Status Epilepticus
Assess the need for SEIZURE prophylaxis
As a critical care pharmacist, questions are still popping up about seizure prophylaxis after a neurological injury, trauma, intracranial hemorrhage, etc. Who should get it? Continue to use seizure prophylaxis after a SEVERE traumatic brain injury (TBI); Glasgow Coma Scale 3 to 8. About 1 in 10 TBI patients have seizures…
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Stroke
DAPT after an ischemic stroke or TIA?
New data will raise questions about optimal use of short-term dual antiplatelet therapy (DAPT) after an ischemic stroke or TIA. We know that short-term DAPT, such as aspirin plus clopidogrel for 21 days, reduces recurrent stroke risk compared to aspirin alone. But most evidence is with starting DAPT within 24 hours. And data are mostly for patients with a minor st…
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SNRIs
Explore treatment options for Generalized Anxiety Disorder
As a clinical pharmacist, it's essential to recognize that about 1 in 13 adults in the US will be diagnosed with generalized anxiety disorder in their lifetime. Recommend cognitive behavioral therapy or meds as the initial treatment for generalized anxiety disorder, efficacy seems similar. Be ready to use a stepwise approach if meds are preferred... …
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Stress
Battling stress with Ashwagandha
As a nutrition support pharmacist, you may receive inquiries about using Ashwagandha to combat stress. Ashwagandha , along with American ginseng and astragalus, are popular adaptogens known for their ability to help the body resist physical, environmental, and emotional stress. Studies suggest that taking 240-1000 mg of…
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Stalevo
Treating Parkinson's disease AFTER the honeymoon is over
As a clinical pharmacist, you will see more emphasis on treating Parkinson's disease AFTER the "honeymoon" is over. For the first few years, symptoms are usually well controlled with low doses of carbidopa/levodopa or a dopamine agonist (pramipexole, etc). But eventually drug efficacy decreases as the disease progresses. Suggest these tips for movement …
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Quetiapine
Stronger WARNINGS about quetiapine and QT prolongation
As a clinical pharmacist, you will see stronger warnings about quetiapine ( Seroquel , etc) and QT prolongation. Many of the antipsychotics can prolong the QT interval , but not all of them are associated with torsades or sudden death. Torsades with quetiapine is very rare, and usually linked to an overdose. But the problem is that you can't predict who will get …
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Vitamin B12
Is it necessary to give VITAMIN B12 by injection
As a clinical pharmacy specialist, you will be asked, is it ever necessary to give vitamin B12 by injection?.. Only rarely . Many patients have trouble absorbing B12 from food due to reduced gastric acidity or lack of intrinsic factor. We used to think that these patients needed B12 by injection, but in many cases supplements can be given orally instead. About 1% …
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SNRIs
Cymbalta for lower back pain
Cymbalta (duloxetine) will be used more for chronic musculoskeletal pain in the lower back or due to osteoarthritis . Cymbalta is already approved for neuropathic pain . Plus, it's approved for chronic musculoskeletal pain, so physicians are hearing more about this use, too. Some antidepressants do have analgesic effects, especially tricyclics (amitriptyline, …
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SSRIs
Limiting doses of citalopram
As a hospital or community pharmacist, you will hear about limiting doses of citalopram ( Cipram , etc). Experts say citalopram doses should not exceed 40 mg/day for anyone, or 20 mg/day for most patients over age 60. Higher doses of citalopram increase the risk of QT prolongation and the life-threatening arrhythmia, torsades. …
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SSRIs
Think of BUSPirone as 2nd option for managing anxiety
As a clinical pharmacist, you will be asked more about medications for managing anxiety and RECENT spot shortages of buspirone will raise questions about its role in treating anxiety, since it's unrelated to other anxiety medications. Don't think of buspirone as similar to a benzodiazepines. Buspirone doesn't provide quick symptom relief, muscle…
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Stroke
Update your INTRAcerebral Hemorrhage protocol
As a hospital pharmacist, you will be asked about spontaneous intracerebral hemorrhage (ICH) treatment , due to updated guidelines. Follow these points... Anticoagulant reversal. Use 4-factor prothrombin complex concentrate ( Kcentra ) for warfarin-related ICH when INR is 1.3 or higher, along with IV vitamin K to reduce risk of INR reb…
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SSRIs
Make sense when combining antidepressants
As a clinical pharmacist, you should individualize the choice of antidepressant combos. So the question is, does it make sense to combine antidepressants? Yes, sometimes. Fewer than half of patients with depression achieve remission with one first-line medication (SSRI, SNRI, etc). Adding a different medication class may wor…
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Tenecteplase
Do your part as a PHARMACIST in acute strokes
Clinicians will sort through new evidence looking for the best ways to bust clots in patients with acute ischemic stroke . Optimal stroke care is a big focus. The Joint Commission looks at whether patients get IV alteplase ( Activase ) appropriately and Medicare penalizes excess 30-day stroke readmissions. We know that one patient will have minimal or no disability …
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Neurology and Psychiatry
Atypical antipsychotics will be used more for treating depression
As a pharmacist, don't be surprised if you see atypical antipsychotics being used more often in treating depression. Both aripiprazole ( Abilify ) and olanzapine/fluoxetine ( Symbyax ) are already approved for resistant depression and quetiapine ( Seroquel ) will likely get a similar indication. More than half of patients with depression still have symptoms despi…
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Status Epilepticus
Phenytoin is difficult drug to dose
Phenytoin ( Epanutin, Epilog ) is one of the most difficult drugs to dose. This is because phenytoin metabolism depends on the dose. Higher doses take longer to metabolize, so doubling the dose can more than double the serum concentration. Follow these steps... Loading doses help get to therapeutic levels faster. Give 15 to 20 mg/kg PO or IV, about 1000 mg fo…
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Tenecteplase
Acute stroke protocol update
The treatment of acute ischemic stroke will change due to new American Heart Association and American Stroke Association guidelines. Help update your hospital's screening and treatment protocols... Strive for faster turnaround times in stroke patients. For example, aim to rule out a hemorrhagic stroke with brain imaging within 20 minutes even though the qualit…
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TIA
Start with HIGH-dose atorvastatin after stroke
New evidence will spark questions about whether to aim for an LDL goal in patients with a prior ischemic stroke or TIA . For several years, we’ve been using target DOSES of statins shown to reduce cardiovascular (CV) risk rather than titrating to an LDL goal. Now data suggest treating to an LDL below 70 mg/dL instead of about 95 mg/dL prevents a re…
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TIA
Don’t use ticagrelor PLUS aspirin after stroke
As a hospital pharmacist, you will hear ticagrelor ( Brilique, Brilinta ) plus aspirin promoted after a MINOR ischemic stroke or high-risk TIA. New evidence shows that taking this combo for 30 days after a minor stroke or high-risk TIA decreases the composite of death or stroke in 1 in 91 patients, compared to aspirin monotherapy. But the benefit is mostly fro…
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