Limitations of A1c Interpretation.

Hemoglobin A1c is the measurement of glycated hemoglobin and can aid in both the diagnosis and continued management of diabetes mellitus. Accurate glycosylated hemoglobin A1c (A1c) measurements are an essential part of decision making in the diagnosis and treatment of type 2 diabetes mellitus. Although national standards exist to eliminate technical error with A1c testing, multiple patient conditions can falsely decrease or elevate the A1c. In this review, we discuss the methods to measure A1c and the corresponding conditions that can affect the clinical utility of the test. Conditions that affect the A1c can be either those that impair erythrocyte production or alter the normal process of glycation. Some variation also has been associated with patient ethnicity and even with normal aging. We describe alternatives to A1c testing for the above clinical scenarios in an effort to make the practicing clinician aware of alternatives for glucose evaluation.

Pharmacist-physician collaboration for diabetes care: cardiovascular outcomes.

BACKGROUND: Only 23% of patients are meeting all goals for cardiovascular complications of diabetes. OBJECTIVE: The purpose of our study is to evaluate the effect of a pharmacist-physician collaboration on attainment of cardiovascular-related goals in patients with type 2 diabetes. METHODS: This prospective, multicenter cohort enrolled patients from 7 practice sites that were members of the University of Tennessee Pharmacist Practice Based Research Network (UT Pharm Net). Patients were included if they were diagnosed with type 2 diabetes, at least 18 years of age and English speaking. Pregnant patients were excluded. Patients were followed for 12 months after enrollment. Primary cardiovascular outcomes included reduction in systolic blood pressure, diastolic blood pressure, and low-density lipoprotein (LDL) as well as the proportion of patients achieving a blood pressure goal of <130/80 mm Hg and proportion of patients achieving an LDL goal of <100 mg/dL. RESULTS: For the 206 patients enrolled, the average age was 59.7 years; the majority were male (59.7%) and white (66%). When compared with baseline, the postintervention mean systolic (P < .0001), diastolic blood pressure (P = .0003), and LDL (P < .0001) decreased significantly. The proportion of patients achieving a blood pressure of <130/80 mm Hg increased 21.8% (P < .0001), and the proportion of patients achieving an LDL of <100 mg/dL increased 12% (P = .0023). CONCLUSIONS: The results of our study indicate that collaborative management has a positive impact on decreasing cardiovascular risk and assists patients in attaining national goals for blood pressure and cholesterol.

Key articles of dietary interventions that influence cardiovascular mortality.

Lifestyle modifications, particularly diet, are a key component to the reduction of cardiovascular events. Diets high in carbohydrates and saturated fat have been shown to negatively affect blood cholesterol, thereby increasing the risk for cardiovascular disease (CVD). Dietary interventions that emphasize the consumption of whole grains, fruits, and vegetables have been shown to be successful in reducing cardiovascular risk. Clinical pharmacist practitioners need to be knowledgeable regarding lifestyle modifications, specifically dietary issues, to develop a comprehensive, effective, and evidence-based plan for patients who are either at risk for or who have established CVD. Numerous studies have been published over the past few years with regard to the rapidly growing field of dietary interventions that influence cardiovascular risk, and the amount of literature can be overwhelming. Thus we chose to focus our review on articles that assess changes in dietary patterns that affect overall mortality risk from CVD. As such, literature describing the impact of dietary factors that influence weight, lipid changes, or other risk factors alone were not included in this review. A group of practitioners with expertise and interest in CVD were involved in the compilation of this article.

Smoking cessation: barriers to success and readiness to change.

BACKGROUND AND OBJECTIVES: Smoking cessation interventions should be individualized based on patient history and readiness for change. The objective of this study was to assess stages of change and key components of smoking and cessation history among a sample of primary care patients. METHODS: A telephone survey of current or recent smokers identified smoking status, stage of change, motivation, concerns, relapse history, pharmacotherapy, and social support. RESULTS: Of 150 participants, most were within precontemplation (22.7 percent) or contemplation (44.0 percent) stages of change; 14.0 percent were in preparation, 4.7 percent in action, and 14.7 percent in maintenance. The primary motivation for quitting was to improve general health (42.3 percent). The most common cessation-related concerns were: breaking the habit, stress, and weight gain. Pharmacotherapy was discontinued due to adverse events in 31.5 percent of users. Intratreatment social support was reported by 17.5 percent. The most common reasons for relapse were falling back into the habit (36 percent), stressful situations (27 percent), and being around other smokers (25 percent). CONCLUSIONS: Targeted interventions are needed for patients in either precontemplation or contemplation stages. Counseling should focus on helping patients resolve barriers to cessation and reasons for relapse, particularly stress and weight management. Pharmacotherapy should be utilized when patients are ready to quit. Increased intratreatment social support and counseling appear warranted to support behavior change and appropriate medication use.

Probable drug interaction between warfarin and hormonal contraceptives.

OBJECTIVE: To report a single patient case that presented with a probable drug interaction between warfarin and 3 methods of hormonal contraceptives, as assessed by the Horn Interaction Probability Scale. CASE SUMMARY: A 33-year-old female patient required long-term anticoagulation following an aortic valve replacement. While taking warfarin (38.5 mg weekly), she transitioned from a monophasic combined oral contraceptive (ethinyl estradiol plus norethindrone) to an implantable progestin-only contraceptive (etonogestrel) on the advice of her cardiologist. Nineteen days following etonogestrel implant insertion, her international normalized ratio (INR) decreased to 1.8 and required a 55.8% warfarin dose increase (resulting dose of 60 mg weekly). Within 10 months, the patient elected to have the implant removed due to vaginal bleeding. Nine days following removal of etonogestrel, she experienced a transient INR increase to 6.5. Her INR returned to within goal range after her warfarin dose was decreased to 55.5 mg weekly. After using barrier methods of contraception for 48 days, she initiated an oral progestin-only contraceptive (norethindrone). Further warfarin dose adjustments were made, resulting in a weekly warfarin dose of 53.5 mg. Thirty-nine days after initiation of oral norethindrone, she elected to discontinue use due to vaginal bleeding and no longer uses hormonal contraceptive methods. No further adjustments to her warfarin dose were warranted. DISCUSSION: The increased warfarin requirement observed in this patient may have been a result of multiple factors. Based on a literature review, we hypothesize that the predominant mechanism of interaction was ethinyl estradiol inhibition of CYP1A2 and 2C19. CONCLUSIONS: We recommend that further in vivo studies be completed to definitively identify the mechanism of the interaction. It is necessary to intensify warfarin monitoring upon initiation or alteration of hormonal contraceptives.

Clinical outcomes and pharmacists' acceptance of a community hospital's anticoagulation management service utilizing decentralized clinical staff pharmacists.

BACKGROUND: In 2008, the Joint Commission released an updated National Patient Safety Goals document that requires institutions to implement practices that reduce the likelihood of patient harm associated with use of anticoagulation therapy. One of the expectations associated with this goal was that each organization would establish an anticoagulant management program. To our knowledge, few data exist to describe the implementation and assessment of anticoagulation programs in smaller, nonteaching community hospitals using decentralized pharmacists in an integrated practice model. OBJECTIVE: To compare the performance of a protocol-driven anticoagulation management service led by decentralized pharmacists in a nonteaching community hospital with that of usual medical care provided by hospitalist physicians before this program was implemented. Based on these results, as well as a pharmacist satisfaction survey, evaluate the service and identify barriers to expansion. METHODS: We conducted a retrospective cohort study comparing 50 consecutive patients who were starting warfarin for the first time beginning in November 2003 with 50 patients managed by hospitalist physicians prior to November 2002 (the time of program implementation). RESULTS: There were no significant differences between groups with regard to time in therapeutic range once therapeutic, length of stay, international normalized ratios (INRs) greater than 3.5, or INRs less than 2. Patients in the pharmacy management group had significantly fewer drug interactions with antimicrobials than did the usual medical care group. Although time to therapeutic range was longer in the pharmacy protocol group, there were fewer patients with INRs greater than 3.5, although this did not reach statistical significance. CONCLUSIONS: The efficacy of the pharmacist-led anticoagulation management service was no different from that of usual medical care. Patient safety appeared improved, in part due to more careful initial dose selection based on patient-specific factors. Although this program was accepted by pharmacists, time limitations were perceived to be a major barrier to quality care and expansion of the service.

Aspirin resistance: disparities and clinical implications.

Abstract Aspirin is one of the most widely prescribed drugs for the prevention of thrombosis in patients with vascular disease. Yet, aspirin is unable to prevent thrombosis in all patients. The term "aspirin resistance" has been used to broadly define the failure of aspirin to prevent a thrombotic event. Whether this is directly related to aspirin itself through biochemical aspirin resistance or treatment failure, or if it is because of aspirin's inability to overcome the thrombogenic aspects of the disease process itself, has not been elucidated. This can have dramatic clinical implications for a variety of vascular disease subsets and is cause for concern, considering the high prevalence of aspirin use for both primary and secondary prevention. Disparities exist in the rates of aspirin resistance among certain patient populations, such as women, patients with diabetes mellitus, and those with heart failure, and across clinical conditions, such as cardiovascular and cerebrovascular disease. Clinical trial data from studies observing resistance have revealed that regardless of study size, dose of aspirin, control for drug interactions and adherence, or assay used to measure platelet function, aspirin resistance is associated with an increased risk for adverse events. Although the evidence is mounting, there has yet to be a consensus on the appropriate clinical response to aspirin resistance.