Impact of attention-deficit hyperactivity disorder on school performance: what are the effects of medication?

ADHD is a disorder that can detrimentally affect a student’s performance in school and extracurricular activities. ADHD medications are highly regulated medications because they have a high abuse/theft rate because students who don’t have ADHD take them in attempts to approve their academic performance. This study looks at how much these medications actually improve quantifiable performance of students with ADHD. This study looked at academic performance (GPA, work completed) and academic skills (achievement and cognitive tests), and academic enablers (study skills, motivation) of school-age children to determine how much these stimulants improve students’ overall performance, synthesizing data from many long- and short-term studies. The results found that CNS stimulant use improved teacher perceptions of students’ classroom behavior the most, reducing disruptive behavior and increasing focus on classroom activities. It was also observed that use of stimulants increase students’ productivity, which could possibly lead to a long-term increase in GPA. The efficacy of these medications is mainly reduced by adherence, and can also be affected by the learning environment. Optimizing the effects of these medications is achieved by constant reassessment of efficacy and patient adherence.

I found this study really interesting because I know many people who have really struggled with academic performance because of ADHD, and how much being properly medicated helped their performances. As prescription of ADHD medications becomes increasing more prevalent, it is important as pharmacists to make sure that the people who actually need these types of medications are the one taking them, and that they are properly counseled in order to achieve maximum efficacy.

Baweja R, Mattison RE, Waxmonsky JG. Impact of attention-deficit hyperactivity disorder on school performance: what are the effects of medication? Paediatr Drugs. 2015; 17:459-477.

http://ovidsp.tx.ovid.com/sp-3.18.0b/ovidweb.cgi?&S=HLDPFPANCDDDICOANCJKFFGCJFFLAA00&Complete+Reference=S.sh.22.23.25%7c5%7c1

High-dose perioperative atorvastatin and acute kidney injury following cardiac surgery

Atorvastatin is a commonly prescribed medication for hyperlipidemia. It has also been recently found in a study that preoperative statin treatment could decrease the risk of acute kidney injury in patients recovering from cardiac surgery. Acute kidney injury (AKI) affects up to 30% of cardiac surgery patients, and patients who suffer from this complication increase their risk of death by as much as five-fold. This study looked at the efficacy of perioperative statin treatment in prevent AKI occurrences in cardiac surgery patients. The study included cardiac surgery patients who had never received statin treatment before and patients already on statin therapy. The statin-naïve patients were given 40 mg of atorvastatin that morning of and daily after surgery, and patients on statin therapy took regular dosage up to surgery and 80 mg after surgery, or they received a placebo. The study found that perioperative dosing of atorvastatin in patients already on statin did not reduce AKI risk and may even increase AKI risk in statin-naïve patients and in patients with CKD compared to the placebo treatment. These results did not support statin initiation to prevent AKI post-cardiac surgery.

I think it is really interesting to investigate new indications for already well-established medications. In terms of the drug development process, it is much easier and more cost-effective to find new indications for an already approved drug than it is to come up with an entirely new compound. It is also interesting that a previous study had found that statin treatment could possibly decrease the risk of AKI, while this study found that it did not or even could potentially increase the risk of AKI incidence in certain patients. This shows that many different studies’ results must be taken into account before using any of them to support any claims, find proper treatments techniques, or provide patient counseling.

Billings FT, Hendricks PA, Schildcrout JS et al. High-dose perioperative atorvastatin and acute kidney injury following cardiac surgery. JAMA. 2016; 315:877-888.

http://jama.jamanetwork.com/article.aspx?articleid=2492851

Weekly vs. every-3-weekly Paclitaxel and Carboplatin for ovarian cancer

Ovarian cancer is the most lethal gynecologic cancer and causes about 14,000 deaths in the US every year. Paclitaxel is a common first-line therapy for prolonging survival of ovarian cancer patients and is often used in combination with cisplatin or carboplatin, medications that interfere with DNA function within the cell cycle to cause cell death. This study looked at the differences in effectiveness of prolonging progression-free survival of ovarian cancer by giving patients weekly paclitaxel/carboplatin doses or dosing them every three weeks. 84% of the patients were also taking bevacizumab, another cancer treatment. The study found that in patients that were also taking bevacizumab, weekly versus triweekly dosing of paclitaxel and carboplatin did not show a significant difference in progression-free survival, while those not taking bevacizumab who were administered paclitaxel and carboplatin every week instead of every three weeks showed some association with a longer progression-free survival. Patients who received paclitaxel/carboplatin weekly also exhibited higher rates of anemia and sensory neuropathy. The study concluded that there wasn’t a strong enough correlation between higher frequency dosing and longer survival rates to conclude that weekly dosing was more effective in prolonging progression-free survival than triweekly dosing.

I thought this study was really interesting because it ties into what we have been doing in Drug Development in terms of figuring out dosing regimens for optimal efficacy of our trial drugs. In terms of real-world application, more studies with findings like these could really impact patients’ lives with respect to how often they must receive IVs of these types of medications and their health care costs, since they wouldn’t have to receive them as frequently and I’m sure these types of medications are incredibly expensive. I’d like to see results of more studies like this in the future to see if more of these types of drugs can be as effective when dosed less frequently.

Chan JK, Brady MF, Penson RT et al. Weekly vs. every-3-weekly Paclitaxel and carboplatin for ovarian cancer. N Engl J Med. 2016; 374:738-748.

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1505067

Impact of the RxVaccinate program for pharmacy-based pneumococcal immunization

Pneumonia is a disease that is very prevalent within society and is one of the leading causes of death, particularly in adults aged 65 or older. A very easy way to prevent contraction and spread of pneumonia is to receive the appropriate vaccinations at the correct time in a patient’s life. Pharmacists are providing an increasingly higher proportion of these vaccines, and are projected to administer even more in the future. This study looked at the effectiveness of a program called RxVaccinate, created by APhA, which was designed to compare the effectiveness of two different types of education programs in increasing the amount of pneumococcal vaccines administered.

The two programs involved in the study were a series of self-directed training webinars and the webinars combined with expert coaching sessions. The webinar focused on the current pneumococcal immunization recommendations, benefits of getting the vaccine, how to identify high-risk patients and provide counseling to them. The coaching sessions involved outlining action plans for the pharmacists and how to implement them. One group of pharmacists received only the self-directed training on pneumococcal vaccines, while the other group received coaching sessions in addition to the self-directed webinars. This study found that while both programs significantly increased the number of pneumococcal vaccines administered at each community pharmacy, the pharmacists who received both the webinar and the coaching session trainings increased the amount of pneumococcal vaccines administered than the pharmacists who only received the webinar training, with a P value of 0.032.

This study is really interesting to me because at my work (in a community pharmacy), we are frequently assigned self-directing online learning modules to teach us about new programs or educate us on new compliance policies within the company. I know for the sake of efficiency it is easier to send us online modules, but it does make it easier for pharmacy team members to dismiss them or not take the training as seriously as they would if the same information was presented in an expert-led training session. However, for something as important as teaching pharmacists the proper methods to identify, counsel, and administer the vaccine to patients, it is definitely necessary to have an in-person training session. As more advanced technological methods of teaching emerges, how do you think the effectiveness of pharmacists’ training will be affected? Do you think these types of online learning modules will completely replace in-person training sessions, or do you think they will only be used as more of a supplement to these sessions?

Westrick SC, Owen J, Hagel H et al. Impact of the RxVaccinate program for pharmacy-based pneumococcal immunization: A cluster-randomized controlled trial. J Am Pharm Assoc. 2016; 56:29-36.

http://www.japha.org/article/S1544-3191(15)00011-4/abstract

 

Association of Proton Pump Inhibitors with Risk of Dementia

Proton pump inhibitors, or PPIs, are medications used to treat gastrointestinal diseases such as acid reflux (GERD). These medications are commonly prescribed to patients in the community, and even more take their over-the-counter counterparts. This article describes a study done to measure the correlation of the use of PPIs with cognitive decline in older adults. The study analyzed data from a German health insurer to determine the association between patients 75 years or older who had prescribed PPIs such as omeprazole, pantoprazole, lansoprazole, esomeprazole, and rabeprazole and diagnoses of incident dementia from August to November 2015. The study also adjusted for confounding factors such as age, sex, comorbidities, and prescription of other medications. The study found that patients regularly taking PPIs had a significantly increased risk of incident dementia compared to patients not taking PPIs. The study concluded that not taking PPIs may decrease the risk of dementia onset, possibly because the use of PPIs has been associated with increased beta amyloid levels in the brains of mice (a characteristic of dementia patients), which may translate to having the same effects in humans.

Dementia is a health problem that pharmacists will continue to face with increasing frequency, especially as the baby boomer generation reaches the ages when the onset of dementia normally occurs. Since this disease state is one that also puts an extreme burden on the family and caregivers of dementia patients, it is imperative to identify its causes so that its onset can be prevented. I am very interested in seeing further studies done on the correlation between PPIs and dementia, as well the correlation of its onset with other frequently prescribed medications. What do you think the pharmacist’s role in patient education of this new finding will be, and how do you think it will affect the pharmacist’s job in the future?

Gomm W, von Holt K, Thomé F et al. Association of Proton Pump Inhibitors with Risk of Dementia. JAMA Neurol. doi:10.001/jamaneurol.2015.4791 (published 15 February 2016).

http://archneur.jamanetwork.com/article.aspx?articleid=2487379

Major Causes of Injury Death and the Life Expectancy Gap between the United States and other High-Income Countries

Drug overdose is becoming an increasingly more prevalent problem that health care providers, especially pharmacists, must work together to prevent. Currently, drug poisoning is the leading cause of injury-related deaths in the United States. This study looks at the differences in the major causes of injury-related deaths between the Unites States and other high-income countries including Italy, Denmark, Finland, United Kingdom, and more. In the US, drug poisonings were the third leading cause of injury-related death for men and the first leading cause for women, compared to the second as well for men and second for women in all of the other countries. Even though the causes of death were ranked similarly to each other in the US and in other countries, the rates themselves differ significantly. In men, the rate per 100,000 population was 16.1 in the US versus only 2.7 in the other countries. For women, the rate was 10.1 in the US versus 1.6 in other countries.

This study is really interesting to me because we have talked about drug overdose-related deaths specifically in the Pittsburgh area and Allegheny County. Through work and community health sites, I have worked with patients who are working through addiction, particularly opioid addiction. I wonder if this increase in overdoses is due to higher prescribing rates of opioids, more illegal access to them, or due to another class of drugs entirely. What are your thoughts on this issue? Can you think of any possible solutions to this problem that we will face in our careers as pharmacists?

Citation: Fenelon A, Chen LH, Baker SP. Major causes of injury death and the life expectancy gap between the United States and other high-income countries. JAMA. 2016; 315:609-611.

http://jama.jamanetwork.com.pitt.idm.oclc.org/article.aspx?articleid=2488300

Effectiveness of a pharmacist-physician collaborative program to manage influenza-like illness

As we progress further through flu season, it is important to consider different options to prevent contracting it or how to treat it if preventive measures fail. This study looked at the effectiveness of physicians and pharmacists working together as a team to diagnose patients with flu-like symptoms and prescribe treatments to them via established collaborative practice agreements. The study found that only 11% of the 121 patients screened tested positive for the flu, but the pharmacists were able to provide timely treatment to patients with the flu and also those who only required symptomatic treatments.

The study looked at community pharmacies throughout Michigan, Minnesota, and Nebraska that offered rapid influenza diagnostic tests, brief physical assessments, then used results to determine a diagnosis for each patient and recommended treatment or prescribed medications by the collaborative practice agreement. The study concluded that pharmacists using the data collected from the evidence-based collaborative practice agreements provided a very streamlined treatment experience to patients, and could possibly overtake urgent care and emergency room visits for these types of health care problems.

This practice set-up is one way that patients who have a hard time accessing health care providers can easily receive treatment for the flu. 34.6% of the patients included in the study who came to the pharmacy to get screened for influenza didn’t have a primary care physician and would have gone to urgent care or the emergency room to seek treatment, which is much less efficient and much more expensive. This also shows how health care providers working together can streamline a patient’s health care experience significantly, and also how pharmacists can use their accessibility to provide much more health care to patients than they normally do now. If this practice became the norm for pharmaceutical care, how do you think the role and the views of pharmacists would change?

Citation: Klepser ME, Klepser DG, Dering-Anderson AM et al. Effectiveness of a pharmacist-physician collaborative program to manage influenza-like illness. J Am Pharm Assoc. 56: 14-21.

http://www.japha.org/article/S1544-3191(15)00009-6/abstract?elsca1=etoc&elsca2=email&elsca3=1544-3191_201601_56_1_&elsca4=Public%20Health%7CPharmacy%7CHealth%20Policy%7CHealth%20Professions%7CPharmacology

Effects of intensive blood pressure on lowering cardiovascular and renal outcomes

This study analyzed data collected from previous trials involving different blood pressure reduction practices to reduce risk of major cardiovascular and renal events to determine which strategies were most effective. The study looked at data from different trials using more intensive blood pressure reduction, such as stricter target blood pressures or antihypertension medication dosing regimens, versus less strict treatment guidelines. The risk of cardiovascular or renal events looked at were myocardial infarctions, stroke, cardiovascular failure, and end-stage kidney diseases.

The study found that ultimately, the more intensive hypertension treatments are more beneficial than the less intensive ones to all populations, including patients with systolic blood pressure under 140 mmHg. 19 trials with 44989 participants were included in that data analysis, with 2496 major cardiovascular events in a 3-8 year range. The patients that underwent more intensive treatments had a mean blood pressure of 133/76 mmHg, while those with less intensive treatments had a mean blood pressure of 140/81 mmHg. The patients with intensive blood pressure treatments had 14% decreased chance of major cardiovascular events, though didn’t seem to have conclusively less risk of total mortality or end-stage kidney disease.

Management of hypertension is becoming a very important subject within the field of pharmacy, especially since an increasing percentage of the population are struggling with lowering blood pressure. It’s interesting to see a comparison of the efficacy of different antihypertensive practices within different patient populations as we have recently discussed these very guidelines in class. One question that this article raises is why are blood pressure guidelines becoming less stringent, and why are less intensive blood pressure treatments not being used as much in higher-risk patient populations?

Citation:

Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016; 387: 435-43.

http://thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00805-3.pdf