Impact and clinical management of depression in patients with coronary artery disease.

The rates of major adverse coronary events, including recurrent ischemic events and death, in patients with coronary artery disease (CAD) have been shown to be significantly increased in patients with depression. In addition, health care costs are higher and health-related quality of life is lower in depressed patients with CAD. Several pathophysiologic mechanisms have been proposed for the association of increased events seen in this population. Studies have focused on antidepressants (specifically, selective serotonin reuptake inhibitors and mirtazapine), psychotherapy (cognitive behavioral therapy and interpersonal psychotherapy), and a wide range of other nonpharmacologic interventions. Pharmacologic and nonpharmacologic treatments are known to improve depressive symptoms in patients with CAD, but their effects on outcomes such as mortality and hospital admissions remain controversial. If treatment of depression is warranted, strategies should include sertraline or citalopram, with or without cognitive behavioral therapy, based on the known efficacy and safety of the drugs in this population. Nonpharmacologic therapy such as aerobic exercise has been shown to improve not only depression but also cardiovascular health. When selecting an appropriate antidepressant, clinicians should consider their patients' comorbid conditions and the potential for drug interactions, and treatment should be frequently monitored. Screening for depression in patients with cardiac disease should be instituted on a routine basis by using either case-finding or symptom-triggered approaches. Based on the high prevalence of depression and its known adverse effects in patients with CAD, future research is needed to help determine the role of antidepressants and nonpharmacologic strategies in improving outcomes in patients with both comorbidities.

Depression in patients with heart failure: clinical implications and management.

Mortality and morbidity rates remain high in patients with heart failure despite advances in medical therapy. Heart failure can also significantly worsen quality of life. Attention has been paid to evaluating the effects of psychological disease in patients with heart failure. Depression rates are higher in patients with heart failure than in the general population. Depression has been associated with worse outcomes in patients with heart failure. Those at highest risk for depression include patients with implantable cardioverter-defibrillators, alcohol abuse, history of depression, and multiple comorbidities. Depression may be underdiagnosed in the heart failure population, as symptoms can often be similar in the two disease states. Evidence is limited on the effects of pharmacologic and nonpharmacologic therapy for depression, specifically in patients with heart failure. Based on the available literature, patients with heart failure should be screened routinely for depression. Treatment is known to improve quality of life, but its effect on outcomes such as mortality and hospital admissions for heart failure remains unknown. If treatment includes pharmacologic strategies, selective serotonin reuptake inhibitors (especially paroxetine and sertraline), mirtazapine, and nefazodone have the strongest efficacy evidence in this population. Based on safety data of these agents and after consideration of comorbid conditions and the potential for drug interactions, a selective serotonin reuptake inhibitor should be used as first-line therapy. Finally, clinicians should not avoid beta-blockers in those with a diagnosis of depression, as recent evidence demonstrates that these agents are not associated with inducing or worsening depressive symptoms.

Key articles and guidelines in the management of hypertension: 2008 update.

Hypertension remains a major risk factor for cardiovascular disease. The optimal choice of pharmacologic and nonpharmacologic treatment regimens is based on a plethora of published literature. This compilation is the initial update to the Key Articles and Guidelines in the Management of Hypertension authored by members of the Cardiology Practice and Research Network of the American College of Clinical Pharmacy, which appeared in Pharmacotherapy in 2004. We present synopses of clinical trials, meta-analyses, clinical practice guidelines, and other pertinent literature published between May 2003 and June 2007.

Dalbavancin: a new lipoglycopeptide antibiotic.

PURPOSE: The activity, pharmacokinetics, pharmacodynamics, efficacy, safety, and formulary considerations of dalbavancin are reviewed. SUMMARY: Dalbavancin is a novel second-generation lipoglycopeptide antimicrobial with unique pharmacokinetics and excellent activity against resistant gram-positive pathogens, including methicillin-resistant Staphylococcus aureus. Available only in i.v. form, it exhibits excellent tissue penetration, particularly in the skin, and a long half-life that allows once-weekly administration. Clinically relevant drug interactions involving dalbavancin have not been identified. While sharing a similar mechanism of action and spectrum of activity with other glycopeptides, dalbavancin has demonstrated in vitro and in vivo bactericidal potency superior to that of vancomycin, teicoplanin, and other commonly used antimicrobials. Clinical trials indicate that dalbavancin is efficacious for skin and soft-tissue infections and catheter-related bloodstream infections. Dalbavancin appears to be noninferior to linezolid and superior to vancomycin. Adverse events are mild to moderate and include pyrexia, headache, and nausea. CONCLUSION: Dalbavancin has enhanced activity against gram-positive bacteria and unique pharmacokinetics compared with existing drugs in its class. It appears to be safe and efficacious for use against common infections, including complicated skin infections and catheter-related bloodstream infections.

Cost-effectiveness analysis of antithrombotic therapy in nonurgent percutaneous coronary intervention.

STUDY OBJECTIVE: To perform a cost-effectiveness analysis comparing three treatment approaches during nonurgent percutaneous coronary intervention (PCI): bivalirudin with provisional glycoprotein (GP) IIb-IIIa inhibitor therapy, unfractionated heparin (UFH) with eptifibatide, and UFH with abciximab. DESIGN: Literature-based decision model from an institutional perspective. DATA SOURCE: Patient data from the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 study and three other randomized controlled trials that included UFH and routine GP IIb-IIIa inhibitor (eptifibatide or abciximab) therapy. All included studies were comparable based on patient population, procedural techniques, and general treatment approaches. MEASUREMENTS AND MAIN RESULTS: We included patient populations undergoing contemporary nonurgent PCI to identify probabilities of success or complications (myocardial infarction, urgent revascularization, thrombocytopenia, and major or minor bleeding at 30 days). Costs were assigned to each outcome by incorporating diagnosis-related group-- and/or Current Procedural Terminology--associated costs, institutional drug acquisition costs, and unit replacement costs of platelets and red blood cells. In the base-case analysis, the use of bivalirudin with provisional GP IIb-IIIa inhibitor therapy dominated the UFH and planned GP IIb-IIIa inhibitor approach: UFH with eptifibatide was 74 US dollars more expensive and 1.2% less effective, and UFH with abciximab was 777 US dollars more expensive and 2.3% less effective. Sensitivity analyses indicated that the model results were robust, but also revealed that bivalirudin lost its cost-effectiveness, resulting in UFH with eptifibatide becoming more cost-effective, when two or more vials of bivalirudin were necessary in greater than 27% of cases or when the use of provisional GP IIb-IIIa inhibitor therapy exceeded 20%. CONCLUSION: This analysis indicates that bivalirudin with provisional GP IIb-IIIa inhibitor therapy is the most cost-effective antithrombotic treatment strategy in nonurgent PCI when its use and dosing are consistent with the REPLACE-2 trial.

Rituximab treatment of refractory rheumatoid arthritis.

OBJECTIVE: To review published literature using rituximab for treatment of refractory rheumatoid arthritis (RA). DATA SOURCES: An English-language literature search was conducted using MEDLINE (1966-May 2005) and EMBASE (1980-May 2005). References of identified articles were subsequently reviewed for additional data. DATA SYNTHESIS: Evidence suggests that B lymphocyte depletion in patients suffering from refractory RA may be a key component in the interruption of the disease pathogenesis. Successful depletion of B lymphocytes with rituximab in patients with RA has been reported in case reports, open-label pilot studies, and a randomized, double-blind, placebo-controlled trial. CONCLUSIONS: Based on the limited published data, rituximab, when used in combination with other agents (ie, cyclophosphamide or methotrexate), appears to be a reasonable treatment option for refractory RA. However, additional controlled trials need to be conducted to further define optimal dosing, response rates, comparative long-term efficacy, and RA treatment algorithm placement of rituximab in this patient population.

Impact of pharmacist-led community bone mineral density screenings.

BACKGROUND: Osteoporosis-associated fractures burden both individuals and the overall healthcare system. Bone mineral density (BMD) screening remains the gold standard measure for identifying patients at risk. OBJECTIVE: To determine the impact of convenient, pharmacist-led BMD screening and counseling sessions on identification and education of patients at risk for or with osteoporosis. METHODS: Nonpregnant persons >18 years of age were eligible for enrollment in this descriptive study. At an urban retail pharmacy, participants underwent risk factor assessment, peripheral BMD scanning, and personalized counseling. At 3 and 6 months after screening, subjects were questioned by telephone regarding any subsequent primary care provider (PCP) interactions, as well as any behaviors initiated and/or medications modified. RESULTS: Of the 102 subjects screened, 22.6% and 11.7% were identified as being at medium risk (T score -1.0 to -2.5) and high risk (T score -2.5 or less) for osteoporosis, respectively. By 6 months, 42.5% of the participants reported increasing their dietary intake of calcium, 29.3% began or increased calcium supplements, and 54.9% positively modified smoking status, exercise level, alcohol consumption, or caffeine intake. Additionally, 24 of 52 subjects who had discussed their results with a PCP by 6 months also received a treatment recommendation. Eighty-nine participants reported the community location increased their likelihood of receiving a BMD scan. CONCLUSIONS: Overall, pharmacist-led BMD screenings that include individualized counseling sessions appear convenient, accessible, and beneficial for patients. With the establishment of clinical benefit of and positive reception to such screenings, pharmacists can now look toward securing consistent reimbursement for this vital pharmaceutical care service.

Pharmacogenomics: implications and considerations for pharmacists.

The Renaissance period of world history is analogous to the renewal of healthcare that will arise from pharmacogenomic discoveries. Just as geography, science, art and communication were reawakened by the works of Columbus, da Vinci, Michelangelo and Gutenberg; genetic science will revitalize the clinical role of pharmacists and generate new interest in pharmacy research and education.