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1.
Expert Rev Clin Pharmacol ; 15(8): 959-976, 2022 Aug.
Article in English | MEDLINE | ID: mdl-35920615

ABSTRACT

INTRODUCTION: Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB), and hydroxocobalamin can be added to maintain blood pressure. AREAS COVERED: VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP. EXPERT OPINION: Evidence supporting additional vasopressor agents in catecholamine-resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor, is used in VS to maintain adequate MAP. MB and/or hydroxocobalamin, vitamin C, thiamine, and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.


Subject(s)
Cytomegalovirus Infections , Shock, Septic , Shock , Angiotensin II/therapeutic use , Ascorbic Acid/pharmacology , Ascorbic Acid/therapeutic use , Cardiotonic Agents/pharmacology , Cardiotonic Agents/therapeutic use , Catecholamines/therapeutic use , Dobutamine/therapeutic use , Humans , Hydroxocobalamin/therapeutic use , Methylene Blue/therapeutic use , Milrinone/therapeutic use , Shock/drug therapy , Shock, Septic/drug therapy , Thiamine/therapeutic use , Vasoconstrictor Agents/pharmacology , Vasoconstrictor Agents/therapeutic use , Vasopressins/pharmacology , Vasopressins/therapeutic use
2.
Curr Opin Pulm Med ; 27(5): 374-387, 2021 09 01.
Article in English | MEDLINE | ID: mdl-34183525

ABSTRACT

PURPOSE OF REVIEW: The term interstitial pneumonia with autoimmune features (IPAF) was first proposed by an international task force in 2015 as a research classification to standardise nomenclature regarding patients with idiopathic interstitial pneumonia and features of connective tissue disease. However, how the use of this term and its proposed definition translates to clinical practice remains uncertain. This review will provide a comprehensive overview of studies of IPAF cohorts to date, discuss the consideration of IPAF as a distinct diagnostic entity and outline a suggested approach to patient management. RECENT FINDINGS: Considerable heterogeneity exists between published IPAF cohorts, with some cohorts exhibiting similarities to those with connective tissue disease-associated interstitial lung disease (CTD-ILD), and others more similar to idiopathic interstitial pneumonias including idiopathic pulmonary fibrosis (IPF). Little data exist to inform the management of patients who fulfil the IPAF criteria. Preliminary data supports pragmatic management of these patients as having a working clinical diagnosis of either idiopathic interstitial pneumonia or CTD-ILD. Future research studies into this approach are required. SUMMARY: The term IPAF, and its definition, have been of fundamental benefit to facilitating research in this diverse patient group. However, to date, there remain many unanswered questions regarding their natural histories and response to treatment.


Subject(s)
Autoimmune Diseases , Connective Tissue Diseases , Idiopathic Interstitial Pneumonias , Idiopathic Pulmonary Fibrosis , Lung Diseases, Interstitial , Autoimmune Diseases/diagnosis , Connective Tissue Diseases/diagnosis , Humans , Idiopathic Interstitial Pneumonias/diagnosis , Idiopathic Pulmonary Fibrosis/diagnosis , Lung Diseases, Interstitial/diagnosis
3.
Expert Opin Pharmacother ; 21(16): 1991-2010, 2020 Nov.
Article in English | MEDLINE | ID: mdl-32686969

ABSTRACT

INTRODUCTION: Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines. AREAS COVERED: A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed. EXPERT OPINION: Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.


Subject(s)
Adrenal Cortex Hormones/therapeutic use , Anti-Inflammatory Agents/therapeutic use , Asthma/drug therapy , Bronchodilator Agents/therapeutic use , Leukotriene Antagonists/therapeutic use , Muscarinic Antagonists/therapeutic use , Administration, Inhalation , Adrenal Cortex Hormones/administration & dosage , Adult , Aged , Anti-Inflammatory Agents/administration & dosage , Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome/drug therapy , Humans , Leukotriene Antagonists/administration & dosage , Macrolides/administration & dosage , Macrolides/therapeutic use , Medication Adherence , Metered Dose Inhalers , Muscarinic Antagonists/administration & dosage , Smoking/adverse effects
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