Nesiritide: Bad news from JAMA

Again, never be the first, and never be the last to use a new drug.  Looks like the jury’s still out on this one.  Here’s some of a review from Medscape about today’s JAMA article (emphasis added):

April 20, 2005 ? The bad news is getting worse regarding the
natriuretic nesiritide (Natrecor)
, a medication with both diuretic and
vasodilatory properties that is often given in the treatment of acute
exacerbation of decompensated heart failure.

Earlier research had shown that nesiritide, despite claims, is not
associated with preservation of renal function. Now, in a meta-analysis
published in the April 20 issue of JAMA, investigators report
that patients treated with nesiritide are more likely to die in the 30
days after treatment than are patients treated with noninotrope
therapies used in acute congestive heart failure.

The investigators found that
nesiritide-treated patients were 1.74 times more likely to die
within
the 30-day window. Among the nesiritide-treated patients, 35 (7.2%)
died in this time period compared with 15 (4.0%) of those treated with
other medications (P = .059). After adjusting for different variables, the risk of death in the nesiritide group increased slightly to 1.80 (P = .057).

And, it turns out it isn’t completely unexpected:

"These results were disappointing but not surprising," Stephen A.
Siegel, MD, said in a phone interview. Dr. Siegel, who was not involved
in the study, is a clinical assistant professor of medicine in the
division of cardiology at the New York University School of Medicine in
New York City.

"The inotropic support concept has never worked," Dr.Siegel pointed
out. "It’s paradoxical, because if the heart is lacking contractility,
it would make sense to give a medication that increases contractility.
However, this treatment approach doesn’t seem to reduce the risk of
death."

Dr. Siegel concluded, "It may be that we need to explores other ways
to treat congestive heart failure, such as the neuronal-hormonal
effect. The definitive answer of how to treat it hasn’t been identified
yet, but considering that inotropes don’t work, this drug class just
may be the wrong way to go."

JAMA. 2005;293:190-195    By

  Paula Moyer, MA Freelance Medical Writer

This drug has never caught on in our ED, and when used it’s been at the behest of the cardiologist who admits the patient.  Given this, I don’t see that changing.

Emergency Room Manners

Astounding rant from an ER triage nurse: Emergency Room Manners.

To review:

1) Don?t be an asshole
2) Lose the weight, stop smoking, take your damn psych meds, and take care of yourself!
3) Its not our fault or responsibility that you?re sick/injured. In fact, it?s probably yours.
4) Folks that arrive dead usually stay dead
5) It?s not like on TV
6) Years of patient abuse have (clearly) left us all a bit burnt out and jaded, so. . .
7) Don?t forget your manners when you come to my ER : )

Wow.  Couldn’t have said it better myself.  (Warning, actual ED language).

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