DRUG DOSING IN EXTRACORPOREAL THERAPIES

To encourage research on the pharmacokinetics and pharmacodynamics of drug dosing in extracorporeal therapies; further,

To support development and use of standardized models of assessment of the pharmacokinetics and pharmacodynamics of drug dosing in extracorporeal therapies; further,

To collaborate with stakeholders in enhancing aggregation of data on the pharmacokinetics and pharmacodynamics of drug dosing in extracorporeal therapies; further,

To encourage the education of the pharmacy workforce and other healthcare providers regarding the basic principles of and drug dosing in extracorporeal therapies.

This policy supersedes ASHP policy 1606.

Rationale

There are few resources and recommendations for drug dosing in patients receiving the varied forms of extracorporeal therapies, including renal replacement therapy, extracorporeal membrane oxygenation (ECMO) support, apheresis, plasmapheresis, molecular adsorbent recirculating system (MARS) support, single pass albumin dialysis (SPAD), fractionated plasma separation and adsorption (PROMETHEUS), therapeutic plasma exchange (TPE), extracorporeal liver assist device (ELAD) support, modular extracorporeal liver (MELS) support, peritoneal dialysis, and use of ventricular assist devices.

Appropriate dosing is very important in optimizing patient outcomes and achieving goals of therapy. Often drug properties are used to make educated guesses on appropriate dosing and are based on estimations of clearance. In the critically ill population, serious infections and renal issues often occur simultaneously. Solute removal has a significant impact on dosing and appropriate dosing. Many patient characteristics and device variables need to be considered when dosing patients receiving these therapies. These factors include flow rate, membrane pore size, volume of distribution, and patient status. Protein binding helps sustain the drug in tissue, and drugs with a large molecular weight may clog the porous membranes.

Research on drug removal by these extracorporeal means is scarce, and ASHP encourages independent clinical and practice-based research to further define clinical use of drugs for patients receiving these modes of treatment as well as clinician reporting of patient experience via published articles and clinical registries. ASHP also encourages education of the pharmacy workforce and other healthcare providers regarding the basic principles of and drug dosing in extracorporeal therapies.