Need CEs? Here is a good one from ASHP

http://elearning.ashp.org/

:)

FDA Approvals: Plasma-Derived Agent for Anticoagulation Reversal

Patients with atrial fibrillation or an artificial heart valve often need long-term anticoagulation to reduce their high risk for thrombotic events. Warfarin and other vitamin K antagonist (VKA) anticoagulants can prevent thrombosis, but there is an increased risk of major bleeding.
Human prothrombin complex concentrate can be used more quickly than plasma for reversal of VKA anticoagulation, as it can be used without blood group typing or thawing. This therapy offers clinicians a new option for patients requiring urgent reversal of VKA anticoagulation.
cont. reading 

New Drugs Approved for Treating Hypercholesterolemia

Unique mechanisms of action

Lomitapide is a microsomal triglyceride transfer protein (MTP) inhibitor. MTP resides in the lumen of the endoplasmic reticulum, thereby preventing the assembly of apo B–containing lipoproteins in enterocytes and hepatocytes. This inhibition leads to a reduction in the synthesis of chylomicrons and very low–density lipoprotein, resulting in a reduction in plasma LDL levels. This is the first MTP inhibitor approved by FDA for any indication.
Mipomersen is an oligonucleotide inhibitor of apo B-100 synthesis that reduces LDL cholesterol by preventing the formation of atherogenic lipids. It decreases the production of apo B, which provides the structural core for all atherogenic lipids, including LDL cholesterol, which carry cholesterol through the bloodstream.

VERY COOL! :)

Ref: Pharmacy Today 2013 (APhP)

Strategy for managing acid suppression in the ICU

http://www.pharmacypracticenews.com//ViewArticle.aspx?ses=ogst&d=Operations+%26+Management&d_id=53&i=ISSUE%3a+April+2013&i_id=950&a_id=22973

Every evening during a two-month verification phase, tele-ICU nurses assessed the risk for GI bleeding for each patient in the 38-bed ICU at one of the system’s hospitals. The three-week intervention phase that followed involved all adult ICU beds. On-site nurses and pharmacists recommended 102 conversions from IV to oral PPIs; 86 (84.3%) were accepted. Discontinuation of SUP was recommended 173 times; prescribers accepted 91 (52.6%) of the recommendations. The cost of SUP treatment decreased from $1.06 per adjusted patient-day to 77 cents and the projected annual cost savings from decreased SUP amounted to $78,052.

from Pharmacy Practice News 2013

Pharmacologic and Complementary Therapy for Migraine Prophylaxis

Ref: US Pharmacist

 

The revised guidelines developed by the AAN and the AHS for the use of pharmacologic agents and complementary therapies for migraine prophylaxis provide recommendations that were based on evidence-based clinical trials conducted after the release of the 2000 guidelines. This in-depth analysis gives an oversight of the methods, designs, and results of the clinical trials examining the efficacy of these agents. The updated guidelines address new therapies for the short-term prevention of MAM, namely, frovatriptan, naratriptan, and zolmitriptan. Also, new evidence in correlation with already established trial-based evidence supports the ineffectiveness of lamotrigine for migraine prophylaxis. Finally, the use of complementary therapies, such as herbal formulations, for migraine prophylaxis has been advanced by evidence-based efficacy in clinical trials, providing a new arsenal of evidence-based treatment during a time when the use of herbal formulations has become increasingly popular.

 http://www.uspharmacist.com/content/d/feature/c/38550/

2012's Top 5 for Pharmacists

http://www.medscape.com/viewarticle/775232?src=mp 

After many busy months, I finally get a chance to update this blog.
I personally think number 1 read article is good for everyone.

click here to view the article

IV Acetaminophen Improves Pain Management and Reduces Opioid Requirements in Surgical Patients: A Review of the Clinical Data and Case-based Presentations.

I found this quite interesting since acetaminophen is such an old and common drug. We've been using it for ages. We can use IV acetaminophen as an "add-on" to opioid and/or NSAIDs especially in patients who cannot take pills such as post op patients.

http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Special%2bReports&d_id=62&i=April+2012&i_id=829&a_id=20499

Tuberculosis and PDR/MDR-TB

Key Point from Updated WHO Guideline

1. Rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone allows earlier identification of patients with drug-resistant TB. It is considered the most cost effective approach.
   
2. Monitoring patients with sputum smear microscopy and culture, rather than sputum smear microscopy alone, for multidrug-resistant TB (MDR-TB) to detect failure as early as possible during treatment.
3. The use of fluoroquinolones and ethionamide, with later-generation fluoroquinolone, rather than earlier-generation forms of the drug recommended for patients with MDR-TB. For example avoiding the use of ofloxacin and use later generation instead.
4. For patients with MDR-TB, the minimum duration of treatment has been extended by 2 months from previous guidelines to reflect research showing improved treatment success with the longer duration. Intensive treatment should therefore last at least 8 months, and for those who have not been treated with second-line drugs for TB in the past, treatment should extend to 20 months. The duration may be adjusted for some patients according to their clinical and bacteriologic response.
5. Early use of antiretroviral agents for HIV-infected patients with TB who are receiving second-line drug regimens, irrespective of CD4 cell-count, as early as possible (within the first 8 weeks) after initiation of anti-TB treatment.

2011 Updated WHO Guidelines for Drug-Resistant Tuberculosis

New guidelines from the World Health Organization (WHO) on the management of drug-resistant tuberculosis (TB) offer the latest approaches for better control of the disease that claims millions of lives each year.

The guidelines, published online August 4 in the European Respiratory Journal, update recommendations from previous guidelines published in 2008 and are intended to help inform practitioners, particularly those in lower-income settings, of the very latest and most cost-effective standards of care for achieving optimal patient outcomes.

Click Here for full guideline

Clinical Practice Guideline

ICH Good Clinical Practice Guideline (Thai Version)
from Thailand FDA
contain ICH GCP (International Conference on Harmonization)

Guideline on how to conduct a research by ICH standard

Cardiac Emergencies (Thai Version)

PDF file in Thai language - Cardiac Emergencies By Chaisit Wongwipaporn, Srinakarin Hospital Khonkaen University
ภาวะฉุกเฉินระบบหัวใจและหลอดเลือด

Medscape - Patient Handout in English

Patient Handout

Beers Criteria

Beers Criteria

Potentially Inappropriate Medications for Elderly According to the Revised Beers Criteriia

Ref: Duke Clinical Research Institute

Pediatric Manual

click here


ref from UCDenver

Beta Blocker Overdose

http://www.courses.ahc.umn.edu/pharmacy/6124/handouts/Beta%20blockers.pdf

from John Gualtieri, College of Pharmacy, U of Minnesota
guideline and summary on beta blockers poisoning

Today's Hospitalist - Good resource for hospital protocols and guidelines

This website contains good number of order sets from various hospitals which I find very helpful as a quick reference.

click here

Pharmacokinetic Overview

http://www.globalrph.com/kinetics.htm

By D.McAuley, GlobalRPh Inc

Note:
changes in renal function may not reflect nephrotoxicity.
Other causes of acute renal failure occurring in hospitalized patients, include:
- Severe or prolonged hypotension (decreased renal perfusion)
- Surgery
- Other nephrotoxic drugs: amphotericin, cisplatin, etc.
- Acute cardiovascular dysfunction

Neonatal Drug Guidelines: UCSF Children's Hospital

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Great reference for neonate click here
and this is a ref for GERD in pediatric click here [from California Pacific Medical Center]

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Treatment and Management of Atrial Fibrillation [โรคหัวใจเต้นผิดจังหวะ]

Ref: US Pharmacist [health system editions] February 2010

Atrial fibrillation or AF is the most common cardiac arrhythmia in general population. AF is a supraventricular tachyarryhythmia characterized by uncoordinated atrial electrical conduction, which resulted in a deterioration of mechanical function.

Signs and symptoms are chest pain, palpitations, dyspnea, fatigue and syncope. Diagnosis of AF requires ECG which will display rapid oscillations of varying amplitude, shape and timing that replace consistent P waves.




Management
The treatment goals for AF are the restoration and maintenance of sinus rhythm and the prevention of thromboembolic complications.
Elective cardioversion
Pharmacologic cardioversion

Amiodarone
[po/iv]
for po route
Inpatient: 1.2-1.8 gm/day in divided doses until 10gm total then 200-400 mg per day.
Outpatient: 600-800 mg per day until 10gm then 200-400 mg per day
for iv route
5-7mg/kg over 30-60min then 1.2-1.8 gm/day cont iv or divided po doses until 10gm total then 200-400 mg per day

Dofetilide
for po route
500 mcg bid - must adjust if CrCl < 60 ml/min

Flecainide
[po/iv]
for po route 200-300 mg
for iv route 1.5-3 mg/kg over 10-20 min [available only in Europe]

Ibutilide
for iv route only
pt over 60 kg: 1mg over 10 min - may repeat 1mg when necessary
pt less than 60 kg: 0.01 mg/kg over 10 min and may repeat the same dose only once after 10 min if necessary

Propafenone
[po/iv]
for po route 600 mg
for iv route 1.5-2 mg/kg over 10-20 min [available only in Europe]

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