Adult Problems in Pediatric Patients 2018/Peds1.pdf · Adult Problems in Pediatric Patients ... ACT...

2/20/2018

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Adult Problems in Pediatric Patients

February 21, 2018

Lauren Haney, PharmD, BCPS, BCPPS

Clinical Pharmacy Specialist

Describe barriers and considerations in anticoagulation therapy in pediatric patients.

Discuss options for pulmonary hypertension treatment in pediatric patients.

Develop understanding of challenges in pain management in pediatric patients during an opioid epidemic.

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Mahajerin A, Webber E, Morris J, et al. Hospital Pediatrics 5:12;2015:630-36

Subcutaneous Enoxaparin (Lovenox®)

Fondaparinox (Arixtra®)

Oral Vitamin K antagonist▪ Warfarin (Coumadin®)

Direct thrombin inhibitor ▪ Dabigatran (Pradaxa®)

Factor Xa inhibitor ▪ Rivaroxaban (Xarelto®)▪ Apixaban (Eliquis®) ▪ Edoxaban (Savaysa®)▪ Betrixaban (Bevyxxa®)

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Vitamin K Antagonist Indications DVT/PE

Nonvalvular atrial fibrillation

Prosthetic heart valves

Mechanism of action: Inhibits coagulation factors II, VII, IX, and X and proteins C and S

Guideline for Warfarin Initiation (for goal INR 2‐3)

Loading dose: Day 1 If baseline is INR 1.0‐1.3 0.2 mg/kg (max dose 10 mg)

Loading Days 2‐4 INR 1.1 – 1.3 Repeat initial loading dose

INR 1.4 – 3.0 0.1 mg/kg/dose (50% of loading dose)

INR 3.1 – 3.5 0.05 mg/kg/dose (25% of loading dose)

INR >3.5 Hold until INR <3.5 then restart dose 50% lower than previous dose

Maintenance dosing INR 1.1 – 1.4 Increase dose by 20%

INR 1.5 – 1.9 Increase dose by 10%

INR 2.0 – 3.0 No change

INR 3.1 – 3.5 Decrease dose by 10%

INR >3.5 Hold until INR <3.5 then restart dose 20% lower than previous dose

Modified from Antithrombotic and Thrombolytic Therapy 9th Ed: ACCP Guidelines, Chest 2012;141:e737s-e801s.

Available dosage forms

Scored tablets only

1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg

Tablets able to be split and crushed

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http://www.aboutkidshealth.ca/En/HealthAZ/Drugs/Pages/Warfarin.aspx [accessed 2/14/18]

RISK OF CLOTS

Foods

▪ Vitamin K containing foods

▪ lettuce, spinach, broccoli, cabbage

▪ liver or soybean‐containing food such as mayonnaise, soy milk

RISK OF BLEEDING

Juices

▪ Cranberry, grapefruit and mango can make the medicine too effective and increase risk of bleeding.

https://www.cincinnatichildrens.org/health/w/warfarin [accessed 2/14/18]

Reversal

Vitamin K (phytonadione)

▪ PO

▪ IV

▪ SQ

Prothrombin complex concentrate (Kcentra®)

Fresh frozen plasma

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Oral Factor Xa inhibitor Indications (adult) DVT/PE

Nonvalvular atrial fibrillation

DVT prophylaxis after knee or hip replacement

Mechanism of action: Factor Xa inhibitor causing platelet inactivation and prevents fibrin clot formation

Reversal No specific antidote

Consider Prothrombin complex (FEIBA NF®) or recombinant factor VIIa

NOT dialyzable

Renally eliminated: Avoid use for CrCl < 30 mL/min (PE/DVT and post‐op thrombophrophylaxis) and CrCl < 15 mL/min for atrial fibrillation

Review for drug interactions

Administer with food

Routine monitoring of coagulation tests not required

Monitor for signs & symptoms of bleeding or intolerance to drug

Crushed tablets in water (via NG tube) or applesauce: Stable for ≤4 hours.

Rivaroxaban: Clinical Pearls

Oral Factor Xa inhibitor Indications (Adult) Nonvalvular atrial fibrillation

DVT prophylaxis after knee or hip replacement

Treatment of DVT/PE


Reversal

No specific antidote

Consider Prothrombin complex (FEIBA NF®) or recombinant factor VIIa

NOT dialyzable

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Oral Factor Xa inhibitor Indications (Adult) Nonvalvular atrial fibrillation

Treatment of DVT/PE

Black Box Warning: reduced efficacy in atrial fibrillation pts with CrCl >95 mL/min


Reversal No specific antidote

NOT dialyzable

Dose reduction if weight < 60 kg or CrCl < 50 mL/min

Mechanism of action: small effect on aPTT and strongly inhibit factor Xa

Indications: systemic anticoagulation Monitoring: LMWH heparin AntiXa Special considerations

Contraindications: bleeding

Risks: bleeding

Limitations: bleeding, monitoring, thrombosis, SQ injection

Pharmacokinetics

Half life: 4 to 7 hours

Elimination: 40% urine

Organ dysfunction

▪ Do not use in CrCl <30 mL/min

▪ Hepatic metabolism

▪ Active metabolites Reversal Protamine may be useful but does not completely reverse

effects

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Available package sizes

Prefilled syringes

▪ 100 mg/mL concentration: 30 mg, 40 mg, 60 mg, 80 mg, 100 mg

▪ 150 mg/mL concentration: 120 mg and 150 mg

Multidose vial

▪ 100 mg/mL

▪ May need insulin syringes to measure doses ▪ Example: 8 mg = 0.08 mL = 8 units on insulin (100 unit/mL) syringe

▪ Will need prescription for syringes

Subcutaneous injection (not IM) Site of administration

Recommended site

▪ Abdomen: 1‐2 inches away from belly button and scars

Alternative site

▪ Thighs▪ More erratic absorption

Rotate injection sites

To lesson pain and anxiety

Numb injection site with ice

Insuflon catheter

Have patient look away

Self‐administered injections

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Counseling points

Great instructional videos on www.lovenox.com

Monitor signs of bleeding and bruising

May experience injection site pain…rotate sites

Best site = abdomen

Store at room temperature (do NOT refrigerate)

Place used syringe in plastic or metal container and place in regular bagged trash for disposal (stickers available from DHEC)

Lexicomp dosing Round dose to nearest commercially‐available syringe when possible.

MAY NEED HIGHER DOSES

Prophylaxis Dose (mg/kg) q12hr

< 2 months 0.75

≥ 2 months 0.5

Treatment

< 2 months 1.5

≥ 2 months 1

Modified from Antithrombotic and Thrombolytic Therapy 9th Ed: ACCP Guidelines, Chest 2012;141:e737s-e801s.

Monitoring AntiXa

Draw 4 to 6 hours after dose administered

Ensure correct lab is ordered

Ranges

▪ Therapeutic 0.5‐1 units/mL

▪ Prophylaxis 0.1‐0.3 units/mL

Monagle P, Chan A, Goldenberg NA, et al, "Antithrombotic Therapy in Neonates and Children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition)," Chest, 2012, 141(2 Suppl):e737-801.

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No established dosing in pediatric patients

Mechanism of action: Inhibits Factor Xa and impairs hemostasis by causing inhibition thrombin formation

Indications DVT prophylaxis in patient with history of HIT DVT/PE treatment

Monitoring� Fondaparinux Anti‐Xa levels – draw 3 hours post‐administration of dose Anti‐Xa goals vary based on indication

Dose adjustments� Give 50% of dose if CrCL < 50 mL/min, contraindicated if CrCl < 30 mL/min� If for acute DVT/PE treatment:

�< 50kg: 5mg daily; 50‐100kg: 7.5mg daily,;> 100kg: 10mg daily

Fondaparinux (Arixtra®)

Pharmacokinetics

Half life: 17 to 21 hours

Elimination: 75% urine

Organ dysfunction: prolonged elimination in renal dysfunction

Effects may persist for 2‐4 days after discontinuation

Reversal: NONE

IV

Bivalirudin (Angiomax®)

Argatroban

Oral

Dabigatran (Pradaxa®)

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Onset (min)

Vd(L/kg)

Protein Binding

T1/2 (min)

MetabolismReversalAgent

Argatroban 30 0.174 54 % 39‐51CYP 3A4/5 (minor)

No

Bivalirudin <1 0.24 0 % 25

Proteolysis (blood)

Elimination: urine

No

Angiomax® (bivalirudin). The Medicines Company 2016.Argatroban. Sandoz Inc. 2011.

Starting doses based on indication

Heparin induced thrombocytopenia:

0.15‐0.2 mg/kg/hr

ECMO: 0.03‐0.05 mg/kg/hr

Berlin heart: 0.5 mg/kg/hr

Impella: 0.03 mg/kg/hr

Other indication: varies

Nagle EL, et al. Pediatr Crit Care Med 2013;14:e182-188.Ranucci M, et al. Critical Care 2001;15:R275.

DTI effects on labs

Direct thrombin inhibitorsACT Anti‐Xa aPTT PT/INR TT

Argatroban ↑ ↔ ↑ ↑ ↑

Bivalirudin ↑ ↔ ↑ ↑ ↑

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INR 2‐3

INR >4

On warfarin for minimum 4‐5 days

INR 4‐5 at time of stopping DTI

Repeat INR 4‐6 hours after stopping infusion

New Oral Anticoagulants/Direct Oral Anticoagulants

(NOAC/DOAC) Dabigatran (Pradaxa®)

Rivaroxaban (Xarelto®)

Apixaban (Eliquis®)

Edoxaban (Savaysa®)

Oral Anticoagulant Agents

NEW

Oral direct thrombin inhibitor (DTI)

Indications (adult)

▪ Anticoagulation therapy in patients with non‐valvular atrial fibrillation

▪ DVT/PE

▪ Mechanism of action: Inhibits free and bound thrombin causing activation of factors V, VIII, XI, and XIII and inhibiting platelet aggregation

Reversal▪ Idarucizumab (Praxbind ®)

▪ Consider Prothrombin complex (FEIBA NF®) or recombinant factor VIIa

▪ Partially dialyzable

Dabigatran (Pradaxa®)

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Humanized monoclonal antibody Reverses effects of dabigatran

Emergent procedures and surgeries

Life threatening bleeding

Not stocked in every hospital $$$$

https://www.praxbind.com/ [accessed 2/14/18]

Warfarin Dabigatran Rivoraxaban Apixaban Endoxaban

Evidence in pediatric patients?

Mechanism Vitamin K antagonist

Direct thrombin inhibitor

Factor XaInhibitor

Factor XaInhibitor

Factor XaInhibitor

Once daily dosing?

Reversal agent? Vitamin K & Kcentra®

Yes

Monitoring required?

PT/INR No No No No

PharmacologyPearls

5‐7 days until reaches steady state after any changes

Renal dosing with CrCl<30Pgp drug interations

Renal dose adjustments, avoid with liver disease; Pgpand CYP3A4 interactions

No renal dosing but avoid with CrCl <25; Pgpand CYP3A4 interactions

Not for patients with CrCl >95 or <15, renal dosing when CrCl <50

Wear medic alert bracelet or necklace Carry wallet card Write information on sticker on back of car seat

Avoid contact sports Report head injuries Alert school nurse

http://patientblog.clotconnect.org/2012/07/04/children-and-blood-thinners/

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http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_pulmonary_hypertension.htm[accessed 2/14/18]

1. Pulmonary Arterial Hypertension2. Pulmonary HTN due to Left Heart Disease3. Pulmonary HTN due to Lung Diseases and/or Hypoxia4. Chronic Thromboembolic Pulmonary HTN5. Pulmonary HTN with Unclear Multifactorial

Mechanisms

Ivy DD, Abman SH, Barst RJ, et al. J Am Coll Cardiol. 2013; 62(25) D117-D126.

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Idiopathic Hereditary Congenital heart disease

Sickle Cell anemia Pulmonary embolism Bronchopulmonary dysplasia

Connective tissue disorders

Medications

Cocaine

Amphetamines

Chemotherapy

SSRIs in pregnancy?

Updated Clinical Classification of Pulmonary Hypertension JACC 2013;62(25); Supp D.

https://www.fda.gov/Drugs/DrugSafety/ [accessed 2/17/18]JAMA 2015;313(21):2142-2151.

Galiè N, et al. J Am Coll Cardiol 2013;62(25):D60‐72

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Oral anticoagulation: IPAH/HPAH, anorexigen induced (IIa‐C)APAH (IIb‐C)

Diuretics (I‐C)Oxygen (I‐C)Digoxin (IIb‐C)

Diuretics (I‐C)

Used to decrease right ventricular volume overload (preload)

Decrease preload, dyspnea, peripheral edema, and hepatic congestion

No randomized trials, but loop diuretics are most common

Caution with decreased cardiac output, hypokalemia, and metabolic alkalosis

Vorhies EE, Ivy DD. Pediatr Drugs. 2014; 16:43-65.

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Anticoagulation (IIa‐C or IIb‐C)

High risk for intrapulmonary thrombosis and thromboembolism (sluggish blood flow, dilated chambers, venous stasis, and sedentary lifestyle)

Should be considered in:

▪ WHO Groups 1 (PAH) and 4 (CTEPH)

▪ Advanced disease (continuous IV therapy)

▪ High risk of VTE (HF, sedentary lifestyle, thrombophilic predisposition)


Anticoagulation (IIa‐C or IIb‐C)

Warfarin

▪ Retrospectively shown to improve survival

▪ Goal INR 1.5 – 2.5 based on 2 small studies (retrospective and prospective)

▪ Bleeding risk may be higher in certain subsets (e.g., connective tissue disease APAH)

Limited data with DOACs


Digoxin (IIb‐C)

Controversial use as an adjunct for right heart failure or atrial arrhythmias

▪ Improves RVEF in Group 3 PH due to COPD

▪ No data in Group 1 PAH

▪ Possibly more sensitive to toxicity

Goal level unknown, but probably should be 0.5 –0.8 ng/mL


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Phosphodiesterase-5 Inhibitors

Endothelin Receptor

Antagonists

Prostacyclin and

Analogues

• Sildenafil (Revatio®)• Tadalafil (Adcirca®)

• Bosentan (Tracleer®)• Ambrisentan (Letairis®)

• Epoprostenol (Flolan®, Veletri®)• Treprostinil (Remodulin®, Tyvaso®)• Iloprost (Ventavis®)


Inhibit PDE5 in vascular smooth muscle

Inhibits cGMP breakdown → increasing local NO

Vasodilation and inhibition of smooth muscle cell growth

Improves hemodynamics, functional class, and quality of life

Easier to administer


Sildenafil (Revatio®)

Dosage forms

▪ 20 mg tablets ($900 for 45 tablets)

▪ 10 mg/mL suspension commerically available ($9000/bottle)

Likely requires prior authorization

Tadalafil (Adcirca®)

Available as tablets only ($2100 for 30 tablets)

Compounded suspension recipe

Lexicomp

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Sildenafil

Pediatrics: 0.5‐1 mg/kg PO q6‐8hr (max 20 mg)

Adults: Sildenafil started at 20 mg PO TID

Give doses 4 – 6 hrs apart

Tadalafil

Pediatrics: 15‐40 mg PO daily

Adults: 40 mg PO daily

Decrease to 20 mg PO daily if CrCl <80 mL/min

Avoid if CrCl <30 mL/min or on hemodialysis

LexiComp Sabri RM, et al. Pediatr Cardiol (2014) 35:699–704

Sildenafil Tadalafil

Headache ✔� ✔�

Flushing ✔� ✔�

Nasal congestion ✔� ✔�

Dyspepsia ✔� ✔�

Dizziness ✔�

Epistaxis ✔�

Visual disturbance(blue‐tint, sudden loss)

✔�

Rash ✔�

Sudden decrease or loss of hearing

✔�

Myalgia ✔�

Nausea ✔�

Contraindicated with nitrates or riociguat due to potential severe hypotension

PDE‐5 degrades cGMP

Additive vasodilatory effects of nitric oxide

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www.fda.gov [accessed 2/17/18Revatio package insert Jan 2014

Sildenafil Citrate in Treatment‐Naïve Children with Pulmonary Arterial Hypertension

Primary objective: Assess sildenafil effectiveness on exercise capacity

• Measured peak oxygen consumption (PVO2) at week 16

• Assessed 106 of 235 patients using Cardiopulmonary Exercise Test (CPET)

• Limited due to developmental functionality of patients

• Patients on monotherapy

Secondary objectives: Change from baseline to week 16• Pulmonary artery pressure (PAP)

• Pulmonary vascular resistance index

• WHO functional class

• Cardiac index

• Right atrial (RA) pressure

• Exercise duration

• Child Health Questionnaire

Barst RJ, Ivy D, Gaitan G, et al. Circ 2012;125:324-334.

o Patient heterogeneityo Differences in ageo Etiology of disease (IPAH and HPAH compared to secondary

PAH)o Infant population: PAH secondary disease processo Variable WHO functional class

o Primary outcomeo Difficult to accurately measure in majority of patients

o Overall survival o 3 year survival is higher than without treatment o Natural disease progression: Median survival is 10 months o No deaths were thought to be treatment relatedo No explanation in pharmacokinetic differences


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• After 2 years of treatment

• Increased risk of death in high dose group


If sildenafil is not safe….

Block vasoconstriction and cellular proliferation caused by endothelin‐1 (ET‐1)

Improve exercise capacity, functional class, hemodynamics and delay clinical worsening

Efficacy of dual ETA and ETB and selective ETAreceptor antagonists appear comparable

Dual (or nonselective): bosentan, macitentan

Selective ETA: ambrisentan

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To initiate

Discuss indication, dosing, and length of treatment with primary patient care team

Contact and assist case manager about insurance and acquisition for home (usually takes 7‐10 business days)

Verify approval for home supply BEFORE initiating therapy inpatient

Discuss implications with family for home use (ie, cutting tablets, teratogen)

Refer to website for Patients on maintenance therapy

ERA Starting Dose Target DoseDose

Reduction

Bosentan 62.5 mg PO BID x4 weeks

125 mg PO BID LFTs 3‐5x ULN

Ambrisentan 5 mg PO daily 10 mg PO daily Concomitant cyclosporine

Macitentan 10 mg PO daily 10 mg PO daily None

• All 3 ERAs may be taken with or without food

• Bosentan is a potent CYP 3A4 and 2C9/19 inducer

Lexicomp

FIXED DOSING

5 to <10 kg: 15.6 mg daily for 4 weeks; increase to 15.6 mg BID

10 to 20 kg: 31.25 mg daily for 4 weeks; increase to 31.25 mg BID

>20 to 40 kg: 31.25 mg BID for 4 weeks; increase to 62.5 BID

>40 kg: 62.5 mg BIDfor 4 weeks; increase to 125 mg BID

WEIGHT‐BASED DOSING

Children ≥2 years: Initial: 0.75 to 1 mg/kg/dose twice daily for 4 weeks (maximum dose: 62.5 mg); then increase to 2 mg/kg/dose twice daily

Lexicomp

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Wear gloves and mask when cutting and handling tablets.

Use a pill cutter to cut the tablet. Store the unused tablet pieces in the original bottle from the manufacturer for up to 4 weeks.

Bosentan tablets should not be crushed. Place the split tablet in 5 mL of water and allow to dissolve. Do not crush.

If women who are pregnant or may become pregnant do not handle the split tablets with bare hands.

www.tracleer.com [accessed 1/20/18]

Serious liver injury Bosentan: black box warning

Dose‐dependent and reversible hepatocellular damage and increased total bilirubin

Liver function tests (LFTs) prior to initiation and monthly thereafter

▪ Avoid initiation or dose adjust if AST/ALT >3x ULN

▪ D/C if AST/ALT elevated with symptoms (N/V, fever, abdominal pain, jaundice, lethargy) or bili ≥2x ULN


Peripheral edema (most common for all) Anemia

CBC at baseline, 1, and 3 months and Q3 months

Male infertility

Testicular tubular atrophy and infertility

Decreased sperm counts

Embryo‐fetal toxicity Pregnancy tests in women of childbearing potential

▪ Prior to initiation of therapy

▪ Monthly during therapy

Counsel to use 2 forms of contraceptives


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Embryo‐fetal toxicity ‐ likely to cause major birth defects

Pregnancy tests in women of childbearing potential

Prior to initiation of therapy (at least 11 days after last unprotected sexual intercourse)

Monthly during therapy

Counsel to use 2 forms of contraceptives

Hormonal methods less effective with bosentan


Two‐fold mechanism

Stimulate NO receptor

Increase sensitivity of soluble guanylate cyclase to endogenous NO

Improves exercise capacity, hemodynamics, and symptoms

Riociguat (Adempas®)

Syncope (most common) Headache, dizziness Hypotension (C/I with concomitant PDE‐5i or nitrate therapies)

Dyspepsia Peripheral edema Vomiting, diarrhea Embryo‐fetal toxicity

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Restores inadequate levels of prostaglandin I2 (prostacyclin)

Potent vasodilation of pulmonary vasculature Improve hemodynamics, functional class, and in IPAH patients also survival

IV

Epoprostenol (Flolan® or Veletri®)

Treprostinil (Remodulin®)

Subcutaneous

Treprostinil (Remodulin®)

Inhaled

Treprostinil (Tyvaso®)

Iloprost (Ventavis®)

Oral

Selexipag (Uptravi®)

Newer, more stable, longer half life Dosing

SQ (preferred) or IV therapy usually started at 1.25 ng/kg/min

Decrease to 0.625 ng/kg/min if not tolerated and do not re‐titrate for 4 weeks

Increase by ≤ 1.25 ng/kg/min weekly for first 4 weeks, then by ≤ 2.5 mg/kg/min

Transition from epoprostenol: start at 10% of epoprostenol dose and increase by 1.25 ng/kg/min but ≤ 2.5 ng/kg/min per week

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Alternative to parenteral in patients who refuse or cannot tolerate the complexity of those agents

Avoid in patients with pulmonary infections or lung disease

Dosing: Start with 3 breaths (18 mcg) 4 times daily while awake (~4 hrs apart)

Reduce to 1‐2 breaths if not tolerated

Increase by 3 breaths at 1‐2 week intervals

Goal dose is 9 breaths (54 mcg) 4 times daily

Alternative to parenteral in patients who refuse or cannot tolerate the complexity of those agents

WHO FC III [I‐A or B] or IV [IIa‐C] who have failed or are not candidates for CCBs

Avoids infectious complications associated with IV access for drug delivery

Start at 2.5 mcg inhaled 6 – 9 times daily (≥2 hour intervals while awake)

Increase to 5 mcg 6 – 9 times daily (max 45 mcg/day)

Must use AAD aerosolized device

Selective agonist of prostacyclin‐IP receptor Smooth muscle vasodilation, inhibition of smooth muscle proliferation, and inhibition of platelet aggregation

Easy to administer WHO Group 1 FC II‐III Decreased time to first event by 40%

First event: disease progression, hospitalization, PAH worsening, or all‐cause death

No current recommendation for use

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Pharmacokinetics

99% protein bound

Metabolized by CYP 3A4 and 2C8

Major active metabolite

Adult Dosing

Initially 200 mcg PO BID

Increase weekly in BID increments of 200 mcg

Max dose 1600 mcg PO BID

Re‐titration required if interrupted for ≥ 3 days

Once daily for mod hepatic impairment (CP Class B)

Similar to prostanoids… Headache

Diarrhea

Nausea

Jaw pain

Pain in extremities

Myalgia

Arthralgia

Flushing Avoid use with severe hepatic impairment (Child Pugh Class C)

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Drug overdoses leading cause of accidental death

Opioid deaths in US 2015

▪ Heroin: 12,990 deaths

▪ Prescription opioids: 20,100 deaths

https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis [accessed 2/18/18]

CDC press release – November 11, 2001

Death toll tripled in previous decade

In US, 40 people die every day from opioid pain relievers

In 2010‐ 1:20 people ≥12 years old admits to using prescription pain medication non‐medically

5,500 people START to misuse pain medications EVERY DAY

78.5 BILLION dollar burden per year in US


Opioid prescription fill rates

Illinois has lowest rate

Florida has highest rate

Overdose deaths

Nebraska has lowest rate

New Mexico has lowest rate


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In 2016

3.9 million adult estimated in SC

5 million opioid prescriptions filled in SC

Equals 1.3 opioid prescriptions per adult

https://www.census.gov/quickfacts/SC [accessed 2/19/18]

Access

In 2012, 259 million prescriptions written for opioid pain reliever = enough to give every American adult a bottle

Doctor shopping “Pill mills” Sharing and saving

ASAM Opioid Addiction Facts and Figures 2016

In 2015

276,000 adolescents were current nonmedical users of pain reliever

122,000 addicted to prescription pain relievers

21,000 adolescents had used heroin in the past year, and 5,000 were current heroin users


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Where does it come from?

Given to them for free by a friend or relative

Prescribing rates for prescription opioids among adolescents and young adults nearly doubled from 1994 to 2007


Talk about it!

Pain medications in homes

Safe storage

Disposal

Prescribing

Only give enough supply for minimal pain

Promote distraction techniques

Set expectations

South Carolina Reporting and Identification Prescription Tracking Program

Monitors transactions to discourage abuse and diversion

Allows exchange of information with participating states

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December 18, 2017

SC Public Health Emergency declared by Gov. Henry McMaster

Effort to decrease opioid abuse in SC

Limit days supplies

Return to prescriber if additional supply needed

http://www.thestate.com/news/politics-government/article190314649.html [accessed 2/19/18]

https://www.scdhec.gov/Health/Opioids/ [accessed 2/18/18]

EMS and First responders in SC

Naloxone administration

4,600 times in 2015

6,400 times in 2016

Increase of 39% in just one year


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2015 2016


Prescription Auto –injector

Evzio®

Prescription Nasal Spray

Narcan®

https://www.evzio.com/patient/https://www.narcan.com/ [accessed 2/19/18]

Where to get naloxone

Retail pharmacies (including CVS and Walgreens)

Naloxone is available without a prescription in 41 states

AL, AK, AR, AZ, CA, CO, CT, FL, GA, IA, ID, IL, IN, KY, LA, MA, MD, MN, MO, MS, MT, NC, NH, ND, NJ, NM, NV, NY, OH, OR, PA, RI, SC, TN, TX, UT, VA, VT, WA, WI and WV

https://www.cvs.com/content/prescription-drug-abuse/save-a-life

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JAMA

60% report leftover opioids in the past year

20% report sharing medications with others

Do NOT flush down toilet to keep out of water supply

Mix with liquid or deterrant such as coffee grounds or cat liter

Place in regular household garbage for disposal

Unwanted medications (NOT controlled substances)

Retails pharmacies

▪ CVS 1‐888‐607‐4287

▪ Rite Aid 1‐800‐748‐3243

▪ Walgreens 1‐800‐925‐4733

Local government take back programs

Local hospitals

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Widely used opioid in pediatric patients for decades

In 2007: pediatric death reported attributed to cytochrome P2 CD6 polymorphism

In 2009: 2 year old previously healthy child die after tonsillectomy

In 2013: World Health Organization (WHO) removed codeine from pediatric pain guidelines

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2013: American, European, Canadian, and British warnings issued about use of codeine in pediatric patients

2015: Australia issues contraindication for patients <12 years of age

2016: American Academy of Pediatrics issues statement that further investigation needed

FDA summary memorandum. The safety of codeine in children 18 years of age and younger. Silver Spring, MD: Joint Pulmonary Allergy Drugs and Drug Safety and Risk Management Advisory Committee, 2015.www.AAP.org [accessed 11/18/17]

Codeine is metabolized to morphine through CYP2D6 enzyme

Altered metabolism may lead to respiratory depression

High risk patients

Breastfed babies

Post Tonsillectomy and Adenoidectomy

Ultra rapid CYP2D6 metabolizers

Crews KR. Clin Pharmacol Ther 2014;95(4):376-82.

http://www.aappublications.org/news/2017/04/20/Codeine042017 [accessed 11/18/17]

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Obesity

Gout

Hypertension Diabetes

Depression

Infection

Hyperlipidemia

Kidney disease

Adult Problems in Pediatric Patients 2018/Peds1.pdf · Adult Problems in Pediatric Patients ... ACT...

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