Anthony Lau, PharmD BCPS

a man with a beard is smiling and looking through a hole in a door . ALT: a man with a beard is smiling and looking through a hole in a door .

1/🧵what happens after stopping #glp1 agonists like #semaglutide (#Wegovy #Ozempic) or tirzepatide (#Mounjaro #Zepbound)?

Recent BMJ analysis looked at #weight regain & cardiometabolic changes after discontinuation. Let’s break it down 👇 #medsky #pharmsky #IMsky #Endosky #diet #lifestyle

YouTube video by EMSwami Crystalloids in Hemorrhagic Shock #criticalcare #emergencymedicine #trauma

Avoid crystalloid in hemorrhagic shock
-May incr BP but not O2 carrying
-Dilute Hgb + clotting factors
-Saline contributes to acidosis + cold fluids contribute to hypothermia which worsens clotting

Patients don’t bleed crystalloid so don’t give crystalloid

youtube.com/shorts/QltA6...
#EMIMCC

The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema.

There is NO discussion or any additional text about this topic.

I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC

YouTube video by EMSwami Bicarb Pushes Utility #criticalcare #emergencymedicine

Bicarb Pushes
-Na channel blockade on heart: TCA + diphenhydramine toxicity (narrows QRS + stabilizes patient)
-Salicylism: alkalinizes urine incr toxin excretion
-HypoNa w/ seizures or significant neurological dysfunction when hypertonic saline not available

youtube.com/shorts/gQrwA...
#EMIMCC

10/ TLDR: before stopping glp1 therapy, discuss long-term plans for weight maintenance, lifestyle support, patient expectations...

glp1 agonists are highly effective but stopping them often leads to predictable weight regain, similar to stopping meds for other chronic diseases

a man in a yellow jersey with the number 11 on it is playing basketball ALT: a man in a yellow jersey with the number 11 on it is playing basketball

9/ Why does rebound occur? 🤔

- appetite suppression ends
- metabolic adaptation persists
- behavioural supports may not be sufficient alone

8/ This doesn’t mean glp1 agonists don’t work...

it just reinforces that obesity is a chronic disease, not a short-term treatment problem...

7/ It wasn’t just weight...

cardiometabolic benefits (HbA1c, BP, lipids) also gradually reversed after discontinuation, often within ~1–1.5 years!

6/ Greater initial weight loss = greater rebound!

Patients who lost the most weight on glp1 receptor agonists also tended to regain weight more quickly after stopping...

5/ At this rate, many participants were projected to return to baseline weight within ~1.5–2 years after stopping therapy

4/ After stopping medication, weight regain was common...

On average, ~0.4 kg (0.9 lb) regained per month once treatment was discontinued

3/ While on treatment, participants lost an average of ~8.3 kg (18 lb) overall...

glp1 agents (semaglutide, tirzepatide) produced even greater weight loss

2/ BMJ study analyzed 37 randomized trials (9,300+ adults) across multiple weight-loss drugs, including glp1 receptor agonists

www.bmj.com/content/bmj/...

a man with a beard is smiling and looking through a hole in a door . ALT: a man with a beard is smiling and looking through a hole in a door .

1/🧵what happens after stopping #glp1 agonists like #semaglutide (#Wegovy #Ozempic) or tirzepatide (#Mounjaro #Zepbound)?

Recent BMJ analysis looked at #weight regain & cardiometabolic changes after discontinuation. Let’s break it down 👇 #medsky #pharmsky #IMsky #Endosky #diet #lifestyle

Had a great time running workshop on cardiogenic shock/critical care cardiology for early career cardiology trainees yesterday. A repeat question was wether I have a blood pressure limit for when I give diuretics. I don’t. If the patient is truly volume overloaded, the bp won’t ⬇️ from the diuretic

YouTube video by EMSwami Bicarb Pushes + Acidosis #criticalcare #emergencymedicine

No role for bicarb pushes in metabolic acidosis
-Bicarb only incr pH if incr ventilation
-Met acidosis w/ resp alkalosis are maximally ventilating + blowing off CO2
-Intubating unlikely to help
-Bicarb pushes will worsen acidosis if not increasing ventilation

youtube.com/shorts/uS2VN...
#EMIMCC

a close up of a woman 's face with her eyes closed and her mouth open . ALT: a close up of a woman 's face with her eyes closed and her mouth open .

antiseizure medications has a PK/PD profile similar to beta-lactam antibiotics:

-efficacy relates to the trough level
-toxicity relates to the peak level

so benefit/risk ratio is maximized with smaller, frequent dosing

hard to do outside the hospital re: adherence

but easy to do for inpatients

Empirical evidence is limited...this concern of hydralazine ↑ICP largely stems from a 2-patient case series, not robust or contemporary trials...based on what I could find.

www.ahajournals.org/doi/epdf/10....

journals.lww.com/ccmjournal/p...

a man in a suit is taking his blood pressure with a device that says tcm ALT: a man in a suit is taking his blood pressure with a device that says tcm

In ICH, should we be cautious w/ hydralazine for BP control?

Commonly used w/ labetalol...hydralazine is a direct cerebral vasodilator that can ↑cerebral blood volume and ICP, potentially ↓CPP in patients with impaired autoregulation or mass effect

Thoughts? #EMsky #EMIMCC #neurosky #pharmsky

↑ICP is a concern in ICH due to its association with early deterioration, poor outcomes, and need for prompt management. Curious what BP agents others are using for ICH...what’s your go-to? 🤔

a man in a suit is taking his blood pressure with a device that says tcm ALT: a man in a suit is taking his blood pressure with a device that says tcm

In ICH, should we be cautious w/ hydralazine for BP control?

Commonly used w/ labetalol...hydralazine is a direct cerebral vasodilator that can ↑cerebral blood volume and ICP, potentially ↓CPP in patients with impaired autoregulation or mass effect

Thoughts? #EMsky #EMIMCC #neurosky #pharmsky

updated the IBCC chapter on BRASH

added a treatment checklist that walks you through resus of a sick BRASH pt

BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components

emcrit.org/ibcc/brash/ #EMIMCC

*Pulmonary embolism* versus *Acute myocardial infarction*:

Above and below the pen: the size of the clots in each scenario

I was looking for a picture like this and found it in a lecture by Dr Sripal Bangalore

#foamed #foamcc #meded #Medsky #emimcc

YouTube video by EMSwami Hypotension + Bradycardia #criticalcare #emergencymedicine #trauma

Hypotension + Bradycardia: Updated Differential

-HyperK
-Beta blocker/CCB tox (can occur outside overdose)
-Clonidine or digoxin tox
-Blood in belly (vagal stim)
-Neurogenic shock
-Severe hypothyroid
-HyperMg
-Inferior MI
-Advanced AV blocks
-BRASH Syndrome

youtube.com/shorts/S3ibt...
#EMIMCC

YouTube video by EMSwami The RSI Trial: Etomidate vs Ketamine #criticalcare #emergencymedicine #intubation

RSI Trial(PMID:41369227): Etomidate vs Ketamine
-No diff 28d mortality
-Incr HD collapse w/ ketamine (driven by incr/new pressors)
-Not clear why (More aggressive resus in etomidate group?)
-Forces us to reconsider our induction agent choice

youtube.com/shorts/CFWOR...
#EMIMCC

List of drug names and Pokemon names. Can you tell which one is which?

😨 for all my medical and #pharmacy friends (and/or #Pokemon fans!), try this challenge!!! Is it a Pokemon or drug name?? 🤔 #medsky #pharmsky #RxSky #nursesky

I failed miserably lol 🤦🏻‍♂️ (I’m not familiar with my brand names for medications…)

Inpatient pharm pearl:

Infusion durations for IV iron & bisphosphonates were designed to be *short* to improve patient throughput at *outpatient* infusion centers

For inpatients, SLOWING DOWN the infusion reduces infusion reactions/toxicity with *same* efficacy (these drugs work slowly) #EMIMCC

🔥Fresh blog🔥 Hot take on RSI trial of ketamine vs etomidate

RSI & EvK trials both show *more* BP instability with ketamine *but* lower mortality with ketamine 🤔

Cause of BP drops with ketamine?
- Less pressor pre-intubation?
- Ketamine provides analgesia (eliminating pain-as-a-pressor)?

... #1/2

Imi-rel in A1? At that point we’re not treating an infection…we’re marinating the patient! lol 🧂😬