Perioperative Anticoagulation Management.

Management of anticoagulation in individuals undergoing operative procedures is a complex situation. Each case should be assessed individually with proper risk assessment, monitoring, and plan for perioperative and postoperative anticoagulation. Clinical evidence for the management of these patients is relatively scarce, and clinicians are often assessing each individual case with minimal guidance. This review provides nurses with a summary of available literature on the assessment, laboratory monitoring, timing of adjusting anticoagulation, and bridging prior to procedures. In addition to general perioperative anticoagulation management, this review discusses perioperative management in special populations and provides a summary on principles when anticoagulation should be resumed following a procedure.

Hydroxychloroquine-Induced Hypoglycemia in a Patient Without Diabetes.

Hydroxychloroquine is a disease-modifying antirheumatic drug commonly used in the treatment of autoimmune diseases. Although rare, hydroxychloroquine is associated with hypoglycemia in patients with or without diabetes due to its ability to alter insulin metabolism. There have been several cases described in the literature, but none of which, to our knowledge, detail follow-up and time to resolution of hypoglycemia. We describe a 55-year-old female who presents for episodes of hypoglycemia. She reported hypoglycemic symptoms and fasting blood glucoses in the 60-70s mg/dL regularly. Based on the Naranjo adverse drug reaction probability scale, hydroxychloroquine was the probable etiology of her hypoglycemic episodes due to the improvement at her 3-month follow up appointment after discontinuing the drug. Providers should be mindful of the hypoglycemia risk when using hydroxychloroquine and be aware that the effects may take an extended amount of time to resolve given the drug's long half-life.

Prolonged course of eravacycline leading to acute pancreatitis.

Eravacycline is the newest member of the broad-spectrum class of tetracycline antimicrobials. Pancreatitis has been previously associated with the tetracycline class of antibiotics, but, to our knowledge, we believe that this is the first reported case of eravacycline-induced pancreatitis. We describe a 46-year-old male who received eravacycline for treatment of a perirectal abscess. While the patient had slightly elevated lipase levels at baseline post-cardiopulmonary arrest, he developed abdominal pain and a further increase in lipase levels following 10 days of eravacycline, consistent with pancreatitis. Based on the Naranjo adverse drug reaction probability scale, eravacycline was the probable etiology of acute pancreatitis given improvement immediately after discontinuation. Clinicians should be aware of this potential adverse effect of eravacycline and should not initiate eravacycline in those with risk factors for acute pancreatic injury. However, acute pancreatitis should be suspected in all patients complaining of symptoms followed by immediate discontinuation of eravacycline.

Evaluating Time to In-Hospital Venous Thromboembolism in Obese Patients.

BACKGROUND: Currently, no consensus approach exists for optimal venous thromboembolism (VTE) prophylaxis in obese (BMI ≥30 kg/m2) patients. Time to development of in-hospital VTE is not well studied. OBJECTIVE: This study evaluates time to in-hospital VTE in obese patients. METHODS: A single-center, retrospective study evaluated obese patients that developed an in-hospital VTE. Patients were categorized into 3 BMI groups: 30 to 34.9 (group 1), 35 to 39.9 (group 2), and ≥40 (group 3) kg/m2. The primary end point compared time to VTE between the groups. RESULTS: A total of 246 patients were included, and time to VTE was similar between the groups, 8 (group 1) versus 8 (group 2) versus 9 days (group 3); P = .38. Secondary outcomes showed time to VTE was shorter in acute care versus ICU patients (7.5 vs 10 days; P = .01), nonsurgical versus surgical patients (6 vs 9 days; P = .004), and no prophylaxis versus mechanical plus pharmacologic prophylaxis (4.5 vs 9 days; P < .001). CONCLUSIONS: BMI category did not significantly impact time to in-hospital VTE. This study provides insight into the timing of in-hospital VTE in obese patients. The differences in prophylactic strategies highlight the importance of optimized prophylaxis.

Combined Insulin and GLP-1 Receptor Agonists: Simplifying Treatment or Adding Obstacles?

The US Food and Drug Administration recently approved 2 combination products containing a basal insulin and a glucagon-like peptide 1 receptor agonist: insulin glargine/lixisenatide and insulin degludec/liraglutide. These agents were shown to be noninferior in lowering hemoglobin A1c compared to basal insulin and are indicated for patients inadequately controlled on basal insulin or glucagon-like peptide 1 receptor agonists alone. The clinical implications of these agents are unclear due to limitations in the clinical trials and limited recommendations in current guidelines. While these agents may provide financial and adherence benefits, their role is likely limited to the outpatient setting. With the availability of these agents, concerns with transitions of care arise due to multiple vulnerabilities in reconciling these agents throughout the inpatient admission and discharge process. Provider awareness of the availability and dosing of insulin glargine/lixisenatide and insulin degludec/liraglutide is essential to reduce errors in the medication reconciliation process.

Assessing Guideline-Directed Medication Therapy for Heart Failure in End-Stage Renal Disease.

BACKGROUND: Treatment of heart failure with reduced ejection fraction (HFrEF) requires guideline-directed medication therapy (GDMT) consisting of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker in combination with an indicated beta-blocker. There is concern that end-stage renal disease (ESRD) patients are not being prescribed GDMT. The study aim was to determine whether outcomes differ for patients with HFrEF and ESRD receiving GDMT compared to those not receiving GDMT. MATERIALS AND METHODS: Adult patients with ESRD and HFrEF admitted to a tertiary teaching hospital over a 2-year period were included. Patients were categorized into GDMT or non-GDMT groups based on their home medications. The length of stay (LOS), mortality, and 30-day hospital readmissions were compared between groups. The incidence of hyperkalemia, hypotension and bradycardia were also evaluated. RESULTS: A total of 109 patients were included: 88% African-American, 61% males, median age 63 (28-93) years with 25 in the GDMT group and 84 in the non-GDMT group. The LOS did not differ between the GDMT (5 days; 3-14) compared to the non-GDMT group (7 days; 3-28), P = 0.14. Thirty-day hospital readmission and in-hospital mortality were also similar. Hypotension occurred less frequently in the GDMT group compared to the non-GDMT group, 4% versus 27% (P = 0.01). CONCLUSIONS: Although there were no differences in the primary outcomes, the shorter LOS in the GDMT group may be clinically significant. The fact that most patients with ESRD and HFrEF were not receiving GDMT is a finding that requires further evaluation.

A review on cardiovascular effects of newer hypoglycaemic medications.

Cardiovascular disease (CVD) is the most prevalent cause of morbidity and mortality in diabetic patients. Improvement in cardiovascular complications with glycaemic control and managing cardiovascular risk factors is well established. However, the impact of hypoglycaemic medications on CVD is of increasing importance. In 2008, the U.S. Food and Drug Administration issued study regulations for hypoglycaemic agents after rosiglitazone was shown to increase the incidence of myocardial infarction, and the European Medicines Agency provided their own guidance in 2012. As a result, multiple studies have been published evaluating the cardiovascular safety of newer hypoglycaemic medications. Empagliflozin and liraglutide are among the newer agents that have shown cardiovascular benefit and are now recommended for patients with CVD or are at an increased risk of CVD per the 2017 American Diabetes Association Guidelines. Given the influx of new literature and other ongoing studies, it is important to understand the cardiovascular safety of newer hypoglycaemic medications. The purpose of this article is to provide a comprehensive review of clinical trials conducted evaluating cardiovascular outcomes of newer hypoglycaemic medications and their role within diabetic management. Key Messages With the prevalence of cardiovascular disease in diabetic patients, clinicians should develop a medication regimen that provides both sufficient efficacy for diabetes while also maintaining cardiovascular safety. Of the new diabetic classes, empagliflozin, a sodium-glucose co-transporter 2 inhibitor, and liraglutide, a glucagon-like peptide-1 receptor agonist, have shown cardiovascular benefit in diabetic patients with established cardiovascular disease and are now recommended in current guidelines for this population. Ongoing trials will give more insight to whether cardiovascular benefit is a class effect with sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists and the cardiovascular safety of dipeptidyl peptidase-4 inhibitors.

Should Pharmacies Be Included in Medication Reconciliation? A Report of Recurrent Valproic Acid Toxicity.

Including outpatient pharmacies in the medication reconciliation process upon hospital discharge is not commonly performed. This case highlights the consequences of a patient refilling a discontinued prescription for valproic acid (VPA). We present a 32-year old male found unresponsive after ingesting delayed release divalproex sodium. Cerebral edema was visualized on magnetic resonance imaging. Hemodialysis and levo-carnitine treatment led to improved mental status, and VPA was discontinued. The same patient presented with VPA overdose eight months later after he continued to fill an outdated prescription. This case highlights consequences of VPA toxicity; it also demonstrates an opportunity to improve patient safety and high-value care by collaborating with outpatient pharmacies in the medication reconciliation process upon hospital discharge.