A few clinical questions

[GravityBeetle]

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Just to keep things interesting, here's a post that's not related to how much retail sucks. I work in both retail and hospital and here are some questions I've come across that I can't find a definitive answer to:
1) Vitamin B12 sublingual tablets: do they have 100% bioavailability? Could you potentially use them in place of IM injections and dose them QW?
2) How significant is NSAID + SSRI interaction increasing risk of bleeding? How do you handle these inpatient and outpatient? I figure short term NSAID outpatient use would be okay. What about if the NSAID is toradol which has higher risk of bleeds, do you handle things differently?
3) How do you decide whether to use ciprofloxacin or levofloxacin for pneumonia? Unlike levo, cipro is not considered a respiratory fluoroquinolone. However in my region, ciprofloxacin actually has lower resistance rates for Pseudomonas compared to levo.

 

[lane one]

Just to keep things interesting, here's a post that's not related to how much retail sucks. I work in both retail and hospital and here are some questions I've come across that I can't find a definitive answer to:
1) Vitamin B12 sublingual tablets: do they have 100% bioavailability? Could you potentially use them in place of IM injections and dose them QW?
2) How significant is NSAID + SSRI interaction increasing risk of bleeding? How do you handle these inpatient and outpatient? I figure short term NSAID outpatient use would be okay. What about if the NSAID is toradol which has higher risk of bleeds, do you handle things differently?
3) How do you decide whether to use ciprofloxacin or levofloxacin for pneumonia? Unlike levo, cipro is not considered a respiratory fluoroquinolone. However in my region, ciprofloxacin actually has lower resistance rates for Pseudomonas compared to levo.

1. Not sure. I don't think its absorbed buccally so the kinetic profile should closely match PO route.
2. I don't think the anti-platelet effects of SSRIs are clinically significant so I don't pay much attention to that interaction.
3. Levofloxacin covers strep pneumoniae where as ciprofloxacin does not.

 

[JustFillIt]

Just to keep things interesting, here's a post that's not related to how much retail sucks. I work in both retail and hospital and here are some questions I've come across that I can't find a definitive answer to:
1) Vitamin B12 sublingual tablets: do they have 100% bioavailability? Could you potentially use them in place of IM injections and dose them QW?
2) How significant is NSAID + SSRI interaction increasing risk of bleeding? How do you handle these inpatient and outpatient? I figure short term NSAID outpatient use would be okay. What about if the NSAID is toradol which has higher risk of bleeds, do you handle things differently?
3) How do you decide whether to use ciprofloxacin or levofloxacin for pneumonia? Unlike levo, cipro is not considered a respiratory fluoroquinolone. However in my region, ciprofloxacin actually has lower resistance rates for Pseudomonas compared to levo.

1.) customers ask this all the time in retail (or at least renditions of this question). I just show them where the sl drops are and say something about intrinsic factor and go back to work.

2.) this is an interaction that I would only ever pay attention to if it was a patient that had active gi bleeds (especially the elderly) that were associated with LT heavy use of nsaids. Otherwise it’s a nothing interaction. Just my opinion

3.) I stopped reading sorry

 

[Subvisual]

#2 - On the whole the benefits usually outweigh the risks. As long as the patient has good indication to be on both NSAIDs and SSRIs (and doesn't have a history of GI bleed) I wouldn't bother the provider or hold up an rx. I would definitely mention it to the patient though, especially when initiating a therapy. The GI bleed association with SSRIs is actually surprisingly high, possibly even comparable to NSAIDs. It isn't so much an "interaction" in my opinion, as it is two drug classes that independently increase the risk of GI problems, and thus in combination would be a simple increased increased risk (by which I mean, there isn't some fancy therapeutic or CYP interaction going on here, just 2 largely independently irritating agents). This is of course guesswork on my part, but there appears to increases in risk from both agents independently and a larger (but not enormously larger) risk when the two classes are combined.

Even with the GI adverse effects from serotonergic agents though, SSRIs are still generally the best option with regard to side effect profile for first line therapy for coming depression/anxiety type disorders. The NSAID would generally be the one I'd want to stop or limit the use of if possible/necessary.

I would also add the important caveat though that "SSRIs" are not a homogenous medication class, they can have wide intraclass variability in individual patient adverse effects due to minor differences in subreceptor profile and magical bs we honestly don't understand. Sertraline in particular is commonly regarded as the "worst" SSRI if GI concerns are your primary worry, likely due to its additional effects on dopamine receptors. No study has been large enough to distinguish individual SSRI variability in this regard, but I would expect it to exist and likely be significant.

 

[Rockinacoustic]

Q: 3) How do you decide whether to use ciprofloxacin or levofloxacin for pneumonia?

A: Just Don't

 

[GravityBeetle]

1. Not sure. I don't think its absorbed buccally so the kinetic profile should closely match PO route.
2. I don't think the anti-platelet effects of SSRIs are clinically significant so I don't pay much attention to that interaction.
3. Levofloxacin covers strep pneumoniae where as ciprofloxacin does not.

1.) customers ask this all the time in retail (or at least renditions of this question). I just show them where the sl drops are and say something about intrinsic factor and go back to work.

2.) this is an interaction that I would only ever pay attention to if it was a patient that had active gi bleeds (especially the elderly) that were associated with LT heavy use of nsaids. Otherwise it’s a nothing interaction. Just my opinion

3.) I stopped reading sorry

1) In that case no real advantage over regular tablets other than not having to swallow pills. Would not recommend using it in place of IM injections right?
2) Fair enough. I used to never pay attention to that interaction either in retail. It does come up as a major interaction though on most references so it made me worry especially with ketorolac
3) so of course never use Cipro as monotherapy for pneumonia, but if you're doing combination empiric regimen in which strep is already covered, would you ever choose Cipro over levo?

Q: 3) How do you decide whether to use ciprofloxacin or levofloxacin for pneumonia?

A: Just Don't

Which do you suggest then for HAP? Do you prefer an aminoglycoside? Or do you choose just not to double cover for pseudomonas?

 

[JustFillIt]

1) In that case no real advantage over regular tablets other than not having to swallow pills. Would not recommend using it in place of IM injections right?
2) Fair enough. I used to never pay attention to that interaction either in retail. It does come up as a major interaction though on most references so it made me worry especially with ketorolac
3) so of course never use Cipro as monotherapy for pneumonia, but if you're doing combination empiric regimen in which strep is already covered, would you ever choose Cipro over levo?

Which do you suggest then for HAP? Do you prefer an aminoglycoside? Or do you choose just not to double cover for pseudomonas?

Lol - you trying to flex up?

1.) nunya
2.) cool bro you let meloxicam/sertraline keep you up at night and give you cold sweats - I’ll continue to operate in reality. I’ll just fill that ****

 

[owlegrad]

Questions like these make me second guess myself as a pharmacist. But here are my thoughts:

1) Follow the directions on the bottle. Anything else is guess work. Actually don't even bother buying it in the first place, you are probably wasting your money since you can not even be sure that what is in the bottle matches what the label says.

2) Is it a level 1 interaction? No? Ok you can skip it.

3) Why would *I* ever decide between Cipro and Levo in any situation for any indication? Order is written correctly, no contraindications, etc.? Ok good here is your prescription, be sure to watch out for that tendon rupture I hear so much about.

 

[Rockinacoustic]

Which do you suggest then for HAP? Do you prefer an aminoglycoside? Or do you choose just not to double cover for pseudomonas?

I don't routinely recommend "double-coverage" because of the poor evidence. If warranted then yes would add an AG onto a B-lactam for suspected MDR gram neg/Pseudomonas.

 

[lane one]

1)
3) so of course never use Cipro as monotherapy for pneumonia, but if you're doing combination empiric regimen in which strep is already covered, would you ever choose Cipro over levo?

No. Flouroquinolones are not preferred due to risk of tendon rupture, QT prolongation and various other toxicities. We only really use them if the patient has significant drug allergies preventing us from using a beta-lactam. Not a last resort, but definitely not first line.

 

[GravityBeetle]

Lol - you trying to flex up?

1.) nunya
2.) cool bro you let meloxicam/sertraline keep you up at night and give you cold sweats - I’ll continue to operate in reality. I’ll just fill that ****

Questions like these make me second guess myself as a pharmacist. But here are my thoughts:

1) Follow the directions on the bottle. Anything else is guess work. Actually don't even bother buying it in the first place, you are probably wasting your money since you can not even be sure that what is in the bottle matches what the label says.

2) Is it a level 1 interaction? No? Ok you can skip it.

3) Why would *I* ever decide between Cipro and Levo in any situation for any indication? Order is written correctly, no contraindications, etc.? Ok good here is your prescription, be sure to watch out for that tendon rupture I hear so much about.

Yeah just started this hospital/clinical position. I have to brush up.
1) Fair enough. Some people just like to pick your brain I guess and unfortunately there isn't a lot of info on sublingual B12's pharmacokinetics.
2) I always let those go through when working retail. Hospital is more of a concern IMO because patients are in more critical condition, usually higher risk of SUP, and most will be on an anticoagulant for VTE ppx. But from everybody else's response here, I guess I'll this interaction go through too.
3) This is more of a hospital question. Providers contact us frequently here for abx recommendations.

I don't routinely recommend "double-coverage" because of the poor evidence. If warranted then yes would add an AG onto a B-lactam for suspected MDR gram neg/Pseudomonas.

No. Flouroquinolones are not preferred due to risk of tendon rupture, QT prolongation and various other toxicities. We only really use them if the patient has significant drug allergies preventing us from using a beta-lactam. Not a last resort, but definitely not first line.

Very interesting! Are you guys using any specific guidelines? I'm just going off IDSA's 2016 HAP guidelines which recommends double Pseudomonas coverage for high risk patients. They also only recommend AGs as last line (thus I'm assuming FQs are preferred). What is your go-to regimen then for HAP? If you were to double cover for Pseudomonas in addition to MRSA and if say zosyn and vanco are already onboard, it would sound unwise to me to add on an AG due to nephrotoxicity.

 

[BidingMyTime]

Very interesting! Are you guys using any specific guidelines? I'm just going off IDSA's 2016 HAP guidelines which recommends double Pseudomonas coverage for high risk patients. They also only recommend AGs as last line (thus I'm assuming FQs are preferred). What is your go-to regimen then for HAP? If you were to double cover for Pseudomonas in addition to MRSA and if say zosyn and vanco are already onboard, it would sound unwise to me to add on an AG due to nephrotoxicity.

Do you have any sensitivity cultures? I wouldn't throw on a 3rd antibiotic without having sensitivity cultures.

 

[rxkrafted]

Yeah just started this hospital/clinical position. I have to brush up.
1) Fair enough. Some people just like to pick your brain I guess and unfortunately there isn't a lot of info on sublingual B12's pharmacokinetics.
2) I always let those go through when working retail. Hospital is more of a concern IMO because patients are in more critical condition, usually higher risk of SUP, and most will be on an anticoagulant for VTE ppx. But from everybody else's response here, I guess I'll this interaction go through too.
3) This is more of a hospital question. Providers contact us frequently here for abx recommendations.



Very interesting! Are you guys using any specific guidelines? I'm just going off IDSA's 2016 HAP guidelines which recommends double Pseudomonas coverage for high risk patients. They also only recommend AGs as last line (thus I'm assuming FQs are preferred). What is your go-to regimen then for HAP? If you were to double cover for Pseudomonas in addition to MRSA and if say zosyn and vanco are already onboard, it would sound unwise to me to add on an AG due to nephrotoxicity.

You would only use double coverage for pseudomonas if pt has high risk of MDR-gram negatives or your facility has a history of high rates of resistance to one of the antipseudomonals you were going to use empirically.
Also I don't see a reason why you would use cipro over levaquin if used empirically when levaquin covers strep pneumo and is only dosed once a day.

 

[Rockinacoustic]

Very interesting! Are you guys using any specific guidelines? I'm just going off IDSA's 2016 HAP guidelines which recommends double Pseudomonas coverage for high risk patients. They also only recommend AGs as last line (thus I'm assuming FQs are preferred). What is your go-to regimen then for HAP? If you were to double cover for Pseudomonas in addition to MRSA and if say zosyn and vanco are already onboard, it would sound unwise to me to add on an AG due to nephrotoxicity.

Agree with your toxicity concerns- which is why I would treat with Vanco + Cefepime +/- Tobra if circling the drain septic or hx of MDRO Gram-neg organisms.

If you read the 2016 HAP/VAP guidelines, the recommendation for empiric dual anti-psuedomonal coverage is a "weak" recommendation based on "low to very low" quality of evidence. Further, the guidelines allude to being pragmatic by tailoring therapy to the individual patient and your antibiogram rather than funneling them through a risk-diagram. Empirically, I'd rather gamble with Cefepime's 80-90% coverage of psuedomonas at my institution than giving both Zosyn and Levaquin (70's at my place) together.

SIDP has a fantastic (and free) CE on the controversy and nuances of this practice: ProCE - Activity Detail

 

[GravityBeetle]

Also I don't see a reason why you would use cipro over levaquin if used empirically when levaquin covers strep pneumo and is only dosed once a day.

My thoughts exactly until I saw our antibiogram showing Cipro having better susceptibility rate than Levo for pseudomonas. Not by much though

Agree with your toxicity concerns- which is why I would treat with Vanco + Cefepime +/- Tobra if circling the drain septic or hx of MDRO Gram-neg organisms.

If you read the 2016 HAP/VAP guidelines, the recommendation for empiric dual anti-psuedomonal coverage is a "weak" recommendation based on "low to very low" quality of evidence. Further, the guidelines allude to being pragmatic by tailoring therapy to the individual patient and your antibiogram rather than funneling them through a risk-diagram. Empirically, I'd rather gamble with Cefepime's 80-90% coverage of psuedomonas at my institution than giving both Zosyn and Levaquin (70's at my place) together.

SIDP has a fantastic (and free) CE on the controversy and nuances of this practice: ProCE - Activity Detail

Very cool I was not aware of that, thanks. So far I've just been following the risk diagram which was the only thing they taught us in school. Cefepime is even >90% over here.