Evaluation of a Pharmacy Service to Lower BMI Prior to Total Joint Arthroplasty.

BACKGROUND: Total joint arthroplasty (TJA) postsurgical complications are increased in patients with a body mass index (BMI) greater than 30 kg/m2. Reducing BMI prior to surgery can be complicated and it is important to find effective methods to achieve weight loss goals prior to surgery. Pharmacy services have proven to be effective models for weight loss in prior studies and may be an avenue for achieving BMI reduction prior to TJA surgeries. OBJECTIVE: The purpose of this study was to examine the benefit of pharmacist-driven interventions in an ambulatory care setting to achieve weight loss goals prior to TJA orthopedic surgeries. METHODS: A retrospective chart review was conducted on patients referred from an orthopedic surgeon's office to a clinical pharmacist service providing chronic disease state management. Patients were referred based on need to decrease BMI prior to TJA orthopedic surgeries. Visits included evaluations of medications, education on weight loss management techniques, including therapeutic lifestyle changes, and recommendations for weight loss medications. RESULTS: There was a statistically significant difference in post-BMI when compared with pre-BMI (P = .007). Of 16 subjects who had complete pre- and post-BMI measurements, 4 (25%) subjects met their BMI goal. There was a statistically significant relationship between the number of appointments and difference in BMI (ρ = -0.71, P = .002). CONCLUSION: Pharmacists may be utilized in a collaborative health care model in the ambulatory care setting to assist patients with lifestyle or medication management to achieve weight loss prior to orthopedic surgeries.

Nebivolol/Valsartan: A Novel Antihypertensive Fixed-Dose Combination Tablet.

DATA SOURCES: A PubMed (1966 to October 2018) search was conducted using the following keywords: nebivolol, valsartan, and hypertension (HTN). Additional sources were identified by references. STUDY SELECTION AND DATA EXTRACTION: Articles written in English were included if they evaluated the pharmacology, pharmacokinetics, efficacy, safety, or place in therapy of nebivolol/valsartan in human subjects. DATA SYNTHESIS: Most patients with HTN require combination therapy; however, ß-adrenergic antagonists and AII type 1 receptor blockers have been considered less effective because of overlapping mechanisms of action. A phase III, randomized trial demonstrated that nebivolol/valsartan produced statistically significant blood pressure (BP) lowering as compared with monotherapy with the individual components or placebo. Substudy analyses confirmed this among subgroups and demonstrated that nebivolol/valsartan decreased plasma renin and aldosterone levels. One trial reported continued BP lowering at 52 weeks. Another study showed that nebivolol/valsartan had similar additivity scores as compared with other antihypertensive combinations. Relevance to Patient Care and Clinical Practice: This review discusses drug information, efficacy, and safety of nebivolol/valsartan and discusses its clinical relevance as a novel combination product in managing patients with HTN. CONCLUSION: Nebivolol/valsartan combination may offer a benefit to patients with an indication for both classes who desire to decrease pill burden. Although BP lowering was statistically significant in comparison to the individual components as monotherapy, the combination does not offer clinically significant benefits that would elevate its place in HTN management.

Lixisenatide: A New Daily GLP-1 Agonist for Type 2 Diabetes Management.

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, and safety of the glucagon-like peptide-1 receptor agonist (GLP-1RA), lixisenatide, in the treatment of type 2 diabetes mellitus. DATA SOURCES: A PubMed (1966-2016) search was conducted using the following keywords: lixisenatide, AVE0010, glucagon-like peptide-1 agonist, and type 2 diabetes. References were reviewed to identify additional sources. STUDY SELECTION AND DATA EXTRACTION: Articles written in English were included if they evaluated the pharmacology, pharmacokinetics, efficacy, or safety of lixisenatide in human subjects. DATA SYNTHESIS: Lixisenatide lowers blood glucose through a glucose-dependent increase in insulin release from pancreatic ß-cells and a decreased release of glucagon from pancreatic α-cells. Additionally, lixisenatide delays gastric emptying and increases satiety. Lixisenatide has been studied head to head against exenatide and insulin glulisine. It has also been studied as monotherapy and in combination with metformin, sulfonylureas, pioglitazone, and insulin glargine. In the GetGoal clinical trial series, lixisenatide resulted in a hemoglobin A1C reduction of 0.6% to 1% and a reduction in body weight of 0.2 to 2.96 kg. The adverse effect profile of lixisenatide was consistent with that of other GLP-1RAs, with nausea, vomiting, and diarrhea most commonly reported. CONCLUSION: Lixisenatide provides an additional GLP-1RA option, which may have more postprandial blood glucose-lowering effects than the other agents in the class because of its shorter half-life and effects on delaying gastric emptying.

Adjunctive Role of Glucagon-Like Peptide-1 Receptor Agonists in the Management of Type 1 Diabetes Mellitus.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are commonly used in combination with insulin to manage type 2 diabetes mellitus, and four agents are currently approved for this indication: exenatide, liraglutide, dulaglutide, and albiglutide. The distinctive properties of GLP-1 RAs-potential hemoglobin A1c (A1C) reduction, weight loss, potential to reduce insulin doses, and lower hypoglycemia risk-have made these agents potential treatment options for patients with type 1 diabetes mellitus (T1DM) as well. These positive effects are due to glucose-dependent insulin secretion, reduced glucagon secretion, increased satiety, and delayed gastric emptying. Patients with T1DM are unable to suppress glucagon during meals, which contributes to postprandial hyperglycemia and may be improved with GLP-1 therapy. In this review, we evaluated the available literature on the clinical efficacy and safety of GLP-1 RAs in patients with T1DM. We conducted a search of the PubMed (1966-May 2016) and Ovid (1946-May 2016) databases. Abstracts presented at the scientific and clinical sessions of the American Diabetes Association and the American Association of Clinical Endocrinologists were also searched. The references of the published articles were also reviewed to identify additional studies appropriate for inclusion. All identified articles published in English were evaluated. Studies were included if they evaluated the clinical use or safety of GLP-1 RAs in patients with T1DM. Twelve studies were included, with four evaluating exenatide, one evaluating exenatide extended release, and seven evaluating liraglutide. Both exenatide and liraglutide showed significant reductions in hemoglobin A1C, plasma glucose concentration, body weight, and insulin doses when administered to patients with T1DM already receiving insulin therapy, without increasing the occurrence of hypoglycemia. Adverse effects were mostly gastrointestinal in nature but were mild and transient. Patients who may benefit most are those experiencing adverse effects from insulin, those not at their A1C goal but hypoglycemia prevents insulin titration, and those who may benefit from weight loss.

Pharmacological management of obesity in pediatric patients.

OBJECTIVE: To review current evidence of pharmacological options for managing pediatric obesity and provide potential areas for future research. DATA SOURCES: A MEDLINE search (1966 to October 2014) was conducted using the following keywords: exenatide, liraglutide, lorcaserin, metformin, obesity, orlistat, pediatric, phentermine, pramlintide, topiramate, weight loss, and zonisamide. STUDY SELECTION AND DATA EXTRACTION: Identified articles were evaluated for inclusion, with priority given to randomized controlled trials with orlistat, metformin, glucagon-like peptide-1 agonists, topiramate, and zonisamide in human subjects and articles written in English. References were also reviewed for additional trials. DATA SYNTHESIS: Whereas lifestyle modification is considered first-line therapy for obese pediatric patients, severe obesity may benefit from pharmacotherapy. Orlistat is the only Food and Drug Administration (FDA)-approved medication for pediatric obesity and reduced body mass index (BMI) by 0.5 to 4 kg/m(2), but gastrointestinal (GI) adverse effects may limit use. Metformin has demonstrated BMI reductions of 0.17 to 1.8 kg/m(2), with mild GI adverse effects usually managed with dose titration. Exenatide reduced BMI by 1.1 to 1.7 kg/m(2) and was well-tolerated with mostly transient or mild GI adverse effects. Topiramate and zonisamide reduced weight when used in the treatment of epilepsy. Future studies should examine efficacy and safety of pharmacological agents in addition to lifestyle modifications for pediatric obesity. CONCLUSIONS: Lifestyle interventions remain the treatment of choice in pediatric obesity, but concomitant pharmacotherapy may be beneficial in some patients. Orlistat should be considered as second-line therapy for pediatric obesity. Evidence suggests that other diabetes and antiepileptic medications may also provide weight-loss benefits, but safety should be further evaluated.

Evaluating second-line treatment options for type 2 diabetes: focus on secondary effects of GLP-1 agonists and DPP-4 inhibitors.

OBJECTIVE: To discuss the controversy surrounding selection of second-line type 2 diabetes mellitus (T2DM) therapy by reviewing available data regarding secondary effects of glucagon-like peptide-1 receptor (GLP-1) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors, which include low hypoglycemia risk, weight loss, and cardiovascular (CV) and ß-cell function benefits. DATA SOURCES: A MEDLINE search (1966-March 2013) was conducted using the following key terms: ß-cell protection, blood pressure, DPP-4 inhibitors, exena tide, exenatide extended-release, GLP-1 agonists, hypoglycemia, lina glip tin, lipid, liraglutide, pancreatitis, saxagliptin, sitagliptin, and type 2 diabetes. STUDY SELECTION AND DATA EXTRACTION: Identified articles published in English were evaluated for inclusion, with priority given to randomized controlled trials in humans receiving incretin monotherapy or incretin combination therapy with metformin. References identified in these articles were reviewed for additional trials. DATA SYNTHESIS: Most patients with T2DM use combination therapy; however, determination of the second-line agent that is most appropriate is debatable. Prior to the use of incretin therapies, traditional second-line agents included sulfonylureas, thiazolidinediones, and basal insulin, all of which demonstrate undesirable adverse effects. In addition to improving glycemic control, incretin therapies have demonstrated benefits concerning hypoglycemic risk and weight loss in addition to potential improvements in CV risk factors and ß-cell function. While there are risks associated with using incretins, most patients with T2DM are good candidates for incretins and could benefit from their potential secondary effects. Cost remains a barrier to initiating these agents. CONCLUSIONS: Demonstrated secondary benefits in addition to efficacy may make GLP-1 agonists and DPP-4 inhibitors a more favorable option than other second-line T2DM therapies.