Pharmacy & Therapeutics - March 2009 - (Page 126) NEW DRUGS imab and bevacizumab. These monoclonal antibodies are designed to starve tumors; however, bevacizumab can raise blood pressure. Patients who received the four drugs did not have higher blood pressure, suggesting that cetuximab may interfere with bevacizumab. Other studies have shown that combining more drugs can sometimes help patients with cancers such as lung cancer. Sources: N Engl J Med 2009;360:563– 572; Thomson Reuters, February 4, 2009 DRUG NEWS The researchers suggest that because patients can receive SQ insulin on medical floors or step-down units, emergency departments may see a cost savings as well as improved patient flow when ICU beds are scarce. Source: Ann Emerg Med 2009;53:259– 263 Case Report: Inhaled Pentamidine And Toxic Epidermal Necrolysis Japanese physicians have reported that aerosolized pentamidine caused toxic epidermal necrolysis, a life-threatening side effect, in a 42-year-old patient with systemic lupus er ythematosus (SLE). The patient began prophylactic treatment with inhaled pentamidine once a month for Pneumocystis pneumonia. He was already being treated for SLE and aspergilloma with prednisolone, sodium valproate, voriconazole (Vfend, Pfizer), and lansoprazole (Prevacid, Takeda). On the day after the pentamidine was started, generalized erythroderma and a fever of 104.4° F developed. More than half of the patient’s body surface was covered with serum-filled blisters and bullae. He also had conjunctival erythema and blisters in the oral mucosa. A skin biopsy revealed ballooning keratinocytes and numerous individual necrotic keratinocytes. The physicians subjected all the suspected drugs to the lymphocyte-stimulating test, but only the results for pentamidine were positive. They stopped the pentamidine and treated the patient with plasma exchange, followed by methylprednisolone and immunoglobulin. The dose of prednisolone was then reduced. The eruption slowly resolved and did not recur. The authors cite three case reports of a cutaneous eruption caused by pentamidine and add that toxic epidermal necrolysis has been described with intramuscularly injected pentamidine. To their knowledge, this is the first report of the condition resulting from any inhalant drugs, including pentamidine. Inhaled pentamidine may remain in the tissue for more than two months, which suggests that symptoms of a drug-related eruption can also linger. The researchers caution that the underlying diseases of patients treated with pentamidine may be ones in which drug eruptions are common. Source: Am J Med 2009;122:e1–e2 Men and Women Respond Differently In Metabolic Syndrome The effect of the metabolic syndrome on the response to IV thrombolysis may depend on the patient’s sex, according to researchers from Chile and Spain. It has been noted that the risk of stroke is greater in women than men with the syndrome. Sometimes called insulin resistance syndrome, metabolic syndrome comprises risk factors for heart disease, diabetes, and stroke. Patients with the syndrome have abdominal obesity, high blood pressure, high blood glucose levels, and low levels of high-density lipoprotein-cholesterol (HDL-C). In the study, the researchers observed resistance to clot lysis at 24 hours in 42% of the patients. The syndrome was associated with significantly higher odds of resistance to thrombolysis in women. Although the reasons for the sex difference are not clear, this finding might be explained by a derangement of the endogenous fibrinolytic system related to insulin resistance, which may be more pronounced in postmenopausal women. Citing pediatric studies indicating that girls are intrinsically more insulin-resistant than boys, the researchers suggest that this difference may reappear later in life after the protection afforded by estrogen is lost. Insulin resistance may also lead to a more severe impairment of the fibrinolytic system in women. Women with type-2 diabetes mellitus have higher continued on page 129 For Ketoacidosis, SQ Insulin Works as Well as IV Subcutaneous (SQ) administration of rapid-acting insulin analogues such as insulin lispro (Humalog, Lilly) may be a reasonable alternative to intravenous (IV) infusions of regular insulin for treating uncomplicated diabetic ketoacidosis. According to researchers from the University of Pennsylvania in Philadelphia, their meta-analysis shows that the SQ choice is both safe and cost-effective, because it obviates the need for infusion pumps and admissions to intensive-care units (ICUs). Forty-five patients were treated with IV insulin in an ICU or with SQ lispro on a medical floor or step-down unit. Biochemical profiles, mean venous pH, and mean anion gap were similar in the three groups. There were no statistical differences among the groups in time to resolution of ketoacidosis, the amount of insulin required, or the number of hypoglycemic episodes (one in each group). In addition, no differences were evident in the rate of decrease in plasma glucose levels, correction of acid-base characteristics, or length of hospital stay. 126 P&T® • March 2009 • Vol. 34 No. 3
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