Journal of Pharmacy Practice recent issues

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

Introduction: Hepatitis

Hemstreet, B. A., MacLaren, R. — Wed, 22 Jul 2009 13:28:18 PDT

Chronic Hepatitis B Infection: Principles of Therapy

Scarsi, K. K., Darin, K. M. — Wed, 22 Jul 2009 13:28:18 PDT

Chronic hepatitis B is a global health concern in many resource-limited settings due to perinatal or pediatric hepatitis B virus transmission. In the United States, pediatric infection has been virtually eliminated due to maternal screening during pregnancy and the availability of an effective vaccine. However, young adults remain an at-risk group for hepatitis B virus infection due to sexual transmission and injection drug use. The frequency of progression from acute hepatitis B virus infection to chronic hepatitis B infection depends on multiple factors, including host immune function and age at time of hepatitis B virus infection. Fortunately, there are 7 currently approved therapies for chronic hepatitis B infection, and several emerging therapies that show promise. Despite the availability of these agents, many clinical questions still surround chronic hepatitis B therapy including when to start therapy, which agent is ideal for first and second line therapy, the appropriate duration of therapy, and the role of combination antiviral therapy. This review focuses on agents available for chronic hepatitis B management, including pharmacology, safety and efficacy data, monitoring parameters, and the role for each in chronic hepatitis B therapy in adult patients.

Nonviral Hepatitis

Wilbur, K. — Wed, 22 Jul 2009 13:28:18 PDT

Chronic liver diseases are a significant cause of death worldwide. Cirrhosis is most frequently caused by hepatitis C or alcohol abuse, but other nonviral etiologies are now recognized as important contributors to the development of hepatitis. Nonalcoholic fatty liver disease, caused by abnormal accumulation of lipids in hepatocytes, can progress from simple steatosis to necroimflammation and cirrhosis. It is estimated to occur in up to 40% of the general population, and its pathophysiology is closely linked to features of metabolic syndrome. There is currently no proven treatment for nonalcoholic fatty liver disease. Management strategies largely address identification and treatment of associated risk factors and include drug therapy for obesity, insulin resistance (eg, metformin, thiazolidinediones), and dyslipidemia (eg, fibrates, HMG-CoA reductase inhibitors). Autoimmune hepatitis is characterized by necroinflammation mediated by autoantibody attack against liver antigens in genetically predisposed patients. It is considered a rare form of chronic liver disease but can progress to cirrhosis if unrecognized and untreated. Autoimmune hepatitis usually responds well to long-established immunosuppressive regimens with prednisone and azathioprine; however, new approaches are required for those patients who do not achieve or sustain desired outcomes or are intolerant to standard therapy.

Trends in the Treatment of Chronic Hepatitis C Virus Infection

Kiser, J. J. — Wed, 22 Jul 2009 13:28:18 PDT

Despite reductions in the incidence of new hepatitis C virus infections, infections from previous decades continue to place a substantial burden on our health care system. Although the course of the disease is highly variable, approximately 20% to 30% of patients develop cirrhosis, end-stage liver disease, or hepatocellular carcinoma. Fortunately, treatment with our current standard of care, peginterferon a and ribavirin, can reduce the complications of chronic liver disease. However, these drugs are associated with significant adverse effects, many patients are ineligible for treatment, and only 50% are cured. Thus, there is a tremendous need to improve our current therapies and develop new compounds for this disease. This review highlights the transmission, pathophysiology, and course of illness; the pharmacokinetics, proposed mechanisms of action, adverse events, and potential drug interactions with peginterferon a and ribavirin; current treatment trends; the role of the pharmacist in the treatment of this disease; and investigational drugs in later stages of clinical development. Despite the initial hope that these new drugs would replace our current standard of care, it has become clear that ribavirin and peginterferon a will continue to play an important role in the treatment of chronic hepatitis C virus in the years to come.

Continuing Education Test Questions

Wed, 22 Jul 2009 13:28:18 PDT

Simvastatin- and Fluvastatin-Associated Nightmares

Wood, R. L., Cummins, D. F. — Wed, 22 Jul 2009 13:28:18 PDT

The authors present a case of nightmares induced by the 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors simvastatin and fluvastatin. A 79-year-old Caucasian male initially treated with simvastatin 10 mg every evening developed nightmares after the dose was increased to 40 mg. No relief was provided with a dose reduction to 20 mg, and simvastatin was held. Simvastatin was restarted 7 weeks later at 10 mg, with no complaints of nightmares until the dose was escalated to 20 mg. Simvastatin therapy was subsequently stopped. One month later, fluvastatin 80 mg was initiated and nightmares returned within 3 months, necessitating discontinuation of fluvastatin. The patient was rechallenged with fluvastatin 80 mg, and the nightmares returned 1 month later. Statin therapy was discontinued, and the patient was started on ezetimibe 10 mg. Lipophilic statins such as atorvastatin, lovastatin, and simvastatin have been associated with sleep disturbances. However, lipophilicity may not predict the likelihood of these adverse effects among the statins. Patients prescribed a statin should be counseled on sleep disturbances as potential adverse effects and should be encouraged to notify their providers if these disturbances develop.

Reconstitution of Plenaxis(R) (Abarelix) 100 mg for Injection Is More Effective With a Vortex-Like Mixer Than When Performed Manually

Watters, K., Wragg, G., Van Renen, J. — Wed, 22 Jul 2009 13:28:18 PDT

Abarelix, which is used in the treatment of advanced or metastatic prostate cancer, is supplied in lyophilized (freeze-dried powder) form and needs to be reconstituted to an injectable suspension prior to administration. The advantages of lyophilized forms of medications are their stability and their prolonged shelf-life. Reconstitution to an injectable solution, however, takes time and requires training of the health care professionals who administer these drugs. In addition, inadequate dosing may occur if not all the powder is reconstituted. Development studies of abarelix have shown difficulties with its reconstitution in certain centers, with a proportion of the dried powder still remaining in the used vials. These difficulties appeared to be center-specific, probably as a result of staff not following the manual reconstitution procedure in a rigorous manner. Patients who had been treated with the vials still containing the undissolved powder may have been underdosed, resulting in an apparently intermittent reduced efficacy of the drug. The present study compares the manual reconstitution of abarelix with mechanical reconstitution using a vortex-like mixer. Our results show that the use of this simple, reusable mechanical device ensures a higher and more consistent mean delivered dose of abarelix, compared with manual reconstitution.

Book Review: Medical-Legal Aspects of Alcohol (4th Edition): Edited by James C. Garriott Lawyers & Judges Publishing Company, Inc. 2003. 452 pages. US$81.27. http://www.lawyersandjudges.com

Dougherty, P. — Wed, 22 Jul 2009 13:28:18 PDT

Erratum

Wed, 22 Jul 2009 13:28:18 PDT

Erratum

Do You Just Belong?

Powell, V. — Wed, 22 Jul 2009 13:28:18 PDT

Introduction: Hepatology

Hemstreet, B. A., MacLaren, R. — Wed, 20 May 2009 10:49:45 PDT

Drug-Induced Liver Disease and Drug Use Considerations in Liver Disease

Kim, J. W., Phongsamran, P. V. — Wed, 20 May 2009 10:49:45 PDT

Chronic liver disease encompasses a large number of hepatic disorders. One of the most important etiologies of liver disease is drug-induced liver disease, which is the leading cause of liver failure in patients referred for liver transplantation in the United States. Drug-induced liver disease can present in all forms of acute and chronic liver disease with highly variable clinical presentations. There is no effective treatment for most drug-induced liver disease and the recognition and prevention of drug-induced liver disease remain the most important management strategy. Drug dosing in patients with liver disease represents an even more challenging task to clinicians, as there is only scant information on biomarkers that can be used to predict the pharmacokinetic changes of drugs in patients with underlying liver disease. Several factors contribute to alterations in drugs metabolism and clearance in cirrhotic patients, including the severity of the liver disease and the metabolic pathways of each individual drug. Only general guidelines on dosage adjustment in patients with hepatic impairment are available. When drugs with extensive hepatic metabolism are required in patients with preexisting liver disease, benefit of therapeutic effect must be evaluated against the risk of toxicity, and the drugs must be initiated with extreme caution with appropriate dosage reduction.

Management of Cirrhosis and Associated Complications

MacLaren, R. — Wed, 20 May 2009 10:49:45 PDT

Liver cirrhosis is the encapsulation or replacement of injured tissue by collagen, resulting in end-stage liver disease and portal hypertension. The consequences of cirrhosis are impaired hepatocyte function, increase intrahepatic circulatory resistance, portal hypertension, and the development of hepatocellular carcinoma. Complications include encephalopathy, coagulopathy, varices, ascites, spontaneous bacterial peritonitis, epatorenal syndrome, and hepatopulmonary syndrome. Managing patients with acute or chronic liver failure is challenging, and liver failure may have profound effects on other organ systems. Most therapies are directed at managing the complications and bridging patients to liver transplantation. The clinician must be aware of the pathologic presentations and the appropriate management, including pharmacologic and nonpharmacologic therapies, goals and end points of therapy, and monitoring of therapy. This review focuses on the management of the complications directly associated with liver dysfunction (encephalopathy and coagulopathy) and portal hypertension (varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome).

Continuing Education Test Questions

Wed, 20 May 2009 10:49:45 PDT

Determining Change in Self-Perceived Knowledge and Skills About Disease/ Medication Therapy Management Programs in P3 Students

Pinto, S. L. — Wed, 20 May 2009 10:49:45 PDT

The study objectives were to determine a change in the self-perceived knowledge and skills of the third-professional year Doctor of Pharmacy students after taking a course on developing, implementing, and evaluating a disease/medication therapy management program. The study used a cross-sectional before-and-after design in which the data were collected once at the beginning of the course and then upon course completion. A self-administered questionnaire that had 4 sections and 36 questions, focusing on self-perceived knowledge and skills was administered. The data were analyzed using SPSS version 14.0. Descriptive statistics, paired sample t tests, and repeated measures analysis of variance were conducted. A total of 95 students completed the pretest, and 69 students completed the posttest. There was an overall increase in average self-perceived knowledge and skills about disease/medication therapy management programs after the students completed the course. Therefore, classes focusing on disease/medication therapy management can significantly increase the knowledge and skills about these programs for the Doctor of Pharmacy students who will soon enter professional careers and be expected to perform these services.

Novel Approaches to the Treatment of Type 2 Diabetes

St. Onge, E. L., Miller, S. A., Taylor, J. R. — Wed, 20 May 2009 10:49:45 PDT

The emergence of the glucoregulatory hormone, glucagon-like peptide-1, has expanded our understanding of glucose homeostasis. The glucoregulatory actions of glucagon-like peptide-1 include enhancement of glucose-dependent insulin secretion, suppression of inappropriately elevated glucagon secretion, slowing of gastric emptying, and reduction of food intake. Two approaches have been developed to potentiate the effects of glucagon-like peptide-1 in those with type 2 diabetes. The glucagon-like peptide-1 analogs, such as exenatide, and dipeptidyl peptidase-IV inhibitors, such as sitagliptin, are currently available whereas others are in the final stages of development. These agents effectively reduce hemoglobin A1c while providing the other benefits associated with increased glucagon-like peptide-1. They also offer the potential to preserve the β-cell function. The effects on cardiovascular disease, if any, are unknown. Based on the current evidence, these agents represent viable second-and third-line options in the management of type 2 diabetes.

The Journey--The New Beginning

Blumenfeld, M. — Wed, 20 May 2009 10:49:45 PDT

Each One Teach One

Powell, V. — Wed, 20 May 2009 10:49:45 PDT

New York State Council of Health-system Pharmacists 2009 Poster Abstracts

Wed, 20 May 2009 10:49:45 PDT

Injuries and the Cost of Falls Among Older Adults--How Pharmacists Can Help

Limona, D. — Wed, 20 May 2009 10:49:45 PDT

Fall-related injuries are a serious public health issue among older adults. In addition to having a significant impact on our economy, these injuries are associated with considerable morbidity. Each year, 1 out of every 3 adults aged 65 and older fall; of these adults, 10% to 20% sustain serious injuries such as fractures or head traumas. Such injuries account for about 6% of medical expenditures for adults 65 years and older. Pharmacist interventions can prevent falls, thereby improving the quality of life of these older adults, preserving their independence, and significantly reducing health care costs.

Letter of Duplicate Publication

Wed, 20 May 2009 10:49:45 PDT

Introduction: Cardiovascular Therapeutics

Olin, J. L., Spooner, L. M. — Mon, 30 Mar 2009 12:28:03 PDT

Macrovascular Complications of Diabetes Mellitus

Nuzum, D. S., Merz, T. — Mon, 30 Mar 2009 12:28:03 PDT

Adults with diabetes mellitus frequently develop macrovascular complications. Vascular disease is a frequent cause of morbidity and mortality among patients with diabetes. Diabetes and vascular diseases remain among the most common causes of death in the United States. A number of clinical trials and practice guidelines have been published addressing the management of macrovascular complications. The cornerstone of preventing or delaying the progression of macrovascular complications of diabetes is aggressive management of hypertension and cholesterol. Angiotensin-converting enzyme inhibitors have proven effective in managing hypertension and avoiding other complications of diabetes. The body of evidence for angiotensin receptor blockers is growing in this area as well. Statins have been repeatedly proven to be the first-line agents in the management of dyslipidemia. Lifestyle modification strategies and antiplatelet therapy also remain essential. This review will focus on the role of newer diagnostic techniques, clinical trial evidence, and appropriate pharmacotherapy for macrovascular complications of diabetes.

Heparin-induced Thrombocytopenia: Pathophysiology, Diagnosis, and Review of Pharmacotherapy

Kanaan, A. O., Al-Homsi, A. S. — Mon, 30 Mar 2009 12:28:03 PDT

Heparin-induced thrombocytopenia is an adverse drug reaction to heparin therapy leading to devastating clinical outcomes including venous thromboembolism, myocardial infarction, stroke, and limb amputation. Heparin cessation alone is not sufficient for the management of heparin-induced thrombocytopenia. Direct thrombin inhibitors, such as argatroban and lepirudin, are considered the mainstay for the management of heparin-induced thrombocytopenia. Case reports support the use of fondaparinux in the management of heparin-induced thrombocytopenia; however, randomized trials are still lacking. This article will review the pathophysiology, clinical presentation, complications, diagnosis, and pharmacotherapy management of heparin-induced thrombocytopenia.

Prasugrel: A New Thienopyridine Inhibitor

Veverka, A., Hammer, J. M. — Mon, 30 Mar 2009 12:28:03 PDT

The objective of this review is to report the pharmacologic and pharmacokinetic properties of prasugrel, the potential advantages and disadvantages over the other agent in its class, clopidogrel, and the clinical data establishing its efficacy in the management of patients with acute coronary syndromes receiving stent implantation. A MEDLINE (1966 to May 2008) search using the key word prasugrel was performed to identify pertinent literature. Additional references were selected from the bibliographies of the articles cited. Searches were not limited by time or human subject. Preclinical studies evaluating the pharmacologic and pharmacokinetic properties of prasugrel in humans were selected for review. Clinical trials assessing the efficacy of prasugrel for the treatment of patients with acute coronary syndromes receiving percutaneous coronary intervention were included as long as they were randomized, blinded, and controlled. The authors concluded that prasugrel is a thienopyridine antiplatelet agent with a faster onset of action and increased potency, in terms of inhibiting platelet aggregation, than clopidogrel. It has been shown in one major clinical trial that this enhanced pharmacological effect of prasugrel reduces the combined incidence of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke when compared with clopidogrel. However, this enhanced effect of prasugrel did result in an increased risk of bleeding.

Pediatric Pulmonary Hypertension: A Pharmacotherapeutic Review

Pesaturo, K. A., Johnson, P. N., Ramsey, E. Z. — Mon, 30 Mar 2009 12:28:03 PDT

Pulmonary hypertension in children is a disorder associated with increased pulmonary vascular resistance and arterial pressure, decreased cardiac output, and right-sided cardiac dysfunction that is caused by numerous etiologies. Although treatment will vary with underlying cause, pharmacological treatment has historically included inhaled nitric oxide and prostacyclin analogues. Over the past several years new agents have been added to the treatment armamentarium, including phosphodiesterase V inhibitors (eg sildenafil) and endothelin antagonists (eg bosentan). Further, more agents are currently under investigation for pulmonary hypertension in children including immunosuppressives and other endothelin antagonist entities. Limitations to treatment include the availability of appropriate, robust pediatric pharmacological data and constraints with dosage forms.

The Benefit and Risk of Antidiabetic Agents Used in Patients With Heart Disease

Cheng, J. W. M., Bhatt, S. H., Goldman-Levine, J. D. — Mon, 30 Mar 2009 12:28:03 PDT

Diabetes increases the risk of cardiovascular diseases. While improving glycemic control has been demonstrated to reduce microvascular complications, the benefits in reducing macrovascular complications have been controversial. This article reviews the published evidence assessing the benefits and risk of antidiabetic agents as related to cardiovascular outcomes. Current literature revealed that metformin and -glucosidase inhibitors are the two agents that have not been associated with any harm in diabetic patients in terms of cardiovascular events. Clinical studies have demonstrated controversial results in the use of insulin, sulfonylureas, and thiazolidinediones and cardiovascular outcomes. However, the results may be affected by other unknown confounders, the comparative agents, and the degree of control of other cardiovascular risk factors. Clinicians should choose antidiabetic therapy based on patient specific parameters such as current glycemic control, and other concurrent disease states such as heart failure.

Continuing Education Test Questions

Mon, 30 Mar 2009 12:28:03 PDT

Successful Clozapine Rechallenge Following Surgical Repair of a Bowel Obstruction

Dahmen, M. M., Stoner, S. C., Khan, R. — Mon, 30 Mar 2009 12:28:03 PDT

As a consequence of its significant anticholinergic properties, constipation is a commonly reported adverse event in patients treated with clozapine. This side effect is often self-limiting and can be managed with high-fiber diets, adequate hydration, and standard over-the-counter and prescription preparations. However, severe cases of constipation can become more serious and may lead to intestinal obstruction, intestinal perforation, fecal impaction, or paralytic ileus. In this particular case, we report on a 44-year-old woman who presented with a suspected clozapine-induced bowel obstruction. Following total abdominal colectomy with ileosigmoid anastomosis, the patient was rechallenged with clozapine and tolerated the titration to a therapeutic dose and maintenance therapy without further incident.

Dispensary to Dispensary--The Critical Progression for Health System Pharmacy

Blumenfeld, M. — Mon, 30 Mar 2009 12:28:03 PDT

Introduction to the College of Psychiatric and Neurologic Pharmacists 2009 Poster Abstracts

Ellingrod, V. — Mon, 30 Mar 2009 12:28:03 PDT

College of Psychiatric and Neurologic Pharmacists 2009 Poster Abstracts

Mon, 30 Mar 2009 12:28:03 PDT