Bromocriptine mesylate for glycemic management in type 2 diabetes mellitus.

OBJECTIVE: To review the pharmacologic characteristics, safety, and efficacy of bromocriptine mesylate for glycemic control in patients with type 2 diabetes mellitus. DATA SOURCES: A Scopus and MEDLINE search (1950-June 2010) was conducted using the key words bromocriptine, diabetes, and circadian rhythm. Data were also received from the manufacturer. STUDY SELECTION AND DATA EXTRACTION: Available abstracts, studies, and review articles published in English with human data discussing bromocriptine treatment for type 2 diabetes mellitus were reviewed. DATA SYNTHESIS: Bromocriptine is an ergot derivative available for treatment of type 2 diabetes. The mechanism of action of this agent is unclear; however, activity as a dopamine D2 receptor agonist seems to provide the primary mechanism for utility in resetting the circadian rhythm in patients with type 2 diabetes. Other mechanisms, including α-1 antagonist, α-2 agonist, and serotonin and prolactin modulator, may also help to explain bromocriptine's glucose-lowering effects. Studies with bromocriptine have included 4328 patients with type 2 diabetes. The majority of available trials conducted enrolled patients for a study duration of 6-24 weeks. One trial evaluating the safety and efficacy of bromocriptine concluded after 52 weeks of follow-up. Endpoints of hemoglobin A1(c) (A1C) reduction and plasma glucose concentrations were the primary focus of all studies, with statistically significant differences found. Bromocriptine use resulted in a mean A1C reduction of 0.27% (range 0.1-0.6), while placebo resulted in a mean A1C increase of 0.48% (range 0.3-1.1). Incidence of adverse effects of nausea, vomiting, headache, and rhinitis was greater than that of placebo in clinical trials. Cardiovascular endpoints did not differ from those of placebo. CONCLUSIONS: Bromocriptine has demonstrated efficacy as an adjunctive agent in the management of type 2 diabetes. Caution may be warranted in the elderly population or patients at risk for suspected drug-drug interactions. Further studies of longer duration may help to define the role of bromocriptine in the management of diabetes.

Smoking cessation treatment for adolescents.

Cigarette smoking in the adolescent population remains a public health concern. A significant portion of the adolescent population currently uses tobacco. Nicotine is particularly addicting in adolescents, and quitting is difficult. The goals for adolescent cigarette smoking efforts must include both primary prevention and smoking cessation. Bupropion and nicotine replacement therapies-including nicotine patches, gum, and nasal spray-have been studied to a limited extent in the adolescent population. Varenicline has not been evaluated as a treatment modality in adolescents. Long-term quit rates in the pharmacotherapy trials have not been optimal; however, decreases in cigarettes smoked per day have been observed. Several evidencebased guidelines include recommendations for smoking cessation in adolescents that include counseling and pharmacotherapy. Pharmacotherapy may be instituted for some adolescents in addition to counseling and behavioral interventions. Therapy should be individualized, based on smoking patterns, patient preferences, and concomitant disease states. Smoking cessation support for parents should be instituted as well. The pharmacist can play a large role in helping the adolescent quit smoking. Further studies evaluating pharmacotherapy options for smoking cessation in adolescents are necessary. If pharmacotherapy is used, it should be individualized and combined with psychosocial and behavioral interventions.

Evaluation of seven i.v. drug compatibility references by using requests from a drug information center.

PURPOSE: The scope of coverage and clinical performance of i.v. drug compatibility references were evaluated for drug pairs. METHODS: Compatibility pairs were selected from a drug information center database of previous questions. Duplicate pairs, contrast media, and nondrug chemicals were excluded. Scope of coverage was defined as whether i.v. compatibility information was present for each pair and was reported as a percentage. Clinical performance included the agreement among the references on compatibility, the inclusion of specific concentration information for each drug in a pair, and the presence of references for the information provided. The analysis included one print reference (Handbook on Injectable Drugs, 14th edition) and six electronic i.v. drug compatibility references (King Guide to Parenteral Admixtures, Trissel's 2 Clinical Pharmaceutics Database, Micromedex's IV INDEX, Gold Standard's Clinical Pharmacology, Facts and Comparisons 4.0 IV Chek, and CompoundingToday.com). The manufacturers' online labeling was also consulted. RESULTS: A total of 97 unique drug pairs were analyzed. Four databases contained i.v. compatibility information on 76% of the drug pairs, one contained 62%, one contained 58%, one contained 56%, and the manufacturers' labeling contained 13% of the pairs. Seventy-nine percent of the pairs had agreement among the references as to whether the pair was compatible, incompatible, or variable. Compounding Today.com, Facts and Comparisons IV Chek, the Handbook on Injectable Drugs, IV INDEX, and Trissel's 2 reported concentrations and references for the information given on all pairs. CONCLUSION: The highest-performing references included in the evaluation used the compatibility information provided in Trissel's 2 database as their source of information. Other popular references identified fewer pairs, and the manufacturers' labeling rarely contained compatibility information.

Drug information: from education to practice.

Drug information is a specialty area within the realm of clinical pharmacy that has evolved as technology and clinical practice have changed. Drug information specialists are trained individuals who have clinical knowledge and skills that allow them to provide clear, concise, and accurate recommendations regarding drug use. The constant changing culture of drug information and health care in general has prompted the need for continual growth and refinement of the standards that govern drug information practice. This article outlines specific standards to help ensure that the education and practice of drug information will continue to meet the needs of the health care community. This opinion paper is divided into two sections: Education and Training, and Practice Areas. The Education and Training section is organized to describe the role of drug information and that of the drug information specialist in the training of all pharmacy students and advanced trainees, as well as to describe the role of focused training for those individuals wishing to specialize in drug information. This article also affirms the recommendations for the standards-based approach to drug information education and specialty training. The Practice Areas section is organized to describe the role of the drug information specialist within various practice settings, to identify some of the challenges faced by the drug information specialist within those settings, and to provide recommendations for the different practice areas. The areas found within this section include academia, institutional health systems, managed care, industry, medical writing, and informatics.

A regional poison prevention education service-learning project.

OBJECTIVE: To create a service-learning project to provide poison prevention education to preschool through fifth-grade students. DESIGN: The School of Pharmacy collaborated with the Illinois Poison Center and campus departments to train pharmacy students as poison prevention educators. Seventy-eight first-year pharmacy students developed and gave age-appropriate, interactive presentations to more than 8,000 students at preschools and elementary schools. ASSESSMENT: Preintervention and postintervention evaluations and reflections were collected from the pharmacy students. Ninety-nine percent agreed that they enjoyed the experience and 88% stated that they would continue to provide poison prevention presentations. Based on written assessment of the presentations, most of the preschool and elementary teachers agreed or strongly agreed that the presentations were organized, clear, appropriate for the students, and relevant, and that the pharmacy students appeared knowledgeable and professional. CONCLUSION: Poison prevention education was an appropriate service-learning project for pharmacy students and provided a beneficial service to the community.

Weekly active-learning activities in a drug information and literature evaluation course.

OBJECTIVES: To incorporate learning activities into the weekly 2-hour Drug Information and Literature Evaluation class sessions to improve student ability and confidence in performing course objectives, as well as to assess student perception of the value of these activities. METHODS: In-class activities that emphasized content and skills taught within class periods were created and implemented. Three different surveys assessing student ability and confidence in completing drug information and literature retrieval and evaluation tasks were administered prior to and following the appropriate class sessions. At the completion of the course, an additional evaluation was administered to assess the students' impressions of the value of the learning activities. RESULTS: Students reported increased ability and confidence in all course objectives. The teaching activities were also stated to be useful in students' learning of the material. CONCLUSIONS: Incorporation of weekly learning activities resulted in an improvement in student ability and confidence to perform course objectives. Students considered these activities to be beneficial and to contribute to the completion of course objectives.

Evaluating the accuracy of health news publications in a drug literature evaluation course.

OBJECTIVES: To design an assignment for second-professional year pharmacy students to assess the accuracy and quality of health information published in the news. DESIGN: Students in a literature evaluation course were assigned a health-related news publication to review and find the original published research article. They then critically evaluated the quality and accuracy of the news publication based on the original research. All students wrote a critique focusing on the quality and accuracy of the news article and potential responses the lay public might have. ASSESSMENT: Eighty-four percent of students agreed the writing assignment reinforced critical literature evaluation skills, while 90% agreed the assignment contributed to completion of course objectives. CONCLUSIONS: A writing assignment requiring comparison of a news publication to the original research reinforces critical literature evaluation and communication skills, as well as stimulates thought about the accuracy, quality, and public responses to health information published in the news.

Propofol-related infusion syndrome in critically ill pediatric patients: coincidence, association, or causation?

Over the past two decades numerous reports have described the development of a propofol-related infusion syndrome (PRIS) in critically ill adult and pediatric patients who received continuous infusion propofol for anesthesia or sedation. The syndrome is generally characterized by progressive metabolic acidosis, hemodynamic instability and bradyarrhythmias that are refractory to aggressive pharmacological treatments. PRIS may occur with or without the presence of hepatomegaly, rhabdomyolysis or lipemia. To date, the medical literature contains accounts of 20 deaths in critically ill pediatric patients who developed features consistent with PRIS. These reports have generated considerable discussion and debate regarding the relationship, if any, between propofol and a constellation of clinical symptoms and features that have been attributed to its use in critically ill pediatric patients. This paper reviews the literature concerning PRIS, its clinical presentation, proposed mechanisms for the syndrome, and potential management should the syndrome occur.

Evaluation of accuracy of health studies reported in mass media.

OBJECTIVE: To evaluate communication of clinical research in the written media for completeness and accuracy. DESIGN: Observational assessment. SETTING: United States. PARTICIPANTS: Not applicable. INTERVENTIONS: Content of media articles discussing randomized controlled trials was assessed by three reviewers on the basis of the Consolidated Standards of Reporting Trials (CONSORT) criteria modified for the mass media. Reports from October 1 through December 31, 2002, published in the top two U.S. daily newspapers (USA Today and Wall Street Journal), weekly news magazines (Time and Newsweek), and daily news Web sources (CNN.com and MSNBC.com) and the corresponding published RCTs were analyzed. MAIN OUTCOME MEASURES: Total score and score in 10 specific content areas, leading to classification of coverage as poor, fair, or excellent. RESULTS: A total of 60 media reports discussing results of 25 RCTs appeared in these media during the study period. All reports were categorized as fair, and no content area was rated excellent. Several content areas received poor rankings in all and/or most media, including reporting of adverse effects, outcomes data, and statistical tests used. Media reports written by newswire services were rated more highly than were those prepared by nonnewswire services, but only 1 of 10 criteria had statistically significant differences. CONCLUSION: Mass media reports of RCTs are often incomplete. This type of reporting may misinform the lay public and may lead to questions about the applicability of the results to individual patients.

Nephrotoxicity with combination vancomycin-aminoglycoside therapy.

OBJECTIVES: The purpose of this paper is to review the medical literature regarding vancomycinaminoglycoside induced nephrotoxicity in the pediatric population. METHODS MEDLINE: (1966 through June 2005), EMBASE (1980 through 1st quarter 2005), and International Pharmaceutical Abstracts databases were reviewed using appropriate search terms for articles related to nephrotoxicity with vancomycin and aminoglycoside use. Case reports, letters to editors, retrospective and prospective studies evaluating nephrotoxicity with the agents in pediatric patients were compiled and summarized. Studies in animals and adults were also briefly reviewed. RESULTS: One case report, two letters to editors, one retrospective study, and two prospective studies evaluated the nephrotoxicity of combination aminoglycoside and vancomycin therapy in pediatric patients. The collective number of patients in the reports was 165. Patients ranged in age from 3 days to 19 years old. Four out of the six reports, including all of the prospective studies, concluded that combination therapy does not potentiate nephrotoxicity. CONCLUSIONS: Although vancomycin and the aminoglycosides have been associated with drug induced nephrotoxicity, reports in the literature do not appear to support the idea that the combination of vancomycin and an aminoglycoside is more nephrotoxic than either medication alone.

Respiratory stimulant use in chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the use of respiratory stimulants in chronic obstructive pulmonary disease (COPD). DATA SOURCES: MEDLINE (1966-July 2003) and EMBASE (1980-3rd quarter 2003) were searched using the search terms medroxyprogesterone acetate, acetazolamide, chronic obstructive pulmonary disease, and chronic obstructive lung disease. DATA SYNTHESIS: Trials are reviewed evaluating ventilatory parameters with acetazolamide and/or medroxyprogesterone in patients with COPD. All studies found improvements in ventilatory parameters, but failed to demonstrate improvements in survival or quality of life. CONCLUSIONS: Significant improvement in arterial blood gas and ventilatory parameters was reported in COPD patients after acetazolamide and medroxyprogesterone treatment; however, with no improvement in survival or quality of life, the place of these drugs in therapy remains unknown.

Evaluation of angiotensin-converting enzyme inhibitor use in patients with type 2 diabetes in a state managed care plan.

OBJECTIVE: To compare angiotensin-converting enzyme (ACE) inhibitor use in patients with type 2 diabetes at 1 year and 3 years after guidelines were published. STUDY DESIGN: Retrospective database review. PATIENTS AND METHODS: The drug utilization review database of a state managed care plan was accessed to retrieve 2 random samples of 500 patients each. These patients had an International Classification of Diseases, Ninth Revision, Clinical Modification code for diabetes mellitus (250) and a National Drug Code for an oral hypoglycemic agent in both 1998 and 2000. Specific clinical modification codes, prescription claims, and diagnostic codes were obtained from patient profiles. Use of ACE inhibitors in 1998 and 2000 then was evaluated by using Pearson's chi-square test. RESULTS: The proportion of patients with diabetes and hypertension who were taking an ACE inhibitor increased by 10 percentage points over the 2 years; however, ACE inhibitors were only used in 46% of those patients in 2000. A few of the patients receiving an ACE inhibitor had a contraindication to use of the agent. Microalbuminuria screening and glycosylated hemoglobin screening were found to have been conducted in only 4.6% and 54.6%, respectively, of the 496 patients in 2000. CONCLUSIONS: The results of this study indicate that although ACE inhibitor use improved, fewer than 50% of patients received appropriate therapy. Awareness of and adherence to the recommendations in the guidelines need to be improved. Larger studies may be beneficial to determine more clearly the extent of this problem.

Urinary-based ovulation and pregnancy: point-of-care testing.

OBJECTIVE: To review the literature concerning ovulation prediction devices and pregnancy detection tests for home use. DATA SOURCES: Articles were identified through searches of the MEDLINE (1966-May 2003), EMBASE (1980-May 2003), and International Pharmaceutical Abstracts (1970-May 2003) databases using the key words ovulation, ovulation detection, pregnancy test, diagnostic reagent kit, and diagnostic test. Additional references were located through review of the bibliographies of the articles found in the literature search. Searches were not limited by time restriction, language, or use of human or animal subjects. STUDY SELECTION AND DATA EXTRACTION: Review articles, textbook chapters, and experimental and observational studies on home use ovulation and pregnancy tests were selected. DATA SYNTHESIS: Luteinizing hormone (LH)-based ovulation tests have demonstrated accurate and superior ovulation detection when compared to basal body temperature charting, calendar calculation, salivary ferning, or observation of vaginal or cervical discharge changes. Systems using LH and estrone-3-glucuronide (E3G) have also demonstrated accurate detection of the fertile period. Literature evaluating home use of pregnancy tests has demonstrated accurate use by lay persons. CONCLUSIONS: Urinary-based ovulation prediction and pregnancy detection tests available for use by nonprofessionals enable women and couples to take an active role in the family planning process. Numerous products are available at reasonable costs to the consumer.

Comparing therapies for postmenopausal osteoporosis prevention and treatment.

OBJECTIVE: To review the literature concerning the efficacy of calcium, hormone replacement therapy (HRT), bisphosphonates, selective estrogen receptor modulators, and calcitonin in the prevention and treatment of postmenopausal osteoporosis. DATA SOURCES: Articles were identified through searches of the MEDLINE (1966-July 2002), EMBASE (1980-July 2002), and International Pharmaceutical Abstracts (1970-July 2002) databases using the key words osteoporosis, postmenopausal, fracture, calcium, vitamin D, hormone replacement therapy, bisphosphonates, alendronate, risedronate, raloxifene, and calcitonin. Additional references were located through review of the bibliographies of the articles cited. Searches were not limited by time restriction, language, or human subject. STUDY SELECTION AND DATA EXTRACTION: Experimental and observational studies of the use of calcium and antiresorptive therapies for the prevention and treatment of postmenopausal osteoporosis were selected. Articles evaluating bone mineral density (BMD) or fracture efficacy were included in this review. DATA SYNTHESIS: HRT, bisphosphonates, raloxifene, and calcitonin have demonstrated stabilization of and improvement in BMD. Randomized clinical trials have shown fracture risk reduction with bisphosphonates, raloxifene, HRT, calcium, and calcitonin. The largest risk reductions have been reported with use of bisphosphonates in several trials. CONCLUSIONS: Several therapeutic options with well-documented improvements in BMD and reductions in fracture risk are available to women for the prevention and treatment of postmenopausal osteoporosis.