Developments in Oral Antiplatelet Agents for the Treatment of Acute Coronary Syndromes: Clopidogrel, Prasugrel, and Ticagrelor.

A review of the literature was conducted for clinical trials evaluating the antiplatelet P2Y12 receptor antagonists, clopidogrel, prasugrel, and ticagrelor, as well as the guidelines for the management of acute coronary syndrome (ACS) or myocardial infarction. Clinical guidelines recommend that patients with ACS be treated with dual oral antiplatelet therapy of aspirin plus clopidogrel, prasugrel, or ticagrelor. The selection of an appropriate antiplatelet agent depends on the treatment approach and a patient's bleeding risk and clinical history. With respect to antiplatelet activity, prasugrel and ticagrelor demonstrate greater potency and less interpatient variability than clopidogrel. In phase III clinical trials, prasugrel and ticagrelor reduced the incidence of ischemic events in patients with ACS compared with clopidogrel. Ticagrelor and clopidogrel were associated with a similar risk of major bleeding, whereas patients receiving prasugrel had an increased risk of major bleeding versus those receiving clopidogrel. Pharmacists can provide guidance on the appropriate use of antiplatelet agents as well as the use of concomitant medications, while being vigilant for any potential drug interactions.

Considerations in patients receiving oral antiplatelet therapy after acute coronary syndrome and percutaneous coronary intervention.

PURPOSE: Adverse events that can occur in patients with acute coronary syndrome (ACS) following percutaneous coronary intervention (PCI), and with the use of oral antiplatelet agents are discussed. SUMMARY: Disruption of the vascular endothelium routinely occurs during PCI and stent placement, resulting in vascular injury. This injury can increase the risk of intracoronary thrombosis and subsequent ACS after PCI. Appropriate antiplatelet therapy reduces the risk of intracoronary thrombosis after PCI; however, health care providers should be aware of the possible limitations associated with specific antiplatelet agents and how to tailor therapy to improve outcomes. Platelet response after a clopidogrel loading dose is highly variable, and platelet hyporesponsiveness to clopidogrel may result in a variety of ischemic complications. A number of methods are available for assessing the antiplatelet effects of clopidogrel. However, none of these tests has been standardized as a measurement for clopidogrel responsiveness. Several polymorphic CYP enzymes are involved in the activation of clopidogrel, and genetic polymorphisms may affect the activity of these enzymes. Genetic variants, particularly the presence of the CYP2C19*2 allele, are associated with poor clinical outcomes after stent placement, along with increased ischemic events in clopidogrel-treated patients. Health care providers should also be aware that drug-drug interactions can occur in patients receiving clopidogrel and other CYP2C19 inhibitors. CONCLUSION: Prevention and proper management of adverse events can help to optimize outcomes in patients with ACS who have undergone PCI with stent placement.

Growth of a pharmacy school through planning, cooperation, and establishment of a satellite campus.

University of Maryland School of Pharmacy was in a quandary: its comprehensive mission required meeting state workforce needs while increasing educational quality, expanding research, and responding to service needs, but state resources were declining, faculty members were stressed, construction of a long-needed new building was stalled, and pressure to increase doctor of pharmacy (PharmD) enrollment was growing. A sharp challenge from the Board of Regents mobilized the school to quickly launch a growth initiative to accelerate PharmD program expansion through a satellite campus. Within 4 months, a plan was approved that not only led to enrollment growth, but also to a significant expansion of the faculty and staff, increased operating and capital budgets, and ground breaking for an $83 million new building. This case study illustrates how seemingly competitive needs such as teaching, research, and service can be woven together synergistically to accomplish multiple goals.

The impact of advanced pharmacy practice experiences on students' readiness for self-directed learning.

OBJECTIVE: To evaluate the impact of advanced pharmacy practice experiences (APPEs) on doctor of pharmacy (PharmD) students' readiness for self-directed learning. METHODS: The Self-Directed Learning Readiness Scale (SDLRS) was administered to students prior to and after completing their APPEs. SDLRS is a validated instrument that determines the relative degree to which students have the attitudes and motivation to engage in self-directed learning. RESULTS: Seventy-seven (64%) students completed the SDLRS prior to starting their APPEs and 80 (67%) students completed the instrument after completing their APPEs. Forty-six (38%) students completed both. Prior to starting their APPEs, 74% of students scored greater than 150 on the SDLRS, indicating a high level of readiness for self-directed learning. No significant difference was found between the mean scores of students who took the SDLRS both prior to (159 +/- 20) and after completing their APPEs (159 +/- 24; p > 0.05). CONCLUSION: Students at our institution appear to be ready for self-directed learning but APPEs had a minimal impact on their readiness for self-directed learning.

White paper: value of specialty certification in pharmacy.

OBJECTIVE: To address the value of Board of Pharmaceutical Specialties (BPS) certification, particularly as perceived by different stakeholders (pharmacists, employers, government, and academia), and to draw a parallel between specialization and certification in pharmacy and in medicine. DATA SOURCES: Electronic databases (Medline, International Pharmaceutical Abstracts, Sociological Abstracts), associations/health care organizations Web sites, outside reports, and clinical pharmacists involved in certification processes. STUDY SELECTION: Studies and reports that addressed the value of specialty certification were selected by the authors. DATA EXTRACTION: By the authors. DATA SYNTHESIS: Pharmacists with specialty certification report enhanced feelings of self-worth, improved competence, and greater marketability. Other values of certification include increased acceptance by health care professionals, salary increases, and job promotions. Employers have acknowledged board-certified pharmacists through public recognition, increase in responsibility, and some types of monetary compensation. In some governmental organizations, certified pharmacists receive salary raises and are granted prescribing authority. However, the overall value of specialty certification in pharmacy as perceived by the public or payers lags behind when compared with the status of specialty certification in medicine. CONCLUSION: Board-certified pharmacists appreciate the value of pharmacy specialty certification, and in a number of organizations and practice settings, board-certified pharmacists are perceived as valuable. Still, unlike board-certified physicians, board-certified pharmacists are not widely recognized outside or even within the pharmacy profession. To address this challenge, board-certified pharmacists ought to market their services to assure that other stakeholders recognize their value.

High-versus low-dose ACE inhibitor therapy in chronic heart failure.

OBJECTIVE: To discuss the controversy associated with the optimal dosing of angiotensin-converting enzyme (ACE) inhibitors in the management of patients with systolic heart failure; specifically, to review data related to the use of high-dose ACE inhibitors related to both neurohormonal and clinical outcomes associated with doses similar to, lower than, and higher than those used in the large, randomized clinical trials. DATA SOURCES: Primary, review, and meta-analysis articles were identified by MEDLINE search (1987-September 2002) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified from the data sources were evaluated, and all information deemed relevant was included in this discussion. All available comparative dose trials, both prospective and retrospective, were evaluated for clinical and neurohormonal outcomes. DATA SYNTHESIS: The majority of data comparing the effect of high- with low-dose ACE inhibitors on neurohormonal outcomes demonstrate dose-related reduction in various neurohormonal measurements including plasma ACE, aldosterone, atrial natriuretic peptide, B-type natriuretic peptide, and interleukin-6 levels. Clinical endpoints including New York Heart Association class and heart failure-related hospitalizations were reduced by higher doses, but a dose-related survival benefit has not been demonstrated. Differences in duration of therapy and study design may account for variability in neurohormonal and morbidity results among various studies. CONCLUSIONS: Despite documented underutilization in clinical practice of doses of ACE inhibitors demonstrated in large controlled trials to improve morbidity and mortality, clinicians should attempt to reach these target doses if possible in patients with heart failure. Higher doses may improve surrogate markers for heart failure without impacting survival.