Pharmacotherapy
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Review Case Reports
Unfractionated heparin dosing for venous thromboembolism in morbidly obese patients: case report and review of the literature.
Unfractionated heparin infusion therapy is often administered using a weight-based dosing strategy for the treatment of venous thromboembolism. In the last several decades, the prevalence of obesity in the United States has increased significantly. The applicability of weight-based heparin dosing recommendations in the obese and morbidly obese population is uncertain, as limited data are available. ⋯ Standard weight-based heparin dosing protocols that specify maximum doses for initial bolus and infusion rates can result in significant delays in time to achieve therapeutic anticoagulation in the obese and morbidly obese patient. Despite limited data on heparin dosing in obesity, we recommend the use of a dosing weight to determine initial heparin dosing when treating venous thromboembolism in morbidly obese patients. It is reasonable to consider one of the following formulas: dosing weight = ideal body weight (IBW) + 0.3(actual body weight [ABW] - IBW), or dosing weight = IBW + 0.4(ABW - IBW).
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Lenalidomide is a more potent and less toxic oral analog of thalidomide. The drug is indicated for treatment of multiple myeloma and other hematologic disorders and has rarely been associated with pulmonary toxicity. We describe a 73-year-old woman who received lenalidomide therapy for multiple myeloma. ⋯ Another potential mechanism may be an immunologic one similar to that seen in the interstitial pulmonary process in patients with hypersensitivity pneumonitis. To our knowledge, only one other case of lenalidomide-induced pulmonary toxicity has been reported in the literature. Although lenalidomide-induced pulmonary toxicity is uncommon, clinicians should consider this potential adverse drug reaction in the differential diagnosis in patients receiving lenalidomide who present with symptoms of interstitial lung disease for which alternative causes have been excluded.
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The rates of major adverse coronary events, including recurrent ischemic events and death, in patients with coronary artery disease (CAD) have been shown to be significantly increased in patients with depression. In addition, health care costs are higher and health-related quality of life is lower in depressed patients with CAD. Several pathophysiologic mechanisms have been proposed for the association of increased events seen in this population. ⋯ When selecting an appropriate antidepressant, clinicians should consider their patients' comorbid conditions and the potential for drug interactions, and treatment should be frequently monitored. Screening for depression in patients with cardiac disease should be instituted on a routine basis by using either case-finding or symptom-triggered approaches. Based on the high prevalence of depression and its known adverse effects in patients with CAD, future research is needed to help determine the role of antidepressants and nonpharmacologic strategies in improving outcomes in patients with both comorbidities.
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Proton pump inhibitors (PPIs) have been recommended for reducing the risk of gastrointestinal bleeding associated with dual antiplatelet therapy (aspirin plus clopidogrel). However, studies have found decreased efficacy of clopidogrel when concurrently administered with a PPI. To determine the mechanism of and evidence for the potential interaction between clopidogrel and PPIs, along with the clinical implications of this drug interaction, we reviewed recently published reports of trials that examined the interaction. ⋯ Although current data do not show causation of adverse outcomes with PPI use because the available data are conflicting, this topic is still controversial. Careful risk-benefit assessment is required before prescribing PPIs for individual patients taking dual antiplatelet therapy. More evidence from randomized controlled trials is needed to clarify this drug interaction dilemma.
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Case Reports
Use of methylene blue for refractory septic shock during continuous venovenous hemodiafiltration.
As an inhibitor of nitric oxide, methylene blue has been investigated as an alternative vasopressor in patients with septic shock refractory to catecholamine vasopressors and as an agent to maintain hemodynamic stability in patients receiving intermittent hemodialysis. However, to our knowledge, the use of methylene blue as a vasopressor in patents receiving continuous renal replacement therapy has not been evaluated. We describe a 56-year-old man who was receiving continuous venovenous hemodiafiltration (CVVHDF) for acute renal failure secondary to sepsis. ⋯ Because the filter was blue, a sample of the patient's effluent was analyzed by using ultraviolet-visible spectroscopy. No methylene blue was detected in the sample, suggesting that the drug was not being removed by CVVHDF. Clinicians should use caution when they are considering the use of methylene blue in patients with refractory shock who are also receiving CVVHDF.