Apretude and Code Blue

Episode 98: Apretude and code blue. 

Apretude is a new injectable medication for HIV pre-exposure prophylaxis (PrEP), Dr. Yomi presents how to use it. Then, Mandeep, Jon, and.  

Introduction: Apretude, a new injectable for HIV PrEP.  
By Timiiye Yomi, MD. Moderated by Jennifer Thoene, MD.  

What is HIV PrEP? Pre-exposure prophylaxis (or PrEP) consists of taking medication when a patient has a high risk of contracting HIV to lower their chances of getting infected. 

Who can take HIV PrEP? Individuals who may benefit from PrEP include but are not limited to: Male who have sex with male (MSM), people with multiple sexual partners with no consistent use of condoms, or people who have been diagnosed with an STD in the past 6 months, IV drug users who share needles, syringes, or other injection equipment.

History of HIV PrEP: In 2012, the first medication for HIV PrEP was approved—Truvada® (tenofovir-emtricitabine). Truvada is a once-daily oral prescription drug. Seven years later, in 2019, the next medication for HIV PrEP was approved— Descovy® (tenofovir alafenamide and emtricitabine). It is also a daily PO medication. But today we want to introduce you to the newest medication for HIV PrEP—Apretude® (cabotegravir). On Dec 20, 2021, FDA approved Apretude (cabotegravir), an extended-release injectable for HIV-1 pre-exposure prophylaxis for at-risk adolescents and adults who weigh at least 35 kg (77 lbs).

Mechanism of action: Apretude is a long-acting integrase inhibitor that works by binding to the HIV integrase active site and blocking the strand transfer step of retroviral DNA integration.

How is it given? 

Comes as a 600-mg (3-mL) injection. Patients receive 2 initiation injections administered 1 month apart, thereafter every 2 months. Patients can start medication immediately or first take the oral formulation for 4 weeks to assess how well they tolerate the medication before beginning the injection.

Trials: The safety and efficacy of Apretude in reducing the risk of contracting HIV-1 were evaluated in two randomized double-blind trials comparing Apretude and Truvada (once-daily oral medication).

Trial 1: Participants who took Apretude had a 69% less risk of contracting HIV compared to Truvada.

Trial 2: Participants who took Apretude had a 90% less risk of contracting HIV compared to Truvada.

Common side effects: Fever, malaise, fatigue, sleep problems, myalgias and arthralgias, headache, rash, red and swollen eyes, edema of face, lips, mouth, tongue; GI discomfort, hepatotoxicity, and depression.

Note: Some drug-resistant HIV variants have been identified in people with undiagnosed HIV prior to beginning Apretude. People who test positive for HIV while on Apretude must transition to a complete HIV treatment regimen as Apretude is not approved for HIV treatment. 

Requirements to receive Apretude: 

-Patient must be HIV-1 negative

-Patient must remain negative to continue receiving Apretude

-Patient must not miss any injections as this increases their risk of contracting the virus 

Apretude does not protect against other sexually transmitted infections. Patients must be sexually responsible and use other forms of protection such as condoms during sexual intercourse.

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

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A code blue in clinic.  

By Manpreet Singh, MS3; Jon-Ade Holter, MS3; and Sheinnera Gerongay, MS3. Ross University School of Medicine.

What is a code blue?

Arreaza: Today we will present to you a case to remind you about some principles of cardiopulmonary resuscitation (CPR). The term “code blue” in the United States refers to a situation where a patient is in cardiac arrest, respiratory arrest, unresponsive, or experiencing another medical emergency that requires immediate attention. “Code blue” is commonly used in hospitals and clinics to call a rapid response team to arrive immediately to evaluate the patient. We hope you can benefit from this brief review and feel ready for your next code blue. Of course, you will need more than we provide during these few minutes, but we hope it triggers your curiosity to keep learning or practicing. By the way, “code blue” is not standard for medical emergency in the whole world. For example, in the United Kingdom, they call it “code red”.

Case presentation: Mr. DD 56-year-old man with a past medical history of coronary artery disease, recent MI, DM2, and CHF presents today to our clinic for hospital follow. He had an MI 2 weeks ago. He reports that when he was at home working in the yard, he suddenly had 8/10 retrosternal chest pain, pressure-like, accompanied by shortness of breath and diaphoresis. The pain radiated to the left side of his neck/jaw and down his left shoulder and arm. 

Jon: Nitroglycerin was taken by Mr. DD 3 times without resolution of symptoms. The patient was taken by EMS to Kern Medical ER. In the hospital, there was a 4mm ST elevation on ECG on leads II, III, and aVF. Q waves were also seen in anterior leads V4-V6. Patient was taken to cath lab and stent was placed in the RCA. ECHO showed decreased left ventricle wall motion and dilated left ventricle with an ejection fraction of 28%. Mr. DD was discharged after 5 days in the hospital.

M: He is currently on lisinopril, carvedilol, atorvastatin, aspirin, clopidogrel, metformin, and digoxin. He states he is not compliant with all the medications because he forgets to get refills at times. He has a 35-pack year history of smoking and drinks 3-4 4oz drinks every day after work. He states he has used methamphetamine and cocaine intermittently within the last 6 months.

J: Today, he lets the MA know that he is having some chest pain at night, shortness of breath with minimal activity for the last week, and at times he feels his heart is beating too fast. He has a follow-up appointment with cardiology in 2 weeks. The MA tells you that the patient vitals today are BP:195/105, HR: 108, RR: 28, and O2% 89% on room air. 

M: You are reviewing the patient’s chart when you hear a loud thud coming from the room, you rush into the room and find the patient on the ground. The patient is unresponsive and is not moving. What is your next action? 

A. Try to lift the patient off the ground and back onto the chair or bed 

B. Give the patient nitroglycerin sublingually 

C. Call and wait for the EMS before proceeding 

D. Obtain IV access

E. See if the patient is arousable and check pulse and breathing 

E is the correct answer to this question because before initiating any type of treatment, first, you must assess the patient for alert response and their basic vitals such as their pulse and breathing.

J: We do this because we need to know if the cardiopulmonary systems are intact. When they are not intact, regardless of the level of medical training, we must start CPR protocol. 

M: This patient most likely suffered a tachyarrhythmia, a very common post-MI-complication that causes the highest mortality rates. The most common cause of death are ventricular fibrillation and ventricular tachycardia. 

J: These are the steps we must take in order to start resuscitation of the cardiopulmonary system in any environment before the patient can be taken to a higher level of care. In this situation, Doctor Holter and Doctor Singh will perform 2-patient CPR. This is only an introduction of basic life support and advanced cardiac life support. You will need additional training to get the BLS and ACLS certificates. 

M: First, assure your environment is safe before preceding to render care. You want to be able to give the best uninterrupted care to your patient without becoming a patient yourself. 

Jon: Doctor Holter. Mandeep: Doctor Singh.

J - Doctor Holter: I will reach down and check the patient. “Sir, Sir, are you okay” – I am assessing for reactions from visual or verbal cues given by me. When the patient is unresponsive to verbal and visual cues, I will give a painful stimulus to the patient such as a nail bed pinch or sternal rub. Next, it is necessary to assess the pulse and breathing of the patient. 

Narrator: The reason we check if the patient is alert is to assess the neurologic activity. The lack of response to painful stimuli indicates there is no self-protect response. To assess the carotid pulse, you must palpate the carotid artery by placing the index and middle fingers near the upper neck between the sternomastoid and trachea roughly at the level of the cricoid cartilage. Assess breathing by checking the rise and fall of the chest. Lack of responsiveness, pulse, and breathing indicates that immediate Cardiopulmonary Resuscitation (CPR) needs to be initiated. 

J - Doctor Holter: Please call 911 and get an AED.

M - Doctor Singh: I will call 911 and get an AED.

J- Doctor Holter: I will place the person on their back and start single-person CPR until Doctor Singh comes back. 

Narrator: CPR is performed by placing the patient flat on their back on an even surface. Place the heel of your hand on the center of the person’s chest (on the mid sternum) then place the palm of your other hand on top. Press down 5-6 cm (2-2.5 inches) at a rate of 100-120 beats per minute. Compressions should not be interrupted because they serve as an artificial way of contracting the heart and circulating the blood to maintain blood perfusion. 

For 1 or 2 person CPR on an adult: Give 5 cycles of 30 compressions to 2 breaths.

For 1 person CPR on a child: Give 5 cycles of 30 compressions to 2 breaths.

For 2 person CPR on a child: Give 5 cycles of 15 compressions to 2 breaths.

M - Doctor Singh : Doctor Holter, continue the compressions and I will give rescue breaths and start to place the AED pads on the patient. Let me know if you are tired and we can switch to give high-quality CPR with adequate depth and rate. 

Narrator: The AED comes with a diagram made on the pads to instruct where to place the pads. Once an AED is positioned correctly on the patient’s chest, let it detect if a shockable rhythm is present. Shockable rhythms include ventricular fibrillation and ventricular tachycardia. If there is not a shockable rhythm detected, then continue with CPR until a higher level of care is reached. If a shockable rhythm is detected, the AED will advise the users to step back and verbalize “clear” in order to ensure that everyone is clear of the patient. It will then administer a shock to the patient in the range of 120-200 Joules, based on the device manufacturer’s recommendation.

M - Doctor Singh: Doctor Holter, stay clear of the patient. The AED advises shocking the patient. I will press the button to administer the shock now.

Narrator: After administration of the first shock, ACLS guidelines recommend continuing CPR for 2 minutes without checking for a pulse, as effective cardiac contractility lags behind the restoration of an organized electrical rhythm. After the next 2-minute cycle of CPR, the AED will reanalyze the patient’s rhythm to determine if the rhythm is once again shockable. 

J - Doctor Holter: Doctor Singh , continue high-quality CPR while I initiate ACLS protocol. I will get an IV and start epinephrine. 

M- Doctor Singh: I will continue CPR in the meantime. 

Narrator: ACLS starts with again CPR, AED rhythm reading, and shock administration but with a higher level of care (ACLS). You must obtain IV or IO access. Epinephrine is administered every 3-5 minutes during the cycle in doses of 1 mg at a time. After each dose of epinephrine and CPR for 2 minutes the AED should reassess if the rhythm is shockable, and then continue CPR for another 2 minutes. At this time, it is recommended to use amiodarone or lidocaine. CPR will continue but at this time patient will likely be in the ambulance on the way to the hospital, and EMS will be managing the cycles. The cycles will continue until return of spontaneous circulation is obtained.

J: Myocardial infarction is the most common cause of shock-refractory ventricular fibrillation, along with coronary artery disease. If CPR does not resume spontaneous circulation within 40-50 minutes, there is a decreased chance of recovery. Spontaneous circulation may be achieved in patients with refractory Vfib with coronary revascularization. Therefore, in addition to traditional CPR, venoarterial ECMO (extracorporeal membrane oxygenation) can be used as an adjunct and can result in much better systemic perfusion. Essentially, this is a technique in which blood is drained from the body and circulated outside through an oxygen and heat exchanger and is then reintroduced into the body. This technique can be used if preparing for coronary revascularization. 

M: Vfib is a great risk in the acute phase after MI, up to 72 hours after revascularization, due to the recent ischemia and reperfusion. After the first 72 hours and up to a month following, Vfib remains a risk due to the continued remodeling of the heart. This newly remodeled tissue can cause interruptions in the normal electrical signaling of the heart leading to dissociated contractions and subsequent lack of perfusion through the body, which can quickly lead to death within minutes if not recognized and managed immediately with CPR and defibrillation as described.

J: Clinicians should be aware of their patients who would be more susceptible to serious events such as this and be on top of their training about management. This may not be a common occurrence in clinics, but it is a very serious event and requires a prompt and appropriate response.

Conclusion: Now we conclude our episode number 98 “Apretude and code blue.” Dr. Yomi concisely explained how to use the new injectable medication for HIV Pre-Exposure Prophylaxis (PrEP). Then, Manpreet, Jon, and Sheinnera presented a case that can actually happen in clinic and anywhere. CPR is a life-saving skill that needs to be learned and practiced over and over so we are not taken by surprise. Remember that heart disease continues to be the number 1 killer in the United States. So, make sure you know where your AED is and be ready to use it when needed. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Timiiye Yomi, Jennifer Thoene, Manpreet Singh, Jon-Ade Holter, and Sheinnera Gerongay.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week!

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References:

American Heart Association 2022 CPR cheat sheet. American Heart CPR Class, BLS, ACLS Ft. Myers all Lee County. (n.d.). Retrieved June 2, 2022, from https://www.cprblspros.com/cpr-cheat-sheet-2022.

Algorithms. CPR & First Aid, Emergency Cardiovascular Care, American Heart Association, cpr.heart.org. Retrieved June 2, 2022, from https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms.

Bhar-Amato J, Davies W, Agarwal S. Ventricular Arrhythmia after Acute Myocardial Infarction: 'The Perfect Storm'. Arrhythm Electrophysiol Rev. 2017 Aug;6(3):134-139. doi: 10.15420/aer.2017.24.1. PMID: 29018522; PMCID: PMC5610731.

Farkas, J. (2021, November 29). Post-mi complications. EMCrit Project. Retrieved June 2, 2022, from https://emcrit.org/ibcc/post-mi-complications/#ventricular_tachycardia.