Sunday, October 25, 2015

Dabigatran reversal with idarucizumab (Praxbind)

A 77 year old black patient is admitted to the hospital for a gastrointestinal bleed.  He has a past medical history of CAD (MI 15 years ago), CKD (stage 4), atrial fibrillation, PUD, and hyperlipidemia for which he is taking ASA 81 mg daily, metoprolol tartrate 50 mg twice a day, atorvastatin 20 mg daily, lisinopril 20 mg daily, omeprazole 20 mg daily, and dabigatran 75 mg orally twice a day.  Initial labs indicate an aPTT of 95 seconds, hemoglobin of 6.8 g/dL, and serum creatinine 2.3 mg/dL.

Monday, August 3, 2015

Direct oral anticoagulants to treat VTE in patients with cancer?

Four direct oral anticoagulants were approved by the FDA in the last few years and are all now indicated for the treatment of DVT and PE.  These include:
  • Direct thrombin inhibitor:
     -Dabigatran (Pradaxa)
  • Factor Xa inhibitors:
     -Rivaroxaban (Xarelto)
     -Apixaban (Eliquis)
     -Edoxaban (Savaysa)

These medications are given orally at fixed doses and do not require coagulation monitoring or titration.  Compared to warfarin (which needs close INR following and can vary drastically

Monday, July 20, 2015

New drugs for heart failure plus review chart

The pharmacotherapy management of patients with heart failure with reduced ejection fraction is a populated landscape with multiple drugs affecting morbidity and mortality.  Two new medications that are the first in two new classes were approved recently - a neprilysin inhibitor and a hyperpolarization-activated cyclic nucleotide-gated channel blocker.

But first here's a quick table and a few notes about the current use of medications for treating heart failure with reduced ejection fraction.

Wednesday, June 10, 2015

10 things you should know about target-specific oral anticoagulants

Here are some stand-out facts and tips about the target-specific oral anticoagulants.  These agents are becoming increasingly popular in the last few years and there are some nuances among them that you’ll find here. 

To review, target-specific oral anticoagulants (TSOACs) includes dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa).  They’re given orally with either once or twice daily dosing and you don’t need to (and in fact, can’t) monitor any coagulation labs in the typical clinical setting. 

Sunday, April 12, 2015

Risk of hyperglycemia from glucocorticoids

A 65 year old patient with COPD sees his primary care provider for worsening shortness of breath over the past week.  His current medications include tiotropium and albuterol.  He has no other significant past medical history but has a family history of diabetes.  His current labs include a fasting plasma glucose of 96 mg/dL, HbA1c of 6.1%, Scr = 0.8 mg/dL.  His primary care provider determines that the patient is having a COPD exacerbation and is opting to initiate a 5 day course of prednisone 40 mg orally daily (click here for more on a 5 days course versus longer steroid courses for COPD exacerbations).  What are some of the risk factors, the time-course, and the mechanism for developing hyperglycemia in a situation like this?

Monday, March 30, 2015

Use of cephalosporins in penicillin-allergic patients

Let's start with a patient case.  A 71 year old patient arrives to the emergency room complaining of shortness of breath and sputum production that has worsened from when it started about three days ago.  She has a past medical history of diabetes mellitus type 2, myasthenia gravis, and atrial fibrillation and is taking metformin, pyridostigmine, prednisone, warfarin, and sotalol.  Her BP = 132/88, HR = 78, RR = 24, and T = 37.5 C and CXR reveals a left lower lobe infiltrate.  The diagnosis of pneumonia is made and as you begin to type orders for your standard ceftriaxone/azithromycin combination, you note that the patient has a penicillin allergy.  What is the risk of continuing this antibiotic regimen given the patient's allergy?

Sunday, March 15, 2015

Effectiveness of homeopathy for various conditions

Homeopathy is a part of complementary and alternative medicine (CAM) that is an undeniable component of the healthcare industry in the United States.  A nationwide government survey from 2007 estimated that U.S. adults spent approximately $33.9 billion out-of-pocket on CAM.  Of this, $3.1 billion was spent on homeopathic medicine (compare this to $14.8 billion spent on natural products (nonvitamins and nonminerals) and $47.6 billion which was spent on prescription medications)1.  For more of an explanation of what homeopathy is with an example, see below. 

Sunday, January 18, 2015

Aspirin for primary prevention of cardiovascular disease and predicting risk of first cardiovascular event

The benefit of aspirin in reducing cardiovascular (CV) events or mortality in those patients with known CV disease (secondary prevention) is well established.  However, the benefit of aspirin in those without CV disease (primary prevention) is less clear.  Various organizations have differing opinions and recommendations regarding who, if anyone, should receive aspirin in this capacity, and their recommendations are summarized further below.  To go straight to the current recommendations, skip down to 'Current Recommendations'.

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