Journal of Pharmacy Practice current issue

Introduction: Topics in Internal Medicine

Tue, 20 Oct 2009 17:17:20 PDT

Recent Advances in Pharmacotherapy

Kemp, D. W., Brown, J. N. — Tue, 20 Oct 2009 17:17:20 PDT

Many unique and clinically important medications were approved by the Food and Drug Administration from December 2007 through May 2008 for various conditions encountered in an internal medicine setting. These new treatments dramatically vary in their targeted body system and include agents for the cardiovascular system (nebivolol), central nervous system (desvenlafaxine), gastrointestinal tract (certolizumab, methylnaltrexone, and alvimopan), immunological function (etravirine), and metabolic function (sapropterin). This article discusses medications by their respective body system. Each review is comprised of an overview of the Food and Drug Administration–approved indication and the drug’s role in treatment of that disease state. Current dosing guidance, clinical efficacy and clinically relevant adverse drug reactions, drug interactions, contraindications, and precautions are also presented. This review is designed to focus on the new molecular entities and biological approvals clinicians may potentially encounter in an internal medicine practice.

Hyperglycemia Management in Non-critically Ill Hospitalized Patients

Arnold, L. M., Keller, D. L. — Tue, 20 Oct 2009 17:17:20 PDT

There is increasing evidence demonstrating negative consequences and poor clinical outcomes associated with untreated hyperglycemia in hospitalized patients. Data in specific patient populations, primarily critically ill patients, demonstrate improved patient outcomes with tight glycemic control. To date, no clear evidence exists to determine optimal glycemic targets in non-critically ill patients; however, experts agree that better glycemic control in hospitalized patients is warranted. Glycemic control is complicated by numerous factors in hospitalized patients including increased circulating stress hormones, changing nutritional status, and administration of medication therapies that contribute to hyperglycemia. In addition, fear of hypoglycemia among health care providers, a commonly cited barrier, contributes to the failure to adopt more intensive insulin regimens. Current practice trends have proven ineffective and major changes are needed. Some of those trends include the use of sliding scale insulin, continuation of oral agents or combination insulins upon admission, and provider reluctance to initiate insulin in patients not receiving insulin prior to admission. With proper education, safe and effective use of insulin can be used during hospitalization to improve glycemic control. The following article reviews the benefits of glycemic control, identifies barriers to achieving glycemic control, and describes strategies for health care providers and institutions to realize glycemic control in medically ill hospitalized patients.

Metabolic and Cardiac Side Effects of Second-generation Antipsychotics: What Every Clinician Should Know

Breden, E. L., Liu, M. T., Dean, S. R. — Tue, 20 Oct 2009 17:17:20 PDT

In 2007, 5 of the 7 second-generation antipsychotics were listed in the Top 200 Drugs prescribed by retail sales in the United States. Cardiovascular disease is the leading cause of natural death in individuals with schizophrenia. Second-generation antipsychotics have been implicated with metabolic and cardiovascular adverse effects, and it is important for nonpsychiatric practitioners to be familiar with the monitoring parameters recommended for these agents. This article discusses the risk of weight gain, hyperglycemia, hyperlipidemia, hyperprolactinemia, and cardiovascular concerns associated with second-generation antipsychotic agents. It also discusses the proposed mechanisms for each of these adverse effects. Furthermore, it reviews suggested monitoring parameters to help manage cardiovascular disease in this patient population, and to improve the gap that exists between mental health care and physical health care in the schizophrenic population.

Psychosis From Anticholinergic Medications Administered at a Smoking Cessation Clinic

Minton, J. A., Tofade, T. S., Shah, S. A. — Tue, 20 Oct 2009 17:17:20 PDT

Anticholinergic medications are used for a variety of reasons, from their effects on the central nervous system to their effects on the gastrointestinal tract. They are used in the treatment of Parkinson’s disease, vertigo, gastroesophageal reflux disease, and peptic ulcer disease. They have also been used in the treatment of motion sickness. These medications must be used with caution due to their effects on other systems, including the central nervous system. Common central nervous system side effects due to anticholinergic medications include sedation, delirium, amnesia, and in the case of the patient presented in this report, psychosis. A 61-year-old man presented to the emergency department with visual and auditory hallucinations secondary to anticholinergic medications (scopolamine and atropine) he received in a smoking cessation clinic. Previous cases of anticholinergic medication–induced psychosis are also summarized.

Caring for the Elderly in an Inpatient Setting: Managing Insomnia and Polypharmacy

Kim, J., Tofade, T. S., Peckman, H. — Tue, 20 Oct 2009 17:17:20 PDT

Caring for the elderly in an inpatient setting can be difficult because of the lack of literature to provide clinical guidelines addressing issues in this population. Insomnia and polypharmacy are common concerns. This article addresses these concerns by highlighting key points from the available literature. Insomnia may be a problem in the elderly because of their increased sensitivity to changes in environment among other factors. First, obtain a sleep history and a comprehensive medical and medication history to identify the cause. Next, treat the underlying cause with nonpharmacological interventions to restore restful and qualitative sleep. When nonpharmacological interventions are not successful, pharmacological means are indicated. Remember to start low, go slow, and treat for a short duration of time (less than 4 weeks) to avoid withdrawal or rebound insomnia. First-line agents are trazodone, triazolam, temazepam, and lorazepam followed by zaleplon and zolpidem. As people age, it is common for them to have multiple chronic comorbidities, which may result in polypharmacy and an increased risk of adverse events. Clinical practitioners should identify and prevent potential complications of polypharmacy. This should prevent further hospitalizations, decrease health care costs, and ultimately improve the quality of care in the elderly.

Continuing Education: Caring for the Elderly in an Inpatient Setting: Managing Insomnia and Polypharmacy

Tue, 20 Oct 2009 17:17:20 PDT

Interventional Case Series: Angiotensin-Converting Enzyme Inhibitor (ACE-I)-Induced Cough: Is Rechallenge With a Second ACE-I Worthwhile?

Herner, S. J., Kinikar, S. A., Miyashiro, L. A., Billups, S. J. — Tue, 20 Oct 2009 17:17:20 PDT

Angiotensin-converting enzyme inhibitors (ACE-Is) are a cornerstone of therapy with proven morbidity and mortality benefit in many disease states. The unpredictable, bothersome cough that occurs in 15% to 41% of patients oftentimes leads to noncompliance or discontinuation. Management of ACE-I-induced cough remains controversial. The authors’ objective was to determine whether patients experiencing an ACE-I-induced cough could be successfully switched to a different ACE-I without recurrent cough. A total of 10 participants deemed to have ACE-I-induced cough were enrolled in an interventional case series to assess whether they could tolerate rechallenge with an alternative ACE-I. During phase 1, ACE-I therapy was stopped for up to 4 weeks to allow the cough to resolve. During phase 2, participants were rechallenged with an alternative ACE-I and followed for 4 months. Of the 10 participants who consented to enroll, 6 were rechallenged with a second ACE-I. Cough recurred in 4 of these within 1 week (5-7 days), whereas 2 participants continued ACE-I therapy cough-free. Results suggest that a small percentage of patients with ACE-I-induced cough tolerate an alternative ACE-I. For patients with a true ACE-I-induced cough who are motivated to continue an ACE-I, a trial of a second ACE-I may be worthwhile.

A Practical Approach for Training Pharmacists and Pharmacy Students to Prevent Disease by Immunizations

Tue, 20 Oct 2009 17:17:20 PDT

Immunization provides an important means for preventing communicable diseases. In recent years, administering immunizations has become part of contemporary pharmacy practice. Some view pharmacist-administered immunizations as a significant advance in the practice of pharmacy for providing care to patients. In Ohio, pharmacists may administer immunizations and pharmacists are not required to notify the patient’s physician or the local health department. There is a need for pharmacy students to obtain immunization certification so they are prepared for practice in the pharmacies of today. Including a training program for pharmacy students as immunizers is consistent with the American Association of Colleges of Pharmacy Center for the Advancement of Pharmaceutical Education Educational Outcomes 2004. The objective of this article is to describe an immunization certification program for pharmacists and pharmacy students based on the requirements of Ohio Law and guidelines of the Centers for Disease Control and Prevention. Program structures for certification programs for pharmacists and pharmacy students are described and include an immunology review, a review of specific immunization medications, a review of aseptic technique, administration techniques, proper disposal procedures, accidental needle sticks, and basic life support training. Teaching methodologies are identified and methods of assessment for mastery of the course elements are listed.

The Necessity of Considering Serotonin Toxicity as a Differential Diagnosis for NMS-Like Symptoms

Tue, 20 Oct 2009 17:17:20 PDT

President's Message: The Surprise Beneath the Surface

Powell, V. — Tue, 20 Oct 2009 17:17:20 PDT

Members in the News

Tue, 20 Oct 2009 17:17:20 PDT