Many patients I’ve encountered on the wards (especially those receiving chemotherapy) have been directly affected by our country’s drug shortage. It’s incredibly disheartening to know they’re receiving suboptimal therapy as many times their prognoses are dismal to begin with. Read more  

In the course of pregnancy, sometimes it becomes necessary to deliver a baby prior to the mother going into spontaneous labor. Indications for induction of labor (IOL) can include suspected fetal compromise, pregnancy-induced hypertension (PIH), premature rupture of membranes (PROM), and chorioamnionitis. Read more  

C. difficile is a bacteria part of our normal bowel flora, but when certain antibiotics (namely clindamycin) wipe out the other healthy organisms, C. diff’s growth is left unchecked. C. diff colitis is something I saw all the time in February while working on the gastroenterology service at St. Luke’s, so I learned quite a bit about it’s presentation – crampy abdominal pain, profuse and watery diarrhea, pseudomembraneous colitis visualized by colonoscopy, high leukocytosis, and in the very severe/late stages, toxic megacolon. Read more  

Electroconvulsive therapy (ECT) is routinely used to treat refractory depression and catatonia, especially in the elderly where pharmacotherapy could result in undesirable side effects. Essentially, it involves jolting the brain to create a controlled clonic seizure – the patient loses consciousness, has convulsions, and cannot recollect the procedure. I had the opportunity to witness ECT first hand this morning with a group of my colleagues. Read more  

The overwhelming majority of the patients I’ve encountered on the wards have diabetes mellitus (DM). While there are countless ways to manage DM as an outpatient (insulin injections, biguanides, sulfonylureas, etc.), sliding scale insulin (SSI) seems to be the most routinely used method of controlling blood glucose (BG) for hospital inpatients. SSI provides patients with a dose of short-acting insulin based on their pre-meal glucose reading (typically four times a day). Read more  

After all the patients I’ve seen with ascites secondary to hepatic cirrhosis, I wondered why we tend to start them on 100 mg Aldactone (spironolactone) with a 40 mg Lasix (furosemide) adjuvant. What’s the rationale behind this ratio? What’s the added benefit of using two different kinds of diuretics to reduce the excessive fluid volume typically found in cirrhotics?

I searched PubMed and Harrison’s Principles of Internal Medicine, but no where did I see a reference to a clinical trial which established the 100:40 mg ratio. Further research from multiple sources led to the following conclusion.

Aldactone is a relatively weak potassium-sparing diuretic which works in the cortical collecting tubule by inhibiting aldosterone receptors (typically responsible for the reabsorption of sodium with concurrent excretion of potassium into the urine). Lasix is a significantly more potent diuretic which works in the ascending Loop of Henle by inhibiting the Na-K-2Cl channel which can lead to secondary hypomagnesemia and hypocalcemia.

Using Aldactone in conjunction with Lasix essentially creates a diuretic effect with twice the efficacy of Lasix alone without having to worry about the side effects (namely hypocalcemia and hypokalemia) associated with a double dose of Lasix. In fact, since Aldactone is a potassium-sparing diuretic which works distal to Lasix in the nephron, it essentially offsets the hypokalemia.

Another way to think about this is that, in a normal kidney, more distal delivery of sodium leads to a rapid reabsorption of that sodium while sacrificing potassium (thanks to unopposed aldosterone). Aldactone counteracts this by blocking aldosterone receptors. Its been cited by many different sources I’ve read that the 100 mg Aldactone : 40 mg Lasix ratio maintains normokalemia while diuresing patients with volume overload.

Pretty nifty.

Is Pradaxa (dabigatran etexilate) better at reducing the risk for stroke than Coumadin (warfarin) in patients with atrial fibrillation? Read more  

With former Surgeon General Joycelyn Elders suggesting that, for the sake of reallocating our law-enforcement resources to more worthy causes, the US should legalize marijuana, I’m beginning to wonder if she’s right. Read more  

Hepatitis C virus (HCV), a liver infection which has been linked to cirrhosis and hepatocellular carcinoma, is a potentially chronic condition if left untreated. Because of its extremely long latency period, patients who have recently contracted the virus can go decades without becoming symptomatic.

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Sometimes, medical therapy is just funny. Disulfiram, one of the drugs we had to learn for pharmacology months ago, is a treatment for chronic alcoholism.

We’re familiar with antibiotics working with the body’s immune system to destroy bacteria and resolve infections. In this case, antibiotics typically interact directly with the bacterial organism (halting protein synthesis, preventing cell wall formation, etc.) and the body has a chance to “catch up” with its immunological onslaught.

Disulfiram works in an interesting way. Since you can’t “target” chronic alcoholism, it’s mechanism is quite simple – if you’re caught drinking alcohol while on disulfiram, you’re going to regret it. Yes, it’s a drug therapy of intimidation.

Alcohol is metabolized by the liver to acetaldehyde (one of the main culprits of the “hangover”) which is subsequently metabolized to harmless acetic acid through acetaldehyde dehydrogenase. Disulfiram acts by inhibiting said enzyme and effectively raising the levels of acetaldehyde in the blood. The result? If you drink even a little alcohol, you’re going to have a miserably prolonged hangover – based on statistics, this has been a sufficient reason for chronic alcoholics to practice abstinence.