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Rx News Advisory Feed View All
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Drug Therapy Updates & Reviews/CE View All
  • Interest in medication errors was heightened by publication of the Institute of Medicine (IOM) report “To Err is Human,” which revealed the burden of medical errors and the impact on patients in the US. Following publication of the report in 2000, health care organizations bolstered efforts to reduce medical errors and the illness and death that result. Despite these efforts, a recent analysis based on studies conducted since the IOM’s report highlighted medical errors (including medication errors) as the third leading cause of death in the US. Extrapolating to the total number of US hospital admissions in 2013, the authors estimated that more than 250,000 deaths per year are caused by medical errors – and that includes only inpatient deaths.

    Medication errors have been identified as the most common type of medical error. The FDA estimates that medication errors occur in about 1.3 million people annually and result in at least one death every day in the US. In the hospital setting, adverse drug events (ADEs) occur in nearly 5% of patients; preventable ADEs are one of the most common types of inpatient errors. In the outpatient setting, ADEs account for more than 3.5 million physician office visits, 1 million emergency department (ED) visits, and 125,000 hospital admissions annually. It is estimated that nearly half of these ADEs are preventable. Given the impact of medication errors and ADEs on healthcare utilization and costs in the US, error prevention practices remain key for both prescribers and pharmacists. Because pharmaceutical care involves the identification, resolution, and prevention of drug therapy problems and medication errors, pharmacy personnel, as well as prescribers and patients, have a key role in error prevention.

    This issue provides background information on medication errors and ADEs, and discusses medication error identification and prevention...

  • Marijuana has been used for thousands of years for medical conditions, as well as for recreational purposes. The terms “marijuana” and “cannabis” are used interchangeably; however, cannabis is the more contemporary clinical designation. The use of marijuana has increased recently among US adults (18 years and older), from 10% in 2002 to 13% in 2014. The rise in marijuana use coincides with a declining perception of risk linked with its use, and its use is more prevalent in states with permissive medical marijuana laws. As of November 2016, 28 states and the District of Columbia have legalized medical marijuana, and 16 states have laws permitting the use of cannabidiol (CBD; a nonpsychoactive constituent of cannabis) for medical purposes. Seven states (Alaska, California, Colorado, Massachusetts, Nevada, Oregon, and Washington) and the District of Columbia have legalized both medical and recreational cannabis use.
  • Pediatric patients often suffer from

    viral upper respiratory infections (“the common cold”)

    with symptoms including congestion, rhinorrhea (runny nose), cough and, occasionally, fever. Children experience approximately 3 to 8 colds each year, about twice as many as adults. The annual cost of colds and cold-like illnesses in the US is an estimated $40 billion – due to lost work days for parents, medical appointments, and the cost of medications. Cough, a common symptom of several childhood illnesses, is the second most common reason for emergency department visits by children aged 15 years and younger. Another common symptom among children, fever, accounts for an estimated 6% of all office visits to pediatricians. Typically, colds and related symptoms of cough and fever are self-limiting, but nondrug measures and over-the-counter (OTC) medications may be used to relieve bothersome symptoms. Although many OTC medications are recognized as safe and effective through the FDA’s OTC monograph process, clinical trial evidence to support their use in children is limited.

    In 2001, concern began to escalate about serious adverse effects and deaths related to cough and cold medication use in infants and young children. In addition, adverse events related to

    cough and cold medications

    were implicated as a common reason for emergency department visits, especially among young children.11 These reports led to a 2008 Public Health Advisory from the FDA recommending that cough and cold products not be used in infants and children under the age of 2 years. Following this recommendation, manufacturers voluntarily updated the cough and cold product labels to advise against use in children younger than 4 years.

    Pharmacists and other easily accessible healthcare providers

    are key sources of information about the drug and nondrug options for treating colds, cough and fever in children. Placing emphasis on nondrug options is important to avoid unnecessary medication use and potential side effects. When OTC medication is recommended, caregivers need advice about identifying and measuring the correct dose (which can be quite confusing) as well as any contraindications or side effects of concern for the individual child. This issue focuses on OTC options for cold symptom management; prescription medications (eg, ipratropium nasal solution for rhinorrhea) are not included.
  • The number of people affected by diabetes worldwide is growing rapidly. A 2014 national report estimates that 21 million people in the United States have diabetes and another 8.1 million people remain undiagnosed. All together, that is 9.3% of the US population. Around the world, 387 million people have diabetes, - which accounts for 8.3% of the global population. This burden is expected to increase by 205 million people by 2035. Despite advances in technology and drug therapy, many patients do not achieve adequate glycemic control. National guidelines generally recommend hemoglobin A1c (A1C) values less than 6.5-7%. However, the A1C goal should be individualized based on the patient's specific circumstances. The National Committee for Quality Assurance (NCQA) reported that in 2013, only 52-59% of adults with type 1 or type 2 diabetes who had commercial insurance had A1C levels less than 8%. For Medicaid patients, the percentage was even lower at 45.5%.

    Expert guidelines generally recommend dual therapy (metformin plus another agent) for patients with A1C values over 7.5%. If the A1C goal has not been achieved after 3 months of dual therapy, progression to triple therapy is recommended. Preferred options (in addition to metformin) for dual therapy include glucagon-like peptide-1 (GLP-1) agonists, sodium glucose transporter-2 (SGLT-2) inhibitors, and dipeptidyl peptidase- 4 (DPP-4) inhibitors. Since about half of the patients with diabetes in the community are not achieving adequate glycemic control, pharmacists have an excellent opportunity to impact and improve their care. They can advocate for medication changes to achieve optimal glycemic control and educate patients about diabetes goals, medication side effects, administration, and potential drug interactions.

    SGLT-2 inhibitors are the newest class of diabetes medications, with 3 agents available: canagliflozin (Invokana®), dapagliflozin (Farxiga®), and empagliflozin (Jardiance®). This article will prepare community practitioners to support and educate patients who are already taking these medications, and recommend or initiate their use for patients who are good candidates.
  • Heart Failure

    (HF) is a common disease affecting approximately 5 million adult Americans.The likelihood of developing HF increases with age and is greater in men. The 5-year mortality rate is remarkably high at 50%, and nearly 300,000 deaths annually are directly attributable to HF. HF creates a significant economic burden on the healthcare system; in 2012, direct medical costs were approximately $21 billion. Despite advances in therapy over the past few decades, the prevalence of HF is expected to rise to over 8 million by 2030.

    Role of the Community Practitioner:

    Approximately 1 out of every 4 patients hospitalized for HF is readmitted within 30 days. Readmission accounts for a significant portion of HF costs and is linked with decreased survival.

    Pharmacists and nurses

    can play an important role during transitions of care (eg, from hospital to home) by providing medication reconciliation and patient education, which can help reduce hospital readmissions. Pharmacists in community practice should reinforce discharge instructions through medication counseling and lifestyle modification support.
  • For more than 50 years, vitamin K antagonists such as warfarin were the only oral anticoagulation option for patients with blood clotting disorders. Dabigatran (Pradaxa®), an oral direct thrombin (factor IIa) inhibitor, finally broke onto the scene with FDA approval in October 2010 as the first of the next generation of oral anticoagulants.Since that time, 3 additional oral anticoagulants have been approved in the US. Rivaroxaban (Xarelto®), apixaban (Eliquis®), and the very recently approved edoxaban (SavaysaTM) are oral direct factor Xa inhibitors that share the convenient attributes of dabigatran: fixed dosing, no routine coagulation monitoring (eg, INR testing), and no known dietary interactions – to name just a few.

    This issue will review the evidence supporting these next generation oral anticoagulants and their place in therapy for atrial fibrillation (AF), acute treatment and long-term secondary prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE), and DVT and PE prophylaxis after major orthopedic surgery. The differences between the agents will be highlighted,as well as comparisons with warfarin for conditions where both are indicated. Educational and counseling tips for pharmacists and other community-based providers will be presented. Finally, limitations and challenges to the use of the next generation oral anticoagulants will be discussed.

    Before we begin, here’s a word on nomenclature. Early on, this next generation of oral anticoagulants was convincingly called NOACs (Novel Oral AntiCoagulants), but these drugs would not be novel forever. An Institute For Safe Medication Practices (ISMP) safety alert noted that “NoAC” was interpreted as “no anticoagulation” in a patient at high risk of stroke. The ISMP has designated “NoAC” a potentially dangerous abbreviation and discourages its use. The acronym DOAC for Direct-Acting Oral Anticoagulant provides a reasonably short, easily pronounced, accurately descriptive abbreviation that distinguishes the class from warfarin, which acts indirectly. Wewill use the term DOAC throughout this issue; but be aware that other acronyms (eg, TSOAC [target-specific oral anticoagulant]) are also found in the literature and may work their way into clinical practice.

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