Apixaban vs. Rivaroxaban in Morbidly Obese Patients

Background

Direct oral anticoagulants (DOACs) like apixaban and rivaroxaban are commonly used for the prevention and treatment of thromboembolic disorders. However, their efficacy in morbidly obese patients (BMI ≥ 40 or 50) remains of clinical interest due to concerns over altered pharmacokinetics in this population.

Efficacy Considerations

Research on the efficacy of apixaban and rivaroxaban specifically in morbidly obese patients is limited. However, available studies and expert guidelines offer some insights:

• Apixaban: Some evidence indicates that apixaban maintains its efficacy in morbidly obese patients due to its favorable pharmacokinetic profile, which is less affected by body weight compared to other DOACs.
• Rivaroxaban: Rivaroxaban's efficacy may be slightly reduced in morbidly obese patients, though it still remains a viable option. Adjustments in clinical monitoring and dosing may be necessary.

Guidelines and Recommendations

Guidelines from organizations such as the International Society on Thrombosis and Haemostasis (ISTH) suggest caution when using DOACs in patients with a BMI ≥ 40 or weight > 120 kg. They recommend considering alternative anticoagulants, such as dose-adjusted warfarin, if concerns arise about the efficacy or safety of DOACs in these patients.

Conclusion

While both apixaban and rivaroxaban can be used in morbidly obese patients, the choice should be individualized based on patient characteristics, potential risks, and monitoring capabilities. Consultation with a healthcare professional is essential to ensure optimal treatment outcomes.

Overlapping Long-Acting Insulin During Insulin Drip Transition

Patients with persistent hyperglycemia who are not in diabetic ketoacidosis (DKA) may require an insulin drip for better glycemic control in an inpatient setting. Transitioning these patients from an insulin drip to subcutaneous insulin involves careful planning to maintain glycemic control and prevent rebound hyperglycemia.

Evidence supports the overlap of long-acting insulin during this transition process. This approach is based on the pharmacokinetics of insulin and aims to ensure continuous basal insulin coverage as the intravenous insulin is tapered off. Some key points include:

• Pharmacokinetic Considerations: As the half-life of intravenous insulin is relatively short, discontinuing it without an overlapping long-acting insulin can lead to gaps in insulin coverage. Long-acting insulins, such as glargine, detemir, or degludec, provide a steady, prolonged release of insulin that mimics the body's natural basal insulin.
• Preventing Rebound Hyperglycemia: Overlapping long-acting insulin with the insulin drip helps maintain stable blood glucose levels and reduces the risk of rebound hyperglycemia as the insulin drip is weaned off.
• Clinical Guidelines: Various clinical guidelines and expert consensus suggest administering long-acting insulin several hours (typically 2-4) before discontinuing the insulin drip to ensure that adequate insulin levels are maintained.
• Individualized Approach: The specific timing and dosage may be adjusted based on individual patient factors, including insulin sensitivity, previous insulin requirements, and overall health status.

Overall, overlapping long-acting insulin during the transition from an insulin drip is a widely endorsed practice in clinical settings to ensure continuous glycemic control and improve patient outcomes.

Fluconazole 150 mg in Pregnancy: Recent Evidence

Fluconazole, an antifungal medication, is commonly used to treat yeast infections. It is important to understand its safety profile during pregnancy.

Recent Findings

• Systematic Reviews: Recent systematic reviews suggest that low-dose fluconazole (150 mg single dose) may be used with caution in pregnancy, particularly in the first trimester. However, high-dose or prolonged use has been associated with a higher risk of congenital anomalies.
• Epidemiological Studies: Some epidemiological studies indicate a slight increase in the risk of specific birth defects with the use of fluconazole during pregnancy, but these findings are not consistent across all studies.
• Clinical Guidelines: Guidelines generally recommend using topical antifungals as the first-line treatment for yeast infections during pregnancy, reserving oral fluconazole for cases where topical treatments are ineffective.

Recommendations

Healthcare providers should consider the following:

1. Evaluate the necessity of fluconazole use in each individual case.
2. Consider alternative treatments such as topical antifungals.
3. Discuss potential risks and benefits with pregnant patients who require treatment.

Conclusion

While a single low dose of fluconazole may be used cautiously during pregnancy, especially after the first trimester, alternative treatments are generally preferred. Ongoing research and careful clinical judgment are essential to ensure the safety of both the mother and the developing fetus.

IV Push Fosphenytoin: Overview and Guidelines

Introduction

Fosphenytoin is a prodrug of phenytoin, commonly used for the treatment of status epilepticus and seizure prophylaxis. It is preferred over phenytoin for intravenous administration due to its improved solubility and reduced risk of local irritation.

Evidence Supporting IV Push Administration

Fosphenytoin has been studied for rapid administration in emergency settings. Clinical guidelines and studies suggest its safety and efficacy under appropriate conditions.

• A study published in "Epilepsy & Behavior" (2016) demonstrated that IV push administration of fosphenytoin is effective for rapid seizure control.
• The American Epilepsy Society guidelines recommend fosphenytoin as an alternative to phenytoin and other antiepileptic drugs in status epilepticus due to its favorable safety profile (source).

Maximum Recommended IV Push Dose

The maximum recommended dose for IV push administration of fosphenytoin is typically:

• The manufacturer’s prescribing information advises a maximum rate of 150 mg PE/minute (where PE represents phenytoin equivalent).
• In emergency settings, more rapid administration may be considered, but should be guided by institutional protocols and monitored closely for adverse effects such as hypotension or arrhythmias.

References

• Prescribing Information for Fosphenytoin Sodium Injection.
• American Epilepsy Society's Guidelines for Treatment of Convulsive Status Epilepticus in Adults and Children.

Always refer to institutional protocols and professional guidelines when administering fosphenytoin.