Thrombocytopenia in the critically ill occurs frequently, rarely reaches severely depressed concentrations, and primarily represents a manifestation of disease processes initiated prior to admission. Hemodynamic instability and/or heparin exposure appear to be the strongest identifiable correlates with thrombocytopenia. Although these may cause infrequent isolated cases, other specific drug causes of thrombocytopenia are not responsible for the majority of cases of thrombocytopenia in the critically ill.
Objective To report a possible drug interaction between clarithromycin and warfarin in a patient with chronic atrial fibrillation. Case Summary A patient with chronic atrial fibrillation was placed on warfarin therapy. International normalized ratios (INRs) ranged from 1.61 to 3.99 while the dosage was being adjusted during the first 5 months of warfarin therapy. The dosage was titrated to 20 mg/wk; laboratory tests obtained 2 weeks after this dosage was started indicated an INR of 2.1. The same dosage was continued. Clarithromycin 500 mg bid was started for an acute exacerbation of bronchitis 10 days after the last INR was obtained and was continued for 14 days of therapy. An INR obtained 3 days after completion of the clarithromycin therapy was 16.8. The warfarin was withheld and vitamin K 20 mg im was administered. The INR obtained the next day was 1.52. The warfarin was restarted and the dosage was titrated to between 22.5 and 25 mg/wk, with INRs ranging from 0.85 to 3.14. Discussion Many factors influence the metabolism of warfarin, including disease states, medications, age, and diet. Data collected in this case suggested clarithromycin may have contributed to the increase in the effect of warfarin. Inhibition of the cytochrome P450 oxidizing system appears to be the reason for the increase. Numerous drugs and disease states affect the rate at which this system metabolizes drugs. Conclusions The potential interaction between clarithromycin and warfarin warrants prudent monitoring of the INR during concurrent administration of these drugs. Warfarin dosages may need to be reduced during concurrent clarithromycin therapy to prevent bleeding complications. Further controlled clinical trials are needed to substantiate the interaction between clarithromycin and warfarin.
Training in the scientific method and research design in doctor of pharmacy (Pharm.D.) curricula enables critical thinking, acquisition of reliable information, rigorous evaluation of emerging literature, and application of evidence‐based medicine in practice. Although research skills are essential for clinical pharmacists and many professional societies recognize the critical need for research in the Pharm.D. curriculum, standardization regarding essential research curricular competencies and content is lacking. Consequently, research skill development is often de‐emphasized in pharmacy education in favor of clinical knowledge and skills. This update to the recommendations of the American College of Clinical Pharmacy's 2008‐2009 Task Force on Research in the Professional Curriculum is provided to meet the evolving needs of contemporary pharmacy practice. The update discusses the importance of research training for Pharm.D. students, proposes essential research competencies and curriculum content for Pharm.D. programs, and highlights several successful strategies for fostering research among Pharm.D. students. In particular, the update advocates enhanced adoption of minimum standards for research skill development across Pharm.D. programs and integration of advanced research competencies to support the development of Pharm.D.‐trained scientists.
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