Background: Deprescribing is a patient-centered solution to reducing polypharmacy in patients on hemodialysis (HD). In a deprescribing pilot study, patients were hesitant to participate due to limited understanding of their own medications and their unfamiliarity with the concept of deprescribing. Therefore, patient education materials designed to address these knowledge gaps can overcome barriers to shared decision-making and reduce hesitancy regarding deprescribing. Objective: To develop and validate a medication-specific, patient education toolkit (bulletin and video) that will supplement an upcoming nationwide deprescribing program for patients on HD. Methods: Patient education tools were developed based on the content of previously validated deprescribing algorithms and literature searches for patients’ preferences in education. A preliminary round of validation was completed by 5 clinicians to provide feedback on the accuracy and clarity of the education tools. Then, 3 validation rounds were completed by patients on HD across 3 sites in Vancouver, Winnipeg, and Toronto. Content and face validity were evaluated on a 4-point and 5-point Likert scale, respectively. The content validity index (CVI) score was calculated after each round, and revisions were made based on patient feedback. Results: A total of 105 patients participated in the validation. All 10 education tools achieved content and face validity after 3 rounds. The CVI score was 1.0 for most of the tools, with 0.95 being the lowest value. Face validity ranged from 72% to 100%, with majority scoring above 90%. Conclusion: Ten patient education tools on deprescribing were developed and validated by patients on HD. These validated, medication-specific education tools are the first of its kind for patients on HD and will be used in a nationwide implementation study alongside the validated deprescribing algorithms developed by our research group.

What is known and Objective Patients on haemodialysis (HD) are at increased risk of both bleeding and thrombotic events, due to comorbidities and nature of dialysis treatment. However, there is a lack of research on evidence-based treatment strategies and prescribing patterns for antithrombotic therapies (ATT) in this population. To characterize ATT use and its main indications in an outpatient HD unit. Methods A single-centre retrospective chart review was conducted in a Toronto outpatient HD unit (n = 329). Medical histories, number of ATTs and corresponding indications were collected from adult patients prescribed at least one ATT from 1 October 2019 to 31 December 2019, inclusive. Results and Discussion Of 329 patients in the unit, a total of 135 (41%) patients were on at least one ATT. Of these 135 patients, 80% were on monotherapy (55% antiplatelet, 25.1% anticoagulant), 12.6% were on dual antiplatelet therapy (DAPT), and 7.4% were on a antiplatelet and anticoagulant combination. Primary indications for ATT in our cohort were coronary artery disease (CAD; 55%), atrial fibrillation (18.5%) and venous thromboembolism (VTE; 17%). Described ATT use was in-line with current clinical guidelines. Monotherapy was primarily used in our HD cohort, whereas few patients were on dual therapy. Low-dose aspirin was the most common antiplatelet prescribed for secondary prevention of cardiovascular events. Warfarin monotherapy was primarily indicated for VTE, and DAPT aspirin/clopidogrel was the most commonly prescribed for CAD. What is new and conclusion Our characterization of ATT use in this HD cohort demonstrates that ATT is often prescribed for a number of different CVD reasons. Overlapping and confounding indications for prescribing ATTs, lack of randomized controlled trials and unclear clinical guidelines mean that individualized risk-benefit assessments for ATT use are still needed to provide care for these high-risk patients. More research to address the safety and efficacy of ATTs is warranted to develop more robust evidence-based treatment guidelines for the HD population.

INTRODUCTION:The cause of constipation is multifactorial and common problem for patients on hemodialysis. A lack of strong evidence on suitable treatment strategies means there is an unorganized approach to selecting therapies, which can exacerbate constipation or worsen symptoms. Clinicians and patients would benefit from a content and face validated treatment algorithm for treating constipation. In this study, our objective was to develop and content and face validate a constipation treatment toolkit for patients on hemodialysis, consisting of treatment algorithm, and patient information tools (pamphlet and video).METHODS:Literature searches were performed to develop an initial toolkit using Lynn's method for developing content-valid clinical tools. Content and face validity were evaluated as per Lynn's method for determining content validity; the algorithm was evaluated by Canadian nephrology clinicians, while patient information tools were evaluated by clinicians and patients. Components were rated on a Likert scale for content relevance and on a 5-point scale for face validity. After each round, the content validity index (CVI) score was calculated and revisions were made based on feedback.FINDINGS:A total of 23 clinicians and 15 patients were interviewed across three validation rounds. After three rounds, the treatment algorithm achieved content (overall CVI = 0.93) and face (91% agreement) validity. Our patient information tools achieved content and face validity (pamphlet overall CVI = 0.99, 85.5% agreement; video overall CVI = 0.99, 90.5% agreement).DISCUSSION:A treatment algorithm and patient information toolkit for the treatment of constipation in patients on hemodialysis were content and face validated via expert review. Further research will be needed to ascertain the effectiveness and implementation of this toolkit.

Objectives To examine current knowledge on the clinical utility of therapeutic drug monitoring (TDM) in voriconazole therapy, the impact of CYP2C19 genotype on voriconazole plasma concentrations, and the role of CYP2C19 genotyping in voriconazole therapy. Data Sources Three literature searches were conducted for original reports on (1) TDM and voriconazole outcomes and (2) voriconazole and CYP2C19 polymorphisms. Searches were conducted through EMBASE, MEDLINE/PubMed, Scopus, and Cochrane Central Register of Controlled Trials from inception to June 2020. Study Selection and Data Extraction Randomized controlled trials, cohort studies, and case series with ≥10 patients were included. Only full-text references in English were eligible. Data Synthesis A total of 63 studies were reviewed. TDM was recommended because of established concentration and efficacy/toxicity relationships. Voriconazole trough concentrations ≥1.0 mg/L were associated with treatment success; supratherapeutic concentrations were associated with increased neurotoxicity; and hepatotoxicity associations were more prevalent in Asian populations. CYP2C19 polymorphisms significantly affect voriconazole metabolism, but no relationship with efficacy/safety were found. Genotype-guided dosing with TDM was reported to increase chances of achieving therapeutic range. Relevance to Patient Care and Clinical Practice Genotype-guided dosing with TDM is a potential solution to optimizing voriconazole efficacy while avoiding treatment failures and common toxicities. Conclusions Voriconazole plasma concentrations and TDM are treatment outcome predictors, but research is needed to form a consensus target therapeutic range and dosage adjustment guidelines based on plasma concentrations. CYP2C19 polymorphisms are a predictor of voriconazole concentrations and metabolism, but clinical implications are not established. Large-scale, high-methodological-quality trials are required to investigate the role for prospective genotyping and establish CYP2C19-guided voriconazole dosing recommendations.

With the passing of Robert (Bob) B. Kaplan we have lost not only a distinguished scholar in the field of Applied Linguistics but also one of the founding editors of Current Issues in Language Plann...

Research in the clinical practice of medicine is focused on how, when, and why caregivers should start new medications in patients. Although prescribing medications is appropriate for many clinical conditions, this may lead to polypharmacy. For instance, many patients have multiple conditions,

Background: Polypharmacy is ubiquitous in patients on hemodialysis (HD), and increases risk of adverse events, medication interactions, nonadherence, and mortality. Appropriately applied deprescribing can potentially minimize polypharmacy risks. Existing guidelines are unsuitable for nephrology clinicians as they lack specific instructions on how to deprescribe and which safety parameters to monitor. Objective: To develop and validate deprescribing algorithms for nine medication classes to decrease polypharmacy in patients on HD. Design: Questionnaires and materials sent electronically. Participants: Nephrology practitioners across Canada (nephrologists, nurse practitioners, renal pharmacists). Methods: A literature search was performed to develop the initial algorithms via Lynn’s method for development of content-valid clinical tools. Content and face validity of the algorithms was evaluated over three interview rounds using Lynn’s method for determining content validity. Canadian nephrology clinicians each evaluated three algorithms (15 clinicians per round, 45 clinicians in total) by rating each algorithm component on a four-point Likert scale for relevance; face validity was rated on a five-point scale. After each round, content validity index of each component was calculated and revisions made based on feedback. If content validity was not achieved after three rounds, additional rounds were completed until content validity was achieved. Results: After three rounds of validation, six algorithms achieved content validity. After an additional round, the remaining three algorithms achieved content validity. The proportion of clinicians rating each face validity statement as “Agree” or “Strongly Agree” ranged from 84% to 95% (average of all five questions, across three rounds). Limitations: Algorithm development was guided by existing deprescribing protocols intended for the general population and the expert opinions of our study team, due to a lack of background literature on HD-specific deprescribing protocols. There is no universally accepted method for the validation of clinical decision-making tools. Conclusions: Nine medication-specific deprescribing algorithms for patients on HD were developed and validated by clinician review. Our algorithms are the first medication-specific, patient-centric deprescribing guidelines developed and validated for patients on HD.

What is known Opioids are often used to treat chronic non-cancer pain (CNCP) in patients on haemodialysis. Altered pharmacokinetics in this population increases risk for opioid-related adverse events. Although useful in pain management, there is a lack of opioid prescribing guidance for end-stage kidney disease. Objective To characterize opioid usage for CNCP in an outpatient haemodialysis unit. Methods Cross-sectional, single-centre, retrospective cohort study of 272 patients receiving outpatient haemodialysis between 01 June and 31 December 2017. Prevalence of prescription or non-prescription opioids, formulation, indication, dosing, prescriber type and therapeutic effectiveness were evaluated. Results A total of 27 (10%, aged 58 + 12.1 years, 59% women) patients received opioids for CNCP during the study period. Pain aetiology was diverse; 14 (52%) patients experienced multiple concurrent chronic pain conditions. Hydromorphone (55%) and oxycodone (37%) were the most common prescriptions. A majority (85%) of patients used non-opioid analgesics as adjunct therapy, while half (48%) used benzodiazepines or zopiclone concurrently. Patients who completed a pain scale (n = 10) reported a median pain intensity of 6.8/10 ([IQR], 4.5-7.3). Discussion Opioid usage was lower than expected despite a higher prevalence of concurrent chronic pain conditions. Though this was within opioid usage guidelines, pain may not be sufficiently controlled. High concomitant use of benzodiazepines and Z-drugs introduces the potential for additive adverse effects. Judicious opioid usage can be facilitated with stewardship to effectively treat pain while avoiding associated harms and manage potential drug-drug interactions with common concomitant medications. What is new and conclusion The prevalence of chronic opioid use for non-cancer pain in haemodialysis patients was lower than expected at our centre. Despite following the recommended guidelines, pain management was relatively ineffective, and concomitant use of non-opioid analgesics was widespread. Opioid stewardship is recommended to optimize pain treatment and mitigate drug interaction risks.