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Room for improvement in drug dosage timing in hospitals uncovered at Cincinnati Children's Hospital

Drugs were administered in a series of surges and lulls that corresponded to changing shifts rather than patient need.

Jeff Lagasse, Associate Editor

Too many hospitals provide medications according to the practicalities of their staffing schedules rather than the ideal dosing times for their patients, according to a new study led by experts at Cincinnati Children's Hospital.

The study, published Tuesday, was led by David Smith, MD, PhD, Divisions of Pediatric Otolaryngology and Pulmonary Medicine; Marc Ruben, PhD; and John Hogenesch, PhD, co-director, Center for Circadian Medicine at Cincinnati Children's.

The study examined the daily distribution of approximately 500,000 doses of 12 drugs in 1,486 inpatients at a major U.S. children's hospital.

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For every drug, order times were dependent on the time of day, with morning surges and overnight lulls. Those rhythms corresponded to shift changes and rounding times.

But those time peaks don't always line up with when patients need medications the most, be it to relieve pain, control blood pressure or battle infections.

For example, the study found a day shift-driven rhythmic order for morphine, acetaminophen and other pain medications, which raises questions about whether night-time pain goes undertreated. Meanwhile, some corticosteroids are administered in the evening, which can lead to insomnia and overnight hunger.

The team is currently working with other doctors and nurses at Cincinnati Children's to adjust drug administration protocols where warranted. They also are reminding caregivers to conduct night-time check-ins with patients at highest risk of experiencing pain.

There exists roughly 60 years' worth of research it drug timing, and the authors hope this data can be more fully integrated into hospital drug administration practices. The pilot work happening at Cincinnati Children's represents some of the early steps in a growing recognition of how circadian rhythms -- a person's set of internal body clocks -- can influence the outcomes of medical care.


While the Cincinnati Children's cohort didn't hone in specifically on opioid medications, it could open a path toward consistently sound opioid administration and prescribing practices -- which to date has been elusive, as the ongoing opioid addiction epidemic suggests.

In May, The Centers for Disease Control and Prevention clarified its guidelines on opioid prescribing, citing the findings of a review panel led by Regenstrief Institute Research Scientist Dr. Kurt Kroenke. Kroenke and his colleagues found that many clinicians, policymakers and payers are misapplying the CDC's guidelines, and these actions are negatively affecting patients.

The CDC issued the guidelines in 2016 in response to the increase in abuse of opioid medications. Those recommendations include trying other pain treatments first, limiting opioid doses and prescriptions and discussing the risks of opioids with patients.

Twitter: @JELagasse

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