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Possible Acute Thrombocytopenia Post Esomeprazole and Hydantoin Coadministration

Ranzino, A. M., Sorrells, K. R., Manor, S. M. — Fri, 18 Sep 2009 11:37:05 PDT

Thrombocytopenia, defined as a platelet count less than 150 000/µL, occurs as a result of decreased production, sequestration, or peripheral destruction. Drug-induced thrombocytopenia is a clinically important adverse drug event involving many drugs including hydantoins. This report details an acute reaction of thrombocytopenia in a 55-year-old, critically ill, African American male patient after receiving a loading dose of fosphenytoin and a subsequent dose of IV phenytoin. The patient presented with an intracranial hemorrhage with hematoma and a blood pressure of 204/143 mm Hg. A fosphenytoin load infused for seizure prophylaxis and the first dose of a phenytoin maintenance regimen were followed by episodes of hypotension. In response to the hypotension, phenytoin was discontinued. On hospital day 2, the patient’s platelet count had dropped dramatically from the morning before, 150 000 to 28 000/µL. The platelet count subsequently returned to baseline within 7 days of phenytoin discontinuation. The proposed cause of phenytoin-induced blood dyscrasias is direct or hapten-mediated toxicity by an arene oxide intermediate metabolite. Most documented cases of thrombocytopenia occur after a week or longer of phenytoin administration with the coadministration of glucocorticoids and cimetidine or proton pump inhibitors. An immediate decrease in platelets as seen in this case has not been previously described in the literature. Such a rapid induction of thrombocytopenia from phenytoin is suggestive of a direct cytotoxic effect on circulating platelets.

Asymptomatic Bradycardia Possibly Associated With Travoprost Therapy

Yamreudeewong, W., Dell, A. A., Pulley, K. R., Stepp, P. D. — Mon, 31 Aug 2009 09:40:43 PDT

Travoprost (Travatan^®), a prostaglandin ophthalmic solution, is a second-line therapy for open-angle glaucoma, according to the Clinical Practice Guideline of the American Optometric Association. Recently, travoprost has been used as a first-line therapy in many patients because of its effectiveness and a once-daily dosing. It lowers the intraocular pressure by enhancing the aqueous humor outflow. Based on the product information, adverse effects such as ocular hyperemia, eye pain, pruritus, and bradycardia have been associated with travoprost therapy. Significant bradycardia is defined as heart rate or pulse of less than 60 beats per minute. We report on an 87-year-old man who experienced asymptomatic bradycardia while using travoprost ophthalmic solution. The pulse in our patient ranged from 42 to 50 beats per minute while receiving travoprost therapy during his hospitalization. Travoprost ophthalmic solution was discontinued because it was thought to be the likely cause of significant sinus bradycardia in our patient. After travoprost discontinuation, the average pulse of the patient was 66 beats per minute. Based on Naranjo’s Scoring System (an objective tool) for assessing the likelihood of drug-induced adverse effects, the score of 3 was obtained, which indicated a "possible" adverse effect. To our knowledge, this is the first case report about significant bradycardia possibly associated with travoprost therapy.

Marked Transaminase Elevations and Worsening Glycemic Control Associated With Counterfeit Polyherbal Use in a Patient With Diabetes

Henyan, N. N., Riche, D. M., Pitcock, J. J., Strickland, D. C. — Mon, 03 Aug 2009 10:23:20 PDT

Dietary and herbal supplements, a US$20.3 billion entity, are used by more than half of the adult population in the United States. Since weight loss is beneficial in obese patients at high risk for cardiovascular disease, many obese Americans are ingesting herbal weight loss supplements under the assumption that they are inherently safe. We report the case of a 55-year-old morbidly obese Caucasian female with diabetes, who started multiple polyherbal supplements. Six months after starting several herbal products, the patient’s A1C increased from 7.8% to 9.4% and the AST/ALT were markedly elevated. After discontinuation, transaminases normalized in 28 days. On follow-up visit, the patient reported compliance with prescribed medications and denied use of herbal products. The patient’s A1C approached target goal. The potential for counterfeit herbal supplement production exists. Our patient’s products were analyzed for purity, and 0% Hoodia gordonii was found. A misconception of herbal products is that they are safe because they are natural. Unfortunately, many natural products can act in the same capacity as drugs, educing both benefit and harm. Health care providers, particularly pharmacists, should be aware of counterfeit herbal supplements and closely monitor for dangers of herbal supplement use.

A Review of Pharmacist Contributions to Diabetes Care in the United States

Armor, B. L., Britton, M. L., Dennis, V. C., Letassy, N. A. — Thu, 28 May 2009 11:14:17 PDT

This paper summarizes the outcomes associated with pharmacist involvement in diabetes care in all pharmacy practice settings. Published literature was identified through a search of MEDLINE (1960 to September, week 1, 2008) and International Pharmaceutical Abstracts using the search terms "pharmacist," "pharmaceutical care," and "diabetes mellitus." Only articles reporting clinical or behavior change outcomes were selected for review; papers written outside the United States and citations only in abstract form were not reviewed. The specific data extracted included the following: practice setting, model of care, roles of the pharmacist, study design, number of patients studied, duration of the evaluation, and documented outcomes such as changes in hemoglobin A_1c values, adherence to standards of care (lipids, blood pressure, eye exams, foot exams, aspirin use), and changes in quality of life. The greatest improvements in hemoglobin A_1c values tend to be observed when pharmacists work in collaborative practice models. Growing evidence demonstrates that pharmacists, working as educators, consultants, or clinicians in partnership with other health care professionals, are able to contribute to improved patient outcomes.

Web Site Review: www.aspergers.com

Bokor, G., Anderson, P. D. — Fri, 22 May 2009 12:44:48 PDT

Evaluating the Validity and Reliability of a Modified Survey to Assess Patient Satisfaction With Mail-Order and Community Pharmacy Settings

Pinto, S. L., Sahloff, E. G., Ramasamy, A. — Fri, 10 Apr 2009 09:46:17 PDT

The level of patient-pharmacist interactions and services provided varies across different distribution methods and could affect patient satisfaction with services. Determining patient satisfaction with these medication distribution methods is important for improving care of chronic disease patients. This study evaluated the validity and reliability of a modified survey to assess patient satisfaction with mail-order and community pharmacy settings. Exploratory cross-sectional design using a convenience sample of HIV-infected patients at a university clinic was used. Satisfaction scale was modified from previously validated instrument resulting in 21 items on the final survey. Data collection occurred for 7 months, and 178 surveys were completed. An exploratory factor analysis was conducted using principal components and varimax rotation. Reliability and item analyses were conducted. Factor analysis resulted in a 2-factor solution, namely "satisfaction with the efficient functioning of the pharmacy" and "satisfaction with the managing therapy role of the pharmacist," respectively. Cronbach’s alpha for factors 1 and 2 with mail-order were .951 and .795, for independent were .977 and .965, and for chain were .841 and .823. The study provides a valuable tool to assess patient satisfaction with pharmacy services provided through different distribution methods.

Web Site Review: Armed Forces Radiobiology Research Institute (www.afrri.usuhs.mil)

Anderson, P. D. — Mon, 06 Apr 2009 13:20:18 PDT

Suspected Neuroleptic Malignant Syndrome During Quetiapine-Clozapine Cross-Titration

Stoner, S. C., Berry, A. — Tue, 24 Mar 2009 13:03:37 PDT

Neuroleptic malignant syndrome (NMS) is a physiologic phenomenon that has been associated with the use of both first- and second-generation antipsychotics resultant to their ability to block dopamine blockade in the basal ganglia and hypothalamic regions of the brain. The typical reaction involves the presentation of muscle rigidity, changes in mental status, temperature elevation, labile blood pressure, and elevations in creatinine kinase and white blood cell counts. The reaction is most often reported early in the course of therapy but is well documented to have the potential to occur at any point in time. Untreated NMS can be fatal, often from secondary causes such as deep venous thrombosis and pulmonary embolism. Treatment involves immediate discontinuation of the offending agent, supportive therapy of clinical symptoms, and may include the use of the skeletal muscle relaxant, dantrolene sodium, or the dopaminergic agents bromocriptine or amantadine. In this case, we present a patient who developed symptoms of NMS during the cross-taper and conversion from quetiapine to clozapine. The patient was treated for NMS; however, his clinical diagnosis was never able to be definitively determined as he was initially evaluated for septicemia and later treated for suspected bacterial infection with antibiotics, and clozapine-associated side effects cannot be ruled-out as a contributing source to the clinical presentation. The estimated Naranjo Scale score for this case report is 3.

Case Report of SIADH Associated With Escitalopram Use

Koski, R. R., Covyeou, J. A., Morissette, M. — Mon, 23 Mar 2009 09:29:32 PDT

The authors report a case of syndrome of inappropriate antidiuretic hormone (SIADH) associated with the use of escitalopram in an elderly female patient. A 97-year-old white female was admitted to the hospital for a suspected vertebral fracture and hyponatremia. Her serum sodium concentration was 113 mEq/L (113 mmol/L) at admission. She was started on escitalopram 5 mg daily 1 week prior to admission for anxiety. During admission, her laboratory tests revealed serum hyponatremia and hypo-osmolality and urine hyperosmolality and hypernatremia. Her escitalopram was stopped, and she was diagnosed with syndrome of inappropriate antidiuretic hormone. She was treated with hypertonic (3%) saline. She was discharged 1 week later with a serum sodium concentration of 121 mEq/L (121 mmol/L). There have been hundreds of case reports of SIADH associated with selective serotonin reuptake inhibitors (SSRIs), including 5 cases associating escitalopram with syndrome of inappropriate antidiuretic hormone. The median time to onset of SIADH after initiating SSRIs is approximately 2 weeks. Risk factors include advanced age, concomitant diuretic use, low baseline sodium, and low body mass index. Treatment options include fluid restriction, normal saline, diuretics, hypertonic saline, and discontinuing the SSRI. The authors conclude that elderly patients receiving escitalopram or other SSRIs should be monitored carefully for SIADH in the first couple of weeks of treatment and with dose increases, especially if other risk factors are present.

Diabetic Kidney Disease: A Renin-Angiotensin-Aldosterone System Focused Review

Hite, P. F., DeBellis, H. F. — Fri, 20 Mar 2009 09:03:56 PDT

Diabetic nephropathy, also referred to as diabetic kidney disease, is a multifaceted complication of one of the largest epidemics in the United States. Diabetic patients currently represent approximately 8% of the US population. Aggressive screening and control of diabetes, hypertension, and dyslipidemia as well as dietary protein restriction are vital to the prevention and management of diabetic kidney disease. Because there are no direct pharmacologic options for diabetic kidney disease, treatment is focused on controlling comorbidities that exacerbate the development and progression of diabetic kidney disease. This article will provide an overview of structural renal alterations during the progression of diabetic kidney disease as well as a concise review of current diabetic kidney disease management guidelines with a focus on agents that affect the renin-angiotensin-aldosterone system. At this point in time, the mainstays of therapy are angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. More research is currently needed to determine if renin inhibitors will have an active role in the management of diabetic kidney disease.

Preparing Future Pharmacists for Diabetes Management

Thurmon, T. B., Schwartz, L. L. — Fri, 20 Mar 2009 09:03:56 PDT

The Integrated Pharmacy Skills laboratory is a laboratory-based approach to many different aspects of pharmacy education. As diabetes is one of the most common disease states in the United States, it is a primary focus of the educational experience at South University School of Pharmacy. The laboratory experience at South University School of Pharmacy includes the application of diabetes management in a hospital setting, a community setting, and a clinic setting. The class has been developed for the first professional year of a 3-year professional curriculum. Laboratory exercises include calculations, case studies, intravenous preparation, assessment tools, and patient-counseling exercises. The Integrated Pharmacy Skills laboratory provides a practical experience for teaching our future pharmacists about diabetes and diabetes management.

Treatment Considerations for Diabetes: A Pharmacist's Guide to Improving Care in the Elderly

Nicholas, A. S., Nadeau, D. A., Johnson, C. L. — Wed, 18 Mar 2009 09:23:53 PDT

The management of diabetes in elderly patients has many nuances that are important to the pharmacist, regardless of his or her practice setting. General guidelines and treatment modalities applied to the younger population cannot necessarily be applied to the elderly population and in most cases, should be tailored to meet their needs. The purpose of this article is to gain a better understanding of the complex nature of diabetes and management in the elderly by (1) reviewing the pathogenesis and pathophysiology of diabetes in the patients, (2) understanding complications and geriatric syndromes that may affect management of diabetes, (3) becoming familiar with nationally accepted diabetes care guidelines in the elderly, (4) reviewing recent literature pertaining to management of diabetes, and (5) reviewing medications (including newer agents) to treat diabetes in the elderly.

Understanding ADA Education Program Recognition and the Pharmacist's Role

Divine, H. S. — Mon, 16 Mar 2009 08:56:11 PDT

Diabetes is a prevalent chronic disease with costly humanistic and clinical outcomes. Pharmacists have proven their value in the provision of diabetes education and management services that lead to improvement in disease. A primary barrier to pharmacists’ providers has been compensation for services. Although pharmacists are not recognized as providers by most nationally recognized payers, pharmacists can serve as instructors through diabetes self-management education programs accredited by the American Diabetes Association. These accredited programs are recognized by Medicare and can receive payment for diabetes self-management education services. Newly revised national standards have further recognized the role of a pharmacist educator and have made it more attainable for pharmacies to achieve program recognition status.

Enteral and Parenteral Nutrition for the Diabetic Patient: A Case-Based Approach

McKeever, A. L., Fetterman, J. W. — Thu, 12 Mar 2009 11:19:54 PDT

Patients’ nutritional status is essential to ensure beneficial outcomes. However for the diabetic, the caloric energy required is not only sustaining but problematic if not managed appropriately. Uncontrolled hyperglycemia places these patients at risk of complications such as infections, neuropathy, and retinopathy. Health care providers can assist in tailoring nutritional support for diabetic patients. Possible interventions include adjusting caloric requirements to minimize carbohydrates and maximize fat as a main calorie substitute and to suggest appropriate macronutrient sources. Other disease state complications such as diabetic-associated nephropathy and gastroparesis affect nutritional support and present opportunity for further interventions. Diligence regarding blood glucose monitoring is imperative. Additional anti-diabetic therapies can be used to maintain tight glucose control; however, close monitoring must occur to minimize hypoglycemic episodes, which can be life-threatening.

Practical Use of Exenatide and Pramlintide for the Treatment of Type 2 Diabetes

Meade, L. T. — Thu, 12 Mar 2009 11:19:54 PDT

Type 2 diabetes is a progressive disease that affects more than 20.8 million Americans. Traditional antihyperglycemic therapy can cause weight gain and hypoglycemia in this population. Research shows that type 2 diabetic patients have low levels of glucagon-like peptide-1 and amylin. This discovery led to the creation of 2 newer agents, exenatide and pramlintide. Exenatide, a glucagon-like peptide-1 agonist, stimulates insulin secretion, suppresses glucagon secretion, and slows gastric motility. Transient nausea is the most common side effect, which can be minimized with slow titration. Weight loss associated with exenatide is between 0.9 and 2.8 kg. Hypoglycemia occurs more frequently when exenatide is used with a sulfonylurea. There are some case reports of pancreatitis in patients taking exenatide. Pramlintide, a synthetic form of amylin, inhibits the postmeal rise in glucagon, slows gastric emptying, and promotes satiety. Common side effects of pramlintide include transient nausea, headache, and modest weight loss (1.6 kg). Exenatide and pramlintide are contraindicated in patients with gastroparesis. The success of therapy with both agents is enhanced with slow titration to minimize nausea and patient counseling. Exenatide and pramlintide offer improved postprandial control with the potential for weight loss in patients with type 2 diabetes.

Complementary and Alternative Medicines for the Treatment of Diabetes

Tackett, K. L., Jones, M. C. — Tue, 10 Mar 2009 09:34:54 PDT

There is a growing interest among diabetic patients in the role of complementary and alternative medicine (CAM) in controlling blood sugar and prevention of complications. It is being used among diabetic patients in addition to usual medical treatment and lifestyle modifications. Complementary and alternative medicine products are marketed for the treatment of diabetic complications and lowering of blood glucose, but the actual therapeutic role remains controversial due to lacking information regarding safety and efficacy. The majority of evidence for the use of CAM is as an adjunctive therapy to the patient’s current diabetic regimen. Trials have shown CAM to be effective for diabetes treatment, but further rigorous study is needed to establish safety, efficacy, and the exact mechanism of action. As the use of CAM increases among the diabetic population, there is a need for patients to communicate with health care professionals to educate them about the safety and efficacy of alternative therapy.

Diabetes-Related Medication-Induced Hypoglycemia

Tackett, K. L., Lancaster, C. S. — Tue, 10 Mar 2009 09:34:54 PDT

Hypoglycemia is a common adverse event in patients with both type 1 and type 2 diabetes and may be a barrier to patients achieving tight glycemic control. It is diagnosed either biochemically, as a blood glucose value, or clinically based on symptoms caused by an autonomic response to changes in blood glucose. Patients that experience repeated episodes of hypoglycemia lose the counterregulatory response that produces symptoms and results in hypoglycemia unawareness. Medications account for the most frequent cause of hypoglycemia in both the inpatient and outpatient setting. Treatment of hypoglycemia may be accomplished via the oral or parenteral route with 15 to 20 g of carbohydrate. Following treatment of the episode, it is important to evaluate for the cause and, if medication related, adjust the patient’s treatment regimen.

Infectious Disease Concepts and Considerations in the Diabetic Patient

Schwartz, M. D., Kincaid, S. E. — Tue, 03 Mar 2009 15:52:53 PST

Diabetic patients present their providers with unique clinical challenges when dealing with prevention and treatment of infectious diseases. By the very nature of their diabetes, these patients are at much higher risk of complications from seemingly benign infections as well as increasingly susceptible to more resistant or invasive disease. Targeted prevention where possible, regular follow-up, and early, aggressive treatment are crucial to diabetic patients’ longevity and quality of life. This review will focus on key vaccine-preventable issues as well as management of common conditions such as urinary tract infection and skin and soft tissue infection often seen in diabetic patients.