iForumRx.org: Recent Episodes
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We explore the evidence that informs ambulatory care pharmacy practice. Check out our website & podcasts, & consider submitting a commentary!
The BedMed study attempted to resolve a longstanding debate: Does the timing of administration for antihypertensive medication matter? As it turns out, the timing of medication administration isn't terribly important so long as the medication is taken consistently.
Guest Authors: Stefanie C. Nigro, PharmD, BCACP and Eric J MacLaughlin, PharmD, BCPS
Music by Good Talk
This iForumRx podcast episode, produced in collaboration with the ACCP Ambulatory Care Practice and Research Network (PRN), focuses on layered-learning and how to structure your practice to engage learners at different levels of experience.
Expert panelists Dr. Adenike Atanda-Oshikoya, Dr. Michelle Patterson, and Dr. Michelle Musser share their experiences working with students and residents.
Arm position can affect blood pressure accuracy. The ARMS study evaluated the effect of arm position on blood pressure readings, with implications for health care providers and patients with uncontrolled hypertension.
Guests: Emily Nuttall, PharmD, MBA and Tracie Eshelbrenner, PharmD, BCPS
Music by Good Talk
Heart failure with preserved ejection fraction (HFpEF) poses a significant challenge because of its heterogeneous nature and the scarcity of therapies that meaningfully alter its course. The SUMMIT study evaluated the impact of tirzepatide on symptoms and mortality in people with HFpEF and obesity.
Guests: Jennifer N. Clements, Pharm.D., FCCP, FADCES, BCPS, BCACP, BC-ADM, CDCES and Dawn C. Fuke, Pharm.D., BCPS, BCACP
Music by Good Talk
This iForumRx podcast episode, produced in collaboration with the ACCP Ambulatory Care Practice and Research Network (PRN), focuses on the crucial role pharmacists can play in caring for the LGBTQIA+ community. The discussion highlights the unique healthcare needs and barriers faced by this community due to societal stigma.
Expert panelists Dr. Jordan Rowe, Dr. Sarah Amering, and Dr. Kevin Astle share their experiences in providing gender-affirming care and addressing health disparities. They discuss common health problems, medication considerations, and essential resources for pharmacists seeking to enhance their knowledge and expertise. The episode also addresses the impact of current political landscapes on patient access to care and how pharmacists can advocate for and support LGBTQIA+ individuals.
Artificial intelligence (AI) will bring many opportunities to the pharmacy profession, but it can be tempting to use AI in place of critical thinking or reliable research around drug information questions (DIQs). One must wonder, will the pharmacist be held liable if AI gets it wrong?
Guest Authors: Elizabeth B. Hearn, PharmD, BCACP, CDCES; Karlyn E. Hood, PharmD, BCPS; Abigail L. Torres, PharmD
Music by Good Talk
Electronic cigarettes (e-cigarettes; also known as e-cigs, electronic nicotine delivery systems, vapes, mods, pods, and vape pens) have surged in popularity since their market introduction in 2007. Some view e-cigarettes as a less harmful alternative to traditional cigarettes and a potential harm reduction strategy. Others worry about their addictive potential and see them as a setback in our quest for a tobacco-free society.
Guest Authors: Elizabeth S. Yett, PharmD, BCACP, CTTS and Kirk E. Evoy, PharmD, BCACP, BC-ADM, CTTS
Music by Good Talk
Asthma and chronic obstructive pulmonary disease (COPD) are underdiagnosed due to the underuse of spirometry, underreporting of symptoms, and economic barriers. Is there an effective way to capture undiagnosed but symptomatic patients and route them for appropriately managing their respiratory symptoms? That's what the UCAP study attempted to answer.
Guest Authors: Michelle Balli, PharmD, BCACP and Michelle Hernandez, PharmD
Music by Good Talk
Despite advances in the management of acute myocardial infarction (MI), up to 38% of patients will experience signs of heart failure (HF) and many have a reduced left ventricular ejection fraction (LVEF). Sodium-glucose cotransporter 2 (SGLT2) inhibitors have well-documented cardiovascular benefits. However, data are limited regarding their use after an acute MI.
Guest Authors: Amy Hu, PharmD and Kathleen Pincus, PharmD, BCPS, BCACP, CDCES
Music by Good Talk
One of the most debilitating aspects of dementia is the behavioral and psychological symptoms of dementia (BPSD) that impact nearly 90% of patients. These symptoms significantly diminish the quality of life and functional abilities of those affected. To combat the most severe of these symptoms, antipsychotic medications are often prescribed, but not without possibly harmful consequences. A new study sheds additional light on these detrimental consequences.
Guest Authors: Melissa C. Palmer, PharmD, BCPS, BCPP and Jessa Marie Koch, PharmD, APh, BCPP
Music by Good Talk
It is still difficult for patients to quit despite their best efforts. Of the nearly 70% of current smokers who want to quit smoking, only about 7.5% succeed. Unfortunately, there is a lack of evidence to inform subsequent treatment strategies if the initial quit attempt is unsuccessful.
Guest Authors: Elizabeth Yett, PharmD, BCACP, TTS and Katherine Montag Schafer, PharmD, BCACP, CDCES
Music by Good Talk
Reason for Visit: The patient is a 76-year-old Hispanic referred to the ambulatory care pharmacist for dyslipidemia management. The patient has a remote history of an MI (15 years ago) but states he is unable to take statins.
Guest Authors: Mayela Warner, PharmD and Maricar Conson, PharmD, BCPS
Expert Panelists: Sara Wettergreen, PharmD, BCACP, BC-ADM and Tomasz Jurga, PharmD, BCPS, BCACP, BCCP, CDCES
Music by Good Talk
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are one of the established treatments used to slow the progression of CKD and improve outcomes. Could perhaps the glucagon-like peptide 1 (GLP-1) receptor agonists provide similar, additive, or different benefits in patients with CKD?
Guest Author: John Swegle, PharmD, BCPS, BCACP
Music by Good Talk
Over the last several decades, the popularity of cannabis (aka marijuana, weed) has increased significantly, and the recognition of medical benefits is evolving. Cannabis is often celebrated in popular culture as a relaxation-promoting, pain-relieving, harmless substance, and its use among young adults and pregnant women is increasing steadily. A recently published ancillary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) aimed to characterize the association between maternal cannabis use and adverse pregnancy outcomes.
Guest Author: Courtney Cameron, PharmD, BCACP
Special Guest: Leah Sera, PharmD, MA, BCPS
Music by Good Talk
This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
We speak with three panelists who describe the use of remote patient monitoring within their cardiology practices. From measuring weight, blood pressure, heart rate, blood glucose, and even pulmonary artery pressure, the use of remote patient monitoring devices has the potential to revolutionize patient care by making more data available "real-time" and engaging patients more in their care. Nonetheless, there are significant barriers too.
Panelists: Christine Cadiz PharmD, BCPS; Rachel Klosko, PharmD, BCCP, and Aimon Miranda, PharmD, BCPS
Produced by Rebecca Khaimova, PharmD, BCACP, CDCES and Anna K Love, PharmD, BCACP
Music by lemonmusicstudio from Pixabay
It is now uncommon to see warfarin therapy initiated for stroke prevention. However, quality patient care is never a “one-size-fits-all” approach. New evidence from the FRAIL-AF trial suggests that some of our most vulnerable older adults might be better off maintained on a vitamin K antagonist rather than (automatically) switched to a direct oral anticoagulation (DOAC).
Guest Author: Matthew Cantrell, PharmD, BCPS
Music by Good Talk
Reason for Visit: Patient presents today for routine follow-up in the heart failure clinic to optimize his medications.
Guest Authors: Jushua W. Skaggs, PharmD, and Jessica Wooster Thomas, PharmD, BCACP
Expert Panelists: Kristin Watson, PharmD, MS, BCCP and Robert DiDomenico, PharmD
Music by Good Talk
Direct oral anticoagulants (DOACs) are the standard of care for stroke prevention in most patients with nonvalvular atrial fibrillation (NVAF). Data on the safety and efficacy of DOACS in patients with obesity are limited and, at times, contradictory. What would you recommend for a patient with a BMI>40: warfarin, which requires periodic monitoring and dose adjustments, or a DOAC, which may not be as effective?
Guest Authors: Taylor M. Benavides, PharmD, BCPS and Elizabeth B. Hearn, PharmD, BCACP
Music by Good Talk
This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
The treatment of COPD has evolved significant over the past few years. The GOLD classification system was recently changed with a greater focus on exacerbations, and the role of inhaled corticosteroids (ICS) is limited to those with evidence of inflammation. Pharmacists can play a critical and positive role in the lives of people with COPD by encouraging lifestyle changes, administering vaccines to immunize against respiratory illnesses, ensuring proper inhaler technique, and assisting with medication access.
Panelists: Melissa Lipari, PharmD, BCACP; Thomas Levi Lancaster, PharmD, BCACP, BC-ADM; and Rachel Basinger, PharmD, BCACP, CTTS, DipACLM
Produced by Rebecca Khaimova, PharmD, BCACP, CDCES and Anna K Love, PharmD, BCACP
Music by lemonmusicstudio from Pixabay
Patients with diabetes mellitus are at increased risk of dementia; therefore, knowledge about medications and their possible impact on the development of dementia is critical. Historically, metformin has been the most frequently prescribed medication for type 2 diabetes. Does metformin impact the risk of dementia? Should providers be hesitant to prescribe … or discontinue metformin therapy?
Guest Authors: Benjamin King, PharmD, BCACP, Amber Lilly, PharmD, and Jordan Cloonan, PharmD
Music by Good Talk
Reason for Visit: Referred by her community pharmacist to see a medical professional after frequent reports of low blood glucose readings. This is her first visit to this family medicine office — her previous PCP retired over a year ago.
Guest Authors: Katherine A Owen, PharmD, and Allison Zeurn, PharmD, BCACP
Expert Panelists: Jennifer N. Clements, PharmD, BCPS, BCACP, CDCES, BC-ADM and Stefanie Nigro, PharmD, BCACP, CDCES
Music by Good Talk
Pharmacogenomics (PGx) is a rapidly evolving field of precision medicine that studies how genetic variability influences drug response. PGx testing can improve patient care through personalized medication adjustments for a variety of conditions, including pain, mental health, cardiology, and oncology.
Guest Authors: Lauren Jackson, PharmD, MPH and Jacob Marler, PharmD, BCCCP
Music by Good Talk
While driving autonomy plays a crucial role in supporting mobility, social connections, and access to healthcare, older adults face elevated risks on the road. Rigorously collected data would equip us to educate patients about potential dangers, help us engage in collaborative discussions with patients and providers about deprescribing, and improve road safety for this vulnerable demographic.
Guest Authors: Mary Eva McClure, PharmD and Tavajay Campbell, PharmD, BCACP, CDCES
Guest Expert: Michael Brodeur, PharmD, BCGP
Music by Good Talk
Emerging data suggests we may have been overzealous with systemic corticosteroid prescribing and that allowing patients to self-manage their exacerbations with steroid rescue therapy may be harmful. However, we can now identify a subgroup of COPD patients who might benefit from systemic corticosteroids to treat their exacerbation.
Guest Authors: Hope Shrader Sherman, PharmD and Maricar Conson, PharmD, BCACP
Music by Good Talk
Identifying and addressing the social determinants of health (SDOH) influences health outcomes and can positively impact health equity in our society. While health systems in the US are screening for SDOH more often, information on how to improve screening efficiency and effectiveness is lacking. A recently published study was designed to determine what patient and clinician factors are associated with early implementation of SDOH screening in primary care.
Guest Author: Sharmon P. Osae, PharmD, BCACP, CDCES
Music by: Good Talk
This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
Mental illness is very common - 1 in 5 adults in the United States will have a mental illness during their lifetime. Every ambulatory care (and community) pharmacist should be confident in their ability to recognize mental health challenges and how to use medications in an optimal manner to treat them. This is a FOLLOW-UP conversation from the ACCP Annual Meeting program entitled Ambulatory Care PRN Focus Session — Breaking Down Depression and Anxiety Management for the Ambulatory Care Pharmacist.
Expert Panelists: Richard Silvia, PharmD, BCPP and Jordan Baye, PharmD, BCPS
Music by lemonmusicstudio from Pixabay
Reason for Visit: Referred by primary care provider to pharmacy services for education and management; diabetes not responding to oral therapy.
Guest Authors: Jillian Cerullo, PharmD and Michelle Gauvin, PharmD, BCACP, BCGP, CDCES
Expert Panelists: Jennifer Trujillo, PharmD, BCPS, CDCES, BC-ADM and Joshua Neumiller, PharmD, CDCES
Music by Good Talk
Weight extremes, a body-mass index (BMI) either very underweight or obese, are associated with increased all-cause mortality. Mortality attributable to obesity is caused by many secondary conditions like metabolic disorders and cardiovascular (CV) disease. Enter the glucagon-like peptide-1 (GLP-1) receptor agonists—initially approved in the treatment of type 2 diabetes— which induce significant weight loss regardless of diabetes status. But can a weight loss drug decrease CV mortality?
Guest Authors: Gregory Castelli, PharmD, BCPS, BC-ADM, CDCES and Drake Meaney, PharmD, BCPS
Music by Good Talk
Pharmacists are the most accessible health professionals and can play a vital role in screening and managing hypertension. But would an expanded scope of practice that enabled pharmacists to prescribe and manage antihypertensive therapies be cost-effective?
Guest Authors: Stefania Cian, PharmD and Candice Garwood, PharmD, FCCP, BCPS, BCACP
Special Guest: Dave Dixon, PharmD, BCACP, CLS
Music by Good Talk
Omeprazole ranks among the top 10 most prescribed medications in the United States, and many patients take proton pump inhibitors (PPIs) for years. Widespread PPI use persists despite data about potential serious adverse effects. Some worry that PPI use increases the risk of dementia. Are those worries supported by data?
Guest Authors: Molly M. Corder, PharmD, BCPS, BCACP and Ryan S. Ades, PharmD, BCPS
Music by Good Talk
Most clinical settings now use oscillometric BP devices to measure patients’ BP, and over half of people with hypertension (HTN) use a home BP monitor. Can we trust these BP readings if an inappropriate cuff size was used? How will this impact the way we assess BP control?
Guest Authors: Vincent Lam, PharmD and Kathleen Pincus, PharmD, BCPS, BCACP, CDCES
Music by Good Talk
Over 75% of heart failure with preserved ejection fraction (HFpEF) patients have a comorbid diagnosis of obesity. Obesity is an independent risk factor for the development of HFpEF and contributes to disease progression. Obese patients with HFpEF have greater symptom burden, reduced functional capacity, and impaired quality of life when compared to those without obesity. We know that patients often struggle to adhere to lifestyle modifications long enough to see meaningful weight loss, but the benefits of GLP-1 agonists for patients with HFpEF who are obese are not yet clear.
Guest Authors: Alicia M. Nordberg-Payne, PharmD; Rebecca Munger, PharmD, BCACP; Jason Zupec, PharmD, BCACP
Music by Good Talk
As people living with HIV age, the risk of cardiovascular disease becomes the greatest threat to their health and quality of life. Not only does inflammation from HIV infection contribute to atherosclerotic cardiovascular disease (ASCVD), but dyslipidemia from the antivirals commonly used to treat HIV further enhances that risk. But does statin therapy reduce ASCVD risk in patients living with HIV? That's the question that the REPRIEVE study attempted to answer.
Guest Authors: Laura Lerner, PharmD and Joseph Nardolillo, PharmD, BCACP
Music by Guest Talk
Respiratory syncytial virus (RSV) is a common respiratory virus that typically causes mild cold-like symptoms but can potentially cause severe illness in children and older adults. Every year, thousands of older adults and infants are hospitalized due to RSV, and 10,000 or more die. In 2023, two vaccines (Abrysvo and Arexvy) and a monoclonal antibody (Beyfortus) became available to help prevent lower respiratory tract disease (LRTD) associated with RSV.
Reason for Visit: JT was referred by his PCP to the ambulatory care pharmacist for hypertension management.
Chief complaint: “My medication is making my mouth dry. I want to stop it.”
Guest Authors: Sabrina Silviera, PharmD and Megan Scalia, PharmD, BCACP
Expert Panelists: Eric MacLaughlin, PharmD, BCPS and Joseph Saseen, PharmD, BCPS, BCACP, CLS
Music by Good Talk
Can supplements marketed for cardiovascular health be used in place of statin therapy? Health professionals have long been wary of nutraceuticals and dietary supplements due to the lack of safety and efficacy regulations. The SPORT trial attempts to provide robust data, to practitioners and patients, on how common supplements perform compared to statin therapy.
Guest Authors: Kaitlyn Phillips, PharmD, Lindsey Pitt, PharmD, and Anna Love, PharmD, BCACP
Music by Good Talk
Do pharmacists providing remote care using telehealth technologies to patients who self-monitor their blood pressure perform as well as physicians and care managers providing care face-to-face? Is BP control better (or worse)? What about patient satisfaction? The Hyperlink 3 study provides more evidence the telehealth is safe and effective ... and patients prefer it.
Guest Authors: Elizabeth Yett, PharmD, BCACP, TTS, and Jessica Wooster, PharmD, BCACP
Music by Good Talk
Less than 1 in 4 patients with hypertension in the United States have achieved their blood pressure (BP) goal, according to the CDC. Many clinicians only think of changing medications if a patient is having an intolerance to the current regimen. However, individual patients might respond differently to each of the four major anti-hypertensive medication classes and, if we could determine in advance which class(es) would lower the blood pressure the most, we could minimize the number of medications eventually needed to attain control.
Guest Author: Anthony Ishak, PharmD, BCPS
Music by Good Talk
Approximately 1 in 6 adults in the United States report some trouble with their hearing. Despite the prevalence and implications of hearing loss, hearing aid use is strikingly low due to cost and accessibility. In late 2022, the FDA finalized regulations for over-the-counter hearing aids to be sold without medical evaluation or the services of a hearing professional. But will self-fitting OTC hearing aids be as effective as audiologist-fitted prescription hearing aids?
Guest Authors: Lucas A. Berenbrock, PharmD, MS, BCACP and Elaine Mormer, PhD, CCC-A
Music by Good Talk
More than 46 million people in the US met diagnostic criteria for a substance use disorder (SUD) in 2021. These numbers are staggering and suggest that SUD is more common than diabetes in the United States. However, only 6% received treatment. Expanding the care delivery model is essential to improving treatment access and enhancing physical, mental, and social/societal outcomes. Pharmacists can play a key role.
Guest Authors: Melissa C. Palmer, PharmD, BCPS, BCPP and Amanda Stahnke, PharmD, BCACP
Music by Good Talk
Did you know that iForumRx has resource pages related to a wide range of therapeutic areas, patient populations, and practice management issues? Each resource page provides a succinct annotated list of key clinical trials, clinical practice guidelines, and websites. A content expert manages each resource page, and the materials are regularly updated to reflect the latest evidence and guidance. Our newest resource page — Gender Affirming Care — was released in August 2023.
Guest Authors: Alex Mills, PharmD, BCACP, AAHIVP and Jordan Rowe, PharmD, BCACP, BC-ADM
Music by Good Talk
Thiazide diuretics are a first-line treatment for patients with high blood pressure (BP), either as monotherapy or, more often, in combination with other first-line agents, but which one should clinicians use? Chlorthalidone was used in several landmark clinical trials and has a favorable pharmacokinetic profile. But hydrochlorothiazide is the most commonly used (and cheapest) thiazide.
Guest Authors: Brian T Terrell, PharmD, BCACP and Eric J MacLaughlin, PharmD, BCPS
Music by Good Talk
This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
The treatment of dyslipidemia has gotten a lot more complex in recent years as we now have several non-statins that can substantially lower LDL cholesterol and reduce cardiovascular event rates - including PCSK9 monoclonal antibodies, ezetimibe, bempedoic acid, and inclisiran. When and how should we be using these agents?
Panelists: David Dixon, PharmD, BCACP, CDCES, CLS; Kathryn Litten, PharmD, BCACP; and Tomasz Jurga, PharmD, BCPS, BCACP, BCCP, CDCES
Produced by Jonathan Hughes, PharmD, BCPS, BCACP and Anna Love, PharmD, BCACP
Music by lemonmusicstudio from Pixabay
There has been a long-standing debate about the optimal approach to statin use, including whether we should initiate therapy using a “fixed-dose”, high-potency statin, or whether we should “start low and go slow” by titrating the dose to a specific LDL-C target. The LODESTAR study was designed to determine if treating LDL-C to a target level produces similar cardiovascular outcomes when compared to a fixed-dose approach.
Guest Authors: Dawn Fuke, PharmD, BCPS and Catherine Behret, PharmD, BCACP
Music by Good Talk
Type 2 diabetes (type 2 DM) is a progressive disease caused by a variety of pathophysiologic defects. However, even with substantial advances in treatment, glycemic control remains elusive, and most patients require combination therapy. The Glycemia Reduction Approaches in Type 2 Diabetes: A Comparative Effectiveness (GRADE) study sought to investigate the glucose-lowering efficacy of several diabetes medications in combination with metformin.
Guest Authors: Katelyn Currier, PharmD and Jennifer Trujillo, PharmD, BCPS, CDCES, BC-ADM
Music by Good Talk
This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
Population health pharmacists play a critical role in delivering high-quality, cost-effective care to populations at the most risk for adverse outcomes.
Panelists: Ryan Wargo, PharmD, BCACP; Rochelle Rubin, PharmD, BCPS, CDCES; and Shauta Chamberlin, PharmD, BCPS
Produced by Jonathan Hughes, PharmD, BCPS, BCACP and Anna Love, PharmD, BCACP
Music by lemonmusicstudio from Pixabay
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines were recently updated with a focus on kidney health in patients with diabetes. The updated guidelines include recommendations on screening, prevention, and treatment of chronic kidney disease (CKD), including the use of SGLT2 inhibitors, finerenone, and ACE inhibitors or ARBs. The written commentary posted on the iForumRx website provides a succinct summary of the Top Ten Things Every Clinician Should Know.
Guest Authors: Kara Olstad, PharmD; Gurminder Sanghera, BSc, PharmD; and Darren Grabe, PharmD
Music by Good Talk
If we’ve learned anything from the COVID-19 pandemic, it’s that delivering healthcare to patients at a distance is possible. Telehealth can help increase access to care for patients in medically underserved communities and for those who have transportation, cost, and time barriers. But one question has not been adequately answered—is telehealth an effective method to deliver primary care?
Guest Authors: Keaton Thomas, PharmD and Haley M. Klassing, PharmD,
Music by Good Talk
Several studies have shown the benefits of involving pharmacists in the primary care setting. And there are some recommendations regarding an appropriate physician-patient panel size per pharmacist. But what's the ideal ambulatory care pharmacist-patient panel size?
Guest Authors: Benjamin King, PharmD, BCACP, Jubilee Winar, PharmD, and Jasmin Ortiz, PharmD
Music by Good Talk
There are a variety of non-statin lipid-lowering medications with proven cardiovascular benefits; however, most of the evidence supporting their use has been as an adjunct with a statin. Bempedoic acid offers a novel mechanism of action to treat hypercholesterolemia. But is there a CLEAR role for bempedoic acid in the treatment and prevention of ASCVD in statin-intolerant patients?
Guest Authors: Sarah B. Edwards, PharmD and Briana Williams, PharmD, BCPS, BCACP
Special Guest: Joseph Saseen, PharmD, BCPS, BCACP
Music by Good Talk
One in five people in the U.S. report suffering from anxiety in the past year, and one in three will experience an anxiety disorder in their lifetime, but 40% of patients go untreated. Perhaps patients are disinterested (or distrust) in traditional pharmacotherapy ... or perhaps it is due to a lack of availability of services (like cognitive behavioral therapy – CBT). Many patients (and clinicians) are interested in exploring and using alternative treatment approaches, but are they effective?
Guest Authors: Cindy King, PharmD, BCACP and Chris Paxos, PharmD, BCPP, BCPS, BCGP
Music by Good Talk
*MBSR = Mindfulness-base Stress Reduction
The cost of diabetes in the United States has nearly doubled over the past decade in part due to rising prices and the cost of newer medications used to manage the disease. With new, improved, but costly alternatives available, it’s going to be challenging for ambulatory care practitioners to evaluate if the potential benefits of using these newer medication classes as first-line therapy (instead of metformin) outweigh their big price tag.
Guest Authors: Amanda Smith, PharmD and Nicole Slater, PharmD, BCACP
Music by Good Talk
Several medication classes can be used to treat DPNP; however, many patients have a suboptimal response or experience dose-limiting side effects. Treatment guidelines suggest several first-line options but, in the absence of compelling evidence, offer no direction as to which agent to try first or if we should consider combination therapy.
Guest Authors: Shilpa Klocke, PharmD, BCPS and Nicole Hahn, PharmD, BCACP
Music by Good Talk
You’ve probably encountered many patients who have experienced muscle symptoms after starting a statin. Statin-associated muscle symptoms (SAMS) contribute to treatment discontinuation and significantly increase cardiovascular (CV) adverse events and mortality. What strategies do you recommend to increase statin tolerance?
Guest Author: Rick Hess, PharmD, CDCES, BCACP
Music by Good Talk
This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
Measuring blood pressure (BP) and managing hypertension are among the essential roles that pharmacists play in ambulatory care and community-based practice environments. This program is a question-and-answer session as a follow-up to the Ambulatory Care PRN program at the 2022 ACCP Global Conference on Clinical Pharmacy. The panelists answer YOUR questions about the role of manual vs. automated BP readings, using self-monitored BP readings to make clinical decisions, 24-hour ambulatory care BP monitoring, and bedtime administration of antihypertensive agents.
Guests: Andrew Hwang, PharmD, BCPS; Dr. Anthony Ishak, PharmD, BCPS, and Dr. Lalita Prasad-Reddy, PharmD, BCPS, BCACP
Produced by Jonathan Hughes, PharmD, BCPS, BCACP and Anna Love, PharmD, BCACP
Music by lemonmusicstudio from Pixabay
Patient for pharmacists' patient care services remains a challenge. While provider status at the federal level has not yet been realized, there has been a steady growth of payers and programs covering services provided by pharmacists in recent years.
Guest Author: E. Michael Murphy, PharmD, MBA
Music by Good Talk
Reason for Visit: The patient is here today for hypotension and diabetes follow-up. The primary care physician has consulted the clinical pharmacist regarding hypotension.
Chief Complaint: “I feel dizzy when I stand up and feel like my heart is racing. I have never passed out, but it feels like I might, and I usually have to sit back down."
Guest Authors: Kellie Ball, PharmD and Johnathon Proctor, PharmD
Expert Panelists: Morgan Weaver Godfrey, PharmD, BCPS and Richard J. Silvia, PharmD, BCPP
Currently, there are no known safe, effective, and inexpensive ways that can prevent or reduce the risk of developing autoimmune diseases. Any strategy that could reduce the chances of developing an autoimmune disorder would be welcomed by practitioners and patients alike. Perhaps vitamin D and omega 3 fatty acid supplementation can get the job done.
Guest Authors: Rileigh Provenza, PharmD and Nicole Slater, PharmD, BCACP
Music by Good Talk
Obesity is a chronic, progressive, multi-factorial, neurobehavioral disease characterized by excessive adipose tissue. Here are some things every clinician should know about treating overweight and obesity but be sure to read the written commentary posted on iForumRx.org
Guest Authors: Jennifer N. Clements, PharmD, BCPS, BCACP, CDCES, BC-ADM and Seena L. Haines, PharmD., BCACP, NBC-HWC, CHWC
Music by Good Talk
Hyperkalemia is a common electrolyte disorder in patients with CKD that can be exacerbated by renin-angiotensin-aldosterone system (RAAS) inhibitors. While hyperkalemia poses potential risks to patients with CKD, the potentially negative impact of discontinuing RAAS inhibitor therapy on long-term renal and cardiovascular outcomes in CKD patients is unclear.
Guest Author: Michelle A. Fravel, PharmD, BCPS
Music by Good Talk
Reason for Visit: JS was referred by her PCP to the ambulatory care pharmacist for contraceptive counseling.
Chief Complaint: “I think I’m leaning more towards the pill, but I’m really open to anything. It’s also itchy again down there, probably another yeast infection.”
Guest Author: Elizabeth Salisbury, PharmD
Expert Panelists: Ashley Meredith, PharmD, MPH, BCACP; Rebecca Stone, PharmD, BCACP, and Sally Rafie, PharmD, BCPS
Check out the Birth Control Pharmacist website.
What is the secret to staying up to date with clinical updates, tips for flourishing in your practice and life, and inspirational stories about pharmacist entrepreneurs…all at the click of a button? No, it is not magic. It is a podcast!
Guest Authors: Elizabeth Yett, PharmD, BCACP, TTS and Elizabeth Hearn, PharmD, BCACP
Music by Good Talk
Would you be willing to pay three times more for a brand-name levothyroxine product than a generic equivalent? Clinical practice guidelines recommend against switching between products. As a result, levothyroxine has higher brand-name product dispensing rates than other medications, costing patients and the healthcare system much more money.
Guest Authors: Connie Liang, PharmD and Kathleen Pincus, PharmD, BCPS, BCACP
Music by Good Talk
The landmark REDUCE-IT trial demonstrated that icosapent ethyl (IPE) 4 g daily significantly reduced cardiovascular events in high-risk patients when added to statin therapy, but is a fancy fish oil supplement really worth our coin?
Guest Authors: Joseph Nardolillo, PharmD, BCACP and Vivian Cheng, PharmD, BCPS, BCACP
Music by Good Talk
Smoking remains a habit for many people, even among those who are motivated to quit. Historically, most smoking cessation interventions have targeted individuals who are ready to quit smoking in the next 30 days, overlooking those who are not yet ready to quit. Perhaps an abstinence game, Take a Break, can move people in pre-contemplation and contemplation toward quitting.
Guest Authors: Anna Rhett, PharmD and Ha K. Pham, PharmD, BCACP
Music by Good Talk
It is well established that overuse of short-acting beta-agonists (SABA) increases the risk of poor asthma control, exacerbations, and increased mortality. Several studies have combined a beta-agonist with an inhaled corticosteroid (ICS). The combination provides symptom relief and decreases the risk of poor outcomes. The days of using albuterol monotherapy should be coming to an end; two drugs are better than one!
Guest Authors: Katherine Montag Schafer, PharmD, BCACP, CDCES and Stefanie C. Nigro, PharmD, BCACP, CDCES
Music by Good Talk
Health professionals must deal with a lot of uncertainty in their work, such as weighing the risks and benefits of various treatment options, determining whether a patient’s symptoms are an adverse effect of medication therapy, or deciding if adding a new drug to the formulary will be cost-effective. A lower tolerance of uncertainty increases the risk of burnout and other stress-related harms. A new study sheds light on several contextual factors that contribute to low tolerance of uncertainty and some potential opportunities for intervention.
Guest Author: Brent Reed, PharmD, MS, BCCP
Music by Good Talk
The 2022 AHA/ACC/HFSA Heart Failure Guidelines is a much-needed update and consolidates previously published recommendations. In the written commentary we describe the top ten things every clinician should know about the 2022 AHA/ACC/HFSA Heart Failure Guidelines. This podcast episode highlights some of the key recommendations from the guidelines and addresses some of the practical implications.
Guest Authors: Madison Yates, PharmD and Megan Supple, PharmD, BCACP, CPP
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When was the last time your patients or loved ones were screened for cognitive changes and dementia? Patients and caregivers both fear and accept cognitive decline as part of the aging process, but often delay screening. However, early detection of cognitive impairment can assist healthcare teams to make proactive interventions to slow cognitive decline and promote healthy aging. Guest Authors: Rebecca Heath, PharmD, MSCR and Kimberly L. Zitko, PharmD, BCACP, BCGP Music by Good Talk
When was the last time your patients or loved ones were screened for cognitive changes and dementia? Patients and caregivers both fear and accept cognitive decline as part of the aging process, but often delay screening. However, early detection of cognitive impairment can assist healthcare teams to make proactive interventions to slow cognitive decline and promote healthy aging. Guest Authors: Rebecca Heath, PharmD, MSCR and Kimberly L. Zitko, PharmD, BCACP, BCGP Music by Good Talk
Unsurprisingly, medication burden increases as we age. At each clinic visit, we consider starting new medications, but it’s still relatively uncommon to critically evaluate medications that could be deprescribed. How can we change the culture to embrace deprescribing as an integral part of patient care? The OPTIMIZE study was a provider- and patient-level educational intervention that attempted to increase deprescribing.
Guest Authors: Kashelle Lockman, PharmD, MA and Sarah Greiner, PharmD
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Unsurprisingly, medication burden increases as we age. At each clinic visit, we consider starting new medications, but it’s still relatively uncommon to critically evaluate medications that could be deprescribed. How can we change the culture to embrace deprescribing as an integral part of patient care? The OPTIMIZE study was a provider- and patient-level educational intervention that attempted to increase deprescribing.
Guest Authors: Kashelle Lockman, PharmD, MA and Sarah Greiner, PharmD
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Most practitioners won’t hesitate to start drug therapy in an adult patient with chronically elevated blood pressure (BP) … except, perhaps, if the patient is pregnant. In this vulnerable population, we frequently take a “wait-and-see” approach and withhold therapy unless the BP elevations become severe. But is this the right decision?
Guest Authors: Timothy D. Gladwell, PharmD, BCPS, BCACP and Scott Baker, PharmD, BCPS
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Nonalcoholic steatohepatitis (NASH) is quickly emerging as one of the most common reasons for both liver cirrhosis and liver transplant in the United States – soon predicted to overtake hepatitis C virus as the predominant etiology. Currently, there are no FDA-approved medications to treat these disorders. Hopefully, that will soon change.
Guest Author: Scott Malinowski, PharmD
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Pain and hypertension are two of the most prevalent conditions worldwide. Acetaminophen is often considered the “go-to” and the “safe” over-the-counter analgesic for patients with hypertension because it is not commonly believed to increase blood pressure or cardiovascular events. But is that assumption grounded in evidence?
Guest Authors: Lizzie Baumeister, PharmD and Austin Morgan, PharmD, BCACP, CDCES
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This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
Wondering if a continuous glucose monitor (CGM) is right for your patient? Worried about workflow, prior authorization, billing, and payment? Our expert panelists explain how they manage patients in their practices and how they bill for their services.
Guests: Jennifer Trujillo, PharmD, BCPS, CDCES, BC-ADM; Edward Saito, PharmD, BCACP; and Christina Sherrill, PharmD, BCACP, CPP
Produced by Jonathan Hughes, PharmD, BCPS, BCACP and Anna Love, PharmD, BCACP
Music by lemonmusicstudio from Pixabay
Physical activity is critical to preventing and treating diabetes and reduces cardiovascular disease (CVD) and mortality. Although moderate-to-high intensity aerobic exercise of any type is likely beneficial, cycling is particularly attractive because it is a low-impact exercise (e.g. easier on the joints) and can potentially be used as a transportation method.
Guest Author: Kristin Lutek, PharmD, BCACP, CDCES
Special Guest: Seena L. Haines, PharmD, BCACP, NBC-HWC
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Many older adults do not receive recommended screening exams or treatments and frequently take multiple medications that place them at high risk of adverse effects and drug-drug interactions. Pharmacists performing an Annual Wellness Visit (AWV) provides an opportunity to conduct a comprehensive medication review to identify and correct medication-related problems as well as close care gaps.
Guest Authors: Brenna Gelen, PharmD and Nicole Slater, PharmD, BCACP
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This episode is a collaboration between the ACCP Ambulatory Care Practice and Research Network (PRN) ... and iForumRx.org.
Do you experience FOMO (aka fear of missing out) when it comes to the primary literature? How can you keep on top of the never-ending stream of new evidence that's published (and presented) every day! Of course, iForumRx is one way to keep abreast of the latest evidence ... but there are lots of great tools out there! Our guests share with us their favorite tools for keeping up.
Guests: Greg Castelli, PharmD, BCPS and Kate Cozart, PharmD, BCACP, BCPS, BCGP
Produced by Jonathan Hughes, PharmD, BCPS, BCACP and Anna Love, PharmD, BCACP
Music by lemonmusicstudio from Pixabay
The thrombotic antiphospholipid syndrome (TAPS) is associated with atypical thromboembolic events and/or recurrent pregnancy loss. Patients with TAPS are at very high risk of recurrent thrombotic events and require indefinite therapy. Warfarin therapy is very challenging to manage in this patient population and requires frequent monitoring. Thus a direct oral anticoagulant would be a welcomed alternative to warfarin by many patients with TAPS. But are they effective?
Guest Authors: Leslie Walters, PharmD, BCACP and Jennifer Carie, PharmD, BCACP, BC-ADM
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Sacubitril/valsartan is considered part of the backbone of guideline-recommended therapies for the management of patients with heart failure. In 2021, sacubitril/valsartan became the preferred treatment over an ACEi or ARB in patients with heart failure with reduced ejection fraction (HFrEF) because it reduces the risk of cardiovascular death and hospitalization for heart failure in nearly all adult patients with chronic heart failure. All clinicians should be familiar with the indications, dosing, safety, and monitoring of sacubitril/valsartan. Affordability, access, and inappropriate dose titration remain major barriers to achieving optimal outcomes.
Guest Authors: Jessica Wooster, PharmD, BCACP and Elizabeth Yett, PharmD, BCACP
Special Guest: Dustin (DJ) Clark, PharmD, BCACP
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Unfortunately, many patients with CAD do not receive the influenza vaccine every year. And many patients being discharged from hospital after an acute coronary event don't receive it either. The IAMI (Influenza Vaccination After Myocardial Infarction) study was the first, large, randomized, double-blind, placebo-controlled, multi-center trial to investigate whether influenza vaccination could reduce the rate of cardiovascular events in high-risk adults with CAD.
Guest Authors: Noelle Cordova, PharmD and Laura McAuliffe, PharmD, BCACP, CDCES
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Two novel oral antiviral agents were granted emergency use authorization (EUA) by the U.S. Food and Drug Administration (FDA) for the treatment of mild to moderate COVID-19 in late December 2021. Although it is named after Thor’s hammer, Mjölnir, molnupiravir was given a last place (4th line) recommendation by the National Institutes of Health (NIH) COVID-19 Treatment Guideline Panel. What gives?
Guest Authors: Amanda Applegate, PharmD, BCACP and Mary Beth Dameron, PharmD, BCACP
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Published in Diabetes Care every January, the Standards of Medical Care in Diabetes by the American Diabetes Association (ADA) provides recommendations for the care of patients with diabetes. And every year clinicians eagerly read, discuss, and apply them in their practices. In this episode, we discuss some of the highlights.
Guest Author: Jennifer N. Clements, PharmD, BCPS, BCACP, CDCES, BC-ADM
Special Guest: Joshua Neumiller, PharmD, CDCES
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Is my patient’s forgetfulness due to dementia or diphenhydramine? In older adults, adverse drug events (ADEs) can often be misinterpreted and lead to the initiation of new medications, which carry their own risks of ADEs … that can be misinterpreted as a new problem … leading to even more medications being prescribed. In this episode, our guests critically examine a study that identified a new prescribing cascade: gabapentinoid -> diuretics.
Guest Authors: Veronica Arceri, PharmD and Mallory Telese, BA, PharmD, BCACP
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Thiazide diuretics have been in clinical use for more than 60 years. Small studies published in the 1950s/60s reported that chlorothiazide had less diuretic and antihypertensive effect in patients with lower glomerular filtration rates which led to the belief that thiazides are ineffective in advanced CKD. The Chlorthalidone in Chronic Kidney Disease (CLICK) Trial challenges this dogma.
Guest Authors: Michael Ernst, PharmD, BCGP and Michelle A. Fravel, PharmD, BCPS
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Traditionally, hypertension management involves a stepwise approach where agents are titrated and added. Thus, achieving optimal BP control requires close follow-up, time, and resources. Outside of these logistics, providers are prone to clinical inertia (aka fail to advance therapy when they should) and sometimes “push back” from patients who experience the burdens of treatment and follow-up. Perhaps it’s time to reconsider our approach to managing hypertension.
Guest Authors: Erin Connolly, PharmD and Laura Varnum, PharmD, BCACP
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Despite prevention efforts, about 1 in 3 patients diagnosed with diabetes have comorbid CKD. Half of these individuals have moderate to severe disease. Unlike patients with type 1 diabetes where it develops after many years after the diagnosis, CKD is commonly present at diagnosis in patients with type 2 diabetes. While many interventions are available to prevent the progression of CKD, more are needed.
Guest Authors: Katherine Montag Schafer, PharmD, BCACP, CDCES and Kyle Hunt, MD
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More than half of women in the United States aged 15 to 49 years use a form of contraception. However, many women discontinue use during the first 12 months. Reasons for discontinuation include inconvenience, method failure, adverse effects, and cost. But another potential factor that is not as well-studied is the sexual acceptability of the contraceptive method.
Guest Authors: Katherine Harte, PharmD and Allison Zuern, PharmD, BCPS, CDCES
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Although guideline-directed medical therapy substantially improves morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF), treatments that clearly improve outcomes in those with HF and an EF >40% remain elusive. Unfortunately, the incidence and prevalence of HF are expected to substantially increase in the coming decades. More evidence and effective treatments for those with HF with preserved ejection fraction are clearly needed. Enter the EMPEROR-Preserved trial.
Guest Authors: Gabrielle Givens, PharmD, BCPS and Robert Parker, PharmD
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Continuous glucose monitors (CGMs) are now commonplace, and every clinician should know the basics about who can benefit from CGM use and how to address common questions and problems.
Authors: Brianna Patacini, PharmD, BCACP, CDCES and Dawn Fuke, PharmD, BCPS
Special Guest: Jennifer Trujillo, PharmD, BCPS, CDCES, BC-ADM
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Every day, millions suffer from poor sleep that disrupts their lives, and long-term sleep disorders can cause attention deficits, mood disorders, anxiety, and depression. Several prescription treatment options for sleep are available but they often have undesirable side effects and can lead to tolerance and dependency. Thus, a natural product that has been documented to improve sleep with minimal adverse events may be a better choice.
Guest Authors: Alyssa Korman, PharmD and Nicole Slater, PharmD, BCACP
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There are now over 30 unique therapeutic entities (and countless different products!) to treat hyperglycemia in patients with type 2 diabetes mellitus (T2DM). While the glucagon-like peptide-1 (GLP-1) receptor agonists improve glycemic control, renal, and cardiovascular outcomes and induce significant weight loss, drugs that target more than one incretin hormone may have even greater therapeutic benefits.
Guest Authors: Nadila Faridi, PharmD and Kathleen Pincus, PharmD, BCPS, BCACP
Special Guest: Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES
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WARNING: Patient has a penicillin allergy! Do you want to continue with this cephalexin order?
Although these warnings are commonplace, immunologic cross-reactivity between penicillins and cephalosporins is uncommon. When B-lactams are indicated as first-line therapy for therapy, cephalosporins are often avoided if the patient has a penicillin allergy listed. Would the removal of EHR warnings about potential penicillin allergies when cephalosporins are ordered be helpful or harmful?
Guest Authors: Brian Wenger, PharmD and Nora Sharaya, PharmD, BCPS, BCACP, BC-ADM
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There is no consensus regarding the preferred dosage of aspirin in patients with atherosclerotic cardiovascular disease (ASCVD) and this has led to variability in prescribing patterns. This is likely due to the lack of head-to-head trials evaluating different aspirin doses and data weighing the clinical benefits and adverse effects experienced with aspirin. Until now?
Guest Authors: Ivy Nwogu, PharmD and Megan Supple, PharmD, BCACP, CPP
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Short courses of corticosteroids, also known as “steroid bursts,” are frequently utilized in both pediatrics and adults; however, evidence supporting the safety of these bursts is lacking. Long-term use of oral corticosteroids is associated with a number of serious adverse effects. New evidence suggests that a steroid burst is not risk-free.
Guest Authors: Irene Ruiz, PharmD and Kristine A. Parbuoni, PharmD, BCPPS
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Variability in clopidogrel pharmacokinetics among patients has been appreciated for years and this results in inconsistent effects on platelet inhibition and poor outcomes. Multiple strategies to personalize antiplatelet therapy intended to balance the risks and benefits of therapy have been tested. A recent systematic review and meta-analysis attempts to answer the question: Is a personalized approach worth it?
Guest Authors: Kiana R. Green, PharmD and Augustus (Rob) Hough, PharmD, BCPS, BCCP
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Although there are numerous medications available to treat major depressive disorder, not all patients respond, and some experience intolerable side effects. Thus, we need to find and develop new treatment options. There has been considerable interest in psychedelic compounds that may have antidepressant activity. Recent research using psychedelics for mental health conditions has made news headlines, but most health professionals have only a vague awareness about psilocybin and its potential role.
Guest Authors: Brittany L. Parmentier, PharmD, MPH, BCPS, BCPP and Andria F. Church, PharmD, BCPS, BCPP
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Nearly half of all pregnancies are unintended and a high percentage of unwanted pregnancies lead to an abortion. Reducing the number of unintended pregnancies and increasing the use of effective birth control are two public health priorities. Could the implementation of pharmacist contraception prescribing combined with EC on the same day help “bridge the gap?”
Guest Authors: Ashley H. Meredith, PharmD, MPH, BCACP, BCPS, CDCES and Veronica P. Vernon, PharmD, BCPS, BCACP, NCMP
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We now have “diabetes medications” to treat heart failure with reduced ejection practice (HFrEF). Many clinicians have not yet used a sodium-glucose transporter 2 inhibitor (SGLT2i) for the treatment of HF and are (rightfully) concerned about potential drug-drug interactions, particularly when using an SGTL2i with a mineralocorticoid (MRA). A recent secondary analysis using data from the EMPEROR-Reduced study may provide some reassurance.
Guest Authors: B. Blake Miller, PharmD, BCPS and Jennifer Clements, PharmD, BCPS, BCACP, CDCES, BC-ADM
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Allergic rhinitis affects millions of children and adults. Indeed, it is the fifth most common chronic disease in the United States. Although people do not die from allergic rhinitis, it sure can make you feel miserable, disturb sleep, and impair daily activities. Guidelines recommend the use of intranasal corticosteroids on a daily basis since the onset of action takes a few days. In reality, however, patients adjust their treatment according to the severity of their symptoms. As-needed corticosteroid use is effective for the treatment and prevention of asthma symptoms. Can we apply this same concept to allergic rhinitis? Could the as-needed use of intranasal corticosteroids achieve the same outcomes as daily use?
Guest Authors: Lalitha Sukumar, PharmD; Alyssa Gallipani, PharmD, BCACP; and Rahul Jacob, PharmD
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More than two-thirds of adults in the United States are overweight or obese — thus, obesity is, by far, the most common preventable health-related problem seen in practice today. Obesity is associated with several comorbidities, and weight reduction leads to positive outcomes in many diseases. Studies have shown that a weight loss of 10% improves cardiovascular risk and outcomes. Unfortunately, current pharmacological options for weight loss do not consistently achieve a 10% weight loss. Can semaglutide deliver?
Guest Panelists: Teney Mathew, PharmD, Jason Zupec, PharmD, BCACP, and Amy Heck Sheehan, PharmD, BCPS
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The prevalence of heart failure in patients with diabetes is four times higher than in the general population. Likewise, chronic kidney disease (CKD) and diabetes are common morbidities. As new drug classes emerge in the management of diabetes and heart failure and CKD, it is important to thoroughly evaluate available literature and identify opportunities to reduce complications and costs. Sotagliflozin is a first-in-class dual SGLT-1 and 2 inhibitor approved in Europe. Does it improve outcomes in patients with heart failure or CKD?
Guest Authors: Maren Richards Brinton, PharmD and Jonathan C. Hughes, PharmD, BCPS, BCACP
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In blinded clinical trials the percentage of patients who experience muscle symptoms while taking a statin is typically in the 3-5% range. In practice, the percentage of patients who report muscle symptoms is 10-25%. This disparity between what has been observed in blinded trials and what patients experience when treated with a statin is due, in part, to the nocebo effect — a belief that a medication may cause harm. How many lives could be saved if we routinely used tiny randomized, controlled, blinded trials to determine when statin therapy can be safely continued?
Guest Panelists: Elizabeth Hearn, PharmD; Stuart T Haines PharmD, BCPS, BCACP; and Kathryn (Katie) Kiser, PharmD, BCACP
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An infographic is an “informational graphic” that integrates design with data in order to visually communicate information in a clear, concise, and comprehensive manner. The use of these visual tactics can be powerful tools to enhance engagement, increase comprehension, and long-term retention of information. Our guests explain how to create a successful infographic that can amplify the key educational messages to your targeted audience. Be sure to download the Infographic about creating Infographics on the iForumRx website!
Guest Authors: Ashley Barlow, PharmD and Brooke Barlow, PharmD
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Nearly 12% of the population suffers from migraine headaches — which not only negatively impacts patients, but causes a major “headache” for the healthcare system, costing billions for treatment, evaluation, and lost productivity costs in the United States alone. Two-thirds of patients discontinue prophylactic or abortive migraine therapies due to ineffectiveness or adverse effects. Can mindfulness exercises help migraine sufferers find their “Zen”?
Guest Authors: Denver Shipman, PharmD, BCPP and Elizabeth Cook, PharmD, AE-C, BCACP, CDCES
Guest Panelist: Rebecca Castner, PharmD, BCACP, AAHIVP
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Nearly 67 million people, which equates to 3 out of every 4 people, living with high blood pressure in the US remain uncontrolled, despite the clear and compelling benefits of achieving good control. Remote monitoring and self-management of BP may enable us to broadly achieve optimal BP control in most patients. Increased use of telehealth technology improves access to care, but the effects on the cost and quality of care, particularly in the context of hypertension management, have not been clearly established.
Guest Authors: Mary Taylor, PharmD and Megan Supple, PharmD, BCACP, CPP
Guest Panelist: Joseph Saseen, PharmD, BCPS, BCACP, CLS
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Amidst scientific and technological advancements and an increasing focus on administrative tasks and metrics, meaningful connections with patients are falling by the wayside. Mindlessly using technology can be distracting and lower patient perceptions of their quality of care. How can the busy practitioner increase “presence” with patients while still meeting clinical and administrative demands?
Guest Authors: Emily Prohaska, PharmD, BCACP, BCGP and Nick Schulte, PharmD, BCPS
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We know gout is among the many comorbidities that increase the risk of cardiovascular disease (CVD). In 2018, the cardiovascular safety of febuxostat and allopurinol in patients with gout and cardiovascular morbidities (CARES) trial concluded that febuxostat was non-inferior to allopurinol. BUT, two of the secondary endpoints were very concerning. Febuxostat was inferior to allopurinol in terms of cardiovascular death and all-cause mortality. Many clinicians were left wondering whether febuxostat was cardiotoxic …. or conversely, perhaps allopurinol was cardioprotective. Will another cardiovascular outcome trial provide greater clarity to guide clinical practice?
Guest Authors: Sophia Dietrich, PharmD and Michael W. Nagy, PharmD, BCACP
Guest Panelist: Dawn Fuke, PharmD, BCPS
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The American Diabetes Association (ADA) currently recommends insulin as the preferred agent for the management of type 2 diabetes mellitus during pregnancy. However, metformin is routinely used as it has several advantages over insulin including the lower cost, less maternal weight gain, and less maternal hypoglycemia. The MiTy study explores the benefits and risks of a combination of metformin plus insulin.
Guest Authors: Hugh Quinn, PharmD and Mallory Telese, PharmD Guest Panelists: Erin Raney, PharmD, BCPS, BC-ADM and Rebecca Stone, PharmD, BCPS, BCACP
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Creating an ideal therapeutic regimen is often like putting a puzzle together, with adherence being a critical piece of that puzzle. Studies, and clinical experience, show that patients are more likely to adhere to once-daily medication administration when compared to regimens that require more frequent dosing. Given that pill burden and medication cost are an increasing problem, would our patients benefit from a simple, low-cost, one-size-fits-all approach to addressing cardiovascular risk?
Guests: Ebony Isis Evans, PharmD, Katy Pincus, PharmD, BCPS, BCACP, and Sara Wettergreen, PharmD, BCACP
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Despite numerous anti-smoking campaigns, millions of adults continue to use traditional tobacco-cigarettes or e-cigarettes. Nearly 70% of smokers state they want to quit, however, less than 10% are successful. Disappointingly, less than 60% of smokers report being offered any advice from healthcare professionals when trying to quit. Smartphone applications are a new option for patients attempting to quit smoking in the digital age, but it is unclear if these apps improve quit rates.
Guest Authors: Yue Pheng Vang, PharmD and Michelle Balli, PharmD, BCACP
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Until now, only two classes of medications have been definitively shown to delay the decline in renal function in patients with CKD: angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). The sodium glucose co-transporter 2 inhibitors are increasingly prescribed to a wider and wider population of patients. And the latest data suggest they may have an important role in the treatment of chronic kidney disease (CKD) in patients with ... or without ... diabetes.
Guest Authors: Stefanie C. Nigro, PharmD, BCACP and Jennifer N. Clements, PharmD, BCPS, BCACP, CDCES, BC-ADM
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Insulin pumps and continuous glucose monitors (CGM) have changed the standard of care for managing Type 1 Diabetes. A closed-loop system (also described as an artificial pancreas or automated insulin delivery system) consists of a CGM, an insulin pump, and a control algorithm that automatically calculates basal insulin delivery based on real-time glucose levels. Closed-loop insulin pumps may offer an opportunity to improve glycemic management while reducing some of the associated stress. However, there are limited data evaluating the safety and efficacy of this technology in children less than 14 years old.
Guest Authors: Mary K Culp, PharmD and Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES
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Systemic inflammation appears to be an important contributor to atherosclerotic cardiovascular disease but, to date, no medications have been approved that specifically target systemic inflammation. Could colchicine, an anti-inflammatory drug that has been used for decades, move from “perhaps-do” to a “must-do” standard of care for patients with coronary artery disease (CAD)? Data from two previous trials have demonstrated colchicine’s positive impact on cardiovascular outcomes. The LoDoCo2 study asks us, again, to consider colchicine for patients with CAD.
Guest Authors: Augustus (Rob) Hough, PharmD, BCCP and Taylor Huff, PharmD
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Patients with diabetes are 10 times more likely to experience lower limb amputations than the general population and amputations have very significant morbidity, mortality, and financial implications. While common risk factors for amputation in patients with diabetes include poor glycemic control, diabetic peripheral neuropathy, or peripheral arterial disease, canagliflozin use was implicated in the CANVAS and CANVAS-R trials. However, the CANVAS Program trials were not specifically designed to evaluate the risk of lower-extremity amputations. Clearly, we need more information about the magnitude of risk when canagliflozin is used widely in a general population and who is at most risk.
Guest Authors: Julie Dally, PharmD, BCPS, BCACP and Amanda Schartel, PharmD, BCACP
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There’s no denying that shared decision making (SDM) is an effective communication approach for making patient-centered medical decisions across a variety of health conditions. However, while tools for SDM are often useful during patient visits with practitioners, studies have yielded mixed results with regard to patient outcomes. A new study explores the impact of a SDM tool for anticoagulation selection in patients with atrial fibrillation compared to standard care.
Guest Authors: Ashley Meredith, PharmD, BCACP, BCPS, CDCES and Chandler Howell, PharmD
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Health care professionals often don’t think twice about adding a new medication when a patient is not at goal. But we’re reluctant to stop a medication for a chronic condition when the patient appears to be stable and doing well. Polypharmacy in older adults is a significant problem. It’s costly and increases the likelihood of adverse effects. Several observational studies have suggested that lower blood pressure and multiple antihypertensive medications may be harmful in the elderly. Is it possible to discontinue medications without causing serious harm?
Guest Authors: Keturah Weaver Pharm D, BCPS and Daniel Longyhore Pharm D, M.S., BCACP
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Sales of cannabinoid-containing products continue to rise. In 2020 it became a billion-dollar industry. With the increased use and popularity of CBD products, every clinician needs to critically appraise the evidence to determine if CBD should play a role in pain management and help educate patients about the potential risks.
Guest Author: Alex R. Mills, PharmD, BCACP, AAHIVP
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Nearly 1 in 8 Americans older than 12 used illicit substances in 2018, including misuse of prescription medications. In addition, more than 80% of those who would benefit from substance use treatment in the past year did not receive it. Thus, the importance of identifying and offering treatment should be a priority — particularly in primary care settings. However, there are many barriers to implementing unhealthy substance use screening including pervasive stigma, lack of clinician comfort, logistics, and limited knowledge of or avenues for treatment when unhealthy drug use is uncovered. The US Preventative Services Task Force (USPSTF) recently published updated recommendations on drug use screening.
Guest Authors: Melissa C. Palmer, PharmD, BCPS, BCPP; Jordan Cooler, PharmD, BCPP; and Amanda Stahnke, PharmD, BCACP
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Pharmacists providing effective comprehensive medication management (CMM) services in interprofessional care settings can contribute to improved patient outcomes. Core components of a successful practice include a clearly articulated philosophy of practice, a systematically implemented process of care, and an effective practice management system. Although much has been written about the first two components, less is known about what is required to create an effective practice management system.
Guest Authors: Elizabeth Cook, PharmD, BCACP, AE-C, CDE and Leslie Walters, PharmD, BCACP
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Peripheral artery disease (PAD) impacts 8.5 million Americans age 40 years or older, often leading to acute limb ischemia, amputation, hospitalization, revascularization, major adverse cardiac events (MACE), and death. In addition to being at very high risk of MACE, more than 10% of PAD patients who had revascularization surgery are hospitalized for major adverse limb events, including acute limb ischemia leading to amputation. Could combination therapy, an antithrombotic regimen comprised of a direct oral anticoagulant and an antiplatelet agent, help prevent limb ischemia and cardiovascular (CV) events in these high-risk patients?
Guest Authors: Navya Varshney, PharmD, BCPS and Rachel Lowe, PharmD, BCPS
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Current guidelines recommend statins for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) due to their well-established therapeutics benefits. Unfortunately, many patients are unable to tolerate statins due to statin-associated muscle symptoms (SAMS), most commonly manifested as myalgias. Patients who are unable to tolerate a statin can be challenging to treat. Even if the patient is willing to try a lower dose or a different statin, the patient’s low-density lipoprotein cholesterol (LDL-C) may still be above the recommended threshold. This puts patients unable to tolerate statins at increased risk of ASCVD or of a recurrent cardiovascular event. Is bempedoic acid a useful therapeutic option in patients with SAMS?
Guest Authors: Kara Gurries, PharmD, BCACP and Janeen Ibarreta, PharmD
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Hypertension is poorly managed in the United States with only 25% of patients achieving optimal blood pressure (BP) control (BP less than 130/80 mmHg). To achieve optimal control, patients require close follow-up and BP-lowering medication regimens need to be titrated and periodically adjusted. Community pharmacists are in a unique position to manage patients who have poorly controlled hypertension. However, significant barriers exist to implementing hypertension management services by community pharmacists including a lack of reimbursement. Is chronic care management (CCM) a viable payment model to support these services?
Guest Authors: Kimberly Zitko, PharmD, BCACP, BCGP and Brittany Schmidt, PharmD, BCACP
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Imagine you have recommended statin therapy to a patient with diabetes. A few weeks later, the patient experiences leg pain and stops it. Was this patient’s leg pain caused by the statin? Or was it a nocebo effect? Muscle symptoms in placebo-controlled trials of statin therapy range from 3-5%, while rates in real-world observational studies are between 15-20%. Ambulatory care pharmacists have an important role in recognizing and managing placebo and nocebo effects. Understanding the placebo effect allows clinicians to harness the power of placebos. Reframing risks during patient education may decrease nocebo effects.
Guest Authors: Sara Wettergreen, PharmD, BCACP and Joseph Nardolillo, PharmD
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Lipid management continues to be an essential component in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD). For the past decade, clinical practice guidelines have gone back and forth about optimal treatment goals but guidelines all agree that statins should be used as the preferred initial therapy. However, there is still a lack of clarity about the optimal add-on therapies. The newest LDL-lowering therapy is inclisiran, a small interfering RNA (siRNA) that targets the PCSK9 pathway.
Guest Authors: Joshua O. Holmes, PharmD, MS and Amanda Schartel, PharmD, BCACP
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Do we finally have enough evidence to establish a preferred direct-acting oral anticoagulant (DOAC) for stroke prevention in patients with atrial fibrillation? The use of DOACs for a-fib has rapidly increased due to their ease of use and favorable safety profile. The AHA/ACC/HRS and CHEST guidelines now recommend DOACs over warfarin for stroke prevention in a-fib, but do not state a preference for one DOAC over another. Factor Xa inhibitors, specifically apixaban and rivaroxaban, are the most commonly prescribed DOACs suggesting they are preferred by clinicians in real-world practice but is one better than the other?
Guest Authors: Amy D. Robertson, PharmD, BCACP and Michelle Balli, PharmD, BCACP
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Many, many, many patients report they have penicillin (PCN) allergy. But while nearly 10% report being allergic to PCN, fewer than 1% have a true allergy. And this hampers antimicrobial stewardship efforts because clinicians are often forced to turn to agents with a broader spectrum, that are more expensive, and more likely to cause adverse effects including the development of resistance. However, determining whether a patient has a true PCN allergy is time-consuming and expensive. Historically, patients were sent to an allergist for PCN allergy skin testing (PAST) followed by oral provocation challenge (OPC). What if patients could skip past the skin test and receive a direct OPC instead? Direct OPC may not only increase patient willingness to be tested but also the feasibility of offering testing in primary care (and perhaps community pharmacy) settings.
Guest Authors: Frank A Fanizza, PharmD, BCACP and Emily S Prohaska, PharmD, BCACP, BCGCP
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Many studies have linked proton pump inhibitor (PPI) use to several adverse effects including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fractures, and nutritional deficiencies. Other reports have linked PPI use with chronic kidney disease, cognitive decline, myocardial infarction (MI), stroke, and even death. Many patients take PPIs chronically and may be concerned about the risk of these side effects. This poses a challenge for healthcare providers as safety data has been primarily based on retrospective and observational studies. A recently pre-planned analysis using data from the prospective COMPASS study sheds some reassuring light.
Guest Authors: Hindu Rao, PharmD and Jelena Lewis, PharmD, BCACP, APh
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Cannabis use is a hot topic among patients and in healthcare circles. Cannabis is used by an estimated 20% of multiple sclerosis (MS) patients to ameliorate symptoms such as spasticity, pain, and insomnia. Unfortunately, both MS and regular cannabis use can negatively impact cognition. Determining whether cognitive impairment can be reversed upon discontinuation of cannabis can help to distinguish its beneficial and harmful effects in patients with MS. It might also provide insights regarding the reversibility of cognitive impairment when cannabis is used for recreational purposes.
Guest Authors: Lindsey Trotter, PharmD; Sean Smithgall, PharmD, BCACP; and Nicole Slater, PharmD, BCACP
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Medication adherence plays a very significant role in achieving positive patient health outcomes and when medication regimens are not followed, patients often fail to reach optimal disease control. This is especially concerning in ambulatory care settings where chronic disease states are most often treated. One of the potential barriers to optimal medication use is cost.
Guest Authors: Emily Eddy, PharmD, BCACP, BC-ADM; Brittany Long, PharmD, BCACP; and Lindsey Petters, PharmD, BCPS
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Few medications are specifically dosed at night to optimize outcomes. However, antihypertensive medications may soon belong on our patients’ nightstands. It is common practice for patients to take all antihypertensive medications in the morning, but perhaps daytime dosing doesn’t maximize cardiovascular risk reduction? The potential benefits of chronotherapy and its impact on BP and CV outcomes have been investigated since the 1980s. However, current practice guidelines do not explicitly recommend dosing antihypertensive medications at bedtime.
Guest Authors: Vivian Cheng, PharmD, BCPS and Joseph Saseen, PharmD, BCPS, BCACP
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Millions of Americans will have a myocardial infarction in their lifetime and 20% will have a recurrent fatal or non-fatal coronary heart disease event. Several modifiable risk factors, including elevated blood pressure, cholesterol, and glucose as well as tobacco use, can and should be addressed to reduce the risk of recurrent cardiovascular events. Systemic inflammation has also been associated with poor CV outcomes. Is systemic inflammation a modifiable CV risk factor? And if so, should an anti-inflammatory agent be added to the recommend post-MI drug cocktail to reduce the risk of morbidity and mortality? That's the question that the COLCOT Study attempted to answer.
Guest Authors: Jessica Wearden, PharmD and Augustus (Rob) Hough, PharmD, BCPS, BCCP
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Patients with subclinical hypothyroidism often complain of symptoms commonly seen in patients with overt hypothyroidism: cold insensitivity, dry skin, fatigue, constipation, muscle cramps, poor memory, slowed thinking, and depression. Indeed, up to a quarter of people with normal TSH levels report up to two of these symptoms, pointing to the non-specific nature of these symptoms. How then should a clinician decide which patients might benefit from thyroid replacement therapy?
Guest Authors: Mallory Kuchis, PharmD and Michael P. Kane, PharmD, BCPS, BCACP
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More than 14 million Americans age 75 years and older face a dilemma. They are at high risk for atherosclerotic cardiovascular disease (ASCVD). On the other hand, older adults are more susceptible to adverse effects associated with statins. Many adults, often in their 60s or early 70s, decide to initiate statin therapy for the primary prevention of ASCVD. However, at some point in a patient’s life, the potential benefits may no longer be so clear … or the risks and costs increase. Unfortunately, there is little information on the potential consequences of stopping statin in patients who are tolerating statins.
Guest Authors: Maricar Conson, PharmD and W. Cheng Yuet, PharmD, BCACP
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One in six patients with atrial fibrillation (AF), or an estimated six million patients worldwide, will require perioperative anticoagulant management this year. Ambulatory care pharmacists commonly face the scenario where a patient taking a direct oral anticoagulant (DOAC) for AF requires an elective surgery or procedure. Best practices for periprocedural management of DOACs are unclear and current guidelines differ in their recommended approaches. Having a simple, systematic periprocedural DOAC management protocol would be helpful. But would a straightforward protocol that is easily understood by clinicians and patients be safe and effective? The PAUSE study investigators attempt to establish the standard of care.
Guest Authors: Maggie Faraj, PharmD and Candice Garwood, PharmD, BCPS, BCACP
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Should we target uric acid levels when working to reduce cardiovascular risk? Cardiovascular (CV) disease remains the leading cause of death with many contributing risk factors, including hyperuricemia. Evidence suggests an elevation in uric acid levels is associated with and can lead to worse outcomes for individuals with CV disease and heart failure. The Cardiovascular Safety of Febuxostat and Allopurinol in Patients with Gout and Cardiovascular Morbidities (CARES) trial was conducted to evaluate whether febuxostat was noninferior to allopurinol with regard to CV events in patients with gout and CV disease.
Guest Authors: Sophia Dietrich, PharmD and Michael W. Nagy, PharmD, BCACP
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Antiplatelet therapy is a mainstay treatment for the prevention of recurrent cardiovascular events in patients with stable coronary artery disease (CAD). Anticoagulation therapy is the cornerstone of therapy for most patients with atrial fibrillation (AF). AF and CAD are frequent comorbid conditions, occurring in 20-30% of patients with stable CAD. Unfortunately, combining antiplatelet and anticoagulation therapy increases the risk of major bleeding over 50% compared to anticoagulation alone. Recent real-world observational data suggest that direct oral anticoagulation (DOACs) therapy can reduce cardiovascular event rates. This begs the question: In patients with stable CAD and AF, is combination therapy necessary or is anticoagulation monotherapy sufficient? The AFIRE study attempted to address this important clinical question.
Guest Authors: Alina Kukin, PharmD and Zachary R. Noel, PharmD, BCCP
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Heart failure with reduced ejection fraction (HFrEF) is associated with significant morbidity and mortality. Current guidelines recommend a renin-angiotensin inhibitor, beta-blocker, and aldosterone antagonist to reduce morbidity and mortality in these patients. Despite the use of multiple drug classes, 5-year mortality rates hover near 50% in patients with heart failure (HF). Despite the numerous medications available, mortality and the risk of HF hospitalizations remains high. Sodium-glucose cotransporter-2 inhibitors (SGLT2-I) have been shown to reduce HF hospitalizations in patients with diabetes. Could this medication class be useful for HF treatment even in patients without diabetes?
Guest Authors: John Andraos, PharmD; Alexa Zeiger, PharmD; and Michael S. Kelly, PharmD, BCACP
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Heart failure (HF) affects at least 5.7 million people in the United States alone and requires a strict self-care regimen to avoid hospitalizations. Patients with HF have high readmission rates, high medical costs, and many experience a poor quality of life. But what if patients with HF do not understand or are not capable of carrying out the recommended HF “self-care regimen”? Subjective questionnaires are often used to assess HF symptoms and self-care behaviors but may not accurately depict a patient’s functional capabilities. The FRAIL-HF study attempted to objectively evaluate patients’ ability to perform HF self-care tasks and correlate self-care ability with readmissions rates and one-year mortality.
Guest Authors: Holly Porras, PharmD and Emily Prohaska, PharmD, BCACP, BCGP
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Several guidelines now recommend direct oral anticoagulants (DOACs) as the preferred anticoagulants for patients with non-valvular atrial fibrillation (a-fib). However, the landmark clinical trials focused largely on the primary prevention of stroke. Moreover, real-world data using DOACs for secondary prevention is lacking. Many have argued that warfarin might be a better choice in these high-risk patients because it requires routine monitoring and increases the patient’s contact with the healthcare system. Does the choice of anticoagulant make a difference in preventing recurrent stroke?
Guest Authors: Blaire White, PharmD; Amber Cizmic, PharmD, BCACP; and Tish Smith, PharmD, BCACP
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Treatment-resistant hypertension, the need for 4 or more medications to achieve goal blood pressure (BP), occurs in nearly 1 in 5 patients.1 But is it truly treatment-resistant? Nonadherence is often regarded as the primary cause in many patients. But how can we distinguish between other causes of hypertension that should prompt additional diagnostic testing or treatment intensification? A recent study suggests there is a simple solution: watch them take their pills.
Guest Authors: Meagan Brown, PharmD, BCACP and Raven Jackson, PharmD
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Until recently, glucagon-like-peptide-1 (GLP-1) receptor agonists were only available as injectable products. Some clinicians and patients are reluctant to use injectable agents because they require additional patient education and can be intimidating. If a GLP-1 receptor agonist were available in an oral dose form, it would be welcomed treatment option. But would the cardiovascular safety and benefits of oral GLP-1 receptor agonists be better, similar, or worse than their injectable siblings?
Guest Authors: Sally Earl, PharmD, BCPS and Megan Supple, PharmD, BCACP
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Patients frequently present to outpatient clinics and community pharmacies with acute exacerbations of chronic obstructive pulmonary disease and clinicians have an important decision to make. Should they prescribe antibiotics? Patients may seek antibiotics as a quick fix to their symptoms, but many AECOPD are not caused by bacterial infection. Prescribing unnecessary antibiotics exposes patients to adverse effects and can increase antimicrobial resistance. But not prescribing antibiotics could delay recovery if the exacerbation is of bacterial origin … or worse, result in an avoidable hospitalization and death. Could a simple, bedside test empower patients and prescribers to use antimicrobials more selectively?
Guest Author: Brittany Schmidt, PharmD, BCACP
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The “silent killer” that impacts every ambulatory care practice is medication non-adherence. Today, medication non-adherence is estimated to cause 125,000 preventable deaths every year and costs all of us $300 billion. It is no surprise that pharmacists have an important roll to play tackling this critical issue. Many pharmacies have now implemented medication synchronization or med sync programs to proactively address medication adherence. While some have called med sync a “golden ticket,” research is clearly needed.
Guest Authors: Michael Kachmarsky, PharmD, BCACP and Daniel Longyhore, PharmD, MS, BCACP
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Patients who have had acute coronary syndromes (ACS) are more likely to suffer from major depression than the general population with rates of clinically relevant symptoms of depression as high as 45%. Unfortunately, even if patients are routinely screened for depression with a PHQ-2 and PHQ-9 in primary care settings, appropriate treatments are often not initiated. Depression causes psychological stress which activates the sympathetic nervous system which leads to increased cortisol levels, inflammation, and platelet activation that can contribute to atherosclerosis and accelerate plaque formation. Thus, untreated depression may worsen cardiac outcomes.
Guest Authors: Hansita B. Patel, PharmD and Abigail L. Hulsizer, PharmD
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The transgender/gender nonconforming (TGNC) community faces a variety of challenges including access to healthcare, societal stigma, and discrimination. As a profession, pharmacy is well-positioned to reduce and address the barriers to care faced by TGNC individuals and to provide them with positive experiences within the healthcare system. However, formal instruction about this patient population’s social and medical needs is lacking in most pharmacy school curricula.
Guest Authors: Justin Bachman, PharmD and Abby Frye, PharmD, BCACP
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Hospital readmissions are often medication-related and potentially preventable. Pharmacists can play a vital role in improving medication outcomes during transitions of care (TOC). Although numerous TOC practice models have been described, it remains unclear what practices will promote optimal continuity of care. A recently published study in the Journal of the American Pharmacists Association (JAPhA) examined the impact of pharmacist-to-pharmacist handoffs using electronic communications to reduce hospital readmissions in high-risk patients.
Guest Authors: Jessica Wooster, PharmD, BCACP and Laressa Bethishou, PharmD, BCPS
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The opioid overdose epidemic, primarily driven by potent synthetic opioids, has rapidly intensified in recent years. Overdose education and naloxone distribution (OEND) efforts appear to have a positive impact on opioid-overdose mortality. As many states continue to expand naloxone access through various legislation efforts, it’s important to identify which laws have the greatest impact on reducing fatal opioid overdoses.
Guest Authors: Scott Coon, PharmD, BCPS, BCACP and Matthew Thomas, PharmD
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Staying abreast of the constant changes to clinical practice guidelines (CPGs) and determining their quality is difficult. The general consensus in the medical community is that CPGs reduce inappropriate care and improve treatment quality and patient safety. However, concerns have been raised about the reliability, quality, and validity of CPGs. A recently published systematic review critically appraised the quality of published CPGs for the treatment of chronic diseases in primary care.
Guest Authors: Frank Yu, Pharm.D. and Takova Wallace-Gay, Pharm.D., BCACP
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Dilated cardiomyopathy is the leading cause of sudden cardiac death and heart failure (HF) and the chief indication for cardiac transplantation. However, approximately 40% of patients see a significant improvement in left ventricular ejection fraction and reduction in the left ventricle size over time with pharmacologic treatment. As deprescribing becomes an increasingly important part of our clinical practice, we need more data about how deprescribing impacts outcomes, particularly in chronic diseases such as heart failure. The recently published TRED-HF is attempted to address this important question: Is the burden of lifelong therapy with medications necessary or worth it in patients with "recovered" dilated cardiomyopathy?
Guest Author: Jennifer Pruskowski, PharmD, BCPS, BCGP, CPE
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Chronic obstructive pulmonary disease (COPD) exacerbations contribute to mortality, disease progression, worsening quality of life, and increased health care costs. Respiratory tract infections are a common cause of COPD exacerbations. While prophylactic antibiotics may play a role, vitamin D supplementation is an attractive option by stimulating innate and adaptive immune responses. Although severe vitamin D deficiency (25(OH)D
While there are several proven smoking cessation medications available over-the-counter and by prescription, e-cigarettes are being increasingly used for smoking cessation despite the lack of data or official FDA approval for this indication. To appropriately advise our patients, it is important to understand the safety and efficacy of e-cigarette use as a potential smoking cessation aid.
Guest Authors: Diane Kim, PharmD and Amanda Schartel, PharmD, BCACP
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Vitamin D and fish oil (aka omega-3 fatty acids) were the most widely used vitamin and nutritional supplement in 2011-2012. Both have been commonly touted for their potential benefits in reducing cancer and cardiovascular disease. While vitamin D and omega-3 fatty acid supplements are wildly popular, the evidence supporting their health benefits is inconclusive and inconsistent. The VITAL study sought to determine whether vitamin D and/or marine omega-3 fatty acids can prevent cardiovascular disease (CVD) and cancer when used by the general population.
Guest Authors: Anthony M Todd, PharmD; Sean E Smithgall, PharmD, BCACP; and Nicole A Slater, PharmD, BCACP
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The D-PRESCRIBE study provides compelling evidence that a focused, systematic medication review conducted by community-based pharmacists coupled with patient education and written recommendations to prescribers results in a significant reduction in the use of potentially inappropriate medications. In this episode, Christine Dimaculangan reviews the methods and results of the D-PRESCRIBE study and our expert panelists discuss its implications and implementation.
Guests: Christine Dimaculangan, PharmD.; Nicole Brandt, PharmD, MBA, BCPP, BCGP; and Emily Prohaska, PharmD, BCACP, BCGP
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Intensive blood pressure (BP) control reduces the risk of cardiovascular events and mortality, but the verdict isn't in yet on the benefits of intensive control to prevent the development of dementia. Previous studies have shown an inconsistent relationship between blood pressure control and cognitive decline. SPRINT-MIND, using data from SPRINT, was designed to evaluate the effects of intensive BP control on cognitive outcomes including probable dementia and mild cognitive impairment.
Guest Authors: Michelle Balli, PharmD, BCACP and Amy Robertson, PharmD, BCACP
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A team-based approach to patient care is well established in acute care settings, but not as widely adopted in primary care settings. Working within a team could have a positive impact on the efficiency of visits, quality of care, workload, job satisfaction, and patient satisfaction. Previous studies in acute-care hospital settings reveal positive outcomes, but there have been mixed results in primary care settings. Are the extra time, effort, and money necessary to change to a collaborative team-based approach worth it? Will it positively impact health care utilization, quality, and cost?
Guest Authors: Lily Van, PharmD and Courtney Davis, PharmD, BCACP
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Although hypertriglyceridemia has consistently been associated with increased CV events, medications that lower triglycerides have failed to reel in a significant reduction in major CV events when combined with statin therapy. Could purified fish oil derivatives be the answer? Or just another red herring? The Reduction of CV Events with Icosapent-Ethyl Intervention Trial (REDUCE-IT) sought to clarify the utility of icosapent ethyl, a highly purified EPA derivative.
Guest Authors: Melissa Norton, PharmD and Elizabeth A. Cook, PharmD, AE-C, BCACP, CDE
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Sciatica is a form of neuropathic pain which can be particularly frustrating for patients and difficult to manage. With a lack of evidence to guide treatment and opioid use becoming increasingly under the microscope, data supporting the use of alternative pain regimens are needed. Gabapentin and pregablin are GABA analogs often used to treat sciatic pain, but is one superior to the other? Pregabalin is newer and available as a branded product only, but is it more effective than generically available gabapentin? A recently published study attempts to answer this question.
Guest Authors: Austin Morgan, PharmD and Frank Fanizza, PharmD
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Older adults are often tormented by insomnia, pain, and other comorbidities that impact their quality of life. Medication therapy is often sought to treat and manage these diseases, but healthcare providers often overlook the risks of prescribing medications to patients who are older, frail, and at high risk for falls. Trazodone is increasingly prescribed for insomnia instead of benzodiazepines presumably because it is considered to be safer and it does not appear on either the Beers or STOP/START lists. But is trazodone really safer for patients than benzodiazepines?
Guest Authors: Anthony M. Todd, PharmD and Nicole A Slater, PharmD, BCACP
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The American Heart Association / American College of Cardiology (AHA/ACC) Task Force recently published the 2018 Guideline on the Management of Blood Cholesterol. The guidelines writing committee had representation from 12 organizations, including the National Lipid Association, American Diabetes Association, and the American Pharmacists Association — all of whom endorsed the guidelines. The previous guidelines (published in 2013) were intended to answer some specific clinical questions and significantly changed our approach to treatment. The 2018 guidelines provide a more comprehensive set of recommendations, akin to the (older) National Heart, Lung, and Blood Institute Adult Treatment Panel (ATP) III guidelines last published in 2002!
Guest Authors: Dawn Fuke, Pharm.D., BCPS, and Zach Conroy, PharmD, BCACP
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Daily low-dose aspirin has long been considered a “wonder drug” for its cardioprotective effects, particularly in patients with pre-existing cardiovascular and cerebrovascular disease; however, despite decades of research, the use of aspirin to prevent a first event is less certain. In 2014, the Food and Drug Administration (FDA) responded to a citizen petition requesting the labeled indications for low dose aspirin be updated to include primary prevention. The FDA concluded that the evidence “fail[ed] to establish that aspirin reduces the risk of primary myocardial infarction (MI) in patients with a coronary heart disease (CHD) risk of 10% or more for over 10 years.” The Asprin to Reduce Risk of Initial Vascular Events (ARRIVE) study is intended to address this gap in our knowledge.
Guest Authors: Amy St. Amand, PharmD, BCPS and Christine Borowy, PharmD, BCPS
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Personalized medicine is at the forefront of health care today, focusing on how best to tailor the treatment approach to each person. But should we be thinking about personalizing the approach for prevention as well? The one-dose-fits-all approach has been used in nearly all aspirin studies. What is poorly understood is the influence of body weight. Perhaps the reason why aspirin has resulted in only modest benefits in clinical trials might be related to under (and over) dosing based on patient weight.
Podcast Case: Weight-based Dosing of Aspirin
Guest Author: Marina Maes, PharmD, BCPS
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Aspirin is no doubt beneficial in patients with overt vascular disease for the secondary prevention of myocardial infarction, stroke, or cardiovascular death. However, evidence supporting use of aspirin for primary prevention in patients who have not had a cardiovascular event is far less compelling. The clinical uncertainty of aspirin use for the primary prevention of CV events in patients with diabetes is reflected in the different recommendations in current guidelines. The investigators of the ASCEND (A Study of Cardiovascular Events in Diabetes) trial set out to determine the safety and efficacy of daily aspirin use in patients with diabetes without known occlusive arterial disease.
Podcast Case: ASA Use in DM - Evidence ASCENDing?
Guest Author: Kirstie Perry, Pharm.D.
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There has been significant debate regarding the safety of achieving very low LDL-C levels, including a potential negative impact on cognitive function. The current ACC/AHA guidelines (circa 2013) suggest decreasing the statin dose in patients with two consecutive LDL-C levels below 40 mg/dL based on expert opinion. The lack of evidence has been a major challenge for clinicians and it is unclear whether medication doses should be reduced in high-risk patients who may benefit from very low LDL-C levels. A recently published meta-analysis sought to address this clinical dilemma.
Podcast Case: Very Low LDL Case
Guest Authors: Apryl Anderson, PharmD and Dave Dixon, PharmD, BCPS, BCACP, CLS, CDE
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The American College of Chest Physicians (ACCP) recently updated their guideline recommendations for the use of antithrombotics for the prevention of stroke in patients with atrial fibrillation (aka the Chest Guidelines). Find out what's new, who shouldn't receive treatment based on the CHA2DS2-VASc score, and why the guideline panel recommends calculating a patient's SAME-TTR score.
Guest Author: Dylan Lindsay, PharmD
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Fredrick Banting, the Canadian scientist who discovered insulin in 1921 and sold the patent for just $1 to the University of Toronto and made it available to pharmaceutical companies royalty-free, would be disappointed to know that the high cost of insulin is now a major barrier to treatment. The average price of insulin has nearly tripled, from $4.34/ml in 2002 to $12.92/ml in 2013. Insulin’s high cost affects everyone: (1) uninsured patients, (2) insured patients with high co-payments and deductibles, (3) Medicare beneficiaries with coverage gaps and fixed income, and (4) everyone else paying higher premiums to offset the insurers’ expenditures. Are the newer insulins really worth the extra cost? A new study by investigators at Kaiser Permanente Northern California suggests that most patients can safely use NPH insulin instead of more expensive insulin analogs.
Download the podcast patient case: NPH vs Insulin Analogs
Guest Authors: Jaini Patel, PharmD, BCACP and Regina Arellano, PharmD, BCPS
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Two recent studies challenge our current approach to managing patients with mild persistent asthma. When patients with asthma are prescribed inhaled corticosteroids (ICSs), we instruct them to use the medication daily. In patients with persistent asthma, guidelines recommend maintenance therapy, with either an ICS or a combination ICS/long-acting beta-agonist (LABA), plus a short-acting beta-agonist (SABA) as needed for rescue treatment. The Symbicort Given as Needed in Mild Asthma (SYGMA) 1 and SYGMA 2 trials challenge the traditional approach comparing combination ICS/LABA (budesonide-formoterol) as needed to traditional ICS maintenance with SABA rescue therapy.
Guest Author: Brittany Schmidt, PharmD, BCACP
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We now have two vaccinations to protect against herpes zoster — a live-attenuated vaccine (Zostavax) and the new recombinant subunit vaccine (Shingrix). While the live-attenuated vaccine has been available for more than a decade and a CDC-recommended vaccine in older adults, only one in three eligible patients have received it. Based on the results of two recently published studies, the new recombinant subunit vaccine appears to provide substantially improved efficacy and duration.
Guest Author: Katherine Montag Schafer, PharmD, BCACP
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Critically-evaluating the literature is essential to engage in evidence-based practice. A key component of assessing studies involves determining whether the comparator groups are appropriate. Most pharmacists are familiar with the use of placebos for evaluating drug treatments, but how many of us have considered the comparator groups in behavioral interventions? For these situations, employing attention placebo controls (APC) is important.
Guest Authors: Elizabeth A. Cook, PharmD, BCACP, CDE, AE-C and Rachel A. Sharpton, PharmD, BCACP
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We’ve been managing asthma, for the most part, the same way for quite some time now … short-acting beta agonist (SABA) for quick relief, inhaled corticosteroids (ICS) as first-line maintenance treatment, step up if needed, step down if possible … plus self-management education and a written asthma action plan. Despite many treatment options, numerous adults, adolescents, and children still suffer from asthma exacerbations, leading to reduced quality of life, missed work and school, higher costs, and increased asthma-related morbidity and mortality. Exacerbations can be triggered by acute respiratory infections, exposure to allergens and other environmental conditions, and poor medication use behaviors. Regardless of cause, finding ways to reduce or prevent exacerbations should be a priority.
Guest Author: Kristen A. Pate, Pharm.D., BCACP
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For the treatment of cancer-associated VTE, LMWHs are recommended over warfarin (Grade 2B) and DOACs (all Grade 2C). Warfarin therapy in cancer-associated VTE is often made more difficult by wildly fluctuating international normalized ratios, procedure-related interruptions, as well as numerous drug-drug and drug-food interactions. While DOACs have been widely used in the treatment of VTE, there is very little data supporting their use in patients with active cancer until now with the publication of the Hokusai VTE Cancer study.
Guest Authors: Elizabeth Scheffel, PharmD and Christa George, PharmD, BCPS, BCACP, CDE
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Traditionally, the management of hypertension requires routine blood pressure checks by a health professional to adjust medications. Could self-monitoring lead to better outcomes? Would a greater percentage of patients achieve their goal blood pressure (BP)? Self-monitoring may be an efficient method to improve blood pressure control; however, results from published reports are inconsistent. The authors of the TASMINH4 study sought to compare the effectiveness of three different approaches to BP monitoring.
Guest Authors: Vicky Shah, PharmD, BCPS and Daniel Longyhore, MS, PharmD, BCPS
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While multi-drug combination therapies for HIV has resulted in longer lifespans, simplified medication regimens are needed to reduce pill-burden in an aging population with HIV. Two-drug regimens are potentially attractive because they may minimize drug exposure; reduce risks for adverse effects, drug-drug interactions, and long-term toxicities; and potentially increase patient adherence. The SWORD-1 and SWORD-2 trials evaluated the efficacy and safety of a two-drug regimen to maintain viral suppression in HIV infected patients.
Guest Authors Tinh An (April) Nguyen, PharmD and Jihae Lim, PharmD
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Forty-five percent of all adults in the United States have high blood pressure — that’s more than 100 million people! Of those treated with pharmacotherapy, more than half are not achieving their blood pressure goals. Thus, millions of Americans are receiving suboptimal care. A recently published systematic review and meta-analysis examined various implementation strategies to improve BP control in patients with high blood pressure. Which implementation strategies work best?
Guest Author: Lauren G Pamulapati, PharmD
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Overuse of broad-spectrum antibiotics can lead to antimicrobial resistance, increased cost, and higher prevalence of adverse drug reactions. Nearly 2 million infections and 23,000 deaths are caused by bacteria that are antibiotic-resistant each year in the United States costing the healthcare system an estimated 20 billion dollars. Moreover, adverse reactions to antibiotics are the most common reason for pediatric patients to visit the emergency department. Narrow-spectrum antimicrobials are generally preferred, but there are instances where broader coverage is recommended. A recent study attempts to “clean up” the debate by examining the benefits and risks of using narrow- versus broad-spectrum antibiotics in children with acute respiratory tract infections.
Guest Authors: Amber Giles, PharmD, MPH, BCPS, AAHIVP and Paige Hughes, PharmD
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Patients with type 1 diabetes often have sub-optimal glycemic control. The gold standard of treatment is basal-bolus insulin or continuous subcutaneous insulin infusion via an insulin pump. However, only a third of patients with type 1 diabetes achieve the American Diabetes Association A1C goal
Opioid-use disorder (OUD), a risk factor and major contributor to opioid-related deaths, is often underdiagnosed and undertreated. Currently there are three FDA-approved pharmacologic treatments for OUD maintenance therapy: methadone, buprenorphine (with or without naloxone), and naltrexone. Despite definitive evidence that methadone and buprenorphine products are effective in the treatment of OUD, there are still considerable accessibility and availability barriers that patients face when seeking Medication Assisted Treatment (MAT). The EXtended-release naltrexone vs Buprenorphine/naloxone for Opioid Treatment (X:BOT) trial compared the efficacy and safety of XR-NTX and BUP-NX to induce and maintain a patient with OUD on MAT as well as reducing opioid overdoses, relapses, and cravings.
Guest Author: Jordan L. Wulz, PharmD, MPH, BC-ADM, CHC
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Female sexual dysfunction (FSD) effects women of all ages but is common among perimenopausal / postmenopausal women and may be related to a reduction in circulating estrogen. Oral estrogens increase sex hormone-binding globulin (SHBG) which lowers available free testosterone and thus may negatively impact sexual function.Transdermal estrogens are typically preferred because they lack a high first-pass effect and are not associated with risk of thromboembolic events. However, additional research – directly comparing oral and transdermal preparations – was needed. An ancillary study of the Kronos Early Estrogen Prevention Study (KEEPS) did just that - examined the impact of oral and transdermal estrogens on sexual functioning.
Guest Authors: Stefanie C. Nigro, PharmD, BCACP and Christine Dimanculangan, Pharm.D.
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A recently published study explores the possible benefits to discontinuing an alpha-1 blocker after receiving combination therapy with a 5-alpha reductase inhibitor for the treatment of benign prostatic hyperplasia (BPH). In more symptomatic patients, or patients with confirmed, enlarged prostates, it is recommended to use both medication classes (alpha-1 blocker and 5-alpha reductase inhibitor) to minimize symptoms by relaxing the prostatic smooth muscle and reducing the size of the prostate – producing a potentially synergistic effect. This study found that withdrawal of alpha 1-blockers after a year of combination therapy did not worsen urinary symptoms, QOL, and voiding or storage function. This provides evidence that combination therapy may not be needed indefinitely for all patients.
Guest Authors: Erica Crannage, PharmD and Stephanie Crist, PharmD
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It’s been 20 years since alendronate was approved to treat osteoporosis. Although effective, bisphosphonates aren’t ideal. Romosozumab is an investigational monoclonal antibody that increases bone formation and decreases bone resorption. Is romosozumab a potentially better alternative to bisphosphonate therapy? That’s what the ARCH study attempted to answer.
Guest Authors: Yanqun Evonne Lee, MClinPharm and Joyce Yu-Chia Lee, PharmD
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Nearly 16 million adults in the United States have chronic obstructive pulmonary disease (COPD) but this is probably a woeful underestimate as many adults are asymptomatic in early stages. Screening is only recommended if patients exhibit symptoms and have risk factors. However, the most rapid decline in lung function occurs during GOLD stage 1. As COPD progresses, mortality, morbidity, and the economic burden increase very significantly. These facts suggest a need to detect and treat early-stage disease to slow its progression. The Tie-COPD study provides some new evidence that early treatment might be beneficial.
Guest Authors: Amy Robertson, Pharm.D. and Michelle Balli (Piel), Pharm.D.
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We’ve all seen and used the American College of Cardiology 10-year atherosclerotic cardiovascular disease (ASCVD) risk calculator. There are several modifiable risk factors such as blood pressure, cholesterol, and smoking status that, if addressed, can lower ASCVD risk. But are there other modifiable risk factors that we are failing to account for and might be able to address? New evidence suggests systemic inflammation may be one.
Guest Authors: Ian Hatlee, Pharm.D and Scott Pearson, Pharm.D.
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We interview Eric MacLaughlin, Joseph Saseen, and Kristin Rieser about the ACC/AHA Guidelines for the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in Adults released in November 2017. Dr. MacLaughin, a member of the Guideline Writing Committee, gives a insiders view of the guidelines development process and explains the rationale for lower blood pressure goals. Drs. Saseen and Rieser talk about some of the practical considerations that we all must consider as we move forward to making these recommendations a reality.
Guests: Kristin Rieser, Pharm.D., Joseph Saseen, Pharm.D, and Eric MacLaughlin, Pharm.D.
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