A Review of the Safety and Efficacy of Apixaban in Patients With Severe Renal Impairment

Background Apixaban is a direct-acting oral anticoagulant (DOAC) used to treat or prevent thromboembolic events. Renal impairment limits DOAC use. Studies supporting Food and Drug Administration (FDA)-approval for apixaban did not include patients with a creatinine clearance < 25 mL/min. Consequently, limited guidance for use in end-stage renal disease (ESRD) exists in the package insert. An in-depth literature search reveals substantial evidence supporting the safety and effectiveness of apixaban in ESRD. Clinicians must have access to this evidence so that patients in need of apixaban therapy are appropriately managed. Objective To provide an up-to-date review of literature surrounding the safety and effectiveness of apixaban in patients with ESRD. Data Sources A PubMed search of research studies published through November 2021 was performed using a combination of the following terms: apixaban, severe renal impairment, end-stage renal disease, DOACs, safety, effectiveness, atrial fibrillation, anticoagulation. Study Selection/Data Extraction Relevant original research, review articles, and guidance recommendations were assessed for the use of apixaban in patients with ESRD. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. Data Synthesis Numerous studies exist supporting the safety and effectiveness of apixaban in patients with ESRD who may or may not be on dialysis. Conclusion Multiple studies suggest that apixaban is possibly associated with a lower prevalence of bleeding and thromboembolic events compared with warfarin therapy in patients with ESRD and can be safely initiated in those within this sub-group who require anticoagulation with a DOAC. Clinicians should monitor for signs of bleeding throughout the duration of therapy.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Late-Onset Dystonia With Low-Dose Olanzapine in an Older Person: A Case Report

Drug-induced dystonias are rare but can occur with second-generation antipsychotics. They are usually dose-related and occur soon after dose initiation. This case describes the development of dystonia after two years of olanzapine 5 mg daily in an older person with Alzheimer's dementia. The dystonia resolved after diphenhydramine treatment on day two of hospitalization, but then the patient became delirious, which was treated with lorazepam on day three. Six days after admission, she developed tremors and rigidity that self-resolved. Her dystonia resolved after 11 days. The recurrence of symptoms during the hospitalization may have been a result of the progression of her dementia. This is the first known case of a patient developing dystonia after chronic use of low-dose olanzapine. This was not characterized as tardive dystonia because the dystonia was resolved with anticholinergic medication. This case illustrates the difficulty of using anticholinergics to treat dystonias in older people, which can precipitate delirium. Choosing an alternative antipsychotic with less extrapyramidal symptom risk is challenging as she had previous trials with quetiapine and risperidone. Clozapine was deemed an unfavorable alternative, as laboratory monitoring would be burdensome. Olanzapine-induced dystonias can develop anytime during therapy. Families must balance the desire for mood stabilization with antipsychotics side effects.

Transcultural Self-Efficacy Perceptions of Baccalaureate Nursing Students

Addressing the health care needs of a 21st-century nation that is experiencing increased diversity and disparity will require new models of educating future providers. The cultural competence and confidence model was the guiding framework in a study evaluating the influence of cultural educational offerings on the transcultural self-efficacy (TSE) perceptions in baccalaureate nursing students. The Transcultural Self-Efficacy Tool was used to measure perceived TSE in a pretest ( N = 260), posttest ( N = 236) study over an academic year. Significant changes were demonstrated in overall self-efficacy and on the cognitive, practical, and affective subscales. A classification and regression tree analysis identified social orientation as the demographic variable most predictive of the TSE level. This study supports previous research where positive changes were found in students’ TSE based on the inclusion of cultural interventions in the nursing curriculum.

Rediscovering community--reflections after Hurricane Sandy

Hoboken, New Jersey, is a town of 50,000 residents located across the Hudson River from New York City. Most of Hoboken's infrastructure was compromised during Hurricane Sandy as a result of flooding and power outages that rendered many businesses inoperable, including all of the pharmacies in town. Despite a focus on emergency preparedness since Hurricane Katrina and 9/11, there were no contingencies in place to facilitate and assess the medication needs of the community in the event of a natural disaster. This essay describes how the author rediscovered the meaning of community, and through working with colleagues in other health care disciplines and non-health care volunteers, provided care to patients in suboptimal circumstances.

Akathisia Induced by Gabapentin Withdrawal

OBJECTIVE:

To report a case of akathisia in a patient with type 2 diabetes after abrupt discontinuation of gabapentin.

CASE SUMMARY:

A 76-year-old female with type 2 diabetes was admitted for change in mental status, agitation, and restless limb movements. She had been taking gabapentin 3600 mg daily for approximately 1 month for diabetic neuropathy. Her other home medications were glyburide 10 mg twice daily, oxycodone/acetaminophen 5 mg/325 mg every 6 hours as needed for leg pain, and zolpidem 5 mg at bedtime. She had taken none of these drugs for 4 days prior to admission because she was unable to have the prescriptions refilled. Subsequently, the patient exhibited repeated arm and leg motions in response to an inner restlessness. Upon admission to the emergency department, she was agitated and restless; all vital signs and results of laboratory studies were within normal limits. Gabapentin was restarted at the original dosage and the symptoms resolved within 8 hours. Because the patient developed lethargy, the gabapentin dosage was reduced and titrated to the original level over 2 days. After 3 days, the patient was well oriented and experienced no further symptoms. She was discharged on the original dosage of gabapentin.

DISCUSSION:

To our knowledge, this is the first reported cases of akathisia induced by gabapentin withdrawal. Available case reports suggest that gabapentin withdrawal can occur at doses ranging from 400-8000 mg/day. Patients experienced symptoms similar to those that develop with benzodiazepine withdrawal and were taking gabapentin for as little as 3 weeks to as long as 5 years. This is the first case report to describe akathisia induced by gabapentin withdrawal. The Naranjo probability scale revealed a probable relationship between akathisia and gabapentin withdrawal.

CONCLUSIONS:

If gabapentin discontinuation is desired, it is prudent to gradually taper the dose to avoid withdrawal symptoms, which may occur after as little as 1 month of treatment. Should the patient experience withdrawal symptoms, the optimal treatment is to restart gabapentin.

Implementation of a Symptom-Triggered Benzodiazepine Protocol for Alcohol Withdrawal in Family Medicine Inpatients

Purpose

The purpose of this pilot study was to review the implementation of symptom-triggered benzodiazepine therapy and evaluate the feasibility and outcomes as compared with a previous hospital standard of fixed-dose phenobarbital protocol for alcohol withdrawal on a family medicine service.

Methods

This retrospective chart review of 46 patients' medical records was performed on admissions to the family medicine service occurring between February and October of 2005 compared with February and October of 2006. Included in the study were adults who were suffering from alcohol withdrawal symptoms (AWS), who admitted to heavy daily alcohol intake, who were intoxicated on admission, and who had a history of AWS and/or history of AWS-related seizures. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) was used to evaluate the impact of individualized symptom-triggered therapy on outcome measurements utilizing symptom-triggered benzodiazepine therapy compared with the previous hospital standard using a fixed-dose phenobarbital protocol.

Results

One hundred percent of the patients in the phenobarbital group required drug compared with 38% in the benzodiazepine group ( P < 0.001). Fewer patients (9.5%) in the benzodiazepine group left the hospital against medical advice (AMA), while 36% of patients in the phenobarbital group left AMA ( P = 0.045). There was no significant difference in length of stay or the number of days on the protocol.

Conclusion

The results of the pilot study demonstrated that symptom-triggered therapy using benzodiazepines resulted in better outcomes than fixed-dosing phenobarbital. Importantly, most patients in the benzodiazepine group required no drug administration.

Choosing a skeletal muscle relaxant

Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain. Systematic reviews and meta-analyses support using skeletal muscle relaxants for short-term relief of acute low back pain when nonsteroidal anti-inflammatory drugs or acetaminophen are not effective or tolerated. Comparison studies have not shown one skeletal muscle relaxant to be superior to another. Cyclobenzaprine is the most heavily studied and has been shown to be effective for various musculoskeletal conditions. The sedative properties of tizanidine and cyclobenzaprine may benefit patients with insomnia caused by severe muscle spasms. Methocarbamol and metaxalone are less sedating, although effectiveness evidence is limited. Adverse effects, particularly dizziness and drowsiness, are consistently reported with all skeletal muscle relaxants. The potential adverse effects should be communicated clearly to the patient. Because of limited comparable effectiveness data, choice of agent should be based on side-effect profile, patient preference, abuse potential, and possible drug interactions.

Exenatide

Maintaining glycemic control is the primary goal for preventing macrovascular and microvascular complications associated with type 2 diabetes. Currently available antidiabetic drugs work in different ways to lower blood glucose levels; unfortunately, each of them has its tolerability and safety concerns. Exenatide is the first drug in a new class known as the incretin mimetic agents. It improves glucose control by mimicking the effects of glucagon-like peptide-1, a natural mammalian incretin hormone secreted during food intake. Exenatide was approved by the U.S. Food and Drug Administration for the treatment of type 2 diabetes in conjunction with metformin and/or sulfonylurea. The recommended dosage is 5 mug to 10 mug twice daily subcutaneously before breakfast and dinner. In randomized, placebo-controlled, 30-week clinical studies, exenatide improved glycemic control and promoted weight loss of up to 2.8 kg. The most common adverse effects were nausea (44%), vomiting (13%), diarrhea (13%), and hypoglycemia (5-36%). Hypoglycemia occurred in a dose-dependent fashion. Patients should be closely monitored for hypoglycemia, especially when exenatide is added to sulfonylurea therapy. Overall, exenatide provides a treatment option for patients with type 2 diabetes who fail to obtain glycemic control while on a maximum dose of metformin and/or sulfonylurea therapy. It is also an alternative therapy for those patients who cannot tolerate other antidiabetic drugs.

Penicillin-Induced Jarisch–Herxheimer Reaction

OBJECTIVE

To report a case of Jarisch–Herxheimer reaction (JHR) in a patient with presumed neurosyphilis and HIV.

CASE SUMMARY

A 45-year-old HIV-positive man (CD4+ count 450 cells/mm3 and history of AIDS-defining illness) presented with JHR after an initial intravenous dose of penicillin G for presumed neurosyphilis. The patient described feeling cold with worsening headache and chills approximately one hour after infusion of the first dose of penicillin. On examination, rigors, shallow inspirations, and chills were noted. He was afebrile, tachycardic, and tachypneic and had an oxygen saturation of 94% while breathing room air. His symptoms resolved within 10 minutes. Initially, this reaction was thought to be a result of a drug allergy, but upon further review, we determined that it was JHR.

DISCUSSION

It is not uncommon to confuse drug allergy with JHR. An objective causality assessment suggests that the JHR in our patient was probably related to penicillin. JHR is a self-limiting condition that warrants the continuation of antibiotic treatment in syphilis patients.

CONCLUSIONS

JHR should be an anticipated reaction to early doses of antibiotic treatment for treponemal diseases, such as syphilis. Treatment of JHR is largely supportive, such as administering antipyretic and antiinflammatory agents. Antibiotic treatment should be continued.

Digoxin increases mortality among women with congestive heart failure

Digoxin increases mortality in women with congestive heart failure, compared with men; however, the clinical significance of this is unknown since gender is a nonmodifiable risk factor. More importantly, there is a suggestion of harm when looking at women treated with digoxin versus placebo. Since there are other therapies with definite benefit in congestive heart failure (angiotensin-converting enzyme inhibitors, beta-blockers, spironolactone), it is prudent to reconsider the use of digoxin in women with ejection fractions less than 45%.

Angiotensin II receptor blockers for the treatment of hypertension

The rising incidence of stroke, congestive heart failure (CHF) and end stage renal disease (ESRD) has signalled a need to increase awareness, treatment and control of hypertension. There continues to be a need for effective antihypertensive medications since hypertension is a major precursor to various forms of cardiovascular disease. The renin-angiotensin (AT) aldosterone system (RAAS) is a key component to the development of hypertension and can be one target of drug therapy. Angotensin II (ATII) receptor blockers (ARBs) are the most recent class of agents available to treat hypertension, which work by by inhibiting ATII at the receptor level. Currently, national consensus guidelines recommend that ARBs should be reserved for hypertensive patients who cannot tolerate angiotensin converting enzyme (ACE) inhibitors (ACEIs). ARBs, however, are moving to the forefront of therapy with a promising role in the area of renoprotection and CHF. Recent trials such as the The Renoprotective Effect of the Angiotensin-Receptor Antagonist Irbesartan in Patients with Nephropathy Due to Type 2 Diabetes Trial (IDNT), the Effect of Irbesartan on the Development of Diabetic Nephropathy in Patients with Type 2 Diabetes (IRMA2), and The Effects of Losartan on Renal and Cardiovascular Outcomes in Patients with Type 2 Diabetes and Nephropathy (RENAAL) study have demonstrated the renoprotective effects of ARBs in patients with Type 2 diabetes. The Valsartan Heart Failure Trial (Val-HeFT) adds to the growing body of evidence that ARBs may improve morbidity and mortality in CHF patients. As a class, ARBs are well tolerated and have a lower incidence of cough and angioedema compared to ACEIs. This article reviews the differences among the ARBs, existing efficacy data in hypertension, and explores the role of ARBs in CHF and renal disease.

Trimethoprim/sulfamethoxazole-induced toxic epidermal necrolysis

OBJECTIVE

To report a case of toxic epidermal necrolysis (TEN) associated with trimethoprim/sulfamethoxazole (TMP/SMX).

CASE SUMMARY

A 34-year-old Asian woman developed a severe, desquamating mucocutaneous reaction (TEN) after six days of taking TMP/SMX to treat a presumed urinary tract infection (UTI).

DISCUSSION

TMP/SMX is often recommended as first-line therapy for UTIs, sinusitis, bronchitis, and as prophylaxis and treatment for Pneumocystis carinii pneumonia. TEN is a rare, but severe condition associated with sulfonamide use. This article describes a typical case and offers an opportunity for review of this potentially serious reaction.

CONCLUSIONS

Sulfonamides are often implicated in the majority of drug-induced cases of TEN. This case report illustrates the typical presentation of sulfonamide-induced TEN with a prodrome, characteristic rash, mucous membrane lesions, and systemic involvement. Practitioners should be aware of this rare adverse effect and closely observe patients for cutaneous manifestations or complaints. Any suspected drug should be discontinued if clinical evaluation leads to the suspicion of Stevens-Johnson syndrome or TEN.

Candesartan cilexetil: an angiotensin II-receptor blocker

The mechanism of action, pharmacokinetics, pharmacodynamics, clinical efficacy, and adverse effects of candesartan cilexetil are reviewed. Candesartan is an angiotensin II-receptor blocker (ARB). It is administered as a pro-drug that undergoes activation during gastrointestinal absorption. The agent is excreted mostly unchanged and has a terminal half-life of about nine hours (slightly longer in the elderly). Candesartan differs from other agents in its class in that it is tightly bound to angiotensin II type 1 receptors, allowing prolonged activity. In clinical trials, candesartan cilexetil has produced a dose-dependent effect when given in dosages of 2-32 mg/day. Observed trough-to-peak blood pressure ratios support a once-daily dosage regimen. The antihypertensive effect of candesartan cilexetil 4-16 mg/day was as great as that of enalapril 10-20 mg/day and amlodipine 5 mg/day and larger than that of losartan potassium 50 mg/day. Adding candesartan cilexetil to hydrochlorothiazide 12.5-25 mg/day and amlodipine 5 mg/day led to enhanced blood-pressure reductions and was well tolerated. It appears that candesartan can decrease renal perfusion without adversely affecting renal blood flow and may mediate a decrease in albuminuria in hypertensive patients with type 2 diabetes. No clinically important drug interactions have been reported. Adverse effects include headache, dizziness, nausea, diarrhea, and transient elevations in liver transaminases. The frequency of cough is similar to that seen with placebo. Candesartan cilexetil is an effective antihypertensive agent that can be used alone or in combination with other antihypertensive drugs. It is generally well tolerated and may be an option for patients who cannot tolerate angiotensin-converting-enzyme inhibitors because of cough.