tag:blogger.com,1999:blog-92022135191309311862026-09-13T14:09:50.238-04:00 Internal Medicine Pharmacotherapy HughesMedicine - Pharmacotherapy Pearls from the Internal Medicine Clinical PharmacistGregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.comBlogger77125tag:blogger.com,1999:blog-9202213519130931186.post-6079277930918674072026-07-27T15:01:18.570-04:002026-07-27T15:01:18.595-04:00Phosphate Dosing - Units and Terminology ConfusionA previous discussion was about selecting a phosphate repletion product. Selecting a drug product can be confusing because of the similar names of the various formulations - which are not interchangeable. Harm can come if one is unaware of the other electrolytes (sodium and potassium)
that are necessarily included in the phosphate salt drug. This discussion
aims to clarify Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-17183370089332245892026-06-08T15:31:39.111-04:002026-06-08T15:48:26.181-04:00Phosphorus Repletion: Products and their ElectrolytesMonitoring and balancing electrolytes seems to be an inevitable daily function of physicians and other healthcare professionals in the internal medicine and intensive care settings. Sodium, potassium, magnesium, calcium, and phosphorus seem to constantly need attention when a patient is ill in the hospital (and also because you're checking them every day, sometimes with and sometimes Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-30717551680575511162026-05-05T12:08:00.001-04:002026-05-05T12:08:30.157-04:00Heart Failure with Preserved Ejection Fraction - Managing ComorbiditiesHeart failure (HF) is a complex condition characterized by signs of volume overload or symptoms such as dyspnea, exercise intolerance, and fatigue. Being a syndrome, HF is not explained by one unifying pathophysiologic cause. Rather, various mechanisms lead to the deficit between the amount of blood delivered and the amount of blood that needs to be delivered through the body to maintain Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-20205922398670117332026-01-20T08:00:00.001-05:002026-01-20T20:53:01.535-05:00Goodbye to Andexanet Alfa (AndexxaⓇ)Andexanet alfa (Andexxa) made its quiet exit from the U.S. market just a few weeks ago. It's an interesting story so in case you missed it, I'll recap what andexanet alfa is, or rather was, and what happened that led to its removal. Being pulled from the U.S. market may have come to a surprise for some considering its main study (ANNEXA-I) was stopped early for successfully meeting Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-75908231674484102602025-12-18T13:39:00.006-05:002025-12-31T14:33:31.187-05:00Treating Insomnia in Older Adults: Doxepin HighlightsThe American Geriatrics Society recently published their Alternative Treatments to Selected Medications in reference to the most recent update to the AGS Beers Criteria in 2023. This guidance is helpful because while the 2023 AGS Beers Criteria warned about which medications were "potentially inappropriate" in older adults, they left clinicians guessing by not offering suggestions as Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-24800983407791111162024-07-18T09:59:00.000-04:002024-07-18T09:59:25.159-04:00Dyspnea Associated with Ticagrelor<!--[if gte mso 9]>
Normal
0
false
false
false
EN-US
X-NONE
X-NONE
<![endif]--><!--[if gte mso 9]>
Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-43604967442848402362024-03-11T13:18:00.001-04:002024-03-11T13:19:05.214-04:00Thiamine deficiency and supplementation in heart failure
Thiamine is a
water-soluble vitamin that is an important coenzyme for various metabolic
processes in the body. These include the
regulation of glucose metabolism, the Krebs cycle (generates ATP), the pentose
shunt (generates NADPH), and maintenance of sodium/potassium gradients in the
brain (necessary for conducting nerve impulses). Thiamine is mostly obtained from dietary
intake Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-76213882000684406532023-10-03T10:27:00.002-04:002023-10-03T10:28:48.771-04:00Beers Criteria Update 2023 - Seven Changes<!--[if gte mso 9]>
Normal
0
false
false
false
EN-US
X-NONE
X-NONE
<![endif]--><!--[if gte mso 9]>
Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com0tag:blogger.com,1999:blog-9202213519130931186.post-87952853607749730432018-10-22T06:00:00.000-04:002018-10-22T10:51:40.741-04:00Sulfamethoxazole/trimethoprim and increase in serum creatinine: When to be concerned
A 65 year old male is being treated for an infection on his forearm that developed purulent drainage within the last few days. He denies experiencing any penetrating trauma to his arm and denies any other complaints at this time. He weighs 70 kg, His WBC count is 14.7 x 109/L, serum creatinine is 1.3 mg/dL, and his vital signs are within normal limits. His past medical historyGregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com3tag:blogger.com,1999:blog-9202213519130931186.post-76940676817796382532018-10-07T21:38:00.001-04:002018-10-07T21:38:44.646-04:00Inhaled isopropyl alcohol for nausea
An elderly male presents to the emergency department with complaints of nausea, vomiting, and diarrhea starting a day and a half ago. The diarrhea started abruptly, has occurred almost 10 times, and is non-bloody. His abdomen is soft but has mild diffuse tenderness. Vital signs and basic laboratory results are normal except for a potassium of 2.9 mEq/L and an EKG with a QTc Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com2tag:blogger.com,1999:blog-9202213519130931186.post-32163658603918330392018-09-23T20:21:00.002-04:002018-09-23T20:21:52.101-04:00"How it works" series: Midodrine
Midodrine is a peripherally-acting selective alpha1 receptor agonist. Let's take that sentence apart to see what we should expect from this medication. Being an alpha1 agonist, this means that it binds to the alpha1 receptor and activates it, causing it to perform the function that it would usually perform if its endogenous catecholamine (ie. norepinephrine) were to bind to it.&Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com4tag:blogger.com,1999:blog-9202213519130931186.post-44528372108750002572018-09-09T21:10:00.000-04:002018-09-09T21:10:34.084-04:00Nitrofurantoin in renal impairment
A 74 year old female patient presents to clinic describing dysuria and urinary frequency that started within the last few days. She has no vaginal discharge or irritation and has no CVA tenderness, fevers, chills, flank pain, nausea, or vomiting. The diagnosis of uncomplicated UTI is made based on clinical suspicion and you decide to prescribe some antibiotics. She weighs 72 Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com2tag:blogger.com,1999:blog-9202213519130931186.post-943532034368206672017-03-21T09:19:00.000-04:002017-03-21T09:19:57.436-04:00Pneumococcal vaccine: Which, when, and why?
The pneumococcal vaccine was developed to reduce the disease burden of streptococcus pneumoniae, a gram-postive bacteria that has more than 90 serotypes that can cause diseases in humans. Some of these infections include pneumonia, meningitis, bacteremia, otitis media, and sinusitis. There are currently two vaccines on the market to raise immunity against pneumococcal infections - Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com1tag:blogger.com,1999:blog-9202213519130931186.post-59500409158736094482017-03-07T09:34:00.001-05:002017-03-07T09:34:15.739-05:00"How it works" series: Daptomycin
Daptomycin (Cubicin) is the first antibiotic in a class known as lipopeptides and has a unique mechanism of action. Daptomycin is a large molecule with a high molecular weight and has two distinct sections. One section is a 10 member amino acid ring (illustrated as the big red circle) and the other is the attached lipophilic tail (illustrated as the curvy red line). The Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com7tag:blogger.com,1999:blog-9202213519130931186.post-21002307653088072812017-02-07T10:32:00.000-05:002017-02-07T10:32:59.323-05:00Linezolid-induced thrombocytopenia
Thrombocytopenia is a notable adverse effect of linezolid. Some of the evidence behind the onset, duration, and the extent of platelet decrease will briefly be described here and summarized in bullets at the bottom of the discussion. For a discussion of linezolid's mechanism of action and some other notable features, see a prior post here.
Mechanism of thrombocytopenia
Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com3tag:blogger.com,1999:blog-9202213519130931186.post-87605817812255839582017-01-16T12:51:00.000-05:002017-01-16T12:51:11.577-05:00Diabetes discharge checklist
A 55 year old business executive is being discharged from
the hospital after a brief admission for cellulitis. His only PMH is HTN and obesity. During his stay, his casual serum glucoses were
found to be in the high 200s mg/dL and a hemoglobin A1C resulted at 11.6%. What should be done at the inpatient to
outpatient transition to address his diabetes?
Diabetes
Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com15tag:blogger.com,1999:blog-9202213519130931186.post-74185556858973662482016-12-28T12:56:00.001-05:002016-12-28T12:56:25.498-05:00Essentials from the 2016 American Diabetes Association guidelines
The 2016 American Diabetes Association diabetes guidelines is a lengthy document outlining many aspects of diabetes care including evaluation, diagnosis, prevention, management of glycemia, and management of nonglycemic issues. Here are some of the more common elements that come up in the internal medicine setting regarding glycemic control.
Criteria for the diagnosis of diabetesGregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com7tag:blogger.com,1999:blog-9202213519130931186.post-86538973537011578572016-12-08T15:49:00.000-05:002016-12-08T15:49:24.920-05:00Empagliflozin (Jardiance) new indication - reduces mortality in type 2 diabetes mellitus
A middle-aged patient with diabetes mellitus type 2, CAD, HTN, and obesity is in clinic for a followup appointment 1 year after his diagnosis with diabetes. His medications include lisinopril, atorvastatin, aspirin, and metformin (started 1 year ago and titrated to maximum tolerated dose). Today in clinic, his BP = 148/88 mm Hg, HR = 78 bpm, and HbA1c = 7.6%. In addition to Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com5tag:blogger.com,1999:blog-9202213519130931186.post-19859028393223680822016-11-27T11:23:00.001-05:002016-11-27T11:31:44.784-05:00Intrapleural tPA and dornase alfa for pleural infection
A 48 year old male is admitted to the hospital after experiencing a fever and malaise for several days. He states that he has some shortness of breath and chest pain when he coughs. Imaging of the chest reveals a large loculated effusion and empyema in the right lower lung. The decision is made to place a chest tube (thoracostomy) and drain the fluid. The pleural fluid Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com7tag:blogger.com,1999:blog-9202213519130931186.post-49527550999948587282016-11-09T13:51:00.001-05:002016-11-09T13:51:42.509-05:00Management of acute gout - Guideline update
A new guideline from the American College of Physicians for the management of acute and recurrent gout makes a few recommendations based on updated data through March 20161. Some recommendations and strengths differ from the 2012 recommendations from the American College of Rheumatology. Here are the main recommendations from the updated guideline:
About acute treatment (Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com6tag:blogger.com,1999:blog-9202213519130931186.post-76452953326017365482016-10-25T11:12:00.000-04:002016-10-25T13:27:21.474-04:00"How it works" series: Vancomycin
(Click to enlarge)
Vancomycin was the first antibiotic developed of the glycopeptide class. It is termed "glyco-" because it has two saccharides and "peptide" because it has seven peptides, making a structure larger than almost all other antibiotics. The main mechanism of action is inhibition of cell wall synthesis. Under normal conditions in bacteria, as the cell Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com3tag:blogger.com,1999:blog-9202213519130931186.post-1131682654037790382016-10-10T12:23:00.001-04:002016-10-10T12:28:14.844-04:00Metformin in kidney dysfunction - restriction revised
Metformin is the preferred initial pharmacologic therapy in every patient with type 2 diabetes mellitus who does not have a contraindication or intolerance. It is recommended as monotherapy after diagnosis, continued when adding other medications (including insulin regimens), and should even be considered to prevent diabetes in certain patients (see who at the bottom).
Old Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com1tag:blogger.com,1999:blog-9202213519130931186.post-57260951304836669122016-09-27T11:04:00.003-04:002016-10-04T13:05:38.784-04:00"How it works" series: Linezolid
Linezolid (Zyvox) is one of only two antibiotics currently on the market in the oxazolidinone class (see what the other one is at the bottom of this article). The unique structure makes cross resistance to other antibiotics like beta-lactams or vancomycin unlikely. It works by binding to the 50S subunit of ribosomes in bacteria, preventing it from joining its partner 30S subunitGregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com1tag:blogger.com,1999:blog-9202213519130931186.post-89374514095699198862016-09-13T13:54:00.000-04:002016-09-13T13:54:40.214-04:00Legionnaires' disease - reliability of urine antigen testing
A 58 year old male patient presents to the emergency room with shortness of breath for the last few days. He also complains of chills, a cough, myalgia, and diarrhea. His notable findings include WBC = 14 k/uL, Scr = 1.2 mg/dL, BUN = 27 mg/dL, BP = 132/76 mm Hg, RR = 30 breaths/minute, Tmax = 38.5⁰C, and O2sat = 92% on room air. His chest x-ray reveals a patchy Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com2tag:blogger.com,1999:blog-9202213519130931186.post-416401630643570372016-08-30T11:38:00.000-04:002016-08-30T11:38:59.208-04:00Warfarin dosing nomogram for initiating therapy
A 60 year old female patient presents to the emergency department with complaints of swelling and pain in her right leg. She recently had her knee replaced and has healed well since the procedure. She has a PMH of HTN and CKD (Stage IV). She has no other complaints at this time. She is diagnosed with a proximal DVT on lower extremity ultrasound and the decision is made Gregory J. Hugheshttp://www.blogger.com/profile/12066091193808137121noreply@blogger.com3