Chrohn's Disease [โรคลำไส้อุดตัน]

Ref U.S. Pharmacist [health system edition] January 2010

Current Management and Prospective Therapies

Basically, it happens when protective barrier for the intestinal tract is compromised from injury, bacterial products, or exogenous agents. These factors cause cell death. Then endothelial cells recruit leukocytes, fibroblasts, and epithelium into the mucosa from the vascular space, resulting in granulomas [which is a histopathologic lanmark of Chrohn's disease damage to the GI tract.]
Chronic inflamation ultimately thickens the bowel wall and eventually narrows the lumen.

Therapeutic Management Options

Aminosalicylates (5-ASA)
1st line therapy for mild - moderate CD.
Sulfasalazine, mesalamine, olsalazine, balsalazine
Be-careful with sulfasalazine since it contains sulfa so it shouldn't be used in patients who allergic to sulfa. In this case, mesalamine would be an option. Only Pentasa [controlled release cap] and Asacol [delayed release tab] are mesalamine forms used for CD treatment.
Adverse effects include headache, nausea, GI distress

Glucocorticoids
to reduce inflammatory and to induce remission of active CD.
Normally use when 5-ASA compounds are ineffective because of lack of efficacy in maintaining CD remission. Common adverse effects are moon face, acne, weight gain, dyspepsia.

Immunosuppressants
Thiopurines can maintain remission of moderate to severe CD.
Azathioprine, 6-mercaptopurine are steroid-sparing agents that induce cell apotosis.
Methotrexate inhibits cytokine synthesis. It is effective for inducing remission and preventing relapse in patients with CD. MTX treatment; 25mg per week has a slow onset [3-6 months] and requires monitoring.

Antimicrobials
mild to moderate CD associated with fistulas and abscesses.
Fluoroquinolones and metronidazole are drug of choice.
Flagyl 500mg po q12hrs
Ciprofloxacin > or equal to 20mg/kg/day

Biological
Infliximab [Remicade]
Adalimumab [Humira]
and new agents such as nataliumab, certolizumab

Pediatric Care Online

for antibiotic dosing/drugs of choice and more
http://www.pediatriccareonline.org/pco/ub/view/AAP-Textbook-of-Pediatric-Care/394061/4.1/Chapter_61:_Antimicrobial_Therapy

Principles of Drug Addiction Treatment

Pharmacotherapies for Opioids, Tobacco and Alcohol
From NIDA (National Institute on Drug Abuse)

http://nida.nih.gov/PODAT/Evidence.html#Pharm

Off-Label Drug Uses

from Hospital Pharmacy Journal Dec 09

Gabapentin: Cholestatic Pruritis
in adults with chronic, severe, refractory cholestatic pruritus
Initial dose at 100mg tid for 3 days then adjust dose based on tolerance and efficacy
Max dose = 2400mg per day in divided doses.
Total duration of therapy = 4 weeks

Drug/Substance Abuse

Drug abuse is a serious public health problem that affects almost every community and family in some way. Each year drug abuse results in around 40 million serious illnesses or injuries among people in the United States.


Factors


Trends in Drug Abuse (Ref: NIDA)

The National Survey on Drug Use and Health (NSDUH) supported by the Substance Abuse and Mental Health Services Administration also tracks drug use in populations aged 12 and older. Both surveys (MTF and NSDUH) indicate that disturbing patterns in overall drug use are still evident.

• An estimated 19.5 million Americans aged 12 or older were current users of an illicit drug in 2003. This estimate represents 8.2 percent of the population.²
  
• Over half (51%) of America’s teenagers have tried an illicit drug by the time they finish high school.¹
  
• An estimated 71 million Americans reported being current users of a tobacco product in 2003, a prevalence rate of 30% for the population 12 years and older.²
  
• Marijuana is the most widely used illicit substance in this country. In 2003, 14.6 million people were current users of marijuana.²
  
• For the second year in a row inhalant use has increased in 8th graders with 17.3% reporting use at least once in their lifetime. These drugs are particularly dangerous because they can damage the nervous system even after a single use, and they can be fatal.

Reference Cards : Hematology Lab Differentials

http://www.med-ed.virginia.edu/pda/refcards/HemLab/index.htm

All basic info about lab values.

Antibiotic dosing in CRRT patients

Continuous renal replacement therapy or CRRT is frequently used to treat patients with acute renal failure or chronic renal failure.

Ref: University of Pennsylvania Health System - Renal Electrolyte and Hypertension Division
http://www.uphs.upenn.edu/renal/important%20pdf%20II/CRRT%20antibiotic%20dosing.pdf

UCSF: Infectious Diseases Management Program

Updated antimicrobial guideline in Adults, Pediatrics.
Latest updated 03/06/09

Very good for quick reference. Click Here

The Heart dot Org - part of WebMD

contains anything from ACS, HTN, HF to surgery guideline
plus related news update quite often

http://www.theheart.org/

good for practical guidelines and cool Video CME lectures

U of Penn - Department of Medicine - Educational Resources

http://www.uphs.upenn.edu/medicine/education/residents/educationalResources/index.html [not working]
http://pennfm.pbworks.com/Intern-Survival-Guide

Intern Survival Guide
Clinical Guidelines
Textbooks and Journals
Other Links


2006

L-Carnitine in VPA overdose

L-carnitine supplementation is recommended for patients with CNS depression, evidence of hepatic dysfunction, and hyperammonemia with dosing ranging from 50 to 100 mg/kg/day up to a maximum dose of 2 g/day.
L-carnitine's mechanism of action is thought to be related to its ability to decrease elevated ammonia levels, which may contribute to development of coma in VPA toxicity. Its use remains investigational but can be considered in patients (such as ours) with coma, elevated ammonia levels, and hepatic dysfunction.[1] In our patient, we elected to start her on L-carnitine at 100 mg/kg/day in an attempt to correct her hyperammonemia and encephalopathy. This therapy was continued until her serum ammonia and VPA levels had normalized.

Other Tx for VPA overdose;
Supportive, naloxone, hemodialysis, hemoperfusion

Ref: Medscape
http://www.medscape.com/viewarticle/445062_print

Notes from Dr. RW

http://doctorrw.blogspot.com/
A hospitalist from Akansas - good blog for interesting med related news summary/review/clinical trials ect.

Ref from BayState Health

http://libraryinfo.bhs.org/secure/

From Baystate Medical Center info in 2004 tho : (

Pocket Guide to Critical Care Pharmacotherapy

by John Papadopoulos

Narc Conversion Guide

http://www.nhhpco.org/opioid.htm

New Hampshire Hospice and Palliative Care Organization
This Opioid Use Guidelines have been prepared by the NHHPCO Palliative Care Clinicians Special Interest Group as part of their 'Best Practices Project'.

Steps to Rotate or Change Opioids
1. Calculate 24 hr dose of current drug.
2. Translate that to equianalgesic 24 hr dose of oral morphine.
3. Calculate 24 hr equianalgesic dose of new drug and reduce dose to 50-75% of calculated dose if pain is well controlled; use 100% otherwise.
4. Divide to attain appropriate interval and dose for new drug.
5. Always have breakthrough dosing available while making changes.

OHSU Pharmacy Pearls (Guidelines)

http://www.ohsu.edu/medicine/residency/handouts/pharmpearls/
Aminoglycoside in Dialysis pts, Conivaptan, ICU drugs, Electrolyte replacement ect

LMWH Bridging

http://www.med.umich.edu/cvc/services/site_anticoag/healthprof.html
From U of M Cardiovascular Center

Peds Dosing Guideline - UCSF

http://clinicalpharmacy.ucsf.edu/idmp/peds_dosing_index.htm

A review of warfarin dosing and monitoring

Mariamma Kuruvilla, PharmD and Cheryle Gurk-Turner, RPH

The goal of anticoagulant therapy with warfarin is to administer the lowest effective dose of the drug to maintain the target international normalized ratio (INR). Warfarin, a vitamin K antagonist, is an oral anticoagulant indicated for the prevention and treatment of venous thrombosis and its extension and the prevention and treatment of the thromboembolic complications associated with atrial fibrillation. Warfarin has also been used to prevent recurrent transient ischemic attacks and to reduce the risk of recurrent myocardial infarction, but data supporting these indications are inconclusive at this time (1).

Warfarin inhibits the synthesis of clotting factors II, VII, IX, and X, as well as the naturally occurring endogenous anticoagulant proteins C and S (2). The anticoagulant and antithrombotic activity of warfarin depends on the clearance of functional clotting factors from the systemic circulation once the drug is administered (2, 3). The earliest changes in INR are typically seen 24 to 36 hours after administration of the dose. The antithrombotic effect of warfarin is not present until approximately the fifth day of therapy, which is dependent on the clearance of prothrombin (1, 2).

Initiation of warfarin therapy is challenging, since the pharmacodynamic response is delayed and difficult to predict. Because prothrombin has a half-life of around 50 hours, loading doses of warfarin are of limited value (4). In clinical practice, loading doses (e.g., 7.5 mg or more per day) of warfarin may increase the patient's risk of bleeding complications early in therapy by eliminating the production of functional factor VII (2, 5). Administration of loading doses may place a patient in a hypercoagulable state due to a severe depletion of protein C (2). The administration of a loading dose is a possible source of prolonged hospitalization secondary to dramatic rises in the INR value that may necessitate the administration of vitamin K (5). If a rapid anticoagulant effect is required, an initial dose of heparin or a low molecular-weight heparin should be used and overlapped with warfarin for approximately 4 to 5 days. Once the INR is therapeutic for at least 2 days, the supplemental anticoagulation treatment may be discontinued. (more)

Dosing Calc

http://prodruginfo.com/Formulary/pharmacokinetic_drug_dosing.htm

For Traditional Gent:
http://www.globalrph.com/aminoglycosides.htm