Geriatric Pharmacotherapy Case Series: Potential Drug Interactions With Antiplatelet Medications and Cannabidiol-A Focus on P2Y12 Inhibitors.

Background A 76-year-old man was admitted to a local rehabilitation inpatient facility following an acute myocardial infarction. Patient history included hypertension and previous stroke. The patient was being treated with clopidogrel and aspirin for secondary stroke prevention along with other medications to treat hypertension. The patient admitted to using cannabidiol (CBD) oil up to three times a day for knee pain prior to acute myocardial infarction and requested to continue its use in the facility. Assessment Prior to this hospital stay, the patient was able to continue activities of daily living with knee pain that was controlled by CBD oil used three times daily. The option to continue CBD oil would create a possible drug interaction with current cardiovascular medications leading to increased cardiovascular or bleeding risks. Outcome The patient was advised against the use of CBD products because of potential interaction with clopidogrel and was prescribed acetaminophen for osteoarthritis (knee pain). The patient continued to improve and was discharged to his home after two weeks of rehabilitation. Conclusion Based on limited pharmacodynamic and pharmacokinetic studies in older people, patients should avoid using cannabidiol and products containing its derivatives with P2Y12 inhibitors. A potential interaction between cannabidiol and its derivatives with P2Y12 inhibitors may increase a patient's cardiovascular or bleeding risks. Patients and health care providers must be adequately informed about potential risks associated with cannabidiol products and oral antiplatelets to prevent negative outcomes.

Perspectives of Pharmacists on the Structure, Decision-Making, and Communication Practices of Multidisciplinary Cancer Teams in Alabama.

Introduction: A multidisciplinary team (MDT) approach within cancer care settings is increasingly being adopted to improve patient outcomes due to the rising complexity of diagnosis and treatment. This study aims to explore the perspective of pharmacists on the structure, decision-making process, and communication practices of cancer MDTs. Methods: A 25-item online questionnaire was distributed to oncology-related clinical pharmacists in Alabama. Data were analyzed using descriptive statistics. Results: A total of 15 pharmacists completed the survey. More than half of the respondents reported that MDT meetings were held mostly in person on a set schedule. While physicians primarily facilitated the meetings, patients and/or their caregivers were largely not invited to participate in them. The treating physician oversaw delivering and update to the patient and/or their caregivers after the MDT meetings. Most respondents indicated that positron emission and computed tomography were the most common sources of information available at initial case presentations. Overall, respondents strongly agreed that they felt comfortable sharing their opinions with others health professionals during MDT meetings. Conclusions: This study provides evidence that oncology pharmacists are involved in MDT decision-making processes and communications but suggests the need to promote conditions to further their participation.

Imaging Pericytes and the Regulation of Cerebral Blood Flow.

The brain's high energy requirements drive the need for close coupling of local neuronal activity to blood supply. Capillaries have been shown to dilate before arterioles in response to sensory stimulation, pointing to a key role for microvascular pericytes in mediating cerebrovascular dynamics. However, many aspects of these cells' function remain unknown and even controversial, from their identification, to the mechanism and regulation of their contractility in physiology and disease. Investigating how pericytes regulate vascular diameter is therefore likely to be the subject of many future experiments. Here we provide protocols for three different techniques (ex vivo slice imaging, in vivo imaging, and immunohistochemistry) that are highly valuable for performing such experiments.

Gradual Not Sudden Change: Multiple Sites of Functional Transition Across the Microvascular Bed.

In understanding the role of the neurovascular unit as both a biomarker and target for disease interventions, it is vital to appreciate how the function of different components of this unit change along the vascular tree. The cells of the neurovascular unit together perform an array of vital functions, protecting the brain from circulating toxins and infection, while providing nutrients and clearing away waste products. To do so, the brain's microvasculature dilates to direct energy substrates to active neurons, regulates access to circulating immune cells, and promotes angiogenesis in response to decreased blood supply, as well as pulsating to help clear waste products and maintain the oxygen supply. Different parts of the cerebrovascular tree contribute differently to various aspects of these functions, and previously, it has been assumed that there are discrete types of vessel along the vascular network that mediate different functions. Another option, however, is that the multiple transitions in function that occur across the vascular network do so at many locations, such that vascular function changes gradually, rather than in sharp steps between clearly distinct vessel types. Here, by reference to new data as well as by reviewing historical and recent literature, we argue that this latter scenario is likely the case and that vascular function gradually changes across the network without clear transition points between arteriole, precapillary arteriole and capillary. This is because classically localized functions are in fact performed by wide swathes of the vasculature, and different functional markers start and stop being expressed at different points along the vascular tree. Furthermore, vascular branch points show alterations in their mural cell morphology that suggest functional specializations irrespective of their position within the network. Together this work emphasizes the need for studies to consider where transitions of different functions occur, and the importance of defining these locations, in order to better understand the vascular network and how to target it to treat disease.

Romosozumab and Sequential Therapy in Postmenopausal Osteoporosis.

OBJECTIVE: To review and summarize studies on the effects of romosozumab as sequential therapy for improvements in bone turnover markers, bone mineral density (BMD), and clinical fracture in postmenopausal (PMP) women.
DATA SOURCES: A search of PubMed (1966-August 2019) and International Pharmaceutical Abstracts (1970-August 2019) was conducted using the MeSH and key word term romosozumab and limited to controlled clinical trials.
STUDY SELECTION AND DATA EXTRACTION: An initial review yielded 12 articles. Articles that did not evaluate use of romosozumab before or after another osteoporosis treatment were excluded. Five articles that evaluated the effects of sequential treatment with romosozumab in PMP women on bone turnover markers, bone mineral density, and fracture were included in the final review.
DATA SYNTHESIS: Romosozumab is a humanized, monoclonal antibody that increases bone formation and reduces bone resorption via inhibition of sclerostin. This inhibition stimulates signaling pathways resulting in increased bone formation, reduced bone resorption and increases in BMD. Romosozumab is indicated for the treatment of osteoporosis in PMP women who are at high risk for fracture and failed or cannot take other treatments. The current evidence describing the controlled clinical trials that evaluated use of romosozumab in sequence with other therapies for treatment of PMP osteoporosis is summarized.
CONCLUSION: An evaluation of studies where romosozumab was used in sequence to other therapies in PMP women showed that it causes significant reductions in bone resorption markers, increases in bone-formation markers, improves BMD, and reduces the risk of clinical fracture. However, these efficacy improvements must be carefully weighed against the increased risk of cardiovascular adverse effects compared with other treatments.

Role of Novel Oral Anticoagulants in the Treatment of Antiphospholipid Syndrome.

Background: Antiphospholipid syndrome (APS) is an autoimmune disease characterized by thrombosis or pregnancy loss with persistent positive antibodies. Standard treatment for APS with history of thromboembolism is heparin or low-molecular-weight heparin followed by a vitamin K antagonist (VKA). Novel oral anticoagulants (NOACs) could be effective in patients with APS, but none carry indications for treatment related to APS. Clinical Evidence: Five case reports or series with rivaroxaban and dabigatran suggest thrombotic events occur most often in the higher risk population (arterial thrombosis and/or triple positive antibodies) or in patients who had recurrent VTEs on warfarin therapy. An observational cohort in 26 APS patients using dabigatran or rivaroxaban described a recurrent thrombotic event in only 1 patient after 8 months of treatment. The event-free survival rate was 87.9% at 12 months. Three controlled clinical trials are underway to evaluate the thrombotic risk of NOACs (RAPS, TRAPS, and ASTRO-APS). Discussion: There are no completed studies that evaluate the use of NOACs in APS compared to VKAs. One major disadvantage of the NOACs is the limited availability of reversal agents for patients with a major bleeding episode. An increased risk of thrombotic events is associated with arterial occlusions and triple antibody positivity APS with both warfarin and NOACs; this is currently being researched in the TRAPS study. Conclusion: Based on current available evidence, VKAs remain the standard of care in the treatment of APS. Results of ongoing trials may offer more guidance on how to appropriately use NOACs for patients with APS.

α-adrenergic blockers for the treatment of lower-urinary-tract symptoms and dysfunction in women.

OBJECTIVE: To evaluate the efficacy and safety of α-adrenergic blockers in the treatment of female lower-urinary-tract symptoms and dysfunction. DATA SOURCES: Literature searches were conducted using EMBASE (1974 to January 2014), International Pharmaceutical Abstracts (1970 to January 2014), and MEDLINE (1946 to January 2014) to identify clinical trials evaluating the effects of α-adrenergic blockers in the treatment of women with lower-urinary-tract dysfunction. Bibliographies from relevant research articles were also reviewed for inclusion. STUDY SELECTION AND DATA EXTRACTION: All original research articles available in the English language were identified from the data sources. Primary literature evaluating outcomes related to urinary dysfunction and associated symptoms in women were included in this review. Articles describing the use of α-adrenergic blockers in other medical conditions or in men were excluded. DATA SYNTHESIS: A total of 15 clinical studies were identified and evaluated. Many studies showed an improvement in female lower-urinary-tract symptoms and dysfunction using α-adrenergic blockers. Most studies also reported adverse drug events of α-adrenergic blockers such as dizziness and hypotension. However, limitations of the studies conducted to date include small sample sizes, inconsistent study designs, and short duration of therapy. CONCLUSIONS: The role of α-adrenergic blockers in the treatment of urinary dysfunction and associated symptoms in women remains unclear. The majority of evidence suggests that these agents may have a place in therapy for female lower-urinary-tract symptoms and/or bladder outlet obstruction; however, data are conflicting. Clinicians should be aware of the potential clinical benefits but also recognize the potential adverse drug effects of α-adrenergic blockers.