Journal of Pharmacy Technology

To review relevant background information on behavioral and psychological symptoms of dementia (BPSD) and the antipsychotic drugs used to treat it, describe benefits versus risks of antipsychotic drugs for treatment of BPSD, and describe the latest management guidelines for patients with BPSD.

A PubMed literature search (1998–October 2011) was conducted using the following MeSH search terms: dementia, elderly, antipsychotics, behavioral symptoms, and psychological symptoms. Tertiary references and prescribing information for included medications were used for pharmacology, adverse effects, and cost.

English-language reviews, tertiary references, and guidelines were reviewed; only articles that used pharmacotherapy in human models were included.

There are no FDA-approved medications for treatment of BPSD; several classes of drugs are prescribed off-label, including selective serotonin reuptake inhibitors and certain anticonvulsants. Antipsychotics, particularly those from the atypical class, are also commonly used by clinicians as a pharmacologic intervention for dementia. Yet, since these are drugs with a wide array of potentially serious adverse effects, including increased risk for cerebrovascular accidents, clinicians treating patients with dementia must be especially cognizant of the benefits and risk of their use.

Nonpharmacologic treatments should be first-line therapy for BPSD. When these approaches do not produce the desired results, clinicians must weigh the risks versus benefits of continued psychological disease and dangerous behavior with the use of an antipsychotic drug regimen.

Pharmacist-managed clinics have consistently demonstrated improvement in patient outcomes. Quantitative research offers the benefit of objective outcomes to track progress toward therapeutic goals at pharmacist-managed clinics. While quantitative studies are readily available in the literature, there is a paucity of qualitative studies to capture the patients' perspectives of pharmacy services.

To assess through the use of qualitative research methods patient perceptions of pharmacist-managed services within ambulatory care clinics that operate under a collaborative practice agreement.

A semi-structured interview questionnaire was developed, pilot tested, and revised using a focus group of clinical pharmacists. The questionnaire was used to conduct face-to-face patient interviews at 6 pharmacist-managed clinics in central Indiana. English-speaking patients with a minimum of 2 visits with the clinical pharmacist were included in this study. Pharmacist-managed clinics without established collaborative practice agreements were excluded. Patient interviews were conducted by a trained research assistant, audio-recorded, and transcribed verbatim. The interview transcripts were analyzed to identify cross-cutting themes without predetermined definitions via inductive qualitative analysis. Four study investigators independently identified themes using a sample of the transcripts. Additional themes were identified and defined in a series of independent reviews and investigator meetings using the remaining transcripts until theme saturation. All themes were assigned to segments of the interview transcripts according to the consensus definitions.

A total of 30 interviews were conducted across the clinics. Ten themes from the interview transcripts emerged, including disease state management expertise, patient alliance, practice novelty, accessibility, increased sense of patient well-being, and compassion.

Patient perceptions from qualitative interviews revealed that pharmacists are viewed as medication experts who provide patient-centered care. This study highlights unique in-depth perspectives from the patient that further support maintenance and expansion of pharmacist-managed services.

To evaluate the current role of aliskiren, a direct renin inhibitor, in the pharmacologic treatment of essential hypertension.

A literature search of OVID MEDLINE and PubMed (both from 1950 through November 1, 2011) using the terms aliskiren and efficacy was conducted. In addition, reference citations from publications identified were reviewed.

All articles in English comparing aliskiren or an aliskiren-based regimen with another antihypertensive pharmacotherapy regimen in humans were identified. Articles were selected if they were on randomized controlled trials with blood pressure reduction as their primary objective. Trials included over 100 patients with mild-to-moderate essential hypertension.

Aliskiren has been studied against or in combination with hydrochlorothiazide, amlodipine, ramipril, losartan, irbesartan, valsartan, and atenolol. It is statistically superior to hydrochlorothiazide and ramipril at lowering blood pressure, and equally as effective as losartan, irbesartan, and atenolol, with a similar safety profile. Aliskiren is an effective add-on agent to valsartan, amlodipine, and atenolol therapy. Although aliskiren is beneficial, alternative agents exist that can be used with similar efficacy for lower cost.

Aliskiren is an effective antihypertensive agent, used either as monotherapy or in combination with other antihypertensive medications. The lack of evidence for long-term morbidity and mortality benefits makes it difficult to consider aliskiren a primary agent for the treatment of hypertension. The completion of the ASPIRE HIGHER program, a collection of trials whose aim is to demonstrate short- and long-term benefits of aliskiren on end-organ damage, is needed to justify the use of aliskiren other than as a last-line antihypertensive agent.

To review the pharmacology of antidepressants and describe clinical applications of antidepressants in the treatment of depression.

A MEDLINE/PubMed search (1995–July 2011) was conducted for English-language articles using the terms pharmacology, antidepressant, tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, venlafaxine, desvenlafaxine, duloxetine, bupropion, trazodone, nefazodone, mirtazapine, vilazodone, efficacy, adverse effects, and drug interactions. Book chapters related to the pharmacology of antidepressants were also searched.

Articles and book chapters relevant to the pharmacology of antidepressants were reviewed.

Antidepressants exert pharmacologic actions via enzyme inhibition, reuptake inhibition, receptor antagonism, and receptor partial agonism. These actions can cause both therapeutic and adverse effects. Each antidepressant possesses a unique blend of pharmacologic actions, which helps to differentiate antidepressants and aids in the understanding of their particular efficacy profiles, adverse effect profiles, and pharmacodynamic drug interaction profiles.

There are important clinical applications of the pharmacologic properties of antidepressants. Gaining familiarity with antidepressant pharmacology will enable the pharmacy technician to develop a more thorough understanding of the drug class.

To report a case of severe hypoglycemia resulting from a patient's misuse of an insulin glargine pen.

A 61-year-old male with a history of diabetes mellitus type 2 (T2DM), obesity, hypertension, end-stage renal disease, and systolic heart failure was admitted to the emergency department (ED) for severe hypoglycemia. The patient's treatment was recently switched from insulin glargine to an insulin glargine pen and had mistakenly injected the entire insulin pen. He was found lethargic and unresponsive at home and was brought into the ED with an initial blood glucose level of 11 mg/dL. He was given 6 ampules of dextrose 50% in the ED, started on a dextrose 10% infusion and was subsequently transferred to the medical intensive care unit (MICU). Throughout his stay in the MICU, the patient received a dextrose 20% infusion and a total of 11 ampules of dextrose 50% to keep his blood glucose level above 100 mg/dL. After a 6-day hospital course, the patient was stabilized and was discharged on sitagliptin.

The concern for hypoglycemia is present for any patient receiving insulin therapy. A MEDLINE search revealed the rates of hypoglycemia from insulin glargine but we found no previously described cases of severe hypoglycemia due to patient misuse of an insulin glargine pen. Our patient mistakenly injected the entire contents of the pen and became unresponsive and severely hypoglycemic. The long duration properties of insulin glargine likely prolonged the patient's hospital course. According to the Naranjo scale, the adverse reaction experienced by our patient was highly probable.

Medication changes can be confusing for patients, and pharmacists have a unique opportunity to counsel and educate patients on the proper use of their medications, thus helping to prevent adverse events such as hypoglycemia from improper use of an insulin glargine pen.