Impact of a phenytoin loading dose program in the emergency department

Brancaccio, Adam; Giuliano, Christopher; McNorton, Kelly; Delgado, George

doi:10.2146/ajhp140039

Cited by 9 publications

(13 citation statements)

References 30 publications

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“…However, in their conclusions the authors also suggest a dose cap of 2000 mg for patients although this was not specifically addressed in their study. In a more recent report looking at the implementation of a phenytoin loading dose program in the ED, the researchers implemented a protocol that adjusted dosing based on the patient's body mass index, but limited all single doses to no more than 2000 mg . In patients presenting with body weights above 100 kg, the use of the recommended dosing strategy of 20 mg/kg will always exceed this proposed maximum.…”

Section: Discussionsupporting

confidence: 90%

“…Similar results have been found by other investigators in other inpatient settings, often as aspects of pharmacokinetic monitoring services . Only one other group of researchers has explored the impact of an EPh as part of a comprehensive phenytoin loading dose program on the dosing of this agent in the ED . They found a significant improvement in the administration of optimal phenytoin doses (15‐18 mg/kg) in the presence of an EPh (82% vs 50%; P = 0.007).…”

Section: Discussionmentioning

confidence: 99%

“…Phenytoin has been shown in one analysis to have a 33% higher distribution into excess body weight over that of ideal body weight. As a result, some studies have suggested using modified weights in dosing for these patients and some have advocated arbitrarily “capping” in many cases for fear of overdosing, often at a dose of 2000 mg . Furthermore, there are limited studies evaluating dosing in the multiple unique patient populations that present to the ED on an emergent basis.…”

Section: Introductionmentioning

confidence: 99%

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Assessment of dose capping in phenytoin loading practices in the emergency department and the impact of an emergency medicine pharmacist

Holder

Bailey

Baum

et al. 2019

J Am Coll Clin Pharm

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Objectives: Phenytoin is a common anticonvulsant used for the acute treatment of seizures in the emergency department (ED). Certain patient populations, such as the obese, have been shown to present dosing challenges. Often doses are arbitrarily "capped" for fear of overdosing.Emergency medicine pharmacists (EPhs) have been shown to optimize the care of patients receiving phenytoin therapy in other settings, demonstrating reductions in seizure activity, duration of therapy, and cost.Methods: Records of patients presenting to the ED that were at least 18 years old and were prescribed intravenous phenytoin were reviewed. Patients weighing 100 kg or more were compared with those less than 100 kg. To evaluate the impact of an EPh, intravenous phenytoin orders placed during the EPh's hours were compared with those placed outside of those hours.Results: A total of 117 patients were included, 42 (36%) weighed 100 kg or more. No significant difference was found in the achievement of target (10-20 μg/mL) postload concentrations between the two groups (P = 0.795). Patients weighing 100 kg or more received significantly lower weight-based phenytoin doses (16.0 vs 18.6 mg/kg, P = 0.0001). Those 100 kg or more who received less than 15 mg/kg were found to have significantly lower postload concentrations than those that received 15 mg/kg or more regardless of total dose (11.5 vs 16.5 μg/mL; P = 0.003). The presence of an EPh was found to result in significantly higher rates of postload concentrations within the therapeutic range across all groups (72.4% vs 53.7%; P = 0.04). Conclusions:The available data suggest that artificial total dose limitations in patients yield significantly lower postload concentrations, potentially delaying seizure control in the acute setting. The presence of EPhs at the bedside increases the success of initial phenytoin dosing strategies in this population.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Assessment of dose capping in phenytoin loading practices in the emergency department and the impact of an emergency medicine pharmacist

Holder

Bailey

Baum

et al. 2019

J Am Coll Clin Pharm

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“…They showed that pharmacistled dosing programs significantly improved the proportion of patients who received optimal PHT LDs in comparison to prescriber-led programs (82% vs. 49%), and that a 1000 mg LD was used less frequently in the pharmacist-led group (42.9 vs. 65.1%). 23 A similar trend was found for PHT MDs; however, it was not as clear. Patients who received a standard dose of 400 mg/day or a weight-based dose >5 mg/kg per day showed a trend to be equally likely within therapeutic range.…”

Section: Discussionsupporting

confidence: 52%

“…However, this finding has been previously supported and the authors have recommended avoidance of preset PHT LDs. 22 This trend is further explained in a study by Brancaccio et al, 23 which suggested that a fixed dosing strategy of 1000 mg may be used because of prescriber familiarity; however, with the rates of obesity increasing, this approach may lead to a large proportion of patients failing to achieve therapeutic concentrations, subsequently impacting patient outcomes. Interestingly, Brancaccio et al explored the impact of a PHT LD program, which was further stratified into pharmacist-led and prescriber-led.…”

Section: Discussionmentioning

confidence: 99%

Critical Care Management of Status Epilepticus at a Tertiary Care University Hospital

Mahmoud

Marette

Lindqvist

et al. 2019

Can. J. Neurol. Sci.

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ABSTRACT:Background:Status epilepticus (SE) is a neurological emergency associated with significant morbidity and mortality. The objective of this study was to review the critical care management of patients with SE focusing on antiepileptic drugs (AEDs) as well as to determine the optimal dosing strategies of phenytoin (PHT) and predictors of its effectiveness.Methods:A retrospective chart review of adult patients with SE admitted to the University of Alberta Hospital, Canada, was conducted.Results:Fifty-six admissions were included. Benzodiazepines (BDZs) were initially given in 89% of our patients. Following BDZs, PHT and levetiracetam were the most commonly initiated AEDs as first- and second-line agents and were deemed effective in 30/44 and 5/11 patients, respectively. Patients who received a PHT loading dose (LD) of 1000 mg were less likely to reach target levels compared with a weight-based LD ≥15 mg/kg (29% vs. 60%). Likewise, patients who received a maintenance dose (MD) of 300 mg/day were less likely to reach target compared with 400 mg/day or >5 mg/kg per day; however, this did not reach statistical significance. Three variables were found to be associated with PHT effectiveness: tonic-clonic SE (OR 5.01, 95% CI 1.02–24.7, p = 0.048), history of seizures and BMI <30 kg/m2 (OR 0.16, 95% CI 0.03–1.07, p = 0.059).Conclusions:Further studies of the predictors of PHT effectiveness, specifically obesity, are necessary to help individualize care. Finally, we suggest that PHT should be loaded according to the guidelines as 20 mg/kg followed by an MD of at least 400 mg/day or >5 mg/kg per day.

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