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Sahib Din J, Navarro Garcia E, Al-Rubaye H, Julian C. Knee Buckling as an Atypical Adverse Effect of Clozapine: A Case Report. Cureus 2024; 16:e55865. [PMID: 38595866 PMCID: PMC11002468 DOI: 10.7759/cureus.55865] [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] [Accepted: 03/09/2024] [Indexed: 04/11/2024] Open
Abstract
Clozapine has become a widely popular and effective medication in the treatment of refractory schizophrenia and refractory bipolar disorder. Although the use of clozapine proves to be an effective resort, it has to be closely monitored due to its narrow therapeutic range and multiple dangerous adverse effects. In rare cases, clozapine has been known to cause an antagonistic myoclonic jerk that leads to knee buckling. Here, we present the case of a 29-year-old female who is being treated for schizoaffective disorder, bipolar, manic type, who reported two instances of knee buckling associated with falls while taking clozapine.
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Affiliation(s)
| | - Ernesto Navarro Garcia
- Nanotechnology, University of Central Florida, Orlando, USA
- Physiology and Neuroscience, St George's University, St. George's, GRD
| | - Hiba Al-Rubaye
- Physiology and Neuroscience, St. George's University School of Medicine, St. George's, GRD
| | - Carlos Julian
- Physiology and Neuroscience, St. George's University School of Medicine, St. George's, GRD
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Komatsu T, Nakamura M, Uchiyama K, Inoue G, Sakanoue K, Kawamura A, Hiratsuka K, Takayama Y, Takaso M, Atsuda K. Initial trough concentration may be beneficial in preventing linezolid-induced thrombocytopenia. J Chemother 2022; 34:375-380. [PMID: 35209803 DOI: 10.1080/1120009x.2022.2043538] [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: 10/19/2022]
Abstract
We assessed whether prospective therapeutic drug monitoring to optimise the therapeutic range could prevent linezolid-induced thrombocytopenia. This prospective interventional study was conducted from September 2017 to October 2020 among 37 adult patients receiving linezolid. Patients were administered one of the following two initial dosages: 600 mg twice or once daily for patients with a creatinine clearance rate of ≥50 or <50 mL/min, respectively. Linezolid dosage adjustment was performed on days 3-5 based on the trough concentration. The serum linezolid levels in 22 and 15 patients were within and above the therapeutic range (2-7 µg/mL), respectively. The incidence of thrombocytopenia was significantly lower among patients whose linezolid levels were within the therapeutic range (4.5%;1/22) than in those whose levels were above the therapeutic range (80%; 12/15). It is important to maintain the linezolid level within the therapeutic range at the first therapeutic drug monitoring to prevent thrombocytopenia.
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Affiliation(s)
- Toshiaki Komatsu
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Japan
| | - Miho Nakamura
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Japan
| | - Katsufumi Uchiyama
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kazumi Sakanoue
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Japan
| | - Atsushi Kawamura
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Japan
| | - Koki Hiratsuka
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Japan
| | - Yoko Takayama
- Department of Infection Control and Infectious Diseases, Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koichiro Atsuda
- Pharmacy Practice and Science I, Research and Education Center for Clinical Pharmacy, Kitasato University School of Pharmacy, Sagamihara, Japan
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Toulon P, Smahi M, De Pooter N. APTT therapeutic range for monitoring unfractionated heparin therapy. Significant impact of the anti-Xa reagent used for correlation. J Thromb Haemost 2021; 19:2002-2006. [PMID: 33555096 DOI: 10.1111/jth.15264] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 11/12/2020] [Revised: 12/29/2020] [Accepted: 02/03/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Unfractionated heparin (UFH) therapy is monitored by using the anti-activated factor X (anti-Xa) activity, or the activated partial thromboplastin time (APTT), which remains the most widely used assay. One of the main advantages of anti-Xa relies on its hypothesized standardization, with a unique therapeutic range (0.30-0.70 IU/ml) for all reagents, whereas APTT is influenced by numerous preanalytical and analytical parameters not related to the anticoagulant activity of UFH. METHODS The aim of this study was to compare the anti-Xa-correlated APTT therapeutic ranges calculated using different combinations of APTT (n = 4) and anti-Xa reagents (n = 4) in frozen citrated plasmas from 87 inpatients on UFH. RESULTS The median APTT ratio ranged from 2.19 for the less sensitive to 3.23 for the most sensitive reagent, whereas the median anti-Xa activity was between 0.37 IU/ml and 0.57 IU/ml. The APTT therapeutic ranges calculated to correlate with anti-Xa activities between 0.30 and 0.70 IU/ml were found to be highly different from one combination of APTT reagent and analyzer to another. The same applied to the therapeutic range of a single APTT reagent calculated using different anti-Xa assays performed on the same analyzer, leading to a lack of agreement as to whether a sample was classified as subtherapeutic, therapeutic or supratherapeutic in 8.0% to 23.0% of the patients, with kappa coefficients between 0.908 and 0.753. CONCLUSIONS These results suggest that the APTT therapeutic range calculated to correlate with anti-Xa activities between 0.30 and 0.70 IU/ml is influenced not only by the APTT reagent, but also by the anti-Xa reagent used for calculation.
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Affiliation(s)
- Pierre Toulon
- Hematology Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - Motalib Smahi
- Hematology Department, Simone Veil Hospital, Eaubonne, France
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Lozano R, Frutos A, Martinez A. In Silico Model for Predicting CYP2D6-Mediated Drug-Drug Interactions. Curr Rev Clin Exp Pharmacol 2020; 16:124-127. [PMID: 32379594 DOI: 10.2174/1574884715666200507130824] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Successful integration of in vitro into in vivo data on Drug-Drug Interaction (DDI) is dependent on the inhibitory concentration used. Obtaining plasma concentration of a drug is only readily available for a small number of drugs in clinical practice. We propose the use of a therapeutic range as a substitute for inhibitory concentration. OBJECTIVE Because of this, we aimed to construct a linear-regression model based on the areaunder- curve of the victim drugs and the therapeutic range for a set of known inhibitors of the CYP2D6 of interest. METHODS Correlation analysis of linear log-log regression of two main variables: The Area-Under- Curve ratio (AUCr) of the victim drugs and the therapeutic range-to-inhibition constant ratio, with data obtained from literature. RESULTS Data were fitted to linear log-log regression, between the average of AUCr values and mean value of therapeutic range-to-inhibition constant ratio (TRm-to-Ki), of the inhibitory drugs. CONCLUSION According to our results, knowledge of the inhibition constant and therapeutic range (or its plasma levels if disponible) of the inhibitor would be sufficient to determine the intensity and clinical relevance of a CYP2D6-mediated DDI.
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Affiliation(s)
- Roberto Lozano
- Pharmacy Department, Hospital Nuestra Señora de Gracia, Zaragoza, Spain
| | - Alberto Frutos
- Pharmacy Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Alejandro Martinez
- Pharmacy Department, Centro de Reahabilitación Psicosocial de "Nuestra Señora del Pilar", Zaragoza, Spain
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Chang DB, Luttrull JK. Comparison of Subthreshold 577 and 810 nm Micropulse Laser Effects on Heat-Shock Protein Activation Kinetics: Implications for Treatment Efficacy and Safety. Transl Vis Sci Technol 2020; 9:23. [PMID: 32821495 PMCID: PMC7401905 DOI: 10.1167/tvst.9.5.23] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/10/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose To compare the safety and efficacy of 810 versus 577 nm laser wavelengths for micropulse subthreshold (sublethal) laser treatment by mathematical analysis. Methods Two different representative laser parameter sets for micropulsed subthreshold diode laser treatment, one employing 810 nm and the other 577 nm, are compared with regard to efficacy by analysis of the kinetics of laser-induced heat-shock protein (HSP) activation; and for safety, by scaling law analysis. Results Kinetics analysis of laser-induced HSP activation shows that the primary therapeutic effect of laser is thermal incitement of a long-term wavelength-independent increase in the rate of HSP-mediated protein repair specific to sick and dysfunctional cells, rather than from short-term increases in free intracellular HSP concentrations. Scaling law analysis of the same 810 and 577 nm laser parameters, however, finds treatment safety highly wavelength-sensitive, favoring 810 over 577 nm. Conclusions Mathematical analyses of the effects retinal laser-induced HSP activation provide important insights into the mechanism of action and the importance of wavelength selection in modern retinal laser therapy. Our analyses find 810 and 577 nm to be equally effective, but 810 nm having a significantly wider therapeutic range/safety margin, and thus less likely to cause inadvertent, and thus unpredictable, laser-induced retinal damage, than 577 nm. Translational Relevance Mathematical analysis of enzyme reaction kinetics provides important insights into the mechanism of action and clinical implications of wavelength selection in modern retinal laser therapy.
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Anutrakulchai S, Pongskul C, Kritmetapak K, Limwattananon C, Vannaprasaht S. Therapeutic concentration achievement and allograft survival comparing usage of conventional tacrolimus doses and CYP3A5 genotype-guided doses in renal transplantation patients. Br J Clin Pharmacol 2019; 85:1964-1973. [PMID: 31077425 DOI: 10.1111/bcp.13980] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 04/04/2019] [Accepted: 04/27/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS Although cytochromeP450(CYP)3A5 gene polymorphism affects personalized tacrolimus doses, there is no consensus as to whether CYP3A5 genotypes should be determined to adjust the doses. The aims were to compare the therapeutic ranges and clinical outcomes between the conventional and genotype-guided tacrolimus doses. METHODS This randomized controlled study compared 63 cases of the conventional tacrolimus dose group (0.1 mg/kg/day) with 62 cases of the genotype-guided doses group of 0.125, 0.1 and 0.08 mg/kg for CYP3A5*1/*1, *1/*3, and *3/*3 genotypes for the initial 3 days of kidney transplantation. After day 3, dose adjustment occurred in both groups to achieve therapeutic concentrations. RESULTS The genotype-guided group had an increased proportion of patients with tacrolimus concentrations in the therapeutic range at the steady state on day 3 (40.3 vs 23.8%, P = .048). A lower proportion of over-therapeutic concentration patients was noted in the genotype-guided group in the CYP3A5*3/*3 genotype (9.7 vs 27%, P = .013). Unexpectedly, more delayed graft functions (DGFs) were in the genotype-guided group (41.9 vs 22.2%, P = .018) especially in the CYP3A5*1/*1 participants who might have had an aggravated DGF by a longer ischaemic time and higher serum donor creatinine levels than in the control group. There were no significant differences of glomerular filtration rates or graft or patient survivals over a median 37-month follow-up period. CONCLUSIONS Determination of the CYP3A5 genotype improved therapeutic range achievement. CYP3A5*1/*1 patients who have high risks of DGF should be closely monitored because of an increased risk of DGF and reduced glomerular filtration rate with high tacrolimus doses.
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Affiliation(s)
- Sirirat Anutrakulchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Cholatip Pongskul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kittrawee Kritmetapak
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chulaporn Limwattananon
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Thailand
| | - Suda Vannaprasaht
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Sargin M, Erdogan SB, Bastopcu M, Arslanhan G, Tasdemir MM, Orhan G. Cost of Healthcare Associated With Deep Vein Thrombosis in Patients Treated With Warfarin in Turkey: 2010-2013 Database Analysis of a Tertiary Care Center. Value Health Reg Issues 2019; 19:81-86. [PMID: 31254969 DOI: 10.1016/j.vhri.2019.03.007] [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: 11/23/2017] [Revised: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To evaluate the cost of healthcare with respect to the quality of anticoagulation in patients with deep vein thrombosis (DVT) treated with warfarin in daily practice via the database analysis of a tertiary care center in the period 2010 to 2013. METHODS Of 258 307 records in total, 42 582 unique patients with DVT and 32 012 patients with international normalized ratio (INR) measurements were included. Overall, 6720 unique patients with DVT diagnosis and one or more INR measurements were identified, and the records of 4377 out of 6720 unique patients were validated and included in the analysis data set. The cost analysis was based on direct medical costs from the payer's perspective. Cost items were related to healthcare resource utilization (inpatient and outpatient services) during the study period, which provided a basis for calculation of per-patient, outpatient, inpatient, and total direct medical costs. RESULTS Mean outpatient, inpatient, and total hospital admission costs were $578, $2195, and $2785, respectively, for patients with time in the therapeutic range of 70% or more, whereas the same costs were $571, $2163, and $3192, respectively, for patients with time in the therapeutic range of less than 70%. CONCLUSIONS Our findings for a retrospective cohort of patients with DVT undergoing warfarin therapy reveal that patients spent 70% or more, as opposed to less than 70%, of follow-up time within the therapeutic INR range and that outpatient care, as opposed to inpatient care, was associated with lower healthcare costs. Given the significant contribution that hospital stay makes to the cost burden of DVT, our findings also highlight the association between poor warfarin anticoagulant control and increased hospitalization costs.
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Affiliation(s)
- Murat Sargin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
| | - Sevinc Bayer Erdogan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Bastopcu
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokhan Arslanhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muge Mete Tasdemir
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokcen Orhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Abstract
Heparin-induced thrombocytopenia (HIT) is a not-uncommon adverse effect of heparin exposure, with potentially serious and/or fatal thrombotic consequences. Recent studies looking at the off-label use of fondaparinux for HIT show similar efficacy and adverse-effect profiles, as well as improved costs, compared with some commonly used direct thrombin inhibitors. Although routine laboratory monitoring of fondaparinux-specific anti-Xa levels typically is not recommended, we present a case report that suggests fondaparinux monitoring may be needed in patients with hepatic impairment causing acquired antithrombin deficiency. We performed daily assessment of antithrombin- and fondaparinux-specific anti-Xa levels in a 50-year-old female of unknown ethnicity to ensure that fondaparinux dosing was maintained within an acceptable range. With this management strategy, the patient experienced no thrombotic or hemorrhagic complications during the hospital admission or the following 2 months in outpatient treatment.
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Affiliation(s)
- Elizabeth M Staley
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham
| | - Sierra C Simmons
- Independent Researcher, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Alexander Z Feldman
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham
| | - Lance A Williams
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles
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Lunardi M, Lin K, Walz R, Wolf P. Single antiepileptic drug levels do not predict adherence and nonadherence. Acta Neurol Scand 2019; 139:199-203. [PMID: 30256381 DOI: 10.1111/ane.13033] [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: 07/19/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the significance of "subtherapeutic" vs "therapeutic" antiepileptic drug (AED) plasma levels with respect to treatment adherence. MATERIAL AND METHODS One hundred and seventy patients with refractory temporal lobe epilepsy who underwent video-EEG monitoring in view of a surgical indication had their AEDs (carbamazepine, phenobarbital, phenytoin, and valproate) rapidly withdrawn following a standardized schedule. Plasma levels were measured at admission, and during the 2 days of drug withdrawal. Adherence and nonadherence were identified by the development of plasma levels from day 1 through day 3. Frequencies of an initial level below the reference range in both groups were compared. RESULTS Adherence was found in 73.2% of cases, and nonadherence in 26.8%. Low levels were seen equally often (about 1/4 of cases) in adherent and nonadherent cases. The vast majority (73.7%) of low levels had another explanation than nonadherence (eg low-dose treatment or enzyme induction). Of 42 nonadherent cases, the vast majority of 76.2% had unsuspicious plasma levels at admission. CONCLUSIONS "Subtherapeutic" AED plasma levels only rarely are caused by nonadherence whereas levels in the "therapeutic range" by no means prove that the patient is adherent to treatment. For meaningful interpretation, any level needs to be compared with other levels of the same patient. Our findings strongly emphasize the principle of individualized therapeutic AED monitoring as promoted by the Therapeutic Strategies Commission of the ILAE.
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Affiliation(s)
- Mariana Lunardi
- Neurology Division; Federal University of Santa Catarina, (UFSC); Florianópolis Brazil
- Medical Sciences Post-graduate Program; Federal University of Santa Catarina, (UFSC); Florianópolis Brazil
| | - Katia Lin
- Neurology Division; Federal University of Santa Catarina, (UFSC); Florianópolis Brazil
- Medical Sciences Post-graduate Program; Federal University of Santa Catarina, (UFSC); Florianópolis Brazil
- Center for Applied Neurosciences (CeNAp); Federal University of Santa Catarina (UFSC); Florianópolis Brazil
| | - Roger Walz
- Medical Sciences Post-graduate Program; Federal University of Santa Catarina, (UFSC); Florianópolis Brazil
- Center for Applied Neurosciences (CeNAp); Federal University of Santa Catarina (UFSC); Florianópolis Brazil
| | - Peter Wolf
- Medical Sciences Post-graduate Program; Federal University of Santa Catarina, (UFSC); Florianópolis Brazil
- Danish Epilepsy Centre; Dianalund Denmark
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Sargin M, Tasdemir MM, Kuplay H, Erdogan SB, Tandogar N, Akansel S, Kurc E, Orhan G, Aka SA. Retrospective cohort study for evaluating the INR monitoring patterns in patients with deep vein thrombosis in daily practice: Analysis of 2010-2013 database of a tertiary care center. Phlebology 2018; 34:317-323. [PMID: 30336760 DOI: 10.1177/0268355518806117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 11/16/2022]
Abstract
OBJECTIVE To evaluate the international normalized ratio (INR) monitoring patterns in patients with deep vein thrombosis. METHODS Of 32,012 patients with ≥1 outpatient INR measurement and 42,582 patients with confirmed deep vein thrombosis diagnosis registered to our hospital between 1 January 2010 and 31 December 2013, 6720 records were identified to have both deep vein thrombosis and international normalized ratio measurement, and 4.377 out of 6.720 single patient records were determined to be statistically analyzable. RESULTS Median INR measurement frequency was 6.47 times/year and patients had INR levels of 2-3 in 34.3% of follow-up time. Having ≥70% vs. <70% of follow-up time within therapeutic range was associated with lower hospital admission frequency (9.7 vs. 10.3 times/year). CONCLUSION Our study revealed only one-third of the follow-up time to be spent within therapeutic INR, association of INR therapeutic range with lesser number of hospital admissions and INR monitoring frequency of 6.47 times/year despite lack of stable INR control in most of the deep vein thrombosis patients.
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Affiliation(s)
- Murat Sargin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muge Mete Tasdemir
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Huseyin Kuplay
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinc Bayer Erdogan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nehir Tandogar
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serdar Akansel
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Erol Kurc
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokcen Orhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serap Aykut Aka
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Bednasz CJ, Venuto CS, Ma Q, Daar ES, Sax PE, Fischl MA, Collier AC, Smith KY, Tierney C, Yang Y, Wilding GE, Morse GD. Efavirenz Therapeutic Range in HIV-1 Treatment-Naive Participants. Ther Drug Monit 2017; 39:596-603. [PMID: 29135907 PMCID: PMC5718358 DOI: 10.1097/ftd.0000000000000443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efavirenz is currently suggested as an alternative to recommended antiretroviral (ARV) regimens by the Department of Health and Human Services for the treatment of HIV-1 in ARV-naive patients. A mid-dosing interval therapeutic range between 1000 and 4000 ng/mL for efavirenz has been proposed in the literature, with patients more likely to experience virologic failure below this range and adverse effects above. The current study reports an analysis of virologic outcome between those above, below, or within the reported efavirenz therapeutic range (1000-4000 ng/mL) and within subgroups. METHODS This analysis examined efavirenz plasma concentrations obtained from participants enrolled in AIDS Clinical Trials Group Study A5202. This investigation divided subjects into those who experienced virologic failure and those who did not. These subjects were further separated to investigate those who had "high," "within," or "low" plasma concentrations, based on the therapeutic range. The association between virologic failure and plasma concentration was statistically examined in addition to the variables: race/ethnicity, sex, assigned nucleos(t)ide reverse transcriptase inhibitor backbone, age at study entry, history of intravenous drug use, weight, and screening HIV-1 RNA stratification level. RESULTS In univariate analyses, a statistically significant difference was found when comparing the efavirenz concentration groups, (22 failures among the "low" concentration group [19%], 65 failures among the "within" concentration group [12%], and 11 failures among the "high" concentration group [9%]) when evaluating virologic failure as an outcome (P = 0.04). In addition, the proportion of participants with virologic failure differed across race/ethnicity groups (P = 0.03) with black non-Hispanic participants observed to have the highest rate (17%). Efavirenz concentration group, race/ethnicity, age, weight, and the interaction between efavirenz concentration group and weight were found to be significantly associated with virologic failure in multivariable logistic regression analysis. CONCLUSIONS The proposed efavirenz therapeutic range, combined with the impact of a patient's weight, is associated with virologic failure in HIV-infected ARV-naive individuals in the United States. Additional analysis is recommended to determine the most appropriate concentration value that defines the lower limit of the efavirenz therapeutic range.
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Affiliation(s)
- Cindy J. Bednasz
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Charles S. Venuto
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, NY, USA
| | - Qing Ma
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Eric S. Daar
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center and the University of California, Los Angeles,
CA, USA
| | - Paul E. Sax
- Division of Infectious Diseases and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical
School, Boston, MA, USA
| | | | - Ann C. Collier
- University of Washington School of Medicine and Harborview Medical Center, Seattle, WA, USA
| | | | - Camlin Tierney
- Statistical Data Analysis Center, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Yang Yang
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA
| | | | - Gene D. Morse
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
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Abstract
INTRODUCTION Heparin is one of the oldest biological medicines with an established role in prevention and treatment of arterial and venous thromboembolism. Published therapeutic ranges for unfractionated heparin (UFH) mostly precede the large increase in the number of activated partial thromboplastin time (APTT) reagent/instrument combinations that now show wide variability. Areas covered: This paper explores the use of UFH, the development of heparin therapeutic ranges (HTRs), and the strengths and limitations of the methods used to monitor heparin's anticoagulant effect. Expert commentary: Despite longstanding use of UFH for management of thromboembolic conditions, the optimal test for monitoring UFH remains undetermined. Although used extensively for monitoring UFH, routine APTT-derived HTRs are based on limited science that may have little relevance to current laboratory practice. Anti-FXa levels may provide better and more reliable HTRs; however, even these levels show considerable inter-laboratory variation, and there are insufficient clinical studies proving improved clinical efficacy. Alternative tests for monitoring UFH reported over time have not been proven effective nor feasible, secondary to technical or cost issues, or lack of general adoption. Thus, despite limited evidence of clinical utility, an uncomfortable marriage of convenience represented by heparin laboratory monitoring is unlikely to be terminated in the immediate future.
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Affiliation(s)
- Israfil Baluwala
- a Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology , Westmead Hospital , Westmead , Australia
| | - Emmanuel J Favaloro
- a Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology , Westmead Hospital , Westmead , Australia.,b Sydney Centres for Thrombosis and Haemostasis , Westmead , Australia
| | - Leonardo Pasalic
- a Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology , Westmead Hospital , Westmead , Australia.,b Sydney Centres for Thrombosis and Haemostasis , Westmead , Australia
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Abstract
Objective Tablet splitting is frequently performed to facilitate correct dosing, but the practice and implications in low-income settings have rarely been discussed. Methods We selected eight drugs, with narrow therapeutic indices or critical dosages, frequently divided in the Lao PDR (Laos). These were split, by common techniques used in Laos, by four nurses and four laypersons. The mean percentage deviation from the theoretical expected weight and weight loss of divided tablets/capsules were recorded. Results Five of eight study drugs failed, on splitting, to meet European Pharmacopoeia recommendations for tablet weight deviation from the expected weight of tablet/capsule halves with 10% deviating by more than 25%. There was a significant difference in splitting accuracy between nurses and laypersons (P = 0.027). Coated and unscored tablets were less accurately split than uncoated (P = 0.03 and 0.0019 for each half) and scored (0.0001 for both halves) tablets. Conclusion These findings have potential clinical implications on treatment outcome and the development of antimicrobial resistance. Investment by drug companies in a wider range of dosage units, particularly for narrow therapeutic index and critical dosage medicines, is strongly recommended.
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Affiliation(s)
- Ivo Elliott
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR; Centre for Tropical Medicine, Nuffield Department of Medicine, Churchill Hospital, University of Oxford, Oxford, UK
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