Saturday April 28, 2007
Treating malaria (and other parasites) with Xigris - Drotrecogin alfa (activated) ?
While working on our pearl Treating HIT with Xigris? , (April 24, 2007), our team came across 2 interesting case reports, which should be of great interest to our friends from countries where multi-organ failure from malaria and other parasites is still an everyday occurrence. For full length discussion, click on reference # 2 below.
1. ".... We describe the care of a 61-year-old man who developed multi-organ failure secondary to severe falciparum malaria infection with parasitaemia levels of 40%. Included in his care were an exchange blood transfusion and an infusion of Drotrecogin alfa (activated). Within hours of starting the infusion of Drotrecogin alfa (activated), the patient's clinical condition stopped deteriorating. Steady improvement followed with weaning from ventilatory assistance on day 14 post admission. The patient made a full recovery and was discharged home following rehabilitation....Drotrecogin alfa (activated) may be a useful treatment in patients with multi-organ failure resulting from severe malaria 1.
2. "....The patient was a 25-year old male admitted in the Respiratory Intensive Care Unit with fever, haemolysis, acute renal failure, hepatitis, acute lung injury (ALI) and altered sensorium. A syndromic evaluation was done and investigations revealed falciparum parasitaemia. He was treated with parenteral artesunate, ceftriaxone and doxycycline, and adjunctive therapies as for severe sepsis. Infusion of activated protein C was started 20 hours after onset of organ dysfunction, and intensive haemodialysis was instituted. Over the next four days the patient became afebrile with progressive resolution of ALI, renal failure and hepatitis. His Leptospira serology (requested as part of the evaluation) was reported positive on day 5. Dual infections are common and under-recognized in the tropics. Failure to treat potential co-infections may lead to poor outcomes. Acute lung injury in falciparum malaria has high mortality rates and therapy as for severe sepsis may improve survival. Adjunctive therapies, including activated protein C, cannot replace source eradication" 2.
Reference: click to get abstract
1. Drotrecogin alfa (activated) in severe falciparum malaria. - Anaesthesia. 2006 Sep;61(9):899-902
2. Severe sepsis due to severe falciparum malaria and leptospirosis co-infection treated with activated protein C - Malaria Journal 2007, 6:42
Showing posts with label pharmacy. Show all posts
Showing posts with label pharmacy. Show all posts
Saturday, April 28, 2007
Wednesday, April 25, 2007
Wednesday April 25, 2007
Q; Which antibiotic may give false positive urine drug screen for opiates ?
A; Gatifloxacin (Tequin) and other fluoroquinolones.
Fluoroquinolones as a class are among compounds that have a propensity to cross-react with enzyme immunoassay urine drug screens for opiates. The exact mechanism is unknown.
False-positive results could have negative effects on patient care so analysis with another assay method should be done to verify the urine drug screen.
Editors' note: Tequin has been taken off USA market last year but as mentioned in JAMA's article (reference # 2), 13 quinolones were tested and 11 of the 13 quinolones caused some opiate activity by at least 1 assay system. So be careful with all quinolones. Actually, JAMA report mentioned Levaquin as one of the top 3 !
Q; Which antibiotic may give false positive urine drug screen for opiates ?
A; Gatifloxacin (Tequin) and other fluoroquinolones.
Fluoroquinolones as a class are among compounds that have a propensity to cross-react with enzyme immunoassay urine drug screens for opiates. The exact mechanism is unknown.
False-positive results could have negative effects on patient care so analysis with another assay method should be done to verify the urine drug screen.
Editors' note: Tequin has been taken off USA market last year but as mentioned in JAMA's article (reference # 2), 13 quinolones were tested and 11 of the 13 quinolones caused some opiate activity by at least 1 assay system. So be careful with all quinolones. Actually, JAMA report mentioned Levaquin as one of the top 3 !
Tuesday, April 24, 2007
Tuesday April 24, 2007
Treating HIT with Xigris ?
Continuing our theme from yesterday on Heparin-Induced Thrombocytopenia (HIT), we found an interesting case report where treatment has been done with Xigris - drotrecogin alfa (activated) !
"A patient was administered drotrecogin alfa (activated) in addition to the standard of care for presumed severe sepsis and circulatory shock. Heparin-induced thrombocytopenia (HIT) and hepatic and splenic thromboses complicated her clinical course. Because drotrecogin alfa (activated) treatment is associated with improvement in thrombotic manifestations and thrombocytopenia, it was continued as the sole antithrombotic agent after the HIT became apparent. This approach was chosen despite the patient's severe hepatic and renal dysfunction, which made the use of direct thrombin inhibitors unfavorable. She survived with a reasonable outcome and salvage of her limbs. Although this case suggests a potential role of drotrecogin alfa (activated) in the management of HIT, systematic evaluation of its efficacy in this situation is warranted".
Reference:
Pharmacotherapy 2006;26(3):428-434
Treating HIT with Xigris ?
Continuing our theme from yesterday on Heparin-Induced Thrombocytopenia (HIT), we found an interesting case report where treatment has been done with Xigris - drotrecogin alfa (activated) !
"A patient was administered drotrecogin alfa (activated) in addition to the standard of care for presumed severe sepsis and circulatory shock. Heparin-induced thrombocytopenia (HIT) and hepatic and splenic thromboses complicated her clinical course. Because drotrecogin alfa (activated) treatment is associated with improvement in thrombotic manifestations and thrombocytopenia, it was continued as the sole antithrombotic agent after the HIT became apparent. This approach was chosen despite the patient's severe hepatic and renal dysfunction, which made the use of direct thrombin inhibitors unfavorable. She survived with a reasonable outcome and salvage of her limbs. Although this case suggests a potential role of drotrecogin alfa (activated) in the management of HIT, systematic evaluation of its efficacy in this situation is warranted".
Reference:
Pharmacotherapy 2006;26(3):428-434
Monday, April 23, 2007
Monday April 23, 2007
Proposed iceberg model for HIT and HITT
Heparin-Induced Thrombocytopenia (HIT) still remains one of the most underdiagnosed condition in ICUs. Recently an iceberg model has been proposed for Heparin-Induced Thrombocytopenia (HIT) and Heparin-Induced Thrombocytopenia and Thrombosis (HITT). As there may be many patients who may have HIT but not HITT. There may be patients, who just have seroconversions and others who may have full blown thromboses at other end.
Review article on HIT: When Heparins Promote Thrombosis - Review of Heparin-Induced Thrombocytopenia (Circulation. 2005;111:2671-2683.)
Related previous pearl: 4 Ts of HIT
Proposed iceberg model for HIT and HITT
Heparin-Induced Thrombocytopenia (HIT) still remains one of the most underdiagnosed condition in ICUs. Recently an iceberg model has been proposed for Heparin-Induced Thrombocytopenia (HIT) and Heparin-Induced Thrombocytopenia and Thrombosis (HITT). As there may be many patients who may have HIT but not HITT. There may be patients, who just have seroconversions and others who may have full blown thromboses at other end.
Review article on HIT: When Heparins Promote Thrombosis - Review of Heparin-Induced Thrombocytopenia (Circulation. 2005;111:2671-2683.)
Related previous pearl: 4 Ts of HIT
Saturday, April 21, 2007
Saturday April 21, 2007
Resistant (uncontrolled) / Life-threatening diffuse alveolar hemorrhage
Diffuse alveolar hemorrhage remained a condition with high mortality. Usual treatment is high dose IV methylprednisolone (1g/day) for three to five days and in more severe cases to add IV cyclophosphamide (cyclophosphamide has a delayed effect, but may provide synergistic action with steroid). Plasmapheresis has been described to be effective particularly in diffuse alveolar hemorrhage associated with Goodpasture syndrome.
But what if bleeding is non-stop and life-threatening ?
Answer is off label use of activated Factor VII (Novoseven). In 3 cases reported from University of North Carolina at Chapel Hill - bleeding stops and oxygenation improved within minutes 1.
Reference: click to get abstract
Successful Treatment of Diffuse Alveolar Hemorrhage with Activated Factor VII - annals, 16 March 2004 Volume 140 Issue 6 Pages 493-494
Resistant (uncontrolled) / Life-threatening diffuse alveolar hemorrhage
Diffuse alveolar hemorrhage remained a condition with high mortality. Usual treatment is high dose IV methylprednisolone (1g/day) for three to five days and in more severe cases to add IV cyclophosphamide (cyclophosphamide has a delayed effect, but may provide synergistic action with steroid). Plasmapheresis has been described to be effective particularly in diffuse alveolar hemorrhage associated with Goodpasture syndrome.
But what if bleeding is non-stop and life-threatening ?
Answer is off label use of activated Factor VII (Novoseven). In 3 cases reported from University of North Carolina at Chapel Hill - bleeding stops and oxygenation improved within minutes 1.
Reference: click to get abstract
Successful Treatment of Diffuse Alveolar Hemorrhage with Activated Factor VII - annals, 16 March 2004 Volume 140 Issue 6 Pages 493-494
Thursday, April 19, 2007
Q: Which medicine may have cause this "bluish" discoloration of skin, known as "The blue man syndrome"?
Hint: Its a heart medicine and may cause brownish hyperpigmentation of skin as well.
A: Amiodarone
About 5% (some literature described upto 26%) of patients develop skin pigmentation from photosensitivity while on amiodarone treatment depending on dose and length of treatment. It is suggested that that UV exposure induces vasodilatation and increased diffusion of amiodarone and its metabolite desethylamiodarone in perivascular tissue, resulting in chronic accumulation of the drug. On histology, lipofuscin laden macrophages are seen.
Related previous pearls:
Why we call it Am-iod-arone!
Amiodarone Neurotoxicity!
Amiodarone - Digoxin interaction !
References: click to get abstract
1. The Blue Man - Amiodarone-Induced Skin Discoloration, Circulation. 2006;113:e63
2. Dose-dependent appearance and disappearance of amiodarone-induced skin pigmentation. Clin Cardiol 1996; 19: 592-4.
3. The pathogenesis of amiodarone-induced pigmentation and photosensitivity. Br J Dermatol 1984; 110: 451- 6.
Wednesday, April 18, 2007
Wednesday April 18, 2007
(arginine vasopressin) AVP-Receptor Antagonists
Hyponatremia may be caused by a number of conditions, including infections, heart disease, surgery, malignancy, and medication use. Clinical signs and symptoms such as hallucinations, lethargy, weakness, bradycardia, respiratory depression, seizures, coma, and death have been reported. Conventional treatment consists of fluid restriction and administration of hypertonic saline and pharmacologic agents, such as demeclocycline, lithium carbonate, and urea. These treatment options are often of limited effectiveness or difficult for patients to tolerate.
AVP (arginine vasopressin) promotes the reabsorption of water in the renal collecting ducts by activation of V2 receptors, resulting in water retention and dilution of serum solutes. The AVP-receptor antagonists, Conivaptan, Lixivaptan, and Tolvaptan, are being studied for the treatment of hyponatremia.
Conivaptan (Vaprisol) has been shown in clinical trials to increase freewater excretion and safely normalize serum sodium concentrations in patients with hyponatremia and is well tolerated. Also in clinical trials, Lixivaptan and Tolvaptan have safely improved serum sodium concentrations in patients with hyponatremia.
(arginine vasopressin) AVP-Receptor Antagonists
Hyponatremia may be caused by a number of conditions, including infections, heart disease, surgery, malignancy, and medication use. Clinical signs and symptoms such as hallucinations, lethargy, weakness, bradycardia, respiratory depression, seizures, coma, and death have been reported. Conventional treatment consists of fluid restriction and administration of hypertonic saline and pharmacologic agents, such as demeclocycline, lithium carbonate, and urea. These treatment options are often of limited effectiveness or difficult for patients to tolerate.
AVP (arginine vasopressin) promotes the reabsorption of water in the renal collecting ducts by activation of V2 receptors, resulting in water retention and dilution of serum solutes. The AVP-receptor antagonists, Conivaptan, Lixivaptan, and Tolvaptan, are being studied for the treatment of hyponatremia.
Conivaptan (Vaprisol) has been shown in clinical trials to increase freewater excretion and safely normalize serum sodium concentrations in patients with hyponatremia and is well tolerated. Also in clinical trials, Lixivaptan and Tolvaptan have safely improved serum sodium concentrations in patients with hyponatremia.
Thursday, April 12, 2007
Thursday April 12, 2007
Drug Induced Systemic Lupus Erythematosus (DISLE)
Today's pearl contributed by
Jennifer Burns, D.Pharm
Vassar Brothers Medical Center
Poughkeepsie, NY
As many as 10% of diagnosed cases of SLE are drug-related. From Critical Care perspective there are reports of acute DISLE like fulminating hydralazine-induced lupus pneumonitis 1 , acute acalculous cholecystitis and cardiac tamponade 2.
DISLE affects males and females almost equally, whites more often than blacks, and is more common in older patients than idiopathic SLE (Kale, 1985). The average age of SLE at the time of diagnosis is 35.8 whereas that of DISLE is 60.7 and 53.5 associated with procainamide and hydralazine, respectively. This is probably due to the more frequent use of antihypertensive and antiarrhythmic medication in the older population.
There appears to be a racial difference in the incidence of DISLE, with the percentage of DISLE patients who are white being 86 to 95% for hydralazine and 95% for procainamide; likewise 64% of the patients with idiopathic SLE are white (Stratton, 1985). Symptoms of DISLE are the same as in SLE but are less severe (Weinstein, 1980).
Drugs with a hydrazine or amino group linked to an aromatic ring, such as HYDRALAZINE, PROCAINAMIDE and ISONIAZID, are most often linked to DISLE (Reidenberg, 1981). Hydralazine, procainamide, and isoniazid have been demonstrated in controlled prospective studies to cause increased ANA titers or a SLE type illness.
In those patients receiving hydralazine, DISLE is rarely seen in daily doses less than 200 milligrams. Interestingly, there is good evidence that those patients who are identified as slow acetylators are at a higher risk of developing DISLE, but a correlation between idiopathic SLE and the acetylator phenotype is poorly understood (Totoritis, 1985)(Anon, 1974). In fact, the drugs most often implicated in DISLE are all metabolized in the liver by acetylation (eg, hydralazine, procainamide, anticonvulsants, INH).
Reference:
1. Fulminating hydralazine-induced lupus pneumonitis - Arthritis Care & Research - Volume 55, Issue 3 , Pages 501 - 506
2. Acute acalculous cholecystitis and cardiac tamponade in a patient with drug-induced lupus - Rheumatology 2001; 40: 709-711
Drug Induced Systemic Lupus Erythematosus (DISLE)
Today's pearl contributed by
Jennifer Burns, D.Pharm
Vassar Brothers Medical Center
Poughkeepsie, NY
As many as 10% of diagnosed cases of SLE are drug-related. From Critical Care perspective there are reports of acute DISLE like fulminating hydralazine-induced lupus pneumonitis 1 , acute acalculous cholecystitis and cardiac tamponade 2.
DISLE affects males and females almost equally, whites more often than blacks, and is more common in older patients than idiopathic SLE (Kale, 1985). The average age of SLE at the time of diagnosis is 35.8 whereas that of DISLE is 60.7 and 53.5 associated with procainamide and hydralazine, respectively. This is probably due to the more frequent use of antihypertensive and antiarrhythmic medication in the older population.
There appears to be a racial difference in the incidence of DISLE, with the percentage of DISLE patients who are white being 86 to 95% for hydralazine and 95% for procainamide; likewise 64% of the patients with idiopathic SLE are white (Stratton, 1985). Symptoms of DISLE are the same as in SLE but are less severe (Weinstein, 1980).
Drugs with a hydrazine or amino group linked to an aromatic ring, such as HYDRALAZINE, PROCAINAMIDE and ISONIAZID, are most often linked to DISLE (Reidenberg, 1981). Hydralazine, procainamide, and isoniazid have been demonstrated in controlled prospective studies to cause increased ANA titers or a SLE type illness.
In those patients receiving hydralazine, DISLE is rarely seen in daily doses less than 200 milligrams. Interestingly, there is good evidence that those patients who are identified as slow acetylators are at a higher risk of developing DISLE, but a correlation between idiopathic SLE and the acetylator phenotype is poorly understood (Totoritis, 1985)(Anon, 1974). In fact, the drugs most often implicated in DISLE are all metabolized in the liver by acetylation (eg, hydralazine, procainamide, anticonvulsants, INH).
Reference:
1. Fulminating hydralazine-induced lupus pneumonitis - Arthritis Care & Research - Volume 55, Issue 3 , Pages 501 - 506
2. Acute acalculous cholecystitis and cardiac tamponade in a patient with drug-induced lupus - Rheumatology 2001; 40: 709-711
Monday, April 9, 2007
Monday April 9, 2007
Revisiting RSI or Rapid Sequence Induction protocol
RSI protocol is aimed at quick, safe and organized emergent endotracheal intubation by using several medications. Very important consideration to remember is, unlike planned intubation for anesthesia, we should presume that patient’s stomach might be full and complication like aspiration can happen.
Medications fall into three categories:
1) Pretreatment agents:
Fentanyl (3mcg/kg) Lidocaine may suppress the cough reflex (1.5 mg/kg) Atropine may decrease the bradycardia
2) Induction agents:
3) Paralyzing agents:
Revisiting RSI or Rapid Sequence Induction protocol
RSI protocol is aimed at quick, safe and organized emergent endotracheal intubation by using several medications. Very important consideration to remember is, unlike planned intubation for anesthesia, we should presume that patient’s stomach might be full and complication like aspiration can happen.
Medications fall into three categories:
1) Pretreatment agents:
2) Induction agents:
- Pentothal (4 mg/kg)
- Etomidate (0.3 mg/kg) (may induce adrenocortical dysfunction)
- Ketamine (1-2 mg/kg)
- Midazolam (0.25 mg/kg)
- Propofol
3) Paralyzing agents:
- Succinylcholine (2mg/kg) - may induce hyperkalemia
- Vecuronium (0.15 mg/kg),
- Rocuronium (0.8 mg/kg)
Related previous link:
Preventing sympathetic surge during head injury patient's intubation2 great reviews
Airway Management of the Critically Ill Patient Rapid-Sequence Intubation, Chest. 2005;127:1397-1412
Rapid Sequence Induction (emdicine.com)
Other related link Quick dose calculator of drugs used in RSBI, by just entering weight
To share with readers, here is an email from overseas.
"I have to send to you to admire this excellent site which will help a lot physician around the globe to master acute emergency which will help to reduce mortality and morbidity, thank you for such state of art work. I hope it will remain free for all the users!!....
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Thursday, April 5, 2007
Thursday April 5, 2007
Ambien Induced Delirium
Relatively Zolpidem (Ambien) is a safe medicine and recently has been one of a drug of choice in critical care units to induce sleep. But it is important to be aware of reported cases of ambien related psychosis, delirium and mania. Atleast one case is reported with visual perception distortion after a single dose of zolpidem.
One way to combat the problem is to decrease the prescribing dose particularly in elderly population and in hypoalbuminemia (5 mg instead of 10 mg). Also, female population has been reported to have more plasma level with same dose. Also note that Zolpidem metabolized through liver so it may be necessary to decrease the dose in liver insufficiency.
References: click to get abstract/article
1. Delirium associated with zolpidem - The Annals of Pharmacotherapy: Vol. 35, No. 12, pp. 1562-1564
2. Zolpidem-Induced Delirium With Mania in an Elderly Woman - Psychosomatics 45:88-89, February 2004
3. Zolpidem-induced agitation and disorganization. - Gen Hosp Psychiatry. 1996 Nov;18(6):452-3. (pubmed)
4. Zolpidem-induced psychosis. - Ann Clin Psychiatry.1996 Jun;8(2):89-91. (pubmed)
5. Clinical pharmacokinetics of zolpidem in various physiological and pathological conditions, in Imidazopyridines in Sleep Disorders. Edited by Sauvanet JP, Langer SZ, Morselli PL. New York, Raven Press, 1988, pp 155–163
6. Zolpidem-Induced Distortion in Visual Perception - The Annals of Pharmacotherapy: Vol. 37, No. 5, pp. 683-686
Ambien Induced Delirium
Relatively Zolpidem (Ambien) is a safe medicine and recently has been one of a drug of choice in critical care units to induce sleep. But it is important to be aware of reported cases of ambien related psychosis, delirium and mania. Atleast one case is reported with visual perception distortion after a single dose of zolpidem.
One way to combat the problem is to decrease the prescribing dose particularly in elderly population and in hypoalbuminemia (5 mg instead of 10 mg). Also, female population has been reported to have more plasma level with same dose. Also note that Zolpidem metabolized through liver so it may be necessary to decrease the dose in liver insufficiency.
References: click to get abstract/article
1. Delirium associated with zolpidem - The Annals of Pharmacotherapy: Vol. 35, No. 12, pp. 1562-1564
2. Zolpidem-Induced Delirium With Mania in an Elderly Woman - Psychosomatics 45:88-89, February 2004
3. Zolpidem-induced agitation and disorganization. - Gen Hosp Psychiatry. 1996 Nov;18(6):452-3. (pubmed)
4. Zolpidem-induced psychosis. - Ann Clin Psychiatry.1996 Jun;8(2):89-91. (pubmed)
5. Clinical pharmacokinetics of zolpidem in various physiological and pathological conditions, in Imidazopyridines in Sleep Disorders. Edited by Sauvanet JP, Langer SZ, Morselli PL. New York, Raven Press, 1988, pp 155–163
6. Zolpidem-Induced Distortion in Visual Perception - The Annals of Pharmacotherapy: Vol. 37, No. 5, pp. 683-686
Wednesday, April 4, 2007
Wednesday April 4, 2007
Daptomycin (Cubicin) and renal failure
As Daptomycin has now been approved for right-sided MSSA and MRSA endocarditis since our previous pearl *, and as we are seeing it more in ICUs, it would be of worth to re-visit that, Cubicin needs to be adjusted in renal failure. With CrCl less than 30, it should be given every 48 hours. It is recommended to be given on hemodialysis day following hemodialysis. Daptomycin doesn't get cleared in CVVHD and need to adjusted as renal failure dose.
Related previous pearls:
Daptomycin induced rhabdomyolysis
3 new antibiotics *
* Since this previous pearl, Cubicin is approved for right-sided MSSA and MRSA endocarditis.
Daptomycin (Cubicin) and renal failure
As Daptomycin has now been approved for right-sided MSSA and MRSA endocarditis since our previous pearl *, and as we are seeing it more in ICUs, it would be of worth to re-visit that, Cubicin needs to be adjusted in renal failure. With CrCl less than 30, it should be given every 48 hours. It is recommended to be given on hemodialysis day following hemodialysis. Daptomycin doesn't get cleared in CVVHD and need to adjusted as renal failure dose.
Related previous pearls:
Daptomycin induced rhabdomyolysis
3 new antibiotics *
* Since this previous pearl, Cubicin is approved for right-sided MSSA and MRSA endocarditis.
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