Primer on Pharmacoeconomics for the Pharmacist

Abstract:Pharmacoeconomics is a form of economic assessment that involves the description and analysis of drug therapy or services and the impact of these assessments on individuals, health care providers or systems, and society. Pharmacoeconomic evaluations identify, measure, and compare the costs and consequences of 2 more alternatives. These “alternatives” may be pharmaceuticals, where a new drug is compared with an existing therapy, or may be some other intervention (such as a pharmacy service). The 4 basic types of pharmacoeconomic evaluations are cost-minimization analysis, cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Each of these evaluations has unique characteristics and purposes. Cost-minimization analysis is used when the alternatives being compared are considered equally effective. Cost-effective analysis is used when the alternatives have common outcomes but their effectiveness is not equal. Cost-utility analysis is a special form of cost-effectiveness that uses a measure of quality of life (e.g., the quality-adjusted life year), as the measure of effectiveness. Cost-benefit analysis can be used to compare 2 dissimilar programs but requires that the consequence measure be in monetary terms. The practicing pharmacist encounters situations daily where the concepts of pharmacoeconomics may be applied. Pharmacoeconomics can be used as a means to make better, more informed decisions in cases that involve costs and/or consequences of drug therapy or pharmacy services. Examples of such cases will be provided.

Law CE Lesson : "The Medicare Drug Benefit: What Pharmacists Need to Know"

Abstract:This review will provide pharmacists with a basic understanding of the Medicare Drug Benefit. The Medicare Modernization, Improvement, and Prescription Drug Act of 2003 (also known as MMA or the Medicare Drug Benefit), was enacted into law in 2003. The Medicare Drug Benefit represents the single largest change to Medicare since its inception in 1965. It provides coverage for outpatient prescriptions to all Medicare beneficiaries on a voluntary basis. It will be administered by private entities, including prescription drug plans and Medicare Advantage prescription drug plans. Medicare beneficiaries with limited incomes will be entitled to extra help in paying for the benefit. Beneficiaries who are eligible for both Medicare and Medicaid will now receive coverage from Medicare for their prescription drugs. Medicare beneficiaries who sign up for the Medicare Drug Benefit will be required to select a prescription drug plan in their region to receive coverage for prescription drugs. The Medicare Drug Benefit will involve pharmacists and pharmacies at all levels. Pharmacists represent one of the first points of access to the health care system for Medicare beneficiaries. Pharmacists may perform various activities, including advising patients regarding signing up for the Medicare Drug Benefit and selecting a prescription drug plan, eligibility assessment, dispensing and processing prescriptions for the Medicare Drug Benefit, payment assessment, formulary management, appeals, and medication therapy management services. The Medicare Drug Benefit will take effect on January 1, 2006, when pharmacists will begin to accept prescriptions that are covered by the Medicare Drug Benefit.

Herbal-Drug Interactions

Abstract:The general public’s use of herbals has increased over the past 10 years. Aside from the need to appraise these products for safety and efficacy, health care providers and the public need to know whether interactions might occur when these products are used in combination with conventional drugs. Most of the current evidence concerning interactions between natural products and drugs is based on known or suspected pharmacologic activity, data derived from in vitro studies, or anecdotal case reports that frequently lack pertinent information. The relevance of such information in terms of severity and outcome is questionable. More recently, there have been some reliable, documented case reports, in vivo studies, and clinical trials that have evaluated herbal-drug interactions. Results have sometimes been contradictory, and much more research is needed. The purpose of this article is to provide an evidence-based discussion and information to educate patients about potential herbal-drug interactions.

Striving Beyond Patient Satisfaction: A Roadmap for Pharmacists

Abstract:What is the key to having satisfied patients? How does a patient’s level of satisfaction with his or her health care experience impact his or her health status? What is customer delight, and how does one ensure patients experience it? This continuing education (CE) article will answer these and other questions related to the concept of patient (customer) satisfaction and its implications for pharmacists. The article will begin at a broad level and then delve into the concept of satisfaction and its relationship to expectations. The benefits of satisfied patients from a business perspective, including customer loyalty, will be discussed and strategies will be presented for the pharmacist to improve patient satisfaction. Additionally, improving patient satisfaction can also have significant clinical benefits to patients, and these will be explored. This article will provide examples of how pharmacists can measure satisfaction, track it over time, and incorporate it into business plans. Finally, the article will shift to the satisfaction of staff pharmacists and how it relates to quality of life in the workplace. Approaches to retention and recruitment, which are especially critical in this time of shortage of pharmacists, will be presented. After completing this CE article, the pharmacist should be much stronger in his or her ability to improve the satisfaction of his or her patients and colleagues and, as a result, will personally benefit.

Management of Chronic Kidney Disease and Secondary Complications: An Update on Available Guidelines

Abstract:Chronic kidney disease (CKD) is a progressive disease that without appropriate intervention ultimately leads to end-stage kidney disease (ESKD) and the requirement for renal replacement therapy. The growing number of patients with CKD and the projected increase over the next decade have prompted efforts to detect the disease at an earlier stage and initiate therapy targeted at delaying progression. Such therapy includes aggressive blood pressure control, management of hyperglycemia, and initiation of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), as appropriate. Paramount to management of CKD is recognition and treatment of the secondary complications, among which are fluid and electrolyte disorders, metabolic acidosis, anemia, secondary hyperparathyroidism, dyslipidemias, malnutrition, and cardiovascular disease (CVD). These secondary complications, in particular, cardiovascular events, increase morbidity and mortality in the CKD population. In general, the likelihood of developing the associated secondary complications and comorbidities increases as kidney function declines. Guidelines that address identification and management of CKD and common secondary complications have been adopted through efforts of the National Kidney Foundation (NKF), known as the NKF-Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) Guidelines. Despite the availability of these guidelines, secondary complications in patients with CKD often go unrecognized or have been poorly managed by the time a patient develops ESKD. Improved management of CKD and its associated complications may be realized using the NKF-K/DOQI Guidelines as a basis for therapy, while considering modifications as new information is made available. A multidisciplinary approach is also necessary for appropriate diagnosis, selection of drug therapy, dietary intervention, patient education, and assessment of outcomes.

Antiretrovirals: Pharmacotherapy and Adverse Drug Reactions

Abstract:Human Immunodeficiency Virus (HIV) currently affects approximately 850,000 to 950,000 patients in the United States. Since the disease was first discovered, about 524,060 people have died secondary to HIV. There were approximately 18,000 deaths caused by HIV in 2003. With the advent of antiretroviral (ARV) therapy, survival and quality of life have improved significantly. ARV therapy has also dramatically decreased mother-to-child transmission rates, as well as occupational transmission. However, ARV therapy, specifically highly active antiretroviral therapy (HAART), has introduced a number of complications previously unseen in pre-HAART patients. Complex interplay among adverse reactions (ranging from minor to life threatening), factors that affect adherence, and temperamental drug interactions make ARV therapy an art strongly rooted in science; thus, the door is open to many health care professionals, especially pharmacists, for contributions to optimize the care of these patients. This review will explain the pharmacology and appropriate use of ARV agents (ARVAs), including an overview of the current guidelines for initiation of ARV therapy, and describe notable adverse reactions. New and future therapies will also be discussed.

Antimicrobial Resistance in Gram-Positive and Gram-Negative Bacteria

Abstract:Infection attributable to a resistant gram-positive or gram-negative organism has been associated with increased morbidity and mortality. Current National Nosocomial Infections Surveillance System (NNIS) data indicate increasing resistance among many hospital pathogens isolated from the intensive care units (ICUs). This review will discuss the epidemiology of the increasing resistance problem, common mechanisms of antibiotic resistance, methods to slow the development of resistance, resistance issues with specific gram-positive and gram-negative organisms, and management strategies when infection with resistant bacteria is suspected or confirmed.

Drug Interactions Associated with Antidepressant Use

Abstract:Serotonin syndrome is a toxic effect attributable to overstimulation of the 5HT-1A receptor in the central nervous system (CNS). This serious condition is usually caused by a pharmacodynamic drug interaction between 2 or more medications that increase serotonin in the brain. Common signs and symptoms associated with serotonin syndrome are hyperreflexia, fever, mental status changes, agitation, diaphoresis, and diarrhea. Symptoms can range from mild to severe and usually develop within 24 hours of when the causative agent is initiated. Being able to identify the risks and signs of serotonin syndrome might be beneficial for clinicians especially for those who provide care to mental health patients. This syndrome is oftentimes misdiagnosed and results in a delay in treatment. With polypharmacy being common among patients with psychiatric diagnoses, drug interactions and serotonin syndrome are possible complications that occur with treatment. It is important for clinicians to understand the various ways drug interactions can manifest. Knowing the mechanism of action and major metabolic pathways for different antidepressants will help one to recognize the most clinically relevant interactions. Therefore, an alternative agent can be chosen, dosing can be adjusted, or monitoring can be increased to prevent an adverse effect from happening.

Medical Management of the Post-MI Patient

Abstract:The prevalence of coronary disease in the United States (U.S.) continues to increase as the population ages. There are approximately 7.8 million patients in the U.S. who have suffered an acute myocardial infarction (AMI), with almost one-half million new infarcts occurring each year. The 2004 update of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Management of Patients with ST segment Elevation Myocardial Infarction (STEMI) delineates treatment for the acute phase of a MI—AMI—and also addresses the post-discharge care of the patient. Recommendations are weighted according to the body of evidence supporting their use. Aggressive management of risk factors such as smoking, hypertension, hyperlipidemia, diabetes, and obesity are now emphasized. Drug therapy, including aspirin, â-blockers, and statins have been recognized as being able to reduce mortality. Data from several trials evaluating the role of inhibition of the renin-angiotensin-aldosterone system (RAAS) are presented. Pharmacists can play a critical role in the treatment and prevention of AMI. Identification of patients at high risk for cardiovascular events will allow the pharmacist to intervene and provide information to the patient regarding the importance of adherence to the prescribed medical regimen and healthy lifestyle changes. The pharmacist should also monitor the patient for potential adverse reactions, as well as achievement of the goals outlined in the ACC/AHA Guidelines.

Anticoagulation Therapy Update

Abstract:Thrombotic disorders include both acute and chronic syndromes and represent a significant source of morbidity and mortality worldwide. The pharmacologic management of these disorders began over 50 years ago when heparin and warfarin became commercially available. Since that time, there have been significant advances in the management of thrombotic disorders. In the late 1980s, the low-molecular-weight heparins (LMWHs) became available followed by the injectable direct thrombin inhibitors and recently the injectable pentasaccharides. Oral direct thrombin inhibitors are currently undergoing clinical trials and are expected to be available within the next decade. Besides advances in pharmacologic therapy, Guidelines have also been developed regarding the use of antithrombotic agents. These Guidelines are updated and published by the American College of Chest Physicians (ACCP). The first ACCP Guidelines on antithrombotic therapy were published almost 20 years ago. Since that time, there have been multiple revisions to these Guidelines, with the most recent update published in September 2004. This article will review the pharmacology of the available anticoagulant agents and the updated recommendations of the Seventh ACCP Conference Guidelines as they apply to the long-term management of anticoagulation therapy. Two anticoagulation therapy management cases will be presented. Upcoming anticoagulant agents and potential new indications will be reviewed where applicable.

Aromatherapy: Art or Science? Highlights of Aromatherapy in Medicine Today

Abstract:Aromatherapy is categorized as a form of complementary and alternative medicine (CAM), and has been steadily gaining popularity in today’s society. Aromatherapy has roots that can be traced back at least 5,000 years to ancient China, India, Persia, and Egypt. The word aromatherapy is used to describe the use of essential oils for aromatic inhalation, compresses, and topical application through massage. Aromatherapy should not be confused with aromatology, which is the oral use of essential of oils in addition to the application of neat (undiluted) oil through the skin. Aromatic oils are categorized by differences in how long the scent lingers. Those planning self-care with aromatherapy need to use caution when using oils owing to possible adverse reactions. The consumer can easily purchase essential oils on many Internet sites and in stores. Some colleges and universities have academic training programs for those interested in pursuing a career in aromatherapy. Trials using aromatherapy have investigated several therapeutic uses. Studies have attempted to quantify the comfort and symptom relief of blended oil aromatherapy in cancer patients. Other areas of investigation include the effect on central and autonomic nervous systems, such as in the case of neroli massage after cardiac surgery. Rosemary aromatherapy has been studied for its potential to stimulate attention and improve cognition. Dermatologic conditions, insomnia, and pain control have also been studied. Because of increasing popularity and its broad range of use, pharmacists may be asked questions on aromatherapy and should be aware of the potential hazards and lack of demonstrated efficacy.

Cholesterol: How Low Should You Go?

Abstract:Heart disease and stroke, 2 cardiovascular disease (CVD) components, are responsible for the first and third leading causes of death in the United States. Hyperlipidemia is one major risk factor for the development of CVD. The Adult Treatment Panel III (ATP III) was published in 2001 and has provided the most up-to-date guidelines concerning the management of elevated cholesterol levels. Five recent clinical trials have led to the July 2004 publication of the National Cholesterol Education Program (NCEP) Report Implications of Recent Clinical Trials for the NCEP ATP III Guidelines. Critical evaluation of these and other clinical trials provides guidance to the implication and potential implementation of the ATP III Report with a focus on elderly patients, secondary prevention, and patients with high CVD risk. The new treatment goals for high-risk patients are optional at this point. As new studies are designed and completed, additional evidence could be forthcoming that clearly delineates a benefit in reducing low-density lipoprotein cholesterol (LDL-C) values to < 70 mg/dL in high-risk patients. Although reductions in coronary heart disease (CHD) incidence may result from more aggressive use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins), it still remains to be seen whether declines in total mortality will be seen. The impact that low cholesterol levels have in other areas of a person’s life is still being investigated.

Ethical Issues in Investigational Drug Studies

Abstract:There has been an incredible advance in the protection of human research subjects since World War II. Unfortunately, the focus of investigators has not always been on the study participants. Protecting the rights, interests and safety of participants in research is mandatory. Nonetheless, protecting study participants involves more than ensuring the safety of individual study drugs. Protection of participants involves the patients’ understanding of the informed consent information and process, the role and risk of incentives and conflicts of interest and the general harm that patients may be exposed to as being participants in human studies.

Type 2 Diabetes: The Prevention and Treatment

Abstract:The purpose of this continuing pharmacy education (CPE) article is to review the prevention and treatment options for type 2 diabetes. Pathophysiology, diagnosis, and therapeutic approaches in optimizing glycemic control are covered in this paper. This CPE article also gives a brief overview of landmark trials in type 2 diabetes therapies, as well as new and upcoming agents for the treatment of type 2 diabetes.

Current Pharmacotherapy for Alzheimer's Disease

Abstract:This article describes current pharmacologic approaches to Alzheimer’s disease. The author delineates the 2 families of drug treatments currently available and the aspects of Alzheimer’s pathophysiology, which these drugs assess. The cholinesterase inhibitors are described along with their history of development. The newly approved N-methyl-D-aspartate (NMDA) inhibitor memantine is described along with how it will be used in practice, given the prevalence of the cholinesterase inhibitors.

Focus on Women's Health: Prevention and Treatment of Osteoporosis

Abstract:In recent years, Women’s Health issues have gained much attention in the medical community. For many years, diseases that seemed to have been specific to females were somewhat neglected or not focused upon by physicians. No longer is this the case. A disease such as osteoporosis, once thought to only affect elderly Caucasian women, is now being given much attention. The broken hip experienced by a 70-year-old female as a result of brittle bones and a subsequent fall was not thought about at age 20, when she could have started on the road to prevention. Women must be educated about a disease that might be prevented simply by taking precautionary measures such as proper diet, adequate exercise, and calcium supplementation. Women should also be informed that new medications are available that can be used to both treat and prevent this disease. While estrogen maintains a Food and Drug Administration (FDA)-approved indication for the prevention of osteoporosis, recent results of the estrogen plus progestin trial (EPT) of the Women’s Health Initiative (WHI) make continued use of the drug somewhat controversial. The FDA revised estrogen-containing product labels to read, “When these products are being prescribed solely for the prevention of postmenopausal osteoporosis, approved non-estrogen treatments should be carefully considered, and combination estrogen therapy should only be considered for women with significant risk of osteoporosis that outweighs the risks of the drug.” Two medications in the bisphosphonate class, alendronate and risedronate, have garnered a significant portion of the pharmacy market share and have been proven to be very effective in both the prevention and treatment of this disease. Though these drugs have been associated with severe gastrointestinal side effects if not administered properly, patient counseling by a pharmacist as to proper use can alleviate any such occurrence. Raloxifene and calcitonin are other medications used to treat and/or prevent the disease. The newest medication indicated for treatment of osteoporosis is teriparatide. Teriparatide was released onto the market in November 2002, and is a recombinant form of parathyroid hormone (PTH). Reserved for patients who are considered high risk, and unlike other drugs used to treat osteoporosis, which are antiresorptive, this drug is classified as a bone formation agent.

Law CE Lesson: "May You Legally Import Medications for Personal Use?"

Abstract:This continuing pharmacy education article will discuss the legal, political, and professional issues arising when patients import medications from Canada, Mexico, and other countries. Particularly, it will point out the risks to pharmacies, physicians, and other people who assist patients in importing medications. Although there are limited circumstances under which the FDA allows licensed entities to import prescription medications, there are numerous legal issues that make personal importation of prescriptions illegal. This article will discuss how the FDA, state boards of pharmacy, state boards of medicine, and state attorneys general are reacting to the recent surge of personal importation of prescription drugs.

Herbals and Other Dietary Supplements in the United States, Part III: A Historical and Contemporary Perspective

Abstract:Herbals have been used for healing throughout human history. In the U.S., herbal products are regulated as nutritional products rather than drugs. Yet, it is clear that these products are promoted and used as drugs by consumers. As with any health care products, their value and validity depend upon appropriate use. Also, as other health care products, there are pros and cons associated with the use of herbals. These include considerations of efficacy, safety, product quality, and consumer and professional education. Herbals will remain popular self-care products. Their appropriate use will depend upon the ability of both health professionals and consumers to accurately evaluate their health care needs and the products available to treat them. Both the pros and cons must be considered to ensure safety and efficacy.

New Advances in Fungal Pharmacotherapy: Voriconazole and Caspofungin

Abstract:Fungal pathogens are quickly becoming a major cause for concern in hospitalized patients. Particular concern has developed over the rate and severity of systemic mycosis in immunocompromised patients. Until recently, treatment of these severe infections relied on first-generation azole antifungals or amphotericin B. The approval and availability of voriconazole, a second-generation triazole with activity against Candida and Aspergillus species, and the first echinocandin, caspofungin, have expanded the clinician’s armamentarium against fungal infections. This review will help clarify the role in therapy of these 2 new agents. Increased clinical experience with the new agents may reduce the role of amphotericin B in the fight against system mycoses.

Sleep Disorders: Etiology and Treatment

Abstract:Human beings require sleep as a natural process of restoration, and disorders of sleep have been shown to increase morbidity and mortality. Pharmacists may elicit information to assist the patient in identifying appropriate self-care or physician referral through careful interview and assessment skills. Common causes of insomnia may be alleviated through lifestyle behavior modification (e.g., exercise, diet, tobacco, alcohol, and caffeine) and by encouraging patients to adhere to good sleep hygiene principles (e.g., regular wake and sleep times, sleep in bed). OTC sleep aids containing antihistamines, multivitamin supplements, and herbal products (e.g., valerian and melatonin) may be useful for treatment of temporary, mild sleep disorders. Patients should be cautioned regarding the potential side effects of self-care sleep aids, including residual drowsiness and psychomotor impairment. Patients with sleep apnea should avoid medications with central nervous system (CNS) depression. Short-acting benzodiazepines have replaced barbiturates and barbiturate-like drugs as the first-line treatment for transient and short-term insomnia. Ultra short-acting nonbenzodiazepine, sedative hypnotics such as zaleplon and zolpidem may offer an alternative treatment. Patients using sedative hypnotics should be cautioned regarding the potential for daytime psychomotor impairment, tolerance, dependence, and potential for withdrawal. Pharmacists may assist the patient and his or her physician in monitoring the safety and efficacy of self-care and prescription medications for short-term treatment of insomnia.

Hormone-Based Contraception: An Update of Novel Delivery Systems

Abstract:The contraceptive market in the United States has undergone expansion over the last decade, including 4 novel, hormone-based delivery systems. Although oral contraceptives are safe and effective options, the recently marketed intravaginal, transdermal, and injectable combinations and progestin-only intrauterine formulation provide important alternative methods for patients. Determining the most appropriate contraceptive choice can be facilitated by a 3-step approach that matches the goals of 3 reproductive stages, including delaying first pregnancy, spacing births, and completed childbearing. The first step addresses patient safety by screening for a patient’s eligibility for a hormone-based contraceptive. It also involves identification of a need for non-contraceptive benefits, such as cancer prevention or treatment of acne or perimenopausal symptoms. The second step considers factors that influence the efficacy of a method, including the frequency and route of administration and adverse effects. The newer formulations offer non-oral options that are dosed at extended intervals, including weekly, monthly, and every 5 years. The combination methods are associated with efficacy, adverse effect, and bleeding profiles that are similar to oral contraceptives. A patient’s preference is an important determining factor when choosing among the newer delivery systems. The third step is to identify a patient’s concerns regarding future fertility and lactation. All hormone-based methods are reversible, but progestin-only formulations are preferred during lactation. The 3-step approach for initial contraceptive selection must be accompanied by continued monitoring of adverse effects, device placement, and adherence to the regimen. The novel delivery systems allow for further options when matching contraceptive choices with individual patient needs.

Pharmacologic Treatment of Chronic Pain

Abstract:An estimated 48 million Americans suffer from chronic pain. More than 4 out of 10 patients in routine practice settings fail to receive adequate treatment. The undertreatment of pain is a major issue in today’s society. Undertreatment of pain is complicated by a health care professional’s fears of a patient’s addiction and diversion and regulatory action by the Drug Enforcement Agency (DEA). Effective pain management includes determining the underlying cause of pain, performing a physical assessment, using a pain scale, and classifying the type of pain. Three major classifications of pain are neuropathic, nociceptive, and idiopathic. Each class of pain varies in characteristics, etiology, onset of symptoms, and response to various medications. This article discusses in-depth, current treatment options in treating chronic pain, which includes opioids, tricyclic antidepressants (TCAs), antiepileptics, N-methyl-D-asparate (NMDA) receptor antagonists, and antiarrhythmic agents. An in-depth analysis of doses, various dosage forms, mechanisms of action, relative efficacy, adverse reactions, and drug interactions of the medications listed above will be discussed.

Law CE Lesson: "HIPAA Security Rule: Administrative Requirements"

Abstract:The Health Insurance Portability and Accountability Act of 1996 (HIPAA) security will be a pressing item for all covered entities to address. The compliance date for security is April 21, 2005. Larger organizations, especially those in the pharmaceutical industry, have started to examine the requirements defined in the final HIPAA Security Rule. This article establishes the core requirements for the final HIPAA Security Rule, as well as addresses the impact of the HIPAA Privacy Rule on security and the threats that enterprises face for electronic communication.

Rational Prescribing in the Elderly

Abstract:As the number of elderly people in the United States rises, sound medication prescribing for this population with special needs becomes increasingly important. There are a number of normal physiologic changes that occur with aging that may affect a medication, its dose, or frequency of administration, when used in a geriatric patient. In particular, decline in renal function, degeneration of the musculoskeletal system, and changes in the senses (i.e., vision, hearing, etc.) that regularly occur with aging may necessitate alterations in pharmacotherapy. Pharmacokinetic parameters also change with aging, most dramatically exemplified by excretion pathways. As a result, drug dosing and scheduling of medications commonly require adjustment in the elderly. A number of additional factors should be carefully considered when prescribing for the elderly. These include adverse drug reactions, interactions of all kinds, and the general functional decline that occurs with aging. To address these concerns, Beers criteria have been used over the past 10 years to assess medication regimens for geriatric patients. His recommendations serve as a guideline for rational geriatric prescribing. According to the guidelines, certain medications should not be used beyond a maximum dose or length of therapy in elderly patients. Likewise, some medications should be avoided completely in an elderly patient since safer alternatives are available. With the increasing number of medications from which to choose, pharmacists are indispensable for both proper geriatric patient assessment and in the evaluation of medication use for appropriateness and optimal therapeutic efficacy.

The Treatment of Addiction and Withdrawal Associated with Tobacco and Alcohol

Abstract:Alcohol and tobacco are the 2 most abused substances in the United States. More deaths and long-term health care effects result from the abuse of these substances than all other illicit substances combined. Each year, in the United States alone, more than 100,000 people die as a result of alcohol use and over 430,000 as a result of tobacco-related use. A major danger of these 2 drugs is that they are legal, making them widely available and, therefore, acceptable to many individuals. Both are considered “gateway substances,” meaning they can lead to abuse of illegal substances such as marijuana and cocaine. Alcohol has significant acute effects especially on the central nervous system, but most of the more devastating effects occur following chronic consumption. The treatment of ethanol intoxication is usually just supportive. The treatment of withdrawal requires substitution of the depressant effects of alcohol with long-acting sedative/hypnotic drugs like the benzodiazepines. Treatment of addiction to alcohol requires long-term psychosocial therapy and, in most instances, pharmacotherapy. Only 2 drugs are currently marketed for the treatment of alcohol abuse: disulfiram and naltrexone. Nicotine is one of the most psychologically addictive substances known. Although not without acute toxicity, the greatest impact of its effects are because of addiction to nicotine leading to significant increased risk of chronic disease. A very important component of the treatment nicotine addiction is pharmacotherapy. There are 5 drugs that are considered first-line medications (bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch) and 2 drugs that are second-line medications (clonidine and nortriptyline). These have all been shown to increase long-term smoking abstinence rates.

Management of Heart Failure: Part 2, Chronic

Abstract:As a large percentage of our population will soon be reaching 65 years of age, heart failure (HF) is becoming the new epidemic of our time. Organizations and associations have coordinated their resources to produce guidelines and treatment options to better assist health care professionals. HF has been classified into several different categories: right-sided versus left-sided, forward versus backward, systolic versus diastolic, high-output versus low-output, and acute versus chronic. This continuing education series is divided into 2 sections, Part 1 and Part 2. In Part 1, management of "acute" HF has already been addressed, and Part 2 is devoted to "chronic" HF. Currently, there are 2 sets of classifications commonly used for categorizing patients with HF. These include New York Heart Association (NYHA) "classes" and American College of Cardiology, American Heart Association (ACC/AHA) "stages." The NYHA classification system uses "subjective" information to classify patients in a HF category. The new 2001 ACC/AHA guidelines for management of patients with chronic HF use more objective information to classify patients with HF. The ultimate treatment goal is to decrease the development and progression of the disease and eliminate symptoms of HF. By achieving these goals, the patient should have a better quality of life and a longer life expectancy. Since studies and trials have used the NYHA guidelines in their design and eligibility, NYHA and ACC/AHA guidelines should be used together. The ACC/AHA guidelines have constructed an organized system to make a recommendation for an ACC/AHA "staged" patient using NYHA class information. Additionally, the ACC/AHA guidelines have used a recommendation scale to rate each recommendation in each stage based on the level of evidence. The medications in the guideline include diuretics, angiotensin converting enzyme (ACE) inhibitors, -blockers, digoxin, hydralazine-nitrate combination, angiotensin receptor blockers (ARBs), spironolactone, calcium channel blockers, antiarrhythmic agents, and intravenous (IV) inotropic agents.

Management of Heart Failure: Part 1, Acute

Abstract:As a large percentage of our population will soon be reaching 65 years of age, heart failure (HF) is becoming the new epidemic of our time. Organizations and associations have coordinated their resources to produce guidelines and treatment options to better assist health care professionals. HF has been classified into several different categories: right-sided versus left-sided, forward versus backward, systolic versus diastolic, high-output versus low-output, and acute versus chronic. This continuing education series is divided into 2 sections, Part 1 and Part 2. In Part 1, management of "acute" HF will be addressed and Part 2 will be devoted to treatment of "chronic" systolic HF. Most patients experiencing acute HF require hospital admission, especially if their symptoms are severe. The short-term goals of therapy include relief of symptoms, perfusion of organs, and stabilization of the patient. The treatment of acute HF depends on the presentation of the patient. In all cases, the underlying cause needs to be addressed and corrected, if possible. In general, if the pulmonary capillary wedge pressure (PCWP) is elevated, a diuretic may be the first-line agent of choice, followed by a vasodilator, if necessary. If the cardiac index (CI) is decreased, a positive inotropic agent may be the drug of choice. Other medications used in the treatment of acute HF will also be discussed.

Schizophrenia, Part II: Treatment

Abstract:Schizophrenia is a chronic disorder and the most commonly diagnosed psychosis. In the United States, there are over 3 million current cases with an estimated 100,000 new cases diagnosed each year. The drugs used to treat schizophrenia are commonly called antipsychotics and were formally known as neuroleptics or major tranquilizers. For many years, the treatment of schizophrenia relied on therapeutic agents that displayed serious adverse effects (extrapyramidal and anticholinergic effects). One of the most serious of these effects is tardive dyskinesia, a potentially irreversible disorder characterized by involutary, abnormal movements. In the past, treatment with typical antipsychotics was ineffective in a significant proportion of schizophrenics. Typical antipsychotic agents tend to be more effective in reduction of the positive symptoms than the negative symptoms of schizophrenia. Atypical agents are now the first-line therapy for schizophrenia, which are attributable to their efficacy in ameliorating both positive and negative symptoms and reducing the incidence of serious adverse effects. Both the increased efficacy and reduced adverse effects are the result of greater selectivity for antagonism of dopamine receptors in specific regions of the brain and their ability to modulate dopaminergic neurotransmission by blockade of a subset of serotonin receptors.

Time Management Techniques for Pharmacists

Abstract:As pharmacy practice continues to evolve, pharmacists will need to make changes in job design to help optimize time management in pharmacy settings. It is likely, however, that some pharmacists do not have the authority to engage in extensive job redesign efforts. In other cases, even after job redesign, stressors may still be present, and there will be a need for pharmacists to effectively manage their time within those situations. The goal of this article is to help pharmacy practitioners learn about time management techniques that they can apply to their personal practice. The ideas presented in this article are based on a book by Robert W. Bly titled 101 Ways to Make Every Second Count. In his book, Bly offers time management tips and techniques in general terms. In this article some of the techniques outlined in that book are reviewed and applied to pharmacy practice. This article highlights 5 areas: (1) changing work habits to increase productivity, (2) increasing personal efficiency, (3) evaluating technologies that could save time, (4) delegating and outsourcing, and (5) managing information overload. Time is not something that can be stored or saved. It is, however, something in which we can invest. The commonsense approaches to time management outlined in this article can help pharmacists invest their time wisely and help "make every second count."

A Focus on the Pharmacologic Management of Allergic Rhinitis

Abstract:Allergic diseases account for a significant amount of disability than are generally realized. Allergic rhinitis is responsible for over 100 million lost workdays among adults and approximately 1.5 million missed school days among children annually. This manuscript reviews the pathogenesis, clinical presentation, and management of allergic rhinitis, with a focus on pharmacotherapy. Several drug therapies are effective for the management of allergic rhinitis. However, the adverse effect profiles of these drugs differentiate them from one another. The clinical application of various drug therapies, such as first- and second-generation antihistamines and nasal corticosteroids, are discussed with special consideration given to clinically significant adverse effects of these agents.

An Update on Treatment Strategies for Acute Otitis Media

Abstract:Acute otitis media (AOM) is a common infectious disease in children, especially in the age range of 6 to 24 months. It is associated with an annual cost of $3 to $4 billion to the health care system. AOM is an infection of the middle ear space. Blockage of the Eustachian tube leads to a buildup of fluid in the middle ear, facilitating bacterial growth. The most common bacteria causing AOM are Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), and Moraxella catarrhalis (M. catarrhalis). In recent years, an alarming percentage of S. pneumoniae has developed resistance to penicillin and other antibacterials. S. pneumoniae has developed resistance to penicillin by alteration of the penicillin-binding site, also known as penicillin binding proteins (PBPs). H. influenzae and M. catarrhalis have also developed resistance to penicillin; however, the mechanism of resistance most often seen in these bacteria is production of -lactamase, an enzyme that breaks the -lactam bond of penicillin and other -lactam antibacterials. Several recent publications have outlined updated treatment strategies for AOM in light of current resistance trends. A Centers for Disease Control (CDC) experts group recommended in 1999 that amoxicillin (standard or high dose) should remain first-line therapy for AOM. This panel, however, only recommended 3 drugs for treatment of AOM unresponsive to amoxicillin: amoxicillin/clavulanate, cefuroxime axetil, and ceftriaxone. Others have published guidelines that include trimethoprim/sulfamethoxazole (TMP/SMX), cefprozil, ceftibuten, cefixime, cefdinir, and cefpodoxime proxetil, in addition to those medications that the CDC working group recommended. Most recent literature suggests that cefaclor, loracarbef, and the macrolides have limited usefulness in AOM and, in most cases, should be avoided.

Treatment Options for Adult Obesity

Abstract:Obesity is a complex, chronic disorder with a multifactorial etiology. Numerous genetic and environmental factors have been found to contribute to the recent epidemic of obesity. Over half of all United States (U.S.) adults are overweight or obese and between 12% -14% of U.S. children and adolescents are overweight. Obesity-related comorbidities include type 2 diabetes, coronary heart disease, hypertension, and sleep apnea. Obese individuals also experience emotional, social, educational, and economic discrimination. Weight management efforts must be directed at the community as a whole and the individual client. Treatment options include lifestyle interventions, such as dietary, physical activity, and behavioral modifications, and medical interventions, such as pharmacotherapy and surgery. Lifestyle modifications are very low in cost and carry few, if any, potential for risk. Diets with a modest (300-500 kcal/d) reduction in energy intake will result in a gradual loss of ½ to 1 lb/wk with good prospects for long-term weight maintenance. Low fat, high fiber diets further enhance the weight loss and maintenance processes. Physical activity, while inadequate as the sole intervention for weight loss, appears to be a key factor for long-term maintenance of initial weight loss. There are very few drugs approved by the Food and Drug Administration (FDA) for short- or long-term use for weight control, and those with FDA approval often are associated with harmful side effects. Surgical intervention should be reserved as the treatment option of last choice, appropriate only for the morbidly obese client who has failed to achieve or sustain appropriate weight loss through other less intensive approaches. The treatment of obesity must address improvement of health, implementation and continuation of lifestyle change, and enhancement of body composition, rather than focusing solely on the loss of body weight. Treatment plans must be individualized and offered within a multidisciplinary plan of care.

Herbals and other Dietary Supplements in the United States, Part II: Popular Herbal Remedies

Abstract:Safety and efficacy issues surrounding the use of the most popular herbs are discussed. The various herbs classified under the general heading "ginseng" are compared and contrasted. Echinacea is commonly used for treating colds and flu. St. John's Wort is among the best studied herbs in terms of efficacy in treating depression and drug interactions. Saw palmetto is used to treat benign prostatic hypertrophy with a minimum of side effects and drug interactions. Garlic has a wide range of uses, including hyperlipidemia, hypertension, and infections. Kava kava shows promise as an alternative for mild anxiety disorders. Valerian has been used with some success to treat insomnia. Ginkgo has gained acceptance for treating dementia, memory loss, and intermittent claudication. Goldenseal is a popular but probably ineffective antiseptic and agent for masking drug screens. Milk thistle may have a role in treating liver disease of various origins. Aloe is used as a laxative and to treat wounds. Black cohosh is a popular herb for treating the symptoms of menopause.

Topical and Transdermal Drug Delivery: What a Pharmacist Needs to Know

Abstract:The extent and rate of percutaneous drug absorption and transportation are influenced by various factors including skin physiology, physicochemical properties of drugs and excipients, as well as fabrication and design of the delivery systems. The goal of this article is to review some of these important features and to discuss how these relate to patient counseling on various topical and transdermal products.

Optimizing Antiemetic Therapy for Chemotherapy-induced Nausea and Vomiting

Abstract:Patients receiving chemotherapy cite chemotherapy-induced nausea and vomiting (CINV) as the symptom causing the most concern. The symptoms vary from slight nausea to protracted vomiting with subsequent dehydration. While recent progress has been remarkable, CINV continues to be an important problem since many patients experience this side effect. The pathophysiology of CINV is not well understood, but serotonin (5-HT₃) receptors play an apparent important role. However, many other pathways are probably involved in CINV, and a combination of agents may be necessary to prevent nausea. The types and pattern of CINV are acute, delayed, and anticipatory nausea and vomiting. The acute and delayed phases of CINV are unique to the chemotherapy agents administered. An understanding of each of these phases of CINV enables the pharmacist to make prescribing recommendations. Each chemotherapy agent will demonstrate different levels of emetogenic potential. Classification of the agents in a systematic manner is an important tool for guiding the selection of antiemetics. The high and moderately emetogenic chemotherapy agents will require corticosteroid and serotonin antagonists to prevent nausea. Prescribing antiemetics according to practice guidelines can improve outcomes of patients and reduce the cost of therapy. A methodology to provide consistent antiemetic therapy for patients receiving chemotherapy is a necessary to provide the best care for cancer patients.

Lipid-lowering Therapy: A Review for Pharmacists

Abstract:Coronary heart disease (CHD) is the leading cause of death in the United States. Approximately 500,000 Americans die each year of this disease, and associated morbidity costs more than $100 billion annually. An estimated 52 million adults require dietary changes and 12.7 million need lipid-lowering therapy. The National Cholesterol Education Program developed guidelines and clear objectives with treatment goals to reduce the risk of CHD in patients with lipid abnormalities. Despite the established relationship between lipid abnormalities and CHD morbidity and mortality, disparity exists between established guidelines and clinical practices. The majority of patients eligible for lipid-lowering therapy remain untreated, and those that receive treatment fail to reach target cholesterol values. Pharmacists managing lipid-lowering treatment have recently demonstrated an improvement in lipid-lowering outcomes when they were compared with previously published clinical studies. The primary medications used to treat hyperlipidemia are statins, niacin, bile acid resins, and fibric acid derivatives. Of these agents, the statins are the most effective with relatively few adverse effects and are supported by favorable outcome studies. These studies provide evidence that statin therapy reduces the risk of first-time and recurrent coronary events and death from coronary events and all causes. Pharmacists have already made a significant impact in the area of dyslipidemia disease state management. All pharmacists can contribute to improved lipid therapy outcomes using current clinical guidelines, clinical outcomes data, and their unique knowledge of cholesterol-lowering medications.

The National Asthma Education Prevention Program (NAEPP II) Guidelines for the Treatment of Asthma: Implications for the Pharmacist (Manuscript Updated December 2000)

Abstract:The National Asthma Education and Prevention Program (NAEPP II) Expert Panel II Report updated its recommendations for the monitoring and treatment of asthma in February 1997. This article updates the pharmacy practitioner on significant changes from the first panel report published in September 1991. The Report identifies 4 components that are important for effective asthma management: 1) assessment and monitoring, 2) environmental control, 3) comprehensive pharmacologic therapy, and 4) patient education. All patients should perform daily home peak flow monitoring with moderate-to-severe persistent asthma to detect the onset of acute asthma exacerbations. Peak flow monitoring may also be useful in other asthma patients to establish their personal best peak expiratory flow rate (PEFR), assess efficacy of changes in chronic medications, and identify asthma triggers. Patients with moderate to severe asthma or a history of severe asthma exacerbations should also have a written asthma care plan that specifies their chronic medications and recommendations for acute management of asthma exacerbations based on peak flow readings and asthma symptoms. The patient in conjunction with health care professionals should identify goals for asthma therapy. Management of all patients with asthma should include environmental or trigger control and a short-acting beta agonist for acute asthma symptoms. Patients with mild, persistent asthma should also receive an anti-inflammatory agent to minimize the potential for the development of chronic lung impairment. Patients with asthma require asthma education that is "integrated, systematic, and tailored to individual patient needs." Content should include information regarding the disease, monitoring, and treatment of asthma and environmental control of asthma triggers. Pharmacists can be important providers of asthma education and can also verify a patient's understanding and expand on information provided by other health care professionals. Ways pharmacists can implement the NAEPP II Guidelines into their practice are discussed.

Tales of Migraine: Migraine Overview from a Clinician's Perspective

Abstract:In spite of advances in migraine and headache therapy in the last decade, migraine remains underrecognized and undertreated. This may be explained, in part, by the heterogeneity of presentation of migraine and, in part, by an unfamiliarity of the pathophysiology and chronic nature of this condition. Migraine may progress in frequency and severity and may transform into a very frequent or daily headache, particularly with comorbidities such as depression or with excessive analgesic use and analgesic "rebound." Migraine as a primary headache disorder must be differentiated, particularly when progressive, from secondary headache because of intracranial or systemic disease. The treatment of migraine can be complex, as this involves consideration of preventive medications and nonpharmacologic therapies when headaches become frequent and disabling. Many headache-abortive therapies, particularly ergot derivatives, have been successful in the past, and remain important options for migraine, although triptan medications have revolutionized migraine abortive therapy. The proper use of these and other therapies would alleviate not only discomfort but the significant disability associated with migraine.

Primer on Disease Management

Abstract:Since its introduction in the mid-1990s, disease management (DM) has often been a misused and much abused phrase. Nonetheless, DM can best be described as an evaluative approach to health care delivery that attempts to improve outcomes for patients with a specific disease while optimizing the overall use of health care resources. DM differs from traditional health care delivery in many ways, but, most noticeably, DM offers a broader perspective of the health care provided. Numerous organizations, including pharmacy benefit management companies, managed care organizations, pharmaceutical manufacturers, employers, and others, can have roles to play in DM programs, but a direct patient-provider relationship is a prerequisite for DM to be successful. Key components of DM programs include the following: a continuum of care perspective, focus on patient health-related outcomes, optimization of economic outcomes, use of clinical practice guidelines, focus on chronic diseases, implementation of continuous quality improvement, integrated health databases, feedback to health care providers, and an expanded role of pharmacists in drug therapy monitoring. The 8 primary steps to implementing a DM program are explained as well as the primary aspects of DM program evaluation. While DM has captured the attention of most health care organizations, the lack of rigorous evaluations of DM programs and the continued use of component management have prevented DM from being universally implemented with success.

A Primer and Update of Basic Cardiac Electrophysiology and Antiarrhythmic Agents

Abstract:Developing an adequate comprehension of arrhythmias and antiarrhythmic agents (AAAs) requires a basic knowledge of cardiac electrophysiology. Most clinicians find the understanding of arrhythmia and AAAs difficult. There are approximately 60 medications that directly affect cardiac electrophysiology. Additionally, there are several other non-cardiac medications that may affect the cardiac rhythm indirectly. The goal of this article is to present an understandable discussion of basic cardiac electrophysiology and a review of selected AAAs.

Diagnosis and Therapeutic Management of Depression: An Update in the Use of Selective Serotonin Reuptake Inhibitors (SSRIs)

Abstract:Major depression is a very common disorder in the United States. Although effective treatment has been available for almost 40 years, it often goes underdiagnosed and, consequently, undertreated. It has been estimated that the annual cost of depression in the United States totals approximately $43 billion. This figure includes the direct costs of medications and physician visits as well as indirect costs, such as loss of productivity in the workplace. Therefore, it is important to recognize the signs and symptoms of depression in order to treat the disease. The discovery of selective serotonin reuptake inhibitors (SSRIs) has had a major impact on the therapeutic management of depression. Five SSRIs are currently available in the United States market: citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline. This review will focus on the recognition and diagnosis of depression as well as a comparison of the available SSRIs. The SSRIs have made an impact in the treatment of depression because of their favorable side effect profile, tolerability, and relative safety in overdose. Although the SSRIs have, essentially, the same pharmacology, their chemical structures are slightly different; thus, they differ slightly in their side effect profiles as well as their interactions with other medications. The selection of the appropriate SSRI should be based on the patient’s symptoms of depression, concurrent medications (to avoid any potential drug interactions), and side effect profile. Depression is one of the most costly disorders in the United States, and diagnosis is the first step in treatment. Education of the public as well as healthcare providers is the key to the treatment of depression. Once diagnosed, SSRIs can be used effectively to treat depression.

Update on the Management of Common Musculoskeletal Conditions: Osteoarthritis, Rheumatoid Arthritis, and Fibromyalgia

Abstract:Musculoskeletal conditions affect over 40 million people in the United States. The 3 most common are osteoarthritis, rheumatoid arthritis, and fibromyalgia. Osteoarthritis is the most common form of all musculoskeletal conditions affecting more than 20 million people in the United States. Rheumatoid arthritis and fibromyalgia are not as common, but have a significant impact on a patient's quality of life and physical functioning. The exact etiologies of these conditions are not well understood, but research on these topics is providing important information about the pathophysiology of these diseases. Currently, therapy is aimed at reducing the pain and other symptoms associated with these conditions. Non-pharmacologic therapies play an important role in the treatment of these disorders including weight loss, exercise, and physical therapy. Pharmacologic therapy is aimed at pain relief and, in the case of rheumatoid arthritis, disease modification. In addition to therapies that have been available for years, new therapies with fewer side effects and more specific mechanisms of action are being studied and released. Pharmacists should become familiar with these therapies to help patients achieve optimal treatment outcomes.

Herbals and other Dietary Supplements in the United States - Part I - Dietary Supplement Regulations: Impact on Pharmacy. THIS IS A CE PROGRAM ON LAW.

Abstract:Sales of herbal and other dietary supplements have increased sharply in recent years in the United States (U.S.). A 1997 survey of the U.S. herbal markets estimated that 60 million adults (one-third of the adult population) used herbal supplements. Under the Dietary Supplement Health and Education Act of 1994 (DSHEA), dietary supplements are sold as “foods” to be used to supplement the diet. These products are not regulated as nonprescription drugs, or Over-the-Counters (OTCs), and manufacturers do not need Food and Drug Administration (FDA) approval for safety and efficacy prior to marketing dietary supplements. The goal of Part I of this continuing education series is to discuss the issues and controversies surrounding the recent explosion in the use of alternative medicine and dietary supplements. After completing this article, the practicing pharmacist should have a greater understanding of current regulations of dietary supplements, the potential quality assurance problems that may be associated with these products, and how this impacts the practice of pharmacy.

Update on Adult Immunization

Abstract:Vaccine-preventable diseases of adults represent a continued source of morbidity and mortality in the United States. Safe and effective vaccines are available for these infections but they are poorly used. The available vaccines include the pneumococcal, influenza, hepatitis B, hepatitis A, varicella, measles-mumps-rubella, and tetanus-diphtheria vaccines. Among these, the pneumococcal, influenza, and hepatitis B vaccines have the greatest potential for public health benefit. Approximately 50,000 to 70,000 persons die each year in the United States from pneumococcal infection, influenza, and hepatitis B, compared with fewer than 500 children who die from diseases targeted by childhood immunizations. Adult immunization does not receive the same emphasis as the immunization of children despite the fact that deaths from vaccine-preventable diseases occur predominantly in adults. Reasons for low vaccination rates in adults include a limited perception of the significance of vaccine-preventable diseases by health care providers and the public, lingering doubts regarding vaccine efficacy and safety, uncertainty regarding specific recommendations, misconceptions about vaccine contraindications, lack of adult immunization programs, and inadequate reimbursement. Adult immunization should rank among our nation’s highest health priorities. Improved vaccine use will require the development and promotion of formalized adult immunization systems, as well as sustained efforts to educate both health care providers and the public.

Potassium Channel Blocking Agents and Atrial Tachyarrhythmias

Abstract:Epidemiologic studies have shown a high incidence of atrial fibrillation/flutter (AFF) in the elderly population. If left untreated, this type of atrial tachyarrhythmia can lead to the development of ischemic events, heart failure, cardiomyopathy, stroke, or syncope. These secondary complications will increase the comorbid conditions in an already fragile population susceptible to decompensation. Therefore, one priority is to restore sinus rhythm early in the process. Sinus rhythm can be restored either electrically or pharmacologically. Electrical cardioversion requires general anesthesia and a lengthy pre- per- and postcardioversion anticoagulation period, which can become costly, especially in this time of cost-containment restraint. Pharmacologic cardioversion represents an attractive alternative. Among the current, commercially available antiarrhythmic agents, we chose to focus on the therapeutic use of the class III potassium channel blocker agents, such as sotalol, amiodarone, ibutilide, and dofetilide for managing AFF. They have proven to be more tolerable and efficacious in converting AFF back to sinus rhythm as well as maintaining the sinus rhythm for as long as 5 years’ postsuccessful conversion. However, the drug choice must be individualized for each patient based on his clinical status and risk factors. By far, the class III antiarrhythmic drugs were more efficacious in converting AFF to sinus rhythm and preventing the recurrence of AFF than the other agents from class I, II, or IV. The proarrhythmic events, such as polymorphic ventricular tachycardia or torsades de pointes, remain a potential risk and require careful monitoring. Other strategies are also currently under investigation, namely the approach to control the ventricular responses pharmacologically in association with anticoagulation therapy, the surgical procedure maze, the catheter ablation technique, the newer mode of pacing, and the implantable devices.

Primer on Type 2 Diabetes Mellitus

Abstract:Ninety percent of diabetics are classified as diabetes mellitus Type 2 (DM-2), most of them over age 65. DM-2 involves both insulin resistance and a relative deficiency of insulin to achieve glycemic control. New guidelines in the classification and diagnosis of diabetes have been established, which may increase the number of newly diagnosed diabetics. The terms, insulin-dependent diabetes (IDDM) and non—insulin-dependent diabetes (NIDDM) have been eliminated because they describe the therapy for the disease rather than the underlying physiology. The fasting plasma glucose (FPG) levels for diagnosing diabetes have been lowered from 140 mg/dl to 126 mg/dl. Many new oral agents have become available to treat DM-2 since the early 1990s. Sulfonylureas, bedtime insulin-daytime sulfonylurea, metformin, troglitazone, repaglinide, and the -glucosidase inhibitors will be reviewed. The agents have different mechanisms of action, contraindications, and side effect profiles. With the advent of new oral medications for DM-2 and a largely elderly population with altered pharmacokinetics and pharmacodynamics, pharmacists play an increasing role in appropriate drug selection and appropriate management of DM-2. Diabetes education will be a reimbursable service with new Medicare policies. However, currently, there are no guidelines promulgated as who these providers of diabetes education are. Points for counseling can include medications, pathophysiology, complications, hypoglycemia and treatment, hyperglycemia, foot care, diet, exercise, and appropriate goals of therapy. Pharmacists can be instrumental in providing this education.

Emerging Roles of Low-molecular-weight Heparin Derivatives in Anticoagulation

Abstract:Venous thromboembolism is a common problem affecting approximately two million Americans annually. It has been estimated to result in 300,000 to 600,000 hospitalizations in the United States each year. Unfortunately, more patients die each year with pulmonary emboli resulting from venous thromboembolism than American women from breast cancer. Deep vein thrombosis commonly develops in the lower extremities and is associated with advanced age, prior venous thromboembolism, hypercoagulable states, cancer, trauma, and surgery. It can become a chronic health problem with potential for recurrence, development of the postphlebitic syndrome, and impaired mobility of the affected limbs. Venous ultrasonography is a commonly used diagnostic test to rapidly identify symptomatic patients. Low-molecular-weight heparins (LMWHs) are an addition to the prophylactic and treatment options of venous thromboembolism. They display favorable pharmacokinetic profiles over unfractionated heparin and offer once or twice daily dosing convenience using the subcutaneous route. They have been evaluated in a variety of clinical conditions associated with venous thromboembolism and have similar or greater efficacy than unfractionated heparin. LMWHs require minimal monitoring and have a lower incidence of heparin-induced thrombocytopenia. The rates of bleeding complications with these agents are similar or slightly lower than unfractionated heparin. Although LMWHs are more expensive than conventional unfractionated heparin, the overall savings with potentially earlier discharge from the hospital and less monitoring may override the higher drug acquisition costs.

Lyme Disease and other Co-transmitted Tick-borne Agents

Abstract:Lyme disease is the most prevalent tick-borne disease in the United States. The disease caused by Borrelia burgdorferi (B. burgdorferi) is characterized as chronic with multiorgan involvement. Disease manifestations can range from asymptomatic to chronic rheumatologic and neurologic symptoms or, rarely, death. Because of the protean characteristics of the clinical manifestations diagnosis is difficult. Diagnosis is usually performed using a combination of clinical presentations and patient history. The ability of the tick to transmit Lyme disease is confined to those molts beyond the larval stage, with the nymph associated with most of the transmission of the disease agent to humans. Since there is essentially no transovarial transmission of the Lyme disease agent in the tick, reservoir hosts are essential for maintenance of the spirochete in nature. The principle reservoir for the spirochete is the white-footed mouse. In addition to Lyme disease, the clinical picture associated with tick-borne diseases is further complicated by the coinfection of the white-footed mouse with Ehrlichia and/or Babesia. Human granulocytic ehrlichiosis is characterized as having an acute onset with symptoms that can resemble toxic shock syndrome, requiring the hospitalization of approximately 60% of infected individuals. Babesiosis is a malarial-like illness with an insidious onset and the ability to recrudesce. The peak season for all three diseases mirrors that of the tick population (i.e., spring and summer).

Vancomycin-resistant Enterococcus: Implications for Pharmacy

Abstract:Vancomycin-resistant enterococci (VRE) have emerged as a significant problem in the health care system. Normal flora that inhabits the human intestinal tract (enterococci) have increasingly been isolated as pathogens, now being the second most common cause of nosocomial (hospital-acquired) infections. This high prevalence is exacerbated because many of these organisms are beginning to exhibit resistance to vancomycin, as well as many other antibiotics. For over 40 years, vancomycin has been the gold standard for the treatment of gram-positive infections. During this time, the overuse of other antibiotics has exerted selective pressure, which has facilitated the development of organisms resistant to these agents. The resultant multidrug-resistant VRE is extremely difficult to treat in most cases, requiring development of patient-specific treatment plans, often involving multiple antibiotics. Prevention, early detection, and control of this organism make the greatest impact in treating VRE. To facilitate this process, the Centers for Disease Control (CDC) have published extensive guidelines for the prevention and control of VRE. The possibility of further VRE emergence or even the transfer of this resistance to other organisms, such as Staphylococcus aureus (S. aureus), is of great clinical concern. This paper will focus on the two most important implications for today’s health care pharmacist: ·Strategies of antibiotic use to hinder the further development of VRE ·Various treatment options for the medical management of this organism

Pharmacotherapeutic Management of Chronic Heart Failure (CHF)

Abstract:Congestive Heart Failure (CHF) is a chronic, progressive disease associated with high rates of morbidity and mortality. It affects approximately five million Americans, and its associated health care costs are continuing to rise. CHF often results from an initial injury to the myocardial tissue, leading to decreased myocardial contractility, stroke volume, and cardiac output. Early on, compensatory mechanisms, such as the release of endogenous catecholamines and angiotensin II, attempt to maintain adequate cardiac output. When compensatory mechanisms fail, clinical symptoms of heart failure ensue. Left ventricular CHF can be secondary to either systolic or diastolic dysfunction. Clinical signs and symptoms are similar; therefore, diagnosis should be based on objective findings obtained from echocardiography or radionuclide ventriculography. Pharmacotherapeutic management of systolic and diastolic chronic CHF differs, emphasizing the importance of an adequate diagnosis before initiating therapy. Current agents available for treating CHF include angiotensin-converting enzyme inhibitors, angiotensin II antagonists, diuretics, digoxin, beta-adrenergic blocking agents (beta blockers), calcium channel blockers, vasodilators, and nitrates. Appropriate selection of these agents should be based on the type of heart failure, safety and efficacy profile, and available clinical outcomes data.

Adverse Drug Reactions and Events: What, Why, and How?

Abstract:For many years the prevention, documentation, and reporting of adverse drug reactions (ADRs) has been an important part of the pharmacist’s practice. Recently, health care has expanded beyond simple ADR reporting to encompass more inclusive concepts such as drug misadventuring, medication-related problems, and/or adverse drug events. The primary impetus behind this expansion is the growing realization that deleterious consequences that may be associated with medication use (or misuse) extend beyond adverse reactions and may include therapeutic appropriateness, errors, compliance, and other problems that result in sub-optimal outcomes. The recent resurgence of interest in this topic has been driven by a number of factors in the health care environment. There are both regulatory and professional standards for the reporting of adverse drug events. Furthermore, the high incidence and costs associated with these events has caused increased focus on the subject. Another contributing factor is the increasing recognition of the need for extensive post-marketing surveillance for adverse events, especially to detect those adverse reactions that occur infrequently and/or in those new agents whose approval has been expedited. A possible last factor in the rediscovery of this subject has been the continued evolution and implementation of pharmaceutical care in multiple practice settings. While the need for an effective ADR program is essential, establishing an efficient and effective program is not easy. Pharmacists and other health care providers should actively participate in the establishment of an ADR program, including adoption of a working definition, design, and implementation of a user-friendly system, and encouraging the detection and reporting of adverse reactions. This involvement should include data evaluation and ultimately lead to system improvement(s) to avoid preventable reactions and optimize overall medication use.

An Update on the Diagnosis and Management of Peptic Ulcer Disease (PUD)

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Update on Alzheimer's Disease

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Asthma Management

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Identifying and Removing Barriers to Pharmacists' Contributions to Rational Drug Therapy

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The Current Management of Hyperlipidemia

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Disease Management: Looking at the Big Picture

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