Journal of Pharmacy Technology

Although β-blockers are important life-saving medications in heart failure patients, studies evaluating β-blocker dosing in decompensated heart failure are limited.

To determine the clinical outcomes in patients with severe decompensated heart failure receiving the same dose of β-blockers as well as those whose outpatient regimen was altered.

A retrospective chart analysis was conducted in patients with severe decompensated heart failure receiving chronic β-blocker therapy who were admitted to the hospital for decompensated heart failure. Of 245 patients identified, 76 were included in the study: same dose (n = 26), decreased dose (n = 19), discontinued dose (n = 21), or increased dose (n = 10). χ² Analysis for K-independent samples evaluated the incidence of proarrhythmic events, mortality, and the number of recurrent hospitalizations after the index admission. Stepwise forward linear regression analysis determined the variables correlated with morbidity and mortality in these patients.

New arrhythmias during hospital admission occurred in 19 (25%) patients. The discontinued dose group had the most proarrhythmic events (47.6%; n = 10) and the most deaths (50%) in 6 months. Arrhythmias developed 1.8 and 3 days following β-blocker discontinuation or dosage reduction, respectively.

Patients who remained on their outpatient β-blocker dose upon admission for decompensated heart failure had better clinical outcomes than others whose β-blocker dose was changed. A prospective, randomized, controlled clinical trial is warranted to further explore the implications of this drug–disease state interaction.

Blood pressure control has demonstrated significant reductions in strokes and coronary events. Using an evidence-based approach, the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines recommend health-promoting lifestyle modifications, antihypertensive agents, and target blood pressure for different patient care groups.

To assess medication selection(s) and blood pressure goal attainment in a large inner-city, hospital-based, primary care clinic.

A 6 month retrospective, randomized, observational study was conducted to evaluate hypertension management in Bellevue Hospital's adult primary care clinic. Age, sex, ethnicity, comorbidities, blood pressure measurement, and antihypertensive treatment were obtained from computerized medical records. Antihypertensive medication selection was compared with recommendations given by the JNC 7 guidelines. Blood pressure goal attainment sorted by ethnicity, comorbidities, and age was assessed and compared with the National Health and Nutrition Examination Survey (NHANES) data.

A total of 210 patients were evaluated for antihypertensive agent(s) selection. Overall, 72% of patients received antihypertensive agents recommended by the JNC 7 guidelines. More patients in our primary care clinic achieved their systolic blood pressure goal compared with NHANES data. However, hypertensive management at our clinic was below the national average in goal diastolic blood pressure achievement. Patients with frequent follow-up visits were more likely to achieve their goal blood pressure. The most common antihypertensive agents prescribed were β-blockers (40%), followed by angiotensin-converting enzyme inhibitors (35%) and diuretics (33%).

Hypertensive management in the outpatient primary care clinic of our institution warrants improvement in blood pressure goal attainment. Frequent follow-up clinic visits were associated with higher attainment rates of JNC 7 blood pressure goals.

Thousands of people die each year from vaccine-preventable diseases. Pharmacists can be a valuable resource in aiding the success of immunizations.

To determine the barriers to implementing a program utilizing pharmacists as immunizers, as perceived by pharmacists, in a supermarket pharmacy chain.

A 15 question survey regarding the perceived barriers to implementing a pharmacist-run immunization program was distributed to 60 pharmacists in a supermarket chain in northwestern Ohio. The responses were tabulated using a 5 point Likert scale. The data were analyzed utilizing the Statistical Package for Social Sciences.

Of the 60 pharmacists who received the survey, 43 completed the questionnaire (response rate 72.0%). A majority of the pharmacists surveyed believed that patient privacy was an issue in administering adult immunizations in a community pharmacy. The majority of pharmacists were concerned about the risk of adverse reactions to the vaccines and the need for a quick response to control these reactions. Twenty-five pharmacists believed that the prescription volume at their pharmacy limited them from having time to immunize. Twenty-one pharmacists cited cost as the main determining factor in a pharmacy immunization program.

Many barriers to implementing a pharmacist-run immunization program exist. The future success of such an immunization program rests on overcoming the perceived barriers in a formal and timely manner.

Proton-pump inhibitors are often administered by intravenous infusion to raise intragastric pH and prevent rebleeding following endoscopic treatment of bleeding ulcers. Currently, the manufacturers of omeprazole and pantoprazole injections recommend that infusions prepared by dilution in NaCl 0.9% should be used within 12 or 3 hours, respectively. Administration at the ward level would be facilitated if these drugs were known to be stable for up to 24 hours.

To determine whether omeprazole and pantoprazole diluted for infusion in NaCl 0.9% or dextrose 5% are sufficiently stable to allow preparation of 24 hour infusion bags.

Intravenous 500 mL bags of NaCl 0.9% or dextrose 5% containing 200 mg of either omeprazole or pantoprazole were prepared. While stored at 22 °C, samples were withdrawn at intervals up to 10 days, and pH and drug content were measured. ANOVA was used to compare drug concentrations at preparation with those after storage.

The pH of the infusions did not alter by more than 0.2 units over 48 hours, but decreased subsequently. The measured concentrations of both omeprazole and pantoprazole decreased during storage. The decrease in concentration was greater in dextrose 5% than in NaCl 0.9% and was related to storage time. However, for both drugs, the mean decrease did not exceed 6% over the first 48 hours.

Infusions of omeprazole or pantoprazole can be maintained for up to 48 hours without significant loss of active drug content. Maintaining the same bag for 48 hours may provide cost savings compared with the present practice of replacing bags more frequently.

To review the literature on the safety and efficacy of lanthanum carbonate for the treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD).

Primary literature was obtained through a PubMed search (1966–September 2005) using the key terms Fosrenol and lanthanum carbonate. The FDA review, manufacturer-provided data, and published abstracts on lanthanum carbonate were also reviewed and evaluated.

Human studies in which lanthanum carbonate was compared with placebo or active control for the treatment of hyperphosphatemia secondary to renal disease were included. Dose-titration studies were excluded.

Phosphate-lowering agents and dietary phosphate restriction are currently the first-line therapies for initial treatment of hyperphosphatemia associated with ESRD. Lanthanum carbonate is a highly effective non–aluminum, non–calcium-containing phosphate binder. It is the only FDA-approved phosphate binder that is available as an unflavored chewable tablet that may be taken without water.

Clinical studies demonstrate that lanthanum carbonate is more effective than placebo but as or less effective than standard therapies in lowering serum phosphate to target levels. When compared with calcium salts, lanthanum carbonate had a lower incidence of hypercalcemia and a lower risk of patients developing bone disease. However, in clinical trials, patients receiving lanthanum carbonate had greater discontinuation rates, some due to adverse events. The long-term safety data (>5 y), including the potential for lanthanum accumulation in the bone with subsequent development of osteodystrophy, remain unknown.

To review the pharmacology, pharmacokinetics, clinical efficacy and safety studies, adverse effects, drug interactions, dosage, and administration of vildagliptin (LAF 237), a dipeptidyl peptidase IV (DPP-4) inhibitor in Phase III development for the treatment of type 2 diabetes mellitus.

Information was obtained from MEDLINE searches of the English-language literature (1990–September 2005). Search terms included vildagliptin, LAF 237, DPP-IV inhibitor, DPP-4 inhibitor, and GLP-1 agonist.

Available literature reviewed included abstracts, clinical trials with human and animal data, and review articles.

Vildagliptin is a potent and highly selective DPP-4 inhibitor. This novel treatment modality enhances the activity of incretin hormones through inhibition of the enzyme responsible for their degradation.

Vildagliptin demonstrates good tolerability with minimal adverse effects and can effectively improve metabolic control of glucose through an array of mechanisms.

To report a case of possible serotonin syndrome resulting from the addition of methylphenidate and/or escitalopram to venlafaxine.

A 23-year-old woman being treated for bipolar depression experienced suspected serotonin syndrome. During the course of hospitalization, several medication changes were implemented. Despite these treatment interventions, depressive symptoms persisted during combination therapy with venlafaxine, lamotrigine, and gabapentin. Clinical problems developed when escitalopram and methylphenidate were later added to the regimen within a 2 day period. Several hours after receiving the second dose of methylphenidate, the patient developed a fever, exhibited hallucinations, and began hyperventilating. She was managed with supportive measures with some response, but continued to be lethargic and dizzy. Physical examination revealed increased rigidity of the upper extremities and labile blood pressure. Serotonin syndrome was suspected and all medications were withheld; the patient was then transferred to the intensive care unit.

Prompt and accurate diagnosis of serotonin syndrome is difficult but requires the presence of serotonergic agents in addition to core symptoms that have been identified through years of clinical antidepressant use. Additionally, serotonin syndrome is often complicated by other drug-related disorders with overlapping symptoms. Separately and together, escitalopram, venlafaxine, and methylphenidate have the ability to increase serotonin levels. Utilizing the Naranjo probability scale, we determined the likelihood of both methylphenidate and escitalopram contributing to serotonin syndrome as possible. Review of the established criteria for diagnosing serotonin syndrome, the clinical presentation of the patient, and the time frame of symptom development in correlation with drug therapy changes suggests that this is a case of serotonin syndrome.

We believe that this was most likely a case of serotonin syndrome, precipitated by the addition of methylphenidate and/or escitalopram to venlafaxine.