Impact of a pharmaceutical care intervention on blood pressure control in a chain pharmacy practice.

BACKGROUND: Hypertension affects over 50 million Americans, with only 50% of patients being adequately controlled. Several pharmacist counseling and pharmacist-physician comanagement studies have documented that community pharmacist interventions improve blood pressure (BP) management. OBJECTIVE: To determine whether community pharmacists can improve clinical endpoints including hypertension control, drug therapy dosing, adherence to prescribed regimens, adverse drug reaction incidence, patient understanding, response to therapy, and quality-of-life. METHODS: The program included the education and training of a group of 18 chain community pharmacists in hypertension therapies, monitoring, and management. Protocols and documentation tools were based on nationally accepted clinical practice guidelines for hypertension in place at the time of the study. Pharmaceutical care (PC) was then compared with usual care (UC) over a 12-month period. RESULTS: The study initially enrolled 180 PC and 196 UC patients, with 44% (PC) and 32% (UC) of the patients reporting a final BP measurement. A larger proportion (50%) of PC patients who had poorly controlled hypertension at baseline (>140/90 mm Hg) were controlled compared with UC patients (22%). The average reduction in systolic BP was 9.9 mm Hg in PC patients compared with 2.8 mm Hg in UC patients (p < 0.05). Changes in diastolic BP were similar in the PC and UC groups. Based on patient self-report, PC patients were more likely to say that they take their medicines as prescribed compared with UC patients (p < 0.05). The 1- to 6-month antihypertensive adherence rate was higher in PC patients (0.91 +/- 0.15) compared to UC patients (0.78 +/- 0.30) (p = 0.02); there was no significant difference in adherence rate during the 7- to 12-month period. CONCLUSIONS: Community pharmacists can positively affect patient medication adherence during the 6-month period following counseling by a pharmacist along with an improvement in patient BP. However, there is much room for improvement in PC programs and in the number of patients who properly adhere to their medications.

Influence of coagulation factor, vitamin K epoxide reductase complex subunit 1, and cytochrome P450 2C9 gene polymorphisms on warfarin dose requirements.

INTRODUCTION: The primary objective of this study was to determine whether variability in warfarin dose requirements is determined by common polymorphisms in genes whose products are involved in the pharmacodynamics and pharmacokinetics of warfarin, namely, the coagulation factors, vitamin K epoxide reductase complex subunit 1 (VKORC1), and cytochrome P450 (CYP) 2C9. METHODS: Patients (N = 350) receiving stable doses of warfarin at 3 consecutive visits were enrolled, and a deoxyribonucleic acid sample was collected. Samples were genotyped for polymorphisms in the factor II, factor VII, factor X, VKORC1, and CYP2C9 genes. A stepwise linear regression analysis was used to determine the independent effects of genetic and nongenetic factors on mean warfarin dose requirements. RESULTS: Variables associated with lower warfarin dose requirements were VKORC1 3673 AA genotype (P < .0001), VKORC1 3673 GA genotype (P < .0001), 1 variant CYP2C9 allele (P < .0001), 2 variant CYP2C9 alleles (P = .0004), increasing age (P = .0005), concomitant CYP2C9 inhibitors (P = .0005), and goal international normalized ratio (P = .01). Variables associated with higher warfarin dose requirements were weight (P < .0001), current smoker status (P = .0009), mean international normalized ratio (P = .001), concomitant CYP2C9 inducers (P = .006), factor X insertion/deletion genotype (P = .01), factor X insertion/insertion genotype (P = .04), factor VII deletion/deletion genotype (P = .04), and calculated vitamin K intake (P = .05). The linear regression model explained 51.4% of the variability in warfarin dose requirements. CONCLUSION: Polymorphisms in warfarin drug target and metabolizing enzyme genes, in addition to nongenetic factors, were important determinants of warfarin dose requirements.

Comparison of dobutamine versus milrinone therapy in hospitalized patients awaiting cardiac transplantation: a prospective, randomized trial.

BACKGROUND: The use of dobutamine or milrinone for inotropic support in patients with heart failure awaiting cardiac transplantation is largely arbitrary and based on institutional preference. The costs and effectiveness of these drugs have yet to be compared in a prospective, randomized study. METHODS: We compared clinical outcomes and costs associated with the use of dobutamine or milrinone in 36 hospitalized patients awaiting cardiac transplantation. Patients were randomly assigned to receive either dobutamine or milrinone at the time of initial hospitalization and were followed until death, transplantation, or placement of mechanical cardiac support (intra-aortic balloon pump or left ventricular assist device). RESULTS: Seventeen patients were randomly assigned to receive dobutamine (mean dose 4.1 +/- 1.4 microg/kg/min) and 19 patients received milrinone (mean dose 0.39 +/- 1.0 microg/kg/min). Therapy lasted 50 +/- 46 days for those in the dobutamine group and 63 +/- 45 days in the milrinone group. We did not detect differences between the 2 groups in right heart hemodynamics, death, need for additional vasodilator/inotropic therapy, or need for mechanical cardiac support before transplantation. Ventricular arrhythmias requiring increased antiarrhythmic therapy occurred frequently in both groups. Total acquisition cost of milrinone was significantly higher than that of dobutamine (16,270 dollars +/- 1334 vs 380 dollars +/- 533 P <.00001). CONCLUSIONS: Both dobutamine and milrinone can be used successfully as pharmacologic therapy for a bridge to heart transplantation. Despite similar clinical outcomes, treatment with milrinone incurs greater cost.

Managing hyperlipidemia: current and future roles of HMG-CoA reductase inhibitors.

The current and future roles of statins as antilipemic agents for the prevention and management of coronary artery disease (CAD) are reviewed. Therapy with hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) substantially reduces total cholesterol and low-density-lipoprotein (LDL) cholesterol concentrations. Large clinical trials have documented the efficacy of statin therapy for both primary and secondary prevention of CAD. Nevertheless, many eligible patients are either untreated or inadequately treated with these agents. In one study, 61% of patients with documented CAD were not treated with a lipid-lowering agent. Large percentages of high-risk patients receiving such agents are not meeting cholesterol goals set by the National Cholesterol Education Program (NCEP). Populations at increased risk for coronary events include patients with diabetes, women, the elderly, and patients with established CAD. Comparative studies have not shown any one agent as clearly superior to the others. Future possibilities for statin use include early treatment of hypercholesterolemia and acute coronary syndromes consistent with guidelines established by NCEP. Many clinicians now believe that an aggressive approach to lowering LDL cholesterol may yield even greater reductions in coronary events. Treatment may reduce the risk of recurrent ischemic events when initiated within 96 hours of hospitalization for acute myocardial infarction or unstable angina and continued for up to four months. Another use may be the management of atherosclerotic cerebrovascular disease. Closer attention to potential adverse effects will be necessary before any expansion in statin use. Statins are highly effective for improving cardiovascular outcomes in high-risk patients but are frequently underused. Pharmacists can help extend the benefits of statins to more patients.

Key articles and guidelines for the prevention of venous thromboembolism.

Venous thromboembolism (VTE) is an important medical problem that affects millions of patients each year. With appropriate prophylaxis, many of these thromboembolic events can be prevented. Although strong evidence supporting VTE prophylaxis spans several decades, several large American and global registries have documented very poor use of appropriate prophylaxis. Because of increasing regulatory requirements, hospitals nationwide are in the process of developing documentation of appropriate VTE prophylaxis programs for both surgical and medical patients. A wide range of clinicians must understand what constitutes appropriate VTE prophylaxis in various patient populations. With the existence of numerous pharmacologic agents, abundance of data from major clinical trials, and several nationally recognized clinical guidelines, compiling the needed reference material to make evidence-based decisions on appropriate VTE prophylaxis can be difficult for clinicians. Therefore, we provide a bibliography of key articles and guidelines related to the prevention of VTE in various patient groups. We hope this compilation will serve as a resource for pharmacists, physicians, nurses, residents, and students responsible for the care of patients who may be at risk for VTE.

Increased cardiovascular risk with second-generation antipsychotic agent switches.

OBJECTIVE: To model the risk of long-term, adverse cardiovascular events after switching from one second-generation antipsychotic medication (SGA) to another in patients with schizophrenia or schizoaffective disorder. DATA SOURCES: PubMed from 1985 to 2004 using the search terms atypical antipsychotics, obesity, weight, diabetes mellitus, dyslipidemia, hypercholesterolemia, lipids, second generation antipsychotics, antipsychotic agents, schizophrenia, metabolic syndrome, cardiovascular disease, and cardiovascular risk factors. STUDY SELECTION: By the authors. DATA EXTRACTION: By the authors. DATA SYNTHESIS: The selection of an SGA for an individual patient should be primarily based upon its therapeutic effectiveness. However, when two medications are clinically equivalent with respect to treatment outcomes, other important consequences of the medication choice should be considered. Depending upon the type of SGA switch, the risk of an adverse cardiovascular event may be lower, as when olanzapine is switched to risperidone, or may increase by as much as 33%, as when risperidone is switched to olanzapine or clozapine. CONCLUSION: Cardiovascular risk likely differs depending upon SGA choice, but limited data make it difficult to predict the metabolic changes associated with switching. Prospective controlled studies are needed to describe the cardiovascular consequences of switching among the antipsychotic agents so that evidence-based strategies can be developed for selection of the optimal SGA.

Depressive symptoms in coronary artery disease patients after hypertension treatment.

BACKGROUND: Depression is highly prevalent and frequently recurs in patients with coronary artery disease (CAD) and hypertension. Certain medications used to treat hypertension are alleged to be associated with higher risk of depression. OBJECTIVE: To compare depressive symptoms before and during treatment with 2 equivalent hypertension treatment strategies in patients with CAD stratified according to a self-reported history of physician-diagnosed depression. METHODS: Patients enrolled in a randomized hypertension treatment study were mailed baseline and one year follow-up surveys and stratified according to a self-reported history of depression. Patients (N = 1152) were 50 years old or older with hypertension and clinically stable CAD. Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression (CES-D). High risk of depression was defined as a history of physician-diagnosed depression reported by patients on the baseline survey. Depressive symptoms were compared for verapamil sustained-release (SR)- and atenolol-based hypertension treatment. RESULTS: Among patients with a previous history of depression, depressive symptoms improved over the one year follow-up period for patients assigned to both treatment regimens. Depressive symptoms improved for patients with no depression history in the verapamil SR group (p < 0.001) and were unchanged in the atenolol group (p = 0.52). Patients assigned to the atenolol-based strategy without prior history of depression were more likely to worsen 5 or more points on the CES-D. CONCLUSIONS: When antihypertensive treatment options are clinically equivalent, prescribers may first consider using a verapamil SR-based strategy, especially in patients with CAD who have no history of depression.

Rosuvastatin: a high-potency HMG-CoA reductase inhibitor.

OBJECTIVE: To summarize the relevant pharmacologic, clinical, and safety data regarding rosuvastatin (Crestor--AstraZeneca), the most recently marketed 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor approved for the treatment of dyslipidemia. DATA SOURCES: Medline search from years 1990 thru 2005 using the keywords HMG-CoA reductase inhibitor, hypercholesterolemia, lipid-lowering agents, rosuvastatin, and statins. STUDY SELECTION: Review articles, clinical trials, case reports, abstracts, and data on file from the manufacturer concerning rosuvastatin and other statins were considered for inclusion. DATA EXTRACTION: English-language studies were selected for inclusion. DATA SYNTHESIS: Multiple clinical trials have revealed that use of rosuvastatin is associated with greater reductions in low-density lipoprotein cholesterol (LDL-C) across the dose range of 5-40 mg/day than any other currently available statins. Rosuvastatin also significantly increases high-density lipoprotein cholesterol and reduces triglycerides significantly as well. In clinical trials, rosuvastatin was well tolerated, with a low incidence of adverse events and a safety profile similar to that of the other marketed statins. At present, no large-scale primary or secondary prevention clinical trials document either long-term safety of rosuvastatin or its effectiveness in preventing coronary events. CONCLUSION: Compared with other statins, rosuvastatin offers the greatest lipid-lowering efficacy at the lowest dose in treating patients with dyslipidemia and with a similar safety profile over the short-term. Rosuvastatin may allow more patients to achieve their LDL-C goals than any other statin and at a lower dose than other agents.

Home blood pressure monitoring: point-of-care testing.

OBJECTIVE: To review the literature regarding point-of-care blood pressure monitoring and describe its role in pharmacy practice. DATA SOURCES: Primary articles were identified by a MEDLINE search (1966-May 2003); references cited in these articles provided additional resources. STUDY SELECTION AND DATA EXTRACTION: All articles identified from this search were reviewed and all information deemed relevant was included in this article. DATA SYNTHESIS: Hypertension is a well-established risk factor for coronary heart disease, the leading cause of death in the US. The use of at-home blood pressure monitors may help improve identification and management of this disorder. Pharmacists may use many of these devices in their practice and are also in an ideal position to provide patient education on the selection and use of these monitors, as well as interpretation of results. CONCLUSIONS: The availability of at-home blood pressure devices has considerably increased in recent years and likely will continue to do so. Based on currently available but limited data, fully automated or semiautomated upper-arm devices are preferred over wrist- or finger-cuff devices. These devices are best suited for screening and monitoring only and should not be used for diagnosis. Although such devices are potentially cost-effective, there is presently insufficient evidence to support the notion that their use can replace routine office monitoring.

Cholesterol: point-of-care testing.

OBJECTIVE: To review the literature regarding point-of-care (POC) cholesterol monitors and describe their role in pharmacy practice. DATA SOURCES: Primary articles were identified by a MEDLINE search (1966-May 2003); references cited in these articles provided additional resources. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified from this search were reviewed, and all information deemed relevant was included. DATA SYNTHESIS: Hyperlipidemia is a well-established risk factor for coronary artery disease, which is the leading cause of death in the US. The use of POC cholesterol monitors may help to improve the identification and management of this disease. Pharmacists may use many of these devices in their practice and are also in an ideal position to provide patient education on selection and use of these monitors and interpretation of the results. CONCLUSIONS: The availability of POC cholesterol monitors has increased in recent years. Based on currently available data, these monitors are best suited for screening purposes and to assist in the management of hyperlipidemia. There is not enough evidence to support the notion that POC cholesterol monitors can replace laboratory or office monitoring. Their application in the diagnosis of hyperlipidemia is also currently limited.