Nephrotoxic drugs

[RXGuru]

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Does anyone have a list of drugs that are nephrotoxic? A ranked list mild-->moderate would be ideal.

Thank you for your time

 

[StewardshipDude]

high correlation between nephrotoxic agents that are available generically and favorable placement in protocols/algorithms to treat the masses...where did our kind go wrong?

 

[Old Timer]

where did our kind go wrong?

When they gave you a fellowship. By the way, can you sing any other song? See Google for "One Note Charlie" You get the idea...

 

[RXGuru]

When they gave you a fellowship. By the way, can you sing any other song? See Google for "One Note Charlie" You get the idea...

That made me laugh haha, poor fellow

 

[Praziquantel86]

high correlation between nephrotoxic agents that are available generically and favorable placement in protocols/algorithms to treat the masses...where did our kind go wrong?

So what do you propose that we use as alternatives?

 

[Old Timer]

So what do you propose that we use as alternatives?

Anything really new and expensive.....

 

[StewardshipDude]

no, I prefer we use agents that have RCTs that show superiority or at least equivalence combined with fewer AEs. I'm still just amazed at the AmphoB, vanco, etc use simply because of costs.

 

[RXGuru]

no, I prefer we use agents that have RCTs that show superiority or at least equivalence combined with fewer AEs. I'm still just amazed at the AmphoB, vanco, etc use simply because of costs.

Ampho B is fine if the liposomal is used. Vanc is a great drug that is extremely cheap at this point. I don't think hospitals would be able to afford to put everyone on newer and more expensive drugs. From what I understand there are plenty of safety/efficacy RCTs that deem both of those drugs safe and effective (if properly dosed/administered).

 

[chuckle beast]

expired tetracyclines?

 

[RXGuru]

expired tetracyclines?

Except from Doxy and Mino, yeah bad.

 

[Old Timer]

I think he did his fellowship here.

 

[StewardshipDude]

liposomal costs? check it out and you'll be shocked. echinocandins are bad just because they are brand name? they are a commodity and have we've driven the price down through ruthless bid process with the manufacturers...bottom line...we win...it isn't right just because it's generic.

 

[Praziquantel86]

liposomal costs? check it out and you'll be shocked. echinocandins are bad just because they are brand name? they are a commodity and have we've driven the price down through ruthless bid process with the manufacturers...bottom line...we win...it isn't right just because it's generic.

Yes, but brand name status doesn't make the medication better, either. Many of the IDSA practice guidelines recommend vancomycin as first-line therapy for MRSA infections. Amphotericin B (liposomal or otherwise) shows up as a first line treatment option for a variety of disseminated fungal infections. Aminoglycosides, used in combination, are the go-to agents in many pediatric infections (and adult, for that matter).

These guidelines are based upon years of accumulated evidence of efficacy and safety, when used properly. I think you confuse cost with solid evidence.

 

[StewardshipDude]

I'm 100% behind the IDSA guidelines. In fact, they recommend vori 1st line for IAI, yet most hospital guidelines use flu instead. Why? Flu never showed superiority to ampho B, NEVER - vori did yet it has only a 25% share in IAI. Why? Because flu is available generic. Talk to some IDs. Not PharmD-IDs, but some IDs and ask them if a steriod user(COPD), diabetic, or liver patient is 4 days in the ICU/on good antibiotics and still febrile-they think fungus. Ask them if they were the patient, would they want flu or vori? Everyone I ask says vori but let's keep the algorithm flu for costs. Just because it's cheap doesn't mean it right.

 

[Priapism321]

I'm 100% behind the IDSA guidelines. In fact, they recommend vori 1st line for IAI, yet most hospital guidelines use flu instead. Why? Flu never showed superiority to ampho B, NEVER - vori did yet it has only a 25% share in IAI. Why? Because flu is available generic. Talk to some IDs. Not PharmD-IDs, but some IDs and ask them if a steriod user(COPD), diabetic, or liver patient is 4 days in the ICU/on good antibiotics and still febrile-they think fungus. Ask them if they were the patient, would they want flu or vori? Everyone I ask says vori but let's keep the algorithm flu for costs. Just because it's cheap doesn't mean it right.

This post is starting to show what an idiot you actually are.....but just so I am sure, what do you mean by IAI? If it is invasive aspergillus infection, then my suspicion is confirmed.

 

[Praziquantel86]

I'm 100% behind the IDSA guidelines. In fact, they recommend vori 1st line for IAI, yet most hospital guidelines use flu instead. Why? Flu never showed superiority to ampho B, NEVER - vori did yet it has only a 25% share in IAI. Why? Because flu is available generic. Talk to some IDs. Not PharmD-IDs, but some IDs and ask them if a steriod user(COPD), diabetic, or liver patient is 4 days in the ICU/on good antibiotics and still febrile-they think fungus. Ask them if they were the patient, would they want flu or vori? Everyone I ask says vori but let's keep the algorithm flu for costs. Just because it's cheap doesn't mean it right.

I'm confused. The guidelines that I remember for IAI don't even mention voriconazole or AmpB. An echinocandin is recommended for presumed candida infection, unless C. albicans is isolated. Given that the preponderance of fungal infections in many institutions (especially smaller community hospitals) are still caused by C. albicans, it stands to reason that fluconazole would be the empiric drug of choice for many institutions.

And specifically regarding voriconazole, I'd have to say that my empiric observations disagree with your empiric observations. My institution uses far more micafungin than voriconazole, and it has a pretty good success rate for us.

EDIT: Looks like I picked the wrong IAI. Oh well...my points still stand.

 

[Priapism321]

You guys are starting to lose me here, please tell me what IAI stands for in your minds......

 

[Praziquantel86]

You guys are starting to lose me here, please tell me what IAI stands for in your minds......

I was going for intra-abdominal infection...might not be the one he was shooting for, though.

 

[Priapism321]

I was going for intra-abdominal infection...might not be the one he was shooting for, though.

He might have, but the 2010 guidelines for complicated intra-abdominal are more consistent with your post than his......

 

[StewardshipDude]

I was speaking of fungal infections. Our institution is able to speciate, but all aren't. Since you brought up bacterial infections, would you consider cSSSI infections and dapto? At our institution, oxacillin, vanco and linezolid all have shown increased MICs over time, most notabley for vanc with over 60% having MIC >1.0. We are just not convinced vanco is the right choice ALL the time simply because of some macro level guidelines. In fact, for vanco and linezolid, the rising MICs were not easily seen from micro but there was definately creep. For a skin infection with a vanco MIC for MRSA greater than 1.0 is vanco the best choice, or would dapto a reasonable option. All right, it's cold here in OKC, it's been a long shift and I am going home to sleep.

 

[Praziquantel86]

I was speaking of fungal infections. Our institution is able to speciate, but all aren't. Since you brought up bacterial infections, would you consider cSSSI infections and dapto? At our institution, oxacillin, vanco and linezolid all have shown increased MICs over time, most notabley for vanc with over 60% having MIC >1.0. We are just not convinced vanco is the right choice ALL the time simply because of some macro level guidelines. In fact, for vanco and linezolid, the rising MICs were not easily seen from micro but there was definately creep. For a skin infection with a vanco MIC for MRSA greater than 1.0 is vanco the best choice, or would dapto a reasonable option. All right, it's cold here in OKC, it's been a long shift and I am going home to sleep.

How rapidly are you able to speciate? Or are you referring to differentiation between Candida and other fungal infections?

Skin infections are a more interesting discussion. Our institution doesn't have a large amount of VISA/hVISA strains, so we still use vancomycin in in cases where staph is suspected. Once we get sensitivities back, our docs and pharmacists have absolutely no problem switching to daptomycin for intermediate strains. I'd say we have a few patients on daptomycin a month for that indication. We'll also use tigecycline from time to time for cSSI, and switch as necessary.

If you're at an institution with such high MICs to vancomycin, it would make sense to use daptomycin first line. I'd also re-evaluate your use of vancomycin and make sure you're achieving adequate AUIC values on your susceptible strains. That might help a bit.

 

[smileyangel11]

just curious, what MIC do you use as the cut off for vanco? 1, 1.5 or 2?

 

[Praziquantel86]

just curious, what MIC do you use as the cut off for vanco? 1, 1.5 or 2?

That varies depending on the situation. We may have a person getting vanco and improving clinically, and we won't switch when the MIC comes back at 1.5. If the person weren't improving, or getting worse, most folks would have no problem switching, even with an MIC of 1.

I don't think there are any good data supporting a hard cutoff at this point, but it certainly would make life easier.