Another round of clinical questions

[GravityBeetle]

---

Members don't see this ad.

1. Any benefits of administering certain meds as an IV infusion vs bolus (eg lasix, bumex, protonix, famotidine, bumex, rocephin, etc.)?
2. Are there any resources that compare different antibiotics' propensity to cause GI intolerance? I feel like this is a pretty common question I get from doctors, but I've yet to find a good resource for this so I don't have to look up every single drug's adverse effects %. Generally I've just been recommending to avoid augmentin and clindamycin.
3. Thoughts on giving metolazone 30 min before a loop diuretic when a patient is on both? I believe in theory you would get synergistic effects if you time it so that their onsets of action line up. Would you make a point to retime these meds when ordered together? Also I know metolazone is usually the thiazide of choice for diuresis to add on to a loop, but have you ever ran into a situation where you would use HCTZ or chlorthalidone?
4. Is it okay to chew EC aspirin if chewable aspirin isn't available? I don't why one couldn't chew EC aspirin in the event of ACS if chewables aren't available.

 

[zelman]

1. This is drug-specific. I believe your main concern is adverse effects from bolus administration, so there is no general rule.

2. Not that I’m aware of.

3. Taking metolazone 30 minutes before a loop is standard. I had previously posted that metolazone was used for this purpose because that’s what was studied, but someone else replied that it was actually used because it is more efficacious at lower GFRs than other thiazides.

4. Yes, depending on the patient’s dental health. I think the coating on some of the 325mg aspirins could damage a few poorly cared for teeth.

 

[TheBlaah]

1. Drug dependent.
2. Not really.
3. It's pretty standard to schedule them. I've seen a couple of nephrologists who prefer to use Diuril before lasix.
4. Should be fine. Don't know what hospital wouldn't have chewable aspirin, but the only time I'd say it wouldn't be okay to switch to EC is for MI or cardiac intervention where they need it as rapidly as possible.

 

[sakigt]

1. Any benefits of administering certain meds as an IV infusion vs bolus (eg lasix, bumex, protonix, famotidine, bumex, rocephin, etc.)?
2. Are there any resources that compare different antibiotics' propensity to cause GI intolerance? I feel like this is a pretty common question I get from doctors, but I've yet to find a good resource for this so I don't have to look up every single drug's adverse effects %. Generally I've just been recommending to avoid augmentin and clindamycin.
3. Thoughts on giving metolazone 30 min before a loop diuretic when a patient is on both? I believe in theory you would get synergistic effects if you time it so that their onsets of action line up. Would you make a point to retime these meds when ordered together? Also I know metolazone is usually the thiazide of choice for diuresis to add on to a loop, but have you ever ran into a situation where you would use HCTZ or chlorthalidone?
4. Is it okay to chew EC aspirin if chewable aspirin isn't available? I don't why one couldn't chew EC aspirin in the event of ACS if chewables aren't available.

Lasix:

Continuous infusion vs. intermittent bolus injection of furosemide in acute decompensated heart failure: systematic review and meta-analysis of randomised controlled trials - PubMed

Loop diuretics remain a fundamental pharmacological therapy to remove excess fluid and improve symptom control in acute decompensated heart failure. Several recent randomised controlled trials have examined the clinical benefit of continuous vs. bolus furosemide in acute decompensated heart...

www.ncbi.nlm.nih.gov

protonix:

Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis - PubMed

Intermittent PPI therapy is comparable to the current guideline-recommended regimen of intravenous bolus plus a continuous infusion of PPIs in patients with endoscopically treated high-risk bleeding ulcers. Guidelines should be revised to recommend intermittent PPI therapy.

www.ncbi.nlm.nih.gov

rocephin is ok and can be, meropenem can be, but shouldn't

very drug specific, follow hospital protocol

 

[GravityBeetle]

What would be your approach towards recommending an alternate antibiotic that has better GI tolerability?

 

[pharmBear]

On a slight off-topic note : There are new aspirin guidelines fresh off the press regarding when it is recommended.

 

[Rockinacoustic]

What would be your approach towards recommending an alternate antibiotic that has better GI tolerability?

It depends on the indication, sensitivities (if available), and potential DDIs,

GI tolerance is much more variable and can often be managed with proper counseling (i.e. space out your dose from other meds, eat yogurt/probiotics, etc) .

 

[lane one]

1. Any benefits of administering certain meds as an IV infusion vs bolus (eg lasix, bumex, protonix, famotidine, bumex, rocephin, etc.)?
2. Are there any resources that compare different antibiotics' propensity to cause GI intolerance? I feel like this is a pretty common question I get from doctors, but I've yet to find a good resource for this so I don't have to look up every single drug's adverse effects %. Generally I've just been recommending to avoid augmentin and clindamycin.
3. Thoughts on giving metolazone 30 min before a loop diuretic when a patient is on both? I believe in theory you would get synergistic effects if you time it so that their onsets of action line up. Would you make a point to retime these meds when ordered together? Also I know metolazone is usually the thiazide of choice for diuresis to add on to a loop, but have you ever ran into a situation where you would use HCTZ or chlorthalidone?
4. Is it okay to chew EC aspirin if chewable aspirin isn't available? I don't why one couldn't chew EC aspirin in the event of ACS if chewables aren't available.

1. Depends on the drug. As someone pointed out above, some don't matter (protonix, lasix). Some matter a lot, ahem (potassium).
2. No reference, but I consider this a secondary concern. More important questions are; will it kill the bug? is it an appropriate choice? will patient be able to afford it on discharge?.....then tolerability. At this point you're likely to have limited options. Especially since 99% of the population has a PCN allergy that is SERIOUS, although they can't recall the reaction at this time. /rant
3. Not sure if it matters that much, but it's pretty standard to give metolazone first (not first line, first in sequence).
4. Hell yes you can chew it.

 

[GravityBeetle]

2. No reference, but I consider this a secondary concern. More important questions are; will it kill the bug? is it an appropriate choice? will patient be able to afford it on discharge?.....then tolerability. At this point you're likely to have limited options. Especially since 99% of the population has a PCN allergy that is SERIOUS, although they can't recall the reaction at this time. /rant

What if it's a pansensitive strain though? Let's say patient is gets really nauseous and throws up when taking Augmentin for pansensitve strep... I'm thinking you could do amoxicillin, penicillin, clindamycin. Amoxicillin by itself would be much tolerated than with clavulanic acid... but are we worried about aspiration even though C&S are negative for anaerobes? Maybe clindamycin would be a better choice then but is clinda that much better tolerated than augmentin? Perhaps we could even have patient come in as outpatient for daily rocephin injections to be safe albeit inconvenient.

 

[zelman]

What if it's a pansensitive strain though? Let's say patient is gets really nauseous and throws up when taking Augmentin for pansensitve strep... I'm thinking you could do amoxicillin, penicillin, clindamycin. Amoxicillin by itself would be much tolerated than with clavulanic acid... but are we worried about aspiration even though C&S are negative for anaerobes? Maybe clindamycin would be a better choice then but is clinda that much better tolerated than augmentin? Perhaps we could even have patient come in as outpatient for daily rocephin injections to be safe albeit inconvenient.

Bicillin wins that case.