Robert A. Hamilton

Frequency of Hospitalization after Exposure to Known Drug‐Drug Interactions in a Medicaid Population

A matched‐pair case‐control analysis of Medicaid claims was performed to determine the risks of hospitalization associated with drug‐drug interactions. Patients were hospitalized and controls were not. They were randomly matched based on contemporaneous eligibility for Medicaid benefits. Odds ratios for hospitalization in patients exposed to known drug‐drug interactions were compared with those in patients exposed to one of the interacting agents. When confidence intervals did not overlap, the odds ratio was considered to be significantly increased. Odds ratios were significantly increased for many interacting drug pairs, and were associated with commonly recognized interactions as well as less widely recognized ones. Cimetidine interactions achieved significance only with theophylline. In the Medicaid population, exposure to a number of drug‐drug interactions was associated with a significantly increased risk of hospitalization.

Colesevelam Hydrochloride-Ezetimibe Combination Lipid-Lowering Therapy in Patients with Diabetes or Metabolic Syndrome and a History of Statin Intolerance

OBJECTIVE To determine the effectiveness and safety of colesevelam hydrochloride (HCl) and ezetimibe combination therapy in statin-intolerant patients with dyslipidemia and diabetes mellitus (DM) or metabolic syndrome (MS). METHODS We identified potential study subjects through a computerized text search of patient electronic medical records using the terms colesevelam, WelChol, ezetimibe, and Zetia. Medical records were subsequently reviewed to identify all patients with DM or MS. Baseline total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglyceride levels immediately before the initiation of therapy with colesevelam HCl (1.875 g twice a day) or ezetimibe (10 mg daily) were compared with those after a minimum of 3 months of single drug therapy and after a minimum of 3 months of combination therapy. Drug safety was evaluated by review of transaminase levels and reports of side effects or drug discontinuation. RESULTS The computerized search initially identified 91 electronic medical records; 16 patients fulfilled all study criteria. Baseline patient demographics included a mean age of 62.5 (+/-11.8) years and a mean body mass index of 31.4 (+/-5.2) kg/m2; 50% of patients were female, 75% had type 2 DM, and 25% had MS. In comparison with baseline, colesevelam HCl-ezetimibe combination therapy was associated with significant reductions in mean levels of total cholesterol (27.5%), LDL-C (42.2%), and non-HDL-C (37.1%). In addition, 50% of patients achieved the National Cholesterol Education Program Adult Treatment Panel III LDL-C target of less than 100 mg/dL. Therapy was well tolerated, with no significant changes in mean transaminase levels, no reports of myalgia, and no discontinuation of therapy. CONCLUSION Colesevelam HCl-ezetimibe combination therapy was associated with improved TC, LDL-C, and non-HDL-C lipid profiles and was well tolerated. Such therapy may be a reasonable consideration for statin-intolerant patients with DM or MS who have elevated cholesterol levels.

A Glucose Meter Accuracy and Precision Comparison: The FreeStyle Flash Versus the Accu-Chek Advantage, Accu-Chek Compact Plus, Ascensia Contour, and the BD Logic

BACKGROUND This study compared the accuracy and precision of five blood glucose (BG) meters. METHODS Diabetes patients undergoing venipuncture for glucose testing were randomized to one of two groups consisting of three meters: FreeStyle Flash (Abbott Diabetes Care, Alameda, CA), Accu-Chek Advantage (Roche Diagnostics Corp., Indianapolis, IN), and Accu-Chek Compact Plus (Roche Diagnostics) or FreeStyle Flash, Ascensia Contour (Bayer Healthcare, Diagnostic Division, Tarrytown, NY), and BD Logic (BD Diabetes Care, Franklin Lake, NJ). Within 5 min following venipuncture, duplicate finger BG measurements from three ipsilateral fingers were taken. Finger glucose measurements were compared with laboratory reference values. Accuracy was assessed by a Clarke error grid analysis (EGA) and within 10% of the laboratory value criteria. Meter precision was determined by calculating the absolute mean differences in glucose values between duplicate samples. RESULTS Finger sticks were obtained from 202 patients. Mean venipuncture BG was 148 mg/dL (SD +/- mg/64 dL; range 25-439 mg/dL). Accuracy by Clarke EGA (Zone A results) was demonstrated in 69% of Advantage samples, 75% of Compact Plus, and 96% of the first group of Flash versus 88% of the Contour, 67% of the Logic, and 91% of the second Flash samples (P < 0.05 for both Flash and Contour). Meter accuracy using the 10% criteria was demonstrated in 30%, 38%, 70%, 46%, 48%, and 68% of the samples, respectively (P < 0.05 for both Flash groups compared to each of the other meters). There were no differences in meter precision. CONCLUSIONS No statistically significant differences in accuracy were evident using the Clarke EGA criteria (pooled results of Zone A and B), though the more strict 20% accuracy criteria (Zone A results only) found the Flash and Contour to have significantly greater accuracy compared to the Advantage, Compact Plus, and the Logic. Using the 10% accuracy criteria found the Flash to have significantly greater accuracy than each of the other four meters. All five meters demonstrated similar precision.

Angiotensin-Converting Enzyme Inhibitors and Type 2 Diabetic Nephropathy: A Meta-Analysis

Objective. To perform a meta‐analysis on studies evaluating the effect of angiotensin‐converting enzyme (ACE) inhibitors on diabetic nephropathy in patients with type 2 diabetes mellitus.

Medicaid Prescriber Compliance with Joint National Committee VI Hypertension Treatment Guidelines

BACKGROUND: Since the early 1970s, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) has been tasked with the formulation of national guidelines for the management of hypertension. These were significantly changed in 1993 with publication of JNC-5. JNC-6 kept many basic treatment recommendations (i.e., initiation of therapy with a thiazide diuretic or β-blocker), partly in response to the low adoption rate of the treatment recommendations of JNC-5. OBJECTIVE: To describe single-drug outpatient therapy of hypertension and temporally correlate these therapies with the publication of JNC-5 and JNC-6. METHODS: The electronic records of randomly selected New York State Medicaid recipients without hospitalization who had a diagnosis of hypertension and who were receiving only 1 antihypertensive medication were analyzed for 1994, 1997, and 1999. This analysis identified the medications selected for monotherapy of hypertension and compared these therapies with JNC recommendations. The analysis was correlated to patient comorbidities to further account for provider selection of a non—first-line agent. RESULTS: In 1994, angiotensin-converting enzyme (ACE) inhibitors and calcium-channel blockers accounted for 69% of therapies, with 67.5% of these patients having no JNC-recognized individualizing consideration for their use. In 1999, the combined use of ACE inhibitors and calcium-channel blockers accounted for over 65% of all single-drug therapy; 60% of these patients had no individualizing considerations. Also, in 1999, 47.7% of all patients appeared to be receiving antihypertensive therapies that are not compliant with JNC recommendations. CONCLUSIONS: Single-drug therapy of hypertension in a nonhospitalized New York state Medicaid population from 1994 through 1999 did not closely follow JNC recommendations for the single-agent treatment of hypertension.

SGLT-2 INHIBITOR THERAPY ADDED TO GLP-1 AGONIST THERAPY IN THE MANAGEMENT OF T2DM.

OBJECTIVE To assess the real-world efficacy and safety of canagliflozin therapy added to type 2 diabetes mellitus (T2DM) patients who have received a minimum 1 year of glucagon-like peptide-1 (GLP-1) agonist therapy. METHODS This pre-post observational study assessed the efficacy and safety of canagliflozin in a group of T2DM patients from a community endocrinology practice who received GLP-1 agonist therapy for a minimum of 12 months. The primary study outcome was change in mean glycated hemoglobin (HbA1c) level from baseline. Secondary endpoints included changes in average weight, and comparison of the percentage of patients obtaining an HbA1c <7%. RESULTS A total of 75 patients met all the study criteria. Baseline patient characteristics were as follows: average age, 58 ± 9 years; mean duration of T2DM, 14 ± 6 years; 56% male; 92% Caucasian; baseline body mass index (BMI), 39.4 ± 9.4 kg/m(2); and mean baseline HbA1c, 7.94 ± 0.69%. HbA1c and weight were significantly reduced by 0.39% and 4.6 kg, respectively. Adverse effects were reported by 13 (17.3%) patients, including 4 (5.3%) who discontinued canagliflozin because of adverse reactions. CONCLUSION Canagliflozin was generally well tolerated and significantly further reduced mean HbA1c levels and body weight in patients with T2DM when added to GLP-1 regimen.

Cholesterol and Glycemic Effects of Niaspan in Patients with Type 2 Diabetes

Study Objective. To determine the effect of Niaspan—a niacin preparation with both immediate‐ and extended‐release characteristics—on lipid and glycemic control in patients with type 2 diabetes.

Incidence and Cost of Hospital Admissions Secondary to Drug Interactions Involving Theophylline

OBJECTIVE: To determine the incidence and cost of hospital admissions for theophylline toxicity, which occurred as a result of the concurrent use of one of the following medications: cimetidine, erythromycin, or ciprofloxacin. DESIGN: Retrospective chart review (18 months, between June 1989 and November 1990). SETTING: A Department of Veterans Affairs Medical Center. PARTICIPANTS: All patients who were receiving theophylline chronically (913 patients) and also had a prescription for cimetidine (124 patients with 140 treatment courses), erythromycin (66 patients with 93 treatment courses), or ciprofloxacin (39 patients with 59 treatment courses) dispensed. INTERVENTIONS: Each patients medical record was reviewed to identify hospital admissions within 30 days following the dispensing of the interacting drug. MAIN OUTCOME MEASURES: Admissions were considered to be related to theophylline toxicity if appropriate signs and symptoms were present and the theophylline concentration was above 20 μg/mL or had increased significantly from the concentration obtained prior to introduction of the interacting drug. RESULTS: One patient who received cimetidine and one who received ciprofloxacin were admitted for theophylline toxicity (2 of 292 potential interactions, 0.81 percent). Admissions were for 16 and 13 days, respectively, and total costs for the two admissions were

Accuracy and Precision of Four Value-Added Blood Glucose Meters: the Abbott Optium, the DDI Prodigy, the HDI True Track, and the HypoGuard Assure Pro

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A Clinical Perspective of Canagliflozin in the Management of Type 2 Diabetes Mellitus

44.00, respectively, per potential interaction. The entire admission was not for theophylline toxicity; it appeared that iatrogenic factors contributed to the duration. CONCLUSIONS: The incidence of hospital admissions secondary to theophylline drug interactions with cimetidine, ciprofloxacin, or erythromycin is low, but the admissions represent considerable expense, even when distributed among all patients at risk for the interactions.