The Neurotransmitters: Clinical Neurology Education
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The Neurotransmitters: Clinical Neurology Education
Neurocritical Care Pharmacy with Dr. Andy Webb
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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Hello and welcome to the Neurotransmitters. Welcome back. I'm your host, dr Michael Kentris, and I'm happy to introduce our next guest today, dr Andy Webb, a neurocritical care clinical pharmacist from MGH Harvard. Andy, thank you so much for joining us today.
Speaker 2:Yeah, thank you so much for the invitation again.
Speaker 1:So, as so many of the people I'm fortunate enough to talk with, we met on Twitter slash 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 do there A lot of educational content. I particularly, particularly, really enjoy your website with your deep dives on NeuroWiseRxcom, and we'll probably talk more about that later. But I think a lot of people might have a more vague idea of what pharmacy training looks like, and particularly when we get into the realm of clinical pharmacy. So I was hoping you could, just for those who might be less familiar, kind of throw a broad overview of what that looks like.
Speaker 2:Yeah, absolutely. Those are great questions. I think there's a lot of confusion but people may not be aware of all the different kind of training programs and pathways that are out there for pharmacists and so kind of the traditional path for a pharmacist starting out is it's very much so similar to medicine in that most pharmacists will do an undergraduate degree and then we'll go into a four-year kind of professional clinical doctorate program. So the doctor of pharmacy degree program is a four-year program. It's basically three years of didactics 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 really focusing on the pharmacotherapy. So a lot of the coursework that we do is kind of how drugs are used, the rationale for their use, kind of how you navigate, selecting, monitoring and kind of handling drug therapy. And then our final year, what we call like advanced pharmacy practice experiences or APPEs, is rotations out in the world. That could be at a hospital, it could be at a community pharmacy, it could be at a physician's office or really anything in between. So a lot of our APPE experiences can be quite varied if, depending on where a pharmacist wants to go, and after you kind of complete your four-year PharmD program, that's really an entry to practice degree where you could directly start working. So most pharmacists after graduating with a PharmD will start in a community pharmacy like a CVS, walgreens or an independent pharmacy dispensing medications.
Speaker 2:But clinical pharmacy is kind of its own subset of pharmacy practice and so what you can do is actually do specialized residency training after you graduate from your PharmD. And so residency training for pharmacy has been around for a long time. It started in probably the last 20 years or so and basically what that looks like is the first year of PGY-1 residency training is basically just like a general residency. You can kind of think of it like a categorical intern year where you kind of see everything throughout the hospital. So you do internal medicine rotations, you do infectious diseases rotations, you can do an oncology rotation, neurology rotation and ICU rotation, and really the purpose of that first year of training is really to just give new grad pharmacists kind of like a broad overview of what clinical practice in a hospital or some of the residency programs are based in the outpatient setting, like really what clinical practice looks like and how the pharmacist can kind of interface with patient care in that setting. And then after your PGY1 year, basically residents can choose to do a specialty year and so they can select if they want to spend a PGY2 year really focusing in on one individual clinical specialty.
Speaker 2:And so I completed my PharmD program at the University of Rhode Island. I actually did a bit of an accelerated program. So one of the options is doing like a six-year track, so they're like six-year med schools. I kind of have a similar idea where I did basically two years of undergrad and then four years of the PharmD. Then I did my general PGY-1 at Mayo Clinic in Rochester and then I actually selected critical care to be my specialty for PGY-2. And so I went and went through the match again after just one year and did critical care training at Oregon Health and Science University out in Portland I think.
Speaker 2:Throughout that entire time, as I was kind of going through my training, I always knew that I really liked neurology and that aspect of patient care and so the fact that neurocritical care was kind of a facet of that that I could go into was like perfect for me, and so I was lucky enough to land in the position that I am now it's the neuro ICU pharmacist at MassGen. But basically pharmacists can find themselves in those sorts of positions and all different sorts of specialties and so really pharmacists are pretty well embedded into specialties like infectious diseases, oncology, critical care for sure, and I think neurology specifically is probably more of like a growing field within pharmacy. While I think neurocritical care is pretty well established within the field of clinical pharmacy kind of neurology, in general there's definitely a pretty good number of us, but it's more of a growing specialty overall.
Speaker 1:No, that's very interesting. I know at one of my previous practices we would have, I think probably in the pgi one we would have some pharmacy residents coming through like the epilepsy clinic and things like that, which obviously has its own unique challenges as far as pharmacology goes, yeah, but uh, speaking to that you know, so obviously critical care, a lot of sub-specialized knowledge there, and then we niche that down even further. So obviously critical care, a lot of subspecialized knowledge there, and then we niche that down even further to neurocritical care. So so what are some of the unique challenges or kind of the aspects that drew you to that, specifically as far as, like the, the neurologic aspect of pharmacologic care?
Speaker 2:Yeah. So I think when I was in pharmacy school I think I was kind of drawn to neurology and the medications used in epilepsy. There's about 30 plus different seizure medications on the market and so I loved the pharmacology of those agents, the complexity of the diseases and also how much there was still left to learn about how we can kind of best take care of these diseases. So I think research is something else that I'm particularly interested in and I love the fact that there was still so much development happening in how to really best take care and treat some of these hard to treat diseases. And so really the combination of the meds, the interesting diseases, the kind of opportunities for research and discovery drew me to neurology initially. And actually interestingly, when I was in pharmacy school I didn't really even know that critical care was a thing that I could do.
Speaker 2:And so my fourth year, my APPE rotation I took a MICU rotation just because I wanted to kind of get experience. In that I was like I'm never going to do this again. I might as well my initial interest in kind of complex pharmacology and that sort of decision making. I found kind of a home in the ICU where there are these unstructured problems. There was collaborative decision making. There was a lot of complexity, not only in just the patients that we were taking care of, but the medication therapy that were being prescribed to them, and then so I did a Mickey rotation and then, as I was doing my rotations, there's obviously, of course, also a neuro ICU at the hospital. So I went to my preceptor and I was like you know, I have this interest in neurology. Can I just spend a week in the neuro ICU and kind of see what it's like?
Speaker 1:And so that's where I really found that that's what my calling was, so to speak where I could still have that complex, it's always been a real boon, at least from my perspective. Where we're talking about dosing and interactions, because while I might be familiar with, like the neurologic medications, sometimes there are more general things, like the heart or whatever, whatever that might escape my notice.
Speaker 1:And so it's always good to speak with someone who is more broadly familiar with the whole spectrum of interactions and the various pharmacodynamics and connects that go into all that decision-making.
Speaker 2:Yeah, exactly, I think that kind of collaborative, team-based approach is, I think, one of the best parts about critical care, because everybody on the team be that you know the attending the fellow, the resident, the pharmacist, the bedside nurse, pt, ot, speech like we all have a contribution to patient care and being able to kind of ever hand out the care of the patient by really making sure that kind of all the T's are crossed and the I's are dotted, by really thinking through everything about the patient and the medication therapy that's prescribed to them, be that you know their seizure meds or their secondary stroke prevention, but also like making sure we don't forget about, you know, guideline directed therapy for heart failure, those sorts of things that might not be the focus of their neurologic admission, and that's just like the great value of team-based care, with the addition of a pharmacist to a team.
Speaker 1:Absolutely. I couldn't agree more. Now, one thing that I always find because I you know where I'm at now I work a lot more with medical critical care and in particular with internal medicine residents and things like that kind of at a more community teaching hospital and I find that one of the things I always have to hammer on about, probably to people's annoyance, is the importance of the blood-brain barrier in medication delivery. Is the importance of the blood-brain barrier in medication delivery. So I was wondering if you could speak a little bit to some of the unique challenges when we talk about drug considerations, both in the neurology sphere as well as more broadly for other things. What are some unique challenges that you've come across or that you find that you repeatedly have to remind your clinical care teams about?
Speaker 2:Yeah, I think that you make a great point of like considering what's going on with the patient with the medications that we choose is like huge. And so I think, like the bread and butter stuff that we as pharmacists and I myself handle is kind of appropriately dosing medications based on organ function. So recognizing that a patient has a developing AKI or has suddenly worsening synthetic hepatic function is obviously going to greatly change how medications distribute and are eliminated throughout the body. And so I think probably one of the most common things that I do is just optimizing and selecting dosing of medications can do therapeutic drug monitoring for like valproate or phenytoin or antibiotics like vancomycin, or just kind of empirically selecting doses based on those individual patients kind of organ function, like renal and hepatic function, 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 on levotiracetam and they have like moderate to poor renal function but they're in pretty bad status, epilepticus, and I'm going to be like I'm okay pushing the dose up a little bit higher here, even if you know the textbook says that we should be lowering the dose. Sometimes my job is fighting, not lowering doses. So I'm really making sure that we're optimizing the therapies that we have.
Speaker 2:I think that's also I help a lot of my colleagues in other ICUs and other floors to use medications that they're also not super familiar with. So if there's a patient with a neurologic diagnosis on a surgery floor, for instance, you know one of the pharmacists may reach out to me and be like, hey, my team has a question on, you know, to pyramid dosing or some other dosing of some medication they may be less familiar with. And I'm also helpful in helping my colleagues through what considerations to have with these medications. You know like the surgery team may be banging their head against the wall by. This patient has an unexplained metabolic acidosis and I get the question of like, oh, it's probably the tapiramide, and so kind of considering some of those lesser known toxicities that patients you know clinicians may be less familiar with with medications they don't use very often. Education, essentially, is another large role of mine to helping make sure everyone can use the medications they're using rationally and safely.
Speaker 1: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 the ICU who I think her GFR was maybe 20 and she was like on two grams of Cephapim.
Speaker 2:BID A little bit confused.
Speaker 1:If you can guess the reason for the consult it was in fact altered mental status.
Speaker 2:Yeah, I've seen this movie before. Related to that, wrapping in the highest quality, most up-to-date evidence is another huge part of my role. So, for instance, we had a patient who had a seizure overnight, not 100% sure what caused it. They were on cefepime, the dose was appropriate, but we have the ACORN trial. So I could point to evidence and say like well, we have an alternative therapy that we could use. So we switched this patient to Zosyn because it made sense for the infection that we're treating. And so helping my team kind of do the best evidence-based care is the other big thing that I do. I'm the guy who pulls my computer around to point at the most recent trial and like look at this curve and here's why we can do this, and so that's another thing that I absolutely love is using evidence when we're taking care of patients and also teaching other people about what the evidence has to say about the decisions that we make.
Speaker 1:No, that's, that's great. And it just seems there's such a plethora of papers and trials on daily and weekly basis it's very challenging to keep up sometimes.
Speaker 2:A hundred percent, like when the European stroke conference happened a couple of weeks ago. It was like every day I'm like. Well, here's another practice changing landmark trial that we have to consider.
Speaker 1:I know it's uh, it's great, but it's also frustrating because it feels like everything I just learned last year is out of date now, exactly, exactly so but such such as the way of things I suppose Uh but uh, to that effect, you know, like, yes, we have all these new things, sometimes telling us the thing we've been doing for maybe decades is wrong. And there are still some of these older meds on the market. I'm thinking of, in particular, our valproic acid and phenytoin, phosphonytoin, all these things that are still like very much in the guidelines for specific situations, that are still very much in the guidelines for specific situations, and, in particular, I'm thinking of a deep dive you did onto the free versus total valproic acid trial that came out this last year and I was wondering if you would indulge me and talk a little bit about the unique challenges when we're talking about, like high protein bound molecules and free versus total fractions, and how do we deal with that as things get more and more complicated.
Speaker 2:Totally yeah. So you know you hit on a pet project or pet interest of mine and I think that you know, as a pharmacist, pharmacokinetics is like one of the real bread and butter things that we bring to the table. Pharmacists, pharmacokinetics is like one of the real bread and butter things that we bring to the table. And seizure meds have like some of the most complex and like frustrating head banging against the wall pharmacokinetics of all the medications that we have. So like phenytoin is like the perfect case example of you know, when I was in pharmacy school we spent like two weeks on phenytoin PK alone, just because of learning about what Michaelis mentioned kinetics meant and how all the different drug interactions and protein binding interacts with things, and so I think that's also one of the things that really drew me to these sorts of medications is just how interesting and complex they kind of get around the body, and I think valproate is almost like an under-recognized, similarly complex, frustrating seizure medication in that perspective. So as a trainee, I was kind of faced with some of these challenges if we had a patient on valproate. Because, yeah, your point, it's, it's older, we have experience with it, it's in the guidelines there's, you know, quote-unquote good data for using valproate in various seizure types. On valproate, uh, and they just weren't waking up. You know their eeg was suggestive, you know that they they're not seizing, there's nothing 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 like off the charts. And so we had this total level. I was like 50 or 60. Like this shouldn't be that big of a deal. Checked a free level, the free level was like 40 or 50. And you look at the reference range, that should be somewhere between like five and 15 to five to 20. But like this is clearly abnormal and it's something that I think a lot of teams just don't even think about, where they see the total valproate level and they're like we're good to go, like this patient is in range, nothing to worry about, and by lowering the dose and, you know, significantly decreasing the patient's exposure, they woke up and so it's kind of like a perfect seed to say like this is a something is clinically relevant, really does matter to the patients that we take care of and is like very under recognized. And so really, from some of the work that Caitlin Brown, her colleagues, have done got me additionally interested in really looking into this and exactly like why this happens. I think one of the other things that as a pharmacist, I really like to bring to the team in terms of value is like, yeah, those deep dive, like in depth understanding about exactly what these meds are and what they're doing.
Speaker 2:And there's so much about Valproate and the other seizure medications that's just very. Valproate is a bit unique in that it's just this little tiny kind of you know fatty acid that just happens to hit all these different receptors and all these different ion channels and just happens to kind of be this broad spectrum very effective anesthesia medication. But that sort of small fatty acid structure also means that it interacts with a whole bunch of other things you would not exactly expect. And, to your point, yeah, the big thing that is important about it is it's binding to albumin and when it's bound to albumin it's not doing anything. When it's unbound to albumin, that's when it's pharmacologically active and able to have both its clinical effects and its toxicities.
Speaker 2:And not recognizing the difference between the total and the free can really lead clinicians astray in misinterpreting a level and kind of what we've found is that critically ill patients, for a myriad of reasons, have wildly altered protein binding and have wildly extreme exposures to free valproate levels, out of proportion to what you might expect. And so digging into the evidence has helped me. You know, obviously, hepatic dysfunction with changes in how much albumin patients actually have, but also things like unexpected drug interactions like aspirin and warfarin, propofol, you know, intralipid from a TPN all of these things will knock that fatty acid valproate off of its albumin and protein binding site. It will increase patient's exposure.
Speaker 2:And there's actually some work that we're doing. We're looking at what the clinical consequences of that is and basically what we found is that it really is the free level that is what's predictive of patients having side effects. And so we found basically that patients with really high free levels, even if their total level is fine, have more hepatotoxicity. They have lower platelets, they're likely more sedated and you might check a total level and 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 totally off whack and something like that aspect of really digging into the evidence and understanding how these meds are is one of the biggest roles I think a pharmacist can have, because those kinds of like things you don't really think about, that are just unique about a medication, can really have pretty profound impacts on the kind of day-to-day individual care of one patient.
Speaker 1:No, that's, that's awesome and it's, you know, putting kind of our retrospective scopes on. You kind of look back at some of these old papers from, like you know, 40, 50 years ago, yeah, and they're like, oh, a you know non-dose relation, like with hepatic or a Depakote-induced encephalopathy or things like that.
Speaker 2:I'm like, well, maybe maybe it is dose-related, it's just not. You know, it was something we weren't measuring decades ago. Yeah, and I think, like with Depakote in particular, one of the most interesting things is, you know, everybody knows that 50 to 100 or 50 to 125 is a good range. But when you talk about quote, unquote, good evidence when you go back, the authors were essentially they just guessed. They measured levels in a bunch of patients who had seizures, who were on Depakote, and they noticed that patients whose levels were somewhere in the range of 50 to 100 tended not to seize as much. And they're like, this range is pretty convenient. So that's what we're going to go with and that is effectively what the discussion of this paper is. There's no empirical PKPD analyses. It's just like this seems sufficient and that has kind of carried forward, and so there's definitely a lot pkpd analyses. It's just like this seems sufficient and that has kind of carried forward, and so there's definitely a lot more work for us to do to kind of update that.
Speaker 1:Yeah and that's uh. I remember when I was a pgy2 myself and one of my epilepsy uh attendings asked me like you know, it's like so the, the valproate range, you know normal is 50 to 100. You know, for fenny towin it's 10 to 20. It's like, don't those seem awfully rounded off?
Speaker 2:it's like, yeah, there's the evidence is garbage uh yeah, somebody made a good guess and they just kind of ran with it.
Speaker 1:And here we are 40 years later just dealing with the consequences yeah, so it is one of those things where it's like uh, it's kind of that old truism, at least in epilepsy. It's like when's the person toxic when they're having side effects, when are they therapeutic when they're not having seizures?
Speaker 2:Yeah, like I had an attending who's like I don't really pay too much attention to phenytoin levels until they have nystagmus. It's like that's one way to do it.
Speaker 1:I've heard that exact same thing before, yeah.
Speaker 2:And that is.
Speaker 1: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 one of my favorite, maybe not one of their favorite ones is to go around in a circle and name one side effect, yeah, of alproic acid, until you run out yeah, the circle can get quite large until you run out of side effects right, and I think that's that's just so.
Speaker 1:uh, to your point earlier, it's that, it's uh we have to consider not just you know it's easy to put our blinders on and think only about neurologic issues but to think about the broader human body and what we might be causing. Like one of the ones I run into more often, especially with those older meds, is, like you know, folks here with like AFib, rvr, like an amio drip or something like that and just like well, you know, you need to be a little bit careful here.
Speaker 2:Yeah, mean it's. Maybe this patient's platelet count is low because of the depo code or like their abdominal complaints might be pancreatitis from the depo code, and people oftentimes forget about these like pretty rare but can be quite. Concerning toxicities that aren'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 medications.
Speaker 1:Yeah, I know there was that huge class action lawsuit over in the UK a few years back because people weren't being young women in particular weren't being counseled on the teratogenic side effects, which obviously are super well-known for decades, which I thought was just mind-boggling that that wasn't being clearly communicated to like population at large yeah, I think it's to the point where, like, prescribing of valproate to women in the uk is essentially restricted now, where there needs to be like clear documentation that other things have not worked and everyone is on the same page about what the pros and cons of this therapy is.
Speaker 2: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 that reason. But there's a lot of things to consider beyond just seizure reduction yeah, yeah, definitely very important.
Speaker 1:I I remember I I had, uh, a younger woman who you know, she she was a immigrant from central america and uh, you know she had epilepsy, I think as a if I remember correctly, it's been a few years uh sequelae, like sister sarcosis, and um, she'd failed like so many meds and so I was adding just a little bit of depakote. You know, she's in her late 30s and I said multiple times, both myself with my poor spanish, as well as via the official translator, like, like, listen, you cannot get pregnant on this. And God, god help me. She showed up three months later, fortunately or unfortunately, it seems she had not been taking her anti-seizure medication.
Speaker 1:So, it ended up not being relevant 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 where sometimes you know it doesn't matter how much you harp on about it, the worst case still happens sometimes.
Speaker 2:Totally.
Speaker 1:Totally as far as, like you know, we've talked a little bit about kind of your multidisciplinary role. What are your favorite things to treat in the neuro ICU as a clinical pharmacist?
Speaker 2:Yeah. So I think you know, related to this discussion we've been having, honestly, I think you know, related to the discussion we've been having, honestly, I think status is like by far and away the most favorite thing that I have to treat. It's. It's funny because, you know, status epilepticus is can be deeply satisfying as a pharmacist, but can also be one of the most challenging and difficult diseases to take care of, and so obviously, as the pharmacist in the neuro ICU, I have an affinity for the disease state which is largely exclusively treated with pharmacologic agents, you know excluding, you know, vns and RNS and surgical therapies right, and so I think the thing I love doing the most is just making the most of the medications that we have, and so in ensuring that, you know, our Keppra is maxed out, our everything is maxed out, and then when the kind of standard things don't work, the creativity of like what is the best next thing for this patient is like.
Speaker 2:Such a great experience. To like, choose a medication using some rationale, really thinking through the patient case as much as we can, and then seeing it work is like has to be the most satisfying thing out there. It's kind of funny in pharmacy school when we learned about seizures and epilepsy and seizure medications it was essentially like here are the meds, here's what they do, here are the side effects, and there wasn't a lot of focus on like how you actually select an agent in terms of like really what does make the most sense for a patient of the legitimate 30 options that we have? It's been really satisfying to develop that kind of expertise to say like well for this patient. You know Clobazam actually makes the most sense, or Parampanel makes the most sense because they're ketamine responsive or something along those lines. And when it all works out it's like phenomenal.
Speaker 2:It's like to the point of the cases that stick out. There are so many cases of the patient who was burst, suppressed for three days and really difficult to wean, and you know the most recent one. It's like we're all kind of wringing our hands what to do next and I was like, well, like the one thing we haven't tried is cannabidiol and we start that and we're able to wean anesthesia. She wakes up two days later she gets extubated and like when those sorts of cases work out, it's just like such a satisfying experience as a pharmacist to be able to help optimize the perfect regimen to make sure the patient obviously isn't seizing but also can kill kind of have a quality of life and get out of the hospital in a safe way.
Speaker 2:But I think the dark side of that is, you know, it is very frustrating when things don't work out. Which is one of the most challenging things about status is when that patient really just doesn't seem to respond to everything or anything that we try. But the good thing I guess supposedly is that is super inspiring to continue to work towards future therapies for what could work for those patients. And so I've been lucky enough to be involved in, you know, a clinical trial for refractory status epilepticus drug Ganaxolone, you know, as kind of more an operational aspect of helping to screen patients and get patients enrolled in the study and actually get the study drug and also involved in research really seeing like of the stuff that we have done like's working, and so really still being able to be involved in discovery about how to best take care of these patients is also the other thing that I get the most satisfaction out of nice.
Speaker 1:Is that a new neurosteroid agent?
Speaker 2:yeah, exactly, and so it's in phase three trial right now, and so we don't know the results yet, but certainly very promising. It's the kind of drug where it's technically placebo controlled but sometimes you feel like it's kind of hard to blind, you know. So we're all, I think all very excited to see what the final results of that trial are.
Speaker 1:That'll be exciting. Yeah, I remember when they were doing the. I think it was Pregnant Alone. Yeah, was that five or six years ago at this point?
Speaker 2:Yeah, yeah, unfortunately not successful, which I think speaks to just A how challenging it is to pick patients who might be eligible or benefit from these agents. So I think that the challenging thing about the RAISE trial is just how stringent the selection and inclusion criteria were, and so it was hard to find the right patient, and so we'll kind of see what the results are, but we're all very excited.
Speaker 1:And I think to your earlier point right, I'm a big advocate for the kind of the rational polypharmacy for status epilepticus or epilepsy management in general. Obviously I'm biased, since that's my background in particular. But one of the things that I think is so challenging, especially when we're talking about like drug selection, is like what is the underlying etiology of the person's seizures? It's just so heterogeneous in the population that it can be really challenging. Just so heterogeneous in the population that it can be really challenging. Like you know, they've got an old stroke or an old traumatic brain injury or maybe they have some sort of generalized epilepsy. That's not well, you know, distinguished and there's just so many ways that it can shake out. It's very challenging sometimes.
Speaker 2:A hundred percent, yeah. And then you've got the patient with Norse who you are truly, you know wringing your hands about what to do next. And those patients I mean some of the regimens that I've, you know, helped take care of patients on are truly, truly unique. When we're pulling out immunotherapies and we're starting ketogenic diets and that's another big thing that I help with is how many milligrams of carbohydrate are in the, you know, the parampanel tablet. So helping to tinker with all those things to maximize the success of those therapies, it can be a lot of fun, it's a lot of work, uh, but it's. It's a real, you know, honor to be able to take care of those patients no, that's excellent.
Speaker 2:That's, that is something god I I haven't had to think about that since I was a fellow uh, to go through the list of 50 meds, they're on and call manufacturers and be like, hey, is there more than 50 milligrams in this tablet? And they're on and call manufacturers and be like, hey, is there more than 50 milligrams in this tablet?
Speaker 1:And they're like why are you asking me?
Speaker 2:this question, but once you get the answer it's a lot of fun to kind of figure all that out?
Speaker 1:No, definitely Definitely. My wife's a dietician. She's been involved with those conversations as well.
Speaker 2:Yeah, Carmen, who's our dietician on the unit, is like phenomenal about going through all of those considerations, and we work very closely together to make sure everything's all tucked in, tied in a bow, before we start the keto diet.
Speaker 1:Now, as far as like, if you wanted to say like, why should someone who's considering let's say they're in their undergrad pharmacy program? What would you say to those who might be intrigued by neurocritical care? What kind of experiences should they seek out?
Speaker 2:Yeah, 100%. So I think the things to think about if you're thinking about going into neurocritical care is you really need to be the kind of person who likes collaborative decision-making and really thinking through an individual patient who makes the most sense, what therapy makes the most sense for that individual patient. You want to be the kind of person who likes thinking through evidence and applying that to a patient and you have to be able to really like the complexity and a lot of the gray that is within and just inherent to neurology and neurocritical care. And so I think you know, if you're seeking for those opportunities certainly if you're in your PharmD program, seeking out APPEs that are at like an academic center that has a neuro ICU where you can work with a neurocritical care pharmacist, you can introduce you to the team and kind of be part of that decision making and also being, you know, coming involved in the neurocritical care society, where we have a pretty active and well established group of pharmacists who are quite integral to that society. So you know, for instance, gretchen Brophy, who's a pharmacist at VCU, was the primary author on the NCS status guidelines that are now 12 years old, so getting a little dated, but regardless, just really highlighting the fact that pharmacists are pretty well embedded in NCS and are really integral member of that team.
Speaker 2:Really the greatest thing about being a neurocritical care pharmacist is we really get to practice at the top of our knowledge. So in pharmacy sometimes we talk about practicing at the top of our license. So what we're legally able to do, be that independently manage medications or do therapeutic drug monitoring, all these sorts of things. But I think in the neuro ICU I really get to go beyond that because I get to really bring to the table how do the drugs work, how do they interact with this individual patient's disease state, what's my understanding of the patient's pathophysiology, what complications we're handling right now, what's happening at the bedside and everybody can kind of come together and make the best decision.
Speaker 2:For instance, we had a severe traumatic brain injury patient on the unit this week and you know I was at the bedside with the kind of the fellow and the physician assistant thinking through like what is the best next step on the ladder for this patient's ICP crisis? And it's a lot more complicated than just, you know, just increase the propofol or just give 23%. It's really thinking through like how do we understand what's going on inside that patient's skull and what do we have to do? And it's always a little odd when I'm the pharmacist and I'm like I think this patient needs surgery and so like thinking through all of the complexities there. I being able to bring the medication side of things just really helps round out everybody's thinking through how we're going to take best, take care of this patient. And so you know pharmacy students who are thinking about what clinical field they want to go into, that sort of fast-paced, complex decision making with a lot of unknowns.
Speaker 2:Because I think one thing that as a pharmacist is really satisfying when I can point to a trial and be like black and white this is what the thing we need to do is that's very rare in neurology to be able to say that. And so when I have learners, I think the thing that I have to really help them become comfortable with is like there is no correct answer. So being able to be comfortable with what's our understanding of the data, the patient, what options we have available, and just navigating the best path forward, it's really hard but can be really satisfying when you kind of come to a conclusion, implement that plan and kind of see it work out in front of your eyes.
Speaker 1:That's excellent, and you know to your. To your point about the increased ICPs yes, you're the pharmacist, but you're the person who knows, like I don't think, medication is going to work any further beyond where we've pushed it Right. So I think that's that's still a very useful perspective to have on that front.
Speaker 2:I'm talking with the neurosurgery residents and they're like well, you need to maximize medical therapy. And I'm like, I'm telling you we have maximized medical therapy, it is maximized.
Speaker 1:That is excellent. And for, let's say, internal medicine 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 you would recommend?
Speaker 2:Yeah, so I'll go back to NCS. We're like NCS and the group of neurocritical care pharmacists who are involved in NCS have done a really awesome job of producing good resources about neurocritical care pharmacotherapy. So there's the On Call program, the PONS program, which is the pharmacotherapy of neurocritical care series. So there's lots of resources that relate to kind of the science and the knowledge of medication use therapy in neurocritical care. But additionally there's a lot of resources about kind of like how to get in touch with neuro ICU pharmacists if you want to network and get to know somebody in your area, and so I think that's probably the hub to kind of find pharmacists in this field and particularly, you know, if you are at an institution with a neuro ICU that does not have a neurocritical care pharmacist.
Speaker 2:Ncs also has a program called the ICP program, if I'm remembering it correctly, where it's basically what they'll do and I'm now blanking on the what the acronym actually stands for, but it's something about something clinical pharmacist. Well, they'll basically send an experienced neuro ICU pharmacist to an institution to help set up neurocritical care or pharmacy services at your institution. So, for instance, if you're a hospital that's opening up a neuro ICU for the first time and the institution might be interested in having somebody come in help establish pharmacy services, help write guidelines, establish the formulary like figure out where you're going to keep your 23% vials or those sorts of things. Ncs will actually sponsor a more experienced neuro ICU pharmacist to go out to that institution, help mentor a pharmacist who might be establishing their practice site at that institution and also really help the institution maximize the role of the pharmacist in that setting. So that could be, you know, writing a guideline for ICP management or establishing workflows for status response.
Speaker 2:There's a good amount of data now that you know having a pharmacist involved in these critical kind of experience or instances, be that, you know, thrombolysis for stroke, response to seizures and status epilepticus. There's actually a recent paper that came out for anticoagulation reversal in ICH direct involvement of a pharmacist in the care of those patients. Even if, you know, if they weren't necessarily able to directly show benefits in mortality, they were able to show benefits in more surrogate outcomes like faster time to thrombolysis or faster time to anticoagulation reversal or more appropriate seizure medication dosing and faster time to first benzo. And when you put all those things together it's a pretty strong body of evidence that clearly definitively shows that involvement of a pharmacist does improve the outcomes of the patients that we take care of. So particularly for institutions who are either developing or looking to develop pharmacy services in this area, there's a lot of good resources to help support that and establish a good pharmacist presence in their unit.
Speaker 1:Well, that is awesome information. I'm going to have to keep that in mind myself. I know we're in the process of expanding our neuro ICU, so good to know, yeah definitely.
Speaker 2:It's an awesome resource and there's a lot of good examples of you know a new graduating pharmacy resident who's starting out in a new neuro ICU and it can be really intimidating as a new practitioner to step into a subspecialized ICU that doesn't have an established pharmacist already, and so there's a lot of institutional organizational support to make sure that neuro ICU itself can practice as best as possible and that pharmacist is also supported to make sure that they can have the smoothest transition into practice possible.
Speaker 1:Very cool, very cool. Any final, any final thoughts, things that you want to plug, projects that you're wanting to make the public aware of.
Speaker 2:Yeah, definitely. So I mean, I appreciate you kind of throwing out or shouting out my website. So neurowiserxcom I will admit that I am probably not the most loyal poster because it turns out those posts are a lot of work to put together. They look like it, yeah, but basically what I my hope is that I'll probably try to post a little bit more diligently in the future, but it's certainly a lot of work dig through every publication from 1960 on so.
Speaker 2:But my goal is really to answer those sorts of questions in a way that brings up all the evidence that we have available. And certainly people have questions that they want me to look into. I'm certainly open to those as well. I think the other thing to really just plug is that you know pharmacists have a big role in neuro ICU in particular, but really in any care where met. There is certainly of large value in having pharmacists round with your stroke teams or your general neurology teams or the epilepsy monitoring unit and so kind of reaching out to your pharmacy departments at your individual institutions to see what resources are available. You might be surprised at what sort of value a pharmacist can add.
Speaker 1:No, I couldn't agree more. I always considered it. It was that we're just starting to get a pharmacist rounding on a regular neurology team where I was previously a few years ago, and it it provided just this very subtle boost. Yeah, it made everything a little easier.
Speaker 2:Yeah, totally.
Speaker 1:Which was it's always great, yeah, absolutely, but no, I couldn't agree more. It's always good to have more perspectives on the multidisciplinary side of things when when rounding as a team.
Speaker 2:Yeah, absolutely.
Speaker 1:And if people want to find your work, they want to find where you are. I know we mentioned neurowiserexcom Anywhere else they should check out for you.
Speaker 2:Yeah, so I'm certainly busy on Twitter slash X, whatever you want to call it. So my handle is AJWfarm, so I try to post relevant things to neurology, neurocritical care, critical care in general. Do that the most recent evidence that I can find, or my own opinion on kind of interesting things that have happened on the unit or in the field of neurology, and so I would say I'm fairly active there. So certainly excited to interact with everybody who is on that platform to kind of help us all. I think personally, I have learned a ton on Twitter and I've tried to kind of return the favor, and so I always love interacting with new people on that platform.
Speaker 1:Awesome. I certainly appreciate your work on there as well. I've learned a lot myself.
Speaker 2:Awesome, yeah, likewise.
Speaker 1:So, dr Andy Webb, thank you again for coming on. I really appreciate your time today.
Speaker 2:Yeah, awesome. Thank you again for the invitation. This is an awesome time. I really appreciate it.
Speaker 1:And for anyone who wants to find the rest of our stuff, you can find our website theneurotransmitterscom, where we have our old episodes listed, and you can also find me on Twitter, slash X at Dr Kentris D-R-K-E-N-T-R-I-S. Andy, thank you again so much, really appreciate it.
Speaker 2:Yeah, thank you again.
