Timothy Nguyen

Elevated liver enzymes resulting from an interaction between Raltegravir and Panax ginseng: a case report and brief review

Abstract Background: In the last decade, some evidence has arisen supporting the usefulness of Asian ginseng (Panax ginseng, fam. Araliaceae) as a complementary remedy in patients receiving antiretroviral therapy. However, its role in current therapeutics remains unclear. Methods: The patient was admitted for an acute elevation of liver enzymes, marked jaundice, and significant weight loss after taking ginseng-based tablets starting approximately 39 days prior. His past medical history (PMH) was also significant for HIV+, long-term hepatitis C, an episode of mitochondrial toxicity, and several comorbidities. His outpatient medications included raltegravir 400 mg plus lopinavir/ritonavir 400/100 mg twice daily, aspirin 100 mg daily, and esomeprazole 40 mg daily as needed. Results: The cessation of the ginseng lozenges led to a progressive improvement in the performance status and laboratory values. Both the Hansten and Horn nomogram and the Roussel Uclaf Causality Assessment Method indicated that the association between the ginseng medicine and the liver injury was probable (six points). Conclusions: We suggest that ginseng is involved in the episode through an interaction resulting in elevated plasma concentrations of raltegravir. As a consequence, clinicians should be alert when managing patients on other CYP3A4-metabolized drugs or previous liver-damaging conditions. However, larger studies are required to explicitly clarify these statements.

The older adult patient and kidney function.

OBJECTIVE Many older adults have decreased kidney function. Practitioners should be informed that no single clinical assessment method is validated in predicting their kidney function. DATA SOURCES Primary literature identified through MEDLINE/PubMed (1950-2010) and EMBASE (1980-2010) databases. The search was limited to English language, human subjects, and individuals 65 years of age and older. STUDY SELECTION AND DATA EXTRACTION Research, review articles, and additional publications related to geriatric, elderly, kidney function assessment, and cystatin C. DATA SYNTHESIS Screening and diagnosing chronic kidney disease are a challenge in older adults partially because of muscle loss and frailty. The various tools used to estimate creatinine clearance (Clcr) are not validated and may lead to under- or overdiagnosis of kidney function. The clinician must be cautious when using and interpreting results from these values. RESULTS Estimating the glomerular filtration rate (eGFR) with either the Modification of Diet in Renal Disease (MDRD) or Cockcroft-Gault (Clcr) formulae yielded better predictions of kidney function when compared with creatinine alone, or to measured Clcr. These estimation methods should be used in clinical practice to provide a better estimation of kidney function in older adults until a more valid assessment tool becomes available. CONCLUSIONS There is no proven valid method for eGFR in older adults; however, the CG and MDRD equations are routinely applied in clinical practice. Kidney function assessment in older adults remains a challenge, and practitioners should know their limitations.

Hyperkalemia and potential pitfalls of sodium polystyrene sulfonate.

AbstractSodium polystyrene sulfonate (SPS), FDA-approved more than 60 years ago for treating hyperkalemia, is an ion exchange resin that works by exchanging sodium for potassium in the colon. Though widely used in clinical practice, SPS use is not supported by well-designed clinical trials. In 2009, the FDA issued a warning that SPS was associated with colonic necrosis and other serious gastrointestinal adverse reactions. This article reviews the pros and cons of SPS therapy.

A case-based approach to evaluating azithromycin use and cardiovascular risks.

Azithromycin is a commonly prescribed macrolide antibiotic for the management of community-acquired pneumonia in the outpatient setting. Recent data have led to a growing concern of abnormal changes in cardiac electrophysiology and arrhythmias associated with its use. As azithromycin continues to be prescribed, clinicians should be aware of the new safety data and how it may affect concomitant medications or comorbid conditions in a patient. This article utilizes a case-based approach to assess azithromycin use and the risk of QT-prolongation and cardiac arrhythmias.

Incorporating Team-Based Learning Into a Physician Assistant Clinical Pharmacology Course.

Purpose To obtain student perceptions of team-based learning and compare the effectiveness of team-based learning and traditional lecture formats in a clinical pharmacology course for physician assistant (PA) students. Methods Clinical pharmacology is a course offered to PA students in their first year of training at LIU Brooklyn, Brooklyn, NY. In spring 2014, half of the course was offered in a traditional lecture format and the remaining half was offered in a team-based learning format. The team-based learning format had 3 components: (1) prereading assignments, (2) individual readiness assessment tests, and (3) team readiness assessment tests. So that student perceptions of the integration of team-based learning activities into the course could be evaluated, presurveys and postsurveys were administered. The effectiveness of team-based learning was evaluated by comparing overall student performance with student performance in the preceding year. Results Thirty-three students were enrolled in the course and completed the presurveys and postsurveys. The survey results are presented in Table 1. Comparison of student performance on examinations with performance from the previous year showed similar outcomes. Conclusion Incorporating a team-based learning pedagogical approach in the PA pharmacology course yielded similar examination results to those of traditional lecture formats. Presurvey and postsurvey questionnaires yielded various student perceptions of team-based learning.

Gabapentin: a surprising drug with many uses

Gabapentin is an interesting drug and it has many uses. There are two gabapentin formulations with multiple brand names. Gabapentin is approved by the Food and Drug Administration (FDA) for use as an adjunct agent in partial seizures, post‐herpetic neuralgia and restless legs syndrome. It is also used for a variety of other conditions, such as neuropathic pain, alcohol withdrawal syndrome, diabetic peripheral neuropathy, post‐op pain, fibromyalgia, hot sweats, haemodialysis‐associated pruritus, and to potentiate opioids effect.

Managing Hyperkalemia Stepping Into a New Frontier

Maintaining potassium balance in the body is essential for cellular function. Even a slight increase in normal serum potassium levels (3.5-5.0 mEq/L) can interfere with metabolism, electrical action potentials, and cellular processes. Hyperkalemia is commonly seen in patients with chronic kidney disease (CKD) and in patients on renin–angiotensin–aldosterone system (RAAS) inhibitors. Sodium polystyrene sulfonate (SPS), diuretics, and hemodialysis are currently available methods for removing potassium from the body; however, these options have their limitations. Patiromer (Veltassa) and sodium zirconium cyclosilicate are 2 new therapeutic options that can potentially lead a new frontier in the management of hyperkalemia. This article will review these novel treatments.

Comparison of serum ferritin and transferrin saturation values associated with two i.v. iron formulations in hemodialysis patients

PURPOSE The effects of i.v. iron formulations on serum ferritin concentration (SFC) and transferrin saturation (TSAT) are compared in adult hemodialysis patients with anemia receiving erythropoiesis-stimulating agents (ESAs). METHODS This study consisted of 215 patients who were receiving chronic hemodialysis, ESAs, and i.v. iron supplementation from November 2005 to November 2006. All patients received iron sucrose therapy from November 2005 to April 2006. Patients were then switched to sodium ferric gluconate. If the patients SFC was <100 ng/mL and TSAT was <20%, then iron sucrose 100 mg i.v. at every hemodialysis for 10 doses or sodium ferric gluconate 125 mg i.v. at every hemodialysis for 8 doses was administered as loading doses. Maintenance doses of iron sucrose 60 mg or sodium ferric gluconate 62.5 mg were administered every two weeks if the SFC was 100-499 ng/mL and the TSAT was 20-29% or every four weeks if the SFC was 500-600 ng/mL and the TSAT was 30-45%. SFC and TSAT were measured every three months. RESULTS More treatment courses resulted in target SFC and TSAT values during treatment with sodium ferric gluconate than iron sucrose, but neither difference was significant. The proportion of treatment courses resulting in SFCs of >600 ng/mL (above the target range) was significantly greater during treatment with iron sucrose than sodium ferric gluconate. CONCLUSION There was no significant difference between iron sucrose and sodium ferric gluconate in the frequency in which SFC and TSAT values were within target ranges in hemodialysis patients with anemia receiving ESAs. Of the two drugs, iron sucrose was more likely to produce an SFC above the target range.

A Case of an Older Adult Patient and Drugs Associated with Serotonin Syndrome.

Older adults have increased risk for depression, and the use of selective serotonin reuptake inhibitors (SSRIs) is common. Serotonin syndrome is a potential adverse event associated with the use of SSRIs, the combination of SSRIs and trazodone, and the combination of SSRIs and linezolid. Pharmacists are ideal for assessing older adult drug regimens and recognizing potential drug interactions associated with proserotonergic drugs and alleviating adverse events for patients.

Knowing Opioid Medication Formulations and Eliminating Confusion

Timothy Nguyen, PharmD, BCPS Opioid medications are also known as narcotics and are often used for pain management. They workbybinding toopioid receptors and are highly addictive,whichmayproduce feelings of euphoria, warmth, and relaxation. Common side effects associated with opioids involve the central nervous system including sedation, respiratory depression, and mental confusion; the gastrointestinal system including nausea, vomiting, and constipation; and other side effects related to physical dependence and tolerance. Prolonged exposure to opioids will lead to opioid abuse and withdrawal symptoms upon discontinuation. According to the Centers for Disease Control and Prevention, 3 of 4 prescription drug overdoses are caused by inappropriate opioid use. Drug overdoses also contribute to high mortality rates. The current death rates associated with opioid overdose have more than tripled compared with the data in 1990.Opioidmisuse is widespread and represents serious problems for health care practitioners. There are multiple means to abuse opioids, and they may include overingesting pills or capsules, chewing or crushing the tablets into powder for snorting, dissolving content for injection, and altering the integrity of the pill or its purpose for illicit use. Several commercial opioid medications are formulated in “abuse-deterrent” dosage forms to prevent misusage. The Table lists some of these newer