A pharmacy-based approach to cholesterol management.

OBJECTIVE: To determine the clinical and economic impact of a pharmacy-based cholesterol management program in patients with cardiovascular disease. STUDY DESIGN: Demonstration project. PATIENTS AND METHODS: From January 1, 1999, through June 30, 1999, 300 patients with a documented history of cardiovascular disease were enrolled in a pharmacy-based cholesterol program. A similar group of 150 randomly selected patients receiving usual care during the same period served as the comparator group. The following were collected for both groups: patient demographics, comorbidities, fasting lipid profiles, cholesterol medication, cost of medication, and cardiovascular events. The McNemar symmetry chi2 test was used to compare appropriate laboratory monitoring, receipt of cholesterol medication, and achievement of target low-density lipoprotein cholesterol levels at baseline and 1 year for both groups. Kruskal-Wallis analysis of variance was used to compare the cost of therapy for both groups at baseline and follow-up. RESULTS: Mean +/- SD age of program and usual care patients was 67 +/- 10 and 69 +/- 11 years, respectively. At 1 year, >95% of program patients were receiving appropriate laboratory monitoring. In 1 year, the percentage of patients reaching target low-density lipoprotein cholesterol levels increased from 45% to 72% (P< .01) and from 33% to 43% (P = .26) in program and usual care patients, respectively. Despite increased medication use among program patients, their cost per patient per month was lower at 1-year follow-up vs baseline. CONCLUSION: Regular patient interaction and close patient monitoring allowed the pharmacy-based lipid management program to improve cholesterol management in patients with cardiovascular disease.

Acid-suppressive therapy use associated with antihypertensive agents.

Nitrates and calcium channel blockers (CCBs) have been shown to decrease lower esophageal sphincter pressure and theoretically may precipitate or aggravate gastroesophageal reflux. Thus, the authors hypothesized that patients who receive these agents would have greater use of acid-suppressive drug use, defined as histamine2 antagonists or proton pump inhibitors. A retrospective cohort design was used to assess the use of acid-suppressive drug use in hypertensive patients with respect to both nitrates and antihypertensive therapy. Of 15,662 treated hypertensive patients, 20% received acid-suppressive therapy. An increased use of acid-suppressive therapy was associated with nitrate (odds ratio [OR] = 1.71), CCB (OR = 1.46), and alpha 1 antagonist (OR = 1.32) treatment, which appeared to be additive when patients received two or more of the agents. Within the class of CCBs, there was no significant difference among the individual agents. As the clinical and economic burden may be substantial, further study is warranted.

Treatment of hypertension in a managed care setting.

BACKGROUND: Based on recommendations of the Fifth and Sixth Reports of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Health Care Plan (now Univera Healthcare) Buffalo, NY, developed a clinical guideline to improve the management of patients with hypertension. To increase awareness and utilization, the guideline was distributed as hard copy reports and made available through our electronic information system. OBJECTIVE: To determine blood pressure (BP) control rates and adherence to guideline recommendations. STUDY DESIGN: Retrospective chart review. PATIENTS AND METHODS: We randomly sampled hypertensive patients seen during 1998 to evaluate hypertension management. Computerized medical and pharmacy records were reviewed for patient demographics, antihypertensive medications, comorbid conditions, and BP readings. Patient assessment was based on antihypertensive regimen and achievement of target BP according to the recommendations of the guidelines (< 140/90 mm Hg for the general population and < 130/85 mm Hg for special populations). In addition, we assessed control rates using traditional Health Plan Employer Data and Information Set (HEDIS) measures (< 140/90 mm Hg). RESULTS: Overall, 35% of patients achieved target BP and 68% were treated with agents recommended by our JNC-based guideline. In contrast, using traditional HEDIS measures, 41% of patients achieved BP control. Of 39 patients with compelling indications (primarily diabetic patients), 13% achieved BP target and 67% were treated with recommended agents. CONCLUSIONS: The impact of our clinical guideline is reflected through the relatively high utilization of recommended drugs. However, optimal BP control continues to be problematic. In particular, patients with diabetes warrant focused attention.

Potential interaction between troglitazone and atorvastatin.

BACKGROUND: Troglitazone is a CYP3A4 isoenzyme inducer known to decrease the plasma concentration of drugs metabolized by CYP3A4. Atorvastatin, a known substrate of the CYP3A4 pathway, is often used in combination with troglitazone for diabetic patients with dyslipidemia. AIMS: The purpose of this study was to investigate the clinical effects of troglitazone on the fasting lipid profiles of patients receiving atorvastatin. METHOD: We retrospectively reviewed the medical records of patients who received concomitant troglitazone and atorvastatin therapy during a 24-month period. Patients were included in the analysis if during the study period, complete laboratory data were available (fasting lipid profile and glycosylated haemoglobin), the dose of atorvastatin remained unchanged, there were no changes in the diabetic drug regimen, patients received at least 3 months of combination therapy and patients were adherent with their medication. RESULTS: Four out of 31 (13%) patients satisfied the inclusion criteria. All of these patients were male, with a mean age of 63. All patients were receiving insulin only for diabetes control when the troglitazone was added. There was an increase in LDL-cholesterol and triglycerides of 23.3% and 21.3%, respectively. CONCLUSION: The increase in LDL-cholesterol and triglycerides on atorvastatin and troglitazone combination therapy compared with atorvastatin mono-therapy is suggestive of a drug interaction. Further studies involving troglitazone and atorvastatin may be warranted to substantiate this interaction.

Underutilization of ACE inhibitors in heart failure.

Although the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors in patients with ventricular systolic dysfunction are well documented, historically, a large proportion of patients have not received optimal therapy. Published studies to describe the trends in ACE inhibitor utilization and determinants of their use were reviewed. In recent years the number of patients treated with ACE inhibitors has increased; however, a relatively small proportion of these patients received adequate therapeutic dosages. Attention to factors that impair proper use of these agents is essential to realize improved outcomes in these patients.