Primary prevention aspirin use in high-risk patients: A pharmacist intervention and comparison of risk stratification tools.

OBJECTIVES: The objectives of this project are 1) to describe aspirin use for primary prevention in an underserved, minority population; 2) to determine the impact of a pharmacist-led intervention on the prevalence of aspirin use for primary prevention; and 3) to compare aspirin indications based on Framingham Risk Score (FRS) and atherosclerotic cardiovascular disease (ASCVD) risk score. METHODS: Men and women age 45-79 and 55-79 years, respectively, without ASCVD were screened for aspirin use. An FRS of 10% or greater and low risk for a serious bleed were considered indications for primary prevention aspirin on the basis of guideline-directed medical therapy recommendations. When treatment with aspirin was indicated, providers were notified with patient-specific messages. Patients' FRS and ASCVD risk score distributions were plotted and compared. Primary prevention aspirin indications were identified using both risk stratification tools. RESULTS: One hundred sixteen patients were evaluated for aspirin use in a predominantly black (80%), middle-aged (mean age, 58 years), and indigent population. Thirty-one patients (27%) had an FRS of 10% or greater and low risk for bleeding, and 10 patients (9%) were taking aspirin at baseline. Providers approved recommendations to start administering aspirin in 19 of 31 patients (61%), which significantly increased the overall proportion receiving aspirin compared to baseline (9%-25%; P < 0.01). Patients were more than twice as likely to meet the minimum risk score threshold (≥10%) for a primary prevention aspirin indication using ASCVD risk scores versus FRS (70% vs. 30%; P < 0.01). CONCLUSIONS: Baseline utilization of primary prevention aspirin was low in an indigent, minority population. A provider-focused pharmacist intervention improved the prevalence of aspirin use for primary prevention, while minimizing risk for serious bleeding events. Among our cohort, more patients had indications for primary prevention aspirin using ASCVD risk scores versus FRS.

Treatment of hypertension with chronotherapy: is it time of drug administration?

OBJECTIVE: To review evidence for dosing antihypertensives at bedtime and possible cardiovascular risk reduction. DATA SOURCES: A PubMed, EMBASE, and Cochrane Controlled Trials database literature search (1990-September 2014) limited to human subjects was performed using the search terms hypertension, chronotherapy, ambulatory blood pressure, morning administration, evening administration, and antihypertensives. Additional references were identified from literature citations. STUDY SELECTION: All prospective studies assessing cardiovascular outcomes or comparing morning to evening administration of antihypertensives were selected. DATA SYNTHESIS: Compared with morning administration, dosing one or more antihypertensive medications at bedtime helps induce a normal circadian blood pressure pattern and reduces the risk of cardiovascular disease morbidity and mortality in individuals with hypertension. Similar results have been reported in high-risk individuals with diabetes, chronic kidney disease, and resistant hypertension. A lack of diversity among studied populations and reliance on subgroup analyses are among the limitations of these data. All antihypertensive medications have not been studied in chronotherapy and do not uniformly achieve desired results. The most substantial evidence exists for medications affecting the renin-angiotensin-aldosterone system. CONCLUSIONS: Despite growing evidence and promise as a cost-effective strategy for reducing cardiovascular risk, chronotherapy is not uniformly recommended in the treatment of hypertension. Careful selection of patients and antihypertensives for chronotherapy is required. Further investigation is needed to evaluate the definitive impact of chronotherapy on cardiovascular outcomes.

Patient considerations in the management of type 2 diabetes - critical appraisal of dapagliflozin.

Type 2 diabetes affects more than 350 million people worldwide, and its prevalence is increasing. Many patients with diabetes do not achieve and/or maintain glycemic targets, despite therapy implementation and escalation. Multiple therapeutic classes of agents are available for the treatment of type 2 diabetes, and the armamentarium has expanded significantly in the past decade. Selective sodium glucose co-transporter 2 inhibitors, including dapagliflozin, represent the latest development in pharmacologic treatment options for type 2 diabetes. This class has a unique mechanism of action, working by increasing glucose excretion in the urine. The insulin-independent mechanism results in decreased serum glucose, without hypoglycemia or weight gain. Dapagliflozin is a once-daily oral therapy. Expanding therapy options for a complex patient population is critical, and dapagliflozin has a distinct niche that can be a viable option for select patients with diabetes.

Pharmacist membership in a medical group's diabetes health management program.

PURPOSE: An evaluation of the effectiveness of a program at achieving improved glycemic control, lipid levels, and adherence to preventive care measures in diabetes mellitus patients was conducted. SUMMARY: An interdisciplinary diabetes health management program (DHMP) was implemented, which included physicians, clinical pharmacists, registered nurses, and registered dieticians. The patients are seen by a clinical pharmacist with the option of individual or group visits with other members of the multidisciplinary team. Clinical pharmacist interventions include education and comprehensive medication management through collaborative practice agreements held with physicians. The collaborative agreements allow the clinical pharmacist to initiate, adjust, or discontinue pharmacotherapy and order pertinent laboratory tests and podiatry referrals that are within the scope of the medication management protocol. A retrospective review was conducted of the 707 patients enrolled in the program between April 2002 and April 2004. The mean +/- S.D. number of days between baseline and follow-up values was 140 +/- 62. Eighty-four percent of the enrolled patients were diagnosed with type 2 diabetes mellitus, 69% met the National Cholesterol Education Program's criteria for metabolic syndrome, and 51% were male. The mean glycosylated hemoglobin (HbA(1c)) value dropped significantly, and the percentage of patients who were at or below the American Diabetes Association's established HbA(1c) goal of < or = 7% increased significantly. Lipid values for enrolled patients improved, with the percentage achieving a low-density-lipoprotein cholesterol concentration of <100 mg/dL increasing from 25% to 44% [corrected] Adherence to preventive care measures (e.g., annual eye and foot examinations) also significantly improved from baseline to follow-up. CONCLUSION: Involvement of pharmacists in an interdisciplinary DHMP has improved patient care.