Retrospective review of Andexanet Alfa versus 4-Factor Prothrombin Complex Concentrate for reversal of DOAC-Associated Intracranial Hemorrhage.

Background: Mortality of oral anticoagulation-associated ICH is around 60%, with oral anticoagulation increasing the risk of ICH seven to ten-fold compared to no anticoagulation. Current guidelines recommend DOACs (direct oral anticoagulants) as first-line therapy in the treatment of VTE (Venous Thromboembolism) due to their more favorable safety profile. There are two agents available for DOAC reversal, Coagulation Factor Xa (recombinant), inactivated-zhzo (andexanet alfa, Andexxa®) and 4-factor prothrombin complex concentrate (4FPCC). There is little data comparing the two agents in real-life clinical settings. OBJECTIVE: The primary objective of this study was to determine if there was a difference in hemostatic efficacy of andexanet alfa and 4FPCC in patients with a factor Xa inhibitor-related intracranial hemorrhage. METHODS: This was a retrospective, single-center study conducted in adult patients admitted at a quaternary academic medical center from September 2017 to March 2021. Adults with a diagnosis of intracranial hemorrhage (ICH) were included if they received either 4FPCC or andexanet alfa for reversal of apixaban or rivaroxaban. In addition to hemostatic efficacy per imaging, we assessed disposition location, cerebral performance score, blood product consumption, and the development of a new thrombus. RESULTS: A total of 46 patients were included in this study, 15 received 4FPCC (32%) and 31 received andexanet alfa (68%). There was no difference in the proportion of patients with excellent (4FPCC 9 [60%] vs. andexanet alfa 16 [51.6%], p = 0.61), good (4FPCC 2 [13.3%] vs. andexanet alfa 7 [22.6%]), or poor (4FPCC 1 [6.7%] vs. andexanet alfa 5 [16.1%]) hemostasis after administration of each agent. There were no significant differences in any secondary outcomes. CONCLUSION AND RELEVANCE: Our study found no difference in hemostatic efficacy between andexanet alfa and 4FPCC. At this time, clinicians should choose an agent based on individual patient presentation and resource availability. Further research will help clarify the role of each agent in the management of DOAC-related intracranial hemorrhage.

Impact of delayed transition off intravenous vasoactive agents for aortic dissection on intensive care unit length of stay.

Background: The initial management of acute aortic dissection centers around rapid control of blood pressure and heart rate, commonly requiring initiation of continuous intravenous (IV) antihypertensive agents and intensive care unit (ICU) admission. However, there is limited guidance for when and how to transition off IV infusions to enteral agents, potentially extending ICU length of stay (LOS) in stable patients who are otherwise ready for floor transfer. The objective of this study is to compare the impact of rapid vs. slow transition from IV to enteral vasoactive medications on ICU LOS. Methods: In this retrospective cohort study of 56 adult patients admitted with aortic dissection requiring IV vasoactive infusions for >6 hours, patients were grouped by time required to fully transition from IV to enteral vasoactive agents. Patients who transitioned in ≤72 hours were considered the "rapid" group, and the "slow" group required >72 hours to fully convert. The primary endpoint was ICU LOS. Results: For the primary endpoint, the median ICU LOS was 3.6 days for the "rapid" group, compared to 7.7 days in the "slow" group (P<0.001). The "slow" group required a significantly longer duration of IV vasoactive infusions (115.7 vs. 36.0 hours, P<0.001) and also trended towards longer median hospital LOS. The two cohorts had similar incidences of hypotension. Conclusions: In this study, rapid transition to enteral antihypertensives within 72 hours was associated with a shorter ICU LOS without an increase in hypotension.

Managing Hyperkalemia: Stepping Into a New Frontier.

Maintaining potassium balance in the body is essential for cellular function. Even a slight increase in normal serum potassium levels (3.5-5.0 mEq/L) can interfere with metabolism, electrical action potentials, and cellular processes. Hyperkalemia is commonly seen in patients with chronic kidney disease (CKD) and in patients on renin-angiotensin-aldosterone system (RAAS) inhibitors. Sodium polystyrene sulfonate (SPS), diuretics, and hemodialysis are currently available methods for removing potassium from the body; however, these options have their limitations. Patiromer (Veltassa) and sodium zirconium cyclosilicate are 2 new therapeutic options that can potentially lead a new frontier in the management of hyperkalemia. This article will review these novel treatments.

Review of Lisdexamfetamine Dimesylate in Adults With Attention-Deficit/Hyperactivity Disorder.

Lisdexamfetamine dimesylate (LDX) is the first prodrug stimulant used for the treatment of attention-deficit/hyperactivity disorder (ADHD) dosed once daily. Due to its long-acting properties, LDX remains pharmacologically inactive until an enzymatic process predominantly associated with red blood cells converts it to the active ingredient, d-amphetamine and the amino acid lysine. The efficacy of LDX over placebo has been demonstrated in several studies in adults with moderate to severe ADHD with significant improvements noted in ADHD rating scales, Clinical Global Improvement scores, and assessments of executive function, for all doses of LDX (30-70 mg daily). Lisdexamfetamine dimesylate has demonstrated efficacy at 14 hours post dose in adults and may be used as a long-acting stimulant for managing ADHD symptoms, which may extend late into the day. Lisdexamfetamine dimesylate has demonstrated a safety profile consistent with long-acting stimulants use. Relevant English language articles were identified through computerized searches of MEDLINE (PubMed and EMBASE) from 1995 to 2016 using the following search terms: lisdexamfetamine dimesylate, attention-deficit hyperactivity disorder, NRP104, and Vyvanse.

A new Ru(II)Rh(III) bimetallic with a single Rh-Cl bond as a supramolecular photocatalyst for proton reduction.

A new Ru(II)Rh(III) structural motif [(bpy)2Ru(dpp)RhCl(tpy)](4+) with one halide on the Rh(III) center demonstrates light-driven proton reduction ability, establishing that two halide ligands are not mandatory despite all prior systems containing a cis-RhCl2 catalytic site. This new design provides a novel approach to modulate Rh(III) redox behavior and catalytic activity with insight into catalytic intermediates.