Genevieve M. Hale

The Treatment of Primary Orthostatic Hypotension

Objective: To review the efficacy and safety of pharmacological and nonpharmacological strategies used to treat primary orthostatic hypotension (OH). Data Sources: A literature review using PubMed and MEDLINE databases searching hypotension, non-pharmacological therapy, midodrine, droxidopa, pyridostigmine, fludrocortisone, atomoxetine, pseudoephedrine, and octreotide was performed. Study Selection and Data Extraction: Randomized or observational studies, cohorts, case series, or case reports written in English between January 1970 and November 2016 that assessed primary OH treatment in adult patients were evaluated. Data Synthesis: Based on the chosen criteria, it was found that OH patients make up approximately 15% of all syncope patients, predominantly as a result of cardiovascular or neurological insults, or offending medication. Nonpharmacological strategies are the primary treatment, such as discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, adding salt to diet, and so on. If these fail, pharmacotherapy can help ameliorate symptoms, including midodrine, droxidopa, fludrocortisone, pyridostigmine, atomoxetine, sympathomimetic agents, and octreotide. Conclusions: Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms. Pyridostigmine and fludrocortisone can be used in patients who fail to respond to these agents. Emerging evidence with low-dose atomoxetine is promising, especially in those with central autonomic failure, and may prove to be a viable alternative treatment option. Data surrounding other therapies such as sympathomimetic agents or octreotide are minimal. Medication management of primary OH should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions.

Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education

BACKGROUND The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal. PROGRAM DESCRIPTION As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care. Pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits. Although pharmacists have become key team members of interdisciplinary teams within traditional care settings, their role has often been overlooked in the primary care-based ACO. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care, while providing unique learning experiences for pharmacy students by partnering with ACOs in the South Florida region. Five opportunities are presented for pharmacists to improve medication use specifically in primary care-based ACOs: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care. OBSERVATIONS Several challenges and barriers that prevent the full integration of pharmacists into primary care-based ACOs include lack of awareness of pharmacist roles in primary care; complex laws and regulations surrounding clinical protocols, such as collaborative practice agreements; provider status that allows compensation for pharmacist services; and limited access to medical records. By understanding and maximizing the role of pharmacists, several opportunities exist to better manage the medication-use process in value-based care settings. IMPLICATIONS/RECOMMENDATIONS As more organizations realize benefits and overcome barriers to the integration of pharmacists into patient care, programs involve pharmacists will become an increasingly common approach to improve outcomes and reduce the total cost of care and will improve the financial viability of primary care-based ACOs. DISCLOSURES No outside funding supported this research. The authors report no conflicts of interest related to this manuscript. Study concept and design were contributed by Joseph, Hale, and Eltaki, with assistance from the other authors. Prados and Jones took the lead in data collection and data interpretation and analysis, with assistance from the other authors. The manuscript was written primarily by Joseph and Hale, along with the other authors, and revised primarily by Seamon and Gernant, along with the other authors.

Pharmacotherapy of Vasospastic Angina

Vasospastic angina is a diagnosis of exclusion that manifests with signs and symptoms, which overlap with obstructive coronary artery disease, most often ST-segment elevation myocardial infarction. The pharmacotherapy that is available to treat vasospastic angina can help ameliorate angina symptoms. However, the etiology of vasospastic angina is ill-defined, making targeted pharmacotherapy difficult. Most patients receive pharmacotherapy that includes calcium channel blockers and/or long-acting nitrates. This article reviews the efficacy and safety of the pharmacotherapy used to treat vasospastic angina. High-dose calcium channel blockers possess the most evidence, with respect to decreasing angina incidence, frequency, and duration. However, not all patients respond to calcium channel blockers. Nitrates and/or alpha1-adrenergic receptor antagonists can be used in patients who respond poorly to calcium channel blockers. Albeit, evidence for use of nitrates and alpha1-adrenergic receptor antagonists in vasospastic angina is not as robust as calcium channel blockers and can exacerbate adverse effects when added to calcium channel blocker therapy. Despite having a clear benefit in patients with obstructive coronary artery disease, the benefit of beta-adrenergic receptor antagonists, statins, and aspirin remains unclear. More data are needed to elucidate whether or not these agents are beneficial or harmful to patients being treated for vasospastic angina. Overall, the use of pharmacotherapy for the treatment of vasospastic angina should be guided by patient-specific factors, such as tolerability, adverse effects, drug–drug, and drug–disease interactions.

Impact of a Pharmacist-Managed Heart Failure Postdischarge (Bridge) Clinic for Veterans:

Background: Hospitals that provide early postdischarge follow-up after heart failure (HF) hospitalization tend to have lower rates of readmission. However, HF postdischarge (bridge) clinics have not been extensively evaluated. Objective: To assess the impact of a pharmacist-managed HF bridge clinic in a veteran population. Methods: HF patients hospitalized from November 2010 to August 2013 were identified. Retrospective chart review was conducted of 122 HF patients seen at bridge clinic compared with 122 randomly selected HF patients not seen at this clinic (usual care). Primary end point was 90-day all-cause readmission and death. Secondary outcomes were 30-day all-cause readmission and death, time to first postdischarge follow-up, first all-cause readmission. Results: Bridge clinic patients were at higher baseline risk of readmission and death; other characteristics were similar. 90-day death and all-cause readmission trended lower in bridge clinic patients (adjusted hazard ratio [HR] = 0.64; 95% CI = 0.40-1.02; P = 0.06). Time to first follow-up was shorter in bridge clinic patients (11 ± 6 vs 20 ± 23 days; P < 0.001); time to first all-cause readmission trended longer (40 ± 20 vs 33 ± 25days; P = 0.11). 30-day death and all-cause readmission was significantly lower in bridge clinic patients (adjusted HR = 0.44; 95% CI = 0.22-0.88; P = 0.02). Conclusions: In veteran patients hospitalized for HF, pharmacist-managed HF bridge clinic significantly reduced the time to initial follow-up compared with usual care. Improved short-term outcomes and trend toward improvement of longer-term outcomes in bridge clinic patients was shown.

Atomoxetine for Orthostatic Hypotension in an Elderly Patient Over 10 Weeks: A Case Report

Several nonpharmacologic strategies for orthostatic hypotension exist including avoiding large carbohydrate‐rich meals; limiting alcohol consumption; maintaining adequate hydration; adding salt to foods; and using compression stockings, tilt‐table exercises, or abdominal binders. If these fail, however, only limited evidence‐based pharmacologic treatment options are available including the use of fludrocortisone, midodrine, pyridostigmine, and droxidopa as well as pseudoephedrine, ocetreotide, and atomoxetine. This report discusses a case of atomoxetine use for 10 weeks in an elderly patient with primary orthostatic hypotension. An 84‐year‐old man with long‐standing primary orthostatic hypotension presented to our ambulatory cardiology pharmacotherapy clinic after several unsuccessful pharmacologic therapies including fludrocortisone, midodrine, and pyridostigmine. Nonpharmacologic strategies were also implemented. Atomoxetine was initiated, and the patient showed gradual improvements in symptoms and blood pressure control over the course of 10 weeks. Our data suggest that low‐dose atomoxetine is an effective and safe agent for symptom improvement and blood pressure control in elderly patients with primary orthostatic hypotension.

Third-year pharmacy students propose an interprofessional prediabetes educational programme: PreDiaMe (Prediabetes + Me)

ABSTRACT The American Diabetes Association announced in 2012 that 86 million Americans were diagnosed with prediabetes compared to 79 million in 2010. Prediabetes + Me (PreDiaMe) is an innovative educational programme developed by pharmacy students at Nova Southeastern University College of Pharmacy, which provides collaborative interprofessional care for patients with prediabetes. A literature review using EBSCOhost, EMBASE, and MEDLINE databases searching the terms education, health services, interprofessional team, and prediabetes was conducted. Human studies published in English between 2006 and 2016 were included. Investigators interviewed a community pharmacist and a consultant pharmacist certified in diabetes education. Based on these interviews and the literature found, PreDiaMe was created to unite healthcare professionals through a three-step community outreach programme. The goal of PreDiaMe is to identify patients at risk of prediabetes, to decrease the prevalence of type 2 diabetes mellitus (T2DM), to reduce healthcare costs, and to improve the quality of life for patients with prediabetes. PreDiaMe benefits patients with prediabetes, the healthcare system, and pedagogy as it aims to decrease in the prevalence and economic burden and increase health outcomes of patients with prediabetes while being used as a tool to provide integrative education in health professional programmes.

Evaluating the effectiveness of atomoxetine for the treatment of primary orthostatic hypotension in adults

Orthostatic hypotension (OH) is a common condition characterized by a reduction in systolic blood pressure (SBP) of at least 20 mm Hg and/or in diastolic blood pressure (BP) of at least 10 mm Hg within 3 minutes of standing.1–6 It is often accompanied by symptoms of dizziness/lightheadedness, fatigue, vision disturbance, and loss of concentration, which can greatly hinder quality of life.2 The prevalence of OH increases with age, affecting approximately 5% of patients younger than 50 years, 30% of patients older than 70 years, and up to 50% of nursing home patients older than 80 years.3,4 Generally, OH is a result of autonomic failure and abnormal BP regulatory mechanisms. In normal situations, standing induces baroreceptor unloading, which leads to increased venous return and regulation of resting BP. Patients with OH show increased resistance to this regulatory mechanism, leading to abnormal BP.1,5 Nonpharmacological interventions remain firstline strategies for OH, followed by pharmacological therapy if nondrug treatments are unsuccessful.1,2,5–7 Current guidelines list midodrine and droxidopa as the primary pharmacological agents to treat OH.8 However, several studies have shown that atomoxetine, a selective norepinephrine reuptake inhibitor, increases seated and standing SBP and improves orthostatic symptoms when given in a pediatric dose of 18 mg.1–3,5,9–13 This evidence demonstrates the benefit of atomoxetine as an alternative pharmacological agent in the treatment of OH. Through a pharmacotherapy review, this report aims to justify the need for updated OH guidelines, including atomoxetine as a viable treatment option.

Oral anticoagulation therapy upon discharge in hospitalized patients with nonvalvular atrial fibrillation: a retrospective cohort study

ABSTRACT Objectives: Availability of direct oral anticoagulants and CHA2DS2VASc/HAS-BLED scoring tools underscore the importance of appropriate and safe use of oral anticoagulation therapy (OACT). The purpose of this study was to evaluate stroke prevention pharmacotherapy in adult patients with nonvalvular atrial fibrillation (NVAF) discharged from a large, community-based hospital. Methods: A retrospective cohort study was conducted using a de-identified data collection sheet for data extraction (demographics, admitting diagnosis, OACT prior to admission and at discharge, concomitant medications that could increase bleed risk and/or acid-suppressive therapies). CHA2DS2VASc and HAS-BLED scores were calculated. Descriptive statistics were generated to describe all parameters. Frequency counts and percentages summarized categorical variables while mean ± standard deviation were determined for continuous variables. Results: Data from 180 patients were evaluated and of these 177 (98.3%) received OACT regardless of stroke risk upon discharge, as determined by CHA2DS2VASc scoring tool. The mean CHA2DS2VASc and HAS-BLED scores were 3.61 ± 1.7 and 2.13 ± 1.26, respectively. At discharge, eight patients at low-stroke risk received OACT for unclear reasons, one intermediate-stroke risk patient received aspirin only, and two patients at high-stroke risk did not receive OACT due to concerns about bleeds. In 66 patients at high-bleed risk, only half received concomitant acid-suppressive therapy. Conclusions: Decision to add OACT is often guideline-driven, however, individualized circumstances in which clinicians and patients find themselves are also important considerations. Determination of ischemic stroke risk should be performed with CHA2DS2VASc scoring tool to exclude patients who may not benefit from OACT. HAS-BLED scoring tool should be used to identify any modifiable bleeding risk factors present with subsequent initiation of management strategies. Availability of complete medical histories and meticulous documentation are necessary for multiple clinicians to continuously determine optimal pharmacotherapy during follow-up visits.

Treatment of Adults with Idiopathic Recurrent Pericarditis: Novel Use of Immunotherapy

Idiopathic recurrent pericarditis (IRP) can be challenging to treat. Even after guideline‐directed first‐line treatment consisting of aspirin (ASA) or a nonsteroidal antiinflammatory drug (NSAID) in combination with colchicine therapy, recurrences still occur in greater than 20% of patients. Many patients then require treatment with long‐term corticosteroids, which is not a favorable option due to their short‐ and long‐term adverse effects. Because it is theorized that the pathophysiology of IRP may possess autoimmune sequelae, the use of immunotherapy for the treatment of IRP has emerged. In this review, we describe the literature associated with immunotherapy used to treat IRP in an adult population as well as provide an overview of the safety and monitoring parameters for each agent. The most common immunotherapies used after patients have had multiple recurrences of IRP are anakinra, intravenous immunoglobulin (IVIG), and azathioprine. In most cases, these immunotherapies are adjunctive therapy, with the goal of tapering and discontinuing immunosuppressive corticosteroids. After reviewing the data, anakinra resulted in more patients discontinuing corticosteroids and prevented further recurrences of pericarditis. IVIG resulted in symptom resolution and no further recurrences in most of the patients. Azathioprine was associated with more than half of patients becoming recurrence free; however, many patients required a restart of corticosteroids due to recurrence. Clinicians should be aware of the adverse effects of immunotherapy, ranging from mild gastrointestinal events to risk of infection and serious blood dyscrasias that may require diligent monitoring. The use of immunotherapy for the treatment of adults with IRP should be restricted to patients who have multiple recurrences. Ideally, immunotherapy would be adjunctive to first‐line combination therapy with ASA/NSAID plus colchicine, with the goal of tapering and discontinuing immunosuppressive corticosteroids. Furthermore, clinicians should consider cost, drug‐drug and drug‐disease interactions, and safety, as well as the quality of the retrospective evidence before considering any immunotherapy.