What medications should be held in a patient with sepsis?

Medications to Hold in Patients with Sepsis

In patients with sepsis, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), non-steroidal anti-inflammatory drugs (NSAIDs), and oral hypoglycemic agents should be held to prevent worsening organ dysfunction and mortality. 1

Medications That Should Be Held

1. Medications Affecting Hemodynamics

• ACEIs and ARBs: These medications can worsen hypotension in septic patients who are already experiencing vasodilation and may compromise organ perfusion
• Beta-blockers: May blunt compensatory tachycardia and further compromise cardiac output
• Diuretics: Should be held unless there is clear fluid overload, as patients with sepsis require adequate volume resuscitation

2. Medications Affecting Renal Function

• NSAIDs: Can worsen acute kidney injury in sepsis by reducing renal perfusion
• Metformin: Should be held due to risk of lactic acidosis, especially with impaired renal function
• Nephrotoxic agents: Including aminoglycosides, vancomycin (if alternative available), amphotericin B, and contrast agents unless absolutely necessary

3. Oral Medications

• Oral hypoglycemic agents: Switch to insulin therapy for glycemic control
• Oral anticoagulants: Hold and consider switching to parenteral agents if anticoagulation is still indicated
• Oral medications in general: Consider holding if patient has significant gastrointestinal dysfunction or is on vasopressors (poor gut perfusion)

Medications That Should Be Continued or Started

1. Antimicrobials

• Broad-spectrum antibiotics: Should be started within 1 hour of recognition of sepsis 1, 2
• Appropriate antimicrobial therapy: Based on suspected source, local resistance patterns, and previous culture data

2. Hemodynamic Support

• Vasopressors: Norepinephrine is the first-choice vasopressor for septic shock 1, 3
• Vasopressin: Can be added to norepinephrine (up to 0.03 U/min) when target MAP cannot be achieved with norepinephrine alone 3
• Epinephrine: Can be added when an additional agent is needed to maintain adequate blood pressure 1, 3

3. Supportive Medications

• VTE prophylaxis: Continue or start pharmacologic prophylaxis (LMWH preferred over UFH) unless contraindicated 1
• Stress ulcer prophylaxis: Continue in patients with risk factors for GI bleeding 1
• Corticosteroids: Consider in patients with refractory shock 1

Special Considerations

Medication Dosing in Sepsis

• Loading doses: Initial loading doses of antimicrobials should be administered regardless of organ dysfunction 4
• Maintenance doses: Should be adjusted based on organ function, particularly for medications cleared by the kidneys or liver
• Extended infusions: Consider for beta-lactams to optimize pharmacokinetic/pharmacodynamic parameters 4

Medication Review

• Perform daily medication review to:
  • De-escalate antimicrobial therapy when possible
  • Reassess the need for vasopressors
  • Evaluate for medication interactions
  • Adjust dosing based on changing organ function

Common Pitfalls to Avoid

1. Delaying antimicrobial therapy: Antibiotics should be administered within 1 hour of recognition of sepsis
2. Continuing ACEIs/ARBs: Can worsen hypotension and shock
3. Continuing oral hypoglycemic agents: Can lead to hypoglycemia or lactic acidosis
4. Inadequate VTE prophylaxis: Sepsis creates a hypercoagulable state
5. Failing to adjust medication doses: Pharmacokinetics are altered in sepsis due to increased volume of distribution and organ dysfunction

By following these guidelines for medication management in sepsis, clinicians can optimize patient outcomes while minimizing adverse effects and complications.