Peripheral Artery Disease and ACE Inhibitors

Peripheral artery disease (PAD) is a multifaceted disease that involves the arteries of the brain, visceral organs, and extremities. It is an atherosclerotic disorder that can lead to an increased risk of cardiovascular morbidity and mortality. In particular, PAD is known to cause lower extremity claudication, which is basically a condition that affects an individual’s ability to walk.

The study in this article examined the effect of ACE inhibitors on the walking capacities of patients with lower extremity PAD. This particular study conducted a systematic literature search that looked at 4 studies, which included randomized, double-blind, and placebo-controlled trials comparing the effectiveness of an ACE inhibitor with a placebo in patients with PAD. Researchers then used Comprehensive Meta Analysis to analyze the data of all the studies.

The results of this study were all over the place and a bit contradictory. There was a general trend among all of the studies that moved towards improving patients’ walking capacity, but some of the studies challenged this as well. Moreover, the results that demonstrated the effectiveness of ACE Inhibitors in treating claudication were from studies that only tested patients on treadmills and patients did not have any other conditions that may hinder their walking capacity. While the results for the usage of ACE inhibitors in treating claudication are inconclusive, current guidelines still recommend ACE inhibitors to be used for the cardioprotective effects in PAD.

I found this article to be interesting because we have been learning about the most common uses of Top Drugs in PoP and it’s easy to forget just how complex the mechanism of action of each drug is. There is so much research to be done in this field. A drug that has been commonly used for the past century may be able to treat another symptom or disease that no one has looked into yet. This article also emphasizes what we have been learning in Drug Development about the extent to which it takes for a drug to be developed and approved. Just as the multiple studies in this article showed, just because a drug shows efficacy or safety in a group of patients that does not mean that it is marketable. Extensive trials and studies should be undertaken to ensure the safety and efficacy of all drugs.

Barrons R, Woods A. The Role of ACE Inhibitors in Lower Extremity Peripheral Artery Disease. Am J Ther. 2016;23(1):7-15.

http://ovidsp.tx.ovid.com/sp-3.18.0b/ovidweb.cgi?&S=KAKLFPGHBODDLCNDNCJKNAFBPJNOAA00&Link+Set=S.sh.22.23.26%7c3%7csl_10

Using Medication Adherence as an Indicator of Cognitive Dysfunction Among the Elderly

Anyone who has been required to take a medication on a daily basis can attest to the fact that it is very easy to forget or skip a dose. Imagine having to remember to take 6 or 7 medications everyday at different times of the day. This undoubtedly requires a certain level of cognitive ability and a clear mind to be able to organize all of one’s medications and to proceed to remember to take them. While one can usually stay adherent to his medications if some sort of system is set up for him, a decline in cognitive function and the development of dementia may nullify all efforts to keep track of and remain adherent to his medications.

This study assesses the possibility of using medication adherence as an indicator of the development of cognitive dysfunction in elderly individuals. This was a retrospective cross-sectional study, which examined 3351 Japanese patients with a mean age of 78.9 years old. Participants completed a comprehensive cognitive function test and got their medication use checked by clinical pharmacists. The Lawton’s instrumental activities of daily living (IADLs) scale assessed participants’ abilities to carry out self-care tasks in 8 categories such as the ability to use a telephone, transportation use, ability to handle finances, and responsibility for own medications. The Barthel Index score assessed another 10 self-care categories and the MMSE (Mini-Mental State Examination) measured participants’ orientation in time and space, attention, memory, language, and constructive skills.

The results of this study demonstrated that those in the early stage of cognitive failure were unable to perform activities of daily living (ADLs) in the “shopping” and “responsibility for own medications” categories. Moreover, the data from this study showed that there was a significant association between poor medication adherence and many other factors such as the use of Alzheimer’s disease medication, advanced age, and low Barthel index scores. Of the 3351 patients in this study, 2753 had some sort of cognitive dysfunction, and almost all patients diagnosed with dementia demonstrated a lower adherence to their medications in this study.

This study reveals that IADL scores are an effective method of predicting cognitive dysfunction in elderly individuals. Medication adherence and the development of dementia are both extremely important issues that require immediate attention. Pharmacists can play a huge role in caring for the elderly by providing screenings to measure for cognitive dysfunction and, in doing so, monitoring the elderly’s medication adherence as well.

Mizokami F, Mase H, Kinoshita T, et al. Adherence to Medication Regimens is an Effective Indicator of Cognitive Dysfunction in Elderly Individuals. Am J Alzheimers Dis Other Demen. 2016; 31(2):132-36

http://aja.sagepub.com.pitt.idm.oclc.org/content/31/2/132.full.pdf+html

Deintensification of Blood Pressure and Glycemic Medication Treatment in Diabetic Patients

In the world of health and medicine, overtreatment is not a topic that is on the forefront of many people’s minds. Some of today’s most common chronic medical conditions such as hypertension and diabetes have target values that health practitioners aim to meet by prescribing medications and providing effective treatments. Unfortunately, overtreatment is possible, can be dangerous, and need to be replaced with the deintensification of treatment in many cases.

This article describes a study which looks at the effect of deintensifying blood pressure- and blood glucose-lowering medicine in older adults with type 1 or 2 diabetes mellitus and who might currently be receiving overtreatment. In particular, this study examines potentially dangerously low blood pressure and blood glucose levels due to overtreatment and the lack of deintensification of treatment. The patients included in this study had low blood pressure or HbA1c at their last measurement in 2012. Low blood pressure was defined as less than 120/65 mmHg and low HbA1c was defined as less than 6.0%.

The results of this study demonstrated that more than half of the participants in this study received treatment that resulted in low blood pressure and more than 20% developed low HbA1c levels. Moreover, of the patients with low BP or HbA1c values, most did not have documented values in an electronic medical record in the 6 months after the values were taken. This reveals that many practitioners did not acknowledge the low values or see them as problematic.

The findings from this article show that the deintensification of therapy is not a common practice. Furthermore, aside from this study, there have not been many studies done on this topic of overtreatment and deintensification. I believe that overtreatment and the dangers that come with it is an imperative issue health practitioners need to address. Moreover, I believe that pharmacists can play a huge role in caring for patients and educating both patients and other health care professionals on the importance of overtreatment and deintensification. Pharmacists understand the actions of drugs more thoroughly than any other health care professional and can contribute to not only educating others on the dangers of overtreatment but also to developing deintensification treatment plans.

J Sussman, E Kerr, S Saini, et al. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients with Diabetic Mellitus. JAMA Intern Med. 2015;175(12):1942-1949

 

Racial Differences and the Need for Personalized Medication

The topic of personalized medications has become increasingly prevalent these past few years – and for a very good reason. Genetics evidently play a major role in an individual’s body composition, which affects an individual’s predisposition towards a medical condition and his or her ability to metabolize certain drugs.

This particular study compares testosterone levels among white and black males, which may contribute to the racial discrepancies seen in prostate cancer incidence and mortality. Black men have the highest incidence of prostate cancer in the world. Researchers examined the 1999-2004 National Health and Nutritional Examination Survey, comparing testosterone levels of 355 black and 631 white males. The results of this study demonstrated that between the ages of 12 and 15, black males had lower testosterone levels than white males and levels continued increasing until reaching a peak. Black males’ testosterone levels reached a higher peak at an earlier time and declined faster afterwards than those of the white males. The rapid decrease in testosterone levels of black males in comparison with white males may very well parallel the high number of prostate cancer incidences seen in black males.

The results of this study emphasize the effect genetics has on an individual’s health and pharmacological needs. Due to the correlation between rapidly dropping testosterone levels and high incidences of prostate cancer among black males, personalized medication for hormone replacement therapy could be a necessity for black males.

While patients are usually aware of their family history of medical conditions, they may not be aware of the extent to which genetics plays a role in many aspects of their health and well being. Personalized medications could be the answer to patients’ questions regarding why they need to take a certain medication or why certain medications do not work on them. Educating both health care practitioners and patients on the importance of genetics and personalized medication can pave the way to prevent or treat many of today’s prevalent diseases and improve the overall health of patients.

Hu H, Odedina FT, Reams RR, et al. Racial Differences in Age-Related Variation of Testosterone Levels Among US Males: Potential Implications for Prostate Cancer and Personalized Medication. J Racial Ethn Health Disparities. 2015 Mar;2(1):69-76

Medical Marijuana and Migraine Headaches

Migraines are common headache disorders that range from being moderate to severe and from lasting hours to days. They are often accompanied by nausea, photophobia, and many other symptoms. Pharmacologic interventions can play a key role in reducing the severity, duration, and frequency of attacks and improving patients’ overall quality of life. There are no clinical trials that prove the effect of marijuana on migraines but the potential effects of cannabinoids on serotonin in the central nervous system imply that marijuana may be a pharmacological agent in treating migraines.

This article describes a study that was carried out as an observational chart review of patients seen at Gedde Whole Health. At this specific clinic, physicians specialize in applying the use of medical marijuana for various conditions. 121 adults with a diagnosis of migraine headache and a recommend migraine treatment with medical marijuana were reviewed and the number of migraines experienced and the amount of marijuana used each month were collected as data.

The primary outcome of this study was the number of migraine headaches per month with medical marijuana use and the results of this study demonstrated that headache frequency decreased from 10.4 to 4.6 headaches per month. The most common effects reported by patients were the prevention of migraine headache and decreased frequency of migraine headache. Many different types of marijuana were used and edible marijuana was found to have more negative effects compared to other types.

While many side effects persisted in this study, there was still a statistically significant decrease in the number of migraine headaches per month with the use of medical marijuana. Evidently, this is only one of the first studies done on the effectiveness of medical marijuana and further research is needed to investigate adverse effects and preferred delivery method and dose, verifying the effectiveness of medical marijuana as a prophylaxis and treatment for migraine headaches.

Pharmacists play a key role in the development of drug therapies and the treatment of sicknesses or diseases. As demonstrated with this case of migraines and medical marijuana, pharmacists’ knowledge of the body systems and the actions of chemicals on these systems can contribute immensely to the innovation of new drugs or therapies that could potentially treat or prevent many of today’s prevalent illnesses.

Rhyne, D. N., Anderson, S. L., Gedde, M. and Borgelt, L. M. (2016), Effects of Medical Marijuana on Migraine Headache Frequency in an Adult Population. Pharmacotherapy. doi:10.1002/phar.1673

 

 

Combining provider and patient intervention for the management of osteoarthritis

As with many chronic medical conditions, osteoarthritis is a condition that requires constant care and attention in order to properly manage the pain and disability that comes with the condition. Unfortunately, patients often go home from health facilities and immediately forget the exact medication regimens or additional treatments that they need to continue properly caring for themselves.  While the consequences may not be life threatening, they heavily affect a patient’s general health and quality of life.  In the case with osteoarthritis, physical activity and weight management are key elements of managing hip and knee osteoarthritis but many adults with osteoarthritis are physically inactive or overweight. Furthermore, many treatments such as physical therapy, joint injections, and pain medications are often underused. This article describes a study in which researchers examined the effect of combined patient and provider intervention for managing osteoarthritis.

In this study, primary care providers were randomly assigned to either an osteoarthritis intervention group or a usual care control group. About 10 patient participants were enrolled from each of 30 PCPS. If in the osteoarthritis intervention group, providers received the provider intervention and patients received the patient intervention. Both groups continued on with usual medical care and those in the control group received no additional intervention.

On the patient side, interventions in this study focused on weight management, physical activity, and cognitive behavior pain management strategies. Interventions were carried out via telephone calls, which took place twice per month for the first six months and monthly for the last six months. They were carried out by a counselor with training in osteoarthritis and behavior change. The counselor used motivational interviewing and included goal setting and action planning in the intervention.

On the provider side, interventions included providing the PCPs with patient-specific osteoarthritis treatment recommendations, such as referring the patient to a physical therapist or recommending a topical NSAID. Moreover, PCPs received patient-specific recommendations.

The outcome of this study was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), which is a self-reported measure of lower extremity pain, stiffness, and function. The Short Physical Performance Battery (SPPB) was also used and includes 3 tests of balance, a timed 8-foot walk, and 5 chair stands. Finally, researchers also collected “process measures” related to behaviors or outcomes intermediate to changes in symptoms.

The results of this study showed that WOMAC scores were 4.1 points lower in the osteoarthritis intervention group, demonstrating that combining patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis.

Although this was a rather small study done in only one hospital, I believe that it is a stepping-stone for future treatment plans of chronic conditions. This study presents a different aspect of interventions that is not commonly seen: intervening on both the patient and provider side. People often view interventions as something that is done solely on the patient side. Furthermore, I believe that pharmacists can play a major role in intervening with both patients and primary care providers once patients leave the health facility. A patient’s medication management is a vital element of receiving adequate care for his or her health condition and pharmacists can care for patients by helping providers with specific drug therapy problems or any drug-related issue.

 

Allen K, Yancy W, Bosworth H, et al. A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial. Ann Intern Med. 2016;164(2):73-83

 

http://annals.org.pitt.idm.oclc.org/article.aspx?articleid=2478159

 

Improving Adherence to Therapy and Clinical Outcomes While Containing Costs: Opportunities From the Greater Use of Generic Medications

Almost everyone in the United States can agree to the fact that medications are not cheap. Moreover, brand name medications are infamous for being unnecessarily expensive. The issue with expensive medications lies not just within the costs themselves but also within the fact that the costs affect patients’ medication adherence and willingness to receive treatment. Both health care practitioners and patients are often drawn towards brand name products without knowing that the equivalent generic medications may produce equally effective results.

This article describes a study in which researchers conducted a Google Scholar literature review, answering five questions regarding the usage of generic medications, effectiveness of generic medications, and barriers against using generic medications. Articles containing original empirical data that were relevant to each of the key questions were included in this review.

The results of this study demonstrated that many health care providers prescribe brand-name medications when generic versions are available. Furthermore, studies show that when managing common chronic conditions, physicians tend to choose medications that are newer and relatively expensive. “Therapeutic interchange” is the substitution of a similarly effective but less expensive chemical entity to treat the same condition and, when combined with generic substitution, studies have shown that Medicare could save $1.4 billion for patients with diabetes alone.

As I mentioned earlier, high costs are not the only issues in these situations because the impact high costs have on the patients’ medication adherence are just as important of an issue. In a study done on patients initiating therapy in long-term medications, results showed that patients beginning therapy with a generic medication had adherence rates that were 5-7% higher than those initiating therapy with a brand-name drug.

In response to the question, “What is the evidence that brand-name and generic medications have similar clinical effects?” there have been conflicting results. Bioequivalence is defined as “the absence of a significant difference in the availability of the active ingredient at the site of drug action”. While generic versions of bupropion were not found to be bioequivalent to the brand-name version, a meta-analysis of forty-seven studies comparing generic and brand name drugs in nine classes of cardiovascular medications demonstrated that the generic drugs were just as effective as the brand-name equivalents.

The future for generic drug use is still unclear because, while generic drug use has been increasing, there is still a lot of room for even greater use of these medications and for the improvement of health care quality and reduction of costs. The perceptions of patients and health care providers continue to heavily affect the use of generic medications. Many approaches to increasing the use of generic drugs have been proposed, the first one being the development of data demonstrating the safety and effectiveness of generic drugs relative to their brand-name counterparts. I personally am affected by the high costs of brand-drugs and am also guilty of misperceiving generic drugs as being not as effective as their brand-name counterparts. I believe that more concrete data and evidence would play an enormous in increasing generic medication use and medication adherence while substantially decreasing costs.

 

Choudhry M, Denberg T, Qaseem A. Improving Adherence to Therapy and Clinical Outcomes While Containing Costs: Opportunities From the Greater Use of Generic Medications: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2016; 164(1): 41-49

http://annals.org/article.aspx?articleid=2471597

 

Physician Prescribing Habits for Pediatric Insomnia

Pediatric insomnia is not an issue that many people are aware of because it is not as prevalent as insomnia among adults. Nevertheless, safe and effective interventions are necessary in treating pediatric insomnia because if unaddressed, pediatric insomnia can lead to many negative effects for children and their families.

This article describes the common practice of physicians prescribing over the counter and prescription medications for children with pediatric insomnia. A study was done in Ontario, Canada surveying various pediatricians and family physicians on the amount of formal training they had on pediatric sleep disorders and whether or not they prescribed OTC or prescription medications to children with sleep problems. The results of this study showed that over a six month interval, 89% and 66% of the physicians recommended OTC and prescription medications, respectively, to children with insomnia and only 20% of the physicians had received formal training on pediatric sleep disorders. Furthermore, 30% of the physicians surveyed recommended OTC and prescription medications to otherwise healthy children with sleep problems.

This study demonstrates that many physicians prescribe medications to children with sleep problems but most physicians do not even have the formal training to do so. In this day and age, healthcare professionals often turn to pharmacotherapy to solve health related issues. While medications are important interventions, it is vital that healthcare professionals be adequately educated and trained on the subject at hand before making any recommendations. Over the counter and prescription medications should not be taken lightly, especially among children, because any medication has the potential to be harmful and to produce unknown adverse side effects.

Pediatric insomnia should be adequately studied among physicians because effective interventions can prevent the misuse of OTC and prescription medications and the development of future mental and psychosocial issues among children.

Bock DE, Roach-Fox E, Seabrook JA, et al. Sleep-promoting medications in children: physician prescribing habits in Southwestern Ontario, Canada. Elsevier B.V. 2016; 10.003.
http://www.ncbi.nlm.nih.gov/pubmed/26847974