Review of isolated systolic hypertension in older adults.

A 75-year-old patient comes to a community pharmacy to refill her blood pressure (BP) medications. She approached the pharmacist complaining of a headache and an unusually high BP reading that she had gotten from the automated machine. The patient was unaware of her usual BP, but knew that the reading was unusually high for her. Following evaluation of the patient and after obtaining several high systolic BP readings, the pharmacist appropriately calls for an ambulance. At the hospital, the patient is told she is in need of triple-bypass surgery. After her hospital stay, the patient is now diligent about refilling her BP medications on time and consistently monitors and records her BP at home. Isolated systolic hypertension is a growing concern in older adults, and a large percentage of adults are not appropriately managed. Pharmacists play an active role in educating patients on the importance of high BP monitoring and adherence to minimize the risk of cardiovascular events.

Vitamin D deficiency: appropriate replenishment therapies and the effects of vitamin D toxicity.

An 84-year-old patient diagnosed with a vitamin D deficiency was given a prescription for ergocalciferol (vitamin D2) 50,000 units weekly. The prescription was incorrectly filled for ergocalciferol 50,000 units daily. Incorrect therapy continued for two months. The patient's vitamin D level increased from < 7.0 ng/mL to 100 ng/mL over a six-month span. The patient complained of decreased appetite and significant weight loss and presented with an elevated International Normalized Ratio at a pharmacist-run anticoagulation clinic. In conjunction with the physician, the pharmacist discontinued vitamin D therapy and monitored levels.Vitamin D plays an integral role in the body's ability to absorb calcium and regulate calcium homeostasis. Further benefits have been reported regarding the role of vitamin D in muscle strength, cardiovascular health, and in preventing osteoporosis and falls. Vitamin D deficiency is widespread in the older adult population as a result of low dietary intake, decreased sun exposure, decreased intrinsic vitamin D production, and decreased vitamin D receptor activity. Replenishment using high-dose ergocalciferol is one common replenishment therapy. Patients also are able to supplement with nonprescription vitamin D products of varying strengths. While many older patients can be expected to have vitamin D deficiencies, pharmacists should be aware of appropriate replenishment therapies and correct dosing of different vitamin D products. Pharmacists also should be familiar with possible toxic effects of vitamin D, particularly as public awareness of benefits continues to increase.

Treatment of postherpetic neuralgia: focus on pregabalin.

Postherpetic neuralgia (PHN) is a devastating, chronic pain syndrome that can develop following an outbreak of herpes zoster and becomes increasingly common as patients age. PHN can be difficult to treat and often requires trials of multiple agents to achieve significant pain relief. Pregabalin is the newest agent to gain approval for PHN. Data suggest efficacy for relief of pain and sleep disturbance secondary to PHN in affected patients. Although there are no head-to-head comparisons, pregabalin appears comparable to gabapentin and other first-line agents for treating PHN.

Communicating with seniors and their caregivers.

Conducting a patient interview is an important initial step in evaluating patients and monitoring their drug therapy. Communicating with seniors can be challenging, and ensuring optimal communication is key to a successful interview. Pharmacists can help patients optimize patient health care outcomes by understanding and preparing for potential factors that can influence the communication process, being prepared for the interview, and using good communication techniques.

Diagnosis and treatment of early active rheumatoid arthritis.

A 59-year-old patient comes to a community pharmacy with unexplained, worsening bilateral foot pain and inflammation. Following evaluation of the situation, the pharmacist suggests that the patient has rheumatoid arthritis (RA). After a visit and consultation with her physician, the patient begins a complicated, rapidly evolving therapeutic regimen for RA. Through extensive counseling and education, the pharmacist is able to help the patient better manage her new medication regimen and understand expected outcomes. Pharmacists can play a very active role in helping patients with RA manage their therapies to optimize health outcomes.

Postherpetic neuralgia in an elderly patient.

A 67-year-old patient presented to the community pharmacy with poorly controlled postherpetic neuralgia (PHN) pain following an episode of herpes zoster. The clinical pharmacist did a medication review and found that, although the patient was receiving medications proven effective in the treatment of PHN, she was not receiving optimal therapy. Additionally, the patient was experiencing intolerable side effects. The pharmacist provided recommendations to the patient's primary care physician that ultimately improved the patient's pain control. Managing PHN pain requires practitioners to be vigilant in titrating pain regimens and trying various combinations of therapies with different mechanisms of action. Such an approach is one that tailors medication therapy to each individual patient, provides the most relief, and restores a patient's quality of life.

Herbal product use in a patient with polypharmacy.

A 70-year-old homebound patient was experiencing new onset porthostatic hypotension and lightheadedness. The pharmacist conducted a thorough medication review, which revealed the use of several herbal products, including St. John's wort, in addition to several prescription medications. The pharmacist counseled the patient on the potential hazards of using herbal products with prescription medications. This prompted the patient to discontinue all herbal supplements with the subsequent resolution of his lightheadedness and orthostasis. He also experienced improvement in his pain control. Pharmacists need to be vigilant in establishing a dialogue with their patients about the pros and cons of herbal product use, particularly with prescription medications.

Opportunities for improving post-hospital home medication management among older adults.

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g. Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.

Anticoagulation in elderly patients who fall frequently: a therapeutic dilemma.

There is general agreement that patients with persistent atrial fibrillation, who are at risk of having a stroke, need to be anticoagulated. However, clinicians often are in a difficult dilemma when these patients also are at increased risk of falling. Falls can lead to serious injuries in anticoagulated individuals, including intracranial hemorrhages. This case study describes an 88-year-old patient with a history of falling. She received multiple injuries following a fall, including a subdural hematoma. Warfarin was among the patient's many medications. Upon admission to the hospital this patient had a supratherapeutic INR that most likely contributed to her injuries. A question facing the medical team was should she continue to receive warfarin to prevent stroke after discharge from the hospital? Much controversy exists over whether older patients receiving anticoagulation therapy are at increased risk of major hemorrhagic complications. This article discusses the relationship between anticoagulation, falling, and the risks of hemorrhagic events. It also discusses opinions on when to restart anticoagulation following resolution of the subdural hematoma. In addition, the patient was taking multiple medications that are known to contribute to falls in older people. Recommendations for lowering this patient's fall risks are presented.

Teriparatide for severe osteoporosis.

OBJECTIVE: To review the pharmacology, toxicology, pharmacokinetics, pharmacodynamics, efficacy, safety, therapeutic controversies, administration, patient counseling, and formulary recommendations for teriparatide (rDNA origin). DATA SOURCES: A MEDLINE search (1966-May 2003) of articles using the key words parathyroid hormone and osteoporosis, parathyroid hormone and fracture, and teriparatide was conducted to identify relevant literature in the English language. Additional references were obtained from bibliographies of those articles. Some clinical trial data not yet published were obtained from the manufacturer. STUDY SELECTION AND DATA EXTRACTION: All articles obtained from the data sources were reviewed; all data deemed relevant were included. DATA SYNTHESIS: Teriparatide, recombinant human parathyroid hormone (1-34) [rhPTH (1-34)], is the first anabolic agent to treat postmenopausal women with osteoporosis and men with idiopathic or hypogonadal osteoporosis who are at high risk for osteoporotic fracture. Daily subcutaneous injections of teriparatide significantly increase both spine and hip bone-mineral density (BMD) while decreasing the incidence of fractures in both women and men. Common adverse effects noted with teriparatide use were nausea, headache, dizziness, and arthralgias. An increased incidence of osteosarcoma in rats during preclinical trials with teriparatide led to a black box warning for the drug. CONCLUSIONS: Teriparatide substantially increases spine and hip BMD and may offer additional benefits to patients with severe osteoporosis. Clinical trials comparing teriparatide with other available agents to treat osteoporosis are needed to more clearly define its place in therapy. Long-term safety and efficacy are not known.