Expert opinion on drug safety
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The altered pathophysiology in critically ill patients presents a unique challenge in both the diagnosis of infection and the appropriate prescription of antibiotics. In this context, the importance of effective and timely treatment needs to be weighed against the individual and community harms associated with antibiotic collateral damage and antibiotic resistance. ⋯ Prescribing teams must be aware of the impact of critical illness on their patients and tailor antibiotic therapy appropriately to prevent the significant harms associated with suboptimal antibiotic administration.
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The management of sepsis essentially relies on effective resuscitation with fluids and vasopressors, appropriate and adequate antimicrobial therapy, and organ support. Any of these interventions can have beneficial but also harmful effects. ⋯ Patients with septic shock are heterogeneous, making it particularly difficult to provide therapeutic recommendations that are safe and effective for all. A personalized medicine approach should be used with treatment decisions carefully considered and the risks and benefits of each intervention balanced in each individual patient.
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Dual antiplatelet therapy with aspirin and an oral ADP P2Y12 receptor antagonist is the standard-of-care for treatment of patients undergoing percutaneous coronary intervention (PCI). However, oral P2Y12 receptor antagonists have several limitations, including inter- and intra-individual response variability, drug-drug interactions, slow onset and offset of action and delayed platelet inhibition in high-risk clinical settings, such as patients with ST-segment elevation myocardial infarction. ⋯ Cangrelor is approved by drug regulating authorities worldwide as adjunctive antithrombotic therapy for the full spectrum of patients undergoing PCI, not pre-treated with a P2Y12 receptor inhibitor and not with intent to receive a glycoprotein IIb/IIIa inhibitor. Its unique pharmacological properties and its favorable safety and efficacy profile make it an attractive treatment strategy, especially in clinical settings where immediate platelet inhibition is required.
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Statins were introduced as lipid-lowering agents with a specific action to decrease plasma cholesterol concentrations and they have led to significant reductions in cardiovascular morbidity and mortality. Since their introduction, they have been found to have highly pleiotropic effects and potential use in many medical conditions well beyond cardiovascular disease alone. With their widespread and increasing use, adverse effects have also become apparent and it is suggested from the interrogation of observational data from large datasets that an early complication of statin use may be acute kidney injury (AKI). ⋯ The question of whether statins cause AKI remains unresolved. Evidence suggests that statins may both protect or harm kidneys acutely and that risk varies with the condition and the dose and type of statin used. However, any current adverse data should not deter prescription of statins in patients where there is clear evidence for either primary or secondary prevention of cardiovascular events.
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Seizures in pregnancy are particularly challenging, as their management requires careful consideration of not only the etiology of the seizure, but also the physiologic changes of pregnancy as well as potential adverse effects on the developing embryo or fetus. Newer antiepileptic drugs (AEDs) have increasingly shown promising results of lower rate of teratogenesis, as well as better seizure control during pregnancy. ⋯ In summary, morbidity associated with seizure in pregnancy is decreasing as treatments and supportive therapies have improved. The understanding of teratogenesis as well as novel targeted therapeutics will allow women on AEDs during their pregnancy, to receive the safest drug for their developing fetus as well as themselves.