Giapreza experiences?

[jdh71]

Has your pharmacy approved this? Have you had a chance to use it yet? When are you pulling the trigger?

We just finally got pharmacy approval. I’ve not used yet.

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[Hamhock]

It has been used twice at our hospital.

I used it once by titrating to 40ng quickly and then holding there (on a crashing ICH patient). The response was impressive, given the patient was already on massive doses vasopressor/inotropes. It seemed to allow time to get through the hemi-crani and back to the ICU.

I wasn't involved in the other case, but I heard they went quickly to 80ng and then back down. The patient was in refractory septic shock and nothing seemed to be able to maintain perfusion pressure. Reportedly, comfort care was pursued before any real conclusions about the giapreza could be made.

Maybe this isn't to helpful, but it's all I have to share at this point.

I plan to use it early in multi-pressor dependent septic shock patients in the coming weeks. I would also like to talk to some of my anesthesiology-cardiac friends, as it seems potentially very useful for vasoplegics coming off bypass poorly.

HH

 

[deleted547339]

It’s fine. We’ve used it a good bit. It’s not some magic bullet, but it’s another pressor that seems to work. Have seen some robust responses and some less robust responses. Our institution uses it as a third pressor only.

 

[tartesos]

Has your pharmacy approved this? Have you had a chance to use it yet? When are you pulling the trigger?

We just finally got pharmacy approval. I’ve not used yet.

Used it 3 times so far, one of them was miraculous.



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[njac]

Used it 3 times so far, one of them was miraculous.



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I heard this from a few people who were involved in the trial.

Our experience has been dismal - we initially were reserving it for 3rd line or higher vasopressor but were unimpressed. We’re trying to use it earlier to see if it may have more effect.

I believe the manufacturer is starting a rebate program to incentivize use.


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[tartesos]

I heard this from a few people who were involved in the trial.

Our experience has been dismal - we initially were reserving it for 3rd line or higher vasopressor but were unimpressed. We’re trying to use it earlier to see if it may have more effect.

I believe the manufacturer is starting a rebate program to incentivize use.


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They will re stock the medicine for the hospital if it doesn’t work. Let’s see how long this lasts.


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[drmwvr]

I would also like to talk to some of my anesthesiology-cardiac friends, as it seems potentially very useful for vasoplegics coming off bypass poorly.

Post bypass vasoplegia is pretty predictable and transient. Can't remember the last time worrisome refractory vasoplegia didn't ultimately respond to a single dose of methylene blue.

 

[deleted547339]

Post bypass vasoplegia is pretty predictable and transient. Can't remember the last time worrisome refractory vasoplegia didn't ultimately respond to a single dose of methylene blue.

It’s certainly saved my ass.

 

[WheezyBaby]

x2, 1 miraculous turn around, 1 :thumbsdown:

 

[psychbender]

So, what I'm hearing is...

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[lymphocyte]

So, what I'm hearing is...View attachment 284283

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Interestingly, that's what the ATHOS-3 trial showed; MAP response in about 2/3 of patients.

There was also a MAP response in 1/3 of patients with placebo -- i.e. just needing time to let the underlying shock sort itself out with other treatment.

No change in mortality or even SOFA. The trial made it seem like an unimpressive drug.

https://www.nejm.org/doi/full/10.1056/NEJMoa1704154

 

[dchz]

Post bypass vasoplegia is pretty predictable and transient. Can't remember the last time worrisome refractory vasoplegia didn't ultimately respond to a single dose of methylene blue.

What was the longest pump run at your institution?

 

[drmwvr]

What was the longest pump run at your institution?

The longest? Don't know, but in the time I've been there the surgeons have pushed cumulative pump times to around 3 hours I guess. That is unusual. But short circ arrest, in my experience, the problems those times present are bleeding and poor myocardial preservation/stunning. It's the longer DHCA cases that I'm more expecting isolated vasomotor tone issues.

 

[dchz]

The longest? Don't know, but in the time I've been there the surgeons have pushed cumulative pump times to around 3 hours I guess. That is unusual. But short circ arrest, in my experience, the problems those times present are bleeding and poor myocardial preservation/stunning. It's the longer DHCA cases that I'm more expecting isolated vasomotor tone issues.

You haven't really experienced that much post CPB vasoplegia until you've seen pump runs way longer than 3 hours. If you have surgeons or cases bad enough to go on for like a 6 hour pump run. you're gonna wish you had angiotensen II available. Those cases of vasoplegia is gonna be predictable, predictably bad and very difficult to treat.

 

[drmwvr]

You haven't really experienced that much post CPB vasoplegia until you've seen pump runs way longer than 3 hours. If you have surgeons or cases bad enough to go on for like a 6 hour pump run. you're gonna wish you had angiotensen II available. Those cases of vasoplegia is gonna be predictable, predictably bad and very difficult to treat.

Yeah...not that kind of place or that kind of surgeon. Don't know what 'much' post bypass vasoplegia means, but yes, methylene blue has been useful in the absence of angiotensin II. And after a 6 hour pump run, I'd consider myself lucky to have vasoplegia as my only problem.

 

[deleted547339]

You haven't really experienced that much post CPB vasoplegia until you've seen pump runs way longer than 3 hours. If you have surgeons or cases bad enough to go on for like a 6 hour pump run. you're gonna wish you had angiotensen II available. Those cases of vasoplegia is gonna be predictable, predictably bad and very difficult to treat.

Glad those days are behind me....

 

[MoMoGesiologist]

The longest? Don't know, but in the time I've been there the surgeons have pushed cumulative pump times to around 3 hours I guess. That is unusual. But short circ arrest, in my experience, the problems those times present are bleeding and poor myocardial preservation/stunning. It's the longer DHCA cases that I'm more expecting isolated vasomotor tone issues.

3hr pump run? Those are rookie numbers! U gotta get those numbers up!

 

[DrGasPasser]

I was surprised to learn that Giapreza costs our hospital less than methylene blue. Not by much, but we’re talking real dollars when added across a high volume institution. Interesting- learn something new every day.

 

[kemper6036]

Has your pharmacy approved this? Have you had a chance to use it yet? When are you pulling the trigger?

We just finally got pharmacy approval. I’ve not used yet.

used it a couple of times in fellowship. MAP did increase but patients did not survive. tried to get it in my current institution but was told since there was no evidence of mortality benefit, they wouldn't approve it. do any pressors have head to head mortality benefit shown? some have advocating for starting it once you get to 0.2 mcg/kg/min or 20 mcg/min depending on how you dose vasopressors in your unit. one intensivist i spoke to started it prior to starting vasopressin but i think most would start vasopressin first. i thought i had heard something about reducing the need for RRT with Giapreza, but cant quite remember.

 

[deleted547339]

used it a couple of times in fellowship. MAP did increase but patients did not survive. tried to get it in my current institution but was told since there was no evidence of mortality benefit, they wouldn't approve it. do any pressors have head to head mortality benefit shown? some have advocating for starting it once you get to 0.2 mcg/kg/min or 20 mcg/min depending on how you dose vasopressors in your unit. one intensivist i spoke to started it prior to starting vasopressin but i think most would start vasopressin first. i thought i had heard something about reducing the need for RRT with Giapreza, but cant quite remember.

No. There’s no mortality benefit. Ask them about the mortality benefit of levo or vaso - or methylene blue. Or albumin. There’s reasons not to have it, but that’s dumb.

We do levo and vaso as a prereq but can do only angII if you turn it on and can titrate off the other two.

 

[Hernandez]

tried to get it in my current institution but was told since there was no evidence of mortality benefit,

Agreed others, there are reasons not to get it, but this isn’t a legitimate one.

 

[deleted697535]

Kinda wish I had it right now.

 

[aafisahar]

can someone explain why there was a need/space for another pressor (other than money)? I may be wrong-headed on this, but it feels like we have enough options and by the time 3 pressors are in play, the patient has a dismal prognosis anyways, adding a 4th or 5th pressor isn't going to turn things around.

 

[deleted697535]

Do you do cardiac? A 6 hour pump run in a triple valve replacement on a tri do sternotomy will do it...

Some of them make it

 

[jdh71]

can someone explain why there was a need/space for another pressor (other than money)? I may be wrong-headed on this, but it feels like we have enough options and by the time 3 pressors are in play, the patient has a dismal prognosis anyways, adding a 4th or 5th pressor isn't going to turn things around.

it hits a different receptor

first principle physiology is why it makes sense

 

[aafisahar]

it hits a different receptor

first principle physiology is why it makes sense

I get that but if you can't someone normotensive or they are requiring more and more pressor support, then it doesn't matter what you use, the patient has a dismal prognosis. It's one thing if angiotensin was compared against norepi and found to have any advantage but right now, it's being used as a phenylephrine alternative in select cases and as you know in the MICU, once you are on 3 pressors and faltering, your prognosis is dismal.

If giapreza was shown to have an advantage upfront over norepi or vs vaso, then yes, it would have been a welcome change. Right now, it looks like it's only useful in select cases (eg as above).

 

[jdh71]

I get that but if you can't someone normotensive or they are requiring more and more pressor support, then it doesn't matter what you use, the patient has a dismal prognosis. It's one thing if angiotensin was compared against norepi and found to have any advantage but right now, it's being used as a phenylephrine alternative in select cases and as you know in the MICU, once you are on 3 pressors and faltering, your prognosis is dismal.

If giapreza was shown to have an advantage upfront over norepi or vs vaso, then yes, it would have been a welcome change. Right now, it looks like it's only useful in select cases (eg as above).

why would you add phenylephrine?

 

[aafisahar]

why would you add phenylephrine?

epi dobutamine phenyl, it's all the same, what space is giapreza filling that wasn't there before?

fwiw, and you should know this better than most, first principles in physiology haven't exactly panned out in critical care (or cardiology, or primary care, or any other myriad of specialties and conditions).

 

[jdh71]

epi dobutamine phenyl, it's all the same, what space is giapreza filling that wasn't there before?

fwiw, and you should know this better than most, first principles in physiology haven't exactly panned out in critical care (or cardiology, or primary care, or any other myriad of specialties and conditions).

Those drugs are NOT the same.

I’ll ask again WHY would you ADD phenylephrine?

First principles pan out all day and every day in critical care. Lol. Have you not been paying any attention in your training? Are we in a sophomore dorm room marijuana’s smoking session taking gigantic bong rips?

 

[lymphocyte]

Has your pharmacy approved this? Have you had a chance to use it yet? When are you pulling the trigger?

We just finally got pharmacy approval. I’ve not used yet.

Speaking of first principles, Bellomo advocates checking a renin level. If it's above 180pmol/mL, they're probably going to be a AT II responder. This is based on a reanalysis of the ATHOS-3 data. I have no doubt there will be a RCT based on these idea, but, in the meantime, it makes beautiful physiological sense.

https://www.atsjournals.org/doi/abs/10.1164/rccm.201911-2172OC

 

[chessknt]

Speaking of first principles, Bellomo advocates checking a renin level. If it's above 180pmol/mL, they're probably going to be a AT II responder. This is based on a reanalysis of the ATHOS-3 data. I have no doubt there will be a RCT based on this idea, but, in the meantime, it makes beautiful physiological sense.

https://www.atsjournals.org/doi/abs/10.1164/rccm.201911-2172OC

It takes a week to get this lab at the hospital Im at (ordered it for secondary HTN workup in repeat malignant HTN offender--got the result in my box after he had been dc).

 

[jdh71]

My pharmacy won’t let me anywhere near this stuff. Might as well not exist. Hopefully something does come out that shows the kind of signal or the kind of situation where it would make sense.