a pathologic condition or procedure that causes pain. "Many institutions are inserting this hierarchy into their policies and procedures," she said. "At the top of the hierarchy is a self-report of pain. Always attempt to obtain this. It will give us much of what you need."

Numerical pain rating scales can help patients tell clinicians their level of discomfort. The most common self-report pain intensity tools are the 0-10 numerical scale and two faces scales, the Faces Pain Scale – Revised tool developed by the International Association for the Study of Pain, and the Wong-Baker FACES Pain Rating Scale.

Another self-report tool used in ICUs is the Iowa Pain Thermometer (Pain Med. 2007;8:585-600). This measure was originally developed for cognitively impaired elderly, but it is useful for assessing pain in all patients who have limited ability to express themselves, Ms. Pasero said.

She emphasized the importance of being sensitive to cultural differences when assessing for pain. "Folks who do not speak the language of the person caring for them are at very high risk for undertreated pain," she said. "We need to be careful about using family members to do our translation. Studies show that family members from some cultures may hesitate to discuss pain. Get as close as you can to the patient’s own report of pain."

Certain patient behaviors are good indicators of pain, such as frowns, grimaces, tears, guarding the site of pain, pulling at tubes, seeking attention, resisting passive movement, being combative, being intolerant of ventilators, and being confused. "Physiologic measures such as increased heart rate and blood pressure are considered very poor indicators of pain," noted Ms. Pasero, who is coauthor along with Margo McCaffery, R.N., of "Pain Assessment and Pharmacologic Management." (St. Louis: Mosby/Elsevier, 2011). "There are multiple factors that influence vital signs. You give a lot of drugs to keep vital signs stable, so to expect a patient to fight against that to show you that they have pain with an elevated heart rate or elevated blood pressure is not a good idea. However, abnormalities or changes in vital signs should serve as a trigger to perform a good pain assessment."

She recommends using reliable and valid behavioral pain assessment tool such as the Critical Care Pain Observation Tool or the Behavioral Pain Scale in those who cannot report pain. "In unresponsive patients who cannot demonstrate behaviors and have underlying pathology or conditions thought to be painful, such as surgery, trauma, or mechanical ventilation, we need to assume they have pain and do the best we can to manage it with the administration of recommended doses of analgesics," she said. "Also assume pain is present in patients undergoing painful activities or procedures such as turning, suctioning, or wound care. It’s important to document the underlying pathology or activity assumed to be painful."

Ms. Pasero said that she had no relevant financial conflicts to make.

dbrunk@frontlinemedcom.com

SAN DIEGO – Pain management in critically ill patients is vital because most of them experience pain during their ICU stay, both at rest and during activity, Chris Pasero, R.N., said at the University of California, San Diego Critical Care Summer Session.

Research has demonstrated that 13- to 18-year-old patients in the ICU rate wound care as the most painful, but all other patient populations rate simple turning as the most painful procedure in the ICU, said Ms. Pasero, a pain management educator and clinical consultant based in El Dorado Hills, Calif. "It’s no surprise that patients in the ICU remember their pain, and they identify it as a major source of stress and anxiety," she said. "Pain is often undertreated, and I think it’s because we have so many barriers in the ICU."

Barriers to effective pain management in critically ill patients include comorbidities and coadministered drugs that affect the pharmacodynamics and pharmacokinetics of analgesics. Conflicting goals of care also factor into play. "When we are managing pain, many of the drugs we use sedate," said Ms. Pasero, who cofounded the American Society for Pain Management Nursing. "That may conflict with what you’re trying to accomplish, such as the need to control pain in the presence of respiratory compromise. One of the biggest problems is that many of your patients are unable to report their own pain and a failure to properly assess patients for pain. Our failure to properly assess those who are challenging to assess is a major cause of their unrelieved pain and unnecessary suffering."

She described a framework for assessment known as the Hierarchy of Pain Measures. This includes obtaining a self-report of pain, behaviors, physiologic measures, and the presence of a pathologic condition or procedure that causes pain. "Many institutions are inserting this hierarchy into their policies and procedures," she said. "At the top of the hierarchy is a self-report of pain. Always attempt to obtain this. It will give us much of what you need."

Numerical pain rating scales can help patients tell clinicians their level of discomfort. The most common self-report pain intensity tools are the 0-10 numerical scale and two faces scales, the Faces Pain Scale – Revised tool developed by the International Association for the Study of Pain, and the Wong-Baker FACES Pain Rating Scale.

Another self-report tool used in ICUs is the Iowa Pain Thermometer (Pain Med. 2007;8:585-600). This measure was originally developed for cognitively impaired elderly, but it is useful for assessing pain in all patients who have limited ability to express themselves, Ms. Pasero said.

She emphasized the importance of being sensitive to cultural differences when assessing for pain. "Folks who do not speak the language of the person caring for them are at very high risk for undertreated pain," she said. "We need to be careful about using family members to do our translation. Studies show that family members from some cultures may hesitate to discuss pain. Get as close as you can to the patient’s own report of pain."

Certain patient behaviors are good indicators of pain, such as frowns, grimaces, tears, guarding the site of pain, pulling at tubes, seeking attention, resisting passive movement, being combative, being intolerant of ventilators, and being confused. "Physiologic measures such as increased heart rate and blood pressure are considered very poor indicators of pain," noted Ms. Pasero, who is coauthor along with Margo McCaffery, R.N., of "Pain Assessment and Pharmacologic Management." (St. Louis: Mosby/Elsevier, 2011). "There are multiple factors that influence vital signs. You give a lot of drugs to keep vital signs stable, so to expect a patient to fight against that to show you that they have pain with an elevated heart rate or elevated blood pressure is not a good idea. However, abnormalities or changes in vital signs should serve as a trigger to perform a good pain assessment."

She recommends using reliable and valid behavioral pain assessment tool such as the Critical Care Pain Observation Tool or the Behavioral Pain Scale in those who cannot report pain. "In unresponsive patients who cannot demonstrate behaviors and have underlying pathology or conditions thought to be painful, such as surgery, trauma, or mechanical ventilation, we need to assume they have pain and do the best we can to manage it with the administration of recommended doses of analgesics," she said. "Also assume pain is present in patients undergoing painful activities or procedures such as turning, suctioning, or wound care. It’s important to document the underlying pathology or activity assumed to be painful."

Ms. Pasero said that she had no relevant financial conflicts to make.

dbrunk@frontlinemedcom.com

SAN DIEGO – Pain management in critically ill patients is vital because most of them experience pain during their ICU stay, both at rest and during activity, Chris Pasero, R.N., said at the University of California, San Diego Critical Care Summer Session.

Research has demonstrated that 13- to 18-year-old patients in the ICU rate wound care as the most painful, but all other patient populations rate simple turning as the most painful procedure in the ICU, said Ms. Pasero, a pain management educator and clinical consultant based in El Dorado Hills, Calif. "It’s no surprise that patients in the ICU remember their pain, and they identify it as a major source of stress and anxiety," she said. "Pain is often undertreated, and I think it’s because we have so many barriers in the ICU."

Barriers to effective pain management in critically ill patients include comorbidities and coadministered drugs that affect the pharmacodynamics and pharmacokinetics of analgesics. Conflicting goals of care also factor into play. "When we are managing pain, many of the drugs we use sedate," said Ms. Pasero, who cofounded the American Society for Pain Management Nursing. "That may conflict with what you’re trying to accomplish, such as the need to control pain in the presence of respiratory compromise. One of the biggest problems is that many of your patients are unable to report their own pain and a failure to properly assess patients for pain. Our failure to properly assess those who are challenging to assess is a major cause of their unrelieved pain and unnecessary suffering."

She described a framework for assessment known as the Hierarchy of Pain Measures. This includes obtaining a self-report of pain, behaviors, physiologic measures, and the presence of a pathologic condition or procedure that causes pain. "Many institutions are inserting this hierarchy into their policies and procedures," she said. "At the top of the hierarchy is a self-report of pain. Always attempt to obtain this. It will give us much of what you need."

Numerical pain rating scales can help patients tell clinicians their level of discomfort. The most common self-report pain intensity tools are the 0-10 numerical scale and two faces scales, the Faces Pain Scale – Revised tool developed by the International Association for the Study of Pain, and the Wong-Baker FACES Pain Rating Scale.

Another self-report tool used in ICUs is the Iowa Pain Thermometer (Pain Med. 2007;8:585-600). This measure was originally developed for cognitively impaired elderly, but it is useful for assessing pain in all patients who have limited ability to express themselves, Ms. Pasero said.

She emphasized the importance of being sensitive to cultural differences when assessing for pain. "Folks who do not speak the language of the person caring for them are at very high risk for undertreated pain," she said. "We need to be careful about using family members to do our translation. Studies show that family members from some cultures may hesitate to discuss pain. Get as close as you can to the patient’s own report of pain."

Certain patient behaviors are good indicators of pain, such as frowns, grimaces, tears, guarding the site of pain, pulling at tubes, seeking attention, resisting passive movement, being combative, being intolerant of ventilators, and being confused. "Physiologic measures such as increased heart rate and blood pressure are considered very poor indicators of pain," noted Ms. Pasero, who is coauthor along with Margo McCaffery, R.N., of "Pain Assessment and Pharmacologic Management." (St. Louis: Mosby/Elsevier, 2011). "There are multiple factors that influence vital signs. You give a lot of drugs to keep vital signs stable, so to expect a patient to fight against that to show you that they have pain with an elevated heart rate or elevated blood pressure is not a good idea. However, abnormalities or changes in vital signs should serve as a trigger to perform a good pain assessment."

She recommends using reliable and valid behavioral pain assessment tool such as the Critical Care Pain Observation Tool or the Behavioral Pain Scale in those who cannot report pain. "In unresponsive patients who cannot demonstrate behaviors and have underlying pathology or conditions thought to be painful, such as surgery, trauma, or mechanical ventilation, we need to assume they have pain and do the best we can to manage it with the administration of recommended doses of analgesics," she said. "Also assume pain is present in patients undergoing painful activities or procedures such as turning, suctioning, or wound care. It’s important to document the underlying pathology or activity assumed to be painful."

Ms. Pasero said that she had no relevant financial conflicts to make.

dbrunk@frontlinemedcom.com

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – If you’re skeptical about the impact that you as a primary care provider can make on patients who seek assistance from you with weight loss, think again, advised Dr. Lindsay Botsford.

"You can really make a big difference in your office," Dr. Botsford, a family physician who practices in Sugar Land, Tex., said at the annual meeting of the American Academy of Family Physicians.

During her presentation, she spotlighted the success of Practice-Based Opportunities for Weight Reduction (POWER-UP), a 2-year randomized controlled trial of obesity treatment in the primary care setting. For the trial, 390 patients at six primary care practices were randomized to one of three interventions: usual care, which consisted of quarterly visits that included education about weight management; brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control; and enhanced brief lifestyle counseling, which consisted of quarterly primary care visits combined with short monthly sessions with lifestyle coaches who instructed patients about behavioral control, plus meal replacements or orlistat or sibutramine to potentially increase weight loss (N. Engl. J. Med. 2011;365[2]:1969-79).

At the end of the second year, patients in the enhanced lifestyle counseling group lost an average of 4.6 kg, which exceeded the average weight loss experienced by patients in the brief lifestyle counseling and usual care groups (an average of 2.9 kg and 1.7 kg, respectively). The proportion of patients who achieved a weight loss of more than 5% at the end of the second year was also greatest in the enhanced lifestyle group (34.9% vs. 26% and 21.5% in the other two groups, respectively).

Some patients harbor sensitivity about their weight, so if they want to talk about the issue, Dr. Botsford recommended avoiding the term "obesity" and instead using terms such as "weight," "excess weight," "unhealthy body weight," and "BMI." She also recommended involving other members of the staff. For example, front desk staff can ask patients to fill out a fitness inventory and medical assistants can check BMI, measure waist circumference, and provide basic counseling advice about weight loss strategies such as keeping a food journal and portion control.

Regarding how patients perceive overweight physicians, Dr. Botsford noted, "In general, patients find overweight physicians less credible. I find that a little sad, but your view on the subject can influence patients. If you are not at your healthy weight, try to overcome this by sharing personal stories with them."

In counseling patients who express interest in losing weight, she said she begins with a 24-hour dietary recall and then reviews the U.S. Preventive Services Task Force’s "5 A’s" framework to create goals. The five A’s include assess (ask about or assess behavioral health risk[s] and factors affecting choice of behavior change goals); advise (give clear, specific, and personalized behavior change advice, including information about harms and benefits); agree (collaboratively select treatment goals and methods based on interest and willingness to change); assist (using behavior change techniques, help patient to acquire the skills, confidence, and social or environmental supports for behavior change, supplemented with medical treatments when needed); and arrange (schedule follow-up to provide ongoing assistance or support and to adjust the treatment plan as needed).

Other evidence-based counseling tips include recommending that patients avoid artificial sweetener, eating out of a bag, eating in front of the television, eating bread when dining out, and being mindful of liquid calorie intake. She also said she advises patients to stay hydrated, leave one-third of the portion on the plate when dining out, order "small" sizes when possible, and use small plates and bowls at home.

"Study after study has shown that low-calorie diets – 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men are the most successful for maintaining weight loss in the long term," Dr. Botsford said. "Adherence is a big thing when it comes to diets. The most common thing is that people stop. They can’t stick with it. Low glycemic load may help adherence. That’s still within the context of a low-calorie diet. There is certain evidence that having more fiber and more protein will make you feel fuller along the way, but in the end, a low-calorie diet is best."

Tools that can help patients keep a handle on food intake include the AAFP\'s initiative Americans in Motion Healthy Interventions and smartphone apps such as Lose It!, Calorie Counter and Diet Tracker by MyFitnessPal.com, healthfinder.gov, and Weight Watchers Mobile. "Exercise alone is better than nothing, but it only translates into a small weight loss," Dr. Botsford said. "However, exercise reduces blood pressure, triglycerides, and fasting glucose, and it decreases abdominal adipose tissue. To make the real difference you need exercise and diet. You also improve your strength, balance, and peak oxygen consumption. The more intense your exercise, [the more] you will increase your weight loss."

Medicare will reimburse for obesity counseling, but the patient’s BMI has to be greater than 30 kg/m²; the patient has to be competent and alert, and the counseling has to be done in a primary care setting or by the primary care provider. "Medicare will cover up to 22 visits in 12 months in a staged way," Dr. Botsford said, noting that the ICD-9 code for a BMI of 30 or more is G0447. "For the first month they’ll cover once a week. The only caveat is that you cannot bill for any other services on the same day as the visit for obesity counseling."

Dr. Botsford said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

DENVER – A four-variable risk score predicted acute kidney injury with high specificity in patients receiving vancomycin, results from a single-center study demonstrated.

During a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Joseph J. Carreno, Pharm.D., discussed findings from a study that set out to identify patients at high risk for AKI during vancomycin therapy.

Doug Brunk/IMNG Medical Media

"Vancomycin has been the standard therapy for infections with methicillin-resistant Staphylococcus aureus for many years," Dr. Carreno of Albany College of Pharmacy and Health Sciences and his associates wrote in their abstract. "Treatment with vancomycin can be limited by the onset of renal dysfunction, which has been associated with additional morbidity. Recently, numerous investigations have evaluated and identified multiple risk factors for acute kidney injury in patients receiving vancomycin. However, few have validated the predictive probability of only those risk factors readily available at bedside at the initiation of therapy."

In a study conducted during his infectious disease pharmacy fellowship at Henry Ford Hospital, Detroit, the researchers retrospectively evaluated the medical records of 112 adult patients who were prescribed intravenous vancomycin for any suspected or confirmed infection between January 2011 and January 2012. They excluded patients who were pregnant, had end-stage renal disease at baseline, or had an absolute neutrophil count of less than 1,000/mm³.

Four risk factors were evaluated: receiving at least 4 g of vancomycin daily or having a body weight of at least 110 kg; a history of renal dysfunction; concurrent use of intravenous vasopressors, and use of concurrent nephrotoxins.

The mean age of the 112 patients was 58 years, and more than half (54%) were male. The majority (84) had fewer than two risk factors while the remaining 28 had at least two risk factors. The most common indications for therapy were infections of the lower respiratory tract and/or skin and soft tissue (49% and 27%, respectively).

Dr. Carreno and his associates reported that the prevalence of AKI was 46%. In logistic regression analysis adjusted for the other three risk factors, the odds for the development of AKI was greatest among patients on vasopressors (odds ratio, 5.92), followed by those with a history of AKI or preexisting chronic kidney disease (OR, 2.99), those on high dose vancomycin or with a body weight of at least 110 kg (OR, 1.68), and those on nephrotoxins (OR, 1.07).

More than two-thirds of patients (68%) with at least two risk factors at baseline developed AKI, compared with 38% of those who had fewer than two risk factors at baseline. The difference was significant with a P value of less than 0.01.

The sensitivity and specificity of the four-variable prediction model were 78% and 33%, respectively, among patients with at least one risk factor, and 37% and 85% among patients with at least two risk factors.

"This is a bedside tool you can use that condenses 20 years’ worth of research into a small, four-variable score that’s clinically applicable," Dr. Carreno said in an interview at the meeting. "It takes less than 5 minutes to apply this to a patient."

He acknowledged that the study’s retrospective design was a limitation.

Dr. Carreno said he had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

DENVER – A four-variable risk score predicted acute kidney injury with high specificity in patients receiving vancomycin, results from a single-center study demonstrated.

During a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Joseph J. Carreno, Pharm.D., discussed findings from a study that set out to identify patients at high risk for AKI during vancomycin therapy.

Doug Brunk/IMNG Medical Media

"Vancomycin has been the standard therapy for infections with methicillin-resistant Staphylococcus aureus for many years," Dr. Carreno of Albany College of Pharmacy and Health Sciences and his associates wrote in their abstract. "Treatment with vancomycin can be limited by the onset of renal dysfunction, which has been associated with additional morbidity. Recently, numerous investigations have evaluated and identified multiple risk factors for acute kidney injury in patients receiving vancomycin. However, few have validated the predictive probability of only those risk factors readily available at bedside at the initiation of therapy."

In a study conducted during his infectious disease pharmacy fellowship at Henry Ford Hospital, Detroit, the researchers retrospectively evaluated the medical records of 112 adult patients who were prescribed intravenous vancomycin for any suspected or confirmed infection between January 2011 and January 2012. They excluded patients who were pregnant, had end-stage renal disease at baseline, or had an absolute neutrophil count of less than 1,000/mm³.

Four risk factors were evaluated: receiving at least 4 g of vancomycin daily or having a body weight of at least 110 kg; a history of renal dysfunction; concurrent use of intravenous vasopressors, and use of concurrent nephrotoxins.

The mean age of the 112 patients was 58 years, and more than half (54%) were male. The majority (84) had fewer than two risk factors while the remaining 28 had at least two risk factors. The most common indications for therapy were infections of the lower respiratory tract and/or skin and soft tissue (49% and 27%, respectively).

Dr. Carreno and his associates reported that the prevalence of AKI was 46%. In logistic regression analysis adjusted for the other three risk factors, the odds for the development of AKI was greatest among patients on vasopressors (odds ratio, 5.92), followed by those with a history of AKI or preexisting chronic kidney disease (OR, 2.99), those on high dose vancomycin or with a body weight of at least 110 kg (OR, 1.68), and those on nephrotoxins (OR, 1.07).

More than two-thirds of patients (68%) with at least two risk factors at baseline developed AKI, compared with 38% of those who had fewer than two risk factors at baseline. The difference was significant with a P value of less than 0.01.

The sensitivity and specificity of the four-variable prediction model were 78% and 33%, respectively, among patients with at least one risk factor, and 37% and 85% among patients with at least two risk factors.

"This is a bedside tool you can use that condenses 20 years’ worth of research into a small, four-variable score that’s clinically applicable," Dr. Carreno said in an interview at the meeting. "It takes less than 5 minutes to apply this to a patient."

He acknowledged that the study’s retrospective design was a limitation.

Dr. Carreno said he had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

DENVER – A four-variable risk score predicted acute kidney injury with high specificity in patients receiving vancomycin, results from a single-center study demonstrated.

During a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Joseph J. Carreno, Pharm.D., discussed findings from a study that set out to identify patients at high risk for AKI during vancomycin therapy.

Doug Brunk/IMNG Medical Media

"Vancomycin has been the standard therapy for infections with methicillin-resistant Staphylococcus aureus for many years," Dr. Carreno of Albany College of Pharmacy and Health Sciences and his associates wrote in their abstract. "Treatment with vancomycin can be limited by the onset of renal dysfunction, which has been associated with additional morbidity. Recently, numerous investigations have evaluated and identified multiple risk factors for acute kidney injury in patients receiving vancomycin. However, few have validated the predictive probability of only those risk factors readily available at bedside at the initiation of therapy."

In a study conducted during his infectious disease pharmacy fellowship at Henry Ford Hospital, Detroit, the researchers retrospectively evaluated the medical records of 112 adult patients who were prescribed intravenous vancomycin for any suspected or confirmed infection between January 2011 and January 2012. They excluded patients who were pregnant, had end-stage renal disease at baseline, or had an absolute neutrophil count of less than 1,000/mm³.

Four risk factors were evaluated: receiving at least 4 g of vancomycin daily or having a body weight of at least 110 kg; a history of renal dysfunction; concurrent use of intravenous vasopressors, and use of concurrent nephrotoxins.

The mean age of the 112 patients was 58 years, and more than half (54%) were male. The majority (84) had fewer than two risk factors while the remaining 28 had at least two risk factors. The most common indications for therapy were infections of the lower respiratory tract and/or skin and soft tissue (49% and 27%, respectively).

Dr. Carreno and his associates reported that the prevalence of AKI was 46%. In logistic regression analysis adjusted for the other three risk factors, the odds for the development of AKI was greatest among patients on vasopressors (odds ratio, 5.92), followed by those with a history of AKI or preexisting chronic kidney disease (OR, 2.99), those on high dose vancomycin or with a body weight of at least 110 kg (OR, 1.68), and those on nephrotoxins (OR, 1.07).

More than two-thirds of patients (68%) with at least two risk factors at baseline developed AKI, compared with 38% of those who had fewer than two risk factors at baseline. The difference was significant with a P value of less than 0.01.

The sensitivity and specificity of the four-variable prediction model were 78% and 33%, respectively, among patients with at least one risk factor, and 37% and 85% among patients with at least two risk factors.

"This is a bedside tool you can use that condenses 20 years’ worth of research into a small, four-variable score that’s clinically applicable," Dr. Carreno said in an interview at the meeting. "It takes less than 5 minutes to apply this to a patient."

He acknowledged that the study’s retrospective design was a limitation.

Dr. Carreno said he had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – If a patient presents to your office with hives triggered by contact with water, think aquagenic urticaria.

"Aquagenic urticaria is a very rare disorder, with only about 100 cases reported in the medical literature," Patrick Coleman, a second-year medical student at the Uniformed Services University of the Health Sciences, Bethesda, Md., said in an interview. "Water is the inciting trigger. It’s followed by a wheal and flare response within 10-13 minutes. Sometimes it’s associated with pruritus. If it’s left untreated, it can resolve within an hour."

Courtesy Dr. Robert P. Lennon

At the annual meeting of the American Academy of Family Physicians, Mr. Coleman and his colleagues discussed the case of a 24-year-old woman who presented to Dr. Robert P. Lennon at the department of family medicine at the U.S. Naval Hospital in Okinawa, Japan, with skin discoloration on her upper arms and legs, hives, and severe global pruritus after showering. Water challenge testing was positive, and the patient was successfully treated with a daily H₁ antihistamine.

The hallmark feature of aquagenic urticaria is that the reaction is independent of water temperature. "So whether the water is cold or hot, the reaction will still occur," Mr. Coleman said. The pathogenesis of the condition is unclear, but may involve histamine release from the degranulation of mast cells. "Our patient was treated with an H₁ antihistamine and she benefitted," said Mr. Coleman. "For other patients, the care may not be the same. You may need to try different antihistamines to see if they will control it."

In their poster, the researchers noted that urticarias affect 20% of people in the United States. Of these, 25% have urticarias that last more than 6 weeks. Only 10%-20% of urticarias have an identifiable trigger.

The researchers stated that they had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – If a patient presents to your office with hives triggered by contact with water, think aquagenic urticaria.

"Aquagenic urticaria is a very rare disorder, with only about 100 cases reported in the medical literature," Patrick Coleman, a second-year medical student at the Uniformed Services University of the Health Sciences, Bethesda, Md., said in an interview. "Water is the inciting trigger. It’s followed by a wheal and flare response within 10-13 minutes. Sometimes it’s associated with pruritus. If it’s left untreated, it can resolve within an hour."

Courtesy Dr. Robert P. Lennon

At the annual meeting of the American Academy of Family Physicians, Mr. Coleman and his colleagues discussed the case of a 24-year-old woman who presented to Dr. Robert P. Lennon at the department of family medicine at the U.S. Naval Hospital in Okinawa, Japan, with skin discoloration on her upper arms and legs, hives, and severe global pruritus after showering. Water challenge testing was positive, and the patient was successfully treated with a daily H₁ antihistamine.

The hallmark feature of aquagenic urticaria is that the reaction is independent of water temperature. "So whether the water is cold or hot, the reaction will still occur," Mr. Coleman said. The pathogenesis of the condition is unclear, but may involve histamine release from the degranulation of mast cells. "Our patient was treated with an H₁ antihistamine and she benefitted," said Mr. Coleman. "For other patients, the care may not be the same. You may need to try different antihistamines to see if they will control it."

In their poster, the researchers noted that urticarias affect 20% of people in the United States. Of these, 25% have urticarias that last more than 6 weeks. Only 10%-20% of urticarias have an identifiable trigger.

The researchers stated that they had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – If a patient presents to your office with hives triggered by contact with water, think aquagenic urticaria.

"Aquagenic urticaria is a very rare disorder, with only about 100 cases reported in the medical literature," Patrick Coleman, a second-year medical student at the Uniformed Services University of the Health Sciences, Bethesda, Md., said in an interview. "Water is the inciting trigger. It’s followed by a wheal and flare response within 10-13 minutes. Sometimes it’s associated with pruritus. If it’s left untreated, it can resolve within an hour."

Courtesy Dr. Robert P. Lennon

At the annual meeting of the American Academy of Family Physicians, Mr. Coleman and his colleagues discussed the case of a 24-year-old woman who presented to Dr. Robert P. Lennon at the department of family medicine at the U.S. Naval Hospital in Okinawa, Japan, with skin discoloration on her upper arms and legs, hives, and severe global pruritus after showering. Water challenge testing was positive, and the patient was successfully treated with a daily H₁ antihistamine.

The hallmark feature of aquagenic urticaria is that the reaction is independent of water temperature. "So whether the water is cold or hot, the reaction will still occur," Mr. Coleman said. The pathogenesis of the condition is unclear, but may involve histamine release from the degranulation of mast cells. "Our patient was treated with an H₁ antihistamine and she benefitted," said Mr. Coleman. "For other patients, the care may not be the same. You may need to try different antihistamines to see if they will control it."

In their poster, the researchers noted that urticarias affect 20% of people in the United States. Of these, 25% have urticarias that last more than 6 weeks. Only 10%-20% of urticarias have an identifiable trigger.

The researchers stated that they had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

DENVER – In obese patients with vancomycin-resistant enterococcal bacteremia, using a dose of daptomycin based on adjusted body weight rather than actual body weight resulted in similar efficacy and outcomes. It also resulted in more than $1,800 in medication cost savings per patient, judging from findings of a small pilot study.

"I feel very comfortable using adjusted-dose daptomycin for patients with VRE bacteremia, especially in those with uncomplicated bacteremia," lead investigator Jerod Nagel, Pharm.D., said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"I think we need some more data evaluating the right dose for complex patients regardless if they’re obese or not – whether it’s 6, 8, 10 or 12 g/kg."

He and his associates retrospectively evaluated the outcomes of 47 obese adult inpatients with VRE bacteremia being treated with daptomycin at the University of Michigan Hospitals and Health System. Of the 47 patients, 31 received 6 mg/kg daptomycin based on actual body weight (actual body weight group) and 16 received 6 mg/kg daptomycin based on adjusted body weight (defined as 0.35-0.5 [actual body weight minus ideal body weight] plus ideal body weight) from September 2010 to May 2012.

Outcomes of interest included 30-day all-cause mortality, length of stay, microbiologic clearance, recurrent bacteremia, and antibiotic cost based on an average wholesale price of $382.44 per 500 mg. Toxicity also was evaluated.

The rate of clinical cure was similar between the two groups (37.5% in the adjusted body weight group vs. 38.7% in the actual body weight group), as was the rate of recurrent bacteria (13% vs. 3%, respectively), mortality (19% vs. 25%), length of hospitalization (a mean of 26.6 days vs. 41.8 days), time to microbiologic cure (a mean of 2.6 days vs. 2.24 days), and increase in creatine kinase (38% vs. 45%), reported Dr. Nagel of the health system’s department of pharmacy, Ann Arbor.

The researchers also found that, in the adjusted weight group, daptomycin resulted in $1,822 in costs savings per patient, or approximately $44,000 in annual savings.

"I think this study is a good starting point, but more studies are needed for these complex patients and obese patients," Dr. Nagel said. "We have a small sample size, but we showed similar outcomes and a pretty good cost savings. We need a lot more data on how to dose drugs in obese patients, especially in mg/kg, because obese patients will require higher levels and be at risk of toxicity."

Dr. Nagel said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

DENVER – In obese patients with vancomycin-resistant enterococcal bacteremia, using a dose of daptomycin based on adjusted body weight rather than actual body weight resulted in similar efficacy and outcomes. It also resulted in more than $1,800 in medication cost savings per patient, judging from findings of a small pilot study.

"I feel very comfortable using adjusted-dose daptomycin for patients with VRE bacteremia, especially in those with uncomplicated bacteremia," lead investigator Jerod Nagel, Pharm.D., said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"I think we need some more data evaluating the right dose for complex patients regardless if they’re obese or not – whether it’s 6, 8, 10 or 12 g/kg."

He and his associates retrospectively evaluated the outcomes of 47 obese adult inpatients with VRE bacteremia being treated with daptomycin at the University of Michigan Hospitals and Health System. Of the 47 patients, 31 received 6 mg/kg daptomycin based on actual body weight (actual body weight group) and 16 received 6 mg/kg daptomycin based on adjusted body weight (defined as 0.35-0.5 [actual body weight minus ideal body weight] plus ideal body weight) from September 2010 to May 2012.

Outcomes of interest included 30-day all-cause mortality, length of stay, microbiologic clearance, recurrent bacteremia, and antibiotic cost based on an average wholesale price of $382.44 per 500 mg. Toxicity also was evaluated.

The rate of clinical cure was similar between the two groups (37.5% in the adjusted body weight group vs. 38.7% in the actual body weight group), as was the rate of recurrent bacteria (13% vs. 3%, respectively), mortality (19% vs. 25%), length of hospitalization (a mean of 26.6 days vs. 41.8 days), time to microbiologic cure (a mean of 2.6 days vs. 2.24 days), and increase in creatine kinase (38% vs. 45%), reported Dr. Nagel of the health system’s department of pharmacy, Ann Arbor.

The researchers also found that, in the adjusted weight group, daptomycin resulted in $1,822 in costs savings per patient, or approximately $44,000 in annual savings.

"I think this study is a good starting point, but more studies are needed for these complex patients and obese patients," Dr. Nagel said. "We have a small sample size, but we showed similar outcomes and a pretty good cost savings. We need a lot more data on how to dose drugs in obese patients, especially in mg/kg, because obese patients will require higher levels and be at risk of toxicity."

Dr. Nagel said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

DENVER – In obese patients with vancomycin-resistant enterococcal bacteremia, using a dose of daptomycin based on adjusted body weight rather than actual body weight resulted in similar efficacy and outcomes. It also resulted in more than $1,800 in medication cost savings per patient, judging from findings of a small pilot study.

"I feel very comfortable using adjusted-dose daptomycin for patients with VRE bacteremia, especially in those with uncomplicated bacteremia," lead investigator Jerod Nagel, Pharm.D., said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"I think we need some more data evaluating the right dose for complex patients regardless if they’re obese or not – whether it’s 6, 8, 10 or 12 g/kg."

He and his associates retrospectively evaluated the outcomes of 47 obese adult inpatients with VRE bacteremia being treated with daptomycin at the University of Michigan Hospitals and Health System. Of the 47 patients, 31 received 6 mg/kg daptomycin based on actual body weight (actual body weight group) and 16 received 6 mg/kg daptomycin based on adjusted body weight (defined as 0.35-0.5 [actual body weight minus ideal body weight] plus ideal body weight) from September 2010 to May 2012.

Outcomes of interest included 30-day all-cause mortality, length of stay, microbiologic clearance, recurrent bacteremia, and antibiotic cost based on an average wholesale price of $382.44 per 500 mg. Toxicity also was evaluated.

The rate of clinical cure was similar between the two groups (37.5% in the adjusted body weight group vs. 38.7% in the actual body weight group), as was the rate of recurrent bacteria (13% vs. 3%, respectively), mortality (19% vs. 25%), length of hospitalization (a mean of 26.6 days vs. 41.8 days), time to microbiologic cure (a mean of 2.6 days vs. 2.24 days), and increase in creatine kinase (38% vs. 45%), reported Dr. Nagel of the health system’s department of pharmacy, Ann Arbor.

The researchers also found that, in the adjusted weight group, daptomycin resulted in $1,822 in costs savings per patient, or approximately $44,000 in annual savings.

"I think this study is a good starting point, but more studies are needed for these complex patients and obese patients," Dr. Nagel said. "We have a small sample size, but we showed similar outcomes and a pretty good cost savings. We need a lot more data on how to dose drugs in obese patients, especially in mg/kg, because obese patients will require higher levels and be at risk of toxicity."

Dr. Nagel said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

DENVER – In obese patients with vancomycin-resistant enterococcal bacteremia, using a dose of daptomycin based on adjusted body weight rather than actual body weight resulted in similar efficacy and outcomes. It also resulted in more than $1,800 in medication cost savings per patient, judging from findings of a small pilot study.

"I feel very comfortable using adjusted-dose daptomycin for patients with VRE bacteremia, especially in those with uncomplicated bacteremia," lead investigator Jerod Nagel, Pharm.D., said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"I think we need some more data evaluating the right dose for complex patients regardless if they’re obese or not – whether it’s 6, 8, 10 or 12 g/kg."

He and his associates retrospectively evaluated the outcomes of 47 obese adult inpatients with VRE bacteremia being treated with daptomycin at the University of Michigan Hospitals and Health System. Of the 47 patients, 31 received 6 mg/kg daptomycin based on actual body weight (actual body weight group) and 16 received 6 mg/kg daptomycin based on adjusted body weight (defined as 0.35-0.5 [actual body weight minus ideal body weight] plus ideal body weight) from September 2010 to May 2012.

Outcomes of interest included 30-day all-cause mortality, length of stay, microbiologic clearance, recurrent bacteremia, and antibiotic cost based on an average wholesale price of $382.44 per 500 mg. Toxicity also was evaluated.

The rate of clinical cure was similar between the two groups (37.5% in the adjusted body weight group vs. 38.7% in the actual body weight group), as was the rate of recurrent bacteria (13% vs. 3%, respectively), mortality (19% vs. 25%), length of hospitalization (a mean of 26.6 days vs. 41.8 days), time to microbiologic cure (a mean of 2.6 days vs. 2.24 days), and increase in creatine kinase (38% vs. 45%), reported Dr. Nagel of the health system’s department of pharmacy, Ann Arbor.

The researchers also found that, in the adjusted weight group, daptomycin resulted in $1,822 in costs savings per patient, or approximately $44,000 in annual savings.

"I think this study is a good starting point, but more studies are needed for these complex patients and obese patients," Dr. Nagel said. "We have a small sample size, but we showed similar outcomes and a pretty good cost savings. We need a lot more data on how to dose drugs in obese patients, especially in mg/kg, because obese patients will require higher levels and be at risk of toxicity."

Dr. Nagel said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

DENVER – In obese patients with vancomycin-resistant enterococcal bacteremia, using a dose of daptomycin based on adjusted body weight rather than actual body weight resulted in similar efficacy and outcomes. It also resulted in more than $1,800 in medication cost savings per patient, judging from findings of a small pilot study.

"I feel very comfortable using adjusted-dose daptomycin for patients with VRE bacteremia, especially in those with uncomplicated bacteremia," lead investigator Jerod Nagel, Pharm.D., said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"I think we need some more data evaluating the right dose for complex patients regardless if they’re obese or not – whether it’s 6, 8, 10 or 12 g/kg."

He and his associates retrospectively evaluated the outcomes of 47 obese adult inpatients with VRE bacteremia being treated with daptomycin at the University of Michigan Hospitals and Health System. Of the 47 patients, 31 received 6 mg/kg daptomycin based on actual body weight (actual body weight group) and 16 received 6 mg/kg daptomycin based on adjusted body weight (defined as 0.35-0.5 [actual body weight minus ideal body weight] plus ideal body weight) from September 2010 to May 2012.

Outcomes of interest included 30-day all-cause mortality, length of stay, microbiologic clearance, recurrent bacteremia, and antibiotic cost based on an average wholesale price of $382.44 per 500 mg. Toxicity also was evaluated.

The rate of clinical cure was similar between the two groups (37.5% in the adjusted body weight group vs. 38.7% in the actual body weight group), as was the rate of recurrent bacteria (13% vs. 3%, respectively), mortality (19% vs. 25%), length of hospitalization (a mean of 26.6 days vs. 41.8 days), time to microbiologic cure (a mean of 2.6 days vs. 2.24 days), and increase in creatine kinase (38% vs. 45%), reported Dr. Nagel of the health system’s department of pharmacy, Ann Arbor.

The researchers also found that, in the adjusted weight group, daptomycin resulted in $1,822 in costs savings per patient, or approximately $44,000 in annual savings.

"I think this study is a good starting point, but more studies are needed for these complex patients and obese patients," Dr. Nagel said. "We have a small sample size, but we showed similar outcomes and a pretty good cost savings. We need a lot more data on how to dose drugs in obese patients, especially in mg/kg, because obese patients will require higher levels and be at risk of toxicity."

Dr. Nagel said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

DENVER – In obese patients with vancomycin-resistant enterococcal bacteremia, using a dose of daptomycin based on adjusted body weight rather than actual body weight resulted in similar efficacy and outcomes. It also resulted in more than $1,800 in medication cost savings per patient, judging from findings of a small pilot study.

"I feel very comfortable using adjusted-dose daptomycin for patients with VRE bacteremia, especially in those with uncomplicated bacteremia," lead investigator Jerod Nagel, Pharm.D., said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"I think we need some more data evaluating the right dose for complex patients regardless if they’re obese or not – whether it’s 6, 8, 10 or 12 g/kg."

He and his associates retrospectively evaluated the outcomes of 47 obese adult inpatients with VRE bacteremia being treated with daptomycin at the University of Michigan Hospitals and Health System. Of the 47 patients, 31 received 6 mg/kg daptomycin based on actual body weight (actual body weight group) and 16 received 6 mg/kg daptomycin based on adjusted body weight (defined as 0.35-0.5 [actual body weight minus ideal body weight] plus ideal body weight) from September 2010 to May 2012.

Outcomes of interest included 30-day all-cause mortality, length of stay, microbiologic clearance, recurrent bacteremia, and antibiotic cost based on an average wholesale price of $382.44 per 500 mg. Toxicity also was evaluated.

The rate of clinical cure was similar between the two groups (37.5% in the adjusted body weight group vs. 38.7% in the actual body weight group), as was the rate of recurrent bacteria (13% vs. 3%, respectively), mortality (19% vs. 25%), length of hospitalization (a mean of 26.6 days vs. 41.8 days), time to microbiologic cure (a mean of 2.6 days vs. 2.24 days), and increase in creatine kinase (38% vs. 45%), reported Dr. Nagel of the health system’s department of pharmacy, Ann Arbor.

The researchers also found that, in the adjusted weight group, daptomycin resulted in $1,822 in costs savings per patient, or approximately $44,000 in annual savings.

"I think this study is a good starting point, but more studies are needed for these complex patients and obese patients," Dr. Nagel said. "We have a small sample size, but we showed similar outcomes and a pretty good cost savings. We need a lot more data on how to dose drugs in obese patients, especially in mg/kg, because obese patients will require higher levels and be at risk of toxicity."

Dr. Nagel said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com