In this episode I’ll:
1. Discuss an article about using high dose heparin for VTE prophylaxis in obese patients.
2. Answer the drug information question “Do the new FDA quinolone warnings for mild infections change how they should be used in the ICU?”
3. Share a resource to help apply the new definitions for sepsis.
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A few announcements before we begin
– In the near future I will be switching hosting companies for the podcast and website. I expect that it will go smoothly, but if for some reason you can’t access the podcast or website – keep trying! The new hosting company will allow me to do some really cool things for the Pharmacy Nation community!
– I’ve had many inquiries about international shipping options for my book A Pharmacist’s Guide to Inpatient Medical Emergencies. Apparently Amazon charges an arm and a leg for shipping overseas. My Createspace store has significantly cheaper international shipping options!
– Shout out to Pharmacy Ashkan for leaving an Amazon review on my book. Ashkan wrote: I am an Emergency Dept. PharmD and would recommend this book to all Pharmacists (as well as other professions). I like how the book is to the point and well organized. This book is a must read for all Pharmacy residents as well as newer pharmacists working in an Emergency Dept or ICU type setting.
Article
Lead author: Mishna Joy
Published in Pharmacotherapy July 2016
Background
The optimal dose of anticoagulant for VTE prevention in obese patients is unknown. While it makes sense that a larger patient would need a larger dose for effective VTE prevention, evidence to support this has not been conclusive enough for the authors of the CHEST guidelines on VTE to make a specific recommendation other than to “consult a pharmacist.”
Purpose
The authors sought to determine the safety and efficacy of high-dose subcutaneous unfractionated heparin (UFH) for prevention of venous thromboembolism (VTE) in overweight and obese patients.
Methods
The study was a single-center retrospective observational cohort study in a large academic tertiary care center. 1335 patients weighing more than 100 kg on admission received either subcutaneous UFH 7500 units every 8 hours (high-dose group) or 5000 units every 8 hours (low-dose group) for VTE prophylaxis.
Results
The incidence of VTE was similar between groups. When the patients were stratified according to obesity class, the incidence of VTE was still similar between the high and low dose groups. Bleeding complications, however, were significantly higher for patients in the high-dose UFH group. The proportion of patients with a 2 g/dL or greater hemoglobin drop from admission was higher in patients in the high-dose groups in obese classes II and III (30% vs. 18% p<0.01). Furthermore, the proportion of patients who received at least 2 units of packed red blood cell transfusion were significantly higher in patients in the high-dose group who were in obese class III (11% vs 5% p<0.01).
Conclusion
The authors concluded that:
Administering a higher dose of heparin to patients weighing more than 100 kg may not impart additional efficacy in reducing the incidence of VTE. However, it may increase the risk for bleeding.
Discussion
I’m honestly surprised that in this patient population the risk of VTE did not go down with a higher heparin dose. My personal practice for adjusting VTE prophylaxis doses of heparin has been to allow the higher doses if the physician wishes to use them, but to not actively recommend that obese patients receive higher heparin doses. I’ve justified this approach based on the lack of evidence in this area. While a single center retrospective study is not conclusive, this data makes me want to recommend against using higher doses of heparin in obese patients for VTE prophylaxis.
Drug information question
Q: Do the new FDA quinolone warnings for mild infections change how they should be used in the ICU?
A: Probably not, as long as you are not using them much right now.
We’ve had a lot of discussion on this topic in the Pharmacy Nation slack group. The slack group is our free community with hundreds of pharmacists collaborating using real-time messaging. You can sign up at pharmacynation.org.
The FDA has added a black box warning to all quinolones as follows:
We have determined that fluoroquinolones should be reserved for use in patients who have no other treatment options for acute bacterial sinusitis, (ABS), acute bacterial exacerbation of chronic bronchitis (ABECB), and uncomplicated urinary tract infections (UTI) because the risk of these serious side effects generally outweighs the benefits in these patients. For some serious bacterial infections, the benefits of fluoroquinolones outweigh the risks, and it is appropriate for them to remain available as a therapeutic option.
“Pharmacy Amichai” linked to the FDA advisory documents and pointed out that the warnings seem to be focused on conditions in which quinolones lack efficacy data. The risk of adverse events appears to be very small for an individual patient.
Will these warnings affect your practice of using quinolones in the ICU or hospital in general? Let me know in the comment section below or by joining pharmacynation.org and sharing your opinion there.
Resource
The resource I’d like to share for this episode is from SCCM. They have put together a page of resources to help apply the new sepsis definitions. This page lists several resources from podcasts to articles to webcasts for helping to apply the new sepsis definitions.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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