Jeffrey C. Delafuente

Teriparatide for Severe Osteoporosis

OBJECTIVE To review the pharmacology, toxicology, pharmacokinetics, pharmacodynamics, efficacy, safety, therapeutic controversies, administration, patient counseling, and formulary recommendations for teriparatide (rDNA origin). DATA SOURCES A MEDLINE search (1966–May 2003) of articles using the key words parathyroid hormone and osteoporosis, parathyroid hormone and fracture, and teriparatide was conducted to identify relevant literature in the English language. Additional references were obtained from bibliographies of those articles. Some clinical trial data not yet published were obtained from the manufacturer. STUDY SELECTION AND DATA EXTRACTION All articles obtained from the data sources were reviewed; all data deemed relevant were included. DATA SYNTHESIS Teriparatide, recombinant human parathyroid hormone (1–34) [rhPTH (1–34)], is the first anabolic agent to treat postmenopausal women with osteoporosis and men with idiopathic or hypogonadal osteoporosis who are at high risk for osteoporotic fracture. Daily subcutaneous injections of teriparatide significantly increase both spine and hip bone-mineral density (BMD) while decreasing the incidence of fractures in both women and men. Common adverse effects noted with teriparatide use were nausea, headache, dizziness, and arthralgias. An increased incidence of osteosarcoma in rats during preclinical trials with teriparatide led to a black box warning for the drug. CONCLUSIONS Teriparatide substantially increases spine and hip BMD and may offer additional benefits to patients with severe osteoporosis. Clinical trials comparing teriparatide with other available agents to treat osteoporosis are needed to more clearly define its place in therapy. Long-term safety and efficacy are not known.

Influenza Vaccination and Warfarin Anticoagulation: A Comparison of Subcutaneous and Intramuscular Routes of Administration in Elderly Men

Study Objectives. To determine if subcutaneous administration of influenza vaccine is as immunogenic as the intramuscular route, and to evaluate the frequency of local adverse events associated with both routes in elderly anticoagulated men.

Drug Use among Functionally Active, Aged, Ambulatory People

BACKGROUND AND METHODS: Only a few pharmacoepidemiology studies have included very old subjects and most studies included both healthy and very ill people. Interpretation of data from these investigations is limited because of the mix of health status in the populations studied. We examined drug use in a group of active, relatively healthy, older people. Sixty-one attendees at a national convention, aged 76–96 years, volunteered to participate in a study on health status in a very old, ambulatory population. Medication histories, selected blood biochemistry analyses, a mental status examination, and other data were collected. RESULTS: The mean number of prescription and nonprescription drugs used per person was 2.02 and 1.85, respectively. More than a quarter of the sample population took no prescription medications and two-thirds used two or fewer prescription drugs. Sixteen percent of those taking prescription medications experienced adverse effects from their current drug regimens. Although falling was prevalent among our study subjects, there were similar drug-use patterns in those who did and who did not fall. CONCLUSIONS: In a group of relatively healthy and functional very old people, we found that drug use was not excessive, although adverse effects were still prevalent. In addition, most subjects were knowledgeable about their medications. These studies demonstrate that extreme age alone does not always result in sickness, frailty, and overuse of medications.

Training and Assessing Interprofessional Virtual Teams Using a Web-Based Case System.

Purpose Today, clinical care is often provided by interprofessional virtual teams—groups of practitioners who work asynchronously and use technology to communicate. Members of such teams must be competent in interprofessional practice and the use of information technology, two targets for health professions education reform. The authors created a Web-based case system to teach and assess these competencies in health professions students. Method They created a four-module, six-week geriatric learning experience using a Web-based case system. Health professions students were divided into interprofessional virtual teams. Team members received profession-specific information, entered a summary of this information into the case system’s electronic health record, answered knowledge questions about the case individually, then collaborated asynchronously to answer the same questions as a team. Individual and team knowledge scores and case activity measures—number of logins, message board posts/replies, views of message board posts—were tracked. Results During academic year 2012–2013, 80 teams composed of 522 students from medicine, nursing, pharmacy, and social work participated. Knowledge scores varied by profession and within professions. Team scores were higher than individual scores (P < .001). Students and teams with higher knowledge scores had higher case activity measures. Team score was most highly correlated with number of message board posts/replies and was not correlated with number of views of message board posts. Conclusions This Web-based case system provided a novel approach to teach and assess the competencies needed for virtual teams. This approach may be a valuable new tool for measuring competency in interprofessional practice.

Orthostatic Hypotension: Therapeutic Alternatives for Geriatric Patients

Symptomatic orthostatic hypotension is a serious problem in the elderly because it can precipitate falls and fractures, myocardial infarctions, and strokes. Several disorders may cause symptomatic orthostatic hypotension including age-related changes in physiology, disorders of the autonomic nervous system, drugs, and a decrease in circulating blood volume. Orthostatic hypotension is defined as a fall in systolic pressure of at least 20–30 mm Hg and a fall in diastolic pressure of at least 10–15 mm Hg upon rising, with symptoms of cerebral ischemia. Management includes a search for reversible causes as well as nonpharmacologic and pharmacologic therapies. No single agent has been universally successful in relieving the symptoms of orthostatic hypotension. Trials of single agents or combinations of agents are needed to identify the most appropriate therapy for individual patients.

Pharmacologic Aspects of Immunization

Immunization has reduced the morbidity and mortality of many diseases. Immunizing agents have been available for many years, with many newer vaccines under investigation. The mechanisms of action of immunizing agents have only been clarified within the last several decades. Immunity may be attained by active immunization using a toxoid, or living or killed organisms. Passive immunity is achieved with serum immune globulins and antitoxins. Mechanisms of human immunity, routine immunization schedules and the pharmacology of immunizing agents are discussed.