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. 

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?

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?

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. 

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'.

Changes to FDA Pregnancy and Lactation Labeling

On December 3, 2014, the FDA issued a new rule revising the current regulations pertaining to the pregnancy, labor and delivery, and nursing mother sections of the prescribing information for prescription drugs and biologic products. Initiation of this amendment was prompted by the FDA’s goal to provide women and their healthcare providers with sufficient information when deciding which medications to prescribe in pregnant and breastfeeding patients.

^{Why the change?}

Recent data indicate that about 90% of pregnant women take at least one medication and 70% take one or more prescription drugs, potentially putting the fetus at high risk for drug-induced developmental abnormalities. Many pregnant women may also be on medications to control chronic disease states such as hypertension or to manage acute conditions developed during pregnancy such as gestational diabetes.  It is also necessary to consider that about half of all pregnancies are unexpected, leading to unintended drug exposure.