Pharmacist-Led Antiretroviral Stewardships
The development and implementation of pharmacist-led antiretroviral stewardships have been seen in numerous published studies across the country.11-14
Current literature reports a profound impact on improving safety in HIV patients through pharmacist interventions via medication error prevention and daily monitoring. Retrospective studies have seen rates of antiretroviral stewardship interventions for medication errors related to antiretrovirals increase from 16% to 52%. Various methods of stewardship interventions have been utilized, including prescriber and pharmacist education,13
customized order entry sets,13,14
and prospective audit and review.11-13
The impact of these methods is discussed below:
- Prescriber and pharmacist education can assist prescribers in appropriate selection and dosing of antiretrovirals. Zucker and colleagues’ study saw modest reduction in medication errors (from 45% to 36%) with provider education and order sets in an urban medical center setting.13
- Customized order entry sets can also facilitate correct prescribing of antiretrovirals and preventing potential drug-drug interactions or improper timing of administration. Another study performed by Guo and colleagues saw error rates reduced by 35% overall, primarily in incorrect doses and drug interactions by over 40%.14
- Prospective audit and review seem to show a significant reduction in these studies. In the previously mentioned Zucker study, prospective audit reduced errors to 12%.13 Other studies saw rates of pharmacist interventions on drug interactions increase from 43% to 95%11 and medication error rates decrease from 50% to 34%.12
Given these results, pharmacists with specialized training and knowledge in HIV are in a unique position to lead stewardship initiatives to significantly reduce medication errors related to ART in numerous ways. In the hospital, there are many opportunities for pharmacist intervention and improving patient safety, including identifying drug-drug interactions. Common inpatient medications such as proton pump inhibitors and statins may have clinically significant and unfavorable consequences. In addition, pharmacists can verify appropriate and complete ART regimens, the accurate route of administration, adjustments for renal and hepatic function, and indications for opportunistic infections associated with HIV/AIDS. Similarly, these interventions can be replicated in the outpatient setting, however, reported data are limited.
Challenges of Pharmacist-Led Antiretroviral Stewardships
Pharmacists, as part of antiretroviral stewardship teams, may face such barriers around therapeutic interchange of newer formulations, such as Genvoya and Descovy, with formulary antiretrovirals or interchange between routes of administration for formulations without alternatives. At times, barriers may lead to a temporary hold on medication administration, which may cause concern for virologic failure. In HIV-treated patients with hepatitis B co-infection, abrupt discontinuation of ART can also lead to an acute flare of hepatitis B. Consequently, in antiretroviral-experienced patients with viral resistance, treatment regimens may become more complex, requiring use of older antiretroviral agents, which have greater potential for drug-drug interactions and toxicity. At this time, further guidance is needed to determine the appropriate process of therapeutic interchange within hospital formularies.