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PURPOSE: Case reports and other published or manufacturer-provided data on the administration of antiretroviral agents through enteral feeding tubes are reviewed. SUMMARY: There is very limited published evidence to guide clinicians in the delivery of therapies for human immunodeficiency virus (HIV) infection by feeding tubes, especially crushed tablets and capsule contents. A search of the primary literature (through February 2012) identified a total of nine articles describing the delivery of highly active antiretroviral therapy (HAART) agents via gastrostomy (G), jejunostomy, and other feeding tubes; correspondence with pharmaceutical manufacturers yielded additional information. Most of the published evidence (from two prospective studies, one retrospective study, and six case reports) pertains to the treatment of HIV-infected children (33 of 40 cases). Although not a primary endpoint of any of the reviewed studies, viral suppression was documented in 29 of the 40 patients referenced in the reviewed articles. Manufacturer-provided information indicates that crushed darunavir tablets in suspension, as well as oral solutions of ritonavir and lopinavir-ritonavir, can be administered through G-tubes without significant loss of therapeutic efficacy. CONCLUSION: Data regarding enteral feeding tube administration are available for 63% of commercially available oral HAART agents and are primarily limited to case reports specific to the pediatric population.

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PURPOSE: The use of recommended practices for preventing and detecting diversion of prescription controlled substances at U.S. acute-care institutions, as reported by a sample of pharmacy service providers, were characterized. METHODS: A 41-item questionnaire was developed for an online survey of directors of pharmacy regarding strategies to combat controlled-substance diversion at their institutions. The survey questions were based on recommendations presented in a 2007 series of articles in the professional literature focusing on diversion control in three areas (the pharmacy, the operating room, and nursing units). Only institutions that had an accredited pharmacy residency program or were members of the University HealthSystem Consortium (UHC), an alliance of U.S. academic medical centers and affiliated hospitals, were targeted for the survey. Four hundred ninety-nine pharmacists were invited to participate in the survey, and 140 survey responses were received; all respondents did not answer all questions. RESULTS: The survey responses indicated considerable variation among the institutions in the use of 37 specific recommended practices, as reported by the pharmacy providers. Statistical analysis of comparative data suggested that larger institutions (400 or more licensed beds) were more likely to be using more of the recommended practices. CONCLUSION: The results of a survey of directors of pharmacy at a sample of U.S. institutions (hospitals that had pharmacy residency programs or were UHC members) suggest wide variation in facilities' use of recommended practices for the prevention and detection of controlled-substance diversion.

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BACKGROUND: Medication Reconciliation and Medication Safety are two themes emphasized in a variety of healthcare organizations. As a result, health care facilities have established methods for obtaining a patient's medication history. However, these methods may vary among institutions or even among the health care professionals in a single institution, and studies have shown that patients are reluctant to disclose their complementary and alternative medicine use to any health care professional. This lack of disclosure is important in surgical patients because of potential herbal interactions with medications and drugs used during the surgical procedure; and the potential for adverse reactions including effects on coagulation, blood pressure, sedation, electrolytes or diuresis. Therefore, the objectives of this study are to identify patterns of natural product use, to identify potential complications among patients scheduled for surgery, to improve existing medication reconciliation efforts, and to develop discontinuation guidelines for the use of these products prior to surgery. METHODS: A retrospective review of surgery patients presenting to the Anesthesia Preoperative Evaluation Clinic (APEC) at the University of Kansas Hospital was conducted to identify the prevalence of natural product use. The following data was collected: patient age; gender; allergy information; date of medication history; number of days prior to surgery; source of medication history; credentials of person obtaining the history; number and name of prescription medications, over-the-counter medications and natural products; and natural product dosage. Following the collection of data and analysis of the most common natural products used, possible complications and interactions were identified, and a protocol regarding the pre-operative use of natural products was developed and implemented. RESULTS: Approximately one-fourth of patients seen in the APEC indicated the use of natural products. Patients taking natural products were significantly older, were more likely to undergo cardiac or chest surgery, and were more likely to be taking more prescription and non-prescription medications (all p < 0.001). CONCLUSION: Based on the results of this study, it is concluded that there is a need for established guidelines regarding discontinuation of selected natural products prior to surgery and further education is needed concerning the perioperative implications of natural products.

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