Kimi S. Vesta

Etoricoxib: A Highly Selective COX-2 Inhibitor

OBJECTIVE: To review the available literature evaluating the pharmacology, pharmacokinetics, clinical efficacy, and adverse effects of etoricoxib, a highly selective cyclooxygenase-2 (COX-2) inhibitor that is not currently approved for use in the US. DATA SOURCES: Literature retrieval was accessed through MEDLINE (1966–December 2004), Current Contents (1998–December 2004), and Cochrane Library (4th quarter 2004). References from retrieved articles, information from the manufacturer, and abstracts from the American College of Rheumatology and Annual European Congress of Rheumatology meetings were searched. STUDY SELECTION AND DATA EXTRACTION: All clinical trials published in English evaluating etoricoxib were included in this review. An abstract was excluded if it presented preliminary data from trials that are now published, analyzed data previously reported in a published clinical trial, or compared etoricoxib with placebo for an indication with published active-comparator controlled trials. DATA SYNTHESIS: Twelve clinical trials evaluating efficacy were reviewed. Efficacy for acute pain has been evaluated in acute gout, primary dysmenorrhea, and dental surgery and for chronic pain in rheumatoid arthritis, osteoarthritis, and chronic lower back pain. For safety, 3 clinical trials and 6 retrospective analyses of gastrointestinal, renovascular, or cardiovascular adverse effects were reviewed. CONCLUSIONS: Available studies demonstrate the efficacy of etoricoxib compared with nonsteroidal antiinflammatory drugs, but no published studies to date have compared etoricoxib with other selective COX-2 inhibitors. While these agents have demonstrated a significant reduction in gastrointestinal adverse effects, the cardiovascular adverse effects of selective COX-2 inhibition are not well defined. Further study is necessary to delineate the benefits and risks of etoricoxib compared with alternative treatment regimens.

Pantoprazole-Induced Thrombocytopenia

Objective: To report 2 cases of thrombocytopenia associated with pantoprazole treatment and discuss existing reports on this drug-induced adverse event. Case Summaries: This paper describes the course of thrombocytopenia associated with pantoprazole 40 mg in 2 hospitalized patients. In both cases, thrombocytopenia appeared after the initiation of pantoprazole and rapidly improved after discontinuation of pantoprazole, although complete resolution of thrombocytopenia occurred in only one patient prior to discharge from the hospital. Discussion: The mechanism of drug-induced thrombocytopenia is often poorly understood, and proton-pump inhibitors are generally not strongly suspected as a cause of thrombocytopenia. However, an objective causality assessment using the Naranjo probability scale revealed a probable relationship between thrombocytopenia and pantoprazole in both of the cases. It is unknown whether this is a class effect. Conclusions: Although drug-induced thrombocytopenia with pantoprazole appears to be rare, it represents a potentially severe adverse effect. This supports the judicious prescribing of pantoprazole and possibly other proton-pump inhibitors.

Cilomilast: Orally Active Selective Phosphodiesterase-4 Inhibitor for Treatment of Chronic Obstructive Pulmonary Disease

Objective: To review available literature evaluating the pharmacology, pharmacokinetics, clinical efficacy, and adverse effects of cilomilast, a selective phosphodiesterase-4 (PDE4) inhibitor. Data Sources: Literature was accessed through MEDLINE (1966–May 2006), Current Contents Clinical Medicine (1998–May 2006), and The Cochrane Library Database (1st quarter 2006) using the terms cilomilast, Ariflo, and SB 207 499. Reference lists from retrieved articles and information from the manufacturer were manually reviewed. Study Selection and Data Extraction: All clinical trials evaluating cilomilast and published in English were included in this review. In addition, articles evaluating the pharmacology, pharmacokinetics, and safety of cilomilast in humans were reviewed. Data Synthesis: Cilomilast is a second-generation PDE4 inhibitor with antiinflammatory effects that target bronchoconstriction, mucus hypersecretion, and airway remodeling associated with chronic obstructive pulmonary disease (COPD). Selective PDE4 inhibition is proposed to maximize the antiinflammatory effects of PDE inhibition while minimizing the adverse effects of nonselective agents. To date, 4 clinical trials have evaluated the efficacy of cilomilast and demonstrated improvement in lung function (forced expiratory volume in 1 second) and quality of life and reduction in the occurrence of COPD exacerbations compared with placebo. Cilomilast is generally well tolerated, with adverse effects being overall mild and self-limiting. Conclusions: COPD is a progressive disease, and available treatment options provide limited efficacy. Given its unique mechanism of action and improved adverse effect profile compared with previous agents, cilomilast may have a promising role for the management of COPD.

Integration of an Introductory Pharmacy Practice Experience With an Advanced Pharmacy Practice Experience in Adult Internal Medicine

Objective. To describe the development, implementation, and assessment of an internal medicine introductory pharmacy practice experience (IPPE) that was integrated with an existing advanced pharmacy practice experience (APPE) in internal medicine. Design. A structured IPPE was designed for first-, second-, and third-year pharmacy (P1, P2, and P3) students. Activities for the IPPE were based on the established APPE and the individual learners educational level. Assessment. Students reported a greater understanding of clinical pharmacists’ roles, increased confidence in their clinical skills, and better preparation for APPEs. Peers viewed the approach as innovative and transferable to other practice settings. Participating faculty members provided a greater number of contact hours compared to traditional one-time site visits. Conclusions. Integrating an IPPE with an existing APPE is an effective and efficient way to provide patient care experiences for students in the P1-P3 years in accordance with accreditation standards.

Evaluating the impact of a pre-rotation workshop on student preparation for clinical advanced pharmacy practice experiences

Objectives This pilot study was designed to evaluate the impact of a pre-rotation workshop (PRW) on pharmacy students’ clinical skills and preparation for clinical Advanced Pharmacy Practice Experiences (APPE) involving direct patient care. Methods Randomized controlled trial of an educational intervention with Institutional Review Board approval. PRW activities designed to simulate rotation activities around five competencies, patient charts, medication histories, SOAP notes, patient presentations, and professionalism. Endpoints were evaluated using clinical rotation preceptors’ evaluation of performance and students’ performance on objective structured clinical exams (OSCE). Results Eight fourth-year students and eight GPA matched controls (20% of the total class) were selected to voluntarily participate. The PRW demonstrated a positive impact on students’ clinical skills and preparation for rotations by improving OSCE performance. However, no significant differences were found between groups when comparing preceptor evaluations of skills on rotations. These results are limited by the small sample size, potential OSCE “test-wiseness” effects, lack of OSCE evaluator blinding to study groups, potential case specificity effects due to the limited number of cases used on the OSCE and possible lack of sensitivity of the rotation evaluation tool to capture true differences among the experimental and control group participants. Conclusion The PRW was successful at advancing students’ clinical skills and preparation for rotations and may be considered as a tool to help bridge didactic to clinical experiences in the Pharm.D. curriculum.

Varenicline-Associated Acute Renal Failure:

Objective: To report an association between acute renal failure and varenicline. Case Summary: A 53-year-old white male with preexisting moderate renal insufficiency was admitted to the hospital for acute renal failure following a change in serum creatinine from 4 mg/dL at baseline to 10.6 mg/dL upon admission. One week prior to admission, the patient started taking varenicline (dose undetermined) for smoking cessation and had been stable on all other medications for 2 months prior to admission. All hospital workup tests were negative for prerenal azotemia, postrenal obstruction, and intrinsic renal disease. Varenicline was discontinued on admission. With no other changes in therapy, the serum creatinine level decreased each day of the patients 5-day hospitalization to 8.6 mg/dL upon discharge, and it was 6.4 mg/dL at a follow-up appointment 2 weeks after discharge. Discussion: Varenicline is a novel medication that is effective for smoking cessation. Adverse effects are generally mild and self-limiting, with gastrointestinal effects most commonly reported. According to the package insert, varenicline does not change creatinine clearance to any appreciable extent, but it should be used with caution in patients with renal impairment. It also states that varenicline can cause acute renal failure rarely; to our knowledge, this is the first published association of varenicline with renal effects. Use of the Naranjo probability scale showed varenicline to be the probable cause of renal dysfunction in this patient because of the temporal relationship and lack of alternative causes. Conclusions: Although there was a probable relationship between varenicline and acute renal failure in this patient, the significant benefit of smoking cessation to overall health outweighs the risk of this rare adverse effect. Clinicians should be aware of this potential adverse effect and should monitor renal function upon initiation of varenicline therapy, especially in patients with chronic kidney disease.

Update in Handheld Electronic Resources for Evidence-Based Practice in the Community Setting

OBJECTIVE To provide an update on the handheld electronic resources for evidence-based practice (EBP) in the community setting. DATA SOURCES Electronic resources for EBP in the community setting were identified by compiling the commonly used, well-established resources and by searching MEDLINE and other Internet sites. Search terms included evidence-based medicine, evidence-based practice, resources, and abstraction. Only sources available for personal digital assistants were included. DATA EXTRACTION Three databases were identified that provided abstraction and evaluation of the medical literature for the handheld platform. Content, features, ease of use, system requirements, and costs of each resource were evaluated. DATA SYNTHESIS FIRSTConsult, InfoRetriever, and UpToDate were evaluated, and the utility of each in the community pharmacy setting was evaluated by tracking a clinically relevant example through each system. FIRSTConsult provides evidence-based information organized by diagnosis but is not searchable on the handheld platform. InfoRetriever focuses on searchable evidence-based summaries, while UpToDate includes comprehensive topic reviews. The latter 2 platforms have large system memory requirements. All 3 sources provide evidence-based abstraction of the medical literature for the PDA platform, convenient for use at the point of care in community pharmacy. CONCLUSIONS While users may select a particular resource based on unique features, each provides evidence-based abstraction of the medical literature that is a practical approach to EBP in the community pharmacy setting.

Stevens-Johnson Syndrome Associated With Furosemide: A Case Report

Purpose: To report a probable association of Stevens-Johnson Syndrome (SJS) with furosemide and suspected cross-sensitivity with lincomycin and silver sulfadiazine cream. Summary: A 28-year-old Hispanic male was admitted for SJS, with a prolonged hospital course and unclear etiology throughout the majority of the stay. Patient’s medications prior to development of SJS symptoms were stable for 3 months and with the exception of furosemide, all were continued throughout the hospitalization while the SJS resolved. During hospitalization, the patient was unintentionally rechallenged with furosemide, after which the rash reappeared and then worsened further with use of silver sulfadiazine cream. At this point in the hospitalization, the prolonged course of the rash prior to admission and the administration of lincomycin 3 days prior to admission were revealed. This suggests the SJS was initially caused by furosemide, a nonaromatic sulfonamide diuretic, with slow progression prior to hospital admission over approximately 7 weeks, followed by an acute worsening caused by lincomycin, a sulfide antibiotic. Conclusion: Use of the Naranjo ADR Probability Scale indicates a probable relationship between SJS and furosemide in this patient. Clinicians should be aware of this rare potential adverse effect, even months after the initiation of therapy.

A Pharmacist-Initiated Method to Improve Venous Thromboembolic Prophylaxis Rates in Medically Ill Patients

Venous thromboembolism (VTE) is among the most preventable causes of hospital death; however, there is a significant underuse of VTE prophylaxis. The purpose of this study was to determine the impact of a pharmacist-initiated screening method on VTE prophylaxis rates. Clinical pharmacists practicing in an internal medicine teaching service at an academic medical center conducted a 6-month pilot project. Consecutive patients admitted to the service were screened for VTE and bleeding risk factors. Pharmacists made recommendations to the physicians in person, provided monthly educational presentations, and monitored patients daily until discharge to confirm continued appropriateness of recommendations. Of the 444 patients who were screened, 107 were identified to be candidates for VTE prophylaxis, and 21 of these patients also had bleeding risk factors. Appropriate use was significantly better after the screening intervention (37% before vs 85% after; P < .05). Moreover, inappropriate use in patients with bleeding risk factors was avoided by the screening intervention (29% before vs 0% after; P < .05). Clear improvements in VTE prophylaxis rates were observed. This pharmacist-initiated screening method presents unique opportunities for pharmacists.