Category: Pharmacology & Therapeutics
Keywords: naltrexone, methylnaltrexone, constipation, opioid dependence (PubMed Search)
Posted: 6/1/2012 by Bryan Hayes, PharmD
(Emailed: 6/2/2012)
(Updated: 6/15/2012)
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Naltrexone and methylnaltrexone are both mu-receptor antagonists that look similar and have similar names. But, they have very different uses.
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Category: Pharmacology & Therapeutics
Keywords: older adult, Beers Criteria, geriatric (PubMed Search)
Posted: 4/30/2012 by Bryan Hayes, PharmD
(Emailed: 5/5/2012)
(Updated: 6/15/2012)
Click here to contact Bryan Hayes, PharmD
The American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults is now available.
The update differs in several ways from the 2003 edition. Medications that are no longer available have been removed, and drugs introduced since 2003 have been added. Research on drugs included in earlier versions has been updated and new information is provided about appropriate prescribing of medications for an expanded list of common geriatric conditions.
Here is an abbreviated list of medications/classes on the list that we may use in the ED. Use caution.
The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012;60(4):616-31.
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Category: Pharmacology & Therapeutics
Keywords: MRSA, antibiotic, pneumonia, VAP, cephalosporin, infection (PubMed Search)
Posted: 5/3/2012 by Ellen Lemkin, MD, PharmD
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If vancomycin resistance is suspected with MRSA infections, there are several other antibiotic choices. They are all extremely expensive.
Antibiotic | ORAL | Indication | Precaution |
Telavancin | N | SSTI | May cause QT prolongation: Caution with azole antifungals, class III antiarrhythmics, antidepressants, antipsychotics. Interferes with coagulation tests. |
Daptomycin | N | SSTI Bacteremia Endocarditis | Not for pneumonia. May cause rhabdomyolysis; Discontinue statins. |
Linezolid | Y | VAP SSTI | Not for bacteremia. May cause serotonin syndrome; Caution with antidepressants, antipsychotics, tramadol, methadone. |
Tigecycline | N |
Intrabdominal infections SSTI | Not for bacteremia. Inhibits clearance of warfarin. Reserve for polymicrobial infections. |
Skin and soft tissue infection (SSTI); ventilator acquired pneumonia (VAP)
Category: Pharmacology & Therapeutics
Keywords: vancomycin, c. diff, clostridium difficile, fidaxomicin (PubMed Search)
Posted: 4/4/2012 by Bryan Hayes, PharmD
(Emailed: 4/7/2012)
(Updated: 4/7/2012)
Click here to contact Bryan Hayes, PharmD
In a recent multicenter, double-blind, randomized, non-inferiority trial, vancomycin was compared to fidaxomixin for Clostridium difficile infection.
Location: 45 sites in Europe and 41 sites in the USA and Canada
Patients: Age 16 years or older with acute toxin-positive C difficile infection.
Treatment: Oral fidaxomicin (200 mg every 12 h) or oral vancomycin (125 mg every 6 h) for 10 days.
Endpoint: Clinical cure, defined as resolution of diarrhea and no further need for treatment.
Results: 198 (91.7%) of 216 patients in the per-protocol population given fidaxomicin achieved clinical cure, compared with 213 (90.6%) of 235 given vancomycin (one-sided 97·5% CI -4·3%). Occurrence of treatment-emergent adverse events did not differ between groups.
Author conclusions: Fidaxomicin could be an alternative treatment for infection with C difficile, with similar efficacy and safety to vancomycin.
Funding: Optimer Pharmaceuticals.
Cornely OA, Crook DW, Esposito R, et al. Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe, Canada, and the USA: a double-blind, non-inferiority, randomised controlled trial. Lancet Infect Dis 2012 Apr;12(4):281-9.
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Category: Pharmacology & Therapeutics
Keywords: egg, influenza, vaccine (PubMed Search)
Posted: 3/2/2012 by Bryan Hayes, PharmD
(Emailed: 3/3/2012)
(Updated: 3/4/2012)
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The seasonal influenza vaccine is produced in chicken eggs. Ovalbumin, an egg protein, is often listed as a component of the purified vaccine on most drug-package inserts. The concentration of ovalbumin indicates the potential egg-allergen content of a vaccine.
Earlier ACIP guidelines recommended against giving the influenza vaccine to people with egg allergy, including those with a history of mild symptoms. However, several studies showed that influenza vaccine containing inactivated, or killed, virus is safe to give to people with egg allergy, especially those with a history of mild allergic reactions.
Influenza vaccines are now made with much lower ovalbumin concentrations than in the past; therefore, the level of potential egg protein allergens in a single dose of vaccine is extremely low.
The following are ACIP recommendations for the 2011 to 2012 influenza season:
http://www.niaid.nih.gov/topics/vaccines/research/Pages/eggAllergy.aspx
Recommended Adult Immunization Schedule - United States, 2012. MMWR Weekly. February 3, 2-12 / 61(04);1-7.
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Category: Pharmacology & Therapeutics
Keywords: droperidol, antiemetic, qt prolongation (PubMed Search)
Posted: 1/31/2012 by Bryan Hayes, PharmD
(Emailed: 2/4/2012)
(Updated: 2/4/2012)
Click here to contact Bryan Hayes, PharmD
In the setting of critical drug shortages of ondansetron, prochlorperazine, and metoclopramide, consider droperidol as a viable option for the treatment of nausea and vomiting.
Although it is similar to haloperidol, it is actually FDA-approved for “prevention and/or treatment of nausea and vomiting from surgical and diagnostic procedures” (unlike haloperidol). Ironically, it is not approved for agitation, although it can be used for that indication.
Dosing for antiemesis is 1.25 to 2.5 mg IV/IM. Additional doses of 0.625 to 1.25 mg can be administered to achieve desired effect. Onset is 3-5 minutes and duration of effect is 2-4 hours. It should be administered via slow IV push over 2 minutes.
Why is it not commonly used? Black Box Warning for QTc prolongation. An ECG is a must prior to administration. Also be cautious in patients who are on other medications that can prolong the QT interval (www.qtdrugs.org).
Category: Pharmacology & Therapeutics
Keywords: ondansetron, zofran, prolonged QT, torsades, drug interactions, ciprofloxacin, antifungal, azoles (PubMed Search)
Posted: 2/2/2012 by Ellen Lemkin, MD, PharmD
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Category: Pharmacology & Therapeutics
Keywords: cystitis, uti, nitrofurantoin, urinary tract infection (PubMed Search)
Posted: 1/3/2012 by Bryan Hayes, PharmD
(Emailed: 1/7/2012)
(Updated: 1/7/2012)
Click here to contact Bryan Hayes, PharmD
In 2011, updated treatment guidelines were published for acute uncomplicated cystitis and pyelonephritis in women. The recommendations differ from the previous iteration due to increased E. Coli resistance. The good news is we have been ahead of the curve in changing our prescribing habits.
Cystitis (recommendations in order of preference)
Take home points:
Gupta K, et al. 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. Clinical Infectious Diseases 2011;52(5):e103-e120.
Category: Pharmacology & Therapeutics
Keywords: MRSA, antibiotic, pneumonia, CAP, cephalosporin, infection (PubMed Search)
Posted: 1/5/2012 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Resistance is expected to be limited, with the exception of VRE, and VSE (vanco resistant or sensitive enterococcus faecalis)
Renally excreted
Common side effects: diarrhea, nausea, headache
Serious side effects: anaphylaxis, renal failure, hepatitis, seizure
Low incidence of C. difficile
Dose : 600 mg IV (over 1 hour) q12 hours X 5-7 days
Category: Pharmacology & Therapeutics
Keywords: older adult, adverse drug event, ade, elderly, warfarin (PubMed Search)
Posted: 11/29/2011 by Bryan Hayes, PharmD
(Emailed: 12/3/2011)
(Updated: 12/3/2011)
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A recent article estimated 100,000 emergency hospitalizations for adverse drug events in U.S. adults 65 years of age or older each year. Nearly half of these hospitalizations were among adults ≥80 years old and two-thirds were due to unintentional overdoses.
Four medications or medication classes were implicated alone or in combination in 67% of hospitalizations:
Opioids were #5. Digoxin was #7 and resulted in the highest percentage of hospitalizations per ED visit at 80%.
Budnitz DS, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:2002-12.
Category: Pharmacology & Therapeutics
Keywords: nicardipine, labetalol, blood pressure (PubMed Search)
Posted: 10/30/2011 by Bryan Hayes, PharmD
(Emailed: 11/5/2011)
(Updated: 11/5/2011)
Click here to contact Bryan Hayes, PharmD
A recent randomized trial compared nicardipine as a continuous infusion to labetalol boluses to determine which one was more effective at lowering blood pressure to a target range within 30 minutes.
Median initial SBP for the 226 patients was 212 mm Hg. Within 30 minutes, nicardipine patients more often reached target range than labetalol (91.7 vs. 82.5%, P = 0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within target range than labetalol (47.3% vs. 32.8%, P = 0.026).
What this means: Nicardipine is a reasonable choice for patients needing acute lowering of blood pressure (e.g., ischemic stroke with tPa). Nicardipine seems to achieve faster and smoother lowering of blood pressure than labetalol therapy with less blood pressure readings outside the target range.
Peacock WF, Varon J, Baumann BM, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care 2011;15(3):R157. Epub 2011 Jun 27.
Category: Pharmacology & Therapeutics
Keywords: Intranasal administration,fentanyl,ketorolac,sumatriptin,glucagon,desmopressin,midazolam (PubMed Search)
Posted: 10/6/2011 by Ellen Lemkin, MD, PharmD
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There are an increasing number of intranasal medications commercially available for use, which is opportune as more and more intravenous medications become scarce.
These now include:
Generic name | Brand Name | Usage |
Fentanyl | Instanyl | Opiate analgesic |
Ketorolac | Sprix | NSAID analgesic |
Desmopressin (DDAVP) | Stimate | Bleeding |
Vitamin B12 | Nasobal | Anti-migraine (yes!) |
Sumatriptan | Imitrex | Anti-migraine |
Zolmitripran | Zomig | Anti-migraine |
*******In addition, you can administer glucagon, midazolam and narcan intranasally as well.
Veldhorst-Jassen, NM, Fiddelers AA, Paul-Hugo M et all. A review of the clinical pharmacokinetics of opioids, benzodiazepines, and antimigraine drugs delivered intranasally. Clinical Therapeutics Nov 12, 20009;31(12):2954-87.
Wolfe TR, Braude DA. Intranasal Medication Delivery for Children: A Brief Review and Update. Pediatrics 2010;126;532:532-7.
Category: Pharmacology & Therapeutics
Keywords: warfarin, creatinine, nephropathy (PubMed Search)
Posted: 9/27/2011 by Bryan Hayes, PharmD
(Emailed: 10/1/2011)
(Updated: 10/1/2011)
Click here to contact Bryan Hayes, PharmD
An acute increase in the INR over 3 in patients with chronic kidney disease (CKD) is often associated with an unexplained acute increase in serum creatinine and an accelerated progression of CKD.
Kidney biopsy in a subset of these patients showed obstruction of the renal tubule by red blood cell casts, and this appears to be the dominant mechanism of the acute kidney injury. This has been termed warfarin-related nephropathy (WRN).
In 15,258 patients who initiated warfarin therapy during a 5-year period, 4006 had an INR over 3 and creatinine measured at the same time. A presumptive diagnosis of WRN was made if the creatinine increased by over 0.3 mg/dl within 1 week after the INR exceeded 3 with no record of hemorrhage. WRN occurred in 20.5% of the entire cohort, 33.0% of the CKD cohort, and 16.5% of the no-CKD cohort. Other risk factors included age, diabetes mellitus, hypertension, and cardiovascular disease. The 1-year mortality was 31.1% in patients with WRN compared with 18.9% in those without WRN, an increased risk of 65%.
Take home message: Although the mechanisms are not clear, be very wary of even a small creatinine bump in patients presenting with an INR > 3 on warfarin therapy. Yet another reason to fear warfarin...
Brodsky SV, et al. Warfarin-related nephropathy occurs in patients with and without chronic kidney disease and is associated with an increased mortality rate. Kidney Int 2011;80(2):181-9.
Category: Pharmacology & Therapeutics
Keywords: thrombin,dabigatran,partial thromboplastin,bleeding (PubMed Search)
Posted: 9/1/2011 by Ellen Lemkin, MD, PharmD
(Updated: 5/8/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Rye J, Stangier J, Haertter S, et al. Dabigatran etexilate - a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity. Thrombosis and Haemostasis 2010. 103;1116-27.
Category: Pharmacology & Therapeutics
Keywords: phenytoin (PubMed Search)
Posted: 8/2/2011 by Bryan Hayes, PharmD
(Emailed: 8/6/2011)
(Updated: 8/6/2011)
Click here to contact Bryan Hayes, PharmD
Category: Pharmacology & Therapeutics
Keywords: argatroban, direct thrombin inhibitor, heparin, HIT (PubMed Search)
Posted: 6/6/2011 by Bryan Hayes, PharmD
(Emailed: 7/2/2011)
(Updated: 7/2/2011)
Click here to contact Bryan Hayes, PharmD
Patients requiring anticoagulation for HIT or with a history of HIT may be initiated on argatroban. We have recently been seeing increased utilization. Here are some important points to remember.
Category: Pharmacology & Therapeutics
Keywords: angioedema, angiotensin, ACE inhibitor (PubMed Search)
Posted: 5/12/2011 by Bryan Hayes, PharmD
(Emailed: 6/4/2011)
(Updated: 6/4/2011)
Click here to contact Bryan Hayes, PharmD
Pathophysiology: Angiotensin converting enzyme (ACE) catalyzes the conversion of angiotensin I to angiotensin II. It also degrades bradykinin. Thus, ACE inhibitors have the effects of decreasing angiotensin II and increasing bradykinin. In the presence of ACE inhibition, bradykinin can accumulate and interact with vascular bradykinin B2 receptors, causing vasodilation, increased vascular permeability, increased c-GMP, and release of nitric oxide.
Treatment: Even though we generally treat with standard allergic reaction medications, none counteract the mechanism causing the problem. Steroids, H1-blockers, and H2-blockers should still be considered but may not alter the progression. Airway monitoring and management is paramount.
Category: Pharmacology & Therapeutics
Keywords: acetaminophen,pain,narcotic,Ofirmev,intravenous (PubMed Search)
Posted: 5/5/2011 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
IV acetaminophen has been approved for use since November 2010
It is indicated for the:
The results of studies demonstrating opoid sparing effects have been mixed; some studies have not demonstrated either a reduction in opioid dose or opioid side effects.
The dose is the same for acetaminophen administered by other routes.
It must be administered over 15 minutes, and onset of activity is 15 minutes. Peak effect occurs at one hour.
The MAJOR drawback is the cost, which is $13 dollars per vial. This is compared to oral acetaminophen and ibuprofen, which are pennies.
Pharmacist's letter/Prescriber's letter Detail document #270212. February 2011 72:270212
Category: Pharmacology & Therapeutics
Keywords: enoxaparin, VTE, obese, low molecular weight heparin (PubMed Search)
Posted: 4/1/2011 by Bryan Hayes, PharmD
(Emailed: 4/2/2011)
(Updated: 4/2/2011)
Click here to contact Bryan Hayes, PharmD
For patients with normal renal function, enoxaparin dosing for treatment of VTE is 1 mg/kg subcut every 12 hours OR 1.5 mg/kg subcut every 24 hours.
Studies have evaluated dosing for patients weighing up to 190 kg and found the 1 mg/kg q 12 hours dose to be safe and effective. It can even be used for patients heavier than 190 kg, but anti-Xa monitoring is recommended.
Nutescu EA, Spinler SA, Wittkowsky A, et al. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother 2009;43(6):1064-83.
Category: Pharmacology & Therapeutics
Keywords: PCP, clindamycin, primaquine, pentamidine, dapsone, atovaquone (PubMed Search)
Posted: 2/22/2011 by Bryan Hayes, PharmD
(Emailed: 3/5/2011)
(Updated: 3/5/2011)
Click here to contact Bryan Hayes, PharmD
Sulfamethoxazole (SMX)/trimethoprim (TMP) is the treatment of choice for PCP pneumonia. The IV formulation has been unavailable for almost a year due to shortage. It is contraindicated in patients with sulfa allergy. Here are the alternatives with adverse effects. You'll quickly see why pentamidine should generally be reserved for those with sulfa allergy and G6PD deficiency.
Mild-to-moderate disease:
Moderate-to-severe disease:
Adverse Effects:
Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. MMWR April 10, 2009 / 58(RR04);1-198.