Assessment of anti-factor Xa activity in critically ill COVID-19 patients receiving three different anticoagulation regimens

Introduction:

Critically ill COVID-19 patients are at increased risk of thrombosis with an enhanced risk of bleeding. We aimed to explore the role of anti-factor Xa levels in optimizing the high-intensity anticoagulation’s safety and efficacy and finding possible associations between D-dimer levels, cytokine storm markers, and COVID-19-induced coagulopathy or thrombophilia.

Methods:

Retrospective cohort study conducted on 69 critically ill COVID-19 patients who received three regimens of higher intensity anticoagulation.

Results:

Seventeen patients (24.6%) received high-dose enoxaparin prophylaxis, 29 patients (42%) received therapeutic doses of enoxaparin, and 23 patients (33.3%) were on therapeutic unfractionated heparin infusion. Fewer than one-third of the whole cohort (n = 22; 31.8%) achieved the target range of anti-factor Xa. The patients were divided into three subgroups based on anti-factor Xa target status within each anticoagulation regimen; when compared, the only association observed among them was for interleukin-6 levels, which were significantly higher in both the “above the expected range” and “below the expected range” groups compared with the “within the expected range” group (p = 0.009). Major bleeding episodes occurred in 14 (20.3%) patients and were non-significantly more frequent in the “below the expected anti-factor Xa range group” (p = 0.415). Seven patients (10.1%) developed thrombosis. The majority of patients had anti-factor Xa levels below the expected ranges (four patients, 57.1%).

Conclusion:

Conventional anti-factor Xa ranges may not be appropriate as a predictive surrogate for bleeding in critically ill COVID-19. The clinical decision to initiate therapeutic anticoagulation preemptively may be individualized according to thrombosis and bleeding risks. Cytokine storm markers, namely, interleukin-6, may play a role in COVID-19-induced coagulopathy or thrombophilia.

Recurrent ciprofloxacin induced hypoglycemia in a non-diabetic patient: A case report

BACKGROUND

Fluoroquinolones are a class of broad-spectrum antimicrobials used for various bacterial infections. Frequent use of fluoroquinolones has been questioned due to severe associated adverse effects, including dysglycemia (hypoglycemia or hyperglycemia) due to an alternation in glucose metabolism. Recent clinical trials showed the association of poor clinical outcomes with hypoglycemia in critically ill patients without diabetes. Many predisposing factors worsen fluoroquinolone-induced hypoglycemia, including diabetes, concomitant medication use like sulfonylureas or insulin, renal disease, and the elderly.

CASE SUMMARY

We report a case of recurrent hypoglycemia after ciprofloxacin initiation for a 71-year-old, non-diabetic, critically ill patient despite the presence of total parenteral nutrition and nasogastric tube feeding. The adverse drug reaction probability (Naranjo) scale was completed with a probable adverse drug reaction. The hypoglycemia resolved entirely after ciprofloxacin discontinuation.

CONCLUSION

Although ciprofloxacin-induced hypoglycemia is rare, special consideration is needed for the elderly due to their higher susceptibility to adverse side effects.

Recurrent ciprofloxacin induced hypoglycemia in a non-diabetic patient: A case report

BACKGROUND

Fluoroquinolones are a class of broad-spectrum antimicrobials used for various bacterial infections. Frequent use of fluoroquinolones has been questioned due to severe associated adverse effects, including dysglycemia (hypoglycemia or hyperglycemia) due to an alternation in glucose metabolism. Recent clinical trials showed the association of poor clinical outcomes with hypoglycemia in critically ill patients without diabetes. Many predisposing factors worsen fluoroquinolone-induced hypoglycemia, including diabetes, concomitant medication use like sulfonylureas or insulin, renal disease, and the elderly.

CASE SUMMARY

We report a case of recurrent hypoglycemia after ciprofloxacin initiation for a 71-year-old, non-diabetic, critically ill patient despite the presence of total parenteral nutrition and nasogastric tube feeding. The adverse drug reaction probability (Naranjo) scale was completed with a probable adverse drug reaction. The hypoglycemia resolved entirely after ciprofloxacin discontinuation.

CONCLUSION

Although ciprofloxacin-induced hypoglycemia is rare, special consideration is needed for the elderly due to their higher susceptibility to adverse side effects.