A new kind of stewardship

Patients taking antiretroviral therapy are at risk for medication errors during hospitalization and care transitions.

Your hospital probably has an antimicrobial stewardship program, but it may not have caught on to the newer concept of antiretroviral stewardship.

“Although antimicrobial stewardship programs have been around for 10 to 20 years, antiretroviral stewardship has much more recently been implemented and does not have national mandates nor standardizations,” said David Koren, PharmD, a clinical pharmacist specialist in infectious diseases/HIV at Temple University Hospital and adjunct assistant professor in the department of medicine at the Lewis Katz School of Medicine in Philadelphia.

Antiretroviral stewardship is important because patients taking these drugs are at risk for medication errors during hospitalization and care transitions, he added. Dr. Koren was lead author of a recent policy paper aimed at improving this. The Infectious Diseases Society of America, the HIV Medicine Association, and the American Academy of HIV Medicine published their joint call to action in Clinical Infectious Diseases in September 2019.

The policy paper was modeled on the success of antimicrobial stewardship programs that have been mandated in hospitals by The Joint Commission since 2017. The co-writing organizations encouraged expansion of this area of practice to include antiretroviral stewardship, defined as coordinated interventions designed to improve continuity of care for patients receiving antiretrovirals. They urged that use of antiretrovirals be evidence-based, with medication reconciliation, appropriate dosing, mitigation of drug interactions, and prevention of viral resistance.

Dr. Koren recently spoke with ACP Hospitalist about how antiretroviral stewardship is being applied at some hospitals and what hospitalists can do to help.

Q: Why are antiretroviral regimens challenging to manage in the inpatient setting?

A: Antiretrovirals, usually used in combination, are generally continued from outpatient therapy, bringing together multiple challenges: the need for accurate medication reconciliation, inpatient formulary demands, and the possible need for multiple adjustments throughout hospitalization given a patient's evolving clinical status. Unfortunately, these challenges create an environment in which errors regularly occur. Antiretroviral-related errors can lead to new or increased adverse effects, sub- or supratherapeutic levels of medications, drug-drug/drug-food interactions, possible treatment or prevention failure, and possible drug resistance if incomplete regimens are ordered.

Q: What are some possible components of an antiretroviral stewardship program, and how does this concept fit with existing antimicrobial stewardship efforts?

A: Different models have been published in the literature: retrospective review of antiretroviral orders placed, specific computerized physician order entry safeguards, or clinical checklists—all with successful implementation. Any approach can be bolstered with education and awareness that such initiatives and interventions exist. These programs are generally championed by clinicians—whether physician, pharmacist, or otherwise—with regular exposure to the usage of these medications. As of right now, all published methods of stewardship interventions have worked well to meet the needs of their local communities, but the literature also shows that continued monitoring is generally needed in the inpatient setting. As we all know, inpatient clinical statuses can change regularly, and a patient might need multiple interventions (e.g. mitigation of drug-drug interactions, renal dosing adjustments, or even changes in enteral access) over the course of an admission.

Unfortunately, these antiretroviral-directed stewardship initiatives have not routinely been incorporated into existing antimicrobial stewardship efforts, which is not to say they can't be. Each institution should conduct an assessment to determine which model and/or resources can best meet the needs of the community they serve.

Q: What are the most common antiretroviral mistakes?

A: Generally, most errors come down to medication reconciliation. Complete antiretroviral regimens for HIV consist of multiple medications which may or may not be co-formulated into a single tablet, which the institution may or may not have on the inpatient formulary. Collaborations with the inpatient pharmacy team can be key. . . . The most widely used resource in the HIV world is available through the University of Liverpool.

Q: Does your hospital have an antiretroviral stewardship program? If so, what does your model look like?

A: At Temple University Hospital, our antiretroviral stewardship team involves an infectious disease-trained pharmacist and an infectious diseases attending physician. In addition to regularly reviewing all antiretroviral formulary lists and ensuring standardized ordering options, a daily list is populated through the electronic medical record of all patients receiving such medications. All patients will have a single stewardship note entered into his or her chart, which includes the results of a medication reconciliation with the external provider, relevant labs, and assessments and/or recommendations as to renal dosing adjustments, if necessary, drug-drug interactions, possible need for opportunistic infection prophylaxis, and enteral access considerations. Throughout the rest of the admission, the team will conduct daily reviews for all of the same things and will intervene if necessary.

Q: How can hospitalists be good antiretroviral stewards?

A: Even if providers do not encounter antiretrovirals on a day-to-day basis, a general awareness of the problem is a good start. Partnerships with local experts, complete medication reconciliation upon hospital admission, and awareness of available resources (including those for drug-drug interactions) can ensure an environment to increase patient safety.