Buprenorphine, a partial μ‐opioid agonist, is an effective treatment for opioid use disorder that conventionally requires symptoms of withdrawal before initiation to avoid precipitating withdrawal. Our institution implemented a microdosing approach to transition patients from full μ‐opioid agonists to buprenorphine without requiring patients to undergo a period of opioid abstinence. Little has been published about this strategy in the inpatient setting in the United States, and even less has been published dealing with the transition from methadone to buprenorphine. Our objective was to demonstrate that a microdosing protocol to transition patients from methadone to buprenorphine can be feasibly implemented in a U.S. hospital setting.
{"title":"Transitioning Hospitalized Patients with Opioid Use Disorder from Methadone to Buprenorphine without a Period of Opioid Abstinence Using a Microdosing Protocol","authors":"Dale Terasaki, Christopher Smith, S. Calcaterra","doi":"10.1002/phar.2313","DOIUrl":"https://doi.org/10.1002/phar.2313","url":null,"abstract":"Buprenorphine, a partial μ‐opioid agonist, is an effective treatment for opioid use disorder that conventionally requires symptoms of withdrawal before initiation to avoid precipitating withdrawal. Our institution implemented a microdosing approach to transition patients from full μ‐opioid agonists to buprenorphine without requiring patients to undergo a period of opioid abstinence. Little has been published about this strategy in the inpatient setting in the United States, and even less has been published dealing with the transition from methadone to buprenorphine. Our objective was to demonstrate that a microdosing protocol to transition patients from methadone to buprenorphine can be feasibly implemented in a U.S. hospital setting.","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"38 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79441530","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
B. Gilbert, J. Dingman, Jacob A. Reeder, Amy L. Kiskaddon
We read with great enthusiasm the article by Ryman et al and wish to highlight a few key concepts not mentioned in their article. Although a large proportion of data for alteplase in acute ischemic stroke (AIS) remains controversial, we propose that the hemostatic variances seen during pregnancy make the women in this patient population ideal candidates for thrombolysis. Pregnancy is associated with a hypercoagulable state secondary to increased clotting factor production, decreased protein C and S activity, and decreased natural thrombolytic activity. It would be expected that clots formed during pregnancy would be fibrin rich, presenting an ideal therapeutic target for alteplase. This is in contrast to the typically more calcified composition of cardioembolic strokes, offering a theoretical explanation for the varied responses to alteplase seen in patients with this type of stroke. Also, although actual body weight has been the only dosing strategy evaluated for AIS during pregnancy in the literature thus far, lower dosing strategies were evaluated in select cohorts that have largely shown success. 5 Given the variances during pregnancy in volume of distribution, cardiac output, plasminogen activator inhibitor concentration, and hepatic clearance, it is reasonable to expect altered serum alteplase concentrations that may affect drug concentration and delivery to affected vessels. Therefore, optimal dosing strategies throughout each trimester should continue to be an area of active research. Given that the fatal bleed risk extends beyond just intracranial hemorrhages for pregnant patients, a question remains as to whether those at high risk for uterine hemorrhage or with mild stroke severity should bypass alteplase administration in favor of thrombectomy or antiplatelet therapies. Lastly, with increasing use of tenecteplase for ischemic stroke, it will be important to consider if alteplase alone or fibrinolytics as a class are safe and effective in pregnancy.
{"title":"Alternative Viewpoint of “Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature”","authors":"B. Gilbert, J. Dingman, Jacob A. Reeder, Amy L. Kiskaddon","doi":"10.1002/phar.2304","DOIUrl":"https://doi.org/10.1002/phar.2304","url":null,"abstract":"We read with great enthusiasm the article by Ryman et al and wish to highlight a few key concepts not mentioned in their article. Although a large proportion of data for alteplase in acute ischemic stroke (AIS) remains controversial, we propose that the hemostatic variances seen during pregnancy make the women in this patient population ideal candidates for thrombolysis. Pregnancy is associated with a hypercoagulable state secondary to increased clotting factor production, decreased protein C and S activity, and decreased natural thrombolytic activity. It would be expected that clots formed during pregnancy would be fibrin rich, presenting an ideal therapeutic target for alteplase. This is in contrast to the typically more calcified composition of cardioembolic strokes, offering a theoretical explanation for the varied responses to alteplase seen in patients with this type of stroke. Also, although actual body weight has been the only dosing strategy evaluated for AIS during pregnancy in the literature thus far, lower dosing strategies were evaluated in select cohorts that have largely shown success. 5 Given the variances during pregnancy in volume of distribution, cardiac output, plasminogen activator inhibitor concentration, and hepatic clearance, it is reasonable to expect altered serum alteplase concentrations that may affect drug concentration and delivery to affected vessels. Therefore, optimal dosing strategies throughout each trimester should continue to be an area of active research. Given that the fatal bleed risk extends beyond just intracranial hemorrhages for pregnant patients, a question remains as to whether those at high risk for uterine hemorrhage or with mild stroke severity should bypass alteplase administration in favor of thrombectomy or antiplatelet therapies. Lastly, with increasing use of tenecteplase for ischemic stroke, it will be important to consider if alteplase alone or fibrinolytics as a class are safe and effective in pregnancy.","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"328 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86779428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We recently read with great interest the article by Ryman et al entitled “Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature.” We would like to congratulate the authors for achieving a successful outcome in such a high-risk patient for acute ischemic stroke (AIS) during pregnancy, and we want to share our experience in pregnant women with prosthetic valve thrombosis (PVT) who underwent AIS during thrombolytic therapy (TT). A prosthetic heart valve is highly thrombogenic and increases the risk of thrombosis up to 10% (especially a mechanical prosthetic valve) with the procoagulant condition of pregnancy. We previously reported that a low-dose slow infusion of tissue-type plasminogen activator (tPA [alteplase]) with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of PVT in pregnant women and that TT should be considered firstline therapy in pregnant patients with PVT. The most feared complication is the risk of cerebral embolism that can be up to 5–6% for left-sided PVT. The first 6 hours after cerebral thromboembolism are crucial, and early diagnosis and exclusion of hemorrhage by multidetector computed tomography is very important. Although the recommended dose of alteplase according to the stroke guideline is 0.9 mg/kg (maximum dose 90 mg) for 60 minutes for AIS according to current guidelines, with 10% of the dose given as a bolus for 1 minute, we used lower doses for safety concerns. Our success reported in our case reports may have been due to the early diagnosis and fresh nature of the thrombus. 4 Faster TT regimens may induce new thromboembolisms in patients with concomitant PVT. In conclusion, low-dose and slow-infusion TT is effective and safe in AIS during PVT treatment.
{"title":"Critique of “Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature”","authors":"A. Guner, M. Kalçık, M. Özkan","doi":"10.1002/phar.2303","DOIUrl":"https://doi.org/10.1002/phar.2303","url":null,"abstract":"We recently read with great interest the article by Ryman et al entitled “Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature.” We would like to congratulate the authors for achieving a successful outcome in such a high-risk patient for acute ischemic stroke (AIS) during pregnancy, and we want to share our experience in pregnant women with prosthetic valve thrombosis (PVT) who underwent AIS during thrombolytic therapy (TT). A prosthetic heart valve is highly thrombogenic and increases the risk of thrombosis up to 10% (especially a mechanical prosthetic valve) with the procoagulant condition of pregnancy. We previously reported that a low-dose slow infusion of tissue-type plasminogen activator (tPA [alteplase]) with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of PVT in pregnant women and that TT should be considered firstline therapy in pregnant patients with PVT. The most feared complication is the risk of cerebral embolism that can be up to 5–6% for left-sided PVT. The first 6 hours after cerebral thromboembolism are crucial, and early diagnosis and exclusion of hemorrhage by multidetector computed tomography is very important. Although the recommended dose of alteplase according to the stroke guideline is 0.9 mg/kg (maximum dose 90 mg) for 60 minutes for AIS according to current guidelines, with 10% of the dose given as a bolus for 1 minute, we used lower doses for safety concerns. Our success reported in our case reports may have been due to the early diagnosis and fresh nature of the thrombus. 4 Faster TT regimens may induce new thromboembolisms in patients with concomitant PVT. In conclusion, low-dose and slow-infusion TT is effective and safe in AIS during PVT treatment.","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"48 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79420617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"2018 ACCP Updates in Therapeutics","authors":"","doi":"10.1002/phar.2122","DOIUrl":"https://doi.org/10.1002/phar.2122","url":null,"abstract":"","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"48 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2018-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85285404","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"ACCP Updates in Therapeutics® 2018 May 23–24, 2018 UT Clinical Pharmacy Forum","authors":"","doi":"10.1002/phar.2101","DOIUrl":"https://doi.org/10.1002/phar.2101","url":null,"abstract":"","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"13 1","pages":"e29–e40"},"PeriodicalIF":0.0,"publicationDate":"2018-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83363400","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"ACCP Virtual Poster Symposium","authors":"Pouran Manzouri","doi":"10.1002/phar.1964","DOIUrl":"https://doi.org/10.1002/phar.1964","url":null,"abstract":"","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"30 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85019908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kate Morizio, R. Baum, A. Dugan, Julia Martin, Abby M. Bailey
To characterize the differences between patients who had heroin and nonheroin opioid overdoses and to determine whether there were any significant differences in their management with regard to the naloxone use.
{"title":"Characterization and Management of Patients with Heroin versus Nonheroin Opioid Overdoses: Experience at an Academic Medical Center","authors":"Kate Morizio, R. Baum, A. Dugan, Julia Martin, Abby M. Bailey","doi":"10.1002/phar.1902","DOIUrl":"https://doi.org/10.1002/phar.1902","url":null,"abstract":"To characterize the differences between patients who had heroin and nonheroin opioid overdoses and to determine whether there were any significant differences in their management with regard to the naloxone use.","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77205478","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Painter, R. Owen, K. Henderson, M. Bauer, D. Mittal, T. Hudson
A substantial proportion of antipsychotic (AP) use in veterans is for nonapproved indications (i.e., off‐label prescribing). Not all off‐label use is necessarily detrimental to patients, however, and in certain situations, off‐label prescribing could be considered justifiable. The objective of this study was to determine the extent to which off‐label AP prescribing in a veteran population was potentially appropriate.
{"title":"Analysis of the Appropriateness of Off‐Label Antipsychotic Use for Mental Health Indications in a Veteran Population","authors":"J. Painter, R. Owen, K. Henderson, M. Bauer, D. Mittal, T. Hudson","doi":"10.1002/phar.1910","DOIUrl":"https://doi.org/10.1002/phar.1910","url":null,"abstract":"A substantial proportion of antipsychotic (AP) use in veterans is for nonapproved indications (i.e., off‐label prescribing). Not all off‐label use is necessarily detrimental to patients, however, and in certain situations, off‐label prescribing could be considered justifiable. The objective of this study was to determine the extent to which off‐label AP prescribing in a veteran population was potentially appropriate.","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"128 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88677523","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The U.S. Food and Drug Administration approval of the use of apixaban in patients with a creatinine clearance (CrCl) of < 15 ml/minute or in those receiving dialysis is based only on pharmacokinetic data as clinical trials of apixaban excluded patients with a CrCl of < 25 ml/minute or a serum creatinine concentration (SCr) of > 2.5 mg/dl. Thus, the objective of this study was to evaluate the safety and effectiveness of apixaban versus warfarin in patients with severe renal impairment.
{"title":"Comparison of the Safety and Effectiveness of Apixaban versus Warfarin in Patients with Severe Renal Impairment","authors":"Brooke E. Stanton, Naomi S Barasch, K. Tellor","doi":"10.1002/phar.1905","DOIUrl":"https://doi.org/10.1002/phar.1905","url":null,"abstract":"The U.S. Food and Drug Administration approval of the use of apixaban in patients with a creatinine clearance (CrCl) of < 15 ml/minute or in those receiving dialysis is based only on pharmacokinetic data as clinical trials of apixaban excluded patients with a CrCl of < 25 ml/minute or a serum creatinine concentration (SCr) of > 2.5 mg/dl. Thus, the objective of this study was to evaluate the safety and effectiveness of apixaban versus warfarin in patients with severe renal impairment.","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"12 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81785608","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Floroff, N. Palm, D. Steinberg, E. Powers, B. Wiggins
To evaluate the time to achieve therapeutic activated partial thromboplastin time (aPTT) values and occurrence of bleeding based on standard unfractionated heparin (UFH) weight‐based dosing recommendations compared with an aggressive weight‐based UFH dosing strategy using higher maximum doses and infusion rates in both obese and nonobese patients who presented with non–ST‐segment elevation myocardial infarction or unstable angina (NSTEMI/UA) or atrial fibrillation.
{"title":"Higher Maximum Doses and Infusion Rates Compared with Standard Unfractionated Heparin Therapy Are Associated with Adequate Anticoagulation without Increased Bleeding in Both Obese and Nonobese Patients with Cardiovascular Indications","authors":"C. Floroff, N. Palm, D. Steinberg, E. Powers, B. Wiggins","doi":"10.1002/phar.1904","DOIUrl":"https://doi.org/10.1002/phar.1904","url":null,"abstract":"To evaluate the time to achieve therapeutic activated partial thromboplastin time (aPTT) values and occurrence of bleeding based on standard unfractionated heparin (UFH) weight‐based dosing recommendations compared with an aggressive weight‐based UFH dosing strategy using higher maximum doses and infusion rates in both obese and nonobese patients who presented with non–ST‐segment elevation myocardial infarction or unstable angina (NSTEMI/UA) or atrial fibrillation.","PeriodicalId":19812,"journal":{"name":"Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy","volume":"36 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81107095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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