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iForumRx.org

We explore the evidence that informs ambulatory care pharmacy practice. Check out our website & podcasts, & consider submitting a commentary!

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Top Ten Things Every Clinician Should Know About the 2018 Cholesterol Guidelines

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 Music by Good Talk

14mins

9 Jan 2019

Rank #1

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Will Oral Semaglutide PIONEER the Way to Lower Cardiovascular Risk?

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 Music by Good Talk

16mins

24 Oct 2019

Rank #2

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Secondary Stroke Prevention in A-Fib: Do DOACs PROSPER in High-Risk Patients?

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 Music by Good Talk

17mins

22 Nov 2019

Rank #3

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Is Dapagliflozin aDAPtAble to Treating HFrEF in Patients Without Diabetes?

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 Music by Good Talk

15mins

13 Dec 2019

Rank #4

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Up in Flames: Antiplatelet Therapy in Patients with Stable Ischemic Heart Disease Receiving Anticoagulation for A-fib

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 Music by Good Talk

19mins

4 Jan 2020

Rank #5

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Cardiovascular Risk with Elevated Triglycerides - Does Icosapent Ethyl REDUCE-IT?

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 Music by Good Talk

16mins

22 Feb 2019

Rank #6

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Are Older Adults with Heart Failure Self-Care Aware?

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 Music by Good Talk

15mins

6 Dec 2019

Rank #7

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Stop the Shots: Edoxaban vs Dalteparin in Cancer-Associated VTE Treatment

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 Music by Good Talk

11mins

29 Jun 2018

Rank #8

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Another Case of Newer Isn’t Always Better! Gabapentin vs. Pregabalin for Chronic Sciatica

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 Music by Good Talk

17mins

8 Feb 2019

Rank #9

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Another Attempt to ARRIVE at an Answer Using Aspirin for Primary Prevention

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 Music by Good Talk

14mins

14 Dec 2018

Rank #10

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Breaking Up is Hard to Do: Are E-Cigarettes the Solution Tobacco Cessation?

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 Music by Good Talk

16mins

10 May 2019

Rank #11

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LDL Limbo: How Low is Too Low?

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 Music by Good Talk

12mins

26 Oct 2018

Rank #12

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Top Ten Things Every Clinician Should Know About the 2018 Antithrombotic Therapy Atrial Fibrillation Guidelines

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 Music by Good Talk

12mins

12 Oct 2018

Rank #13