Clinical Reference Updates – January 2012 Summary for Medscape App for Android™

• 487 diseases & conditions updated
• 114 drug monographs updated
• 4 new drug monographs added

Featured Content of the Month – Heart Failure

This month we bring you an expanded collection of over 30 Heart Failure topics that have been updated with the most recent developments from medical literature and guideline recommendations from the American Heart Association, the New York Heart Association, and the European Society of Cardiology.

Comprehensive coverage on Heart Failure, including:

Heart Failure – includes the latest guidelines from the ACCF/AHA, NYHA, and ESC, as well as a greatly expanded multimedia library of clinical images and videos

Echocardiography – discusses the technical aspects of 2-D and Doppler echocardiography and provides an overview of equipment and patient preparation

Transvenous Cardiac Pacing - provides details on obtaining venous access, a technique for placement of the pacing lead, and complications that may occur

Permanent Pacemaker Insertion – offers information on devices and equipment, details on the implantation technique, and a discussion of technical considerations

New Drug Monographs

azilsartan/chlorthalidone (Edarbyclor)
New drug combination of an angiotensin II receptor blocker and thiazide-like diuretic indicated for treatment of hypertension.

glucarpidase (Voraxaze)
New carboxypeptidase enzyme indicated for toxic plasma methotrexate concentrations in patients with delayed methotrexate clearance due to impaired renal function.

Drug Monograph Updates

brentuximab (Adcetris)
A new black box warning was added that describes cases of progressive multifocal leukoencephalopathy, a rare but serious brain infection that can result in death.

C1 inhibitor human (Berinert)
Expanded indication includes treatment of acute attacks for laryngeal hereditary angioedema.

pneumococcal vaccine 13-valent (Prevnar 13)
New indication for prevention of pneumonia caused by Streptococcus pneumoniae in adults aged 50 years or older.

raltegravir (Isentress)
New pediatric indication for HIV-1 infection in children aged 2 years or older.

Fentanyl transmucosal (Subsys)
New sublingual spray indicated for breakthrough cancer pain.

Practice Changing Updates

Our app is continually being updated with new FDA drug approvals, the latest clinical updates from medical literature and current guidelines to help you stay informed and make the best decisions in the treatment of your patients. Here are this month’s featured updates:

Bacterial Pneumonia – Prevnar 13, a pneumococcal 13-valent conjugate vaccine, has been approved by the U.S. Food and Drug Administration for people aged 50 years and older to prevent pneumonia and invasive disease caused by the bacterium, Streptococcus pneumoniae.

Human Papillomavirus – The CDC now recommends the quadrivalent HPV vaccine (Gardasil) for routine use in boys aged 11 or 12 years. Current recommendations advise vaccination for males aged 13-21 years who have not been vaccinated previously or who have not completed the 3-dose series.

Abstract

Satisfactory adherence to aptly prescribed medications is essential for good outcomes of patient care and reliable evaluation of competing modes of drug treatment. The measure of satisfactory adherence is a dosing history that includes timely initiation of dosing plus punctual and persistent execution of the dosing regimen throughout the specified duration of treatment. Standardized terminology for initiation, execution, and persistence of drug dosing is essential for clarity of communication and scientific progress. Electronic methods for compiling drug dosing histories are now the recognized standard for quantifying adherence, the parameters of which support model-based, continuous projections of drug actions and concentrations in plasma that are confirmable by intermittent, direct measurements at single time points. The frequency of inadequate adherence is usually underestimated by pre-electronic methods and thus is clinically unrecognized as a frequent cause of failed treatment or underestimated effectiveness. Intermittent lapses in dosing are potential sources of toxicity through hazardous rebound effects or recurrent first-dose effects.

Reliance on pharma-sponsored digital resources among online U.S. adults is significant. The research found “51% of online U.S. adults (ages 18+) use pharma-sponsored digital resources, such as condition and treatment information, disease management tools, doctor discussion guides, or mobile apps or websites.” This validates that the interactive information and tools produced by biopharma are being utilized and appreciated.

Use of these materials results in action: a conversation about a prescription drug. The study learned “43% of consumers using pharma-sponsored digital resources have discussed prescription drugs with a doctor, nurse, or pharmacist as a result.” This data point supports the business objective behind providing these interactive resources: generating a conversation with a healthcare professional. Note that the study was fielded online among 6,634 U.S. adults, ages 18+ during Q4 2011.

For comparison, Prevention Magazine’s Direct to Consumer Study 2011 found that as a result of seeing an advertisement – not necessarily online – 77% of survey respondents talked to a doctor and 23% asked for a prescription.

How scary is this! Getting consumers to talk about their medication with their physician is a good thing; talking with their pharmacist even better. However, many times this type of advertising (“digital resource”) results in consumers asking about something completely inappropriate. Which, as we all know, can lead to  a physician prescribing an unnecessary medication, using something that they’re not familiar with or prescribing something they wouldn’t consider first line.

All you have to do is look at the top 5 “patient and caregiver groups to agree that pharma should be involved in online health consumer communities” to understand why this is such a bad idea.

1. ADD/ADHD Caregivers
2. Bipolar Disorder Caregivers
3. Epilepsy Caregivers
4. Cystic Fibrosis Patients
5. Rheumatoid Arthritis Patients

Yikes! Choosing drug therapy is quite a bit different than picking out a book on Amazon and it should be treated that way.

Abstract

Anti-infective shortages pose significant logistical and clinical challenges to hospitals and may be considered a public health emergency. Anti-infectives often represent irreplaceable life-saving treatments. Furthermore, few new agents are available to treat increasingly prevalent multidrug-resistant pathogens. Frequent anti-infective shortages have substantially altered patient care and may lead to inferior patient outcomes. Because many of the shortages stem from problems with manufacturing and distribution, federal legislation has been introduced but not yet enacted to provide oversight for the adequate supply of critical medications. At the local level, hospitals should develop strategies to anticipate the impact and extent of shortages, to identify therapeutic alternatives, and to mitigate potential adverse outcomes. Here we describe the scope of recent anti-infective shortages in the United States and explore the reasons for inadequate drug supply.

Unfortunately the abstract doesn’t say much and a subscription is required to read the full article [grrr!]. The authors of the article basically evaluate the shortage of anti-infective agents over a multi-year period (2005-2010) and conclude that “anti-infective drug shortages continue to pose significant problems for clinicians and are a rapidly evolving public health emergency.” In addition they call for further research “regarding the clinical impact of drug shortages on patient outcomes”. How would one perform such a study?

Drug shortages have received a lot of attention lately. Shortages are certainly nothing new, but they seem to have become a bigger issue lately as the sheer number of unavailable medications is staggering. Areas like oncology and infectious disease are particularly hard hit as the number of treatment options in these specialties are limited to start with.

While there is no doubt that the shortages have impacted healthcare, I tend to agree with the authors of a commentary piece on the article that conclude that " it is difficult to systematically measure the resulting clinical problem or draw quantitative conclusions about differences in outcomes." Sounds overly simplified, but it’s true.

For more information on drug shortages make sure to visit the ASHP Drug Shortages Resource Center. Over 200 drugs and counting…

I Googled “epatient”, and here’s what I found: “e-Patients are health consumers who use the Internet to gather information about a medical condition of particular interest to them, and who use electronic communication tools in coping with medical conditions The term encompasses both those who seek online guidance for their own ailments and the friends and family members who go online on their behalf. e-Patients report two effects of their online health research: “better health information and services, and different (but not always better) relationships with their doctors.”” This definition comes from Wikipedia. I’m not a big fan of Wikipedia, but in this case it seems appropriate.

Here are some thoughts on the e-patient movement:

• It assumes free time – If you don’t already have a working knowledge of the heathcare system, diagnoses, use of medications, etc, then it can take you quite a bit of time to figure it out. Many families have their hands full trying to make a living and survive in this crazy world without having to worry about whether or not they’re getting proper care.
• Assumes access to information – Information on disease states and treatment options is found online, in journals and books, long discussions with your healthcare provider, etc.
• Assumes intelligence – Is it wrong to assume that the “average” person may not have the skill set necessary to keep up with their own health care? Some of this stuff gets complicated. Healthcare providers spend years in school plus years of training to do this stuff. If the average person can effectively manage their care, why the heck are we spending all this time, energy and money on training doctors, nurses and pharmacists? Shouldn’t the system be designed for the lowest common denominator? This isn’t a shot at those without PhD’s, it’s a legitimate concern. I consider myself a fairly intelligent guy, but I don’t think I’d try to build a nuclear submarine from some manuals and an internet search. Know what I mean?
• Assumes access to not only computers, but the internet – My girls go to school with kids that don’t have a computer at home, much less access to the internet. Don’t even get me started on the idea behind mHealth.
• Creates more silos; those that have the time, energy and resources to make sure they’re getting good care, and those that don’t. Many sick people simply want to be taken care of, and I think that is appropriate. We’re not fixing a car, we’re fixing people.

It’s always good to be an active participant in your care, but it shouldn’t reach a point where the care becomes substandard if you can’t. What if the e-patient becomes the “normal” patient? Will those that can’t manage their own health fall through the cracks and receive worse care? Probably. I’ve already experienced this while working closely with chronically ill family members; some with end-stage diseases. If you stay on top of things you get better care. If not, you receive worse care.

Should we really be developing a system that encourages people to provide their own care because it’s better than the care the system provides, or should we build a system that provides better care for every patient? With available resources we can’t do both. Build a better healthcare system. Think about it.

My mother has been doing well since here liver transplant earlier this year, but was recently admitted to a local emergency department with some complications. She was immediately transferred to UCSF where her liver transplant team is. I received the call telling me as much late Thursday night. I couldn’t get any information Thursday night and her life was not in danger so I waited until Friday morning to try to get more details on the situation.

I tried calling my mom’s room directly on Friday morning, but no one answered so I called the nurses station and was told I couldn’t speak with her nurse because they don’t take phone calls between 8:00 – 10:00am. I understand that. It’s prime time for medication distribution on the units and they try to minimize interruptions to prevent medication errors. I get it. Makes sense. However, all I needed to know was what was going on, what they’re doing and what I need to do on my end. I didn’t need her nurse to provide me with the information I needed. They ever so politely told me to call back after 10:00am. Needless to say I was irritated.

Fast forward to 10:00am. I got ahold of the nurse only to be told that she couldn’t tell me anything secondary to patient privacy. Hey, I get it, but I am her son and my name is all over her chart, her durable power of attorney, her medical records, her super secret list of people in the know, etc. Heck, I even set up the password for family members to get updates on her condition when she was there for her transplant. The nurse wouldn’t budge.

My mood went from irritated to pissed. I wanted to reach through the phone and slap the nurse upside the head. I’m several hours away, my mom is in the hospital and I can’t find out what’s going on. After handing up I redialed my mom’s room and eventually reached her. She was tired, in quite a bit of pain and loopy from the meds; not the right person to be giving me information over the phone. While my mom is an intelligent woman she’s not the one that should be answering my questions and being interrogated about tests and procedures. Fortunately she was doing better, but ia am still unclear about the nature of the problem.

According to the UCSF Medical Center website they “define quality as”:

• Superior care and outcomes
• Outstanding patient safety
• Excellent service and patient satisfaction

I think they nailed the first two things on their list, but failed miserably with the third. This is one time when doing the right thing took a backseat to meeting regulatory compliance. In other words, the patient wasn’t the primary focus of the care, the rules were.

And before you privacy and safety nuts start foaming at the mouth consider this: I am the primary decision maker for my mom’s medical care for the past several years; her medical records say as much, at no point did I ask them to risk her safety and all they had to do was check their records to know that they can tell me anything.

I’ve given UCSF the benefit of the doubt many times because I love the university and the medical center, but not this time. This time they get an epic fail.

Anyway, the ISMP alert shared several examples of oral overdoses with Lugol’s solution secondary to confusion between drops and mL’s. However, mixed in with all the “typical” errors, was the little gem below. Even though the error is more than a decade old, I can’t help but wonder “what the heck were they thinking!”. By the way, my initial read through had me thinking cursive “OS” (oculus sinister, i.e. LEFT eye). With that said, I wouldn’t have actually dispensed it because nothing else on the prescription fits.

One of the errors reported more than a decade ago involved an order to administer 10 drops of Lugol’s solution mixed with "OJ" (orange juice), but nurses misinterpreted "OJ" as OD (right eye). The patient received several doses of Lugol’s solution in his right eye. The error was identified when the patient complained to the physician about how painful the eye drops were.

The CDC has additional information on NIVW here, and a whole lot more information on seasonal influenza (Flu) as well. Need to know more about types of influenza viruses? No problem, you can find that at the CDC site too. The most common form of influenza is Type A. For most healthy people the flu is self-limiting. Sure you feel like crap for a few days, but you get over it and truck on. With that said, influenza can be quite dangerous to elderly and those with compromised immune systems. Get vaccinated.

If you do happen to get the flu it’s probably too late to use an antiviral, but if you and your physician feel compelled to do so you can find more information on this handy-dandy Influenza Antiviral Medication Summary sheet from the CDC (PDF). And no, you can’t treat the flu with antibiotics like amoxicillin, SMX/TMP, cirprofloxacin, azithromycin, etc. So don’t use them if you have the flu. If you do you’re just contributing to a bigger problem.

The best treatment for the flu? TV remote, a comfortable couch and rest.

www.YouCanStopTheFlu.com

Next week is National Influenza Vaccination Week. As experts and educators in safe and effective medication use, pharmacists are uniquely qualified to lead efforts within health systems to encourage influenza immunization of health care workers. Encourage your co-workers to get vaccinated. Public health campaigns such as these are the first line of defense against a potentially deadly illness.

Recognizing that influenza infection in health care workers can lead to outbreaks with serious consequences for patients, the American Society of Health-System Pharmacists (ASHP) launched an initiative for pharmacists to improve influenza immunization rates among health care workers. Health care workers can acquire influenza and unwittingly transmit the virus to patients, other health care workers, and members of their household and the community a day or two before symptoms appear.
The resource center includes the following features:

• Essential influenza immunization resources and helpful links
• Practical toolkit to advocate immunization to your co-workers
• Success stories from other pharmacists
• Downloadable widget to track your facility’s progress toward 100% influenza immunization
• Test your Influenza IQ

We’ve been fortunate in the United States as the American Society of Health System Pharmacists (ASHP) have been instrumental in helping pharmacists deal with the issue. In fact the article goes as far as to say that the shortages “have prompted physicians, pharmacists and other health care professionals to call for a national registry or portal modelled on one hosted by the American Society of Health System Pharmacists” Kudos to ASHP.

Don’t expect shortages to go away anytime soon. In the meantime creating a registry to track them might be the way to go.

The article is available for free here.