January 30, 2025 • 38 mins
It was a blast talking about all things neuro-ICU pharmacy with Dr. Andy Webb!
Check out his very informative website NeuroWiseRx
You can also find him on X/Twitter @AJWPharm
Some of the resources mentioned in the podcast can be found here:
Editing by Avani Bhadang
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello and welcome to the Neurotransmitters.
Welcome back.
I'm your host, dr MichaelKentris, and I'm happy to
introduce our next guest today,dr Andy Webb, a neurocritical
care clinical pharmacist fromMGH Harvard.
Andy, thank you so much forjoining us today.
Speaker 2 (00:16):
Yeah, thank you so much for the invitation again.
Speaker 1 (00:19):
So, as so many of the people I'm fortunate enough to
talk with, we met on Twitterslash X, many of the people I'm
fortunate enough to talk with,we met on Twitter slash X, and
I'm a big fan of the work you dothere A lot of educational
content.
I particularly, particularly,really enjoy your website with
your deep dives onNeuroWiseRxcom, and we'll
probably talk more about thatlater.
(00:39):
But I think a lot of peoplemight have a more vague idea of
what pharmacy training lookslike, and particularly when we
get into the realm of clinicalpharmacy.
So I was hoping you could, justfor those who might be less
familiar, kind of throw a broadoverview of what that looks like
.
Speaker 2 (01:00):
Yeah, absolutely.
Those are great questions.
I think there's a lot ofconfusion but people may not be
aware of all the different kindof training programs and
pathways that are out there forpharmacists and so kind of the
traditional path for apharmacist starting out is it's
very much so similar to medicinein that most pharmacists will
do an undergraduate degree andthen we'll go into a four-year
kind of professional clinicaldoctorate program.
So the doctor of pharmacydegree program is a four-year
(01:21):
program.
It's basically three years ofdidactics and then one year of
clinical.
So a little bit different there, where the focus is a lot on
pharmacology, pharmacokinetics,also the kind of pathophysiology
of the diseases, but reallyfocusing on the pharmacotherapy.
So a lot of the coursework thatwe do is kind of how drugs are
used, the rationale for theiruse, kind of how you navigate,
(01:43):
selecting, monitoring and kindof handling drug therapy.
And then our final year, whatwe call like advanced pharmacy
practice experiences or APPEs,is rotations out in the world.
That could be at a hospital, itcould be at a community
pharmacy, it could be at aphysician's office or really
anything in between.
So a lot of our APPEexperiences can be quite varied
if, depending on where apharmacist wants to go, and
(02:05):
after you kind of complete yourfour-year PharmD program, that's
really an entry to practicedegree where you could directly
start working.
So most pharmacists aftergraduating with a PharmD will
start in a community pharmacylike a CVS, walgreens or an
independent pharmacy dispensingmedications.
But clinical pharmacy is kind ofits own subset of pharmacy
practice and so what you can dois actually do specialized
(02:26):
residency training after yougraduate from your PharmD.
And so residency training forpharmacy has been around for a
long time.
It started in probably the last20 years or so and basically
what that looks like is thefirst year of PGY-1 residency
training is basically just likea general residency.
You can kind of think of itlike a categorical intern year
where you kind of see everythingthroughout the hospital.
(02:49):
So you do internal medicinerotations, you do infectious
diseases rotations, you can doan oncology rotation, neurology
rotation and ICU rotation, andreally the purpose of that first
year of training is really tojust give new grad pharmacists
kind of like a broad overview ofwhat clinical practice in a
hospital or some of theresidency programs are based in
(03:10):
the outpatient setting, likereally what clinical practice
looks like and how thepharmacist can kind of interface
with patient care in thatsetting.
And then after your PGY1 year,basically residents can choose
to do a specialty year and sothey can select if they want to
spend a PGY2 year reallyfocusing in on one individual
clinical specialty.
And so I completed my PharmDprogram at the University of
(03:30):
Rhode Island.
I actually did a bit of anaccelerated program.
So one of the options is doinglike a six-year track, so
they're like six-year medschools.
I kind of have a similar ideawhere I did basically two years
of undergrad and then four yearsof the PharmD.
Then I did my general PGY-1 atMayo Clinic in Rochester and
then I actually selectedcritical care to be my specialty
for PGY-2.
And so I went and went throughthe match again after just one
(03:53):
year and did critical caretraining at Oregon Health and
Science University out inPortland I think.
Throughout that entire time, asI was kind of going through my
training, I always knew that Ireally liked neurology and that
aspect of patient care and sothe fact that neurocritical care
was kind of a facet of thatthat I could go into was like
perfect for me, and so I waslucky enough to land in the
position that I am now it's theneuro ICU pharmacist at MassGen.
(04:14):
But basically pharmacists canfind themselves in those sorts
of positions and all differentsorts of specialties and so
really pharmacists are prettywell embedded into specialties
like infectious diseases,oncology, critical care for sure
, and I think neurologyspecifically is probably more of
like a growing field withinpharmacy.
While I think neurocriticalcare is pretty well established
within the field of clinicalpharmacy kind of neurology, in
(04:35):
general there's definitely apretty good number of us, but
it's more of a growing specialtyoverall.
Speaker 1 (04:41):
No, that's very interesting.
I know at one of my previouspractices we would have, I think
probably in the pgi one wewould have some pharmacy
residents coming through likethe epilepsy clinic and things
like that, which obviously hasits own unique challenges as far
as pharmacology goes, yeah, butuh, speaking to that you know,
so obviously critical care, alot of sub-specialized knowledge
(05:04):
there, and then we niche thatdown even further.
So obviously critical care, alot of subspecialized knowledge
there, and then we niche thatdown even further to
neurocritical care.
So so what are some of theunique challenges or kind of the
aspects that drew you to that,specifically as far as, like the
, the neurologic aspect ofpharmacologic care?
Speaker 2 (05:19):
Yeah.
So I think when I was inpharmacy school I think I was
kind of drawn to neurology andthe medications used in epilepsy
.
There's about 30 plus differentseizure medications on the
market and so I loved thepharmacology of those agents,
the complexity of the diseasesand also how much there was
still left to learn about how wecan kind of best take care of
these diseases.
So I think research issomething else that I'm
(05:39):
particularly interested in and Ilove the fact that there was
still so much developmenthappening in how to really best
take care and treat some ofthese hard to treat diseases.
And so really the combinationof the meds, the interesting
diseases, the kind ofopportunities for research and
discovery drew me to neurologyinitially.
And actually interestingly,when I was in pharmacy school I
(06:00):
didn't really even know thatcritical care was a thing that I
could do.
And so my fourth year, my APPErotation I took a MICU rotation
just because I wanted to kind ofget experience.
In that I was like I'm nevergoing to do this again.
I might as well my initialinterest in kind of complex
pharmacology and that sort ofdecision making.
I found kind of a home in theICU where there are these
unstructured problems.
There was collaborativedecision making.
(06:21):
There was a lot of complexity,not only in just the patients
that we were taking care of, butthe medication therapy that
were being prescribed to them,and then so I did a Mickey
rotation and then, as I wasdoing my rotations, there's
obviously, of course, also aneuro ICU at the hospital.
So I went to my preceptor and Iwas like you know, I have this
interest in neurology.
Can I just spend a week in theneuro ICU and kind of see what
it's like?
Speaker 1 (07:01):
And so that's where I really found that that's what
my calling was, so to speakwhere I could still have that
complex, it's always been a realboon, at least from my
perspective.
Where we're talking aboutdosing and interactions, because
while I might be familiar with,like the neurologic medications
, sometimes there are moregeneral things, like the heart
or whatever, whatever that mightescape my notice.
(07:25):
And so it's always good to speakwith someone who is more
broadly familiar with the wholespectrum of interactions and the
various pharmacodynamics andconnects that go into all that
decision-making.
Speaker 2 (07:37):
Yeah, exactly, I think that kind of collaborative
, team-based approach is, Ithink, one of the best parts
about critical care, becauseeverybody on the team be that
you know the attending thefellow, the resident, the
pharmacist, the bedside nurse,pt, ot, speech like we all have
a contribution to patient careand being able to kind of ever
hand out the care of the patientby really making sure that kind
of all the T's are crossed andthe I's are dotted, by really
thinking through everythingabout the patient and the
(07:59):
medication therapy that'sprescribed to them, be that you
know their seizure meds or theirsecondary stroke prevention,
but also like making sure wedon't forget about, you know,
guideline directed therapy forheart failure, those sorts of
things that might not be thefocus of their neurologic
admission, and that's just likethe great value of team-based
care, with the addition of apharmacist to a team.
Speaker 1 (08:17):
Absolutely.
I couldn't agree more.
Now, one thing that I alwaysfind because I you know where
I'm at now I work a lot morewith medical critical care and
in particular with internalmedicine residents and things
like that kind of at a morecommunity teaching hospital and
I find that one of the things Ialways have to hammer on about,
(08:38):
probably to people's annoyance,is the importance of the
blood-brain barrier inmedication delivery.
Is the importance of theblood-brain barrier in
medication delivery.
So I was wondering if you couldspeak a little bit to some of
the unique challenges when wetalk about drug considerations,
both in the neurology sphere aswell as more broadly for other
(08:58):
things.
What are some unique challengesthat you've come across or that
you find that you repeatedlyhave to remind your clinical
care teams about?
Speaker 2 (09:06):
Yeah, I think that you make a great point of like
considering what's going on withthe patient with the
medications that we choose islike huge.
And so I think, like the breadand butter stuff that we as
pharmacists and I myself handleis kind of appropriately dosing
medications based on organfunction.
So recognizing that a patienthas a developing AKI or has
suddenly worsening synthetichepatic function is obviously
(09:28):
going to greatly change howmedications distribute and are
eliminated throughout the body.
And so I think probably one ofthe most common things that I do
is just optimizing andselecting dosing of medications
can do therapeutic drugmonitoring for like valproate or
phenytoin or antibiotics likevancomycin, or just kind of
empirically selecting dosesbased on those individual
patients kind of organ function,like renal and hepatic function
(09:50):
, I think.
Other than that, I think also,yeah, like basically thinking
about therapy for that patient,because sometimes it's you know,
we have a patient who's onlevotiracetam and they have like
moderate to poor renal functionbut they're in pretty bad
status, epilepticus, and I'mgoing to be like I'm okay
pushing the dose up a little bithigher here, even if you know
the textbook says that we shouldbe lowering the dose.
Sometimes my job is fighting,not lowering doses.
(10:11):
So I'm really making sure thatwe're optimizing the therapies
that we have.
I think that's also I help a lotof my colleagues in other ICUs
and other floors to usemedications that they're also
not super familiar with.
So if there's a patient with aneurologic diagnosis on a
surgery floor, for instance, youknow one of the pharmacists may
reach out to me and be like,hey, my team has a question on,
you know, to pyramid dosing orsome other dosing of some
(10:32):
medication they may be lessfamiliar with.
And I'm also helpful in helpingmy colleagues through what
considerations to have withthese medications.
You know like the surgery teammay be banging their head
against the wall by.
This patient has an unexplainedmetabolic acidosis and I get
the question of like, oh, it'sprobably the tapiramide, and so
kind of considering some ofthose lesser known toxicities
that patients you knowclinicians may be less familiar
(10:53):
with with medications they don'tuse very often.
Education, essentially, isanother large role of mine to
helping make sure everyone canuse the medications they're
using rationally and safely.
Speaker 1 (11:02):
No, that's great of use the medications they're
using rationally and safely.
No, that's great.
So yeah, as you were answering,I was coming to mind of a
consult I had for someone in theICU who I think her GFR was
maybe 20 and she was like on twograms of Cephapim.
Speaker 2 (11:19):
BID A little bit confused.
Speaker 1 (11:21):
If you can guess the reason for the consult it was in
fact altered mental status.
Speaker 2 (11:26):
Yeah, I've seen this movie before.
Related to that, wrapping inthe highest quality, most
up-to-date evidence is anotherhuge part of my role.
So, for instance, we had apatient who had a seizure
overnight, not 100% sure whatcaused it.
They were on cefepime, the dosewas appropriate, but we have
the ACORN trial.
So I could point to evidenceand say like well, we have an
(11:48):
alternative therapy that wecould use.
So we switched this patient toZosyn because it made sense for
the infection that we'retreating.
And so helping my team kind ofdo the best evidence-based care
is the other big thing that I do.
I'm the guy who pulls mycomputer around to point at the
most recent trial and like lookat this curve and here's why we
can do this, and so that'sanother thing that I absolutely
love is using evidence whenwe're taking care of patients
and also teaching other peopleabout what the evidence has to
(12:09):
say about the decisions that wemake.
Speaker 1 (12:11):
No, that's, that's great.
And it just seems there's sucha plethora of papers and trials
on daily and weekly basis it'svery challenging to keep up
sometimes.
Speaker 2 (12:19):
A hundred percent, like when the European stroke
conference happened a couple ofweeks ago.
It was like every day I'm like.
Well, here's another practicechanging landmark trial that we
have to consider.
Speaker 1 (12:28):
I know it's uh, it's great, but it's also frustrating
because it feels likeeverything I just learned last
year is out of date now, exactly, exactly so but such such as
the way of things I suppose Uhbut uh, to that effect, you know
, like, yes, we have all thesenew things, sometimes telling us
the thing we've been doing formaybe decades is wrong.
(12:50):
And there are still some ofthese older meds on the market.
I'm thinking of, in particular,our valproic acid and phenytoin
, phosphonytoin, all thesethings that are still like very
much in the guidelines forspecific situations, that are
still very much in theguidelines for specific
situations, and, in particular,I'm thinking of a deep dive you
(13:12):
did onto the free versus totalvalproic acid trial that came
out this last year and I waswondering if you would indulge
me and talk a little bit aboutthe unique challenges when we're
talking about, like highprotein bound molecules and free
versus total fractions, and howdo we deal with that as things
get more and more complicated.
Speaker 2 (13:30):
Totally yeah.
So you know you hit on a petproject or pet interest of mine
and I think that you know, as apharmacist, pharmacokinetics is
like one of the real bread andbutter things that we bring to
the table.
Pharmacists, pharmacokineticsis like one of the real bread
and butter things that we bringto the table.
And seizure meds have like someof the most complex and like
frustrating head banging againstthe wall pharmacokinetics of
all the medications that we have.
So like phenytoin is like theperfect case example of you know
(13:51):
, when I was in pharmacy schoolwe spent like two weeks on
phenytoin PK alone, just becauseof learning about what
Michaelis mentioned kineticsmeant and how all the different
drug interactions and proteinbinding interacts with things,
and so I think that's also oneof the things that really drew
me to these sorts of medicationsis just how interesting and
complex they kind of get aroundthe body, and I think valproate
(14:12):
is almost like anunder-recognized, similarly
complex, frustrating seizuremedication in that perspective.
So as a trainee, I was kind offaced with some of these
challenges if we had a patienton valproate.
Because, yeah, your point, it's, it's older, we have experience
with it, it's in the guidelinesthere's, you know,
quote-unquote good data forusing valproate in various
seizure types.
On valproate, uh, and they justweren't waking up.
(14:33):
You know their eeg wassuggestive, you know that they
they're not seizing, there'snothing else obvious going on.
And so my preceptor at the time, caitlin Brown, was like we
should check a free level,because this you know this has
complex protein binding was likeoff the charts.
And so we had this total level.
I was like 50 or 60.
Like this shouldn't be that bigof a deal.
Checked a free level, the freelevel was like 40 or 50.
(14:55):
And you look at the referencerange, that should be somewhere
between like five and 15 to fiveto 20.
But like this is clearlyabnormal and it's something that
I think a lot of teams justdon't even think about, where
they see the total valproatelevel and they're like we're
good to go, like this patient isin range, nothing to worry
about, and by lowering the doseand, you know, significantly
decreasing the patient'sexposure, they woke up and so
it's kind of like a perfect seedto say like this is a something
(15:18):
is clinically relevant, reallydoes matter to the patients that
we take care of and is likevery under recognized.
And so really, from some of thework that Caitlin Brown, her
colleagues, have done got meadditionally interested in
really looking into this andexactly like why this happens.
I think one of the other thingsthat as a pharmacist, I really
like to bring to the team interms of value is like, yeah,
(15:38):
those deep dive, like in depthunderstanding about exactly what
these meds are and what they'redoing.
And there's so much aboutValproate and the other seizure
medications that's just very.
Valproate is a bit unique inthat it's just this little tiny
kind of you know fatty acid thatjust happens to hit all these
different receptors and allthese different ion channels and
(16:00):
just happens to kind of be thisbroad spectrum very effective
anesthesia medication.
But that sort of small fattyacid structure also means that
it interacts with a whole bunchof other things you would not
exactly expect.
And, to your point, yeah, thebig thing that is important
about it is it's binding toalbumin and when it's bound to
albumin it's not doing anything.
When it's unbound to albumin,that's when it's
(16:24):
pharmacologically active andable to have both its clinical
effects and its toxicities.
And not recognizing thedifference between the total and
the free can really leadclinicians astray in
misinterpreting a level and kindof what we've found is that
critically ill patients, for amyriad of reasons, have wildly
altered protein binding and havewildly extreme exposures to
(16:44):
free valproate levels, out ofproportion to what you might
expect.
And so digging into theevidence has helped me.
You know, obviously, hepaticdysfunction with changes in how
much albumin patients actuallyhave, but also things like
unexpected drug interactionslike aspirin and warfarin,
propofol, you know, intralipidfrom a TPN all of these things
will knock that fatty acidvalproate off of its albumin and
(17:06):
protein binding site.
It will increase patient'sexposure.
And there's actually some workthat we're doing.
We're looking at what theclinical consequences of that is
and basically what we found isthat it really is the free level
that is what's predictive ofpatients having side effects.
And so we found basically thatpatients with really high free
levels, even if their totallevel is fine, have more
(17:28):
hepatotoxicity.
They have lower platelets,they're likely more sedated and
you might check a total leveland see that it's 50.
And you're like we're great.
But if they're not waking up,it very well may be because
their protein binding is totallyoff whack and something like
that aspect of really digginginto the evidence and
understanding how these meds areis one of the biggest roles I
think a pharmacist can have,because those kinds of like
(17:48):
things you don't really thinkabout, that are just unique
about a medication, can reallyhave pretty profound impacts on
the kind of day-to-dayindividual care of one patient.
Speaker 1 (17:57):
No, that's, that's awesome and it's, you know,
putting kind of ourretrospective scopes on.
You kind of look back at someof these old papers from, like
you know, 40, 50 years ago, yeah, and they're like, oh, a you
know non-dose relation, likewith hepatic or a
Depakote-induced encephalopathyor things like that.
Speaker 2 (18:15):
I'm like, well, maybe maybe it is dose-related, it's
just not.
You know, it was something weweren't measuring decades ago.
Yeah, and I think, like withDepakote in particular, one of
the most interesting things is,you know, everybody knows that
50 to 100 or 50 to 125 is a goodrange.
But when you talk about quote,unquote, good evidence when you
go back, the authors wereessentially they just guessed.
(18:35):
They measured levels in a bunchof patients who had seizures,
who were on Depakote, and theynoticed that patients whose
levels were somewhere in therange of 50 to 100 tended not to
seize as much.
And they're like, this range ispretty convenient.
So that's what we're going togo with and that is effectively
what the discussion of thispaper is.
There's no empirical PKPDanalyses.
It's just like this seemssufficient and that has kind of
(18:56):
carried forward, and so there'sdefinitely a lot pkpd analyses.
It's just like this seemssufficient and that has kind of
carried forward, and so there'sdefinitely a lot more work for
us to do to kind of update that.
Speaker 1 (19:03):
Yeah and that's uh.
I remember when I was a pgy2myself and one of my epilepsy uh
attendings asked me like youknow, it's like so the, the
valproate range, you know normalis 50 to 100.
You know, for fenny towin it's10 to 20.
It's like, don't those seemawfully rounded off?
Speaker 2 (19:21):
it's like, yeah, there's the evidence is garbage
uh yeah, somebody made a goodguess and they just kind of ran
with it.
Speaker 1 (19:26):
And here we are 40 years later just dealing with
the consequences yeah, so it isone of those things where it's
like uh, it's kind of that oldtruism, at least in epilepsy.
It's like when's the persontoxic when they're having side
effects, when are theytherapeutic when they're not
having seizures?
Speaker 2 (19:41):
Yeah, like I had an attending who's like I don't
really pay too much attention tophenytoin levels until they
have nystagmus.
It's like that's one way to doit.
Speaker 1 (19:49):
I've heard that exact same thing before, yeah.
Speaker 2 (19:52):
And that is.
Speaker 1 (19:52):
You know, it's especially for those two drugs
in particular, when I have round, like students or residents
around me with me.
Uh, one of my I should say oneof my favorite, maybe not one of
their favorite ones is to goaround in a circle and name one
side effect, yeah, of alproicacid, until you run out yeah,
the circle can get quite largeuntil you run out of side
(20:13):
effects right, and I thinkthat's that's just so.
uh, to your point earlier, it'sthat, it's uh we have to
consider not just you know it'seasy to put our blinders on and
think only about neurologicissues but to think about the
broader human body and what wemight be causing.
Like one of the ones I run intomore often, especially with
(20:33):
those older meds, is, like youknow, folks here with like AFib,
rvr, like an amio drip orsomething like that and just
like well, you know, you need tobe a little bit careful here.
Speaker 2 (20:44):
Yeah, mean it's.
Maybe this patient's plateletcount is low because of the depo
code or like their abdominalcomplaints might be pancreatitis
from the depo code, and peopleoftentimes forget about these
like pretty rare but can bequite.
Concerning toxicities thataren't necessarily neurologic
and related in and in nature, uh, because there are so many kind
of off-target effects of a lot,particularly these older
(21:06):
medications.
Speaker 1 (21:07):
Yeah, I know there was that huge class action
lawsuit over in the UK a fewyears back because people
weren't being young women inparticular weren't being
counseled on the teratogenicside effects, which obviously
are super well-known for decades, which I thought was just
mind-boggling that that wasn'tbeing clearly communicated to
(21:28):
like population at large yeah, Ithink it's to the point where,
like, prescribing of valproateto women in the uk is
essentially restricted now,where there needs to be like
clear documentation that otherthings have not worked and
everyone is on the same pageabout what the pros and cons of
this therapy is.
Speaker 2 (21:42):
So that I think yeah to your point.
It's, if it's easy to forget,like as an effective seizure man
, we'll just start it for thatreason.
But there's a lot of things toconsider beyond just seizure
reduction yeah, yeah, definitelyvery important.
Speaker 1 (21:53):
I I remember I I had, uh, a younger woman who you
know, she she was a immigrantfrom central america and uh, you
know she had epilepsy, I thinkas a if I remember correctly,
it's been a few years uhsequelae, like sister sarcosis,
and um, she'd failed like somany meds and so I was adding
(22:13):
just a little bit of depakote.
You know, she's in her late 30sand I said multiple times, both
myself with my poor spanish, aswell as via the official
translator, like, like, listen,you cannot get pregnant on this.
And God, god help me.
She showed up three monthslater, fortunately or
unfortunately, it seems she hadnot been taking her anti-seizure
medication.
(22:34):
So, it ended up not beingrelevant in that case, but oh
man those cases stick with you,for sure.
Yes, I was just like oh my God,yeah, but yes, it's.
It's one of those things wheresometimes you know it doesn't
matter how much you harp onabout it, the worst case still
happens sometimes.
Speaker 2 (22:50):
Totally.
Speaker 1 (22:50):
Totally as far as, like you know, we've talked a
little bit about kind of yourmultidisciplinary role.
What are your favorite thingsto treat in the neuro ICU as a
clinical pharmacist?
Speaker 2 (23:00):
Yeah.
So I think you know, related tothis discussion we've been
having, honestly, I think youknow, related to the discussion
we've been having, honestly, Ithink status is like by far and
away the most favorite thingthat I have to treat.
It's.
It's funny because, you know,status epilepticus is can be
deeply satisfying as apharmacist, but can also be one
of the most challenging anddifficult diseases to take care
of, and so obviously, as thepharmacist in the neuro ICU, I
(23:22):
have an affinity for the diseasestate which is largely
exclusively treated withpharmacologic agents, you know
excluding, you know, vns and RNSand surgical therapies right,
and so I think the thing I lovedoing the most is just making
the most of the medications thatwe have, and so in ensuring
that, you know, our Keppra ismaxed out, our everything is
maxed out, and then when thekind of standard things don't
(23:44):
work, the creativity of likewhat is the best next thing for
this patient is like.
Such a great experience.
To like, choose a medicationusing some rationale, really
thinking through the patientcase as much as we can, and then
seeing it work is like has tobe the most satisfying thing out
there.
It's kind of funny in pharmacyschool when we learned about
seizures and epilepsy andseizure medications it was
(24:04):
essentially like here are themeds, here's what they do, here
are the side effects, and therewasn't a lot of focus on like
how you actually select an agentin terms of like really what
does make the most sense for apatient of the legitimate 30
options that we have?
It's been really satisfying todevelop that kind of expertise
to say like well for thispatient.
You know Clobazam actuallymakes the most sense, or
(24:25):
Parampanel makes the most sensebecause they're ketamine
responsive or something alongthose lines.
And when it all works out it'slike phenomenal.
It's like to the point of thecases that stick out.
There are so many cases of thepatient who was burst,
suppressed for three days andreally difficult to wean, and
you know the most recent one.
It's like we're all kind ofwringing our hands what to do
next and I was like, well, likethe one thing we haven't tried
(24:47):
is cannabidiol and we start thatand we're able to wean
anesthesia.
She wakes up two days later shegets extubated and like when
those sorts of cases work out,it's just like such a satisfying
experience as a pharmacist tobe able to help optimize the
perfect regimen to make sure thepatient obviously isn't seizing
but also can kill kind of havea quality of life and get out of
the hospital in a safe way.
(25:08):
But I think the dark side ofthat is, you know, it is very
frustrating when things don'twork out.
Which is one of the mostchallenging things about status
is when that patient really justdoesn't seem to respond to
everything or anything that wetry.
But the good thing I guesssupposedly is that is super
inspiring to continue to worktowards future therapies for
what could work for thosepatients.
And so I've been lucky enoughto be involved in, you know, a
(25:30):
clinical trial for refractorystatus epilepticus drug
Ganaxolone, you know, as kind ofmore an operational aspect of
helping to screen patients andget patients enrolled in the
study and actually get the studydrug and also involved in
research really seeing like ofthe stuff that we have done
like's working, and so reallystill being able to be involved
in discovery about how to besttake care of these patients is
(25:50):
also the other thing that I getthe most satisfaction out of
nice.
Speaker 1 (25:54):
Is that a new neurosteroid agent?
Speaker 2 (25:56):
yeah, exactly, and so it's in phase three trial right
now, and so we don't know theresults yet, but certainly very
promising.
It's the kind of drug whereit's technically placebo
controlled but sometimes youfeel like it's kind of hard to
blind, you know.
So we're all, I think all veryexcited to see what the final
results of that trial are.
Speaker 1 (26:13):
That'll be exciting.
Yeah, I remember when they weredoing the.
I think it was Pregnant Alone.
Yeah, was that five or sixyears ago at this point?
Speaker 2 (26:19):
Yeah, yeah, unfortunately not successful,
which I think speaks to just Ahow challenging it is to pick
patients who might be eligibleor benefit from these agents.
So I think that the challengingthing about the RAISE trial is
just how stringent the selectionand inclusion criteria were,
and so it was hard to find theright patient, and so we'll kind
of see what the results are,but we're all very excited.
Speaker 1 (26:40):
And I think to your earlier point right, I'm a big
advocate for the kind of therational polypharmacy for status
epilepticus or epilepsymanagement in general.
Obviously I'm biased, sincethat's my background in
particular.
But one of the things that Ithink is so challenging,
especially when we're talkingabout like drug selection, is
like what is the underlyingetiology of the person's
seizures?
It's just so heterogeneous inthe population that it can be
(27:03):
really challenging.
Just so heterogeneous in thepopulation that it can be really
challenging.
Like you know, they've got anold stroke or an old traumatic
brain injury or maybe they havesome sort of generalized
epilepsy.
That's not well, you know,distinguished and there's just
so many ways that it can shakeout.
It's very challenging sometimes.
Speaker 2 (27:17):
A hundred percent, yeah.
And then you've got the patientwith Norse who you are truly,
you know wringing your handsabout what to do next.
And those patients I mean someof the regimens that I've, you
know, helped take care ofpatients on are truly, truly
unique.
When we're pulling outimmunotherapies and we're
starting ketogenic diets andthat's another big thing that I
help with is how many milligramsof carbohydrate are in the, you
(27:39):
know, the parampanel tablet.
So helping to tinker with allthose things to maximize the
success of those therapies, itcan be a lot of fun, it's a lot
of work, uh, but it's.
It's a real, you know, honor tobe able to take care of those
patients no, that's excellent.
That's, that is something god II haven't had to think about
that since I was a fellow uh, togo through the list of 50 meds,
(28:00):
they're on and callmanufacturers and be like, hey,
is there more than 50 milligramsin this tablet?
And they're on and callmanufacturers and be like, hey,
is there more than 50 milligramsin this tablet?
Speaker 1 (28:07):
And they're like why are you asking me?
Speaker 2 (28:08):
this question, but once you get the answer it's a
lot of fun to kind of figure allthat out?
Speaker 1 (28:11):
No, definitely Definitely.
My wife's a dietician.
She's been involved with thoseconversations as well.
Speaker 2 (28:16):
Yeah, Carmen, who's our dietician on the unit, is
like phenomenal about goingthrough all of those
considerations, and we work veryclosely together to make sure
everything's all tucked in, tiedin a bow, before we start the
keto diet.
Speaker 1 (28:28):
Now, as far as like, if you wanted to say like, why
should someone who's consideringlet's say they're in their
undergrad pharmacy program?
What would you say to those whomight be intrigued by
neurocritical care?
What kind of experiences shouldthey seek out?
Speaker 2 (28:44):
Yeah, 100%.
So I think the things to thinkabout if you're thinking about
going into neurocritical care isyou really need to be the kind
of person who likescollaborative decision-making
and really thinking through anindividual patient who makes the
most sense, what therapy makesthe most sense for that
individual patient.
You want to be the kind ofperson who likes thinking
through evidence and applyingthat to a patient and you have
(29:05):
to be able to really like thecomplexity and a lot of the gray
that is within and justinherent to neurology and
neurocritical care.
And so I think you know, ifyou're seeking for those
opportunities certainly ifyou're in your PharmD program,
seeking out APPEs that are atlike an academic center that has
a neuro ICU where you can workwith a neurocritical care
pharmacist, you can introduceyou to the team and kind of be
(29:26):
part of that decision making andalso being, you know, coming
involved in the neurocriticalcare society, where we have a
pretty active and wellestablished group of pharmacists
who are quite integral to thatsociety.
So you know, for instance,gretchen Brophy, who's a
pharmacist at VCU, was theprimary author on the NCS status
guidelines that are now 12years old, so getting a little
(29:46):
dated, but regardless, justreally highlighting the fact
that pharmacists are pretty wellembedded in NCS and are really
integral member of that team.
Really the greatest thing aboutbeing a neurocritical care
pharmacist is we really get topractice at the top of our
knowledge.
So in pharmacy sometimes wetalk about practicing at the top
of our license.
So what we're legally able todo, be that independently manage
(30:09):
medications or do therapeuticdrug monitoring, all these sorts
of things.
But I think in the neuro ICU Ireally get to go beyond that
because I get to really bring tothe table how do the drugs work
, how do they interact with thisindividual patient's disease
state, what's my understandingof the patient's pathophysiology
, what complications we'rehandling right now, what's
happening at the bedside andeverybody can kind of come
(30:31):
together and make the bestdecision.
For instance, we had a severetraumatic brain injury patient
on the unit this week and youknow I was at the bedside with
the kind of the fellow and thephysician assistant thinking
through like what is the bestnext step on the ladder for this
patient's ICP crisis?
And it's a lot more complicatedthan just, you know, just
increase the propofol or justgive 23%.
(30:52):
It's really thinking throughlike how do we understand what's
going on inside that patient'sskull and what do we have to do?
And it's always a little oddwhen I'm the pharmacist and I'm
like I think this patient needssurgery and so like thinking
through all of the complexitiesthere.
I being able to bring themedication side of things just
really helps round outeverybody's thinking through how
(31:13):
we're going to take best, takecare of this patient.
And so you know pharmacystudents who are thinking about
what clinical field they want togo into, that sort of
fast-paced, complex decisionmaking with a lot of unknowns.
Because I think one thing thatas a pharmacist is really
satisfying when I can point to atrial and be like black and
white this is what the thing weneed to do is that's very rare
in neurology to be able to saythat.
(31:34):
And so when I have learners, Ithink the thing that I have to
really help them becomecomfortable with is like there
is no correct answer.
So being able to be comfortablewith what's our understanding
of the data, the patient, whatoptions we have available, and
just navigating the best pathforward, it's really hard but
can be really satisfying whenyou kind of come to a conclusion
, implement that plan and kindof see it work out in front of
(31:56):
your eyes.
Speaker 1 (31:57):
That's excellent, and you know to your.
To your point about theincreased ICPs yes, you're the
pharmacist, but you're theperson who knows, like I don't
think, medication is going towork any further beyond where
we've pushed it Right.
So I think that's that's stilla very useful perspective to
have on that front.
Speaker 2 (32:12):
I'm talking with the neurosurgery residents and
they're like well, you need tomaximize medical therapy.
And I'm like, I'm telling youwe have maximized medical
therapy, it is maximized.
Speaker 1 (32:21):
That is excellent.
And for, let's say, internalmedicine or neurology residents
out there, or even nursing staff, if they want to learn more
about neurocritical care,pharmacy, pharmacology what are
some good resources that youwould recommend?
Speaker 2 (32:36):
Yeah, so I'll go back to NCS.
We're like NCS and the group ofneurocritical care pharmacists
who are involved in NCS havedone a really awesome job of
producing good resources aboutneurocritical care
pharmacotherapy.
So there's the On Call program,the PONS program, which is the
pharmacotherapy of neurocriticalcare series.
So there's lots of resourcesthat relate to kind of the
(32:58):
science and the knowledge ofmedication use therapy in
neurocritical care.
But additionally there's a lotof resources about kind of like
how to get in touch with neuroICU pharmacists if you want to
network and get to know somebodyin your area, and so I think
that's probably the hub to kindof find pharmacists in this
field and particularly, you know, if you are at an institution
with a neuro ICU that does nothave a neurocritical care
(33:20):
pharmacist.
Ncs also has a program calledthe ICP program, if I'm
remembering it correctly, whereit's basically what they'll do
and I'm now blanking on the whatthe acronym actually stands for
, but it's something aboutsomething clinical pharmacist.
Well, they'll basically send anexperienced neuro ICU
pharmacist to an institution tohelp set up neurocritical care
(33:41):
or pharmacy services at yourinstitution.
So, for instance, if you're ahospital that's opening up a
neuro ICU for the first time andthe institution might be
interested in having somebodycome in help establish pharmacy
services, help write guidelines,establish the formulary like
figure out where you're going tokeep your 23% vials or those
(34:02):
sorts of things.
Ncs will actually sponsor amore experienced neuro ICU
pharmacist to go out to thatinstitution, help mentor a
pharmacist who might beestablishing their practice site
at that institution and alsoreally help the institution
maximize the role of thepharmacist in that setting.
So that could be, you know,writing a guideline for ICP
management or establishingworkflows for status response.
(34:25):
There's a good amount of datanow that you know having a
pharmacist involved in thesecritical kind of experience or
instances, be that, you know,thrombolysis for stroke,
response to seizures and statusepilepticus.
There's actually a recent paperthat came out for
anticoagulation reversal in ICHdirect involvement of a
pharmacist in the care of thosepatients.
(34:46):
Even if, you know, if theyweren't necessarily able to
directly show benefits inmortality, they were able to
show benefits in more surrogateoutcomes like faster time to
thrombolysis or faster time toanticoagulation reversal or more
appropriate seizure medicationdosing and faster time to first
benzo.
And when you put all thosethings together it's a pretty
strong body of evidence thatclearly definitively shows that
(35:08):
involvement of a pharmacist doesimprove the outcomes of the
patients that we take care of.
So particularly forinstitutions who are either
developing or looking to developpharmacy services in this area,
there's a lot of good resourcesto help support that and
establish a good pharmacistpresence in their unit.
Speaker 1 (35:24):
Well, that is awesome information.
I'm going to have to keep thatin mind myself.
I know we're in the process ofexpanding our neuro ICU, so good
to know, yeah definitely.
Speaker 2 (35:32):
It's an awesome resource and there's a lot of
good examples of you know a newgraduating pharmacy resident
who's starting out in a newneuro ICU and it can be really
intimidating as a newpractitioner to step into a
subspecialized ICU that doesn'thave an established pharmacist
already, and so there's a lot ofinstitutional organizational
support to make sure that neuroICU itself can practice as best
(35:56):
as possible and that pharmacistis also supported to make sure
that they can have the smoothesttransition into practice
possible.
Speaker 1 (36:02):
Very cool, very cool.
Any final, any final thoughts,things that you want to plug,
projects that you're wanting tomake the public aware of.
Speaker 2 (36:09):
Yeah, definitely.
So I mean, I appreciate youkind of throwing out or shouting
out my website.
So neurowiserxcom I will admitthat I am probably not the most
loyal poster because it turnsout those posts are a lot of
work to put together.
They look like it, yeah, butbasically what I my hope is that
I'll probably try to post alittle bit more diligently in
the future, but it's certainly alot of work dig through every
publication from 1960 on so.
(36:31):
But my goal is really to answerthose sorts of questions in a
way that brings up all theevidence that we have available.
And certainly people havequestions that they want me to
look into.
I'm certainly open to those aswell.
I think the other thing toreally just plug is that you
know pharmacists have a big rolein neuro ICU in particular, but
really in any care where met.
There is certainly of largevalue in having pharmacists
(36:52):
round with your stroke teams oryour general neurology teams or
the epilepsy monitoring unit andso kind of reaching out to your
pharmacy departments at yourindividual institutions to see
what resources are available.
You might be surprised at whatsort of value a pharmacist can
add.
Speaker 1 (37:04):
No, I couldn't agree more.
I always considered it.
It was that we're just startingto get a pharmacist rounding on
a regular neurology team whereI was previously a few years ago
, and it it provided just thisvery subtle boost.
Yeah, it made everything alittle easier.
Speaker 2 (37:21):
Yeah, totally.
Speaker 1 (37:22):
Which was it's always great, yeah, absolutely, but no
, I couldn't agree more.
It's always good to have moreperspectives on the
multidisciplinary side of thingswhen when rounding as a team.
Speaker 2 (37:32):
Yeah, absolutely.
Speaker 1 (37:34):
And if people want to find your work, they want to
find where you are.
I know we mentionedneurowiserexcom Anywhere else
they should check out for you.
Speaker 2 (37:41):
Yeah, so I'm certainly busy on Twitter slash
X, whatever you want to call it.
So my handle is AJWfarm, so Itry to post relevant things to
neurology, neurocritical care,critical care in general.
Do that the most recentevidence that I can find, or my
own opinion on kind ofinteresting things that have
happened on the unit or in thefield of neurology, and so I
would say I'm fairly activethere.
(38:02):
So certainly excited tointeract with everybody who is
on that platform to kind of helpus all.
I think personally, I havelearned a ton on Twitter and
I've tried to kind of return thefavor, and so I always love
interacting with new people onthat platform.
Speaker 1 (38:16):
Awesome.
I certainly appreciate yourwork on there as well.
I've learned a lot myself.
Speaker 2 (38:19):
Awesome, yeah, likewise.
Speaker 1 (38:21):
So, dr Andy Webb, thank you again for coming on.
I really appreciate your timetoday.
Speaker 2 (38:26):
Yeah, awesome.
Thank you again for theinvitation.
This is an awesome time.
I really appreciate it.
Speaker 1 (38:29):
And for anyone who wants to find the rest of our
stuff, you can find our websitetheneurotransmitterscom, where
we have our old episodes listed,and you can also find me on
Twitter, slash X at Dr KentrisD-R-K-E-N-T-R-I-S.
Andy, thank you again so much,really appreciate it.
Speaker 2 (38:45):
Yeah, thank you again .
Hello and welcome to the Neurotransmitters.
Welcome back.
I'm your host, dr MichaelKentris, and I'm happy to
introduce our next guest today,dr Andy Webb, a neurocritical
care clinical pharmacist fromMGH Harvard.
Andy, thank you so much forjoining us today.
Speaker 2 (00:16):
Yeah, thank you so much for the invitation again.
Speaker 1 (00:19):
So, as so many of the people I'm fortunate enough to
talk with, we met on Twitterslash X, many of the people I'm
fortunate enough to talk with,we met on Twitter slash X, and
I'm a big fan of the work you dothere A lot of educational
content.
I particularly, particularly,really enjoy your website with
your deep dives onNeuroWiseRxcom, and we'll
probably talk more about thatlater.
(00:39):
But I think a lot of peoplemight have a more vague idea of
what pharmacy training lookslike, and particularly when we
get into the realm of clinicalpharmacy.
So I was hoping you could, justfor those who might be less
familiar, kind of throw a broadoverview of what that looks like
.
Speaker 2 (01:00):
Yeah, absolutely.
Those are great questions.
I think there's a lot ofconfusion but people may not be
aware of all the different kindof training programs and
pathways that are out there forpharmacists and so kind of the
traditional path for apharmacist starting out is it's
very much so similar to medicinein that most pharmacists will
do an undergraduate degree andthen we'll go into a four-year
kind of professional clinicaldoctorate program.
So the doctor of pharmacydegree program is a four-year
(01:21):
program.
It's basically three years ofdidactics and then one year of
clinical.
So a little bit different there, where the focus is a lot on
pharmacology, pharmacokinetics,also the kind of pathophysiology
of the diseases, but reallyfocusing on the pharmacotherapy.
So a lot of the coursework thatwe do is kind of how drugs are
used, the rationale for theiruse, kind of how you navigate,
(01:43):
selecting, monitoring and kindof handling drug therapy.
And then our final year, whatwe call like advanced pharmacy
practice experiences or APPEs,is rotations out in the world.
That could be at a hospital, itcould be at a community
pharmacy, it could be at aphysician's office or really
anything in between.
So a lot of our APPEexperiences can be quite varied
if, depending on where apharmacist wants to go, and
(02:05):
after you kind of complete yourfour-year PharmD program, that's
really an entry to practicedegree where you could directly
start working.
So most pharmacists aftergraduating with a PharmD will
start in a community pharmacylike a CVS, walgreens or an
independent pharmacy dispensingmedications.
But clinical pharmacy is kind ofits own subset of pharmacy
practice and so what you can dois actually do specialized
(02:26):
residency training after yougraduate from your PharmD.
And so residency training forpharmacy has been around for a
long time.
It started in probably the last20 years or so and basically
what that looks like is thefirst year of PGY-1 residency
training is basically just likea general residency.
You can kind of think of itlike a categorical intern year
where you kind of see everythingthroughout the hospital.
(02:49):
So you do internal medicinerotations, you do infectious
diseases rotations, you can doan oncology rotation, neurology
rotation and ICU rotation, andreally the purpose of that first
year of training is really tojust give new grad pharmacists
kind of like a broad overview ofwhat clinical practice in a
hospital or some of theresidency programs are based in
(03:10):
the outpatient setting, likereally what clinical practice
looks like and how thepharmacist can kind of interface
with patient care in thatsetting.
And then after your PGY1 year,basically residents can choose
to do a specialty year and sothey can select if they want to
spend a PGY2 year reallyfocusing in on one individual
clinical specialty.
And so I completed my PharmDprogram at the University of
(03:30):
Rhode Island.
I actually did a bit of anaccelerated program.
So one of the options is doinglike a six-year track, so
they're like six-year medschools.
I kind of have a similar ideawhere I did basically two years
of undergrad and then four yearsof the PharmD.
Then I did my general PGY-1 atMayo Clinic in Rochester and
then I actually selectedcritical care to be my specialty
for PGY-2.
And so I went and went throughthe match again after just one
(03:53):
year and did critical caretraining at Oregon Health and
Science University out inPortland I think.
Throughout that entire time, asI was kind of going through my
training, I always knew that Ireally liked neurology and that
aspect of patient care and sothe fact that neurocritical care
was kind of a facet of thatthat I could go into was like
perfect for me, and so I waslucky enough to land in the
position that I am now it's theneuro ICU pharmacist at MassGen.
(04:14):
But basically pharmacists canfind themselves in those sorts
of positions and all differentsorts of specialties and so
really pharmacists are prettywell embedded into specialties
like infectious diseases,oncology, critical care for sure
, and I think neurologyspecifically is probably more of
like a growing field withinpharmacy.
While I think neurocriticalcare is pretty well established
within the field of clinicalpharmacy kind of neurology, in
(04:35):
general there's definitely apretty good number of us, but
it's more of a growing specialtyoverall.
Speaker 1 (04:41):
No, that's very interesting.
I know at one of my previouspractices we would have, I think
probably in the pgi one wewould have some pharmacy
residents coming through likethe epilepsy clinic and things
like that, which obviously hasits own unique challenges as far
as pharmacology goes, yeah, butuh, speaking to that you know,
so obviously critical care, alot of sub-specialized knowledge
(05:04):
there, and then we niche thatdown even further.
So obviously critical care, alot of subspecialized knowledge
there, and then we niche thatdown even further to
neurocritical care.
So so what are some of theunique challenges or kind of the
aspects that drew you to that,specifically as far as, like the
, the neurologic aspect ofpharmacologic care?
Speaker 2 (05:19):
Yeah.
So I think when I was inpharmacy school I think I was
kind of drawn to neurology andthe medications used in epilepsy
.
There's about 30 plus differentseizure medications on the
market and so I loved thepharmacology of those agents,
the complexity of the diseasesand also how much there was
still left to learn about how wecan kind of best take care of
these diseases.
So I think research issomething else that I'm
(05:39):
particularly interested in and Ilove the fact that there was
still so much developmenthappening in how to really best
take care and treat some ofthese hard to treat diseases.
And so really the combinationof the meds, the interesting
diseases, the kind ofopportunities for research and
discovery drew me to neurologyinitially.
And actually interestingly,when I was in pharmacy school I
(06:00):
didn't really even know thatcritical care was a thing that I
could do.
And so my fourth year, my APPErotation I took a MICU rotation
just because I wanted to kind ofget experience.
In that I was like I'm nevergoing to do this again.
I might as well my initialinterest in kind of complex
pharmacology and that sort ofdecision making.
I found kind of a home in theICU where there are these
unstructured problems.
There was collaborativedecision making.
(06:21):
There was a lot of complexity,not only in just the patients
that we were taking care of, butthe medication therapy that
were being prescribed to them,and then so I did a Mickey
rotation and then, as I wasdoing my rotations, there's
obviously, of course, also aneuro ICU at the hospital.
So I went to my preceptor and Iwas like you know, I have this
interest in neurology.
Can I just spend a week in theneuro ICU and kind of see what
it's like?
Speaker 1 (07:01):
And so that's where I really found that that's what
my calling was, so to speakwhere I could still have that
complex, it's always been a realboon, at least from my
perspective.
Where we're talking aboutdosing and interactions, because
while I might be familiar with,like the neurologic medications
, sometimes there are moregeneral things, like the heart
or whatever, whatever that mightescape my notice.
(07:25):
And so it's always good to speakwith someone who is more
broadly familiar with the wholespectrum of interactions and the
various pharmacodynamics andconnects that go into all that
decision-making.
Speaker 2 (07:37):
Yeah, exactly, I think that kind of collaborative
, team-based approach is, Ithink, one of the best parts
about critical care, becauseeverybody on the team be that
you know the attending thefellow, the resident, the
pharmacist, the bedside nurse,pt, ot, speech like we all have
a contribution to patient careand being able to kind of ever
hand out the care of the patientby really making sure that kind
of all the T's are crossed andthe I's are dotted, by really
thinking through everythingabout the patient and the
(07:59):
medication therapy that'sprescribed to them, be that you
know their seizure meds or theirsecondary stroke prevention,
but also like making sure wedon't forget about, you know,
guideline directed therapy forheart failure, those sorts of
things that might not be thefocus of their neurologic
admission, and that's just likethe great value of team-based
care, with the addition of apharmacist to a team.
Speaker 1 (08:17):
Absolutely.
I couldn't agree more.
Now, one thing that I alwaysfind because I you know where
I'm at now I work a lot morewith medical critical care and
in particular with internalmedicine residents and things
like that kind of at a morecommunity teaching hospital and
I find that one of the things Ialways have to hammer on about,
(08:38):
probably to people's annoyance,is the importance of the
blood-brain barrier inmedication delivery.
Is the importance of theblood-brain barrier in
medication delivery.
So I was wondering if you couldspeak a little bit to some of
the unique challenges when wetalk about drug considerations,
both in the neurology sphere aswell as more broadly for other
(08:58):
things.
What are some unique challengesthat you've come across or that
you find that you repeatedlyhave to remind your clinical
care teams about?
Speaker 2 (09:06):
Yeah, I think that you make a great point of like
considering what's going on withthe patient with the
medications that we choose islike huge.
And so I think, like the breadand butter stuff that we as
pharmacists and I myself handleis kind of appropriately dosing
medications based on organfunction.
So recognizing that a patienthas a developing AKI or has
suddenly worsening synthetichepatic function is obviously
(09:28):
going to greatly change howmedications distribute and are
eliminated throughout the body.
And so I think probably one ofthe most common things that I do
is just optimizing andselecting dosing of medications
can do therapeutic drugmonitoring for like valproate or
phenytoin or antibiotics likevancomycin, or just kind of
empirically selecting dosesbased on those individual
patients kind of organ function,like renal and hepatic function
(09:50):
, I think.
Other than that, I think also,yeah, like basically thinking
about therapy for that patient,because sometimes it's you know,
we have a patient who's onlevotiracetam and they have like
moderate to poor renal functionbut they're in pretty bad
status, epilepticus, and I'mgoing to be like I'm okay
pushing the dose up a little bithigher here, even if you know
the textbook says that we shouldbe lowering the dose.
Sometimes my job is fighting,not lowering doses.
(10:11):
So I'm really making sure thatwe're optimizing the therapies
that we have.
I think that's also I help a lotof my colleagues in other ICUs
and other floors to usemedications that they're also
not super familiar with.
So if there's a patient with aneurologic diagnosis on a
surgery floor, for instance, youknow one of the pharmacists may
reach out to me and be like,hey, my team has a question on,
you know, to pyramid dosing orsome other dosing of some
(10:32):
medication they may be lessfamiliar with.
And I'm also helpful in helpingmy colleagues through what
considerations to have withthese medications.
You know like the surgery teammay be banging their head
against the wall by.
This patient has an unexplainedmetabolic acidosis and I get
the question of like, oh, it'sprobably the tapiramide, and so
kind of considering some ofthose lesser known toxicities
that patients you knowclinicians may be less familiar
(10:53):
with with medications they don'tuse very often.
Education, essentially, isanother large role of mine to
helping make sure everyone canuse the medications they're
using rationally and safely.
Speaker 1 (11:02):
No, that's great of use the medications they're
using rationally and safely.
No, that's great.
So yeah, as you were answering,I was coming to mind of a
consult I had for someone in theICU who I think her GFR was
maybe 20 and she was like on twograms of Cephapim.
Speaker 2 (11:19):
BID A little bit confused.
Speaker 1 (11:21):
If you can guess the reason for the consult it was in
fact altered mental status.
Speaker 2 (11:26):
Yeah, I've seen this movie before.
Related to that, wrapping inthe highest quality, most
up-to-date evidence is anotherhuge part of my role.
So, for instance, we had apatient who had a seizure
overnight, not 100% sure whatcaused it.
They were on cefepime, the dosewas appropriate, but we have
the ACORN trial.
So I could point to evidenceand say like well, we have an
(11:48):
alternative therapy that wecould use.
So we switched this patient toZosyn because it made sense for
the infection that we'retreating.
And so helping my team kind ofdo the best evidence-based care
is the other big thing that I do.
I'm the guy who pulls mycomputer around to point at the
most recent trial and like lookat this curve and here's why we
can do this, and so that'sanother thing that I absolutely
love is using evidence whenwe're taking care of patients
and also teaching other peopleabout what the evidence has to
(12:09):
say about the decisions that wemake.
Speaker 1 (12:11):
No, that's, that's great.
And it just seems there's sucha plethora of papers and trials
on daily and weekly basis it'svery challenging to keep up
sometimes.
Speaker 2 (12:19):
A hundred percent, like when the European stroke
conference happened a couple ofweeks ago.
It was like every day I'm like.
Well, here's another practicechanging landmark trial that we
have to consider.
Speaker 1 (12:28):
I know it's uh, it's great, but it's also frustrating
because it feels likeeverything I just learned last
year is out of date now, exactly, exactly so but such such as
the way of things I suppose Uhbut uh, to that effect, you know
, like, yes, we have all thesenew things, sometimes telling us
the thing we've been doing formaybe decades is wrong.
(12:50):
And there are still some ofthese older meds on the market.
I'm thinking of, in particular,our valproic acid and phenytoin
, phosphonytoin, all thesethings that are still like very
much in the guidelines forspecific situations, that are
still very much in theguidelines for specific
situations, and, in particular,I'm thinking of a deep dive you
(13:12):
did onto the free versus totalvalproic acid trial that came
out this last year and I waswondering if you would indulge
me and talk a little bit aboutthe unique challenges when we're
talking about, like highprotein bound molecules and free
versus total fractions, and howdo we deal with that as things
get more and more complicated.
Speaker 2 (13:30):
Totally yeah.
So you know you hit on a petproject or pet interest of mine
and I think that you know, as apharmacist, pharmacokinetics is
like one of the real bread andbutter things that we bring to
the table.
Pharmacists, pharmacokineticsis like one of the real bread
and butter things that we bringto the table.
And seizure meds have like someof the most complex and like
frustrating head banging againstthe wall pharmacokinetics of
all the medications that we have.
So like phenytoin is like theperfect case example of you know
(13:51):
, when I was in pharmacy schoolwe spent like two weeks on
phenytoin PK alone, just becauseof learning about what
Michaelis mentioned kineticsmeant and how all the different
drug interactions and proteinbinding interacts with things,
and so I think that's also oneof the things that really drew
me to these sorts of medicationsis just how interesting and
complex they kind of get aroundthe body, and I think valproate
(14:12):
is almost like anunder-recognized, similarly
complex, frustrating seizuremedication in that perspective.
So as a trainee, I was kind offaced with some of these
challenges if we had a patienton valproate.
Because, yeah, your point, it's, it's older, we have experience
with it, it's in the guidelinesthere's, you know,
quote-unquote good data forusing valproate in various
seizure types.
On valproate, uh, and they justweren't waking up.
(14:33):
You know their eeg wassuggestive, you know that they
they're not seizing, there'snothing else obvious going on.
And so my preceptor at the time, caitlin Brown, was like we
should check a free level,because this you know this has
complex protein binding was likeoff the charts.
And so we had this total level.
I was like 50 or 60.
Like this shouldn't be that bigof a deal.
Checked a free level, the freelevel was like 40 or 50.
(14:55):
And you look at the referencerange, that should be somewhere
between like five and 15 to fiveto 20.
But like this is clearlyabnormal and it's something that
I think a lot of teams justdon't even think about, where
they see the total valproatelevel and they're like we're
good to go, like this patient isin range, nothing to worry
about, and by lowering the doseand, you know, significantly
decreasing the patient'sexposure, they woke up and so
it's kind of like a perfect seedto say like this is a something
(15:18):
is clinically relevant, reallydoes matter to the patients that
we take care of and is likevery under recognized.
And so really, from some of thework that Caitlin Brown, her
colleagues, have done got meadditionally interested in
really looking into this andexactly like why this happens.
I think one of the other thingsthat as a pharmacist, I really
like to bring to the team interms of value is like, yeah,
(15:38):
those deep dive, like in depthunderstanding about exactly what
these meds are and what they'redoing.
And there's so much aboutValproate and the other seizure
medications that's just very.
Valproate is a bit unique inthat it's just this little tiny
kind of you know fatty acid thatjust happens to hit all these
different receptors and allthese different ion channels and
(16:00):
just happens to kind of be thisbroad spectrum very effective
anesthesia medication.
But that sort of small fattyacid structure also means that
it interacts with a whole bunchof other things you would not
exactly expect.
And, to your point, yeah, thebig thing that is important
about it is it's binding toalbumin and when it's bound to
albumin it's not doing anything.
When it's unbound to albumin,that's when it's
(16:24):
pharmacologically active andable to have both its clinical
effects and its toxicities.
And not recognizing thedifference between the total and
the free can really leadclinicians astray in
misinterpreting a level and kindof what we've found is that
critically ill patients, for amyriad of reasons, have wildly
altered protein binding and havewildly extreme exposures to
(16:44):
free valproate levels, out ofproportion to what you might
expect.
And so digging into theevidence has helped me.
You know, obviously, hepaticdysfunction with changes in how
much albumin patients actuallyhave, but also things like
unexpected drug interactionslike aspirin and warfarin,
propofol, you know, intralipidfrom a TPN all of these things
will knock that fatty acidvalproate off of its albumin and
(17:06):
protein binding site.
It will increase patient'sexposure.
And there's actually some workthat we're doing.
We're looking at what theclinical consequences of that is
and basically what we found isthat it really is the free level
that is what's predictive ofpatients having side effects.
And so we found basically thatpatients with really high free
levels, even if their totallevel is fine, have more
(17:28):
hepatotoxicity.
They have lower platelets,they're likely more sedated and
you might check a total leveland see that it's 50.
And you're like we're great.
But if they're not waking up,it very well may be because
their protein binding is totallyoff whack and something like
that aspect of really digginginto the evidence and
understanding how these meds areis one of the biggest roles I
think a pharmacist can have,because those kinds of like
(17:48):
things you don't really thinkabout, that are just unique
about a medication, can reallyhave pretty profound impacts on
the kind of day-to-dayindividual care of one patient.
Speaker 1 (17:57):
No, that's, that's awesome and it's, you know,
putting kind of ourretrospective scopes on.
You kind of look back at someof these old papers from, like
you know, 40, 50 years ago, yeah, and they're like, oh, a you
know non-dose relation, likewith hepatic or a
Depakote-induced encephalopathyor things like that.
Speaker 2 (18:15):
I'm like, well, maybe maybe it is dose-related, it's
just not.
You know, it was something weweren't measuring decades ago.
Yeah, and I think, like withDepakote in particular, one of
the most interesting things is,you know, everybody knows that
50 to 100 or 50 to 125 is a goodrange.
But when you talk about quote,unquote, good evidence when you
go back, the authors wereessentially they just guessed.
(18:35):
They measured levels in a bunchof patients who had seizures,
who were on Depakote, and theynoticed that patients whose
levels were somewhere in therange of 50 to 100 tended not to
seize as much.
And they're like, this range ispretty convenient.
So that's what we're going togo with and that is effectively
what the discussion of thispaper is.
There's no empirical PKPDanalyses.
It's just like this seemssufficient and that has kind of
(18:56):
carried forward, and so there'sdefinitely a lot pkpd analyses.
It's just like this seemssufficient and that has kind of
carried forward, and so there'sdefinitely a lot more work for
us to do to kind of update that.
Speaker 1 (19:03):
Yeah and that's uh.
I remember when I was a pgy2myself and one of my epilepsy uh
attendings asked me like youknow, it's like so the, the
valproate range, you know normalis 50 to 100.
You know, for fenny towin it's10 to 20.
It's like, don't those seemawfully rounded off?
Speaker 2 (19:21):
it's like, yeah, there's the evidence is garbage
uh yeah, somebody made a goodguess and they just kind of ran
with it.
Speaker 1 (19:26):
And here we are 40 years later just dealing with
the consequences yeah, so it isone of those things where it's
like uh, it's kind of that oldtruism, at least in epilepsy.
It's like when's the persontoxic when they're having side
effects, when are theytherapeutic when they're not
having seizures?
Speaker 2 (19:41):
Yeah, like I had an attending who's like I don't
really pay too much attention tophenytoin levels until they
have nystagmus.
It's like that's one way to doit.
Speaker 1 (19:49):
I've heard that exact same thing before, yeah.
Speaker 2 (19:52):
And that is.
Speaker 1 (19:52):
You know, it's especially for those two drugs
in particular, when I have round, like students or residents
around me with me.
Uh, one of my I should say oneof my favorite, maybe not one of
their favorite ones is to goaround in a circle and name one
side effect, yeah, of alproicacid, until you run out yeah,
the circle can get quite largeuntil you run out of side
(20:13):
effects right, and I thinkthat's that's just so.
uh, to your point earlier, it'sthat, it's uh we have to
consider not just you know it'seasy to put our blinders on and
think only about neurologicissues but to think about the
broader human body and what wemight be causing.
Like one of the ones I run intomore often, especially with
(20:33):
those older meds, is, like youknow, folks here with like AFib,
rvr, like an amio drip orsomething like that and just
like well, you know, you need tobe a little bit careful here.
Speaker 2 (20:44):
Yeah, mean it's.
Maybe this patient's plateletcount is low because of the depo
code or like their abdominalcomplaints might be pancreatitis
from the depo code, and peopleoftentimes forget about these
like pretty rare but can bequite.
Concerning toxicities thataren't necessarily neurologic
and related in and in nature, uh, because there are so many kind
of off-target effects of a lot,particularly these older
(21:06):
medications.
Speaker 1 (21:07):
Yeah, I know there was that huge class action
lawsuit over in the UK a fewyears back because people
weren't being young women inparticular weren't being
counseled on the teratogenicside effects, which obviously
are super well-known for decades, which I thought was just
mind-boggling that that wasn'tbeing clearly communicated to
(21:28):
like population at large yeah, Ithink it's to the point where,
like, prescribing of valproateto women in the uk is
essentially restricted now,where there needs to be like
clear documentation that otherthings have not worked and
everyone is on the same pageabout what the pros and cons of
this therapy is.
Speaker 2 (21:42):
So that I think yeah to your point.
It's, if it's easy to forget,like as an effective seizure man
, we'll just start it for thatreason.
But there's a lot of things toconsider beyond just seizure
reduction yeah, yeah, definitelyvery important.
Speaker 1 (21:53):
I I remember I I had, uh, a younger woman who you
know, she she was a immigrantfrom central america and uh, you
know she had epilepsy, I thinkas a if I remember correctly,
it's been a few years uhsequelae, like sister sarcosis,
and um, she'd failed like somany meds and so I was adding
(22:13):
just a little bit of depakote.
You know, she's in her late 30sand I said multiple times, both
myself with my poor spanish, aswell as via the official
translator, like, like, listen,you cannot get pregnant on this.
And God, god help me.
She showed up three monthslater, fortunately or
unfortunately, it seems she hadnot been taking her anti-seizure
medication.
(22:34):
So, it ended up not beingrelevant in that case, but oh
man those cases stick with you,for sure.
Yes, I was just like oh my God,yeah, but yes, it's.
It's one of those things wheresometimes you know it doesn't
matter how much you harp onabout it, the worst case still
happens sometimes.
Speaker 2 (22:50):
Totally.
Speaker 1 (22:50):
Totally as far as, like you know, we've talked a
little bit about kind of yourmultidisciplinary role.
What are your favorite thingsto treat in the neuro ICU as a
clinical pharmacist?
Speaker 2 (23:00):
Yeah.
So I think you know, related tothis discussion we've been
having, honestly, I think youknow, related to the discussion
we've been having, honestly, Ithink status is like by far and
away the most favorite thingthat I have to treat.
It's.
It's funny because, you know,status epilepticus is can be
deeply satisfying as apharmacist, but can also be one
of the most challenging anddifficult diseases to take care
of, and so obviously, as thepharmacist in the neuro ICU, I
(23:22):
have an affinity for the diseasestate which is largely
exclusively treated withpharmacologic agents, you know
excluding, you know, vns and RNSand surgical therapies right,
and so I think the thing I lovedoing the most is just making
the most of the medications thatwe have, and so in ensuring
that, you know, our Keppra ismaxed out, our everything is
maxed out, and then when thekind of standard things don't
(23:44):
work, the creativity of likewhat is the best next thing for
this patient is like.
Such a great experience.
To like, choose a medicationusing some rationale, really
thinking through the patientcase as much as we can, and then
seeing it work is like has tobe the most satisfying thing out
there.
It's kind of funny in pharmacyschool when we learned about
seizures and epilepsy andseizure medications it was
(24:04):
essentially like here are themeds, here's what they do, here
are the side effects, and therewasn't a lot of focus on like
how you actually select an agentin terms of like really what
does make the most sense for apatient of the legitimate 30
options that we have?
It's been really satisfying todevelop that kind of expertise
to say like well for thispatient.
You know Clobazam actuallymakes the most sense, or
(24:25):
Parampanel makes the most sensebecause they're ketamine
responsive or something alongthose lines.
And when it all works out it'slike phenomenal.
It's like to the point of thecases that stick out.
There are so many cases of thepatient who was burst,
suppressed for three days andreally difficult to wean, and
you know the most recent one.
It's like we're all kind ofwringing our hands what to do
next and I was like, well, likethe one thing we haven't tried
(24:47):
is cannabidiol and we start thatand we're able to wean
anesthesia.
She wakes up two days later shegets extubated and like when
those sorts of cases work out,it's just like such a satisfying
experience as a pharmacist tobe able to help optimize the
perfect regimen to make sure thepatient obviously isn't seizing
but also can kill kind of havea quality of life and get out of
the hospital in a safe way.
(25:08):
But I think the dark side ofthat is, you know, it is very
frustrating when things don'twork out.
Which is one of the mostchallenging things about status
is when that patient really justdoesn't seem to respond to
everything or anything that wetry.
But the good thing I guesssupposedly is that is super
inspiring to continue to worktowards future therapies for
what could work for thosepatients.
And so I've been lucky enoughto be involved in, you know, a
(25:30):
clinical trial for refractorystatus epilepticus drug
Ganaxolone, you know, as kind ofmore an operational aspect of
helping to screen patients andget patients enrolled in the
study and actually get the studydrug and also involved in
research really seeing like ofthe stuff that we have done
like's working, and so reallystill being able to be involved
in discovery about how to besttake care of these patients is
(25:50):
also the other thing that I getthe most satisfaction out of
nice.
Speaker 1 (25:54):
Is that a new neurosteroid agent?
Speaker 2 (25:56):
yeah, exactly, and so it's in phase three trial right
now, and so we don't know theresults yet, but certainly very
promising.
It's the kind of drug whereit's technically placebo
controlled but sometimes youfeel like it's kind of hard to
blind, you know.
So we're all, I think all veryexcited to see what the final
results of that trial are.
Speaker 1 (26:13):
That'll be exciting.
Yeah, I remember when they weredoing the.
I think it was Pregnant Alone.
Yeah, was that five or sixyears ago at this point?
Speaker 2 (26:19):
Yeah, yeah, unfortunately not successful,
which I think speaks to just Ahow challenging it is to pick
patients who might be eligibleor benefit from these agents.
So I think that the challengingthing about the RAISE trial is
just how stringent the selectionand inclusion criteria were,
and so it was hard to find theright patient, and so we'll kind
of see what the results are,but we're all very excited.
Speaker 1 (26:40):
And I think to your earlier point right, I'm a big
advocate for the kind of therational polypharmacy for status
epilepticus or epilepsymanagement in general.
Obviously I'm biased, sincethat's my background in
particular.
But one of the things that Ithink is so challenging,
especially when we're talkingabout like drug selection, is
like what is the underlyingetiology of the person's
seizures?
It's just so heterogeneous inthe population that it can be
(27:03):
really challenging.
Just so heterogeneous in thepopulation that it can be really
challenging.
Like you know, they've got anold stroke or an old traumatic
brain injury or maybe they havesome sort of generalized
epilepsy.
That's not well, you know,distinguished and there's just
so many ways that it can shakeout.
It's very challenging sometimes.
Speaker 2 (27:17):
A hundred percent, yeah.
And then you've got the patientwith Norse who you are truly,
you know wringing your handsabout what to do next.
And those patients I mean someof the regimens that I've, you
know, helped take care ofpatients on are truly, truly
unique.
When we're pulling outimmunotherapies and we're
starting ketogenic diets andthat's another big thing that I
help with is how many milligramsof carbohydrate are in the, you
(27:39):
know, the parampanel tablet.
So helping to tinker with allthose things to maximize the
success of those therapies, itcan be a lot of fun, it's a lot
of work, uh, but it's.
It's a real, you know, honor tobe able to take care of those
patients no, that's excellent.
That's, that is something god II haven't had to think about
that since I was a fellow uh, togo through the list of 50 meds,
(28:00):
they're on and callmanufacturers and be like, hey,
is there more than 50 milligramsin this tablet?
And they're on and callmanufacturers and be like, hey,
is there more than 50 milligramsin this tablet?
Speaker 1 (28:07):
And they're like why are you asking me?
Speaker 2 (28:08):
this question, but once you get the answer it's a
lot of fun to kind of figure allthat out?
Speaker 1 (28:11):
No, definitely Definitely.
My wife's a dietician.
She's been involved with thoseconversations as well.
Speaker 2 (28:16):
Yeah, Carmen, who's our dietician on the unit, is
like phenomenal about goingthrough all of those
considerations, and we work veryclosely together to make sure
everything's all tucked in, tiedin a bow, before we start the
keto diet.
Speaker 1 (28:28):
Now, as far as like, if you wanted to say like, why
should someone who's consideringlet's say they're in their
undergrad pharmacy program?
What would you say to those whomight be intrigued by
neurocritical care?
What kind of experiences shouldthey seek out?
Speaker 2 (28:44):
Yeah, 100%.
So I think the things to thinkabout if you're thinking about
going into neurocritical care isyou really need to be the kind
of person who likescollaborative decision-making
and really thinking through anindividual patient who makes the
most sense, what therapy makesthe most sense for that
individual patient.
You want to be the kind ofperson who likes thinking
through evidence and applyingthat to a patient and you have
(29:05):
to be able to really like thecomplexity and a lot of the gray
that is within and justinherent to neurology and
neurocritical care.
And so I think you know, ifyou're seeking for those
opportunities certainly ifyou're in your PharmD program,
seeking out APPEs that are atlike an academic center that has
a neuro ICU where you can workwith a neurocritical care
pharmacist, you can introduceyou to the team and kind of be
(29:26):
part of that decision making andalso being, you know, coming
involved in the neurocriticalcare society, where we have a
pretty active and wellestablished group of pharmacists
who are quite integral to thatsociety.
So you know, for instance,gretchen Brophy, who's a
pharmacist at VCU, was theprimary author on the NCS status
guidelines that are now 12years old, so getting a little
(29:46):
dated, but regardless, justreally highlighting the fact
that pharmacists are pretty wellembedded in NCS and are really
integral member of that team.
Really the greatest thing aboutbeing a neurocritical care
pharmacist is we really get topractice at the top of our
knowledge.
So in pharmacy sometimes wetalk about practicing at the top
of our license.
So what we're legally able todo, be that independently manage
(30:09):
medications or do therapeuticdrug monitoring, all these sorts
of things.
But I think in the neuro ICU Ireally get to go beyond that
because I get to really bring tothe table how do the drugs work
, how do they interact with thisindividual patient's disease
state, what's my understandingof the patient's pathophysiology
, what complications we'rehandling right now, what's
happening at the bedside andeverybody can kind of come
(30:31):
together and make the bestdecision.
For instance, we had a severetraumatic brain injury patient
on the unit this week and youknow I was at the bedside with
the kind of the fellow and thephysician assistant thinking
through like what is the bestnext step on the ladder for this
patient's ICP crisis?
And it's a lot more complicatedthan just, you know, just
increase the propofol or justgive 23%.
(30:52):
It's really thinking throughlike how do we understand what's
going on inside that patient'sskull and what do we have to do?
And it's always a little oddwhen I'm the pharmacist and I'm
like I think this patient needssurgery and so like thinking
through all of the complexitiesthere.
I being able to bring themedication side of things just
really helps round outeverybody's thinking through how
(31:13):
we're going to take best, takecare of this patient.
And so you know pharmacystudents who are thinking about
what clinical field they want togo into, that sort of
fast-paced, complex decisionmaking with a lot of unknowns.
Because I think one thing thatas a pharmacist is really
satisfying when I can point to atrial and be like black and
white this is what the thing weneed to do is that's very rare
in neurology to be able to saythat.
(31:34):
And so when I have learners, Ithink the thing that I have to
really help them becomecomfortable with is like there
is no correct answer.
So being able to be comfortablewith what's our understanding
of the data, the patient, whatoptions we have available, and
just navigating the best pathforward, it's really hard but
can be really satisfying whenyou kind of come to a conclusion
, implement that plan and kindof see it work out in front of
(31:56):
your eyes.
Speaker 1 (31:57):
That's excellent, and you know to your.
To your point about theincreased ICPs yes, you're the
pharmacist, but you're theperson who knows, like I don't
think, medication is going towork any further beyond where
we've pushed it Right.
So I think that's that's stilla very useful perspective to
have on that front.
Speaker 2 (32:12):
I'm talking with the neurosurgery residents and
they're like well, you need tomaximize medical therapy.
And I'm like, I'm telling youwe have maximized medical
therapy, it is maximized.
Speaker 1 (32:21):
That is excellent.
And for, let's say, internalmedicine or neurology residents
out there, or even nursing staff, if they want to learn more
about neurocritical care,pharmacy, pharmacology what are
some good resources that youwould recommend?
Speaker 2 (32:36):
Yeah, so I'll go back to NCS.
We're like NCS and the group ofneurocritical care pharmacists
who are involved in NCS havedone a really awesome job of
producing good resources aboutneurocritical care
pharmacotherapy.
So there's the On Call program,the PONS program, which is the
pharmacotherapy of neurocriticalcare series.
So there's lots of resourcesthat relate to kind of the
(32:58):
science and the knowledge ofmedication use therapy in
neurocritical care.
But additionally there's a lotof resources about kind of like
how to get in touch with neuroICU pharmacists if you want to
network and get to know somebodyin your area, and so I think
that's probably the hub to kindof find pharmacists in this
field and particularly, you know, if you are at an institution
with a neuro ICU that does nothave a neurocritical care
(33:20):
pharmacist.
Ncs also has a program calledthe ICP program, if I'm
remembering it correctly, whereit's basically what they'll do
and I'm now blanking on the whatthe acronym actually stands for
, but it's something aboutsomething clinical pharmacist.
Well, they'll basically send anexperienced neuro ICU
pharmacist to an institution tohelp set up neurocritical care
(33:41):
or pharmacy services at yourinstitution.
So, for instance, if you're ahospital that's opening up a
neuro ICU for the first time andthe institution might be
interested in having somebodycome in help establish pharmacy
services, help write guidelines,establish the formulary like
figure out where you're going tokeep your 23% vials or those
(34:02):
sorts of things.
Ncs will actually sponsor amore experienced neuro ICU
pharmacist to go out to thatinstitution, help mentor a
pharmacist who might beestablishing their practice site
at that institution and alsoreally help the institution
maximize the role of thepharmacist in that setting.
So that could be, you know,writing a guideline for ICP
management or establishingworkflows for status response.
(34:25):
There's a good amount of datanow that you know having a
pharmacist involved in thesecritical kind of experience or
instances, be that, you know,thrombolysis for stroke,
response to seizures and statusepilepticus.
There's actually a recent paperthat came out for
anticoagulation reversal in ICHdirect involvement of a
pharmacist in the care of thosepatients.
(34:46):
Even if, you know, if theyweren't necessarily able to
directly show benefits inmortality, they were able to
show benefits in more surrogateoutcomes like faster time to
thrombolysis or faster time toanticoagulation reversal or more
appropriate seizure medicationdosing and faster time to first
benzo.
And when you put all thosethings together it's a pretty
strong body of evidence thatclearly definitively shows that
(35:08):
involvement of a pharmacist doesimprove the outcomes of the
patients that we take care of.
So particularly forinstitutions who are either
developing or looking to developpharmacy services in this area,
there's a lot of good resourcesto help support that and
establish a good pharmacistpresence in their unit.
Speaker 1 (35:24):
Well, that is awesome information.
I'm going to have to keep thatin mind myself.
I know we're in the process ofexpanding our neuro ICU, so good
to know, yeah definitely.
Speaker 2 (35:32):
It's an awesome resource and there's a lot of
good examples of you know a newgraduating pharmacy resident
who's starting out in a newneuro ICU and it can be really
intimidating as a newpractitioner to step into a
subspecialized ICU that doesn'thave an established pharmacist
already, and so there's a lot ofinstitutional organizational
support to make sure that neuroICU itself can practice as best
(35:56):
as possible and that pharmacistis also supported to make sure
that they can have the smoothesttransition into practice
possible.
Speaker 1 (36:02):
Very cool, very cool.
Any final, any final thoughts,things that you want to plug,
projects that you're wanting tomake the public aware of.
Speaker 2 (36:09):
Yeah, definitely.
So I mean, I appreciate youkind of throwing out or shouting
out my website.
So neurowiserxcom I will admitthat I am probably not the most
loyal poster because it turnsout those posts are a lot of
work to put together.
They look like it, yeah, butbasically what I my hope is that
I'll probably try to post alittle bit more diligently in
the future, but it's certainly alot of work dig through every
publication from 1960 on so.
(36:31):
But my goal is really to answerthose sorts of questions in a
way that brings up all theevidence that we have available.
And certainly people havequestions that they want me to
look into.
I'm certainly open to those aswell.
I think the other thing toreally just plug is that you
know pharmacists have a big rolein neuro ICU in particular, but
really in any care where met.
There is certainly of largevalue in having pharmacists
(36:52):
round with your stroke teams oryour general neurology teams or
the epilepsy monitoring unit andso kind of reaching out to your
pharmacy departments at yourindividual institutions to see
what resources are available.
You might be surprised at whatsort of value a pharmacist can
add.
Speaker 1 (37:04):
No, I couldn't agree more.
I always considered it.
It was that we're just startingto get a pharmacist rounding on
a regular neurology team whereI was previously a few years ago
, and it it provided just thisvery subtle boost.
Yeah, it made everything alittle easier.
Speaker 2 (37:21):
Yeah, totally.
Speaker 1 (37:22):
Which was it's always great, yeah, absolutely, but no
, I couldn't agree more.
It's always good to have moreperspectives on the
multidisciplinary side of thingswhen when rounding as a team.
Speaker 2 (37:32):
Yeah, absolutely.
Speaker 1 (37:34):
And if people want to find your work, they want to
find where you are.
I know we mentionedneurowiserexcom Anywhere else
they should check out for you.
Speaker 2 (37:41):
Yeah, so I'm certainly busy on Twitter slash
X, whatever you want to call it.
So my handle is AJWfarm, so Itry to post relevant things to
neurology, neurocritical care,critical care in general.
Do that the most recentevidence that I can find, or my
own opinion on kind ofinteresting things that have
happened on the unit or in thefield of neurology, and so I
would say I'm fairly activethere.
(38:02):
So certainly excited tointeract with everybody who is
on that platform to kind of helpus all.
I think personally, I havelearned a ton on Twitter and
I've tried to kind of return thefavor, and so I always love
interacting with new people onthat platform.
Speaker 1 (38:16):
Awesome.
I certainly appreciate yourwork on there as well.
I've learned a lot myself.
Speaker 2 (38:19):
Awesome, yeah, likewise.
Speaker 1 (38:21):
So, dr Andy Webb, thank you again for coming on.
I really appreciate your timetoday.
Speaker 2 (38:26):
Yeah, awesome.
Thank you again for theinvitation.
This is an awesome time.
I really appreciate it.
Speaker 1 (38:29):
And for anyone who wants to find the rest of our
stuff, you can find our websitetheneurotransmitterscom, where
we have our old episodes listed,and you can also find me on
Twitter, slash X at Dr KentrisD-R-K-E-N-T-R-I-S.
Andy, thank you again so much,really appreciate it.
Speaker 2 (38:45):
Yeah, thank you again .
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