Bradley R. Williams

Which Providers Should Communicate Which Critical Information About a New Medication? Patient, Pharmacist, and Physician Perspectives

OBJECTIVES: To investigate older patient, pharmacist, and physician perspectives about what information is essential to impart to patients receiving new medication prescriptions and who should provide the information.

Older patient, physician and pharmacist perspectives about community pharmacists' roles.

Objectives  To investigate older patient, physician and pharmacist perspectives about the role of pharmacists in pharmacist‐patient interactions.

Alzheimer's disease management guideline: update 2008.

Frequent review and update of guidelines are necessary for them to remain current and useful for clinical practices. This second revision of the postdiagnostic management of Alzheimers disease (AD) guideline by the California Workgroup was prompted by significant advances in knowledge about appropriate care management, including pharmacologic and nonpharmacologic approaches to treatment of the disease, accompanying behavioral problems, and functional decline. The focus remains explicitly on primary care, where the majority of it occurs for those with AD and other dementias.

Cardiovascular Drug Therapy in the Elderly: Theoretical and Practical Considerations

The elderly population is expanding rapidly throughout the world. Hypertension, heart disease and other cardiovascular disorders are prevalent conditions among this age group. Consequently, clinicians will spend a large proportion of their practices managing older adults with cardiovascular disorders. A large proportion of this time will be devoted to using pharmacotherapeutic strategies for the long-term management of chronic conditions.The physiological changes that accompany aging affect cardiovascular function, and the pharmacokinetics and pharmacodynamics of many cardiovascular medications are altered by these physiological changes. The interactions of these changes can have a profound effect on the agents used to treat cardiovascular disorders and may alter their therapeutic outcomes.Several classes of medications are used to treat chronic cardiovascular disorders in older adults. These include the ACE inhibitors and angiotensin II receptor antagonists, calcium channel antagonists, β-adrenoceptor antagonists (β-blockers), oral antiarrhythmic agents and warfarin. Drugs such as β-blockers may aggravate decreased cardiac output and increase peripheral resistance, but are valuable adjuncts in many patients with congestive heart failure. Agents that reduce angiotensin II activity may have several benefits for treating heart failure and hypertension. Successful treatment of cardiovascular disorders in older adults requires the choice of the most appropriate agent, taking into consideration the complex interactions of pharmacokinetics, pharmacodynamics and disease effects.

Association between use of warfarin with common sulfonylureas and serious hypoglycemic events: retrospective cohort analysis

Study question Is warfarin use associated with an increased risk of serious hypoglycemic events among older people treated with the sulfonylureas glipizide and glimepiride? Methods This was a retrospective cohort analysis of pharmacy and medical claims from a 20% random sample of Medicare fee for service beneficiaries aged 65 years or older. It included 465 918 beneficiaries with diabetes who filled a prescription for glipizide or glimepiride between 2006 and 2011 (4 355 418 person quarters); 71 895 (15.4%) patients also filled a prescription for warfarin (416 479 person quarters with warfarin use). The main outcome measure was emergency department visit or hospital admission with a primary diagnosis of hypoglycemia in person quarters with concurrent fills of warfarin and glipizide/glimepiride compared with the rates in quarters with glipizide/glimepiride fills only, Multivariable logistic regression was used to adjust for individual characteristics. Secondary outcomes included fall related fracture and altered consciousness/mental status. Summary answer and limitations In quarters with glipizide/glimepiride use, hospital admissions or emergency department visits for hypoglycemia were more common in person quarters with concurrent warfarin use compared with quarters without warfarin use (294/416 479 v 1903/3 938 939; adjusted odds ratio 1.22, 95% confidence interval 1.05 to 1.42). The risk of hypoglycemia associated with concurrent use was higher among people using warfarin for the first time, as well as in those aged 65-74 years. Concurrent use of warfarin and glipizide/glimepiride was also associated with hospital admission or emergency department visit for fall related fractures (3919/416 479 v 20 759/3 938 939; adjusted odds ratio 1.47, 1.41 to 1.54) and altered consciousness/mental status (2490/416 479 v 14 414/3 938 939; adjusted odds ratio 1.22, 1.16 to 1.29). Unmeasured factors could be correlated with both warfarin use and serious hypoglycemic events, leading to confounding. The findings may not generalize beyond the elderly Medicare population. What this study adds A substantial positive association was seen between use of warfarin with glipizide/glimepiride and hospital admission/emergency department visits for hypoglycemia and related diagnoses, particularly in patients starting warfarin. The findings suggest the possibility of a significant drug interaction between these medications. Funding, competing interests, data sharing JAR and DPG receive support from the National Institute on Aging, the Commonwealth Fund, and the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California. ABJ receives support from the NIH Office of the Director. No additional data are available.

Reaching the homebound elderly: the Prescription Intervention and Lifelong Learning (PILL) program.

SUMMARY This article describes the Prescription Intervention and Lifelong Learning (PILL) program, a three-year pilot project to develop in-home pharmacy care services to clients of a community-based social service agency. Clients who were homebound, at least 62 years of age, and taking at least five medications were eligible for inclusion. Potential participants were referred by care managers to the pharmacist, who conducted an in-home evaluation of the medication regimen and assessed the risk for medication-related problems. The pharmacist provided instruction for hypertension and diabetes mellitus self-monitoring, extensive medication counseling for clients with complex medications regimens, and conducted other activities to promote positive medication-related outcomes. The clients served were primarily female, between 70 and 90 years of age, and almost one-half lived alone. They were taking an average of more than nine medications daily, and had at least one chronic disease. The clients of the social service agency were highly vulnerable to medication-related problems and were in need of in-home pharmacy care services.

Hormone Replacement: The Fountain of Youth?

Natural aging brings reduced production of growth and sex hormones, beginning in middle age, with noticeable physiologic changes by the sixth or seventh decade of life: reduced muscle mass, energy, and exercise capacity and alterations in sexual function. Hormones and hormone precursors have been investigated to delay changes in body composition, strength, and physical and cognitive function. Menopausal hormone therapy is effective for vasomotor and genitourinary symptoms. Testosterone is effective in men with hypogonadism and declines in physiologic function. The lack of clinical studies evaluating the long-term effects and risks of hormone replacement limits its use.

Authors’ reply to Bosco-Lévy and Salvo

We thank Bosco-Levy and Salvo for their comments,1 2 and we deal with each in turn. Warfarin dosing is hard to measure in a claims database (because of important interaction with patient physiology), but glipizide/glimepiride dosing is more readily assessed. Bosco-Levy and Salvo are correct that hypoglycemia risk increases with dose. Our findings reflect low and high dose users, and future research should …