Series Editor: Mike O’Brien, PharmD
Quick evidence-based pearls on all things pharmacology and pharmacy-related in Emergency Medicine
A common question is how much should we expect the blood glucose concentration to increase after dextrose 50% (D50) administration. Fortunately, there is an answer from 3 studies.
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
Urine drug tests are commonly sent for patients in the emergency department, however care should be taken when interpreting the results of these tests given their limitations. The American College of Medical Toxicology published a position statement on the interpretation of urine opiate and opioid tests [1]. In this publication, they outline many of the limitations of opioid urine drug tests and explain why they exist.
Cross-reactivity of Various Opioids with Morphine Urine Drug Test [2] | ||
---|---|---|
Compound | Equivalent to 300 ng/mL Morphine (ng/mL) | Cross-reactivity (%) |
Codeine | 224 | 134 |
Heroin | 366 | 82 |
Hydrocodone | 1,086 | 28 |
Hydromorphone | 1,425 | 21 |
Oxycodone | >75,000 | <0.4 |
Meperidine | >100,000 | <0.3 |
Previous ALiEM posts discuss further limitations of urine drug tests, specifically for benzodiazepines and opiates.
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
Acute agitation in the emergency department is a common issue that frequently requires the use of chemical sedation to preserve safety for patients and healthcare workers. A commonly employed treatment regimen is the combination of haloperidol 5 mg + lorazepam 2 mg + diphenhydramine 50 mg (B-52). Diphenhydramine is included in this treatment regimen primarily to prevent extrapyramidal symptoms [1,2]. However, the incidence of extrapyramidal symptoms (EPS) with haloperidol is quite low when treating agitation in the emergency department (ED) [3,4]. Therefore, the excessive and prolonged sedation from adding prophylactic diphenhydramine may outweigh the intended benefit and should be reserved for treatment of EPS if symptoms occur.
Jeffers et al. conducted a multicenter, retrospective, cohort study which compared the efficacy and safety of haloperidol, lorazepam, and diphenhydramine (B-52) (n=200) vs. haloperidol and lorazepam (52) (n=200) in treating patients >18 years old with acute agitation in the ED [5]. Their primary outcome was the administration of additional agitation medication(s) within 2 hours.
Outcomes | 52 (n=200) | B52 (n=200) | p-Value |
---|---|---|---|
Administration of additional sedative within 2 h, n (%) | 40 (20) | 28 (14) | 0.11 |
Median ED LOS (hours) | 13.8 | 17 | 0.03 |
Use of restraints, n (%) | 53 (26.5) | 86 (43) | 0.001 |
Hypotension, n (%) | 7 (3.5) | 32 (16) | <0.001 |
Administration of anticholinergic within 2 days, n (%) | 15 (7.5%) | 6 (3%) | 0.04 |
Itching/allergies, n (%) | 1 (0.5) | 1 (0.5) | 1.00 |
Home benztropine, n (%) | 2 (1) | 4 (2) | 0.41 |
Insomnia, n (%) | 4 (2) | 0 (0) | 0.06 |
Unknown, n (%) | 8 (4) | 1 (0.5) | 0.02 |
Overall, the B-52 combination resulted in more oxygen desaturation, hypotension, physical restraint use, and longer length of stay. However, the conclusions from this study may be limited as it was a relatively small study and it used surrogate markers to assess clinical endpoints.
Further discussion regarding the onset and duration of IM medications for acute agitation may be found in this blog post.
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
Direct-acting oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban, and dabigatran, are widely used for various indications and considered first-line therapy for prevention of acute ischemic stroke in patients with nonvalvular atrial fibrillation [1]. The management of acute ischemic stroke in patients on DOACs presents a difficult clinical scenario in the emergency department due to concern for increased risk of hemorrhage. IV thrombolytics (e.g., alteplase, tenecteplase), a mainstay in acute ischemic stroke management, are not recommended in current guidelines for patients whose last DOAC dose was within the last 48 hours [2, 3]. Therefore, patients with an acute ischemic stroke who are compliant with their DOACs are often excluded from guideline recommended therapy. Additionally, as covered in a previous ALiEM post, it is not recommended to reverse anticoagulation status in order to administer a thrombolytic.
The use of IV thrombolytics in patients on DOACs was evaluated by Kam et al in a 2022 study published in JAMA [4]. This retrospective analysis included 163,038 patients from the AHA/ASA Get With The Guidelines-Stroke registry with acute ischemic stroke who received IV alteplase within 4.5 hours of symptom onset. Of the total number of patients, only 2207 had documented use of a DOAC within the last 7 days, with 25 of these patients reporting DOAC use within 48 hours. Patients on warfarin or other anticoagulants were excluded. The primary outcome was symptomatic intracranial hemorrhage (ICH) within 36 hours of IV alteplase administration. After adjusting for clinical factors, the rate of symptomatic ICH was not significantly different between patients taking DOACs and those not on anticoagulation (3.7% vs. 3.2%, adjusted OR 0.88, 95% CI 0.70 to 1.10). However, when stratified based on time from last DOAC dose, patients who took their DOAC 0-48 hours prior had an 8% rate of symptomatic ICH compared to 3.2% among those not on DOACs. Furthermore, the rate of any alteplase complication was 12% vs. 6% in those taking DOACs within 48 hours vs. no DOAC.
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
Jessica Mason, PharmD
PGY-2 Emergency Medicine Pharmacy Resident
Massachusetts General Hospital
An acute aortic dissection (AAD) can be a life-threatening emergency which frequently requires rapid and precise control of the patient’s heart rate and blood pressure. The 2010 guidelines for management of patients with thoracic aortic disease suggest a heart rate goal of <60 bpm and a systolic blood pressure between 100-120 mmHg. In order to achieve this, a rapid-acting beta-blocker (i.e., esmolol) may be used in combination with an IV calcium channel blocker (i.e., nicardipine or clevidipine). These medications need to be monitored closely to avoid overshooting these goals and causing hemodynamic compromise. Ideally, an arterial line would be used to monitor the patient’s blood pressure, however this may not always be feasible so a traditional, noninvasive blood pressure cuff can be used. This may be complicated if the patient has the classic, but not universal, finding of unequal systolic blood pressure values between their left and right extremities. This raises the question, in a patient with an AAD and disparate blood pressures in each arm, which arm reading should be used for monitoring?
A 2018 study from Um et al. evaluated 111 patients with an AAD and compared them with 111 control patients. This study found that while a systolic blood pressure difference of >20 mmHg between sides was a positive predictor for an AAD, the presence of a pulse deficit had a higher diagnostic accuracy. For the purpose of this study, a pulse deficit was defined as “any recorded difference in volume/force or difference in obvious signs of malperfusion”. The cause of an unequal blood pressure or pulse deficit in the upper extremities in this population is typically due to dissection of the brachiocephalic or subclavian arteries. In order to properly achieve the desired blood pressure reduction in patients with divergent blood pressure values, the higher value should be used for titration of antihypertensives. This is due to the occurrence of pseudohypotension occurring in the limb with the dissected artery.
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
Caring for a patient that is critically-ill secondary to a toxic ingestion is complicated and, in severe cases, extracorporeal treatments (ECTRs) may be considered. The most commonly used ECTRs are intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT), but ECTRs also include exchange transfusion, hemoperfusion, liver dialysis, and therapeutic plasma exchange. Finding and evaluating the supporting literature for these treatment modalities in a timely manner is not feasible in most situations. In order to assist in this effort, the EXtracorporeal Treatments In Poisoning (EXTRIP) workgroup has reviewed and provided free, evidence-based recommendations regarding the use of ECTRs for many common toxins and toxicants [1]. These recommendations can be found in a summarized format on the EXTRIP website and the links to their comprehensive reviews are published on PubMed with direct links on their website. This international workgroup is made up of experts in toxicology, nephrology, emergency medicine, pediatrics, pharmacology, critical care, and more. An excellent example of this resource is their review and recommendations on ECTRs for poisoning secondary to beta-adrenergic antagonists (BAAs).
The EXTRIP workgroup included 76 publications in this comprehensive review on the use of ECTRs in BAA poisoning [2]. They evaluated pharmacokinetic/toxicokinetic data for a total of 334 patients poisoned with various BAAs, of which ~90% of the data was published prior to 1990 and does not necessarily represent the improved clearance of these medications with modern ECTR modalities. Based on this evidence, they deemed atenolol, nadolol, and sotalol as dialyzable BAAs. They also reviewed case reports/series of 37 patients with BAA toxicity and made recommendations for those agents with sufficient evidence. Based on the above data, the EXTRIP group recommends iHD over CRRT in patients severely poisoned with atenolol or sotalol and kidney impairment. They make no recommendation for or against ECTR in patients severely poisoned with atenolol or sotalol with normal kidney function and they recommend against ECTR in patients severely poisoned with propranolol.
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
Two new oral agents were given Emergency Use Authorization to be used in patients with mild-moderate COVID-19 at high risk of progression to severe infection, molnupiravir and nirmatrelvir/ritonavir (Paxlovid) [1,2]. Prior to this authorization, most evidence-based COVID therapies were parenteral and required significant healthcare resources to coordinate and administer.
Nirmatrelvir/ritonavir [3] | Molnupiravir [4] | |
---|---|---|
Mechanism | Protease inhibitor leadings to interruption of viral replication Ritonavir has no role in treating COVID-19, it is only included to boost levels of nirmatrelvir via CYP3A4 inhibition | Increased frequency of RNA mutations and impaired replication [5] |
Efficacy vs Placebo (Hospitalization or Death) | 0.8% vs 6.3% (CI -7.21 to -4.03) | 6.8% vs 9.7% (CI -5.9 to -0.1) |
Drug Interactions | CYP3A4 inducers, inhibitors, and substrates May decrease efficacy of hormonal contraceptives, non-hormonal contraceptives should be considered Contraindicated medications include: amiodarone, carbamazepine, clozapine, colchicine, dihydroergotamine, dronedarone, flecainide, lovastatin, ranolazine, sildenafil, simvastatin Many other important interactions exist so care should be taken to assess all medication interactions | N/A |
Cost* | Patient: $0 US government: $530 [6] | Patient: $0 US Government: $700 [7] |
Dose | 300 mg/100 mg BID for 5 days Must be started within 5 days of symptom onset | 800 mg BID for 5 days Must be started within 5 days of symptom onset |
Notes | Approved for patients ≥ 12 years old AND ≥ 40 kg Not approved for inpatient initiation If patient is hospitalized, continuation is up to the discretion of the provider Not used as pre-/post-exposure prophylaxis | Approved for patients ≥ 18 years Not approved for inpatient initiation If patient is hospitalized, continuation is up to the discretion of the provider Not used as pre-/post-exposure prophylaxis |
Renal/Hepatic Dose Adjustments | eGFR ≥30 to <60 mL/min: 150 mg/100 mg BID eGFR <30 mL/min: Not recommended Child-Pugh class C: Not recommended | None |
*Note: The US federal government has purchased 10 million doses of nirmatrelvir/ritonavir and 3 million doses of molnupiravir [8,9]. These supplies will be allocated to states and territories as needed and will be available to patients at no charge.
Nirmatrelvir/ritonavir (Paxlovid)
Paxlovid was evaluated in the EPIC-HR trial, which is not fully published at this time [3]. This was a phase 2/3, double-blinded, randomized placebo controlled trial including nonhospitalized, unvaccinated patients adults with mild-moderate COVID-19 within 5 days of symptom onset with at least 1 risk factor† for development of severe illness from COVID-19. Exclusion criteria included patients with a history of COVID-19 infection or COVID vaccination. Patients were given Paxlovid 300 mg/100 mg or placebo BID for 5 days. The primary outcome was hospitalization or death at day 28. The modified intention-to-treat1 (mITT1) group excluded patients who did not receive nor were expected to receive COVID-19 mAb treatment. In the mITT1 group, the primary outcome occurred in 0.8% of patients receiving Paxlovid vs 6.3% of patients in the placebo group (8/1039 vs 66/1046, CI -7.21 to -4.03).
These results appear quite robust with a fragility index of 37. Additionally, in patients with detectable COVID antibodies there was less of an impact of the study medication. However, these patients still appeared to have some benefit (0.2% vs 1.5%, CI -2.45 to -0.23) which suggests that vaccinated patients may still benefit from Paxlovid.
†Risk factors for progression to severe disease: BMI >25, chronic lung disease, asthma, chronic kidney disease, current smoker, immunosuppressive disease or immunosuppressive treatment, cardiovascular disease, hypertension, sickle cell disease, neurodevelopmental disorders, active cancer, medically-related technological dependence, or age >60 years
Molnupiravir
Molnupiravir was evaluated in the MOVe-OUT trial [10]. This was a phase 3, double-blinded, randomized, placebo controlled trial including nonhospitalized, unvaccinated adults with mild-moderate COVID-19 within 5 days of symptom onset with at least 1 risk factor‡ for development of severe illness from COVID-19. Exclusion criteria included anticipated hospitalization within 48 hours, eGFR <30 or dialysis dependent, pregnancy, and COVID vaccination. Patients were able to receive steroids but not monoclonal antibodies (mAbs) nor remdesivir. Patients were given molnupiravir 800 mg or placebo BID for 5 days. The primary outcome was hospitalization or death at 29 days. In the mITT population, the primary outcome occurred in 6.8% of patients in the study group vs 9.7% in the placebo group (48/709 vs 68/699, CI -5.9 to -0.1). Death occurred in 1 patient on molnupiravir and in 9 patients on placebo (0.1% vs 1.3%, RRR 89%, CI 14 to 99).
Despite the above results, this may not be the positive trial it initially appears. First of all, for the primary outcome, the fragility index is 0, meaning that if 1 more patient in the study group experienced the primary outcome then it would have changed the statistical significance. Additionally, when the mITT analysis was adjusted for sex, the absolute risk reduction remained 2.8% but the confidence interval was not significant (-5.7 to 0.1). Lastly, in the subgroup analysis, there was no benefit in patients that had positive COVID antibody tests and there was a slight preference towards placebo over molnupiravir (3.7% vs 1.4%, ARR 2.3, CI -1.7 to 7.1). This suggests that vaccinated patients may not benefit from this therapy as much (or at all) as compared to unvaccinated patients.
‡Risk factors for progression to severe disease: age >60 years, active cancer, chronic kidney disease, COPD, BMI ≥30, heart failure, coronary artery disease, cardiomyopathy, or diabetes mellitus
Note: Both the EPIC-HR and MOVe-OUT studies were funded by their respective pharmaceutical company.
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.