Category: Pharmacology & Therapeutics
Keywords: naloxone,overdose,heroin,opioid (PubMed Search)
Posted: 4/3/2014 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
1. https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf (Contains each law per state as of March 15, 2014)
2. http://www.usatoday.com/story/news/nation/2014/02/20/stateline-drug-overdose-deaths/5637519/
3. Intranasal Naloxone for Treatment of Opioid Overdose. The Medical Letter. Volume 56 (Issue 1438). March 17, 2014
Category: Pharmacology & Therapeutics
Keywords: aseptic meningitis,antibiotics,sulfamethoxazole,valacyclovir,antiepileptics,levetiracetam (PubMed Search)
Posted: 3/6/2014 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Aseptic meningitis is meningitis with negative bacterial cultures. Overall, viral infections are the most common etiology, however medications can also cause this illness.
Well known causes of aseptic meningitis include: antimicrobials (particularly sulfamethoxazole/trimethoprim), NSAIDS, antivirals (valacyclovir), and antiepileptics.
Recently an abstract was published that suggests that patients on levetiracetam have a higher risk of developing aseptic meningitis than those on topiramate and gabapentin. Lamotrigine has also been implicated, but appears to have a lower risk than levetiracetam, topiramate and gabapentin.
Teigland C, Chen P, Parente A, Bhattacharjee R. FDA Black Box Warning on Risk of Aseptic Meningitis with Use of Antiepileptic Drug Lamotrigine: Comparative Risk of Alternative Medications. Abstract, American Epilepsy Society. 2013
http://www.aesnet.org/go/publications/aes-abstracts/abstract-search/mode/display/st/parente/sy/2013/sb/Authors/id/1751398
Category: Pharmacology & Therapeutics
Keywords: anterior epistaxis, tranexamic acid, antifibrinolytic (PubMed Search)
Posted: 2/6/2014 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Tranexamic Acid (TXA) topically applied was compared to anterior nasal packing in 216 patients with acute anterior epistaxis. Cotton pledgets (15 cm) soaked in injectable TXA (500 mg/5 ml) were inserted into the bleeding nostril and removed after bleeding had arrested. This was compared to standard anterior packing.
RESULTS
TXA Anterior packing |
% pts bleeding stopped in 10 min: 71% 31.2% |
Discharge after 2 hours 95.3% 6.4% |
Rebleeding in 24 h hours 4.7% 11% |
Satisfaction scores 8.5 4.4 |
Bottom line: topical tranexamic acid looks promising for control of uncomplicated anterior epistaxis.
Zahed R, Moharamzadeh P, AlizadeArasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. AJEM 2013 (31):1389-92.
Category: Pharmacology & Therapeutics
Keywords: Tranexamic acid, trauma, CRASH-2 (PubMed Search)
Posted: 1/2/2014 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Tranexamic acid (TXA) is an antifibrinolytic that prevents clot breakdown by inhibiting plasminogen activation and plasmin activity
The CRASH-2 trial enrolled 20,211 adult trauma patients with significant hemorrhage (SBP <90 or HR 110) or at significant risk of hemorrhage
Patients were randomized to 1 gram TXA over 10 minutes followed by an infusion of 1 gm over 8 hours vs placebo
There was a significant reduction in the relative risk off all cause mortality of 9% (14.5% vs 16%, RR 0.91, CI 0.85-0.97, p = 0.0035)
The patients that benefited most were those most severely injured, and in those treated in less than 3 hours of injury.
1. CRASH-2 Trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo controlled trial. The Lancet. 2010; 376:23-32.
2. Cap AP, Baer DG, Orman JA, Aden J, Ryan K, Blackbourne LH, Ryan K. Tranexemic Acid for Trauma Patients: A Critical Review of the Literature. Journal of Trauma, Injury, Infection and Critical Care. July 2011 Vol 71(1):S9-S14.
Category: Pharmacology & Therapeutics
Keywords: oral anticoagulant,edoxaban,atrial fibrillation,stroke,Xa (PubMed Search)
Posted: 12/5/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
It has linear, predictable pharmacokinetics, achieves maximal concentration within 1-2 hours, is 50% renally excreted, and has a half life is 9-11 hours.
Edoxaban was evaluated in a recent trial comparing warfarin in patients with atrial fibrillation.
The primary end point or first stroke or systemic pulmonary embolic event occurred in 1.5% with warfarin, compared with 1.18% in the high dose edoxaban (HR 0.79; 97.5% CI 0.63-0.99, P<0.001). In the intention to treat there were trends favoring high dose edoxaban and unfavorable trends with the lower dose.
The principal safety end point of major bleeding occurred in 3.43% with warfarin versus 2.75% with high dose edoxaban (HR 0.86; 95% CI 0.71-0.91, P<0.001).
Bottom line: Both high dose (60 mg) and low dose (30 mg) edoxaban were non-inferior to warfarin with prevention of stroke or systemic emboli, and were associated with significantly lower rates of bleeding and death from cardiovascular causes.
Currently it is approved for use in Japan.
Edoxaban versus Warfarin in Patients with Atrial Fibrillation. Giuliano, RP et al. NEJM Nov 28, 2013; 369(22):2093-2104.
Category: Pharmacology & Therapeutics
Keywords: Cephalosporin,penicillin,anaphylaxis,urticaria,cross sensitivity (PubMed Search)
Posted: 11/7/2013 by Ellen Lemkin, MD, PharmD
(Updated: 8/14/2024)
Click here to contact Ellen Lemkin, MD, PharmD
When patients with severe allergies to penicillin (urticarial, bronchospasm, anaphylaxis, angioedema) are excluded, the cross reactivity to cephalosporins is very low (approximately 0.1%)
The reaction is related to structures in the side chain, not the cyclical structure as thought in the past.
There are several cephalosporins with IDENTICAL side chains that should not be given to patients with allergies to specific penicillins, namely:
The Medical Letter on Drugs and Therapeutics • December 24, 2012 (Issue 1406) p. 101.
Category: Pharmacology & Therapeutics
Keywords: procainamide,atrial fibrillation,prolonged QT,monomorphic VT (PubMed Search)
Posted: 10/3/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
ACLS recommendation for procainamide in tachycardic rhythms is:
Loading dose 20 mg/minute (up to 50 mg/minute for more urgent situations) until:
Maintenance infusion is 1 to 4 mg/min.
An easier method for dosing acute onset atrial fibrillation in stable patients was used in the Ottawa Aggressive Protocol, in which they administered 1 gm over 60 min, which was interrupted if BP < 100 mmHg; if corrected by a 250 ml IV bolus, the infusion was resumed. This was not used, however if the patient was to be admitted.
A strategy for treating stable monomorphic VT with procainamide used:
100 mg IV over 1-2 minutes, repeat as necessary until an endpoint of
If no slowing of the tachycardia occurred with a dose of 400 mg, the administration was ceased.
1. Steil IG, Clement CM, Perry JJ et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010;12(3):181-91.
2. Komura S, Chinushi M, Furushima H. et al. Efficacy of Procainamide and Lidocaine in Terminating Sustained Monomorphic Ventricular Tachycardia. Circulation May 2010 Vol 72
Category: Airway Management
Keywords: NMS, haldol, haloperidol, fluphenazine, dantrolene, bromocriptine, diazepam (PubMed Search)
Posted: 9/5/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
NMS is most often seen with the typical high potency neuroleptic agents (e.g haldol, fluphenazine)
All classes of antipsychotics can cause NMS, including low potency and newer atypical agents; antiemetics can cause this as well.
Symptoms usually occur after the first 2 weeks of therapy, but may occur after years of use
Signs and symptoms include:
mental status changes
muscular rigidity (“lead pipe”)
hyperthermia (>38 - 40 degrees).
Autonomic instability (tachycardia, tachycardia and diaphoresis)
Treatment includes discontinuation of the offending agent and providing supportive care.
While no clinical trials have ever been undertaken, dantrolene (muscle relaxant) is commonly used.
Bromocriptine (dopamine agonist) may also be used, and amantadine (dopaminergic and anticholinergic agent) is used as an alternative to bromocriptone
Recently, several case reports have documented the successful use of diazepam as a sole pharmacologic agent. This may be an alternative or a supplement to the above agents
Category: Toxicology
Keywords: bicarbonate, acetate, TCA, salicylate, poisoning, alkalinization (PubMed Search)
Posted: 8/1/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
A recent article was published in the Journal of Medical Toxicology reviewing the use of sodium acetate for treatment of overdoses and poisonings.
Acetate is metabolized to bicarbonate, causing a net increase in cations; this increased strong anion difference leads to alkalemia.
It has been used to treat acidosis in uremia, diarrhea, and in trauma patients.
Although no studies have been conducted using sodium acetate as an antidote, if bicarbonate is unavailable this is a viable option for management of salicylate overdose, and for qrs widening or arrhythmias due to overdoses.
Sodium acetate, if given rapidly (in animals and hemodialysis patients), causes myocardial depression, hypotension, and hypopnea.
The bolus dose should be given as 1-2 mEq/L given over 15-20 minutes. For the maintenance infusion, dilute 150 mEq diluted to 1 L in dextrose 5%, infuse at 2X the maintenance rate.
It must be diluted in dextrose 5% and NOT normal saline.
Neavyn MJ, Boyer EW, Bird SB, Babu KM. Sodium Acetate as a Replacement for Sodium Bicarbonate in Medical Toxicology: a Review. Published online 30 April 2013. J. Med. Toxicol.
Category: Pharmacology & Therapeutics
Keywords: insulin, metformin, sulfonylureas, repaglinide (PubMed Search)
Posted: 7/4/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Diabetes. Pharmacist's Letter March 2013;29(3):13-4.
Category: Toxicology
Keywords: Opioid, methadone, pain management, tolerance, analgesia (PubMed Search)
Posted: 6/6/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Gussow, L. Toxicology Rounds. When Opioids Increase Pain. Emergency Medicine News Feb 2013. 35(2):6.
Category: Pharmacology & Therapeutics
Keywords: Prothrombin Complex Concentrate, warfarin, coumadin, vitamin K antagonist, anticoagulant, PCC (PubMed Search)
Posted: 5/2/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Approval of Kcentra™ may open the door for studying treatment of the bleeding patient on newer oral anticoagulants.
Category: Pharmacology & Therapeutics
Keywords: Status epilepticus, Keppra, seizures, valproic acid, levetiracetam (PubMed Search)
Posted: 4/4/2013 by Ellen Lemkin, MD, PharmD
(Updated: 8/14/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Trinka E. What is the evidence to use new intravenous AED in status epilepticus? Epilepsia 2011 52(Suppl 8):35-8.
Zelano J, Kumlien E. Levetiracetam as alternative stage two antiepileptic drug in status epilepticus: A systematic review. Seizure 2012. 21:233-6.
Category: Pharmacology & Therapeutics
Keywords: Statins, Acute Coronary Syndrome, Myocardial Infarction (PubMed Search)
Posted: 3/7/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Statins for acute coronary syndrome. Cochrane Database of Systemic Reviews. Volume 9, 2011.
Category: Toxicology
Keywords: anabolic, bodybuilding, weightlifting, beta agonist, myocardial infarction (PubMed Search)
Posted: 2/7/2013 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Category: Toxicology
Keywords: creatine, supplement, weight lifting (PubMed Search)
Posted: 1/3/2013 by Ellen Lemkin, MD, PharmD
(Updated: 8/14/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Creatine
Adverse effects: weight gain, edema, GI cramping, fatigue and diarrhea
Dandoy C, Gereige RS. Performance-Enhancing Drugs. Pediatrics in Review June 2012;33(6):265-72.
Category: Critical Care
Keywords: anaphylaxis, tryptase, diagnosis (PubMed Search)
Posted: 12/6/2012 by Ellen Lemkin, MD, PharmD
(Updated: 8/14/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Simons EF, Ardusso LE, Bilo MB, et al. 2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis.
Category: Pharmacology & Therapeutics
Keywords: ACE inhibitors, angioedema, icatibant (PubMed Search)
Posted: 11/1/2012 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Category: Pharmacology & Therapeutics
Keywords: ACE inhibitors, angioedema, icatibant (PubMed Search)
Posted: 11/1/2012 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Wilerson G. Angioedema in the Emergency Department: An evidence-based review. Emergency Medicine Practice, Nov 2012.
Category: Toxicology
Keywords: Cannabinoid,hyperemesis, marijauna (PubMed Search)
Posted: 10/4/2012 by Ellen Lemkin, MD, PharmD
(Updated: 8/14/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Michael Hiotis PharmD, CSPI. ToxTidbits. Maryland Poison Center Sep 2012