Use of sodium polystyrene sulfonate for hyperkalemia

Let's start with a patient case.  A 58 year old male is sent to the hospital from his PMD for hyperkalemia.  He has a past medical history of diabetes mellitus type 2, hypertension, osteoarthritis, and obesity for which he is taking sitagliptin 100 mg daily, lisinopril 20 mg daily, atorvastatin 80 mg daily, and aspirin 81 mg daily.  Pertinent findings on arrival to the emergency department are SCr = 1.2 mg/dL (at his baseline), K+ = 5.9 mEq/L (previously 4.2), blood pressure = 152/96 mm Hg, Hb A1c = 10.8%, and a normal EKG.  Upon further questioning about his medication and supplement use, he admits to occasional ibuprofen and oxycodone use this past month for his osteoarthritis and is newly using Morton's Salt Substitute (as he's trying to avoid salt because of his uncontrolled hypertension).  What is the role of sodium polystyrene sulfonate (SPS) in this situation?

Risk of peripheral neuropathy with fluoroquinolones

Last year, the FDA issued a drug safety communication, warning about the risk of nerve damage from fluoroquinolone antibiotics.  You can read last year's post about the warning and other information on fluoroquinolones here: Serious peripheral neuropathy and fluoroquinolones.  

The questionable role of digoxin in atrial fibrillation

Let's start with a patient case.  An elderly patient is admitted to the hospital with complaints of intermittent shortness of breath and a fluttering feeling in his chest.  He has a past medical history of hypertension, atrial fibrillation, and heart failure (EF 6 months ago = 30%).  He is currently taking ramipril 10 mg daily, metoprolol succinate 50 mg daily, and warfarin 6 mg M/W/F and 3 mg the rest of the week.  Other findings include a BP of 106/56 mm Hg, a creatinine clearnace of 40 mL/minute, an INR of 1.28, and atrial fibrillation with a heart rate in the 80s but a rapid ventricular response intermittently into the 120s bpm.  What should be recommended at this time to control this patient's atrial fibrillation and what is the role of digoxin, if any?

Role for polyethylene glycol in treating hepatic encephalopathy?

Hepatic encephalopathy is a frequent and debilitating complication of liver disease.  The mainstay of treatment, lactulose, has been used since the 1960s, even without a strong evidence-base for efficacy.  Currently, in the AASLD guidelines for hepatic encephalopathy, updated in 2014, lactulose is recommended as first line therapy for the treatment of episodic overt hepatic encephalopathy (Grade II-1,B,1 which means controlled trials without randomization, moderate evidence strength, strong recommendation)1.  It's notable that there is a cost appeal of lactulose compared to alternative or add-on therapies such as rifaximin and this is considered in their recommendation.

Bridging anticoagulation when treating venous thromboemboli

Given the rising number of options for treating venous thromboemboli (VTE), questions occasionally arise on what is the standard for initiating and continuing anticoagulation.  Questions such as, "How long do we need to overlap parenteral anticoagulation for?" and "Can we begin monotherapy with a new oral anticoagulant?" will be discussed below.

Interpreting minimum inhibitory concentrations

Several previous discussions have dealt with the concept of the minimum inhibitory concentration (MIC) such as extended-infusion piperacillin/tazobactam (Zosyn) and vancomycin dosing in hemodialysis.  Though this concept was learned at some point, questions occasionally arise as to what these numbers represent and what to make of them when they show up on a culture and sensitivity result.  This post will discuss the MIC and hopefully address some common misconceptions.  For the take home points, skip down to the bullets at the end.