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DRUG DIALOGUES
Year : 2017  |  Volume : 15  |  Issue : 2  |  Page : 160-161

Drug dialogues


Date of Web Publication18-May-2017

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DOI: 10.4103/0973-4651.206527

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How to cite this article:
. Drug dialogues. Curr Med Issues 2017;15:160-1

How to cite this URL:
. Drug dialogues. Curr Med Issues [serial online] 2017 [cited 2020 Jul 7];15:160-1. Available from: http://www.cmijournal.org/text.asp?2017/15/2/160/206527



DRUG DIALOGUES – Medication news and new medications

Source: CMC Pharmacy Bulletin, a publication of the Pharmacy Service (DISH), Christian Medical College, Vellore.

Crisaborole ointment for eczema



Crisaborole ointment has been approved to treat mild to moderate eczema (atopic dermatitis) in patients two years of age and older. Crisaborole, applied topically twice daily, is a phosphodiesterase 4 (PDE-4) inhibitor, although its specific mechanism of action in atopic dermatitis is not known. Serious side-effects of crisaborole include hypersensitivity reactions. The drug should not be used in patients who have had a hyper-sensitivity reaction to crisaborole. The most common side effect of crisaborole is application site pain, including burning or stinging.

Aspirin for those with recurrent miscarriages

According to a new study published in the Journal of Clinical Endocrinology and Metabolism[1] [online, 03 Feb 2017], preconception-initiated low dose aspirin (81 mg) may help certain women who have had miscarriages in the past to sustain their pregnancy to a live birth. Aspirin is currently being used in many clinical settings to improve the live-birth rate of women with previous miscarriages.[2] It has been suggested that aspirin, because of its antiplatelet property helps in thrombophilia associated with antiphospholipid syndrome. But aspirin is not associated with improved outcomes in women without antiphospholipid syndrome.

The researchers randomly assigned 1228 healthy women of 18 to 40 years old with 1 - 2 prior miscarriages and actively attempting to conceive to receive either aspirin or placebo preconceptionally taken up to 6 menstrual cycles attempting pregnancy and through 36 weeks' gestation in women who conceived. The women, who were mostly white were recruited from four medical centers in the US from 2007 to 2012. The intervention group received 81 mg aspirin and 400 mcg folic acid daily while the other group received placebo plus 400 mcg folic acid.

The researchers classified the women into three groups depending on their CRP levels: low CRP, mid CRP and high CRP. The low CRP and mid CRP groups did not differ in clinically confirmed pregnancies (low CRP: 70% vs. 68% and mid CRP: 72% vs. 67%). However, in the high CRP group, women taking placebo had the lowest pregnancy rate (54%) while those taking aspirin had a pregnancy rate of 71%.

When live birth rates were considered, there was no difference found in low CRP group and mid CRP group. But, in the high CRP group, the live birth rate was lower (44%) among women receiving placebo while the rate was 59% among those receiving aspirin.

Results summarized above reflects that the women of high CRP group were benefited more from aspirin with respect to both pregnancy rate and live birth rate, while the other two groups had no difference at all. The researchers claim that the study highlights two concepts for the first time. First: systemic, low-grade inflammation may significantly harm women's ability to become pregnant and her inflammation changes through pregnancy, and secondly, this detriment may be restored to expected levels using preconception-initiated aspirin therapy. Unlike the previous mechanism of action mentioned above, researchers say that the mechanism involved here is the ability of aspirin to inhibit COX-2 function which is interrelated with many inflammatory mediators involved in reproductive processes and aspirin may inhibit downstream effects of chronically upregulated inflammatory pathways. They also say that, it is possible that processes of repair, scarring, and embryo receptivity in women with a history of pregnancy loss, which affects 20 - 30% of all conceptions, may be linked to systemic, chronic inflammation that is improved by low dose aspirin.

References

  1. Sjaarda LA, Radin RG, Silver RM et al. Preconception low-dose aspirin restores diminished pregnancy and live birth rates in women with low grade inflammation: a secondary analysis of a randomized trial. J Clin Endocrinol Metab 2017.
  2. Management of couples with recurrent pregnancy loss - Up-ToDate [Internet]. [Last accessed 2017 Feb 17].


Long term PPIs can injure kidneys

Long-term use of proton pump inhibitors (PPIs) including omeprazole, pantoprazole and rabeprazole has been reported to have increased risk of developing chronic kidney disease (CKD), according to an observational study1 published in Kidney International [online, 22 Feb 2017]. The study analyzed a cohort of 144,032 new users of acid suppression therapy [either PPIs (n=125,596) or H2 blockers (n=18,436)] without kidney disease at baseline. As reported by the researchers, when compared to H2 blocker users, PPI users were significantly more likely to develop estimated glomerular filtration rate (eGFR) under 60 mL/min, incident CKD, eGFR decline over 30% and end-stage renal disease (ESRD) or eGFR decline over 50% over a period of 5 years. However, the researchers found that only around 50% of chronic renal outcomes emerging in PPI users could be explained by acute kidney injury (AKI). Researchers quoted previous findings which link PPIs to an increased risk of AKI, CKD and ESRD, and it was generally assumed that PPI-related AKI was a stepping stone for some patients on the way to chronic renal outcomes. The researchers concluded advising that relying on a previous AKI as warning sign to guard against the risk of the development of CKD and progression to ESRD among PPI users is not sufficient to reduce risk. Exercising vigilance in PPI use, even in the absence of AKI, and careful attention to kidney function in PPI users may be a reasonable approach.

References

  1. Xie Y, Bowe B, Li T et al. Long-term kidney out-comes among users of proton pump inhibitors without intervening acute kidney injury. Kidney International 2017; doi: 10.1016/j.kint.2016.12.021


For nebulization, use normal saline as water for injection may provoke bronchospasm



Sterile water for injection is commonly used to dilute salbutamol nebulization solutions, though this is not really recommended by any standard guideline. Water for injection should never be used as a diluent as this may result in bronchospasm. The reason behind why sterile water for injection is commonly used as a diluent is may be due at least partly to its availability as 5 mL vials which are easy to use, when compared to normal saline which is available only as 100 mL bottles, which makes it difficult to withdraw, measure and reconstitute from the bottles. Where the volume of fluid is insufficient and drugs to be nebulized require dilution, 0.9% sodium chloride should be used, as hypotonic solutions including water for injection may provoke bronchospasm. Using respules is an alternative, since it is premixed and does not require further dilution.

Is topical minoxidil solution safe during pregnancy?

Majority of the oral and topical minoxidil product literature recommend not using minoxidil during pregnancy[1],[2] due to the risk of adverse effects in newborns based on inconclusive evidence. There are no adequate and well controlled studies in pregnant women. Fetotoxicity with oral minoxidil has been observed in rabbits. Exceptionally, two infants exposed in utero to oral minoxidil developed hypertrichosis (which is a known side-effect in adults). One of these infants was observed to have multiple anomalies while the other had heart defects without a known cause. Multiple anomalies have also been observed in two fetuses after topical application of minoxidil even though the cause is unknown.

Upon topical application, 0.3% - 4.5% of minoxidil reaches systemic circulation. Systemically absorbed minoxidil is also secreted in breast milk. Although the causal relationship to malformations after topical application is not strong enough, one standard reference suggests avoiding applying topical minoxidil during the 1st trimester.

References

  1. Minoxidil: Drugs in Pregnancy & Lactation [https://www.medicinescomplete.com/mc/dpl/current/Briggs-chM-topic206.htm]. [Last accessed 2017 Feb 14].
  2. Minoxidil: Martindale: The Complete Drug Reference 37th ed London: Pharmaceutical Press; 2011


5 Drugs / 5 Points (Antimicrobials for MRSA)

VANCOMYCIN

  • Is a bactericidal glycopeptide antibiotic.
  • Usually the preferred drug of choice for infections due to MRSA.
  • It requires serum concentration monitoring especially in renal impairment patients.
  • The most common adverse reaction is “red man syndrome” (rate-related infusion reaction).
  • The target trough serum concentration depends on the nature of infection (usually 10 to 20 mcg/mL).


TEICOPLANIN

  • Is a bacteriostatic glycopeptide antibiotic.
  • Favoured in patients with intolerance to vancomycin.
  • It has a longer half-life and can be given OD.
  • There are reports of cross-sensitivity to teicoplanin in patients hypersensitive to vancomycin.
  • Unlike vancomycin, it does not cause tissue necrosis and can be given as an intramuscular injection.


LINEZOLID

  • It is a bacteriostatic oxazolidinone antibiotic (covers MRSA & VRE).
  • Not preferred in blood stream infections.
  • Due to its side-effects, blood counts and serum chemistries should be performed at least weekly.
  • Usual dose (adults) is 600mg every 12 hours by oral or IV route.
  • Inhibits MAO enzyme and hence should not be taken with tyramine rich foods.




DAPTOMYCIN

  • Is a bactericidal cyclic lipopeptide antibiotic (covers MRSA & VRE).
  • Inactivated by lung surfactants and hence not useful in pneumonia due to MRSA.Usual dose (adults) is 6 mg/kg given IV OD (up to 10 mg/kg IV OD may be given in critically ill patients).
  • Can be used as an alternative to vancomycin but is costly.
  • Can induce myopathy and hence requires serum creatine kinase monitoring


TIGECYCLINE

  • Is a bacteriostatic glycylcycline antibiotic (covers MRSA).
  • Structurally similar to tetracycline and hence potentially induce same adverse effects.
  • Usual dose (adults) is 50mg every 12 hours given as IV infusion
  • Does not require renal dose adjustment.
  • Structurally similar to tetracycline and hence may induce photosensitivity.


References:

https://www.uptodate.com/contents/search Martindale: The Complete Drug Reference [Internet]. [Cited 2017 Mar 10]

8: Empiric Antibiotic Selection in the ICU - Critical Care Resources by Pharmacy Joe - [Internet]. Critical Care Resources by Pharmacy Joe. 2015 [cited 2017 Mar 10].




 

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