In this episode, we review the clinical presentation, diagnosis, and treatment of uncomplicated urinary tract infections.

Key Concepts

1. Uncomplicated urinary tract infections (UTI) are defined as an infection localized to the bladder without any systemic signs or symptoms of infection in someone who is not immunocompromised, pregnant, catheterized, and has normal urologic anatomy.
2. UTIs are most commonly seen in younger women. E. coli is by far the most common urinary pathogen. Symptoms alone drive most of the diagnosis of UTI; however, urinalysis and urine culture can be helpful in some circumstances.
3. Nitrofurantoin (Macrobid) is recommended for men and women for first-line therapy in most patients. Fosfomycin, Bactrim, pivmecillinam, and certain B-lactams can be considered in certain circumstances. Women are usually treated for 3-5 days and men 5-7 days.
4. Some evidence suggests inferior clinical outcomes for B-lactam; however, the amount of data in general is lacking for B-lactams. Recommended B-lactams (aside from pivmecillinam) include amoxicillin/clavulanate, cephalexin, cefadroxil, cefpodoxime, and cefdinir.

References

1. Nelson Z, Aslan AT, Beahm NP, et al. Guidelines for the Prevention, Diagnosis, and Management of Urinary Tract Infections in Pediatrics and Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open. 2024;7(11):e2444495. Published 2024 Nov 4. doi:10.1001/jamanetworkopen.2024.44495
2. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257
3. Kurotschka PK, Gágyor I, Ebell MH. Acute Uncomplicated UTIs in Adults: Rapid Evidence Review. Am Fam Physician. 2024;109(2):167-174.
4. https://www.wikiguidelines.org/

In this episode, we review the pharmacology, indications, adverse effects, and unique drug characteristics of 5-HT3 receptor antagonists such as ondansetron (Zofran) and palonosetron (Aloxi).

Key Concepts

1. There are four 5-HT3 (serotonin subtype 3) receptor antagonists on the market: ondansetron, granisetron, dolasetron, and palonosetron. These have primarily been studied for acute chemotherapy-induced nausea and vomiting (within 24 hours of chemotherapy administration) and for post-operative nausea and vomiting.
2. When used for chemotherapy-induced nausea/vomiting, 5-HT3 receptor antagonists are given prior to chemotherapy (usually 30-60 minutes before) on day #1. They are not given on subsequent days because they are not as effective for delayed nausea and vomiting.
3. Palonosetron has the longest half-life, longer binding affinity to the 5-HT3 receptor, and trends towards having the best efficacy among the 5-HT3 receptor antagonists.
4. 5-HT3 receptor antagonists are associated with QTc prolongation and may cause headache, dizziness, constipation, or diarrhea. Their association with an increased risk of serotonin syndrome is controversial and not supported from a mechanistic perspective.

References

• Simino GP, Marra LP, Andrade EI, et al. Efficacy, safety and effectiveness of ondansetron compared to other serotonin-3 receptor antagonists (5-HT3RAs) used to control chemotherapy-induced nausea and vomiting: systematic review and meta-analysis. Expert Rev Clin Pharmacol. 2016;9(9):1183-1194. doi:10.1080/17512433.2016.1190271
• Tricco AC, Soobiah C, Blondal E, et al. Comparative efficacy of serotonin (5-HT3) receptor antagonists in patients undergoing surgery: a systematic review and network meta-analysis. BMC Med. 2015;13:136. Published 2015 Jun 18. doi:10.1186/s12916-015-0371-y
• Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol. 2020;38(24):2782-2797. doi:10.1200/JCO.20.01296
• Herrstedt J, Clark-Snow R, Ruhlmann CH, et al. 2023 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting. ESMO Open. 2024;9(2):102195. doi:10.1016/j.esmoop.2023.102195
• Rojas-Fernandez CH. Can 5-HT3 Antagonists Really Contribute to Serotonin Toxicity? A Call for Clarity and Pharmacological Law and Order. Drugs Real World Outcomes. 2014;1(1):3-5. doi:10.1007/s40801-014-0004-3
• Li WS, van der Velden JM, Ganesh V, et al. Prophylaxis of radiation-induced nausea and vomiting: a systematic review and meta-analysis of randomized controlled trials. Ann Palliat Med. 2017;6(2):104-117. doi:10.21037/apm.2016.12.01

In this episode, we review the recommendations from the 2024 SCCM/ASHP stress ulcer prophylaxis guidelines and highlight three of the more recent landmark critical care trials investigating the role of stress ulcer prophylaxis.

Key Concepts

1. After 25 years, the stress ulcer prophylaxis guidelines have been updated by SCCM and ASHP. These guidelines make 13 recommendations in a PICO format.
2. Three large, landmark randomized controlled trials (SUP-ICU, PEPTIC, and REVISE) have significantly contributed to the body of literature regarding stress ulcer prophylaxis.
3. The SCCM/ASHP guidelines recommend stress ulcer prophylaxis in patients with coagulopathy, shock, chronic liver disease, and possibly in neurocritical care patients. They do not specifically recommend prophylaxis in mechanically ventilated patients; this is a controversial recommendation.
4. The SCCM/ASHP guidelines equally prefer proton pump inhibitor (PPI) and histamine-2 receptor antagonists (H2RA) drug therapies given either intravenously or orally. The prophylaxis regimen should be continued until the indication for prophylaxis has resolved or the patient leaves the ICU.

References

• MacLaren R, Dionne JC, Granholm A, et al. Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Crit Care Med. 2024;52(8):e421-e430. doi:10.1097/CCM.0000000000006330
• SUP-ICU study. Krag M, Marker S, Perner A, et al. Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU. N Engl J Med. 2018;379(23):2199-2208. doi:10.1056/NEJMoa1714919
• PEPTIC study. PEPTIC Investigators for the Australian and New Zealand Intensive Care Society Clinical Trials Group, Alberta Health Services Critical Care Strategic Clinical Network, and the Irish Critical Care Trials Group, Young PJ, Bagshaw SM, et al. Effect of Stress Ulcer Prophylaxis With Proton Pump Inhibitors vs Histamine-2 Receptor Blockers on In-Hospital Mortality Among ICU Patients Receiving Invasive Mechanical Ventilation: The PEPTIC Randomized Clinical Trial. JAMA. 2020;323(7):616-626. doi:10.1001/jama.2019.22190
• REVISE study. Cook D, Deane A, Lauzier F, et al. Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. 2024;391(1):9-20. doi:10.1056/NEJMoa2404245

In this episode, we will review the pharmacology, efficacy, and safety of the most common NSAIDs on the market.

In this episode, we discuss the changes made in the American Diabetes Association's 2019 Standards of Diabetes Care guideline as well as updates in therapy recommendations per ADA and ESDA consensus statement published in Fall 2018.

In this episode, we take a deep dive into the use of stimulants and other medications for management of ADHD. After decades of use, technology has resulted in changes to how they are administered. Furthermore new agents have become available, but are they an improvement?

In this episode, we discuss IV fluids for hospitalized patients, including normal saline (0.9% NaCl) and lactated ringer's. In addition, we review the newest literature supporting the use of balanced crystalloids over normal saline from the SMART and SALT-ED trials.

In this episode, we are excited to have a special guest with us. Dr. Dyson Wake is Senior Clinical Specialist in Pharmacogenomics at NorthShore University HealthSystem's Center for Molecular Medicine here in Chicagoland and is here to explain the current and future applications of pharmacogenomics to the area of personalized medicine, as well as expose some misconceptions.

In this episode, we review some of the most important new recommendations from the 2018 ACC/AHA guidelines for the management of blood cholesterol.

In this episode, we will review the FDA's Unapproved Drugs Initiative and how it has impacted the availability and pricing of commonly used (but old) medications, such as colchicine and vasopressin.

In this episode, we will discuss a new class of medications for preventing migraines called CGRP antagonists, including an overview of their development, clinical efficacy, and future goals of further research in this area.

In this episode, we continue to review insulin therapy including dosing-related specifications, dosing adjustments, injection technique, patient counseling pearls, and the concept of a sliding scale.

In this episode, we discuss a broad overview of insulin topics ranging from the various types of insulins, dosage forms, brand/generic names, pharmacokinetic nuances, injection technique, and a wide variety of clinical pearls.

In this episode, we discuss the approach to deprescribing for several drugs such as benzodiazepine receptor agonists, cholinesterase inhibitors, memantine, antipsychotics, and antihyperglycemics.

Key Concepts

1. Medication appropriateness including indication and risk vs. benefit should be evaluated for all stages of life; however, more importantly in older individuals to address polypharmacy.
2. There is an emerging trend of deprescribing networks that conduct research and provide evidence-based recommendations for how to deprescribe certain medications used for specific indications.
3. Evidence-based deprescribing guidelines for PPIs, benzodiazepines, benzodiazepine receptor agonists, opioids, antipsychotics, cholinesterase inhibitors, memantine, and antihyperglycemics are available for patient-provider shared decision making. 
4. A general deprescribing approach is gradual tapering of the drug leading to discontinuation over several weeks while monitoring patients for withdrawal symptoms or benefits of discontinuation. 

References

• http://deprescribing.org
• https://www.australiandeprescribingnetwork.com.au

In this episode, we discuss vaccine related updates with our vaccine expert, Dr. Lauren Angelo. The updates discussed in this episode include the new shingles vaccine, the variety of influenza vaccines on the market, and several other updates.

In this episode, we will discuss the advantages and disadvantages of a rate versus rhythm control strategy for atrial fibrillation.

In this episode, we discuss the importance of accurately recognizing depressive symptoms in patients with kidney disease and provide review the limited available literature regarding treatment in this population. We then discuss guidelines to determine some of the best treatment options for this unique subgroup of patients.

In this episode, we take a closer look at deuteration, specifically involving the medication deutetrabenazine (discussed back in episode 76). We feature a guest contributor from our pharmacy sciences department who assists us as we look at the drug design aspects of this unique molecule and its implications for research moving forward.

In this episode, we discuss some ways APPE students not only survive, but excel in the APPE rotations.

In this episode, we will review the diagnosis and treatment of heparin-induced thrombocytopenia (HIT).

In this episode, we interview Kathleen Lynch, PharmD and Ciantel (Adair) Blyler, PharmD, coauthors of the New England Journal of Medicine article, published in March 2018, investigating the role of pharmacist-led interventions for blood pressure reduction in black barbershops.

In this episode, we interview Janeen Winnike, Dean of the Office of Students Affairs at the RFUMS College of Pharmacy, regarding transitions from a student life to a practitioner life. With her previous role as an HR official within a large community pharmacy chain, she offers some "do's and don'ts" for students transitioning into new practitioners.

In this episode, we discuss five clinical pearls about pulmonary embolism ranging from PE diagnosis, classification, and treatment. We specifically examine when and how alteplase is given for PE and its use with concurrent anticoagulation.

In this episode, we discuss two new agents (valbenazine and deutetrabenazine) -- the first of their kind to receive FDA approval to manage tardive dyskinesia most commonly associated with antipsychotic use.

In this episode, we review the pharmacology, pharmacokinetics, adverse effects, monitoring, medicinal chemistry, and more of loop diuretics.

Key Concepts

1. Loop diuretics (furosemide, torsemide, bumetanide, ethacrynic acid) are the most potent type of diuretic and are used to relieve edema.
2. Loop diuretics cause an increased loss of sodium, chloride, potassium, hydrogen, magnesium, and calcium ions into the urine. Excessive loss of these ions manifests as hypokalemia, hypomagnesemia, and metabolic alkalosis.
3. Loop diuretics have an S-shaped dose response curve – a minimum dose is required for diuresis and a "ceiling" effect occurs at higher doses (leading to more ADRs). Doses should be individualized based on the clinical response of the patient.
4. Ethacrynic acid is incorrectly used in patients with a "sulfa" allergy. The other loop diuretics contain a sulfa moiety but are safe for use in patients with "sulfa" allergy (e.g. allergy to sulfamethoxazole-trimethoprim).
5. The TRANSFORM-HF trial strongly suggests that there is no clinical difference between furosemide and torsemide.

References

• Rachoin JS, Cerceo EA. Four nephrology myths debunked. J Hosp Med. 2011;6(5):E1-E5. doi:10.1002/jhm.703
• Strom BL, Schinnar R, Apter AJ, et al. Absence of cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics. N Engl J Med. 2003;349(17):1628-1635. doi:10.1056/NEJMoa022963
• Buggey J, Mentz RJ, Pitt B, et al. A reappraisal of loop diuretic choice in heart failure patients. Am Heart J. 2015;169(3):323-333. doi:10.1016/j.ahj.2014.12.009
• Mentz RJ, Anstrom KJ, Eisenstein EL, et al. Effect of Torsemide vs Furosemide After Discharge on All-Cause Mortality in Patients Hospitalized With Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. JAMA. 2023;329(3):214-223. doi:10.1001/jama.2022.23924

In the previous episodes, we discussed how we should evaluate a patient's bleeding and clotting risks as well as looked at recommendation for management for various anticoagulants. In this episode, we will continue the discussion to management of antiplatelets as well as when to resume both antiplatelets and anticoagulants following a procedure.

In this episode, we will discuss some important factors to consider in management of various anticoagulants. We will also provide agent specific pharmacodynamic and pharmacokinetic based recommendations.

In this episode, we discuss the efficacy and safety of probiotics for the prevention of antibiotic-associated diarrhea (AAD) and Clostridium difficile-associated diarrhea (CDAD).

In this episode, we will review the surprising results of the VA/DoD's 2017 Clinical Practice Guidelines on Management of PTSD, particularly as it relates to the use of one particular agent, prazosin.

In this episode, we review the important changes in 2017 ACC/AHA guidelines for hypertension management in adults.

In this episode, we discuss the difficulty in identifying adverse drug reactions (ADR) that ACTUALLY occur from a drug therapy, how tertiary drug references (such as Micromedex or LexiComp) may be misleading, and what tips and tricks you can use to recognize the most clinically relevant ADRs for patient counseling.

In this episode, we interview Dylan Moe, PharmD, our very own alumnus, regarding the new Illinois rule requiring patient counseling for all new prescriptions and inquire how the new rule has impacted his pharmacy, work environment, and his opinions on the implementation of the rule.

In this episode, we will discuss the current state of benzodiazepine use, expected trends in prescribing, and risks associated with use. Lastly, we will discuss techniques for ensuring that a benzodiazepine taper is performed in a safe manner with lowest risk of harm.

In this episode, we discuss new evidence for cardiovascular outcomes in diabetics based on the LEADER trial (liraglutide) and CANVAS trials (canagliflozin). We also discuss the new FDA warning for canagliflozin regarding amputation risk.

In this episode, we discuss updates in diabetes management that includes nuances from the ADA's Standards of Care 2017. We also review some newer pharmacologic agents, a fixed dose GLP-1 agonist and basal insulin combinations.

In this episode, we discuss principles for medication use in the geriatric patient population and summarize the updated 2023 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

Key Concepts

1. The Beer's Criteria was originally developed by Dr. Mark Beers in 1991 to identify medications in which the risks may outweigh the benefits in nursing home patients. This list is now maintained by the American Geriatrics Society and includes a variety of drug safety information related to elderly patients including medications that are considered potentially inappropriate (Table 2 and 3), medications used with caution (Table 4), drug-drug interactions (Table 5), drugs with renal dose adjustments (Table 6), and drugs with anticholinergic properties (Table 7).
2. The newest update prefers apixaban over other DOACs for VTE and atrial fibrillation in elderly patients. This is a very controversial recommendation given that other guidelines (e.g. from the ACC/AHA) have not published a similar preference of one DOAC over another.
3. Many of the medications that are potentially inappropriate involve drugs that have anticholinergic properties and drugs that increase the risk of incoordination and falls.
4. Other resources exist to guide drug therapy decisions in elderly patients. As an example, the STOPP/START criteria (published in the European Geriatric Medicine journal) outlines drugs to avoid but also drugs to consider in elderly patients.

References

• By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J AM Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372.
• O'Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, Gudmundsson A, Cruz-Jentoft AJ, Knol W, Bahat G, van der Velde N, Petrovic M, Curtin D. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med. 2023 Aug;14(4):625-632. doi: 10.1007/s41999-023-00777-y.

In this episode, we discuss three "older" antihypertensives that are not preferred first-line therapies: clonidine, methyldopa, and minoxidil.  We outline why these agents are not first-line therapies and review their pharmacology and adverse effect profiles.

In this episode, we discuss the history of ergot products for treatment of migraines. We compare their safety and efficacy to newer agents such as the triptans and assess their resultant place in therapy.

In this episode, we discuss several aspects of serotonin syndrome including the typical clinical presentation, its etiology and common drug-induced combinations, and how to appropriately manage the syndrome.

In this episode, we discuss the pathophysiology of embolic stroke in patients with atrial fibrillation and review the use of left atrial occlusion devices, such as the WATCHMAN device, to reduce the risk of stroke in patients with atrial fibrillation without the use of anticoagulants like warfarin.

In this episode, we review the 12 recommendations from the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.  These recommendations are intended to help curb the opioid epidemic and provide guidance to healthcare providers regarding safer use o

In this episode, we discuss the concept of professional advocacy, with a particular focus on how to advocate for the profession of pharmacy and what tools and organizations are available to assist in being an advocate.

In this episode, we discuss with Dr. Megan Hartranft the five oncology drugs that every pharmacist should know about, which is a great review for P4 students who are currently preparing for the NAPLEX.  We cover cyclophosphamide, cisplatin, methotrexate, doxorubicin, and vincristine.

In this episode, we discuss the newest definition of sepsis and septic shock according to the Sepsis-3 criteria and the 2016 Surviving Sepsis guidelines.  We also review the scoring systems of "qSOFA" and "SOFA" and use a patient case to help demonstrate the new definitions.

In this episode, we discuss the overuse of proton pump inhibitor (PPI) therapy and several concerns regarding chronic use of this medication class, including hypomagnesemia, fracture risk, low seurm B12 levels, anemias, and increased risk of certain infections.

In this episode, we discuss the new FDA categorizations of biosimilars, the legal implications of biologic/biosimilar prescriptions, and the new "follow-on" approval pathway of Basaglar, a new insulin glargine U-100 product.

In this episode, we discuss artificial intelligence large language models (LLMs) and how these will impact the future of the practice of pharmacy.

Key Concepts

1. Generative AI with large language models (LLMs) have already changed how healthcare is delivered to patients. In the future, these changes will be more substantial and require pharmacists and other healthcare professionals to understand the benefits and downsides of this technology.
2. Commercial LLMs, such as ChatGPT, are not HIPAA compliant and should not be used with protected health information. Companies currently offer software products that are HIPAA compliant and can integrate directly into electronic health records in a HIPAA-compliant manner.
3. Currently, most commercial use cases of LLMs for healthcare providers focus on expediting or simplifying the documentation process (e.g. generating a first draft of a progress note or summarizing a patient encounter from an audio recording).
4. In the future, LLMs will be used to perform a variety of clinical tasks, including drug interaction checking, renal dose adjustments, duplication of therapy, and even the appropriateness of a patient's drug regimen for a given medical condition. These clinical tasks will almost certainly be done as a "first pass" to highlight or flag specific aspects of a patient's chart and will then be reviewed by a licensed (human) healthcare provider as a final check prior to clinical decisions being made.

References

1. Large Language Models (LLMs) referenced in the episode: https://chat.openai.com, https://coral.cohere.com, https://claude.ai, https://gemini.google.com.
2. Prompt Engineering Guide (https://www.promptingguide.ai/techniques)
3. OpenAI - Prompt engineering (https://platform.openai.com/docs/guides/prompt-engineering/six-strategies-for-getting-better-results)
   

In this episode, we discuss the SPRINT trial (intensive vs. standard blood pressure control) using a case vignette of Mr. Wilson, a 55 year old patient presenting to a clinic with a blood pressure of 139/89 mmHg.

In this episode, we discuss precepting tips and clinical pearls with Dr. Brad Cannon.

In this episode, we discuss more of the most important drug interactions, including grapefruit juice with statins and calcium channel blockers, QT prolonging medications, levothyroxine with cations and PPIs, and PDE-5 inhibitors with nitrates.