Combination inhaled bronchodilator therapy in the management of chronic obstructive pulmonary disease.

The Global Obstructive Lung Disease (GOLD) guidelines suggest the potential use of combination bronchodilator therapy in patients with stage II or higher chronic obstructive pulmonary disease (COPD). Guidelines from the American Thoracic Society also mention that certain combinations of bronchodilators may prevent exacerbations. Combinations of several agents may benefit patients with COPD not only by improving lung function, but also by decreasing exacerbation rates and improving overall symptoms. A MEDLINE search was conducted to gather published data and clinical trial reports regarding the clinical effect of combining bronchodilators in the treatment of COPD. Agents such as oxitropium, which is not available in the United States, were not included in the analysis. Although the data are somewhat limited, trials suggest many potential benefits for combination bronchodilator therapy in patients with COPD. Information on combining long-acting anticholinergic drugs with long-acting beta2-agonists is scarce, but the combination of two long-acting agents may provide additional benefits by improving patient compliance with prescribed regimens. More studies evaluating outcomes in patients with COPD may help solidify the potential benefits of combination inhaled bronchodilator therapy.

Treatment algorithms from the pharmacist perspective.

Hospitals across the United States develop treatment algorithms for acute bronchospasm, asthma, and chronic obstructive pulmonary disease by following several different pathways. Some institutions use established national guidelines and protocols, some revise national guidelines to apply to their particular environment, and others create specific institution-related treatment algorithms with input from various departments, such as emergency medicine, respiratory therapy, and pharmacy. Although some institutions track outcomes on either a formal or an informal basis, others have not yet implemented outcomes-based programs.

A narrative review of clinical inertia: focus on hypertension.

Clinical practice guidelines report standards of care for the management of medical conditions based on review of evidence-based medicine. The inherent responsibility and challenge for health care providers is devising a patient-specific care plan through adaptations of established treatment recommendations using the latest clinical evidence and clinical decision-making skills. Clinical inertia (CI) is viewed as the failure of health care providers in adherence to or persistence with established treatment recommendations. The ability to implement an appropriate care plan is often limited not by available clinical evidence, but rather by humanistic influences. CI may result from being complacent with moderate to poor control resulting from a multitude of factors. The purpose of this review is to present existing evidence-based literature investigating CI, with an emphasis in hypertension. A literature search was performed using MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. Review of the literature addressing CI finds that many authors offer solutions primarily directed at physician behavior, although it is also influenced by patient- and system-based factors. Programs that increase communication and influence behaviors based on clinical guidelines, such as academic detailing, medication-therapy management, and disease management programs, are warranted to combat CI.