The Jury is STILL Deliberating

The title of this post comes from one of the education sessions I attended at Midyear this year. So, the JNC-8 was supposed to come out last year or the year before, and is now set to be released next year in 2012 (hopefully!). The session was presented by two pharmacists - the first one was discussing all the major articles published about hypertension in that last few years - papers that the JNC committee cannot ignore when releasing the latest guidelines. The second speaker went over cases. I thought this talk was very interesting, and jotted down the following notes.

*The guidelines used today for hypertension come from the JNC-7 (published in 2003) and the AHA Scientific Statement (published in 2007). 

*BP goals:

• JNC7 states: <140/90, and <130/80 for patients with DM or CKD. 
• AHA states: <140/90, and <130/80 for patients with DM, CKD, and/or an increased CAD risk. 
• The diabetes goal being lower is interesting - because according to the speaker, this isn't really evidence-based medicine. The ACCORD trial (done in DM patients) for example, compared a SBP goal of either <140 or <120. The primary endpoints were stroke and MI. Results - more meds were needed to reach SBP <120 and no difference between primary outcomes (p = 0.20). I believe there was a study that showed that patients with proteinuria of 300-1000mg (probably signifies diabetics) had better outcomes when their blood pressure goals were lower. In the HOT trial, blood pressure goals were also studied. In the diabetic population, there were better outcomes with a DBP <80 rather than <90. However, the latter was a subgroup analysis. This is important to consider in my opinion, because diabetic patients are likely already on a couple medications. Is adding more blood pressure medication to reach a lower goal blood pressure worth it if it's not truly evidence-based?

*Treatment schemes:

• In 2003
• If a patient had compelling indications other than hypertension, then specific BP meds would be prescribed (ex. comorbid disease DM, then ACEI/ARB, or post MI, BB, etc.).
• Non-compelling indication stage 1 HTN: HCTZ first line usually, or ACEI/ARB/CCB/BB
• Non-compelling indication stage 2 HTN: 2-drug combo of any of the above with HCTZ as one of the choices. 
• In 2007 (AHA Scientific Statement) 
• If a patient had compelling indications, then no change to above.
• Changes to non-compelling indications: BB were taken off the list and no preference to HCTZ. 
• The ACCOMPLISH trial was a study that looked at combination HTN medications - CCB/ACEI vs. HCTZ/ACEI. The trial was stopped early because the CCB/ACEI combination was significantly better than the other combination. This may have been one of the reasons to take away the preference for HCTZ. 

*ACEI/ARBS

• How are these two different?
• ACEI: dry cough, more data, less expensive. 
• ARB: no dry cough, less data, more expensive; however, 2 generics are supposed to be coming out in 2012, so the use of ARBs may increase. 
• the ONTARGET trial studied the effects of ACEI alone, ARB alone, and combination ACEI/ARB. The results showed increased renal dysfunction, increased incidences of hyperkalemia, with no added benefit. This is why we don't see the combination used very often (except in severe CHF or proteinuria). 

*Chlorthalidone and HCTZ

• If a patient is on HCTZ, and has resistant HTN (on 3 or more meds not at goal OR on 4 or more meds at goal), then consider switching to chlorthalidone. 
• Also, something that the speaker said about HCTZ caught my attention - I've always thought that 25mg/day of HCTZ was maximum that should be recommended - and that anything above causes increased hypokalemia with no benefit. The speaker, however, encouraged going up to 50mg/day HCTZ or adding another agent if BP wasn't at goal with just HCTZ. I haven't completely made up my mind about this, but it's something to look into. 

*What We MAY See in JNC8

• BB as second line therapy or just for compelling indications. 
• Goal SBP <140 for ALL patients, with specific individual goals between patient and PCP. 
• The HCTZ vs. chlorthalidone issue
• ACEI or ARB with CCB as first line combination therapy
• Tailored recommendations for the elderly with HTN.

Long Time No Talk

So…it’s been a while! But, to be fair, my last rotation ended on October 31, and I haven’t been on rotations since. I get back to it on January 2 at a psychiatric ambulatory care site, which I’m looking forward to. So what exactly have I been doing since then…?

1. I started a job with Fry’s pharmacy! I did the bulk of my training in November, which included a week of computer work, and then 80 hours of in-pharmacy training. Now, I’m working 12 hours a week until rotations begin again, and then most likely 8 hours/week after that. This is my first real experience with community pharmacy as an employee, which is crazy since I’m a fourth year student.  But, it’s better late than never. My favorite part of the job is counseling patients. It’s amazing how much I remember (and don’t remember) about certain medications. This also gives me a reason to go back into lexicomp and pull up specific counseling points for different drugs, especially the ones that keep coming up. For example…

Antibiotics in General (most of them)…

• Each dose should be taken with food to increase absorption and decrease GI upset (which is the main side effect)
• Take entire prescription (even if you feel better)
• Talk to your doctor if your condition worsens or dose not improve upon completing the prescription
• Can decrease the effectiveness of birth control (Use back up form of contraception to be safe)
• The pharmacist at my training store also emphasized having yogurt included in the patient’s diet while on antibiotics (but not within 2 hours of the medication). This is to help with digestion.
• For tetracyclines specifically – no dairy, vitamins, antacids 1 hour before and 2 hours after the medication.

Steroids in General…

o        Take with food

o        Can increase blood glucose (so careful in patients with diabetes)

o        Can cause water retention, but this goes away after the course of treatment

o        Can make people moody

o        Can cause early morning insomnia

o        If patient becomes puffy, then PCP needs to be called

Beta Blockers…

o        Can cause dizziness

o        Can cause coldness of the hands and feet

o        Can cause water retention

Ace Inhibitors…

o        Can cause dizziness

o        Take with food

o        Can cause the dry cough

o        Need to get potassium checks

Pain Medications in General…

o        Can cause dizziness and drowsiness

o        NO alcohol due to additive effects

o        Can cause constipation (so offer ideas on some OTC products to help with this, encourage increased fiber in diet)

o        For combination products, watch the Tylenol intake

I also had to do ProAir a few times…

o        Go over how to use an inhaler (prime it – 4 test sprays into the air before the first time of use or if it hasn’t been used in over 2 weeks). When using the inhaler, exhale first, and then inhale deeply while pushing down the inhaler and hold your breath for 10 seconds. Wait 60 seconds between puffs.

o        If also using this with another inhaler, use your proair (albuterol) first, so it opens up your lungs. This will make the other inhaler more effective. 

I’m sure I’ll be asked to counsel on a lot of other meds, but that will come with time. I also sent in my immunization certification from APhA to the state board of pharmacy. I think this will make it official for me to start giving immunizations at Fry’s! My least favorite part of community pharmacy has to be all the insurance claims – this is the part that makes me shy away from the community setting. It becomes more about who owes who money rather than patient care at times. Other than that, it’s the perfect part-time job for now J.

2. I’ve been busy preparing for residency applications. Everyone now a days is encouraging students to apply to about 12 programs, since it’s become so competitive, so that’s exactly how many I’m applying to! At this point, I’ve got my letter of recommendation writers lined up, my CV updated, and a table with specifics for each program/when things are due. Now, all I have to do is actually apply! I was hoping to get everything done by the 17^th, but we’ll see how that goes. I made my finalized list after attending Midyear – which really pushed me towards some programs, and made me eliminate others. I would highly recommend anyone fourth year student who wants to do a residency to go. It’s worth it! And it was in New Orleans this year, which was a blast.
   
   
3. In addition to absolutely loving pharmacy, I love to dance! My sister, myself, and four of our friends founded UofA Om Shanti, which is University of Arizona’s Bollywood Dance Team in 2008. Since then, we’ve competed in competitions in LA, Berkeley, and New York…plus do tons of local performances. Just last month we won first place in New York, which qualifies us for the BIG competition called “Bollywood America,” which is coming up in a few months. I’ve also been busy with this since my break began on October 31^st.

I should have more rotations-related posts about what I’m learning once I start again in January. Until then, I’ll have summaries on what I read in all the pharmacy journals I need to catch up on!