Levaquin BID?

[pharmaz88]

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Here's an I.D. (admittedly my weak spot) question for you all...

Are there any new indications for using Levaquin twice daily?
Lexi, F&C, and the PPI don't mention any (in adult patients), but
I've seen 2 Rx's in the last few weeks written this way.

On both, I called the prescriber to verify the dosing, and they
changed to QD dosing. ...but, I just want to make sure I'm not
missing something here.

 

[StaviZFingerZ]

It would not be out of question to dose Levofloxacin Q12H for Pneumonia if it's dosed at 250mg or 500mg.. t1/2 for Levo isn't quite long enough to call it a true QD antibiotic.. hence the poplularity of 750mg dosing.

The QD dosing was a marketing ploy to gain advantage over Cipro during the early years.

You may want to look up some European studies with Levo BID dosing..

 

[StaviZFingerZ]

Cipro reps argued hard that Levaquin was a BID drug...

http://jac.oxfordjournals.org/cgi/content/full/48/2/253

 

[metrarx]

....

 

[StaviZFingerZ]

the serum kinetics demonstrated that following single dose administration, the levofloxacin was nearly undetectable after 12 h. Therefore, the once per day dosing schedule of the levofloxacin rabbit group may have not been sufficient to maintain bactericidal concentrations within the infected tibias of rabbits.

Huh, interesting.

Any studies done in humans? I really don't know how well rabits' data extrapolate to humans. Maybe the p'kinetics are very close??

yeah..look at the package insert... Levaquin level post 12h in human was low... why do you think out of the blue Levaquin 750mg gained poplularity? Because 500mg Q24h wasn't cutting it... Don't you know this stuff???

 

[StaviZFingerZ]

http://www.levaquin.com/levaquin/shared/pi/levaquin.pdf#zoom=100


Page 9, look at the PK graph for 500mg.... serum concentration falls below 2ug/ml after 9 hour or so...

Before 750mg came about, the 750mg graph wasn't around..
obviously..

 

[Aznfarmerboi]

Same thing with Lantus. Suppose to be once daily and works well once daily for most people. However its half life can mean bid dosing for a lot of people.

 

[Praziquantel86]

yeah..look at the package insert... Levaquin level post 12h in human was low... why do you think out of the blue Levaquin 750mg gained poplularity? Because 500mg Q24h wasn't cutting it... Don't you know this stuff???

I thought that was also due to rising MIC values against levofloxacin.

Aren't the quinolones dose-dependant killers anyways? The half life of aminoglycosides leads to undetectable levels with extended-interval pulses, but they're still effective when used that way.

(I'm not arguing that twice-daily is a bad thing, just wondering aloud).

 

[StaviZFingerZ]

I thought that was also due to rising MIC values against levofloxacin.

Aren't the quinolones dose-dependant killers anyways? The half life of aminoglycosides leads to undetectable levels with extended-interval pulses, but they're still effective when used that way.

(I'm not arguing that twice-daily is a bad thing, just wondering aloud).

You're not wrong. And it works for AG because of post antibiotic effect which FQ exhibits also. Dose dependency is important yet MIC plays a role in bacteriocidal effect. Hence when Levo is below MIC for such a long extended period (12h +), clinical efficacy is questionable.

 

[StaviZFingerZ]

Are there any new indications for using Levaquin twice daily?
Lexi, F&C, and the PPI don't mention any (in adult patients), but
I've seen 2 Rx's in the last few weeks written this way.

This is probably most likely due to physicians used to writing Cipro BID.... not because they feel Levaquin should be dosed BID. Not too many physicians are aware of quinolone PK to that detail. Of course some ID physicians are.

 

[metrarx]

.....

 

[StaviZFingerZ]

ID be easy yo. Know your classes and then know your drugs. Then match it up with what it kills... We're talking about 10 classes and 30 antibiotics... and about 20 bugs...

 

[metrarx]

....

 

[StaviZFingerZ]

....coming from master wushu, 6th degree black belt ID sensei


I bet you even know what the Chinese characters on Sanford mean

never noticed... haven't used Sanford in years..

Like today for example, we had a CF kid (with a really, really bad attitude) admitted for hemoptysis (hates taking his vitamins with the most important of them all....K). Turns out he also was growing some staph so they started him on vanco and gent. Then the ID doc decides to d/c vanco and just keep gent on board. And we're all wondering WTH

Maybe it was either C-MRSA or MSSA susceptible to gent. Then again for a CF kid, I would have opted for Tobra yet I do not know your institution's antibiogram.

 

[StaviZFingerZ]

And I will go out on the limb and say pharmacoeconomics of ID is my forte including the cost.. I have most of the Abx cost memorized.. not intentionally..

 

[WVUPharm2007]

Levaquin q12h...pssh...I doubt that its intentional...

Hypothetically, it could be legit, but its probably a case of them being confused.

 

[WVUPharm2007]

And I will go out on the limb and say pharmacoeconomics of ID is my forte including the cost.. I have most of the Abx cost memorized.. not intentionally..

I've somehow gotten really good at electrolytes/metabolic pharmacology. I have no idea why I think its interesting...

 

[metrarx]

....

 

[StaviZFingerZ]

I've somehow gotten really good at electrolytes/metabolic pharmacology. I have no idea why I think its interesting...

Nice..but that don't pay the bills yo...

 

[metrarx]

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[StaviZFingerZ]

Really?? what do you use then? The other reference I like is the john hopkins abx guide

Anyway, yea, it was gent sensitive. But monotherapy?? I thought that was only for UTIs.

I refer to IDSA guidelines. I suggest you familiarize yourself with it.

http://www.idsociety.org/Content.aspx?id=9088

BTW... nothing wrong with monotherapy for Staph.

 

[WVUPharm2007]

Nice..but that don't pay the bills yo...

Yeah...but sitting in the IV room mixing together calcium and phosphate solutions is fun...


The renal docs hate me though. Because I actually notice when they **** up. Haha.

 

[StaviZFingerZ]

Yeah...but sitting in the IV room mixing together calcium and phosphate solutions is fun...

LOL... put it in a syringe and make white emulsion!

Why you mixing IVs.. not that there's anything wrong with that.

 

[metrarx]

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[KARM12]

ID be easy yo. Know your classes and then know your drugs. Then match it up with what it kills... We're talking about 10 classes and 30 antibiotics... and about 20 bugs...

Shhhh! Don't give away the secret. I want a job a year from now.

 

[metrarx]

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[StaviZFingerZ]

Why have a surgery that can leave a permanent scar?

Why amputate that can leave you limbless?

Why risk C-Difficile by taking Abx that can make you blast your colon off?

Why why why?

Risk vs. Benefit. Aminoglycoside requires that analysis. I've dosed hundreds ..maybe thousands of patients with Gent and Tobra.. Only saw a handful of transient renal episodes..but never ototoxicity.

Aaaaaaaaahahahahahaha.....doing a some quick google searches I stumbled on this website

http://www.gentamicin.com/CM/Custom/For-Physicians-Pharmacists.asp

It's a lawyer writing a letter to "pharmacists and physicians" about the dangers of getting sued your ass off for using gent.

Z, I think he's bringing your pharmacoeconomics of ID skills into question:

Gentamicin is inexpensive. The cost-containment folks love it. Why use gentamicin, with its well-known, permanent side effects, when a different, albeit more expensive antibiotic would suffice? Is the risk of gentamicin therapy outweighed by the benefit? A few hundred dollars savings to the patient’s healthcare insurer could cost your malpractice carrier millions.

Freakin golden!👍

 

[metrarx]

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[StaviZFingerZ]

Shhhh! Don't give away the secret. I want a job a year from now.

You doing ID fellowship? If so, you aint got nothing to worry about ..

 

[StaviZFingerZ]

Z, screw your advice, Keith S. Douglas J.D. knows what's up.

Hell, I'll be recommending Zyvox, Avelox, Tygacil to everyone

Zyvox can cause myelosuppression..and/or Serotonin syndrome

Avelox may cause permanent hepatic injury..

Tygacil causes nasty nausea..

Keith S. Douglas, J.D. will come and sue you for using above 3 drugs..

 

[metrarx]

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[Praziquantel86]

Z, screw your advice, Keith S. Douglas J.D. knows what's up.

Hell, I'll be recommending Zyvox, Avelox, Tygacil to everyone

Bleeding, ruptured tendons and pancreatitis for all!

 

[StaviZFingerZ]

Hell, I'll be recommending Zyvox, Avelox, Tygacil to everyone

Too bad above combo can't treat simple Pseudomonal UTI...

Uh-oh..watch out...Keith S. Douglas, J.D. at your door with a subpeona!

 

[StaviZFingerZ]

Bleeding, ruptured tendons and pancreatitis for all!

Heh... not bad kid..

 

[metrarx]

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[Praziquantel86]

The ruptured tendons is nothing to worry about.

It just happened in poor beagles.

Nope. My old doctor ruptured his achilles after a week of Avelox. Nothing more strenuous than golf and gardening.

 

[metrarx]

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[StaviZFingerZ]

I don't know, I don't think I'd consider gardening as a non-strenuous activity.

I'm sure there's case reports but it's still very, very, very rare.

quinlone induced ruptured tendon is more common than we think..I think..

 

[Praziquantel86]

I don't know, I don't think I'd consider gardening as a non-strenuous activity.

I'm sure there's case reports but it's still very, very, very rare.

Those would have to be some nasty weeds to pop a tendon pulling them out.

 

[WVUPharm2007]

Why you mixing IVs.. not that there's anything wrong with that.

Nah, just bored. Between 1-5:30 we have 4-5 pharmacists around. When it isn't crazy, the 1-11 RPh (me) tends to do nothing. Then from 5:30-11, I work harder than anyone else has all day, so it equals out.

Since we're talking about random ****....today a surgeon called and asked me for a beta blocker that didn't reduce blood pressure for tachycardia. I wuz like, "Wahhhhh?" He then asked fro Inderal and I gave it to him...so WTF was he talking about? Or is this more crazy hill person medicine?

Critical care **** is what I'm going to start expanding on myself...

 

[Farmercyst]

Nah, just bored. Between 1-5:30 we have 4-5 pharmacists around. When it isn't crazy, the 1-11 RPh (me) tends to do nothing. Then from 5:30-11, I work harder than anyone else has all day, so it equals out.

Since we're talking about random ****....today a surgeon called and asked me for a beta blocker that didn't reduce blood pressure for tachycardia. I wuz like, "Wahhhhh?" He then asked fro Inderal and I gave it to him...so WTF was he talking about? Or is this more crazy hill person medicine?

Critical care **** is what I'm going to start expanding on myself...

If I remember right our cardiothoracic surgery/transplant pharmacist mentioned he needed that once for some odd thing, I think it was d/t respiratory depression in a post-transplant pt that was tachy, but I wouldn't swear to it.

 

[IWantTheGenetic]

Did the patient have HTN? The usual doses of beta-blockers won't cause hypotension in patients with normal blood pressures but will cause slowed HR.

 

[WVUPharm2007]

Did the patient have HTN? The usual doses of beta-blockers won't cause hypotension in patients with normal blood pressures but will cause slowed HR.

Yeah...well I told the dude I had lopressor iv at first and he said he "no, no, I need something that doesn't reduce pressure." And then I was like 😕.

I seriously have no idea what he's talking about...and I'd like to know...

 

[njac]

Nah, just bored. Between 1-5:30 we have 4-5 pharmacists around. When it isn't crazy, the 1-11 RPh (me) tends to do nothing. Then from 5:30-11, I work harder than anyone else has all day, so it equals out.

Since we're talking about random ****....today a surgeon called and asked me for a beta blocker that didn't reduce blood pressure for tachycardia. I wuz like, "Wahhhhh?" He then asked fro Inderal and I gave it to him...so WTF was he talking about? Or is this more crazy hill person medicine?

Critical care **** is what I'm going to start expanding on myself...

isn't esmolol better for rate control than BP? And it's quick on/off titratability.

I looked it up. I was right - only at higher doses does esmolol affect BP.
Per epocrates:
for intraop/postop htn/tachycardia:
load 80 mg IV over 30 seconds, then 150 mcg/kg/min, can increase in 50 mcg/kg/min increments. BP Control may ned 250-300 mcg/kg/min.

 

[pharmaz88]

Thanks for the replies, people. I kinda' figured that the prescribers were thinking Cipro's BID dosing when writing the Rx's.

 

[aboveliquidice]

isn't esmolol better for rate control than BP? And it's quick on/off titratability.

I looked it up. I was right - only at higher doses does esmolol affect BP.

Per epocrates:
for intraop/postop htn/tachycardia:
load 80 mg IV over 30 seconds, then 150 mcg/kg/min, can increase in 50 mcg/kg/min increments. BP Control may ned 250-300 mcg/kg/min.

Instant BAN for referencing epocrates... you should know better 😡

 

[Praziquantel86]

isn't esmolol better for rate control than BP? And it's quick on/off titratability.

I looked it up. I was right - only at higher doses does esmolol affect BP.
Per epocrates:
for intraop/postop htn/tachycardia:
load 80 mg IV over 30 seconds, then 150 mcg/kg/min, can increase in 50 mcg/kg/min increments. BP Control may ned 250-300 mcg/kg/min.

If the patient wasn't in a unit, the titration part could be an issue.

 

[metrarx]

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[bigpharmD]

No sure if any of you turkey's said this because I am not gonna read all of the posts but we use BID in CF patients (500 mg BID) there is a study that shows this is best.

 

[StaviZFingerZ]

No sure if any of you turkey's said this because I am not gonna read all of the posts but we use BID in CF patients (500 mg BID) there is a study that shows this is best.

shut up fool