Management of patients with type 2 diabetes by pharmacists in primary care clinics.

OBJECTIVE: To determine the impact of clinical pharmacists involved in direct patient care on the glycemic control of patients with type 2 diabetes mellitus. DESIGN: Eligible patients included those with type 2 diabetes who received insulin or were initiated on insulin therapy by the pharmacists and were willing to perform self-monitoring of blood glucose. The pharmacists provided diabetes education, medication counseling, monitoring, and insulin initiation and/or adjustments. All initial patient interactions with the pharmacists were face-to-face. Thereafter, patient-pharmacist interactions were either face-to-face or telephone contacts. SETTING: Two primary care clinics in a university-affiliated Veterans Affairs Medical Center. PARTICIPANTS: Study subjects were patients with type 2 diabetes who were referred to the pharmacists by their primary care providers for better glycemic control. OUTCOME MEASURES: Primary outcome variables were changes from baseline in glycosylated hemoglobin, fasting blood glucose, and random blood glucose measurements. Secondary outcomes were the number and severity of symptomatic episodes of hypoglycemia, and the number of emergency room visits or hospitalizations related to diabetes. Twenty-three veterans aged 65-9.4 years completed the study. Fifteen (65%) patients were initiated on insulin by the pharmacists; 8 (35%) were already using insulin. Patients were followed for a mean-SD of 27-10 weeks. Glycosylated hemoglobin, fasting blood glucose concentrations, and random blood glucose concentrations significantly decreased from baseline by 2.2% (p = 0.00004), 65 mg/dL (p < 0.01), and 82 mg/dL (p = 0.00001), respectively. Symptomatic hypoglycemic episodes occurred in 35% of patients. None of these episodes required physician intervention. CONCLUSIONS: This study demonstrates that pharmacists working as members of interdisciplinary primary care teams can positively impact glycemic control in patients with type 2 diabetes requiring insulin.

Potential interaction between warfarin and fluvastatin.

OBJECTIVE: To report three cases of a suspected interaction between warfarin and fluvastatin. CASE SUMMARIES: Three patients receiving stable warfarin dosages with therapeutic international normalized ratios (INRs) exhibited increased INRs when fluvastatin was added to their maintenance regimens. While none of the patients experienced a bleeding episode, they did require a reduction in their weekly warfarin dosage to achieve an appropriate level of anticoagulation. DISCUSSION: Reports of an interaction between warfarin and lovastatin have been described previously; however, to our knowledge, this is the first published report of a possible interaction between warfarin and fluvastatin. These cases were chosen because other factors that could potentially increase the INR were ruled out as significant contributors. CONCLUSIONS: The exact mechanism for the potential interaction between warfarin and fluvastatin is unknown. Until more is known, it is advisable to monitor patients more frequently when fluvastatin is initiated, discontinued, or adjusted in patients taking warfarin.

Lisinopril overdose and management with intravenous angiotensin II.

OBJECTIVE: This report describes a case of lisinopril overdose managed in part with an infusion of angiotensin II in a patient with dilated cardiomyopathy and reviews other literature reporting angiotensin-converting enzyme (ACE) inhibitor overdose. DATA SOURCES: Information concerning this patient was obtained through review of the medical chart, conversation with the attending physician, and personal involvement late in the course of the patient's therapy. We conducted MEDLINE and PAPERCHASE searches of the English language literature (restricted to human studies) from 1976 to the present, manually searched Current Contents and references from each publication reviewed, and contacted the manufacturer of lisinopril for any further references they could provide. STUDY SELECTION: All case reports that described an ACE inhibitor overdose. DATA EXTRACTION: Case reports were evaluated for the ACE inhibitor involved, amount ingested, and therapeutic management. DATA SYNTHESIS: Ten patients with ACE inhibitor overdose have been reported, most of whom required only intravenous fluids for blood pressure support. The case presented here is the second report in which the patient's blood pressure was not adequately controlled with fluid and traditional vasopressors and required an infusion of angiotensin II. CONCLUSIONS: Although only a few cases of ACE inhibitor overdose have been reported, it is possible that with widespread use of these agents, overdose may become a more common problem. Management of ACE inhibitor overdose should include general supportive care, gut decontamination when possible, intravenous fluids, and vasopressors if necessary. Intravenous angiotensin II may be effective in situations in which traditional vasopressors fail, and is a physiologically rational treatment.