Valacyclovir Neurotoxicity in Patients with End-Stage Renal Disease: Two Cases Reviewed.

Purpose: The objective of this case series is to highlight different manifestations of valacyclovir associated neurotoxicity (VAN) and demonstrate the importance of adjusting medication appropriately in patients with end-stage renal disease (ESRD) on hemodialysis to prevent these complications. Summary: Valacyclovir is a medication used to treat herpes zoster infection, commonly known as shingles. Valacyclovir is renally cleared and can accumulate in patients with renal dysfunction leading to severe side effects due to the prolonged half-life. VAN is a common adverse effect in patients with underlying kidney disease, that can be easily prevented if valacyclovir is properly dosed. This case series details the clinical outcomes of two elderly patients who were prescribed valacyclovir at six-times the recommended dose based on their renal function. Failure to reduce the dose of valacyclovir resulted in severe neurological and physical manifestations that required hospital admission and emergent hemodialysis. Conclusion: This case series details the importance of adjusting valacyclovir dose based on renal function. In patients with ESRD, the half-life of valacyclovir can be up to 14 hours, therefore hemodialysis should be utilized in severe cases of neurotoxicity to improve rapid excretion of the drug and promote rapid recovery from VAN.

Ambulatory Intravenous Diuretic Clinic Associated with Short-Term Risk Reduction in Mortality and Rehospitalizations in Patients Discharged with Heart Failure.

BACKGROUND: Data on effectiveness of ambulatory intravenous (IV) diuretic clinics for volume management in patients with heart failure to prevent rehospitalization and mortality are limited. Therefore, the primary goal of this research is to evaluate the effectiveness of an out- patient multidisciplinary IV diuretic clinic versus standard observational hospitalizations of less than 48 hours for decompensated heart failure on the time to rehospitalization or death. METHODS: A retrospective cohort study of patients with heart failure (n=90) at the Providence Veterans Affairs Medical Center was conducted. Patients were included in the analyses if they received at least one ambulatory IV diuretic clinic visit or an observational hospitalization of less than 48 hours for decompensated heart failure between January 1, 2014 and June 30, 2016. Using Cox proportional hazards modeling, we compared the time to any hospitalization or death between the IV clinic and the observational hospitalization cohort over 180 days of follow-up. RESULTS: In the ambulatory IV diuretic clinic group, 27 patients (mean age 78.3 ± 8.3 years) received a median of 3 (interquartile range [IQR] 2-12), IV diuretic treatments. In the comparison group, 63 patients (mean age 80.3 ± 11.0 years) were hospitalized for observation for 48 hours or less during the same time period. Adjusting for age and imbalances in baseline characteristics, left ventricular ejection fraction and enrollment in hospice care, the hazards of any hospitalization or death (HR 0.39, 95% confidence interval 0.19 to 0.83) were reduced for patients in the ambulatory IV diuretic clinic versus those in the observational hospitalization cohort. CONCLUSIONS: In patients with decompensated heart failure, an ambulatory IV diuretic clinic was associated with risk reduction of any rehospitalization or death over 180 days of follow up when compared to a strategy of observational hospitalization for less than 48 hours. Future research should prospectively analyze outpatient IV therapy in a larger and more diverse population.

ERRATUM: Unexpected Serious Cardiac Arrhythmias in the Setting of Loperamide Abuse.

Loperamide (Imodium) is a non-prescription opioid receptor agonist available over-the-counter for the treatment of diarrhea. When ingested in excessive doses, loperamide can penetrate the blood-brain barrier and is reported to produce euphoria, central nervous system and respiratory depression, and cardiotoxicity. There is an emerging trend in its use among drug abusers for its euphoric effects or for self-treatment of opioid withdrawal. We report a case of ventricular dysrhythmias associated with loperamide abuse in a 28-year-old man who substituted loperamide for the opioids that he used to abuse. [Full article available at http://rimed.org/rimedicaljournal-2017-04.asp, free with no login].

Unexpected Serious Cardiac Arrhythmias in the Setting of Loperamide Abuse.

Loperamide (Imodium) is a non-prescription opioid receptor agonist available over-the-counter for the treatment of diarrhea. When ingested in excessive doses, loperamide can penetrate the blood-brain barrier and is reported to produce euphoria, central nervous system and respiratory depression, and cardiotoxicity. There is an emerging trend in its use among drug abusers for its euphoric effects or for self-treatment of opioid withdrawal. We report a case of ventricular dysrhythmias associated with loperamide abuse in a 28-year-old man who substituted loperamide for the opioids that he used to abuse. [Full article available at http://rimed.org/rimedicaljournal-2017-04.asp].