The Annals of pharmacotherapy
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To review the literature regarding the use of antiarrhythmic agents in the management of atrial flutter (AF), atrial fibrillation (Afib), junctional ectopic tachycardia (JET), and atrial ectopic tachycardia (AET) in infants and children. To discuss the advantages and disadvantages of specific agents in each type of arrhythmia in an effort to develop treatment guidelines. ⋯ Because of greater clinical experience, conventional antiarrhythmic agents generally remain as first-line therapy in the management of most supraventricular tachycardias in children. Atrial pacing or cardioversion to reestablish sinus rhythm is indicated for initial episodes of AF in infants, followed by chronic prophylactic therapy in those with significant structural heart disease or in infants in whom AF recurs. Attempts to eliminate AF in children outside the neonatal or infancy period should begin with trials of traditional agents such as digoxin or procainamide, and if unsuccessful, subsequent trials of amiodarone. Digoxin and beta-blockers remain the mainstay of therapy for children with Afib, followed by procainamide for treatment failures. Intravenous amiodarone, the newest addition to our antiarrhythmic armamentarium, is the most promising agent in the treatment of postoperative JET. This arrhythmia has been traditionally managed with corporal cooling and/or digoxin therapy; however, intravenous amiodarone may now be a valuable option. Although relatively unsuccessful in the management of congenital JET and AET, conventional agents are typically used prior to the initiation of long-term therapy with potentially more toxic agents such as amiodarone or propafenone. Additional well-designed, controlled trials are needed to further evaluate the comparative efficacy of agents such as flecainide, sotalol, moricizine, propafenone, and amiodarone in the management of AF, Afib, JET, and AET in children, as well as to evaluate the dosing and toxicity in various age groups.
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Comparative Study
Mechanism of anaphylactoid reactions: improper preparation of high-dose intravenous cyclosporine leads to bolus infusion of Cremophor EL and cyclosporine.
During a Phase I/II trial of high-dose intravenous cyclosporine, a high incidence of anaphylactoid reactions was observed. Epidemiologic investigations revealed that the occurrence of anaphylactoid reactions was significantly associated with improper mixing during preparation of the infusions. It was hypothesized that improper mixing during the preparation of the infusion may have caused initial bolus infusions of the vehicle, Cremophor EL. These inadvertent bolus infusions may have caused the anaphylactoid reactions. ⋯ Inappropriate mixing of high-dose cyclosporine infusions can lead to initial bolus infusion of cyclosporine and Cremophor EL. Bolus infusions of Cremophor EL have been associated with anaphylactoid reactions. Thus, through mixing of high-dose cyclosporine infusions may be important to reduce the possibility of life-threatening anaphylactoid reactions.
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Case Reports
Continuous intrathecal meperidine via an implantable infusion pump for chronic, nonmalignant pain.
To report a continuous infusion of intrathecal meperidine via an implanted infusion pump for nonmalignant, chronic pain. ⋯ Continuous intrathecal meperidine via an implantable infusion pump may be an effective alternative in the treatment of chronic pain.
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Comment Letter Case Reports
Correction and comment: possible toxicity from propylene glycol in injectable drug preparations.
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To review the literature regarding the use of antiarrhythmic agents in the management of Wolff-Parkinson-White (WPW) syndrome and atrioventricular nodal reentry tachycardia (AVNRT) in infants and children, and to discuss the advantages and disadvantages of specific agents in each arrhythmia in an effort to develop treatment guidelines. ⋯ Because of greater clinical experience with these conventional antiarrhythmic agents, they continue to be first-line therapy in the management of most supraventricular tachycardia (SVT) in children. The management of SVT in children with WPW syndrome should begin with the use of a beta-blocker with the addition of digoxin or procainamide for treatment failures. The use of digoxin monotherapy, although frequently used by many practitioners in infants and children with WPW, cannot be recommended. For failures to conventional agents, flecainide is the preferred agent, while therapy with propafenone, amiodarone, and sotalol remains to be elucidated. The management of AVRNT is similar to that of WPW; however, digoxin is the agent of first choice. Trials of beta-blockers and procainamide should follow for treatment failures with flecainide again being the preferred "newer" antiarrhythmic for use in resistant cases. Additional well-designed, controlled trials are needed to further evaluate the comparative efficacy of antiarrhythmics in the management of WPW and AVNRT in children, as well as to evaluate dosing and toxicity in various age groups.