Shared decision making and medication therapy management with the use of an interactive template

Shared decision making (SDM) is a method to make the medical field more patient-centered. Shared decision is where both the process where both the patients and the clinician work together to come up with a treatment option. The clinician provides the medical knowledge and the patient provides their preferences. This approach has been shown to improve medication knowledge, accurate expectations, and satisfaction. The main barrier to using this approach is time constraint therefore health professionals are looking to pharmacists to provide this service during medication therapy management (MTM) sessions. The purpose of the study in the article is to see if this idea is feasible and how the resolution to the identified drug therapy problems are reported back to the primary care physicians (PCP).

The study took place in the Medicine Clinic at Hennepin County Medical Center in Minneapolis. The intervention was centered around an electronic template to help the pharmacist incorporate SDM into their MTM consultation. At the end of the study all the patients and the pharmacists responded positively after the encounter. The patient felt they understood their medications more and are more likely to discuss management concerns with their PCP. The drug therapy problems that were identified during the consultation were reported back to the PCP in many ways. 25% were reported back by the patients themselves, 30% were reported by pharmacists, and the other 40% were reported back by the patients and the pharmacists together.

I think this study is innovative. It shows how people are trying to make the healthcare field more patient centered and how pharmacists can help make it happen. This study is the first of its kind, therefore there are still some areas that needs to be improved on. One is the number of participants in the study. The total number of patients involved was only 20 patients and these patients on average are on 19 different medications. Because of the small number of participants, the result might be biased. What other weaknesses or strengths can be found in this study?

http://www.sciencedirect.com/science/article/pii/S154431911500062X

Schafer Montag Katherine, Gionfriddo R. Michael, Boehm H. Deborah. Shared decision making and medication therapy management with the use of an interactive template. JAPHA. doi:10.1016/j.japh.2015.12.013. (published 18 Feb 2016).

Researchers Focus on Solving the Zika Riddles

The recent raise in the number of infants borned with microcephaly has been suspected to be caused the Zika virus. A team of researchers from Yale, Fiocruz, and UTMB have been recruiting volunteers for the study to determine whether the Zika virus causes microcephaly in newborns. The investigators will examine the women for the presence of other viruses that are known to cause microcephaly such as rubella and cytomegaloviruses and for the presence of the Zika virus in the women’s amniotic fluid. The research team will also sequence samples of the Zika virus to study if the virus has mutated.

Anthony Fauci, MD, director of National Institute of Allergy and Infectious Diseases (NIAID), said that a DNA-based Zika vaccine will for ready for a phase 1 testing later this year. There are also other forms of vaccines that are currently being developed. NIAID is also testing a live attenuated vaccine and a vaccine based on recombinant vesicular stomatitis virus.  Besides the vaccines, NIAID is also planning to develop an antiviral drugs to treat other flaviviruses infections. Although many vaccines are currently being developed, it will take a few more years until they are ready for the public.

The World Health Organization (WHO) is recommending the best way to control the spread of the Zika virus is by using public health strategies to control the mosquito population. Other options currently considered are postponing pregnancy, using genetically insects, and distributing Ivermectin to control the mosquito population. Ivermectin can kill mosquitoes when they bite a human who is taking the drug.

This article really shows how people from different professional fields can come together to solve a problem. Researchers are currently developing vaccines for the Zika virus. Teams of scientists from different countries are gathering to conduct studies and experiments to test whether the recent rise in microcephaly is caused by the Zika virus. The governments from different countries has also came up with ways to deal with the Zika virus outbreak before the vaccine becomes available.

Jacob A Julie. Researchers Focus on Solving Zika Riddles. JAMA. doi:0.1001/jama.2016.1219. (published 24 Feb 2016).

http://jama.jamanetwork.com/article.aspx?articleid=2498483

 

Immunization Policy and the Importance of Sustainable Vaccine Pricing

Since the invention of vaccines, it has saved countless lives and money. The CDC reported from the 2009 birth cohort, an estimated 20 million cases of vaccine-preventable disease will not occur, 42,000 early deaths related to these diseases will be avoided, and $76 billion in direct and indirect costs will be averted. These numbers makes developing a novel vaccine a very lucrative business.

The cost of developing a new vaccine may exceed $1 billion so companies have to make sure the return revenue must be more than what they invested. The question now is what is a reasonable return revenue? How much is society will to pay for a vaccine? It is up to the CDC to keep the price of vaccines in check but at the same time keep the incentive for vaccine development.

In 2014 there was a outbreak of all-serogroup- invasion Neisseria meningitidis in the United States. There is a vaccine for this disease, but is not included in the current recommended vaccine. These vaccines are issued a B recommendation, meaning it is up to the clinician to decide whether to give that vaccine or not. Because of the low incidences of this disease and the high cost of the vaccine, it is rarely used.

The article mention the creation of an advisory group to provide clear guidelines for new vaccines and to advise physicians the most appropriate vaccine to use. According to the author of this article, physicians are knowledgeable on the use of vaccines but are not trained in evaluating vaccine costs. This is especially important when an expensive vaccine with minimal public health benefit is used.

The need for a certain vaccine is also dependent on the disease. For example in 2003, there was an outbreak of coronavirus that causes severe acute respiratory syndrome. At that time, the world was in need for a vaccine against coronavirus. However, by the time the vaccine was created, it was no longer needed. This shows the financial risk of vaccine development.

In Drug Development 1, we are experiencing the different phases of developing a drug. I think this process is comparable to vaccine development. Companies are willing to invest the large sum of money to develop new vaccine because there is a probability of making a large profit. There is a financial and time risk factor in vaccine development. If the disease is no longer causing a problem when the vaccine is created, the demand for the vaccine no longer exists which could result in a huge financial lost.

Meissner H. Cody. Immunization Policy and the Important of Sustainable Vaccine Pricing. JAMA. doi:10.1001/jama.2016.0469 (published 8 February 2016).

http://jama.jamanetwork.com/article.aspx?articleid=2491460

Use of SSRI, But Not SNRI, Increased Upper and Lower Gastrointestinal Bleeding

Selective serotonin receptor inhibitors (SSRIs) are usually used as the first line medications to treat depression and other psychogenic disorders. The main concerns of using SSRIs is the increased risk of internal bleeding including gastrointestinal, genitourinary, and intracranial bleeding. This article is about the nationwide study that was done in Taiwan to discover whether SSRI or serotonin- noradrenaline reuptake inhibitors (SNRIs) usage causes increased risk of internal bleeding.

The subjects were randomly picked from Taiwan National Health Insurance Research Database.  The study group consists of 8809 SSRI users and 944 SNRI users. Patients with alcohol related disease, inflammatory bowel disease, bleeding of GI tract before January 1, 2000 were excluded from the study. The control group consists of 39,012 subjects who had not taken SSRI or SNRI. Both groups were followed from 2000 to 2010.

The results showed that the SSRI group users had a much higher incidence of upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB) than the control group. The results also showed that SSRI are more likely to cause LGIB than UGIB. The possible reason behind this is that SSRI decreases serotonin availability which is an important factor in platelet aggregation. SSRIs also increases gastric acid secretion and aggravation of NSAID-induced gastric mucosal injury. The study also noticed that male are more likely to experience UGIB and LGIB than female.

This study is very interesting to me. SSRIs and SNRIs are relatively new classes of medications so this study shows that researchers are still trying to find out possible side effects of these medications. Now that there is strong evidence that there is a strong link between SSRIs and GI bleeding, I am interested in whether SSRIs will still continue to be the first line medications used to treat depression and other psychogenic disorders. I am also interested in other differences between SSRIs and SNRIs.

Citation:

Cheng Yuan-Lung, Hu Hsiao-Yun, Lin Xi-Hsuan, Luo Jiing-Chyuan, Peng Yen-Ling, Hou Ming-Chih, Lin Han0chien,Lee Fa-Yauh. Use of SSRI, But Not SNRI, Increased Upper and Lower Gastrointestinal Bleeding: A Nationwide Population-Based Cohort Study in Taiwan. Medicine.10.1097/MD.0000000000002022. (published 20 November 2015).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652818/

The Emerging Zika Pandemic Enhancing Preparedness

The Zika virus is related to the yellow fever, West Nile, and dengue. It was first discovered in 1947 and since May 2015, it has appeared in at least 20 countries in the Americas. The virus infection typically have mild symptoms and fatalities are uncommon. The main concerning symptom is microcephaly, where newborns are born with a non-exisiting forehead. This is a concern because, the effects of this mutation is unknown. To prepare for the Zika virus, the United States should adopt strategies set by the International Health Regulations.

Strategies include vector control, risk communications, enhanced Zika surveillance, travel advisories and many more. Vector control is controlling mosquito breeding grounds. Risk communication is educating the public to avoid mosquito exposures, such as using insect repellents and using physical barriers to keep out mosquitoes. Countries are required to report unusal Zika-related cases which falls under enhanced Zika surveillance. Travel advisories are strageties to decrease the spread of the Zika virus such as advising women to consider avoid traveling to Zika infected countries. The implementations of these strategies are the responsibilities of the IHR.  The World Health Organization (WHO) has yet to created a IHR Emergency Committee to advise countries on how to prepared for the Zika virus.

In 2015 during the Ebola Panel, WHO did not react appropriately to the Ebola epidemic, costing thousands of lives and now during the Zika pandemic, WHO is still not taking a leadership role. The article mentions the director-general of WHO was heavily criticized for  declaring a Public Health Emergency of International Concern(PHEIC) four months after the first cross border transmission of Ebola. The authors are hoping WHO will not have a repeat of the Ebola incident with the current Zika pandemic.

I’m sure that the Zika virus will appear in the news more often as the weather becomes warmer. The United States is predicted to be affected by the Zika virus too. There is currently no vaccine or drug to combat the Zika virus so how should the healthcare field respond if this prediction is correct?

Citation

Gostin Lawrence, Lucey Daniel. The Emerging Zika Pandemic Enhancing Preparedness. JAMA. doi:10.1001/jama.2016.0904 (published January 27, 2016)

http://jama.jamanetwork.com/article.aspx?articleid=2485361

Ethical and Societal Questions Loom Large as Gene Editing Moves Closer to the Clinic

Recently, new scientific discoveries has been made that will allow gene altering to be less expensive and less complicated. This breakthrough could be the answer to a disease-free world but it rises many ethical concerns.

A team from the United Kingdom used this gene editing method to treat an infant with acute B lymphoblastic leukemia. The team used transcription activator-like effector nucleases to deactivate genes in the T- cells that were extracted from a healthy donor. If the genes were not deactivated it will attack the recipient’s cells. The T-cell was also modified so that it is protected from the effects of alemtuzumab, an antileukemia drug. Another team used gene editing to disable the coreceptor on the T-cell for the HIV virus. The results was that there was a decrease in blood levels for HIV DNA.

Gene editing can also be used to edit genes in embroys and gametes. This application is where most of the concerns and controversy arises. On one hand, it will eliminate the transmission of genetic disease but on the other hand, the consequences of this action is unknown. Whatever mistake happens in the germline cells will be passed on to the next generation. The human biological pathways are very interconnected, so scientists are concerned with how pathways will be affected by gene editing. Dr. Eric Lander, the founding director of the Broad Institute of MIT and Harward said gene editing should not be considered, there are other alternatives to avoiding genetic diseases.

During the recent International Summit on Human Gene Editing, attendees highlighted how difficult is would be to regulate the application of gene editing. Some questions posed were, “…what are the rights of future generations, if any, not o have or to have their genomes tampered with?” and ” How will all sectors of society, whether or not they have an interest in the research per se, have a say in the collective inheritance that is the human genome?”  The summit is tentatively scheduled for more meeting on February 11th and 12th in Washington, DC to further discuss this topic.

If the technology behind gene edit is perfected, it could possibly wipe out all diseases and could create a race of “perfect” human. If all diseases were eradicated, then drugs would not be needed. How do you think this will impact the role of pharmacists? Would the need for pharmacists still exist?

Citation:

Hampton Tracy. Ethical and Societal Questions Loom Large as Gene Editing Moves Closer to the Clinic. JAMA. doi:10.1001/jama.2015.19150 (published January 25, 2016).

http://jama.jamanetwork.com/onlineFirst.aspx

Advances in HIV Treatment

New advances in HIV therapies has changed HIV from a death sentence to a manageable chronic disease. Although some infected individuals can still die from infection, there are about 1 million HIV-positive Americans that are living with the HIV virus.

In the 1980’s, Zidovudine (Retrovir) was the only drug available to treat HIV. Since then 25 HIV medications were discovered and were grouped into six classes. Two classes are entry inhibitors and integrase inhibitors. Entry inhibitors prevent the HIV virus from entering the CD4 cells by blocking the receptors on the cell’s surface that the virus needs to gain entry too. Integrase inhibitors blocks the virus from replicating itself. The HIV virus produces integrase that will allow it to combine its DNA with the DNA of an infected person’s CD4 cell. When this happens the cell now becomes a replication factory for the HIV virus, allowing it to spread to other parts of the body.

Aside from the HIV new medications, there has been advances in combination therapy. Combination therapy is using multiple drugs to treat one disease. Because patients are taking multiple drugs, it might be difficult to manage and can cause adherence problems. The advancement in combination therapy allows the professional to combine anywhere from two to four medicines into one pill. A study shows that these combination pills reduces the virus and enhances the immune system of 80% of the HIV-positive subjects. Traditionally, therapy starts once the patient shows symptoms but there is growing evidence that early treatment may result in fewer deaths and complications.

This article shows how far we have come. Before being diagnosed with HIV is like receiving a death sentence and affected individuals are usually stigmatized. Now affected individuals can not only have a greater chance of survival, they can also live normal lives. The advancement in combination therapy is amazing. If the concept of combining multiple drugs into one pill is developed more, it can be used for the general public. It will greatly simplify drug therapies for patients who are constantly taking multiple prescription drugs for their health conditions. It can also lead to a more personalized drug therapy experience for these patients.

Citation:

Advances in HIV treatment. CNN September 11,2015. http://inhealth.cnn.com/taking-control-of-your-hiv-treatment/advances-in-hiv-treatment?did=t1_rss7 (accessed 2016 Feb 7)

http://inhealth.cnn.com/taking-control-of-your-hiv-treatment/advances-in-hiv-treatment?did=t1_rss7

 

An Eating Disorder in People With Diabetes

This article talks about how diabetic people can have eating disorders too. In the article, it tells a story of a Type 1 diabetic teenage girl who accidentally missed a dose of her insulin one day. The next day, she weighed herself and realized she lost a couple pounds overnight. She took advantage of this discovery to lose weight. She knew what she was doing was very dangerous, but she was more concerned about her body image.

People with Type 1 diabetes can not produce their own insulin due to a defect in their genes. Therefore, they can not uptake or use the glucose that they are consuming. When Type 1 diabetics skip their dose of insulin, a behavior called insulin restriction, it causes the body to use other sources of fuel to power itself. In most cases the body uses sugars which end up in the  urine. This is the cause of the rapid weight loss. If the body does not get enough energy from the sugars, it will start breaking down fat which will produce ketone bodies. Ketone bodies are poisonous to the body and may cause ketoacidosis.

The teenage girl’s story is not uncommon. The act of insulin restriction and uncontrolled eating is called diabulimia. A study done in Germany found that Type 1 diabetics ages from 11-21, one in three girls and one in six boys reported either disordered eating, insulin restriction or both. The study done at Joslin Diabetes Center in Boston found that out of 234 adult women with Type 1 diabetes, 30% engaged in insulin restriction behaviors.

The treatment for diabulimia is very tricky because the treatment for diabetes and managing eating disorders are opposites from each other. Treatment for diabetes usually include instructing the patient to count their calories and eating a balanced diet. Treatment for eating disorders include telling patients that there is no “good” food or “bad” food and to not focus too much on the calories.

Women in today’s society are receiving so many messages of what is considered beautiful. This usually involves being tan and thin. Teenagers are especially concerned with their body image, so it is not surprising that this eating disorder exists among Type 1 diabetics. In recent years however, there has been some changes. Models no longer have to be stick thin. It has been shown that it is not about the size that makes the model beautiful, it is the confidence that they display. If this message gets accepted by society, then I think there will be a decrease in the percentage of people with eating disorders.

Citation:

An Eating Disorder in People with Diabetes. New York Times February 1, 2016.http://well.blogs.nytimes.com/2016/02/01/an-eating-disorder-in-people-with-diabetes/?ref=health (accessed 2016 Feb 6).

http://well.blogs.nytimes.com/2016/02/01/an-eating-disorder-in-people-with-diabetes/?ref=health

 

A Scary New Superbug Gene has Reached at Least 19 Countries

The race between bacteria and antibiotics has been happening for centuries. Currently, the most powerful and last resort antibiotic is Colistin. Colistin works by disrupting the outer membrane of gram-negative bacteria, causing the leakage of intracellular contents and cell death.  Because of its potency, it has some harmful side effects. According to Micromedex, the adverse effects include nephrotoxicity in 31% of patients, respiratory failure, and neurological muscular paralysis.

On November 18, 2015,  Colistin-resistant E. Coli was discovered in China. Since then the resistant gene, MCR-1, has been found in 19 countries including Southeast Asia, Europe, Canada, and Japan. The E-coli bacteria itself can survive on human, live animals, and food. The Colistin-resistant gene can travel between multiple types of bacteria, making it even harder to target.

Due to the discovery of the MCR-1 gene, drug developers have been calling for more efforts and investments to be put into the discovery of new antibiotics; ones that will be potent than Colistin. At the same time, the NRDC, Natural Resource Defense Council, has been advising for a more careful usage of antibiotics especially in livestocks. Antibiotics are used in livestocks to not only treat diseases but to also promote faster growth. There has also been an increased effort from the public to decrease the usage of antibiotics in livestocks. At the end of the article it mentioned that to combat the creation of a superbug, it has to be a global effort. Due to the connectivity of today’s society, the creation of a superbug in one country can easily be spread to other countries.

Question: The main concern in this article is the fear of a superbug and that scientists can not create a new antibiotic to treat the bug. The author of this article thinks that the MCR-1 gene has the potential of the creation of a superbug and other organizations are taking precaution by reducing the usage of antibiotics. Other companies such as Johnson and Johnson has agreed to join the first industry-wide Declaration on Combating Antimicrobial Resistance in the effort of bring awareness to the general public about drug resistant bacteria. How do you think the different professional fields can collaborate together to prevent the emergence of a superbug?

Citation:

A Scary New Superbug Gene has Reached at Least 19 Countries. Bloomberg Business January 22,2016.http://www.bloomberg.com/news/articles/2016-01-22/a-scary-new-superbug-gene-has-reached-at-least-19-countries (accessed 2016 Jan 26).

http://www.bloomberg.com/news/articles/2016-01-22/a-scary-new-superbug-gene-has-reached-at-least-19-countries