Pharmacist's Letter Podcast

***NEW FEED IS CALLED "MEDICATION TALK"*** TRC Healthcare, home of Pharmacist's Letter, is excited to announce a brand-new way to get our concise, actionable, unbiased information about the latest developments in medication therapy. Our first episode is coming soon, but in order to listen you'll need to subscribe to the brand NEW “Medication Talk” feed, just search for it in your favorite podcast app to make sure you don't miss out. https://trchealthcare.com/

You'll hear more about the dangers of using dietary supplements. People often think of supplements as "safe." But new evidence shows that supplement adverse events lead to about 23,000 ED visits every year. Over half of these visits are for CV issues, such as chest pain or palpitations, in younger people using weight loss or energy supplements. That's because these often contain stimulants or caffeine sources such as guarana, yerba mate, kola nut, bitter orange, etc. Use this as an opportunity to help patients use a common sense approach with supplements. Point out that "natural" doesn't mean "safe." Give examples of plants that are well known to be toxic...poison ivy, deadly nightshade, hemlock, jimson weed, oleander, foxglove, etc. Explain that FDA doesn't regulate supplements like Rx drugs. It doesn't require testing for efficacy and safety...or require proof of quality before marketing. Plus, supplements aren't required to have warnings about side effects or drug interactions. But this doesn't mean they don't exist. For example, yohimbine can cause arrhythmias...and American ginseng can significantly decrease warfarin efficacy and INR. If people want to use a supplement, suggest choosing one with the USP Verified Mark when possible. Pick your battles...and know when to step in. For example, CoQ10 is unlikely to harm when used for statin muscle pain...but St. John's wort shouldn't be used with oral contraceptives because it can reduce efficacy. Use our Natural Medicines to check for interactions, efficacy, etc...and use our Natural MedWatch to report supplement side effects. PL Detail-Document #311209

One in four heart failure patients are readmitted within 30 days of hospital discharge...often due to medication-related problems. But early follow-up from you...their pharmacist...can help. For example, talking with patients within 2 days of discharge PLUS an office visit within 7 days prevents one ED visit for every 9 heart failure patients...and one readmission for every 52 patients. Expect to see more hospitals, prescribers, and payers looking to work with YOU to help reduce readmissions. Your expertise can improve care...and save money. Think of your role managing heart failure as similar to managing anticoag patients. There'll be professional and financial opportunity in it. Offer comprehensive med reviews to identify and resolve problems. Recommend an ACEI or ARB plus an "evidence-based" beta-blocker...bisoprolol, carvedilol, or metoprolol SUCCINATE...for systolic heart failure. Suggest adding an aldosterone antagonist if symptoms persist. Recommend trying to titrate to target doses that improve survival, such as lisinopril 20 to 40 mg/day or metoprolol succinate 200 mg/day. Consider suggesting Entresto (sacubitril/valsartan) instead of the ACEI or ARB if hospitalization occurs despite use of target doses. But be aware of hypotension, and avoid Entresto when systolic BP < 100 mmHg. Educate patients about self-management...and when to get help. Include caregivers...they are crucially important to success in many cases. Consider using a heart failure questionnaire from our PL Detail-Document to identify red flags BEFORE patients get worse. For example, advise patients to report if weight changes by more than a few pounds. Emphasize adherence with meds, limiting fluids, diet, etc. For example, help patients understand how taking their ACEI or ARB improves their outcomes. Plus this also impacts Star Ratings. Suggest pillboxes or consider offering med sync to boost adherence. Use our PL Conversation Starter to guide your discussions. Communicate with colleagues if you find problems with med lists or identify adherence issues...to prevent gaps in therapy.

You'll see more top-selling drugs go generic in 2016. But don't expect drastic price drops initially...the first generic usually has 180-day exclusivity before other generics come out. Prepare patients for these switches. Explain these are best-guess release dates...they can change due to legal maneuverings, etc. OxyContin (oxycodone ER)...available now. But advise patients generics are only out for the 10, 20, 40, and 80 mg tabs so far. Gleevec (imatinib)...February. This could be a game changer for certain leukemias...since the brand costs about $10,000/month. Crestor (rosuvastatin)...May. This is big...it's the only high-intensity statin besides atorvastatin. Consider rosuvastatin if interactions or muscle problems are an issue with atorvastatin. Nuvigil (armodafinil)...June. Explain armodafinil may last longer than modafinil...but there's no proof it's better or safer. Suggest either option for shift workers if nondrug treatments (sleep hygiene, etc) and caffeine aren't enough. Benicar (olmesartan)...October. It will join a handful of other generic ARBs. Pick one based on payer preference. ProAir HFA (albuterol)...December. Explain this generic will NOT be equivalent to Ventolin HFA, Proventil HFA, or ProAir RespiClick. Encourage prescribers to write "albuterol HFA" to give you flexibility. Zetia (ezetimibe)...December or early 2017. Suggest saving ezetimibe as an add-on for high-risk patients who can't tolerate a high-intensity statin. For patients on Vytorin, consider suggesting generic ezetimibe plus a generic statin instead...at least until Vytorin goes generic. Also look for Basaglar in late 2016. It's a new BRAND of insulin glargine that will be similar to Lantus...NOT a generic or biosimilar.

Does ORAL phenylephrine work for congestion? Not really. Pharmacists generally see that oral phenylephrine (Sudafed PE, etc) doesn't work as well as pseudoephedrine (Sudafed, etc). Now new evidence reinforces that oral phenylephrine isn't better than placebo...likely because it's poorly absorbed. Recommend alternatives for congestion due to the common cold. Encourage nondrug measures first...fluids, saline nasal products, bulb syringes to remove nasal mucus in young children, etc. Explain that humidifiers or vaporizers SOMETIMES help. Lean toward a cool-mist humidifier...the heated steam from some vaporizers and warm-mist humidifiers could pose a burn risk. Recommend oral pseudoephedrine next...for more severe congestion. Feel comfortable suggesting pseudoephedrine for a few days in patients with CONTROLLED hypertension. Encourage monitoring BP. Suggest a TOPICAL decongestant, including phenylephrine, for some patients...such as those with uncontrolled hypertension or BPH. Advise using for a max of 3 days...to avoid rebound congestion. Discourage inhaled camphor and menthol (Vicks VapoRub, etc). Just small ingested amounts can be toxic in small children...and applying beneath the nostrils can cause irritation and actually worsen congestion. Also discourage intranasal steroids...intranasal cromolyn sodium (NasalCrom)...or oral OR topical antihistamines (Astepro, etc). These aren't effective for congestion due to the common cold.

You'll see renewed focus on appropriate med use in patients 65 and older...due to new Beers Criteria from the American Geriatrics Society. Continue to think of these guidelines as a "warning light" to be cautious with certain meds...NOT a "stop sign" to always avoid them. PPIs are new to the list. Discourage using PPIs for over 8 weeks without a good reason, such as chronic oral steroid use. Explain PPIs are linked to a higher risk of C. difficile, fractures, pneumonia, etc. Help patients taper off a PPI if needed. Advise lowering the dose, then taking it every OTHER day for a week or more before stopping. "Z drugs" (zolpidem, zaleplon, eszopiclone) are a concern now when used for ANY duration...not just over 90 days. Potential harms...such as delirium, falls, and fractures...seem to outweigh any benefit. Keep in mind not to turn to benzos...they're still on the list and aren't safer for sleep. Instead, emphasize nondrug strategies. Or consider suggesting low doses of trazodone or doxepin...or ramelteon. Nitrofurantoin used to be discouraged for UTIs if CrCl < 60 mL/min. But now feel comfortable suggesting it short-term if CrCl ≥ 30 mL/min...since new evidence supports its safety and efficacy in these patients. Digoxin should now be saved for atrial fib or heart failure patients only when other options aren't enough...since it may increase mortality. If digoxin must be used, recommend a max of 0.125 mg/day. Warfarin with amiodarone, anticholinergic combos, and other interactions can be riskier in seniors. Suggest avoiding if possible. Direct oral anticoagulants (dabigatran, etc), famotidine, gabapentin, and others may cause more side effects in renal impairment. Advise reducing the med's dose or avoiding it...based on renal function. Expect the Star Ratings high-risk med list to catch up eventually.

Diabetes patients will need your help sticking with metformin...since about 1 in 3 patients will have GI problems with it. We know metformin is our go-to med for type 2s due to well-established safety and efficacy...possible CV benefits...and low cost. Plus it seems safer than previously thought in stable kidney disease. But GI side effects can lead to poor adherence...impacting glucose control AND Star Ratings. Be ready to help patients give metformin a fair trial. Set the stage for what to expect. Explain that GI problems such as diarrhea are usually short-lived...especially with a slow titration. Recommend starting with 500 mg daily...or even just 250 mg daily for some. Suggest titrating by 250 to 500 mg every 1 or 2 weeks as tolerated. Advise backing off to the previous dose if GI side effects are a problem...and trying another dose increase after about 2 weeks. It's okay if it takes weeks or months to reach the target dose of 2 g/day. And don't feel compelled to aim for doses higher than this...they don't lower glucose much more, but may increase GI side effects. Consider REtitrating if a patient stops metformin for even a couple of days...especially if GI problems occurred when it was started. Avoid administration pitfalls. For example, suggest taking metformin during or right after a large meal to improve tolerability. If needed, suggest giving the ER dose BID instead of once daily. Suggest switching metformin products if needed. Extended-release forms often need less frequent dosing...and seem to cause fewer GI side effects. Plus, some of the ER generics now cost as little as $10/month. Discourage Glumetza. It's the only metformin ER product without a generic, and it costs about $6700 per month...and that's not a typo. Plus, there's no good evidence any ER product is better tolerated than another. Also consider a different generic if pill odor is a problem. Odor varies between products...and ER tabs may not smell as bad.

This PL Voices episode is a clip from one of our many editorial discussions. This one took place on February 17, 2016 and is led by our Editor, Sherri Boehringer, PharmD, BCPS. You’ll hear the voices of preventive medicine expert JoAnn E. Manson, MD, DrPH, FAHA, Harvard Medical School, Massachusetts; and guest panelist Barbara P. Yawn, MD, MSc, MPSH, FAAFP, University of Minnesota. You can read our brief, to-the-point Recommendation and dive into the evidence-based details if you wish. To learn more, visit pharmacistsletter.com.

This PL Voices episode is a clip from one of our many editorial discussions. This one took place on February 17, 2016 and is led by our Editor, Sherri Boehringer, PharmD, BCPS. You’ll hear the voice of Editorial Board member Craig D. Williams, PharmD, FNLA, BCPS, Oregon Health and Science University. You’ll also listen to depression expert, Barbara P. Yawn, MD, MSc, MPSH, FAAFP, University of Minnesota. You can read our brief, to-the-point Recommendation and dive into the evidence-based details if you wish. To learn more, visit pharmacistsletter.com.

This PL Voices episode is a clip from one of our many editorial discussions. This one took place on February 17, 2016 and is led by our Editor, Sherri Boehringer, PharmD, BCPS. You’ll hear the voices of Editorial Board members Steven E. Nissen, MD, MACC, Cleveland Clinic, Ohio; and Craig D. Williams, PharmD, FNLA, BCPS, Oregon Health and Science University. You’ll also listen to cardiovascular disease expert Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS, University of Alabama at Birmingham. You can read our brief, to-the-point Recommendation and dive into the evidence-based details if you wish. To learn more, visit pharmacistsletter.com.