Category: Pharmacology & Therapeutics
Keywords: Pneumonia, MRSA, Antibiotics (PubMed Search)
Posted: 3/7/2020 by Wesley Oliver
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Empirical Anti-MRSA vs Standard Antibiotic Therapy and Risk of 30-Day Mortality
A recent article published in JAMA Internal Medicine questioned the utility of empiric anti-MRSA pneumonia therapy. It was a retrospective multicenter cohort study conducted in the Veteran’s Health Administration healthcare system that looked at 88,605 patients with community-onset pneumonia. They compared 30-day mortality of patients hospitalized for pneumonia receiving empirical anti-MRSA therapy plus standard therapy against standard therapy alone. Secondary outcomes analyzed development of kidney injury and secondary infections with C. difficile, VRE, or gram-negative rods. They also analyzed subgroups: ICU admission, MRSA risk factors, positive MRSA surveillance test, and positive MRSA culture on admission.
Anti-MRSA Therapy: Vancomycin (98%), Linezolid (2%)
Standard Therapy: Beta-lactam + macrolide/tetracycline, or respiratory fluoroquinolone
Outcomes
Mortality: aRR=1.4 [95% CI, 1.3-1.5]
Kidney Injury: aRR=1.4 [95% CI, 1.3-1.5]
Secondary C. difficile: aRR=1.6 [95% CI, 1.3-1.9]
Secondary VRE: aRR=1.6 [95% CI, 1.0-2.3]
Secondary gram-negative rods: aRR=1.5 [95% CI, 1.2-1.8]
Mortality in Subgroups
ICU: aRR=1.3 [95% CI, 1.2-1.5]
MRSA Risk Factors*: aRR=1.2 [95% CI, 1.1-1.4]
Positive MRSA Surveillance: aRR=1.6 [95% CI, 1.3-1.9]
MRSA Detected on Culture: aRR=1.1 [95% CI, 0.8-1.4]
*MRSA Risk Factors
-History of MRSA infection/colonization within the past year
-Or 2 of the following: previous hospitalization, nursing home residence, and previous intravenous antibiotic therapy
Take-Home Point
Empirical anti-MRSA therapy did not decrease mortality for any groups of patients hospitalized for pneumonia. Given that healthcare-associated pneumonia is no longer a definition supported by the IDSA/ATS, be judicious in your use of anti-MRSA therapy in community-onset pneumonia and reserve for those patients at higher risk for MRSA, such as those with post-influenza pneumonia.
Jones BE, Ying J, Stevens V, et al. Empitical anti-MRSA vs standard antibiotic therapy and risk of 30-day mortality in patients hospitalized for pneumonia [published online ahead of print, February 17, 2020]. JAMA Intern Med. doi: 10.1001/jamainternmed.2019.7495.
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Resp Crit Care. 2019;200:e45-e67.
Smith C. Is Empiric Anti-MRSA Pnumonia Therapy Harmful? https://journalfeed.org/article-a-day/2020/is-empiric-anti-mrsa-pneumonia-therapy-harmful. March 4, 2020. Accessed March 6, 2020.
Category: Pharmacology & Therapeutics
Keywords: Influenza, Pneumonia, MRSA, Antibiotics (PubMed Search)
Posted: 1/4/2020 by Wesley Oliver
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Influenza is a common cause of community-acquired pneumonia and invasive bacterial coinfection may occur. In addition, secondary bacterial pneumonia due to MRSA is becoming more prevalent. Due to the higher incidence of MRSA, it is recommended that antibiotics with activity against MRSA (vancomycin or linezolid) be included in the empiric treatment regimen, especially if the patient is critically ill.
Take Home Point: Don’t forget to add MRSA coverage to your empiric treatment regimen in those influenza patients with severe disease or secondary bacterial pneumonia.
1. Uyeki, Timothy M et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis. 2019;68: e1-e47.
2. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200:e45–e67.
Category: Pharmacology & Therapeutics
Keywords: adenosine, SVT (PubMed Search)
Posted: 12/8/2019 by Ashley Martinelli
(Updated: 4/26/2024)
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Adenosine is an atrioventricular nodal blocking agent that is commonly used in the treatment of supraventricular tachycardia. It is dosed as 6 mg IV Push x 1, followed by dose escalation to 12 mg IV Push if the initial dose was unsuccessful. In patients with central access or prior orthotopic heart transplantation, the initial recommended dose is 3 mg.
Due to its short half-life (< 10 seconds) it is imperative to administer in the most proximal access and follow with a 20 mL bolus of saline. Traditionally this is done using a two-way stopcock.
A new study compared single syringe (adenosine 6mg + 18 mL saline) vs two syringes (adenosine 6mg in one, 20 mL saline in the other) in 53 patients with SVT. The single syringe arm converted to NSR 73.1% after one dose compared to 40.7% in the two-syringe arm (p=0.0176). After up to three doses, the single syringe arm had 100% conversion compared to 70.4% in the two-syringe arm (p=0.0043).
Single syringe adenosine has been recommended in FOAM for several years. Although small, this study is the first to compare the two methods. This method simplifies administration and may improve cardioversion rates.
McDowell M, Mokszycki R, Greenberg A, et al. Single-syringe administration of diluted adenosine. Acad Emerg Med. 2019;00:1-3.
Category: Pharmacology & Therapeutics
Keywords: Phenytoin, Fosphenytoin (PubMed Search)
Posted: 11/2/2019 by Wesley Oliver
(Updated: 11/3/2019)
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Phenytoin can be a complex medication. There are different levels than can be ordered, adjustments based on albumin, various pharmacokinetic equations, and multiple formulations. Below are the simplified answers to some of the most common questions (see in-depth section for explanations):
Which phenytoin level (free or total) do I order?
Total Phenytoin Level.
What do I do after the level results?
Undetectable Level: Load patient with 20 mg/kg of total body weight (max dose 1,500 mg).
Subtherapeutic Level (<10 mcg/mL): Calculate an approximate loading dose using this equation….Phenytoin Dose (mg)=(15-measured total level)*(0.7*patient weight).
Therapeutic Level (10-20 mcg/mL): Add an additional agent.
Supratherapetutic/Toxic Level (>20 mcg/mL): Contact Poison Center (1-800-222-1222).
What formulation do I order for loading?
IV: Use fosphenytoin.
PO: Any formulation will work. Give as a single loading dose or, if concerned for GI upset, give in 2-3 divided doses separated by 2 hours.
***Disclaimer: These answers are simplified for the initial management of most patients in the ED. More complex answers may be required in some situations.***
Which phenytoin level (free or total) do I order?
Total Phenytoin Level
Free and total phenytoin levels are available at most institutions. Free levels are more predictive of efficacy and toxicity; however, free levels are tested only at certain times at most institutions which can lead to a delay in results. Total phenytoin levels are a good approximation of therapeutic levels and are easier to perform pharmacokinetic caculations.
What do I do after the level results?
Undetectable Level: Load patient with 20 mg/kg of total body weight (max dose 1,500 mg)
For phenytoin naive or noncompliant patients that present with an undetectable level, the guideline recommended loading dose is phenytoing 20 mg/kg.
Subtherapeutic Level (<10 mcg/mL): Calculate an approximate loading dose using this equation….Phenytoin Dose (mg)=(15-measured total level)*(0.7*patient weight)
Phenytoin has many complex equations related to the pharmacokinetics of the medication. There are adjustments for albumin, approximations of free/total levels, estimations of loading doses, etc. A simple PK equation that can be applied to most medications is concentration=(dose*salt factor)/(volume of distribution). For application to clinical cases with phenytoin this equation can be manipulated to yield the dose=(desired concentration-measured concentration)*(population Vd*patient weight).
For the equation given to you above, this equation has modified. The equation was manipulated to solve for dose. The salt correction factor was removed. For phenytoin the salt correction factor is 0.92, thus removing it does not significantly affect the results. There are also two variables of the equation that are prepopulated. Therapeutic levels of phosphenytoin are 10-20 mcg/mL. A simplified desired concentration is to aim for the middle concentration of 15 mcg/mL. The population Vd is a range; however, we use 0.7 L/kg for ease of caculations.
Therapeutic Level (10-20 mcg/mL): Add an additional agent
There is no therapeutic benefit to giving additional phenytoin in these patients. Phenytoin has complex pharmacokinetics and giving patient additional phenytoin will likely lead to phenytoin toxicity.
Supratherapetutic/Toxic Level (>20 mcg/mL): Contact Poison Center (1-800-222-1222)
Experts in toxicology are available 24/7 to assist in the managment of patients with phenytoin toxicity.
What formulation do I order for loading?
IV: Use fosphenytoin
For initial IV loading, fosphenytoin (a prodrug of phenytoin) is preferred. Compared to phenytoin, fosphenytoin can be administer faster, has less side effects, and does not require a filter for administration; making fosphenytoin the preferred product. Fosphenytoin is doses in phenytoin equivalents (PE) to prevent confusion with dosing.
PO: Any formulation will work. Give as a single loading dose or, if concerned for GI upset, give in divided doses separated by 2 hours.
Any oral formulation of phenytoin (immediate release, extended release, oral solution) is appropriate for oral loading of phenytoin. There is evidence supporting a single oral loading dose of phenytoin can be tolerated; however, due to historical guidance of limiting the oral dose to <400 mg and separating doses by 2 hours due to concern for absorption and potential for GI upset some providers may find a single dose controversial. An alternative method is to divide the total phenytoin dose into 2-3 doses and administer separated by 2 hours for each dose.
1. Abernethy DR, Greenblatt DJ. Phenytoin disposition in obesity. Determination of loading dose. Arch Neurol. 1985;42(5):468-71.
2. Anderson GD, Pak C, Doane KW, et al. Revised Winter-Tozer equation for normalized phenytoin concentrations in trauma and elderly patients with hypoalbuminemia. Ann Pharmacother. 1997;31(3):279-84.
3, Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48
4. Kane SP, Bress AP, Tesoro EP. Characterization of unbound phenytoin concentrations in neurointensive care unit patients using a revised Winter-Tozer equation. Ann Pharmacother. 2013;47(5):628-36.
5. Osborn HH, Zisfein J, Sparano R. Single-dose oral phenytoin loading. Ann Emerg Med. 1987;16(4):407-12.
6. Ratanakorn D, Kaojarern S, Phuapradit P, Mokkhavesa C. Single oral loading dose of phenytoin: a pharmacokinetics study. J Neurol Sci. 1997;147(1):89-92.
7. Soriano VV, Tesoro EP, Kane SP. Characterization of Free Phenytoin Concentrations in End-Stage Renal Disease Using the Winter-Tozer Equation. Ann Pharmacother. 2017 May 1.
8. Winter MG, Tozer TN. Chapter 25. Phenytoin. In: Evans WE, Schentag JJ, Jusko WJ. Applied pharmacokinetics: principles of therapeutic drug monitoring. 3rd ed. Vancouver, WA: Applied Therapeutics, 1992:1-44.
Category: Pharmacology & Therapeutics
Keywords: droperidol (PubMed Search)
Posted: 9/7/2019 by Ashley Martinelli
(Updated: 4/26/2024)
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Droperidol is a butyrophenone with primary action as a dopamine D2 receptor antagonist. Historically, it has been used to treat a variety of conditions from nausea and headaches to acute agitation. In 2001, the FDA issued a black box warning for risk of cardiac arrhythmias. Following this warning, droperidol was on national shortage for several years, further limiting its use.
Several months ago, droperidol returned to the US market and is available at some institutions. Below is a refresher on dosing and monitoring. Similar to haloperidol, droperidol can cause extrapyramidal symptoms. Consider pre-treatment with diphenhydramine.
Dosing Recommendations:
Nausea and vomitting: 1.25 mg IV
Headache: 2.5 mg IV, 5 mg IM
Acute agitation: 5mg IM/IV
QTc prolongation is still a concern, especially at higher doses. If using doses > 2.5mg, or using repeated doses, obtain an ECG to ensure safe use of this medication. If the QTc is greater than 440 msec for males or 450 msec for females, droperidol is not recommended. There is little data regarding the risk with lower doses. Utilize clinical judgement and assess patient risk factors.
Perkins J, et al. American Academy of Emergency Medicine position statement: Safety of droperidol use in the emergency department. J Emerg Med. 2014;49(1): 91-97.
Category: Pharmacology & Therapeutics
Keywords: DKA, SGLT2 Inhibitors (PubMed Search)
Posted: 8/3/2019 by Wesley Oliver
(Updated: 4/26/2024)
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The American Diabetes Association requires a plasma glucose concentration greater than 250 mg/dL to diagnose diabetic ketoacidosis (DKA). However, with the new diabetic agents this is not always the case. With the introduction of SGLT2 inhibitors (canagliflozin [Invokana], dapagliflozin [Farxiga], empagliflozin [Jardiance]) there have been reported cases of DKA and patients being euglycemic.
Take Home Point
Patients with a low/normal blood glucose can still have DKA. Especially if they are taking newer medications, such as the SGLT2 inhibitors.
AE Kitabchi, GE Umpierrez, JM Miles, JN Fisher. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009;32:1335-1343.
U.S Food and Drug Administration. FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood. https://www.fda.gov/media/92185/download. Accessed August 3, 2019.
Category: Pharmacology & Therapeutics
Keywords: alteplase, pulmonary embolism (PubMed Search)
Posted: 7/6/2019 by Wesley Oliver
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Alteplase may be considered in some patients with a presumed or confirmed pulmonary embolism. Below is a list of the different patient populations and the associated alteplase dosing.
-Hemodynamically Stable/Submassive: Alteplase usually not indicated.
-Hemodynamically Unstable/Massive: Alteplase IV 100 mg as an infusion over 2 hours.
-Cardiac Arrest: Alteplase IV/IO 50 mg bolus over 2 minutes. Can repeat a second 50 mg bolus 15 minutes later if unable to achieve return of spontaneous circulation.
Alteplase. Lexicomp. UpToDate. Waltham, MA: UpToDate Inc. Available at: https://www.uptodate.com. Accessed on July 6, 2019.
Kearon C, Aki EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e419-e496S.
Kearon C, Aki EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-352.
Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S501-S518.
Category: Pharmacology & Therapeutics
Keywords: Milrinone, dobutamine, insulin, pumps (PubMed Search)
Posted: 5/4/2019 by Ashley Martinelli
(Updated: 4/26/2024)
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Continuous home infusion therapies of medications such as insulin, milrinone, dobutamine, and pulmonary hypertension medication such as treprostinil are becoming more common. As a result, you may see these patients present to the emergency room and need to know the basics for checking the pump.
These questions are very important to determine if you will need to order a replacement infusion bag and run it on a hospital infusion pump, or if the patient can safely remain on their pump during the initial medical evaluation.
Category: Pharmacology & Therapeutics
Keywords: Serotonin Syndrome, SHIVERS (PubMed Search)
Posted: 4/6/2019 by Wesley Oliver
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Identifying serotonin syndrome in the emergency department can be difficult without an accurate patient history. Furthermore, the physical symptoms may look similar to many other disorders such as neuroleptic malignant syndrome and anticholinergic toxicity. If you remember the acronym SHIVERS, you can easily recognize the signs and symptoms of serotonin syndrome.
Shivering: Neuromuscular symptom that is unique to serotonin syndrome
Hyperreflexia and Myoclonus: Seen in mild to moderate cases. Most prominent in the lower extremities. This can help differentiate from neuroleptic malignant syndrome which would present with lead-pipe rigidity.
Increased Temperature: Not always present, but usually observed in more severe cases
Vital Sign Abnormalities: Tachycardia, tachypnea, and labile blood pressure
Encephalopathy: Mental status changes such as agitation, delirium, and confusion
Restlessness: Common due to excess serotonin activity
Sweating: Autonomic response to excess serotonin. This symptom can help differentiate from anticholinergic toxicity in which the patients would present with increased temperature but dry to the touch
Once serotonin syndrome is identified, it is important to discontinue all serotonergic agents, provide supportive care with fluids, and sedate with benzodiazepines. Sedation with benzodiazepines helps to decrease myoclonic jerks which also helps with temperature control. If patients are hyperthermic, they will require intensive cooling. Cyproheptadine, a potent antihistamine and serotonin antagonist, should also be administered. The initial dose of cyproheptadine in serotonin syndrome is 12mg which can be followed by 2 mg every 2 hours as needed for symptom control.
1. Christensin RC. Get serotonin syndrome down with cold shivers. [Internet] 2006 [cited 2019 Apr 4]. Available from: https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0502CP_Pearls2.pdf
2. Ables AZ, Nagubilli R. Prevention, Recognition, and Management of Serotonin Syndrome. AFP. 2010;81(9):1139-1142.
Category: Pharmacology & Therapeutics
Keywords: bleeding, epistaxis, tranexamic acid (PubMed Search)
Posted: 3/2/2019 by Ashley Martinelli
(Updated: 4/26/2024)
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Mechanism of Action | Tranexamic Acid (TXA) is an antifibrinolytic agent that is a competitive inhibitor of plasminogen activation, and a non-competitive inhibitor of plasmin Inhibits the breakdown of fibrin mesh allowing clot formation
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When is it Indicated? | Epistaxis/Oral Bleeds/Fistula Bleeds
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Trauma
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Adverse Reactions |
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Category: Pharmacology & Therapeutics
Keywords: hypoglycemia, hyperkalemia (PubMed Search)
Posted: 2/2/2019 by Ashley Martinelli
(Updated: 4/26/2024)
Click here to contact Ashley Martinelli
Scott NL, Klein LR, Cales E, Driver BE. Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department. Am J Emerg Med. 2019;37(2):209-213.
Category: Pharmacology & Therapeutics
Keywords: Flu, Treatment, Oseltamivir (PubMed Search)
Posted: 1/8/2019 by Wesley Oliver
(Updated: 4/26/2024)
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---Early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of some complications from influenza.
---Early treatment of hospitalized adult influenza patients with oseltamivir has been reported to reduce death in some observational studies.
---Clinical benefit is greatest when antiviral treatment is administered within 48 hours of influenza illness onset.
Antiviral treatment is recommended for patients with confirmed or suspected influenza who:
---are hospitalized;
---have severe, complicated, or progressive illness; or
---are at higher risk for influenza complications. (See below for in-depth information)
Oral oseltamivir is the recommended antiviral for patients with severe, complicated, or progressive illness who are not hospitalized, and for hospitalized influenza patients.
Treatment:
Doses: Oseltamivir 75 mg twice daily
Renal Impairment Dosing
CrCl >60 mL/minute: No dosage adjustment necessary
CrCl >30 to 60 mL/minute: 30 mg twice daily
CrCl >10 to 30 mL/minute: 30 mg once daily
ESRD undergoing dialysis: 30 mg immediately and then 30 mg after every hemodialysis session
Duration of Treatment:
Recommended duration for antiviral treatment is 5 days for oral oseltamivir. Longer daily dosing can be considered for patients who remain severely ill after 5 days of treatment.
People at higher risk for influenza complications recommended for antiviral treatment include:
---children younger than 2 years;
---adults 65 years and older;
---people with chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cell disease), and metabolic disorders (including diabetes mellitus), or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle, such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury);
---people with immunosuppression, including that caused by medications or by HIV infection;
---women who are pregnant or postpartum (within 2 weeks after delivery);
---people younger than 19 years old who are receiving long-term aspirin- or salicylate-containing medications
---American Indians/Alaska Natives;
---people who are extremely obese (i.e., body mass index is equal to or greater than 40); and
---residents of nursing homes and other chronic care facilities.
Centers for Disease Control and Prevention. Influenza antiviral medications: summary for clinicians. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm (Accessed on January 8, 2019).
Category: Pharmacology & Therapeutics
Keywords: naloxone, overdose (PubMed Search)
Posted: 12/3/2018 by Ashley Martinelli
(Updated: 4/26/2024)
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Providing naloxone to patients at risk for opioid overdose is now standard of care. A retrospective study evaluated the rate of naloxone obtainment after standardizing the process for prescribing naloxone in the emergency department and dispensing from the hospital outpatient pharmacy.
55 patients were prescribed naloxone. Demographics: mean age 48 years old, 75% male, 40% primary diagnosis of heroin diagnosis, 45.5% were prescribed other prescriptions.
Outcomes:
Barriers identified included lack of ED dispensing program, cost of medication, even though cost is minimal and can be waived, and likely multifactorial reasons why patients did not present to pharmacy as instructed.
Take Home Points:
Verdier M, Routsolias JC, Aks SE. Naloxone prescriptions from the emergency department: An initiative in evolution. Am J Emerg Med. 2018;37(1)164-165.
Category: Pharmacology & Therapeutics
Keywords: Intranasal Administration, Alternative Administration (PubMed Search)
Posted: 11/2/2018 by Wesley Oliver
(Emailed: 11/3/2018)
(Updated: 11/8/2018)
Click here to contact Wesley Oliver
The most common methods of medication administration in the emergency department are oral, intravenous (IV), and intramuscular (IM). If the oral route is not available, if IV/IM are not necessary, or if obtaining IV access is challenging, intranasal (IN) medication delivery is a reasonable alternative. More concentrated products are preferred and a volume of 1 mL or less per nostril should be utilized. Below is a table of the commonly used medications used via the IN route.
Drug | Concentration | Indication | IN Dose | Time to Peak Effect | Adverse Events |
Fentanyl | 50 mcg/mL | Analgesia | 0.5-2 mcg/kg | 5 min | Nasal irritation, rhinitis, headache |
Ketamine | 100 mg/mL | Analgesia, Agitation, Sedation | 3-6 mg/kg | 5-10 min | Poor taste, HTN, hypersalivation, agitation, emergence reaction |
Lorazepam | 2 mg/mL | Agitation, Seizures | 0.1 mg/kg Max: 4 mg | 30 min | Poor taste, lacrimation, nasal/throat irritation |
Midazolam | 5 mg/mL | Agitation, Sedation, Seizures | 0.1-0.4 mg/kg Max: 10 mg | 5-10 min | Same as lorazepam |
Naloxone | 1 mg/mL | Opioid Reversal | 0.1 mg/kg Usual dose: 0.4-2 mg | 1-5 min | N/V, headache, withdrawal symptoms |
Bailey AM, Baum RA, Horn K, et al. Review of intranasally administered medications for use in the emergency department. J Emerg Med. 2017;53:38-48.
Category: Pharmacology & Therapeutics
Keywords: Clonidine, opioid withdrawal (PubMed Search)
Posted: 10/6/2018 by Ashley Martinelli
Click here to contact Ashley Martinelli
Clonidine is an alpha-2 agonist commonly used to treat hypertension. Clonidine can also be used to mitigate symptoms of opioid withdrawal as it easily crosses the blood brain barrier and reduces sympathetic effects.
When using clonidine for acute withdrawal or blood pressure control, oral tablets are the preferred route. Clonidine transdermal patches have slow absorption and take 2-3 days for the effect to be seen. Once removed, clonidine patches can provide therapeutic levels for up to 20 hours.
Bottom Line: If clonidine is needed acutely for your patient, select oral tablets and titrate to effect.
Catapres-TTS [package insert] Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT, August 2016.
Category: Pharmacology & Therapeutics
Keywords: Sepsis, Antibiotics, CMS, Core Measures (PubMed Search)
Posted: 9/1/2018 by Wesley Oliver
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The Centers for Medicare and Medicaid Services (CMS) require broad spectrum antibiotics to be administered within 3 hours of presentation of sepsis to be in compliance with the sepsis measure.
Not only do the antibiotics that are chosen determine compliance with this measure, but the order in which antibiotics are given can also significantly affect compliance.
According to CMS, for combination antibiotic therapy, both antibiotics must be started within the three hours following presentation; however, they do not need to be completely infused within this time frame.
Combination therapy typically includes a monotherapy antibiotic (see list in detailed information below) plus vancomycin (daptomycin or linezolid could also be used).
So which antibiotic should be given first?
If a monotherapy antibiotic is given first within the 3 hours of presentation, then compliance for the sepsis measure is met. These antibiotics cover a broader range of bacteria and are typically infused over ~30 minutes, which allows plenty of time for your second antibiotic to be initiated.
If vancomycin is given first, compliance with this measure can become difficult. First, vancomycin has a narrower spectrum of activity and is not a monotherapy antibiotic. Second, vancomycin infusion rates range from 1 to 2 hours. Given that antibiotics are usually given after sepsis is flagged, this infusion rate only gives a short period of time for the second antibiotic to be initiated. Thus, vancomycin should almost always be the second antibiotic infused.
In addition, patients may also have limited intravenous access or antibiotics may not be compatible with resuscitation fluids. All of these factors together must be considered when trying to gain compliance with this measure.
Take-Home Point:
Administer monotherapy antibiotics (e.g. piperacillin/tazobactam and cefepime) prior to administering vancomycin in your septic patients to improve compliance with the sepsis measure.
Specifications Manual for National Hospital Inpatient Quality Measures v5.4. The Joint Commission. https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Updated December 29, 2017. Accessed August 31, 2018.
Category: Pharmacology & Therapeutics
Keywords: Diabetes, DKA (PubMed Search)
Posted: 7/7/2018 by Wesley Oliver
(Updated: 4/26/2024)
Click here to contact Wesley Oliver
Woodward RS, Flore MC, Machnicki G, Brennan DC. The long-term outcomes and costs of diabetes mellitus among renal transplant recipients: tacrolimus versus cyclosporine. Value Health. 2011;14(4):443-9.
Category: Pharmacology & Therapeutics
Keywords: steroids, infection, leukocytosis (PubMed Search)
Posted: 6/2/2018 by Ashley Martinelli
(Updated: 4/26/2024)
Click here to contact Ashley Martinelli
Steroids induce leukocytosis through the release of cells from bone marrow and the inhibition of neutrophil apoptosis. This effect typically occurs within the first two weeks of steroid treatment.
Leukocyte elevation is commonly used in the diagnosis of septic patients; however, this can be hard to discern in patients on concomitant steroid therapy.
A retrospective cohort study of adult patients presenting with fevers and a diagnosis of pneumonia, urinary tract infection, bacteremia, cellulitis, or COPD exacerbation was conducted to determine the maximal level of WBC within the first 24h of admission between patients on acute, chronic, or no steroid treatment.
Results: maximal WBC levels (p< 0.001)
· Acute steroid therapy: 15.4 ± 8.3 x 10 9/L
· Chronic steroid therapy: 14.9 ± 7.4 x 10 9/L
· No steroid therapy: 12.9 ± 6.4 x 10 9/L
An increase in WBC of 5 x 10 9/L can be found in acute and chronic steroid use when presenting with an acute infection and fever.
Frenkel A, Kachko E, Cohen K, Novak V, Maimon N. Estimations of a degree of steroid inducted leukocytosis in patients with acute infections. Am J Emerg Med. 2018;36(5):749-753.
Category: Pharmacology & Therapeutics
Keywords: Fosfomycin, urinary tract infection, cystitis (PubMed Search)
Posted: 3/3/2018 by Wesley Oliver
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Fosfomycin is an antibiotic infrequently used for the treatment of urinary tract infections (UTIs). It has a broad spectrum of activity that covers both gram-positive (MRSA, VRE) and gram-negative bacteria (Pseudomonas, ESBL, and carbapenem-resistant Enterobacteriaceae), which is useful in the treatment of multidrug-resistant bacteria.
Fosfomycin is FDA approved for the treatment of uncomplicated UTIs in women due to susceptible strains of Escherichia coli and Enterococcus faecalis (3g oral as a single dose). Data has also demonstrated that it can be used for complicated UTIs; however, dosing is different in this population (3 g oral every 2-3 days for 3 doses). Fosfomycin is not recommended for pyelonephritis.
The broad spectrum of activity, in addition to only needing a single dose in most cases, makes fosfomycin an attractive option; however, it should be reserved for use in certain circumstances. Fosfomycin should not be considered as a first-line option. It is also more expensive than other medications (~$100/dose) and in countries with high rates of utilization bacteria are developing resistance to fosfomycin. In addition, most outpatient pharmacies do not keep this medication in stock.
Take-Home Point:
Fosfomycin should be reserved for multidrug-resistant UTIs in which other first-line options have been exhausted.
Gupta K, Hooton TM, Naber KG, et al; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5): e103-e120. doi: 10.1093/cid/ciq257.
Michalopoulos AS, Livaditis IG, Gougoutas V. The revival of fosfomycin. Int J Infect Dis. 2011;15(11):e732-e739. doi: 10.1016/j.ijid.2011.07.007.
MONUROL [prescribing information]. St. Louis, MO: Forest Pharmaceuticals, Inc; 2007. www.accessdata.fda.gov/drugsatfda_docs/label/2008/050717s005lbl.pdf. Accessed 9/7/2017September 7, 2017.
Oteo J, Bautista V, Lara N, et al; Spanish ESBL-EARS-Net Study Group. Parallel increase in community use of fosfomycin and resistance to fosfomycin in extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli. J Antimicrob Chemother. 2010;65(11):2459-2463. doi: 10.1093/jac/dkq346.
Raz R. Fosfomycin: an old—new antibiotic. Clin Microbiol Infect. 2012;18(1): 4-7. doi: 10.1111/j.1469-0691.2011.03636.x
Reffert JL, Smith WJ. Fosfomycin for the treatment of resistant gram-negative bacterial infections. Insights from the Society of Infectious Diseases Pharmacists. Pharmacotherapy. 2014;34(8):845-857. doi: 10.1002/phar.1434.
Vardakas KZ, Legakis NJ, Triarides N, Falagas ME. Susceptibility of contemporary isolates to fosfomycin: a systematic review of the literature. Int J Antimicrob Agents. 2016;47(4):269-285. doi: 10.1016/j.ijantimicag.2016.02.001.
Wankum, Michael, et al. “Fosfomycin Use.” Pharmacy Times, 30 Nov. 2017, www.pharmacytimes.com/publications/health-system-edition/2017/november2017/fosfomycin-use.
Category: Pharmacology & Therapeutics
Keywords: Epinephrine, Asthma (PubMed Search)
Posted: 1/8/2018 by Wesley Oliver
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Patients with severe asthma exacerbations that are unresponsive to inhaled beta-agonists may require the use of epinephrine to control their symptoms. When patients get to this point what route of administration should be used for the administration of epinephrine?
The most recent asthma guidelines (published in 2007) recommend the use of SubQ epinephrine 0.3-0.5 mg every 20 minutes for 3 doses. Drug references typically list SubQ or IM epinephrine 0.01 mg/kg (~0.3-0.5 mg) every 20 minutes as appropriate routes of administration. There is currently no data demonstrating that one route of administration is better than the other in patients with asthma; however, in other disease states, such as anaphylaxis, IM epinephrine is preferred due to the more rapid and reliable absorption over SubQ administration.
Auto-injectors that administer IM epinephrine 0.3 mg are available. These auto-injectors may decrease the risk of medications error; however, they can be expensive. SubQ administration requires the use of a syringe and a vial/ampule of 1 mg/mL epinephrine.
Bottom Line: Either SubQ or IM epinephrine administration is appropriate for patients with severe asthma exacerbations. The preferred method at a given institution will be dictated by historical practice, risk of medication dosing errors, and drug cost.
1. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK7232/
2.Simons FER, Ardusso LRF, Bilo MB, El-Gamal YM, Ledford DK, Ring J, et al. World Allergy Organization Anaphylaxis Guidelines: Summary. J Allergy Clin Immunol. 2011;127(3):587–93. e1-e20.