Devra K. Dang

Management of Chronic Nonmalignant Pain with Nonsteroidal Antiinflammatory Drugs : Joint Opinion Statement of the Ambulatory Care, Cardiology, and Pain and Palliative Care Practice and Research Networks of the American College of Clinical Pharmacy

Chronic nonmalignant pain is a major burden on the health care system in the United States. Frequently, nonsteroidal antiinflammatory drugs (NSAIDs) are used to assist in the management of various chronic pain syndromes. Although evidence is accumulating on the potential toxicities associated with NSAIDs, clear recommendations are lacking to guide the appropriate use of these drugs. Equivocal data, especially with respect to cardiovascular risk, further confuse a clear treatment pathway when assessing pharmacotherapy. Originally, cyclooxygenase selectivity appeared to be a determining factor in choosing an agent because of the presumed lack of effect on the cardiovascular and gastrointestinal renal systems. This theory, however, was recently dispelled. To provide guidance on the selection of an NSAID for various chronic pain syndromes, members of the Ambulatory Care, Cardiology, and Pain and Palliative Care Practice and Research Networks of the American College of Clinical Pharmacy evaluated evidence‐based use of NSAIDs for frequently encountered pain syndromes, with special focus on the adverse effects of this class of agents.

E-Prescribing: Clinical Implications for Patients with Diabetes

With the recent Center for Medicare and Medicaid Services and stimulus package incentives for health information technology, many clinicians are expected to adopt or enhance their use of e-prescribing systems. E-prescribing has nearly eradicated medication errors resulting from prescriber handwriting interpretations, yet several other patient-care and workflow benefits still remain a promise. As prescribers select or update their e-prescribing systems (whether stand-alone or integrated with electronic health records), close attention is needed to the e-prescribing application features and level of clinical decision support to avoid clinical blind spots, including incomplete or inaccurate patient medication lists, poor drop-down menu or screen design, and lack of clinically relevant and actionable drug interaction and drug allergy alerts. This article presents three case studies that highlight common e-prescribing problems involving diabetes patients.

Search for Predictors of Nontherapeutic INR Results with Warfarin Therapy

BACKGROUND The effectiveness and safety of warfarin require maintaining an international normalized ratio (INR) within the therapeutic range. OBJECTIVE To identify predictors of nontherapeutic INR results in patients receiving warfarin. METHODS A retrospective study was conducted using 350 ambulatory care patients from a broad geographic region, all receiving long-term warfarin therapy and followed in a tertiary-care cardiology clinic. Possible predictors of nontherapeutic INR results (gender, age, body weight, body mass index, height, race, tobacco use, alcohol use, warfarin dose, therapeutic indication, regimen intensity, INR monitoring frequency/category, interacting medications, adverse events) were assessed with logistic regression models. Subset analysis involved 146 patients concurrently monitored with capillary whole blood INR (CoaguChek). RESULTS As measured on venous specimens, 52% (182/350) of the patients had subtherapeutic INR results and 13% (44/350) had supratherapeutic INR results despite frequent (≤4 wk) monitoring in 75% of the patients. Due to the small sample size, supratherapeutic INR results could not be further analyzed. Of 19 predictors tested, only daily warfarin dose (p < 0.02) and regimen intensity (p < 0.03) were significant independent and additive predictors of subtherapeutic results. Patients on the high-intensity regimen (INR 2.5–3.5) and receiving warfarin ≤6 mg/day had >50% risk of having subtherapeutic INR results. Subtherapeutic CoaguChek results were independent predictors of subtherapeutic venipuncture INR results in the subset (p = 0.001). CONCLUSIONS In the absence of readily identifiable predictors, only higher warfarin dosing and/or more frequent monitoring (possibly with point-of-care/home monitoring devices) may minimize the time that INRs are subtherapeutic, especially in patients receiving low-dose and/or high-intensity anticoagulation therapy.

Analysis of Symposium Articles on Insulin Pen Devices and Alternative Insulin Delivery Methods

Insulin therapy is a fundamental component of diabetes management, yet there is often resistance to insulin initiation by both prescribers and patients. A barrier to insulin use is the perceived shortcomings with the traditional vial-and-syringe administration method (inconvenience, difficulty of use, association with disease and addiction, etc.). This symposium in the journal discusses the advantages of alternative insulin delivery methods, primarily insulin pen devices. Although these administration methods, especially insulin pens, have some clear advantages over the vial/syringe, there are also limitations to their use and careful patient selection and education are still needed.