Nsaids for oa of hip and knee

STUDY HIGHLIGHTS

• Researchers searched for RCTs of NSAIDs, acetaminophen, and placebo for the treatment of OA of the hip and knee. Only trials with at least 100 participants were included in the meta-analysis.
• Researchers searched for published and unpublished data available before February 24, 2015.
• The main outcome of the network meta-analysis was pain, and researchers also evaluated NSAIDs in their effects on function.
• From a total of 8973 reports, 74 trials with a total of 58,556 patients were included in the meta-analysis.
• Celecoxib 200 mg/day was the most commonly studied treatment, followed by naproxen 1000 mg/day. In contrast, relatively few patients participated in trials of diclofenac 70 mg/day and etoricoxib 90 mg/day.
• The collective research was generally at low risk for bias, except for the specific bias of incomplete outcome data.
• Most trials were less than 3 months in duration, but there was no evidence that the length of treatment affected analgesic efficacy.
• Insufficient data were available to demonstrate a statistically significant reduction in pain vs placebo for the following treatments:
  • Acetaminophen less than 2000 mg/day and 3000 mg/day
  • Diclofenac 70 mg/day
  • Naproxen 750 mg/day
  • Ibuprofen 1200 mg/day
• In contrast, reductions in pain judged clinically significant by the authors vs placebo were noted for the following medications:
  • Diclofenac 150 mg/day
  • Etoricoxib 30 mg/day, 60 mg/day, and 90 mg/day
  • Rofecoxib 25 mg/day and 50 mg/day
• The difference between ineffective treatment and the most effective treatment as judged by the study authors was approximately 10 mm on a 100-mm pain scale.
• In general, higher doses of NSAIDs were more effective in relieving pain. This trend was most remarkable for celecoxib, diclofenac, and naproxen.
• Data regarding the treatment effect on physical function mirrored that for pain. A clinically significant effect was noted for diclofenac 150 mg/day and rofecoxib 25 mg/day.
• The researchers conclude that diclofenac 150 mg/day appears to be the most effective NSAID for OA.

Empowered Pharmacists Lower Patients' Cardiac Risk in RxEACH

CHICAGO, IL — A community-based pharmacist intervention in Alberta, Canada—where authorized pharmacists can prescribe and adjust medications and doses—reduced the estimated risk for cardiovascular events by 21% in 3 months^[1].
These benefits were seen in the RxEACH study of 700 high-risk patients who had at least one uncontrolled risk factor (hypertension, hyperglycemia, hyperlipidemia, smoking) and were randomized to usual pharmacist care or a targeted intervention designed to lower CVD risk.
Dr Ross T Tsuyuki (University of Alberta, Edmonton) presented these findings in a clinical research session at the American College of Cardiology (ACC) 2016 Scientific Sessions, and the paper was simultaneously published in the Journal of the American College of Cardiology.
"We think [this] represents a new paradigm of community-based cardiovascular risk reduction," he said, adding that patients like the intervention and stressing that it involves close collaboration their family-care physicians.
"Engaging pharmacists could bring another 450,000 'helping hands' in the United States and Canada to help reduce the burden of cardiovascular disease," according to Tsuyuki and colleagues. "We would encourage policy makers to consider broadening the scope of practice of pharmacists (as in Alberta) and for pharmacists and pharmacy professional organizations to seize these opportunities for the betterment of patient care," they conclude.
Session panelist Dr Allen J Taylor (MedStar Georgetown University Hospital and MedStar Washington Hospital Center, Washington, DC) told heartwire from Medscape that the results have to be interpreted with caution, because risk score calculators such as Framingham are based on long-term exposure to risks, and this was a 3-month study.
Nevertheless, the researchers looked at four risk factors and "were able to make a fair amount of changes across the board, [which] is laudable," he said. "There's a physician shortage, and there's no reason why we can't rely upon the pharmacist as part of the healthcare team to deliver more prevention," according to Taylor.

Community pharmacists are accessible, frontline healthcare professionals who often see patients with or at high risk for CVD, and prior studies have shown that this can be effective in managing certain CVD risk factors, Tsuyuki noted.
RxEACH evaluated how a comprehensive, provincewide, pharmacist-delivered intervention designed to improve four risk factors (diabetes, hypertension, hyperlipidemia, and smoking) would affect predicted risk of a CVD event.
In 2014 and 2015, pharmacists in 56 practices in Alberta identified and randomized 723 adults aged 18 and older who had diabetes, chronic kidney disease, cerebrovascular disease, cardiovascular disease, peripheral artery disease, or multiple risk factors and a Framingham risk score >20%.
The patients also had to have at least one uncontrolled risk factor (blood pressure >140/90 mm Hg or >130/80 mm Hg if diabetic, LDL cholesterol >2.0 mmol/L, HbA_1c >7%, or current smoker).
The researchers randomized 353 patients to usual care and 370 patients to the intervention. The patients had a mean age of 62, 58% were male, and their mean estimated risk of a CV event was 26%.
 A fair number of patients had diabetes, vascular disease, and coronary heart disease, and a relatively small group [7%] were primary-prevention patients," Tsuyuki noted. Many patients (72%) had poorly controlled blood pressure, 59% had poorly controlled dyslipidemia, 27% were smokers, and 79% of the patients with diabetes had poor glycemic control.
   Patients in the intervention group received a medication-therapy-management consultation with their pharmacist, in which the pharmacist measured their blood pressure, waist circumference, height, and weight; ordered laboratory tests to determine HbA_1c, lipid levels, and kidney function; and discussed CVD risk factors and their specific CVD risk scores (calculated from risk engines such as the UKPDS, the international score, and the Framingham risk score).
The pharmacists saw the patients in the intervention group every 3 to 4 weeks for 3 months, adjusted medications and doses based on Canadian clinical practice guidelines, and relayed information to the patient's physician after each patient contact. "Pharmacists did adjust doses, but more often they added drugs or discontinued drugs that weren't working," Tsuyuki noted.
At 3 months, the patients' estimated cardiovascular disease risk was virtually unchanged in the usual-care group, but it dropped from 25.5% to 20.5% in the pharmacist-intervention group.
Patients in the intervention group were more likely to achieve guideline-recommended targets for LDL cholesterol (55.5% vs 45.6%), blood pressure (50.9% vs 27.8%), and HbA_1c (42.2% vs 24.6%), and more likely to not smoke.
In the intervention group, mean blood pressure decreased from 137/81 mm Hg to 127/77 mm Hg; mean LDL cholesterol decreased from 2.47 mmol/L to 2.07 mmol/L; mean HbA_1c dropped from 8.61% to 7.60%; and the number who smoked fell from 26.2% to 19.7%, but these measures remained unchanged in the control group.
Compared with patients in the control group, those in the intervention group had a 0.2-mmol/L greater reduction in LDL cholesterol, a 9.37-mm-Hg greater reduction in systolic blood pressure, a 0.92% greater reduction in HbA_1c, and there were 20.2% fewer smokers (all P<0.0001).
 
Panelist Dr Prediman K Shah (Cedars Sinai Medical Center, West Hollywood, CA) wanted to know if all pharmacists in Canada can prescribe medications or change doses. In some places in the United States, there are collaborative drug-therapy management programs with pharmacists and physicians, Tsuyuki noted, but Alberta is the only Canadian province with this broadly expanded scope of pharmacist practice.
That the number of smokers in the intervention group dropped by 20% in 3 months is "really rather remarkable," Taylor noted. The pharmacists "are not just providing pills, they are providing general health advice, and you can only imagine what they could do if they built in things like adherence and monitoring, exercise recommendations, dietary recommendations. . . . It's turning the interaction at a pharmacy window, which used to be to simply sliding a prescription in one direction and pills coming back in the other direction, to an actual healthcare interaction. 'Are you taking your medications? What are your risk factors? What numbers have you achieved?' "
Funding for the RxEACH study was provided by Alberta Health, the Cardiovascular Health and Stroke Strategic Clinical Network of Alberta Health Services, and Merck Canada (for development of the educational materials only). Tsuyuki received investigator-initiated research grants from Merck, Sanofi, and AstraZeneca and is a consultant for Merck; the coauthors have no relevant financial relationships. Taylor reports receiving consultant fees/honoraria from Amgen and Eli Lilly and being on the speaker's bureau of Sanofi.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

- See more at: file:///C:/Users/vanwash85/Downloads/Community-Based%20Pharmacist%20Program%20Can%20Lower%20Cardiovascular%20Risk%20-%20NEJM%20Journal%20Watch.htm#sthash.yLjbO9IG.dpuf

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Thomas L. Schwenk, MD reviewing Tsuyuki RT et al. J Am Coll Cardiol 2016 Apr 4.

Longer-term studies are warranted to assess clinical outcomes.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Thomas L. Schwenk, MD reviewing Tsuyuki RT et al. J Am Coll Cardiol 2016 Apr 4.

Longer-term studies are warranted to assess clinical outcomes.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Thomas L. Schwenk, MD reviewing Tsuyuki RT et al. J Am Coll Cardiol 2016 Apr 4.

Longer-term studies are warranted to assess clinical outcomes.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

Comment

The results of this community-based effectiveness trial warrant longer assessments of persistent risk reduction and actual CVD outcomes. However, although many U.S. jurisdictions allow pharmacists to provide most of these intervention services, providing new prescriptions would require changes in scope-of-practice legislation in nearly all states.

At the time that NEJM Journal Watch reviewed this article, its publisher noted that it was an accepted manuscript and that subsequent changes could be made.

Editor Disclosures at Time of Publication

• Disclosures for Thomas L. Schwenk, MD at time of publication

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Thomas L. Schwenk, MD reviewing Tsuyuki RT et al. J Am Coll Cardiol 2016 Apr 4.

Longer-term studies are warranted to assess clinical outcomes.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

Comment

The results of this community-based effectiveness trial warrant longer assessments of persistent risk reduction and actual CVD outcomes. However, although many U.S. jurisdictions allow pharmacists to provide most of these intervention services, providing new prescriptions would require changes in scope-of-practice legislation in nearly all states.

At the time that NEJM Journal Watch reviewed this article, its publisher noted that it was an accepted manuscript and that subsequent changes could be made.

Editor Disclosures at Time of Publication

• Disclosures for Thomas L. Schwenk, MD at time of publication

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Summary and Comment |

General Medicine

Informing Practice

April 12, 2016

Community-Based Pharmacist Program Can Lower Cardiovascular Risk

Thomas L. Schwenk, MD reviewing Tsuyuki RT et al. J Am Coll Cardiol 2016 Apr 4.

Longer-term studies are warranted to assess clinical outcomes.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

Comment

The results of this community-based effectiveness trial warrant longer assessments of persistent risk reduction and actual CVD outcomes. However, although many U.S. jurisdictions allow pharmacists to provide most of these intervention services, providing new prescriptions would require changes in scope-of-practice legislation in nearly all states.

At the time that NEJM Journal Watch reviewed this article, its publisher noted that it was an accepted manuscript and that subsequent changes could be made.

Editor Disclosures at Time of Publication

• Disclosures for Thomas L. Schwenk, MD at time of publication

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Summary and Comment |

General Medicine

Informing Practice

April 12, 2016

Community-Based Pharmacist Program Can Lower Cardiovascular Risk

Thomas L. Schwenk, MD reviewing Tsuyuki RT et al. J Am Coll Cardiol 2016 Apr 4.

Longer-term studies are warranted to assess clinical outcomes.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

Comment

The results of this community-based effectiveness trial warrant longer assessments of persistent risk reduction and actual CVD outcomes. However, although many U.S. jurisdictions allow pharmacists to provide most of these intervention services, providing new prescriptions would require changes in scope-of-practice legislation in nearly all states.

At the time that NEJM Journal Watch reviewed this article, its publisher noted that it was an accepted manuscript and that subsequent changes could be made.

Editor Disclosures at Time of Publication

• Disclosures for Thomas L. Schwenk, MD at time of publication

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Summary and Comment |

General Medicine

Informing Practice

April 12, 2016

Community-Based Pharmacist Program Can Lower Cardiovascular Risk

Thomas L. Schwenk, MD reviewing Tsuyuki RT et al. J Am Coll Cardiol 2016 Apr 4.

Longer-term studies are warranted to assess clinical outcomes.

Many patients who are at risk for cardiovascular disease (CVD) do not receive optimal counseling, medication, and monitoring. Several smaller studies have shown that using clinical pharmacists to administer risk-reduction strategies for individual CVD risk factors is effective. Now, in a large, community-based, Canadian study, researchers assessed the effect of a pharmacist-administered medication therapy management program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with diabetes, 27% smokers) and received care from 56 pharmacies in Alberta. Patients were randomized to usual care or to a protocol of care provided directly by pharmacists that included baseline clinical and risk-factor assessment, validated calculation of CVD risk, counseling and education, guideline-based new or revised prescriptions, and monthly monitoring for 3 months. All care was communicated to patients' family physicians, and pharmacists billed for their services.

Mean baseline 10-year risks for CVD were 25.6% in the intervention group and 26.6% in the usual-care group. At 3 months, mean recalculated risk in the intervention group was 20.5%, versus 25.9% in the usual-care group — a significant difference. Significantly more patients in the intervention group than in the usual-care group achieved prespecified goals for each assessed risk factor, including an absolute difference of 7% in smoking-cessation rates. No adverse events were reported.

Comment

The results of this community-based effectiveness trial warrant longer assessments of persistent risk reduction and actual CVD outcomes. However, although many U.S. jurisdictions allow pharmacists to provide most of these intervention services, providing new prescriptions would require changes in scope-of-practice legislation in nearly all states.

At the time that NEJM Journal Watch reviewed this article, its publisher noted that it was an accepted manuscript and that subsequent changes could be made.

Editor Disclosures at Time of Publication

• Disclosures for Thomas L. Schwenk, MD at time of publication

- See more at: http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf

Targeting Suboptimal Prescribing in the Elderly: A Review of the Impact of Pharmacy Services

Castelino RL, Bajorek BV, Chen TF
Ann Pharmacother. 2009;43:1096-1106

Study Summary
The objective of this review was to determine the impact of pharmacist interventions on suboptimal prescribing of medication (ie, overuse, misuse, or underuse) in the elderly. Castelino and colleagues searched databases used in several studies published between 1992 and 2008. Inclusion criteria included: patients 65 years of age or older, randomized controlled trials, intervention made by a pharmacist or team with a pharmacist, and assessment of at least 1 outcome measure of suboptimal prescribing. Studies focusing on a single drug or drug class and those that had selected patients based on a specific preexisting condition were excluded.

Twelve studies were reviewed, most of which focused on drug misuse and overuse. The studies used various methods of assessing suboptimal prescribing, both explicit (ie, rigid standards) and implicit (ie, subjective). Several studies used the implicit Medication Appropriateness Index (MAI) to assess prescribing. Nine of the 12 studies demonstrated a statistically significant improvement in prescribing after the pharmacist intervention. Interventions were usually made after medication profile review by a clinical pharmacist or during regimen review by a multidisciplinary team.

Viewpoint
The proportion of elderly patients is expected to rise significantly over the next few decades, and this group accounts for at least 30% of prescription medication costs.[1] Pharmacists can significantly improve the appropriateness of prescription drug usage, and literature reviews such as this one can help pharmacists justify their services.

Such reviews can also identify problems that deserve more attention. Studies included in this review focused on misuse and overuse of medications, while the underuse of medications in the elderly demands more research.

This problem deserves more attention in clinical practice as well. For example, the Beers criteria are often used to identify drugs that can be harmful if used in the elderly. But what about conditions that are undertreated? Clinicians should pay close attention to issues in the elderly, such as adequate pain control and management of hypertension, diabetes, and cardiovascular disease. Unfortunately, these conditions may not be maximally treated due to the belief that patients of a given age require less aggressive treatment.

Thus, pharmacists must also consider what medications may be missing from a given regimen. Is a patient receiving secondary stroke prophylaxis? Is a heart failure patient receiving a beta-blocker or angiotensin-converting enzyme (ACE) inhibitor? Clinical judgment needs to be used when weighing benefits of such things as tight low-density lipoprotein (LDL) control or tight blood pressure control. The evidence base for treatment of such diseases in the elderly is growing to help support these decisions. Trials such as PROSPER[2] and HYVET[3] demonstrated benefit of treating LDL and blood pressure in the elderly by significantly reducing negative cardiovascular outcomes.

References
1.Baum C, Kennedy DL, Forbes MB, Jones JK. Drug use in the United States in 1981. JAMA. 1984;251:1293-1297.
2.Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomized controlled trial. Lancet. 2002;360:1623-1630.
3.Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.

BMJ 2001; 323 : 1340 doi: 10.1136/bmj.323.7325.1340 (Published 8 December 2001)

Abstract
Objective: To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice.

Design: Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review.

Setting: Four general practices.

Participants: 1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community.

Intervention: Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment.

Main outcome measures: Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services.

Results: 590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference £4.72 per 28 days, −£7.04 to -£2.41); equivalent to £61 per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference −0.2, −0.4 to −0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate.

Conclusions: A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.


What is already known on this topic
What is already known on this topic Review of patients on long term drug treatment is important but is done inadequately

Evidence from the United States shows that pharmacists can improve patient care by reviewing drug treatment

What this study adds
What this study adds Consultations with a clinical pharmacist are an effective method of reviewing the drug treatment of older patients

Review by a pharmacist results in more drug changes and lower prescribing costs than normal care plus a much higher review rate

Use of healthcare services by patients is not increased