Category Archives: PACULit

2020 American College of Rheumatology Guideline for the Management of Gout





Clinical Content
1 min read
September 26, 2024

2020 American College of Rheumatology Guideline for the Management of Gout

J

Jimmy

PharmD





Clinical Content
1 min read
September 26, 2024

2020 American College of Rheumatology Guideline for the Management of Gout

J

Jimmy

PharmD

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Management of Hypertensive Emergency





Clinical Content
7 min read
February 23, 2023

Management of Hypertensive Emergency

J

Jimmy

PharmD





Clinical Content
5 min read
February 23, 2023

Management of Hypertensive Emergency

J

Jimmy

PharmD

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Introduction

  1. Hypertensive emergency is characterized by systolic blood pressure (SBP) > 180 mmHg or diastolic blood pressure (DBP) > 120 mmHg with evidence of target organ damage. 
  2. Rapid blood pressure lowering with intravenous antihypertensives is warranted to prevent further organ damage. 
  3. Patients presenting with intracranial hemorrhage, aortic dissection, preeclampsia, or pheochromocytoma crisis should achieve target blood pressure within one hour of presentation. 
  4. Current literature lacks evidence of mortality benefit with any one antihypertensive drug. Selection of a medication should consider target organ(s) affected, underlying disease states, and time to target blood pressure. 

Treatment in Selected Co-Morbidities

Condition BP Goal Preferred Agents
Acute aortic dissection   SBP < 120 mmHg within 20 min Esmolol Labetalol Nicardipine Nitroprusside
Eclampsia or Preeclampsia   SBP < 140 mmHg  within 1 hour Nicardipine Labetalol Hydralazine
Pheochromocytoma (catecholamine excess)   SBP < 140 mmHg  within 1 hour Nicardipine Phentolamine*
Intracranial hemorrhage SBP < 160 mmHg within 6 hours Nicardipine Labetalol
Acute ischemic stroke Pre-alteplase: < 185/110 mmHg Post-alteplase: < 180/105 for 24 hours No thrombolytic: SBP reduced 15% in 24 hours**                                                                        Nicardipine Labetalol
*Phentolamine currently unavailable due to nationwide shortage
**Permissive hypertension may be reasonable; maintain SBP < 220 mmHg or DBP < 120 mmHg

Pharmacology: Intravenous Antihypertensives

 First-line Agents  
Medication Class Onset Duration Dosing Clinical Pearls
Nicardipine     Ca channel blocker  IV: 5-10 min IV: 2-6 hours Initial: 5 mg/hr  Titration: 2.5 mg/hr every 15 min  Maximum: 15 mg/hr  No dose adjustments in elderly patients 
Esmolol             Beta-blocker  IV: 1-2 min IV: 10-20 min Bolus: 500-1,000 mcg/kg Initial: 50 mcg/kg/min  Titration: repeat bolus dose, then increase by 50 mcg/kg/ min every 10 min Maximum: 200 mcg/kg/min  Contraindications:  Bradycardia Decompensated HF 
Labetalol     Beta-blocker  Alpha-1 antagonist IV: 2-5 min Peak: 5-15 min IV: 2-6 hours Peak: 18 hours Bolus: 10-20 mg IV push every 10 min IV infusion: 0.5 – 10 mg/min titrated 1-2 mg/min every 2 hours Maximum: 300 mg total  Precaution: Second-/thirddegree heart block Bradycardia Heart failure
 
Second-line Agents		  
Phentolamine* Non-selective alpha antagonist IV: Seconds IV: 15 min   Initial: 5 mg IV push  May repeat every 10 min PRN   Useful in catecholamine excess and clonidine withdrawal 
  Nitroglycerin         NOdependent vasodilator IV: 2-5 min IV: 5-10 min ACS: Initial: 5 mcg/min  Titration: 5 mcg/ min every 3-5 min Maximum: 20 mcg/min  Pulmonary edema: Initial: 100-200 mcg/min Titration: 50 mcg/min every 3-5 min Maximum: 400 mcg/min Indicated in ACS or pulmonary edema  Use caution in volume-depleted patients 
Sodium nitroprusside     NOdependent vasodilator IV: Seconds IV: 1-2 min Initial: 0.3-0.5 mcg/kg/min  Titration: 0.5 mcg/kg/min every 1 min Maximum: 10 mcg/kg/min  Requires intra-arterial BP monitoring   Tachyphylaxis and cyanide toxicity with prolonged use – Limit treatment duration
Hydralazine   Direct vasodilator IV: 10 min IM: 20 min IV: 1-4 hours IM: 2-6 hours Initial: 10-20 mg IV push  Repeat every 4-6 hours PRN  Not available as an IV infusion 
Enalaprilat         ACE inhibitor IV: 15-30 min IV: 12-24 hours Initial: 1.25 mg IV over 5 min  Titration: increase by 5 mg every 6 hours as needed  Slow onset (~15 min)  Contraindications:  Pregnancy MI Bilateral renal stenosis 
*Phentolamine currently unavailable due to nationwide shortage

Overview of Evidence

Author (Title), Year  Design Purpose Outcome
Anderson (INTERACT), 2008 RCT (N=404) Comparison of BP goals  (SBP < 140 vs SBP < 180)  in patients with acute ICH Mean hematoma expansion was smaller in the intensive group (13.7% vs 36.3%) No difference in death or disability at 3 months (48% vs 49%) Limitation: included patients with SBP > 150 mmHg, over 30% of patients were treated with oral antihypertensive therapy
Quereshi (ATACH-2), 2016 RCT (N=1,000) Comparison of BP goals  (SBP 110-139 vs SBP 179-140)  in patients with acute ICH All patients received nicardipine infusion No difference between death or disability at 3 months (38.7% vs 37.7%) Increased renal adverse events within 24 hours in the intensive group (9.0% vs 4.0%) Limitation: mean SBP differed by only 10 mmHg between groups 2 hours post-randomization (129 mmHg vs 141 mmHg)
Peacock (CLUE), 2011 RCT (N=226) Nicardipine IV infusion versus labetalol IV bolus for management of hypertensive emergency Patients receiving nicardipine were more likely to reach target BP within 30 min (91.7% vs 82.5%) Rescue antihypertensive use did not differ significantly between groups within first 6 hours Limitation: only 63.3% of patients had evidence of target organ damage at randomization
Yang, 2004 Prospective cohort (N=40) Nitroprusside IV versus nicardipine IV for hypertensive emergency with pulmonary edema No significant difference between blood pressure readings across groups at any time point No adverse events reported in either group Limitation: nicardipine dosing started at 3 mcg/kg/min (12.5 mg/hr in a 70 kg patient)

Conclusions

  1. Selection of a first-line antihypertensive should consider compelling indications and acute blood pressure goals, as robust literature comparing long-term outcomes across drug classes is lacking for most indications.
  2. Nicardipine may provide more consistent blood pressure control than labetalol. This is particularly important in patients with acute stroke, as large fluctuations in blood pressure are believed to negatively impact cerebral perfusion.
  3. Aggressive lowering of SBP less than 140 mmHg in patients with acute ICH has not been shown to improve long-term outcomes and may negatively impact renal perfusion. 
  4. Nicardipine has been shown to provide similar blood pressure control to nitroprusside. In patients with acute ICH, nitroprusside use within 24-hours of presentation was associated with higher in-hospital mortality. 

References

  1. Whelton, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. J Amer Heart Assoc 2018;71(6):e13-e115. 
  2. Benken ST. Hypertensive emergencies. CCSAP 2018;1:7-30.
  3. Anderson, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol 2008;7:391-9. 
  4. Quereshi, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. New Engl J Med 2016;375(11):1033-43. 
  5. Peacock WF, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Critical Care 2011;15(R157):1-8. 
  6. Yang HJ, Kim JG, Lim YS, et al. Nicardipine versus nitroprusside infusion as antihypertensive therapy in hypertensive emergencies. J Int Med Res 2004;32:118-23. 

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Fibrinolytics for STEMI





Clinical Content
6 min read
February 16, 2023

Fibrinolytics for STEMI

J

Jimmy

PharmD


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Introduction

  1. Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy during a cardiac arrest; thrombolytic therapy is an option without PCI capability, followed by transfer to a PCI capable center.
  2. Thrombolytic therapy is most effective when administered within 30 minutes of first medical contact, however, may be considered within 12–24 hours of symptom onset and ongoing ischemia or extensive ST elevation.
  3. During ACS-Induced Cardiac Arrest, the goal for fibrinolysis is 30 minutes and reperfusion with PCI is preferred, however, if PCI is delayed, fibrinolytics therapy could be considered.

Pharmacology

Alteplase Tenecteplase
MOA Initiates fibrinolysis by binding to fibrin in a thrombus and converts entrapped plasminogen to plasmin. Promotes initiation of fibrinolysis by binding to fibrin and converting plasminogen to plasmin; similar to alteplase but more fibrin specific.
Dose Weight based:
>67kg: infuse 15mg IV bolus over 1–2 min, followed by 50mg infusion over 30 min, then 35mg over 1 hour (max 100mg)
≤67kg: infuse 15mg IV bolus over 1–2 min, followed by 0.75mg/kg infusion over 30 min, then 0.5mg/kg over 1 hour (max 100mg) 		Weight based:
<60kg: 30mg
≥60 to <70kg: 35mg
≥70 to <80kg: 40mg
≥80 to <90kg: 45mg
≥90kg: 50mg
Administration Bolus administered over 1 minute followed by infusion. Single bolus over 5 seconds.
PK/PD Duration: 1 hour after infusion terminated
Distribution: approximates plasma volume
Half-life elimination: 5 minutes
Excretion: hepatic and plasma clearance 		Distribution: weight related
Metabolism: hepatic
Half-life elimination: biphasic; initial 20–24 min, terminal 90–130 min
Excretion: plasma clearance
Adverse Effects Intracranial hemorrhage, ecchymosis, GI/GU hemorrhage, sepsis, cerebrovascular accident. Hemorrhage and hematoma, cerebrovascular accident.
Drug Interactions & Warnings Tranexamic acid — avoid combination. Internal bleeding, thromboembolic events, cholesterol embolization. Tranexamic acid — avoid combination. Internal bleeding, thromboembolic events, arrhythmias.
Contraindications Active internal bleeding; ischemic stroke within 3 months (except when within 4.5 hours); severe uncontrolled hypertension. Active internal bleeding; severe uncontrolled hypertension; recent intracranial/intraspinal surgery; ischemic stroke within 3 months.
Compatibility May be diluted in equal volume with 0.9% sodium chloride or D5W. Incompatible with dextrose.

Overview of Evidence

Author, Year Design / Sample Size Intervention & Comparison Outcome
Guillermin 2016a Meta-analysis of RCT (n=18,208) Tenecteplase 30–50mg vs alteplase 80–100mg Bleeding 4.8% in tenecteplase vs 5.8% alteplase (p=0.0002). No difference in mortality at 30 days.
Llevadot 2001 Retrospective review (38 studies) Reteplase, anoteplase, tenecteplase Tenecteplase and reteplase associated with accelerated infusion and more convenient bolus administration. Less fibrin-specific agents may cause greater systemic coagulopathy with potential for more bleeding.
Boersma 1996 Retrospective review (n=50,246) Fibrinolytic therapy vs placebo Mortality reduction in patients treated within 2 hours compared to later (p=0.001).
GUSTO 1993 Randomized, controlled trial (n=41,021) Streptokinase + SQ heparin; streptokinase + IV heparin; alteplase + IV heparin; alteplase + streptokinase + IV heparin Alteplase administered over 1.5 hours with IV heparin provided survival benefit over standard therapy. Thrombolytic therapy administered within 24–48 hours of admission.
Armstrong 2013b Randomized controlled trial (n=1,892) PCI vs bolus tenecteplase, clopidogrel, and enoxaparin Tenecteplase prehospital resulted in effective reperfusion when PCI was not completed within 1 hour. Fibrinolytic therapy associated with increased risk of intracranial bleeding.
Cardiac Arrest Data
Bottiger 2001 Prospective cohort (n=40) Alteplase 50mg bolus, repeat 50mg in 30 min vs placebo Increase in ROSC (68% vs 44%) and ICU admission compared to placebo.
Schreiber 2002 Retrospective chart review (n=157) Alteplase 15mg bolus followed by 50mg infusion over 30 min and 35mg over 60 min Thrombolytic therapy achieved better functional neurological recovery more frequently (p=0.03).
Lederer 2004 Retrospective chart review (n=108) Alteplase 100mg (15mg followed by 85mg over 90 min) 81% of patients discharged without neurological deficit. 67% of patients still alive 5–10 years after the event.
Li 2006 Meta-analysis Alteplase 15mg bolus followed by 50mg infusion over 30 min and 35mg over 60 min Thrombolytic therapy improved the rate of ROSC (p<0.01). 48% of patients had acute coronary artery obstruction.
Bottiger 2008 Randomized, double-blind, multicenter trial (n=1,050) Tenecteplase 30mg if <60kg
Tenecteplase 35mg if 60–69kg
Tenecteplase 40mg if 70–79kg
Tenecteplase 45mg if 80–89kg
Tenecteplase 50mg if >90kg
vs placebo 		No difference between tenecteplase and placebo in 30-day survival, ROSC, or neurologic outcomes. Increased intracranial hemorrhages in tenecteplase patients.
RuizBailen 2001 Retrospective cohort (n=303) Streptokinase; alteplase accelerated regimen; alteplase double bolus Systemic thrombolysis patients had lower mortality, less mechanical ventilation, fewer CPR attempts (p<0.0001). No fatal hemorrhagic complications.

a Administered as tenecteplase 30–50mg bolus and alteplase 15mg bolus followed by 0.75mg/kg infusion over 30 min.
b Half-dose tenecteplase administered in patients ≥75 years old.
c Reteplase administered as two boluses of 10 million units given 30 minutes apart.

Conclusions

  1. Evidence supports PCI is the first-line option for management of patients requiring reperfusion during cardiac arrest when a STEMI is suspected.
  2. Available evidence suggests tenecteplase and alteplase are appropriate fibrinolytic therapies when PCI is unavailable.
  3. Tenecteplase is an alternative fibrinolytic therapy and has been evaluated as safe and efficacious as a bolus dose of 30–50mg.
  4. When alteplase is the only fibrinolytic therapy available, there is data to support bolus therapy +/- a weight-based infusion during cardiac arrest.
  5. Thrombolytic agents administered during CPR can improve the rate of survival but are associated with a risk of severe bleeding.

References

  1. Lexicomp [Electronic version]. Macedonia, OH: Truven Wolters Kluwer Health. Retrieved January 26, 2021, from https://online.lexi.com/lco/action/login.
  2. Guillermin A, Yan D, Perrier A, Marti C. Safety and efficacy of tenecteplase versus alteplase in acute coronary syndrome: a systematic review and meta-analysis of randomized trials. Arch Med Sci 2016; 12(6):1181–1187.
  3. Llevadot J, Giugliano R, Antman E. Bolus fibrinolytic therapy in acute myocardial infarction. JAMA. 2001;286(4):442–449.
  4. Boersma E, Maas A, Deckers J, Simoons M. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996;348:771–775.
  5. GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. NEJM. 1993;329(10):673–682.
  6. Armstrong P, Gershlick A, Goldstein P, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. NEJM. 2013;268(15):1379–1387.
  7. Wilcox R. Randomized, double-blind comparison of reteplase double-bolus administration with streptokinase in acute myocardial infarction (INJECT). Lancet. 1995;346(8971):329–336.
  8. Van de Werf F, Cannon CP, Luyten A, et al. Safety assessment of single-bolus administration of TNK tissue-plasminogen activator in acute myocardial infarction: the ASSENT-1 trial. Am Heart J. 1999;137(5):786–791.
  9. Lederer W, Lichtenberger C, Pechlaner C, et al. Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest. Resuscitation. 2001;50(1):71–76.
  10. Schreiber W, Gabriel D, Sterz F, et al. Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation. 2002;52(1):63–69.
  11. Lederer W, Lichtenberger C, Pechlaner C, et al. Long-term survival and neurological outcome of patients who received recombinant tissue plasminogen activator during out-of-hospital cardiac arrest. Resuscitation. 2004;61(2):123–129.
  12. Li X, Fu QL, Jing XL, et al. A meta-analysis of cardiopulmonary resuscitation with and without the administration of thrombolytic agents. Resuscitation. 2006;70(1):31–36.
  13. Bottiger BW, Arntz HR, Chamberlain DA, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. NEJM. 2008;359(25):2651–2662.
  14. Kurkciyan I, Meron G, Sterz F, et al. Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment. J Intern Med. 2003;253(2):128–135.
  15. Ruiz-Bailén M, Aguayo de Hoyos E, Serrano-Córcoles M, et al. Efficacy of thrombolysis in patients with acute myocardial infarction requiring cardiopulmonary resuscitation. Intensive Care Med. 2001;27(6):1050–1057.
  16. Richling N, Herkner H, Holzer M, et al. Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac arrest due to acute ST-segment elevation myocardial infarction. Am J Emerg Med. 2007;25(5):545–550.
  17. Böttiger B, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet. 2001;357(9268):1583–1585.

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Procainamide for Wide Complex Tachycardia





Clinical Content
5 min read
February 9, 2023

Procainamide for Wide Complex Tachycardia

J

Jimmy

PharmD





Clinical Content
4 min read
February 9, 2023

Procainamide for Wide Complex Tachycardia

J

Jimmy

PharmD

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Introduction

  1. Ventricular tachycardia (VT) is an uncommon but dangerous medical condition, with an extremely variable clinical presentation.
  2. Intravenous procainamide is guideline recommended and is the drug of choice for the treatment of hemodynamically stable VT with a class IIa recommendation.
  3. Procainamide is an old drug with new evidence that supports it’s use but dosing strategies and administration techniques makes it difficult to use at the bedside.

Pharmacology

  Procainamide
Dose and administration
  • Bolus Dosing
    • 10-17 mg/kg over 20-60 minutes (Max dose suggest 1g and max rate of 20-50 mg/min)                   
    • alternative Dosing: 100 mg every 5 minutes at max rate of 50 mg/min to max dose 1g 
  • Renal Adjustments
    • eCrCl 10-50 ml/min: Reduce initial dosing by 25-50 %
    • eCrCL < 10 ml/min: Reduce initial dosing by 50-75%  
  • Maintenance Infusion Dosing 1-6 mg/min 
Mechanism of Action  •      Class 1A anti-arrhythmic that binds to fast sodium channels inhibiting recovery after repolarization. It also prolongs the action potential and reduces the speed of impulse conduction
PK/PD
  • Onset: IV <2 minutes; IM 10-30 minutes
  • Time to Peak: IV 25-60 minute; IM 15-60 minutes
  • Duration: IV/IM: 3-4 hours
  • Metabolism: Converted by the liver to N-acetylprocainamide (NAPA), an active compound
  • Half-life: 2.5– 4.7 hr (NAPA— 7 hr); increased in renal impairment
  • Excretion: 40– 70% excreted unchanged by the kidneys
Adverse Effects Hypotension Hepatotoxicity Positive ANA titer Lupus-like syndrome Anaphylaxis caused by sulfite salt Myasthenia gravis exacerbation  Angioedema
Drug Interactions and warnings         •      Interacts with diazepam, diltiazem, milrinone, phenytoin, and hydralazine
Compatibility Compatible in  o                0.9 % Sodium Chloride and 0.45% sodium chloride,  Incompatible with  o        D5 (depending on procainamide concentration), LR, and D5NS 
Comments •      Define hospital’s dosing and administration policy as there is a risk for adverse event’s due to multiple dosing strategies in the literature

Overview of Evidence

Author, year  Design/ sample size Intervention & Comparison Outcome
Ortiz,2017 Randomized controlled trial   n= 62 IV procainamide 10 mg/kg over 20 min IV amiodarone 5mg/kg over 20 min Major cardiac adverse occurred in 3 of 33 (9%) procainamide and 12 of 29 (41%) amiodarone patients.   Tachycardia terminated within 40 min in 22 (67%) procainamide and 11 (38%) amiodarone patients. 
Maril,2010 Multicenter cohort study    n= 187 IV Amiodarone 2 mg/kg infusion at a rate of at least 10 mg⁄ min   IV Procainamide 10 mg/kg infusion at a rate of at least 15 mg⁄ min •      The rates of VT termination were 25% (13 ⁄ 53) and 30% (9 ⁄ 30) for amiodarone and procainamide, respectively.
Komura,2010 Retrospective analysis   n= 90 IV Procainamide 100 mg over 1–2 min   IV Lidocaine bolus of 50 mg •      Procainamide and lidocaine terminated VTs in 53/70 (75.7%) and in 7/20 (35.0%) respectively.
Maril,2006 Retrospective case series   n= 33 IV Amiodarone 150 mg over 15 minutes Amiodarone rate of successful ventricular tachycardia termination was 8 of 28 (29%).   Two of 33 patients (6%) required direct current cardioversion for presyncope or hypotension temporally associated with amiodarone treatment.
Gorgels,1996 Randomized parallel study   n= 79 IV Procainamide 10 mg/kg   IV Lidocaine 1.5 mg/kg Lidocaine terminated 6 of 31 VTs and procainamide 38 of 48 (p <0.001).    A comparison of the QRS width and QT interval before and at the end of the injection revealed significant lengthening of these values after procainamide but no change after lidocaine.
Callans,1992 Observational study   n= 15 IV Procainamide rate of 50 mg/min until the arrhythmia terminated or a total dose of 15 mg/kg  •      Procainamide was well tolerated and resulted in termination of ventricular tachycardia in 93% of patients after administration of 100 to 1,080 mg (median dose 600 mg).

References

  1. Procainamide. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved July 6, 2020, from http://www.micromedexsolutions.com/
  2. Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med 2017;52:484-492.
  3. Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017;38(17):1329-1335. doi:10.1093/eurheartj/ehw230
  4. Marill KA, deSouza IS, Nishijima DK, et al. Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison. Acad Emerg Med. 2010;17(3):297-306. doi:10.1111/j.1553-2712.2010.00680.x
  5. Komura S, Chinushi M, Furushima H, et al. Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Circ J. 2010;74(5):864-869. doi:10.1253/circj.cj-09-0932
  6. Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN. Amiodarone is poorly effective for the acute termination of ventricular tachycardia. Ann Emerg Med. 2006;47(3):217-224. doi:10.1016/j.annemergmed.2005.08.022
  7. Gorgels AP, van den Dool A, Hofs A, et al. Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Am J Cardiol. 1996;78(1):43-46. doi:10.1016/s0002-9149(96)00224-x
  8. Callans DJ, Marchlinski FE. Dissociation of termination and prevention of inducibility of sustained ventricular tachycardia with infusion of procainamide: evidence for distinct mechanisms. J Am Coll Cardiol. 1992;19(1):111-117. doi:10.1016/0735-1097(92)90060-z
  9. Wellens HJ, Bär FW, Lie KI, Düren DR, Dohmen HJ. Effect of procainamide, propranolol and verapamil on mechanism of tachycardia in patients with chronic recurrent ventricular tachycardia. Am J Cardiol. 1977;40(4):579-585. doi:10.1016/0002-9149(77)90074-1

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Digoxin Poisoning Management





Clinical Content
4 min read
February 3, 2023

Digoxin Poisoning Management

J

Jimmy

PharmD





Clinical Content
2 min read
February 3, 2023

Digoxin Poisoning Management

J

Jimmy

PharmD

Digoxin Poisoning Management

Pharmacy Friday Pearl – Pharmacy & Acute Care University



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Introduction

  • Digoxin treats atrial flutter, atrial fibrillation, and heart failure.
  • Toxicity occurs when Na+/K+-ATPase inhibition raises intracellular Na+/Ca2+, triggering dysrhythmias.
  • EKG red flags: PVCs, biphasic T waves, shortened QT interval, variable AV block.
  • Therapeutic range 0.8 – 2.0 ng/mL; toxicity often begins > 2 ng/mL.

Digoxin Immune Fab (DigiFab / DigiBind)

Parameter Key Details
Dose 1 vial = 40 mg (binds 0.5 mg digoxin).
Unknown ingestion → 10-vial empiric dose.
Alternative: vials = 2 × total body load (mg).
Chronic unknown: adults 3 – 6 vials; children 1 – 2 vials.
Administration IV infusion over 30 min (rapid bolus if arrest imminent).
Onset / Duration Onset 20 – 90 min • Duration 15 – 20 h.
Adverse Effects Orthostatic hypotension, ventricular tachycardia, hypokalemia.
Mechanism Fab fragments swiftly bind circulating digoxin, neutralising toxicity.
Compatibility Compatible only with 0.9 % sodium chloride.

Clinical pearl: monitor serum K+ closely—intracellular shifts often trigger hypokalemia post-Fab.

Overview of Key Evidence

Author / Year Design (n) Key Findings
Wei 2021 Case series (121) FAERS: DigiBind serious AEs 87 % vs DigiFab 63 %; hypotension, cardiac arrest, death most frequent.
Ward 2000 Observational (16) Both Fab products reduced free digoxin below assay limits; total digoxin ↑ ≈10-fold (binding confirmed).
Renard 1997 Observational (16) Fab clearance declined linearly with renal impairment & age; t½ 11 – 34 h; all patients recovered without AEs.
Antman 1990 Open-label (150) 90 % toxicity resolved/improved; median dose 5 vials (200 mg); maximum 40 vials.
Roberts 2016 Systematic review Fab therapy remains first-line; hyperkalemia & ventricular arrhythmias are key toxicity predictors.
Ujhelyi 1995 PK review Fab exhibits two-compartment kinetics; repeat dosing may be needed in large body-load poisonings.

Clinical Conclusions

  • Digoxin toxicity is life-threatening but rapidly reversible with Digoxin Immune Fab.
  • If the ingested amount is unknown, administer an empiric 10-vial dose.
  • Do not delay Fab therapy for age- or renal-based calculations.

Full Reference List

  1. Bismuth C, Gaultier M, Conso F, Efthymiou ML. Hyperkalemia in acute digitalis poisoning. Clin Toxicol. 1973;6(2):153-162.
  2. David MNV, Shetty M. Digoxin. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
  3. Lexicomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc. January 2023.
  4. Antman EM et al. Treatment of life-threatening digitalis intoxication with digoxin-specific Fab fragments. Circulation. 1990;81(6):1744-1752.
  5. Renard C et al. Pharmacokinetics of digoxin-specific Fab: effects of renal function & age. Br J Clin Pharmacol. 1997;44(2):135-138.
  6. Roberts DM et al. Pharmacological treatment of cardiac glycoside poisoning. Br J Clin Pharmacol. 2016;81(3):488-495.
  7. Ujhelyi MR, Robert S. Pharmacokinetic aspects of digoxin-specific Fab therapy. Clin Pharmacokinet. 1995;28(6):483-493.
  8. Wei S et al. Adverse events with digoxin Immune Fab in FAERS 1986-2019. Drugs – Real World Outcomes. 2021;8:253-262.
  9. Ward SB et al. Pharmacokinetics & bioaffinity of DigiTAb vs Digibind. Ther Drug Monit. 2000;22(5):599-607.

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Push Dose Vasopressors





Clinical Content
5 min read
January 27, 2023

Push Dose Vasopressors

J

Jimmy

PharmD





Clinical Content
4 min read
January 27, 2023

Push Dose Vasopressors

J

Jimmy

PharmD

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Patient Case  

  • The team gets a call that there is a 75 year old male that triggered a sepsis alert in route with EMS and is currently desaturating on 15 L of oxygen with decision made to intubate this patient  
  • Prior to intubation, the patient hasn’t responded to  a NS bolus infusion these are the patient’s vitals: 
  • Knowing that pre-intubation hypotension has been associated with peri-intubation cardiac arrest, which agent do you order? If it is not commercially available, how do you make it?  

Pharmacology  

  Phenylephrine (PE)   Epinephrine (EPI)  
Properties   A1 ++++   ↑ BP   B1  ±        ↔HR   B2  ±      A1 +++      ↑ BP   B1 +++++   ↑ HR   B2 +++++  
Dose   100-200 mcg PRN Q 1-5 minute   10- 20 mcg PRN Q 1-5 minute  
Formulation   Premixed Syringe- 1000 mcg/10 ml   Not commercially available  
PK/PD   Onset: 1 minute   Duration: ~10-20 minutes   Onset: 1 minute   Duration: ~5-10 minutes  
Adverse Effects   Reflex bradycardia Hypertension   Tachycardia   Hypertension  
 Precautions   Bradycardia, heart block, heart failure, angina, acute MI   Tachycardia  
Compatibility   Compatible with NS, LR, D5   Compatible with NS, LR, D5  
Location in GHS   CPR, Trauma, Zone 2+3 Pyxis   1 mg/ml: CPR, Trauma, Zone 2+3 Pyxis  
Comments   Administer through a large bore peripheral IV; Low extravasation risk   Administer through a large bore peripheral IV; Low extravasation risk   
Making Epinephrine and Phenylephrine the “EASY WAY” Supplies: 10 ml of NS, Insulin syringe, epinephrine or phenylephrine vial, tape, pen Instructions:    Take an insulin syringe and draw up 0.1 ml of epinephrine 1 mg/ml or phenylephrine 10 mg/ml, dilute in 10 ml of NS, label epinephrine 10 mcg/ml (100 mcg total) or phenylephrine 100 mcg/ml (1000 mcg total) 
Making Epinephrine and Phenylephrine the Alternative Way   Epinephrine    Draw up 9 mL of normal saline into a 10 mL syringe (DO NOT use 10ml IV line “flush” syringes)  Into this syringe, draw up 1 mL of EPINEPHphrine 0.1 mg/mL (1 mg/10ml) from a cardiac syringe   Label syringe epinephrine 10 mcg/ml      Phenylephrine o Draw up 1 mL of phenylephrine from a 10 mg/mL vial into a 3 mL syringe o Inject this into a 100 mL bag of normal saline. Label bag; safely discard when finished  o Draw up 10 mL into a 10 mL syringe o Label syringe phenylephrine 100 mcg/ml         

Overview of Evidence  

Author, year    Design/ sample size   Intervention & Comparison   Outcome  
Rotando, 2019   Observational   ED/ICU   N=146   PE 100 mcg/ mL   or   Ephedrine 50 mg/10 mL   Most common indication = peri-intubation hypotension   Both agents associated with:   ↑ SBP by 26 mmHg   ↑ SBP by 26 mmHg   ↓ HR by 6 beats per minute   
Schwartz, 2016   Observational   ED   N=76   PE 100 mcg/ mL     (pre-filled syringe)      46.5%  patients were initiated on vasopressor drip ≤ 30 minutes;   mean MAP ↑ from 56.5 to 79.3 mmHg most common dose 100 mcg most common indication = peri-intubation hypotension  
Panchal, 2015   Observational   ED   N=119   PE 100 mcg/1 mL     PE given during the peri-intubation period: ↑ SBP by 20 mmHg, ↑ DBP by 10 mmHg, HR unchanged  
Doherty, 2012   RCT   OR   N=60   PE  IV push 120 mcg    (pre-filled syringe)   Vs    PE infusion @ 120 mcg/min   The infusion used more drug ( 1740 v 964  mcg)      Push dose pressor  had favorable impact of MAP compared to infusion   

References

  1. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved March 18, 2019, from http://www.micromedexsolutions.com/ 
  2. Scott Weingart. EMCrit Podcast 205 – Push-Dose Pressors Update. EMCrit Blog. Published on August 7, 2017. Accessed on March 19th 2019. Available at [https://emcrit.org/emcrit/push-dose-pressor-update/ ] 
  3. Holden D. Ann Emerg Med. 2018 Jan;71(1):83-92. 
  4. Panchal AR. J Emerg Med. 2015 Oct;49(4):488-94. 
  5. Rotando A. Am J Emerg Med. 2019 Mar;37(3):494-498. 
  6. Doherty A. Anesth Analg. 2012 Dec;115(6):1343-50. 
  7. Schwartz MB. Am J Emerg Med. 2016 Dec;34(12):2419-2422 

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