Impact of cardiologist intervention on guideline-directed use of statin therapy.

BACKGROUND: Statins have an important and well-established role in the prevention of atherosclerotic cardiovascular disease (ASCVD). However, several studies have reported widespread underuse of statins in various practice settings and populations. Review of relevant literature reveals opportunities for improvement in the implementation of guideline-directed statin therapy (GDST). AIM: To examine the impact of cardiologist intervention on the use of GDST in the ambulatory setting. METHODS: Patients with at least one encounter at the adult Internal Medicine Clinic (IMC) and/or Cardiology Clinic (CC), who had an available serum cholesterol test performed, were evaluated. The 2 comparison groups were defined as: (1) Patients only seen by IMC; and (2) Patients seen by both IMC and CC. Patients were excluded if variables needed for calculation of ASCVD risk scores were lacking, and if demographic information lacked guideline-directed treatment recommendations. Data were analyzed using student t-tests or χ 2, as appropriate. Analysis of Variance was used to compare rates of adherence to GDST. RESULTS: A total of 268 patients met the inclusion criteria for this study; 211 in the IMC group and 57 in the IMC-CC group. Overall, 56% of patients were female, mean age 56 years (± 10.65, SD), 22% Black or African American, 56% Hispanic/Latino, 14% had clinical ASCVD, 13% current smokers, 66% diabetic and 63% hypertensive. Statin use was observed in 55% (n = 147/268) of the entire patient cohort. In the IMC-CC group, 73.6% (n = 42/57) of patients were prescribed statin therapy compared to 50.7% (n = 107/211) of patients in the IMC group (P = 0.002). In terms of appropriate statin use based on guidelines, there was no statistical difference between groups [IMC-CC group 61.4% (n = 35/57) vs IMC group, 55.5% (n = 117/211), P = 0.421]. Patients in the IMC-CC group were older, had more cardiac risk factors and had higher proportions of non-white patients compared to the IMC group (P < 0.02, all). CONCLUSION: Although overall use of GDST was suboptimal, there was no statistical difference in appropriate statin use based on guidelines between groups managed by general internists alone or co-managed with a cardiologist. These findings highlight the need to design and implement strategies to improve adherence rates to GDST across all specialties.

Sacubitril/Valsartan (Entresto®)-Induced Hyponatremia.

Sacubitril/valsartan (Entresto®) is the first commercially available angiotensin receptor neprilysin inhibitor (ARNI) approved for use in heart failure patients with a reduced ejection fraction. It is a combination drug that contains sacubitril, a neprilysin inhibitor, and valsartan, an angiotensin II receptor blocker. Our report outlines a case of probable ARNI-induced hyponatremia occurring in an elderly woman with heart failure with a reduced ejection fraction. According to Naranjo Adverse Drug Reaction Assessment, score indicated a likely association between patient's hyponatremia and her use of sacubitril/valsartan.

Cardiotoxic effects of chemotherapy: A review of both cytotoxic and molecular targeted oncology therapies and their effect on the cardiovascular system.

Cardiotoxic effects of chemotherapy and targeted drugs are ubiquitous and challenging in the field of oncology therapeutics. The broad spectrum of toxicities ranging from ischemic, hypertensive, cardiomyopathic, and arrhythmic complications can present as a significant challenge for clinicians treating cancer patients. If early diagnosis and intervention of cardiotoxic complications is missed, this can lead to delay or abrogation of planned treatment, which can potentially culminate to significant morbidity due to not only the cardiotoxic complications but also the progression of cancer. Hence, full knowledge of cardiovascular complications of chemotherapeutic agents, essential diagnostics tests to order, and appropriate management is paramount to oncologist, oncology pharmacists, and scientific clinical investigators. The aforementioned is particularly true in the current oncology era of plenteous early clinical trials studying several pathway/molecular-targeting agents with an increased cardiotoxic potential and the rapid expedited approval of those drugs by the FDA. Herein, we present a review discussing cardiotoxic effects of drugs and guidelines for management of the toxicities to assist the medical field in general managing patients with cancer.

Modification of a pharmacokinetics course design to improve student performance.

OBJECTIVE: To determine if the addition of weekly quizzes or reducing the number of faculty members teaching improved third-year (P3) pharmacy students' final grades in a clinical pharmacokinetics course. DESIGN: Four sections of a pharmacokinetics and pharmacodynamics course were divided according to the number of faculty members teaching the course and the administration of weekly quizzes. Two sections were taught by 6 faculty members and 2 were taught by 3 faculty members. Also, 1 section in each group received weekly quizzes, creating a 2-by-2 design. ASSESSMENT: The performance of the 201 P3 students enrolled in the course was assessed by comparing the average of 3 examination grades while excluding quiz grades. The mean final grade of classes in which quizzes were not administered was lower than that for classes in which quizzes were administered (p=0.019). The mean final grade in classes taught by 3 faculty members vs 6 faculty members was higher, but not significantly. A positive significant correlation existed between performance in a prerequisite biopharmaceutics class and this advanced class. CONCLUSION: Making minor modifications to the delivery of a course, such as number of quizzes administered and number of faculty members teaching the course, had a positive impact on student performance. Grades in a prerequisite course may enable earlier identification of students at risk of poor performance in advanced courses.

New therapeutic alternatives for the management of dyslipidemia.

Hypercholesterolemia affects over 34 million adults in the United States and is a major cause of coronary heart disease (CHD). Conventional therapies, such as statins, have demonstrated their ability to improve clinical end points and decrease morbidity and mortality in patients with CHD. Lomitapide (Juxtapid(®)), mipomersen (Kynamro(®)), and icosapent (Vascepa(®)) are 3 novel agents approved by the US Food and Drug Administration in the past 2 years, which offer new lipid-lowering treatment options with unique pharmacology.

The therapeutic use of vaptans for the treatment of dilutional hyponatremia.

Hyponatremia is a very common electrolyte abnormality. Dilutional hyponatremia is very difficult to treat effectively due to the complications of conventional treatment. Arginine-vasopressin (AVP) plays an integral role in circulatory and water homeostasis. AVP is a hormone released in response to increases in plasma tonicity or decreases in plasma volume in an attempt to maintain the plasma osmolality between 284 and 295 mOsm/L. AVP receptor antagonists or "vaptans" are a new class of drugs that allow for the safe and efficacious treatment of dilutional hyponatremia. Conivaptan, a mixed V1a/V2 receptor antagonist, and tolvaptan, a selective V2 receptor antagonist, are the only 2 vaptans approved by the US Food and Drug Administration.

The impact of FDA's warning on the use of antipsychotics in clinical practice: a survey.

OBJECTIVES: Determine the influence of warnings from the Food and Drug Administration (FDA) regarding antipsychotic use for the management of dementia-related psychosis on clinical practice. DESIGN/SETTINGS/PARTICIPANTS: A survey of health care professionals specializing in geriatrics was conducted with the use of a Web-based software program. The questions focused on practitioners' familiarity with recent FDA warnings, perceptions of their validity, and changes in antipsychotic use patterns. Sixty-five geriatric practitioners belonging to major national geriatric organizations completed the survey. INTERVENTION: Responses were reviewed once the survey was closed, six weeks after Web posting. MAIN OUTCOME MEASURE(S): Changes in prescribing practices for the management of dementia-related psychosis in light of the antipsychotic FDA warnings. RESULTS: The majority of participants responded that they were "very familiar" with the FDA warnings. The results indicated that 68% of participants reported using antipsychotic medications in elderly patients with known cerebral/cardiovascular diseases. Forty-nine percent of participants reported that they changed the way they managed elderly patients with dementia-related psychosis based on this notification. The most commonly reported barriers for not taking into consideration the FDA warnings were: no alternative treatment available, lack of guidance, lack of evidence, and poor availability of data. The majority of participants reported the use of atypical antipsychotics more frequently than the typical antipsychotics. CONCLUSIONS: Despite FDA warnings, antipsychotics are still being used for the management of dementia-related psychosis; management of behaviors associated with dementia either through drug therapy or nonpharmacologic interventions remains a challenge.

Desvenlafaxine: a new serotonin-norepinephrine reuptake inhibitor for the treatment of adults with major depressive disorder.

BACKGROUND: Desvenlafaxine succinate, a serotonin-norepinephrine reuptake inhibitor (SNRI), was approved by the US Food and Drug Administration (FDA) in February 2008 for the treatment of adult patients with major depressive disorder (MDD). Desvenlafaxine is the third SNRI approved by the FDA for this indication. OBJECTIVE: This article reviews the available information for desvenlafaxine, focusing on its pharmacodynamics, pharmacokinetics, clinical efficacy, and safety profile. METHODS: A comprehensive search of MEDLINE (1950-March 2009), International Pharmaceutical Abstracts (1970-March 2009), ISI Web of Knowledge (1996-March 2009), and EMBASE (1974-March 2009) was conducted using the terms desvenlafaxine, O-desmethylvenlafaxine, and Pristiq. Reference lists of articles were reviewed for other relevant publications. Abstracts of unpublished clinical studies presented at the American Psychiatric Association annual meetings (2004-2008) were included in the review; also included were data from the FDA and the European Medicines Agency Web sites. RESULTS: After oral administration, desvenlafaxine reaches T(max) in 7 to 8 hours and is slowly eliminated, with t((1/2)) values of 9 to 15 hours. With once-daily dosing, steady-state plasma concentrations are achieved within 4 to 5 days. Alternate-day dosing should be implemented in patients with severe renal impairment (creatinine clearance, < or =30 mL/min) and those with end-stage renal disease. In patients with moderate to severe hepatic impairment, daily doses should not exceed 100 mg. Nine short-term studies of desvenlafaxine have been conducted but only 8 were published. These 8 clinical studies evaluated oral desvenlafaxine 50 to 400 mg/d using randomized controlled trials for the treatment of MDD in adult outpatients. Significantly greater efficacy in the reduction of depressive symptoms was found in patients taking desvenlafaxine 50 mg/d (P < 0.05) compared with placebo. No additional therapeutic benefits were found at doses >50 mg/d. Preliminary data support desvenlafaxine's efficacy and tolerability in the treatment of menopause-associated vasomotor symptoms. Desvenlafaxine was generally well tolerated in clinical trials; the most common adverse events were nausea, suicidal ideation, and changes in blood pressure and weight. CONCLUSIONS: Desvenlafaxine 50 mg/d has been found to be efficacious and generally well tolerated in short-term trials for the treatment of adults with MDD. Further studies are needed to determine des-venlafaxine's role in the management of MDD and its efficacy compared with other antidepressants.