A review of smoking cessation: potentially risky effects on prescribed medications.

AIMS AND OBJECTIVES: To identify prescription drugs that require dosage adjustment or monitoring in patients who quit smoking and to provide recommendations for dosage adjustment based on available evidence. BACKGROUND: Health care providers are urged to facilitate smoking cessation for patients who smoke, but the effects of smoking cessation on the metabolism of some drugs is not routinely considered. DESIGN: A comprehensive literature review. METHODS: The review was conducted in 2008 using a computerised drug interaction program and multiple PubMed and CINAHL searches to identify prescription drugs with clinically significant pharmacokinetic or pharmacodynamic changes caused by smoking cessation. RESULTS: Although much of the evidence is case report, dosage adjustments are clearly indicated for warfarin, olanzapine, clozapine and theophylline since they are metabolised by cytochrome P450 CYP1A2 and also have narrow therapeutic ratios. Careful monitoring is recommended for other CYP1A2 metabolised drugs, including those for hypertension and Alzheimer's disease. For many affected drugs, smoking cessation reverses smoking-induced CYP1A2 hepatic enzyme levels to normal, increasing plasma concentrations in patients whose dose was established while smoking. Because the effect on hepatic microsomal enzymes is not related to the nicotine component of tobacco, nicotine replacement will not alter the effect. CONCLUSIONS: The effects of smoking cessation on drugs metabolised by CYP1A2 have been under-appreciated by health care providers. Smoking cessation may increase plasma levels of some drugs to potentially toxic levels. Further research is warranted to clarify this effect. RELEVANCE TO CLINICAL PRACTICE: When patients stop smoking, providers should carefully review prescribed drug regimens and adjust or monitor drugs whose metabolism is affected by smoking cessation. This is particularly important for patients who abruptly stop smoking due to hospitalisation and for older patients who are likely to be taking multiple medications.

Measuring asthma self-management knowledge in adults.

PURPOSE: To present the development and psychometrics of a brief asthma self-management questionnaire for adults incorporating the five content areas considered essential for asthma self-management by the National Asthma Education and Prevention Program. DATA SOURCES: After development of the criterion-referenced questionnaire, determination of content validity, pilot testing, and revision, the questionnaire was administered to 305 adults with asthma. CONCLUSIONS: After exploratory principal component factor analysis, the final 24-item questionnaire had a reliability of .69, close to the preferred reliability of .70. IMPLICATIONS: The questionnaire is recommended for assessing self-management knowledge in clinical settings and for evaluation of asthma education programs.

The Effect of an Interprofessional Heart Failure Education Program on Hospital Readmissions.

Heart failure (HF) is an increasing concern to public health, affecting approximately 5.1 million Americans and costing the United States over $32 billion annually. Compounding the concern, research has exposed the significant problem of hospital readmissions for the HF population, with an estimated 25% of HF patients are rehospitalized within 30 days of discharge. This project focuses on an education-based strategy designed to decrease hospital readmissions for this at-risk population. In particular, an interprofessional outpatient educational program (Heart Failure University [HFU]) was initiated to reduce healthcare costs and increase the quality of care for HF patients at a large private hospital in Florida. A retrospective case-control study was conducted to compare 30-day hospital readmissions of patients who attended HFU to patients who received standard education. Results indicated a significant association between HFU attendance and reduced 30-day hospital readmissions (χ [1, N = 106] = 5.68, p = .02). Strengthening this effect, the results showed patients who attended HFU had a significantly greater functional disability than those who did not attend (t(104) = 2.40, p = .018). These findings corroborate with current research on transitional care interventions and emphasize the importance of interprofessional, educational-based disease management programs for the HF population.

Herbal supplements used to treat common chronic conditions.

This is part 2 of a three-part series designed to provide clinicians with a working knowledge of the use of herbal supplements for health and disease states. Part 2 of the series focuses on the efficacy of herbal supplements used in the treatment of common chronic conditions.

Herbal supplements for health promotion and disease prevention.

This three-part series is designed to provide clinicians with a working knowledge of using herbal supplements for health and disease states. Common herbal preparations used for health promotion or disease prevention will be featured in this part of the series.

Laws and guidelines governing the use of herbal supplements.

In the last of a three-part series on herbal supplements, laws and guidelines impacting the use of herbal supplements are discussed. Distinct differences exist between regulations for herbal supplements and those products defined as drugs. Consideration of herbal therapy should be approached within a context of holistic treatment.

Promoting adherence: effects of theory-based asthma education.

This study compared the effects of a theoretically focused audiotape and a standard educational booklet on asthma preventive medication adherence and other asthma outcomes. Forty-six adult asthmatics were randomly assigned to receive either an experimental audiotape incorporating components of protection motivation theory, a standard asthma management booklet, both, or no educational materials. Outcomes were assessed at baseline, 3 months, and 6 months. Mean pharmacy-verified adherence improved 15% to 19% in the intervention groups and declined 22% in the control group at 6 months. Using analysis of covariance (ANCOVA) to control for baseline adherence, these changes were significant between the control and booklet group (t = 2.47; p = .02) and between control and combined group (t = 2.07; p = .04). Providing a minimal educational intervention can have a beneficial effect on asthma medication adherence that persists at least 6 months.

Improving wait times and patient satisfaction in primary care.

A strong and inverse relationship between patient satisfaction and wait times in ambulatory care settings has been demonstrated. Despite its relevance to key medical practice outcomes, timeliness of care in primary care settings has not been widely studied. The goal of the quality improvement project described here was to increase patient satisfaction by minimizing wait times using the Dartmouth Microsystem Improvement Curriculum (DMIC) framework and the Plan-Do-Study-Act (PDSA) improvement process. Following completion of an initial PDSA cycle, significant reductions in mean waiting room and exam room wait times (p = .001 and p = .047, respectively) were observed along with a significant increase in patient satisfaction with waiting room wait time (p = .029). The results support the hypothesis that the DMIC framework and the PDSA method can be applied to improve wait times and patient satisfaction among primary care patients. Furthermore, the pretest-posttest preexperimental study design employed provides a model for sequential repetitive tests of change that can lead to meaningful improvements in the delivery of care and practice performance in a variety of ambulatory care settings over time.

Herbal, prescribed, and over-the-counter drug use in older women: prevalence of drug interactions.

Older adults are at particular risk for drug and herbal interactions because they have multiple health problems that require treatment and are generally more susceptible to adverse drug effects. This study used a database containing self-reported herbal, prescription, and over-the-counter (OTC) drugs concurrently taken by a sample of 58 women who were aged 65 years or older. Drug-drug interactions (DDIs) were identified using a Web-based pharmaceutical program. At least 1 moderate or high-risk DDI was identified in 74% of participants, with 136 total DDIs identified. Fifty-two percent (71) of total DDIs were between prescribed and OTC or herbals, with 63% (45) of these involving nonsteroidal antiinflammatory drugs (NSAIDs). It is imperative that health care providers identify all prescribed, OTC, and herbal drugs taken by their patients and assess all interactions in order to avoid the possibility of adverse drug effects.

Obesity-related cardiovascular risk factors: intervention recommendations to decrease adolescent obesity.

The incidence of adolescent obesity is increasing dramatically in the United States with associated risks of hypertension, adverse lipid profiles, and Type II diabetes. Unless reversed, this trend predicts an epidemic of adult cardiovascular disease. Interventions at home, at school, and in the community are required to empower teens to increase physical activity and to modify eating habits. This article describes assessment for obesity-related health problems as well as scientific guidelines and research-based intervention strategies to decrease obesity in adolescents.