Medical News
H1N1 and Seasonal Flu Items
CDC H1N1 resource site link
Dr. Vokes makes flu vaccination mandatory for faculty, fellows, and residents (9/09) link
CDC guidance on influenza vacccination (ACIP 7/09) link
Flu vaccine consent form (occ med) link
AHA and ACG Issue Guidance on GI Risks of Antiplatelet Therapy (10/08)
Important consensus statement from AHA that calls for a lot more PPI Rx as prevention for antiplatelet associated GI bleeding, including all pts on dual antiplatelet therapy, such as the not uncommon Plavix / baby ASA combo. Lowering INR target ( to 2.0-2.5) is suggested for warfarin/Plavix/ASA pts (plus adding a PPI). Using chronic PPI in all pts over 60 on low-dose ASA and who also have dyspepsia would be another substantial change in practice.
Algorithm, summary recommendations, and full article
CDC Reports Measles Outbreaks in 4 States, including Wisconsin (5/08)
Measles is making a comeback (tripling recent historical rates), in part due to persons claiming personal or religious exemption from vaccination. A third are adults, and over 20% have been hospitalized. Importation is an important source of exposure, including Europe and India. Prior to measles vaccination programs in the U.S., 3-4 million persons in the U.S. were infected each year, of whom 400-500 died, 48,000 were hospitalized, with another 1,000 developing chronic disability from measles encephalitis. MMWR article
CDC Reports New Virulent Adenovirus Strain
Potentially important recent outbreaks of a virulent serotype of adenovirus (Ad14) first identified 1955, but involved in several recent outbreaks -- nearly 40% of patient have been hosptialized, 17% in intensive care. More information.
DRUG NEWS
Anti-epileptic medications (Lyrica, Klonopin, Neurontin, etc) and suicide risk. The FDA has announced ‘medication guides’ addressing roughly twice the risk of suicidal behavior or ideation (0.43%) seen in pts receiving anti-epileptic medications (AEDs), compared to patients receiving placebo (0.22%). AEDs include agents commonly used in primary care of neuropathic pain, and therapy/prophylaxis of conditions like migraines, anxiety, and bipolar disease (valproic acid, neurontin, lyrica, klonopin). FDA alert (5/09)
Methadone and Long QT A potentially important paper published as an early release in Annals of Internal Medicine. They suggest that the QTc prolongation that can be seen in patients receiving methadone (especially with low potassium and/or magnesium, or other QT-prolonging drugs) may warrant additional clinical vigilance. Article in Ann Int Med (12/08)
Dilantin (phenytoin) in Asians and South Asians Another possible association of HLA-B*1502 (more common in Asians and South Asians) with SJS/TEN. The FDA previously suggested testing these groups for this allele if Tegretol (carbamazepine) therapy was being considered, and they’ve now extended consideration of this testing if phenytoin and fosphentoin therapy is planned. Risk is greatest in the first few months of therapy. FDA letter (11/08)
Amiodarone and simvastatin interaction The FDA has received reports of muscle injury, rhabdomyolysis, which can lead to kidney failure or death, when simvastatin ( esp >20mg per day) is used with amiodarone (8/08).
Severe musculoskeletal pain with biphosphonates (1/7/08); jaw osteonecrosis, a fib updates
The FDA reports severe and sometimes incapacitating musculoskeletal pain in patients taking bisphosphonates, which may occur within days, months, or years after starting therapy. Discontinuation may lead to complete, slow or incomplete resolution. The risk factors for and incidence of severe musculoskeletal pain associated with bisphosphonates are unknown.
This severe musculoskeletal pain is in contrast to the acute phase response characterized by fever, chills, bone pain, myalgias, and arthralgias that sometimes accompanies initial use of IV or less commonly, oral therapy. Acute phase response symptoms tend to resolve within several days even with continued drug use.
The FDA has previously discussed the potential risks of atrial fibrillation with IV bisphophonates, as well as jaw osteonecrosis especially (but not always) seen in patients who have had head and neck cancer radiation therapy and IV bisphosphonate therapy. A recent review of 714,000 patients in the J of the American Dental Association was generally reassuring about the risk of jaw necrosis with oral agents, and the risk of oral bisposphonates causing a fib by appears to be "vanishingly small." A useful web resource has also been published by 'snorenet.com'.
Phosphate Nephropathy with Colonoscopy Prep
Useful population based study from Detroit reviewed renal dysfunction following colonoscopy prep with sodium phosphate or PEG agents. “Univariate predictors of impaired renal function after colonoscopy were older age (>65), black race, low baseline GFR, hypertension, and use of ACE inhibitors, angiotensin-renin blockers, or thiazide diuretics”. The authors suggest “Sodium phosphate should not be used in patients with preexisting serious renal disease, adequate hydration should be assured in all patients, and renal function should be monitored before and after colonoscopy in those at risk of renal dysfunction.”
Another Caution Regarding Fentanyl Patches -- Don't Expose to Heating Pad (12/21/07) From the FDA: "Patients must avoid exposing the patch to excessive heat as this promotes the release of fentanyl from the patch and increases the absorption of fentanyl through the skin which can result in fatal overdose. Directions for prescribing and using the fentanyl patch must be followed exactly to prevent death or other serious side effects from fentanyl overdose" Full FDA letter here.
Carbamazepine (Tegretol) in Asians and South Asians (12/12/07)
Somewhat analogous to how we approach G6PD and dapsone, a federal advisory has just been released making appropriate prescribing of carbamazepine (tegretol) contingent on genetic screening for HLA-B*1502, due to risk of Stevens-Johnson and TEN. Asian patients tolerating the drug for at least several months appear to be a low risk for future events. Full FDA letter here.