Renu F. Singh

Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial.

PURPOSE A collaborative pharmacist-primary care provider (PharmD-PCP) team approach to medication-therapy management (MTM), with pharmacists initiating and changing medications at separate office visits, holds promise for the cost-effective management of hypertension, but has not been evaluated in many systematic trials. The primary objective of this study was to examine blood pressure (BP) control in hypertensive patients managed by a newly formed PharmD-PCP MTM team versus usual care in a university-based primary care clinic. METHODS This randomized, pragmatic clinical trial was conducted in hypertensive patients randomly selected for PharmD-PCP MTM or usual care. In the PharmD-PCP MTM group, pharmacists managed drug-therapy initiation and monitoring, medication adjustments, biometric assessments, laboratory tests, and patient education. In the usual-care group, patients continued to see their PCPs. Participants were aged ≥ 18 years, were diagnosed with hypertension, had a most recent BP measurement of ≥ 140/≥ 90 mm Hg (≥ 130/≥ 80 mm Hg if codiagnosed with diabetes mellitus), were on at least 1 antihypertensive medication, and were English speaking. The primary outcome was the difference in the mean change from baseline in systolic BP at 6 months. Secondary outcomes included the percentage achieving therapeutic BP goal and the mean changes from baseline in diastolic BP and low- and high-density lipoprotein cholesterol. FINDINGS A total of 166 patients were enrolled (69 men; mean age, 67.7 years; PharmD-PCP MTM group, n = 75; usual-care group, n = 91). Mean reduction in SBP was significantly greater in the PharmD-PCP MTM group at 6 months (-7.1 [19.4] vs +1.6 [21.0] mm Hg; P = 0.008), but the difference was no longer statistically significant at 9 months (-5.2 [16.9] vs -1.7 [17.7] mm Hg; P = 0.22), based on an intent-to-treat analysis. In the intervention group, greater percentages of patients who continued to see the MTM pharmacist versus those who returned to their PCP were at goal at 6 months (81% vs 44%) and at 9 months (70% vs 52%). No significant between-group differences in changes in cholesterol were detected at 6 and 9 months; however, the mean baseline values were near recommended levels. The PharmD-PCP MTM group had significantly fewer PCP visits compared with the usual-care group (1.8 [1.5] vs 4.2 [1.0]; P < 0.001). IMPLICATIONS A PharmD-PCP collaborative MTM service was more effective in lowering BP than was usual care at 6 months in all patients and at 9 months in patients who continued to see the pharmacist. Incorporating pharmacists into the primary care team may be a successful strategy for managing medication therapy, improving patient outcomes and possibly extending the capacity of primary care. ClinicalTrials.gov identifier: NCT01973556.

Waterpipe smoking among health sciences university students in Iran: perceptions, practices and patterns of use

BackgroundIn recent years waterpipe smoking has become a popular practice amongst young adults in eastern Mediterranean countries, including Iran. The aim of this study was to assess waterpipe smoking perceptions and practices among first-year health sciences university students in Iran and to identify factors associated with the initiation and maintenance of waterpipe use in this population.ResultsOut of 371 first-year health sciences students surveyed, 358 eight students completed a self-administered questionnaire in the classrooms describing their use and perceptions towards waterpipe smoking. Two hundred and ninety six responders met study inclusion criteria. Waterpipe smoking was common among first-year health sciences university students, with 51% of students indicating they were current waterpipe smokers. Women were smoking waterpipes almost as frequently as men (48% versus 52%, respectively). The majority of waterpipe smokers (75.5%) indicated that the fun and social aspect of waterpipe use was the main motivating factor for them to continue smoking. Of waterpipe smokers, 55.3% were occasional smokers, using waterpipes once a month or less, while 44.7% were frequent smokers, using waterpipes more than once a month. A large number of frequent waterpipe smokers perceived that waterpipe smoking was a healthier way to use tobacco (40.6%) while only 20.6% thought it was addictive. Compared to occasional smokers, significantly more frequent smokers reported waterpipe smoking was relaxing (62.5% vs. 26.2%, p = 0.002), energizing (48.5% vs. 11.4%, p = 0.001), a part of their culture (58.8% vs. 34.1%, p = 0.04), and the healthiest way to use tobacco (40.6% vs. 11.1%, p = 0.005).ConclusionsSocial and recreational use of waterpipes is widespread among first-year health sciences university students in Iran. Women and men were almost equally likely to be current waterpipe users. Public health initiatives to combat the increasing use of waterpipes among university students in Iran must consider the equal gender distribution and its perception by many waterpipe smokers as being a healthier and non-addictive way to use tobacco.

An Evidence-Based and Practical Approach to Using Bydureon™ in Patients With Type 2 Diabetes

Glucagon-like peptide (GLP)-1 agonists are one of the newer classes of medications for use in type 2 diabetes. There are currently three GLP-1 agonists on the market: exenatide twice daily, liraglutide, and exenatide extended release (ER). Exenatide ER is a new weekly formulation of exenatide. Exenatide ER reduces glycosylated hemoglobin by 1.6%, with fewer gastrointestinal side effects compared with twice-daily exenatide. Like other GLP-1 agonists, exenatide ER can be used in combination with metformin, sulfonylureas, or thiazolidinediones. Patients should be assessed for risk of pancreatitis and renal impairment. Education about proper administration technique is vital with the novel delivery system. Prescribers may also consider the use of exenatide ER to improve medication adherence in patients who have successfully tolerated exenatide twice daily or use in patients who have gastrointestinal side effects with exenatide twice daily. Exenatide is a reasonable option that can be added to the regimen of a patient with type 2 diabetes.

Strategies to Improve Medication Adherence Reported by Diabetes Patients and Caregivers: Results of a Taking Control of Your Diabetes Survey

BACKGROUND: Published studies assessing specific methods that patients with diabetes and their caregivers perceive as helpful means of increasing medication adherence are lacking. OBJECTIVE: To determine methods that patients with diabetes and their caregivers have used to improve medication adherence, investigate the perceived helpfulness of these methods, and identify motivating factors and medication characteristics that may positively influence adherence. METHODS: A cross-sectional survey was distributed to patients with diabetes and caregivers of patients with diabetes at the 11th annual Taking Control of Your Diabetes conference in October 2005 at the San Diego Convention Center. Outcome measures were self-reported medication adherence, perceived helpfulness of methods employed to improve adherence, motivating factors that may improve adherence, and medication characteristics that may improve adherence. RESULTS: A total of 524 (40.5% response rate) questionnaires were included in the final analysis, 357 from patients with diabetes and 167 from caregivers. Taking medications as part of a daily routine and using pill boxes were the most frequently reported helpful methods for improving medication adherence. The 3 motivating factors most commonly identified as improving medication adherence were: knowing that diabetes medications work effectively to lower blood glucose, knowing how to manage medication adverse effects, and understanding medication benefits. Many participants thought that newer injectable diabetes medications resulting in weight loss or no additional blood glucose monitoring would be helpful in optimizing adherence. CONCLUSIONS: Participants in this study identified medication education as a key factor in improving adherence. To empower patients to overcome medication adherence barriers, pharmacists could perform more proactive and thorough counseling sessions that include education on indication, mechanism of action, and therapeutic effects of drugs. They could recommend that patients take medications concurrently with a daily routine and use a pill box, as these actions were reported to be likely to improve medication adherence. However, our results also remind us that motivating factors and tools that may improve adherence may be very patient specific and that pharmacists should incorporate an assessment of this variance in their counseling sessions.