Dual atypical neuroleptic use: prescribing patterns at a Veterans Affairs outpatient clinic.

The use of two atypical neuroleptics (ANs) in a single patient is rising. In the study described herein, 57 patients receiving dual ANs were retrospectively evaluated at a Veterans Affairs outpatient medical center in South Carolina. Only 3% of all patients receiving ANs were prescribed two such drugs, and only 58% of patients taking dual ANs met the age-specific criteria for addition of a second drug. In 90% of cases, both prescriptions were written by the same prescriber. No evidence was noted of lack of communication between two prescribers treating the same patient.

Assessment of clinical pharmacist management of lipid-lowering therapy in a primary care setting.

BACKGROUND: Pharmacists have been shown to positively impact the outcomes of care for treatment of many different kinds of disease states. In particular, pharmacist-run lipid clinics have enjoyed varying degrees of success, depending on the outcome assessed. At our hospital, when a patient is transferred to the pharmacist-coordinated lipid clinic, the primary care pharmacist is responsible for ordering and interpreting labs and prescribing and monitoring lipid-altering therapy. OBJECTIVE: This study was designed to assess if there is a statistically significant difference between the magnitude of serum cholesterol reduction for patients receiving lipid-altering pharmacotherapy when clinically trained pharmacists are actively prescribing and adjusting the drug therapy compared to other health care practitioners (usual care). METHODS: Patient records from the hospital computer databases were retrospectively and randomly selected for analysis. Following evaluation for inclusions and exclusions, 41 patient records remained for statistical analysis for the cohort group, and 47 records remained from the group of patients managed by a clinical pharmacist. RESULTS: Management of dyslipidemia by a clinical pharmacist was associated with a significant reduction in overall mean low-density lipoprotein (LDL, 18.5%) compared to the cohort that did not have a clinical pharmacist as the primary manager of dyslipidemia (6.5%, P=0.049). This suggests improved clinical outcomes, defined as greater LDL reduction, when clinical pharmacists participate in lipid management, including drug prescribing. The magnitude reduction in LDL was found to be related to the number of clinical pharmacy visits (11.4% for 1 visit, 23.2% for 2 visits, and 23.7% for >3 visits), compared to the usual care group (-11.0%, 18.0%, and 7.4%; statistically significant, P=0.038, for >3 visits only). These results occurred even though the group of dyslipidemic patients managed primarily by a clinical pharmacist contained a statistically greater number of patients with 2 or more risk factors and high-density lipoprotein (HDL) levels less than 40 mg/dL. CONCLUSION: Interdisciplinary medical teams that include clinical pharmacists who are actively prescribing and adjusting lipid drug therapy may achieve greater reductions in LDL for patients who have been assessed with multiple risk factors compared to patients managed without clinical pharmacists. Active participation by clinical pharmacists in lipid management for patients with elevated LDL resulted in improved treatment success as measured by the magnitude reduction in LDL. The reduction in LDL was between 5% and 22% per visit greater for patients being treated by clinical pharmacists versus usual care, even in a patient population with more risk factors. These intermediate outcomes may translate into long-term outcomes in fewer cardiovascular events, improved quality of life for patients with dyslipidemia, and lower costs associated with sequelae of dyslipidemias.

Nonsteroidal antiinflammatory drug starter packs for chronic musculoskeletal pain.

STUDY OBJECTIVE: To determine whether prescribing a nonsteroidal antiinflammatory drug (NSAID) starter pack for chronic musculoskeletal pain expedites the process of finding an appropriate drug for a given patient. DESIGN: Prospective patient interviews. SETTING: Veterans Affairs Medical Center. PATIENTS: Sixty-four patients with chronic musculoskeletal pain were prescribed NSAID starter packs. Of those, 42% were interviewed and their data evaluated. INTERVENTION: Between March and June 2001, patients received starter packs containing 1-week supplies of the following NSAIDs: ibuprofen, salsalate, etodolac, naproxen, sulindac, and piroxicam. The patients took one drug each week, then returned to their providers to receive a prescription for the agent that was considered most effective and tolerable. MEASUREMENTS AND MAIN RESULTS: Patients assessed pain each day based on a numeric pain-rating scale. During telephone interviews, seven patients reported better pain control when they were able to select a drug from the starter pack than when they were prescribed a specific drug by their providers. Providers rated the starter pack as easy to use by patients and generally effective for finding the best NSAID for a particular patient. Drugs prescribed after completing the starter pack were salsalate 25.9%, piroxicam 22.2%, etodolac 14.8%, ibuprofen 14.8%, naproxen 11.1%, celecoxib 7.4%, and an opiate 3.7%. CONCLUSION: The NSAID starter pack appears to be a successful method for quickly and easily finding an NSAID that is effective and tolerated.

Nefazodone in the treatment of patients with post-traumatic stress disorder.

Post-traumatic stress disorder occurs in patients who have undergone a traumatic experience and manifests itself through a cluster of symptoms, including re-experiencing, avoidance and hyperarousal. Post-traumatic stress disorder is commonly found among veterans of war and victims of sexual trauma, natural disasters and accidents. Nefazodone is a medication that has an FDA-approved indication for treating depression. Nefazodone has also been reported to be efficacious in treating post-traumatic stress disorder. Despite recent reports of hepatotoxicity, when used appropriately, nefazodone is generally as well-tolerated as the medications currently FDA-indicated for post-traumatic stress disorder, the selective serotonin reuptake inhibitors. Through its mechanism inhibiting neuronal uptake of serotonin and norepinephrine and as a potent postsynaptic serotonergic antagonist, nefazodone has proven to be effective in treating post-traumatic stress disorder in several open-label trials. The results of such trials warrant its study in larger, double-blind, placebo-controlled clinical trials.