Uses and limitations of bone mineral density measurements in the management of osteoporosis.

CONTEXT: Bone mineral density (BMD) is used to diagnose osteoporosis, and often to measure efficacy in osteoporosis treatment trials; however, there is a poor correlation between lumbar spine BMD increases and vertebral fracture risk reduction in patients receiving treatment for osteoporosis. OBJECTIVE: The purpose of this article is to review the uses and limitations of BMD measurements and the relationship between BMD and bone strength. DATA SOURCE/STUDY SELECTION: A MEDLINE literature search was conducted with the terms bone mineral density , fracture , osteoporosis , and bone strength as well as the generic names of osteoporosis therapies (alendronate, risedronate, raloxifene, teriparatide, and calcitonin). Search results were limited to English language journals and articles published within the last 20 years. Published abstracts from scientific meetings were also reviewed. CONCLUSION: BMD measurement remains the most useful diagnostic tool for identifying patients with osteoporosis. Although they are helpful in guiding decisions to initiate osteoporosis treatment, subsequent changes in BMD provide an imperfect indicator of treatment efficacy. Analyses of clinical trials show an inconsistent relationship between increased spinal BMD and a decreased risk of vertebral fracture. Increased BMD accounts for less than 25% of the overall reduction in fracture risk in most instances. Consequently, fracture risk reduction itself remains the most clinically relevant therapeutic outcome of osteoporosis therapy.

Smoking cessation: pharmacists helping patients kick the habit.

Nicotine is just as habit forming as "harder" drugs, and more deaths occur due to tobacco than other substances of abuse. Several treatments are available for pharmacists to recommend or dispense to patients attempting to stop smoking. The health benefits of quitting tobacco far outweigh the potential obstacles when beginning a smoking-cessation program. Pharmacists need to evaluate patients and their level of commitment to the program, provide education about behavioral modification, and follow-up with patients to support their efforts to quit smoking.

Optimizing outcomes in rheumatoid arthritis.

A chronic systemic inflammatory disease, rheumatoid arthritis can cause progressive joint destruction, deformity, disability, and premature death. Pain management is an important component of patient care, and short-term opioid analgesics should be considered in those with severe arthritis pain. Treatment with DMARDs should be initiated early in the course of the disease to control synovitis and disease progression. Biological therapies that block specific cytokines are important advances in the treatment of rheumatoid arthritis.

Modeling the cost-effectiveness of a smoking-cessation program in a community pharmacy practice.

OBJECTIVES: To describe some of the costs of providing a smoking-cessation program in a community pharmacy practice, and to model the program's cost-effectiveness compared with that of a self-directed quit attempt. DESIGN AND SETTING: Data used were based primarily on results from a pharmacist-directed smoking-cessation program in a community pharmacy chain practice that achieved continuous abstinence for at least 1 year in 25% of patients. Baseline assumptions were formulated from a MEDLINE literature review and were varied in the sensitivity analysis. Overall costs were based on program costs and retail cost of the selected cessation method (cold turkey, nicotine patch, nicotine gum, or bupropion). PATIENTS: Forty-eight patients, more than two thirds of whom were women, aged 21-70 years, who had tried at least once to quit smoking. MEASUREMENTS AND MAIN RESULTS: Incremental cost-effectiveness was measured in terms of cost/successful quit attempt based on the payer's perspective. Cost/life-year saved and cost/quality-adjusted life-year saved also were calculated for the societal perspective. Incremental cost for an additional patient to quit smoking using the pharmacist-directed program alternatives versus a self-directed quit attempt was $236 for the cold turkey method, $936 for nicotine patch, $1232 for nicotine gum, and $1150 for bupropion. Depending on the smoker's age at the time of cessation, the incremental discounted cost-effectiveness was $720-1418/life-year saved. CONCLUSION: This analysis demonstrates that a pharmacist-directed cessation program is a cost-effective alternative to a self-directed quit attempt with respect to payers and society. Additional analyses conducted in community pharmacy practice are necessary to corroborate our results.

Cost of treating hypertension in the elderly.

Hypertension is a common disease among the elderly, a population that will continue to grow over the next decade. Untreated hypertension can lead to cardiovascular events and mortality. Given the seriousness of this disease and the increase in the number of elderly with hypertension, this review focuses on the cost of treating hypertension in the elderly as described in recent publications. We found a limited number of articles related to the treatment of hypertension in the elderly. One publication provided insightful information pertaining to expenditures in the United States for hypertension in 1998. This article was the first to examine age distribution among persons 65 years and older. It has been shown that antihypertensive pharmacologic treatment significantly reduces the incidence of cardiovascular events. Without any other medical conditions, thiazide-like diuretics are recommended for the treatment of hypertension in the elderly due to their beneficial effects, low risk for side effects, and low cost. In general, it was found that the elderly have higher expenditures per capita for hypertension and per hypertensive condition.

Intranasal corticosteroids for allergic rhinitis.

Intranasal corticosteroids are accepted as safe and effective first-line therapy for allergic rhinitis. Several intranasal corticosteroids are available: beclomethasone dipropionate, budesonide, flunisolide, fluticasone propionate, mometasone furoate, and triamcinolone acetonide. All are efficacious in treating seasonal allergic rhinitis and as prophylaxis for perennial allergic rhinitis. In general, they relieve nasal congestion and itching, rhinorrhea, and sneezing that occur in the early and late phases of allergic response, with studies showing almost complete prevention of late-phase symptoms. The rationale for topical intranasal corticosteroids in the treatment of allergic rhinitis is that adequate drug concentrations can be achieved at receptor sites in the nasal mucosa. This leads to symptom control and reduces the risk of systemic adverse effects. Adverse reactions usually are limited to the nasal mucosa, such as dryness, burning and stinging, and sneezing, together with headache and epistaxis in 5-10% of patients regardless of formulation or compound. Differences among agents are limited to potency, patient preference, dosing regimens, and delivery, device and vehicle.

Results of a smoking cessation clinic in community pharmacy practice.

OBJECTIVES: To describe and assess the effectiveness of a smoking cessation clinic. DESIGN: Single group, unblinded study. SETTING: Seven chain (mass-merchandise) community pharmacies in Virginia. PARTICIPANTS: Forty-eight patients who were smokers when admitted to the study. INTERVENTIONS: Fifteen community chain pharmacists were trained using a smoking cessation training manual developed at the Virginia Commonwealth University School of Pharmacy. From April 1, 1997, through December 31, 1999, interested patients met individually with a study pharmacist during scheduled clinic times in semiprivate counseling areas. A patient chart was maintained at the site and updated after each visit. The first 30 patients completed a questionnaire after the third visit to the smoking cessation clinic to assess satisfaction with pharmacists and the overall program. MAIN OUTCOME MEASURE: Rate of long-term smoking cessation. RESULTS: Of the 48 patients, 12 (25.0%) abstained from smoking cigarettes for 12 months or more beyond their predetermined quit dates. Abstinence rates for 1, 3, and 6 months were 43.8%, 31.3%, and 25.0%, respectively. Women were nearly five times more successful in attaining long-term abstinence than were men (33.3% versus 6.7%; P= .047). No significant differences were observed in cessation rates related to age, number of cigarettes smoked per day, level of nicotine dependence, number of previous quit attempts, or method of cessation. Increased appetite and weight gain were the most frequently reported withdrawal symptoms (16.7% of patients). Patients expressed satisfaction with the pharmacists and the smoking cessation program. CONCLUSION: Compared with other types of previously reported interventions, a community pharmacist-managed smoking cessation clinic achieved greater long-term smoking cessation rates.

Development and implementation of a smoking cessation clinic in community pharmacy practice.

OBJECTIVE: To describe a pharmacist-operated program to help people stop smoking. SETTING: Community chain (mass-merchandise) pharmacy practice sites in Virginia. PARTICIPANTS: Faculty at the Virginia Commonwealth University School of Pharmacy (VCU) and 15 practicing pharmacists. PRACTICE DESCRIPTION: Smoking cessation clinics within the pharmacy departments of seven Target stores. PRACTICE INNOVATION: With input from the practicing pharmacists and using the most current strategies reported in the literature, faculty at VCU developed a training manual for smoking cessation counseling. This manual was used to facilitate a 4-hour training session and also served as a resource for pharmacists in the smoking cessation clinics. Pharmacists were taught about behavioral modifications, the Transtheoretical Model of Change as applied to smoking cessation, documentation, the Fagerström Test for Nicotine Dependence, smoking cessation therapies, patient counseling techniques, physical assessment skills, and how to develop an individualized action plan for smoking cessation. As pharmacists established smoking cessation clinics, issues such as workflow, continuous quality improvement, and marketing were addressed by the faculty members and practitioners. RESULTS: Using the process and tools described in this article, pharmacists successfully established and operated smoking cessation clinics. CONCLUSION: The process and materials developed for this demonstration project can serve as templates for other pharmacy faculty members and community pharmacists who wish to offer smoking cessation clinics.

Clinical use of methadone.

Methadone hydrochloride is a mu-opioid agonist that has been used for the treatment of pain and for the management and maintenance of opioid withdrawal for over 50 years. Several characteristics make methadone a useful drug. However, these same characteristics and wide interpatient variability can make methadone difficult to use safely. A MEDLINE search was conducted on publications between January 1996 and May 2001 to identify literature relevant to this subject. Those publications were reviewed, and from them, other literature was identified and reviewed. Published studies demonstrate methadone's efficacy in pain management and in opioid withdrawal. However, interpatient variability in pharmacokinetic variables of methadone produces difficulties in developing guidelines for methadone use. Clinicians should not be deterred from use of this drug which has been shown to benefit patients in both pain management and methadone maintenance, but an individualized patient approach must be taken to use methadone safely.