Effects of Certain Chemotherapies on Cognitive Function in Breast Cancer Survivors

When most of us here cancer we probably immediately think of the cure or possible treatments that someone may receive to fight it. Few of us however would immediately wonder what side effects may be involved in the long-term after being treated and cured of cancer. The idea of cancer also seems as though it is completely associated with a loss of quality of life, but what if cancer treatments were also associated with this same drop in quality of life?

To observe the effects of a specific chemotherapy drug on breast cancer survivors compared to a different treatment or no chemotherapy at all, a study examined the cognitive function of 62 breast cancer survivors that had been off therapy for about two years. All women involved had been enrolled at Stanford University between 2008 and 2014. Twenty of the women had received anthracycline-based chemotherapy, the type of chemotherapy being specifically examined for its reputation in decreasing cognitive function post-therapy. Nineteen women had received nonanthracycline therapy and the final twenty-three women did not receive chemotherapy at all. Standardized neurological tests and resting state functional magnetic resonance imaging on the brain were completed. Results found that the women receiving anthracycline-based treatment had significantly lower verbal memory. Both groups of women that had received chemotherapy of some sort self-reported psychological distress and cognitive dysfunction. The journal article concluded that more research needs to be done on how the brain can be protected during chemotherapy treatments.

It is unnerving to think the few treatments we have for cancer may be causing more anguish to these women after they have been ‘treated’. Considering the women that did not receive any type of chemotherapy seemed to have no cognitive or psychological problems, should a more natural approach to cancer treatment be more heavily considered?

Reference: Kesler SR, Blayney DW. Neurotoxic effects of anthracycline- vs nonanthracycline-based chemotherapy on cognition in breast cancer survivors. Jama Oncol. 2016; 2(2): 185-192. http://oncology.jamanetwork.com.pitt.idm.oclc.org/article.aspx?articleid=2473507

Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients

Unfortunately, after elderly patients leave the hospital from an acute hospitalization, most lose the ability to complete some daily living activities, some are readmitted to the hospital, and some die, all within six months. A comprehensive geriatric assessment is completed while the patient is admitted, setting up interventions and taking care of the patient until they are discharged. Transitional care can also be completed when the patient is moving back home after this hospitalization. This care is provided for a limited amount of time, during which nurses attempt to limit the number of adverse drug events, remind patients of discharge information, and follow up with the doctors. A study was completed to measure the effectiveness of patients receiving both comprehensive geriatric assessment services as well as a transitional care program.

Three hospitals from the Netherlands participated in a double-blind randomized clinical trial between September 1, 2010 and March 1, 2014 involving 674 patients 65 or older that were acutely hospitalized for 48 hours or more in the internal medicine department and were at risk for further decline in health. The participants that consented to participating were randomly placed into a group receiving both interventions or purely comprehensive geriatric assessments. Patients receiving transitional care had a nurse visit about four days after they were admitted to the hospital, then two days after discharge and two weeks, six weeks, twelve weeks, and twenty-four weeks after discharge to monitor the patients’ conditions and initiate or follow through with interventions.

It was found that there was no difference in the ability to complete daily living activities between those receiving both treatments and those just receiving comprehensive geriatric assessments. There was a statistical difference however in the ability to complete daily activities between those who died after their acute hospitalization and those who survived for at least six months. 85 participants died among those receiving both treatments and 104 died among those receiving only comprehensive geriatric assessments. There were 106 readmissions among those receiving both interventions and 88 among those receiving only comprehensive geriatric assessments but no time difference was noticed. It was concluded that although there was a lower mortality rate within 1 month and 6 months of discharge in the group receiving both interventions, there was no difference in effect on ability to complete daily living tasks.

Even if this addition of therapy may cause a slight extension of life, is it worth the extra time and cost of nurses to continue providing transitional care when there is no benefit on the patient’s ability to complete everyday tasks?

Reference: Buurman BM, Parlevliet JL, Allore HG, et al. Comprehensive geriatric assessment and transitional care in acutely hospitalized patients: the transitional care bridge randomized clinical trial. Jama Intern Med. Published online February 15, 2016. http://archinte.jamanetwork.com/article.aspx?articleid=2491684

Examining Why Women With Urinary Incontinence Do Not Step Forward

As the growing population gets older, more people are being faced with medical conditions typically associated with the elderly population. Some may not want to admit they are aging while others may just feel uncomfortable talking about the subject, as some patients prefer to not or refuse to speak to their healthcare providers about medical conditions they may be experiencing, such as urinary incontinence.

Although more than a third of middle-aged women or older deal with the signs and symptoms of urinary incontinence, less than half of those women receive treatment or even an evaluation for their condition. An observational study was conducted to attempt to determine why so many women that suffer from this condition do not come forward for assistance. 969 women aged forty and older who reported at least weekly incontinence were included in the study, including 55% from racial or ethnic minorities and 55% discussing their condition with their doctor at some point. It was found that women were less likely to talk about their condition if their household income was less than thirty thousand dollars a year or if they were diabetic. Being of the black race or having the low income were associated with not discussing their condition but all those participating that had severe cases were more likely to address it.

Overall the study found that lower income and concomitant diabetes were associated with lower likelihood of women speaking with their doctors about their urinary incontinence.

Even though this condition is associated with depression, social isolation, and admission to long-term care facilities, women continue to keep urinary incontinence a secret. Do you think there is anything society can do as a whole to make this taboo less embarrassing? Or do you think we as pharmacists could play a bigger role in making these patients more comfortable? Or perhaps healthcare professionals as a whole may seem unapproachable to those of lower socioeconomic status; how can we change that?

Reference: Duralde ER, Walter LC, Van Den Eeden SK, et al. Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women. Am J Obstet Gynecol. 2016; 214(2): 266.

https://www-clinicalkey-com.pitt.idm.oclc.org/#!/content/journal/1-s2.0-S0002937815010200

A New Possible Type 2 Diabetes Injection: IDegLira

As we learn more about diabetes and the huge impacts it can have on patients’ everyday lives, it is almost natural to wonder why treatment has not become easier or safer or perhaps more importantly, more convenient. A massive aspect of medication adherence is the convenience, especially when focusing on diabetes. Most patients do not understand that nonadherence to one diabetes medication however can lead to the addition of more and therefore a further inconvenience to the patient. Patients also understandably dislike the adverse effects that typically accompany diabetes medications, such as hypoglycemia and weight gain. Hopefully, a new drug may be able to diminish this growing issue.

IDegLira is an injectable diabetes management medication that is a combination of basal insulin and GLP-1RA, or liraglutide. The medication is injected once daily and tackles two different physiological deficits in patients with type 2 diabetes. The basal insulin reduces fasting blood glucose while the GLP-1RA keeps postprandial glucose values under control. A study with patients already on basal insulin was completed to see if adding insulin aspart or liraglutide would control their glucose levels better. The addition of liraglutide was recorded to be more effective as well as less hindering, as it had lower rates of hypoglycemia and weight loss in patients as opposed to weight gain.

Positive results have been seen in several clinical trials involving the combination drug of insulin basal and GLP-1RA. Hopefully this more convenient, effective, and safe medication will come out on the market soon to aid those with type 2 diabetes.

Do you think patients would truly be more adherent to this medication, a single injection, than metformin, a single oral tablet per day? Even if this is more effective, will patients choose an injection over a pill?

Reference: Hughes E. IDegLira: Redefining insulin optimisation using a single injection in patients with type 2 diabetes. Primary Care Diabetes. Article in Press. https://www-clinicalkey-com.pitt.idm.oclc.org/#!/content/journal/1-s2.0-S1751991815001837

Possible Association Between Marijuana Use and Cognitive Function

With the number of states considering and approving the use of medical marijuana as well as recreational use increasing, the possible negative long-term effects of using marijuana should also be brought to light. A recent article uncovered a study that followed research participants from 1986 to 2011 who documented their marijuana use periodically as well as their tobacco and other drug use and possible issues with depression. The study began with 5115 randomly selected black and white, male and female participants between 18 and 30 years old. On seven different occasions throughout the twenty-five years of the study, participants were asked how many days in the last month did they use marijuana. They were also asked at the beginning of the study how many times in their life they had used marijuana to gauge what their lifetime exposure to the drug was. Years using marijuana was then estimated based on the number of days in the last thirty that person reported used marijuana and using the scale that 365 days using marijuana is equal to one marijuana year.

3326 participants returned after the full twenty-five years for assessment regarding three cognitive outcomes. Although most of the participants had reported using marijuana throughout the years of the study, they had not accumulated many total marijuana use years. The study used standardized tests of verbal memory, processing speed, and executive function both at the start and end of the time period to determine if there was a significant difference both between their scores before and after and between scores of those with no marijuana exposure compared to a large amount of exposure.

A larger amount of lifetime exposure to marijuana was associated with lower verbal memory, with no significant differences based on race and sex. Current use was associated with both lower verbal memory and processing speed. Although their findings were significant, the researchers pointed out that the marijuana use was self-reported and more studies should be done in the future to solidify their evidence.

When you consider the huge potential benefits that some may receive by taking marijuana for medical purposes now, do you think this impairment in verbal memory in their future still makes it worth it?

Reference: Auer R, Vittinghoff E, Yaffe K, et al. Association between lifetime marijuana use and cognitive function in middle age: the coronary artery risk development in young adults study. Jama Intern Med. Published online February 1, 2016. Accessed February 6, 2016.

Potential Bias of Speakers on Behalf of New Cancer Drugs

The number of cancer cases throughout the world is clearly on the rise, requiring an ever increasing need for a cure and more effective treatments. Many speculate that a cancer cure has already been discovered but it is being hidden because of all the money cancer as a disease generates. Others question why cancer is so prominent now but was not spoken of this often in their childhood. With so much confusion abound about the treatment of cancer and its widespread effects, an article delving a little into the processes of the FDA when it comes to cancer and possible conflicts of interest may be helpful.

The authors of this article decided to search into the meetings held by the Oncologic Drugs Advisory Committee, the advising committee to the FDA concerning cancer treatments, to determine what other influences may be at play when deciding if a drug should go to market. They reviewed twenty-eight meetings between 2009 and 2014. The main investigation for this study was to determine what biases may be present within these extra speakers, who usually have taken the drug discussed or represent an organization. The researchers recorded what the speakers’ affiliations may be as well as their financial association or lack thereof.

It was found that amongst the 103 speakers present at the 28 meetings, 58 were representing an organization associated with the type of cancer being potentially treated, 46 were diagnosed with the specific type of cancer, and 31 had taken the drug. Almost all of the speakers throughout these twenty-eight meetings (92%) supported the approval of the drug. Thirty percent of the speakers revealed that they did indeed have financial associations with the company seeking approval while two speakers did have associations but did not disclose them when asked.

The authors concluded that the FDA committee should consider possible financial associations and personal biases of speakers when reviewing a cancer drug company’s marketing approval. When we look at how huge of a problem cancer has become and how much it could affect both us and those around us, does this potential bias matter so much? If the drug trials show that the drug works, should a small financial association hold this FDA committee back from approving their marketing?

Reference: Abola MV, Prasad V. Characteristics and conflicts of public speakers at meetings of the Oncologic Drugs Advisory Committee to the US Food and Drug Administration. Jama Intern Med. Published online February 1, 2016. Accessed February 6, 2016.

Studying the Effect of Text Messaging on Medication Adherence in Chronic Disease

A recent article reviewed the effectiveness of text messages as a tool for medication adherence for adult patients with chronic diseases. The reviewers recognized that although apps can be very helpful for those with smart phones, unfortunately many of those in the older population with chronic diseases do not have the most up-to-date technology. In the past, special pagers or devices with reminders were proposed to aid in adherence but due to low availability and an uncertain relation to routine care, they have been relatively ineffective as a reliable assistant.

As we have learned, adherence is clearly a very large issue, costing the United States almost $1 billion each year and $2000 for each patient in extra physician visits alone. Not only is cost a major factor, but the health of the patient is obviously a huge concern as well. Many patients with chronic disease states will become nonadherent to their therapy because they are not experiencing a noticeable difference in their health. Unfortunately this could cause their disease to worsen and require the need for additional medications.

The authors of the article conducted a literature search to find randomized clinical trials involving adults over the age of eighteen with a chronic disease that received a text message to promote adherence. Studies were excluded if their primary intervention was not a text message or if the study involved psychiatric, military, or institutionalized patients to avoid other possible controls on adherence. Sixteen randomized clinical trials were identified that included over 2,500 patients with a mean participant age of thirty-nine, a median intervention duration of 12 weeks, and including disease states of HIV, cardiovascular disease, asthma, allergic rhinitis, diabetes, and epilepsy. The type and frequency of text messages varied among the studies, with some texting at fixed time intervals and others sending only if the patient did not open their medication dispenser. Some messages included personalization with the medication name and dosage while others were generic.

It was concluded that text messages did in fact increase adherence and the study participants were moderately to highly satisfied with the assistance. The researchers did emphasize however that further studies with longer time periods and more objective measures of the outcome are necessary to come to significant conclusions.

What personalization of a text message do you think would be most effective, or should it change based on the patient’s beliefs, social activities, age, etc?

Reference: Thakkar J, Kurup R, Laba T, et al. Mobile telephone text messaging for medication adherence in chronic disease. Jama Intern Med. Published online February 1, 2016.

http://archinte.jamanetwork.com/article.aspx?articleid=2484905

Cardiovascular Risks and Clarithromycin

After reviewing some inconclusive data regarding a correlation between clarithromycin and cardiovascular outcomes, the Hospital Authority of Hong Kong decided to carry out an observational study to determine the presence or lack of a correlation. Patient’s data was collected anonymously from a database containing more than seven million residents’ personal characteristics and health information. Adults eighteen and over that had been prescribed either clarithromycin or amoxicillin between January 1, 2005 and December 31, 2009 were selected. Patients taking clarithromycin were then matched up with one or two patients taking amoxicillin based on age, sex, and time when it was used. Patients were excluded if they had a previous cardiac episode but those included had a primary outcome of the first reported heart attack. Patients were also excluded if they had received inpatient treatment with clarithromycin, which would suggest a more serious problem.

Heart attacks and arrhythmia were identified among the patients and a cardiologist reviewed the records and determined that 95% of the reported cases were in fact verified episodes. Poisson regression was then used to compare the rate of heart incidents in amoxicillin versus clarithromycin users.

Results of the study found that clarithromycin users were more likely to have diagnoses of COPD, obesity, hepatic problems, and heart failure. They were also more likely to be prescribed insulin, oral corticosteroids, proton pump inhibitors, and H2 receptor blockers. Despite increased rate ratios, the study concluded that the increases were not statistically significant in comparing clarithromycin and amoxicillin use. Long term, no increased cardiovascular risks were associated with clarithromycin but there may be a short term risk of heart attack, arrhythmia, and cardiac death in the Hong Kong population while taking clarithromycin. Basically, caution should be taken when prescribing clarithromycin, especially to those that may be at increased risk of heart problems. So should clarithromycin even be considered as a possible therapy treatment when other options, such as amoxicillin exist?

http://www.bmj.com/content/352/bmj.h6926

Citation: Wong AW, Root A, Douglas IJ, et al. Cardiovascular outcomes associated with use of clarithromycin: population based study. BMJ 2016;352:h6926.