Hydrochlorothiazide versus chlorthalidone: evidence supporting their interchangeability

Thiazide diuretics are one of the preferred pharmacologic treatments for hypertension. Hydrochlorothiazide and chlorthalidone have been the 2 most commonly used diuretics in major clinical trials. Treatment guidelines and compendia often consider these 2 drugs interchangeable agents within the class of thiazide or thiazide-like diuretics. Many sources list them as equipotent. Despite these beliefs, there is some suggestion that cardiovascular outcomes are not necessarily the same with these 2 drugs. We conducted a literature search from 1960 to 2003 to identify studies that evaluated the pharmacokinetic and blood pressure-lowering effects of these 2 agents. There are significant pharmacokinetic and pharmacodynamic differences between these diuretics. Chlorthalidone is approximately 1.5 to 2.0 times as potent as hydrochlorothiazide, and the former has a much longer duration of action. Whether these pharmacokinetic and pharmacodynamic features cause differences in outcomes is not known.

Favorable patient acceptance of ambulatory blood pressure monitoring in a primary care setting in the United States: a cross-sectional survey

Background

The use of ambulatory blood pressure monitoring (ABPM) in the diagnosis and management of hypertension in primary care settings in the United States is increasing. Insufficient information is available describing patients' experiences and acceptance of this technology in the United States, where medical insurance coverage of the procedure is often limited. The objective of this study was to describe patient satisfaction with ABPM performed in a primary care office in the United States, using modern ABPM technology.

Methods

Cross-sectional survey performed on consecutive patients referred to the ABPM service of the Family Care Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa from January 2001 to July 2003. Measures of patient satisfaction and acceptance with the device, comfort, and overall session were assessed via a 9-question, Likert-scale response survey.

Results

Since its inception two and a half years ago, 245 total ABPM sessions have been conducted in 235 unique patients. Of the 235 eligible respondents, 177 returned completed surveys, yielding a 75% response rate. Three-fourths (75%) of patients believed that undergoing the test was worthwhile considering the time and monetary cost involved, while most (90%) reported they thought the information provided by the test would be helpful to their physician in making treatment decisions. Patients reporting that their physician had clearly explained the benefit of undergoing the testing were more likely to report that they thought the results of the test would be more helpful in making treatment decisions. Few patients (20%) found that wearing the monitor was uncomfortable.

Conclusions

When clinically indicated, clinicians should not hesitate to order ABPM testing for fear of subjecting patients to an uncomfortable test, or an uncovered insurance benefit. When ordering ABPM, they should be sure to educate the patient about the potential benefits of undergoing the testing. Most patients believe the test will provide useful information in making treatment decisions, despite probable lack of insurance coverage, and appear willing to experience some discomfort for the overall gain of the results obtained from undergoing the session.

Effect of a Telephone Medication Renewal Service on Blood Pressure Control

OBJECTIVE

To evaluate the effect of a pharmacist-staffed telephone medication renewal service on blood pressure (BP) control.

DESIGN

Retrospective review of telephone call logs and patient charts.

SETTING

University-based family medicine clinic.

PATIENTS AND OTHER PARTICIPANTS

All patients seen at the clinic with an International Classification of Diseases 9 code for hypertension during 2000.

INTERVENTIONS

Age, sex, diagnosis of heart failure and/or diabetes, and frequency of clinic visits were recorded. Telephoned prescription renewal requests for 2000 were logged; patient name, age, medication requested, strength, and directions were recorded. Each log entry was reviewed to identify patients requesting a renewal for an antihypertensive agent. Patients with hypertension who used the renewal service were compared with those who did not.

MAIN OUTCOME MEASURES

BP control rates were calculated for each group as the number of patients who met BP goals from the 1997 guidelines of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Analysis of variance and regression analysis were performed to examine the effect use of the renewal service had on BP control in both groups of patients. Covariables such as age, sex, and clinic visits were included in the model.

RESULTS

Of the 938 patients seen for hypertension, 332 used the renewal service at least once. We found no statistical difference between the two groups with respect to BP control (P = .86; confidence interval [CI], 0.7-1.3). BP control did not improve more for patients who used the renewal service more frequently (P = .48; CI, 0.9-1.2).

CONCLUSION

Use of the telephone medication renewal service had no effect on BP control. While increasing patients' access to medications is necessary, the results of this study suggest that this in itself is not sufficient to ensure good BP control.

Development of a computer algorithm for defining an active drug list using an automated pharmacy database

BACKGROUND AND OBJECTIVE

Increasingly, pharmacy databases are being used to assist in evaluating the appropriateness of drug therapy. Such determinations often require the creation of a drug regimen at a particular point in time. The objective of this study was to develop a computer algorithm for defining a cross-sectional active drug list.

METHODS

Electronic pharmacy data were obtained as part of the Iowa Medicaid Pharmaceutical Case Management Program. The active drug lists generated by the computer algorithm were compared with active drug lists generated by independent pharmacist review of the pharmacy refill data.

RESULTS

In a sample of 25 patients who received 379 potentially active medications, the interrater reliability between pharmacist reviewers was excellent (kappa=0.94). In a second sample of 100 patients who received 1476 potentially active medications, the computer algorithm had a sensitivity of 93.8% and specificity of 91.7%, using pharmacist review as the comparison standard.

CONCLUSION

The computer algorithm was found to be a valid method of processing electronic pharmacy data to yield a characterization of drug exposure at a point in time. The potential benefits and limitations of using this approach are discussed.

Ambulatory blood pressure monitoring

Noninvasive, 24-hour ambulatory blood pressure monitoring (ABPM) has evolved over the past 25 years from a novel research tool of limited clinical use into an important and useful modality for stratifying cardiovascular risk and guiding therapeutic decisions. Early clinical uses of ABPM were mostly focused on identifying patients with white-coat hypertension; however, accumulated evidence now points to greater prognostic significance in determining risk for hypertensive end-organ damage compared with office blood pressure measurements. Ambulatory measurement of blood pressure using automated devices has also demonstrated benefit in other indications, such as treatment resistance and borderline hypertension, and is recommended by the Joint National Committee for the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in a number of clinical scenarios. Medicare recently announced plans to begin reimbursement for ABPM, which will likely increase demand for ABPM services. Clinicians should become familiar with the role of this technology in the care of the hypertensive patient.

Medication administration in day care centers for children

OBJECTIVE

To determine the frequency with which children attending day care centers (DCCs) receive medications, what types of medications are administered, whether standardized procedures are used in the dispensing of medications, and whether any self-reported errors occur.

DESIGN

Cross-sectional descriptive survey.

SETTING

DCCs in eastern Iowa licensed by the Iowa Department of Health and Human Services.

PARTICIPANTS

Day care supervisors at DCCs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Descriptive, self-reported information, including frequency of medication administration on-site, types of medications administered, procedures for storing and dispensing medications, record keeping, and training of staff.

RESULTS

Response rate was 38.9% (82 of 227 mailed surveys were returned completed). On average, 5.5% of children received medications while attending a DCC during a 2-week period. DCCs administered the following medications during the year preceding the survey: antibiotics (86.5% of DCCs reporting having administered), cold medications (85.0%), analgesics (78.0%), and attention-deficit/hyperactivity disorder medications (67.0%). The two most common errors reported were missed dose (55.6% of DCCs reporting having happened) and medication not available for administration (50.6%). All DCCs surveyed reported having written policies for medication administration, but staff at only 50.0% of DCCs received special training on medication administration.

CONCLUSION

Medications are often administered in DCCs, and the types of medications administered in this setting have the potential to pose significant risks if their use is not monitored properly. DCC staff receive little, if any, education regarding proper storage, handling, and administration of medications. Pharmacists should take an active role in providing education to this poorly served group to help reduce risks of medication misadventures.

Drug-related problems and quality of life in arthritis and low back pain sufferers

OBJECTIVE

The objective of this study was to determine the relationship between drug-related problems (DRPs) and health-related quality-of-life (HRQoL) in ambulatory, community-dwelling patients with musculoskeletal disorders.

METHODS

A 12-month, prospective, observational study was conducted in 12 independent community pharmacies in eastern Iowa. Ambulatory patients with self-reported diagnoses of osteoarthritis, rheumatoid arthritis, or low back pain were invited to participate. During quarterly visits to the pharmacy, patients used touch-screen computers to fill out the Short Form-36 (SF-36) general health survey. Using the results of these point-of-service health status assessments, community pharmacists interviewed patients to assess for DRPs. To examine the influences of different DRP characteristics on HRQoL and controlling for potential confounders, both univariate and multivariate analyses were performed using the change in physical component summary (PCS) score and mental component summary (MCS) score of the SF-36 from baseline to 12 months as the dependent variables. In each regression, the independent variables were those significant variables from the univariate analyses, as well as the types of DRPs and their outcomes.

RESULTS

A total of 461 patients were enrolled in the study. Through 12 months, 926 cumulative DRPs were identified. Overall regression models were significant for the PCS and MCS scores, respectively. Two types of DRPs showed significant negative associations with change in PCS: wrong drug and needs additional drug therapy. One type of DRP showed significant negative association with change in MCS: needs additional drug therapy. Resolution or improvement in DRPs showed a significant positive correlation with change in MCS but not PCS.

CONCLUSIONS

Two DRPs, needs additional drug therapy and wrong drug, are associated with reduced self-reported physical health in arthritis and low back pain, while the DRP needs additional drug therapy is also associated with reduced self-reported mental health. Resolution of DRPs is associated with improvement in mental health in this cohort.

Noninvasive 24-hour ambulatory blood pressure monitoring: overview of technology and clinical applications

During the last 25 years, 24-hour noninvasive ambulatory blood pressure monitoring (ABPM) has evolved from a research tool of limited clinical use into an important tool for stratifying cardiovascular risk and guiding therapeutic decisions. Until recently, clinical use of ABPM focused on identifying patients with white-coat hypertension, but accumulated evidence now points to greater prognostic significance of ABPM in determining risk for target-organ damage compared with that of office blood pressure measurements. Clinicians involved in the care of patients with hypertension should familiarize themselves with the role of this technology and how to use it in an appropriate and cost-effective manner.

Health outcomes assessment in community pharmacy practices: a feasibility project

OBJECTIVES

To evaluate the feasibility and benefit of capturing outcomes data in community pharmacy settings, and to characterize the health status, resource use, and medication use of patients with musculoskeletal disorders.

METHODS

Patients (n = 460) with musculoskeletal disorders including osteoarthritis (OA), rheumatoid arthritis (RA), and low back pain from 12 community pharmacy sites responded to disease-specific questions, the Medical Outcomes Study Short Form-36 (SF-36) health survey, demographics, and resource use using touch screen computer technology. Patients provided information and met with a community pharmacist for scheduled visits at baseline, 3, 6, 9, and 12 months. Pharmacists, with the aid of the patient-reported information, documented medication use and identified and addressed drug therapy problems of the patients at each visit. Baseline results, based on descriptive statistics are reported.

RESULTS

OA was reported by 71% of the patients, 55% reported low back pain, and 19% reported RA. Despite receiving a variety of analgesic medications, a majority of the patients reported experiencing moderate to severe pain. SF-36 scores of the study population were significantly lower than age-adjusted population norms, with arthritis patients reporting worse physical health than patients with low back pain. Drug therapy problems were identified in 58% of the population, with need for additional drug therapy (31%) and adverse drug reactions (18%) being the most common problems identified.

CONCLUSIONS

Results indicate that routine capture of patient-reported health outcomes data is feasible in community pharmacy settings using touch screen technology.

Use of metformin in polycystic ovary syndrome

OBJECTIVE

To review the use of the insulin-sensitizing agent metformin in women with polycystic ovary syndrome (PCOS).

DATA SOURCES

Biomedical literature was accessed through MEDLINE (1996-March 2001) and the Iowa Drug Information Service. Key terms included metformin and polycystic ovary syndrome.

DATA SYNTHESIS

A number of small clinical studies have examined the use of metformin in the treatment of PCOS. Women treated with metformin demonstrated normalization of endocrine function with minimal adverse effects.

CONCLUSIONS

Metformin can be beneficial in normalizing menstrual irregularities and stimulating ovulation in previously anovulatory women. Metformin therapy is well tolerated by the majority of patients and should be considered for use in women with PCOS.

Leukotriene receptor antagonists in the treatment of allergic rhinitis

OBJECTIVE

To review the literature examining the clinical use of leukotriene receptor antagonists in the treatment of allergic rhinitis.

DATA SOURCES

Biomedical literature accessed through MEDLINE (1990-November 2000) and Current Contents (week 35 of 1999 to week 48 of 2000). Key terms included leukotriene antagonists, montelukast, zafirlukast, and rhinitis (allergic).

DATA SYNTHESIS

Preliminary evidence on the clinical use of either montelukast or zafirlukast as monotherapy is equivocal, with one study noting benefit and another noting lack of benefit in symptom amelioration. A third study suggests that these agents may have a role in further modifying allergic rhinitis symptoms when used in combination with standard treatments.

CONCLUSIONS

Future large-scale studies should assess the efficacy of these agents in the treatment of allergic rhinitis, in particular, to identify subsets of patients likely to derive the most benefit. Available data suggest it is reasonable and safe to add these agents to standard therapy if symptomatology remains unresolved.

Use of point-of-service health status assessments by community pharmacists to identify and resolve drug-related problems in patients with musculoskeletal disorders

STUDY OBJECTIVE

To determine whether community pharmacists can use point-of-service health status assessments to identify and resolve drug-related problems (DRPs) in ambulatory patients with selected musculoskeletal (MSK) disorders.

DESIGN

Twelve-month, prospective, multicenter demonstration project.

SETTING

Twelve independent community pharmacies in eastern Iowa.

PATIENTS

Ambulatory patients with self-reported diagnosis of osteoarthritis, rheumatoid arthritis, or low back pain.

MEASUREMENTS

During quarterly pharmacy visits for 1 year, patients used touch-screen computers to report their health status. Patients answered questions on the Short Form-36 (SF-36) general health survey, as well as questions assessing limitations associated with their MSK condition. Pharmacists used this data in interviewing patients to assess for DRPs.

MAIN RESULTS

The study enrolled 461 patients, of whom 388 returned for the 12-month visit. During this 1-year period, community pharmacists identified 926 cumulative DRPs. Patients with no DRPs had significantly higher physical component summary scores on the SF-36 (p<0.05) than patients with more than one DRP at baseline (36.2 vs 31.6), 6 months (39.2 vs 33.3), and 12 months (40.1 vs 35.4). At 12 months, actions performed by pharmacists led to resolution or improvement of 70.7% of DRPs.

CONCLUSION

Drug-related problems are numerous in community-dwelling patients with MSK disorders and correspond to decreased physical health status. Community pharmacists can use patient-reported measures of health status to identify DRPs and initiate processes to resolve them.

Newer dopamine agonists in the treatment of restless legs syndrome

OBJECTIVE

To review the use of newer dopamine agonists pramipexole and ropinirole, in the treatment of restless legs syndrome (RLS).

DATA SOURCES

Biomedical literature was accessed through MEDLINE (1990-June 2000); key terms included restless legs syndrome, pramipexole, ropinirole, and dopamine agonists. References cited in those articles were also evaluated.

DATA SYNTHESIS

A number of small clinical studies of short duration have examined the use of pramipexole and ropinirole in the treatment of RLS. Patients treated with either agent demonstrated marked improvement in RLS symptoms with minimal adverse effects. Recent postmarketing surveillance of the use of these drugs for Parkinson's disease reported problems with daytime somnolence; thus, patients should be counseled appropriately.

CONCLUSIONS

Although the published trials show promising results for efficacy of pramipexole and ropinirole in the treatment of RLS, they are subject to many limitations. At present, these agents can be considered a reasonable alternative after failure of traditional therapies for RLS, such as carbidopa/levodopa. The encouraging results underscore the need for a large double-blind study comparing pramipexole and ropinirole with traditional agents.

Physician perceptions about administration of immunizations outside of physician offices

BACKGROUND

Expanding nonphysician participation in the administration of immunizations has been suggested as a means of increasing immunization rates. However, there is little information about physician interest in collaborating with nonphysicians to provide out-of-office immunizations.

METHODS

All active members of the Iowa Academy of Family Physicians were surveyed by mail. Physicians reported on their collaboration histories, their willingness to collaborate in the future, their concerns with collaboration, and whether they approved of their patients' using nonphysicians for immunizations.

RESULTS

Of 898 eligible physicians, 476 (53%) returned questionnaires that were analyzed. Seventy-five percent (n = 357) of the physicians reported that they had voluntarily collaborated with a person outside their office to provide immunizations. Ninety-five percent (n = 452) of physicians indicated a willingness to collaborate in some form in the future. However, physicians had concerns about (a) being able to be kept informed about immunizations their patients receive outside of their offices, (b) adequate training of the nonphysician to administer immunizations and respond to complications of immunization, and (c) loss of preventive health opportunities if patients ceased coming to physicians for routine immunizations.

CONCLUSION

The majority of family physicians have collaborated to deliver immunizations and indicate support for nonphysician participation. Almost all physicians would consider future collaborative arrangements although they have concerns about record keeping and the safety of out-of-office immunization programs.

Patients' acceptance of traditional and nontraditional immunization providers

OBJECTIVE

To examine patients' acceptance and reported use of traditional and nontraditional immunization providers and settings.

DESIGN

Survey.

SETTING

Stratified sample of private family physician clinics, family medicine residency training programs, community pharmacies that provide immunizations under standing order protocols, and nonimmunizing community pharmacies, all located in Iowa.

PATIENTS OR OTHER PARTICIPANTS

Individuals presenting for medical care or pharmacy services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Sources of past immunizations, 'access to immunizations, importance of immunization records, and future use of different health care providers and settings for immunizations. Univariate and multivariate analyses were performed to examine the relationships between patient demographics and recruitment site on the question responses.

RESULTS

420 surveys were returned (67% response rate). Respondents frequently received immunizations at sites other than physician offices. Younger patients and those living in smaller towns were more likely to report receiving an immunization from a nonphysician. Patients recruited in immunizing pharmacies more often reported previous immunization by a pharmacist (P < .001), most often for influenza. Respondents often reported that it was more convenient to receive an immunization outside a physician office. Greater support was noted for receiving adult immunizations from nonphysicians and in nontraditional settings, whereas traditional settings and providers (physician offices, community health departments) were preferred for childhood immunizations.

CONCLUSION

Iowans report accessing different health care providers and settings for their routine immunizations. In general, they are more likely to support using traditional immunization providers and settings for childhood immunizations but are less exclusive about where they receive adult immunizations. Pharmacists should consider focusing initial efforts on administering adult immunizations, due to greater patient acceptance of nontraditional immunizers for adult immunizations.

Prescription medication costs: a study of physician familiarity

BACKGROUND

Studies in the past 25 years have suggested that physicians are not familiar with the costs of common prescription medications.

OBJECTIVES

To determine physician familiarity with the cost of common prescription medications and to determine the value physicians place on knowing information regarding the cost of medications.

DESIGN

Survey.

SETTING

Seven community-based family medicine residency teaching clinics in Iowa.

PARTICIPANTS

Two hundred five practicing resident and faculty physicians.

INTERVENTIONS

From a series of $10 price intervals (range, $0.01-$80.00), physicians were asked to select the interval containing the cash price of the medication to an uninsured patient for 50 medications commonly prescribed in outpatient family medicine clinics. Physicians were also questioned about the value of medication cost information to their practice.

MAIN OUTCOME MEASURES

The percentage of correct responses and the mean pricing scores were calculated for each respondent and for all medications.

RESULTS

One hundred seventy-eight physicians responded (86.8%). Only 22.9% of the responses correctly identified the cost of the medication. More than two thirds (68.3%) of the responses underestimated the correct price interval. Branded drugs were underestimated in 89.9% of responses, while generic drugs were overestimated in 90.2% of responses. Overall, 64.4% of physicians believed they did not receive sufficient information in their practices regarding prescription drug costs, and nearly all (93.6%) reported that regular information on prescription medication costs would help them prescribe more cost-effectively.

CONCLUSIONS

Physicians are unfamiliar with the costs of medications they commonly prescribe, and they report that regular access to information on prescription medication costs would help them prescribe more cost-effectively. Arch Fam Med. 2000;9:1002-1007

Assessment of patients' perceptions and beliefs regarding herbal therapies

We evaluated the demographics and beliefs regarding safety and efficacy of herbal therapy among individuals in Iowa and assessed the willingness to discuss the use of these products with health care providers. We distributed 1300 surveys to two random samples: patients attending eight clinics, and residents of the state (mailing). Data were categorized according to herb use and compared between users and nonusers. The response rate was 61% (794 people), with 41.6% of respondents reporting herb use. They were predominately white women and were likely to have had education beyond high school (p<0.05). Their use of prescription drugs was high (p<0.05). Although users rated safety and efficacy of herbs higher than nonusers (p<0.05), both groups believed that health care providers should be aware of use and would provide this information.

Current perspectives on the management of seasonal affective disorder

OBJECTIVE

To concisely review the etiology and current treatment modalities of seasonal affective disorder (SAD).

DATA SOURCES

A MEDLINE search (1966-1999) was performed using the search term "seasonal affective disorder." The search was subsequently focused to "drug therapy" with limits of human studies and English-language papers. The search term "light therapy" was combined with "seasonal affective disorder."

STUDY SELECTION AND DATA EXTRACTION

Articles discussing the epidemiology and treatment of SAD were independently examined by each author. Additional literature was reviewed from selected references identified by the original articles.

DATA SYNTHESIS

SAD most likely results from a deficiency in serotonin. Light therapy remains the therapeutic intervention with the most experience and success. Selective serotonin reuptake inhibitors (SSRIs) have also shown benefit in treating the disorder.

CONCLUSION

SAD is an important subtype of major depressive disorder. Clinicians should remain vigilant for signs and symptoms of the illness. Successful treatment may include light therapy or antidepressants, particularly SSRIs.