Cerebral Spinal Fluid Penetration of Tigecycline in a Patient with Acinetobacter baumannii Cerebritis (March).

Ann Pharmacother. 2010 Feb 23;

Authors: Ray L, Levasseur K, Nicolau DP, Scheetz MH

OBJECTIVE: To describe cerebral spinal fluid (CSF) penetration of tigecycline. CASE SUMMARY: A 38-year-old woman experienced a right internal carotid artery dissection and right anterior and middle cerebral artery strokes due to unknown causes and subsequently developed vasogenic edema requiring right hemicraniectomy. Her postoperative course was complicated by multiple infections, and she developed multidrug, carbapenem-resistant Acinetobacter baumannii cerebritis. She was treated with a prolonged course of multiple antibiotics, including 18 days of therapy with tigecycline. Time-paired serum and CSF samples were obtained, and tigecycline concentrations were analyzed by high-performance liquid chromatography. We report serial, steady-state, serum, and CSF concentrations of tigecycline when administered in the Food and Drug Administration-approved dose of 50 mg every 12 hours. CSF concentrations remained relatively stable, suggesting that tigecycline did not accumulate in the CSF, at least in our patient. Tigecycline concentrations in the CSF were between 0.035 and 0.048 mg/L, while corresponding serum concentrations were 0.097-0.566 mg/L. The calculated tigecycline penetration ratio in this patient ranged from 0% to 52%, depending on the calculation methodology utilized. DISCUSSION: Concentrations, regardless of sample timing relative to dose, remained relatively stable in the CSF of our patient. The pharmacodynamic profile of tigecycline is not completely elucidated; however, it is presumed that the drug must be at the site of infection for efficacy. Our patient never obtained tigecycline concentrations in excess of the minimum inhibitory concentration for A. baumannii in either the serum or the CSF. CONCLUSIONS: Our patient experienced low CSF tigecycline concentrations and failed to achieve a clinical response while on therapy. CSF drug disposition of tigecycline requires further systematic study to fully elucidate the pharmacokinetic profile. Reduced CSF concentrations urge caution in the treatment of cerebritis with standard dosing of tigecycline.

PMID: 20179255 [PubMed - as supplied by publisher]

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Takotsubo Cardiomyopathy, or Broken-Heart Syndrome (March).

Ann Pharmacother. 2010 Feb 2;

Authors: Nykamp D, Titak JA

OBJECTIVE: To report a case of takotsubo cardiomyopathy, also known as apical ballooning syndrome or stress cardiomyopathy. CASE SUMMARY: A 68-year-old female with a history of hypertension, hyperlipidemia, and anxiety presented with symptoms that mimicked acute coronary syndrome (ACS); the chief symptom was chest tightness. An electrocardiogram showed normal sinus rhythm, with minimal ST elevation in the anterior leads. The patient was initially treated for ST-segment elevation myocardial infarction and symptoms resolved. Coronary angiography ruled out ACS and confirmed a diagnosis of takotsubo cardiomyopathy. DISCUSSION: Takotsubo cardiomyopathy is commonly triggered by severe emotional or psychological stress and occurs primarily in postmenopausal women. A reversible contractility abnormality of the left ventricle causes the ventricle to take on a balloon-like appearance; hence the name of tako-tsubo, a Japanese octopus fishing pot that has a narrow neck and a wide midsection. Signs and symptoms of takotsubo cardiomyopathy mimic those of ACS. Takotsubo cardiomyopathy is best diagnosed with coronary angiography, which can rule out blockage. Treatment usually consists of carvedilol and an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocking agent if left ventricular ejection fraction is less than 40%. The syndrome is usually spontaneously reversible and cardiovascular function returns to normal after a few weeks. CONCLUSIONS: Takotsubo cardiomyopathy causes a reversible left ventricle dysfunction which occurs most commonly in postmenopausal women with or without cardiovascular disease. Recognition is detected with coronary angiography. It is thought to primarily be due to an abnormally high sympathetic stimulation after emotional or psychological stress. Treatment consists of an angiotensin converting enzyme inhibitor and/or beta blocker if needed for left ventricular dysfunction and possibly an anxiolytic agent.

PMID: 20124462 [PubMed - as supplied by publisher]

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Hypokalemia Following Polyethylene Glycol-Based Bowel Preparation for Colonoscopy in Older Hospitalized Patients with Significant Comorbidities(March) (FREE).

Ann Pharmacother. 2010 Feb 2;

Authors: Ho JM, Juurlink DN, Cavalcanti RB

BACKGROUND: Polyethylene glycol-based bowel preparations (PEGBPs) are widely perceived as safe and effective alternatives to oral sodium phosphate for bowel cleansing prior to colonoscopy. Most studies supporting this belief involve young patients with few comorbidities. OBJECTIVE: To characterize the incidence of electrolyte disturbances following PEGBPs administered prior to colonoscopy among elderly inpatients and hypothesize that PEGBP would be associated with hypokalemia in this setting. METHODS: This retrospective chart review, conducted at 3 tertiary care teaching hospitals in Toronto, Canada, from 2005 to 2007, included 96 consecutive patients aged 65 or older who were admitted to the hospital and given PEGBP prior to their first inpatient colonoscopy. Patients were excluded if they received additional cathartics, underwent colonoscopy while admitted to a critical care unit, or were admitted for a complication arising from an outpatient colonoscopy. The primary outcome was hypokalemia (serum potassium </=3.2 mEq/L) within 48 hours of PEGBP. RESULTS: Of 96 patients, 73 had serum electrolytes measured at baseline and within 48 hours following PEGBP administration. Hypokalemia was identified in 4 patients (5.5%) prior to PEGBP and in 15 patients (20.5%) after PEGBP (p < 0.001). The incidence of significant hypokalemia, defined as serum potassium <3.0 mEq/L, in this group was 9.6% (p = 0.008). We found consistent results among patients with and without concomitant diuretic treatment. CONCLUSIONS: Among older patients, administration of PEGBP is commonly complicated by the development of hypokalemia, which is occasionally severe. Monitoring of electrolytes may be necessary following colonoscopy, particularly in patients with cardiac or renal disease.

PMID: 20124467 [PubMed - as supplied by publisher]

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Safety of Subcutaneous Octreotide in Patients with Sulfonylurea-Induced Hypoglycemia and Congestive Heart Failure (February).

Ann Pharmacother. 2010 Jan 5;

Authors: Vallurupalli S

OBJECTIVE: To report the safe use of subcutaneous octreotide in the treatment of sulfonylurea-induced hypoglycemia in 2 patients with severe congestive heart failure. CASE SUMMARY: Two patients with congestive heart failure with systolic dysfunction presented with severe hypoglycemia (blood glucose level: patient 1, 31 mg/dL; patient 2, 36 mg/dL) secondary to sulfonylurea agents. The mechanism of hypoglycemia was poor oral intake and prolonged half-life of the drugs due to renal failure. Hypoglycemia was refractory to glucose supplementation. Patient 1 received 2 doses of octreotide 50 mug subcutaneously 12 hours apart, with resolution of hypoglycemia (blood glucose level: <33 mg/dL before administration of octreotide, 62 mg/dL after first dose, 121 mg/dL after second dose). Patient 2 received an initial dose of octreotide 25 microg subcutaneously; hypoglycemia persisted after this dose, and the patient was given 2 doses of 50 microg subcutaneously 12 hours apart, leading to resolution of hypoglycemia (blood glucose level: 57 mg/dL before administration of octreotide, 80 mg/dL after first dose, 85 mg/dL after second dose, 146 mg/dL after third dose). Resolution of hypoglycemia with octreotide treatment obviated the need for prolonged intravenous dextrose infusions. No local or systemic adverse effects, especially cardiac adverse events, were noted during the course of treatment. DISCUSSION: Octreotide is considered the antidote for sulfonylurea-induced hypoglycemia. It may be especially useful in patients with congestive heart failure who may not tolerate intravenous infusions of dextrose. The package insert cautions of the occurrence of cardiac adverse effects such as bradycardia, heart block, and worsening heart failure. Patients with heart failure may theoretically be at a higher risk of these adverse effects due to the concurrent use of atrioventricular blocking agents. However, a review of current literature reveals that the adverse effect profile depends on the route, dose, and formulation of the octreotide used along with the clinical indication. These adverse effects may not be clinically significant with the doses used for treatment of sulfonylurea-induced hypoglycemia and the benefits of the drug may outweigh the risks. CONCLUSIONS: In these cases, octreotide was safely and effectively used in the treatment of sulfonylurea-induced hypoglycemia in patients with congestive heart failure by adhering to dosing guidelines and close monitoring.

PMID: 20118140 [PubMed - as supplied by publisher]

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Intensive Insulin Protocol Implementation and Outcomes in the Medical and Surgical Wards at a Veterans Affairs Medical Center(February).

Ann Pharmacother. 2010 Jan 26;

Authors: Chen HJ, Steinke DT, Karounos DG, Lane MT, Matson AW

BACKGROUND: Hyperglycemia is an important marker for clinical outcomes and mortality in hospitalized patients. New national standards have been established emphasizing the importance of improving inpatient glycemic control in individuals with diabetes or new-onset hyperglycemia. Implementation of these new standards is complex and requires a multidisciplinary team approach. A basal-bolus insulin regimen approach has been shown to improve inpatient glycemic control. Few studies have been published regarding basal-bolus insulin protocol outcomes in the non-intensive care unit (ICU) setting. OBJECTIVE: To evaluate the efficacy of a basal-bolus insulin protocol on inpatient glycemic control in a non-ICU setting, as measured by mean blood glucose and number of hypoglycemic episodes per patient admission. METHODS: A retrospective, observational, single-center study was conducted to compare blood glucose control pre- (October 2006-March 2007) and postprotocol (November 2007-January 2008) implementation. Inclusion criteria consisted of patient admission to a medical or surgical ward for at least 72 hours, with a diagnosis of diabetes, or presentation with 2 blood glucose readings greater than 180 mg/dL. Patients admitted to the ICU or those not admitted to a medical or surgical ward were excluded. RESULTS: Following protocol implementation, the mean +/- SD blood glucose level increased from 174 +/- 88 mg/dL to 188 +/- 95 mg/dL (p < 0.001) and the hypoglycemic incidents significantly decreased, from 1.11 to 0.51 events per patient admission (p < 0.0025). CONCLUSIONS: In this pilot study, implementation of a basal-bolus insulin protocol significantly reduced hypoglycemic events; however, mean blood glucose values increased. These results suggest that a basal-bolus insulin protocol can reduce hypoglycemia; however, factors such as protocol compliance, barriers in overcoming the use of the traditional sliding scale insulin regimens, staff education, and change of work-flow habits can influence the overall efficacy and impact of a basal-bolus insulin protocol on inpatient glycemic control.

PMID: 20103610 [PubMed - as supplied by publisher]

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Fidaxomicin: A Macrocyclic Antibiotic for the Management of Clostridium difficile Infection (February).

Ann Pharmacother. 2010 Jan 13;

Authors: Sullivan KM, Spooner LM

OBJECTIVE: To evaluate the efficacy and safety of fidaxomicin for the treatment of Clostridium difficile infection. DATA SOURCES: Literature retrieval was accessed through MEDLINE (1966-January 2010) and International Pharmaceutical Abstracts (1970-January 2010) using the terms OPT-80, difimicin, PAR-101, fidaxomicin, tiacumicin, lipiarmycin, and Clostridium difficile. In addition, reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles published in English that were identified from the data sources were evaluated and pertinent information was included. DATA SYNTHESIS: Fidaxomicin is an 18-membered macrocyclic antibiotic with activity against gram-positive aerobes and anaerobes, including C. difficile. Microbiologic studies comparing in vitro activity of fidaxomicin with that of metronidazole and vancomycin have shown good activity against all strains of C. difficile tested; however, minimum inhibitory concentrations were consistently lower for fidaxomicin. Studies showed that fidaxomicin lacks activity against gram-negative pathogens, thereby preserving normal gastrointestinal flora. Small pharmacokinetic trials have shown that fidaxomicin administration leads to low concentrations in plasma, high concentrations in stool, and a postantibiotic effect of greater than 24 hours, all of which are potentially advantageous characteristics for treating C. difficile infection. Data from 2 Phase 2A trials and 1 Phase 3 (multicenter, randomized, double-blind) trial suggest that fidaxomicin is effective for the treatment of mild-to-moderate C. difficile infection at a dose of 200 mg orally every 12 hours. Limited early results from the Phase 3 trial showed favorable outcomes for fidaxomicin when compared to oral vancomycin. Overall, fidaxomicin has been well tolerated to date. CONCLUSIONS: The activity of fidaxomicin and limited clinical data suggest that it may have a future role in the treatment of mild-to-moderate C. difficile infection. The complete pharmacokinetic/pharmacodynamic profile, safety, and place in therapy have yet to be determined as trials comparing this agent to vancomycin are forthcoming.

PMID: 20071495 [PubMed - as supplied by publisher]

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Related Articles

Interventions to improve medication reconciliation in primary care.

Ann Pharmacother. 2009 Oct;43(10):1667-75

Authors: Bayoumi I, Howard M, Holbrook AM, Schabort I

OBJECTIVE: To systematically review all primary care intervention studies designed to implement medication reconciliation for effects on medication discrepancies, clinical outcomes, and patient knowledge of their medications. DATA SOURCES: We searched MEDLINE (1988-March 2008); Healthstar (1966-March 2008); CINAHL (1982-March 2008); EMBASE (1980-March 2008); Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Methodology Register, and Health Technology Assessments; and unpublished material. No language restrictions were applied. Search terms included medication reconciliation, medication errors, prescribing error, medication systems, adverse drug events, drug utilization review, medication list, medication record, and medications management. STUDY SELECTION AND DATA ABSTRACTION: Randomized controlled trials or before-and-after studies that examined the effect of various interventions on medication discrepancies either in ambulatory settings or at hospital discharge among community-dwelling adults were included. Two reviewers independently assessed studies to determine inclusion. Level of agreement between the reviewers was good, with unweighted Cohen’s kappa of 0.71. Two of 3 independent reviewers abstracted data and evaluated validity from included studies. Disagreements between reviewers were resolved by consensus. DATA SYNTHESIS: Four trials met the inclusion criteria. Two before-and-after studies (n = 275) in ambulatory care examining systematic medication reconciliation at each visit produced conflicting results. One study showed a reduction in the proportion of medication discrepancies from 88.5% to 49.1% (OR 0.13; 95% CI 0.07 to 0.21); the other showed no benefit. One randomized controlled trial and one before-and-after study (n = 202) evaluated pharmacist medication review at hospital discharge. Neither showed a benefit. Heterogeneity precluded pooling of studies. All included studies had significant design flaws. CONCLUSIONS: There is no good quality evidence demonstrating the effectiveness of medication reconciliation in the primary care setting. Further research is needed.

PMID: 19737997 [PubMed - indexed for MEDLINE]

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Daptomycin Versus Other Antimicrobial Agents for the Treatment of Skin and Soft Tissue Infections: A Meta-Analysis(January).

Ann Pharmacother. 2009 Nov 24;

Authors: Bliziotis IA, Plessa E, Peppas G, Falagas ME

BACKGROUND: Skin and soft tissue infections (SSTIs) are common in everyday clinical practice. Daptomycin has been shown to achieve very good concentrations in skin and soft tissues. OBJECTIVE: To compare the effectiveness and toxicity of daptomycin with that of other antimicrobials for the treatment of SSTIs. METHODS: PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up to March 2009. Comparative studies in which daptomycin was used in the intervention group were included in this meta-analysis. The primary outcome of interest was clinical success; secondary outcomes were microbiologic success, clinical success in subsets with complicated SSTIs (cSSTIs) or infections due to methicillin-resistant Staphylococcus aureus (MRSA), clinical success of daptomycin- versus vancomycin-treated patients, time to clinical cure, treatment-related adverse events, withdrawal from treatment due to toxicity, all-cause mortality, and development of resistance. RESULTS: Four studies were included in the analysis (3 were randomized controlled trials [RCTs]). Vancomycin and semisynthetic penicillins were used in the comparator arm. Three studies reported on patients with cSSTIs. The intention-to-treat (ITT) population was 1557 patients. No statistically significant difference between daptomycin and comparators was found regarding clinical success in clinically evaluable (OR 0.89; 95% CI 0.63 to 1.25 in the 3 RCTs and OR 1.34; 95% CI 0.38 to 4.66 with all 4 studies included), ITT, MRSA-infected patients, and those with cSSTIs. Two studies reported that significantly fewer patients with cSSTIs required prolonged treatment in the daptomycin arm and that clinical cure was faster than with comparators. No difference between the compared regimens was found in other outcomes. CONCLUSIONS: Daptomycin is effective and safe for the treatment of SSTIs. Studies evaluating the optimal duration of daptomycin therapy for cSSTIs, comparing daptomycin with new agents, and focusing on proven MRSA SSTIs will be helpful for the further evaluation of the drug.

PMID: 19934396 [PubMed - as supplied by publisher]

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Propylene Glycol Accumulation in Critically Ill Patients Receiving Continuous Intravenous Lorazepam Infusions(December).

Ann Pharmacother. 2009 Nov 17;

Authors: Horinek EL, Kiser TH, Fish DN, Maclaren R

BACKGROUND: Lorazepam is recommended by the Society of Critical Care Medicine as the preferred agent for sedation of critically ill patients. Intravenous lorazepam contains propylene glycol, which has been associated with toxicity when high doses of lorazepam are administered. OBJECTIVE: To evaluate the accumulation of propylene glycol in critically ill patients receiving lorazepam by continuous infusion and determine factors associated with propylene glycol concentration. METHODS: A 6-month, retrospective, safety assessment was conducted of adults admitted to the medical intensive care unit who were receiving lorazepam by continuous infusion for 12 hours or more. Propylene glycol serum concentrations were obtained 24-48 hours after continuous-infusion lorazepam was initiated and every 3-5 days thereafter. Propylene glycol accumulation was defined as concentrations of 25 mg/dL or more. Groups with and without propylene glycol accumulation were compared and factors associated with propylene glycol concentration were determined using multivariate correlation regression analyses. RESULTS: Forty-eight propylene glycol serum samples were obtained from 33 patients. Fourteen (42%) patients had propylene glycol accumulation, representing 23 (48%) serum samples. Univariate analyses showed the following factors were related to propylene glycol accumulation: baseline renal dysfunction, presence of alcohol withdrawal, sex, age, Acute Physiology and Chronic Health Evaluation (APACHE II) score, rate of lorazepam continuous infusion, and 24-hour lorazepam dose. Multivariate linear regression modeling demonstrated that propylene glycol concentration was strongly associated with the continuous infusion rate and 24-hour dose (adjusted r(2) >/=0.77; p < 0.001). Independent correlation analyses showed that these 2 variables were so strongly associated with propylene glycol concentration (r(2) >/=0.71; p < 0.001) that they alone predicted propylene glycol concentration. Seven (21%) patients developed renal dysfunction after continuous-infusion lorazepam was initiated, but associated causes were indeterminable. Other possible propylene glycol-associated adverse effects were not observed. CONCLUSIONS: The continuous infusion rate and cumulative 24-hour lorazepam dose are strongly associated with and independently predict propylene glycol concentrations. Despite the absence of confirmed propylene glycol-associated adverse effects, clinicians should be aware that propylene glycol accumulation may occur with continuous-infusion lorazepam.

PMID: 19920159 [PubMed - as supplied by publisher]

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Does Simvastatin Cause More Myotoxicity Compared with Other Statins? (December).

Ann Pharmacother. 2009 Nov 17;

Authors: Backes JM, Howard PA, Ruisinger JF, Moriarty PM

OBJECTIVE: To review the literature regarding statins and myotoxicity and evaluate these data to determine whether incidence rates are higher with simvastatin. DATA SOURCES: Literature was identified from a search of MEDLINE (1966- August 2009) and International Pharmaceutical Abstracts (1970-August 2009), as well as references of selected articles. Key search terms included the names of individual statins, rhabdomyolysis, myopathy, myalgia, myotoxicity, statins, and drug interactions. STUDY SELECTION AND DATA EXTRACTION: All English-language articles discussing statin-related myotoxicity and relevant drug interactions that involved human subjects were examined. DATA SYNTHESIS: Simvastatin is a commonly prescribed, moderately potent statin. Recent evidence suggests that the risk of severe muscle toxicity with simvastatin may be higher than that with other statins, particularly when used in combination with cytochrome P450 isoenzyme inhibitors. However, the lack of direct comparative clinical trials assessing the risk of myotoxicity among the statins in equivalent doses precludes definitive conclusions. Data sources examining low-to-moderate doses of simvastatin suggest that myotoxicity with this agent is infrequent, with rates similar to those seen with other statins. Conversely, findings from clinical trials using the maximum daily dose (80 mg) and a clinical trials database of varying doses of simvastatin suggest a possible increase in rates of myotoxicity with the 80-mg dose compared with lower doses and a higher incidence rate when compared with maximum doses of other statins. CONCLUSIONS: Overall, the rates of severe myotoxicity with all statins are low, especially with low-to-moderate doses. However, recent trials for those using simvastatin 80 mg daily suggest a higher incidence of myotoxicity compared with maximum approved doses of other statins. Practitioners should be aware of these possible risks and individualize therapy to limit myotoxicity.

PMID: 19920157 [PubMed - as supplied by publisher]

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Seasonal, Avian, and Novel H1N1 Influenza: Prevention and Treatment Modalities (December).

Ann Pharmacother. 2009 Nov 17;

Authors: Sym D, Patel PN, El-Chaar GM

OBJECTIVE: To review the pathophysiology, pandemics/epidemics, transmissibility, clinical presentation, treatment, prevention/immunization, and resistance associated with seasonal, avian, and swine influenza. DATA SOURCES: Literature was obtained from MEDLINE (1966-October 2009) and International Pharmaceutical Abstracts (1971-October 2009) using the search terms influenza, seasonal influenza, avian influenza, swine influenza, H1N1, novel H1N1, H3N2, and H5N1. STUDY SELECTION AND DATA EXTRACTION: Available English-language articles were reviewed, along with information obtained from the Centers for Disease Control and Prevention, the Food and Drug Administration, and the World Health Organization. DATA SYNTHESIS: The influenza virus has caused disease in birds, swine, and humans for many centuries. Pandemics and epidemics have occurred throughout history and reports of new strains continue to emerge. Two major surface antigenic glycoproteins, hemagglutinin and neuraminidase, have various subtypes, resulting in numerous combinations of these proteins. For example, combinations occur when an influenza strain from a bird “mixes” with a strain from a human. This mixing occurs in a host, often in pigs, resulting in a new strain. This new strain can cause pandemics since people have no immunity to the new strain. An H1N1 subtype pandemic occurred in 1918, causing millions of deaths. Simultaneously, veterinary reports of “influenza” in pigs also emerged. It is postulated that humans infected pigs with this H1N1 virus. H1N1 reappeared in humans in 1976, and more recently in 2009. Other pandemics have occurred with H2N2 and H3N2 strains. In 1997, strain H5N1, which usually causes disease in fowl, was able to infect humans. CONCLUSIONS: Influenza subtypes continue to change, causing disease in animals and humans. Utilization of immunization and antiviral treatment options are available to prevent, treat, and contain the spread of this infection.

PMID: 19920156 [PubMed - as supplied by publisher]

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Colchicine for the Primary and Secondary Prevention of Pericarditis: An Update(December).

Ann Pharmacother. 2009 Nov 10;

Authors: Kuo IF, Pearson GJ, Koshman SL

OBJECTIVE: To review the efficacy and safety of colchicine as primary and secondary prophylaxis for pericarditis. DATA SOURCES: We searched MEDLINE, EMBASE, PubMed, BIOSIS Previews, International Pharmaceutical Abstracts, Web of Science, and CENTRAL for controlled studies from database inception date to July 2009. Search terms included colchicine, pericarditis, and postpericardiotomy syndrome (PPS). STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized, controlled trials investigating the use of colchicine in preventing pericarditis were included. Data extracted included design, inclusion criteria, demographics, interventions, background therapy, and pericarditis-related clinical outcomes. DATA SYNTHESIS: Data were synthesized qualitatively, given variable study designs. Three trials were identified. A single trial examining primary prevention evaluated the use of colchicine versus placebo for preventing PPS in patients undergoing cardiopulmonary bypass grafting. No significant reduction in PPS was found. Two studies examined secondary prevention of pericarditis, comparing colchicine plus aspirin versus aspirin alone. One study examined using these comparators to treat a first episode of pericarditis. After 3 months, there was a significant reduction in recurrent pericarditis with colchicine plus aspirin (11.7% vs 33%; p = 0.009). Another study examined this same regimen in recurrent pericarditis, finding a significant reduction in recurrence after 6 months (21% vs 45%; p = 0.02). CONCLUSIONS: Despite limitations in study designs, current evidence suggests a role for colchicine in the secondary prophylaxis for recurrent pericarditis. The evidence for use of colchicine as primary prophylaxis in PPS is indeterminate; therefore, colchicine cannot be recommended routinely. While colchicine should be recommended for the prevention of recurrent pericarditis, questions regarding the optimal regimen and long-term safety profile need to be further elucidated.

PMID: 19903861 [PubMed - as supplied by publisher]

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Sliding Scale Versus Tight Glycemic Control in the Noncritically Ill at a Community Hospital(November).

Ann Pharmacother. 2009 Oct 13;

Authors: Patel GW, Roderman N, Lee KA, Charles MM, Nguyen D, Beougher P, Kleja K, Casteneda E

BACKGROUND: Development of hyperglycemia during hospitalization is an area of concern in patients with and without diabetes mellitus. Tight glycemic control has been debated for critically ill and noncritically ill patients with hyperglycemia. Although many studies have been performed in the critically ill, adequate data are not available in the noncritically ill population. OBJECTIVE: To compare traditional sliding scale (SS) with a tight glycemic control (TC) algorithm. The primary endpoint was the percentage of total blood glucose measurements in the target range of 80-150 mg/dL. The secondary endpoint evaluated was safety, defined as percentage of all blood glucose measurements that were 0-60 mg/dL. METHODS: A 1-year, retrospective analysis from June 1, 2007, to May 31, 2008, was performed evaluating all inpatients with hyperglycemia within the first 48 hours of admission to the Medical Center of Plano, Plano, TX. A cohort of patients managed with SS (n = 121) was compared with those treated with TC (n = 210). Patients on SS insulin received a traditional SS regimen with regular insulin or insulin aspart based on physician preference. RESULTS: Demographics and comorbidities were similar between the 2 groups; however, the TC cohort was younger (64.8 +/- 14.1 vs 70.8 +/- 13.7 y; p < 0.001). There were more persons with type 2 diabetes mellitus in the TC cohort (81.9%) versus the SS cohort (60.3%; p < 0.001). In the TC cohort, 42.9% of blood glucose measurements were in the target range of 80-150 mg/dL compared with 30.6% of the measurements in the SS cohort (p < 0.001). Regarding safety, 2% of blood glucose measurements of the TC cohort were in the range of 0-60 mg/dL versus 0.3% of the SS cohort (p < 0.001). No clinical sequelae of hypoglycemia were observed. Patients achieved more blood glucose measurements in the target range when treated with TC versus SS insulin, without regard to prior history of diabetes. CONCLUSIONS: Patients treated with TC experienced more blood glucose measurements in the target range as compared with patients treated with SS with relatively low hypoglycemia rates.

PMID: 19826097 [PubMed - as supplied by publisher]

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Impact of a Renal Drug Dosing Service on Dose Adjustment in Hospitalized Patients with Chronic Kidney Disease(October).

Ann Pharmacother. 2009 Sep 23;

Authors: Hassan Y, Al-Ramahi RJ, Aziz NA, Ghazali R

BACKGROUND: Appropriate drug selection and dosing for patients with chronic kidney disease (CKD) is important to avoid unwanted drug effects and ensure optimal patient outcomes. OBJECTIVE: To assess the rate of inappropriate dosing in patients with CKD in a nephrology unit and to evaluate the impact on dose adjustment, adverse drug events (ADEs), and drug cost of having a pharmacist accompany a team of physicians on their rounds. METHODS: This was a comparative study with a preintervention and post-intervention design. The preintervention phase served as the control; it was prospective and observational only and was conducted from the beginning of February to the end of May 2007. The second phase (intervention phase) was conducted from the beginning of March to the end of June 2008. Two random samples of 300 patients with an estimated creatinine clearance less than or equal to 50 mL/min were included. During the intervention phase, a clinical pharmacist made rounds with the nephrology unit team and gave dosing adjustment recommendations when needed. A collection of reliable and up-to-date drug information references that are commonly used globally were used during the intervention. RESULTS: In the preintervention group, drug dosage adjustment or avoidance, based on renal function, was necessary in 607 of 2814 (21.6%) prescriptions. Of these, 322 (53.0%) did not comply with guidelines. In the intervention group, adjustment was necessary for 640 of 2981 (21.5%) prescriptions. The pharmacist made 388 recommendations related to dosing adjustment, 212 (54.6%) of which were accepted by physicians. Clinicians' noncompliance with dosing guidelines decreased to 176 (27.5%) (p < 0.001). In the preintervention group, 64 (21.3%) patients had a suspected ADE, with a total of 73 events. In the intervention group, this number was significantly lower with 49 events in 48 (16.0%) patients (p < 0.05). The intervention resulted in drug cost savings of $2250 US. CONCLUSIONS: A renal drug dosing service for patients hospitalized with CKD can increase the proportion of drug dosing that is adjusted to take into account renal function. This can save drug costs and may prevent ADEs.

PMID: 19776297 [PubMed - as supplied by publisher]

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Related Articles

Prevalence of sodium bicarbonate-induced alkalemia in cardiopulmonary arrest patients.

Ann Pharmacother. 2009 Jul;43(7):1245-50

Authors: Geraci MJ, Klipa D, Heckman MG, Persoff J

BACKGROUND: Intravenous sodium bicarbonate (SB) administration during cardiopulmonary arrest (CPA) is intended to counteract lactic acidosis due to hypoxia, poor perfusion, and anaerobic metabolism. Despite a lack of documented efficacy and a level III recommendation from the American Heart Association, SB is widely used during resuscitation events. SB has both theoretical and measurable adverse effects. Excess or poorly timed administration during a CPA may elevate a patient’s pH, inducing alkalemia. Despite decades of controversy surrounding use of this drug, the prevalence of SB-induced alkalemia has not been previously documented. OBJECTIVE: To estimate the prevalence of SB-induced alkalemia in inpatients after CPA and to investigate the pattern of SB administration. METHODS: Medical records were retrospectively reviewed with attention to SB administration and arterial blood gas (ABG) data. After application of inclusion and exclusion criteria to 264 CPA patients, the study group comprised 88 patients. When measured, if PCO(2) and pH were above normal limits after SB administration, we concluded that SB contributed to the alkalemia. RESULTS: Twenty-seven (31%) patients received SB without any ABG data, and 70 (79%) patients received at least one empiric SB dose. Of the 61 patients with ABG data, alkalemia occurred in 10, a prevalence of 16%. Administration of SB increased pH in only 9 (15%) other CPA patients and had no effect in the 42 (69%) remaining patients. CONCLUSIONS: Administration of SB during CPA was causally linked with inducing alkalemia in 16% of patients. Early collection of ABG samples may assist in optimizing pH during CPA and thus reduce unwarranted empiric use of SB.

PMID: 19567654 [PubMed - indexed for MEDLINE]

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