The American journal of medicine
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Review
Untying the knot of thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome.
Patients presenting with microangiopathic hemolysis and thrombocytopenia are often given the diagnosis of thrombotic thrombocytopenic purpura and treated with plasma exchange until the acute episode is over. Recent findings have shown that acquired thrombotic thrombocytopenic purpura is a chronic autoimmune disease with inhibitory antibodies of a disintegrin and metalloprotease with thrombospondin repeat, member 13 and are at risk of relapses that may be preventable. Furthermore, many of the patients given the diagnosis of thrombotic thrombocytopenic purpura really have atypical hemolytic uremic syndrome due to defective complement regulation that can be more effectively treated to prevent death and end-stage renal failure with eculizumab, a humanized monoclonal antibody of complement C5. These advances indicate that an accurate differential diagnosis of microangiopathic hemolysis is essential for optimal patient management.
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Opioids are an established option in the analgesic armamentarium for managing moderate-to-severe chronic pain. Long-term opioid use, however, is associated with several potential adverse effects and toxicities, such as peripheral edema, immune suppression, hyperalgesia, sleep apnea, and changes in endocrine function, many of which are not fully appreciated. ⋯ Indeed, diagnosing hypogonadism as opioid-related can be challenged by other influences on endocrine function, such as pain pathophysiology, comorbidities, other drug therapies, and patient age. Management options for opioid endocrinopathy include discontinuing opioid therapy, reducing the opioid dose, switching to a different opioid, and hormone supplementation.
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In the United States, the prevalence and burden of chronic pain is large and still growing. Older adults (aged ≥65 years) make up a large portion of the population with chronic pain, and their presentation, diagnosis, and treatment tends to be more complicated because of age-related physiological changes and comorbidities. Guidelines on treating patients with severe back pain recommend opioids as an option for those who do not find adequate pain relief from acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). ⋯ Opioids may also be an appropriate option for patients with neuropathic pain who have not achieved adequate analgesia from maximum doses of first- and second-line antineuropathic agents. Still, opioids are not appropriate for all patients; rather, a differential diagnosis, consideration of other comorbidities, and the potential for opioid-related adverse effects and substance abuse are required to confirm the value of opioid treatment for each individual. For nonresponders to opioid therapy, opioid rotation should be considered before discontinuation is pursued.
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Sodium polystyrene sulfonate (Kayexalate; Sanofi-Aventis, Paris, France) is a cation-exchange resin routinely used in the management of hyperkalemia. However, its use has been associated with colonic necrosis and other fatal gastrointestinal adverse events. Although the addition of sorbitol to sodium polystyrene sulfonate preparations was previously believed to be the cause of gastrointestinal injury, recent reports have suggested that sodium polystyrene sulfonate itself may be toxic. Our objective was to systematically review case reports of adverse gastrointestinal events associated with sodium polystyrene sulfonate use. ⋯ Sodium polystyrene sulfonate use, both with and without sorbitol, may be associated with fatal gastrointestinal injury. Physicians must be cognizant of the risk of these adverse events when prescribing this therapy for the management of hyperkalemia.