Christa M. George

Smoking and Asthma

Background: The purpose of this review is to describe the current understanding of the prevalence and adverse effects of cigarette smoking and secondhand smoke (SHS) in asthmatics in terms of patient outcomes and response to inhaled corticosteroids. Methods: We searched the English biomedical literature via PubMed, Embase, and Scopus using the terms “smoking and asthma,” “secondhand smoke and asthma,” “environmental tobacco smoke and asthma,” and “smoking/secondhand smoke and corticosteroids.” We also reviewed reference lists of identified articles for relevant citations. Results: In asthmatic patients who smoke, disease control is poorer than in asthmatic nonsmokers. Of all forms of SHS, maternal exposure seems to have the largest impact on asthma by increasing the frequency and severity of the disease and decreasing lung function. Asthmatic children exposed to multiple household smokers face an increased risk for respiratory illness-related absences from school, and these effects persist during adolescence but weaken during adulthood. Airway mucosal permeability is increased in smokers, which could lead to increased clearance of inhaled corticosteroids from the airways. Smokers also have decreased histone deacetylase activity, which is necessary for corticosteroids to fully suppress cytokine production, and can lead to corticosteroid resistance. Conclusions: Cigarette smoking and SHS in asthmatics lead to detrimental effects in patient outcomes and effectiveness of steroid therapy.

Warfarin-Cranberry Juice Interaction

Objective: To report a case of warfarin-cranberry juice interaction, which resulted in an international normalized ratio (INR) elevation on 2 separate occasions. Case Summary: A 46-year-old female was receiving a total weekly dose of 56 mg of warfarin. During the 4 months prior to the incident INR. her average INR was 2.0. with a range of 1.6-2.2, while taking the same weekly dose of warfarin. Her INR increased to 4.6 after drinking approximately 1.5 quarts (1420 mL) of cranberry juice cocktail daily for 2 days. Her INR 14 days later without cranberry juice cocktail consumption was 2.3. For the next 3 months, while taking warfarin 56 mg per week, her average INR was 2.1, with a range of 1.4-2.5. At a subsequent visit, after drinking approximately 2 quarts (1S93 mL) of cranberry juice cocktail daily for 3-4 days, her INR had increased to 6.5. Her INR after holding warfarin for 3 days was 1.86. Her INR 7 days after resuming the weekly dose of warfarin 56 mg was 3.2. During both of the elevated INR episodes, no other factors were identified that would have resulted in an elevated INR, such as drug, herbal, disease, or other food interactions. An objective causality assessment revealed the interaction was highly probable. Discussion: Warfarin is the most commonly used anticoagulant for chronic therapy. There have been several case reports of cranberry juice or cranberry sauce potentiating the effects of warfarin by elevating the INR; however, clinical trials evaluating this interaction have failed to demonstrate a significant effect on an INR. Conclusions: Our case report describes INR elevations in a patient previously stable on warfarin after ingestion of cranberry juice cocktail daily for several days. This elevation occurred on 2 separate occasions, which distinguishes our case from other published literature.

Pancreatitis: A Potential Complication of Liraglutide?

OBJECTIVE: To review the evidence surrounding a potential association between liraglutide and pancreatitis. DATA SOURCES: A literature search was conducted in MEDLINE (1948-July 12, 2012) and EMBASE (1974-week 27, 2012) using the search terms pancreatitis, liraglutide, and glucagon-like peptide 1/adverse effects. Reference citations from identified publications were reviewed. The manufacturer was contacted and regulatory documents from the Food and Drug Administration website were reviewed for unpublished data related to cases of pancreatitis associated with liraglutide use. STUDY SELECTION AND DATA EXTRACTION: All identified sources that were published in English were considered for inclusion. DATA SYNTHESIS: Eleven cases of pancreatitis have been reported in patients taking liraglutide. Seven were from the LEAD (Liraglutide Effect and Action in Diabetes) studies, 1 was reported in the extension of a clinical trial, and 1 was in an unpublished obesity trial. Two were published postmarketing case reports. Nine of the cases reported were diagnosed as acute pancreatitis, while 2 were classified as chronic pancreatitis. The mean age of the patients was 57.5 years and mean body mass index was 33.92 kg/m2. Six of the 11 cases occurred in male patients. Nine of the patients were white and 1 was African American. In 7 of the cases, onset occurred at liraglutide doses at or above 1.8 mg daily. Common comorbidities included history of pancreatitis, cholelithiasis, and diabetes. One case was fatal. CONCLUSIONS: Pancreatitis is a potential complication with liraglutide therapy. Liraglutide should be used cautiously in patients at risk of pancreatitis (eg, alcohol abuse, history of pancreatitis, cholelithiasis).

Pharmacist-Physician Collaboration for Diabetes Care: The Diabetes Initiative Program:

BACKGROUND: Multiple complications can arise secondary to poor control of glucose, blood pressure, and cholesterol in a patient with diabetes. OBJECTIVE: To evaluate the effect of a pharmacist-physician collaboration on attainment of diabetes-related measures of control. METHODS: This was a prospective, multicenter, cohort study. Patients were enrolled from 7 practice sites throughout Tennessee if they had been diagnosed with type 2 diabetes, were aged 18 years or older with a life expectancy greater than 1 year, and were English speaking. Pregnant women were excluded. Patients were followed for 12 months following enrollment by informed consent. The pharmacist-physician collaboration method was established prior to study initiation. Primary outcomes included hemoglobin A1c (A1C), number of patients with A1C less than 7%, and percentage of patients with A1C greater than 9%. RESULTS: Of the 206 patients enrolled, the mean age was 59.73 years, and most were male (59.71%) and white (66.02%). The A1C was reduced by an average of 1.16% (p < 0.0001). The proportion of patients with A1C less than 7% increased from 12.75% at baseline to 36.76% at study conclusion (p = 0.0002). The proportion of patients with A1C greater than 9% decreased from 34.15% to 16.50%, (p < 0.0001). CONCLUSIONS: Pharmacist-physician collaborative management at multiple practice locations and types of setting (eg, private, academic, Veterans Affairs medical center) has a positive impact on glycemic control and diabetes-related health maintenance. This was accomplished without increasing the total number of antihyperglycemic agents prescribed and without an increase in patient-reported episodes of hypoglycemia.

An evaluation of peak expiratory flow monitoring: a comparison of sitting versus standing measurements.

Introduction: Current guidelines for the diagnosis and management of asthma suggest that patients perform peak expiratory flow (PEF) measurements while standing; however, recent literature suggests this may not be necessary. The purpose of this study was to determine the impact of patient position on PEF measurements. Methods: A randomized observational analysis of PEF measurements for 211 patients in sitting and standing positions was performed. The highest PEF measurement from tests performed with correct technique in both the sitting and standing position was compared. Results: Overall, PEF measurements did not significantly differ between the sitting and standing positions (506 ± 2 L/min versus 508 ± 2 L/min; P = .45). No differences were seen between mean PEF measurements in the sitting or standing positions for either women or men, nor were there significant differences between mean PEF values for the sitting and standing positions in participants who reported a history of asthma. Conclusions: PEF measurements do not significantly differ based on sitting or standing measurements among healthy participants. Based on the results of this study it may not be necessary for the patient to stand while performing PEF measurements. Further study among patients with asthma is warranted.

Gender differences in metered-dose inhaler-spacer device technique.

Study Objective. To determine whether gender affects the correct use of a metered‐dose inhaler (MDI)‐spacer device.

Peak Expiratory Flow in Bed? A Comparison of 3 Positions

BACKGROUND: Current guidelines for the correct peak expiratory flow (PEF) maneuver include standing. In the hospital setting, PEF values are often ordered to assess response to asthma therapy for exacerbations. We have observed that the PEF is sometimes performed with the patient in bed. METHODS: Healthy adults performed the PEF maneuver in random order, standing, lying back at an ∼45° angle on pillows, and sitting, slumped forward ∼10° with legs extended. PEF was recorded for 3 attempts in each of the 3 positions. RESULTS: We enrolled 94 subjects (39 male, 55 female, mean age 24 y) in 2011. Mean PEF in the standing position (669 ± 42 L/min) was significantly higher than in the lying back (621 ± 42 L/min) (P < .001) and sitting (615 ± 42 L/min) positions in males (P < .001), and, similarly, in females, standing produced a significantly higher mean PEF (462 ± 42 L/min) than the lying back (422 ± 42 L/min) (P < .001) and sitting (447 ± 42 L/min) positions (P < .05). CONCLUSIONS: Clinicians should ensure that PEF is obtained with patients out of bed and in the standing position.

Are there gender differences in the use of peak flow meters

To determine if there are gender differences in correct use of peak flow meters (PFM), third-year doctor of pharmacy students (n = 83; 52 females, 31 males) were instructed in a classroom on correct use of a PFM, including demonstrations. Students were then immediately divided into five groups, given a PFM, and assessed for three attempts in private individual sessions. Males had superior performance on the first attempt for total score (p < 0.05) and for “inhale fully” (p < 0.05). On the second attempt, the total score was not different, but males scored higher on “exhale as fast and as hard as you can” (p < 0.05). Controlled gender studies examining use of PFM in adult and pediatric patients with asthma are warranted.

Incorrect use of peak flow meters: are you observing your patients?

Abstract Background: Monitoring peak expiratory flow (PEF) values is one option as part of asthma action plans per national guidelines. PEF assessment is also recommended in emergency department and hospitalized patients. Incorrect use of peak flow meters (PFM) has obvious implications for appropriate decisions by patients and clinicians. Methods: We searched the English literature via PubMed and SCOPUS using the following search terms: PEF maneuver; incorrect use of PFM. When pertinent articles were found, we assessed publications cited in those papers. All studies related to incorrect use of PFM in patients with asthma were included. Results: Nine studies have reported errors in performing the PEF maneuver, including three pediatric and six adult studies. Errors were found at most steps of the maneuver, and inability to perform all steps correctly was common in these investigations. Examples of errors included failure to inhale fully or give maximum effort on exhalation, accelerating air with the tongue and buccal musculature, and performing only one attempt versus three. Gender differences in correct use of PFM are suggested by three adult studies. One study described falsifying PEF values by manipulating the PFM indicator, and another investigation assessed the PEF maneuver in two positions in bed versus the correct posture of standing. Conclusion: Many pediatric and adult patients do not use PFM correctly. Clinicians should regularly observe patients use PFM to detect errors and help ensure correct use and accurate PEF measurements.

New Injectable Agents for the Treatment of Type 2 Diabetes Part 1 – Injectable Insulins

The United States Food and Drug Administration has recently approved several new insulin products and new formulations of existing insulin products. These new products may provide advantages over older products, such as a lower risk of nocturnal hypoglycemia and ease of dosing; however, they are costly. The first of 2 articles in a series, this review will describe the potential advantages and disadvantages of these new insulin products.