Intestinal Necrosis Associated with Orally Administered Calcium Polystyrene Sulfonate Without Sorbitol (February).

Ann Pharmacother. 2011 Feb 8;

Authors: Goutorbe P, Montcriol A, Lacroix G, Bordes J, Meaudre E, Souraud JB

OBJECTIVE: To describe a case of extensive intestinal necrosis with oral intake of calcium polystyrene sulfonate without sorbitol. CASE SUMMARY: A 73-year-old woman was admitted to the emergency department with abdominal pain. Abdominal computed tomography (CT) scan showed widespread dilatation of the bowel. The diagnosis of acute colonic pseudoobstruction was made. On day 3, her serum potassium level rose to 5.6 mEq/L. It was treated with hydrocortisone 100 mg/day and calcium polystyrene sulfonate 15 g/day via jnasogastric tube from day 3 to day 6. On day 6, the severe abdominal pain recurred, with abdominal tenderness. CT scan showed pneumoperitoneum and peritoneal effusion. At surgery, 2 lenticular jejunal perforations and an ischemic cecum were found. Microscopic findings indicated that the transmural abscess contained massive inflammatory infiltrate and the cecal mucosa showed ulceration and inflammation with a fibrinous and purulent coating. Small gray-purple or blue angulated crystals were embedded in the cecal and most of the jejunal mucosal ulcers. On day 19, the patient died of multiple organ failure after her third laparotomy. DISCUSSION: Ion-exchanging resins are given orally or by retention enema for the treatment of hyperkalemia. The most commonly used and best-established resin is sodium polystyrene sulfonate. However, it is known to promote colonic necrosis when sorbitol is also given or especially in patients with renal failure or postoperative ileus. Calcium polystyrene sulfonate is another ion-exchange resin. There are few reports of adverse effects in the literature. Our case is interesting for 2 reasons: the resin given was calcium polystyrene sulfonate and sorbitol was not used. CONCLUSIONS: Like sodium polystyrene sulfonate, calcium polystyrene sulfonate is an ion-exchanging resin that can promote bowel necrosis. We believe that it should not be used with sorbitol or when bowel transit time is slowed.

PMID: 21304040 [PubMed - as supplied by publisher]

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Thienopyridines in Acute Coronary Syndrome (February).

Ann Pharmacother. 2011 Feb 8;

Authors: Goodwin MM, Desilets AR, Willett KC

OBJECTIVE: To evaluate the safety and efficacy of the thienopyridines in order to identify their current place in therapy for the treatment of acute coronary syndrome (ACS). DATA SOURCES: Literature was accessed through MEDLINE (1966-October 2010 week 1), EMBASE (1980-2010 week 40), and a bibliographic review of published articles using the search terms acute coronary syndrome, clopidogrel, and prasugrel. Articles were limited to clinical trials conducted in humans and published in the English language. STUDY SELECTION AND DATA EXTRACTION: Head-to-head clinical trials evaluating the safety and efficacy of the thienopyridines in patients with ACS were critically reviewed. Trials evaluating ticlopidine were excluded due to its limited clinical use. DATA SYNTHESIS: Thienopyridines are an integral part of the treatment of ACS. Prior to the approval of prasugrel, clopidogrel was considered the agent of choice due to safety concerns associated with ticlopidine. A randomized controlled trial comparing prasugrel and clopidogrel has demonstrated superior efficacy with prasugrel, and post hoc analyses suggest additional benefit with prasugrel is derived in patients with ST-segment elevation myocardial infarction and patients with diabetes. However, safety concerns exist linking prasugrel with an increased risk of bleeding, which diminishes its advantage in elderly patients, underweight patients, and those with a history of stroke. Pharmacokinetic and pharmacodynamic studies discussing differences in response variability, platelet inhibition, interactions with proton pump inhibitors, and genetic factors between the thienopyridines are numerous, although more clinical data are needed to determine clinical implications. CONCLUSIONS: Clinical trial data have suggested prasugrel is superior to clopidogrel at preventing ischemic events in patients with ACS undergoing percutaneous coronary intervention. However, this coincides with an increased risk of bleeding. Clinicians must carefully interpret the current evidence, including limitations in study design and pharmacologic differences between agents, in order to balance the risks and benefits as new data become available.

PMID: 21304037 [PubMed - as supplied by publisher]

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Prescriber Compliance with a New Computerized Insulin Guideline for Noncritically Ill Adults (February).

Ann Pharmacother. 2011 Jan 18;

Authors: Clemens E, Cutler T, Canaria J, Pandya K, Parker P

BACKGROUND: In March 2008, the University of California, Davis Medical Center(UCDMC), implemented a guideline for the inpatient management of diabetes in noncritically ill adults. In accordance with national guidelines, all patients with type 2 diabetes are prescribed basal, nutritional, and correctional insulin. The guideline was added to the electronic medical record as a standardized physician order set in April 2008 and provider training on the insulin guideline occurred in May 2008. OBJECTIVE: To evaluate provider compliance with a new electronic standardized insulin order set in a hospital setting. METHODS: All patients with insulin orders admitted to the general internal medicine service between June 1, 2008, and November 1, 2008, were evaluated in this single-center retrospective chart review at UCDMC in Sacramento. Patients older than 18 years with a history of type 2 diabetes were included in the analysis. Insulin orders were categorized as preferred (followed the guideline) or nonpreferred regimens (did not follow all components of the guideline). RESULTS: A total of 265 patients were identified during the study period. The preferred regimen was ordered in 82 (30.9%) of the evaluated patient admissions. Of the 183 (69.1%) nonpreferred regimens, more than half (54.6%) contained correctional insulin alone; 84.2% of patient admissions prescribed nonpreferred regimens lacked nutritional insulin. Average admission blood glucose readings were higher in the preferred versus nonpreferred regimen group (224.4 vs 164.8 mg/dL, p < 0.001). CONCLUSIONS: The preferred regimen was not prescribed for the majority of patients admitted with a history of type 2 diabetes, despite computerized decision support. Nutritional insulin was the most common missing component in the nonpreferred regimens. Baseline clinical factors, educational modalities, and guideline content may have influenced prescribing patterns.

PMID: 21245289 [PubMed - as supplied by publisher]

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Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home.

Ann Pharmacother. 2010 Oct;44(10):1596-603

Authors: Steurbaut S, Leemans L, Leysen T, De Baere E, Cornu P, Mets T, Dupont AG

Accurate medication histories at hospital admission are an important element of medication safety. Discrepancies may have clinically significant consequences, especially in the elderly population.

PMID: 20736427 [PubMed - indexed for MEDLINE]

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Octreotide for Symptomatic Treatment of Diarrhea due to Cytomegalovirus Colitis (January).

Ann Pharmacother. 2010 Dec 28;

Authors: Bartels MC, Mergenhagen KA

OBJECTIVE: To report the improvement of diarrhea in a patient with cytomegalovirus (CMV) colitis who was treated with octreotide after failure of loperamide. CASE SUMMARY: An 84-year-old male presented with chronic diarrhea and CMV colitis; he had been experiencing protracted diarrhea since 2006. In October 2009 he failed a 21-day course of valgancyclovir 900 mg orally twice daily. Several months later, due to continuing diarrhea and progressive malnutrition, a colonoscopy and subsequent biopsy again showed CMV. In March 2010 he was started on a 28-day course of intravenous ganciclovir 130 mg daily. Three weeks into treatment he continued with copious amounts of diarrhea, with no relief from loperamide, which was titrated from 2 mg/day to 2 mg every 6 hours. On day 20 of ganciclovir treatment he was started on octreotide 50 ?g subcutaneously every 8 hours; within a few days, the patient began to experience decreased stool frequency and consistency. He completed the full 28-day course of ganciclovir, with octreotide continuing unchanged, with much improvement in his diarrheal symptoms and improvement in appetite, nutritional status, and quality of life. DISCUSSION: Studies regarding the treatment of CMV colitis-associated diarrhea are scarce, and are typically limited to treating the underlying cause with antiviral medications and with the addition of antimotility agents. Three cases have been reported in the literature in which octreotide was used for the symptomatic treatment of diarrhea, none of which was refractory to loperamide. CONCLUSIONS: This is the first known case of a patient with chronic diarrhea due to CMV colitis that was unresponsive to loperamide, required protracted antiviral treatment (valgancyclovir and gancyclovir), and subsequently experienced relief by the use of octreotide 50 ?g subcutaneously every 8 hours.

PMID: 21189368 [PubMed - as supplied by publisher]

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Central Nervous System Toxicity Associated with Ertapenem Use (January).

Ann Pharmacother. 2010 Dec 21;

Authors: Duquaine S, Kitchell E, Tate T, Tannen RC, Wickremasinghe IM

OBJECTIVE: To report stroke-like symptoms and unusual central nervous system adverse effects in 2 elderly patients receiving ertapenem. CASE SUMMARY: Two patients ?70 years of age experienced unusual mental status changes while receiving ertapenem. Patient 1 developed garbled speech and miosis 1 week after starting appropriately dosed ertapenem (1 g/day) for sacral osteomyelitis. Symptoms resolved upon ertapenem discontinuation but recurred upon rechallenge. Patient 2, a cachectic male with acute renal insufficiency, became delirious and progressively obtunded 5 days after starting ertapenem 1 g/day. Nine days after initiation of therapy, he required intubation and mechanical ventilation; ertapenem was discontinued at that time. Within 2 days of ertapenem discontinuation, his mental state cleared and the ventilator was removed. DISCUSSION: Carbapenems, including ertapenem, have been implicated in causing central nervous system toxicity, including hallucinations and seizures. However, published reports of other, nonseizure-related central nervous system events are limited. Considerable resources were expended on extensive medical interventions before ertapenem was identified as a potential cause of the delirium in our patients. When applied to our patients, the Naranjo probability scale indicated a highly probable relationship for patient 1 and a probable relationship for patient 2 between the adverse effects and ertapenem use. CONCLUSIONS: Clinicians should be cognizant of ertapenem’s potential to induce profound changes in mental status that may mimic other conditions in elderly patients.

PMID: 21177419 [PubMed - as supplied by publisher]

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Treatment of Meningitis Caused by Vancomycin-Resistant Enterococcus faecium: High-Dose and Combination Daptomycin Therapy (December).

Ann Pharmacother. 2010 Nov 30;

Authors: Le J, Bookstaver PB, Rudisill CN, Hashem MG, Iqbal R, James CL, Sakoulas G

OBJECTIVE: To report 3 successful treatments of vancomycin-resistant Enterococcus faecium meningitis in adults using daptomycin and either linezolid or gentamicin. CASE SUMMARY: Three case reports involving males (aged 58-78 years) are presented; in each case (trigeminal nerve microvascular decompression and subdural hygroma; paraspinal abscess; and hydrocephalus with subsequent craniotomy and ventriculo-peritoneal shunt placement) CSF examination revealed vancomycin-resistant Enterococcus (VRE) susceptible to daptomycin, gentamicin, and/or linezolid. Three- to four-week treatment regimens with daptomycin 6-12 mg/kg and either gentamicin or linezolid led to clinical resolution and microbiological clearance of infection. DISCUSSION: Daptomycin has previously been shown to be successful in treating methicillin-resistant Staphylococcus aureus-associated meningitis and other serious VRE and enterococcal infections. Higher than approved doses of daptomycin were used in 2 cases where in theory higher CSF concentrations would thus be obtained. Gentamicin and linezolid were added to daptomycin therapy based on in vitro data synergy results and because of documented successful treatment for VRE meningitis, respectively. CONCLUSIONS: The difficulty in treating VRE CSF infections involves both drug kinetics and microbial resistance factors, as well as external factors such as foreign bodies like shunts. This report highlighted 3 cases where daptomycin use in concert with either gentamicin or linezolid was successful in treating this infection. Additional controlled trials will be helpful in identifying the best strategies when using daptomycin to treat CSF infections.

PMID: 21119097 [PubMed - as supplied by publisher]

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Thrombolytics for Cardiac Arrest: Case Report and Systematic Review of Controlled Trials (December).

Ann Pharmacother. 2010 Nov 30;

Authors: Perrott J, Henneberry RJ, Zed PJ

OBJECTIVE: To describe a successful case involving the use of tenecteplase during cardiac arrest for presumed pulmonary embolism (PE) and to systematically review the evidence from controlled trials supporting the efficacy and safety of thrombolysis during cardiac arrest. CASE SUMMARY: A 48-year-old male presented to the emergency department with an acute onset of shortness of breath that began approximately 2 hours prior to presentation. Prior to undergoing a computed tomography (CT) scan to rule out PE, the patient went into cardiac arrest, with an initial rhythm of pulseless electrical activity at a rate of 140 beats/min. Cardiopulmonary resuscitation (CPR) was initiated and, due to suspected PE, a bolus dose of tenecteplase 50 mg was administered immediately following a single 1-mg dose of epinephrine. CPR was continued and 4 additional 1-mg doses of epinephrine and three 1-mg doses of atropine were given. After 13 minutes of CPR, return of spontaneous circulation (ROSC) was achieved, with a blood pressure of 144/50 mm Hg. After the patient was stabilized, a CT scan demonstrated extensive bilateral pulmonary emboli in most segmental arteries. He was admitted to the intensive care unit where he was sedated, paralyzed, and treated with induced hypothermia for 24 hours. He was discharged from the hospital 2 weeks later on warfarin, with no noted neurologic deficits. DISCUSSION: A systematic search of MEDLINE (1950-August 2010), Embase (1980-August 2010), and Google Scholar (to August 2010) was conducted to identify prospective controlled trials that investigated the use of thrombolytic medications to treat cardiac arrest. Five trials involving 1544 undifferentiated cases of cardiac arrest were found. Overall, some trials reported an improved rate of ROSC following administration of thrombolytics, but there was no overall mortality reduction in any trial. There was, however, an increased risk of bleeding events following administration of a thrombolytic drug. CONCLUSIONS: Controlled trials demonstrate that there is a lack of benefit and potential harm in administering thrombolysis in an undifferentiated patient with cardiac arrest. However, the case we present provides evidence that fibrinolysis may benefit selected patients with cardiac arrest in whom PE is confirmed or in whom there is high index of suspicion of PE.

PMID: 21119096 [PubMed - as supplied by publisher]

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Beyond the Beers Criteria: A Comparative Overview of Explicit Criteria (December).

Ann Pharmacother. 2010 Nov 16;

Authors: Levy HB, Marcus EL, Christen C

OBJECTIVE: To provide a comparative overview of explicit criteria that have been developed since 2003 for inappropriate prescribing in older adults and to contrast these newer criteria with the most recent Beers criteria, published in 2003. DATA SOURCES: MEDLINE and Google Scholar searches were performed from 2003 through July 2010. Within MEDLINE, MeSH terms included aged, drug prescriptions, medication errors, and polypharmacy. Free-text search terms included elderly, guideline adherence, inappropriate prescribing, and medications. Related articles, as identified by MEDLINE, were used as well. Free-text search was performed on Google Scholar, using “potentially inappropriate prescribing elderly.” Additional articles were identified in reference lists of key articles. STUDY SELECTION AND DATA EXTRACTION: Studies were selected if they were published after the most recent revision of the Beers criteria in 2003 and addressed the development and application of explicit criteria for the elderly. We independently reviewed pertinent literature to extract key information. DATA SYNTHESIS: The first explicit criteria published were the Beers criteria, and most research regarding inappropriate medication use applied these criteria. Criteria developed subsequent to the Beers criteria include the French Consensus Panel list, STOPP (Screening Tool of Older Persons’ Prescription) and START (Screening Tool to Alert doctors to Right Treatment), the Australian Prescribing Indicators tool, and the Norwegian General Practice Criteria. Newer criteria offer several improvements on the Beers criteria, namely drug-drug interactions, omission of potentially beneficial therapy, and more broadly applicable criteria across international borders. CONCLUSIONS: Although no criteria may ever be globally applicable, STOPP and START make significant advances. Regional drug availability, economic considerations, and clinical practice patterns impact criteria selection. Research to validate the several newer criteria in various practice settings and to explore the effect of adhering to the guidelines on patient outcomes is warranted. Data from such research will aid practitioners in identifying preferred criteria.

PMID: 21081709 [PubMed - as supplied by publisher]

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Intravenous Opioids for Severe Acute Pain in the Emergency Department (November).

Ann Pharmacother. 2010 Oct 26;

Authors: Patanwala AE, Keim SM, Erstad BL

OBJECTIVE: To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy. DATA SOURCES: Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department. STUDY SELECTION AND DATA EXTRACTION: The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED. DATA SYNTHESIS: At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 ?g/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction. CONCLUSIONS: Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.

PMID: 20978218 [PubMed - as supplied by publisher]

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Assessing the Effect of the Surviving Sepsis Campaign Treatment Guidelines on Clinical Outcomes in a Community Hospital (November).

Ann Pharmacother. 2010 Oct 26;

Authors: Patel GW, Roderman N, Gehring H, Saad J, Bartek W

BACKGROUND: Bundles yield a reduction in mortality in patients with sepsis, but the majority of the data is from large academic centers. The ability of a community hospital to implement a sepsis bundle successfully, however, has not been investigated. OBJECTIVE: To examine the effect of a collaborative 2-part sepsis bundle on clinical outcomes and mortality at a community hospital. METHODS: The study included all patients with severe sepsis/septic shock over the age of 18 years admitted to the intensive care unit (ICU) from 2006 to 2007 who were not treated with a bundle (n = 53) and those who were treated with a bundle (n = 59). Data collected included demographics; initiation of vasopressors; days on vasopressors; blood glucose; use of drotrecogin alfa (activated), steroids, and ventilator; ICU/hospital lengths of stay; ventilator days; time to culture; time to first dose of antibiotics; time to transfer from emergency department to ICU; fluid resuscitation in the first 24 hours; percentage of patients started on dialysis; and mortality. RESULTS: Demographics; blood glucose; use of drotrecogin alfa (activated), steroids and ventilator; ICU/hospital lengths of stay; and ventilator days were statistically similar between groups. Median time to cultures, first dose of antibiotics, and transfer to ICU were all reduced with the bundle. Percentage of non-bundle patients on vasopressors was 87% versus 66.7% of bundle patients (p = 0.011) and number of median days on vasopressors was reduced. Fewer bundle patients were initiated on dialysis (0%) versus non-bundle patients (14.8%) (p = 0.02). Median fluid administered in the first 24 hours was 2200 mL (10-13,996 mL) for non-bundle patients and 7143 mL (1000-19,104 mL) for bundle patients (p < 0.001). Mortality was 61.1% in the non-bundle group versus 20% with the bundle (p < 0.001). CONCLUSIONS: Implementation of a 2-part sepsis bundle based on the Surviving Sepsis Campaign Guidelines can yield a positive impact on clinical outcome and mortality in a nonacademic, community hospital setting.

PMID: 20978215 [PubMed - as supplied by publisher]

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Spironolactone Management of Resistant Hypertension (November).

Ann Pharmacother. 2010 Oct 26;

Authors: Marrs JC

OBJECTIVE: To review the pharmacology, pharmacokinetics, pharmacodynamics, efficacy data, and adverse effects of spironolactone in the treatment of resistant hypertension. DATA SOURCES: A literature search was conducted using MEDLINE (1966-July 2010), International Pharmaceutical Abstracts (1970-July 2010), and Cochrane database (2009) for the key words spironolactone or resistant hypertension. References cited in the articles were reviewed for additional information. STUDY SELECTION AND DATA EXTRACTION: English-language literature reporting pharmacology data from animal studies and clinical trials evaluating the pharmacology, pharmacokinetics, pharmacodynamics, efficacy data, and adverse effects of spironolactone were included. DATA SYNTHESIS: Spironolactone is a potassium-sparing diuretic with antialdosterone effects that are beneficial in the management of hypertension. Spironolactone has shown improvement in 5 prospective studies and 1 retrospective study evaluating its blood pressuring-lowering abilities in patients with resistant hypertension. Specifically, the average blood pressure lowering noted in these trials with the addition of spironolactone in patients with resistant hypertension was 22/10 mm Hg. Trials evaluating spironolactone’s role in resistant hypertension treatment have identified hyperkalemia, gynecomastia, and renal insufficiency as the major adverse effects that warrant monitoring. CONCLUSIONS: Spironolactone is an appropriate antihypertensive medication to add to treatment of patients with resistant hypertension (?3 antihypertensive medications at optimal doses) not at their blood pressure goal. In patients considered to have resistant hypertension, secondary causes should be ruled out.

PMID: 20978214 [PubMed - as supplied by publisher]

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Sepsis Bundles: Just Do It (November).

Ann Pharmacother. 2010 Oct 26;

Authors: Micek ST, Sawyer AM

The initial management of patients with septic shock appears to be critical in terms of determining outcome; a standardized systematic approach for the management of patients with severe infections appears to consistently improve the delivery of recommended therapies and, as a result, may improve patient outcomes. With minimal-to-no risk or acquisition costs, severe sepsis bundle implementation should become the standard of care for the management of septic shock. A multifaceted approach may aid in the success of implementation of sepsis bundles in teaching and nonteaching institutions. Bundle implementation should change clinical practice by including surveillance, feedback reporting, and staff education to organize the target interventions into packages that must be implemented in strict compliance, for every patient, to ensure uniformity and provide practical applicability. Quality improvement via utilization of protocols can be achieved, regardless of institution size or academic status, and should continue to be promoted in the intensive care unit setting.

PMID: 20978213 [PubMed - as supplied by publisher]

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Assessing anticoagulation knowledge in patients new to warfarin therapy.

Ann Pharmacother. 2010 Jul-Aug;44(7-8):1152-7

Authors: Winans AR, Rudd KM, Triller D

BACKGROUND: Warfarin is highly efficacious for the treatment and prevention of thromboembolic disorders. However, anticoagulation control has been a long-standing challenge, as patients' lack of knowledge of warfarin therapy is a predictor of nonadherence and compromised patient safety. OBJECTIVE: To ascertain whether hospitalized patients newly initiated on warfarin are provided adequate anticoagulation education during hospitalization, as measured at discharge, as well as determine whether there is a difference in the knowledge obtained by patients educated via a structured program versus those counseled by "usual care." METHODS: A prospective evaluation of warfarin education of inpatients new to warfarin therapy was performed at Bassett Medical Center, Cooperstown, NY. Patients who were admitted to the hospital and receiving warfarin for any given diagnosis, were >18 years of age and able to give informed consent, and spoke English were recruited. Patients with dementia or cognitive impairment, those who were pregnant, or those who had previously been on warfarin therapy were excluded. Recruited patients received warfarin education in the form of a structured program provided by a pharmacist or counseling by usual care during hospitalization. Prior to discharge, the Oral Anticoagulation Knowledge (OAK) test, a prevalidated tool used to measure warfarin knowledge, was administered to evaluate outcomes. Further warfarin education was provided posttest if necessary. RESULTS: The intervention group (n = 20) scored significantly higher on the OAK test than the usual care group (n = 20): 74% versus 55%, respectively (p = 0.004). CONCLUSIONS: This preliminary study demonstrated that there is a large amount of variability regarding patient knowledge of warfarin on discharge from an inpatient facility. A formalized inpatient warfarin education program may empower patients to achieve a larger degree of initial warfarin knowledge than those educated by usual care. Previous studies have demonstrated that this may improve adherence and subsequently increase long-term safety associated with oral anticoagulation. Larger, prospective, randomized studies are necessary to further evaluate patient education and safety outcomes.

PMID: 20571105 [PubMed - indexed for MEDLINE]

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Low-Molecular-Weight Heparin Overdose: Management by Observation (November).

Ann Pharmacother. 2010 Oct 5;

Authors: Monte AA, Bodmer M, Schaeffer TH

OBJECTIVE: To describe 3 episodes of low-molecular-weight heparin (LMWH) overdose in 2 patients and discuss the clinical presentations, outcomes, and therapeutic options. CASE SUMMARIES: The first patient, a 35-year-old female, presented after an intentional overdose of 72,000 units of dalteparin. The peak measured anti-Xa activity was 6.2 U/mL at 7.5 hours postinjection. No interventions were performed and there were no bleeding complications. The patient presented 20 days later following another overdose of 72,000 units. Anti-Xa activity was 4.5 U/mL 2 hours postinjection. No treatment was given and the patient was discharged with plans for follow-up the next day. There was no evidence of bleeding complications on follow-up. The second patient, a 29-year-old male, presented after an intentional overdose of 480 mg of enoxaparin. The anti-Xa activity was 1.9 U/mL measured 2 hours postinjection. The patient was observed without intervention. There were no bleeding complications. DISCUSSION: To our knowledge, there is only one previous report of an LMWH overdose in the literature, an iatrogenic overdose in an infant treated with protamine. In our 3 presented episodes of LMWH overdose, no therapeutic interventions were performed and there were no bleeding complications. Review of the literature regarding the efficacy of protamine and recombinant factor VIIa for reversal of LMWH coagulopathy revealed that protamine is only partially effective and recombinant factor VIIa is effective in in vitro studies and case reports. CONCLUSIONS: In cases of LMWH overdose, observation seems to be appropriate in the absence of clinically significant bleeding. Prolonged monitoring may be necessary for patients with renal failure. Use of protamine or recombinant factor VIIa is not supported by this case series in patients without significant bleeding. There is a lack of data regarding how to treat patients with significant bleeding.

PMID: 20923945 [PubMed - as supplied by publisher]

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