Sunday, April 1, 2018

BCPS Recertification- High-Yield Med Reviews

I’ve always been a huge fan of stand up comedy. For the longest time, I admired the ability of comedians to be able to speak so conversationally, and naturally while being hilarious. Over time, I’ve come to learn that some of my favorite comedians (Jerry Seinfeld, Jim Gaffigan, Tom Papa) extensively plan out every minute detail of their jokes, practice like crazy and never stop trying to improve. The grand illusion that most professional comedians natural abilities that don’t require much effort to maintain translates into what it takes to be a pharmacist.  I think many would be surprised at the amount of effort I put in to try to continuously improve (I’d guess the same holds true with folks like Bryan and Nadia). So when the time came to recertify BCPS, I had to find a strategy that would match the level of effort I needed to exert.


Since my initial certification, I’ve become entrenched in all things emergency medicine. I started to spend more time reading what I enjoyed and had interest in, with little interest or effort put into other topics. While I suppose you could say, an emergency medicine pharmacist should know Nutrition (TPN and the like) inside out, I had zero interest in reading or staying up to date on it. Nutrition to an EM pharmacist consists of turkey sandwiches and graham crackers. So when it came to deciding whether to elect to sit for BCPS recertification or 120 hours of PSAP, the choice was easy.


What wasn’t easy was trying to establish an effective way to prepare for the exam. Through professional connections, I was lucky enough to have been connected with Dr. Anthony Busti, who created High-Yield Med Reviews. Dr. Busti is one of many educators who provide online education and exam preparation. I must say that I’ve partnered with Dr. Busti who is sponsoring the EMPharmD blog, but had nothing to do with this post or me reviewing the program at all. Plus Dr. Busti isn’t just anybody, as you’ll find out later. Nevertheless, I went with the BCPS Premium plan which fit my learning style with a self-directed learning model, online lectures, and many many practice questions.


Before diving into the content and structure of High-Yield Med Reviews, it’s critical to know where (or from whom) the content is coming from. Online pharmacy education can be pretty hit or miss. If you’ve tried to watch pharmacology and pharmacotherapy lectures on YouTube, they’re almost all horrible: somewhere on the spectrum of inaccurate to unwatchable. What stood out to me with High-Yield Med Reviews BCPS preparation and why I’ve been using it for my recertification is the credibility Dr. Busti brings to the online content. Although Dr. Busti is an EM attending physician at UT Southwestern Medical Center in Dallas, he is also a nurse, and a pharmacist. Not only was he a nurse, but an critical care and emergency medicine nurse. Not only was he a pharmacist, but a residency trained clinical pharmacist, faculty at Texas Tech University and residency program director. As if he needed any more credibility, he’s now pursuing a MSc in Evidence-Based Health Care at Oxford University. Needless to say, the online lectures, provided content and practice questions are high quality, effective and reliable.


The structure of High-Yield Med Reviews fits with my learning style and my teaching philosophy. I like to picture medical/pharmacy education as a spiral (Kolb spiral): Experience with structure, Reflection/Refinement, Meta-cognition/abstract concepts, Testing. Visualized as a spiral, rather than a circle, is significant because since each cycle where new knowledge is gained builds upon what was previously known by assimilating new information with prior knowledge.  However, since different people have varying levels of prior knowledge, the knowledge they can gain from a given lesson is limited by their “zone of proximal development.” For example, because of my practice, my knowledge level of acute coronary syndrome (ACS) pharmacotherapy is high, so I would easily be able to learn advanced topics. On the flip side, my knowledge of TPNs and nutrition is pretty basic, so I would require a number of sequential lessons to reach the same level of knowledge as with ACS. High-Yield Med Reviews online lectures compliments this learning method by providing > 100 different lectures to build knowledge.


Clinical practice is the best way to gain experience. But experience can also be acquired through lectures, as long as their effective. Effective lectures that not only provide knowledge, but also context. In the online lectures by Dr. Busti, his lecture style effectively provides this context either through the case based teaching or building upon basic concepts in sequential lectures. There are several lectures ranging from basic pharmacology to detailed evidence based medicine discussions. For example, rather than just a 60-90 minute lecture on hypertension guidelines, High-Yield Med Reviews has 16 lectures on hypertension, each around 10-20 minutes in length covering topics ranging from specific drug classes to guidelines to special populations like hypertension in pregnancy. So I can spend less than an hour on reviewing updates in guidelines rather than have to start with the basic pharmacology. Whereas a new pharmacist would benefit from the pharmacology lectures in order to build up to the guideline reviews. Since I’m a pharmacology geek, I watched the pharmacology lectures anyways - Dr Busti and I share the same attitude towards beta-blockers in the management of hypertension.


A crucial step in the Kolb spiral is reflection and refinement. The learner needs time to reflect on what was learned, and be able to return to the content to sharpen understanding. The lectures are able to be watched as many times as you’d like in a 24 hour period (for up to 3 separate 24 hour periods) where you can pause, rewind, rewatch or fast forward. This allows you to think about the content just presented, identify points of confusion or anything that's unclear, and identify further questions you may have. Being able to rewatch lectures allows refinement of these topics.


However, if cramming for two weeks before the exam is your desired method of preparation, High-Yield Med Reviews is not for you. It’s also not a good idea anyways. As a result of the breadth of content covered on a BCPS exam, sufficient time is required to prepare - somewhere between 1-3 months for most residency trained pharmacists, and 6-12 for non residency trained pharmacists. This time is required for meta-cognition. In other words, you need time to think about thinking and identify gaps in your understanding. High-Yield Med Reviews is a subscription package of 1, 3, 6 or 12 months. Based on my experience, and the degree I stay up-to-date 1 month is right for me, but that is probably pushing it. Sure, I could probably wing it and walk into the exam without preparation, but my earlier career experience with the Dunning-Kruger effect, taught me that the amount of information I DON’T know is greatly outweighed by the information I DO know.


Finally, the last element to this learning cycle is testing and application. With more than 2000 questions to practice from High-Yield Med Reviews provides ample testing to ensure learning and compliment the lecture. The questions are in the format and level of difficulty of the BCPS exam and written by pharmacotherapy experts (including myself). To deliver not just testing and application, but supplementary learning, each question has a detailed explanation and rationale for the correct and incorrect answers, high-yield core concepts, take home points, and are referenced. By putting in the effort to review each question, you still benefit from whether you scored 100% or 20%. If you scored particularly low, or identified things you know you need to know, the questions are able to be flagged for further review at later time.


There are different modes that you can utilize with the practice questions: testing, tutorial and flashcards. Personally, I only use the testing mode. Tutorial provides answers and explanations after each question, rather than the end of your session; Flashcards provide the question with no multiple choices, which forces you to think of an answer rather than simply selecting one.


I’ve been extremely satisfied so far with High-Yield Med Reviews. But there are a few things that I would have liked to be different or improved. While the testing mode for questions tells you what percentage of people got the answer correct, there is no correlation to how you perform overall to your likelihood of passing the exam. While the difficulties of tracking down exam results of subscribers while maintaining privacy would make that sort of data challenging to collect.


Another aspect is practicing in a full length practice exam to not only become familiar with the style of the exam, but also to identify areas of weakness.  While currently, you can set up a mock exam yourself by selecting 200 questions in testing mode, there’s no guarantee the questions will be in the same proportion of the 3 exam domains. However, this will be a new feature where there will be full length mock exams in the near future.


Lastly, is the cost. FOAM (free open access medical education) has spoiled us with high quality medical education. But, as I said before, FOAM is lacking in high quality pharmacology and pharmacotherapeutic content in areas outside of emergency medicine, and anything available for free on Youtube is worth what you pay for it: nothing.  So while I am extremely cheap, and would prefer to not pay for anything, I would say the cost of High-Yield Med Reviews is fair given the quality of content and it’s actually quite a lot more affordable than other “review courses” and PSAP modules.


High-Yield Med Reviews is a high quality, modern educational platform that offers me exactly what I was looking for with BCPS exam preparation. Dr. Busti has a wealth of knowledge and experience that you can benefit from, and become a better pharmacist by securing board certification, and by simply improving your knowledge and expanding your new zone of proximal development. I’m proud to continue my partnership with Dr. Busti through the EMPharmD blog and through contributions to the content of High-Yield Med Reviews.




Friday, March 23, 2018

StoweEM18 Day 3

StoweEM18 Day 3 audio

Also available on iTunes

Credit:
Meghan Groth, PharmD BCPS @EMpharmgirl
Kyle DeWitt, PharmD, BCPS @EmergPharm
Blake Porter, PharmD, BCPS @RxEmergency

Show notes:

https://www.ncbi.nlm.nih.gov/pubmed/27276234

Thursday, March 1, 2018

StoweEM18 Day 1

StoweEM18 Day 1 audio

Speakers at the Emergency Medicine Update conference in Stowe, Vermont discuss success, failure, evidence-based medicine, and controversy encountered in the emergency department on a daily basis. In this podcast series Meghan Groth (@EMpharmgirl), Kyle DeWitt (@EmergPharm), and colleagues recap memorable conference moments and provide clinical pearls that can be taken directly to the bedside to improve patient care. Check out the conference website for more information and videos of each presentation



Also available on iTunes

Credit:
Meghan Groth, PharmD BCPS @EMpharmgirl
Kyle DeWitt, PharmD, BCPS @EmergPharm
Blake Porter, PharmD, BCPS @RxEmergency

Show notes:






















Monday, February 19, 2018

ID in the ED: C.difficile- New Guidelines, Not the Same old S*!%

The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) convened a group of experts to publish an update to their 2010 C.difficile infection (CDI) guidelines. Below is a summary of the new guidelines from the perspective of an emergency medicine (EM) pharmacist.

Clostridioides is the new Clostridium

Diagnosis
  • A multi step algorithm is now recommended  for diagnosis:1
  • Only patients with risk factors for CDI and  ≥ 3 unformed stools in a 24 hour period should be tested

Pertinent Changes From Previous Guideline
  • Metronidazole is no longer recommended first line for any severity of CDI.
    • This change is based on data to support vancomycin and fidaxomicin providing patients with a better chance of sustained symptom resolution one month after treatment.
  • Serum creatinine (Scr) values for classification of severity is an absolute value rather than being compared to a change from baseline values
    • Justification by the authors was that baseline values are often unavailable, which is certainly common in the ED setting, making the scoring easier for us to complete.
  • For the first time fecal microbiota transplantation (FMT) is mentioned as a therapeutic option. Although not something that will be completed in the ED, it is something we should be aware of as this practice will continue to increase.

CDI Prevention & Control
  • Antimicrobial Stewardship
    • The most important modifiable risk factor for the development of CDI is exposure to antibiotic agents, making the appropriate use of antibiotics of paramount importance. The new guidelines flat-out recommend implementing a stewardship program. The ED is a great place for stewardship, ripe with opportunity, including decreasing CDI incidence.
      • Consider restricting antibiotics that are most strongly associated with CDI such as fluoroquinolones, clindamycin, and broad-spectrum cephalosporins.
      • Appropriate duration of therapy is also extremely important. There is a growing body of evidence for many infections that a shorter course of therapy than what has been historically used is equally efficacious. A  great read on this is The New Antibiotic Mantra—“Shorter Is Better” by Dr. Brad Spellberg.2  
      • EM pharmacists have a unique opportunity to be major players in antimicrobial stewardship activities. We can potentially decrease the risk of CDI by advocating for patients and recommending narrower-spectrum antibiotics when appropriate. Additionally, we can recommend evidenced-based, appropriate durations for patients being discharged with an antibiotic prescription.
  • Proton Pump Inhibitors (PPIs)
    • There is an epidemiologic association between PPI use and CDI, though the authors of the guidelines felt there is insufficient evidence for discontinuing PPIs solely to prevent CDI.
      • Avoiding the use of unnecessary PPIs, and using them for limited durations is never a bad idea.
  • Probiotics
    • Primary prevention- while there are multiple meta-analyses suggesting probiotics may prevent CDI in patients taking antibiotics, the data was not deemed sufficient to recommend their use.
    • Secondary prevention- Saccharomyces boulardii (Florastor®) and Lactobacillus spp. (Culturelle®, Yakult®) may be of benefit to decrease CDI recurrence, although significant and reproducible results have yet to be shown in controlled trials.
    • Ultimately, the data isn’t yet strong enough to make recommendations for or against. Probiotics are certainly not without risk, as the contents can cause invasive disease, and they can be costly.3 Last I checked, no one has died of a yogurt-related complication, so that is probably a safe recommendation to make.
  • C.diff Scoring Tool
    • While the new guidelines don’t make specific recommendations on the use of a predictive risk scoring system, such a tool would be very useful for identification of patients who would most benefit from risk mitigation.
      • A study by Kuntz et al. produced such a tool that proved useful for stratifying CDI risk following an outpatient healthcare visit.4
      • A more recent study by Reveles et al. produced a clinical prediction tool to be used to identify patients at high risk for CDI recurrence.5

Treatment Considerations
  • Discontinue Systemic Antibiotics as Soon as Possible
    • If discontinuing antibiotics isn’t possible, use the narrowest spectrum agent that will be effective.  
  • Patients with Active CDI Requiring Antibiotics
    • One retrospective study has been published and suggests no benefit to extending anti-CDI therapy beyond 14 days for patients receiving concurrent systemic antibiotics. Relapse rates were similar for the regular and extended treatment groups in the univariate (17% and 23%, respectively; odds ratio [OR]: 1.4, 95% confidence interval [CI]: 0.7–2.7, p = 0.286) and multivariate analyses (OR: 0.7, 95% CI: 0.3–1.7, p = 0.425).6
    • With only one retrospective study evaluating this topic, and minimal risk of extending therapy until after systemic antibiotics have been completed, many clinicians may still opt to do so. The new guidelines state that vancomycin 125mg PO daily may be sufficient to prevent recurrence after the initial course is complete.
  • Patients Who Have Completed Anti-CDI Therapy and Now Require Antibiotics
    • Two retrospective studies have been published that investigate the utility of giving oral vancomycin as secondary prophylaxis to patients requiring systemic antibiotics. Both studies showed decreased incidence of CDI for patients given prophylaxis.7,8
    • One of these studies showed oral vancomycin prophylaxis decreased the risk of further recurrence in patients whose CDI itself was a recurrence (AHR, 0.47; 95% CI, 0.32–0.69; P<0.0001) but not in those whose CDI was an initial episode (AHR, 0.91; 95% CI, 0.57–1.45; P=0.68). This suggests patients with multiple recurrences of CDI will benefit most from prophylactic therapy when requiring systemic antibiotics.8
    • While lacking prospective trials, it may be prudent to prophylax patients who have a history of CDI and now require systemic antibiotics with vancomycin 125mg PO daily. Patients with multiple recurrences may benefit most from this practice. While lacking data, metronidazole IV is an option when patients are unable to receive oral medications, but preference should be given to vancomycin when enteral administration is available.
  • Antimotility Agents
    • Historically, antimotility agents, such as loperamide, have been discouraged in CDI out of concern for worse outcomes like toxic megacolon. Koo et al. published a review article where they sought to study the literature to determine the basis of this practice. They found that all patients who experienced complications or died were given antimotility agents alone initially, without concurrent anti-CDI therapy. The authors of the new guidelines suggest that it may be safe to give antimotility agents adjunctively to patients also receiving anti-CDI therapy.9
  • Intravenous Vancomycin
    • IV vancomycin has no effect on CDI as it is not excreted appreciably into the colon and therefore is not discussed in this, or any other guideline as a therapeutic option.
  • Duration of CDI Treatment
    • Nearly all randomized trials utilized 10 day regimens which are usually sufficient.
    • If patients improve but do not have symptom resolution at 10 days, extending the course to 14 days can be considered.
    • If metronidazole is used, it should be limited to one course out of concern for neurotoxicity (including irreversible peripheral neuropathy) which has been associated with treatment durations > 4 weeks.10
  • CDI Treatment Recommendations:

    Logistics of First Line Therapy
    • Vancomycin capsules and fidaxomicin are both expensive, and often not covered by insurance. Estimated cash prices are below.11
      • Vancomycin 125mg PO capsules (40 caps) ~ $1,250.00
      • Fidaxomicin 200mg PO capsules (20 caps) ~ $4,400.00
    • Intravenous vancomycin is often utilized orally in the inpatient setting to minimize cost, and compounding pharmacies may offer more affordable options using this method. However, compounding pharmacies typically have limited hours and often retail pharmacies do not have compounding capabilities which can make this option difficult.
    • FIRVANQTM, a commercially manufactured vancomycin oral liquid has recently been approved by the FDA. Per their website, CutisPharma is targeting a launch date of April 2, 2018. We will have to wait to see how much FIRVANQ costs to ultimately determine its role, though a commercially available, reasonably priced vancomycin liquid is appealing.

    Take Home Points
    • IDSA/SHEA have released new CDI guidelines.
    • Emergency medicine pharmacists should play a huge role in antimicrobial stewardship, which is a key component in minimizing the occurrence of CDI.
    • Vancomycin PO or fidaxomicin are now the recommended first line agents for CDI, however, the high cost associated with these therapies may prohibit their use in some patients.
    • Metronidazole should only be considered when vancomycin PO or fidaxomicin are unavailable for adults. It is still a first line option for children.
    • Vancomycin PO therapy may be extended in patients with active CDI, or used prophylactically in patients with previous CDI episodes to prevent recurrent infection while on systemic antibiotics.
    • FIRVANQTM, a new oral liquid vancomycin formation, will soon be available, but cost information is currently unknown.

    Tony Mixon, PharmD, BCPS
    Emergency Medicine/Infectious Disease Clinical Pharmacist

    Peer reviewed by:
    Craig Cocchio, PharmD, BCPS

    Scott Dietrich, PharmD
    @PCC_PharmD
    Emergency Medicine Clinical Pharmacist


    References
    1. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Disease. 2018.
    2. Spellberg B. The New Antibiotic Mantra-"Shorter Is Better". JAMA Intern Med. 2016 Sep 1;176(9):1254-5.
    3. Gouriet F, Million M, Henri M, Fournier PE, Raoult D. Lactobacillus rhamnosus bacteremia: an emerging clinical entity. Eur J Clin Microbiol Infect Dis 2012; 31:2469–80.
    4. Kuntz JL, Johnson ES, Raebel MA. Predicting the risk of Clostridium difficile infection following an outpatient visit: development and external validation of a pragmatic, prognostic risk score. Clin Microbiol Infect. 2015 Mar;21(3):256-62
    5. Reveles KR, Mortensen EM, Koeller JM et al. Derivation and Validation of a Clostridium difficile Infection Recurrence Prediction Rule in a National Cohort of Veterans. Pharmacotherapy. 2018 Feb 2. doi: 10.1002/phar.2088.
    6. R Kaki, A Brooks, C Main, P Jayaratne, D Mertz. Does Extending Clostridium Difficile Treatment In Patients Who Are Receiving Concomitant Antibiotics Reduce The Rate Of Relapse?. The Internet Journal of Infectious Diseases. 2016 Volume 15 Number 1
    7. Van Hise NW, Bryant AM, Hennessey EK et al. Efficacy of Oral Vancomycin in Preventing Recurrent Clostridium difficile Infection in Patients Treated With Systemic Antimicrobial Agents. Clin Infect Dis. 2016 Sep 1;63(5):651-3
    8. Carignan A, Poulin S, Martin P et al. Efficacy of Secondary Prophylaxis With Vancomycin for Preventing Recurrent Clostridium difficile Infections. Am J Gastroenterol. 2016 Dec;111(12):1834-1840
    9. Koo HL, Koo DC, Musher DM, et al. Antimotility agents for the treatment of Clostridium difficile diarrhea and colitis. Clin Infect Dis. 2009 Mar 1;48(5):598-605
    10. Tiffany A. Goolsby, Bernadette Jakeman, Robert P. Gaynes, Clinical
      relevance of metronidazole and peripheral neuropathy: a systematic review of the literature,
      International Journal of Antimicrobial Agents (2017), http://dx.doi.org/doi:
      10.1016/j.ijantimicag.2017.08.033
    11. Lexicomp Online®, Lexi-Drugs®, Hudson, Ohio: Lexi-Comp, Inc.; February 17, 2018.


    Wednesday, January 17, 2018

    Amiodarone: Push It, Push It Real Good


    Amiodarone is one of the most pimpable drugs for pharmacy residents/students. From its pharmacology to excipients, there are so many nuances, important points, and pharmacy trivia. In terms of administration, we’re all taught to dilute and filter while administering amiodarone intravenously. In almost all circumstances, this is referring to administration of amiodarone to patients with a pulse. But when we’re at the bedside of a patient with pulseless ventricular tachycardia or fibrillation (pVT/VF) the question becomes should amiodarone be pushed undiluted, or further diluted with D5W?
    Naturally, there are conflicting answers and practices. According to the prescribing information, amiodarone MUST be diluted with D5W to concentrations between 1 and 6 mg/mL (for a 300mg load, that would be between 50mL to 300 mL).1 Furthermore, anything more concentrated than 2 mg/mL (that would be 300mg in 150mL) should be administered via a central venous catheter. There are obvious problems to doing this in a cardiac arrest scenario.

    What’s the risk of undiluted amiodarone?
    Rapid administration of amiodarone is associated with hypotension, based on animal and some human data.2-4 There are three leading theories as to the cause of the hypotension:

    1) Excipients in intravenous forms of amiodarone, which are polysorbate 80 and benzyl alcohol (for every 50 mg of amiodarone there is 100mg of polysorbate 80, and 20.2 mg benzyl alcohol).
    2) Amiodarone’s beta-blocking/calcium channel blocking properties.
    3) Local allergic reaction to one or many of amiodarone’s components.

    While the overall quality of the data describing this problem is poor, there are some interesting findings that may support a more rapid, undiluted administration.

    A commonly cited paper that supports the undiluted administration of amiodarone, is unfortunately, often misquoted. This study examined the hemodynamic effects of rapid, undiluted amiodarone bolus in pulseless patients was this paper from Finland.5 This was a retrospective study investigating the occurrence of side-effects and outcomes of the patients who received undiluted amiodarone during resuscitative efforts in Helsinki during a 2-year period. The local protocol had been updated to no longer stipulate further dilution of amiodarone (300mg) prior to administration in patients who after three ineffective shocks, one sequence of CPR, and epinephrine 1mg. The protocol included a rapid bolus of approximately 200 mL of Lactated Ringer’s immediately following the amiodarone bolus.

    This study showed no difference in blood pressure between patients who received amiodarone versus those who did not. However, that’s not really an appropriate comparison since the populations were too heterogeneous (pVT/VF vs PEA vs asystole) and fails to answer the clinical question at hand. It would have been better to compare a diluted amiodarone versus an undiluted amiodarone bolus in patients with pVT/VF.

    Since there is no data that directly answers this question, extrapolating other data sheds some light on the magnitude of the risk.

    Munoz et al looked at 20 patients undergoing coronary arteriography who received 5 mg/kg IV of either amiodarone or a polysorbate 80 (aka Tween 80) free amiodarone product.6 Looking at the left ventricular systolic pressure three minutes before and three minutes after administration, the authors found that the polysorbate 80-free version was associated with a significantly smaller decrease in this outcome (amiodarone: 110 + 11 to 86 +/- 11 mmHg; polysorbate 80 free amiodarone: 114 +/- 22 to 106 +/- 19, P = 0.01).  A drop in SBP to the 80s is certainly concerning, however, the dose in this study is much larger than used in routine clinical practice for pVT/VF. For the average 80kg adult this dose would be 450mg. For the average Texan I see, the dose would be 500mg. While this evidence supports the animal models suggesting a hemodynamic effect of rapid undiluted amiodarone, it still does not describe the risk to the patient population I've been referring to.2-4

    While the evidence is unclear regarding potentially clinically significant vasodilation/hypotension in patients in pVF/VT, it seems as though further dilution and slower infusions do nothing to reduce the incidence of hypotension. In a retrospective cohort analysis, patients that received IV loading doses of conventional amiodarone (polysorbate 80/benzyl alcohol) were compared with patients who received amiodarone with cyclodextrin.7  These patients did not receive “code dose” boluses, but rather, received the initial infusion load (1 mg/min for 6 hours, followed by 0.5 mg/min for 18 hours). Despite the lower rate of infusion, and dilution, there was still a statistically significant difference in incidence of hypotension across all measurements: 0-6 hours, 12-18 hours, 24 hours and requirement of fluid boluses.

    The more recent PROCAMIO study, best described elsewhere, also used 5 mg/kg dosing for amiodarone administered over 20 minutes (unclear if the dose was diluted or not).8 Compared to procainamide, amiodarone was associated with more severe hypotension requiring immediate electrocardioversion (amiodarone, 6 patients versus 2 receiving procainamide).  Although, there were more patients in the procainamide arm experiencing hypotension not requiring cessation of infusion (procainamide, 5 patients versus 2 in the amiodarone group).

    So where do I land on this? Since we have the backing of AHA, in a pVT/VF scenario, it is reasonable to continue to administer the 300mg bolus of amiodarone undiluted.9 However, in any other case, consider dilution/filter/slow(er) rate of administration. Alternatively, consider stocking non polysorbate 80 containing formulations since they appear to have a smaller hemodynamic impact.

    (Side note, cyclodextrin containing amiodarone may not contain polysorbate 80, but must still be filtered during infusion).

    1. "Amiodarone injection [prescribing information].", Irvine, CA: Teva Parenteral Medicines, Inc., 2008
    2. Platou ES, Refsum H. Acute electrophysiologic and blood pressure effects of amiodarone and its solvent in the dog. Acta Pharmacol Toxicol (Copenh) 1986;58:163-168
    3. Gough WB, Zeiler RH, Barreca P, El-Sherif N. Hypotensive action of commercial intravenous amiodarone and polysorbate 80 in dogs. J Cardiovasc Pharmacol 1982;4:375-380
    4. Somberg JC, Cvetanovic I, Ranade V, Molnar J. Comparative effects of rapid bolus administration of aqueous amiodarone versus 10-minute cordarone I.v. infusion on mean arterial blood pressure in conscious dogs. Cardiovasc Drugs Ther. 2004 Sep; 18(5):345-51
    5. Skrifvars MB, Kuisma M, Boyd J, Määttä T, Repo J, Rosenberg PH, Castren M. The use of undiluted amiodarone in the management of out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2004 May;48(5):582-7
    6. Munoz A, Karila P, Gallay P, et al. A randomized hemodynamic comparison of intravenous amiodarone with and without Tween 80. Eur Heart J 1988;9:142-8
    7. Lindquist DE, Rowe AS, Heidel E, Fleming T, Yates JR. Evaluation of the Hemodynamic Effects of Intravenous Amiodarone Formulations During the Maintenance Phase Infusion. Ann Pharmacother. 2015 Dec;49(12):1317-21
    8. Ortiz M et al. Randomized Comparison of Intravenous Procainamide vs. Intravenous Amiodarone for the Acute Treatment of Tolerated Wide QRS Tachycardia: the PROCAMIO Study. Eur Heart J 2016
    9. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(suppl 2):S414–S435

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