Pharmacists Making House Calls: Innovative Role or Overkill?

Background

The Medication Management Program was established at the Fraser Health Authority in 2005, in response to evidence suggesting that having pharmacists provide care to patients in their homes after discharge from hospital could reduce subsequent utilization of health service resources.

Objective

To determine the effectiveness of the Medication Management Program in its first 2 years of operation.

Methods

For patients who had received a home visit by a pharmacist, the utilization of health services (admissions to hospital, physician office visits, and dispensed medications) in the year before the home visit was compared with utilization during the year after the intervention. The net cost of the program was also determined.

Results

In the first 2 years of the Medication Management Program (2005/2006 and 2006/2007), a total of 1171 patients received a home visit from a pharmacist. Of these, 836 (71%) were included in the before-and-after analysis. The median per-patient cost for utilization of health services was $11 014 lower in the year after the intervention than in the year preceding the intervention. After the costs of the program were taken into account, this resulted in a net median cost reduction of $3047.43 per patient.

Conclusion

The Medication Management Program was effective as a clinical program in its first 2 years.     

Atypical antipsychotics and polydipsia: a cause or a treatment?

Primary polydipsia (PP) is a frequent complication that affects many chronic schizophrenic inpatients. Due to possible lethal consequences, for example, hyponatremia, coma and death, it's fundamental for the physician achieving early diagnosis and treating this condition. The first step is identifying polydipsia by clinical, biochemical and pharmacological means. Nowadays, the pathophysiology of PP remains unclear, and this limits the possibility of detecting an appropriate drug treatment. Typical antipsychotics have been associated to a worsening of polydipsic behavior, while more recently atypical antipsychotics have been reported as being useful. However results are still mixed and controversial. It appears that risperidone and olanzapine are not clearly effective; clozapine may improve symptoms, although it is difficult to manage from a therapeutic point of view; quetiapine has been poorly studied so far, nonetheless it has given interesting results. Through a case study analysis, this report presents a brief, yet selective, overview of the current state of psychopharmacology in the treatment of PP with atypical antipsychotics in schizophrenia.     

Direct-to-consumer drug marketing: public service or disservice?

Pharmaceutical industry spending on direct-to-consumer advertising has been increasing rapidly. While the primary goal of direct-to-consumer advertising is to sell drugs, supposed secondary goals include patient education and improved health. However, these benefits of direct-to-consumer advertising are unproved. Moreover, such advertising may create unnecessary tension between the patient and the patient's physician and insurer, and may divert physicians' efforts away from important patient concerns, and toward marketing-generated discussions. On the other hand, direct-to-consumer advertising may lead to patient-doctor encounters that would not have occurred otherwise. Direct-to-consumer advertising should be modified to unambiguously benefit the health-care interests of consumers and patients.     

Depression and acitretin: a true association or a class labeling?

The potential relationship between systemic retinoids used in dermatology and affective disorders is controversial. Acitretin, which is widely used in the treatment of psoriasis is part of this controversy secondary to its chemical relation to isotretinoin, a drug which has been associated with a large number of anecdotal case reports of depression and suicidal ideation. Moreover, an FDA package insert precaution regarding acitretin's association with depression and suicide has elevated the level of concern for patient safety. The objective of this article is to review the evidence in the literature regarding acitretin's association with affective disorders. After 12 years of worldwide use only two cases involving acitretin have been reported in the literature. In addition, despite many anecdotal cases involving isotretinoin, there have been no clinical studies that have proven a causal relationship between isotretinoin and depression or suicidal ideation. For acitretin there have been no systematic clinical studies that examine such a relationship. Moreover, it is notable that the FDA precaution regarding depression and suicide on the package insert of acitretin predates the publication of the aforementioned two cases. This suggests that a relationship between acitretin and affective disorders is a class labeling rather than a scientifically proven association.     

Erlotinib and pantoprazole: a relevant interaction or not?

AIMS

There is increasing evidence that erlotinib exposure correlates well with treatment outcome. In this report we present a case of therapeutic drug monitoring of erlotinib in a patient with a gastric ulcer, treated with the proton pump inhibitor pantoprazole. This agent may cause an unwanted, but not always unavoidable, interaction since absorption of erlotinib is pH dependent.

METHODS

Erlotinib trough concentrations were monitored in a patient during treatment with orally and intravenously administered pantoprazole.

RESULTS

Erlotinib trough concentrations were diminished during high dose intravenously administered pantoprazole, but returned to normal when the dose was reduced and pantoprazole was administered orally.

CONCLUSIONS

More studies are needed to assess the dose dependency of the interaction between pantoprazole and erlotinib. Furthermore, we advise to monitor closely erlotinib plasma concentrations and adjust the erlotinib dose accordingly when a clinically relevant interaction is suspected and no proper dosing guidelines are available.     

Redox-modulated xenobiotic action and ROS formation: a mirror or a window?

A number of xenobiotics require redox reactions to form the reactive intermediates involved in the ultimate toxic events (e.g., adduct formation). The same mechanisms lead to the formation of reactive oxygen species (ROS), which can themselves exert direct toxicity including, e.g., DNA oxidative damage or glutathione depletion. The occurence of both mechanistic features in xenobiotic activation and toxicity may raise some difficulties in ascertaining the respective roles of reactive intermediates versus ROS-related mechnisms. An example is provided by the toxicity mechanisms of mitomycin C (MMC) and diepoxybutane (DEB), which are commonly referred to as 'cross-linkers'. Their toxic actions, however, are well-known to be modulated via redox parameters, such as oxygen tension, antioxidants levels, or thioredoxin overexpression. The diagnostic assessment of Fanconi's anaemia (FA) relies on MMC and DEB sensitivity, which is usually referred to as 'cross-linker sensitivity'; thus the redox-dependent toxicities of MMC and DEB may have direct implications for the definition of FA phenotype. Another major aspect in ROS formation relies on the extensive evidence pointing to the requirement for oxidative, as well as nitrosative activities in triggering a number of key events in cell division and differentiation, and in early embryogenesis. In turn, antioxidants that may prevent ROS-associated cellular damage in adult cells may prove to exert adverse or fatal outcomes when administered in early life stages. The overall information available on xenobiotic redox biotransformation and on the physiopathological roles of ROS points to the need of addressing ad hoc studies that should take into account the multiplicity of mechanistic events involved.     

IL-6 and arthritis: a detrimental or beneficial mediator?

Acute inflammation is accompanied by changes in the concentrations of several plasma proteins. Cytokines play a crucial role in the regulation of inflammatory events. Inflammatory disorders such as rheumatoid arthritis are characterized by an overproduction of several cytokines including interleukin-6 (IL-6). Recent data suggest that IL-6 and other members of the IL-6-cytokine family have anti-inflammatory and immunosuppressive properties, and therefore may negatively regulate inflammatory processes.     

Spinal and bulbar muscular atrophy: a motoneuron or muscle disease?

Kennedy disease (KD, or spinal and bulbar muscular atrophy) is caused by a CAG/polyglutamine expansion in the androgen receptor (AR) gene. Both motoneurons and muscles are affected by KD, but where mutant ARs act to initiate this disease is not clear. We discuss recent insights into this disease with two main themes. (1) KD is androgen-dependent, suggesting that blocking androgen action may be an effective treatment. (2) Androgens may trigger KD by acting in muscles, which indirectly affects the motoneurons, suggesting that blocking AR function in muscles may rescue motoneurons from disease and provide an effective treatment. Future research will provide a better understanding of how androgens trigger KD and the relative contributions of motoneurons versus muscles in this disease.     

Systemic racism: Pharmacists’ role and responsibility

Systemic racism is a public health emergency and disproportionately impacts communities of color, specifically black Americans. Pharmacists took an oath to protect the welfare of humanity and protect our patients. As such, to practice truly patient-centered care, pharmacists must recognize racism as a root cause of social determinants of health and use their privilege to educate themselves and their colleagues around dismantling structural racism.     

Pharmacists’ spiritual care perspectives and experiences: Qualitative findings from a statewide survey

ObjectivePharmacists are encouraged to provide whole-person care. Because holistic care is conceptualized as including spiritual care (SC), this study investigated the experiences and perspectives of pharmacists regarding SC in pharmacy practice.MethodsData for this cross-sectional, qualitative study were collected from a survey mailed to 1000 randomly selected registered pharmacists in California in 2019. The data reported here are the responses to open-ended questions eliciting information about the last time the pharmacists provided SC to a patient, indicators that a patient needs spiritual assistance, and religious beliefs thought to be harmful. The data were content-analyzed by 2 investigators.ResultsAlthough 215 pharmacists responded to the survey, only 141 responded to the open-ended questions. Most of the respondents were women (58%), Christian (70%), religious (73%), attended religious services (78%), and practiced in an urban setting (56%). The themes observed indicated that these pharmacists prayed with, and for, patients; talked to patients about God and religion; referred patients to spiritual services; were sensitive to patients’ spiritual or religious beliefs; and listened to patients’ expressions of spirituality. Some respondents, however, avoided religious conversations and requests; some also reported unwillingness to provide SC to patients. The pharmacists had limited education, knowledge, and awareness about SC.ConclusionsThe pharmacists in this sample reported diverse perspectives about SC that ranged from acceptance to rejection of SC in patient care. Pharmacists are not fully engaged in providing SC because of several challenges, including limited education and training on SC. Scholarly inquiry is needed to examine how pharmacists can best provide SC in pharmacy practice.     

Pharmacists’ knowledge and attitudes toward medication therapy management service and the associated challenges and barriers for its implementation

BackgroundThe literature demonstrated a positive impact of medication therapy management (MTM) services provided by the pharmacists to improve the overall health outcomes. Nevertheless, limited data is available with regard to MTM service implementation by community pharmacists and its associated factors in Jordan.ObjectiveTo evaluate community pharmacists’ knowledge, attitude and practice of MTM service and to explore the challenges and barriers for its implementation.MethodsThe present cross-sectional study utilized a validated online survey which was filled by community pharmacists in different areas across Jordan. In addition to the socio-demographic variables, the study questionnaire evaluated pharmacists’ knowledge and attitudes towards MTM service, extent of MTM implementation and its associated challenges and barriers.ResultsA total of 250 pharmacists completed the survey. The study pharmacists showed moderate knowledge level (median of the total knowledge score = 6 (4–7) out of 10) and positive attitude (median of the attitude score was 23 (19–26) out of 30) towards MTM services. The participating pharmacists recognized performing or obtaining necessary assessments of patient’s health status as the most frequently provided MTM service (84.8%), while the least one was documenting the care delivered and communicating essential information to other healthcare providers (62%). Furthermore, collecting patient-related information was the most commonly recognized challenge to MTM service provision (36.8%), followed by referring the patient to a physician or consultant (36%) and collaboration with them (35.6%). The most reported barrier was negative physician attitudes (40.4%), followed by the lack of training on MTM provision (38.4%), and lack of adequate support staff (37.2%).ConclusionEfforts are needed to enhance collaboration between pharmacists and other health care professional, to develop documentation systems that would preserve and facilitate access to patient information, and to implement appropriate training programs which aim to overcome the challenges and barriers for MTM implementation.     

Cabenuva®: Differentiated service delivery and the community Pharmacists’ roles in achieving UNAIDS 2030 target in Nigeria

The approval of the novel long-acting HIV injection; Cabenuva®- Cabotegravir and Rilpivirine injectable formulation) and the recent call by the World Health Organization for promoting community-based ART management, underscore the remarkable progress towards meeting the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95–95–95 targets by 2030.As the availability of antiretroviral therapy (ART) for the treatment of HIV/AIDS has increased in resource-limited settings, there has been a move to develop and implement alternative treatment delivery models such as Differentiated Service Delivery (DSD) in high prevalence countries to meet the global targets for HIV treatment while maintaining the quality of care. However, there is limited data on the involvement of community pharmacies in the delivery of ART within the community. Although, in western countries, several studies have documented the different roles community pharmacists can play in the management of HIV/AIDS. Community pharmacists are the most accessible and first points of health care for most clients. They are trusted, highly trained health care professionals. They should be incorporated and allowed to administer the Cabenuva® injection if the battle against the HIV pandemic is to be totally won. In this paper, we, therefore, aim to explore how the community pharmacist can be positioned in HIV service delivery regarding the administration of the Novel long-acting Cabenuva® injection formulation. It is therefore recommended that the Nigerian government embrace community pharmacy-led drug administration initiatives and embark on accredited training programmes for the profession in line with drug administration services. The government should also put in place necessary funding mechanisms for community pharmacists for the extra workload placed on them in administering injection drug formulation in their respective pharmacies.     

Combination of clopidogrel and statins: a hypothetical interaction or therapeutic dilemma?

BACKGROUND: The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and clopidogrel are frequently used in the treatment of patients with various cardiovascular disorders. The possibility of a drug-drug interaction between certain statins and clopidogrel has been extensively investigated in the literature recently. Investigators have proposed that the use of statins that are metabolized by the cytochrome P450 (CYP) system may diminish the conversion of clopidogrel to its active form by inhibiting the CYP3A4 isoenzyme. This inhibition could result in a decreased antiplatelet effect of clopidogrel, which could translate into an increased risk of cardiovascular events. METHODS: We performed a MEDLINE search of the literature from 1993-2005 to evaluate and discuss the existing data on a possible interaction between clopidogrel and statins and to provide clinicians with relevant and practical recommendations. Additional studies were identified from the bibliographies of the reviewed literature. RESULTS: Several articles were discovered that discuss this potential drug-drug interaction. Whereas some studies indicated that there was not a relevant interaction between statins and clopidogrel, other studies demonstrated that the concomitant administration of some statins with clopidogrel resulted in diminished platelet inhibition activity of clopidogrel. CONCLUSIONS: Although the interaction between certain statins and clopidogrel seems to be a pharmacologic certainty, the clinical relevance of this interaction needs further clarification. While investigators continue to evaluate the clinical relevance, we provide several recommendations for clinicians responsible for treating patients who require combination therapy with statins and clopidogrel.     

Pharmacoeconomics and pharmacoepidemiology: curious bedfellows or a match made in heaven?

Pharmacoepidemiology is an established subdiscipline of epidemiology concerned with estimating the efficacy, effectiveness and safety of pharmaceutical products. Pharmacoeconomics is an established subdiscipline of health economics concerned with the evaluation of pharmaceutical products in terms of their value for money. Despite a common focus on the evaluation of pharmaceuticals, practitioners in the two disciplines appear to work largely in isolation of each other, as evidenced by lines of reasoning developed in one field that do not appear in the other. The purpose of this paper is to explore the interface between pharmacoepidemiology and pharmacoeconomics with the aim of identifying the potential synergies that exist from greater communication of ideas between practitioners in both disciplines. Issues are illustrated by means of a simple example of safety and efficacy in deep vein thrombosis prophylaxis. Issues surrounding safety and efficacy exemplify the need for a framework that allows trade-off between such benefits and risks of drug therapy. Health economics provides such a framework and it is suggested that those working in pharmacoepidemiology might make more of this framework in seeking to address essential trade-offs and inform policy. Similarly, it is argued that pharmacoeconomics could benefit from the robust methods of estimation used in epidemiological research as part of evaluation studies, in particular surrounding issues of unbiased estimation and scale of measurement. A closer working relationship between the disciplines could allow for economic assessment to be made earlier in the product cycle, which could bring benefits to society in terms of delaying the uptake of cost-ineffective products and speeding the uptake of products offering clear value for money.