Lisa Kroon

Tobacco education in U.S. schools of pharmacy.

This study is the first to characterize tobacco-related content in pharmacy school curricula in the United States. A national survey mailed to 83 U.S. schools of pharmacy assessed the extent to which tobacco is addressed in required coursework, educational methods of instruction, perceived importance of addressing tobacco in the doctor of pharmacy degree program, perceived adequacy of current levels of tobacco education in curricula, and perceived barriers to enhancing the tobacco-related content. A total of 82 surveys (98.8% response) revealed a median of 170 min of tobacco education throughout the doctor of pharmacy program. The most heavily emphasized topics are aids for cessation, assisting patients with quitting, nicotine pharmacology and principles of addiction, and drug interactions with smoking, yet more than 40% of respondents believed that each of these topics was covered inadequately. Key barriers to enhancing tobacco training are lack of curriculum time and lack of clinical clerkship sites focusing on tobacco interventions. Pharmacy faculty members perceive tobacco cessation training to be important, yet a mismatch exists between the perceived importance and the perceived adequacy of current levels of training in pharmacy school curricula. The results of this study will serve as a baseline measure against which future, parallel assessments will be compared as faculty at schools of pharmacy across the United States work together toward enhancing the tobacco cessation training of student pharmacists.

Improving Chronic Care of Type 2 Diabetes Using Teams of Interprofessional Learners

Purpose To improve the care and outcomes of adult patients with type 2 diabetes by teaching interprofessional teams of learners the principles and practices of the Improving Chronic Illness Care Model. Method The study population consisted of 384 adult patients with type 2 diabetes. The study design was a nonrandomized, parallel-group, clinical trial conducted during 18 months in the University of California, San Francisco internal medicine clinics. Interprofessional team care provided by primary care internal medicine residents, nurse practitioner students, and pharmacy students was compared with usual care by internal medicine residents only. Processes of care, clinical status, and health utilization were measured in both patient groups. Learner outcomes also were assessed and compared. Results At study completion, intervention patients more frequently received assessments of glycosolated hemoglobin (79% versus 67%; P = .01), LDL-C (69% versus 55%; P = .009), blood pressure (86% versus 79%; P = .08), microalbuminuria (40% versus 30%; P = .05), smoking status assessment (43% versus 31%; P = .02), and foot exams (38% versus 20%; P = .0005). Intervention patients had more planned general medicine visits (7.9 ± 6.2 versus 6.2 ± 5.7; P = .006) than did control patients. Interprofessional learners rated themselves significantly higher on measures of accomplishment, preparation, and success for chronic care than did the usual care learners. Conclusions Interprofessional team care by learners was effective in improving quality of care for adult patients with diabetes treated in general medicine clinics. The chronic illness framework resulted in more appropriate health care utilization.

Effect of culturally tailored diabetes education in ethnic minorities with type 2 diabetes: a meta-analysis.

Background:Diabetes is a major cause of cardiovascular morbidity and mortality. Ethnic minorities experience a disproportionate burden of diabetes; however, few studies have critically analyzed the effectiveness of a culturally tailored diabetes intervention for these minorities. Objective:The aim of this study was to evaluate the effectiveness of a culturally tailored diabetes educational intervention (CTDEI) on glycemic control in ethnic minorities with type 2 diabetes. Method:We searched databases within PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), PsycINFO, and ProQuest for randomized controlled trials (RCTs). We performed a meta-analysis for the effect of diabetes educational intervention on glycemic control using glycosylated hemoglobin (HbA1c) value in ethnic minority groups with type 2 diabetes. We calculated the effect size (ES) with HbA1c change from baseline to follow-up between control and treatment groups. Results:The 12 studies yielded 1495 participants with a mean age of 63.6 years and a mean of 68% female participants. Most studies (84%) used either group education sessions or a combination of group sessions and individual patient counseling. The duration of interventions ranged from 1 session to 12 months. The pooled ES of glycemic control in RCTs with CTDEI was −0.29 (95% confidence interval, −0.46 to −0.13) at last follow-up, indicating that ethnic minorities benefit more from CTDEI when compared with the usual care. The effect of intervention was greatest and significant when HbA1c level was measured at 6 months (ES, −0.41; 95% confidence interval, −0.61 to −0.21). The ES also differed by each participant’s baseline HbA1c level, with lower baseline levels associated with higher ESs. Conclusions:Based on this meta-analysis, CTDEI is effective for improving glycemic control among ethnic minorities. The magnitude of effect varies based on the settings of intervention, baseline HbA1c level, and time of HbA1c measurement. More rigorous RCTs that examine tailored diabetes education, ethnically matched educators, and more diverse ethnic minority groups are needed to reduce health disparities in diabetes care.

Public perceptions of the ban on tobacco sales in San Francisco pharmacies

Background In October, 2008, legislation was implemented in the city and county of San Francisco, California, prohibiting the sale of tobacco products in pharmacies. Objective To characterise public awareness and perceptions of the ban on tobacco sales in San Francisco community pharmacies. Methods A brief, anonymous survey was used to assess public awareness and perceptions of a ban on tobacco sales approximately 1 year after implementation. Individuals were approached by researchers outside of chain pharmacies in San Francisco. Smokers and non-smokers were included, and participants did not have to be patrons of the pharmacy. Results Of 198 participants, 56% were in favor of the ban, 27% opposed it and 17% were undecided. A greater proportion of current tobacco users (81%) than former/never users (48%) were aware of the ban (p<0.001), and a lesser proportion were supportive of the ban (21% of current users vs 66% of former/never users; p<0.001). Most current tobacco users (88% of n=43) had not considered quitting smoking as a result of the ban. The majority of consumers indicated that the ban on cigarette sales did not influence their shopping behaviour at retail pharmacies. Conclusions In the city and county of San Francisco, public support exists for prohibiting the sale of tobacco products in pharmacies.

Overview of insulin delivery pen devices

OBJECTIVES To review currently available insulin delivery pen devices for use in diabetes and to describe their primary benefits and drawbacks in comparison with the traditional vial/syringe method of insulin administration. DATA SOURCE Not applicable. SUMMARY Insulin delivery pen devices are available for most types of insulin, including all insulin analog preparations and insulin premixes with rapid-acting insulin or regular insulin with neutral protamine Hagedorn insulin. Some devices have a replaceable insulin cartridge (categorized as reusable or durable); other devices are prefilled and are disposed of after the insulin reservoir is emptied. Insulin delivery pens offer several advantages over the vial and syringe method of injection, including greater ease and discretion of use and improved portability, adherence, and dosing accuracy. The tactile and auditory feedback provided by the dosing dial on insulin delivery pen devices may be particularly helpful for patients who have impaired manual dexterity or vision. Studies also show a strong preference among patients in favor of insulin delivery pen devices compared with the vial/syringe method. Finally, despite greater per-unit cost, insulin delivery pen devices have also been associated with reductions in health resource use and associated costs compared with vial/syringe therapy. CONCLUSION Insulin delivery pen devices offer another option to patients with diabetes for insulin administration. They are associated with not only improved ease of use but also improved dosing accuracy and adherence to therapy. To develop the most suitable insulin regimens for their patients, health providers should be informed about available insulin delivery pen devices.

Reducing Pulmonary Disease: The Pharmacist’s Role in Smoking Cessation

As an important interface with the healthcare system for many patients, pharmacists are in a unique position to assist patients with quitting smoking, thereby improving patients’ pulmonary health. Because nicotine replacement therapy products and bupropion are available to patients largely via pharmacies, the pharmacist has become a logical candidate for providing smoking cessation assistance. Furthermore, research has shown that when pharmacists counsel patients on medications for quitting smoking, their intervention positively impacts smoking cessation rates. This article provides a review of methods for cessation and provides pharmacists with feasible and effective smoking cessation counseling strategies for implementation into everyday practice. The intervention approach draws heavily upon the U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence.

Lipid Management with Statins in Type 2 Diabetes Mellitus

OBJECTIVE: To provide an update on lipid management and recent modifications in cholesterol guidelines for use of hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), specifically in patients with diabetes. DATA SOURCES: Studies and guidelines were identified through a MEDLINE search (1996–April 2005). STUDY SELECTION AND DATA EXTRACTION: Studies were selected for review if the primary treatment intervention was a statin, at least 4% of the study population held a diagnosis of diabetes, and diabetes subgroup analysis was available. DATA SYNTHESIS: The Heart Protection Study demonstrated an approximately 25% relative risk reduction of a first coronary event in patients with diabetes, a reduction similar to those without diabetes. In subjects with diabetes, a significant reduction in coronary events was noted regardless of the baseline cholesterol level. The Collaborative Atorvastatin Diabetes Study demonstrated a 37% relative risk reduction in the primary prevention of cardiovascular morbidity in patients with diabetes. CONCLUSIONS: Based on the current literature, a low-density lipoprotein cholesterol (LDL-C) level <100 mg/dL remains an appropriate goal for patients with diabetes in the absence of established cardiovascular disease. For higher-risk patients, such as those with diabetes and a history of cardiovascular disease, a more stringent LDL-C goal of <70 mg/dL is an option according to current clinical trial evidence. At least a 30–40% reduction in the LDL-C level is advisable when initiating statin therapy.

An Analysis of Patient Acceptance and Safety of a Prefilled Insulin Injection Device

This article summarizes and interprets the findings of Carter and colleagues in this issue of Journal of Diabetes Science and Technology, a study of the real world use of a prefilled insulin pen device. In this observational study, people with type 1 and type 2 diabetes rated their experience with the SoloSTAR pen device after 6–10 weeks of use. Data on patient satisfaction, product technical complaints, and adverse effects were reported. Randomized, controlled trials are needed that compare the various pen devices and the vial/syringe in terms of accuracy of dosing, adherence to therapy, and ease of use (including patient perception of injection force required) to assess whether a particular method of insulin delivery or pen delivery device provides a clinical advantage over another.

An Analysis of Dosage Volume for Halfway Doses in the Victoza Pen

King and Wolfe1 assessed the accuracy of liraglutide doses at the halfway marks between the three indicated or marked doses (0.6, 1.2, and 1.8 mg) of the Victoza® pen device. The presumed doses at each halfway mark was 0.3, 0.9, and 1.5 mg. The clinical rationale the authors provided for using a dose other than the marked doses is that patients could use a slightly lower dose if the 1.2 or 1.6 mg doses were not tolerable due to side effects. The main side effects associated with liraglutide that can be challenging for patients are gastrointestinal (GI) effects, primarily nausea and vomiting. The Victoza pen is a prefilled, multidose pen that is designed to deliver 0.6, 1.2, or 1.8 mg and contains 3 ml of solution with a 6 mg/ml concentration of liraglutide. The halfway marked doses are 5 clicks between the marked dose settings (as there are 10 clicks between the marked dosages). Using a 6 × 6 randomization schedule, volume measurements for each halfway dose and the three marked doses (i.e., six doses) were determined and then converted to milligrams. All six doses were found to be linear and equivalent to the marked and assumed halfway doses: 0.3, 0.6, 0.9, 1.2, 1.5, and 1.8 mg. The recommended dosing schedule for liraglutide (Victoza) is to initiate therapy with the 0.6 mg dose daily for 1 week and then titrate to 1.2 mg; the 0.6 mg dose is considered a starting dose, to alleviate GI symptoms during the dose titration period. After 1 week taking 1.2 mg, the dose can be increased to 1.8 mg if the 1.2 mg dose does not result in the desired glycemic control. In the phase 3 clinical trials with liraglutide, the Liraglutide Effect and Action in Diabetes (LEAD) program, both the 1.2 and the 1.8 mg dose resulted in significant reductions in hemoglobin A1c (A1C) compared with baseline (∼1–1.5% lowering when added as combination therapy and 0.8–1.1% as monotherapy);2–5 in two of the LEAD studies, only the 1.8 mg dose was studied.6,7 It is important to note that the difference in A1C lowering achieved with a 1.2 and 1.8 mg dose may not be clinically significant. In LEAD-1 (liraglutide added to glimepiride), the A1C change was -1.08% and -1.13% for the 1.2 and 1.8 mg doses, respectively, and in LEAD-2 (liraglutide added to metformin), both the 1.2 and the 1.8 mg dose resulted in the same A1C lowering on average (-1.0%).2,3 Therefore, it seems reasonable to use a dose lower than 1.8 mg if this dose causes intolerable GI side effects. Additionally, since some studies have demonstrated clinical efficacy with just the 1.8 mg dose (e.g., LEAD-5, which compared liraglutide with insulin glargine, and LEAD-6, which compared liraglutide with exenatide),6,7 if a patient is not able to tolerate the 1.8 mg dose, using the dose of 1.5 mg (the halfway dose) seems like a logical approach to alleviate the GI effects. Liraglutide has been demonstrated to have dose-dependent GI symptoms.8 The GI symptoms associated with liraglutide are seen early in treatment and are most often transient. In LEAD-5, which studied the 1.8 mg dose, 14% of patients initially experienced nausea; this decreased after 1 to 3 weeks, and by 4 weeks, the incidence of nausea was only 1.5%.6 As liraglutide is dose titrated, if the marked dose (1.2 or 1.8 mg) is not tolerated, a lower dose (the halfway doses studied by King and Wolfe1) could be tried. Then, after the GI symptoms resolved, it would be reasonable to reattempt the higher marked dose if needed for the desired glycemic control. Prior to considering use of a nonmarked dose, it would be important to assess that a patient was taking Victoza properly, such as not increasing the dose too rapidly (e.g., less than 1 week titration), which could increase the chance for GI symptoms. One consideration in using a halfway unmarked dose is that this would require a patient to count clicks (i.e., five clicks between a marked dose), as there are no visible lines on the pen device at these interim clicks. If a patient were not diligent with accuracy in counting the necessary clicks, it could result in difficulty determining the actual dose a patient is taking and further confusion in how to dose adjust liraglutide. However, there should be no concern for overdosing if a halfway unmarked dose is used, as the pen can only deliver a maximum of 1.8 mg per dose. Another consideration is the accuracy of the halfway unmarked dose after repeated use of the Victoza pen device. While King and Wolfe1 determined the dose at each halfway point to be 0.3, 0.9, and 1.5 mg, it is possible with repeated use of the pen that the accuracy of these doses could be affected. Therefore, a conservative approach would be to use the halfway unmarked dose on a temporary basis until a patients GI symptoms were alleviated and then increase back to the marked dose (1.2 or 1.8 mg). In conclusion, King and Wolfe1 demonstrated the accuracy of the dose volume for the halfway doses in six Victoza pens. From a practical standpoint, use of a halfway dose (0.3, 0.9, and 1.5 mg) could be considered on a temporary basis until GI symptoms are alleviated, and then liraglutide could be retitrated to the marked dose.