Weight-Based Dosing

In this week's episode of GameChangers, we focus on how pharmacists can prevent weight-based dosing errors. 

Listen in to learn more about:

• Which body weights to use for which medication-based dosing
• The four different scales of weight
• “Normal” weights for kids
• The Rule of 5 for dosing pediatric patients
• What the formula is for switching from pediatric dosing to adult dosing
• The definition of “Patient first language”

 
The GameChanger
Too often, health care providers don't dose medications based on weight. The pharmacist should be ensuring doses are correct based on patient weight.
 
Guests

Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
 
Jake Galdo, PharmD, MBA, BCPS, BCGP
CEO
Seguridad

Stephanie Weightman, PharmD, BCPS, BCPPS, BCEMP
Clinical Pharmacy Manager
Perfecting Peds

Reference
Pediatric Weight is Crucial to Perfecting the Dose
Updated antimicrobial dosing recommendations for obese patients

Pharmacist Members, REDEEM YOUR CPE HERE!
 
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)


CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Discuss strategies to verify weight-based dosing accuracy to improve patient safety and therapeutic outcomes.
2. Explain appropriate dosing adjustments for commonly prescribed antibiotics in pediatric patients and patients with obesity.

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-208-H01-P
Initial release date: 06/24/2024
Expiration date: 06/24/2025
Additional CPE details can be found here.

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Transcript

Speaker 1: 0:12

Hey, ce Plan members From CE Impact, this is Game Changer. Today I have with me not one, not two, but three experts on weight-based antibiotic dosing, so I am super excited to get into it. I know that you know a couple of our people that we have on the podcast on a regular basis. So with me today we have Jeff Wall Good morning, Jeff, good morning. How are you doing? Great, great. And we also have Jake Galdo, who has been on the Game Changers podcast. I guess we were just talking for the last four years-ish. We started this four years ago. We just had our four-year anniversary, so that is super exciting. So I know all of you are really familiar with Jake. Welcome, jake.

Speaker 2: 1:00

Hey, jen and everybody else, I'm excited to talk about this topic.

Speaker 1: 1:03

Yeah, me too. Me too. And also introducing you to also an expert in the pediatric area is Stephanie Waitman. And Stephanie is from Perfecting Peds, and I'll let her just give you a quick context of sort of what she does so that we can bring her into the conversation.

Speaker 3: 1:25

Thanks, jen, welcome Stephanie. My name is Stephanie. Like Jen said, I am the head of clinical operations at Perfecting Peds and we are the only pediatric comprehensive medication management service provider currently within the United States and what we do is help work with kids with complex medical needs to bridge the gap between different providers in the ambulatory care space, with the goal to try and keep these kiddos out of the hospital, decrease healthcare utilization and improve their quality of life. We look to try and decrease polypharmacy, monitor and recommend alternatives for any adverse drug reactions. We're really big fans of pharmacogenetic testing to kind of help optimize any dosing opportunities for these kiddos and we work with their entire care team to kind of help them navigate the complex medical care system.

Speaker 1: 2:20

So cool. I just was introduced to Perfecting Peds a couple of months ago and I know we had Mary Vong on one of our podcasts as well a few weeks ago. So we've met her, have yet to have Jenna on, but we will do that. So I just think what you all are doing is really cool and it, you know it's so important for these pediatric patients.

Speaker 1: 2:43

And I think, you know, when we talk about weight-based dosing in medication, we always think of peds, and so I think it makes a lot of sense to talk about that today, even though we don't really, I think, in the community, do a bang up job of collecting that weight.

Speaker 1: 2:58

So we're going to talk about why that is so important, but we also, I think, don't think about it much in adults. I mean, we just, you know, take for granted we just dose that and everybody is the same. So, jake, I know that you have actually had a couple of articles in the last month or two, one of them with Jenna from Perfecting Peds, talking about the importance of weight-based dosing, not just in antibiotics but in general. So today we're going to specifically talk about antibiotic dosing, but I want you, jake, if you could sort of tell us a little bit about why that's important, why this is getting a little bit of press lately, and why it's important for our listeners to understand and to do. I think to act on this is a really important part of it, so let's get into it.

Speaker 2: 3:51

That sounds great, and what's funny is I'm kind of like skimming my phone right now looking for a text I got from one of our colleagues. We've been talking about this idea of pediatric weights for a while. We look at it from a community pharmacy lens and ask the question like what does the pharmacy do in a community? Do they have documentation of a child's weight so that they can make sure that the dose is correct for kids? And the results are terrible. Right, we did some empirical validity. We found that 60% of pediatric antibiotics coming from the pediatrician to the pharmacy are dosed wrong. And so for me as a community pharmacist, to make sure that I'm dispensing the right dose, I need to have the weight of the child to verify it's correct. And it's just abysmal. There are many pharmacy management systems out there, many chains, that have a 0% performance on that kind of quality measure because they don't even document weight. And then it's scary because from an NCPDP standpoint, this is a data element. It can get transferred over from Jeff and the health system to me and it doesn't happen. Or if that data element is attached to Jeff's prescription because he's doing a great job, me and my pharmacy management system say I don't want to know that and I hit delete and I ignore it, which then creates such an unsafe environment. And one of my co-workers and colleagues was he sent me a text recently and he said so the average weight I'm going to make the numbers up because I don't remember and I can't find his text. He said the average weight of, like an 11-year-old boy is 50 pounds. Probably not 50 pounds, stephanie, ear muscles. It's like what you're going to clinically say is terrible, right, so just ignore me, but it's 50 pounds and he's like my nephew is like six and a half feet Again, these numbers are wrong and he's 100 pounds. Has anyone ever told you know my sister-in-law or I'm going to see in the news that my sister-in-law is about to go beat up a pharmacist in Tennessee because they're dosing her son incorrectly, because no one's asking about this.

Speaker 2: 5:42

That was kind of the thrust of the various articles we had in Pharmacy Times and Pharmacy Today, talking with Jenna and others saying like why aren't we doing this in a community setting? And so then, when we look at it from a more holistic perspective, it's not just am I routinely looking at the weight of a child? Am I routinely looking at the weight of an adult. And then that gets us down to where we had this recent JAMA article that I'm going to have Jeff kind of give us a better deep dive into and I don't even think it's a JAMA, I think I said that wrong, jeff, but it's a new article that came out and it talks about updated antimicrobial dosing recommendations for obese patients. So then what's really interesting is we have like this multifactorial, like Venn diagram that's going on.

Speaker 2: 6:24

We have obese patients, which include adults and, honestly, kids.

Speaker 2: 6:28

Nowadays we have kids in and of themselves and then we also have adults in and of themselves, right, because you could say, the adult on the GLT-1 for weight loss is no longer obese because we've treated their chronic medical condition, but we still need to be monitoring and managing their weight on a routine basis so we know the efficacy of what's going on. And so what I'm really excited about talking with Jeff and with Stephanie about is this whole idea of how do we make this data element of weight more interoperable and more transparent in all members of the healthcare system so that we can do effective management of persons it's not even persons with obesity, it's just with persons. So, jeff, I'm going to come to you first. You're in a health system setting right, so you're seeing probably the obese patients, you're getting some folks on IVs and so like this is a very critical aspect of what you're seeing day to day. So you know, help us understand what's happening in your world and how this new recommendations from the Antimicrobial Chemotherapy Journal really talks about what's going on.

Speaker 4: 7:34

Okay, yeah, no, I agree, and it's a pretty common issue unfortunately for, I think, inpatient pharmacists, especially when we're dealing with the super morbidly obese patients. So you know, we're talking patients with BMIs, you know, 50 plus. You know, as you might imagine, we really don't have a lot of information on how to dose antimicrobials in those patients and, of course, it all falls down to something that I think you guys will talk about is you know, something we deal with all the time is what weight are we talking about? Are we talking about total body weight? Are we talking about adjusted body weight? Are we talking about lean body weight? And you know which? You know type of weight should we use when we are dosing drugs by weight? So I mean, I think there's a couple of pieces to talk about and, as you pointed out, this was a nice, fairly comprehensive narrative review article that came out of JAG or no, you're right, I think it was AAC and we've got a link to the article in the show notes and I was very impressed with it. I think they did a really good job pulling the data together and making you know practical recommendations instead of just kind of going on and on about it. You know.

Speaker 4: 8:37

We know for a fact that obesity in infectious diseases associated with poorer outcomes. Certainly we saw that during the COVID epidemic where you know we had, you know, patients who were morbidly obese definitely had higher risk of death and higher risk of hospitalization. But even for bacterial infections we know, that's true and the evidence has been shown in bacteremias and surgical site infections and skin infections, that just obesity in and of itself is associated with worse outcomes. There's a number of hypotheses why that might be. Is it that we're underdosing patients? I do think that plays a role in a lot of these patients. But in and of themselves, for example, obese patients tend to have actually believe it or not, decreased gastric emptying times and they actually have decreased absorption, for example. So I mean there's some pharmacokinetic changes there and obesity in and of itself is probably an immunosuppressive state. And you know you could do probably an entire podcast about why that would be. But bottom line is, is that it seems that morbid obesity in particular leads to, you know, impaired immune response and particularly with chemotaxis and things along those lines. So I mean that, plus the high burden of morbidity they have with it, because people rarely just have, you know, obesity in and of themselves, of course, they usually have diabetes, usually have dyslipidemia, they usually have hypertension, et cetera, et cetera, et cetera. So that's all going to add up to poorer outcomes, right?

Speaker 4: 10:12

So then we go. Well, okay, what are we trying to do with antimicrobials? Well, with antimicrobials we want to make sure that we get systemic antimicrobial concentrations to the site of infection while minimizing toxicity. And that's kind of the goal. And we know, because there's some PK alterations in patients with morbid obesity, that what we think is correct just very well may not be. And so these authors, you know, I think, did a pretty good job of, you know, pulling the data together. Again, there was no way for them to do a meta-analyses or systematic reviews, because there's almost no randomized control trial data on this. It's basically, you know, in vitro or in vivo, single studies looking at PK stuff.

Speaker 4: 10:57

So the first thing you do in the paper is and again, something that my students, I think, struggle with and I think even farms struggle with is what mass you're using for what drug, right, and you know they talk about, you know, kind of the four big types of weight we use in dosing. The first, of course, most common, is total body weight, you know, and the problem with using total body weight is that assumes that the kinetics are completely scalable based on weight, right? So there's a linear response. You know, if I'm 20% overweight, then all the kinetics and everything else is 20% better or 20% different. We know, of course, that that isn't the case and you put patients at serious risk for toxicity because you tend to overdose patients who are morbidly obese.

Speaker 4: 11:40

Then they talk about ideal body weight, which is important to remember even though I've dosed ideal body weight 97,000 times since I've been a pharmacist that that was actually designed by insurance companies. It was not designed for health care, it was actually designed for actuarial tables to basically assess mortality associated with body weight. That's all it was for. So you know, even though we use ideal body weight a lot of the time, it has never been shown to be correlating with drug dosing at all, even though we use it sometimes.

Speaker 4: 12:12

Lean body weight, especially in the morbidly obese, actually has been shown, and with lean body weight, really, you're basically trying to assess total body weight devoid of adipose tissue, and there are some complex formulas out there. Unfortunately they're pretty, you know, hairy, but they have been shown in several studies and morbidly obese patients. They'd probably be the overall best metric. And as far as clearance of drugs, I try to use those in super morbidly obese. But it's sometimes, you know, there's some disconnect between you know what I'm doing and what some of the other staff pharmacists are doing or what the physicians are doing. And then finally, I think the, the one that we're most familiar with in the inpatient settings adjusted body weight, where we kind of give a fudge factor, that kind of deals with not. You know, we want to account for adipose tissue but not all the way to total body weight right, and, for example, we do that quite a bit with, you know, glycoside dosing and stuff like that.

Speaker 2: 13:10

So the article goes into it Just really quick. I got some crucial questions for you here. These are, you know, hot off the press questions. Okay, one in my community pharmacy do I need four scales and do I need to label them as real?

Speaker 1: 13:24

weight adjusted.

Speaker 2: 13:26

I've never really thought about this. I just think again from a community perspective. I have a data element that just says weight, but it's not telling me what type of weight. Now I'm kind of a little worried. One, we're not even collecting weight and then when we do collect weight, like who the heck knows what kind of weight is happening? Secondly, I really had to interrupt you because I really wanted to highlight the fact that you called it a fudge factor and I feel like that's a little tongue in cheek and it deserved re-emphasis for when we are talking about obesity. So I apologize, we needed to highlight that because that just kind of went over. Nobody said anything.

Speaker 4: 14:05

Yeah, no, I missed a good joke there. So, yeah, I appreciate you helping me out there. So, yeah, it's a good point. And unfortunately, I think in the community pharmacy you're only going to have one metric. You're going to have total body weight and it's going to be up to you and up to your staff to know okay, I've got to manipulate that, and that means you're not only going to have to have weight, but you're going to have to have height to do all that right. And so you know, are you going to whip out the yardstick when patients walk into the community pharmacy and say you know, stand up against the wall.

Speaker 2: 14:35

Well, as Stephanie will tell you, we care for kids for their entire life, so we actually track them on the side of the wall and we put a little mark and say this is a little himmy.

Speaker 4: 14:43

And this is how they've grown almost like in a house yeah, so, yeah, you know, so, yeah, I mean your, but your, your points will take in that that you know if, for the community-based pharmacist, you're going to have to have that information to make these determinations. And so now you've added another factor in you know, because patients because patients, I mean you know, sometimes don't know how tall they are. I know that's amazing to say, but I've certainly asked patients, you know so, how tall are you? And they're like, I don't know, more than five feet, less than seven feet. I'm like, thanks, so you know. So, yeah, so you know, yeah, that's a good point worth mentioning.

Speaker 4: 15:16

And so the next part of the article talks about again it goes into some depth about that kinetics, and I'm not going to put the audience to sleep talking about that, because that's what we do usually when we talk about kinetics. Again, suffice it to say that absorption can be very difficult, especially with water-soluble drugs. There's a difference in absorption, much more compelling, and I always thought it was kind of funny and I have this paper in my files. They note that in super morbidly obese patients you may go to give them intramuscular injections but unfortunately they have so much fat that the intramuscular injection actually becomes a sub-Q injection and there's a paper that's at least 15 years old that was published in BMJ. Actually, they looked at that. I think they reviewed something like 40 or 50 patients who were super morbidly obese and gave them what they thought were regular IM injections with regular IM needles and found like 60% of them that actually didn't penetrate into the muscle because there's a lot of fat there. So you know, yeah, so you know, there's obviously some issues there with absorption Distribution. As you might imagine, patients who are getting hydrophilic drugs, the volume distribution of those drugs and the morbid obesity is going to dramatically increase, and so that is going to mean increased chances for side effects. But it's also going to mean you're probably going to have up in the dose as well.

Speaker 4: 16:41

And then clearance is interesting obesity actually, since most patients with with a long-standing obesity, especially morbid obesity, often have you know, I don't know what we're calling it this week, but you know non-alcoholic fatty liver disease. But now I see we're now calling it metabolic syndrome associated. You know something, something, something, but something, something. But you know, basically what I was taught was NASH or non-onclytified liver disease. Most patients with obesity have at least some of that and, interestingly, recent evidence suggests that that messes with the cytochrome P450 system and it can actually elevate the effect of some of the subsystems, like 1A2 and 2C9, but it actually dramatically decreases cytochrome P453A4 activity which, as pharmacists know, is one of the most common pathways by which drugs are metabolized. So again, we know that it probably affects metabolism, but we don't know. You know, how are we going to translate that to the bedside? And then renal clearance is interesting, because when patients are morbidly obese, well, they often have larger kidneys than controllable patients who aren't obese. So does that affect, you know, clearance? And again, a lot of it goes down to whether you have hydrophilic or lipophilic drugs. So there's some significant kinetic differences, but unfortunately, you know, there's been a real difficulty in translating that to the bedside. So the paper itself, I think, rounds up with some really good charts and again, I encourage the listeners to take a look at that, especially the ID practitioners out there, to maybe get a copy of some of these charts and have it handy for you about some specific drugs, and they do do a good job.

Speaker 4: 18:16

Going into way depth, I tried to pick for the um some of the more common medications, um that that I think pharmacists are going to be dealing with. The first, of course, is aminoglycosides, and you know, ever since I started out being a pharmacist, you know, back when dinosaurs roamed the earth, you know we were taught to use uh, adjusted body weight for um aminoglycoside dosing. Uh, because aminoglycosides are largely hydrophilic, so they go to total body water, not total body fat. So you wouldn't want to use total body weight in morbidly obese patients because you're absolutely going to overshoot them and I've definitely seen that happen before. So they note that the current guidelines suggest that you should use an adjusted weight factor of 0.4, so basically adding roughly about 40% to the difference between ideal body weight and total body weight and that's been the guidelines for that with immunoglycosides for at least two decades and obviously use total therapeutic drug monitoring.

Speaker 4: 19:14

Where I think things get a little more interesting is beta-lactams, because every pharmacist deals with beta-lactams, no matter where you practice, and they note that there is a lot of evidence suggesting a lot of individual variability in beta-lactams drug levels, particularly in morbidly obese patients. And they note that in morbidly obese patients that we tend to vastly underdose beta-lactam drugs. We tend to vastly underdose beta-lactam drugs and I've certainly seen this and in my world we have patients who are more obese, who come in with skin and soft tissue infections, so they have cellulitis and we start them on antibiotics. They do better, they're feeling better, and now we switch them over to oral medications and in my world, since almost all skin and soft tissue infections in adults is either strep or staph, we'll often send them home on cephalexin. Okay, well, what dose of cephalexin do you send somebody who's 400 pounds home on? And we'll often send them home on the standard kind of 500 TID or 500 QID.

Speaker 4: 20:19

There's evidence to suggest that is dramatically an underdose in those patients. And if you actually take a look at the package insert of cephalexin, max dose is one gram four times a day, not 500 TID or 500 four times a day. And I am convinced you know anecdotally that I have seen failures because patients who are morbidly obese get sent home from the emergency department or their doctor's office on low doses of cephalexin. And again, I think this is an opportunity for the community pharmacists when they see a morbidly obese patient come in and they look at a, you know, 254 times a day dose of Keflex going. Hmm, I don't know if this is going to be enough for you. So you know. I think that that's certainly something I've seen empirically, but there's other instances of that too. We need to take a look at how we dose beta-lactams in the morbidly obese, and I'm not sure in fact I'm actually pretty sure that we tend to underdose beta-lactam drugs in those patients. So that was kind of interesting. They note that, jake, you were going to say something.

Speaker 2: 21:20

Yeah, so it of interesting. They note that, jake, you were going to say something. Yeah, so it's interesting, the phrase like when the morbidly obese patient comes into the pharmacy, because I would almost argue some of those individuals may be more homebound or have limited mobility, so I don't know how frequently they might actually be coming into the pharmacy. So, again, this emphasizes the need to document the weight in a pharmacy management system, to have that awareness as you're verifying prescriptions. So, jeff, I know that you have a couple other kind of notes that you want to emphasize, but I want to ask Stephanie a couple questions around this kind of topic. Sure, absolutely Particularly around this idea of, like, morbidly obese, Because, stephanie, your world is pediatrics. Yes, right, and Jeff just said a patient, that's 200 kilograms, mm-hmm, I'm going to again, pediatrics is a big number. It's from one day or one minute to 17 years old, right is the definition I would argue is pediatrics. Generally speaking. You might correct me, because I'm looking at your face and you're like, I'm like it's fair.

Speaker 3: 22:22

I'm thinking from like yeah, it depends who you ask on what the age panels are for pediatrics, even within the pediatric world.

Speaker 2: 22:29

Perfect. So like it is variable and so like, if you tell me a 17 year old is 200 kilograms, I'll still have some questions, but I have less questions than if you tell me a five-year-old is 200 kilograms. And so if you tell me a five-year-old is 200 kilograms, I think that's a data entry error, right? So can you give us some general awareness or foul lines? Because, again, I like to think you know I'm going to act like I'm a hospital pharmacist when I'm making IVs. If I need to grab seven vials to make one IV, I think something is wrong. Right, the way that a drug is designed should imply that you don't need a lot of it. And so, stephanie, you know what are my guardrails. From a pediatric, morbidly obese number.

Speaker 3: 23:17

Yeah Well. So fantastic question and one of the things I was going to bring up so by training. I am a pediatric emergency medicine clinical pharmacist before I joined Perfecting Peds, so I am very much a big fan of how do I translate what this means? How do I use it in real life, at the point of care? And so one of the things I would always teach our residents and med students, all our physicians, and something that's great for all pharmacists, whether you're in the community setting or inpatient setting, is what are normal weights for kids? Like when should a red flag go off in your mind? Like, oh, this might be a wrong error? And so one of the easiest things to remember, we call it the rule of fives or the finger counting method for estimating weight, and so now you're on my level.

Speaker 2: 24:08

You're counting by fingers. Okay, I'm tracking you, I'm with you.

Speaker 3: 24:11

If you have all the knowledge where you can't apply it, like what's the point right, and we're all busy in our practice settings and so you've got to have something tangible really quickly. I was going to talk a little bit more about the growth charts and that's great kind of in the textbook world, but I like to also talk about the real world and what you're going to do like when you don't have a ton of time. So the general premise is, for the first year of life, a traditional non-obese patient should get should weigh 10 kilos. So one year of life, you're weighing 10 kilos. So for the counting rule of fives or finger counting method for weight, we've got our years in odd numbers.

Speaker 3: 24:47

So one year of age, three years old, five years old, seven year old, nine year old, we're starting off at 10 kilos and for every finger we're going to add five kilos. So one year old should be 10 kilos. A three year old should be 15 kilos. Five-year-olds should be 20. Seven-year-olds should be 25. Nine-year-olds should be 30 kilos traditionally. So those are just general, like kind of rules of thumb. If you are seeing a weight that's vastly different than that, one great point it's either data entry error or, two, it's a pediatric patient with obesity, and so those are, I think, a really good like kind of background of where to start when evaluating the weights, because, again, as a pediatric pharmacist, the one thing I cannot function without is a weight. Anytime someone asks you a dose, the very first question we're going to fire back is well, how much do they weigh? And so having that general background of like what's a weight that I should kind of be expecting for this age is super helpful.

Speaker 2: 25:49

And so then, how often do you balance between the four scales? You know, we know that Jeff and his DI office has four scales. He's very lucky. But like, did you have that in the emergency room? Like, how do you differentiate between those? Because I think that was a really salient and practical call out that Jeff gave us.

Speaker 3: 26:06

So it kind of depends.

Speaker 3: 26:08

Being in the ER we're really fortunate because I was at the bedside I'd just go walk over lay eyes and be like, oh, that might be a real weight or oh, that might be data entry.

Speaker 3: 26:18

The other kind of thing is that, working in pediatrics, you've got to be able to work in the gray because we just don't have as much data as the adult world does, and so you kind of get familiar with how weights are and what you dose, which I'm at the point in my career where I can say, like back when I was in school, there really just wasn't a ton of information about it, but within the last, like especially five to seven years, there's been much more pediatric information come out about how we should dose in obesity, and so now that those resources are becoming a little bit more familiar, a little bit more accessible, we're talking about it, which is a good and a bad thing, right, like on the bad side, it's like well, you need to study this. It helps us take care of the pediatric patient a little bit better, because those resources are becoming more widely available and give guidance on with this drug, you should use this weight. With this drug, you should use this weight.

Speaker 2: 27:21

Awesome. So you know, again, I'm going to put on my community pharmacy hat on and you're caring for patients in emergency room and they're dosed correctly because you did it. But you know, I'm over here in Alabama and we might not have an emergency room pediatrician pharmacist, we might got nothing. So you know, help me out. What are the drugs that I should be worried about that you saw, more often than not were dosed incorrectly. Do I need to be worried about Tylenol or do I need to be worried about augmenting?

Speaker 3: 27:56

Both Absolutely Great question. So kind of antibiotics are going to be the most common doses that people should question? Most common doses that people should question, especially if we're unsure about a weight I think number one, remember, for pediatrics and same for adult world, but always in kids we're always using kilos instead of pounds. So if there's ever a weight, too, that you're like, this looks a little funky. First question did they put it in pounds when they meant kilos, or vice versa Should always be kind of a thought in the back of your mind.

Speaker 3: 28:33

When I was working in the emergency department, we fielded calls from all the community pharmacies, so I would get to interact with our community pharmacists all the time and see like what questions they had about medications, because we also verified all the discharge scripts before they printed and so you know we'd be pretty familiar with it and we could see kind of like where people were getting hung up on on what the dose is. And I think two really great questions you brought, or two great drugs you brought up, were Tylenol and Augmentin or Amoxicillin. So PPA, or the Pediatric Pharmacy Association, came out with a paper back in 2017 that really helped kind of simplify what should we be doing when it comes to weights, especially, again, more at the point of care if you don't have a ton of resources. And one of their big takeaways was that if a patient is under 18 and under 40 kilos, we're doing straight weight-based dosing, whether that's make per kg, gram per kg, most of the time make per kg. Once they're over 40 kilos, that's when you need to start evaluating. Should I be using adult dosing? And so if you're over 40 kilos, under 18, ideally you want to max at the adult dose. So when it comes to Tylenol, we're not going to be writing for 1,500 milligrams for a one-time dose. We're going to want to max at that adult dose, based on what their weight is and considering that they're under 18. For amoxicillin, slash Augmentin.

Speaker 3: 30:02

I love this topic because this is a hot debate, big point of clinical debate. Whether you're in the adult world or the pediatrics world, it also can be. It's something we see on pediatric listservs all the time. It's like what dose are you maxing your amoxicillin at? Number one? It's always going to be what's the indication, right? Strep throat is going to be super easy. It maxes at a thousand milligrams, no matter what your age is, what your size is. That one's done, let's take that one off the table.

Speaker 3: 30:30

Where we kind of see a little bit more debate is when it comes to strep pneumo coverage. Whether that is for otitis media pneumonia are the two big ones that you see With the acute otitis media guidelines. Fantastic from the AEP, they've been updated. We love them, all the things. It doesn't have a max dose provided and so, as we've seen pediatric patients with obesity increase, this has become a bigger topic of what do I max my dose at, the adult dose or do we go higher?

Speaker 3: 31:01

Where that even got a little bit more debated is when the community acquired pneumonia guidelines came out and supported a four gram max of amoxicillin. And so, circling back to the acute otitis media guidelines, what I think is a really interesting paper that came out was they surveyed the original physician authors of the acute otitis media guidelines and said, hey, where would you max your amoxicillin dose at? Would you max at 875, traditional adult dosing or would you go higher, even potentially to the four grams that we see with the pneumonia guidelines? And it was split between the physicians. So again, it's a big, it's a lot of gray, and so I think also when it comes to pediatrics the other part that we miss sometimes when we're looking at what their weight is is how old they are as well, so kind of a little shoot-off when we're looking at ACLS and PALS guidelines. There was also kind of guidance of like, well, when do I switch to adult dosing in a CPR setting? And the ACLS guidelines you deep dive those pretty far down.

Speaker 3: 32:09

They do have a little bit of a caveat where they talk about evaluating tanner stage or pubertal status of the patient, and so if the pediatric patient has started puberty, you can then kind of consider them more of an adult from a pharmacokinetics, pharmacodosing side of things. And so where that ties back into amoxicillin, I think that if you had a 12-year-old that was 100 kilos which I think we can all say is, you know that's not within that traditional pediatric dosing range you might be a little bit more inclined to max them at the adult dose. However, if you had a 5-year-old which we know should be 1, 3, 5, so 10, 15, a five-year-old traditionally is around 20 kilos. Let's say you had a five-year-old that was 30 kilos, you might consider one, do I have my high dose of moxicillin dosing appropriately? And two, I might be able to max a little bit higher at that pediatric dose of potentially three to four grams.

Speaker 3: 33:12

But it also kind of ties back into what Jeff was bringing up, in that a lot of times beta-lactams are underdosed and so that was something a lot we would see too. Getting calls back for cephalexin is that it was not uncommon because we want to use total body weight for cephalexin. So when we have the skin soft tissue infections it would not be uncommon for us to discharge kiddos, you know, with a total daily dose of two to three grams and get a call back from a community pharmacy just making sure, like hey, is the weight right, which one I applaud always. Please, please, please, please question. It's never dumb to ask. It's never bad to ask you are taking care of your patients when you are double-checking their weight and double-checking that it's the right dose, but then also helping say yeah, actually it's okay. We do want to do that higher dose and this is why Awesome.

Speaker 2: 34:01

So I love that you ended with please always ask, because I get yelled at sometimes. So it's nice to know that I should still ask, even when getting slapped on the wrist with the proverbial ruler, you know, and what's funny is you talk about that 40 kilogram kind of threshold, right, which, by the way, I really like that unbeknownst. I asked you what is the age of a pediatric patient? Because you just gave me like eight different definitions, including a guideline based one. But we're going to ignore all that. When you said 40 kilos, I started counting on my fingers like how old was 40 kilos? And then you know it stops at 9 years old. So I'm going to go with I don't know, like 12, 13. To your point, puberty.

Speaker 2: 34:38

So I thought that was really interesting, kind of seeing that correlation. So I know that this is something that we could all probably talk about again and again and again and forever and ever and ever. So what I want to do is maybe kind of start to wrap us up. I saw, jeff, your face when Stephanie said four grams. She went ooh. So any commentary on any of the things that she said from your world, your perspective, as kind of like a wrap-up.

Speaker 4: 35:05

I mean, I agree that I think we need to be less concerned. I mean, again, p's is not my world. There's a reason I did my residency in adult and general medicine but you know, I think that you know, as a community pharmacist, yeah, I probably would call the call and say, gee, that seems like a lot, you know. But I do think that the evidence is clear and I think this evidence has been clear in otitis for a long, long time that you need to push the dose of amoxicillin in these patients right. And I think, as pharmacists with beta-lactams, I just think we need to take a step back and think you know what are the toxicities versus, you know what are the risks of overdose versus the risk of underdose.

Speaker 4: 35:48

And in this case, the risk of underdose is, you know, a failure of an antibiotic regimen. The risk of overdose is what diarrhea you know, I mean. So you know, it's one of those things where I mean beta-lactam is an enormously safe drug and you know, yes, if you, you know, slam somebody with a super oh my God dose, yeah, they may have a seizure, but that's pretty obviously vanishingly rare. And so you know, on the whole, these meds are pretty well tolerated, especially in the short term, and so I think we need to be less afraid about pushing doses in obese patients with beta-lactams.

Speaker 2: 36:20

I like it and, jeff, we always like to make our references to pop culture, and so when you told me that like we should just walk off the diarrhea, all I thought about was his butt of flesh wound.

Speaker 4: 36:34

Well, you're time for my dad joking. You don't know that new evidence suggests that diarrhea is genetic, that it runs in the genes.

Speaker 2: 36:41

Oh, yeah, I really like that one.

Speaker 4: 36:45

Yeah, that's my dad joke for today.

Speaker 2: 36:48

We appreciate it, Stephanie. Any final thoughts about hereditary diarrhea or anything else that we've talked about today?

Speaker 3: 36:58

You know, I think I'm going to leave it at the dad joke. I don't know if I could top that. There is one other drug I would love to call out just to let everyone, from wherever you practice from a pediatric standpoint, there is one drug that actually has FDA labeling, approved, information about how to dose with children with obesity, and that's clindamycin. In the PEAS world, we love any time we get something like in black and white FDA approved. We've got some data it supports it fantastic. And if you look at the prescribing information for clindamycin, it does actually have in there now that it should be dosed on total body weight. So that is another one that we would kind of sometimes get some calls back when, let's say, you have a four-year-old that is 35 kilos and they're getting discharged with 360 milligrams of liquid clindamycin three times a day. Seems like a lot, but it's actually been really, really well studied. There's some really good data out there to support still using that high dosing.

Speaker 3: 38:00

And so, again, I just think that please always ask questions. You are doing what's best for the patient. This is our job as pharmacists to make sure we're taking care of our patients and providing them the safest and most appropriate therapy possible. And then one other thing I would love to just kind of tie into this is that, especially with pediatrics, I want to make sure that we're using patient-first language because it's been shown, children with obesity instead of obese children right, children with obesity start to pick up on that as they're growing up and they experience bullying, they experience different perceptions from educators, and so making sure that you know if you're checking that weight, asking the parent, especially if the child is there, making sure we're using appropriate language so that we don't, you know, drive any stigmas or contribute to any bias, to kind of help from a pediatric patient standpoint.

Speaker 2: 38:58

Awesome. I love that you pulled that out at the very end and I appreciate that, and I think it's inclusive, not just to pediatrics but to all persons. Right, we don't define the individual by the medical condition. We start to see evolution in that and some other guidelines. The American Diabetes Association removed the term diabetic and the way that I always think about it there's a lot of pushback, particularly around obesity in this type of topic is my mom was not my Alzheimer's mom. My mom was my mom with Alzheimer's, and so it is not an obesity mom, it is a mom with obesity, and so I think that if we keep that in mind, I think it really emphasizes that.

Speaker 2: 39:34

And then, jen, before I hand it to you and I appreciate everyone for being on this call and letting us talk through this is when Jen and I wrote the article recently. One of the questions that appeared was well, how do I know what pharmacy to go to? That's actually checking the weight. You know, how do we educate the patient or the parent? And I would say that it's about empowerment of the patient, knowing that not all pharmacies are the same. So make sure that you go to the pharmacy that's asking you weight, so you're not like my colleague's sister-in-law that's going to beat up a pharmacist in Tennessee somewhere. So, jen, thank you for having us.

Speaker 1: 40:12

Absolutely With that. I think it is a great example that we need to listen to the podcast all the way through, because I think both of those very last points were some of the most important today. So thank you for calling all of that out, and I think this is just such a good topic. It sort of is back to the basics. I mean, you know, when you say weight-based dosing, you're like, yeah, all drugs are weight-based. But you know to your point, jake, I think not everybody is collecting that or paying attention to it. I think you know Jeff in the hospital setting, obviously, and you know Stephanie from your experience in the ER. Yes, I mean, those questions are being asked, but not always in the community setting. So it's such an important check to make sure that we are collecting that. So, thank you all. Such a good conversation today. I really appreciate it.

Speaker 1: 41:02

And as we wrap up, I just want to ask two favors. One, if you love this podcast and I know so many of you do please share it with friends and colleagues. I think this topic in particular, like we've all talked about, has so many great reminders for every pharmacist, no matter what practice you're in and no matter whether you are an adult-based practitioner or with PEDS, so I think it's got something for everyone, as most of our podcasts do. And two, if you aren't a CE plan member, please join us. You're listening, so there's no reason that you shouldn't get CE credit for listening to this. So it's super easy to check the box with podcast CE, so please join us in that regard. So, with that said, that's it for this week. Thank you so much to Jeff and Jake and Stephanie for joining us today. It was a great conversation and if you are a CE plan member, please be sure to claim your CE credit for this episode by logging into ceimpactcom. And, as always, have a great week, keep learning and we'll talk to you next week. Thank you.

Speaker 5: 42:20

Thanks for listening in. Claim your CE credit by clicking on the link in the show notes and check out CE Impact's other education at CEimpactcom, where we curate the most important information in pharmacy and medicine to deliver straight to you. Join today to connect your learning to practice.