Pharmacotherapy
-
Recent literature has demonstrated significant improvements in neurologic outcomes in patients who have received induced hypothermia in the setting of out-of-hospital cardiac arrest. Through multiple metabolic mechanisms, the induction of hypothermia slows the progression and devastation of transient cerebral hypoxia. Despite these benefits, the desired reduction in core temperature is often a challenging venture as the body attempts to maintain homeostasis through the induction of thermoregulatory processes aimed at elevating body temperature. ⋯ We conducted a PubMed search (1966-March 2009) to identify all human investigations published in English that discussed pharmacologic mechanisms for the control of shivering. Among these options, clonidine, dexmedetomidine, and meperidine have demonstrated the greatest and most clinically relevant impact on depression of the shivering threshold. More research in this area is needed, however, and the role of the clinical pharmacist in the development and implementation of this therapy needs to be defined.
-
Review
Management of drug and food interactions with azole antifungal agents in transplant recipients.
Azole antifungal agents are frequently used in hematopoietic stem cell and solid organ transplant recipients for prevention or treatment of invasive fungal infections. However, because of metabolism by or substrate activity for various isoenzymes of the cytochrome P450 system and/or P-glycoprotein, azole antifungals have the potential to interact with many of the drugs commonly used in these patient populations. Thus, to identify drug interactions that may result between azole antifungals and other drugs, we conducted a literature search of the MEDLINE database (1966-December 2009) for English-language articles on drug interaction studies involving the azole antifungal agents fluconazole, itraconazole, voriconazole, and posaconazole. ⋯ Initiation of an azole antifungal in transplant recipients nearly ensures a drug-drug interaction, but often these drugs are required. Management of these interactions first involves knowledge of the potential drug interaction, appropriate dosage adjustments when necessary, and therapeutic or clinical monitoring at an appropriate point in therapy to assess the drug-drug interaction (e.g., immunosuppressive drug concentrations, signs and symptoms of toxicity). These aspects of drug interaction management are essential not only at the initiation of azole antifungal therapy, but also when these agents are removed from the regimen.
-
Intrapleural tissue plasminogen activator (t-PA) has emerged over the past several years as a treatment option for patients with complicated parapneumonic effusion that does not respond to medical management and drainage. Fibrinolytics are thought to dissolve fibrin deposits and loculations within the pleural space, facilitating drainage of the trapped pleural fluid surrounding the lungs. Whereas older fibrinolytics (streptokinase and urokinase) have been studied for intrapleural use with conflicting results, t-PA is currently the agent most commonly used in adults for this indication. ⋯ The usefulness of t-PA in all patients with resistant parapneumonic effusions or empyema before surgical intervention remains undetermined, but several studies have taken this approach. Sufficient evidence is available to indicate that this therapy does have potential in patients for whom surgery is not a safe or desired option. Further study is needed to better understand the role of t-PA and its optimal dosage in patients with complicated parapneumonic effusion.