1
|
Brancaccio A, Giuliano C, McNorton K, Delgado G. Impact of a phenytoin loading dose program in the emergency department. Am J Health Syst Pharm 2015; 71:1862-9. [PMID: 25320136 DOI: 10.2146/ajhp140039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use of a combined physician-and pharmacist-directed phenytoin loading dose program in an emergency department (ED) was evaluated. METHODS This single-center, observational, preimplementation-postimplementation study evaluated adult patients who received a phenytoin loading dose in the ED. The primary outcome compared the proportion of optimal phenytoin loading doses in the preimplementation and postimplementation groups. The postimplementation group was further stratified into pharmacist- and prescriber-dosing groups. Other outcomes evaluated included the numbers of appropriate serum phenytoin concentrations measured, adverse drug reactions (ADRs), and recurrence of seizures within 24 hours of loading dose administration in the preimplementation and postimplementation groups. RESULTS There was no difference in the proportion of optimal phenytoin loading doses between the preimplementation and postimplementation groups (50% versus 62%, respectively; p=0.19). When stratified by individual groups, the rate of optimal phenytoin loading doses increased by 64% in the postimplementation pharmacist group (50% versus 82%, p=0.007), while the rate in the prescriber-dosing group remained relatively unchanged (50% versus 49%, p=0.91). The number of appropriate serum phenytoin concentrations significantly improved in the postimplementation versus preimplementation group (65% versus 40%, p=0.025). Rates of ADRs and recurrence of seizures did not differ across the study groups. CONCLUSION No change in the percentage of optimal phenytoin loading doses in the ED was observed after implementation of a combined pharmacist- and physician- dosing program. When stratified into pharmacist or prescriber dosing, the pharmacist-led dosing program significantly improved the proportion of patients who received optimal phenytoin loading doses.
Collapse
Affiliation(s)
- Adam Brancaccio
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
| | - Christopher Giuliano
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC.
| | - Kelly McNorton
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
| | - George Delgado
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
| |
Collapse
|
2
|
Eagleson JS, Platt SR, Strong DLE, Kent M, Freeman AC, Nghiem PP, Zheng B, White CA. Bioavailability of a novel midazolam gel after intranasal administration in dogs. Am J Vet Res 2012; 73:539-45. [PMID: 22452501 DOI: 10.2460/ajvr.73.4.539] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare the pharmacokinetics of a novel bioadhesive gel formulation of midazolam after intranasal (IN) administration with that of midazolam solution after IN, IV, and rectal administration to dogs. ANIMALS 10 (5 males and 5 females) healthy adult Beagles. PROCEDURES Dogs were assigned to 4 treatment groups for a crossover study design. Initially, midazolam solution (5 mg/mL) was administered (0.2 mg/kg) IV to group 1, rectally to group 2, and IN to group 3; a 0.4% hydroxypropyl methylcellulose midazolam gel formulation (50 mg/mL) was administered (0.2 mg/kg, IN) to group 4. Each dog received all 4 treatments; there was a 7-day washout period between subsequent treatments. Blood samples were collected before and after midazolam administration. Plasma concentration of midazolam was determined by use of high-performance liquid chromatography. RESULTS The peak plasma concentration after IN administration of the gel formulation was significantly higher than that after IN and rectal administration of the solution. Mean ± SD time to peak concentration was 11.70 ± 2.63 minutes (gel IN), 17.50 ± 2.64 minutes (solution IN), and 39 ± 14.49 minutes (solution rectally). Mean bioavailability of midazolam was 70.4% (gel IN), 52.0% (solution IN), and 49.0% (solution rectally). Bioavailability after IN administration of the gel formulation was significantly higher than that after IN and rectal administration of the solution. CONCLUSIONS AND CLINICAL RELEVANCE IN administration of midazolam gel was superior to both IN and rectal administration of midazolam solution with respect to peak plasma concentration and bioavailability.
Collapse
Affiliation(s)
- Joseph S Eagleson
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA.
| | | | | | | | | | | | | | | |
Collapse
|
4
|
Wermeling DP. Intranasal delivery of antiepileptic medications for treatment of seizures. Neurotherapeutics 2009; 6:352-8. [PMID: 19332330 PMCID: PMC5084214 DOI: 10.1016/j.nurt.2009.01.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 01/12/2009] [Accepted: 01/13/2009] [Indexed: 11/15/2022] Open
Abstract
Acute isolated seizure, repetitive or recurrent seizures, and status epilepticus are all deemed medical emergencies. Mortality and worse neurologic outcome are directly associated with the duration of seizure activity. A number of recent reviews have described consensus statements regarding the pharmacologic treatment protocols for seizures when patients are in pre-hospital, institutional, and home-bound settings. Benzodiazepines, such as lorazepam, diazepam, midazolam, and clonazepam are considered to be medications of first choice. The rapidity by which a medication can be delivered to the systemic circulation and then to the brain plays a significant role in reducing the time needed to treat seizures and reduce opportunity for damage to the CNS. Speed of delivery, particularly outside of the hospital, is enhanced when transmucosal routes of delivery are used in place of an intravenous injection. Intranasal transmucosal delivery of benzodiazepines is useful in reducing time to drug administration and cessation of seizures in the pre-hospital setting, when actively seizing patients arrive in the emergency room, and at home where caregivers treat their dependents. This review summarizes factors to consider when choosing a benzodiazepine for intranasal administration, including formulation and device considerations, pharmacology and pharmacokinetic/pharmacodynamic profiles. A review of the most relevant clinical studies in epilepsy patients will provide context for the relative success of this technique with a number of benzodiazepines and relatively less sophisticated nasal preparations. Neuropeptides delivered intranasally, crossing the blood-brain barrier via the olfactory system, may increase the availability of medications for treatment of epilepsy. Consequently, there remains a significant unmet medical need to serve the pharamcotherapeutic requirements of epilepsy patients through commercial development and marketing of intranasal antiepileptic products.
Collapse
Affiliation(s)
- Daniel P Wermeling
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky 40536-0082, USA.
| |
Collapse
|
5
|
A pharmacokinetic and pharmacodynamic study, in healthy volunteers, of a rapidly absorbed intranasal midazolam formulation. Epilepsy Res 2008; 83:124-32. [PMID: 19046855 DOI: 10.1016/j.eplepsyres.2008.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 10/02/2008] [Accepted: 10/17/2008] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare 2.5 mg and 5.0 mg single-dose pharmacokinetics (PK), pharmacodynamics (PD) and tolerability of an intranasal (i.n.) midazolam formulation, to a 2.5-mg intravenous (i.v.) dose. METHODS Design was an open-label, three-way crossover, randomized PK and PD study in seventeen healthy volunteers. Twelve-hour PK parameters were determined for each treatment arm. Subjects completed serial self-ratings for sedation and other drug effects. Nurse observers made serial observations for sedation and adverse effects. An otolaryngologist conducted a nasal endoscopy, pre-dose, 2-4 h, and at end of study, to examine the nasal cavity for formulation-induced changes in nasal anatomy. RESULTS Midazolam was rapidly absorbed following i.n. administration, with a median t(max) of 10 min; dose proportionate increases for C(max) and AUC; t(1/2) of 4 h; and, 60% (+/-23) nasal administration bioavailability compared to the i.v. dose. PD responses were rapid, paralleled the PK, and in magnitude was in a rank order of i.v. 2.5 mg > or = i.n. 5.0 mg > i.n. 2.5 mg doses. The formulation was well tolerated with no serious cardiovascular or respiratory complications. Fourteen subjects complained of at least one of the following: a brief and mild to moderate intensity facial flushing, nasal passage burning, sore throat or bad taste after drug administration. There were no adverse findings from the nasal endoscopic exam. CONCLUSION Dosages of an investigational i.n. midazolam formulation resulted in rapid absorption and attained plasma concentrations that correlated with pharmacodynamic effects.
Collapse
|
6
|
An alternative perspective on the management of status epilepticus. Epilepsy Behav 2008; 12:349-53. [PMID: 18262847 DOI: 10.1016/j.yebeh.2007.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 12/25/2007] [Indexed: 02/08/2023]
Abstract
The definition of status epilepticus (SE) has been reduced from 30 minutes to 5 minutes and this article questions if treatment should not be offered before reaching that window. After provision of first aid, benzodiazepines (BDZ) are the initial form of intervention, with either nasal or buccal midazolam being favored for nonprofessionals. Proper patient supervision, including admission to an intensive care unit for more difficult patients, is endorsed, and the need to warn nonprofessionals of the potential risk of respiratory depression is imperative. The article criticizes the use of phenytoin as the antiepileptic medication (AEM) with which to load patients, as it is no longer a first-line AEM, and argues in favor of using a first-line AEM such as valproate or carbamazepine, or preferably the AEM that previously proved efficacious in a patient with known epilepsy who was noncompliant. Alternative routes of administration of AEMs are discussed, and the use of blood level monitoring, as an adjunct to management, to protect against further episodes of SE, is supported. Touched on in this article are the use of some of the newer AEMs in the management of SE and exploration of treatment strategies that acknowledge that treatment must also include patient education that incorporates techniques to enhance compliance.
Collapse
|
7
|
Pang T, Hirsch LJ. Treatment of convulsive and nonconvulsive status epilepticus. Curr Treat Options Neurol 2005; 7:247-259. [PMID: 15967088 DOI: 10.1007/s11940-005-0035-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Status epilepticus (SE) should be treated as quickly as possible with full doses of medications as detailed in a written hospital protocol. Lorazepam is the drug of choice for initial treatment. If intravenous access is not immediately available, then rectal diazepam or nasal or buccal midazolam should be given. Prehospital treatment of seizures by emergency personnel is effective and safe, and may prevent cases of refractory SE. Home treatment of prolonged seizures or clusters with buccal, nasal, or rectal benzodiazepines should be considered for all at-risk patients. Nonconvulsive SE is underdiagnosed. An electroencephalogram should be obtained immediately in anyone with unexplained alteration of behavior or mental status and after convulsive SE if the patient does not rapidly awaken. Delay in diagnosis of SE is associated with a worse outcome and a higher likelihood of poor response to treatment. For refractory SE, continuous intravenous midazolam and propofol (alone or in combination) are rapidly effective. Randomized trials are needed to determine the best treatment for SE after lorazepam.
Collapse
Affiliation(s)
- Trudy Pang
- Comprehensive Epilepsy Center, Columbia University, Neurological Institute, Box NI-135, 710 W. 168th Street, New York, NY 10032, USA.
| | | |
Collapse
|
10
|
Gaitanis JN, Drislane FW. Status epilepticus: a review of different syndromes, their current evaluation, and treatment. Neurologist 2003; 9:61-76. [PMID: 12808369 DOI: 10.1097/01.nrl.0000051445.03160.2e] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Status epilepticus (SE) encompasses a wide range of seizure types with different clinical presentations, pathophysiologies, treatment imperatives, and outcomes. The most dramatic and life-threatening form, generalized convulsive status epilepticus, has been reviewed in all of these aspects, but other less common types of SE have been described less extensively. REVIEW SUMMARY Definitions of generalized convulsive SE and its pathophysiology are reviewed briefly. Defining SE by a specific duration of seizures is controversial and has implications for studies and for clinical management. Several types of SE are different in their causes, presentations, and outcomes. Many are underdiagnosed. This article focuses on the pharmacology and clinical studies of several anticonvulsant medications used to treat SE. A protocol approach is not detailed. Rather, the clinical evaluation begins with meticulous diagnosis of the type of SE. Establishing the SE syndrome diagnosis and use of anticonvulsants with demonstrated effectiveness facilitate an appropriate treatment plan for individual patients. Recent developments in the basic science of SE raise the possibility of better treatments in the future. CONCLUSIONS As there are many types of seizures, there are also many types of SE. Each has unique presentations and treatment considerations. Review of actual clinical data from SE treatment studies should be helpful in devising the best treatment for an individual patient.
Collapse
Affiliation(s)
- John N Gaitanis
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | | |
Collapse
|
11
|
Rüegg SJ, Dichter MA. Diagnosis and Treatment of Nonconvulsive Status Epilepticus in an Intensive Care Unit Setting. Curr Treat Options Neurol 2003; 5:93-110. [PMID: 12628059 DOI: 10.1007/s11940-003-0001-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nonconvulsive status epilepticus (NCSE) in adults is a heterogeneous epileptic emergency and includes absence status (AS), complex-partial status epilepticus (CPSE), and the status epilepticus of epileptic encephalopathy (SEEE). The latter seems to be strikingly frequent among patients in intensive care units (ICU). Diagnosis of NCSE is difficult, but has to be made quickly. It relies on clinical signs and a confirmation electroencephalography (EEG). According to the different etiologies and outcomes of AS, CPSE, and SEEE, treatment has to be individually adapted, but needs to follow some basic principles--treatment should take place in the ICU and be monitored by continuous EEG. With a few exceptions, the first drug is an intravenous benzodiazepine, mainly lorazepam. Intravenous fosphenytoin or phenytoin or valproate may follow next. If some forms of NCSE are resistant to first- and second-line treatments, single or combinations of anesthetics and enteral antiepileptic drugs (AEDs) may be added. This opinion is not evidence-based, and randomized controlled prospective trials to evaluate optimal treatment of NCSE are of first priority.
Collapse
Affiliation(s)
- Stephan J. Rüegg
- *Division of Clinical Neurophysiology, Department of Neurology, University Hospitals, Petersgraben 4, Basel CH-4031, Switzerland.
| | | |
Collapse
|