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.

 

http://www.uspharmacist.com/content/d/pharmacy_focus/c/59395/

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.

 

http://www.uspharmacist.com/content/d/feature/c/59340/

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

 

New Drug to Prevent Heart Failure

In the event of a myocardial infarction or another related episode concerning one’s cardiovascular health, it is common for an angiotensin converting enzyme inhibitor to be prescribed in addition to a beta adrenergic blocker, and a diuretic or aldosterone antagonist. In place of an ACE inhibitor an angiotensin II receptor blocker (ARB) may be prescribed. However, a new class of drug is being studied that may become an additional team player in the fight against cardiovascular disease.

Sacubitril is a prodrug which is converted to LBQ657 by esterases in the body. This metabolite is a neprilysin inhibitor. Neprilysin is an endopeptidase that can degrade peptides that are responsible for regulating actions in the blood vessels. This can lead to vasoconstriction and increased sodium retention. Thus, sacubitril would work to reduce vasoconstriction and sodium retention.

So far the formulation of this drug has been only in a form coupled with valsartan; it has not been administered as the single drug, sacubitril. It was administered to 8,400 patients with symptomatic heart failure and a left ventricle ejection of 40% or lower. The patients involved had been treated with an ACE inhibitor and a beta adrenergic blocker for at least 4 weeks. Many of the patients were also taking a diuretic. The rate of cardiovascular deaths for those taking sacubitril was 13.3% which was considered significantly lower than that of those taking the ACE inhibitor, enalapril, which was 16.5%.

Thus there is reason to believe that sacubitril, and other drugs from this class of neprilysin inhibitors, may account for a new model of first line drug therapy in the treatment of cardiovascular disease.

Reference

Hussar D, Abdelsayed M. Sacubitril/valsartan, ivabradine hydrochloride, alirocumab, and evolocumab. Journ Am Pharm Assoc. 2015; 55(6): 674-78.

J Am Pharm Assoc. 2016; 55(6): 674-678

Prevalence of Excess Sodium Intake in The United States

This article addresses a problem that is facing the United States and is contributing to many health concerns- sodium intake. The National Health and Nutrition Examination Survey found that out of 14,728 people, 89% of adults and over 90% of children had sodium intake over the recommended daily amount, which is 2,300 mg. In addition, for patients with hypertension, 86% of them exceeded the daily dietary sodium intake. Hypertension is a major risk factor for developing cardiovascular disease and is prevalent in about 29% of the United States. Increased sodium consumption can increase blood pressure, and thus cause hypertension, and by reducing sodium intake, people will also reduce their blood pressure and risk for developing cardiac problems down the road. When analyzing why the sodium intake is so high in America, there were some major food sources identified such as breads, deli meats, pizza, soup, meatloaf, and tomato sauce. In order to help combat this problem, the CDC is recommending an decrease in consumption of these foods, an increase in consumption of fruits and vegetables, and is implementing guidelines and recommendations for food manufacturers and restaurants to reduce the sodium content added to their foods.

MMWR Morb Mortal Wkly Rep. 2016; 64(52):1393-1397.

I believe this article is addressing a major problem in our country because “fast food” is heavily relied on for our on-the-go society. These foods are fried, battered, and have high sodium and caloric contents. This high reliance on and intake of sodium is contributing to the growing problem of obesity and heart disease in America. Specifically, this is contributing to the epidemic of hypertension that we see in pharmacies, and in my pharmacy alone, the vast majority of the “fast mover” medications are related to hypertension. I make sure my diet is low in sodium and other food additives, but not everyone has the time or resources to do this. How can we help fix our country’s dependence on sodium-rich foods so that we can target the source of a disease state that affects so many people and requires them to go on so many medications?

Community pharmacist screening for chronic kidney disease

The authors conducted this study as a part of the RxEACH study, which assesses reduction of cardiovascular risk intervention versus usual care as led by pharmacists. This part of the study analyzed pharmacists’ application of the CKD Clinical Pathway criteria (which is an online tool to aid practitioners in diagnosis and management of those with CKD) to screen their patients who are at risk for chronic kidney disease. CKD is defined as a reduction in kidney function with a GFR less than 60 mL/min/1.73m^2 or markers of kidney damage for more than 3 months. Markers of kidney damage includes albuminaria greater than 3 mg/mmol or any abnormalities in urine sediment or renal imaging. The pharmacists systematically identified patient based on their prescriptions (looking for oral hypoglycemic, antihypertensives, lipid-lowering, antiplatelet, and anticoagulants). They also checked the patient’s lab values. Once a patient iss eligible, the patient was screened based on serum creatinine, GFR, and urine albumin-to-creatinine for 12 months. Patients were categorized into the following: no CKD, known CKD, and unrecognized CKD. Of the 720 patients, 60% had known CKD. Forty percent of those with CKD had unrecognized CKD. Overall, the study identified a high number of unrecognized CKD patients, emphasizing the importance of expanding the pharmacist’s role to include laboratory testing and adjusting medication regimens according to those results. Because the study was conducted on patients with a high risk for cardiovascular disease, the results may be higher than in an otherwise healthy population.

Can Pharm J. 2016;149(1):13-17.
I think this study really shows the healthcare world just how important the role of the pharmacist is. We are more than just dispensers. We can optimize a patient’s medication regimen based on the health of their kidneys. Additionally, we can identify patients at risk for chronic kidney disease that a physician may otherwise not have diagnosed. In addition to screening patients for CKD, what other disease may a pharmacist be able to screen for? How can we as student pharmacists advocate for the expansion of the role of the pharmacist to include these screenings at all pharmacy locations?