Risk of Common Mental Disorders in Relation to Symptoms of Obstructive Sleep Apnea Syndrome among Ethiopian College Students

We can all relate to the problem of getting enough sleep with a busy schedule in college.  This study used questionnaires to analyze symptoms related to obstructive sleep apnea syndrome or OSAS, which can lead to death.  From two universities in Ethiopia, a total of 2,639 students were included in the study as test subjects.  The questionnaires consisted of questions related to demographic and behavior information such as age, sex, education level, smoking, alcohol, and Khat which is a plant that has amphetamine-like effects that is commonly used as a stimulant in Ethiopia.  The Epworth Sleep Scale (ESS) was used to measure the subject’s level of daytime sleepiness, and the General Health Questionnaire (GHQ-12) was used to screen for mental disorders such as depression and anxiety.

It was found that 19% of the subjects had a high risk for obstructive sleep apnea and 26.4% had excessive daytime sleepiness.  Those students with excessive daytime sleepiness only were also more prone to have common mental disorders.  This study is novel in that it is the first to assess the risk of obstructive sleep apnea in the sub-Saharan young adult population.  The results that show an increase of common mental disorders among those with symptoms of obstructive sleep apnea syndrome are congruent with previous studies that focus on different populations.

A question arising from this study is whether or not common mental disorders are caused by sleep disorders such as obstructive sleep apnea or if the mental disorder is already pre-existing.  With the amount of stress students face, sleep disorders are a health issue that should be addressed by healthcare professionals.  Pharmacists should also be aware of the relation to common mental disorders when seeing a patient with a sleep disorder.

J Sleep Disord Treat Care. 2015 ; 4(3): .

Role of Bupropion Plus Naltrexone for the Management of Obesity

Obesity has been and still is a concern among the American population.  By the American Medical Association, obesity is a recognized disease state and is a risk for chronic diseases such as diabetes and osteoarthritis.  Lifestyle modifications including exercise and healthy diet are pertinent in treatment, however, if obesity is not cured which includes a high BMI of at or above 30 kg/m2, intervention of pharmacologic treatment may be necessary.  One of such treatments is branded as Contrave, which is bupropion plus naltrexone and is FDA indicated for chronic weight management.  This article reviews the clinical evidence in that regard.

There is evidence that suggests bupropion may help with weight loss by itself, however, working in conjunction with naltrexone, naltrexone can increase bupropion’s effect on the POMC neurons in the hypothalamus to cause appetite suppression.  It blocks the mu-receptors and results in an increased activity of POMC neurons leading to weight loss.

Five articles were included in this study as a data source.  In the clinical trials evaluated, it can be noted that there is substantial evidence that supports the efficacy of bupropion plus naltrexone, compared to placebo, in obesity management.  Results from these trials show that the average weight loss was 6.8% from baseline and 4.3% from baseline with the placebo subtracted.  About 66% and 42% of patients randomized to treatment also respectively lost 5% and 10% of weight from baseline.  Adverse effects which include nausea and constipation were the most common reason patients stopped the medication during the trials.  Dry mouth, vomiting, dizziness, and heartache were also experienced.  A limitation is that this drug’s efficacy hasn’t been studied in the Hispanic, African American, and Asian populations.

Since weight management medications are becoming more popular in the treatment of obesity, it is valuable that this review was done on these clinical trials to show the efficacy.  This also may lead to the possibility of a generic formulation.  In the future I hope to see an established efficacy of the drug in other racial populations.

J Pharm Technol. doi:10.1177/8755122515624220 (published 11 January 2016).

Asthma control and cold weather-related respiratory symptoms

A common condition affecting many people around the world is asthma.  This condition, if not well controlled, can decrease the quality of life of those patients.  It is possible that the amount of respiratory symptoms during cold weather are more prevalent in those with a current respiratory condition because breathing cold air can cause a change in the airways.  This study tested whether there was difference between good asthma control and poor asthma control on the occurrence of cold weather-related respiratory symptoms.

A total of 5,000 subjects were given two different questionnaires to fill out.  From the 2,033 subjects who responded, 1,995 subjects were eligible for the study.  The questionnaires contained questions such as how much times the asthma kept the subject from achieving at work, or how often the subject experienced shortness of breath.  The questions ultimately were trying to assess if the subject experienced more asthma symptoms (shortness of breath, prolonged cough, wheezing, phlegm production, and chest pain) during cold weather.

After an analysis of the results, it was determined that cold weather does increase respiratory symptoms among adults with asthma.  This study is also the first to show that a poorer control of asthma does lead to more respiratory symptoms related to cold weather.  The most common symptom was that of cold weather induced chest pain among those with poor asthma control.  A low or high BMI and smoking also affects asthma control negatively.

I feel that this is something for pharmacists to keep in mind.  There may be a higher importance on controlling asthma in patients who live in colder areas.  For pharmacists working in the community setting in a cold area, there could be emphasis placed on assessing the adherence of those with asthma medications.

Respir Med. 2016;113:1-7.

Inhaled Toxicants from Hookah vs. Cigarette Smoking

Although smoking cigarettes may be declining among the US college population, it seems that smoking one of its counterparts, the hookah, is on the rise.  The hookah contains communal pipes that allow users to draw tobacco smoke through water.  This specially made tobacco comes in many unique flavors.  There seems to be the misconception that smoking from a water pipe (hookah) is less harmful, however, many of the health risks are the same as smoking cigarettes.  In fact, since users often believe this misconception, one hookah smoking session can often become more dangerous.

In a recent systematic review and meta-analysis of inhaled toxicants from water pipe and cigarette smoking, it was discovered that, compared with a single cigarette, one hookah session delivers approximately 125 times the smoke, 25 times the tar, 2.5 times the nicotine and 10 times the carbon monoxide.  This study clearly shows that a hookah smoking session exposes users to higher amounts of smoke volume and toxicants.  Led by lead author Dr. Brian A. Primack,M.D., Ph.D., a University of Pittsburgh School of Medicine professor, he states that the results show that smoking hookah tobacco poses real health concerns and should be monitored more closely than it currently is.  The methods to this study include searching through biomedical bibliographic databases for relevant articles and conducting meta-analysis to calculate the parameters of smoke volume, nicotine, tar, and carbon monoxide between a single cigarette and a single hookah smoking session.  Out of 542 potentially relevant studies, only 17 were qualified for meta-analysis.

A caveat is that due to the various ways of usage of cigarette and hookah smoking, it is difficult to accurately analyze the effects of both counterparts and develop a perfect comparison.  Thus, the researchers cannot say which is “worse,” however, it can be noted that hookah users are probably being exposed to a lot more toxicants than they realize.

I feel that this is an important issue that needs to be brought up more often in healthcare, with a focus on the college aged population.  More education and media coverage on the dangers of this activity should also be exposed.  It has been studied that about one-third of U.S. college students have used a hookah, and many of those individuals had not used other forms of tobacco previously.

Public Health Rep. 2016;131(1):76-85.

Development of an opioid reduction protocol in an emergency department

Pain is the leading cause of emergency department (ED) visits.  With the frantic and stressful environment, it doesn’t seem surprising that opiods are commonly prescribed to a patient.  This is more efficient than taking the time to carefully address the patient’s specific needs and concerns and also seems to give the patient instant relief and satisfaction.  As a result, there has been a significant increase in the amount of opioids prescribed in the ED.  This study hopes to test a multimodal pharmacologic approach to analgesic therapy for patients with acute pain which is known as the public health initiative, the “Opioid-Free Shift.”  This multimodal therapy involves using a combination of pharmacologic agents to target multiple receptors that are known to mediate pain transmission.

The research was conducted at the Maimonides Medical Center which has excess visits to their emergency department.  An interprofessional team consisting of physicians, research staff, a clinical pharmacy manager, and nurses worked together to guide the care during the opioid-free shift.  The pain-scale was used as a rationale to determine the type of treatment needed for the patient. For instance, a score of 1-4 yielded a treatment of oral analgesics such as ibuprofen.  Pain scores of 5-10 yielded IV acetaminophen or ketamine along with other IV treatments.  During this opioid-free shift which took place from 7am to 3pm, only 1 out of 17 patients were given an opioid as rescue therapy.  For those patients on the opioid-free treatment, about 83% of the patients were satisfied with the pain relief at 30 minutes, and 86.7% reported satisfaction at 60 minutes. No adverse drug reactions were reported during the study.

This alternative to prescribing opioids seems to prove efficacious, and may be beneficial to potentially decrease the amount of opioid addiction conditions.  My questions posed to colleagues are: What do you think are the benefits or downsides to this approach being potentially practiced more often in hospitals?  How do you think a pharmacist could assist in this treatment?  Would involving a pharmacist specializing in palliative care be beneficial or detrimental?

 Am J Health Syst Pharm. 2015;72(23):2080-2086.

Methylphenidate for ADHD in children and adolescents

Methylphenidate is often prescribed to children and adolescents for the treatment of ADHD, or attention-deficit/hyperactivity disorder, however, there is no known comprehensive systematic review on the harms and benefits of administering the medication to the young patients.  Previous reviews have bias or contain flaws, thus, this research study agrees to use guidelines following the Cochrane Handbook and PRISMA guidelines.  Full texts of randomized clinical trials that compared methylphenidate with or without a placebo in the age range of about 3 to 18 years were selected.  Pharmaceutical companies were contacted for additional information.  Primary outcomes included serious adverse effects and symptoms of ADHD, while secondary outcomes included non-serious adverse effects.  No patients were involved in the study.  The data was extracted from the trials by reviewers and the authors were contacted for more information.  The dose of methylphenidate, design of trials, bias, sex of participants, type of ADHD, and other factors were analyzed in the clinical trials.  Concerning quality of evidence, the potential levels of bias associated with the trials evaluated.

Out of 14,431 records, 761 of the publications were included in this review.  In the results, a high possibility of bias was found in most trials due to the passion, failure of full coverage blinding, choosy in reporting data, etc.  Thus, although many of the outcomes suggest that methylphenidate shows benefits, this cannot be deemed as a true conclusion due to the high risk of bias associated with many trials.  Conclusions show that symptoms associated with methylphenidate may be improved and may not cause increase serious adverse effects.  However, methylphenidate may result in a high risk of non-serious adverse effects, such as decreased appetite and sleep problems.

I hope to see a future trial that has little risk of bias, which accounts for all the adverse effects that occur as a result.  This could help with children and adolescent patients who are currently diagnosed with ADHD and could potentially unveil that they are not receiving the benefits that they believe they are supposed to receive.

BMJ. 2015 ; 351(5203): .


Antidepressants may double the risk of aggression and suicide in children

It is has been researched that suicidal behavior may be increased with children aged <18 who take popular antidepressants such as SSRIs and SNRIs, however, few systemic research has been done to correlate the effects of aggressive behavior with popular antidepressants.  This systematic review and meta-analysis was conducted to analyze the mortality, suicidality, aggression, and akathisia associated with five popular antidepressants—duloxetine, fluoxetine, paroxetine, sertraline, and venlafaxine—using clinical study reports.  Akathisia is an extreme state of restlessness, agitation, and distress that can increase the risk of suicide and violence. No patients were involved in the study.  The methods included obtaining clinical study reports from the European Medicines Agency and Modern Humanities Research Association.  Out of the 198 clinical study reports, only 68 were used.  Using the reports that contained double bind placebo controlled trials and patient narratives, primary outcomes (mortality and suicide) and secondary outcomes (aggressive behavior and akathisia) were assessed by searching for specific terms, such as those used by the FDA.

Quality of the clinical study reports were varied, such as the number of trials conducted and the length of the study designs.  The results of the study showed that 16 deaths occurred in adults, and 155 suicidality events occurred with an odds ratio in children and adolescents doubled to that in adults.  The odds ratio for children and adolescents was also double that to adults for aggressive behavior.  The odds of akathisia were roughly the same for both adults and children and adolescents.  Thus, the data from this study shows that there is indeed an increased risk of suicide in children and adolescent taking antidepressants.  However, the study also found that there was a significant increase in aggressive behavior in children and adolescents.  This was a comprehensive review of randomized controlled trial data and is the first to note this finding of increased aggressive behavior.

My questions posed to colleagues are: Do you feel that this is a significant, valuable finding, despite the limitations in the research study?  Do you feel that this information could benefit pharmacists, and if so, how?

BMJ. 2016; 352(65): .


How Oregon Pharmacists Are Prescribing Birth Control

As of January 1st, 2016, in Oregon, it is now legal for pharmacists to prescribe birth control, and among these birth control methods include patches and the pill.  After attending a training course , pharmacists can prescribe to women aged 18 or older and to women younger than 18 if they had previously received a prescription from a doctor.  How this system works is that the female patient will complete a health questionnaire at the pharmacy and get their blood pressure checked.  Questions include history of diseases, smoking, blood clots, etc.  After the pharmacist evaluates the form and no problems are found, oral contraceptives may be prescribed.  Based off of a study published in the Journal of the American Pharmacist Association, the questionnaire was developed from trying to establish a drug therapy protocol through prescribing methods by community pharmacists.  As a result of this study showing high satisfaction and continuation, it showed that pharmacists were capable of prescribing birth control to patients.

Although California has passed a similar law, Oregon is currently the only state that has implemented the law to allow pharmacists to prescribe birth control.  I feel that this is a big step in expanding the profession of pharmacy.  Not only will this allow for a more collaborative future for the pharmacy profession but will more importantly lead to patients having an easier direct access to contraceptive health care.  In the future, I hope to see more states pass and implement laws similar to this.

Pharm Times. 2016.