Heparin‐induced thrombocytopenia (HIT) is a rare, potentially life‐threatening condition secondary to unfractionated heparin or low molecular weight heparin exposure. This immune‐mediated drug reaction manifests as thrombocytopenia with a paradoxical hypercoagulable state that can result in life‐threatening thrombosis. It is imperative to ensure cessation of heparin‐based products as soon as HIT is identified. Traditional treatment options include argatroban, bivalirudin, fondaparinux, and danaparoid with a transition to warfarin upon platelet recovery. These anticoagulants are notwithstanding limitations including parenteral administration and routine laboratory monitoring leading to prolonged hospitalizations, emphasizing the need for new therapies. Direct oral anticoagulants (DOACs) have been increasingly investigated for the management of HIT and may overcome the aforementioned challenges of current therapies. The objective of this narrative review is to summarize the current HIT guidelines, discuss limitations to contemporary treatment options, provide insight into the emerging evidence for the DOACs rivaroxaban, apixaban, and dabigatran, and conclude with a clinical summary for their use in this setting. The PubMed, Google Scholar, and MEDLINE databases were searched for peer‐reviewed literature from January 1, 2012, to June 31, 2018. Twenty‐seven articles met inclusion criteria for review: 1 prospective trial, 5 retrospective cohort studies, and 21 case reports totaling 104 patients treated with a DOAC for HIT. The DOACs prevented new and recurrent thrombosis in 98% (n=102) of cases, and bleeding complications occurred in 3% (n=3). While current literature remains limited, it is suggestive of a potential role of DOACs for HIT, which has led to their integration into the 2018 American Society Hematology Guidelines with a conditional recommendation.

FFP, C1 inhibitor, and icatibant appear to be safe and effective therapeutic options for the management of ACEI-induced angioedema, whereas it appears ecallantide should be avoided.

Corticosteroids are commonly used in the peri-operative setting for patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The infl ammatory response to CPB is associated with organ dysfunction and increased mortality. Corticosteroids reduce biochemical infl ammatory markers associated with CPB, however the impact on clinical outcomes is mixed. The purpose of this article is to evaluate the evidence of changes in clinical outcomes associated with the peri-operative administration of corticosteroids in patients undergoing cardiac surgery with CPB. Randomized, placebo-controlled trials and meta-analyses were reviewed for evidence evaluating the impact of corticosteroids on clinical outcomes including mortality, myocardial infarction, atrial fi brillation (AF), duration of intubation, length of intensive care unit (ICU) or hospital stay, hyperglycemia, and gastrointestinal complications. Most of the relevant studies are underpowered to assess major clinical outcomes. Although corticosteroids likely reduce the risk of AF, this needs to be evaluated when used in addition to or in lieu of other anti-arrhythmic agents. Evidence does not equivocally support the use of corticosteroids to improve clinical outcomes in cardiac surgery patients.

The opioid epidemic remains a critical public health crisis with an estimated 46 802 overdose deaths in the United States in 2018, accounting for 69.5% of all drug overdose deaths. 1 Furthermore, the economic impact of prescription opioid-related overdose, abuse, and dependence is estimated to exceed 78.5 billion dollars annually. 2 A rising clinical dilemma facing healthcare providers in the midst of the opioid crisis has been the appropriate use of opioids for post-surgical pain management. Despite the known risks of opioids, opioid monotherapy remains a core element of peri-operative pain management.Even when intended for short-term use, research demonstrates that patients receiving opioid prescriptions within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those without an opioid prescription. 3 Opioid minimization is of unique interest in liver transplantation, since opioid use after liver transplantation has been associated with worsened mortality and long-term graft survival. 4,5 The American Pain Society and American Society of Anesthesiologists evidenced-based guidelines endorse the use of a multimodal analgesic approach to peri-operative pain management in an effort to minimize opioid use. 6 Multimodal analgesia is a strategy that employs the use of opioid and non-opioid analgesics to target various pain pathways, maximize efficacy, and minimize medication-related complications. In a meta-analysis of 52 randomized control trials, multimodal analgesia in post-operative patients

Patients may intermittently require antimicrobial therapy with a QTc-prolonging antibiotic, which presents a challenge for prescribers of patients already taking a QTc-prolonging antiarrhythmic. Manufacturers recommend close monitoring for evidence of QTc-prolongation with the concomitant use of QTc-prolonging medications, but the monitoring parameters are not well-defined. Previous studies recommend a surveillance electrocardiogram (EKG) be completed both before and after the initiation of QTc-prolonging medications, but it is unknown to what degree EKGs displaying the QTc-interval are used to alter physician order entry and pharmacist order verification during concomitant therapy. A retrospective chart review was conducted between October 2015–September 2016 to assess prescribing and monitoring habits for patients taking an antiarrhythmic and a concomitant QTc-prolonging antibiotic. Of the 42 patients who received at least one dose of two QTc-prolonging agents, 36 (85.7%) received a baseline EKG, and 23 (63.8%) received a follow-up EKG. Pharmacists intervened on this drug–drug interaction and recommended follow-up EKGs only three times (8.3%) and offered alternative therapy recommendations once (2.8%). The QTc-interval was not optimally monitored in some instances for patients concomitantly receiving two QTc-prolonging agents. These results stress the importance of inter-professional communication to place an emphasis on follow-up monitoring or use of alternative therapy agents to avoid the drug–drug interaction altogether.