[영문]BACKGROUND: Anticoagulant and antithrombotic agents are frequentlycited as sources of medication errors. Several factors increase the riskof receiving excess dosing of glycoprotein IIb/IIIa inhibitors in the managementof acute coronary syndrome (ACS), including older age, femalegender, elevated serum creatinine, a history of diabetes mellitus, and ahistory of heart failure. In June 2003, the manufacturer of eptifibatidereleased a recommendation adjusting infusion rate downward to 1 mcgper kg per minute for eptifibatide in patients with renal impairment,defined as an estimated creatinine clearance (CrCl) < 50 ml per minute.Eptifibatide is known to accumulate in patients with renal impairment,thereby increasing hemorrhagic risk.OBJECTIVE: To assess the impact of education on physician adherence tothe renal dosing recommendation for eptifibatide at 2 academic medicalcenters. The primary outcome measure was the proportion of patients withrenal impairment dosed appropriately with eptifibatide before and afterin-service education provided by a clinical pharmacist. Secondary outcomemeasures included the difference in the improvement in dosing adherencebetween the 2 sites and the influence of patient variables on the incidenceof bleeding events.METHODS: This prospective study was conducted in patients withrenal impairment who received eptifibatide for the medical managementof unstable angina (UA) or non?ST-elevation myocardial infarction(NSTEMI) or for the interventional management of chronic stableangina, UA, NSTEMI, or ST-elevation myocardial infarction (STEMI,not a Food and Drug Administration-approved use). Patient datawere assessed at 2 tertiary care teaching institutions between June2003 and December 2005. The preeducation phase for the sites ranfrom June 2003 through April 2005 for Site A and from June 2003through May 2005 for Site B. The posteducation phase ran from May2005 through December 2005 for Site A and from June 2005 throughDecember 2005 for Site B.At site A, a 1-hour educational seminar on ACS management strategieswas employed, in which 5 minutes focused on adherence of prescribersto the guideline for renal dosing recommendations for eptifibatide. Thistutorial was accomplished through (1) an in-service provided by 1 clinicalpharmacist to the cardiology department, and (2) handouts containing therenal dosing recommendations for eptifibatide along with dosing for othermedications used to manage ACS.The intervention at Site B involved an eptifibatide-focused seminarpresented to cardiologists by a clinical pharmacist, 10 minutes of whichwas devoted to renal dosing recommendations that included (1) a summaryof literature supporting the infusion rate reduction in patients withrenal impairment and (2) the specific updated dosing recommendationfor eptifibatide. The data collected in retrospective chart review includedpatient demographics, baseline laboratory values, and risk factors forbleeding. An appropriate eptifibatide dose was defined as a physicianorder for a continuous infusion of 1 mcg per kg per minute in patientswith an estimated CrCl < 50 ml per minute.RESULTS: A total of 148 patients with renal impairment who receivedeptifibatide were evaluated (106 in the preeducation phase and 42 in theposteducation phase). A significant increase in the adherence rate foreptifibatide dosing in patients with renal impairment was observed from 36.8%in the preeducation phase to 69.0% in the posteducation phase (P < 0.001) forthe 2 sites combined. The incidence of major and minor bleeding was 16.7%in the preeducation phase and 14.3% in the posteducation phase (P = 0.742).When bleeding incidence was stratified by the appropriateness of infusion, theincidence of major and minor bleeding was also similar for appropriate dosing(1 mcg per kg per minute, 16.4%) versus inappropriate dosing (2 mcg per kgper minute, 15.7%; P = 0.916).CONCLUSION: This educational intervention provided by a clinical pharmacistwas associated with improved prescriber adherence to dosing recommendationsfor eptifibatide in patients with renal impairment. Improved adherence to thedosing guideline and administration of an appropriate infusion rate were notassociated with reduction in either minor or major bleeding events.