Keeping health professionals current with useful, quick updates on drugs & therapy - with CE for pharmacists, pharmacy technicians and nurse practitioners.

The Asthma and Allergy Foundation of America reports that up to 30 percent of adults and 40 percent of children in the United States have allergies. Allergies occur when the body’s immune system overreacts to a substance because it interprets the substance as harmful. In response to a harmful substance (an allergen), the immune system makes antibodies called immunoglobulin E (IgE) which cause the traditional symptoms of an allergic reaction. Allergens can be anything that the body determines to be harmful including food, drugs, certain insects (such as those that sting, cockroaches, and dust mites), materials such as latex, mold, pets, pollen, or even exercise. Often allergies are not severe and cause symptoms that present as discomforts such as hives, runny nose, sneezing, or watery eyes.

Anaphylaxis is the most severe form of an allergic reaction. The Texas Administrative Code defines anaphylaxis as “a sudden, severe, and potentially lifethreatening allergic reaction that occurs when a person is exposed to an allergen.”

This issue will review the evidence supporting DOACs and their place in therapy for: 1) atrial fibrillation (AF); 2) the acute treatment and long-term secondary prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE); and 3) DVT and PE prevention after major orthopedic surgery and in medically ill patients. The differences among DOACs will be highlighted (eg, side effect profiles, dosing considerations and drug interactions), and DOACs will be compared with warfarin for conditions where both are indicated. Bleeding management and the use of reversal agents will also be addressed.

For more than 50 years, vitamin K antagonists (VKAs) such as warfarin were the only oral anticoagulant options for patients with blood clotting disorders. In 2010, dabigatran (Pradaxa^®) - a direct thrombin inhibitor - became the first approved agent from the next generation of oral anticoagulants. Over the next 7 years, 4 factor Xa inhibitor oral anticoagulants were FDA approved. These include rivaroxaban (Xarelto^®), apixaban (Eliquis^®), edoxaban (Savaysa^™), and most recently, betrixaban (Bevyxxa^®). Early on, this generation of oral anticoagulants was referred to as NOACs (Novel Oral AntiCoagulants). However, the Institute For Safe Medication Practices (ISMP) issued a safety alert because “NoAC” was interpreted as “no anticoagulation” in a patient at high risk of stroke. The ISMP designated “NoAC” a potentially dangerous abbreviation and discourages its use. Today, the acronym DOAC, for Direct-acting Oral AntiCoagulant, is the abbreviation most widely used to distinguish these medications from warfarin.

This issue highlights the use of continuous glucose monitoring (CGM) systems, sodium glucose transport protein-2 (SGLT2) inhibitors, newer insulin formulations, and the expert guideline recommendations focused on individualization of therapy.

In 2017, the Centers for Disease Control reported that over 30 million people in the US (~10% of the population) have diabetes, including 7.2 million who are undiagnosed. The total estimated cost of diagnosed diabetes in the US was $327 billion in 2017.2 Individuals with diabetes incur average annual medical expenses of about $16,750 – more than twice the expense for people without diabetes.

Over the last decade, the options for managing diabetes have grown dramatically – including new medication classes (eg, glucagon- like peptide-1 agonists, sodium-glucose transport protein-2 inhibitors), new insulin analogs (eg, insulin degludec, biosimilar insulins), and new technologies to help patients monitor their diabetes (eg, continuous glucose monitoring).

Clinical practice guidelines have increased the emphasis on individualizing treatment options and goals to meet the needs of each patient. Patients have more say in the management of their diabetes and overall health. It is essential that healthcare providers help patients navigate the vast pool of information available at their fingertips. Diabetes patients can easily get confused by the often-conflicting information or misinformation available on television and the internet, and from friends and family members. Community providers need a good, working knowledge of patient-specific diabetes management, including current treatments and technologies...

This issue provides key information on influenza vaccines and antiviral medications for the 2018-2019 flu season, including precautions, side effects, and use in special populations.

Influenza (commonly referred to as “the flu”) is a contagious viral infection of the respiratory tract (eg, nose, throat, and lungs). Influenza viruses are primarily spread by respiratory transmission – through droplets from coughing or sneezing. The circulation of influenza viruses varies geographically, with transmission occurring between October and May in the Northern Hemisphere of the temperate region (which includes the US), April and September in the Southern Hemisphere of the temperate region, and year-round in tropical/sub-tropical regions. In the US, peak influenza activity often occurs in January and February.

The flu can affect people of all ages, most frequently schoolaged children, usually causing asymptomatic infection or mild to moderate illness. Severe illness and death occur most often in vulnerable populations (eg, infants, elderly, and immunocompromised individuals). Each year, influenza affects 5-20% of the US population and causes 3,000-49,000 deaths from influenza-related complications. In the 2016-2017 season, 31 million Americans were infected, 14.5 million sought medical care, and 600,000 individuals were hospitalized due to influenza.

Influenza vaccination is an important primary prevention strategy. The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination for all persons 6 months and older (unless contraindicated) starting in early fall, as soon as the

vaccine becomes available. The vaccine is available in a variety of formulations; however, the ACIP makes no preferential recommendation and encourages vaccination with any licensed, age-appropriate vaccine during the 2018-2019 season. Despite the ACIP’s universal recommendation for influenza vaccination, only 47% of the target population in the US (individuals 6 months and older) received the vaccine during the 2016-2017 season.

Thirty seven years after the first case of acquired immunodeficiency syndrome (AIDS) was reported, 36.7 million people world-wide are living with HIV. About 1.8 million new HIV infections and 1 million AIDS-related deaths were reported in 2016. However, there has been significant progress in battling the disease over the last 20 years. Since 2001, the number of new cases decreased by 40% worldwide, and since 2005, AIDS-related deaths have declined by 56%. For the first time in the US, the number of new infections declined 18% between 2008 and 2014.

Due to the availability of potent and better-tolerated antiretroviral agents (ARVs) that prolong life, the number of people living with HIV has increased significantly since the late 1990s. About 1.1 million people in the US are currently living with HIV infection. People living with HIV now have a similar life expectancy as the general population. The 50 year old and older age group accounted for almost one-half (45%) of persons living with HIV infection in the US in 2014. However, complete viral suppression with ARV treatment does not fully restore health. Deaths due to non-AIDS related complications worldwide range from 13.8% (sub-Saharan countries) to 62.3% (high-income countries). These include cardiovascular, kidney, and liver diseases; cancers; and neurologic disorders often associated with aging...

Fluoroquinolones are broad-spectrum antibiotics that have been used to treat infections of varying types and severity since the 1980s. They are well-tolerated by most patients; however, a growing body of evidence has linked fluoroquinolone use to rare but disabling, and potentially permanent, side effects involving tendons, peripheral nerves, and the central nervous system (CNS). Cardiac, gastrointestinal (GI), metabolic (glucose), and ocular side effects, as well as allergic reactions, have also been reported. In May 2016, the FDA determined that the risks of fluoroquinolone use for certain uncomplicated infections are generally greater than the benefits when other treatment options are available.

Subsequently, the labels of all systemic (oral and injectable) fluoroquinolones were updated with strengthened warnings, including a revised boxed warning. The revisions include "limitation of use" statements advising that, in the treatment of acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections (UTIs), fluoroquinolones should be reserved for patients who have no other options.

This issue reviews uncommon but serious side effects of systemic fluoroquinolones. Dosing considerations, use in children and during pregnancy, and potential drug interactions are also discussed...