PURPOSE:Iron deficiency (ID) is common in older adults and is associated with adverse clinical outcomes. Oral iron is often limited by poor absorption and gastrointestinal intolerance. The current article reviews considerations for intravenous (IV) iron therapy in older adults with ID. METHOD:To review IV iron efficacy, safety, and practical use in older adults. RESULTS:IV iron effectively restores iron stores; improves hemoglobin, functional status, and quality of life; and reduces transfusion requirements. Comorbidities, such as chronic kidney disease, heart failure, and gastrointestinal disorders, frequently necessitate IV iron therapy. Risks include allergic reactions, infusion reactions, hypophosphatemia, and transient hypotension, although serious adverse events are rare. Therapy should be individualized based on comorbidities and practical considerations. CONCLUSION:IV iron is a safe and effective option for older adults, offering reliable and rapid repletion when oral iron is ineffective or contraindicated. Clinicians must weigh benefits and risks to optimize outcomes.

Patients with chronic kidney disease (CKD) have complex medication needs to treat chronic conditions, CKD complications, and acute illnesses. However, because CKD significantly alters the pharmacokinetic properties of medications and their pharmacodynamic effects, concerns about compromised efficacy and safety occur. Common complications of CKD include hypertension, hyperkalemia, anemia, mineral and bone disease (MBD), and metabolic acidosis. Screening and management of CKD and related comorbidities allows for early interventions to slow kidney function decline and improve health outcomes.

This study confirms the safety of endovascular interventions for thrombosis of hemodialysis access in outpatient and office-based settings.Risk of death in the week after vascular access procedure was not associated with hemodialysis access type (fistula versus graft).

Patients with kidney disease represent a medically complex group of patients with high medication burdens that could benefit from clinical pharmacy services as part of the interdisciplinary care team to optimize medication use. The "Advancing American Kidney Health" executive order includes new value-based reimbursement models to be tested by the Center for Medicare and Medicaid Innovation beginning January 2021 and January 2022. Advancing American Kidney Health executive order poses opportunities for the inclusion of comprehensive medication management. Following an iterative process integrating input from a diverse expert panel, published standards, clinical practice guidelines, peer review, and stakeholder feedback, our group developed practice standards for pharmacists caring for patients with kidney disease in health care settings. The standards focus on activities that are part of direct patient care and also include activities related to public health and advocacy, population health, leadership and management, and teaching, education and dissemination of knowledge. These standards are intended to be used by a variety of professionals, from pharmacists starting new practices to practice managers looking to add a pharmacist to the clinical team, to create standardization in services provided.

People with end-stage kidney disease (ESKD) who require chronic dialysis are often reliant on complicated medication regimens to manage their health conditions. Due to the complexities of the advanced kidney disease, underlying comorbidities, and special instructions, medication regimens for patients on dialysis put patients at high risk for medication therapy problems related to safety, effectiveness, appropriateness, and adherence. This article explores the factors that affect optimal medication use for people on dialysis, including the broader drug use system, and offers recommendations around medication reconciliation, medication review, deprescribing, and considering social determinants of health to improve medication management among patients with ESKD.

ObjectivesPatients on hemodialysis have complicated medication regimens requiring the ability to accurately interpret medication information. Literacy and numeracy skills have been shown to differ by the types of materials provided to patients. The aims of this study were to determine prescription and over-the-counter medication label understanding and to assess the prevalence of low health literacy regarding medication labeling among in-center hemodialysis patients.Design, setting and participantsThe Medication Literacy and Numeracy in Dialysis (MedLitD) tool is an assessment of a person's ability to read and understand medication labels. A comparison with the Rapid Estimate of Adult Literacy in Medicine Short Form (REALM-SF), an established literacy tool, was conducted to determine if there were differences in the literacy results from the 2 tools that could be leveraged to target education initiatives for this specialized population.ResultsA total of 110 patients receiving hemodialysis from 3 dialysis facilities in the Capital Region of upstate New York were enrolled in the study. Most patients (77%) achieved a maximum REALM-SF score, indicating a high level of literacy proficiency; however, their MedLitD scores varied. Patients who were 65 years and older had lower scores on the MedLitD tool compared with younger patients. Gender, education, and the number of medications did not influence the MedLitD scores. Only 16% of all participants correctly answered the question asking for an indication of the phosphate binder (PB), although the most patients were currently taking PBs.ConclusionA continuum of medication literacy levels exists among patients on hemodialysis. Appropriate evaluation of medication literacy should be done to better inform individualized education and counseling.

Preparing for implementation of a medication reconciliation measure for dialysis: Expanding the role of pharmacy technicians Christopher Codd, BS, Christopher Codd, BS University of Michigan College of Pharmacy, Ann Arbor, MI Search for other works by this author on: Oxford Academic Google Scholar Daniel Martinusen, PharmD, ACPR, FCSHP, Daniel Martinusen, PharmD, ACPR, FCSHP British Columbia Renal Network, Vancouver, Canada Search for other works by this author on: Oxford Academic Google Scholar Katie E Cardone, PharmD, BCACP, FASN, FCCP, FNKF, Katie E Cardone, PharmD, BCACP, FASN, FCCP, FNKF Albany College of Pharmacy and Health Sciences, Albany NY Search for other works by this author on: Oxford Academic Google Scholar Katherine Cho, PharmD, Katherine Cho, PharmD University of Michigan College of Pharmacy, Ann Arbor, MI Search for other works by this author on: Oxford Academic Google Scholar Amy Barton Pai, PharmD, MHI, FASN, FCCP, FNKF Amy Barton Pai, PharmD, MHI, FASN, FCCP, FNKF University of Michigan College of Pharmacy, Ann Arbor, MI Address correspondence to Dr. Pai (amypai@med.umich.edu) Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 77, Issue 11, 1 June 2020, Pages 892–896, https://doi.org/10.1093/ajhp/zxaa077 Published: 18 May 2020

Background and purpose: Medication therapy management (MTM) is a comprehensive, patient-centered approach to improving medication use, reducing the risk of adverse events and improving medication adherence. Given the service delivery model and required outputs of MTM services, communication skills are of utmost importance. The objectives of this study were to identify and describe communication principles and instructional practices to enhance MTM training. Educational activity and setting: Drawing on formative assessment data from interviews of both pharmacy educators and alumni, this article identifies and describes communication principles and instructional practices that pharmacy educators can use to enhance MTM training initiatives to develop student communication strategies. Findings: Analysis revealed five key communication challenges of MTM service delivery, two communication principles that pharmacy teachers and learners can use to address those challenges, and a range of specific strategies, derived from communication principles, that students can use when challenges emerge. Implications of the analysis for pharmacy educators and researchers are described. Summary: Proactive communication training provided during MTM advanced pharmacy practice experiences enabled students to apply the principles and instructional strategies to specific patient interactions during the advanced pharmacy practice experiences and in their post-graduation practice settings.

To determine the impact of advanced pharmacy practice experiences (APPE) on student self-confidence related to medication therapy management (MTM), fourth-year pharmacy students were surveyed pre/post APPE to: identify exposure to MTM learning opportunities, assess knowledge of the MTM core components, and assess self-confidence performing MTM services. An anonymous electronic questionnaire administered pre/post APPE captured demographics, factors predicted to impact student self-confidence (Grade point average (GPA), work experience, exposure to MTM learning opportunities), MTM knowledge and self-confidence conducting MTM using a 5-point Likert scale (1 = Not at all Confident; 5 = Extremely Confident). Sixty-two students (26% response rate) responded to the pre-APPE questionnaire and n = 44 (18%) to the post-APPE. Over 90% demonstrated MTM knowledge and 68.2% completed MTM learning activities. APPE experiences significantly improved students’ overall self-confidence (pre-APPE = 3.27 (0.85 SD), post-APPE = 4.02 (0.88), p < 0.001). Students engaging in MTM learning opportunities had higher self-confidence post-APPE (4.20 (0.71)) vs. those not reporting MTM learning opportunities (3.64 (1.08), p = 0.05). Post-APPE, fewer students reported MTM was patient-centric or anticipated engaging in MTM post-graduation. APPE learning opportunities increased student self-confidence to provide MTM services. However, the reduction in anticipated engagement in MTM post-graduation and reduction in sensing the patient-centric nature of MTM practice, may reveal a gap between practice expectations and reality.

As kidney disease progresses, phosphorus retention also increases, and phosphate binders are used to treat hyperphosphatemia. Clinicians prescribe phosphate binders thinking that reducing total body burden of phosphorus may decrease risks of mineral and bone disorder, fractures, cardiovascular disease, progression of kidney disease, and mortality. Recent meta-analyses suggest that sevelamer use results in lower mortality than use of calcium-containing phosphate binders. However, studies included in meta-analyses show significant heterogeneity, and exclusion or inclusion of specific studies alters results. Since no long-term studies have been conducted to determine whether treatment with any phosphate binder is better than placebo on any hard clinical endpoint (including mortality), it is unclear whether possible benefit with sevelamer represents net benefit of sevelamer, net harm with calcium-containing phosphate binders, or both. Although one meta-analysis suggested that calcium acetate may be more efficacious gram for gram than calcium carbonate as a binder, calcium acetate did not reduce hypercalcemia, and gastrointestinal intolerance was higher. Data are insufficient to determine whether calcium acetate provides lower risk of vascular calcification than calcium carbonate. Fears of lanthanum accumulation in the central nervous system or bone with long-term treatment do not appear to be warranted. Newer iron-containing phosphate binders have potential benefits, such as lower pill burden (sucroferric oxyhydroxide) and improved iron parameters (ferric citrate). The biggest challenge to phosphate binder efficacy is non-adherence. This article reviews the current knowledge regarding safety, effectiveness, and adherence with currently marketed phosphate binders and those in development.