vancomycin

[obiwan]

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is vancomycin nephrotoxic? i always thought it was but being at the hospital, people seem not to think so much.... any clarifications please?

 

[PharmaTope]

is vancomycin nephrotoxic? i always thought it was but being at the hospital, people seem not to think so much.... any clarifications please?

old vanco used to be called mississippi mud, it was filled with a lot of impurities that people said was probably the reason behind it being nephrotoxic.

now you see it is clear. the stigma kinda stuck with it. this is what i heard.

 

[The Fargoan]

In class, vanco was treated as if it was gold. We learned all about potential nephrotoxicity and ototoxicity, proper levels, etc. On my first rotation in the hospital it appears to be prescribed as often as Tylenol. But I was surprised by it's frequency in charts based on our discussions in ID and Kinetics.

Not that I've answered your question. . .

 

[Its Z]

<p>read the IDSA, ASHP, SIDP guidelines on vanco monitoring. it describes it well.</p>

 

[WVUPharm2007]

By itself, not really. However, there are studies that make it pretty conclusive that it can make more legitimate nephrotoxic drugs like Ampho or the aminoglycosides more nephrotoxic.

 

[Praziquantel86]

is vancomycin nephrotoxic? i always thought it was but being at the hospital, people seem not to think so much.... any clarifications please?

I don't think the nephrotoxicity is quite as significant an issue as it was back in the "Mississippi Mud" days, but it is still an issue.

Two papers published by Tom Lodise (out of Albany Medical Center) pretty recently looked at vanco nephrotoxicity, and found some pretty strong correlations with both inital trough level and total dose given. I'd certainly look at those prior to making any judgments.

You also have to take a look at the dosing guidelines and evaluate them critically. A lot of the dosing information currently used (at least in terms of effective troughs) is derived from Staph endocarditis and then extrapolated to other situations. Not saying this doesn't work, but its certainly something to take into account when considering vanco nephrotoxicity.

 

[psychoandy]

short answer to your question for the purposes of the medical floor, not really. but you do still need to check renal fx daily.

fyi, while we're talking about vanco, let me just say that you should not draw vanco troughs daily and/or on everyone, and if troughs are drawn, time matters. a trough drawn at 5AM when vanco is given at 8am/8pm might seem high but is probably therapeutic. common sense, but when the result is flagged as abnormal my team always freaked out a bit.

 

[thedrunkenpharm]

Recent study in 2007 showed correlation between nephrotoxicity and vancomycin doses above 4 grams daily.

 

[WVUPharm2007]

Recent study in 2007 showed correlation between nephrotoxicity and vancomycin doses above 4 grams daily.

So.

Let's say a patient has osteo MRSA and needs 1.5g q8 to get above 15...

Do you just not give them Vanc? Is there really an increased risk of nephrotoxicity if the concentrations are "normal", regardless of total dose?

...

Oh god,I'm becoming Z...

 

[Its Z]

Oh god,I'm becoming Z...

That's not a bad thing

 

[Praziquantel86]

So.

Let's say a patient has osteo MRSA and needs 1.5g q8 to get above 15...

Do you just not give them Vanc? Is there really an increased risk of nephrotoxicity if the concentrations are "normal", regardless of total dose?

...

Oh god,I'm becoming Z...

I'd have to double-check, but I thought the correlation in that study held regardless of baseline renal function.

I think the real question, though, is what data is there supporting the need to give that much vanco? There is definitely data supporting the toxicity.

 

[WVUPharm2007]

I'd have to double-check, but I thought the correlation in that study held regardless of baseline renal function.

I think the real question, though, is what data is there supporting the need to give that much vanco? There is definitely data supporting the toxicity.

I say do what is necessary to push that trough to over 10 or 15, given the situation, of course. The IDSA pretty much said in their last guideline that monitoring for nephrotoxicity is a waste of money unless the patients are taking other nephrotoxins or are oncology patients.

 

[Its Z]

http://www.ajhp.org/cgi/reprint/66/1/82

You buncha lazy arse bastids.... you couldn't simply go look up the latest guidelines? Page 91 to 94. Read it.


It's like this... total daily dose of 4 gram is lame... rather we need to look at mg/kg and serum concentration to assess renal toxicity.

More importantly...studies have shown very low rate of nephrotoxicity with vanco monotherapy. Even more importantly...it's reversible.....

Most importantly... in my experience..with hundreds and maybe thousands of vanco dosing I've done..I'll say a handful of nephrotoxicity is what I witnessed..and they were probably on concurrent tx with AG.

 

[WVUPharm2007]

http://www.ajhp.org/cgi/reprint/66/1/82

You buncha lazy arse bastids.... you couldn't simply go look up the latest guidelines? Page 91 to 94. Read it.


It's like this... total daily dose of 4 gram is lame... rather we need to look at mg/kg and serum concentration to assess renal toxicity.

More importantly...studies have shown very low rate of nephrotoxicity with vanco monotherapy. Even more importantly...it's reversible.....

Most importantly... in my experience..with hundreds and maybe thousands of vanco dosing I've done..I'll say a handful of nephrotoxicity is what I witnessed..and they were probably on concurrent tx with AG.

Dammit, I know the answer, I was trying to satirically be you and get them to figure it out themselves.

I've given over 4g a day to so many people, I've lost count...

 

[Its Z]

Dammit, I know the answer, I was trying to satirically be you and get them to figure it out themselves.

I've given over 4g a day to so many people, I've lost count...

You aint quite there yet to squeeze out answers from students.... you have to lead them to the water and make them thirsty.

 

[WVUPharm2007]

But case in point...

There was a dude at my last hospital...late 20s upper 300#. Trough on 1.25g q8 was only like 9.4 and he has a nasty ass cellulitis thing going on. Literally, cellulitis on his ass. But the idiots I worked with were afraid we'd kill him because increasing the vanc dose above 4g is apparently a universally a no no under any situation.

I face palmed.

Young + fat = Three course Vanc dinner.

 

[Its Z]

he needs 2grams q8h.

Over 300lb means Vd of 100L... 2 grams get you about 20ug/ml...and 8 hours level will be like 7.... so pump another 2 grams get you 27....... in another 8 hours...about 10ug/ml.. .....at SS, he might barely get up to 15 trough.

I would have given him 25mg/kg loading..then 20mg/kg really.

 

[aboveliquidice]

But case in point...

There was a dude at my last hospital...late 20s upper 300#. Trough on 1.25g q8 was only like 9.4 and he has a nasty ass cellulitis thing going on. Literally, cellulitis on his ass. But the idiots I worked with were afraid we'd kill him because increasing the vanc dose above 4g is apparently a universally a no no under any situation.

I face palmed.

Young + fat = Three course Vanc dinner.

This is the stuff that I am picking up here and there... At my first hospital - we would rock pts well above 4 gm to hit 15... At my recent intern site, HELL NO.

Did your hospital use global RPH for dosing vanc / AG?

 

[WVUPharm2007]

This is the stuff that I am picking up here and there... At my first hospital - we would rock pts well above 4 gm to hit 15... At my recent intern site, HELL NO.

Did your hospital use global RPH for dosing vanc / AG?

They use this custom program they bought. They used ridiculous numbers. Like a Vd of 0.9 on all patients (which, given, will only overdose a tad and only on the initial dose...but still...)

I had to personally bring in the IDSA guidelines when they came out last January because I knew they wouldn't know they existed. I'll leave it at that.

 

[PharMed2016]

I don't think the nephrotoxicity is quite as significant an issue as it was back in the "Mississippi Mud" days, but it is still an issue.

Two papers published by Tom Lodise (out of Albany Medical Center) pretty recently looked at vanco nephrotoxicity, and found some pretty strong correlations with both inital trough level and total dose given. I'd certainly look at those prior to making any judgments.

You also have to take a look at the dosing guidelines and evaluate them critically. A lot of the dosing information currently used (at least in terms of effective troughs) is derived from Staph endocarditis and then extrapolated to other situations. Not saying this doesn't work, but its certainly something to take into account when considering vanco nephrotoxicity.

Question: are you working with Tom right now?

 

[Praziquantel86]

Answer: no.

He just does a lot of the work with this, and I like pop-PK and outcomes. So it fits nicely.

 

[PharMed2016]

Answer: no.

He just does a lot of the work with this, and I like pop-PK and outcomes. So it fits nicely.

Only reason I was wondering because I worked with him the last two years on pretty much all the reason you've stated. Was wondering if I knew you, lol. Small world if I do.