Pharmacist-physician comanagement of hypertension and reduction in 24-hour ambulatory blood pressures

BACKGROUND

Pharmacist-physician comanagement of hypertension has been shown to improve office blood pressures (BPs). We sought to describe the effect of such a model on 24-hour ambulatory BPs.

METHODS

We performed a prospective, cluster-randomized, controlled clinical trial, enrolling 179 patients with uncontrolled hypertension from 5 primary care clinics in Iowa City, Iowa. Patients were randomized by clinic to receive pharmacist-physician collaborative management of hypertension (intervention) or usual care (control) for a 9-month period. In the intervention group, pharmacists helped patients to identify barriers to BP control, counseled on lifestyle and dietary modifications, and adjusted antihypertensive therapy in collaboration with the patients' primary care providers. Patients were seen by pharmacists a minimum of every 2 months. Ambulatory BP was measured at baseline and at study end.

RESULTS

Baseline and end-of-study ambulatory BP profiles were evaluated for 175 patients. Mean (SD) ambulatory systolic BPs (SBPs), reported in millimeters of mercury, were reduced more in the intervention group than in the control group: daytime change in (Δ) SBP, 15.2 (11.5) vs 5.5 (13.5) (P < .001); nighttime ΔSBP, 12.2 (14.8) vs 3.4 (13.3) (P < .001); and 24-hour ΔSBP, 14.1 (11.3) vs 5.5 (12.5) (P < .001). More patients in the intervention group than in the control group had their BP controlled at the end of the study (75.0% vs 50.7%) (P < .001), as defined by overall 24-hour ambulatory BP monitoring.

CONCLUSION

Pharmacist-physician collaborative management of hypertension achieved consistent and significantly greater reduction in 24-hour BP and a high rate of BP control. Trial Registration  clinicaltrials.gov Identifier: NCT00201045.

Diuretic therapy: key aspects in hypertension and renal disease

Diuretics are a heterogeneous class of drugs of tremendous importance in both the prevention and treatment of cardiovascular and renal disease. Used as antihypertensives, diuretic-based therapy to lower blood pressure reduces cardiovascular events. In addition to their role as preventive agents, diuretics are critical to the management of several commonly encountered edematous conditions, including chronic kidney disease and the nephrotic syndrome. Because a threshold amount of diuretic is necessary to elicit the intended natriuretic effect, alterations in the pharmacokinetic and pharmacodynamic parameters occurring in the presence of a variety of renal conditions necessitate careful dose titrations and adjustment. Higher doses or more frequent administration may be necessary to maintain the drug level above the diuretic threshold. In refractory cases, diuretics with differing sites of action in the nephron can be combined to potentiate therapeutic effects. Selection of the proper diuretic agent and its dosing strategy are dependent on knowledge of within-class characteristics, as well as a commensurate understanding of the physiology of the disease being treated.

Febuxostat: a selective xanthine-oxidase/xanthine-dehydrogenase inhibitor for the management of hyperuricemia in adults with gout

BACKGROUND

Febuxostat, a nonpurine selective inhibitor of both the oxidized and reduced forms of xanthine oxidase, was approved in February 2009 by the US Food and Drug Administration for the management of hyperuricemia in adults with gout.

OBJECTIVE

The purpose of this review was to summarize available information about the clinical use of febuxostat, including its chemistry, pharmacology, pharmacokinetics, pharmacodynamics, clinical efficacy, and safety profile.

METHODS

A search of the medical literature using PubMed (1949-August 2009) and the Iowa Drug Information Service (1966-August 2009) was performed to identify all published articles about febuxostat. Key search terms included febuxostat, hyperuricemia, gout, TMX-67, and TEI-6720. Articles were limited to those published in English. Reference lists of the primary set of articles identified were reviewed for pertinent articles and scientific meeting abstracts not identified in the original search.

RESULTS

A total of 88 published articles (including 14 human studies) were identified in the original search. Review of the references of these 88 articles yielded 7 additional trials published in abstract form. Clinical trial data from this review were obtained from these 21 studies. Dose-dependent reductions from baseline in serum urate occur with febuxostat. Clinical trials found that 40 mg/d of febuxostat was noninferior to conventionally dosed allopurinol (300 mg/d) in the percentage of subjects achieving the primary end point of serum urate <6.0 mg/dL (45% for febuxostat vs 42% for allopurinol), whereas 80 mg/d of febuxostat was reported to be superior (67% vs 42%; P < 0.001). Febuxostat 40 and 80 mg/d appeared to be well tolerated in the populations studied, with adverse events mostly limited to liver enzyme elevations (6.6% and 4.6%, respectively), nausea (1.1% and 1.3%), arthralgias (1.1% and 0.7%), and rash (0.5% and 1.6%). Febuxostat does not require dosage adjustment in patients with mild to moderate renal impairment (creatinine clearance, 30-89 mL/min). Because of the risk of acute gout flares occurring when febuxostat treatment is initiated, concomitant therapy with colchicine or an NSAID for >or=8 weeks is recommended.

CONCLUSIONS

Febuxostat is the first agent marketed in the United States to treat hyperuricemia of gout since allopurinol was approved in 1964. In English-language published clinical trials, it was found to be noninferior to allopurinol and generally well tolerated.

Atmospheric pressure changes and unexplained variability in INR measurements

Changes in atmospheric pressure may influence hepatic blood flow and drug metabolism. Anecdotal experience suggests international normalized ratio (INR) variability may be temporally related to significant atmospheric pressure changes. We investigated this potential association in a large sample of patients with multiple INRs. This is a retrospective review of outpatient anticoagulation records from the Iowa City Veteran's Affairs Medical Center and affiliated outpatient clinics from October 1999 to July 2007. All patients, receiving at least one prescription for warfarin and INR at least 30 days or more from the date of the first warfarin prescription, were identified. INRs during periods of hospitalization and vitamin K use were excluded. Proximity analysis using geocoding of ZIP codes of identified patients to the nearest National Oceanic and Atmospheric Administration station was performed to assign atmospheric pressure with INR. Spearman's Rho and Pearson's correlation were used to evaluate atmospheric pressure and INR. Unique patients (1441) with 45 187 INRs were analyzed. When limited to nontherapeutic INRs following a previously therapeutic INR (1121 unique patients/5256 INRs), a small but clinically insignificant association between delta INR and delta atmospheric pressure was observed (r = -0.025; P = 0.038), but not for actual INR and atmospheric pressure (P = 0.06). Delta atmospheric pressure demonstrated greater variation during fall/winter months compared with spring/summer (0.23 vs. 0.15 inHg; P < 0.001); however, variability in INRs for the corresponding seasons was not significant (P = 0.136). No significant difference was detected in the proportions of nontherapeutic INRs among the different seasons (P = 0.371). No correlation was observed between atmospheric pressure changes and INR variability. These findings refute the anecdotal experience seen in our anticoagulation clinic.

Influence of patient characteristics on success of ambulatory blood pressure monitoring

STUDY OBJECTIVE

To examine the influence of specific patient characteristics on the success of ambulatory blood pressure monitoring (ABPM).

DESIGN

Retrospective analysis.

SETTING

University-affiliated family care center.

PATIENTS

Five hundred thirty patients (mean age 52.7 yrs, range 14-90 yrs) who were undergoing ABPM between January 1, 2001, and July 1, 2007.

MEASUREMENT AND MAIN RESULTS

Specific patient characteristics were identified through an electronic medical record review and then examined for association with ABPM session success rate. These patient characteristics included age, sex, weight, height, body mass index (BMI), occupation, clinic blood pressure, travel distance to clinic, and presence of diabetes mellitus or renal disease. The percentage of valid readings obtained during an ABPM session was analyzed continuously (0-100%), whereas overall session success was analyzed dichotomously (0-79% or 80-100%). Univariate and multivariate regression analyses were performed to examine the influence of patient characteristics on the percentage of valid readings and the overall likelihood of achieving a successful session. In the 530 patients, the average percentage of valid readings was 90%, and a successful ABPM session (>or= 80% valid readings) was obtained in 84.7% (449 patients). A diagnosis of diabetes was found to negatively predict ABPM session success (continuous variable analysis, p=0.019; dichotomous variable analysis, odds ratio [OR] 0.45, 95% confidence interval [CI] 0.23-0.87, p=0.019), as did renal disease (continuous variable analysis, p=0.006; dichotomous variable analysis, OR 0.39, 95% CI 0.17-0.90, p=0.027) and increasing BMI (continuous variable analysis, p<0.001; dichotomous variable analysis, OR 0.78, 95% CI 0.65-0.93, p=0.005). Renal disease and BMI remained significant predictors in adjusted analyses.

CONCLUSION

For most patients, ABPM was successful; however, elevated BMI and renal disease were associated with less complete ABPM session results. Adaptation and individualization of the ABPM process may be necessary to improve results in these patients.

How well does a shortened time interval characterize results of a full ambulatory blood pressure monitoring session?

Ambulatory blood pressure monitoring (ABPM) is useful in evaluating cardiovascular risk but requires significant time. The authors examined how closely shortened time intervals correlate with the systolic blood pressure (BP) determined from a full 24-hour ABPM session in 1004 ABPM recordings. After excluding the first hour, Pearson correlations performed for the mean systolic BP of the subsequent 3-, 5-, and 7-hour periods (4, 6, and 8 hours total) with the entire, and remainder of the session, demonstrated greatest improvement in correlation when the session is increased from 4 to 6 hours. Bland-Altman analysis of the 6-hour time period revealed a mean difference of 5.41 mm Hg compared with the full session mean. The authors conclude that 6-hour ABPM can approximate the overall mean BP obtained from full 24-hour ABPM. However, shortened sessions do not characterize the influence of circadian variation on the 24-hour mean BP and may overestimate the 24-hour BP levels.

How well does a shortened time interval characterize results of a full ambulatory blood pressure monitoring session?

Ambulatory blood pressure monitoring (ABPM) is useful in evaluating cardiovascular risk but requires significant time. The authors examined how closely shortened time intervals correlate with the systolic blood pressure (BP) determined from a full 24-hour ABPM session in 1004 ABPM recordings. After excluding the first hour, Pearson correlations performed for the mean systolic BP of the subsequent 3-, 5-, and 7-hour periods (4, 6, and 8 hours total) with the entire, and remainder of the session, demonstrated greatest improvement in correlation when the session is increased from 4 to 6 hours. Bland-Altman analysis of the 6-hour time period revealed a mean difference of 5.41 mm Hg compared with the full session mean. The authors conclude that 6-hour ABPM can approximate the overall mean BP obtained from full 24-hour ABPM. However, shortened sessions do not characterize the influence of circadian variation on the 24-hour mean BP and may overestimate the 24-hour BP levels.

Do antibiotics affect the quality of life of patients with upper respiratory tract illnesses? It might depend on one's luck

OBJECTIVE

Upper respiratory tract illnesses (URTI) are known to cause measurable decline in health-related quality of life (HRQL). We studied whether antibiotics impacted patients' HRQL after obtaining medical care for URTI.

METHODS

Adults seeking care for URTI at a family medicine office were eligible for this study. Decisions to prescribe antibiotics were left to their physicians. Subjects completed the Quality of Well-Being questionnaire on enrolment and on days 3, 7, 14 and 28. Analysis of HRQL was undertaken using repeated measures ANOVA and ANCOVA.

RESULTS

Seventy-three patients (mean age 35.8 years) were studied. Thirty-six of the subjects (50.7%) received prescriptions for antibiotics from their physicians at the index visit. By day 28, 78.4% of the subjects in the antibiotic group and 77.8% of the other group reported cure (p = 0.95). Receiving a prescription for an antibiotic at the initial visit did not influence subsequent HRQL reported by subjects (p = 0.98). However, when subjects receiving antibiotics were subgrouped by whether they reported an antibiotic adverse event we found significant differences in final HRQL. Subjects receiving antibiotics but not experiencing adverse events reported higher HRQL by day 28 than did subjects receiving an antibiotic but also reporting adverse events and subjects not receiving any antibiotics (p = 0.02).

CONCLUSION

Providing patients experiencing URTIs with prescriptions for antibiotics does not, on average, positively impact HRQL over the following 28 days. However, the subgroup of patients who receive antibiotics and do not experience an adverse event may come out ahead.

How well does a shortened time interval characterize results of a full ambulatory blood pressure monitoring session?

Ambulatory blood pressure monitoring (ABPM) is useful in evaluating cardiovascular risk but requires significant time. The authors examined how closely shortened time intervals correlate with the systolic blood pressure (BP) determined from a full 24-hour ABPM session in 1004 ABPM recordings. After excluding the first hour, Pearson correlations performed for the mean systolic BP of the subsequent 3-, 5-, and 7-hour periods (4, 6, and 8 hours total) with the entire, and remainder of the session, demonstrated greatest improvement in correlation when the session is increased from 4 to 6 hours. Bland-Altman analysis of the 6-hour time period revealed a mean difference of 5.41 mm Hg compared with the full session mean. The authors conclude that 6-hour ABPM can approximate the overall mean BP obtained from full 24-hour ABPM. However, shortened sessions do not characterize the influence of circadian variation on the 24-hour mean BP and may overestimate the 24-hour BP levels.

The Effects of Androstenedione Supplementation on Serum Gonadal Hormones

Objective:

To review the effects of androstenedione supplementation on serum gonadal hormones.

Data Sources:

Biomedical literature was accessed via PubMed through September 2007; MeSH terms included androstenedione and gonadal hormones.

Study Selection and Data Extraction:

Studies were limited to those published in English, with the primary outcome of change in serum gonadal hormone concentrations following multiple-dose oral androstenedione supplementation. Articles that reported only effects on muscle strength were excluded because our review focuses on the biochemical, not physiological, effects of androstenedione. For studies that evaluated multiple outcomes of therapy that were published in more than one journal, only the article reporting serum gonadal levels was selected for this review.

Data Synthesis:

We reviewed 8 unique studies that evaluated the effect of oral androstenedione supplementation on serum gonadal hormone concentrations. Critical comparison of the studies is challenging due to heterogeneity in methodology and outcomes measured, small sample sizes and short durations, and lack of complete data. The timing of serum gonadal hormone measurements, which is of critical importance, is not standardized among the studies. Subjectively evaluated, these studies suggest that androstenedione supplementation may cause a small, transient increase in serum testosterone. However, this effect is very short (<24 h) and may be completely negated by conversion to estrogens and through feedback inhibition of endogenous testosterone production with long-term use (≥28 days).

Conclusions:

The findings of the studies reviewed suggest that androstenedione supplementation may cause a small, transient increase in serum testosterone levels. More importantly, estrogen-related hormones were also increased. Although androstenedione supplements are no longer available in the US without a prescription, they are available in other countries and potentially via the Internet. Clinicians should be aware of the potentially harmful effects of androstenedione on gonadal hormones in the event that they are involved in the care of a patient who may be using an androstenedione-containing product.

Description of pharmacist interventions during physician–pharmacist co-management of hypertension

OBJECTIVE

The aim of this study is to describe recommendations made by clinical pharmacists when co-managing hypertension with physicians.

SETTING

Two family medicine clinics at a major teaching hospital in the mid-western United States.

METHOD

This report details the specific recommendations made by pharmacists during a prospective randomized controlled clinical trial. Patients with uncontrolled hypertension were enrolled in a 9-month intensive pharmacist-physician co-management study. Clinical pharmacists saw patients at baseline, 2, 4, 6, and 8 month visits. Optional visits were allowed between required visits.

MAIN OUTCOME MEASURE

For this analysis, pharmacist recommendations were grouped. Physician acceptance of the pharmacists' recommendations was also evaluated.

RESULTS

Data from 101 patients were included and analyzed in this study. Changes in drug therapy were recommended 267 times for these 101 patients. Most recommendations for a change in treatment involved adding a new antihypertensive medication (46.4%) or increasing a dose (33.3%). The majority of pharmacist recommendations to modify drug therapy were made at the baseline visit (41.6%), with 76.8% of recommendations made by the 2 month visit. Physicians accepted and implemented 95.9% of the 267 pharmacist recommendations to modify drug therapy. Pharmacists recommended no change in the treatment plan 361 times, most often because the patient's blood pressure (BP) had achieved the goal. Average BP decreased from 153.1+/-10.0/84.9+/-12.0 mmHg (average+/-SD) at baseline to 124.2+/-9.7/74.7+/-9.6 mmHg (P<0.001) at the end of 9 months, with 89.1% (P<0.001) of patients reaching their BP goal.

CONCLUSION

Pharmacist recommendations for alterations in drug therapy generally occurred early in the course of the study and were largely to intensify therapy through higher dosages or additional medications. Pharmacist-physician co-management of BP is effective at reducing BP and improving BP control rates.

Antioxidants, supplements, and Parkinson's disease

OBJECTIVE

To review the use of antioxidants and other supplements for the prevention and treatment of Parkinson's disease (PD).

DATA SOURCES

Biomedical literature was accessed through MEDLINE (1996-June 2005); key search terms included Parkinson's disease, coenzyme Q10 (CoQ10), antioxidants, supplements, and glutathione. Pertinent references cited in those articles were also evaluated for inclusion in this review.

DATA SYNTHESIS

Three main antioxidants or supplements have been studied for use in the prevention or treatment of PD: tocopherol, CoQ10, and glutathione. These agents have been studied because of their potential to alter the course of 2 common theories of PD pathogenesis: free radical generation and mitochondrial complex-1 deficiency. The literature search revealed 3 large clinical studies of tocopherol (2 observational, 1 prospective randomized), 4 trials of CoQ10, and 1 study of glutathione. With the exception of the large observational studies with tocopherol and one study of CoQ10 that enrolled 80 patients, each of the other studies retrieved included fewer than 30 patients and were conducted for 3 months or less. Antioxidant supplementation, in particular tocopherol, did not appear to alter the course of PD. However, in 2 of the studies of CoQ10 and in the study of glutathione, a small but statistically significant improvement in PD symptoms was observed.

CONCLUSIONS

At present, antioxidants and supplements appear to have a limited role in the prevention or treatment of PD. Of those reviewed here, CoQ10 appears to provide some minor treatment benefits. More study is necessary to determine whether CoQ10 has a significant role as primary or adjunctive therapy in PD.

Do Randomized Controlled Trials Always Trump Case Reports? A Second Look at Propranolol and Depression

STUDY OBJECTIVE

To explore reasons for discrepancies between findings from case reports and those from a meta-analysis of randomized controlled trials regarding the association between beta-adrenergic blockers and depression.

DESIGN

Systematic review.

DATA SOURCE

PubMed/MEDLINE database.

MEASUREMENTS AND MAIN RESULTS

We reviewed 24 published case reports showing an association between beta-blockers and depression and eight randomized controlled trials included in a meta-analysis of the adverse effects of these drugs. We abstracted the beta-blocker taken, patients' age and sex, diagnoses, history of depression, type of depressive symptoms reported, and method and timing of the assessment of depression. Naranjo criteria were used to evaluate the strength of evidence from each case report for a possible association between beta-blockers and depression. Twelve case reports had a Naranjo score of 5 or more (suggesting a likely causal relationship), nine of which involved propranolol. In all nine, depression began soon after treatment, and in four, the patient had a history of depression. Three randomized controlled trials assessed propranolol. Depression rates in the control groups of these studies differed substantially from each other (0-40%, p<0.0001). In only one randomized controlled trial did investigators assess depression systematically; they evaluated depression after 1 year of treatment and eliminated patients who had previously been prescribed an antidepressant.

CONCLUSION

A criterion standard to assess the true relationship between beta-blockers and depression is lacking. Factors such as the lack of systematic assessment of depression, the timing of assessments, and the selection of patients may have reduced the ability of researchers in the randomized controlled trials to detect depression as an adverse effect. Evidence from case reports should be carefully considered when relevant randomized controlled trials have not been adequately designed to detect adverse effects.

Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure

Low-dose thiazide-type diuretics are recommended as initial therapy for most hypertensive patients. Chlorthalidone has significantly reduced stroke and cardiovascular end points in several landmark trials; however, hydrochlorothiazide remains favored in practice. Most clinicians assume that the drugs are interchangeable, but their antihypertensive effects at lower doses have not been directly compared. We conducted a randomized, single-blinded, 8-week active treatment, crossover study comparing chlorthalidone 12.5 mg/day (force-titrated to 25 mg/day) and hydrochlorothiazide 25 mg/day (force-titrated to 50 mg/day) in untreated hypertensive patients. The main outcome, 24-hour ambulatory blood pressure (BP) monitoring, was assessed at baseline and week 8, along with standard office BP readings every 2 weeks. Thirty patients completed the first active treatment period, whereas 24 patients completed both. An order-drug-time interaction was observed with chlorthalidone; therefore, data from only the first active treatment period was considered. Week 8 ambulatory BPs indicated a greater reduction from baseline in systolic BP with chlorthalidone 25 mg/day compared with hydrochlorothiazide 50 mg/day (24-hour mean = -12.4+/-1.8 mm Hg versus -7.4+/-1.7 mm Hg; P=0.054; nighttime mean = -13.5+/-1.9 mm Hg versus -6.4+/-1.8 mm Hg; P=0.009). Office systolic BP reduction was lower at week 2 for chlorthalidone 12.5 mg/day versus hydrochlorothiazide 25 mg/day (-15.7+/-2.2 mm Hg versus -4.5+/-2.1 mm Hg; P=0.001); however, by week 8, reductions were statistically similar (-17.1+/-3.7 versus -10.8+/-3.5; P=0.84). Within recommended doses, chlorthalidone is more effective in lowering systolic BPs than hydrochlorothiazide, as evidenced by 24-hour ambulatory BPs. These differences were not apparent with office BP measurements.

Women's quality of life is decreased by acute cystitis and antibiotic adverse effects associated with treatment

Background

Although acute cystitis is a common infection in women, the impact of this infection and its treatment on women's quality of life (QOL) has not been previously described.

Objectives: To evaluate QOL in women treated for acute cystitis, and describe the relationship between QOL, clinical outcome and adverse events of each of the interventions used in the study.

Methods

Design. Randomized, open-label, multicenter, treatment study.

Setting. Two family medicine outpatient clinics in Iowa.

Patients. One-hundred-fifty-seven women with clinical signs and symptoms of acute uncomplicated cystitis.

Intervention. Fifty-two patients received trimethoprim/sulfamethoxazole 1 double-strength tablet twice daily for 3 days, 54 patients received ciprofloxacin 250 mg twice daily for 3 days and 51 patients received nitrofurantoin 100 mg twice daily for 7 days.

Measurements. QOL was assessed at the time of enrollment and at 3, 7, 14 and 28 days after the initial visit. QOL was measured using a modified Quality of Well-Being scale, a validated, multi-attribute health scale. Clinical outcome was assessed by telephone interview on days 3, 7, 14 and 28 using a standardized questionnaire to assess resolution of symptoms, compliance with the prescribed regimen, and occurrence of adverse events.

Results

Patients experiencing a clinical cure had significantly better QOL at days 3 (p = 0.03), 7 (p < 0.001), and 14 (p = 0.02) compared to patients who failed treatment. While there was no difference in QOL by treatment assignment, patients experiencing an adverse event had lower QOL throughout the study period. Patients treated with ciprofloxacin appeared to experience adverse events at a higher rate (62%) compared to those treated with TMP/SMX (45%) and nitrofurantoin (49%), however the difference was not statistically significant (p = 0.2).

Conclusion

Patients experiencing cystitis have an increase in their QOL with treatment. Those experiencing clinical cure have greater improvement in QOL compared to patients fail therapy. While QOL is improved by treatment, those reporting adverse events have lower overall QOL compared to those who do not experience adverse events. This study is important in that it suggests that both cystitis and antibiotic treatment can affect QOL in a measurable way.

Informational Content of Official Pharmaceutical Industry Web Sites about Treatments for Erectile Dysfunction

BACKGROUND

In the last 5 years, several treatments have become available for erectile dysfunction (ED). During this same period, consumer use of the Internet for health information has increased rapidly. In traditional direct-to-consumer advertisements, viewers are often referred to a pharmaceutical company Web site for further information.

OBJECTIVE

To evaluate the accessibility and informational content of 5 pharmaceutical company Web sites about ED treatments.

METHODS

Using 10 popular search engines and 1 specialized search engine, the accessibility of the official pharmaceutical company–sponsored Web site was determined by searching under brand and generic names. One company also manufactures an ED device; this site was also included. A structured, explicit review of information found on these sites was conducted.

RESULTS

Of 110 searches (1 for each treatment, including corresponding generic drug name, using each search engine), 68 yielded the official pharmaceutical company Web site within the first 10 links. Removal of outliers (for both brand and generic name searches) resulted in 68 of 77 searches producing the pharmaceutical company Web site for the brand-name drug in the top 10 links. Although all pharmaceutical company Web sites contained general information on adverse effects and contraindications to use, only 2 sites gave actual percentages. Three sites provided references for their materials or discussed other treatment or drug options, while 4 of the sites contained profound advertising or emotive content. None mentioned cost of the therapy.

CONCLUSIONS

The information contained on pharmaceutical company Web sites for ED treatments is superficial and aimed primarily at consumers. It is largely promotional and provides only limited information needed to effectively compare treatment options.

Selective serotonin-reuptake inhibitors for the treatment of hot flashes

OBJECTIVE

To review the literature evaluating the use of selective serotonin-reuptake inhibitors (SSRIs) for the treatment of hot flashes.

DATA SOURCES

Biomedical literature was accessed through MEDLINE (1966-June 2003), MD Consult, and references of reviewed articles. Key search terms used were hot flashes, vasomotor symptoms, antidepressants, and SSRIs.

DATA SYNTHESIS

Recent evidence from the Women's Health Initiative precludes the use of traditional hormonal therapy in some women. Nonhormonal therapies are possible options, but conflicting evidence of efficacy exists.

CONCLUSIONS

Although further studies are warranted, preliminary data suggest that SSRIs are generally modestly successful in reducing the frequency and severity of hot flashes.

Evaluation of 4 years of clinical pharmacist anticoagulation case management in a rural, private physician office

OBJECTIVES

To evaluate patient outcomes after 4 years of anticoagulation case management by a pharmacist and to document patient and provider satisfaction with the service.

SETTING

Rural, private physician office in Mt. Vernon, Iowa.

PRACTICE DESCRIPTION

Clinical pharmacist anticoagulation clinic.

PRACTICE INNOVATION

Under a protocol reviewed annually, a clinical pharmacist faculty member from the University of Iowa College of Pharmacy provides on-site, point-of-care anticoagulation dose adjustment and monitoring 1 day per week.

MAIN OUTCOME MEASURES

Data on anticoagulation outcomes from 1998 to 2002 were obtained through retrospective review of medical charts of patients served by the clinic. A survey of patient satisfaction with the clinic was mailed to all currently active patients enrolled in the anticoagulation clinic, and a second satisfaction survey was distributed to providers and ancillary staff of the physician office.

RESULTS

Eighty patients met the criteria for evaluation of therapeutic outcomes. The mean +/- standard deviation percentage of international normalized ratios in the therapeutic range ("percent therapeutic") for the anticoagulation clinic population was 57.5 +/- 17.4. The percent therapeutic for patients who had been on warfarin before enrolling in the pharmacist case management anticoagulation clinic (defined as the usual medical care group) was 37.6%, compared with 57.8% for those patients receiving care in the pharmacist case management anticoagulation clinic (P < .001). In nearly all instances, responses to the surveys indicated that patient and provider satisfaction with the anticoagulation service was extremely high.

CONCLUSION

A clinical pharmacist can provide anticoagulation case management services safely and effectively in a private physician office, and the service is highly valued by both patients and providers. We believe case management is an optimal method for systematically monitoring outpatient anticoagulation therapies and is preferable to usual medical care.