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Max Vasopressors? ASA STEMI Dosing? Early High Dose Statins? K-hole Content? - #DrugQueryInbox v1


 


@hairbender6, TikTok: One tab of azithromycin is a full course for treatment (chlamydia)?

  • Azithromycin comes in 250 and 500 mg tablets with the treatment dose being 1000 mg for a one time dose. Technically, this would be considered a full course for treating chlamydia. The 2021 IDSA STI Guidelines changed the preferred therapy of chlamydia from azithromycin to doxycycline 100 mg po bid twice daily for seven days. This was based on evidence that demonstrated reduced rates of treatment failure and and increased incidences of microbiologic cure with doxycycline over azithromycin.

  • Dombrowski and colleagues completed a randomized controlled trial in 2021 comparing doxycycline versus azithromycin for the Treatment of Rectal Chlamydia in Men Who Have Sex With Men. This was a randomized, double-blind trial including 135 men. Patients would receive treatment with either doxycycline or azithromycin and received a confirmatory rectal swab at 2 and 4 weeks. Doxycycline had a higher incidence of microbiologic cure compared to azithromycin.

  • The dosing frequency and treatment duration of doxycycline may not be appropriate for some patients, especially those with concerns of therapy adherence. Azithromycin does provide a single-dose treatment for flexability in certain cases, but it will not be as effective as doxycycline.

@christinec748, TikTok: Could you do one on hydrophilic versus lipophilic beta blockers

  • There are many beta blockers available, so I'll primarily discuss commonly seen oral agents. Beta blockers have several neuropsychaitric benefits. They are typically associated with cardiovascular diseases, but have shown benefit for other indications. Lipophilic beta blockers are more intended for these neuropsychiatric benefits since they cross the blood brain barrier more readily compared to hydrophilic agents.

  • Beta blockers have been used for migraines, tremors, anxiety, withdrawal symptoms, and other behavioral health disorders. Propranolol is the most lipohilic non-selective beta blocker used for these indications. Moderate lipophilic beta blockers include metoprolol and carvediolol, which are selective and nonselective respectively.

@tabikayee2.0, TikTok: What if you have herpes you can get encephalitis??

  • Herpes simplex can cause several different kinds of infections, including genital and mucosal herpes. Herpes simplex can also cause encephalitis; it accounts for up to 10% of cases worldwide actually per IDSA. Generally, it can occur in any age group but it is more common to cause encephalitis in patients with weakened immune systems. Herpes simplex is considered a dormant virus and common amongst the community. HSV-2 is more common in adults, while HSV-1 is more prevelant with neonates.

@pharmacist_gerl: history of ischemic stroke is only within the last year or 3 years right?

  • This was a question to one of my #MEDIGRAM patient cases. Per the guidelines, the general recommendation would be systemic thrombolytics are contraindicated in patients with an ischemic stroke in the past 3 months. Taking a step back quite frankly, the absolute contraindication here would be the systolic greater than 185. Sure, you can go into the timing of when that ischemic stroke was but what if the patient has new significant debilitating symptoms. I actually recommend anyone who has not looked into how the inclusion and exclusion criteria originated, you definitely should. The initial recommendations were extrapolated from alteplase in the use of myocardial infarctions. The AHA/ASA Scientific Statement regarding alteplase and ischemic strokes within the past 3 months indicates,

They also mention that it is an area that requires further study to identify the actual risk in this patient population. The guidelines are obviously general recommendations and that exclusion criteria has remained. Even if a ischemic stroke occurred within the past 3 months, new acute debilitating symptoms proposes an interesting clinical discussion with a time-sensitive complication.


 

References

Plurad et al. Early vasopressor use in critical injury is associated with mortality independent from volume status. J Trauma . 2011 Sep;71(3):565-70; discussion 570-2. Benjo et al. High dose statin loading prior to percutaneous coronary intervention decreases cardiovascular events: a meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv . 2015 Jan 1;85(1):53-60.

Ye et al. Do We Really Need Aspirin Loading for STEMI? Cardiovasc Drugs Ther . 2022 Dec;36(6):1221-1238.

Berger et al. Initial aspirin dose and outcome among ST-elevation myocardial infarction patients treated with fibrinolytic therapy . Circulation . 2008 Jan 15;117(2):192-9.

Mehta et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med . 2010 Sep 2;363(10):930-42.

Nusca et al. Statin loading before percutaneous coronary intervention: proposed mechanisms and applications. Future Cardiol . 2010 Sep;6(5):579-89.

Lee et al. Efficacy of high-dose atorvastatin loading before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: the STATIN STEMI trial. JACC Cardiovasc Interv. 2010 Mar;3(3):332-9.

Zanos et al. Ketamine and Ketamine Metabolite Pharmacology: Insights into Therapeutic Mechanisms. Pharmacol Rev . 2018 Jul;70(3):621-660.


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