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Amin SJ, Aghajan Y, Webb AJ. Clinical experience with bromocriptine for central hyperthermia after brain insult. Brain Inj 2024:1-7. [PMID: 38555516 DOI: 10.1080/02699052.2024.2337231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Bromocriptine is a dopamine receptor agonist used for central hyperthermia with limited data. We describe our single-center experience utilizing bromocriptine for central hyperthermia, including the population treated, most common dosing regimens, adverse events, and discontinuation reasons. METHODS A retrospective study was conducted screening patients who were admitted to intensive care units for acute neurological insults and administered bromocriptine for central hyperthermia between April 2016 and September 2022. Baseline characteristics, disease severity markers, and bromocriptine doses were collected. Body temperatures prior to the first dose of bromocriptine, at the time of dose, and after each dose were recorded. Co-administration of additional hyperthermia management therapies was noted. RESULTS Thirty patients were included. The most common diagnosis was traumatic brain injury (TBI) (N = 14). The most common reason for discontinuation was resolution of indication (N = 14). Discontinuation due to mild adverse effects occurred in four patients; hepatotoxicity was the most common. There was a paired mean difference of -0.37°C (p = 0.005) between temperatures before and after bromocriptine initiation. CONCLUSION Bromocriptine is a potential therapy for the management of central hyperthermia in patients with severe acute neurologic insults who have failed other therapies. Bromocriptine was well tolerated and associated with a low incidence of adverse events.
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Affiliation(s)
- Suneri J Amin
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, USA
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yasmin Aghajan
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, Boston, USA
| | - Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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Webb AJ. "Every beet you take": lowering systolic blood pressure and improving vascular function/exercise capacity via the dietary nitrate-nitrite-NO pathway in patients with COPD. Eur Respir J 2024; 63:2302238. [PMID: 38302179 DOI: 10.1183/13993003.02238-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024]
Affiliation(s)
- Andrew J Webb
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular and Metabolic Medicine and Sciences, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Sinha A, Dutta U, Demir OM, De Silva K, Ellis H, Belford S, Ogden M, Li Kam Wa M, Morgan HP, Shah AM, Chiribiri A, Webb AJ, Marber M, Rahman H, Perera D. Rethinking False Positive Exercise Electrocardiographic Stress Tests by Assessing Coronary Microvascular Function. J Am Coll Cardiol 2024; 83:291-299. [PMID: 38199706 PMCID: PMC10790243 DOI: 10.1016/j.jacc.2023.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Exercise electrocardiographic stress testing (EST) has historically been validated against the demonstration of obstructive coronary artery disease. However, myocardial ischemia can occur because of coronary microvascular dysfunction (CMD) in the absence of obstructive coronary artery disease. OBJECTIVES The aim of this study was to assess the specificity of EST to detect an ischemic substrate against the reference standard of coronary endothelium-independent and endothelium-dependent microvascular function in patients with angina with nonobstructive coronary arteries (ANOCA). METHODS Patients with ANOCA underwent invasive coronary physiological assessment using adenosine and acetylcholine. CMD was defined as impaired endothelium-independent and/or endothelium-dependent function. EST was performed using a standard Bruce treadmill protocol, with ischemia defined as the appearance of ≥0.1-mV ST-segment depression 80 ms from the J-point on electrocardiography. The study was powered to detect specificity of ≥91%. RESULTS A total of 102 patients were enrolled (65% women, mean age 60 ± 8 years). Thirty-two patients developed ischemia (ischemic group) during EST, whereas 70 patients did not (nonischemic group); both groups were phenotypically similar. Ischemia during EST was 100% specific for CMD. Acetylcholine flow reserve was the strongest predictor of ischemia during exercise. Using endothelium-independent and endothelium-dependent microvascular dysfunction as the reference standard, the false positive rate of EST dropped to 0%. CONCLUSIONS In patients with ANOCA, ischemia on EST was highly specific of an underlying ischemic substrate. These findings challenge the traditional belief that EST has a high false positive rate.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom. https://twitter.com/AishSinha1
| | - Utkarsh Dutta
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Ozan M Demir
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Kalpa De Silva
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Howard Ellis
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Samuel Belford
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Mark Ogden
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Matthew Li Kam Wa
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Holly P Morgan
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Ajay M Shah
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Amedeo Chiribiri
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Andrew J Webb
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Michael Marber
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Haseeb Rahman
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom.
| | - Divaka Perera
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom. https://twitter.com/divaka_perera
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Sinha A, Rahman H, Douiri A, Demir OM, De Silva K, Clapp B, Webb I, Gulati A, Pinho P, Dutta U, Ellis H, Shah AM, Chiribiri A, Marber M, Webb AJ, Perera D. ChaMP-CMD: A Phenotype-Blinded, Randomized Controlled, Cross-Over Trial. Circulation 2024; 149:36-47. [PMID: 37905403 PMCID: PMC10752262 DOI: 10.1161/circulationaha.123.066680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Angina with nonobstructive coronary arteries is a common condition for which no effective treatment has been established. We hypothesized that the measurement of coronary flow reserve (CFR) allows identification of patients with angina with nonobstructive coronary arteries who would benefit from anti-ischemic therapy. METHODS Patients with angina with nonobstructive coronary arteries underwent blinded invasive CFR measurement and were randomly assigned to receive 4 weeks of amlodipine or ranolazine. After a 1-week washout, they crossed over to the other drug for 4 weeks; final assessment was after the cessation of study medication for another 4 weeks. The primary outcome was change in treadmill exercise time, and the secondary outcome was change in Seattle Angina Questionnaire summary score in response to anti-ischemic therapy. Analysis was on a per protocol basis according to the following classification: coronary microvascular disease (CMD group) if CFR<2.5 and reference group if CFR≥2.5. The study protocol was registered before the first patient was enrolled (International Standard Randomised Controlled Trial Number: ISRCTN94728379). RESULTS Eighty-seven patients (61±8 years of age; 62% women) underwent random assignment (57 CMD group and 30 reference group). Baseline exercise time and Seattle Angina Questionnaire summary scores were similar between groups. The CMD group had a greater increment (delta) in exercise time than the reference group in response to both amlodipine (difference in delta, 82 s [95% CI, 37-126 s]; P<0.001) and ranolazine (difference in delta, 68 s [95% CI, 21-115 s]; P=0.005). The CMD group reported a greater increment (delta) in Seattle Angina Questionnaire summary score than the reference group in response to ranolazine (difference in delta, 7 points [95% CI, 0-15]; P=0.048), but not to amlodipine (difference in delta, 2 points [95% CI, -5 to 8]; P=0.549). CONCLUSIONS Among phenotypically similar patients with angina with nonobstructive coronary arteries, only those with an impaired CFR derive benefit from anti-ischemic therapy. These findings support measurement of CFR to diagnose and guide management of this otherwise heterogeneous patient group.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Abdel Douiri
- Department of Medical Statistics, School of Life Course & Population Sciences (A.D.), King’s College London, UK
| | - Ozan M. Demir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Kalpa De Silva
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Brian Clapp
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Ian Webb
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
- King’s College Hospital NHS Foundation Trust, London. UK (I.W., A.M.S.)
| | - Ankur Gulati
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Pedro Pinho
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Utkarsh Dutta
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Howard Ellis
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Ajay M. Shah
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
- King’s College Hospital NHS Foundation Trust, London. UK (I.W., A.M.S.)
| | - Amedeo Chiribiri
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Michael Marber
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Andrew J. Webb
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
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Sinha A, Rahman H, Rajani R, Demir OM, Li KamWa M, Morgan H, Ezad SM, Ellis H, Hogan D, Gulati A, Shah AM, Chiribiri A, Webb AJ, Marber M, Perera D. Characterizing Mechanisms of Ischemia in Patients With Myocardial Bridges. Circ Cardiovasc Interv 2024; 17:e013657. [PMID: 37929596 PMCID: PMC10782941 DOI: 10.1161/circinterventions.123.013657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Myocardial bridges (MBs) are prevalent and can be associated with acute and chronic ischemic syndromes. We sought to determine the substrates for ischemia in patients with angina with nonobstructive coronary arteries and a MB in the left anterior descending artery. METHODS Patients with angina with nonobstructive coronary arteries underwent the acquisition of intracoronary pressure and flow during rest, supine bicycle exercise, and adenosine infusion. Coronary wave intensity analysis was performed, with perfusion efficiency defined as accelerating wave energy/total wave energy (%). Epicardial endothelial dysfunction was defined as a reduction in epicardial vessel diameter ≥20% in response to intracoronary acetylcholine infusion. Patients with angina with nonobstructive coronary arteries and a MB were compared with 2 angina with nonobstructive coronary arteries groups with no MB: 1 with coronary microvascular disease (CMD: coronary flow reserve, <2.5) and 1 with normal coronary flow reserve (reference: coronary flow reserve, ≥2.5). RESULTS Ninety-two patients were enrolled in the study (30 MB, 33 CMD, and 29 reference). Fractional flow reserve in these 3 groups was 0.86±0.05, 0.92±0.04, and 0.94±0.05; coronary flow reserve was 2.5±0.5, 2.0±0.3, and 3.2±0.6. Perfusion efficiency increased numerically during exercise in the reference group (65±9%-69±13%; P=0.063) but decreased in the CMD (68±10%-50±10%; P<0.001) and MB (66±9%-55±9%; P<0.001) groups. The reduction in perfusion efficiency had distinct causes: in CMD, this was driven by microcirculation-derived energy in early diastole, whereas in MB, this was driven by diminished accelerating wave energy, due to the upstream bridge, in early systole. Epicardial endothelial dysfunction was more common in the MB group (54% versus 29% reference and 38% CMD). Overall, 93% of patients with a MB had an identifiable ischemic substrate. CONCLUSIONS MBs led to impaired coronary perfusion efficiency during exercise, which was due to diminished accelerating wave energy in early systole compared with the reference group. Additionally, there was a high prevalence of endothelial and microvascular dysfunction. These ischemic mechanisms may represent distinct treatment targets.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Ronak Rajani
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
| | - Ozan M. Demir
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Matthew Li KamWa
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Holly Morgan
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Saad M. Ezad
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Howard Ellis
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Dexter Hogan
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
| | - Ankur Gulati
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
| | - Ajay M. Shah
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Amedeo Chiribiri
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Andrew J. Webb
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Michael Marber
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Divaka Perera
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
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Webb AJ, Avramovska S, Qualls S, Lo CK, Roberts RJ, Barra ME. Impact of an enteral nutrition holding guideline on daily nutrition goals in patients taking phenytoin. Nutr Clin Pract 2023; 38:1334-1342. [PMID: 37537901 DOI: 10.1002/ncp.11051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/26/2023] [Accepted: 07/09/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Concomitant administration of enteral nutrition (EN) and phenytoin decreases phenytoin absorption. Concerns over impaired nutrition, however, may prevent EN from being held surrounding phenytoin administration. This study aimed to evaluate whether EN holding guidelines impacted nutrition goal achievement in patients taking phenytoin. METHODS Adult patients administered enteral phenytoin for acute or chronic seizures while receiving EN during a neurocritical care admission 6 months before and after EN holding guideline implementation were eligible. Patients without phenytoin concentrations or a clinical registered dietitian assessment were excluded. The primary outcome was the percentage of nutrition daily goals attained before and after implementation. Secondary end points included the incidence of hypoglycemia, differences in measured phenytoin concentrations, and rates of therapeutic (10-20 mcg/ml) and high-therapeutic (15-20 mcg/ml) concentration attainment. Concentrations were adjusted for hypoalbuminemia using the Winter-Tozer equation. RESULTS Fifty-five patients representing 412 patient days and 1110 phenytoin administrations were included with 29 preimplementation and 26 postimplementation patients. Median percent attainment of daily EN goals was consistent preimplementation and postimplementation (86% vs 83%, P = 0.48). No significant change in rates of days with hypoglycemia was observed. Adjusted phenytoin concentrations were similar before and after implementation (14.1 vs 15.2 mcg/ml, P = 0.45), but the preimplementation cohort had a lower proportion of high-therapeutic concentrations (23% vs 36%, P = 0.018). CONCLUSION Holding EN for phenytoin did not impact attainment of daily nutrition goals and was not associated with increased rates of hypoglycemia. This is the first study to evaluate the effect of EN holding on nutrition goals in patients receiving phenytoin.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Simona Avramovska
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pharmacy, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Stephanie Qualls
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carmen Kaman Lo
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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Webb AJ, Carver B, Rowe S, Sikora A. The use of electronic health record embedded MRC-ICU as a metric for critical care pharmacist workload. JAMIA Open 2023; 6:ooad101. [PMID: 38058680 PMCID: PMC10697785 DOI: 10.1093/jamiaopen/ooad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/27/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives A lack of pharmacist-specific risk-stratification scores in the electronic health record (EHR) may limit resource optimization. The medication regimen complexity-intensive care unit (MRC-ICU) score was implemented into our center's EHR for use by clinical pharmacists. The purpose of this evaluation was to evaluate MRC-ICU as a predictor of pharmacist workload and to assess its potential as an additional dimension to traditional workload measures. Materials and methods Data were abstracted from the EHR on adult ICU patients, including MRC-ICU scores and 2 traditional measures of pharmacist workload: numbers of medication orders verified and interventions logged. This was a single-center study of an EHR-integrated MRC-ICU tool. The primary outcome was the association of MRC-ICU with institutional metrics of pharmacist workload. Associations were assessed using the initial 24-h maximum MRC-ICU score's Pearson's correlation with overall admission workload and the day-to-day association using generalized linear mixed-effects modeling. Results A total of 1205 patients over 5083 patient-days were evaluated. Baseline MRC-ICU was correlated with both cumulative order volume (Spearman's rho 0.41, P < .001) and cumulative interventions placed (Spearman's rho 0.27, P < .001). A 1-point increase in maximum daily MRC-ICU was associated with a 31% increase in order volume (95% CI, 24%-38%) and 4% increase in interventions (95% CI, 2%-5%). Discussion and conclusion The MRC-ICU is a validated score that has been previously correlated with important patient-centered outcomes. Here, MRC-ICU was modestly associated with 2 traditional objective measures of pharmacist workload, including orders verified and interventions placed, which is an important step for its use as a tool for resource utilization needs.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR 97239, United States
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Bayleigh Carver
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA 30912, United States
| | - Sandra Rowe
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA 30912, United States
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Webb AJ, Borrelli EP, Vyas A, Taylor LE, Buchanan AL. The effect of antiretroviral therapy with high central nervous system penetration on HIV-related cognitive impairment: a systematic review and meta-analysis. AIDS Care 2023; 35:1635-1646. [PMID: 35850626 PMCID: PMC9845421 DOI: 10.1080/09540121.2022.2098231] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 06/30/2022] [Indexed: 01/21/2023]
Abstract
Chronic complications are a significant concern for people living with HIV/AIDS (PLWHA) infection. HIV-associated neurocognitive disorders (HAND) are prevalent in PLWHA. Yet, the efficacy of medications that penetrate the central nervous system (CNS) at preventing or slowing the progression of HAND remains largely unknown. The objective of this study was to determine whether high CNS penetration effectiveness (CPE) regimens improve neurocognitive test scores in PLWHA on combined antiretroviral therapy (cART). Primary literature evaluating cognitive outcomes based on CPE score of cART regimens in PLWHA was assembled from PubMed/Medline and EMBASE. Both randomized controlled trials and observational studies with at least 12 weeks of follow-up were included. A meta-analysis was conducted to calculate the standardized mean difference. Eight trials including a total of 3,303 patients with 13,103 person-years of follow-up were included in the systematic review. Four trials (n = 366 patients) met our inclusion criteria and were included in the meta-analysis. In the meta-analysis, HIV regimens with a high CPE score did not affect NPZ-4 or GDS scores (standardized mean difference (SMD) 0.10, 95% CI -0.19, 0.38; I2 = 26%). Future studies with larger sample sizes are warranted to prospectively evaluate the relationship between CPE and progression of HAND.
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Affiliation(s)
| | | | - Ami Vyas
- University of Rhode Island, College of Pharmacy
| | - Lynn E. Taylor
- University of Rhode Island, College of Pharmacy
- CODAC Behavioral Health, HIV and Viral Hepatitis Services
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9
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El Ghali A, Morrisette T, Alosaimy S, Lucas K, Tupayachi-Ortiz MG, Vemula R, Wadle C, Philley JV, Mejia-Chew C, Hamad Y, Stevens RW, Zeuli JD, Webb AJ, Fiske CT, Simonyan A, Cimino CL, Mammadova M, Umana VE, Hasbun R, Butt S, Molina KC, Thomas M, Kaip EA, Bouchard J, Gore TW, Howard C, Cabanilla MG, Holger DJ, Frens JJ, Barger M, Ong A, Cohen KA, Rybak MJ. Long-term evaluation of clinical success and safety of omadacycline in nontuberculous mycobacteria infections: a retrospective, multicenter cohort of real-world health outcomes. Antimicrob Agents Chemother 2023; 67:e0082423. [PMID: 37768312 PMCID: PMC10583686 DOI: 10.1128/aac.00824-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/13/2023] [Indexed: 09/29/2023] Open
Abstract
Infections due to nontuberculous mycobacteria (NTM) continue to increase in prevalence, leading to problematic clinical outcomes. Omadacycline (OMC) is an aminomethylcycline antibiotic with FDA orphan drug and fast-track designations for pulmonary NTM infections, including Mycobacteroides abscessus (MAB). This multicenter retrospective study across 16 U.S. medical institutions from January 2020 to March 2023 examined the long-term clinical success, safety, and tolerability of OMC for NTM infections. The cohort included patients aged ≥18 yr, who were clinically evaluable, and` had been treated with OMC for ≥3 mo without a previous diagnosis of cystic fibrosis. The primary outcome was 3 mo clinical success, with secondary outcomes including clinical improvement and mortality at 6- and 12 mo, persistence or reemergence of infection, adverse effects, and reasons for OMC utilization. Seventy-five patients were included in this analysis. Most patients were female (48/75, 64.0%) or Caucasian (58/75, 77.3%), with a median (IQR) age of 59 yr (49-67). Most had NTM pulmonary disease (33/75, 44.0%), skin and soft tissue disease (19/75, 25.3%), or osteomyelitis (10/75, 13.3%), and Mycobacterium abscessus (60/75, 80%) was the most commonly isolated NTM pathogen. The median (IQR) treatment duration was 6 mo (4 - 14), and the most commonly co-administered antibiotic was azithromycin (33/70, 47.1%). Three-month clinical success was observed in 80.0% (60/75) of patients, and AEs attributable to OMC occurred in 32.0% (24/75) of patients, leading to drug discontinuation in 9.3% (7/75).
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Affiliation(s)
- Amer El Ghali
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Taylor Morrisette
- Department of Clinical Pharmacy & Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, South Carolina, USA
- Department of Pharmacy Services, Medical University of South Carolina (MUSC) Health, Charleston, South Carolina, USA
| | - Sara Alosaimy
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Kristen Lucas
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Maria G. Tupayachi-Ortiz
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Raaga Vemula
- University of Texas Health Science Center, University of Texas, Tyler, Texas, USA
| | - Carly Wadle
- University of Texas Health Science Center, University of Texas, Tyler, Texas, USA
| | - Julie V. Philley
- University of Texas Health Science Center, University of Texas, Tyler, Texas, USA
| | - Carlos Mejia-Chew
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yasir Hamad
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan W. Stevens
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - John D. Zeuli
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J. Webb
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Christina T. Fiske
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anahit Simonyan
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christo L. Cimino
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mehriban Mammadova
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Virginia E. Umana
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rodrigo Hasbun
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Saira Butt
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kyle C. Molina
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael Thomas
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Emily A. Kaip
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, North Carolina, USA
| | - Jeannette Bouchard
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Tristan W. Gore
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Catessa Howard
- Department of Pharmacy, West Virginia University Medicine, Morgantown, West Virginia, USA
| | - M. Gabriela Cabanilla
- Division of Infectious Diseases, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Dana J. Holger
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Jeremy J. Frens
- Department of Pharmacy Services, Cone Health, Greensboro, North Carolina, USA
| | - Melissa Barger
- Department of Medicine, Ventura County Medical Center, Ventura, California, USA
| | - Aaron Ong
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Marlyand, USA
| | - Keira A. Cohen
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Marlyand, USA
| | - Michael J. Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit Medical Center, Detroit, Michigan, USA
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10
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Roy R, Wilcox J, Webb AJ, O’Gallagher K. Dysfunctional and Dysregulated Nitric Oxide Synthases in Cardiovascular Disease: Mechanisms and Therapeutic Potential. Int J Mol Sci 2023; 24:15200. [PMID: 37894881 PMCID: PMC10607291 DOI: 10.3390/ijms242015200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
Nitric oxide (NO) plays an important and diverse signalling role in the cardiovascular system, contributing to the regulation of vascular tone, endothelial function, myocardial function, haemostasis, and thrombosis, amongst many other roles. NO is synthesised through the nitric oxide synthase (NOS)-dependent L-arginine-NO pathway, as well as the nitrate-nitrite-NO pathway. The three isoforms of NOS, namely neuronal (NOS1), inducible (NOS2), and endothelial (NOS3), have different localisation and functions in the human body, and are consequently thought to have differing pathophysiological roles. Furthermore, as we continue to develop a deepened understanding of the different roles of NOS isoforms in disease, the possibility of therapeutically modulating NOS activity has emerged. Indeed, impaired (or dysfunctional), as well as overactive (or dysregulated) NOS activity are attractive therapeutic targets in cardiovascular disease. This review aims to describe recent advances in elucidating the physiological role of NOS isoforms within the cardiovascular system, as well as mechanisms of dysfunctional and dysregulated NOS in cardiovascular disease. We then discuss the modulation of NO and NOS activity as a target in the development of novel cardiovascular therapeutics.
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Affiliation(s)
- Roman Roy
- Cardiovascular Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK;
| | - Joshua Wilcox
- Cardiovascular Department, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK;
| | - Andrew J. Webb
- Department of Clinical Pharmacology, British Heart Foundation Centre, School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London SE1 7EH, UK;
| | - Kevin O’Gallagher
- Cardiovascular Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK;
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Medicine & Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 9NU, UK
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11
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Phillips KM, Rodriguez-Lopez JM, Webb AJ. Elevations in Norclobazam Concentrations and Altered Mental Status in CYP2C19 Poor Metabolizer Phenotype: A Case Report. Neurohospitalist 2023; 13:434-437. [PMID: 37701253 PMCID: PMC10494815 DOI: 10.1177/19418744231189078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Clobazam is a 1,5-benzodiazepine frequently used as an adjunctive agent for refractory seizures and status epilepticus. Clobazam undergoes metabolism to an active metabolite norclobazam which is subsequently hydroxylated by CYP2C19, a cytochrome with several pharmacogenetic variants. Patients with poor metabolizer phenotypes may have elevated norclobazam levels and subsequent adverse effects. We present a case of an Asian American male receiving clobazam at a standard therapeutic dose for seizure disorder who became comatose secondary to significantly elevated norclobazam concentrations. Genetic testing revealed the patient was a poor CYP2C19 metabolizer, accounting for the impaired clearance. Clinicians should be aware of the patient populations at risk for these genetic polymorphisms and adjust initial doses based on package labeling or consider therapeutic drug monitoring to avoid adverse effects.
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Affiliation(s)
| | - Josanna M. Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew J. Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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12
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Barra ME, Webb AJ, Roberts RJ, Ross M, Hallisey R, Szumita P, Guidon AC. Implementation of a myasthenia gravis drug-disease interaction clinical decision support tool reduces prescribing of high-risk medications. Muscle Nerve 2023; 67:284-290. [PMID: 36691226 DOI: 10.1002/mus.27790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 01/25/2023]
Abstract
INTRODUCTION/AIMS High-risk medication exposure is a modifiable risk factor for myasthenic exacerbation and crisis. We evaluated whether real-time electronic clinical decision support (CDS) was effective in reducing the rate of prescribing potentially high-risk medications to avoid or use with caution in patients with myasthenia gravis. METHODS An expert panel reviewed the available drug-disease pairings and associated severity levels to activate the alerts for CDS. All unique alerts activated in both inpatient and outpatient contexts were analyzed over a two-year period. Clinical context, alert severity, medication class, and alert action were collected. The primary outcome was alert override rate. Secondary outcomes included the percentage of unique medication exposures avoided and predictors of alert override. RESULTS During the analysis period, 2817 unique alerts fired, representing 830 distinct patient-medication exposures for 577 unique patients. The overall alert override rate was 85% (80.3% for inpatient alerts and 95.8% for outpatient alerts). Of unique medication-patient exposures, 19% were avoided because of the alert. Assigned alert severity of "contraindicated" were less likely to be overridden (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.32-0.56), as well as alerts activated during evening staffing (OR 0.69, 95% CI 0.55-0.87). DISCUSSION Implementation of a myasthenia gravis drug-disease interaction alert reduced overall patient exposure to potentially harmful medications by approximately 19%. Future optimization includes enhanced provider and pharmacist education. Further refinement of alert logic criteria to optimize medication risk reduction and reduce alert fatigue is warranted to support clinicians in prescribing and reduce electronic health record time burden.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marjorie Ross
- Department of Neurology, Newton Wellesley Hospital, Newton Lower Falls, Massachusetts, USA
| | - Robert Hallisey
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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13
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Webb AJ. Introduction to the "BRAINS & AIMS" series of pharmacological/prescribing principles of commonly prescribed (top 100) drugs: Education and discussion. Br J Clin Pharmacol 2023; 89:926-930. [PMID: 36691105 DOI: 10.1111/bcp.15654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- Andrew J Webb
- Department of Clinical Pharmacology, British Heart Foundation Centre, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
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14
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Koslover J, Bruce D, Patel S, Webb AJ. Metformin-'BRAINS & AIMS' pharmacological/prescribing principles of commonly prescribed (Top 100) drugs: Education and discussion. Br J Clin Pharmacol 2023; 89:931-938. [PMID: 36575901 DOI: 10.1111/bcp.15653] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Abstract
We review pharmacological/prescribing principles relating to metformin according to our mnemonic framework: 'BRAINS & AIMS' (Benefits, Risks, Adverse Effects, Interactions, Necessary prophylaxis, Susceptibilities, Administering, Informing, Monitoring and Stopping): Benefits: Metformin's licensed uses: Type 2 diabetes mellitus (T2DM) treatment, reduction in risk or delay of onset. No clear evidence metformin influences patient-important outcomes [Cochrane Review (2020) of 18 RCTs (n = 10 680)]. Risks: Inexpensive, essential WHO list drug; use contraindicated/not tolerated in 15%: for example, contraindication: lactic acidosis in renal impairment (eGFR <30 mL/min/1.73 m2 ). Adverse effects: Common gastrointestinal (GI) side effects are dose-related and include abdominal pain, decreased appetite, diarrhoea (usually transient), nausea and vomiting, altered taste; vitamin B12 deficiency. Rare: acute metabolic acidosis (lactic acidosis/diabetic ketoacidosis). Interactions (pharmacokinetic) occur with drugs impairing renal function and hence metformin excretion, and drugs inhibiting organic cation transporter 1 or 2 (OCT1, OCT2), and/or multidrug and toxin extrusion protein 1 (MATE1/2-K), such as cimetidine, ranolazine, trimethoprim and verapamil, and inducers such as rifampicin. The risk of hypoglycaemia may increase when metformin is used in combination with other medications for diabetes (pharmacodynamic interaction). Necessary prophylaxis: Detect/treat vitamin B12 deficiency. Susceptible groups: Elderly/renal/liver impairment (lactic acidosis); safe in pregnancy/breastfeeding. Administering: Initially 500 mg once daily (morning) with breakfast; titrate only after 1 week. Informing (relevant BRAINS & A(I)MS principles). Monitoring: Renal function beforehand, and 6-12 monthly, HbA1c 3-6 monthly until controlled. Serum vitamin B12 levels if deficiency is suspected/risk factors for. Stopping: Encourage patients to continue medication, unless deteriorating renal/liver function. Reasons for deprescribing: no harms from stopping suddenly.
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Affiliation(s)
- Joshua Koslover
- King's College London GKT School of Medical Education, London, UK.,West Hertfordshire Teaching Hospitals NHS Trust (Watford General Hospital), Watford, UK
| | - Deborah Bruce
- King's College London GKT School of Medical Education, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shivani Patel
- King's College London GKT School of Medical Education, London, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew J Webb
- Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular and Metabolic Medicine and Sciences, London, UK
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15
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Webb AJ, Oetken HJ, Plott AJ, Knapp C, Munger DN, Gibson E, Schreiber M, Barton CA. The impact of low-dose aspirin in the Brain Injury Guidelines on outcomes in traumatic brain injury: A retrospective cohort study. J Trauma Acute Care Surg 2023; 94:320-327. [PMID: 35999660 DOI: 10.1097/ta.0000000000003772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Current Brain Injury Guidelines (BIG) characterize patients with intracranial hemorrhage taking antiplatelet or anticoagulant agents as BIG 3 (the most severe category) regardless of trauma severity. This study assessed the risk of in-hospital mortality or need for neurosurgery in patients taking low-dose aspirin who otherwise would be classified as BIG 1. METHODS This was a retrospective study at an academic level 1 trauma center. Patients were included if they were admitted with traumatic intracerebral hemorrhage and were evaluated by the BIG criteria. Exclusion criteria included indeterminate BIG status or patients with missing primary outcomes documentation. Patients were categorized as BIG 1, BIG 2, BIG 3, or BIG 1 on aspirin (patients with BIG 1 features taking low-dose aspirin). The primary endpoint was a composite of neurosurgical intervention and all-cause in-hospital mortality. Key secondary endpoints include rate of intracranial hemorrhage progression, and intensive care unit- and hospital-free days. RESULTS A total of 1,520 patients met the inclusion criteria. Median initial Glasgow Coma Scale was 14 (interquartile range [IQR], 12-15), Injury Severity Scale score was 17 (IQR, 10-25), and Abbreviated Injury Scale subscore head and neck (AIS Head ) was 3 (IQR, 3-4). The rate of the primary outcome for BIG 1, BIG 1 on aspirin, BIG 2, and BIG 3 was 1%, 2.2%, 1%, and 27%, respectively; the difference between BIG 1 on aspirin and BIG 3 was significant ( p < 0.001). CONCLUSION Patients taking low-dose aspirin with otherwise BIG 1-grade injuries experienced mortality and required neurosurgery significantly less often than other patients categorized as BIG 3. Inclusion of low-dose aspirin in the BIG criteria should be reevaluated. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Andrew J Webb
- From the Department of Pharmacy (A.J.W., H.J.O., C.A.B.), Oregon Health and Science University, Portland, Oregon; Department of Pharmacy (A.J.W.), Massachusetts General Hospital, Boston, Massachusetts; Department of Pharmacy (A.J.P.), University Hospital, Newark, New Jersey; Department of Surgery (C.K., E.G., M.S.), Oregon Health and Science University; and Department of Neurosurgery (D.N.M.), Oregon Health and Science University, Portland, Oregon
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16
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Asad SD, Carvalho De Oliveira L, Ponciano A, Webb AJ, Yilmaz P, anand V, Singhal A. Abstract TP162: Age, Weight, And Prior Stroke Predicts Ischemic Stroke Despite Direct Acting Oral Anticoagulant Use In Patients With Atrial Fibrillation. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Direct-acting oral anticoagulants (DOACs) and warfarin are standard of care for secondary prevention of ischemic stroke (IS) in persons with atrial fibrillation (AF). However, despite adequate anticoagulation (AC), patients may still experience recurrent IS. We aimed to study the characteristics of patients who developed IS despite therapeutic AC, specifically with DOACs.
Methods:
Between 2012 and 2021, patients admitted at our hospital with IS despite adequate AC for AF were enrolled. Clinical variables collected included National Institute of Health Stroke Scale (NIHSS), CHA
2
DS
2
-VASc and modified Rankin Score (mRS) at admission. Baseline characteristics were compared between patients taking DOACs and warfarin. Logistic regression analyses were performed to identify predictors of IS in patients using DOACs.
Results:
A total of 595 patients were included. Of these, 291 patients (48.9%) were on DOACs with a mean age of 75.21 and 43.9% were female. The median CHA
2
DS
2
-VASc and NIHSS score in the DOAC group was 4 and 6, respectively. Compared to those on Warfarin, patients on DOACs were younger (75.21 vs. 78.99 p < 0.001), more likely to be men (55.3% vs. 45.2% p = 0.01) and had higher rates of prior TIA/IS (37.5% vs. 29.3% p = 0.04). Both groups had similar rates of hemorrhagic transformation, but more patients in the DOAC group were on antiplatelet agents concomitantly (21% vs. 6.9% p < 0.001). The most prescribed DOAC was apixaban (66.3%) and cardioembolism was the most common stroke etiology (63.6%), followed by cryptogenic, which was significantly higher in the DOAC group (18.2% vs. 8.3% p = 0.02). Notably, DOAC failure in preventing IS was associated with younger age, overweight/obesity, and prior TIA/IS
(Table)
.
Conclusions:
IS despite the use of DOACs is more likely to occur in younger people with prior TIA/IS and obesity. Focusing on preventative strategies and risk factor control for competing mechanisms in this subgroup may help prevent IS recurrence.
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17
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Webb AJ, Brown CS, Rech MA. Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants and Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA 2022; 327:2354-2355. [PMID: 35727284 DOI: 10.1001/jama.2022.6350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - Megan A Rech
- Loyola University Medical Center, Maywood, Illinois
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18
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Morrisette T, Alosaimy S, Lagnf AM, Frens JJ, Webb AJ, Veve MP, Stevens R, Bouchard J, Gore TW, Ansari I, Rybak MJ. Real-World, Multicenter Case Series of Patients Treated with Oral Omadacycline for Resistant Gram-Negative Pathogens. Infect Dis Ther 2022; 11:1715-1723. [PMID: 35567718 PMCID: PMC9334473 DOI: 10.1007/s40121-022-00645-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Antibiotic-resistant Gram-negative bacteria have been associated with substantial morbidity and mortality and have limited treatment options available. Omadacycline (OMC) is an aminomethylcycline antibiotic that has been shown to exhibit broad in vitro activity against antibiotic-resistant Gram-negative bacteria. Given the lack of real-world data, the primary objective of our report was to describe early experience with OMC for the treatment of resistant Gram-negative infections. METHODS This was a real-world, multicenter, observational cases series/pilot study conducted in the USA. Inclusion criteria included any adult patient aged ≥ 18 years who received OMC for ≥ 72 h either in the inpatient and/or outpatient setting. Clinical success was defined as a composite of 90-day survival from initiation of OMC, lack of alteration in treatment/addition of other antibiotic due to concerns of OMC failure, and lack of microbiologic recurrence within 30 days from the end of therapy. RESULTS Oral OMC was used in nine cases primarily for multidrug-resistant (MDR)/extensively drug-resistant (XDR) Gram-negative bacterial infections (55.6% XDR and/or carbapenem-resistant Acinetobacter baumannii [CRAB]). The majority of infections were of bone/joint (55.6%) origin, followed by intra-abdominal (33.3%) origin. Clinical success occurred in 66.7% of cases, with 80.0% success each in infections of bone/joint origin or those caused by CRAB. One patient experienced an adverse effect that was not treatment limiting while on therapy (gastrointestinal). CONCLUSION The use of oral OMC in MDR/XDR Gram-negative infections exhibited a relatively high success rate with minimal adverse effects. Real-world studies with larger case numbers are needed to confirm our initial findings.
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Affiliation(s)
- Taylor Morrisette
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA.,Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, 280 Calhoun Street, Charleston, SC, 29425, USA.,Department of Clinical Pharmacy Services, Medical University of South Carolina Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, Charleston, SC, 29425, USA
| | - Sara Alosaimy
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Jeremy J Frens
- Department of Pharmacy, Cone Health, 1121 North Church Street, Greensboro, NC, 27401, USA
| | - Andrew J Webb
- Department of Pharmacy, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Michael P Veve
- University of Tennessee Medical Center, 1924 Alcoa Hwy, Knoxville, TN, 37920, USA.,Department of Clinical Pharmacy and Transplational Science, College of Pharmacy, University of Tennessee Health Science Center, 1924 Alcoa Hwy, Knoxville, TN, 37920, USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48206, USA
| | - Ryan Stevens
- Department of Pharmacy, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Jeannette Bouchard
- College of Pharmacy, University of South Carolina, 715 Sumter Street, Columbia, SC, 29208, USA
| | - Tristan W Gore
- College of Pharmacy, University of South Carolina, 715 Sumter Street, Columbia, SC, 29208, USA
| | - Iman Ansari
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA. .,Division of Infectious Diseases, Department of Medicine, Wayne State University, 540 E Canfield Street, Detroit, MI, 48201, USA. .,Department of Pharmacy, Detroit Receiving Hospital, 4201 St Antoine, Detroit, MI, 48201, USA.
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19
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Webb AJ, Rowe S, Newsome AS. A descriptive report of the rapid implementation of automated MRC-ICU calculations in the EMR of an academic medical center. Am J Health Syst Pharm 2022; 79:979-983. [PMID: 35187576 PMCID: PMC9171568 DOI: 10.1093/ajhp/zxac059] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Numerous clinical scoring tools exist for a variety of patient populations and disease states, but few tools provide information specifically designed for use by critical care pharmacists. The medication regimen complexity-intensive care unit (MRC-ICU) score was designed to provide high-level information about the complexity of critically ill patients' medication regimens for use by critical care pharmacists. To date, implementation of this score in the electronic medical record (EMR) has not been reported. SUMMARY Using an agile project management framework, the MRC-ICU score was rapidly implemented into an academic medical center's EMR. The score is automatically calculated for all critically ill patients and is available for critical care pharmacists to triage patient review in their individual workflow. Reporting capabilities of the score also allow for granular complexity trending over time and between units, supplementing other objective measures of pharmacist workload. CONCLUSION The MRC-ICU score can be quickly implemented into the EMR for pharmacist use in real time. Future investigations into how pharmacists utilize this information and how to harness reporting capabilities for pharmacist workload assessment are warranted.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, and Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sandra Rowe
- Address correspondence to Dr. Rowe (). Twitter: @AJWPharm, @AndreaSikora
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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20
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Barton CA, Oetken HJ, Hall NL, Webb AJ, Hoops HE, Schreiber M. Incidence of traumatic intracranial hemorrhage expansion after stable repeat head imaging: A retrospective cohort study. Am J Surg 2022; 224:775-779. [DOI: 10.1016/j.amjsurg.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/31/2021] [Accepted: 01/30/2022] [Indexed: 11/01/2022]
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21
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Bath PM, Skinner CJC, Bath CS, Woodhouse LJ, Korovesi AAK, Long H, Havard D, Coleman CM, England TJ, Leyland V, Lim WS, Montgomery AA, Royal S, Avery A, Webb AJ, Gordon AL. Dietary nitrate supplementation for preventing and reducing the severity of winter infections, including COVID-19, in care homes (BEET-Winter): a randomised placebo-controlled feasibility trial. Eur Geriatr Med 2022; 13:1343-1355. [PMID: 36385690 PMCID: PMC9668238 DOI: 10.1007/s41999-022-00714-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Infections cause considerable care home morbidity and mortality. Nitric oxide (NO) has broad-spectrum anti-viral, bacterial and yeast activity in vitro. We assessed the feasibility of supplementing dietary nitrate (NO substrate) intake in care home residents. METHODS We performed a cluster-randomised placebo-controlled trial in UK residential and nursing care home residents and compared nitrate containing (400 mg) versus free (0 mg daily) beetroot juice given for 60 days. Outcomes comprised feasibility of recruitment, adherence, salivary and urinary nitrate, and ordinal infection/clinical events. RESULTS Of 30 targeted care homes in late 2020, 16 expressed interest and only 6 participated. 49 residents were recruited (median 8 [interquartile range 7-12] per home), mean (standard deviation) age 82 (8) years, with proxy consent 41 (84%), advance directive for hospital non-admission 8 (16%) and ≥ 1 doses of COVID-19 vaccine 37 (82%). Background dietary nitrate was < 30% of acceptable daily intake. 34 (76%) residents received > 50% of juice. Residents randomised to nitrate vs placebo had higher urinary nitrate levels, median 50 [18-175] v 18 [10-50] mg/L, difference 25 [0-90]. Data paucity precluded clinical between-group comparisons; the outcome distribution was as follows: no infection 32 (67%), uncomplicated infection 0, infection requiring healthcare support 11 (23%), all-cause hospitalisation 5 (10%), all-cause mortality 0. Urinary tract infections were most common. CONCLUSIONS Recruiting UK care homes during the COVID-19 pandemic was partially successful. Supplemented dietary nitrate was tolerated and elevated urinary nitrate. Together, infections, hospitalisations and deaths occurred in 33% of residents over 60 days. A larger trial is now required. TRIAL REGISTRATION ISRCTN51124684. Application date 7/12/2020; assignment date 13/1/2021.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK ,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH Nottinghamshire UK
| | - Cameron J. C. Skinner
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Charlotte S. Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | | | - Hongjiang Long
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD UK
| | - Diane Havard
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Christopher M. Coleman
- Division of Infection, Immunity and Microbes, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH UK
| | - Timothy J. England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK ,Department of Stroke, University Hospitals of Derby and Burton, Derby, DE22 3NE UK
| | | | - Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, NG7 2RD UK
| | - Simon Royal
- University of Nottingham Health Service, Cripps Health Centre, University Park, Nottingham, NG7 2QW UK
| | - Amanda Avery
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD UK
| | - Andrew J. Webb
- Clinical Pharmacology, School of Cardiovascular Medicine and Sciences, Kings College London and British Heart Foundation Centre of Research Excellence, St Thomas’ Hospital, London, SE1 7EH UK
| | - Adam L. Gordon
- Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Derby, DE22 3NE Derbyshire UK ,NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, UK
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22
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Morrisette T, Alosaimy S, Lagnf AM, Philley JV, Sigler C, Butt S, Kaip EA, MacDougall C, Mejia-Chew C, Bouchard J, Frens JJ, Gore T, Hamad Y, Howard C, Barger M, Gabriela Cabanilla M, Ong A, Veve MP, Webb AJ, Stevens RW, Cohen KA, Rybak MJ. 1082. Real-World Experience with Omadacycline for Nontuberculous Mycobacterial Infections: A Multicenter Evaluation. Open Forum Infect Dis 2021. [PMCID: PMC8644900 DOI: 10.1093/ofid/ofab466.1276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Nontuberculous mycobacteria (NTM) are resistant to numerous antibiotics and lead to significant morbidity and mortality. Omadacycline (OMC) is an aminomethylcycline antibiotic that is Food and Drug Administration-approved for acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. Furthermore, OMC has shown in vitro activity against NTM. Given that real-world evidence is lacking, our primary objective was to evaluate the clinical success and tolerability of OMC when used for a variety of NTM infections.
Methods
This was a multicenter, retrospective, observational study conducted from January 2020 to June 2021. We included all patients ≥ 18 years of age that received OMC of any indication for Mycobacterium spp. The primary outcome was clinical success, defined as a lack of all-cause mortality, lack of persistence or re-emergence of infection during or after therapy, and lack of alteration of OMC. Incidence of adverse effects potentially attributable to OMC and reasons for OMC utilization were also analyzed.
Results
A total of 31 patients were included from 12 geographically distinct academic health systems (median age: 57 (IQR, 45-63) years; 45% male; 81% Caucasian). The majority of isolated pathogens were Mycobacterium abscessus complex (84%) and of those with subspeciation performed (54%), the majority (86%) were subsp. abscessus. The primary infections were of pulmonary origin (67%) and the median (IQR) duration of OMC therapy was 5.3 (3.2-9.4) months. Most isolates did not have OMC susceptibility conducted (87%), while the majority did for tigecycline (90%). Clinical success was reported in 81% of the population. Most patients were on combination antimicrobial therapy, and 39% of patients reported an adverse effect while on OMC (58% gastrointestinal distress). The majority of patients were prescribed OMC due to ease of administration (61%) and antimicrobial resistance to previous antibiotics (42%).
Conclusion
OMC may be a potential option for the therapy of NTM infections. Prospective, randomized clinical trials are needed to confirm our preliminary findings.
Disclosures
Julie V. Philley, MD, Paratek Pharmaceuticals (Advisor or Review Panel member)Paratek Pharmaceuticals, Inc. (Consultant) Michael P. Veve, Pharm.D., Cumberland (Grant/Research Support)Paratek Pharmaceuticals (Research Grant or Support) Michael J. Rybak, PharmD, MPH, PhD, Paratek Pharmaceuticals (Research Grant or Support)
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Affiliation(s)
- Taylor Morrisette
- Anti-Infective Research Laboratory, Wayne State University, Detroit, Michigan
| | | | | | | | - Carly Sigler
- The University of Texas Health Science Center, Tyler, Texas
| | - Saira Butt
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Emily A Kaip
- University of California, San Francisco Medical Center, San Francisco, California
| | - Conan MacDougall
- University of California San Francisco School of Pharmacy, San Francisco, California
| | | | | | | | - Tristan Gore
- Univeristy of South Carolina, Columbia, South Carolina
| | | | | | | | | | - Aaron Ong
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Keira A Cohen
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael J Rybak
- Wayne State University / Detroit Medical Center, Detroit, Michigan
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23
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Abstract
Although the antimicrobial potential of nitric oxide (NO) is widely published, it is little used clinically. NO is a key signalling molecule modulating vascular, neuronal, inflammatory and immune responses. Endogenous antimicrobial activity is largely mediated by high local NO concentrations produced by cellular inducible nitric oxide synthase, and by derivative reactive nitrogen oxide species including peroxynitrite and S-nitrosothiols. NO may be taken as dietary substrate (inorganic nitrate, L-arginine), and therapeutically as gaseous NO, and transdermal, sublingual, oral, intranasal and intravenous nitrite or nitrate. Numerous preclinical studies have demonstrated that NO has generic static and cidal activities against viruses (including β-coronaviruses such as SARS-CoV-2), bacteria, protozoa and fungi/yeasts
in vitro. Therapeutic effects have been seen in animal models
in vivo, and phase II trials have demonstrated that NO donors can reduce microbial infection. Nevertheless, excess NO, as occurs in septic shock, is associated with increased morbidity and mortality. In view of the dose-dependent positive and negative effects of NO, safety and efficacy trials of NO and its donors are needed for assessing their role in the prevention and treatment of infections. Trials should test dietary inorganic nitrate for pre- or post-exposure prophylaxis and gaseous NO or oral, topical or intravenous nitrite and nitrate for treatment of mild-to-severe infections, including due to SARS-CoV-2 (COVID-19). This review summarises the evidence base from
in vitro, in vivo and early phase clinical studies of NO activity in viral, bacterial, protozoal and fungal infections.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, Notts, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, Notts, NG7 2UH, UK
| | - Christopher M. Coleman
- Division of Infection, Immunity and Microbes, School of Life Sciences, University of Nottingham, Nottingham, Notts, NG7 2UH, UK
| | - Adam L. Gordon
- Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Derby, Derbyshire, DE22 3NE, UK
- NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, Notts, UK
| | - Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Andrew J. Webb
- Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, Kings College London British Heart Foundation Centre of Research Excellence, St Thomas' Hospital, London, SE1 7EH, UK
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24
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Moore WJ, Webb AJ, Wang SK. A focus on the perceived value of preceptor support by pharmacy residents and fellows during the COVID-19 pandemic. Am J Health Syst Pharm 2021; 79:324-326. [PMID: 34634103 PMCID: PMC8524540 DOI: 10.1093/ajhp/zxab387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- W Justin Moore
- Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sheila K Wang
- Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA.,Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Chicago, IL
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25
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Abstract
Although the antimicrobial potential of nitric oxide (NO) is widely published, it is little used clinically. NO is a key signalling molecule modulating vascular, neuronal, inflammatory and immune responses. Endogenous antimicrobial activity is largely mediated by high local NO concentrations produced by cellular inducible nitric oxide synthase, and by derivative reactive nitrogen oxide species including peroxynitrite and S-nitrosothiols. NO may be taken as dietary substrate (inorganic nitrate, L-arginine), and therapeutically as gaseous NO, and transdermal, sublingual, oral, intranasal and intravenous nitrite or nitrate. Numerous preclinical studies have demonstrated that NO has generic static and cidal activities against viruses (including β-coronaviruses such as SARS-CoV-2), bacteria, protozoa and fungi/yeasts in vitro. Therapeutic effects have been seen in animal models in vivo, and phase II trials have demonstrated that NO donors can reduce microbial infection. Nevertheless, excess NO, as occurs in septic shock, is associated with increased morbidity and mortality. In view of the dose-dependent positive and negative effects of NO, safety and efficacy trials of NO and its donors are needed for assessing their role in the prevention and treatment of infections. Trials should test dietary inorganic nitrate for pre- or post-exposure prophylaxis and gaseous NO or oral, topical or intravenous nitrite and nitrate for treatment of mild-to-severe infections, including due to SARS-CoV-2 (COVID-19). This review summarises the evidence base from in vitro, in vivo and early phase clinical studies of NO activity in viral, bacterial, protozoal and fungal infections.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, Notts, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, Notts, NG7 2UH, UK
| | - Christopher M. Coleman
- Division of Infection, Immunity and Microbes, School of Life Sciences, University of Nottingham, Nottingham, Notts, NG7 2UH, UK
| | - Adam L. Gordon
- Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Derby, Derbyshire, DE22 3NE, UK
- NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, Notts, UK
| | - Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Andrew J. Webb
- Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, Kings College London British Heart Foundation Centre of Research Excellence, St Thomas' Hospital, London, SE1 7EH, UK
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26
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O'Gallagher K, Cabaco AR, Ryan M, Roomi A, Gu H, Dancy L, Melikian N, Chowienczyk PJ, Webb AJ, Shah AM. Direct cardiac versus systemic effects of inorganic nitrite on human left ventricular function. Am J Physiol Heart Circ Physiol 2021; 321:H175-H184. [PMID: 34018850 PMCID: PMC8505166 DOI: 10.1152/ajpheart.00081.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Inorganic nitrite is a source of nitric oxide (NO) and is considered as a potential therapy in settings where endogenous NO bioactivity is reduced and left ventricular (LV) function impaired. However, the effects of nitrite on human cardiac contractile function, and the extent to which these are direct or indirect, are unclear. We studied 40 patients undergoing diagnostic cardiac catheterization who had normal LV systolic function and were not found to have obstructive coronary disease. They received either an intracoronary sodium nitrite infusion (8.7–26 µmol/min, n = 20) or an intravenous sodium nitrite infusion (50 µg/kg/min, n = 20). LV pressure-volume relations were recorded. The primary end point was LV end-diastolic pressure (LVEDP). Secondary end points included indices of LV systolic and diastolic function. Intracoronary nitrite infusion induced a significant reduction in LVEDP, LV end-diastolic pressure-volume relationship (EDPVR), and the time to LV end-systole (LVEST) but had no significant effect on LV systolic function or systemic hemodynamics. Intravenous nitrite infusion induced greater effects, with significant decreases in LVEDP, EDPVR, LVEST, LV dP/dtmin, tau, and mean arterial pressure. Inorganic nitrite has modest direct effects on human LV diastolic function, independent of LV loading conditions and without affecting LV systolic properties. However, the systemic administration of nitrite has larger effects on LV diastolic function, which are related to reduction in both preload and afterload. These contractile effects of inorganic nitrite may indicate a favorable profile for conditions characterized by LV diastolic dysfunction. NEW & NOTEWORTHY This is the first study to assess the direct and indirect effects of inorganic nitrite on invasive measures of left ventricular function in humans in vivo. Inorganic nitrite has a modest direct myocardial effect, improving diastolic function. Systemic administration of nitrite has larger effects related to alterations in cardiac preload and afterload. The changes induced by nitrite appear favorable for potential use in conditions characterized by LV diastolic dysfunction.
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Affiliation(s)
- Kevin O'Gallagher
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom.,Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Ana R Cabaco
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Matthew Ryan
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Ali Roomi
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Haotian Gu
- Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Luke Dancy
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Narbeh Melikian
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Andrew J Webb
- Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Ajay M Shah
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
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27
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Morselli F, Faconti L, Mills CE, Morant S, Chowienczyk PJ, Yeung JA, Cavarape A, Cruickshank JK, Webb AJ. Dietary nitrate prevents progression of carotid subclinical atherosclerosis through blood pressure-independent mechanisms in patients with or at risk of type 2 diabetes mellitus. Br J Clin Pharmacol 2021; 87:4726-4736. [PMID: 33982797 DOI: 10.1111/bcp.14897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 04/30/2021] [Accepted: 05/09/2021] [Indexed: 12/01/2022] Open
Abstract
AIMS To test if 6 months' intervention with dietary nitrate and spironolactone could affect carotid subclinical atherosclerosis and stiffness, respectively, vs. placebo/doxazosin, to control for blood pressure (BP). METHODS A subgroup of participants in our double-blind, randomized-controlled, factorial VaSera trial had carotid imaging. Patients with hypertension and with/at risk of type 2 diabetes were randomized to active nitrate-containing beetroot juice or placebo nitrate-depleted juice, and spironolactone or doxazosin. Vascular ultrasound for carotid diameter (CD, mm) and intima-media thickness (CIMT, mm) was performed at baseline, 3- and 6-months. Carotid local stiffness (CS, m/s) was estimated from aortic pulse pressure (Arteriograph) and carotid lumen area. Data were analysed by modified intention to treat and using mixed-model effect, adjusted for confounders. RESULTS In total, 93 subjects had a baseline evaluation and 86% had follow-up data. No statistical interactions occurred between the juice and drug arms and BP was similar between the juices and between the drugs. Nitrate-containing vs. placebo juice significantly lowered CIMT (-0.06 [95% confidence interval -0.12, -0.01], P = .034), an overall difference of ~8% relative to baseline; but had no effect on CD or CS. Doxazosin appeared to reduce CS from baseline (-0.34 [-0.62, -0.06]) however, no difference was detected vs. spironolactone (-0.15 [-0.46, 0.16]). No differences were detected between spironolactone or doxazosin on CIMT and CD. CONCLUSIONS Our results show that 6 months' intervention with dietary nitrate influences vascular remodelling, but not carotid stiffness or diameter. Neither spironolactone nor doxazosin had a BP-independent effect on carotid structure and function.
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Affiliation(s)
- Franca Morselli
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Dipartimento di Area Medica, Clinica Medica, Universita' degli Studi di Udine, Udine, Italy.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Luca Faconti
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charlotte E Mills
- King's College London, Department of Nutritional Sciences, School of Life Course Sciences, London, UK.,Department of Food and Nutritional Sciences, School of Chemistry, Food and Pharmacy, University of Reading, Reading, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven Morant
- Medicines Monitoring Unit (MEMO), University of Dundee, UK
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,King's College London, Department of Nutritional Sciences, School of Life Course Sciences, London, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joshua Au Yeung
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Alessandro Cavarape
- Dipartimento di Area Medica, Clinica Medica, Universita' degli Studi di Udine, Udine, Italy
| | - J Kennedy Cruickshank
- King's College London, Department of Nutritional Sciences, School of Life Course Sciences, London, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew J Webb
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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28
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Leung JG, Owen A, Webb AJ, Johnson EK, Dively-White M, Kreps M, Anderson KK, Schak KM. Improvement of Inpatient Psychiatric Facility Quality Reporting program measure: Screening for metabolic disorders through pharmacy collaborative practice agreement. J Am Pharm Assoc (2003) 2021; 61:e126-e131. [PMID: 33931352 DOI: 10.1016/j.japh.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Second-generation antipsychotics are associated with lower risks of extrapyramidal symptoms, including tardive dyskinesia. However, many second-generation antipsychotics are associated with metabolic adverse effects, including weight gain, impaired blood glucose control, and hyperlipidemia. Metabolic monitoring for patients prescribed antipsychotic medication is 1 of several measures of the Centers for Medicare & Medicaid Services' Inpatient Psychiatric Facility Quality Reporting program. Screening for metabolic disorders (SMD) must be obtained within the previous 365 days before the hospital discharge date. National data suggest that compliance with this measure is low. OBJECTIVE To improve compliance of metabolic monitoring by 20% while ensuring that the quality improvement interventions did not cause any unintended adverse effects on other aspects of our system. PRACTICE DESCRIPTION This quality initiative was conducted at a large, 2000-bed academic medical center with approximately 80 inpatient psychiatric beds. PRACTICE INNOVATION To improve the metabolic screening rates, a pharmacist collaborative practice agreement (CPA) was established as part of a quality improvement project. Previously, there were no formal processes at the institution to ensure that appropriate laboratory tests were conducted. EVALUATION METHODS Using an uncontrolled before-and-after design, SMD data were gathered from 6 months before and 6 months after CPA implementation. Pearson chi-square test or Fisher exact test were used to compare the pre- and postintervention groups in this quasi-experimental design. RESULTS Compared with the preintervention period, compliance of SMD monitoring increased by 21.2% in the postintervention phase-from 69.2% to 90.4% (P < 0.001). CONCLUSION The empowerment of clinical pharmacists with a CPA significantly improved guideline-concordant metabolic monitoring of antipsychotics. These findings may have significant impact on the approach to the safe use of these essential psychotropic medications and provide a framework for other inpatient mental health facilities to optimally use the skills of their interdisciplinary team.
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Webb AJ, Brown CS, Naylor RM, Rabinstein AA, Mara KC, Nei AM. Thromboelastography is a Marker for Clinically Significant Progressive Hemorrhagic Injury in Severe Traumatic Brain Injury. Neurocrit Care 2021; 35:738-746. [PMID: 33846901 DOI: 10.1007/s12028-021-01217-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/20/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) is associated with increased risk of poor outcomes, but accurate prediction of clinically significant progressive hemorrhagic injury (PHI) in patients with severe TBI remains a challenge. Thromboelastography (TEG) is a real-time test of whole blood coagulation that provides dynamic information about global hemostasis. This study aimed to identify differences in TEG values between patients with severe TBI who did or did not experience clinically significant PHI. METHODS This was a single-center retrospective cohort study of adult patients with severe TBI. Patients were eligible for inclusion if initial Glasgow coma scale (GCS) was ≤ 8 and baseline head computed tomography (CT) imaging and TEG were available. Exclusion criteria included receipt of hemostatic agents prior to TEG. PHI was defined as bleeding expansion on CT within 24 h associated with 2-point drop in GCS, neurosurgical intervention, or mortality within 24 h. The primary endpoint was TEG value differences between patients with and without PHI. Secondary endpoints included differences in conventional coagulation tests (CCTs) between groups. RESULTS Of the 526 patients evaluated, 141 met inclusion criteria. The most common reason for exclusion was lack of baseline TEG and receipt of reversal product prior to TEG. Sixty-four patients experienced PHI in the first 24 h after presentation. K time (2.03 min vs. 1.33 min, P = 0.035) and alpha angle (65° vs. 69°, P = 0.015) were found to be significantly different in patients experiencing PHI. R time (5.25 min vs. 4.71 min), maximum amplitude (61 mm vs. 63 mm), and clot lysis at 30 min after maximum clot strength (3.5% vs. 1.7%) were not significantly different between groups. Of the CCTs, only activated partial thromboplastin time (30.3 s vs. 27.6 s, P = 0.014) was found to be different in patients with PHI. CONCLUSIONS Prolonged K time and narrower alpha angle were found to be associated with developing clinically significant PHI in patients with severe TBI. Despite differences detected in alpha angle, median values in both groups were within normal reference ranges. These abnormalities may reflect pathologic hypoactivity of fibrinogen, and further study is warranted to evaluate TEG-guided cryoprecipitate administration in this patient population.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA.
| | | | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kristin C Mara
- Department of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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O'Gallagher K, Borg Cardona S, Hill C, Al-Saedi A, Shahed F, Floyd CN, McNeill K, Mills CE, Webb AJ. Grapefruit juice enhances the systolic blood pressure-lowering effects of dietary nitrate-containing beetroot juice. Br J Clin Pharmacol 2021; 87:577-587. [PMID: 32520418 DOI: 10.1111/bcp.14420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 01/07/2023] Open
Abstract
AIMS Dietary nitrate from sources such as beetroot juice lowers blood pressure (BP) via the nitrate-nitrite-nitric oxide (NO) pathway. However, NO and nitrite are inactivated via reoxidation to nitrate, potentially limiting their activity. Cytochrome P450-3A4 inhibition with troleandomycin prevents nitrite re-oxidation to nitrate in rodent liver. Grapefruit juice contains the CYP3A4 inhibitor furanocoumarin. We therefore hypothesized that grapefruit juice would enhance BP-lowering with beetroot juice by maintaining circulating [nitrite]. METHODS We performed a randomized, placebo-controlled, 7-hour crossover study in 11 healthy volunteers, attending on 3 occasions, receiving: a 70-mL shot of active beetroot juice (Beet-It) and either (i) 250 mL grapefruit juice (Active Beet+GFJ), or (ii) 250 mL water (Buxton, Active Beet+H2 O); or (iii) Placebo Beet+GFJ. RESULTS The addition of grapefruit juice to active beetroot juice lowered systolic BP (SBP): Active Beet+GFJ vs Active Beet+H2 O (P = .02), and pulse pressure, PP (P = .0003). Peak mean differences in SBP and PP were seen at T = 5 hours: -3.3 mmHg (95% confidence interval [CI] -6.43 to -0.15) and at T = 2.5 hours: -4.2 mmHg (95% CI -0.3 to -8.2), respectively. Contrary to the hypothesis, plasma [nitrite] was lower with Active Beet+GFJ vs Active Beet+H2 O (P = .006), as was salivary nitrite production (P = .002) and saliva volume (-0.34 mL/min [95% CI -0.05 to -0.68]). The taste score of Beet+GFJ was 1.4/10 points higher than Beet+H2 O (P = .03). CONCLUSION Grapefruit juice enhanced beetroot juice's effect on lowering SBP and PP despite decreasing plasma [nitrite]. Besides suggesting more complex mechanisms, there is potential for maximising the clinical benefit of dietary nitrate and targeting isolated systolic hypertension.
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Affiliation(s)
- Kevin O'Gallagher
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sarah Borg Cardona
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Callum Hill
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Ali Al-Saedi
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Fawzia Shahed
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Christopher N Floyd
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Karen McNeill
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Charlotte E Mills
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Nutritional Sciences, School of Life Course Sciences, King's College London, UK
- Current institution: Food and Nutritional Sciences, University of Reading, England, UK
| | - Andrew J Webb
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Morrisette T, Alosaimy S, Philley JV, Wadle C, Howard C, Webb AJ, Veve MP, Barger ML, Bouchard J, Gore TW, Lagnf AM, Ansari I, Mejia-Chew C, Cohen KA, Rybak MJ. Preliminary, Real-world, Multicenter Experience With Omadacycline for Mycobacterium abscessus Infections. Open Forum Infect Dis 2021; 8:ofab002. [PMID: 33628856 PMCID: PMC7890947 DOI: 10.1093/ofid/ofab002] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/06/2021] [Indexed: 11/12/2022] Open
Abstract
Twelve patients were treated with omadacycline (OMC) as part of a multidrug regimen for Mycobacterium abscessus. The majority of infections were of pulmonary origin (7/12; 58.3%). The median (interquartile range) duration of OMC was 6.2 (4.2-11.0) months. Clinical success occurred in 9/12 (75.0%) patients. Three patients experienced a possible adverse effect while on therapy.
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Affiliation(s)
- Taylor Morrisette
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Sara Alosaimy
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Julie V Philley
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center, University of Texas, Tyler, Texas, USA
| | - Carly Wadle
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center, University of Texas, Tyler, Texas, USA
| | - Catessa Howard
- Department of Pharmacy, West Virginia University Medicine, Morgantown, West Virginia, USA
| | - Andrew J Webb
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Michael P Veve
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Melissa L Barger
- Department of Medicine, Ventura County Medical Center, Ventura, California, USA
| | - Jeannette Bouchard
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Tristan W Gore
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Iman Ansari
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Carlos Mejia-Chew
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Keira A Cohen
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Marlyand, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit Medical Center, Detroit, Michigan, USA
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Morrisette T, Philley JV, Sigler C, Frens JJ, Webb AJ, Stevens RW, Howard C, Bouchard J, Bookstaver PB, Barger M, Lagnf AM, Alosaimy S, Rybak MJ. 1290. Real-World Experience with Omadacycline for Nontuberculous Mycobacterial and Gram-Negative Infections: A Multicenter Evaluation. Open Forum Infect Dis 2020. [PMCID: PMC7776159 DOI: 10.1093/ofid/ofaa439.1473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Omadacycline (OMC) is an aminomethylcycline antibiotic in the tetracycline class that has been Food and Drug Administration-approved for acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. OMC has been shown to have potent in vitro activity against a broad-spectrum of Gram-positive and Gram-negative organisms, as well as Nontuberculous Mycobacteria (NTM). Due to it’s unique activity and availability as an oral agent, off-label use of OMC has been increasing. We evaluated the real-world effectiveness and safety of OMC for a variety of infections. Methods This was a multicenter, retrospective, observational study that was conducted from January 2020 to June 2020. We included all patients ≥ 18 years of age that received OMC for ≥ 72 hours for any indication and/or pathogen. The primary outcome was clinical success, defined as a lack of 30-day (non-NTM) or 90-day (NTM) mortality or microbiologic recurrence and absence of therapy escalation or alteration. Reasons for OMC utilization and incidence of potential adverse effects attributable to OMC were also analyzed. Results A total of 18 patients were included from six geographically distinct academic health systems (median age: 56 (IQR, 49-60.5) years; 61% male; 72% Caucasian). The majority of OMC use was in NTM (61%; 100% Mycobacterium abscessus) and in Acinetobacter baumannii (22%) for bone/joint (39%) and respiratory tract (33%) infections. OMC was used primarily in the outpatient setting alone (83%) and most isolates did not have OMC susceptibility conducted (89%). Clinical success was reported in 83% of the total population (71% non-NTM and 91% NTM). The majority of patients were prescribed OMC due to antimicrobial resistance to previous antibiotic(s) (61%) and/or due to OMC’s availability as an oral agent (44%). Three patients experienced side effects while on therapy (serum creatinine elevation, AST/ALT increase, and gastrointestinal distress). Conclusion OMC appears to be effective and well-tolerated for a variety of infections caused by various pathogens, including M. abscessus and A. baumannii. Disclosures Michael J. Rybak, PharmD, MPH, PhD, Paratek (Grant/Research Support)
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Affiliation(s)
- Taylor Morrisette
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | | | - Carly Sigler
- The University of Texas Health Science Center, Tyler, Texas
| | | | | | | | | | | | - P B Bookstaver
- The University of South Carolina College of Pharmacy, Columbia, South Carolina
| | | | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory; Wayne State University, Detroit, Michigan
| | | | - Michael J Rybak
- Wayne State University / Detroit Medical Center, Detroit, Michigan
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Webb AJ, Seisa MO, Nayfeh T, Wieruszewski PM, Nei SD, Smischney NJ. Vasopressin in vasoplegic shock: A systematic review. World J Crit Care Med 2020; 9:88-98. [PMID: 33384951 PMCID: PMC7754532 DOI: 10.5492/wjccm.v9.i5.88] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/10/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vasoplegic shock is a challenging complication of cardiac surgery and is often resistant to conventional therapies for shock. Norepinephrine and epinephrine are standards of care for vasoplegic shock, but vasopressin has increasingly been used as a primary pressor in vasoplegic shock because of its unique pharmacology and lack of inotropic activity. It remains unclear whether vasopressin has distinct benefits over standard of care for patients with vasoplegic shock.
AIM To summarize the available literature evaluating vasopressin vs non-vasopressin alternatives on the clinical and patient-centered outcomes of vasoplegic shock in adult intensive care unit (ICU) patients.
METHODS This was a systematic review of vasopressin in adults (≥ 18 years) with vasoplegic shock after cardiac surgery. Randomized controlled trials, prospective cohorts, and retrospective cohorts comparing vasopressin to norepinephrine, epinephrine, methylene blue, hydroxocobalamin, or other pressors were included. The primary outcomes of interest were 30-d mortality, atrial/ventricular arrhythmias, stroke, ICU length of stay, duration of vasopressor therapy, incidence of acute kidney injury stage II-III, and mechanical ventilation for greater than 48 h.
RESULTS A total of 1161 studies were screened for inclusion with 3 meeting inclusion criteria with a total of 708 patients. Two studies were randomized controlled trials and one was a retrospective cohort study. Primary outcomes of 30-d mortality, stroke, ventricular arrhythmias, and duration of mechanical ventilation were similar between groups. Conflicting results were observed for acute kidney injury stage II-III, atrial arrhythmias, duration of vasopressors, and ICU length of stay with higher certainty of evidence in favor of vasopressin serving a protective role for these outcomes.
CONCLUSION Vasopressin was not found to be superior to alternative pressor therapy for any of the included outcomes. Results are limited by mixed methodologies, small overall sample size, and heterogenous populations.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR 97239, United States
| | - Mohamed O Seisa
- Robert D and Patricia E Kern Center For The Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, United States
| | - Tarek Nayfeh
- Robert D and Patricia E Kern Center For The Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan J Smischney
- Department of Anesthesia, Mayo Clinic, Rochester, MN 55905, United States
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Affiliation(s)
- Andrew J. Webb
- Oregon Health & Science University Portland Oregon USA
- Mayo Clinic Rochester Minnesota USA
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Webb AJ, McManus D, Rouse GE, Vonderheyde R, Topal JE. Implications for medication dosing for transgender patients: A review of the literature and recommendations for pharmacists. Am J Health Syst Pharm 2020; 77:427-433. [PMID: 32012216 DOI: 10.1093/ajhp/zxz355] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Transgender patients face considerable healthcare disparities. Improved means of recognizing transgender patients and understanding their medical needs is important to provide optimal care. The electronic medical record (EMR) of our health system allows for differentiation of gender identity, legal sex, and sex at birth. With EMR recognition of transgender patients, a recommendation for estimating creatinine clearance (CLcr) and ideal body weight (IBW) was needed to standardize medication dosing. SUMMARY The literature was reviewed for evidence on the effect of gender-affirming hormone therapy on serum creatinine concentration and lean body mass. Findings informed a recommendation for drug dosing based on CLcr and IBW in transgender patients. Four studies that reported the effect of hormone therapy on biometric laboratory values were found. Three studies reported that values of transgender patients more closely resembled the standard values of their gender identity vs sex at birth after hormone therapy; 1 study reported a range of values that more closely resembled those associated with sex at birth while still overlapping with values associated with gender identity. Consequently, it was recommended that pharmacists dose medications based on CLcr and IBW calculations consistent with gender identity after a patient has been on hormone therapy for 6 months or longer. CONCLUSION Providing optimal care to transgender patients includes considering the effect of gender-affirming hormone therapy on overall physiology. Consistently using the appropriate CLcr and IBW calculations for each patient ensures safe and effective care. Additional studies are needed to confirm the effect of hormone therapy on renal clearance and lean body mass.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, School of Health Sciences, Mayo Clinic, Rochester, MN
| | - Dayna McManus
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT
| | - Ginger E Rouse
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT
| | - Robyn Vonderheyde
- Information Technology Services, Yale New Haven Health System, New Haven, CT
| | - Jeffrey E Topal
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT.,Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT
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Webb AJ, McManus D, Rouse GE, Vonderheyde R, Topal JE. The authors’ reply: Assessment of renal function in transgender patients. Am J Health Syst Pharm 2020; 77:1461-1462. [DOI: 10.1093/ajhp/zxaa231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Andrew J Webb
- School of Health Sciences Department of Pharmacy Mayo Clinic Rochester, MN
| | - Dayna McManus
- Department of Pharmacy Services Yale New Haven Hospital New Haven, CT
| | - Ginger E Rouse
- Department of Pharmacy Services Yale New Haven Hospital New Haven, CT
| | - Robyn Vonderheyde
- Information Technology Services Yale New Haven Health System New Haven, CT
| | - Jeffrey E Topal
- Department of Pharmacy Services Yale New Haven Hospital Yale School of Medicine
- Department of Internal Medicine Section of Infectious Diseases New Haven, CT
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Floyd CN, Shahed F, Ukah F, McNeill K, O'Gallagher K, Mills CE, Evangelopoulos D, Lim S, Mudway I, Barratt B, Walton H, Webb AJ. Acute Blood Pressure-Lowering Effects of Nitrogen Dioxide Exposure From Domestic Gas Cooking Via Elevation of Plasma Nitrite Concentration in Healthy Individuals. Circ Res 2020; 127:847-848. [PMID: 32539547 PMCID: PMC7447162 DOI: 10.1161/circresaha.120.316748] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Christopher N Floyd
- From King's College London (KCL) British Heart Foundation (BHF) Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Clinical Research Facility (CRF), Guy's and St Thomas' NHS Foundation Trust (GSTFT), London, UK (C.N.F., F.S., F.U., K.M., K.O.G., A.J.W.)
| | - Fawzia Shahed
- From King's College London (KCL) British Heart Foundation (BHF) Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Clinical Research Facility (CRF), Guy's and St Thomas' NHS Foundation Trust (GSTFT), London, UK (C.N.F., F.S., F.U., K.M., K.O.G., A.J.W.)
| | - Frances Ukah
- From King's College London (KCL) British Heart Foundation (BHF) Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Clinical Research Facility (CRF), Guy's and St Thomas' NHS Foundation Trust (GSTFT), London, UK (C.N.F., F.S., F.U., K.M., K.O.G., A.J.W.)
| | - Karen McNeill
- From King's College London (KCL) British Heart Foundation (BHF) Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Clinical Research Facility (CRF), Guy's and St Thomas' NHS Foundation Trust (GSTFT), London, UK (C.N.F., F.S., F.U., K.M., K.O.G., A.J.W.)
| | - Kevin O'Gallagher
- From King's College London (KCL) British Heart Foundation (BHF) Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Clinical Research Facility (CRF), Guy's and St Thomas' NHS Foundation Trust (GSTFT), London, UK (C.N.F., F.S., F.U., K.M., K.O.G., A.J.W.)
| | - Charlotte E Mills
- Nutritional Sciences, School of Life Course Sciences, King's College London, UK, Food and Nutritional Sciences, School of Chemistry, Food and Pharmacy, University of Reading, UK (C.E.M.)
| | - Dimitris Evangelopoulos
- NIHR Health Protection Research Unit (HPRU) on Health Impacts of Environmental Hazards at KCL in Partnership with Public Health England (PHE) and Imperial College London (ICL), UK (D.E., S.L., I.M., B.B., H.W.)
| | - Shanon Lim
- NIHR Health Protection Research Unit (HPRU) on Health Impacts of Environmental Hazards at KCL in Partnership with Public Health England (PHE) and Imperial College London (ICL), UK (D.E., S.L., I.M., B.B., H.W.)
| | - Ian Mudway
- NIHR Health Protection Research Unit (HPRU) on Health Impacts of Environmental Hazards at KCL in Partnership with Public Health England (PHE) and Imperial College London (ICL), UK (D.E., S.L., I.M., B.B., H.W.)
| | - Benjamin Barratt
- NIHR Health Protection Research Unit (HPRU) on Health Impacts of Environmental Hazards at KCL in Partnership with Public Health England (PHE) and Imperial College London (ICL), UK (D.E., S.L., I.M., B.B., H.W.)
| | - Heather Walton
- NIHR Health Protection Research Unit (HPRU) on Health Impacts of Environmental Hazards at KCL in Partnership with Public Health England (PHE) and Imperial College London (ICL), UK (D.E., S.L., I.M., B.B., H.W.)
| | - Andrew J Webb
- From King's College London (KCL) British Heart Foundation (BHF) Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Clinical Research Facility (CRF), Guy's and St Thomas' NHS Foundation Trust (GSTFT), London, UK (C.N.F., F.S., F.U., K.M., K.O.G., A.J.W.)
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Mills CE, Govoni V, Faconti L, Casagrande M, Morant SV, Crickmore H, Iqbal F, Maskell P, Masani A, Nanino E, Webb AJ, Cruickshank JK. A randomised, factorial trial to reduce arterial stiffness independently of blood pressure: Proof of concept? The VaSera trial testing dietary nitrate and spironolactone. Br J Clin Pharmacol 2020; 86:891-902. [PMID: 31833569 PMCID: PMC7163378 DOI: 10.1111/bcp.14194] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 12/23/2022] Open
Abstract
AIMS To test if spironolactone or dietary nitrate from beetroot juice could reduce arterial stiffness as aortic pulse wave velocity (PWVart), a potential treatment target, independently of blood pressure. METHODS Daily spironolactone (≤50 mg) vs doxazosin (control ≤16 mg) and 70 mL beetroot juice (Beet-It ≤11 mmol nitrate) vs nitrate-depleted juice (placebo; 0 mmol nitrate) were tested in people at risk or with type-2 diabetes using a double-blind, 6-month factorial trial. Vascular indices (baseline, 12, 24 weeks) were cardiac-ankle vascular index (CAVI), a nominally pressure-independent stiffness measure (primary outcome), PWVart secondary, central systolic pressure and augmentation. Analysis was intention-to-treat, adjusted for systolic pressure differences between trial arms. RESULTS Spironolactone did not reduce stiffness, with evidence for reduced CAVI on doxazosin rather than spironolactone (mean difference [95% confidence interval]; 0.25 [-0.3, 0.5] units, P = .080), firmer for PWVart (0.37 [0.01, 0.7] m/s, P = .045). There was no difference in systolic pressure reduction between spironolactone and doxazosin (0.7 [-4.8, 3.3] mmHg, P = .7). Circulating nitrate and nitrite increased on active vs placebo juice, with central systolic pressure lowered -2.6 [-4.5, - 0.8] mmHg, P = .007 more on the active juice, but did not reduce CAVI, PWVart or peripheral pressure. Change in nitrate and nitrite concentrations were 1.5-fold [1.1-2.2] and 2.2-fold [1.3, 3.6] higher on spironolactone than on doxazosin respectively; both P < .05. CONCLUSION Contrary to our hypothesis, in at-risk/type 2 diabetes patients, spironolactone did not reduce arterial stiffness, rather PWVart was lower on doxazosin. Dietary nitrate elevated plasma nitrite, selectively lowering central systolic pressure, observed previously for nitrite.
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Affiliation(s)
- Charlotte E. Mills
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
- Hugh Sinclair Unit of Human Nutrition, Department of Food and Nutritional SciencesUniversity of ReadingUK
| | - Virginia Govoni
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
| | - Luca Faconti
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical PharmacologyUK
| | - Maria‐Linda Casagrande
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
| | | | - Hannah Crickmore
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
| | - Fahad Iqbal
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
| | - Perry Maskell
- Medicines Monitoring Unit (MEMO)University of DundeeUK
| | - Alisha Masani
- Medicines Monitoring Unit (MEMO)University of DundeeUK
| | - Elisa Nanino
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
| | - Andrew J. Webb
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical PharmacologyUK
| | - J. Kennedy Cruickshank
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
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Morselli F, Faconti L, Mills CE, Morant S, Chowienczyk PJ, Cruickshank JK, Webb AJ, Cavarape A. P.55 Dietary Nitrate Prevents Progression of Carotid Subclinical Atherosclerosis Through BP-Independent Mechanisms in Patients with or at Risk of Type 2 Diabetes Mellitus: Results from the Double-Blind, Randomized-Controlled, Factorial Vasera Trial. Artery Res 2020. [DOI: 10.2991/artres.k.201209.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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40
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Webb AJ. Spotlight-Introducing a new Commentary series for the BJCP. Br J Clin Pharmacol 2019; 85:1387-1388. [PMID: 31020700 PMCID: PMC6595374 DOI: 10.1111/bcp.13930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 10/13/2023] Open
Affiliation(s)
- Andrew J. Webb
- School of Cardiovascular Medicine and Sciences, Department of Clinical PharmacologyKing's College London British Heart Foundation CentreLondonUK
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Webster LM, Bramham K, Seed PT, Homsy M, Widdows K, Webb AJ, Nelson-Piercy C, Magee L, Thilaganathan B, Myers JE, Chappell LC. Impact of ethnicity on adverse perinatal outcome in women with chronic hypertension: a cohort study. Ultrasound Obstet Gynecol 2019; 54:72-78. [PMID: 30318830 DOI: 10.1002/uog.20132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To assess the impact of maternal ethnicity on the risk of adverse perinatal outcome in pregnant women with chronic hypertension. METHODS Demographic and delivery data were collated of women with chronic hypertension and singleton pregnancy who delivered at one of three UK obstetric units between 2000 and 2014. Multivariable logistic regression models were used to calculate risk ratios (RR), according to ethnic group, for adverse perinatal outcome, adjusted for other maternal characteristics including age, parity, body mass index, smoking status, deprivation index and year of delivery. The impact of maternal ethnicity on birth-weight centile calculation was investigated by comparing the birth-weight centile chart customized for ethnicity (Gestation Related Optimal Weight; GROW) with a birth-weight centile calculator that does not adjust for that factor (INTERGROWTH-21st ). RESULTS The study cohort included 4481 pregnancies (4045 women) with chronic hypertension. Women of white ethnicity accounted for 47% (n = 2122) of the cohort and 36% (n = 1601) were of black, 8.5% (n = 379) of Asian and 8.5% (n = 379) of other ethnicity. The overall incidence of stillbirth was 1.6%, that of preterm birth < 37 weeks was 16% and that of fetal growth restriction (birth weight < 3rd centile) was 11%. Black women, compared with white women, had the highest risk for all adverse perinatal outcomes, with stillbirth occurring in 3.1% vs 0.6% of pregnancies (adjusted RR (aRR), 5.56 (95% CI, 2.79-11.09)), preterm birth < 37 weeks in 21% vs 11% (aRR, 1.70 (95% CI, 1.43-2.01)) and birth weight < 3rd centile in 15% vs 7.4% (aRR, 2.07 (95% CI, 1.71-2.51)). Asian women, compared with white women, were also at increased risk of adverse perinatal outcome, with stillbirth occurring in 1.6% vs 0.6% (aRR, 3.03 (95% CI, 1.11-8.28)), preterm birth < 37 weeks in 20% vs 11% (aRR, 1.82 (95% CI, 1.41-2.35)) and birth weight < 3rd centile in 12% vs 7.4% (aRR, 1.69 (95% CI, 1.24-2.30)). The sensitivity and specificity for prediction of infants requiring neonatal unit admission were 40% and 93%, respectively, for those with birth weight < 3rd centile according to GROW charts, compared with 16% and 96%, respectively, for those with birth weight < 3rd centile according to INTERGROWTH-21st charts. CONCLUSIONS Black ethnicity, compared with white, is associated with the greatest risk of adverse perinatal outcome in women with chronic hypertension, even after adjusting for other maternal characteristics. Women of Asian ethnicity are also at increased risk, but to a lesser extent. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L M Webster
- Division of Women's Health, King's College London, St Thomas' Hospital, London, UK
| | - K Bramham
- Division of Women's Health, King's College London, St Thomas' Hospital, London, UK
| | - P T Seed
- Division of Women's Health, King's College London, St Thomas' Hospital, London, UK
| | - M Homsy
- Division of Women's Health, King's College London, St Thomas' Hospital, London, UK
| | - K Widdows
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - A J Webb
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St Thomas' Hospital, London, UK
| | - C Nelson-Piercy
- Division of Women's Health, King's College London, St Thomas' Hospital, London, UK
| | - L Magee
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J E Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- St Mary's Hospital, Central Manchester Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - L C Chappell
- Division of Women's Health, King's College London, St Thomas' Hospital, London, UK
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Floyd CN, Lidder S, Hunt J, Omar SA, McNeill K, Webb AJ. Acute interaction between oral glucose (75 g as Lucozade) and inorganic nitrate: Decreased insulin clearance, but lack of blood pressure-lowering. Br J Clin Pharmacol 2019; 85:1443-1453. [PMID: 30845346 DOI: 10.1111/bcp.13913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/08/2019] [Accepted: 03/03/2019] [Indexed: 11/28/2022] Open
Abstract
AIMS Dietary inorganic nitrate (NO3 - ) lowers peripheral blood pressure (BP) in healthy volunteers, but lacks such effect in individuals with, or at risk of, type 2 diabetes mellitus (T2DM). Whilst this is commonly assumed to be a consequence of chronic hyperglycaemia/hyperinsulinaemia, we hypothesized that acute physiological elevations in plasma [glucose]/[insulin] blunt the haemodynamic responses to NO3 - , a pertinent question for carbohydrate-rich Western diets. METHODS We conducted an acute, randomized, placebo-controlled, double-blind, crossover study on the haemodynamic and metabolic effects of potassium nitrate (8 or 24 mmol KNO3 ) vs. potassium chloride (KCl; placebo) administered 1 hour prior to an oral glucose tolerance test in 33 healthy volunteers. RESULTS Compared to placebo, there were no significant differences in systolic or diastolic BP (P = 0.27 and P = 0.30 on ANOVA, respectively) with KNO3 , nor in pulse wave velocity or central systolic BP (P = 0.99 and P = 0.54 on ANOVA, respectively). Whilst there were significant elevations from baseline for plasma [glucose] and [C-peptide], no differences between interventions were observed. A significant increase in plasma [insulin] was observed with KNO3 vs. KCl (n = 33; P = 0.014 on ANOVA) with the effect driven by the high-dose cohort (24 mmol, n = 13; P < 0.001 on ANOVA; at T = 0.75 h mean difference 210.4 pmol/L (95% CI 28.5 to 392.3), P = 0.012). CONCLUSIONS In healthy adults, acute physiological elevations of plasma [glucose] and [insulin] result in a lack of BP-lowering with dietary nitrate. The increase in plasma [insulin] without a corresponding change in [C-peptide] or [glucose] suggests that high-dose NO3 - decreases insulin clearance. A likely mechanism is via NO-dependent inhibition of insulin-degrading enzyme.
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Affiliation(s)
- Christopher N Floyd
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK.,Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Satnam Lidder
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK.,Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joanne Hunt
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK.,Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sami A Omar
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK.,Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Karen McNeill
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK.,Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew J Webb
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK.,Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Faconti L, Ferro A, Webb AJ, Cruickshank JK, Chowienczyk PJ. Hydrochlorothiazide and the risk of skin cancer. A scientific statement of the British and Irish Hypertension Society. J Hum Hypertens 2019; 33:257-258. [PMID: 30842544 DOI: 10.1038/s41371-019-0190-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/22/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Luca Faconti
- Department of Clinical Pharmacology, King's College London, London, UK
| | - Albert Ferro
- Department of Clinical Pharmacology, King's College London, London, UK
| | - Andrew J Webb
- Department of Clinical Pharmacology, King's College London, London, UK
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44
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Affiliation(s)
- Louise M Webster
- Department of Women and Children's Health, King's College London, 10th Floor North Wing, St Thomas' Hospital, London, UK
| | - Andrew J Webb
- Department of Women and Children's Health, King's College London, 10th Floor North Wing, St Thomas' Hospital, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, 10th Floor North Wing, St Thomas' Hospital, London, UK
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45
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Cohen A, Pattanaik S, Kumar P, Bies RR, de Boer A, Ferro A, Gilchrist A, Isbister GK, Ross S, Webb AJ. Organised crime against the academic peer review system. Br J Clin Pharmacol 2018; 81:1012-7. [PMID: 27211251 DOI: 10.1111/bcp.12992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 04/27/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- Adam Cohen
- Centre for Human Drug Research, Leiden, 2333 CL, The Netherlands
| | - Smita Pattanaik
- PGIMER Pharmacology 4015, Research block B, PGIMER, Chandigarh, 160012, India
| | - Praveen Kumar
- Chandigarh Room number 4019, Research block B, Department of Pharmacology, PGIMER, Chandigarh, 160012, India
| | - Robert R Bies
- Department of Pharmaceutical sciences, State University of New York Buffalo, Buffalo, New York, 14214-8033, USA
| | - Anthonius de Boer
- Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands
| | - Albert Ferro
- Department of Clinical Pharmacology, King's College London, London, SE1 9NH, UK
| | - Annette Gilchrist
- Pharmaceutical Sciences, Midwestern University, Downers Grove, Illinois, 60515, USA
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, 2298, Australia
| | - Sarah Ross
- Perth Royal Infirmary, Perth, PH1 1NX, UK
| | - Andrew J Webb
- Cardiovascular Division, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, SE1 7EH, UK
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46
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Mills CE, Govoni V, Faconti L, Casagrande ML, Morant SV, Webb AJ, Cruickshank JK. Reducing Arterial Stiffness Independently of Blood Pressure. J Am Coll Cardiol 2017; 70:1683-1684. [DOI: 10.1016/j.jacc.2017.07.765] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 06/29/2017] [Accepted: 07/24/2017] [Indexed: 11/15/2022]
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47
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Webster LM, Conti-Ramsden F, Seed PT, Webb AJ, Nelson-Piercy C, Chappell LC. Impact of Antihypertensive Treatment on Maternal and Perinatal Outcomes in Pregnancy Complicated by Chronic Hypertension: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:e005526. [PMID: 28515115 PMCID: PMC5524099 DOI: 10.1161/jaha.117.005526] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/17/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic hypertension complicates around 3% of all pregnancies. There is evidence that treating severe hypertension reduces maternal morbidity. This study aimed to systematically review randomized controlled trials of antihypertensive agents treating chronic hypertension in pregnancy to determine the effect of this intervention. METHODS AND RESULTS Medline (via OVID), Embase (via OVID) and the Cochrane Trials Register were searched from their earliest entries until November 30, 2016. All randomized controlled trials evaluating antihypertensive treatments for chronic hypertension in pregnancy were included. Data were extracted and analyzed in Stata (version 14.1). Fifteen randomized controlled trials (1166 women) were identified for meta-analysis. A clinically important reduction in the incidence of severe hypertension was seen with antihypertensive treatment versus no antihypertensive treatment/placebo (5 studies, 446 women; risk ratio 0.33, 95%CI 0.19-0.56; I2 0.0%). There was no difference in the incidence of superimposed pre-eclampsia (7 studies, 727 women; risk ratio 0.74, 95%CI 0.49-1.11; I2 28.1%), stillbirth/neonatal death (4 studies, 667 women; risk ratio 0.37, 95%CI 0.11-1.26; I2 0.0%), birth weight (7 studies, 802 women; weighted mean difference -60 g, 95%CI -200 to 80 g; I2 0.0%), or small for gestational age (4 studies, 369 women; risk ratio 1.01, 95%CI 0.53-1.94; I2 0.0%) with antihypertensive treatment versus no treatment/placebo. CONCLUSIONS Antihypertensive treatment reduces the risk of severe hypertension in pregnant women with chronic hypertension. A considerable paucity of data exists to guide choice of antihypertensive agent. Adequately powered head-to-head randomized controlled trials of commonly used antihypertensive agents are required to inform prescribing.
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Affiliation(s)
- Louise M Webster
- Women's Health Academic Centre, King's College London, St Thomas' Hospital, London, United Kingdom
| | - Frances Conti-Ramsden
- Women's Health Academic Centre, King's College London, St Thomas' Hospital, London, United Kingdom
| | - Paul T Seed
- Women's Health Academic Centre, King's College London, St Thomas' Hospital, London, United Kingdom
| | - Andrew J Webb
- Cardiovascular Division, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, St Thomas' Hospital, London, United Kingdom
| | - Catherine Nelson-Piercy
- Women's Health Academic Centre, King's College London, St Thomas' Hospital, London, United Kingdom
| | - Lucy C Chappell
- Women's Health Academic Centre, King's College London, St Thomas' Hospital, London, United Kingdom
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Abstract
Nitric oxide (NO) is generated endogenously by NO synthases to regulate a number of physiological processes including cardiovascular and metabolic functions. A decrease in the production and bioavailability of NO is a hallmark of many major chronic diseases including hypertension, ischaemia-reperfusion injury, atherosclerosis and diabetes. This NO deficiency is mainly caused by dysfunctional NO synthases and increased scavenging of NO by the formation of reactive oxygen species. Inorganic nitrate and nitrite are emerging as substrates for in vivo NO synthase-independent formation of NO bioactivity. These anions are oxidation products of endogenous NO generation and are also present in the diet, with green leafy vegetables having a high nitrate content. The effects of nitrate and nitrite are diverse and include vasodilatation, improved endothelial function, enhanced mitochondrial efficiency and reduced generation of reactive oxygen species. Administration of nitrate or nitrite in animal models of cardiovascular disease shows promising results, and clinical trials are currently ongoing to investigate the therapeutic potential of nitrate and nitrite in hypertension, pulmonary hypertension, peripheral artery disease and myocardial infarction. In addition, the nutritional aspects of the nitrate-nitrite-NO pathway are interesting as diets suggested to protect against cardiovascular disease, such as the Mediterranean diet, are especially high in nitrate. Here, we discuss the potential therapeutic opportunities for nitrate and nitrite in prevention and treatment of cardiovascular and metabolic diseases.
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Affiliation(s)
- S A Omar
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - A J Webb
- Cardiovascular Division, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| | - J O Lundberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - E Weitzberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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49
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Velmurugan S, Kapil V, Ghosh SM, Davies S, McKnight A, Aboud Z, Khambata RS, Webb AJ, Poole A, Ahluwalia A. Erratum to "Antiplatelet effects of dietary nitrate in healthy volunteers: Involvement of cGMP and influence of sex" [Free Radic. Biol. Med. 65 (2013) 1521-1532]. Free Radic Biol Med 2015; 84:385. [PMID: 28830618 PMCID: PMC5597546 DOI: 10.1016/j.freeradbiomed.2015.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shanti Velmurugan
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Vikas Kapil
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Suborno M Ghosh
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Sheridan Davies
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Andrew McKnight
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Zainab Aboud
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Rayomand S Khambata
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Andrew J Webb
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Alastair Poole
- School of Physiology and Pharmacology, University of Bristol, Medical Sciences Building, University Walk, Bristol BS8 1TD, UK
| | - Amrita Ahluwalia
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ.
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Downham S, Holt C, Dockery F, Webb AJ. Commentary on the medico-legal aspects of prescribing vitamin D. Br J Clin Pharmacol 2015; 80:932-5. [PMID: 25940303 DOI: 10.1111/bcp.12673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/28/2015] [Accepted: 04/28/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Scott Downham
- Guy's and St Thomas' NHS Foundation Trust, Department of Clinical Pharmacology, St Thomas' Hospital, London, SE1 7EH
| | - Christopher Holt
- Quality Assurance Department, Pharmacy, Guy's and St. Thomas' NHS Foundation Trust, St Thomas' Hospital, London, SE1 7EH
| | - Frances Dockery
- Department of Ageing & Health, Guy's and St. Thomas' NHS Foundation Trust, St Thomas' Hospital, London, SE1 7EH
| | - Andrew J Webb
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St Thomas' Hospital, London, SE1 7EH.,Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, SE1 7EH, UK
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