Diffuse Alveolar Hemorrhage: A Fatal Complication of Rituximab

Pulmonary toxicity is a rare but severe adverse effect of Rituximab, associated with significant morbidity and mortality. Despite increased reporting, few case reports associated with alveolar hemorrhage due to Rituximab have been published. The authors present the case of a 61 year old Caucasian male with a diagnosis of small lymphocytic lymphoma who recently completed chemotherapy with Rituximab and Bendamustine. The patient presented to the emergency room with a one week history of nonproductive cough associated with shortness of breath and low grade fevers. Differential diagnosis at the time of presentation included health care associated pneumonia, Rituximab-induced pulmonary toxicity, and Pneumocystis jiroveci infection given his history of lymphoma and treatment with Rituximab. The patient was initiated on intravenous (IV) broad-spectrum antibiotics, oral atovaquone, and IV methylprednisolone. A CT scan showed bilateral diffuse pulmonary opacities and a video-assisted thorascopic surgery guided lung biopsy revealed early diffuse alveolar hemorrhage with no evidence for infection. However, the remaining work-up consisting of blood cultures, blood tests, and bronchopulmonary lavage did not produce any suggestive findings. Despite initiating the above aggressive therapies, the patient continued to rapidly deteriorate. An autopsy revealed diffuse alveolar hemorrhage of the lungs, thought to be secondary to Rituximab toxicity. The authors recommend emphasizing the importance of early identification of worsening pulmonary symptoms in patients receiving Rituximab, with diagnostic consideration given to Rituximab-related toxicity

Rectus Sheath Hematoma Associated with Apixaban.

Apixaban is an oral anticoagulant that directly inhibits Factor Xa and is indicated for the prophylaxis and treatment of deep venous thrombosis and stroke prevention in non-valvular atrial fibrillation. Rectus sheath hematoma is a rare, life-threatening complication of anticoagulant treatment. We describe a case of an elderly patient on apixaban for the treatment of deep venous thrombosis who developed severe abdominal pain during hospitalization. Computed tomography of the abdomen revealed left rectus sheath hematoma. Apixaban was discontinued and the patient was monitored for extension of the hematoma. After 2 days she was discharged home. Outpatient computed tomography 1 month later showed complete resolution of the rectus sheath hematoma. We recommend that clinicians become aware of the potential for rare and serious bleeding complications of anticoagulants and identify the need for early recognition and prompt management

Rectus sheath hematoma associated with apixaban

Apixaban is an oral anticoagulant that directly inhibits Factor Xa and is indicated for the prophylaxis and treatment of deep venous thrombosis and stroke prevention in non-valvular atrial fibrillation. Rectus sheath hematoma is a rare, life-threatening complication of anticoagulant treatment. We describe a case of an elderly patient on apixaban for the treatment of deep venous thrombosis who developed severe abdominal pain during hospitalization. Computed tomography of the abdomen revealed left rectus sheath hematoma. Apixaban was discontinued and the patient was monitored for extension of the hematoma. After 2 days she was discharged home. Outpatient computed tomography 1 month later showed complete resolution of the rectus sheath hematoma. We recommend that clinicians become aware of the potential for rare and serious bleeding complications of anticoagulants and identify the need for early recognition and prompt management

Mobilizing pharmacists to address the opioid crisis: A joint opinion of the ambulatory care and adult medicine practice and research networks of the American College of Clinical Pharmacy

The opioid crisis represents one of the largest failures of our current health care system as it continues to claim lives at an unprecedented rate and has caused a devastating range of preventable morbidity. Although the availability of highly potent synthetic opioids has amplified the urgency of the crisis for patients and communities, this problem has evolved over several decades. Pharmacists are in a position to offer many potential solutions due to their widespread accessibility, extensive drug knowledge, and integration into various health care settings. This opinion paper challenges the status quo by calling on all pharmacists to embrace evidence-based opioid stewardship and harm reduction practices, contribute to the medical management of opioid use disorder, and address the misconceptions and prejudices that serve as barriers to effective, compassionate patient care. Regardless of practice setting or available resources, pharmacists can take deliberate and impactful steps to address the opioid crisis. Some pharmacists may be positioned to implement innovative and far-reaching pharmacist-led clinical services, while others may simply begin with careful consideration of the language they use when speaking to and about patients with substance use disorders. To optimize patient outcomes, the ineffective laws, regulations, and policies that negatively impact pain and addiction care must be addressed so that evidence-based solutions can be widely disseminated. Pharmacists must aggressively advocate for the removal of barriers preventing high-level clinical practice or policies that perpetuate patient harm and abandonment. Finally, there must be support for continued research on pain and opioid use disorder treatments and services, as well as the impacts of harm reduction practices and pharmacist-led clinical services, so that resources can be allocated effectively