Julie A. Stading

Advances in the treatment of congestive heart failure: new approaches for an old disease.

Heart failure is a symptom complex of varied etiology associated with substantial mortality. Approximately 5 million Americans have the disease, with 400,000 new cases diagnosed each year. Despite better understanding of its pathophysiology, therapeutic options remain suboptimal and the syndrome remains associated with high rates of hospitalization and loss of economic productivity. Management traditionally included vasodilators, diuretics, and digoxin, with a focus on controlling symptoms and improving ejection fraction and exercise capacity. Drug therapy now is focused on improving survival, with a reduction in health care costs related to hospitalizations. Drugs with a proven benefit in reducing morbidity and mortality are angiotensin‐converting enzyme inhibitors, (β‐blockers, and the combination of hydralazine plus a nitrate. Diuretics, digoxin, dihydropyridine calcium channel blockers, phosphodiesterase inhibitors, catecholamine infusions, amiodarone, left ventricular assist devices, and transplantation are also options.

Rhabdomyolysis associated with simvastatin-nefazodone therapy

Simvastatin is a hydroxymethyl glutaryl coenzyme A reductase inhibitor commonly used to treat patients with hyperlipidemia. It is a safe and effective medication in most patients when used appropriately. A serious side effect known as rhabdomyolysis may rarely occur in patients who take simvastatin, especially at higher doses and with agents that interact and increase the level of simvastatin in the blood. We describe the case of a patient with rhabdomyolysis that occurred after the patients simvastatin was titrated to 80 mg at approximately the same time that his antidepressant medication was switched to nefazodone. We found only two other similar cases in the literature, both of which were presented as letters to the editor in two different journals. We present this case to add to the literature and to assist practitioners by raising their awareness of this interaction so that it can be monitored.

Impact of Pharmacist Intervention on Diabetes Patients in an Ambulatory Setting

Diabetes is the seventh-leading cause of death in the United States, according to the National Center for Health Statistics at the Centers for Disease Control and Prevention.1 More than 20 million people in the United States have diabetes, and of those > 60 years of age, one in five has the disease.1 Sixty-five percent of patients with diabetes die from heart disease or stroke. Thirty percent of those > 40 years of age have impaired sensation in their feet; 60% of all nontraumatic amputations are attributed to diabetes.1 Diabetes is also the leading cause of kidney failure, accounting for 44% of all new cases in 2002.1 To help prevent long-term complications and deaths related to diabetes, the American Diabetes Association (ADA) publishes an annual position statement titled Standards of Medical Care in Diabetes to provide up-to-date guidelines for the management of diabetes.2 The care of diabetes patients is multifaceted and often requires special attention to achieve optimum results. A1C testing is considered the gold standard measurement for diabetes control. Previous studies have measured A1C values in patients before and after seeing a pharmacist.3-7 The current study assessed A1C changes resulting from seeing a pharmacist and then compared them to changes that result from usual care to find out whether pharmacist care results in any additional benefit. This study investigated the clinical pharmacists impact on type 2 diabetes patients as measured by the change in A1C over a 2-year period in an outpatient clinic at a Veterans Administration institution. Diabetes care for the treatment group included the pharmacist, dietitian, and primary care provider (Team), with patients managed by the primary care provider and dietitian serving as controls (Control). For Team patients, a clinical pharmacist met with patients every 3 months or as needed …

Assessment of Group-Based Diabetes Education Using the “Continuing Your Journey With Diabetes” Conversation Map in the Veteran Population

Both type 1 and type 2 diabetes have been recognized as serious health concerns. The majority of cases of type 2 diabetes are preventable, and, after diagnosis, various complications can be prevented by effective self-management. Although there are multiple pharmacological interventions for the treatment of diabetes, it is difficult to achieve target A1C levels with drug therapy alone. Most patients must also implement various lifestyle modifications such as following a healthy diet and getting adequate physical activity, both of which require willingness and motivation. Therefore, patient education is an important component of diabetes management. Each patient’s unique needs and barriers require an individualized strategy for diabetes management (1). Diabetes self-management education is listed as one of seven crucial elements in the Joint Commission standards of care addressing diabetes care (2). The National Standards for Diabetes Self-Management Education (3) states that group education can be effective and that programs using behavioral and psychosocial strategies result in improved outcomes. A 2009 Cochrane review (4) concluded that group-based training helped participants improve fasting blood glucose and A1C, decreasing the need for diabetes medications. Such programs may also help decrease blood pressure and body weight, although studies evaluating such outcomes are limited. The Conversation Map education tool was developed by Healthy Interactions to empower patients with diabetes and help them proactively manage their health. Reaney et al. (5) recently reviewed this tool in more detail. The Conversation Map promotes effective communication among patients with type 2 diabetes, their health care providers, and their support network. This learner-centered approach is intended to improve health literacy, a significant predictor of health status. A conversation with other patients, led by a facilitator using a Socratic approach, is meant to encourage participants to share personal knowledge and experiences, ultimately engaging and motivating patients to take control of …

Initial Experience of Clinical Pharmacy Services Delivered by Computer Communication via Cisco Jabber Video in a US Veterans Administration Medical Center

Background/Objective: Clinical video telepharmacy is a new initiative of the Department of Veterans Affairs (VA) to provide rural patients access to clinical pharmacy services. This article describes some of the obstacles that pharmacists faced as they initiated this service and early outcomes in diabetes and hyperlipidemia patients. Methods: This study was approved by the institutional review board. This was a single-center, retrospective review of patients seen by 3 clinical pharmacists who developed and administered the telepharmacy clinics. Patients were referred by their primary care providers. Patients traveled to their local community-based outpatient clinic where a nurse set up video conferencing and then paged the pharmacist at the Lincoln VA. Patients were referred for management of anticoagulation, diabetes, hyperlipidemia, or hypertension, with 112 patients screened and 12 patients meeting criteria for hemoglobin A1c (HbA1c) evaluation and 25 patients meeting criteria for low-density lipoprotein (LDL)-cholesterol evaluation. Pharmacists also saw new patients for medication reviews, patients just out of the hospital, and patients with questions about their medication regimens. This study looked specifically at the effect that the pharmacist had on HbA1c and LDL-cholesterol reduction and meeting goals for these 2 parameters. Results: Patients in the diabetes group had a mean ± standard deviation reduction in HbA1c of 1.08 ± 0.85 (95% confidence interval = 0.53-1.62; P = .001). The mean HbA1c decreased from 9.1% to 8% after pharmacist intervention. Patients in the hyperlipidemia group had a mean ± standard deviation reduction in LDL-cholesterol of 23.74 ± 7.76 mg/dL (95% confidence interval = 7.76-39.75; P = .005). The mean LDL-cholesterol decreased from 145 to 121 mg/dL after intervention. There were no significant changes in the number of patients attaining their HbA1c or LDL-cholesterol goals after intervention. Conclusions: This study shows that telepharmacy allows patients to have access to pharmacy services in a rural environment with minimal inconvenience to the patient. This study also suggests that outcomes of disease management are similar to face-to-face visits.