PL CE LIVE March 2014 Forum

Transcription

1 March 2014 PL CE LIVE Rachel Maynard, PharmD Assistant Editor Pharmacist s Letter/Pharmacy Technician s Letter CE Information Pharmacist's Letter / Therapeutic Research Center is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. PL CE LIVE editors disclose: No financial interests related to the content No commercial support and no advertising Supported entirely by subscriptions PL CE LIVE Drug Information Consultant discloses: Dr. O Mara reports that her spouse is employed by Celgene. Pharmacist Objectives Identify emerging trends in drug therapy and their place in patient care practices. Explain two ways that pharmacists can improve colon cancer screening. Identify appropriate medications for treating hypertension in diabetes patients. Describe the role of the new over the counter Nasacort Allergy 24HR (triamcinolone) in managing allergic rhinitis. Summarize current NSAID recommendations for patients with heart disease. Pharmacy Technician Objectives Identify emerging trends in drug therapy and their place in pharmacy practice and operations. List three tips for improving colon cancer screening. Describe the role of the new over the counter Nasacort Allergy 24HR (triamcinolone) in managing allergic rhinitis. Summarize current NSAID recommendations for patients with heart disease. Identify two dispensing considerations with the new drug Farxiga (dapagliflozin). Colon Cancer Screening 1

2 Identify patients Describe the tests Improve the bowel prep Avoid medication problems Identify Patients Recommend screening starting at age 50 Sooner for patients with a family history Look for patients with risk factors Family history, African American, smoking, overweight/obese, heavy alcohol use, etc Consider bringing up when giving vaccines or discussing healthy lifestyle habits Remind patients early identification improves survival Fecal Occult Blood Tests Test for presence of blood in the stool Guaiac fecal occult blood test (FOBT) Fecal immunochemical test (FIT) Structural Examinations Colonoscopy Flexible sigmoidoscopy Virtual colonoscopy (CT colonography) Pill camera Improve the Bowel Prep Explain the importance of a good prep Clean colon improves visibility of polyps Can prevent the need to redo a colonoscopy Improve the Bowel Prep Most patients will start a clear liquid diet one day before the procedure Bouillon, gelatin, soft drinks, popsicles, plain coffee, etc Advise avoiding red, purple, or thick liquids during the prep 2

3 Improve the Bowel Prep Timing When possible, suggest split dose regimen Tell these patients to take ½ the prep evening prior, and ½ about 4 6 hours before the procedure Tolerability Suggest a low volume prep (MoviPrep, etc) for patents wary of 4 L PEG with electrolytes (Colyte, etc) To cut cost, suggest oral bisacodyl + 2 L generic PEG Improve the Bowel Prep Taste Recommend citrus flavor packs to cut seawater taste Add lemon juice or Crystal Light (no red/purple) Suggest slightly chilling after reconstitution Rapidly sip or use a straw to bypass taste buds Chase with hard candies or rub lime on the tongue Improve the Bowel Prep Advise patients to prepare for side effects Walk around if bloating/nausea Hold off for an hour and wait longer between doses Apply petroleum jelly before and between bowel movements and use unscented baby wipes Stay hydrated Remind patients to keep short term discomfort in perspective Avoid Medication Problems Most meds can be continued and taken with sip of water up to 3 4 hours before procedure Be aware of possible exceptions Low dose aspirin usually okay to continue Antithrombotics NSAIDs Iron Fish oil Diabetes meds May need to be held for up to a week before the procedure Avoid Medication Problems Watch for diabetes meds with hypoglycemia risk Prep day: Suggest cutting insulin or sulfonylurea doses in half Recommend frequent blood glucose monitoring Day of procedure: Suggest giving half the dose of BASAL insulin (Lantus, Levemir, NPH) if needed Suggest holding other diabetes meds until patient starts eating again Treating Hypertension in Diabetes Patients 3

4 JNC 7 versus JNC 8: BP Goals JNC 7 JNC 8 Patients < 60 < 140/90 < 140/90 Patients 60 < 140/90 < 150/90 Patients with diabetes < 130/80 < 140/90 or kidney disease Treating Hypertension in Diabetes ACEI or ARB recommended first line for years to treat hypertension in diabetes patients Included as a quality measure for Medicare Part D Star Ratings % of diabetes patients with hypertension taking an ACEI or ARB Higher use can increase Star Ratings JNC 8 Guidelines JNC 8 recommends several first line options for diabetes patients No strong evidence an ACEI or ARB leads to better cardiovascular outcomes in diabetes patients JNC 8 What s the Controversy? Other experts argue diabetes patients are at risk for conditions that benefit from ACEI/ARB Heart disease Heart failure Kidney disease ACE inhibitor ARB Calcium channel blocker Thiazide diuretic Lean toward ACEI or ARB first for hypertension in most diabetes patients Don t be too concerned if some patients get a calcium channel blocker or thiazide instead African Americans CCBs or thiazides preferred over ACEIs or ARBs when used alone Patients already doing well on a CCB or thiazide Continue to recommend ACEI or ARB first for diabetes patients with hypertension and chronic kidney disease Including African Americans Proven to improve kidney outcomes in these patients 4

5 Most patients need 2 drugs to reach BP goal Recommend starting with two meds if BP 160/100 Suggest combos that improve outcomes ACEI or ARB + calcium channel blocker ACEI or ARB + thiazide diuretic Reinforce adherence to lifestyle changes and medications Nasacort Allergy 24HR for Allergic Rhinitis Background: Allergic Rhinitis Response to allergens Seasonal pollens from trees/grass/weeds, mold, etc Perennial animal dander, dust mites, cockroaches, etc Symptoms include: Sneezing, runny nose, nasal congestion, itching, etc Affects up to 30% of adults and 40% of kids Avoidance Outdoor allergens Limit time outside, especially hot, dry, windy days Keep doors and windows closed Don t dry clothes outside Shower before bed Indoor allergens Keep animals out of bedroom Wash bedding weekly in hot water or hot dryer Use mattress/pillow covers Dust regularly and vacuum with HEPA filter Use a dehumidifier OTC Options for Allergic Rhinitis Nasal saline Antihistamines Nasal corticosteroids Decongestants Nasal cromolyn 5

6 Nasal Saline Can help alone or with allergy meds Washes away allergens from nasal passages Administration options: Saline nasal spray (Ocean, etc) Netipot Bulb syringe Suggest a method the patient prefers Use before other nasal sprays Antihistamines Oral antihistamines often first line for mild tomoderate or intermittent symptoms Treat sneezing, itchy/runny nose and eyes Little effect on nasal congestion Antihistamines Stick with 2 nd generation oral antihistamines Loratadine, cetirizine, fexofenadine 1 st generation antihistamines (diphenhydramine, etc) can cause sedation, dry mouth, etc Caution that orange, grapefruit, and apple juice can decrease fexofenadine (Allegra) levels Separate juice from dose by at least 4 hours, or choose different antihistamine Nasal Corticosteroids First line option for more chronic or severe allergic rhinitis symptoms Most effective option for nasal symptoms Help with itchy, runny nose and eyes, like oral antihistamines Especially helpful for nasal congestion May be combined with oral antihistamine if needed Nasal Corticosteroids All are similarly effective Work best when used daily May take several days to reduce symptoms, up to 2 weeks for max relief Most common side effects include nasal irritation and bleeding Don t appear to cause systemic effects Nasacort Allergy 24HR labeling warns that growth rate of some children may be slower Decongestants Relieve nasal congestion Little effect on other allergic rhinitis symptoms Caution about potential side effects Insomnia, rise in BP, irritability, palpitations, etc Pseudoephedrine preferred if needed Phenylephrine poorly absorbed, not very effective Nasal spray decongestants (Afrin, etc) Useful for prompt relief of nasal congestion Limit use to max 3 days to avoid rebound congestion 6

7 Nasal Cromolyn Mast cell stabilizer (NasalCrom, etc) Works best to prevent allergies Takes at least 4 7 days to see symptom relief Requires QID dosing Less effective than nasal corticosteroids or oral antihistamines Nasacort Allergy 24HR Indicated to relieve allergy symptoms Nasal congestion, runny nose, sneezing, itchy nose Same as Rx Nasacort AQ (triamcinolone) Delivers 55 mcg/spray, scent free Rx brand discontinued Costs about $20 for a 120 spray bottle Similar to some generic Rx nasal corticosteroids Watch for insurance rejections with Rx versions Nasacort Allergy 24HR Patient Age Recommended Dosing Adults and children 12 years and older Children 6 years to 11 years Children 2years to 5 years 2 sprays in each nostril once daily Taper to 1 spray in each nostril per day once symptoms improve 1spray in each nostril once daily May increase to 2 sprays in each nostril once daily if needed 1 spray in each nostril once daily Nasacort Allergy 24HR: Practical Pearls Shake well before each use Prime bottle Blow nose to clear nostrils Close off one nostril Tilt head forward slightly Insert tip of nozzle pointing to back of nose (not toward septum) While sniffing gently, spray once into nostril Repeat for other nostril Background NSAIDs in Patients with Heart Disease All NSAIDs have a black box warning about increased cardiovascular risk 7

8 NSAIDs and Risk of Adverse Effects Balance of cardiovascular and gastrointestinal risk may be based on how NSAIDs work NSAIDs inhibit production of prostaglandins by blocking COX 1 and COX 2 COX 1 Inhibition COX 2 Inhibition NSAIDs and Risk of Adverse Effects COX 1 Produces prostaglandins that protect GI mucosa Produces thromboxane A2 causes vasoconstriction and platelet aggregation COX 2 Produces prostaglandins involved in pain, fever, inflammation Produces prostacyclin causes vasodilation COX 1 Inhibition GI Adverse Effects COX 2 Inhibition CV Adverse Effects What About Aspirin? Aspirin permanently inactivates platelet COX 1 Prevents formation of thromboxane A2 prevents platelet aggregation Responsible for aspirin s cardiovascular benefits Other NSAIDs have reversible and variable effects on platelets Can t be relied on for cardiovascular protection Is Naproxen Different? Naproxen has low COX 2 selectivity Longer half life than many traditional NSAIDs Longer platelet inhibition by blocking COX 1 Might translate to fewer CV events Versus other NSAIDs that are shorter acting Versus other NSAIDs that are more COX 2 selective Recent meta analysis suggests naproxen linked to fewer CV events than some other NSAIDs Diclofenac, ibuprofen, or celecoxib (Celebrex) 8

9 Is Naproxen Different? Cardiovascular risk hasn t been directly compared to other NSAIDs in randomized trials FDA not likely to change naproxen labeling now Ongoing PRECISION trial will help give answers Compares cardiovascular, GI, and renal safety of naproxen vs ibuprofen vs celecoxib Results won t be available until late 2015 For now, recommend limiting NSAIDs in patients with high cardiovascular risk Exception: low dose aspirin Remind that even short term use may be risky Suggest other options for pain if possible Acetaminophen, aspirin, tramadol, short term use of opioids, etc If an NSAID is needed: Lean toward naproxen if CV risk a concern Lean toward celecoxib or low dose ibuprofen if GI risk a concern Recommend lowest dose, shortest duration Topical NSAIDs? Try to avoid NSAIDs in patients with high CV and GI risk Dispense MedGuides with NSAID Rxs Remind patients about interaction between NSAIDs and aspirin NSAIDs can interfere with aspirin s antiplatelet effects Recommend taking plain aspirin about one hour before the NSAID Gives aspirin time to bind platelets first Discourage using enteric coated aspirin it might not avoid the interaction Glomerulus New Drug Farxiga (dapagliflozin) Tubule Urine 9

10 Glomerulus Glomerulus Tubule SGLT2 SGLT2 Tubule SGLT2 SGLT2 SGLT2 Inhibitors Urine Circulation Urine Circulation Farxiga vs Invokana Similar Pros Lower A1C by about 1% Modestly lower blood pressure Weight loss of about 4 to 7 pounds Low risk of hypoglycemia Once daily dosing Oral drug Similar Cons Increased urination and possible dehydration Increased risk of urinary tract and genital yeast infections Slightly increase LDL cholesterol Cost about $9 per day Farxiga small increased bladder cancer risk Suggest Farxiga or Invokana as an add on to metformin AFTER other second line options Gliptins (Januvia, etc) Glitazones (pioglitazone, etc) GLP 1 agonists (Byetta, etc) Insulin Sulfonylureas Practical Pearls for Farxiga Recommend starting with 5 mg daily, increasing to 10 mg daily if needed In the morning, with or without food Update patient profiles Avoid in patients with moderate renal impairment Caution patients about hypotension Encourage them to stay hydrated Dispense a MedGuide Polls/Questions 10