Category: Pharmacology & Therapeutics
Keywords: Tdap, tetanus, immunization, vaccine, pertussis (PubMed Search)
Posted: 1/3/2013 by Bryan Hayes, PharmD
(Updated: 1/5/2013)
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The two available Tetanus/reduced diphtheria toxoid/acellular pertussis (Tdap) vaccine products in the U.S. are Boostrix and Adacel. Neither were originally approved in older adults age 65 and older. Boostrix received FDA-approval for use in this age group in July 2011, but Adacel never has.
However, in June 2012 ACIP issued new guidance recommending Tdap for all adults age 65 years and older.
"When feasible, Boostrix should be used for adults aged 65 years and older; however, ACIP concluded that either vaccine administered to a person 65 years or older is immunogenic and would provide protection. A dose of either vaccine may be considered valid."
Bottom line: Regardless of which Tdap product is stocked at your institution, both are considered safe to use in adults 65 years and older.
Centers for Disease Control and Prevention (CDC), “Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older - Advisory Committee on Immunization Practices (ACIP)," MMWR Morb Mortal Wkly Rep, 2012, 61(25):468-70. [PMID 22739778]
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Category: Pharmacology & Therapeutics
Keywords: doxycycline, PID, pelvic inflammatory disease, STD, azithromycin (PubMed Search)
Posted: 11/28/2012 by Bryan Hayes, PharmD
(Updated: 12/1/2012)
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In the rare circumstance you need to treat a patient with suspected PID and an allergy to doxycycline, what is the alternative?
For oral regimens, azithromycin is an option in place of doxycycline.
Suggested regimen for PID with doxycycline allergy:
Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease. J Int Med Res 2003;31:45–54.
Savaris RF, Teixeira LM, Torres TG, et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol 2007;110:53–60.
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Category: Pharmacology & Therapeutics
Keywords: penicillin, cross-reactivity, cephalosporin, IgE, allergy (PubMed Search)
Posted: 10/29/2012 by Bryan Hayes, PharmD
(Updated: 11/3/2012)
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It seems we've finally put to bed the myth that 10% of penicillin-allergic patients will also react to cephalosporins. Dr. Campagna, et al. recently published a review article concluding that the true cross-reactivity is negligible except when side-chains are similar [PMID 21742459].
This topic was also the subject of a recent post on the Academic Life in EM blog (http://academiclifeinem.blogspot.com/2012/08/busting-myth-10-cephalosporin.html).
But what about the reverse question? Can I give a penicillin to a cephalosporin-allergic patient?
Dr. Romano's group tested 98 patients with skin-test postitive cepahlosprin allergy (mostly IgE -mediated anaphylaxis). Patients were then skin tested for penicillin allergy. Those testing negative were challenged with a penicillin.
25% of patients reacted to the penicillin
Similar side-chain was a strong predictor of cross-reactivity
A Letter to the Editor response to this study pointed out that the authors used a smaller-than-standard size threshold for a positive response to the penicllin AND used a higher-than-standard dose of amoxicillin for testing. In light of this, the rate of subjects with cephalosporin allergy who do not have a history of penicillin allergy but with true IgE-mediated allergy to penicillin might be much closer to 5%.
Bottom line: The cross-reactivity of penicillins in cephalosporin-allergic patients is somewhere between 5-25%.
Romano A, et al. IgE-mediated hypersensitivity to cephalosporings: cross-reactivity and tolerability of penicillins, monobactams, and carbapenems. J Allergy Clin Immunol 2010;126(5):994-9.
Macy E. Penicillin allergy might not be very common in subjects with cephalosporin allergy. J Allergy Clin Immunol 2011;127(6):1638-9.
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Category: Pharmacology & Therapeutics
Keywords: ACE inhibitors, angioedema, icatibant (PubMed Search)
Posted: 11/1/2012 by Ellen Lemkin, MD, PharmD
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Category: Pharmacology & Therapeutics
Keywords: ACE inhibitors, angioedema, icatibant (PubMed Search)
Posted: 11/1/2012 by Ellen Lemkin, MD, PharmD
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Wilerson G. Angioedema in the Emergency Department: An evidence-based review. Emergency Medicine Practice, Nov 2012.
Category: Pharmacology & Therapeutics
Keywords: sulfa, allergy, cross-reactivity, antimicrobial, sulfonamide (PubMed Search)
Posted: 9/24/2012 by Bryan Hayes, PharmD
(Updated: 10/6/2012)
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Patients frequently report having a sulfa allergy. In most cases, the allergic reaction was secondary to a sulfonamide antimicrobial agent, such as sulfamethoxazole-trimethoprim.
The question is: Can I use furosemide (or other non-antimicrobial agents containing a sulfa component)?
There is minimal evidence of cross-reactivity between sulfonamide antimicrobials and non-antimicrobials.
Despite this, the U.S. FDA-approved product information for many non-antimicrobial sulfonamide drugs contains warnings concerning possible cross-reactions.
Bottom line: If a patient had a true IgE-mediated anaphylatic reaction to a sulfonamide antimicrobial, it may be best to avoid other sulfa-related medications (use ethacrynic acid if a loop diuretic is needed). Otherwise, the available literature does not support cross-reactivity between sulfonamide antimicrobials and non-antimicrobials.
Strom BL, et al. Absence of cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics. N Engl J Med 2003;349(17):1628-35.
Hemstreet BA, et al. Sulfonamide allergies and outcomes related to use of potentially cross-reactive drugs in hospitalized patients. Pharmacother 2006;26(4):551-7.
Lee AG, et al. Presumed "sulfa allergy" in patients with intracranial hypertension treated with acetazolamide or furosemide: cross-reactivity, myth or reality? Am J Ophthalmol 2004;138(1):114-8.
Johnson KK, et al. Sulfonamide cross-reactivity: fact or fiction? Ann Pharmacother 2005;39(2):290-301.
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Category: Pharmacology & Therapeutics
Keywords: carbapenem, penicillin, allergy, skin test, cross-reactivity (PubMed Search)
Posted: 8/26/2012 by Bryan Hayes, PharmD
(Updated: 9/4/2013)
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Carbapenems (meropenem, ertapenem, doripenem, imipenem/cilastatin) are broad-spectrum antibiotics that have good gram-negative and anaerobic coverage and are used to treat resistant bacterial infections.
Early retrospective studies showed ~10% cross-reactivity in penicillin-allergic patients.
More recent prospective studies verified penicillin allergy by the accepted standard (ie, skin test to the major and minor penicillin determinants) and tested for carbapenem allergy by administering a full therapeutic dose to carbapenem skin test-negative patients.
The cross-reactivity between skin tests appears to be around 1%, with all carbapenem skin test-negative patients tolerating the challenge.
Frumin J, Gallagher JC. Allergic cross-sensitivity between penicillin, carbapenem, and monobactam antibiotics: what are the chances? Ann Pharmacother 2009;43(2):304-15.
Herbert ME, Brewster GS, Lanctot-Herbert M. Medical myth: ten percent of patients who are allergic to penicillin will have serious reactions if exposed to cephalosporins. West J Med 2000;172:341.
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Category: Pharmacology & Therapeutics
Keywords: vasopressor, cardiac arrest, epinephrine, vasopression (PubMed Search)
Posted: 7/30/2012 by Bryan Hayes, PharmD
(Updated: 8/4/2012)
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A recent paper reviewed 53 articles to assess the utility of vasopressors in cardiac arrest. The authors aimed to determine if vasopressors improved ouctomes in this patient population. Here are their conclusions:
Although these conclusions don't support the use of vasopressors in cardiac arrest, we should not abandon these therapies. Most of the trials were completed before wide-spread recognition of the post-cardiac arrest syndrome, implementation of therapeutic hypothermia protocols, and early cardiac catheterization.
Larabee TM, Liu KY, Campbell JA, et al. Vasopressors in cardiac arrest: a systematic review. Resuscitation. 2012;83(8):932-9.
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Category: Pharmacology & Therapeutics
Keywords: Uti,bactrim,smx/tmp,ciprofloxacin,levofloxacin (PubMed Search)
Posted: 8/2/2012 by Ellen Lemkin, MD, PharmD
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Acute, uncomplicated cystitis (in the non-pregnant female):
· The drug of choice is SMX/TMP (provided the resistance rate is <20%) X 3 days.
· An alternative is nitrofurantoin X 5 days.
Acute, uncomplicated pyleonephritis (in the non-pregnanct female) may be treated with:
· Levofloxacin X 5 days, or ciprofloxacin X 7 days (provided resistance rate is <10%).
· Alternatively, SMX/TMP may be used X 14 days.
The Medical Letter. July 23, 2012. Vol 54(1395):57-60.
Category: Pharmacology & Therapeutics
Keywords: alteplase, tPA, warfarin, INR, ischemic stroke (PubMed Search)
Posted: 7/2/2012 by Bryan Hayes, PharmD
(Updated: 7/7/2012)
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Issue 1: Mean INR in study patients was only 1.22 (median 1.2). An INR of 1.2 represents very little actual anticoagulation.
Issue 2: In the small subgroup of patients with INR 1.5 to 1.7 (n = 269) there was a higher risk of ICH (7.8%), but did not reach statistical significance (it was significant in the unadjusted risk population).
Bottom line: Patients with INRs < 1.5 may be ok to receive tPA. Patients with INRs 1.5 or greater need further study.
Xian Y, Liang L, Smith EE, et al. Risk of Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Receiving Warfarin and Treated with Intravenous Tissue Plasminogen Activator. JAMA. 2012;307(24):2600-8.
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Category: Pharmacology & Therapeutics
Keywords: naltrexone, methylnaltrexone, constipation, opioid dependence (PubMed Search)
Posted: 6/1/2012 by Bryan Hayes, PharmD
(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
(Updated: 6/15/2012)
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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
(Updated: 4/7/2012)
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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
(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
(Updated: 2/4/2012)
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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
(Updated: 1/7/2012)
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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
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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
(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.