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Background: The participation of pharmacists on cardiopulmonary resuscitation (CPR) teams has been associated with improvements in patient outcomes secondary to lower rates of adverse drug events and higher rates of compliance with guidelines for advanced cardiac life support (ACLS). The degree to which Canadian pharmacists participate on CPR teams and the services they provide have not previously been assessed. Objectives: To measure the frequency of pharmacists’ involvement on CPR teams in Canadian health care delivery organizations, to characterize the services provided by these pharmacists, to identify positive predictors of participation, and, for health care delivery organizations without pharmacists on CPR teams, to determine the reasons for the lack of involvement. Methods: An electronic survey was distributed to key informants in Canadian health care delivery organizations. The survey consisted of questions about characteristics of the health care delivery organizations, pharmacists’ participation and role on the CPR team, training, and barriers to implementation. The primary outcome was the percentage of health care delivery organizations with pharmacists participating on CPR teams in at least one centre within the organization. The secondary outcomes were pharmacists’ activities, training, and reasons for not participating on CPR teams. Results: Forty-three of 99 key informants responded to the survey. Twenty-nine respondents (67%) indicated that their organization had a CPR team, and 10 (23%) indicated participation by pharmacists on a CPR team. Roles reported to be performed by pharmacists during CPR events were provision of drug information, preparation and administration of medications, record- keeping, and chest compressions. Training for these pharmacists was variable: ACLS training for 4 (40%) of the 10 organizations with pharmacist participation, in-house training for 3 (30%), and no training for 2 (20%); one respondent (10%) did not report the level of training. Reasons for not having pharmacists on CPR teams included inconsistent coverage, lack of training, and staff shortages. Conclusions: This study characterized current pharmacist participation on CPR teams in Canadian health care delivery organizations. As evidence arises showing the impact of this practice on patient outcomes, pharmacist participation on CPR teams may become more common. RESUME Contexte : L’integration des pharmaciens aux equipes de reanimation cardio-respiratoire (RCR) a ete associee a une amelioration des resultats therapeutiques, qui est due a des taux plus faibles d’evenements indesi - rables lies aux medicaments et a un meilleur degre de conformite aux lignes directrices portant sur la technique specialisee de reanimation cardiorespiratoire. Or, aucune etude n’a encore analyse la mesure dans laquelle les pharmaciens canadiens participent aux equipes de RCR et l’eventail des services qu’ils fournissent en leur sein. Objectifs : Evaluer dans quelle mesure les pharmaciens participent aux equipes de RCR des organismes canadiens de prestation de soins de sante, decrire les services fournis par ces pharmaciens, identifier les facteurs predictifs de participation et, dans les organismes de prestation de soins de sante ou aucun pharmacien ne fait partie des equipes de RCR, determiner les raisons expliquant cette absence. Methodes : Un sondage electronique a ete donne aux informateurs cles des organismes canadiens de prestation de soins de sante. Le sondage contenait des questions portant sur les caracteristiques des organimes de prestation de soins de sante, la presence des pharmaciens au sein de l’equipe de RCR et le role qu’ils y jouent, leur formation en RCR et les obstacles s’opposant a leur participation. Le principal parametre d’evaluation etait le pourcentage d’organismes de prestation de soins de sante ou des pharmaciens faisaient partie d’equipes de RCR dans au moins l’un des centres de l’organisme. Les parametres d’evaluation secondaires comprenaient les activites et la formation des pharmaciens ainsi que les raisons expliquant leur absence des equipes de RCR. Resultats : En tout, 43 des 99 informateurs cles ont repondu au sondage. Vingt-neuf repondants (67 %) ont indique que leur organisme avait une equipe de RCR et 10 (23 %) ont souligne la participation de pharmaciens dans l’equipe. Selon les reponses, les pharmaciens jouaient differents roles pendant les episodes de RCR, notamment : fournir des renseignements sur des medicaments, preparer et administrer des medicaments, effectuer la tenue de dossiers et realiser des compressions thoraciques. La formation de ces pharmaciens etait inegale : 4 (40 %) des 10 organismes ou des pharmaciens participaient offraient une formation en technique specialisee de reanimation cardio-respiratoire, 3 (30 %) offraient une formation interne et 2 (20 %) n’offraient aucune formation; un repondant (10 %) n’a pas precise le niveau de formation. L’inegalite du service, le manque de formation et les penuries de personnel faisaient partie des raisons expliquant l’absence des pharmaciens des equipes de RCR. Conclusions : La presente etude a dresse le portrait actuel de la participation des pharmaciens dans les equipes de RCR des organismes canadiens de prestation de soins de sante. Au fur et a mesure qu’apparaitront des donnees illustrant l’effet de cette pratique sur les resultats therapeutiques, il est possible que la participation de pharmaciens dans les equipes de RCR devienne de plus en plus frequente.

Payam Dehghani,1 Varun Chopra,1 Ali Bell,2 Sheila Kelly,1 Lori Zulyniak,2 Jeff Booker,1 Rodney Zimmermann,1 William Semchuk,2 Asim N Cheema,3 Andrea J Lavoie1 1Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, 2Regina Qu’Appelle Health Region, Regina, SK, 3St Michael’s Hospital, University ofToronto, Toronto, ON, Canada Background: As ticagrelor enters into clinical use for acute coronary syndrome, it is ­important to understand patient/physician behavior in terms of appropriate use, adherence, and event rates. Methods: The Saskatchewan Registry is a prospective, observational, multicenter cohort study that identifies consecutive patients started on ticagrelor. We aimed to evaluate both on- and off-label use, identify characteristics of patients who prematurely stop ticagrelor, and describe patient/physician behavior contributing to inappropriate stoppage of this medication. Results: From April 2012to September 2013, 227patients were initiated on ticagrelor, with a mean age of 62.2±12.1years. The participants were 66% men and had a mean follow up of 157.4±111.7days. Seventy-four patients (32.4%) had off-label indications. Forty-seven patients (20.7%) prematurely stopped ticagrelor and were more likely to be older, women, nonwhite, present with shock, and complain of dyspnea. Twenty-six of the 47patients stopped ticagrelor inappropriately because of patient nonadherence (18patients) and physician advice (eight patients). A composite outcome event of death from vascular causes, myocardial infarction, or stroke occurred in 8.8% of the entire cohort and was more likely to occur in those older then 65years, those presenting with cardiogenic shock, and those who prematurely stopped ticagrelor. Conclusion: In this real-world registry of patients started on ticagrelor, a third have off-label indications and a fifth prematurely stop the medication. Premature discontinuation was an independent predictor of major life-threatening bleeding and increased composite event rate of death from vascular causes, myocardial infarction, or stroke. Keywords: ticagrelor, acute coronary syndrome, registry, adherence, compliance, antiplatelets

Background: Many patients who experience a venous thromboembolic event have cancer, and thrombosis is much more prevalent in patients with cancer than in those without it. Thrombosis is the second most common cause of death in cancer patients and cancer is associated with a high rate of recurrence of venous thromboembolism (VTE), bleeding, requirement for long-term anticoagulation and poorer quality of life. Methods: A literature review was conducted to identify guidelines and evidence pertaining to anticoagulation prophylaxis and treatment for patients with cancer, with the goal of identifying opportunities for pharmacists to advocate for and become more involved in the care of this population. Results: Many clinical trials and several guidelines providing guidance to clinicians in the treatment and prevention of VTE in patients with cancer were identified. Current clinical evidence and guidelines suggest that cancer patients receiving care in hospital with no contraindications should receive VTE prophylaxis with unfractionated heparin (UFH), a low-molecular-weight heparin (LMWH) or fondaparinux. Patients who require surgery for their cancer should receive prophylaxis with UFH, LMWH or fondaparinux. Cancer patients who have experienced a VTE event should receive prolonged anticoagulant therapy with LMWH (at least 3 months to 6 months). No routine prophylaxis is required for the majority of ambulatory patients with cancer who have not experienced a VTE event. Most publicly funded drug plans in Canada have developed criteria for funding of LMWH therapy for patients with cancer. Conclusions: Evidence suggests that LMWH for 3 to 6 months is the preferred strategy for most cancer patients who have experienced a thromboembolic event and for hospital inpatients, but this is often not implemented in practice. Concerns about adherence with injectable therapy should not prevent use of these agents. Pharmacists should assess cancer patients for their risk of VTE and should advocate for optimal VTE pharmacotherapy as appropriate. If LMWH is the preferred agent, on the basis of the evidence, the pharmacist should educate the patients appropriately and work with the prescriber to ensure best care. Can Pharm J

Background: In Canada, there is a dose cap for weight-based treatment with low-molecular-weight (LMW) heparins. Objective: To review whether capping of LMW heparin doses is warranted for patients with obesity. Methods: English-language publications concerning the use of LMW heparin in Canada were reviewed, and the literature regarding use of these drugs at treatment doses in patients with obesity was assessed. Results: Five pharmacokinetic or pharmacodynamic studies meeting the inclusion criteria were identified. The evidence in those studies pointed toward no excess accumulation of LMW heparin in patients with obesity. In addition, 5 trials involving patients with acute coronary syndromes and 6 trials involving patients with venous thromboembolism and other indications were identified, but only 7 of these 11 trials included sufficient information for review. Subgroup analysis of patients with acute coronary syndrome whose LMW heparin dose was not capped showed no increased risk of bleeding for obese patients treated with enoxaparin. For patients with venous thromboembolism and other indications, the best evidence was for dalteparin, with anti-Xa levels used as a surrogate end point. In this setting, excess accumulation did not occur when there was no dose cap. Discussion: There is little literature dedicated to the dosing of LMW heparin for obese patients. In particular, there are few data for those with body weight above 150 kg. Despite the limitations of these studies, there appears to be little justification for capping the doses of these drugs. On the basis of the available literature, it is suggested that treatment doses of LMW heparin be based on body weight up to 150 kg. RESUME Contexte : Au Canada un plafond est fixe a la dose pour les traitements par l’heparine de faible poids moleculaire (HFPM) fondees sur le poids ont ete etablies. Objectif : Evaluer si les doses limites d’HFPM sont justifiees chez les patients obeses. Methodes : Des publications de langue anglaise sur l’emploi d’HFPM au Canada ont ete examinees et la litterature sur l’emploi d’HFPM a des doses therapeutiques chez les patients obeses a ete evaluee. Resultats : Cinq etudes de pharmacocinetique ou de pharmacodynamie satisfaisant aux criteres d’inclusion ont ete recensees. Les donnees dans ces etudes portent a croire qu’il n’y a pas d’accumulation excessive de ces medicaments chez cette population de patients. En outre, cinq etudes menees sur le traitement de patients atteints de syndromes coronariens aigus et six autres sur le traitement de patients souffrant de thromboembolie veineuse et pour d’autres indications ont ete identifiees, mais seulement sept de ces onze etudes comportaient suffisamment d’information pour etre analysees. L’analyse de sous-groupes de patients atteints de syndrome coronarien aigu dont la dose d’HFPM ne respectait pas le plafond fixe n’a montre aucune augmentation du risque de saignement chez les patients obeses traites par l’enoxaparine. Chez les patients souffrant de thromboembolie veineuse et pour d’autres indications, les donnees les plus probantes etaient pour la dalteparine, avec les taux de facteur anti-Xa utilises comme critere de substitution. Dans ce contexte, aucune accumulation excessive n’est survenue en l’absence d’un plafonnement de la dose. Conclusions : Il existe peu de documentation portant sur la posologie de l’HFPM chez les patients obeses. On dispose de particulierement peu de donnees pour les patients ayant un poids corporel superieur a 150 kg. Malgre les limites de ces etudes, le plafonnement des doses de l’HFPM semble peut justifie. La litterature disponible porte a croire que les doses therapeutiques d’HFPM peuvent etre fondees sur le poids corporel jusqu’a une taille de 150 kg.