CLINICAL NEWS & UPDATES
Flouroquinolones

​"FDA reinforces safety information about serious low blood sugar levels and mental health side effects with flouroquinolone antibiotics; requires label changes"

The FDA is strengthening current warnings (both po /IV formulations)  of prescribing information on flouroquinolones which may cause significant decreases in blood sugar including hypoglycemic coma. At highest risk are older people and diabetics who are on medications that decrease blood sugar. 
In addition, mental health side effect warnings will be updated which may include agitation, disorientation, nervousness, disturbed attention,  impaired memory, and delirium. Musculoskeletal side effects are inflammation of the tendons, joints, muscle, or nerves (neuropathy). 

Source: FDA U.S. Food & Drug Administrative. Safety Announcement [07-10-2018]
FDA Comment: 
Best to avoid prescribing flouroquinolones for patients who have other treatment options for acute bacterial rhinosinusitis (ABS), uncomplicated urinary tract infections (uUTI), or acute bacterial exacerbation of chronic bronchitis (ABECB) because the risks outweigh the benefits in these patients.


Hyponatremia (sodium <135 mEq/L, severe sodium <120 mEq/L)

The most common type of electrolyte imbalance is hyponatremia. Hundreds of drugs can cause hyponatremia. Be careful with high risk patients such as the elderly, heart failure, or low body weight patients. The most common med that causes hyponatremia in the outpatient setting are the diuretics. For elderly patients, especially if on an SSRI/SNRI with a thiazide diuretic, recheck electrolytes about 2 weeks after starting diuretics in this population.  

Meds (risk of hyponatremia):
Diuretics: thiazides, loop, amiloride combined with HCTZ 
Antidepressants: SSRIs, SNRIs, bupropion, TCAs
Antipscyhotics: thioridazin, clozapine, haloperidol
Antibiotics: ciprofloxacin, trimethoprim/sulfamethoxazole, rifabutin
Anticonvulsants: carbamazepine, gabapentin, lamotrigine, valproate
​Desmopressin, etc.
*Not an all inclusive list.



HPV 9 Vaccine (Gardasil 9)

Gardasil is approved for males and females ages 9 to 26 years. But as of December 2018, it is now approved for ages 27 to 45 years of age.
CDC recommends only two doses of Gardasil if initiated before age 15 years. The first dose is usually given at age    
11-12 year visit, the second dose is due from 6 -12 months later (0, 6-12 months). Catch-up can be done at age 13-14 years or 15-16 years or older. If the child is sexually active early, it can be given as early as age 9 years. 
If the first dose is initiated at age 15 years or older, a total of 3 doses are needed (0, 2, 6 months).

Human papilloma virus can cause cancers of the cervix/vagina/vulva, penis, anus/rectum, mouth/throat. Nearly 80 million people (about one in four) are currently infected with HPV in the U.S. (CDC, 2016).
Aspirin for primary prevention of cardiovascular disease and cancer 

Three large RCT studies evaluating all-cause mortality for aspirin used as primary prevention found that the benefits and harms of using aspirin for primary prevention are very closely balanced. The decision whether to use aspirin on patients aged 40 years or older for primary prevention of cardiovascular disease and cancer be made based on shared decision-making, taking into account the probable benefits and harms of aspirin relative to a specific patient. 

But for secondary prevention of CVD, the absolute benefits of aspirin on occlusive events are greater that the absolute harm of major bleeding. 
Source is UptoDate.com (Nov. 2018).


Third dose of MMR for prevention of mumps in an outbreak setting

The Advisory Committee on Immunization Practices (ACIP) recommended that in the setting of a mumps outbreak, those who have been previously vaccinated with two doses of the MMR vaccine receive a third dose of mumps-virus containing vaccine. 
A university with 20,000 students had a mumps outbreak. Almost all students had previously received two MMR doses. Nearly 5000 received a third dose of MMR. In an adjusted analysis, a third MMR dose was associated with 60% lower risk of mumps at seven days after vaccination. The mumps attack rate was lowest for students who received there MMR second dose with two years of the outbreak. For those whose second MMR was given in the previous 2 years or longer, a third dose will help decrease their risk of mumps in a mumps outbreak situation.
Source: UptoDate (September 2017, Modified Jan. 2018)
Vaccination to prevent herpes zoster

Per the CDC, Shingrix (recombinant zoster vaccine) is the preferred vaccine for shingles over Zostavax (zoster  vaccine live) for the prevention of herpes zoster (shingles) and related complications. The CDC recommends two doses of Shingrix separated by 2 to 6 months for immunocompetent adults age 50 years and older:

>whether or not they report a prior episode of shingles
>whether or not they report a prior dose of Zostavax
>who have chronic medical conditions (e.g.,diabetes, chronic renal failure, RA, chronic lung disease) unless a contraindication or precaution exists. 

It is not necessary to screen, either verbally or by laboratory serology, for evidence of prior varicella infection. 
Zostavax may still be used to prevent shingles in health adults 60 years and older. For example, you could use Zostavax if a person is allergic to Shingrix, prefers Zostavax, or requests immediate vaccination and Shingrix is unavailable. 
Source: CDC, September 2018