Medication therapy management: why it no longer should be considered optional.

Medications are the primary therapeutic intervention in many health care settings. As prescription drug use continues to grow, and medication therapies become more complex, our health care systems have become more prone to medication errors and adverse drug events. Medication Therapy Management services provided by pharmacists have been shown to help reduce medication errors, adverse drug events, and costs. Such services need to be integrated into the health care system and not be regarded as optional. This article is intended to provide pharmacists, pharmacy leaders, and health care policymakers the information needed to broach this topic at the health care policy level.

Reactivation of Chronic Hepatitis C as a Potential Trigger for Guillain-Barré Syndrome.

A 74-year-old man with a past medical history of chronic low back pain presented with two to three weeks of progressive weakness starting in the lower extremities and then spreading to the upper extremities. Distal muscles were more affected than proximal muscles; weakness was accompanied by numbness and paresthesias. There was no preceding acute viral, respiratory, or gastrointestinal illness. Initial workup revealed hepatitis C antibody reactivity, and cerebrospinal fluid (CSF) analysis showed albuminocytologic dissociation. MRI demonstrated multilevel degenerative changes and diffuse enhancement of the cauda equina nerve roots compatible with Guillain-Barré syndrome (GBS). Repeat testing confirmed ongoing hepatitis C infection with increasing quantitative hepatitis C virus (HCV) levels. This case illustrates an interesting presentation of GBS potentially triggered by hepatitis C reactivation. This is the first case, to our knowledge, with serologic evidence demonstrating acute hepatitis C reactivation concurrent with GBS which presented in the absence of immunomodulatory interferon treatment. The patient continues to recover with ongoing rehabilitation at the time of this case report.

Appropriate use of dopamine agonists and levodopa in restless legs syndrome in an ambulatory care setting.

BACKGROUND: Dopaminergic agents are the mainstay therapy for the management of restless legs syndrome (RLS). There are no clear guidelines on RLS management, and no study has evaluated the appropriate use of dopaminergic agents in RLS. OBJECTIVE: To evaluate the appropriateness of use of dopaminergic agents in RLS management in an ambulatory care setting based on the most current scientific evidence. METHODS: A retrospective drug utilization evaluation was conducted in patients who received levodopa or dopamine agonist for RLS from July 1, 2006, to July 31, 2007. Patients' medical records were reviewed and data were collected on demographics; comorbidities; laboratory values; doses of levodopa or dopamine agonists; prescribing physician's specialty; and use of alcohol, tobacco, and caffeine. RESULTS: A total of 27 patients were included in the study for data collection and analysis. Twenty-two (81%) patients were on levodopa and 5 (19%) were on ropinirole. RLS severity was documented in only 2 (7%) patients. Serum ferritin levels and transferrin-iron saturation (Tsat) percentages were not obtained in 18 (67%) and 20 (74%) of the patients, respectively. Two (7%) patients had ferritin levels less than 50 ng/mL, and 7 (26%) patients had ferritin levels greater than 50 ng/mL. Fourteen (52%) patients were taking concurrent antidepressants and 6 (22%) were taking sedating antihistamines. Alcohol and tobacco use was documented in 2 (7%) and 8 (30%) patients, respectively. Twenty-six (96%) of the prescribing physicians were primary care providers. CONCLUSIONS: The findings of this study confirm the need for provider education about the appropriate use of levodopa and dopamine agonists in patients with RLS. Appropriate use of these drugs may help decrease unnecessary adverse effects, complications, and costs.

Neuroleptic malignant syndrome variant in a patient receiving donepezil and olanzapine.

BACKGROUND: A 78-year-old man with a 22-year history of schizoaffective disorder and a 5-year history of dementia presented to the emergency department with a 5-day history of fatigue, progressive weakness, confusion and lethargy, and a 1-day history of severe muscle stiffness. For the past 10 years the patient had been treated with olanzapine for an unspecified psychiatric illness, without adverse effects. One week before presentation the patient was started on donepezil to treat mild dementia. INVESTIGATIONS: Physical examination, serum and urine laboratory evaluation, lumbar puncture, brain CT scan, brain MRI, electroencephalogram, chest X-ray, and electrocardiogram. DIAGNOSIS: A variant of neuroleptic malignant syndrome secondary to drug interaction. MANAGEMENT: Discontinuation of donepezil and olanzapine, aggressive intravenous hydration, intravenous dantrolene, and bromocriptine via a nasogastric tube. The patient was also administered intravenous antibiotics for aspiration pneumonia, and carbidopa-levodopa for residual parkinsonian features.