bluuebunny/crossref_metadata_2025 huggingface dataset:
Community Pharmacists' Impact on an Employer-Initiated Diabetes Disease Management Program
Authors: Sansgiry Sujit S , Agrawal Ruchika N , Patel Harshali K , Mhatre Shivani K , Hayes J David , Roberson Kim , James Clyde J
Published: September 2013

Background:

Diabetes is the third most expensive physical health condition for US employers. Thus, there is a need for employers to engage in disease management programs for their diabetic employees in order to ensure long-term benefits.

Objective:

To evaluate the clinical outcomes of successful implementation of an employer-initiated pharmacist-based disease management program for diabetic patients.

Methods:

This was a longitudinal retrospective study analyzing clinical indicators in diabetic employees after a community pharmacist-based diabetes disease management (DDM) program in a rural setting. The program involved comprehensive drug therapy assessment and individualized disease management education. Outcomes measured in this study were fasting serum glucose (FSG) levels, glycated hemoglobin (A1C) levels, diastolic blood pressure (DBP), systolic blood pressure (SBP), body mass index (BMI), and complete lipid profiles including high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglyceride (TG), and total cholesterol (TC) levels.

Results:

A total of 137 patients were enrolled in this program. Significant improvement in mean clinical outcome scores was achieved for FSG (p = 0.004), DBP (p = 0.018), and SBP (p = 0.044). At the end of the 1-year intervention, targeted FSG and A1C goals were attained by 39.1% (p = 0.029) and 39.4% of patients, respectively. Also, targeted DBP, SBP, BMI, LDL, HDL, TG, and TC levels were achieved by 54.8% (p < 0.001), 38.5%, 38.3%, 56.8%, 38.2%, 37.5%, and 52.4% of patients, respectively.

Conclusions:

This study establishes a need for implementation of long-term employer-initiated pharmacist-based DDM programs that improve clinical outcomes for employees. Further studies evaluating outcomes for a longer time period would provide more conclusive results.
Inhaled Aztreonam Lysine for Cystic Fibrosis
Authors: Hoffman Lindsay E , Lowe Denise K
Published: September 2013

Objective:

To review the mechanism of action, indication, pharmacokinetics, clinical efficacy, safety and tolerability, dosing, availability, and place in therapy for aztreonam lysine in the chronic management of cystic fibrosis (CF).

Data Sources:

PubMed/MEDLINE (1966–December 2011) was searched to identify articles addressing aztreonam lysine use for CF using the terms aztreonam, cystic fibrosis, and inhaled antibiotics. Reference lists of review articles, guidelines, and unpublished data from the manufacturer were also utilized.

Study Selection and Data Extraction:

Limits were set for the English language and humans. Three placebo-controlled trials and 1 active-comparator trial evaluating the efficacy and safety of aztreonam lysine were reviewed for inclusion. Data were also extracted from review articles and the manufacturer's Web site.

Data Synthesis:

Pseudomonas aeruginosa is associated with significant morbidity and mortality in patients with CF; therefore, treatment is imperative. Current guidelines for chronic maintenance therapy recommend using chronic inhaled anti-pseudomonal antibiotics. Tobramycin (Tobi) is the only inhaled antibiotic approved by the FDA for management of CF patients with P. aeruginosa. Tobramycin treatment failures in P. aeruginosa infection have been increasing over the past decade; therefore, other treatment options are needed. Aztreonam lysine (Cayston) was approved by the FDA on February 22, 2010, as an inhaled antibiotic to help improve respiratory symptoms in patients 7 years of age or older with CF and known P. aeruginosa infection.

Conclusions:

Aztreonam lysine is a newer inhaled antibiotic that improves forced expiratory volume in 1 second, respiratory symptoms, and quality of life measures when used as maintenance therapy in patients with CF and chronic P. aeruginosa infection. Availability of aztreonam lysine only from specialty pharmacies may limit its use.
Health-Related Quality of Life in Patients Poststroke: Dapsone versus Placebo
Authors: Cruz-Cruz Copytzy , Altagracia-Martinez Marina , Kravzov-Jinich Jaime , Rios-Castañeda Camilo , Martinez-Nuñez Juan Manuel , Perez Mirza E
Published: September 2013

Background:

Stroke is the second leading cause of death in the world and the main cause of long-term disability in Western countries. Evaluating health-related quality of life (HRQOL) in patients who have survived a stroke provides a more complete picture of the effects of different interventions in a patient's condition. Dapsone has been shown to have neuroprotective effects during the acute phase of stroke.

Objective:

To evaluate HRQOL in patients who received dapsone versus placebo after stroke.

Methods:

This was an observational pilot study of 21 patients who randomly received dapsone or placebo during the acute phase of a stroke. HRQOL was evaluated with the Stroke-Specific Quality of Life (SSQOL) questionnaire 6 months after the stroke.

Results:

There was no significant difference in the total SSQOL score 6 months after a stroke between patients who received dapsone or placebo (3.41 vs 3.19; p = 0.434). Patients who received dapsone had higher mean values for 9 of the 12 domains of the SSQOL than patients who received placebo. However, the difference was not statistically significant. The highest score for the patients who received dapsone was in the self-care domain. Overall SSQOL scores were lower in women than in men (p < 0.01).

Conclusion:

SSQOL was slightly better for patients who received dapsone, showing a possible improvement in their functional level. More prospective, randomized, and placebo-controlled studies with a larger number of patients are needed to confirm these results.
Natural Health Product Utilization in Warfarinized Children; Prevalence and Knowledge
Authors: Bauman Mary E , Mack Gordon , Bruce Aisha K , Bauman Michelle L , Nolan Kyle , Massicotte M Patricia
Published: September 2013

Background:

The need for long-term thromboprophylaxis in children using warfarin therapy is increasing. Natural health products (NHPs) are administered to children by parents who perceive them to be useful and acceptable adjuncts or alternatives to conventional therapies. Interactions of NHPs with prescribed therapies may result in serious adverse events. NHP usage is underevaluated in children and there are no studies evaluating NHP usage in warfarinized children.

Objectives:

To explore NHP use in warfarinized children and their siblings to determine the prevalence, varieties, and reasons for NHP usage, as well as the potential effect on warfarinization (eg, time in therapeutic range [TTR]).

Methods:

This is a 3-phase cross-sectional cohort study that includes the (1) prevalence (2) NHP education and knowledge assessment, and (3) the follow-up NHP utilization phase.

Results:

Forty-six percent of warfarinized children consumed NHPs, with time in therapeutic range of 74%. The mean score for baseline knowledge of NHPs and warfarin following the education phase was 67%. Follow-up NHP use was 30%, and increased consistency of utilization with TTR was 83% (p < 0.05), consistent with education provided.

Conclusions:

The consistent prevalence rates over time of NHP usage in warfarinized children indicate the need for future studies. Education remains vital to combat the potential risks of NHP-warfarin interaction, encouraging patient disclosure and consistency.
Belatacept Post Kidney Transplantation
Authors: Bajjoka Iman , Makowski Charles , Churchill Dennis , Abouljoud Marwan
Published: September 2013

Objective:

To review the use of belatacept as an alternative to calcineurin inhibitor-based regimens for maintenance immunosuppression in renal transplant recipients.

Data Sources:

To provide an extensive overview of the pharmacology, pharmacokinetics, efficacy, and safety of belatacept, a MEDLINE/PubMed search (1980–December 2011) was performed for all articles evaluating belatacept's properties and patient outcomes, as well as abstracts from recent meetings, using key words belatacept, pharmacology, efficacy, pharmacokinetics, and safety.

Study Selection/Data Extraction:

Phase 2 and 3 studies in humans describing use, adverse reactions, pharmacology, pharmacokinetics, efficacy, and safety of belatacept were identified and reviewed. Other articles were identified through PubMed.

Data Synthesis:

Belatacept, a costimulation blocker, is a biologic recombinant fusion protein that has been shown to prevent acute cellular rejection in kidney transplant recipients and preserve renal function. It was recently approved by the FDA as an antirejection immunosuppressant agent for use in kidney transplant recipients. It is the first biologic agent used for maintenance immunosuppression. It acts as an antagonist to CD80 and CD86 receptors located on the surface of antigen presenting cells, thereby blocking CD28 T-cell activation and, thus, preventing acute rejection. In comparison with patients receiving other current therapies, patients on belatacept have demonstrated superior renal function with comparable outcomes in patient and graft survival.

Conclusions:

Belatacept has potential for use as an alternative to current maintenance immunosuppression regimens, with potentially fewer adverse effects.
Opportunity for Pharmacy Intervention on an Urban Teaching Hospital Rapid Response Team: A Pilot Study
Authors: Lasak-Myall Tracey , Peters Michael J , Mlynarek Mark
Published: September 2013

Background:

The role of a rapid response team (RRT) or medical emergency team is to bring the expertise of specialists trained in critical care to patients on general medicine and surgical wards who are rapidly deteriorating and to treat them accordingly. The involvement of pharmacists on cardiopulmonary resuscitation teams has been reported. However, the role of a pharmacist member of an RRT has not been extensively researched.

Objective:

To identify the role of a pharmacist on an RRT and categorize types of pharmacist interventions during cardiopulmonary resuscitation and initial patient assessments.

Methods:

This pilot study documented interventions made by the pharmacist on our RRT over a 1-month period. The pharmacist assisted the RRT with evaluations of patients during assessments and cardiopulmonary resuscitations and provided specialized medical information based on our current organizational standards of practice.

Results:

The pharmacist attended 34 consultations and 8 resuscitations during cardiopulmonary arrests. There were 96 interventions made during 34 RRT assessments—2.6 interventions per assessment. The most common interventions were treatment recommendations (29%), dosing recommendations (15%), and procuring medications for emergent use (12%). In both the treatment and dosing categories, antibiotic recommendations were the most common.

Conclusions:

The pharmacist member of the RRT had the opportunity for intervention on every patient seen by the team. The most common areas for intervention are treatment and dosing recommendations involving antibiotics, as well as providing and preparing emergent medications.
An Intervention to Increase Safety Feature Use on Smart Pumps: A Quality Improvement Initiative
Authors: Herring Holly , Ripley Toni L , Farmer Kevin C , St Cyr Mark
Published: September 2013

Background:

Medication errors due to intravenous administration are common. Metered infusion devices (MIDs) have reduced some administration errors, but the manual programming of these devices allows for continued risk. MIDs with safety features, smart pumps, have been shown to reduce intravenous medication errors, but usage rate of the safety features is reported to be low.

Objective:

To identify obstacles to the use of the smart pump safety feature and investigate the effectiveness of educational interventions to address these obstacles and improve safety feature use rates.

Methods:

This cross-sectional study was designed for quality improvement. A 10-question paper survey targeting potential obstacles was distributed to parttime and full-time nurses on the cardiovascular service of an academic hospital to ascertain the limitations to using the safety feature technology. Based on survey results, educational interventions were developed, which included a required educational active-learning, practical session, and optional didactic presentation. The primary end point was change in the rate of use during a prespecified month before (July 2010) and after (April 2011) targeted interventions. Descriptive analysis was performed on survey results. Student t test and χ2 analyses were used to compare usage rates.

Results:

Surveys were distributed to 60 nurses; 36 were returned and 1 was excluded, leaving 35 in the final analysis. Primary obstacles to using the safety features identified were education/training, technology burden, and drug library accuracy/content. After educational training sessions, usage rates of the smart pump safety feature increased significantly, 5.5 times from baseline (5.5% vs 30.5%; p < 0.001).

Conclusions:

Targeting education and providing hands-on training directed to nurses' perceived barriers to use of smart pumps was an effective method to improve use of safety features, although overall utilization can be improved.
Significant Bleeding in Elderly Patient with Atrial Fibrillation Due to Probable Interaction between Dabigatran and Amiodarone
Authors: Neuffer Elizabeth M , Tofade Toyin S , Galpin Lauren E , Ritchey Amanda J , Roma Domenick J
Published: September 2013

Objective:

To present the case of an elderly patient who developed significant bleeding while receiving a standard dose of dabigatran with concomitant amiodarone therapy.

Case Summary:

A 77-year-old man was admitted for upper gastrointestinal bleeding that presented as coffee ground emesis. A coronary artery bypass graft had been performed 4 weeks earlier, which was well tolerated, except that his postoperative course was complicated by atrial fibrillation, for which amiodarone was initiated; dabigatran was added subsequently. Upon his admission to the hospital, dabigatran was stopped. The patient's bleeding was stabilized and dabigatran 150 mg twice daily was restarted after amiodarone was discontinued. The laboratory was not equipped to measure thrombin clotting time or ecarin clotting time; therefore, the team relied on the measurement of international normalized ratio (INR) and activated partial thromboplastin time to guide therapy based on pharmacokinetic and pharmacodynamic studies of therapeutic dabigatran concentrations. Based on laboratory values the following morning, the team maintained dabigatran 150 mg once daily. Subsequent INR and partial thromboplastin time values were within the desired range. He remained stable, without further evidence of bleeding even after anticoagulation with dabigatran was restarted for atrial fibrillation.

Discussion:

Dabigatran received FDA approval in October 2010 to reduce the risk of stroke and systemic embolization in patients with nonvalvular atrial fibrillation. It has a favorable monitoring profile compared to warfarin. The manufacturer acknowledges the potential for amiodarone to increase the effective concentration of dabigatran because of its inhibition of P-glycoprotein. An objective causality assessment using the Horn Drug Interaction Probability Scale revealed that the interaction was probable.

Conclusions:

A probable interaction suggests that providers should use caution with the coadministration of amiodarone with dabigatran; dose adjustment in the setting of concomitant administration in elderly patients with atrial fibrillation should be considered.
The Patient-Centered Medical Home and Community Pharmacists' Perceptions
Authors: Hohmeier Kenneth C , Mangan Michelle N , Powers Mary F , Lengel Aaron J
Published: September 2013

Background:

As new models of health care delivery are being discussed, it is important to determine the pharmacist's role within each care model to assist in the provision of clinical services. Recent literature suggests that pharmacists are integral members of the patient-centered medical home (PCMH) and should be included as members of the health care team. As the most accessible health care professionals, community pharmacists are uniquely positioned to play a prominent role within the PCMH, as enhanced access is one of the joint principles of the PCMH care model. To date, no studies have described the barriers to community pharmacists' participation in the PCMH model or their acceptance as members of the PCMH team.

Objective:

To evaluate community pharmacists' perceptions of barriers to participation and acceptance within the PCMH in a community pharmacy chain.

Methods:

Online surveys were made available to 244 community pharmacists working for a supermarket pharmacy chain in Ohio. Pharmacists completed the survey anonymously and indicated their opinions on preparedness to participate in the PCMH, their relationship with other health care providers, their relationship with patients, and their perceived barriers to participation in a PCMH.

Results:

Of the 244 pharmacists contacted, 129 completed the survey (52.9%). In total, 32.6% of responding pharmacists were familiar with the PCMH before the survey. A majority of respondents agreed that pharmacists are sufficiently trained and have the skills required to participate within the PCMH (79.8%, 93.8%, respectively). Only 36.4% of pharmacists agreed that physicians are willing to work closely with community pharmacists. Pharmacists also indicated that they do not have adequate opportunities to meet with other members of their patients' health care team (68.5%).

Conclusions:

Most community pharmacists are still unfamiliar with the concept of the PCMH. Once they were made aware of what a PCMH is, the pharmacists surveyed indicated that they want to be members of a PCMH. Before pharmacists participate in this model of care within the community setting, it is important that they first understand and address the barriers identified from this survey in order to facilitate a smooth transition of pharmacy services into the PCMH.
Outpatient Perceptions of the Medtable: A Medication Scheduling Tool
Authors: Conner-Garcia Thembi , Morrow Daniel , Graumlich James , Ellison Jennifer , Wang Huaping
Published: September 2013

Background:

Health literacy is the ability of patients to obtain, process, and understand information needed to make health decisions. Health literacy is a stronger predictor of a person's health than is age, income, employment status, educational level, or race. The Medtable is a paper-based tool that is designed to support comprehension of medication information by patients. A collaborative tool such as the Medtable might facilitate the comprehension of medication information by low-literacy patients and increase communication regarding medications between healthcare pers and their patients. Before evaluating the efficacy of the Medtable to improve health outcomes, it is important to confirm that patients find the tool easy to use and helpful in relevant clinical settings.

Objective:

To investigate whether patients think that the Medtable is a helpful and easy-to-use tool for organizing daily medication regimens.

Methods:

Sixty outpatients participated in this usability study. Patients filled in the Medtable with a healthcare provider. Opinions regarding the usability of the Medtable were elicited with a brief questionnaire afterward.

Results:

Fifty-five of the 60 (92%) patients thought the Medtable would be very or somewhat helpful when figuring out when to take their medications and would be very or somewhat helpful for assisting them with taking their medications at home. Fifty-nine of the 60 (98%) patients thought the Medtable would be very or somewhat easy to fill in with the assistance of their health care provider.

Conclusions:

Patients think that the Medtable is a helpful and easy-to-use tool for organizing their daily medication regimens. Future studies should evaluate Medtable's efficacy to improve patient medication knowledge and adherence.
Salvage Options for Eradication of Helicobacter pylori During Tetracycline Backorder
Authors: Segarra-Newnham Marisel , Coakley Christina
Published: September 2013

Objective:

To review salvage options for Helicobacter pylori eradication regimens during a tetracycline backorder for patients with triple-therapy failure.

Data Sources:

A search of PubMed (1980-June 2012) was conducted using a combination of the terms H. pylori or Helicobacter pylori, salvage therapy, and eradication or treatment as text word searches.

Study Selection and Data Extraction:

Clinical trials and meta-analyses published in English were included. A manual review of the bibliographies of available literature was conducted and relevant articles were reviewed for inclusion.

Data Synthesis:

Treatment of H. pylori consists of a triple-drug regimen that includes a proton pump inhibitor (PPI), amoxicillin or metronidazole, and clarithromycin. Failure with this therapy is becoming increasingly common due to macrolide resistance. Upon failure with this regimen, it is recommended that a quadruple regimen with bismuth subsalicylate, metronidazole, tetracycline, and a histamine2 receptor antagonist or a PPI be used. Recent backorders by the 2 manufacturers for tetracycline restrict the use of this regimen. Options that can be considered include minocycline or doxycycline in place of tetracycline, levofloxacin- or moxifloxacin-based regimens, a tinidazole-based regimen, or a rifabutin-based regimen. This article includes a review of 1 study each of minocycline and doxycycline, 5 levofloxacin studies (including meta-analyses), 2 moxifloxacin studies, 1 rifabutin study, and 1 tinidazole study. There are limited data with other tetracyclines; however, given the resistance to quinolones in some areas and possible drug interactions and adverse effects from rifabutin, minocycline or doxycycline regimens may be a better second-line regimen option.

Conclusions:

Given the current tetracycline shortage, minocycline and doxycycline are options to be considered in patients with a macrolide-based treatment failure. Fluoroquinolones may be an option for patients who have not received these drugs for other indications in the recent past or in areas where resistance is low.
Pharmacotherapeutic Options for the Treatment of Patients with Obesity
Authors: Debellis Lindsay R , Wrobel Mark J
Published: September 2013

Objective:

To assess the safety and efficacy of FDA-approved and in-development antiobesity agents.

Data Sources:

Literature was accessed through MEDLINE (1950-current) and EMBASE using the terms antiobesity agent, diethylpropion, phentermine, orlistat, topiramate, lorcaserin, bupropion, and naltrexone. In addition, reference citations from publications identified were reviewed. Files related to FDA expert panel hearings were retrieved from the FDA website.

Study Selection and Data Extraction:

Randomized double-blind trials assessing the efficacy and safety of antiobesity agents compared with placebo in the treatment of overweight and obese adults were reviewed. Only English-language or English-translated literature was reviewed. Medications were selected based on FDA approval status.

Data Synthesis:

Ten double-blind clinical trials were reviewed. There are currently 5 FDA-approved antiobesity agents and 1 agent recently rejected by the FDA. Study results for all agents showed statistically significant weight loss compared with placebo, but with varying adverse effects. The combination of phentermine and topiramate is the most efficacious antiobesity agent approved by the FDA. However, this combination has various neurologic, cardiovascular, and teratogenic safety risks that may limit its use. Based on its safety profile, orlistat is the preferred antiobesity medication, despite the lesser extent to which it induces weight loss versus newer agents. The incidence of unwanted gastrointestinal adverse effects limits its use.

Conclusions:

Despite a glaring medical need for options to treat obesity, available medications are limited. No current drug option is ideal; each has either safety risks or efficacy concerns. Safe agents that meet FDA efficacy standards are needed to help treat the obesity epidemic.
Quetiapine-Induced Leukopenia and Neutropenia in an Intensive Care Unit Patient with Delirium
Authors: Shewmaker Justin
Published: September 2013

Objective:

To report a case of neutropenia in a critically ill trauma patient who was receiving quetiapine for hyperactive delirium.

Case Summary:

A 30-year-old white female was admitted to the neurosurgical intensive care unit following a motor vehicle crash. During her recovery in the intensive care unit, she received quetiapine for hyperactive delirium. The patient was initially started on quetiapine 50 mg/day, which was eventually increased to 100 mg/day. Her white blood cell count and neutrophil count were both noted to be decreasing, eventually reaching a nadir of 2.29 × 109/L and 0.89 × 109/L, respectively. Quetiapine was discontinued and her white blood cell count and neutrophil count returned to normal.

Discussion:

Quetiapine-induced neutropenia has rarely been reported. A MEDLINE search (1991-August 2012) revealed 12 case reports; however, in none of them had neutropenia occurred in critically ill patients. The available case reports reveal a wide variety of doses and durations of treatment with quetiapine-associated neutropenia. A definite mechanism for quetiapine-induced neutropenia is unknown. Quetiapine is structurally related to clozapine, known to cause neutropenia, and it may share a similar mechanism. The Naranjo probability scale revealed possible neutropenia associated with quetiapine.

Conclusions:

With the increased use of quetiapine for hyperactive delirium in intensive care unit patients, health care professionals should be cognizant of the potential for quetiapine to induce neutropenia.
Management of Xerostomia in Older Adults: A Systematic Review
Authors: Daniels Betty , McNally Mary , Matthews Debora , Sketris Ingrid , Hayden Jill A
Published: September 2013

Background:

Xerostomia (dry mouth) is a common adverse effect of many medications and can severely diminish quality of life for older adults.

Objective:

To assess the effectiveness of 3 categories of interventions used to manage drug-induced xerostomia and xerostomia secondary to Sjögren syndrome and radiation treatment for head and neck cancer in older adults: saliva substitutes, saliva stimulants, and topical fluoride.

Data Sources:

The Cochrane Library, PubMed, EMBASE (to July 2009) and CINAHL (to February 2010) were searched for randomized or quasi-randomized studies involving older adults with drug- or radiation-induced xerostomia or Sjögren syndrome.

Study Selection and Data Extraction:

An updating search focusing on systematic reviews (to June 2012) was conducted prior to publication. Outcomes included perceived dryness of the mouth, reduced sialometry, or increased root caries. Duplicate study selection and data extraction were conducted. Risk of bias was assessed. A random effects meta-analysis was employed.

Data Synthesis:

Four studies of saliva substitutes (N = 116), 3 studies of saliva stimulants (N = 361), and 1 of fluoride treatment (N = 334) met selection criteria. Saliva substitutes were more effective than other treatments at improving perceived dryness of the mouth as determined on a 10-point visual analog scale (weighted mean difference [WMD] −1.91 [95% CI −2.54 to −1.29]) but less effective than placebo (WMD 0.26 [95% CI 0.51–1.02]). Parasympathetic stimulants were more effective than placebo in improving oral dryness (OR = 0.37 [95% CI 0.19–0.72]). Due to lack of data, quantitative synthesis of results for topical fluoride was not possible.

Conclusions:

There is evidence to suggest that saliva substitutes improve symptoms but the clinical significance is minimal. The evidence more strongly supports the effect of saliva stimulants, although the quality of evidence is poor and adverse effects from these medications cannot be overlooked. Evidence demonstrating efficacy of topical fluoride in disease prevention was inconclusive. Addressing underlying causes of xerostomia, including drug choices, may help mitigate the burden of illness and effects on quality of life.
Orthostatic Hypotension in the Patient with Diabetes: A Broad Review of Pharmacologic Treatment Options
Authors: Smith Nicole D
Published: September 2013

Objective:

To provide an evidence-based broad review of the pharmacologic management of orthostatic hypotension (OH) in the patient with diabetes.

Data Sources:

A search of PubMed, MD Consult, International Pharmaceutical Abstracts, and the Cochrane Register of Clinical Trials and Systematic Reviews was performed using the key words diabetes, autonomic neuropathy, orthostatic hypotension, midodrine, fludrocortisone, pyridostigmine, xamoterol, octreotide, pindolol, dihydroergotamine, erythropoietin, clonidine, acarbose, desmopressin, and droxidopa. Literature published between 1976 and August 2012 was included.

Study Selection and Data Extraction:

All articles in English and studies in humans including clinical trials, meta-analyses, practice guidelines, randomized controlled trials, and review articles were identified and evaluated. Studies not including patients with diabetes were excluded. The selection of materials was focused on those that would aid the pharmacist in caring for patients with orthostatic hypotension resulting from diabetic neuropathy.

Data Synthesis:

Definitive guidelines on the pharmacologic management of OH in the patient with diabetes are not available and recommendations must be assessed from available evidence-based sources. Ten trials of medications used in the patient with diabetes were assessed for efficacy and safety. From these trials, evidence-based therapy options were recommended. If nonpharmacologic measures are insufficient in ameliorating symptoms, fludrocortisone or midodrine should be considered as first-line agents in the absence of contraindications. Pyridostigmine, octreotide, or recombinant erythropoietin may be useful as adjunct or alternative agents. Combination therapy may be considered, based on coexisting conditions or response. When recommending both nonpharmacologic and pharmacologic therapy, careful attention should be paid to comorbid conditions such as congestive heart failure, supine hypertension, and kidney disease.

Conclusions:

There is insufficient evidence to recommend the routine use of medications other than the first-line agents fludrocortisone or midodrine in this patient population. Further trials with existing and new therapeutic options in patients with diabetes are warranted.
Effect of Group Diabetes Self-Management Education Classes on Clinical Outcomes and Patient Satisfaction in a Family Medicine Clinic
Authors: Shrader Sarah P , Martin Alison , Cogdill Brittany
Published: September 2013

Background:

The American Diabetes Association (ADA) has emphasized the need for patients to receive diabetes self-management education (DSME) as a standard of care. Various DSME models have been described, including individual or group sessions. There is no preferred method reported in the literature.

Objectives:

To determine the effect of group DSME classes on patients' hemoglobin A1c (A1C), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C). Patient satisfaction was also assessed.

Methods:

Pharmacists offered 4 group education classes to patients over the course of 1 year using the ADA Diabetes Conversation Maps. Patients were encouraged to attend all sessions to cover the entire curriculum; however, many attended only 1 class. Patient A1C, BP, and LDL-C were monitored before the first class and after the last class attended. The Wilcoxon signed-rank test and descriptive statistics were used for data analysis.

Results:

Thirty-two patients attended at least 1 of the group classes, and 9 returned for more than 1 class. Baseline characteristics included a mean age of 58 years, baseline A1C of 9.4%, systolic BP of 140.6 mm Hg, diastolic BP of 77.2 mm Hg, and LDL-C of 99.1 mg/dL. An average decrease of 1.1% in A1C, 5.1 mm Hg in systolic BP, 1.9 mm Hg in diastolic BP, and 4.6 mg/dL in LDL-C was seen from baseline after class participation. For patients who attended more than 1 class, a statistically significant decrease of 3.6% occurred in A1C (p < 0.05). The majority of patients (84%) reported greater satisfaction with the group DSME as compared with individual diabetes education.

Conclusions:

Data from this study support offering group DSME classes as a method of patient education at a family medicine clinic.
The Role of Pictograms for Enhancement of Patient Prescription Medication Information in the US
Authors: Advani Ashish A , Lopez Juan , Jones Jessica , Patel Shreena
Published: September 2013

Background:

Approximately half of American adults have trouble understanding and acting on health information. United States Pharmacopeia (USP) pictograms are standardized graphic images that help convey medication instructions, precautions, and/or warnings to patients and consumers. No published literature exists regarding USP pictogram-based prescription instructions for adults in the US.

Objective:

To gauge the perceived effect of USP pictograms included within patient information handouts in community pharmacy settings in the US.

Methods:

Two sets of patient information handouts were made for each of 2 community pharmacies' self-reported top 20 medications: one containing USP pictogram-based patient information and the other containing the same text without pictograms. Over a 6-week period, patients filling or refilling a prescription for one of the 20 medications were offered counseling using either a pictogram- or non-pictogram-based handout, selected at random. A patient-administered survey assessed 4 criteria of the handout received: user-friendliness, long-term comprehension, likelihood of referring to the handout in the future, and effectiveness.

Results:

The addition of pictograms significantly increased only the likelihood of the patient referring to the handout in the future.

Conclusions:

Results suggest a potential role for USP pictograms that should be evaluated on a larger scale in the future.
Treatment and Management of Postmenopausal Osteoporosis within an Ambulatory Care Network
Authors: Romanelli Robert J , Leahy Angela , Jukes Trevor , Ishisaka Denis Y
Published: September 2013

Background:

Postmenopausal osteoporosis (PMO) is associated with substantial morbidity and mortality. Despite established guidelines for the care of PMO, the treatment and management of this disease remain suboptimal.

Objective:

To examine the treatment and management of PMO in a community-based ambulatory care setting.

Methods:

Women with a new diagnosis of PMO (International Classification of Diseases, 9th Revision, code 733.01) were identified through the electronic health records (EHR) of a community-based ambulatory care network in northern California between January 1, 2007, and December 31, 2008. Patients were included if they were 65 years of age or older and had EHR activity 26 months or more after diagnosis. They were excluded if they had a diagnosis of osteoporosis (ICD-9:733.xx) prior to the study period. A retrospective review of the EHR and medical charts was performed to identify patients who were prescribed FDA-approved pharmacotherapy, who received bone mineral density (BMD) testing via dual-energy X-ray absorptiometry (DXA), and who experienced a fracture.

Results:

One hundred thirty-one PMO patients were identified who met study eligibility criteria. Fifty-nine patients (45%) were prescribed FDA-approved pharmacotherapy at diagnosis. Ninety patients (69%) were prescribed pharmacotherapy at any point during follow-up. Sixty-four patients (49%) had a baseline DXA scan and 95 patients (73%) had 1 or more DXA scans during follow-up. Seventeen of 90 patients (19%) who received pharmacotherapy had 2 DXA scans within 2 years of follow-up. Nineteen fractures were reported among 16 patients during the study period.

Conclusions:

The proportion of patients with PMO who received pharmacologic treatment at diagnosis and had a baseline DXA scan was relatively low; however, the majority of these patients received treatment and had 1 or more DXA scans at some point during the 26-month follow-up period. Future studies should be conducted to assess the role of early BMD testing and pharmacologic intervention in optimizing outcomes among women with PMO.
Raltegravir-Induced Rash in a Patient Receiving Rifampin
Authors: Fulco Patricia Pecora , Kaatz Jane
Published: September 2013

Objective:

To present what we believe to be the first report of a possible case of raltegravir-induced rash in a patient receiving concurrent rifampin treatment.

Case Summary:

A 38-year-old man with newly diagnosed HIV and miliary tuberculosis (TB) was started on 4-drug TB treatment in combination with highly active antiretroviral therapy (HAART) including efavirenz, emtricitabine, and tenofovir. Eleven days later, the patient developed a rash and HAART was discontinued. Eight days later, HAART was reinitiated with raltegravir 400 mg twice daily and standard dose tenofovir/emtricitabine 300 mg/200 mg. After 14 weeks on this HAART regimen, the patient achieved an undetectable viral load with immune reconstitution. Twenty-two weeks after raltegravir initiation, the dosage was increased to 800 mg twice daily with continuation of emtricitabine/tenofovir. Sixteen days later, the patient developed a maculopapular rash leading to HAART discontinuation. The rash resolved in 2 weeks, and raltegravir rechallenge was not attempted.

Discussion:

Raltegravir-associated rash may occur in approximately 6–7.6% of patients with HIV, with onset between 2 and 5 weeks and a usual duration of 2 weeks. Rifampin significantly decreases the raltegravir minimum concentration (Cmin), and doubling the raltegravir dosage is recommended. This results in a slightly improved raltegravir Cmin, with a significant 2.6-fold increase in the maximum concentration. Little is known about the risk factors for raltegravir-associated rash. A concentration-dependent effect may enhance the occurrence of this cutaneous adverse reaction. An objective causality assessment revealed that the adverse drug event was possible, as the patient tolerated raltegravir for 5 months and then presented with a rash after dose escalation.

Conclusions:

Rifampin significantly alters the raltegravir pharmacokinetic profile. Additional safety and efficacy data are necessary to determine the optimal dosing strategy for raltegravir administered with rifampin.
Roles for Pharmacy Technicians in Community Pharmacy Practice Accreditation
Authors: Mihalopoulos Cleopatra C , Powers Mary F
Published: September 2013

Objective:

To review community pharmacy accreditation and identify opportunities for pharmacy technicians to help community pharmacies meet accreditation standards.

Data Sources:

Articles were identified through MEDLINE/PubMed (2001–2012) using search terms designed to locate English-language articles describing the role of the pharmacy technician, community pharmacy accreditation, and health care reform. Additionally, resources on community pharmacy accreditation and health care reform were used from the Institutes of Medicine, American Pharmacists Association, Council on Credentialing in Pharmacy, Center for Pharmacy Practice Accreditation, and Utilization Review Accreditation Commission.

Study Selection and Data Extraction:

Articles describing the role of the pharmacy technician, community pharmacy accreditation, and health care reform were included.

Data Synthesis:

Pharmacy technicians can help community pharmacies meet accreditation standards by taking on specific roles under 5 main domains: practice management, patient counseling, patient care services, technology, and quality improvement. Technicians can help by engaging in management-related tasks; improving communication between pharmacists, patients, and providers; and collecting and analyzing pharmacy data. Further, with proper training, pharmacy technicians can take on an expanded role to aid pharmacists with advanced patient care services and quality improvement measures.

Conclusions:

Pharmacy technicians can play a vital role in helping pharmacies meet standards necessary for community pharmacy accreditation.
Identifying Potential Causes of Opioid Toxicity Necessitating a Rapid Response Team Visit
Authors: Bagnola Aaron J , Escaño Alisa K
Published: September 2013

Background:

Opioids are labeled as high-risk medications because of their propensity to cause significant harm or toxicity to patients if used inappropriately. Many incidents of opioid toxicity are the result of preventable causes.

Objective:

To identify and report the frequency and potential causes of opioid toxicity in the acute care setting.

Methods:

This single-center chart review evaluated patients receiving naloxone for presumed opioid toxicity from January 2008 through July 2010. Patients were identified for this study using rapid response team charted visits. Charts were then reviewed for opioid medications administered, possible causes of opioid toxicity, signs and symptoms of opioid toxicity, patient location by hospital floor, and prescribing physician service.

Results:

One hundred twenty-nine incidents of opioid toxicity met inclusion criteria and were placed in 1 or more of the applicable categories for possible causes: administration of multiple opioids (43.4%), medication errors (31.6%), and the administration of morphine to patients with impaired renal function (7.2%); 17.8% of the causes were unknown.

Conclusions:

Most cases of opioid toxicity were determined to be the result of preventable causes. Prevention strategies for opioid toxicity should consist of educating health care professionals as well as incorporating health information technologies shown to reduce errors. Specific areas of focus should include opioid equianalgesic dosing strategies, removal of duplicate opioid orders, and writing of clear administration guidelines for orders of as-needed opioids or multiple dosage forms of opioids.
Rhabdomyolysis after Concomitant Use of Simvastatin and Voriconazole in an Allogeneic Stem Cell Transplant Patient
Authors: Cool Rita M , Gulbis Alison M
Published: September 2013

Objective:

To report a case of rhabdomyolysis after concomitant use of simvastatin and voriconazole.

Case Summary:

A 65-year-old white male, weight 66 kg, 79 months post allogeneic stem cell transplant for chronic lymphocytic leukemia, was on a stable medication regimen that included voriconazole. He was hospitalized with weakness and elevated creatine kinase a few weeks after initiation of simvastatin for treatment of hyperlipidemia. His symptoms resolved and creatine kinase level returned to within the normal range after fluid administration and discontinuation of simvastatin.

Discussion:

The use of statins has become a standard in the treatment and prevention of atherosclerotic disease. Most statins are metabolized via the cytochrome P450 enzyme system. For simvastatin, metabolism occurs specifically via the CYP3A4 isoenzyme. Drugs known to inhibit this isoenzyme, such as voriconazole, can increase the risk for toxicities, including rhabdomyolysis, when used concomitantly with simvastatin. This case represents a probable drug-drug interaction, based on the Horn Drug Interaction Probability Scale.

Conclusions:

Due to the broad use of statins for the treatment and prevention of atherosclerotic disease, as well as the need for azole antifungals in the stem cell transplant population, interactions between these agents are becoming an increasing possibility. Care should be taken to minimize these interactions and, when feasible, a change to an alternative agent may be warranted to avoid adverse effects.
Simvastatin: A Risk Factor for Angioedema?
Authors: Nisly Sarah A , Kara Areeba , Knight Tamara B
Published: September 2013

Objective:

To report a case of simvastatin-induced angioedema in a patient with near nightly episodes of orofacial angioedema.

Case Summary:

A 75-year-old African American female presented to the emergency department with recurrent face, lip, and tongue swelling. The patient described frequent episodes of orofacial edema, with 4 emergency department visits over the previous 6 months. Her home medications were reviewed and simvastatin was identified as a possible contributing medication. Simvastatin was discontinued with resolution of the symptoms during hospitalization and a significant reduction in episodes.

Discussion:

Drug-induced angioedema has been documented with several agents, most commonly angiotensin-converting enzyme inhibitors. The association with different drug classes has led to several postulated pathways for the development of angioedema. Notable mechanisms include mediation by bradykinin, inhibition of arachidonic acid metabolism, and complement activation. Each pathway culminates in increasing vascular permeability causing fluid accumulation in subcutaneous tissues. While statin use has been associated with drug-induced angioedema in postmarketing reports, there are no published cases involving simvastatin. Use of the Naranjo probability scale demonstrated a probable relationship between simvastatin use and the patient's recurrent angioedema.

Conclusions:

While statin use is not commonly associated with angioedema, clinicians must be aware of this possible adverse reaction. Consideration must also be given to potential drug interactions, increasing the risk of this adverse event.
Nebulizer Choice Affects the Airway Targeting of Amphotericin B Lipid Complex Aerosols
Authors: Lambros Maria Polikandritou , Beringer Paul M. , Wong-Beringer Annie
Published: September 2013

Background: Although amphotericin B is highly effective against fungal infections, it has serious adverse effects. Encapsulation of amphotericin B in liposomes reduces its potential for systemic side effects. Administration of liposomal amphotericin via aerosols to the lungs (a main portal of fungal infections) further reduces its toxicity while increasing its therapeutic index and prophylactic efficacy. However, the effectiveness of aerosol therapy depends on the dose deposited and the distribution of the drug within the lungs. The size of the aerosol particle is an important factor that affects the distribution of the drug within the lungs and the effectiveness of therapy. Objective: This study aims to determine the physicochemical suitability of amphotericin B lipid complex (ABLC) for aerosolization and to compare the performance of 3 commercially available air jet nebulizers in generating ABLC aerosols in terms of aerosol output (mg/min) and drug amount aerosolized within various particle-size ranges, the latter of which affects airway deposition. Methods: We aerosolized 2 concentrations (5 mg/mL and 10 mg/mL) of ABLC and evaluated their physicochemical properties, including osmolality, pH, and viscosity. The aerosolization performances of Pulmo-Aide/Micromist, Envoy/Sidestream, and Proneb/Pari LC Star systems were then evaluated in terms of output rate (mg/min), percent aerosolized, and milligram per minute of drug aerosolized within particle-size ranges of 1 to 3.5 µm, 3.5 to 6 µm, and 1 to 6 µm. Results: The output rate increased with higher drug concentration regardless of device. Pulmo-Aide/Micromist and Envoy/Sidestream showed high output rates. Proneb/Pari LC Star and Envoy/Sidestream delivered the highest percentages of aerosolized particles within the 1 to 3.5 µm particle-size range, favoring deposition within the alveolar/distal end area of the airways. Pulmo-Aide/Micromist delivered a higher percentage of aerosol within the 3.5 to 6 µm than the 1 to 3.5 µm particle-size range, favoring deposition in the central airways. Conclusion: The present study shows that different nebulizers produced different size ranges of aerosolized particles of ABLC preferentially targeting different parts of the airways. Thus, effective aerosol therapies may require the evaluation of different nebulizers for optimal targeting.