Drugs and Labs, what needs to be monitored? Jennifer Rodgers, MSN, ARNP Wichita State University

Drugs and Labs, what Drugs and Labs, what needs to be monitored?needs to be monitored?

Jennifer Rodgers, MSN, ARNPJennifer Rodgers, MSN, ARNP

Wichita State UniversityWichita State University

DRUGS & LABSDRUGS & LABS

• We are a testing societyWe are a testing society

• Over 1100 tests to pick fromOver 1100 tests to pick from

• RIGHT TEST RIGHT PATIENTRIGHT TEST RIGHT PATIENT

• Don’tDon’t get a test you don’t want the get a test you don’t want the answer tooanswer too

• Is the patient willing to participate?Is the patient willing to participate?


• Insurance companies demand we Insurance companies demand we have a code for every testhave a code for every test

• Be cost effective- What test will give Be cost effective- What test will give me the most information with the me the most information with the least amount of $$$?least amount of $$$?

• Understand lab values & also validity Understand lab values & also validity and sensitivity of the tests you are and sensitivity of the tests you are orderingordering


• Let the guidelines, patient clinical Let the guidelines, patient clinical picture, & your experiences guide youpicture, & your experiences guide you

• Remember Remember NONO test takes the place of test takes the place of a thorough history and physical exama thorough history and physical exam

• If you do it in the right order History & If you do it in the right order History & PE will guide youPE will guide you


• 84 Year Old Male Severe COPD, Weight 84 Year Old Male Severe COPD, Weight Loss, Chronic Hypoxemia, HTN, History Loss, Chronic Hypoxemia, HTN, History of Afib & Pulm. Embolism on Coumadinof Afib & Pulm. Embolism on Coumadin

• HPI: Over past 2 months has been HPI: Over past 2 months has been slowly declining several slowly declining several hospitalizations for COPD Exac. hospitalizations for COPD Exac. weakness, 20 # weight loss, fatigueweakness, 20 # weight loss, fatigue

• Presented to the office with Presented to the office with hemoptysis & weakness hemoptysis & weakness

84 YEAR OLD MALE84 YEAR OLD MALE

• PE: Pale, Ill appearing increased PE: Pale, Ill appearing increased dyspnea from baselinedyspnea from baseline

• Lab Hgb 8.0 INR>80 secondsLab Hgb 8.0 INR>80 seconds

• VS Afebrile 110/60 110 SpO2 90% on VS Afebrile 110/60 110 SpO2 90% on 4 Liters4 Liters

84 YEAR OLD MALE84 YEAR OLD MALE

• Obviously Admit, Reverse Coumadin Obviously Admit, Reverse Coumadin with FFP & Vitamin Kwith FFP & Vitamin K

• Coumadin needs careful monitoring Coumadin needs careful monitoring & patient education& patient education

• So often the elderly are the ones So often the elderly are the ones taking this unpredictable medicinetaking this unpredictable medicine

PROTIME w/INRPROTIME w/INR

• International Normalized Ratio International Normalized Ratio SystemSystem

• Factors that can alter: Heparin/LMH/ Factors that can alter: Heparin/LMH/ Coumadin, Liver Failure/Tumor, DIC, Coumadin, Liver Failure/Tumor, DIC, Vit K deficiency, ETOH intake, Vit K deficiency, ETOH intake, Malabsorption Disorders, Diet, Other Malabsorption Disorders, Diet, Other medicationsmedications

THERAPEUTIC INR WITH THERAPEUTIC INR WITH COUMADIN TREATMENTCOUMADIN TREATMENT

• DVT prophylaxisDVT prophylaxis 1.5-2.01.5-2.0• ORTHO. SURGERYORTHO. SURGERY 2.0-3.02.0-3.0• DVTDVT 2.0-3.02.0-3.0• A-FIB prophylaxisA-FIB prophylaxis 2.0-3.02.0-3.0• PEPE 2.0-3.02.0-3.0• Prosthetic ValveProsthetic Valve 2.5-3.52.5-3.5Adapted from: Adapted from: Mosby’s Manual of Diagnostic & Mosby’s Manual of Diagnostic &

Laboratory Tests. Laboratory Tests. (2(2ndnd Ed.). (2002). 112. Ed.). (2002). 112.

HOW TO MONITOR?HOW TO MONITOR?

• ½ Life is 20-60 hours½ Life is 20-60 hours

• Peak time 5-7 daysPeak time 5-7 days

• Bridge with LWH or SQ Heparin Bridge with LWH or SQ Heparin

• Timing of Lab Test has to match half Timing of Lab Test has to match half life of drug life of drug

• Have a system for adjusting or Have a system for adjusting or reversing otherwise you will chase reversing otherwise you will chase your tail!your tail!

Coumadin with Coumadin with HypercoagulationHypercoagulation

• How to reverse or adjust?How to reverse or adjust?

• > 7 OR symptomatic FFP/Vit. K 5-10 mg > 7 OR symptomatic FFP/Vit. K 5-10 mg

• 4-7 Hold X 1 day decrease by 20%4-7 Hold X 1 day decrease by 20%

• 3.6-4 Hold X 1 day decrease by 15%3.6-4 Hold X 1 day decrease by 15%

• 3-3.5 decrease by 10%3-3.5 decrease by 10%

• 3 day ½ life3 day ½ life

• Follow protimes closely, Patient Follow protimes closely, Patient EducationEducation

COUMADIN OTHER COUMADIN OTHER THOUGHTSTHOUGHTS

• If you can’t regulate someone think If you can’t regulate someone think about why?about why?

• Where metabolized? > LiverWhere metabolized? > Liver

• Problem in the Liver?Problem in the Liver?

• 84 year old male 84 year old male

• ? Why so hypercoagulable? Why so hypercoagulable


• 84 Year old male- Remember 84 Year old male- Remember unintentional weight loss, then unintentional weight loss, then developed persistent nausea to the point developed persistent nausea to the point could not eat or drink, even water could not eat or drink, even water bothered bothered

• +RUQ pain+RUQ pain• What tests do we want? GB Sono>stonesWhat tests do we want? GB Sono>stones• HIDA Scan> normal GBHIDA Scan> normal GB• CT Abd Pelvis>Large Hepatic LesionCT Abd Pelvis>Large Hepatic Lesion


• So….Liver Bx + for Cancer with MetsSo….Liver Bx + for Cancer with Mets• Sad outcome>however after being Sad outcome>however after being

stable on Coumadin therapy for 5 stable on Coumadin therapy for 5 years, that explains years, that explains hypercoagulation, wt. loss, general hypercoagulation, wt. loss, general decline in conditiondecline in condition

• Remember to always put the puzzle Remember to always put the puzzle together, look at whole patient not together, look at whole patient not just abnormal lab test!just abnormal lab test!


• 92 year old female on Coumadin for 92 year old female on Coumadin for AfibAfib

• INR remains 1.0 seconds even after INR remains 1.0 seconds even after adjusting doseadjusting dose

• Nursing Home confirms she is getting Nursing Home confirms she is getting the medication dailythe medication daily

• On 10 Mg Coumadin/daily still normal On 10 Mg Coumadin/daily still normal INR???INR???


• Look further….she was getting the Look further….she was getting the medication daily, but on further medication daily, but on further investigation she was pocketing pills investigation she was pocketing pills and not swallowing anything!!!and not swallowing anything!!!

• Then you discuss with DPOA, patients Then you discuss with DPOA, patients wishes risk/benefit of the medswishes risk/benefit of the meds


• 78 year old female 2 months S/P 78 year old female 2 months S/P CABG presents with lethargy, CABG presents with lethargy, bradycardia, has been in nursing bradycardia, has been in nursing home since surgery, prior to that home since surgery, prior to that leaving independently at homeleaving independently at home

• She has been getting progressively She has been getting progressively weak, less interactive with staff, weak, less interactive with staff, decreased appetitedecreased appetite


• What drug might be the cause?What drug might be the cause?

• What do you know about What do you know about

Amiodarone?Amiodarone?

AMIODARONEAMIODARONE

• Very effective Anti-arrhythmic that Very effective Anti-arrhythmic that slowly loads into multiple tissues in slowly loads into multiple tissues in the body it is slow to “load” & slow to the body it is slow to “load” & slow to clearclear

• Not excreted by liver or kidneys but Not excreted by liver or kidneys but through body tissue containing through body tissue containing Amiodarone cells i.e. skin, GI etc.Amiodarone cells i.e. skin, GI etc.

• So even when stopped remains in the So even when stopped remains in the body weeks to months body weeks to months


• This 78 year female developed Afib This 78 year female developed Afib post CABG & was started on post CABG & was started on AmiodaroneAmiodarone

• ? Cause of symptoms? Cause of symptoms

• 1-3 % of patients can develop thyroid 1-3 % of patients can develop thyroid dysfunction after starting on dysfunction after starting on Amiodarone (hyper or hypo)Amiodarone (hyper or hypo)

• So…look at whole patient So…look at whole patient


• Check TSH Sensitivity 89-95% Specificity Check TSH Sensitivity 89-95% Specificity 90-96%90-96%

• 78 year old female TSH 30.6 (2-10)78 year old female TSH 30.6 (2-10)• Confirm with Free T4Confirm with Free T4• This patients symptoms & decline were This patients symptoms & decline were

from Amiodarone induced hypothyroidismfrom Amiodarone induced hypothyroidism• Start levothyroxine, slow to load recheck Start levothyroxine, slow to load recheck

6-8 weeks, not sooner6-8 weeks, not sooner• Stop Amiodarone!!Stop Amiodarone!!

AMIODARONE OTHER AMIODARONE OTHER THOUGHTSTHOUGHTS

• 78 year old female 1 month later, 78 year old female 1 month later, much improved ambulating, eating, much improved ambulating, eating, alert, nearly back to baselinealert, nearly back to baseline

• It can also Cause Pulmonary It can also Cause Pulmonary Toxicity/Fibrosis 4-9%Toxicity/Fibrosis 4-9%

• Review side effects!!Review side effects!!


• TSH-Used to differentiate between primary TSH-Used to differentiate between primary hypothyroidism & secondary (pituitary) hypothyroidism & secondary (pituitary) hypothyroidism hypothyroidism

• 2-10 nml range2-10 nml range

• Goal in suppression (HYPER) therapy <2Goal in suppression (HYPER) therapy <2

• If screening & TSH abnormal check free T4If screening & TSH abnormal check free T4

• REMEMBER INVERSE TSH < = hyperREMEMBER INVERSE TSH < = hyper

TSH> = hypoTSH> = hypo


• Free T4-unbound T4 that enters the Free T4-unbound T4 that enters the cell & is metabolically active >true cell & is metabolically active >true reflection hormonal statusreflection hormonal status

• If < FT4=hypothyroid <0.8 ng/dl If < FT4=hypothyroid <0.8 ng/dl

• >FT4=hyperthyroid >2.4 ng/dl>FT4=hyperthyroid >2.4 ng/dl


• If can’t keep euthyroid on If can’t keep euthyroid on levothyroxinelevothyroxine

• TSH too high- Adherence? Dose too TSH too high- Adherence? Dose too low? Drug Interaction?low? Drug Interaction?

• TSH too low- Dose too high? Taking TSH too low- Dose too high? Taking more than prescribed?more than prescribed?

WHAT ABOUT STATINS?WHAT ABOUT STATINS?

• Work by inhibiting HMG Co-A Work by inhibiting HMG Co-A reductase >reduces the livers ability reductase >reduces the livers ability to make cholesterolto make cholesterol

• In addition, reduce plaque size in the In addition, reduce plaque size in the artery, decrease clot formation, & artery, decrease clot formation, & decrease CRP levels decrease CRP levels

• Impact LDL, Triglyercides, & to a Impact LDL, Triglyercides, & to a small degree HDLsmall degree HDL


• Causes LFT elevation 1 in 100 patientsCauses LFT elevation 1 in 100 patients• Causes myopathy in 1 in 1000 patientsCauses myopathy in 1 in 1000 patients• Most serious avoid rhabdomyolysisMost serious avoid rhabdomyolysis

• In patient with normal liver (no fatty liver, In patient with normal liver (no fatty liver, cholestatic or obstructive jaundice, chronic cholestatic or obstructive jaundice, chronic hepatitis, alcoholic hepatitis, or hepatitis, alcoholic hepatitis, or inflammatory disease of the heart or inflammatory disease of the heart or skeletal muscle) should have normal LFT’sskeletal muscle) should have normal LFT’s


• In patients with asymptomatic In patients with asymptomatic hepatocellular dysfunction, an hepatocellular dysfunction, an elevation of ALT or AST 2-3 times elevation of ALT or AST 2-3 times normal therapy should not be started normal therapy should not be started or if taking statin discontinued.or if taking statin discontinued.

• Pre-treatment baseline LFT’s CKPre-treatment baseline LFT’s CK• Recommendations are to obtain Recommendations are to obtain

LFT’s within 6 weeks of initiating LFT’s within 6 weeks of initiating therapy therapy


• aspartate aminotransferase (AST) aspartate aminotransferase (AST) test is the most sensitive marker of test is the most sensitive marker of the impact of statins and other the impact of statins and other dyslipidemic agents.dyslipidemic agents.

• AST should not be elevated more AST should not be elevated more than 2-3 times the ULN. than 2-3 times the ULN.


• Avoid concomitant use of Avoid concomitant use of clarithromycin, fluconazole, clarithromycin, fluconazole, erythromycin, ketoconazole, rifampin, erythromycin, ketoconazole, rifampin, itraconazole, terbinafine, verapamil, and itraconazole, terbinafine, verapamil, and amiodarone. amiodarone.

• The combination of these medications The combination of these medications and lipid-lowering agents will and lipid-lowering agents will significantly increase the possibility of significantly increase the possibility of Statin Induced Myopathy. Statin Induced Myopathy.

INCREASED RISK FOR STATIN INCREASED RISK FOR STATIN INDUCED MYOPATHYINDUCED MYOPATHY

• > 80 years old (women>men)> 80 years old (women>men)• Small Frame & FragilitySmall Frame & Fragility• CKD, DiabetesCKD, Diabetes• PolypharmacyPolypharmacy• Perioperative PeriodsPerioperative Periods• Alcohol Abuse (independent predisposing factor)Alcohol Abuse (independent predisposing factor)

• Follow ATP III guidelines & don’t exceed Follow ATP III guidelines & don’t exceed recommended doses & treat cautiously in pts at recommended doses & treat cautiously in pts at increased riskincreased risk

http://www.nhlbi.nih.gov/guidelines/cholesterol/statins.pdfhttp://www.nhlbi.nih.gov/guidelines/cholesterol/statins.pdf retrieved 05/21/10 retrieved 05/21/10

http://www.nhlbi.nih.gov/guidelines/cholesterol/statins.pdf

WHAT ABOUT THE STATINS?WHAT ABOUT THE STATINS?

• If myopathy occurs, obtain CK level & If myopathy occurs, obtain CK level & compare to pre-statin levelcompare to pre-statin level

• If >10 times normal dc statinIf >10 times normal dc statin

• If 3-10 times normal < dose or give If 3-10 times normal < dose or give drug holiday & follow until resolved drug holiday & follow until resolved

• Thyroid disease predisposing factor Thyroid disease predisposing factor to myopathy also check TSHto myopathy also check TSH

WHAT ABOUT RHABDO?WHAT ABOUT RHABDO?MOST COMMON SYMPTOMSMOST COMMON SYMPTOMS

• Muscular: muscle pain, weakness, tenderness, and Muscular: muscle pain, weakness, tenderness, and stiffness. These symptoms occur 50% of the time with stiffness. These symptoms occur 50% of the time with muscular symptoms and signs occurring in the large muscular symptoms and signs occurring in the large muscles of the thighs, calves, and lower back. The affected muscles of the thighs, calves, and lower back. The affected muscles become swollen and tender on palpation.[2-4] muscles become swollen and tender on palpation.[2-4]

• Urinary: The most significant diagnostic feature is the Urinary: The most significant diagnostic feature is the change in color of the urine. Dark urine, typically brown, is change in color of the urine. Dark urine, typically brown, is often the first clue to the diagnosis of rhabdomyolysis.[2-4] often the first clue to the diagnosis of rhabdomyolysis.[2-4]

• Constitutional: These symptoms vary widely. The most Constitutional: These symptoms vary widely. The most common symptoms are generalized malaise, fever, common symptoms are generalized malaise, fever, tachycardia, nausea, and vomiting.[2-4] tachycardia, nausea, and vomiting.[2-4]

Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C. ACC/AHA/NHLBI clinical Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. J Am Coll Cardiol. 2002;40:568-572advisory on the use and safety of statins. J Am Coll Cardiol. 2002;40:568-572

WHAT ABOUT RHABDO?WHAT ABOUT RHABDO?

• If suspected, stop Lipid Lowering agentsIf suspected, stop Lipid Lowering agents

• STAT lab LFT’s CK, & CPKSTAT lab LFT’s CK, & CPK

• CPK most important diagnostic criteriaCPK most important diagnostic criteria

• If >10 times normal cause for concernIf >10 times normal cause for concern

Phillips PS, Haas RH, Bannykh S, et al. Statin-associated myopathy with normal creatine Phillips PS, Haas RH, Bannykh S, et al. Statin-associated myopathy with normal creatine kinase levels. Ann Intern Med. 2002;137:581-585. kinase levels. Ann Intern Med. 2002;137:581-585.

Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C. Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. J Am Coll Cardiol. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. J Am Coll Cardiol. 2002;40:568-572 2002;40:568-572


• alanine aminotransferase (ALT) less alanine aminotransferase (ALT) less sensitive to statin sensitive to statin

• Excellent for evaluating “fatty liver” Excellent for evaluating “fatty liver” or steatohepatitis or steatohepatitis

• Usually related to medication, Usually related to medication, obesity, alcohol intake, starvation, obesity, alcohol intake, starvation, diabetes, or high blood triglycerides diabetes, or high blood triglycerides


• AST-Think statinsAST-Think statins

• ALT-Think diabetic meds like ALT-Think diabetic meds like Avandia, ActosAvandia, Actos

• Statins have best effect on lipids if Statins have best effect on lipids if taken at night.taken at night.


• 85 year old female over past week 85 year old female over past week increased fatigue, weakness, increased fatigue, weakness, headache, blurred vision & diplopiaheadache, blurred vision & diplopia

• In addition, family has noticed In addition, family has noticed increased confusionincreased confusion

85 YEAR OLD FEMALE85 YEAR OLD FEMALE

• VS Afebrile 120/70 80 SR with VS Afebrile 120/70 80 SR with Trigeminal PVC’s, SpO2 92% 2 LitersTrigeminal PVC’s, SpO2 92% 2 Liters

• PE Ill appearing elderly female, PE Ill appearing elderly female, confused, lethargic confused, lethargic

• Patient then became unresponsive Patient then became unresponsive and the cardiac monitor revealed…..and the cardiac monitor revealed…..

WHAT DRUG SHOULD WE BE WHAT DRUG SHOULD WE BE THINKING ABOUT AS WE CODE THINKING ABOUT AS WE CODE

THIS PATIENT?THIS PATIENT?

85 YEAR OLD FEMALE85 YEAR OLD FEMALE

• DIGOXINDIGOXIN…patient had been taking for the …patient had been taking for the past 10 years without incidence.past 10 years without incidence.

• 0.4% of all hospital admissions, 1.1% of 0.4% of all hospital admissions, 1.1% of outpatients, & 10-18% of nursing home outpatients, & 10-18% of nursing home patients on Digoxin develop toxicity.patients on Digoxin develop toxicity.

• 2007 Annual Report of the American 2007 Annual Report of the American Association of Poison Control Centers 2565 Association of Poison Control Centers 2565 Digatalis exposures reported with 10 Digatalis exposures reported with 10 deathsdeaths

• http://emedicine.medscape.com/article/814404-overviewhttp://emedicine.medscape.com/article/814404-overview Retrieved 5/25/10 Retrieved 5/25/10

http://emedicine.medscape.com/article/814404-overview

Digoxin ToxicityDigoxin Toxicity

• Normal Range 0.5-2 ng/mLNormal Range 0.5-2 ng/mL

• 50% mortality of Digoxin Level > 50% mortality of Digoxin Level > 6ng/ml6ng/ml

• Usually caused by dehydration, Usually caused by dehydration, electrolyte imbalances, decreased electrolyte imbalances, decreased renal function, or drug interactions, renal function, or drug interactions, new onset hypothyroidism, & AMInew onset hypothyroidism, & AMI

Drugs/supplements that can Drugs/supplements that can cause Digoxin Toxicitycause Digoxin Toxicity

• Amiodarone, Amiloride, Beta Blockers, Amiodarone, Amiloride, Beta Blockers, Calcium Channel Blockers, Calcium Channel Blockers, Erythromycin, Cyclosporine, HTCZ, Erythromycin, Cyclosporine, HTCZ, Spironolactone, Triameterene, Loop Spironolactone, Triameterene, Loop Diuretics, Amphotericin B, Diuretics, Amphotericin B, Succinylcholine Succinylcholine

• Ephedra (cardiac stimulation), natural Ephedra (cardiac stimulation), natural licorice (sodium retention & potassium licorice (sodium retention & potassium loss) loss)

DIGOXIN TOXICITY DIGOXIN TOXICITY REVERSALREVERSAL

Treatment based on clinical course Treatment based on clinical course of patientof patient

Oxygen, cardiac monitoring, IV Oxygen, cardiac monitoring, IV accessaccess

Digibind if Altered mental status, Digibind if Altered mental status, arrhythmias with hemodynamic arrhythmias with hemodynamic instability, Potassium >5, or Serum instability, Potassium >5, or Serum Dig. Level > 10 ng/mlDig. Level > 10 ng/ml

DIGOXIN TOXICITY DIGOXIN TOXICITY REVERSALREVERSAL

• Lidocaine & phenytoin in ventricular Lidocaine & phenytoin in ventricular arrhythmias >depress ventricular arrhythmias >depress ventricular automaticity without significantly automaticity without significantly slowing AV conductionslowing AV conduction

• Quinidine, procainamide, and Quinidine, procainamide, and bretylium are contraindicated bretylium are contraindicated

• Cardioversion is usually Cardioversion is usually contraindicated, it may precipitate contraindicated, it may precipitate Vfib or AsystoleVfib or Asystole


• When you see neutropenia, When you see neutropenia, thrombocytopenia, leukopenia, or thrombocytopenia, leukopenia, or leukocytosis, always ask yourself is leukocytosis, always ask yourself is there a medication that is causing this?there a medication that is causing this?

• Use resources or clinical PharmD. to Use resources or clinical PharmD. to research this if you don’t know the research this if you don’t know the answeranswer

NEUTROPENIA REVIEWNEUTROPENIA REVIEW

• An ANC of less than 1500 per microliter An ANC of less than 1500 per microliter (1500/microL) is the generally accepted (1500/microL) is the generally accepted definition of neutropenia. definition of neutropenia.

• Neutropenia is sometimes further classified as:Neutropenia is sometimes further classified as:MildMild if the ANC ranges from 1000-1500/microL if the ANC ranges from 1000-1500/microLModerateModerate with an ANC of 500-1000/microL with an ANC of 500-1000/microL SevereSevere if the ANC is below 500/microL if the ANC is below 500/microL (Agranulocytosis(Agranulocytosis ) )

• ANC (Absolute Neutrophil Count)=WBC X (% ANC (Absolute Neutrophil Count)=WBC X (% Neutrophils + % Bands) Neutrophils + % Bands)

DRUG INDUCED DRUG INDUCED NEUTROPENIANEUTROPENIA

• Causative drug was given within 4 Causative drug was given within 4 weeks of the onset of neutropenia.weeks of the onset of neutropenia.

• Once drug discontinued, usually Once drug discontinued, usually neutropenia is corrected within 30 neutropenia is corrected within 30 days.days.

DRUG CAUSES OF DRUG CAUSES OF NEUTROPENIANEUTROPENIA

• ChemotherapyChemotherapy

• Immunosuppressive agentsImmunosuppressive agents

• B-lactam antibioticsB-lactam antibiotics

• PTUPTU

• Carbamazepine, Phenothiazines, Carbamazepine, Phenothiazines, PhenytoinPhenytoin

• Psychotropic DrugsPsychotropic Drugs

DRUG CAUSES OF DRUG CAUSES OF THROMBOCYTOPENIATHROMBOCYTOPENIA

• Platelet count <150,000Platelet count <150,000• Early signs Bruising, petechiae, Early signs Bruising, petechiae,

epitaxisepitaxis• Unfractionated Heparin, Thiazide Unfractionated Heparin, Thiazide

diuretics, Cimetidine, Sulfonamides, diuretics, Cimetidine, Sulfonamides, Quinine, Phenytoin, Vancomycin, B-Quinine, Phenytoin, Vancomycin, B-lactam antibiotics, Levaquin, Digoxin, lactam antibiotics, Levaquin, Digoxin, Valporic acidValporic acid

• Improvement within 3-7 days after dcImprovement within 3-7 days after dc

DRUG INDUCEDDRUG INDUCEDLEUKOPENIALEUKOPENIA

• ChemotherapyChemotherapy

• Anti-Psych Drugs such as Abilify, Anti-Psych Drugs such as Abilify, Risperidol, Geodon, Seroquel & Risperidol, Geodon, Seroquel & ZyprexaZyprexa

• B-lactam induced leukopenia rare but B-lactam induced leukopenia rare but serious if not identifiedserious if not identified

DRUG INDUCED DRUG INDUCED LEUKOCYTOSISLEUKOCYTOSIS

• Granulocyte colony stimulating factor Granulocyte colony stimulating factor (G-CSF) meds like Neupogen or (G-CSF) meds like Neupogen or NeulastaNeulasta

• Recent or current steroidsRecent or current steroids

• Certain Anti-seizure medicationsCertain Anti-seizure medications

• AntibioticsAntibiotics


• Remember to adjust to Renal dose if Remember to adjust to Renal dose if increase in creatinineincrease in creatinine

• If patient presents with Acute Renal If patient presents with Acute Renal Failure or a bump in their creatinine Failure or a bump in their creatinine think about medsthink about meds

• Patients on nephrotoxic drugs Patients on nephrotoxic drugs remember to follow creatinineremember to follow creatinine

NEPHROTOXIC DRUGSNEPHROTOXIC DRUGS

• NSAIDS, ACE Inhibitors, NSAIDS, ACE Inhibitors, aminoglycosides, Lithiumaminoglycosides, Lithium

• Cephalosporins, Cimetidine, & Cephalosporins, Cimetidine, & Trimethoprm-sulfa cause falsely Trimethoprm-sulfa cause falsely elevate serum creatinineelevate serum creatinine

• Remember to look at antibiotics that Remember to look at antibiotics that need to be renally dosedneed to be renally dosed

• LMH Renal dosingLMH Renal dosing


• Remember to monitor troughs in Remember to monitor troughs in Vancomycin, Gentamycin, & TobramycinVancomycin, Gentamycin, & Tobramycin

• When admitting or working up patient When admitting or working up patient always review drug list and check levels always review drug list and check levels on meds that can be evaluated by a lab on meds that can be evaluated by a lab test i.e. levothyroxine, Digoxin, test i.e. levothyroxine, Digoxin, Coumadin, Lithium, Valproic acid, Coumadin, Lithium, Valproic acid, Theophylline, Anti-seizure meds, etc. Theophylline, Anti-seizure meds, etc.


• When starting new meds, think about When starting new meds, think about what organs & labs they will impact & what organs & labs they will impact & think about timing of labs and follow upthink about timing of labs and follow up

• Adding HCTZ to a 42 year female who Adding HCTZ to a 42 year female who has HTN and is on ACE > will need has HTN and is on ACE > will need follow up Chem 7 in a week to 10 days follow up Chem 7 in a week to 10 days

DRUGS & LABSDRUGS & LABSPEARLSPEARLS

• With over 1100 lab tests and With over 1100 lab tests and thousands of medications, you can’t thousands of medications, you can’t remember it all!remember it all!

• Know your resources, don’t use a drug Know your resources, don’t use a drug that you don’t know mechanism of that you don’t know mechanism of action & side effectsaction & side effects

• Good clinicians look things up oftenGood clinicians look things up often

DRUGS & LABSDRUGS & LABSPEARLSPEARLS

• Look at the whole patient & clinical picture Look at the whole patient & clinical picture not just the abnormal lab testnot just the abnormal lab test

• Right test, right patient, always think Right test, right patient, always think about cost, cause & effectabout cost, cause & effect

• Consider Drugs as a cause of abnormal Consider Drugs as a cause of abnormal labslabs

• In this world of polypharmacy review drug In this world of polypharmacy review drug list What interacts? What can be toxic? list What interacts? What can be toxic? What don’t they need?What don’t they need?

DRUGS & LABSDRUGS & LABSPUTTING IT ALL TOGETHERPUTTING IT ALL TOGETHER

• Look at whole person and how the Look at whole person and how the drugs, labs, and clinical picture add drugs, labs, and clinical picture add up; the light bulb comes on and the up; the light bulb comes on and the puzzle is solved!puzzle is solved!

Documents

Drugs and Labs, what needs to be monitored? Jennifer Rodgers, MSN, ARNP Wichita State University