Pharmacotherapy
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Riociguat is the first approved medication from the novel class of soluble guanylate cyclase (sGC) stimulators and the only agent approved for treating both chronic thromboembolic hypertension (CTEPH) and pulmonary arterial hypertension (PAH). The novel mechanism of riociguat lies in its ability to restore the homeostatic and therapeutic effects of nitric oxide that are diminished as a result of phenotypic alterations associated with pulmonary hypertension (PH). Improvements in 6-minute walk distance (6MWD) in patients with PAH during the phase 3 PATENT-1 trial were comparable to other oral agents approved for the treatment of PAH. ⋯ Key factors to consider with riociguat are a patient's systolic blood pressure, drug interactions mediated by CYP1A1, CYP3A4, and P-glycoprotein, cost, and teratogenicity requiring enrollment in a Risk Evaluation and Mitigation Strategy program. Recently published guidelines recommend riociguat monotherapy as an option for treatment-naïve patients with World Health Organization Functional Class (WHO FC) II or III symptoms or as add-on therapy for patients with persistent WHO FC III or IV symptoms being treated with an ERA or inhaled prostanoid. Postmarketing experience and ongoing clinical investigations will further define the safety and role of riociguat in patients with PAH and other types of PH.
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Adrenergic β-antagonists, commonly known as β-blockers, are prescribed for many indications including hypertension, heart failure, arrhythmias, and migraines. Metoprolol is a moderately lipophilic β-blocker that in overdose causes direct myocardial depression leading to bradycardia, hypotension, and the potential for cardiovascular collapse. We describe the case of a 59-year-old man who intentionally ingested ~7.5 g of metoprolol tartrate. ⋯ To date, no clear treatment guidelines are available for β-blocker overdose, and the response to toxic concentrations is highly variable. In this case of a life-threatening single-agent metoprolol overdose, the patient was successfully treated with HIE and ILE therapy. Due to the increasing frequency with which ILE and HIE are being used for the treatment of β-blocker overdose, clinicians should be aware of their dosing strategies and indications.
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To determine whether liposomal bupivacaine, a long-acting anesthetic indicated for single-dose wound infiltration to produce postoperative analgesia, has an impact on postoperative pain in patients undergoing total knee arthroplasties (TKAs). ⋯ Liposomal bupivacaine did not improve pain control in patients undergoing TKA when compared with historical management strategies; however, differences may have been obscured by increased utilization of adjunctive analgesics among patients in the control group.