Inpatient Insights
APhA Staff
Can I.V. calcium pretreatment prevent diltiazem-related hypotension?
AFib with rapid ventricular response (RVR) is often treated with diltiazem, a nondihydropyridine calcium channel blocker. However, hypotension is a significant adverse effect of this treatment. Researchers at the Haseki Training and Research Hospital (Instanbul, Türkiye) investigated the efficacy and safety of I.V. calcium pretreatment for preventing diltiazem-induced hypotension. The study was published online in The American Journal of Emergency Medicine on May 1, 2025.
The double-blind, placebo-controlled trial included 217 adults with AFib/atrial flutter and a ventricular rate less than 120 beats per minute, who were randomized into three groups: those who received an I.V. NaCl 0.9% placebo pretreatment prior to I.V. diltiazem and those who received 90 mg or 180 mg I.V. calcium chloride pretreatment before I.V. diltiazem. The researchers compared participants’ systolic BP and heart rate at baseline and at 5, 10, and 15 minutes post-treatment, as well as the incidence of adverse events (e.g., hypotension, urticaria, or nausea) among the groups.
The results indicated that placebo and 90 mg calcium chloride groups had significantly lower heart rate measurements at 10 and 15 minutes compared with the 180 mg calcium chloride group. In addition, at 5 minutes, the mean systolic BP in the placebo group was significantly lower compared with the other two groups. At 10 minutes, the mean systolic BP was significantly higher in the 180 mg calcium chloride group than in the other groups. Furthermore, at 15 minutes, the mean systolic BP was significantly higher in both the 90 mg and 180 mg calcium chloride groups than in the placebo group.
There were no significant differences between the calcium pretreatment and placebo groups in terms of the need for additional diltiazem doses or the incidence of adverse events. The researchers concluded that administration of 180 mg I.V. calcium prior to a slow I.V. bolus of diltiazem can effectively prevent drug-induced hypotension in patients with AFib with RVR over a 15-minute time frame. ■
Oral or ER injectable naltrexone for alcohol use disorder can start at hospitalization
Heavy drinking (defined as five or more drinks per day for men and four or more drinks per day for women) is common in hospital patients, but alcohol use disorder (AUD) medications are not typically initiated in the hospital. Researchers from Boston University compared the effectiveness of oral naltrexone and extended-release injectable naltrexone in a randomized clinical trial, with enrollment between June 2016 and March 2020.
The study, published online in JAMA Internal Medicine on April 21, 2025, involved 248 participants randomized into two groups, one that received oral naltrexone as inpatients and continued post discharge and a second group that received extended-release injectable naltrexone on the day of discharge with two more doses 1 month and 2 months later. The primary outcome was the 3-month change in percentage of heavy drinking days in the past 30 days. The secondary outcome was any acute health care utilization (emergency department or hospitalization) over the past 90 days at the 3-month follow up.
The results indicated that participants in both groups had substantial reductions in heavy drinking days, but there was no significant difference in the reduction of percentage of heavy drinking days in the past 30 days or acute health care utilization between groups. The authors concluded that hospitalization represents an opportunity to start AUD pharmacotherapy and that choice of oral naltrexone versus extended-release injectable naltrexone should be directed by patient preference and insurance. ■
Tapered prednisolone for alcohol-induced hepatitis may be better for infection
Current guidance recommends a 40-mg dose of prednisolone (or equivalent) as initial treatment for alcohol-induced hepatitis.
However, while corticosteroids provide a short-term mortality benefit, they do not improve long-term mortality and are associated with an increase in infection, with steroid-nonresponders at even higher risk of infection.
A group of researchers in India conducted a multicenter randomized clinical trial to determine whether rapid prednisolone tapering regimen mitigates infection in patients with alcohol-induced hepatitis. The primary objective was to assess the incidence of infection by day 90, with secondary objectives of the incidence of mortality, acute kidney injury, readmissions rate, and adverse events.
Over 250 patients at five medical centers were randomly assigned to receive a standard fixed prednisolone dose (40 mg/d) for 4 weeks or 40 mg/d tapered by 10 mg/d every week over 4 weeks.
The incidence of infection on day 90 was 33.1% in the fixed-dose group compared with 19.7% in the tapered dose group. There were no differences in mortality, acute kidney injury incidence, hospitalizations, or all-cause adverse events. The study was published online in The American Journal of Gastroenterology on March 13, 2025.
The authors concluded that in patients with severe alcohol-induced hepatitis, a tapered prednisolone regimen may mitigate the frequency of infections without compromising efficacy. ■
Researchers quantify white blood cell count response to steroids in noninfected hospital patients
Corticosteroids are an essential inpatient treatment of many inflammatory and autoimmune conditions, but they have a wide range of adverse effects, including immune suppression, and it is well-established that they cause leukocytosis. Therefore, patients taking steroids must be closely monitored for infection, and clinicians must decide whether a rise in white blood cell count is a result of steroid use or a developing infection. Using data from a single, large health system, researchers at the Cleveland Clinic aimed to quantify the white blood cell count response to corticosteroids in noninfected patients stratified by dose and observed for up to 4 days of treatment to help clinicians delineate the expected rise in white blood cells from corticosteroids.
The retrospective cohort study, published online in the Journal of Hospital Medicine on February 11, 2025, included over 28,000 patients with at least two white blood cell measurements, of which approximately 1,600 received steroids. The results showed that white blood cell response peaked at 48 hours after steroid administration with a mean increase of 2.4 x 109 cells/L. In all patients on steroids, across doses, the mean increase was 0.3 x 109 cells/L, 1.7 x 109 cells/L, and 4.84 x 109 cells/L in low, medium, and high dose groups, respectively. For patients not on steroids, the mean white blood cell count decreased during hospitalization.
The authors concluded that when interpreting white blood cell counts, clinicians should consider recent initiation of steroids and their dosage. While increases of as much as 4.84 x 109 cells/L may be seen 48 hours after initiating large doses, larger increases, increases following a daily dose of 320 mg or less of a hydrocortisone equivalent, and increases greater than 1 x 109 cells/L occurring within 24 hours after steroid initiation should trigger concern for other causes of leukocytosis. ■