1 Family Medicine Clinical Pharmacy Frum Vl. 3, Issue 5 (September/Octber 2007) Family Medicine Clinical Pharmacy Frum is a brief bi-mnthly publicatin frm the Family Medicine clinical pharmacists distributed t faculty and residents f the Department f Family Medicine. Our intent is t prvide timely infrmatin n brad-based issues f pharmactherapy, as well as regulatry and practiced-based issues affecting yu as a prescriber. If yu have suggestins fr things yu wuld like t see, please cntact us. Pharmacthearpy Issues. Tamper-resistant prescriptin pads fr Medicaid patients As a reminder, Octber 1 st 2007 is when the CMS regulatins g int effect requiring the use f tamper-resistant prescriptin pads fr all Medicaid patients This regulatin was buried in the U.S. Trp Readiness, Veterans Care, Katrina Recvery, and Iraq Accuntability Apprpriatins Act f 2007 and has taken many peple by surprise T be cnsidered tamper-resistant, prescriptin pads must cntain ne f the fllwing industry recgnized features (by Octber 2008, all three features must be met): One r mre industry-recgnized features designed t prevent unauthrized cpying f a cmpleted r blank prescriptin frm One r mre industry-recgnized features designed t prevent the erasure r mdificatin f infrmatin written n the prescriptin by the prescriber One r mre industry-recgnized features designed t preent the use f cunterfeit prescriptin frms Exemptins t the tamper-resistant prescriptin pad requirement: Electrnic prescribing transmissins t the pharmacy Prescriptins which are faxed t the pharmacy Prescriptins called int the pharmacy by the prescriber http://www.cms.hhs.gv/smdl/dwnlads/smd081707.pdf http://www.cms.hhs.gv/deficitreductinact/dwnlads/tamper.pdf New Asthma Guidelines Released In late August, the Natinal Heart Lung and Bld Institute released new guidelines fr the Diagnsis and Management f Asthma This is the Expert Panel Reprt 3 (EPR-3) which builds upn the dcuments frm 1991, 1997, and the 2002 update The guidelines will be similar t the Glbal Initiative fr Asthma (GINA) guidelines released in Nvember 2006 Only the full reprt is available at this time; the expected availability f the summary reprt will be December 2007: Authred by: Jhn M. Swegle, Pharm.D.; BCPS, Masn City Family Practice Residency Prgram
2 http://public.nhlbi.nih.gv/newsrm/hme/getpressrelease.aspx?id=2442 http://www.nhlbi.nih.gv/guidelines/asthma/asthgdln.htm Key features in the new guidelines Assessment and mnitring Patient educatin Cntrl f envirnmental factrs and ther cnditins that can affect asthma Medicatins cntinued use f a stepwise apprach including expanded pediatric recmmendatins New Drug: Budesnide and frmterl (Symbicrt ) Symbicrt is a cmbinatin f budesnide and frmterl indicated fr maintenance treatment f asthma in patients 12 years f age and lder. Bth agents are FDAapprved as individual therapies. Frmterl is listed under the brand name f Fradil whereas budesnide is Pulmicrt. The cmbinatin prduct is very similar t fluticasne and salmeterl cmbinatin (Advair) hwever des nt have an indicatin fr COPD. Dsing Available in tw strengths: 80/4.5 mcg and 160/4.5 mcg (budesnide/frmterl) Adults and children 12 years f age: Patients receiving medium t high dse crticsterid Patients receiving lw t medium dse crticsterid Patients nt currently receiving inhaled crticsterid Symbicrt 160/4.5, tw inhalatins twice daily Symbicrt 80/4.5, tw inhalatins twice daily Symbicrt 80/4.5 r 160/4.5, tw inhalatins twice daily depending n asthma severity Special Patient Ppulatin Inf Pregnancy categry C; cautin in breastfeeding (n data) Safety and effectiveness has nt been established in children <12 years f age Marketplace Assessment Symbicrt will cmpete directly with Advair fr treating asthma patients. The black bx warnings are blanket statements by the FDA fr lng-acting beta2 agnists and this warning is applied t the cmbinatin with inhaled crticsterids. Symbicrt des nt have indicatins fr pediatric patients nr is it apprved fr COPD which is a disadvantage cmpared t Advair. It is nt a dry pwder frmulatin but rather a metered dse inhaler with HFA as the prpellant. Cst will be ~$165-$190 per mnth depending n the strength. -Symbicrt Prescribing Infrmatin. AstraZeneca, 2007 -Drugs 2006;66:2235-2254 Authred by: Jhn M. Swegle, Pharm.D.; BCPS, Masn City Family Practice Residency Prgram
3 New Drug: Zledrnic acid injectin (Reclast ) Zledrnic acid is a bisphsphnate which has been available mainly fr the treatment f hypercalcemia by the brand name Zmeta. This frmulatin is a nce-yearly injectin indicated fr the treatment f steprsis in pstmenpausal wmen as well as Paget s Disease. Dsing: Available as a 5 mg/100 ml ready t infuse slutin It is infused ver at least 15 minutes and given nce yearly It is recmmended that all patients be n calcium 1200 mg daily and vitamin D 400-800 IU daily Adverse Effects: Fever/flu-like symptms, myalgia, arthralgia, and headache which usually reslve within 3 days f the injectin but may last up t 14 days Acetaminphen r an NSAID fllwing the administratin may reduce the incidence f adverse effects Of nte, stenecrsis f the jaw is a cncerning adverse effect that has been assciated with the bisphsphnates; early reprts were linked t intravenus frmulatins hwever reprts exist fr the ral frmulatins as well; assciated risk factrs include cancer, crticsterid use, chemtherapy, and pr dentitin Marketplace Assessment: Less frequent administratin f bisphsphnate is nt a new cncept. Bisphsphnates are taken up int the bne allwing the effect t be prlnged. The ral agents have slwly transitined int less frequent dsing and nw the intravenus frmulatins will make treatment with these agents even mre cnvenient. Befre administering the agent, make sure the payment situatin is in place. The estimated cst fr injectin is $800. -Nvartis Pharmaceuticals, August 2007 Shrt takes Labeling revisins fr ceftriaxne Revisins t the labeling f ceftriaxne highlighting a ptential risk assciated with cncmitant use f IV Rcephin with calcium r calcium-cntaining slutins r prducts Reprts f pulmnary precipitatin have ccurred in nenates receiving bth prducts; althugh n cases have been reprted in patient ppulatins ther than nenates, there is a theretical risk fr all patient ppulatins The labeling will nw state that ceftriaxne and calcium-cntaining slutins including cntinuus calcium-cntaining infusins such as parenteral nutritin shuld nt be mixed r c-administered t any patient irrespective f age even if different lines are used; based n half-life, administratin f ceftriaxne and IV calcium-cntaining slutins shuld nt be administered within 48 hurs f each ther in any patient Authred by: Jhn M. Swegle, Pharm.D.; BCPS, Masn City Family Practice Residency Prgram
4 There is n infrmatin n a ptential interactin between ceftriaxne and ral calcium-cntaining agents r between IM ceftriaxne and calciumcntaining prducts (ral r IV) http://www.rcheusa.cm/prducts/rcephin/rcephin-hcp-letter.pdf Medicatin recnciliatin This is here and will be s everyne needs t get used t it The cncept is t recncile medicatins being used at hme upn admissin t the hspital; many times the admitting physician is unclear f what medicatins the patient is taking r hw they are taking them Every facility is wrking n prcesses t ensure they are in cmpliance with JCAHO standards It is up t the physician signing the rders t ensure the patient is taking the medicatins as prescribed; It is very reasnable t utilize pharmacy and pharmacy students t help with this prcess nt nly in the hspital setting but als n the ambulatry side Hw lng d yu keep peple n Plavix and aspirin? Many questins arise regarding the length f time patients shuld remain n the cmbinatin f aspirin and Plavix after crnary events; the ACC/AHA updated guidelines have the fllwing recmmendatins fr UA/NSTEMI patients at discharge: Medical therapy withut stent: Aspirin 75-162 mg per day indefinitely and clpidgrel 75 mg daily fr at least ne mnth and ideally up t ne year Bare metal stent: Aspirin 162-325 mg daily fr at least ne mnth then 75-162 mg per day indefinitely and clpidgrel 75 mg daily fr at least ne mnth and ideally up t ne year Drug-eluting stent: Aspirin 162-325 mg daily fr at least ne 3-6 mnths then 75-162 mg per day indefinitely and clpidgrel 75 mg daily fr at least ne year These are minimum recmmendatins and patients may require lnger treatment based n need fr anticagulatin versus cntinued antiplatelet therapy -J Am Cll Cardil 2007;50:652-726 - http://cntent.nlinejacc.rg/cgi/reprint/50/7/652 Clinical Pearl. Prper use f per tpical permethrim cream rinse (Nix ) Multiple times we see treatment failures frm first line tpical agents leading t use f medicatins such as ivermectin, Bactrim, r mre ptent tpical medicatins Shamping the hair befre applying permethrin is fine hwever the use f a crème rinse/cnditiner r a cmbinatin f shamp/cnditiner shuld Authred by: Jhn M. Swegle, Pharm.D.; BCPS, Masn City Family Practice Residency Prgram
5 NOT be used the hair befre applying permethrin as this may decrease the activity f the permethrin Als tell patients nt t rewash their hair fr 1-2 days after applying the permethrin Mre infrmatin including a printable patient handut may be fund at the CDC website www.cdc.gv r here is a link t a PDF dcument: http://www.cdc.gv/ncidd/dpd/parasites/lice/2005_pdf_treating_head_li ce.pdf Authred by: Jhn M. Swegle, Pharm.D.; BCPS, Masn City Family Practice Residency Prgram