I want to talk about a patient who died when I was a trainee. He presented with an MI & was treated w/ the usual therapies along with an eptifibatide infusion (an antiplatelet gtt which was commonly used back then). He developed agitated delirium refractory to numerous medications… #EMIMCC #1/5

Eventually he deteriorated to the point of requiring intubation. CT head showed a massive subdural hematoma. Teaching point #1: when new-onset delerium occurs always look for bad things. Subdural hematoma can exert diffuse pressure on the brain with minimal focal neuro findings.

Review showed that the cause of the bleed was probably integrillin accumulation 2/2 renal failure. His GFR was <<30 All the RCTs on eptifibatide excluded patients with GFR <30! This is a classic example of indication creep: a drug is shown to be useful in a subset of patients ➡️ used too broadly

And to this day, the published dosing of eptifibatide doesn’t make much sense. You’re supposed to dose-reduce for GFR <50. But it doesn’t really make sense to give the same dose for GFR 49 & GFR 10 (the drug is renally cleared) 🧐