Initial Experience of Clinical Pharmacy Services Delivered by Computer Communication via Cisco Jabber Video in a US Veterans Administration Medical Center.

Background/Objective: Clinical video telepharmacy is a new initiative of the Department of Veterans Affairs (VA) to provide rural patients access to clinical pharmacy services. This article describes some of the obstacles that pharmacists faced as they initiated this service and early outcomes in diabetes and hyperlipidemia patients. Methods: This study was approved by the institutional review board. This was a single-center, retrospective review of patients seen by 3 clinical pharmacists who developed and administered the telepharmacy clinics. Patients were referred by their primary care providers. Patients traveled to their local community-based outpatient clinic where a nurse set up video conferencing and then paged the pharmacist at the Lincoln VA. Patients were referred for management of anticoagulation, diabetes, hyperlipidemia, or hypertension, with 112 patients screened and 12 patients meeting criteria for hemoglobin A1c (HbA1c) evaluation and 25 patients meeting criteria for low-density lipoprotein (LDL)-cholesterol evaluation. Pharmacists also saw new patients for medication reviews, patients just out of the hospital, and patients with questions about their medication regimens. This study looked specifically at the effect that the pharmacist had on HbA1c and LDL-cholesterol reduction and meeting goals for these 2 parameters. Results: Patients in the diabetes group had a mean ± standard deviation reduction in HbA1c of 1.08 ± 0.85 (95% confidence interval = 0.53-1.62; P = .001). The mean HbA1c decreased from 9.1% to 8% after pharmacist intervention. Patients in the hyperlipidemia group had a mean ± standard deviation reduction in LDL-cholesterol of 23.74 ± 7.76 mg/dL (95% confidence interval = 7.76-39.75; P = .005). The mean LDL-cholesterol decreased from 145 to 121 mg/dL after intervention. There were no significant changes in the number of patients attaining their HbA1c or LDL-cholesterol goals after intervention. Conclusions: This study shows that telepharmacy allows patients to have access to pharmacy services in a rural environment with minimal inconvenience to the patient. This study also suggests that outcomes of disease management are similar to face-to-face visits.

Effects of prednisone on the International Normalized Ratio.

PURPOSE: The effects of prednisone on the International Normalized Ratio (INR) values of a patient were examined. SUMMARY: A 66-year-old white man with a history of multiple myeloma was treated in an ambulatory care anticoagulation clinic for deep vein thrombosis. His INR values were normal during therapy with warfarin 14 mg weekly and thalidomide 300 mg daily. His INR values began to increase after three months of starting prednisone 10 mg daily. His weekly dose of warfarin was changed over the next two years, and his dietary intake of vitamin K was increased. For every INR value that was below the therapeutic goal, the patient was not taking prednisone; every time the INR value was above the therapeutic goal, he was taking prednisone. In November 2004, the prednisone and thalidomide were stopped and only the warfarin was continued. After a few dosage increases, ending with a weekly warfarin dose of 21 mg, the patient's INR values remained in the therapeutic range. Multiple variables must be examined when assessing INR values, as many things interact with warfarin. For example, tobacco use, alcohol consumption, and changes in vitamin K intake can affect the INR. Since this patient did not use tobacco or consume alcohol and had a fairly consistent dietary intake of vitamin K, these variables were ruled out as influencing the INR. In this case, the changes in his INR values corresponded to the addition or deletion of prednisone. CONCLUSION: A patient's INR values increased after the addition of prednisone to his warfarin regimen.

Cost-effectiveness of smoking cessation and the implications for COPD.

The cost burden of COPD is substantial for patients and families, payers, and society as a whole. Smoking has been known for decades to be the leading cause of the disease. Numerous studies have been completed to address the cost-effectiveness of programs created to aid smokers in their efforts to quit. Because several assumptions must be made in order to conduct such a study, and because differences in study design are numerous, comparison of data is difficult. However, studies have consistently shown that regardless of the perspective from which the study was completed, or the methods used to help smokers abstain, the interventions are cost-effective. Although no study has been conducted specifically to assess the cost-effectiveness of smoking cessation interventions as they relate directly to patients with COPD, based on current data it can be concluded that smoking cessation programs are cost-effective for this population.

Lifestyle modification counseling of patients with dyslipidemias by pharmacists and other health professionals.

OBJECTIVES: To establish whether patients who are taking lipid-lowering medications receive information on lifestyle modifications from health care providers when originally prescribed and whether they continue to receive follow-up information on lifestyle modifications, and to establish where patients with dyslipidemias are receiving information about lowering their serum cholesterol levels through lifestyle modifications. DESIGN: Cross-sectional survey. SETTING: Two community pharmacies and two hospitals in two medium-sized cities in the midwestern area of the United States. PARTICIPANTS: 234 patients taking medication to lower serum lipids. INTERVENTION: Paper-based survey. MAIN OUTCOME MEASURE: Responses to survey items. RESULTS: Nearly three quarters (73.9%) of participants received information about lowering their serum lipids through lifestyle modifications when they were first diagnosed with elevated serum cholesterol concentrations. Of these, most (83.8%) said that the information came from their physician. Fewer than one half (48.3%) of all participants said that they continued to receive this type of information. Those who received lifestyle modification information at their original diagnosis and who continued to receive this type of information were more likely to be actively trying to lower their serum lipid levels through diet (93.1%) and exercise (71.6%). Participants visited their pharmacy more often than their physician's office each year, yet they recalled pharmacists offering less patient counseling on lifestyle modifications than did physicians and nurses. CONCLUSION: Despite being well positioned to assist patients with elevated serum cholesterol concentrations, pharmacists offer less patient counseling about therapeutic lifestyle modifications compared with physicians and nurses.

Rhabdomyolysis associated with simvastatin-nefazodone therapy.

Simvastatin is a hydroxymethyl glutaryl coenzyme A reductase inhibitor commonly used to treat patients with hyperlipidemia. It is a safe and effective medication in most patients when used appropriately. A serious side effect known as rhabdomyolysis may rarely occur in patients who take simvastatin, especially at higher doses and with agents that interact and increase the level of simvastatin in the blood. We describe the case of a patient with rhabdomyolysis that occurred after the patient's simvastatin was titrated to 80 mg at approximately the same time that his antidepressant medication was switched to nefazodone. We found only two other similar cases in the literature, both of which were presented as letters to the editor in two different journals. We present this case to add to the literature and to assist practitioners by raising their awareness of this interaction so that it can be monitored.