Category: Pharmacology & Therapeutics
Keywords: nicardipine, labetalol, blood pressure (PubMed Search)
Posted: 10/30/2011 by Bryan Hayes, PharmD
(Updated: 11/5/2011)
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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
(Updated: 10/1/2011)
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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: 2/17/2025)
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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
(Updated: 8/6/2011)
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Category: Pharmacology & Therapeutics
Keywords: argatroban, direct thrombin inhibitor, heparin, HIT (PubMed Search)
Posted: 6/6/2011 by Bryan Hayes, PharmD
(Updated: 7/2/2011)
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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
(Updated: 6/4/2011)
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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
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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
(Updated: 4/2/2011)
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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
(Updated: 3/5/2011)
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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.
Category: Pharmacology & Therapeutics
Keywords: iohexol, iodixanol, radio contrast media, immediate hypersensitivity reactions (PubMed Search)
Posted: 2/5/2011 by Bryan Hayes, PharmD
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Many patients report an allergy to iodinated RCM, sometimes adding to the complexity of diagnostic decision making. Here are a few pearls to help:
Bottom line: Despite the lack of cross reactivity with shellfish/iodine allergies AND the very low risk associated with today’s low osmolality agents, premedication is still indicated in patient’s with a history of IHR to RCM.