Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment.

One in three older women and one in five older men will experience a fracture due to bone fragility and fractures due to osteoporosis occur every 3 seconds around the world. Fractures of the spine and hip are very serious and lead to substantial mortality, morbidity, and huge healthcare costs. As we have learned, bisphosphonates, such as alendronate, are the most commonly used medications for osteoporosis. However, these medications are associated with serious complications, potentially related to the long-term usage of these drugs. The American Society for Bone and Mineral Research suggests regulating bisphosphonate usage with a risk-benefit prospecting, weighing the benefits against the serious complications that can arise down the road. One tool that can be used to lesson these complications is reassessing risk after a few years of use and possibly starting therapy. However, this can only work if continual monitoring is done throughout the duration of the disease. This article suggested that for women not at high fracture risk after 3 to 5 years of Bisphosphonate treatment, a drug holiday of 2 to 3 years can and should be considered. I feel that it is our duty as future pharmacists to counsel patients taking bisphosphonates and have them remind their doctor to reassess their risk after a few years of treatment. This will help alleviate these complications associated with long-term usage.

Link

Adler RA, Fuleihan GE, Bauer DC et al. Managing osteoporosis in patients on long-term bisphosphonate treatment: report of a task force of the American society for bone and mineral research. J Bone Miner Res. 2016; 31(1); 16-25.

Studying Antidepressant Nonadherence Using Discarded Blood Samples

Studies show that antidepressant nonadherence is very common. Published reports vary widely, placing the percentage of nonadherent antidepressant users somewhere between 25-50%. It is no secret that these medications work better when taken on a consistent basis. However, it is hard to measure actual adherence due to the fact that patients may become embarrassed or lie, appearing to be more adherent to their medications than they really are. Robertson and colleagues came up with a unique idea in order to measure adherence and bring light to the fact that more individuals may be nonadherent then we, as pharmacist, are led to believe. This team used discarded blood samples from routine clinical blood draws to measure antidepressant nonadherence. They surveyed the electronic health data and collected patients 14-90 days from treatment initiation who were prescribed sertraline, citalopram, bupropion, or venlafaxine. They examined the discarded blood samples from 109 such individuals with active and recently filled antidepressant prescriptions, and looked for detectable serum levels of that drug. Overall, 17% of the samples lacked a detectible level of antidepressants. I think this was a unique way to study nonadherence and although I do not think it could be used at the community level, I think there are areas of pharmacy in which this might one day play a role.

In what ways do you think this could work in our profession?

Link

Roberson AM, Castro VM, Cagan A, Perlis RH. Antidepressant nonadherence in routine clinical settings determined from discarded blood samples. J Clin Psychiatry. doi.org/10.4088/JCP.14m09612. (published 24 November 2015).

Nonmedical Usage of Prescription Stimulants

This study was aimed at examining the trends regarding the current usage of stimulants, nonmedical use of stimulants, and emergency department visits involving prescription stimulants in the United States. The most commonly abused stimulants are those that are commonly prescribed for attention-deficit/hyperactivity disorder (ADHD). The term prescription stimulant refers mainly to schedule II substances such as methylphenidates and dextroamphetamine-amphetamines. In 2011, 1.1 million American’s admitted to using these prescription stimulants nonmedically in the past year. This study looked at data collected from three national surveys issued between 2006 and 2011. They found that in adolescents, treatment visits for dextroamphetamine-amphetamine and methylphenidate decreased over time, as did the nonmedical usage of these stimulants. However in adults, both nonmedical use and emergency department visits involving stimulants increased. Both age groups cited a friend of relative with a prescription as the source for the stimulants they obtained. The study found no correlation between increased prescribing and increased nonmedical use. Although nonmedical usage rose for adults, prescription trends stayed about the same. This highlights that we have an urgent need for public health campaigns targeted at sharing prescription medication for nonmedical use. One study found that 61.7% of college students diagnosed with ADHD have at one time or another diverted their medication. It also found that nonmedical stimulant users had very limited knowledge of the side effects of these drugs. This tells me that we need to be educating college students on the risks associated with stimulants including the side effects, and how they can affect a person not actually diagnosed with ADHD. I feel that this is a topic that students like ourselves can educate our friends and peers on the dangers of misusing prescription drugs.

Article

Chen L, Crum RM, Strain EC, et al. Prescriptions, nonmedical use, and emergency department visits involving prescription stimulants. J Clin Psychiatry. dx.doi.org/10.4088/JCP.14m09291. (published 16 February 2016)

Healthcare Providers’ Opinions on Pharmacist-Initiated Contraception

With the recent ability of Oregon pharmacists to prescribe contraceptives, there has been talk in other states to pass similar legislature. However, there is not much research done on the opinions of the health care providers and what they feel the role of the pharmacist should be. The purpose of this study was to gain a better understanding of the health care providers’ opinion on expanding the access to hormonal contraception and the role of the pharmacist as a direct provider of this service. A voluntary survey was distributed to participating physicians and midlevel providers who normally provide these reproductive health services. 74% of the 482 provideds surveyed were fully supportive of expanding the access to the pill, patch, and ring through a pharmacist. However, many of these individuals, about 70% of them were concerned that this expanded access would decrease preventative screenings. Participants were also asked what type of additional training they felt that the pharmacists should be required to complete before this movement can be passed. 75% selected that the pharmacist should be required to take an intensive training course on hormonal contraceptives and other reproductive health issues and services.

As a future pharmacist, what do you think your role will be when it comes to the reproductive health of your patients? Do you think you will need additional training to feel comfortable in this role? Also, if you are a male pharmacist, would you feel comfortable educating women on their sexual and reproductive health?

Rafie S., Kelly S., Gray EK., et al. Provider opinions regarding expanding access to hormonal contraception in pharmacies. Women’s Health Issues. 2016;26.2:53-160.

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New Study Links Usage of Tylenol during Pregnancy and Infancy to Asthma in Children

Paracetamol, also known as acetaminophen (APAP), or as many people recognize it, Tylenol®, is the recommended analgesics for pregnant women and for infants. However, recent studies have shown that prenatal and infant exposure to APAP could include a higher risk for that child developing asthma. As the second most chronic child-hood disease, it is important to study what may be causing asthma and how we can prevent it. Using data from the Norwegian Mother and Child Cohort Study, 53,169 children were included in the analysis. The study found modest associations between asthma at 3 years old with prenatal APAP exposure and the use of APAP during infancy. However, maternal and paternal usage of APAP outside of pregnancy did not show any association with asthma development. Because APAP is the most suggested pain reliever in pregnant women and infants, it is important to uncover potential adverse effects of its wide usage. I feel that this study has made the first steps in researching the effects of a commonly used drug that is widely accepted as safe. Do you think we should continue to spend money and time researching drugs that have been determined safe and used so prevalently over the past 60+ years, or focus our time and attention on new and up-coming drugs?

Link

Magnus, Mc., Karlstad, O., Haber, SE., et al. Prenatal and infant paracetamol exposure and development of asthma: the norwegian mother and child cohort study. Int. J. Epidemiol. Published ahead of print: February 9, 2016.

Cognitive Based Therapy versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder. A Clinical Guideline

Major depressive disorder (MDD) is characterized by a depressed mood, loss of pleasure and interest, significant changes in weight or appetite, trouble sleeping or sleeping too much, fatigue and loss of energy, inability to concentrate, feelings of worthlessness, or thoughts of death or suicide that last for at least two weeks and affect the normal functioning of the individual. Major depression disorder effects 16% of American people and the healthcare costs surrounding it totaled around 83.1 billion dollars in the year 2000, and is probably higher today. Various treatment options exist for MDD, including cognitive behavior therapy such as psychotherapy, exercise, alternative medicine, and pharmacotherapy. This study sought to create a clinical guideline that compared the effectiveness and safety of nonpharmacologic treatments, such as cognitive behavioral therapy (CBT) and pharmacotherapy, alone and in combination for the treatment of MDD. The American College of Physicians recommends that the clinician select between either cognitive behavior therapy or second-generation antidepressants to treat individuals diagnosed with MDD. Using them in combination did not prove to be more effective in the treatment of MDD.

Question: As a pharmacist, how do you feel about individuals that forgo prescription medication and choose to go an alternative route such as cognitive behavior therapy. Do you think pharmacist should be able to recognize when prescription medication is unneeded and when behavior therapy would work better for the patient, or should that be up to the MD to recognize?

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Qaseem A, Barry MJ, Kansagara D. Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. Epub ahead of print 9 February 2016.

Weight-Based Dosing in Pediatric Patients

Inappropriate prescribing is a medication error found in almost 15% of pediatric outpatient prescriptions. With more significant pharmacokinetic and pharmacodynamic differences than adults, as well as a greater variation in height and weight, children are more susceptible to prescribing errors. Although many inpatient pharmacies have procedures and safeguards to protect children from these errors, outpatient pharmacies lack these procedures and error prevention strategies in the outpatient setting remain relatively unstudied.

This study was performed in outpatient pharmacy located in an academic teaching hospital. All pediatric prescriptions were reviewed for a six month period. Over five thousand prescripts were reviewed during the sixth month period and of these prescriptions, around 156 of those prescriptions required pharmacist intervention. The majority of those prescriptions needing pharmacist intervention had to be changed because dose too high. This study demonstrated the need for weight-based dosing procedures in outpatients pharmacies as way to proactively reduce medication errors for children. Although this procedure adds time, it’s an important safeguard for children using prescription medications.

Link

Grant JJ. Adams Mb. Decker K et al. Evaluating the impact of a pediatric weight-based dosing procedure in outpatient pharmacy. J Am Pharm Assoc. 2016; 56.1: 54-57.

Battling increasing cases of multi-drug resistant tuberculosis by modifying current treatments

With the upcoming renewal of our TB tests, I thought this article was appropriate. Mycobacterium tuberculosis (Mtb) infects one-third of the world’s population and accounted for 1.5 million deaths in 2013. Recently, first line treatments of TB are decreasing as multidrug-resistant strains are increasing worldwide. Therefore it is imperative to begin researching how to alter and modify our current treatments to combat drug-resistant strains. Fluoroquinolone antibacterials, such as our top drug ciprofloxacin, target DNA gyrase and are used to treat tuberculosis. DNA gyrase alters the coiling of DNA by breaking its strands and then resealing them. Quinolones work by targeting tuberculosis gyrase and preventing the resealing of the DNA, therefore causing the bacteria to die.

In this study, researchers used x-ray crystallography to generate 3-D models of how TB’s gyrase interacts with various drugs. Through this modeling, researchers have discovered two different sites where drugs could potentially interact. However, they found that current drugs only interact with one of the sites, revealing the untapped potential of the other site, or even the possibility of altering current drugs to interact with both sites at once, therefore decreasing the risk of the bacteria developing resistance. Because of this study, researchers have more information on how quinolones work and have a direction to focus their attention on in an attempt to fight tuberculosis antibiotic resistance.

Blower TR, Williamson BH, Kerns RJ et al. Crystal structure and stability of gyrase-fluoroquinolone cleaved complexes from mycobacterium tuberculosis. PNAS. 2016; published ahead of print January 20, 2016.

Link to article