Pharmacotherapy for the Treatment of Hoarding Disorder

Hoarding disorder, which is characterized by difficulty discarding or parting with possessions, is common and potentially “disabling.” In fact, this behavior usually has some harmful effects, such as emotional, physical, social, financial, and even legal implications. Also, people who hoard often exhibit irrational behavior.

In some studies, hoarding has been listed as diagnostic criteria for obsessive-compulsive personality disorder (OCPD); however, some consider hoarding a disorder in itself. There are various routes of treatment for hoarding disorder, including both psychotherapy and pharmacotherapy. For the purpose of this assignment, I will focus more on the pharmacotherapy.

Since hoarding disorder is closely associated with OCD, pharmacotherapy for the treatment of hoarding disorder is similar to treatment of OCD. Studies have shown that OCD patients respond well to the use of selective serotonin reuptake inhibtors (SSRI’s), and some of these drugs have clinical effect in patients with hoarding behavior/disorder. In one study done by Sanjaya Saxena, it was concluded that the use of paroxetine (Paxil), which is an SSRI, improved hoarding symptoms, depression, and anxiety. Furthermore, venlafaxine has also shown good response with hoarding behaviors. In fact, venlafaxine had a trend for greater reduction in hoarding symptoms than that seen with paroxetine. New treatment strategies might also include cognitive enhancers, such as donepezil, to increase attention and executive functioning in patients with hoarding disorder.

In conclusion, hoarding disorder is a common and relevant problem that can tremendously affect someone’s life, but can be treated. Hoarding disorder, along with its signs and symptoms, can be improved by pharmacologic therapy (mostly the use of SSRI’s), psychological therapy, or a combination of both.

Saljoughian, Manouchehr. Hoarding Disorder: Diagnosis and Treatment. US Pharm. 2015:40(11):60-62.

Role of Vitamin D Deficiency in Heart Disease

Cardiovascular disease (CVD) is a major cause of morbidity in the United States. People with CVD or at high risk of CVD need early detection and management of the disease (through counseling or medications).

So you may be wondering, what does vitamin D have to do with cardiovascular disease? First off, vitamin D is a fat-soluble vitamin that plays a hormonal role in skeletal health. Vitamin D does this by regulating calcium and phosphate metabolism. Furthermore, vitamin D deficiency has been identified as a potential risk factor for several diseases, including CVD and cancer. Research has shown evidence suggesting an association between low 25-hydroxyvitamin D levels and CVD.  Vitamin D deficiency has also been associated with atherosclerosis in coronary calcification as well as cardiovascular events like myocardial infarction, stroke, and CHF (congestive heart failure).

In conclusion, a vitamin D deficiency has been proven to have a connection with CVD, but the role of vitamin D supplementation for the management/treatment of the disease still needs to be established.

Saljoughian, Manouchehr. Role of Vitamin D Deficiency in Heart Disease. US Pharm. 2016;41(2):43-45.

Monoclonal Antibodies for the Treatment of Hypercholesterolemia

Cholesterol levels in patients with familial hypercholesterolemia are unfortunately poorly controlled, even with dietary changes and maximum pharmacological therapy. In these patients, there are increased concentrations of proprotein converts subtilisin/kexin type 9 (PCSK9), which contributes to elevated levels of LDL cholesterol. However, monoclonal antibodies have been shown to significantly reduce LDL cholesterol by inhibiting PCSK9 in patients with familial hypercholesterolemia. In fact, PCSK9 inhibitors, such as the monoclonal antibodies, can help the patients achieve an LDL reduction greater than 50%.

Two recently approved monoclonal antibodies, evolocumab and alirocumab, have shown favorable safety profiles in addition to efficacy in lowering LDL cholesterol. These two drugs are given either biweekly or monthly and are injected subcutaneously. Some patients may not be comfortable with subcutaneous injections, but since they are only administered biweekly or monthly, it should not decrease compliance too significantly. Especially because PCSK9 inhibitors, like the monoclonal antibodies, may prove to be the best option for reducing LDL cholesterol and ASCVD risk in these patients.

A third monoclonal antibody is also being investigated and long term studies of these drugs will be necessary in order to determine effectiveness in preventing cardiovascular disease. Cardiovascular disease accounts for nearly one-third of all deaths in the United States and high levels of LDL cholesterol are a well-known risk factor associated with the development of cardiovascular disease. In the future, hopefully these drugs will also prevent the development of cardiovascular disease as well as control the hypercholesterolemia in these patients.

Hole, Eric B., Begley, Kimberly J., Castillo, Shana L. Monoclonal Antibodies for the Treatment of Hypercholesterolemia. US Pharm. 2016;41(2):17-20.


Readmissions, Observation, and the Hospital Readmissions Reduction Program

Hospital readmissions are an ongoing issue in many communities. In attempt to correct this issue, the Hospital Readmissions Reduction Program, which is part of the Affordable Care Act (2010), applies financial penalties to hospitals that have higher-than-expected readmission rates for specific conditions. It is a concern, however, that reductions in readmissions are being achieved by keeping the returning patients in observation units for a longer period of time instead of formally readmitting them. The purpose of this study was to examine changes in readmission rates and stays in observation units over time. This study also assessed whether hospitals that had greater increases in observation-service use had greater reduction in readmissions.

During this study, hospital-level rates of readmission and observation-service use within 30 days after discharge were compared monthly among Medicare beneficiaries. This study took place between October 2007 and May 2015 and 3387 hospitals were analyzed. From 2007 to 2015, readmission rates for targeted conditions declined from 21.5% to 17.8%. Also, rates for non targeted conditions declined from 15.3% to 13.1%. Furthermore, stays in observation units for targeted conditions increased from 2.6% in 2007 to 4.7% in 2015. Overall, there was no significant association between changes in observation-unit stays and readmissions after implementation of the ACA in 2010.

Readmission trends seem to be consistent with hospitals’ responding to incentives to reduce readmissions. There was no conclusive evidence supporting that changes in observation-unit stays solely accounted for the decrease in readmissions.

Zuckerman, Rachael B., Sheingold, Steven H., Orav, John., et al. Readmissions, Observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016.

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

Ischemic stroke or transient ischemic attack (TIA) patients are at increased risk for future cardiovascular events. Interestingly, the identification of insulin resistance has been discovered as a risk factor for stroke and myocardial infarction. The resistance of insulin as a risk factor raised the possibility that pioglitazone might benefit patients with cerebrovascular disease. Pioglitazone, which is normally used in patients with Diabetes, improves insulin sensitivity; therefore, Pioglitazone could possibly help with the insulin resistance associated with cardiovascular complications.

In this article, the authors focused on a particular study using the treatment of pioglitazone in patients who had a recent ischemic stroke or TIA. It was a multi center, double-blind trial using 3876 randomly assigned patients. The patients were either treated with pioglitazone (target dose of 45 mg daily) or a placebo. There were 1939 patients in the pioglitazone group and 1937 in the placebo group. The patients involved in the study were not diagnosed with Diabetes, but were found to have insulin resistance based on the HOMA-IR, or homeostasis model assessment of insulin resistance, index.

After 1 year, the HOMA-IR index was lower in the pioglitazone group than in the placebo group. The results after 4.8 years of this study are as follows: A primary outcome (stroke or myocardial infarction) had occurred in 9.0% of the pioglitazone group and in 11.8% of the placebo group. Diabetes developed in 3.8% of the pioglitazone group as compared to 7.7% of the placebo group. Also, pioglitazone was associated with a higher frequency of weight gain (52.2%), edema (35.6%), and bone fracture requiring surgery or hospitalization (5.1%).

In conclusion, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received the placebo. Pioglitazone was also associated with a lower risk of diabetes, but with a higher risk of some of the side effects, such as weight gain, edema, and fracture.

Kernan, Walter N., Viscoli, Catherine M., Furie, Karen L., et al. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. N Engl J Med. 2016.

Prescription Use Among Children with Autism Spectrum Disorders

The purpose of this article is to focus on the difference between prescription medications given to children with autism spectrum disorders versus children in the general population. Published in February 2016, this article focuses on a study that was conducted during the years 2007-2010. This study was a cross-sectional study of ambulatory prescription fills from Maine, Vermont and New Hampshire.

Autism Spectrum Disorders, or ASDs, affect more children than we may think. In fact, during this study, there were 13,100 children diagnosed with ASD, compared to the 936,721 children without ASD diagnosis. That means that about 1 in every 71 children is diagnosed with ASD. Also, along with the ASD diagnosis comes prescription medications. Furthermore, this study showed that children with ASDs consume more prescription drugs than the general pediatric population.

The overall prescription fill rate was about 4-fold higher in children with ASD compared to the children without ASD. First, psychotropic use among children with ASD was 9-fold higher than the general population rate. The children with ASD made up about 2% of the pediatric population, but received a little over 15% of the psychotropics being prescribed to those pediatric patients. Next, nonpsychotropic drug use was also higher in the population with ASD, particularly in those children age 3 or younger. Furthermore, antibiotic use was 2-fold higher and antacid use was nearly 5-fold higher than the general population.

This increase in drug use was not only observed in the community settings, but also seen in the hospital settings. Antacid and alpha-agonist uses in hospital settings were about 3-fold higher in the ASD population, and benzodiazepines reached nearly 4-fold higher for the ASD population in the hospital setting.

As you can see, autism spectrum disorders really affect the medication use in the pediatric population. There is an overall increase in psychotropic and nonpsychotropic prescription medications in the ASD population, followed by an increase in other prescription drugs as well. There is still more research to be done in this category; however, the correlation is shown relating ASD with prescription drug use as compared to the general population.

Prescription Use among Children with Autism Spectrum Disorders in Northern New England: Intensity and Small Area Variation. House, Samantha A. et al. The Journal of Pediatrics , Volume 169 , 277 – 283.e2