A Case Approach to Perioperative Drug-Drug Interactions

Catherine Marcucci, MD Anesthesia Services Department Philadelphia Veterans Affairs Medical Center Philadelphia, PA, USA   Michael P. Hutchens, MD, MA Department of Anesthesiology & Perioperative Medicine Oregon Health & Science University                                               Portland, OR, USA   Erica D. Wittwer, MD, PhD Department of Anesthesiology Mayo Clinic Rochester, MN, USA   Toby N. Weingarten, MD Department of Anesthesiology Mayo Clinic Rochester, MN, USA   Juraj Sprung, MD, PhD Department of Anesthesiology Mayo Clinic Rochester, MN, USA   Wayne T. Nicholson, MD, PharmD, MSc Department of Anesthesiology Mayo Clinic Rochester, MN, USA   Kirk Lalwani, MD, FRCA, MCR Department of Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland, OR, USA   David G. Metro, MD Department of Anesthesiology University of Pittsburgh School of Medicine Pittsburgh, PA, USA   Randal O. Dull, MD, PhD Department of Anesthesiology University of Illinois at Chicago Chicago, IL, USA   Christopher E. Swide, MD Department of Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland, OR, USA   F. Jacob Seagull, PhD Department of Medical Education University of Michigan Medical School Ann Arbor, MI, USA          Jeffrey R. Kirsch, MD Department of Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland, OR, USA   Neil B. Sandson, MD Department of Psychiatry University of Maryland Medical System Department of Psychiatry VA Maryland Health Care System Baltimore, MD, USA

Part I. Introduction to Drug-Drug Interactions.- 1. Let’s Start at the Very Beginning: Overcoming Fear and Gaining Mastery of Drug-Drug Interactions.- 2. Pharmacodynamic Interactions:  Core Concepts.- 3. Pharmacokinetic Interactions:  Core Concepts.- 4. A Brief Treatise On The Area Under The Curve.- Part II. Introduction to Drug-Drug Interactions:  Brief Review of CYP450 Enzymes, UGTs, and Transporters.- 5. CYP2D6:  Where It All Began.- 6. CYP2E1:  The Anesthesia Enzyme.- 7. CYP3A4:  The Workhorse.- 8. CYP1A2:  The Switch-hitter.- 9. CYP2B:   2B or Not 2B?- 10. CYP2C9:  The Support Crew I.- 11. CYP2C19:   The Support Crew II.- 12. UGTs:  Conjugating Cousins.- 13. The Cytochrome P450 System In Disease States—A Brief Review.- PART III. Drug-Drug Interactions:  Paradigms and Core Concepts.- 14. P-glycoprotein and OATP Transporters.- 15. The  “Fatal” Forty.- 16. The Six Patterns of Pharmacokinetic Drug-Drug Interactions.- 17. The Problem with the Drug-Drug Interaction Software: A Procrustean Dilemma.- 18. Pharmacogenomics.- 19. The Pharmacoepidemiology of Drug Interactions: Why and How They Are Important.- 20. The Lawyers Can Read, Too:  Case Presentations from the Courtroom.- Part IV. Drug-Drug Interactions Involving Inhalational Anesthetic Agents.- 21. Introduction.- 22. That Sums It Up.- 23. 1+1+1+1=?.- 24. A Delayed Surgeon Is A “Dismayed” Surgeon?.- 25. Relax, It’s Only Gentamicin.- 26. Jaundice After Surgery.- 27. Everybody Clear?.- 28. The Hemodynamic Hole.- 29. Alpha-2 To The Rescue But Beware Bradycardia.- 30. Hot Stuff!.- Part V. Drug-Drug Interactions Involving Intravenous Anesthetic Agents.- 31. Introduction.- 32. How to Successfully Occlude an Intravenous Line.- 33. A Curious Cause of Seizures.- 34. Magnesium Mama And The Mad Dad.- 35. Dexy’s Midnight Spinal.- Part VI. Drug-Drug Interactions Involving Local Anesthetics.- 36. Introduction.- 37. Comfortably Numb.- 38. Naturally Occurring And Nasty.- 39. LOL-LOL:  Little Old Lady—Lots of Lido.- 40. The Spinal Countdown.- 41.  Are Drug-Drug Interactions The Smoking Guns of Local Anesthetic Toxicity?  Smoking Gun I.- 42. Are Drug-Drug Interactions The Smoking Guns of Local Anesthetic Toxicity?  Smoking Gun II.- 43. A Perfect Storm?.- 44. Shake Rattle and Roll.- 45. Hello, We Have A Patient With Acute Delirium and We Need An Urgent Psych Consult.- 46. Fatal Pain Relief.- 47. Lipid Lifesaver.- Part VII. Drug-Drug Interactions Involving Opioids.- 48. Introduction.- 49. No ‘Subs’titute for Sobriety.- 50. A Needle And The Damage Done.- 51. Dad’s Not Having Much Pain.- 52. Royal Flush.- 53. The Worry That’s Always With Us:  Afternoon Nap.- 54. The Bawling Baby.- 55. Sleeping Beauty.- 56. Codeine Can’t Do It.- 57. A Shuddering Interaction.- 58. Double Indemnity.- 59. Breaking the Codeine .- 60. The Ultimate Ultram Primer I:  My Mood Is Better, But Boy Do I Hurt!.- 61. The Ultimate Ultram Primer II: I “Haight” Narcotics But I Hate Seizures Worse.- 62. The Ultimate Ultram Primer III:  Tremor-dol Trigger in Serotonin Syndrome.- 63. Too Much of A Good Thing.- Part VIII. Drug-Drug Interactions Involving Non-opioid Pain Medications.- 64. Introduction.- 65. Pining For Pete In The Pain Clinic.- 66. You Do Not Look Well Today, Mon Ami.- 67. My Headache is Gone, But My Leg Now Hurts.- 68. Special ‘K’ase.- 69. Not Manic About NSAIDs.- 70. Keep It Capped!.- 71. The ACE Is Not Always High.- 72. When The Smoke Clears, Relaxation Disappears.- 73. Befuddled by Aspirin.- 74. You Can’t Trick Us!.- Part IX. Drug-Drug Interactions Involving Benzodiazepines and Other Sedatives.- 75. Introduction.- 76. The Worry That’s Always With Us:  Now I’m Depressed.- 77. The Worry That’s Always With Us: Tragic But Not Rare.- 78. Lack of Sedation.- 79. A Cold Isn’t Going to Slow Me Down.- 80. Her Patients Never Wake Up On Time.- 81. When Enough Is Now Too Much.- 82. The Distressed Daughter.- 83. Check Check and Double Check.- 84. Doggone It—The Case is Cancelled.- 85. Noct’ Out.- 86. Predisposed to Doze.- 87. Synergistic Sedation.- Part X. Drug-Drug Interactions Involving Neuromuscular Blockade Agents.- 88. Introduction.- 89. Blocked Again.- 90. Irreversibility Sux.- 91. Keep An “Ion” The Twitches.- 92. A Reversal of Misfortune.- 93. Stop Moving.- 94. There’s Just Not Enough Roc In The World.- 95. Slow Sux I:  A Lengthy Wake-Up Period After Electroconvulsive Therapy.- 96. Slow Sux II:  I Remember Reviewing This For The Boards.- 97. Slow Sux III:  Where Did the Twitches Go?.- 98. Weakened All Weekend.- 99. The Patient Who Could Not Raise Her Head.- 100. An Unexpected Wait.- 101. Diabolical Cough Syrup.- Part XI. Drug-Drug Interactions Involving Antibiotics and Antifungals.- 102. Introduction.- 103. Full Stop.- 104. Flummoxed by the FLOX.- 105. Tales of Terror.- 106. Too Low To Go.- 107. A Fungal Story.- 108. Rejection Protection Turned Kidney Killer.- 109. Can’t Get Well.- 110. Linezolid (I): Be VREy Careful.- 111. Linezolid (II):  Hyper and Hot.- 112. Not Sweet At All.- 113. Where Did All The Sugar Go?.- 114. Exposed! (Part 1).- 115. Exposed! (Part 2).- 116. Seizures on 5 West.- Part XII. Drug-Drug Interactions Involving Cardiovascular Medications.- 117. Introduction.- 118. Riding The Rollercoaster.- 119. A Pressing Need For Vasopressin!.- 120. Too Young To Die.- 121. A Widening Gyre.- 122. Misusing Mom’s Meds.- 123. If the Patient Has No Renal Failure, Why is Her Potassium So High?.- 124. Prazosin and the PTSD Paratrooper.- 125. Nicardipine Notes.- 126. Hypotension Harry.- 127. Too Slow to Flow.- 128. Better Sleep But Slower Heart.- 129. Extreme Blood Pressure After Ephedrine:  Should We Rule Out Pheochromocytoma?.- 130. Heart-Stopping Treatment.- 131. Induction Crashes:  Are There Clues In the Ashes?.- 132. The Wakeup Call: 2AM Trauma.- 133.  Falling Down.- 134. A Hidden Drug.- 135. I’m Listening, I’m Listening.- 136. Jump Start My Heart.- 137. The Statin Trilogy (I): ‘Statin’ From The Beginning.- 138. The Statin Trilogy (II): Tripped And Fell At The Train ‘Statin’.- 139. The Statin Trilogy (III): Welcome To The United ‘Statins’ Of America.- 140. Be Still, My Beating Heart.- 141. The Nice Niece.- 142. Cyclo Killer: Qu’est-ce que c’est?.- 143. Blurry-Eyed With Rapid Heart Beats.- Part XIII. Drug-Drug Interactions Involving Coagulation Modifiers.- 144. Introduction.- 145. Seize the Day.- 146. The Third and Final Complication.- 147. An Interaction With the Furniture.- 148. Macrolide Mishap for Little Miss Muffett.- 149. From Asymptomatic to Symptomatic:  a Cause of Nosebleed.- 150. The Consequences of Not Following A Cardiac Diet.- 151. Clopidogrel (I):  Bagel Brunch.- 152. Clopidogrel (II):  Conferring Over The Kung Pao.- Part XIV. Drug-Drug Interactions Involving Immunosuppressants, Antiemetics, and Chemotherapy.- 153. Introduction.- 154. Beaned.- 155. Addisonian Adjustment.- 156. Tea Time.- 157.  No Fits at Uffizi.- 158. Quit Steroids Quit Kidneys.- 159. The Fall Guy (I).- 160. The Fall Guy (2).- 161. The Topic of the Day.- 162. Bounce Back.- 163. Call The Cath Lab!.- 164. The Imatinib Inquiry:  A Theoretical Case (For Now).- 165. A HAART-Breaking Tale.- Part XV. Drug-Drug Interactions Involving Neuropsychiatric Drugs.- 166. Introduction.- 167. Phenytoin (I): Going Crazy!.- 168. Phenytoin (II):  The Wrong Drug for the Schizophrenic.- 169. Dizzy and Depressed.- 170. The Funeral Is On Monday.- 171. This Antacid Is Making Me Sick!.- 172. Young at Heart.- 173. Shiver Yes, Die No.- 174. Clip and Dip.- 175. Blue Fog.- 176. Confiscated Contraceptives.- 177. Gotta Love Derm.- 178. Desperate for A Drink.- Part XVI. Drug-Drug Interactions Involving QT Prolonging DDIs.- 179. Introduction.- 180. Delusion At Heart.- 181. At Long Last.- 182. Metha-don’t!.- 183. Flash Fire.- 184. I Am Dizzy When I Stand Up.- Part XVII. Drug-Drug Interactions Involving Foods and Nutrition.- 185. Introduction.- 186. High Fat Diet (I): No Juice For The Ketotic Kid.- 187. Protein Huffing and Puffing.- 188. Salty Sam.- 189. A Peak Potassium Problem.- 190. Awake?.- 191. Tropical Punch Packing a Real Knockout.- 192. When The Fire Won’t Go Out.- 193. Peppermint Patty.- 194. From Bleeding Gums to Green Thumbs- A True Story.- 195. Delicious but Malicious.- 196. I Just Can’t Lick This Problem.- 197. Sommelier’s Surprise.- 198. Dairy Carefully.- 199. Cold And Sick, Sick And Cold.- 200. TPN (I):  A Review and Two Interactions.- 201. TPN (II):  A Traumatic Case of Increased Metabolism.- 202. Skin and Bones.- 203. Enough to Make You Sick.- 204. Determined and Desperate to Diet.- Part XVIII. Drug-Drug Interactions Involving Spices and Supplements.- 205. Introduction.- 206. Caffeine Crash.- 207. Sad Sequelae.- 208. The Scary Side of Ginkgo Biloba Is No Match For An Anesthesia Superstar: Seizures.- 209. The Scary Side of Ginkgo Biloba Is No Match For An Anesthesia Superstar:  Sugar.- 210. The Scary Side of Ginkgo Biloba Is No Match For An Anesthesia Superstar: Subdural.- 211. “Khat” Unawares.- 212. Pain on the Plane.- 213. Ca va, c’est Kava.- 214. Summertime and the Herbals are Hot.- 215. Garlic I:  More Than Just Bad Breath.- 216. Garlic II:  A Girl Named Allicin.- 217. “Danshen” the Night Away.- 218. Caught Yellow-Handed.- 219. St. John:  Not Such A Saint.- 220. Hearing the News.