Reversal Agents

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R E V E R S A L A G E N T S Opioids Nalaxone (Narcan) Opioid effects may outlast the reversal's duration of action Continue monitoring 3-4 hrs Benzodiazepines Flumazenil (Romazicon) May lower seizure threshold May cause confusion, agitation, hypertension, and alterations in heart rate Beta Blockers Glucagon Monitor for hyperglycemia May cause hypokalemia Heparin Protamine Sulfate May cause hypotension Risk for anaphylaxis Has weak anticoagulant effect Risk for thrombotic event Warfarin PCC - Vitamin K - FFP Treatment based on severity of bleeding An exhibitImiomne tdoiauter - oPnCC R aandp Vhita Kel Joo's mostF aisct o- FnFiPc works! Within 6 hrs - Vitamin K Risk for thrombotic event Factor Xa Inhibitors Andexanet alfa Risk for thrombotic event May cause cardiogenic shock, heart failure exacerbations, UTI, acute respiratory failure, and pneumonia © Digital Health Media LLC R E F E R E N C E S APSF. (2018, August 5). New Factor Xa Inhibitor (Xarelto®) (Eliquis®) Reversal Agent. Retrieved from Anesthesia Patient Safety Foundation website: https://www.apsf.org/news- updates/new-factor-xa-inhibitor-xarelto-eliquis-reversal-agent/ CHEMM. (n.d.). Naloxone. Retrieved from https://chemm.nlm.nih.gov/countermeasure _naloxone.htm#adminHanley, Deglin, J. H., & Vallerand, A. H. (2007). Davis’s drug guide for nurses (11th ed.). Philadelphia, PA: F. A. Davis Company J. P. (2004). Warfarin reversal. Journal of Clinical Pathology, 57(11), 1132–1139 https://doi.org /10.1136/jcp.2003.008904 Kang, M., & Ghassemzadeh, S. (2019). Benzodiazepine Toxicity. In StatPearls. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK482238/ Ni Ainle, F., Preston, R. J. S., Jenkins, P. V., Nel, H. J., Johnson, J. A., Smith, O. P., …O’Donnell, J. S. (2009). Protamine sulfate down-regulates thrombin generation by inhibiting factor V activation. Blood, 114(8), 1658–1665. https://doi.org/10.1182/blood-2009-05-222109 Peterson, C. D., Leeder, J. S., & Sterner, S. (1984). Glucagon therapy for beta-blocker overdose. Drug Intelligence & Clinical Pharmacy,18(5), 394–398. https://doi.org/10.1177 /106002808401800507 Rx List. (n.d.). Protamine (Protamines): Side Effects, Interactions, Warning, Dosage & Uses. Retrieved from RxList website: https://www.rxlist.com/protamine-drug.htm UC San Diego Health. (n.d.). LMWH Reversal. Retrieved September 14, 2019, from UC Health —UC San Diego website: https://health.ucsd.edu/specialties/anticoagulation/providers /lmwh/Pages/reversal.aspx.

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Oral Anticoagulants
4/26/2018 Disclosure • Kelsey Gander, PharmD, BCACP Direct Oral Anticoagulants: – Declares no financial relationships pertinent to this session When to Use and How to Choose – Declares off-label use of medication will not be discussed during this presentation. Kelsey Gander, PharmD, BCACP Minnesota Academy of Physician Assistants Conference May 11th, 2018 Abbreviations Objectives • DOAC= direct oral anticoagulant 1) Compare and contrast the efficacy and safety • VTE= venous thromboembolism • DVT= deep vein thrombosis of direct oral anticoagulants (DOACs) to • PE= pulmonary embolism warfarin • A-fib, AF= atrial fibrillation 2) Identify which anticoagulant would be most • ESRD= end stage renal disease appropriate for a given patient • ACC= American College of Cardiology • AHA= American Heart Association 3) Recognize when it would not be appropriate • HRS= Heart Rhythm Society to use a DOAC • BID= twice daily Appropriate Abbreviations Patient Case JJ is a 66 y/o male who was hospitalized for pulmonary • NOAC embolism and initiated on anticoagulant therapy one week – Novel Oral Anticoagulant ago. – Chief complaint: – Non-Vitamin K Oral Anticoagulant • Presents to clinic today for INR check, post-hospital discharge follow- up • TSOAC – Past medical history: • Hypertension, hyperlipidemia, osteoarthritis, erectile dysfunction, – Target Specific Oral Anticoagulant BPH, type 2 diabetes, peripheral artery disease – Home medications • DOAC • Acetaminophen 650mg po every 6 hours PRN – Direct Oral Anticoagulant • Diazepam 5mg po at bedtime PRN anxiety
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76. Which of the Following Is Incorrect Based on the 2018 ASRA Checklist for Managing Local Anesthetic Systemic Toxicity?
76. Which of the following is incorrect based on the 2018 ASRA Checklist for managing Local Anesthetic Systemic Toxicity? A. The upper limit of lipid emulsion dosing is 12mL/kg B. Monitoring should be at least 4-6 hours after a cardiovascular event or at least 2 hours after a limited CNS event C. 20% lipid emulsion should be used as the initial drug at the first sign of a serious LAST Event D. Epinephrine doses of > 1mcg/kg are recommended 77. Which of the following statements is NOT true with regard to the management of new oral anticoagulants? A. Rivaroxaban (Xarelto) and Apixaban (Eliquis) should be held for at least 72 hours prior to neuraxial block B. Dabigatran (Pradaxa) should be held for 24 to 48 hours prior to neuraxial block in a patient with a compromised GFR C. Dabigatran can be reversed by the monoclonal antibody idarucizumab D. Factor Xa inhibitors, Rivaroxaban and Apixaban, can be effectivelY reversed with andexanet alfa 78. Which answer the correct spread of local anesthetic for an Erector Spinae Plane Block performed at the T5 level? A. Spread between the erector spinae muscle and rhomboid muscle B. Spread lateral to the transverse process, superficial to the erector spinae muscle C. Spread deep to the erector spinae muscle at the transverse process D. Spread deep to the costotransverse ligament, pushing the pleura ventrallY 79. When assessing the lungs with ultrasound, which of the following signs are suggestive a pneumothorax: A. Absence of lung sliding B. Presence of “comet tails” C. Absence of a “lung point” D.
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Question of the Day Archives: Monday, December 5, 2016 Question: Calcium Oxalate Is a Widespread Toxin Found in Many Species of Plants
Question Of the Day Archives: Monday, December 5, 2016 Question: Calcium oxalate is a widespread toxin found in many species of plants. What is the needle shaped crystal containing calcium oxalate called and what is the compilation of these structures known as? Answer: The needle shaped plant-based crystals containing calcium oxalate are known as raphides. A compilation of raphides forms the structure known as an idioblast. (Lim CS et al. Atlas of select poisonous plants and mushrooms. 2016 Disease-a-Month 62(3):37-66) Friday, December 2, 2016 Question: Which oral chelating agent has been reported to cause transient increases in plasma ALT activity in some patients as well as rare instances of mucocutaneous skin reactions? Answer: Orally administered dimercaptosuccinic acid (DMSA) has been reported to cause transient increases in ALT activity as well as rare instances of mucocutaneous skin reactions. (Bradberry S et al. Use of oral dimercaptosuccinic acid (succimer) in adult patients with inorganic lead poisoning. 2009 Q J Med 102:721-732) Thursday, December 1, 2016 Question: What is Clioquinol and why was it withdrawn from the market during the 1970s? Answer: According to the cited reference, “Between the 1950s and 1970s Clioquinol was used to treat and prevent intestinal parasitic disease [intestinal amebiasis].” “In the early 1970s Clioquinol was withdrawn from the market as an oral agent due to an association with sub-acute myelo-optic neuropathy (SMON) in Japanese patients. SMON is a syndrome that involves sensory and motor disturbances in the lower limbs as well as visual changes that are due to symmetrical demyelination of the lateral and posterior funiculi of the spinal cord, optic nerve, and peripheral nerves.
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Four-Factor Prothrombin Complex Concentrate Improves Thrombin
Schenk et al. Thrombosis Journal (2018) 16:1 DOI 10.1186/s12959-017-0158-9 RESEARCH Open Access Four-factor prothrombin complex concentrate improves thrombin generation and prothrombin time in patients with bleeding complications related to rivaroxaban: a single-center pilot trial Bettina Schenk1* , Stephanie Goerke2,3, Ronny Beer4, Raimund Helbok4, Dietmar Fries1 and Mirjam Bachler1,5 Abstract Background: Direct oral anticoagulants (DOACs) pose a great challenge for physicians in life-threatening bleeding events. The aim of this study was to test the efficacy of reversing the DOAC rivaroxaban using four-factor PCC (prothrombin complex concentrate), a non-specific reversing agent. Methods: Patients with life-threatening bleeding events during rivaroxaban treatment were included and administered 25 U kg−1 of PCC. Blood samples were collected immediately prior to as well as after PCC treatment at predefined time intervals. The primary endpoint was defined as the difference in thrombin generation (TG) parameters ETP (endogenous thrombin potential) and Cmax (peak thrombin generation) prior to and ten minutes subsequent to PCC treatment. Results: Thirteen patients, of whom the majority suffered from intra-cranial haemorrhage (ICH) or subdural haemorrhage (SDH), were included and administered PCC. The results show that the ETP (TG) significantly (p = 0.001) improved by 68% and Cmax (TG) by 54% (p = 0.001) during PCC treatment. In addition, the Quick value (prothrombin time: QuickPT) significantly improved by 28% and the activated partial thromboplastin time (aPTT) was PT decreased by 7% ten minutes after PCC administration. Cmax was reduced at baseline, but not ETP, aPTT or Quick . Lag time until initiation (TG, tlag), thromboelastometry clotting time (CTEXTEM) and time to peak (TG, tmax) correlated best with measured rivaroxaban levels and were out of normal ranges at baseline, but did not improve after PCC administration.
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Pharmacotherapy Pearls for Emergency Neurological Life Support Theresa Human1*, Eljim Tesoro2* and Sarah Peacock3
Neurocrit Care https://doi.org/10.1007/s12028-019-00830-4 PHARMACOTHERAPY Pharmacotherapy Pearls for Emergency Neurological Life Support Theresa Human1*, Eljim Tesoro2* and Sarah Peacock3 © 2019 Neurocritical Care Society Abstract The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient’s organ function, medication allergies, potential adverse drug efects, drug interactions, critical illness, and age-related pathophysi- ologic changes. Medications used during ENLS include hyperosmolar therapy, antiseizures, antithrombotics, antico- agulant reversal hemostatic agents, antishivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors inotropes, and antimicrobials. This chapter focuses on key pharmacokinetic and pharmacodynamic characteristics, advantages and disadvantages, and clinical pearls of these therapies, thereby providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients. Keywords: ENLS, Pharmacotherapy, Medication, Adverse drug event, Drug interaction Introduction provider optimize medication management in the acute Neurocritical care patient management is highly com- period of neurologic injury. plicated, especially when trying to optimize therapy dur- ing the acute injury. Pharmacologic management must Chapter Outline be carefully considered in order to minimize cognitive • Hyperosmolar
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In-Vitro Sorbent-Mediated Removal of Edoxaban from Human Plasma and Albumin Solution
University of Massachusetts Medical School eScholarship@UMMS Open Access Articles Open Access Publications by UMMS Authors 2020-09-01 In-Vitro Sorbent-Mediated Removal of Edoxaban from Human Plasma and Albumin Solution Alexandra A. Angheloiu Temple University Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/oapubs Part of the Fluids and Secretions Commons, Hemic and Immune Systems Commons, Investigative Techniques Commons, Laboratory and Basic Science Research Commons, and the Pharmaceutical Preparations Commons Repository Citation Angheloiu AA, Tan Y, Ruse C, Shaffer SA, Angheloiu GO. (2020). In-Vitro Sorbent-Mediated Removal of Edoxaban from Human Plasma and Albumin Solution. Open Access Articles. https://doi.org/10.1007/ s40268-020-00308-1. Retrieved from https://escholarship.umassmed.edu/oapubs/4354 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Open Access Articles by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. Drugs in R&D (2020) 20:217–223 https://doi.org/10.1007/s40268-020-00308-1 ORIGINAL RESEARCH ARTICLE In‑Vitro Sorbent‑Mediated Removal of Edoxaban from Human Plasma and Albumin Solution Alexandra A. Angheloiu1 · Yanglan Tan2,3 · Cristian Ruse4 · Scott A. Shafer2,3 · George O. Angheloiu5 Published online: 15 May 2020 © The Author(s) 2020 Abstract Background and Objective Based on previous experience of sorbent-mediated ticagrelor, dabigatran, and radiocontrast agent removal, we set out in this study to test the efect of two sorbents on the removal of edoxaban, a factor Xa antagonist direct oral anticoagulant.
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PRAC Draft Agenda of Meeting 11-14 May 2020
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Drug Consumption in Current Year (Period 201901
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Drug Consumption at Wholesale Prices in 2017 - 2020
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The Clinical Insight
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Review Article an Update on the Reversal of Non-Vitamin K Antagonist Oral Anticoagulants
Hindawi Advances in Hematology Volume 2020, Article ID 7636104, 10 pages https://doi.org/10.1155/2020/7636104 Review Article An Update on the Reversal of Non-Vitamin K Antagonist Oral Anticoagulants Mark Terence P. Mujer,1 Manoj P. Rai ,1 Varunsiri Atti,1 Ian Limuel Dimaandal,2 Abigail S. Chan ,3 Shiva Shrotriya,1 Krishna Gundabolu,4,5 and Prajwal Dhakal4,5 1Department of Medicine, Michigan State University, East Lansing, MI, USA 2Department of Internal Medicine, University of Connecticut, Farmington, CT, USA 3Department of Internal Medicine, Sinai Hospital of Baltimore, Baltimore, MD, USA 4Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA 5Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA Correspondence should be addressed to Manoj P. Rai; [email protected] Received 8 May 2019; Revised 26 August 2019; Accepted 25 September 2019; Published 27 January 2020 Academic Editor: Erwin Strasser Copyright © 2020 Mark Terence P. Mujer et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Non-vitamin K antagonist oral anticoagulants (NOACs) include thrombin inhibitor dabigatran and coagulation factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban. NOACs have several benefits over warfarin, including faster time to the achieve effect, rapid onset of action, fewer documented food and drug interactions, lack of need for routine INR monitoring, and improved patient satisfaction. Local hemostatic measures, supportive care, and withholding the next NOAC dose are usually sufficient to achieve hemostasis among patients presenting with minor bleeding.
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Addiction Pharmacy
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