Drug of last resort

A drug of last resort (DoLR), also known as a heroic dose,

.

Purposes

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The use of a drug of last resort may be based on agreement among members of a patient's care network, including physicians and healthcare professionals across multiple specialties, or on a patient's desire to pursue a particular course of treatment and a practitioner's willingness to administer that course. Certain situations such as severe bacterial related sepsis or septic shock can more commonly lead to last resorts.

Therapies considered to be drugs of last resort may at times be used earlier in the event that an agent would likely show the most immediate

With regard to antibiotics, antivirals, and other agents indicated for treatment of infectious pathological disease, drugs of last resort are commonly withheld from administration until after the trial and failure of more commonly used treatment options to prevent the development of drug resistance. One of the most commonly known examples of both antimicrobial resistance and the relationship to the classification of a drug of last resort is the emergence of Staphylococcus aureus (MRSA) (sometimes also referred to as multiple-drug resistant S. aureus due to resistance to non-penicillin antibiotics that some strains of S. aureus have shown to exhibit). In cases presenting with suspected S. aureus, it is suggested by many public health institutions (including the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) in the United States) to treat first with empirical therapies for S. aureus, with an emphasis on evaluating the response to initial treatment and laboratory diagnostic techniques to isolate cases of drug resistance.

Due to the possibility of potential severe or fatal consequences of resistant strains, initial treatment often includes concomitant administration of multiple antimicrobial agents that are not known to show cross-resistance, so as to reduce the possibility of a resistant strain remaining inadequately treated by a single agent during the evaluation of drug response. Once a specific resistance profile has been isolated via clinical laboratory findings, treatment is often modified as indicated.

Agents classified as fourth-line (or greater) treatments or experimental therapies could be considered by default to be drugs of last resort due to their low placement in the treatment hierarchy. Such placement may result from a multitude of considerations, including greater efficacy of other agents, socioeconomic considerations, availability issues, unpleasant side effects or similar issues relating to patient tolerance. Some experimental therapies might also be called drugs of last resort when administered following the failure of all other currently accepted treatments.

Although most of the notable drugs of last resort are antibiotics or antivirals, other drugs are sometimes considered drugs of last resort, such as cisapride.^[2]

Examples

Antimicrobials

• Aminoglycosides — their use is extremely restricted due to risk of hearing loss and kidney damage.
• fungal infections and primary amoebic meningoencephalitis;^[3] its side effects
  are often severe or potentially fatal.
• Carbapenems (such as imipenem/cilastatin) — used as a drug of last resort for a variety of different bacterial infections.
• MRSA); use is limited to prevent development of drug resistance
  .
• Cefiderocol — a cephalosporin used to treat complicated urinary tract infections (cUTI) caused by multi-drug resistant Gram-negative bacteria in patients with limited or no alternative options.
• bacterial conjunctivitis, and systemically for meningitis when allergies to penicillin or cephalosporin exist. Unacceptably high risk of irreversible, fatal aplastic anemia and gray baby syndrome causes intravenous chloramphenicol to be a drug of last resort.^[5]
• Colistin — used against certain life-threatening infections, such as those caused by Pseudomonas; carries risk of kidney and nerve damage.
• Fostemsavir (an HIV attachment inhibitor) and lenacapavir (an HIV capsid inhibitor) are indicated in heavily treatment-experienced adults with multidrug-resistant HIV-1 infection failing their current antiretroviral regimen due to resistance, intolerance, or safety considerations.^[6][7]
• Linezolid — use is limited due to high cost and risk of vision loss or myopathy (due to mitochondrial damage).
• Tigecycline — used to kill Acinetobacter and Legionella species; this drug is limited by high cost and risk of liver injury.

Other drugs

• Alosetron — used in the management of severe chronic diarrhea-predominant irritable bowel syndrome (IBS-D) in females not responsive to conventional therapy. Its use is restricted due to serious gastrointestinal adverse reactions, e.g. ischemic colitis and complications of constipation.^[8]
• heart arrhythmias
  .
• benzodiazepines
  are not effective.
• seizures and myocarditis.^[9]
• Felbamate — an anticonvulsant used in refractory epilepsy. Its use is associated with an increased risk of aplastic anemia and liver failure.^[10]
• Isotretinoin — when all topical treatments or antibiotics against acne have failed, many dermatologists resort to isotretinoin, which is an oral treatment that permanently dries out the sebum production of the skin and is often a permanent solution against acne. It can cause severe nosebleeds, causes birth defects when taken while pregnant, is said to cause depression, hair loss and can permanently dry out the skin all over the body and is therefore not the first treatment.^[11]
• Levosimendan — used in acutely decompensated severe chronic heart failure in situations where conventional therapy is not sufficient.
• Oral minoxidil for hypertension,^[12][13] however topical minoxidil is a first-line drug for hair loss.
• Monoamine oxidase inhibitors — due to potentially lethal dietary and drug interactions which may trigger hypertensive crisis and/or serotonin syndrome,^[14] they are generally used only when other classes of antidepressants (e.g., SSRIs or SNRIs) don't work.^[15][16][17]
• erythema nodosum leprosum (ENL) in 1998, and 2008 for new cases of multiple myeloma (administered with dexamethasone
  ). A large "off-label" business in thalidomide began for rare cancers even while it was only FDA-approved for erythema nodosum leprosum.
• Tolcapone — used in patients with Parkinson's disease who are not appropriate candidates for other adjunctive therapies. Use is restricted due to hepatotoxicity.
• vision loss.^[18]

• Heroic measure

References