Development and Application of an Attribute-Based Taxonomy on the Benefits of Oral Anticoagulant Switching in Atrial Fibrillation: A Delphi Study

INTRODUCTION

Patients with atrial fibrillation (AF) often switch between oral anticoagulants (OACs). It can be hard to know why a patient has switched outside of a clinical setting. Medication attribute comparisons can suggest benefits. Consensus on terms and definitions is required for inferring OAC switch benefits. The objectives of the study were to generate consensus on a taxonomy of the potential benefits of OAC switching in patients with AF and apply the taxonomy to real-world data.

METHODS

Nine expert clinicians (seven clinical pharmacists, two cardiologists) with at least 3 years of clinical and research experience in AF participated in a Delphi process. The experts rated and commented on a proposed taxonomy on the potential benefits of OAC switching. After each Delphi round, ratings were analyzed with the RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness method. Median ratings, disagreement index, and comments were used to modify the taxonomy. The resulting taxonomy from the Delphi process was applied to a cohort of patients with AF who switched OACs in a population-based administrative health dataset from 1996 to 2019 in British Columbia, Canada.

RESULTS

The taxonomy was finalized in two Delphi rounds, reaching consensus on five switch benefit categories: safety, effectiveness, convenience, economic considerations, and drug interactions. Safety benefit (a switch that could lower the risk of adverse drug events) had three subcategories: major bleeding, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding. Effectiveness benefit had four subcategories: stroke and systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), and all-cause mortality. Real-world OAC switches revealed that more OAC switches had convenience (72.6%) and drug interaction (63.0%) benefits compared to effectiveness (SSE 22.0%, ischemic stroke 11.1%, MI 3.1%, all-cause mortality 10.1%), safety (major bleeding 24.3%, GI bleeding 10.6%, ICH 48.5%), and economic benefits (12.1%).

CONCLUSIONS

The Delphi-based taxonomy identified five criteria for the beneficial effects of OAC switching, aiding in characterizing real-world OAC switching.

Adherence to direct or vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a long-term observational study

Our objectives were to measure long-term adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and to identify patient factors associated with adherence. Using linked, population-based administrative data from British Columbia, Canada, an incident cohort of adults prescribed OACs for AF was identified. We calculated the proportion of days covered (PDC) as a time-dependent covariate for each 90-day window from OAC initiation until the end of follow-up. Associations between patient attributes and adherence were assessed using generalized mixed effect linear regression models. 30,264 patients were included. Mean PDC was 0.69 (SD 0.28) over a median follow-up of 6.7 years. 54% of patients were non-adherent (PDC < 0.8). After controlling for confounders, factors positively associated with adherence were number of drug class switches, history of stroke or transient ischemic attack, history of vascular disease, time since initiation, and age. Age > 75 years at initiation, polypharmacy (among VKA users only), and receiving DOAC (vs. VKA) were negatively associated with adherence. PDC decreased over time for VKA users and increased for DOAC users. Over half of AF patients studied were, on average, nonadherent to OAC therapy and missed 32% of their doses. Several patient factors were associated with higher or lower adherence, and adherence to VKA declined during therapy while DOAC adherence increased slightly over time. To min im ize the risk stroke, adherence-supporting interventions are needed for all patients with AF, particularly those aged > 75 years, those with prior stroke or vascular disease, VKA users with polypharmacy, and DOAC recipients.

Prevalence of Acetylsalicylic Acid Use for Primary Prevention of Cardiovascular Disease Amongst Older Adults From 2017-2021: a Retrospective Cross-Sectional Study

Background

Three landmark trials on the use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease (CVD) were published in 2018. Since then, major clinical practice guidelines have been updated with recommendations against the routine use of ASA for primary CVD prevention, particularly in older adults. However, little is known about the uptake of this evidence into real world practice. The purpose of this study was to assess the change in ASA usage for primary prevention of CVD in older adults between 2017 and 2021.

Methods

A retrospective cross-sectional study of ASA use for primary prevention in ambulatory older adults without known CVD in an urban Canadian city was conducted.

Results

Seven hundred and fifty-six participants were included. The mean age was 78.9 years (standard deviation 7.9) and 64.8% were female. One hundred and thirty (17.2%) participants used ASA for primary prevention, including 20.3% in 2017, 17.0% in 2018, 21.8% in 2019, 16.3% in 2020, and 11.0% in 2021 (p = .061). Female sex was associated with lower ASA use (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.29-0.68) and hypertension was associated with higher ASA use (OR 2.72, 95% CI 1.73-4.29).

Conclusions

Use of ASA for primary CVD prevention in older Canadians decreased between 2017 and 2021, suggesting an uptake of clinical trial data and practice guideline recommendations. Focusing on deprescribing of ASA for primary CVD prevention continues to be warranted, given the risks associated with ASA in this population.

Patients' Beliefs About Their Cardiovascular Medications After Acute Coronary Syndrome: A Prospective Observational Study

Background

Adherence to secondary preventive pharmacotherapy after an acute coronary syndrome (ACS) is generally poor and is associated with recurrent cardiovascular events. Patients' beliefs about their medications are a strong predictor of intentional nonadherence.

Methods

This prospective, observational study assessed adult patients' beliefs about their post-ACS medications, using the Beliefs About Medicines Questionnaire (BMQ), and adherence, using the Medication Adherence Report Scale (MARS-5) at St. Paul's Hospital in Vancouver, Canada during May-December, 2022. The BMQ and MARS-5 were administered in-hospital and at 4 weeks after discharge. Outcomes included difference in BMQ necessity-concerns differential (BMQ-NCD) from hospitalization to 4-week follow-up and factors associated with the BMQ-NCD.

Results

Forty-seven participants completed the 4-week follow-up. The mean age was 64 years, and 83% were male. Most presented with a non-ST-segment-elevation ACS. No difference occurred in BMQ-NCD (7.3 vs 6.6, P = 0.29) or MARS-5 scores from discharge to 4 weeks (22.8 vs 23.7, P = 0.06); however, the BMQ specific-necessity subscale score decreased significantly (20.3 vs 18.8, P = 0.002). South Asian and Middle Eastern ethnic origins, compared to European, were associated with a higher BMQ-NCD. Part-time employment and male sex were associated with a lower BMQ-NCD.

Conclusions

Participants held favourable beliefs about their post-ACS medications, which were largely unchanged from hospitalization to 4 weeks postdischarge, except for beliefs about the necessity of taking their medications. Those of European descent, those with part-time employment, and males had the lowest BMQ-NCD. Self-reported adherence was high. Ongoing reassessment of patients' beliefs about the necessity of taking their post-ACS medications may be warranted to mitigate further decline in BMQ-NCD.

Retrospective Cross-sectional Analysis of Older Adults Living with Frailty and Anticoagulant Use for Atrial Fibrillation

Background

Oral anticoagulation (OAC) is recommended for most individuals with atrial fibrillation (AF), including those who are frail. Based on previous literature, those who are frail may be less likely to be prescribed OAC, and up to one-third may receive an inappropriate dose if prescribed a direct oral anticoagulant (DOAC). The objectives of this study were to determine the proportion of frail ambulatory older adults with AF who are prescribed OAC, compare the rates of OAC use across the frailty spectrum, assess the appropriateness of DOAC dosing, and identify if frailty and geriatric syndromes impact OAC prescribing patterns.

Methods

Retrospective cross-sectional review of individuals with AF referred to an ambulatory clinic for older adults living with frailty and/or geriatric syndromes. Rockwood clinical frailty score of ≥4 was used to define frailty and DOAC appropriateness was assessed based on the Canadian Cardiovascular Society AF guidelines.

Results

Two hundred and ten participants were included. The mean age was 84 years, 49% were female and the median frailty score was 5. Of the 185 participants who were frail, 82% were prescribed an OAC (83% with frailty score of 4, 85% with a frailty score of 5, and 78% with a frailty score of 6). Of those prescribed a DOAC, 70% received a guideline-approved dose.

Conclusions

Over 80% of ambulatory older adults with frailty and AF were prescribed an OAC. However, of those prescribed a DOAC, 30% received an unapproved dose, suggesting more emphasis should be placed on initial and ongoing dosage selection.

Decisional Needs and Patient Treatment Preferences for Heart Failure Medications: A Scoping Review

Background

Pharmacologic management of heart failure with reduced ejection fraction (HFrEF) involves several medications. Decision aids informed by patient decisional needs and treatment preferences could assist in making HFrEF medication choices; however, these are largely unknown.

Methods

We searched MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), without language restriction, for qualitative, quantitative, and mixed-method studies that included patients with HFrEF or clinicians providing HFrEF care, and reported data on decisional needs or treatment preferences applicable to HFrEF medications. We classified decisional needs using a modified version of the Ottawa Decision Support Framework (ODSF).

Results

From 3996 records, we included 16 reports describing 13 studies (n = 854). No study explicitly assessed ODSF decisional needs; however, 11 studies reported ODSF-classifiable data. Patients commonly reported having inadequate knowledge or information, and difficult decisional roles. No study systematically assessed treatment preferences, but 6 studies reported on attribute preferences. Reducing mortality and improving symptoms frequently were ranked as being important, whereas cost importance rankings varied, and adverse events generally were ranked as being less important.

Conclusion

This scoping review identified key decisional needs regarding HFrEF medications, notably inadequate knowledge or information, and difficult decisional roles, which can readily be addressed by decision aids. Future studies should systematically explore the full scope of ODSF-based decisional needs in patients with HFrEF, along with relative preferences among treatment attributes to further inform development of individualized decision aids.

Managing Heart Failure With Reduced Ejection Fraction in Patients With Chronic Kidney Disease: A Case-Based Approach and Contemporary Review

Patients with heart failure with reduced ejection fraction (HFrEF) often have concurrent chronic kidney disease (CKD), which can make initiating and titrating the 4 standard pharmacologic therapies a challenge. Drug dosing is often based on a calculation of the patient’s creatine clearance or estimated glomerular filtration rate (eGFR), but it should also incorporate the trend in their renal function over time and the risk of toxicity of the drug. The presence of CKD in a patient should not preclude the use of a renin-angiotensin system inhibitor, although patients should be monitored frequently for worsening renal function and hyperkalemia. Sacubitril/valsartan is not recommended in patients with an eGFR < 30 mL/min per 1.73 m². Of the 3 ß-blockers recommended in the management of HFrEF, only bisoprolol may accumulate in patients with renal impairment; however, patients should still be titrated to the target dose (10 mg daily) or the maximally tolerated dose, depending on their clinical response. The sodium-glucose cotransporter 2 inhibitors are effective at reducing adverse cardiovascular and renal outcomes in patients with HFrEF and CKD (eGFR ≥ 25 mL/min per 1.73 m² with dapagliflozin or ≥ 20 mL/min per 1.73 m² with empagliflozin), although declining kidney function is a risk, due to the osmotic diuretic effect. Finally, mineralocorticoid receptor antagonist therapy should be considered in all patients with HFrEF and an eGFR ≥ 30 mL/min per 1.73 m². The starting dose should be low (eg, 6.25-12.5 mg daily or 12.5 mg every other day) and can be uptitrated based on the patient’s renal function and serum potassium.

The Random Effects Warfarin Days' Supply (REWarDS) Model: Development and Validation of a Novel Method for Estimating Exposure to Warfarin Using Administrative Data

Warfarin's complex dosing is a significant barrier to measurement of its exposure in observational studies using population databases. Using population-based administrative data (1996-2019) from British Columbia, Canada, we developed a method based on statistical modeling (Random Effects Warfarin Days' Supply (REWarDS)) that involves fitting a random-effects linear regression model to patients' cumulative dosage over time for estimation of warfarin exposure. Model parameters included a minimal universally available set of variables from prescription records for estimation of patients' individualized average daily doses of warfarin. REWarDS estimates were validated against a reference standard (manual calculation of the daily dose using the free-text administration instructions entered by the dispensing pharmacist) and compared with alternative methods (fixed window, fixed tablet, defined daily dose, and reverse wait time distribution) using Pearson's correlation coefficient (r), the intraclass correlation coefficient, and the root mean squared error. REWarDS-estimated days' supply showed strong correlation and agreement with the reference standard (r = 0.90 (95% confidence interval (CI): 0.90, 0.90); intraclass correlation coefficient = 0.95 (95% CI: 0.94, 0.95); root mean squared error = 8.24 days) and performed better than all of the alternative methods. REWarDS-estimated days' supply was valid and more accurate than estimates from all other available methods. REWarDS is expected to confer optimal precision in studies measuring warfarin exposure using administrative data.

Longitudinal Oral Anticoagulant Adherence Trajectories in Patients With Atrial Fibrillation

BACKGROUND

Conventional adherence summary measures do not capture the dynamic nature of adherence.

OBJECTIVES

This study aims to characterize distinct long-term oral anticoagulant adherence trajectories and the factors associated with them in patients with atrial fibrillation.

METHODS

Adults with incident atrial fibrillation were identified using linked population-based administrative health data in British Columbia, Canada (1996-2019). Group-based trajectory modeling was used to model patients' 90-day proportions of days covered over time to identify distinct 5-year adherence trajectories. Multinomial regression analysis was used to assess the effect of various demographic and clinical factors on exhibiting each adherence trajectory.

RESULTS

The study cohort included 19,749 patients with AF (mean age: 70.6 ± 10.6 years), 56% male, mean CHA₂DS₂-VASc stroke risk score 2.8 ± 1.4. Group-based trajectory modeling identified 4 distinct oral anticoagulants adherence trajectories: "consistent adherence" (n = 14,631, 74% of the cohort), "rapid decline and discontinuation" (n = 2,327, 12%), "rapid decline and partial recovery" (n = 1,973, 10%), and "slow decline and discontinuation" (n = 819, 4%). Very few patient variables were found to be associated with specific adherence trajectories.

CONCLUSIONS

There is heterogeneity among nonadherent patients in the rate and timing of decline in their medication taking. Clinical and demographic characteristics were found to be inadequate to predict patients' adherence trajectories. Insights from this study could be used to inform the design and timing of adherence interventions, and qualitative studies may be needed to better understand the psychosocial determinants and reasons for the behaviors reflected in the identified trajectories.

Omega-3 fatty acids for the prevention of atherosclerotic cardiovascular disease

Marine-derived omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are a type of polyunsaturated fatty acids with many purported beneficial health effects including the prevention of atherosclerotic cardiovascular disease (ASCVD) events. Omega-3 fatty acid intake may be supplemented via dietary sources, as well as prescription or non-prescription products. Omega-3 fatty acids have been shown to reduce serum triglycerides, but there remains ongoing debate regarding the effect of omega-3 fatty acids on major adverse cardiovascular events in patients with established, or at risk of, ASCVD. Recent evidence from randomized, placebo-controlled trials has demonstrated that low-dose (1 g daily or less) omega-3 fatty acids (DHA and EPA) do not reduce cardiovascular events or death in patients with or without established ASCVD. Contrarily, the REDUCE-IT trial demonstrated that a purified form of EPA ethyl esters (icosapent ethyl) at 4 g daily reduced cardiovascular events and death in patients with ASCVD (or diabetes and multiple cardiovascular risk factors) and elevated triglycerides on background statin therapy. However, 4 g daily of omega-3 carboxylic acids (DHA and EPA) did not show a cardiovascular benefit in the STRENGTH trial, which enrolled a similar population. The explanation for this observed discrepancy remains a source of contention and discourse. For now, icosapent ethyl has the most compelling evidence to support a cardiovascular benefit and should be considered in select patients who meet the REDUCE-IT criteria. Furthermore, alternative versions of omega-3 fatty acids should not be considered equivalent to icosapent ethyl. Patients taking an omega-3 fatty acid supplement should be monitored for potential adverse effects, including gastrointestinal disorders or bleeding, in addition to a possible increased risk of atrial fibrillation.

Antiplatelet therapy with or without anticoagulant therapy for lower extremity peripheral artery disease: A systematic review

PURPOSE

To identify randomized controlled trials that compared antiplatelet monotherapy to combination antiplatelet plus anticoagulant therapy and evaluated major adverse cardiovascular events (MACE) or major adverse limb events (MALE), death, or bleeding in patients with lower extremity peripheral artery disease (PAD).

SUMMARY

A systematic search of MEDLINE, Embase, and CENTRAL databases revealed 5 trials. Two trials consisted of patients with stable PAD, while 3 trials examined patients with PAD post revascularization. Antiplatelet therapy was mostly aspirin (81-325 mg daily), and anticoagulation included rivaroxaban 2.5 mg twice daily or warfarin. Duration of follow-up ranged from 12 to 38 months. Two trials had low risk of bias, whereas 3 trials had high/unclear risk of bias. For patients with stable PAD, one trial showed that use of warfarin (or acenocoumarol) with antiplatelet therapy did not reduce MACE, MALE, or cardiovascular or all-cause death but increased the risk of life-threatening bleeding. A second trial demonstrated that low-dose rivaroxaban plus antiplatelet therapy lowered the risk of MACE and MALE, with no effect in preventing cardiovascular or all-cause death, but increased the risk of major bleeding. For patients with PAD post revascularization receiving warfarin and antiplatelet therapy, 2 trials showed no benefit in MACE or MALE but increased or similar rates of all-cause death and major bleeding. In a third trial, low-dose rivaroxaban plus aspirin reduced occurrence of the composite of MACE and MALE but increased major bleeding, with no effect on cardiovascular or all-cause death.

CONCLUSION

Dual-pathway inhibition with low-dose rivaroxaban and aspirin reduced MACE and MALE in patients with stable or revascularized PAD, but net clinical benefit is questionable.

2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment.

Pharmacotherapy for heart failure with reduced ejection fraction and health-related quality of life: a systematic review and meta-analysis

AIMS

The aim of this study was to synthesize the evidence on the effect of heart failure with reduced ejection fraction (HFrEF) pharmacotherapy on health-related quality of life (HRQoL).

METHODS AND RESULTS

We searched MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in June 2020. Randomized placebo-controlled trials evaluating contemporary HFrEF pharmacotherapy and reporting HRQoL as an outcome were included. Two reviewers independently assessed studies for eligibility, extracted data, and assessed risk of bias and GRADE certainty of evidence. The primary outcome was HRQoL at last available follow-up analysed using a random-effects model. We included 37 studies from 5770 identified articles. Risk of bias was low in 10 trials and high/unclear in 27 trials. High certainty evidence from meta-analyses demonstrated improved HRQoL over placebo with sodium-glucose co-transporter 2 (SGLT2) inhibitors [standardized mean difference (SMD) 0.16, 95% confidence interval (CI) 0.08-0.23] and intravenous iron (SMD 0.52, 95% CI 0.04-1.00). Furthermore, high certainty evidence from ≥1 landmark trial further supported improved HRQoL with angiotensin receptor blockers (ARBs) (SMD 0.09, 95% CI 0.02-0.17), ivabradine (SMD 0.14, 95% CI 0.04-0.23), hydralazine-nitrate (SMD 0.24, 95% CI 0.04-0.44) vs. placebo, and for angiotensin receptor-neprilysin inhibitor (ARNI) compared with an angiotensin-converting enzyme (ACE) inhibitor (SMD 0.09, 95% CI 0.02-0.17). Findings were inconclusive for ACE inhibitors, beta-blockers, digoxin, and oral iron based on low-to-moderate certainty evidence.

CONCLUSION

ARBs, ARNIs, SGLT2 inhibitors, ivabradine, hydralazine-nitrate, and intravenous iron improved HRQoL in patients with HFrEF. These findings can be incorporated into discussions with patients to enable shared decision-making.

Therapeutic Controversies in the Medical Management of Valvular Heart Disease

Objective:

To evaluate the evidence for common therapeutic controversies in the medical management of valvular heart disease (VHD).

Data Sources:

A literature search of PubMed (inception to December 2020) was performed using the terms angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and aortic stenosis (AS); and adrenergic β-antagonists and aortic valve regurgitation (AR) or mitral stenosis (MS).

Study Selection and Data Extraction:

Randomized controlled trials (RCTs) and meta-analyses conducted in humans and published in English that reported ≥1 clinical outcome were included.

Data Synthesis:

Nine articles were included: 3 RCTs and 1 meta-analysis for ACE inhibitors/ARBs in AS, 1 RCT for β-blockers in AR, and 4 RCTs for β-blockers in MS. Evidence suggests that ACE inhibitors/ARBs do not increase the risk of adverse outcomes in patients with AS but may delay valve replacement. β-Blockers do not appear to worsen outcomes in patients with chronic AR and may improve left-ventricular function in patients with a reduced ejection fraction. β-Blockers do not improve and may actually worsen exercise tolerance in patients with MS in sinus rhythm.

Relevance to Patient Care and Clinical Practice:

ACE inhibitors/ARBs and β-blockers can likely be safely used in patients with AS or AR, respectively, who have a compelling indication. There is insufficient evidence to recommend routine use of β-blockers in patients with MS without atrial fibrillation.

Conclusions:

Common beliefs about the medical treatment of VHD are not supported by high-quality data. There remains a need for larger-scale RCTs in the medical management of VHD.

Pharmacist- or Nurse Practitioner–Led Assessment and Titration of Sacubitril/Valsartan in a Heart Failure Clinic: A Cohort Study

ABSTRACTBackground: Sacubitril/valsartan is a first-in-class angiotensin receptor–neprilysin inhibitor indicated in the management of heart failure with reduced ejection fraction, based on the results of the PARADIGM-HF trial. Practice-based studies are needed to validate its effect in real-world settings. Clinical pharmacists are ideally situated to assess and titrate sacubitril/valsartan.Objective: To evaluate the utilization, safety, and tolerability of sacubitril/ valsartan in a multidisciplinary heart failure clinic, with assessment and titration by a clinical pharmacist or a nurse practitioner.Methods: A retrospective cohort study was conducted at a heart failure clinic in Abbotsford, Canada. Included were adult patients with heart failure who were currently or formerly taking sacubitril/valsartan. Data collected for the period October 2015 to February 2019 included patient characteristics, New York Heart Association (NYHA) classification, concurrent medications, sacubitril/valsartan dose, adverse effects, and discontinuation rate.Results: In total, 128 patients were included. Mean age was 70.1 years, 98 (77%) of the patients were men, and 79 (62%) had NYHA class 2 heart failure. The clinical pharmacist managed care for 78 (61%) of the patients, and the nurse practitioner managed care for 50 (39%). Forty-one (32%) of the patients met modified PARADIGM-HF inclusion criteria. Eighty-five (66%) of the patients achieved the target dose of sacubitril/valsartan, with similar proportions for the clinical pharmacist and nurse practitioner groups, over a mean of 2.2 clinic visits. Patients who achieved the sacubitril/valsartan target dose, relative to those who did not, were significantly younger and had higher mean systolic blood pressure at baseline. Twenty-nine percent of patients (35/119) had an improvement in NYHA classification from before initiation of sacubitril/valsartan to achievement of target or maximally tolerated dose. Eighty-five (66%) of the patients experienced an adverse effect, primarily hypotension, and 12 (9%) required a dose reduction. Only 9 (7%) patients discontinued therapy.Conclusions: This study demonstrates the real-world safety and tolerability of sacubitril/valsartan in the treatment of heart failure, and reinforces that clinical pharmacists can effectively assess and titrate medications in a multidisciplinary heart failure clinic.RÉSUMÉContexte : Le sacubitril-valsartan est un inhibiteur novateur des récepteurs de l’angiotensine-néprilysine, indiqué dans la gestion de l’insuffisance cardiaque accompagnée d’une baisse de la fraction d’éjection, selon les résultats de l’essai PARADIGM-HF. Des études fondées sur la pratique sont nécessaires pour valider ses effets en contexte réel. Les pharmaciens cliniciens sont bien placés pour évaluer et titrer le sacubitril-valsartan.Objectif : Évaluer l’utilisation, l’innocuité et le seuil de tolérance du sacubitril-valsartan en clinique multidisciplinaire d’insuffisance cardiaque, l’évaluation et le titrage étant effectués par un pharmacien clinicien ou une infirmière praticienne.Méthodes : Une étude de cohorte rétrospective a été menée au sein d’une clinique d’insuffisance cardiaque à Abbotsford, au Canada. Les patients adultes inclus dans l’étude souffraient d’insuffisance cardiaque, ils prenaient ou avaient pris du sacubitril-valsartan. Les données recueillies entre octobre 2015 et février 2019 comprenaient les caractéristiques des patients, la classification de la New York Heart Association (NYHA), les médicaments pris de façon concomitante, la dose de sacubitril-valsartan, les effets secondaires et le taux d’abandon.Résultats : Au total, 128 patients ont participé à l’étude. L’âge moyen des patients était de 70,1 ans, 98 d’entre eux (77 %) étaient des hommes et 79 (62 %) souffraient d’une insuffisance cardiaque de classe 2 selon la classification de la NYHA. Le pharmacien clinicien gérait les soins de 78 patients (61 %) et la pharmacienne praticienne gérait ceux de 50 patients (39 %). Quarante-et-un patients (32 %) répondaient aux critères d’inclusion modifiés de PARADIGM-HF. Quatre-vingt-cinq (66 %) patients atteignaient le dosage ciblé de sacubitril-valsartan dans des proportions similaires entre le groupe du pharmacien clinicien et celui de l’infirmière praticienne, à raison d’une moyenne de 2,2 visites en clinique. Les patients ayant atteint le dosage ciblé de sacubitril-valsartan, par rapport à ceux ne l’ayant pas atteint, étaient considérablement plus jeunes et leur tension artérielle systolique moyenne de base était plus élevée. Une amélioration de la classification NYHA a été observée chez 29 % des patients (35/119) entre le début de la prise de sacubitril-valsartan et l’atteinte du dosage ciblé ou de la dose maximale tolérée. Des effets secondaires ont été observés chez 85 patients (66 %), principalement une hypotension, et 12 d’entre eux (9 %) ont dû réduire la dose. Seuls 9 patients (7 %) ont dû abandonner la thérapie.Conclusions : Cette étude démontre l’innocuité et le seuil de tolerance en contexte réel du sacubitril-valsartan pour le traitement de l’insuffisance cardiaque. Elle renforce le fait que les pharmaciens cliniciens peuvent efficacement évaluer et titrer des médicaments au sein d’une Clinique d’insuffisance cardiaque multidisciplinaire.

Colchicine for Secondary Cardiovascular Prevention: A Systematic Review

Despite advancements in medical and interventional therapy, patients with cardiovascular disease (CVD) continue to have residual risk for recurrent cardiovascular events. Colchicine has a unique antiinflammatory mechanism that has generated interest in its potential use as a secondary cardiovascular preventive therapy. The objective of this systematic review was to evaluate the evidence for long-term (6 months or more) colchicine therapy in patients with established CVD. A search of Medline and Embase from inception to February 2020 was performed. Included were randomized controlled trials (RCTs) or propensity score-matched observational studies that compared colchicine (at any dose) with placebo or no treatment. Outcomes of interest included any major adverse cardiovascular event, cardiovascular hospitalization, coronary artery restenosis, cardiovascular death, or all-cause death. Five RCTs were included. The dose of colchicine ranged from 0.5 mg/day to 0.6 mg twice/day, and follow-up ranged from ~6-36 months. Two trials (one double blind and one single blind) showed a reduction in composite outcomes of major adverse cardiovascular events. One study failed to demonstrate a benefit with colchicine in restenosis or recurrent ischemia after angioplasty; however, it was conducted before the routine use of modern percutaneous coronary intervention and medical therapies. In contrast, a more recent trial found that colchicine reduced the rate of in-stent restenosis in patients who received a bare metal stent. Finally, one trial in patients with heart failure with reduced ejection fraction did not observe a benefit in death or heart failure hospitalization with colchicine despite a reduction in inflammatory markers. No trial demonstrated a reduction in cardiovascular or all-cause death, and most trials showed an increase in the rate of diarrhea with colchicine. Overall, colchicine has demonstrated promising results for the secondary prevention of CVD; however, further studies are required to confirm these findings before colchicine can be routinely recommended in practice.

Pharmacist- or Nurse Practitioner-Led Assessment and Titration of Sacubitril/Valsartan in a Heart Failure Clinic: A Cohort Study

BACKGROUND

Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor indicated in the management of heart failure with reduced ejection fraction, based on the results of the PARADIGM-HF trial. Practice-based studies are needed to validate its effect in real-world settings. Clinical pharmacists are ideally situated to assess and titrate sacubitril/valsartan.

OBJECTIVE

To evaluate the utilization, safety, and tolerability of sacubitril/valsartan in a multidisciplinary heart failure clinic, with assessment and titration by a clinical pharmacist or a nurse practitioner.

METHODS

A retrospective cohort study was conducted at a heart failure clinic in Abbotsford, Canada. Included were adult patients with heart failure who were currently or formerly taking sacubitril/valsartan. Data collected for the period October 2015 to February 2019 included patient characteristics, New York Heart Association (NYHA) classification, concurrent medications, sacubitril/valsartan dose, adverse effects, and discontinuation rate.

RESULTS

In total, 128 patients were included. Mean age was 70.1 years, 98 (77%) of the patients were men, and 79 (62%) had NYHA class 2 heart failure. The clinical pharmacist managed care for 78 (61%) of the patients, and the nurse practitioner managed care for 50 (39%). Forty-one (32%) of the patients met modified PARADIGM-HF inclusion criteria. Eighty-five (66%) of the patients achieved the target dose of sacubitril/valsartan, with similar proportions for the clinical pharmacist and nurse practitioner groups, over a mean of 2.2 clinic visits. Patients who achieved the sacubitril/valsartan target dose, relative to those who did not, were significantly younger and had higher mean systolic blood pressure at baseline. Twenty-nine percent of patients (35/119) had an improvement in NYHA classification from before initiation of sacubitril/valsartan to achievement of target or maximally tolerated dose. Eighty-five (66%) of the patients experienced an adverse effect, primarily hypotension, and 12 (9%) required a dose reduction. Only 9 (7%) patients discontinued therapy.

CONCLUSIONS

This study demonstrates the real-world safety and tolerability of sacubitril/valsartan in the treatment of heart failure, and reinforces that clinical pharmacists can effectively assess and titrate medications in a multidisciplinary heart failure clinic.

Severe Hypoglycemia in a Patient With Type 1 Diabetes Mellitus Recently Started on Sacubitril/Valsartan: A Case Report

This report describes an episode of severe hypoglycemia in a 55-year-old woman with type 1 diabetes mellitus approximately 2 weeks after initiating sacubitril/valsartan for heart failure. She was receiving a continuous subcutaneous insulin infusion and denied any severe hypoglycemic events in the prior 13 years. She experienced a second hypoglycemic episode 1 week later. She subsequently reduced her insulin dose and continued on sacubitril/valsartan. Eight months later, she did not have any recurrent hypoglycemic episodes. Clinicians should be aware of this potential adverse effect and educate patients on concomitant insulin therapy to monitor for symptoms of hypoglycemia when initiating sacubitril/valsartan.

Use of low-dose acetylsalicylic acid for cardiovascular disease prevention: A practical, stepwise approach for pharmacists

Low-dose acetylsalicylic acid (ASA) is recommended in patients with established cardiovascular disease. However, the role of ASA in those without cardiovascular disease (i.e., primary prevention) is less clear, which has led to discordance among Canadian guidelines. In 2018, 3 double-blind, randomized controlled trials were published that evaluated ASA 100 mg daily versus placebo in patients without established cardiovascular disease. In the ASPREE trial, ASA did not reduce the risk of all-cause death, dementia, or persistent physical disability in patients ≥70 years of age but increased the risk of major bleeding. In the ARRIVE trial, ASA failed to lower the risk of a composite of cardiovascular events but increased any gastrointestinal bleeding in patients at intermediate risk of cardiovascular disease. In the ASCEND trial, ASA significantly reduced the primary composite cardiovascular outcome in patients with diabetes for a number needed to treat of 91 over approximately 7.4 years. Yet major bleeding was increased with ASA for a number needed to harm of 112. Therefore, in most situations, ASA should not be recommended for primary cardiovascular prevention. However, there are additional indications for ASA beyond cardiovascular disease. Thus, a sequential algorithm was developed based on contemporary evidence to help pharmacists determine the suitability of ASA in their patients and play an active role in educating their patients about the potential benefits (or lack thereof) and risks of ASA. Can Pharm J (Ott) 2020;153:xx-xx.

Treatment of chronic noncancer pain in patients on opioid therapy in primary care: A retrospective cohort study

Background

This study sought to characterize the real-world treatment of chronic noncancer pain (CNCP) in patients on opioid therapy in primary care.

Methods

A retrospective cohort study from 2014-18 was conducted at a multidisciplinary primary care clinic in Chilliwack, British Columbia. Included were adults on daily opioid therapy for CNCP. Patients receiving palliative care or ≤1 visit were excluded. Outcomes of interest included use of opioid/nonopioid pharmacotherapy, number/frequency of visits and proportion of patients able to reduce/discontinue opioid therapy.

Results

Seventy patients (mean age 53 years, 53% male, 51% back pain) were included. Median follow-up was 6 visits over 12 months. Sixty-two patients (89%) reduced their opioid dose, 6 patients had no change and 2 patients required a dose increase. Mean opioid dose was reduced from 183 to 70 mg morphine equivalents daily. Twenty-four patients (34%) discontinued opioid therapy, 6 patients (9%) transitioned to opioid agonist therapy and 6 patients (9%) breached their opioid treatment agreement. Nonopioid pharmacotherapy included nonsteroidal anti-inflammatory drugs (64%), gabapentinoids (63%), tricyclic antidepressants (56%) and nabilone (51%).

Discussion

Over half of patients were no longer on opioid therapy by the end of the study. Most patients had a disorder (e.g., back pain) for which opioids are generally not recommended. Overall mean opioid dose was reduced from baseline by approximately 60% over 1 year. Lack of access to specialized pain treatments may have accounted for high nonopioid pharmacotherapy usage.

Conclusions

This study demonstrates that treatment of CNCP and opioid tapering can successfully be achieved in a primary care setting. Can Pharm J (Ott) 2020;153:xx-xx.

Comparison of Preventive Cardiovascular Pharmacotherapy in Surgical vs Percutaneous Coronary Revascularization

Background

Data suggest that patients who undergo coronary artery bypass grafting (CABG) have a lower rate of secondary preventive cardiovascular pharmacotherapy use compared with patients who undergo percutaneous coronary intervention (PCI). This study sought to assess the rate of use of preventive pharmacotherapy at discharge in patients who underwent CABG vs PCI post–acute coronary syndrome (ACS).

Methods

A prospective cohort study was conducted at St Paul’s Hospital in Vancouver, Canada. Patients aged ≥ 18 years who presented with an ACS and underwent CABG or PCI between January and November 2018 were included. Data on preventive pharmacotherapy use and reasons for justified nonuse (eg, intolerance, contraindication) were collected.

Results

A total of 275 patients were included. Mean age was 65 years, and 83% were male. Overall, 141 patients (51%) underwent CABG and 134 patients (49%) underwent PCI. All patients received acetylsalicylic acid, but more patients who underwent CABG received 325 mg (vs 80-81 mg) compared to PCI (25% vs 1%, P < 0.01). Use of P2Y12 inhibitors was higher in patients who underwent PCI (primarily ticagrelor) compared with patients who underwent CABG (primarily clopidogrel) (99% vs 26%, P < 0.01). All patients who underwent CABG received a β-blocker vs 96% of patients who underwent PCI (P = 0.017). Use of angiotensin-modulating agents was higher in patients who underwent PCI (98% vs 65%, P < 0.01). Statin use was similar between groups (99% vs 99%, P = 0.96), but more patients who underwent PCI received maximum-dose therapy (89% vs 64%, P < 0.01).

Conclusions

Use of acetylsalicylic acid, β-blockers, and statins in patients post-ACS was high regardless of revascularization strategy, whereas P2Y12 inhibitors and angiotensin-modulating agents were underused in patients who underwent CABG even after adjusting for justified nonuse.

Newer Oral Antihyperglycemics: From Seinfeld to Breaking Bad

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Health Authority Pharmacists’ Perceptions of Independent Pharmacist Prescribing

ABSTRACTBackground: In many jurisdictions, the pharmacist’s role continues to evolve from drug distribution–based service delivery to expanded scopes of practice, including independent prescribing of medications. Objectives: To assess health authority–based pharmacists’ attitudes, be-liefs, and perceptions about independent prescribing, to determine how independent prescribing may affect their behaviour, and to identify perceived barriers and enablers to incorporating it into their practice.Methods: An anonymous, cross-sectional online survey of 677 health authority–based pharmacists employed by Lower Mainland Pharmacy Services in British Columbia collected information in the following domains: demographic characteristics; attitudes, beliefs, and perceptions regarding pharmacist prescribing; anticipated effect of pharmacist prescribing on behaviour; likelihood of applying for this authority, if granted; and barriers and enablers to applying for prescribing authority and incorporating prescribing into their practice. A multivariate regression analysis was performed.Results: A total of 266 pharmacists (39.3%) responded to the survey. Most respondents agreed that prescribing is important to the profession and relevant to their practice, and that it might enhance job satisfaction. Additionally, respondents agreed that they had the expertise to prescribe. Respondents perceived prescribing as having the potential to positively affect behaviour, including deprescribing, prescribing at time of discharge or transfer, and renewing medications. Enablers to applying for pharma-cist prescribing authority included perceived positive impact on patient care and the profession, level of support from management and coworkers, and personal ability. No barriers were identified. About two-thirds of phar-macists indicated they would likely apply for prescribing authority if it were granted through legislation. Pharmacists with a clinical practice or research role were significantly more likely to apply to be a prescriber, whereas those with more than 10 years of experience were less likely to apply.Conclusions: In this study, health authority–based pharmacists held positive attitudes and beliefs about the value and impact of independent prescribing of medications on their practice and the profession. There were no perceived barriers to applying for prescribing authority or to incorporating prescribing into practice.RÉSUMÉContexte : Dans bien des provinces, le rôle du pharmacien ne cesse d’évoluer, depuis la prestation de services fondée sur la distribution de médicaments à des champs de pratique élargis, comprenant le droit de prescription autonome des médicaments. Objectifs : Évaluer les attitudes, les croyances et les opinions des pharmaciens rattachés à des régies de santé concernant le droit de prescription autonome, déterminer l’influence de ce droit sur leurs habitudes et recenser les éléments qui, selon eux, entravent ou facilitent l’intégration de ce droit dans leur pratique.Méthodes : Une enquête transversale anonyme en ligne s’adressant à 677 pharmaciens rattachés à une régie de santé et employés par les services de pharmacie des basses-terres continentales en Colombie-Britannique a permis de recueillir de l’information sur les domaines suivants : caractéris-tiques démographiques; attitudes, croyances et opinions concernant le droit de prescrire des pharmaciens; effets envisagés sur les habitudes du droit de prescrire accordé aux pharmaciens; probabilité de demander ce droit, s’il existe; et les éléments entravant ou facilitant la demande du droit de prescrire et l’intégration de ce droit dans leur pratique. Une analyse de régression multivariée a été réalisée.Résultats : Au total, 266 pharmaciens (39,3 %) ont répondu au sondage. La plupart d’entre eux ont affirmé que le droit de prescrire est important pour la profession et pertinent dans le cadre de leur pratique et que cet acte pourrait accroître leur satisfaction au travail. De plus, les répondants affirmaient qu’ils possédaient l’expertise requise pour prescrire. Selon eux, le droit de prescrire pouvait influencer positivement leurs habitudes, notamment en ce qui concerne l’interruption de la prescription, la prescription au moment du congé ou d’un transfert et le renouvellement de médicaments. Parmi les éléments incitant les pharmaciens à solliciter le droit de prescrire, on comptait les effets positifs présumés sur les soins offerts aux patients et sur la profession, le soutien de la part de la direction et des collègues et les capacités personnelles. Aucun obstacle n’a été recensé. Environ deux tiers des pharmaciens ont indiqué qu’ils solliciteraient probablement le droit de prescrire s’il était accordé par la loi. Les pharmaciens en pratique clinique et ceux en recherche étaient beaucoup plus enclins à faire la demande pour devenir prescripteurs alors que ceux comptabilisant plus de dix ans d’expérience étaient moins enclins à faire la demande.Conclusions : Dans la présente étude, les pharmaciens rattachés à une régie de santé affichaient une attitude et des croyances positives à propos de la valeur du droit de prescription autonome des médicaments et des effets qu’il aurait sur leur pratique et la profession. On n’a recensé aucun élément perçu comme un obstacle à la formulation d’une demande du droit de prescrire ou à l’inclusion de ce rôle dans la pratique.

Health Authority Pharmacists' Perceptions of Independent Pharmacist Prescribing

BACKGROUND

In many jurisdictions, the pharmacist's role continues to evolve from drug distribution-based service delivery to expanded scopes of practice, including independent prescribing of medications.

OBJECTIVES

To assess health authority-based pharmacists' attitudes, beliefs, and perceptions about independent prescribing, to determine how independent prescribing may affect their behaviour, and to identify perceived barriers and enablers to incorporating it into their practice.

METHODS

An anonymous, cross-sectional online survey of 677 health authority-based pharmacists employed by Lower Mainland Pharmacy Services in British Columbia collected information in the following domains: demographic characteristics; attitudes, beliefs, and perceptions regarding pharmacist prescribing; anticipated effect of pharmacist prescribing on behaviour; likelihood of applying for this authority, if granted; and barriers and enablers to applying for prescribing authority and incorporating prescribing into their practice. A multivariate regression analysis was performed.

RESULTS

A total of 266 pharmacists (39.3%) responded to the survey. Most respondents agreed that prescribing is important to the profession and relevant to their practice, and that it might enhance job satisfaction. Additionally, respondents agreed that they had the expertise to prescribe. Respondents perceived prescribing as having the potential to positively affect behaviour, including deprescribing, prescribing at time of discharge or transfer, and renewing medications. Enablers to applying for pharmacist prescribing authority included perceived positive impact on patient care and the profession, level of support from management and coworkers, and personal ability. No barriers were identified. About two-thirds of pharmacists indicated they would likely apply for prescribing authority if it were granted through legislation. Pharmacists with a clinical practice or research role were significantly more likely to apply to be a prescriber, whereas those with more than 10 years of experience were less likely to apply.

CONCLUSIONS

In this study, health authority-based pharmacists held positive attitudes and beliefs about the value and impact of independent prescribing of medications on their practice and the profession. There were no perceived barriers to applying for prescribing authority or to incorporating prescribing into practice.

Evaluation of Physical Assessment Education for Practising Pharmacists: A Cross-Sectional Survey

ABSTRACTBackground: Pharmacists are now seeking to incorporate physical assess-ment (PA) into their practices. This trend prompted the creation, by the British Columbia Branch of the Canadian Society of Hospital Pharma-cists, of a 30-h course specifically designed for practising pharmacists.Objective: To evaluate pharmacists’ knowledge, skills, and confidence in performing PA after completing the course.Methods: All course participants were invited to complete 2 anonymous online surveys, immediately and 6 months after course completion.Results: Of the 218 participants, 82 (38%) responded to the survey administered immediately after the course, and 77 (35%) completed this survey in full. About half of the respondents (39/79 [49%]) reported use of PA on a real patient before taking the course. Lack of formal training and lack of comfort were the most frequently selected barriers to performing PA. All respondents (79/79) agreed that the course had improved their knowledge of PA, 96% (76/79) agreed that it had improved their skills, and 90% (71/79) agreed that it had improved their ability to care for patients. In addition, 61% (48/79) and 67% (53/79), respectively, agreed that they felt confident performing PA and intervening with regard to a patient’s drug therapy on the basis of physical findings. Thirty-eight (17%) of the course participants completed the 6-month follow-up survey. In that survey, the most frequently selected barrier to performing PA was lack of time. Paired data, available for 23 respondents, showed a significant increase in use of PA on real patients over time (p = 0.013 by 2 test). However, there was no significant improvement in confidence in performing PA or intervening on a patient’s drug therapy on the basis of physical findings (p > 0.05 by 2-sided t test). The primary limitation of this study was potential responder bias.Conclusions: A PA course designed for pharmacists improved participants’ self-reported knowledge and skills, as well as self-perceived ability to care for patients. Six months after the course, two-thirds of respondents had used PA in practice. However, there was no improvement in confidence in performing such assessments or using the findings to intervene on a patient’s drug therapy.RÉSUMÉContexte : Les pharmaciens cherchent désormais à ajouter l’examen physique à leurs pratiques. Cette tendance a motivé la section britanno-colombienne de la Société canadienne des pharmaciens d’hôpitaux à créer un cours de 30 heures conçu spécialement pour les pharmaciens en exercice.Objectif : Évaluer les connaissances, les compétences et le degré d’aisance des pharmaciens ayant suivi le cours portant sur la réalisation d’examens physiques.Méthodes : Tous les participants au cours ont été invités à remplir deux sondages anonymes en ligne : l’un à la fin du cours et l’autre six mois après la fin du cours.Résultats : Des 218 participants, 82 (38 %) ont répondu partiellement au sondage mené immédiatement à la fin du cours et 77 (35 %) y ont répondu en entier. Environ la moitié des répondants (39/79 [49 %]) ont indiqué avoir réalisé un examen physique en situation réelle avant d’avoir suivi le cours. Les facteurs les plus fréquents propres à dissuader le pharma-cien de réaliser un examen physique étaient l’absence de formation officielle et le manque d’aisance. Tous les répondants ont indiqué que le cours avait accru leurs connaissances de l’examen physique, 96 % (76/79) ont affirmé qu’il avait amélioré leurs compétences et 90 % (71/79) ont déclaré qu’il avait amélioré leur capacité à soigner les patients. De plus, 61 % (48/79) et 67 % d’entre eux (53/79) ont indiqué respectivement qu’ils se sentaient à l’aise de réaliser des examens physiques et d’agir sur la pharmacothérapie du patient en fonction des résultats de l’examen. Trente-huit (17 %) participants ont répondu au sondage mené six mois après le cours. Ce sondage a révélé que le manque de temps était le facteur le plus souvent évoqué pour faire obstacle à la réalisation d’examens physiques. Des données appariées de 23 répondants ont montré une aug-mentation significative du recours à l’examen physique en situation réelle au fil du temps (p = 0,013 par test 2). Cependant, on n’a noté aucune amélioration significative de l’aisance à réaliser des examens physiques ou à agir sur la pharmacothérapie d’un patient en fonction des résultats d’un examen physique (p > 0,05 par un test t bilatéral). La principale limite de la présente étude était un biais potentiel dans les réponses. Conclusions : Un cours sur l’examen physique conçu pour les pharmaciens a amélioré les connaissances et les compétences autodéclarées des participants ainsi que ce qu’ils croient être leurs capacités à soigner les patients. Six mois après le cours, deux tiers des répondants avaient réalisé un examen physique dans leur pratique. Cependant, on n’a noté aucune amélioration de l’aisance à réaliser de tels examens ou à en utiliser les résultats pour agir sur la pharmacothérapie du patient.

Evaluation of Physical Assessment Education for Practising Pharmacists: A Cross-Sectional Survey

BACKGROUND

Pharmacists are now seeking to incorporate physical assessment (PA) into their practices. This trend prompted the creation, by the British Columbia Branch of the Canadian Society of Hospital Pharmacists, of a 30-h course specifically designed for practising pharmacists.

OBJECTIVE

To evaluate pharmacists' knowledge, skills, and confidence in performing PA after completing the course.

METHODS

All course participants were invited to complete 2 anonymous online surveys, immediately and 6 months after course completion.

RESULTS

Of the 218 participants, 82 (38%) responded to the survey administered immediately after the course, and 77 (35%) completed this survey in full. About half of the respondents (39/79 [49%]) reported use of PA on a real patient before taking the course. Lack of formal training and lack of comfort were the most frequently selected barriers to performing PA. All respondents (79/79) agreed that the course had improved their knowledge of PA, 96% (76/79) agreed that it had improved their skills, and 90% (71/79) agreed that it had improved their ability to care for patients. In addition, 61% (48/79) and 67% (53/79), respectively, agreed that they felt confident performing PA and intervening with regard to a patient's drug therapy on the basis of physical findings. Thirty-eight (17%) of the course participants completed the 6-month follow-up survey. In that survey, the most frequently selected barrier to performing PA was lack of time. Paired data, available for 23 respondents, showed a significant increase in use of PA on real patients over time (p = 0.013 by χ² test). However, there was no significant improvement in confidence in performing PA or intervening on a patient's drug therapy on the basis of physical findings (p > 0.05 by 2-sided t test). The primary limitation of this study was potential responder bias.

CONCLUSIONS

A PA course designed for pharmacists improved participants' self-reported knowledge and skills, as well as self-perceived ability to care for patients. Six months after the course, two-thirds of respondents had used PA in practice. However, there was no improvement in confidence in performing such assessments or using the findings to intervene on a patient's drug therapy.

Should All Patients with Type 2 Diabetes Mellitus and Cardiovascular Disease Receive an SGLT2 Inhibitor?

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Patients' perceptions and use of natural health products

Background

Despite a lack of good scientific evidence for their benefit, Canadians take a lot of natural health products (NHPs). The objectives of this study were to determine patients' perception of the efficacy, safety and quality of NHPs and to characterize NHP use.

Methods

A standardized, 18-question survey was distributed to the general public through a variety of methods.

Results

A total of 326 individuals completed the survey. Eighty-five percent of respondents take 1 or more NHPs. Forty-seven percent agreed/strongly agreed that NHPs are safer than prescription medications and 24% disagreed/strongly disagreed that prescription medications are more effective than NHPs. Three-quarters of respondents agreed/strongly agreed that health care providers should recommend NHPs more often, as most stated they preferred to take an NHP for both a minor ailment (82%) and chronic medical condition (60%). Respondents used 124 different NHPs, most commonly vitamin D, vitamin B and magnesium. Respondents purchased NHPs primarily from health/vitamin stores (66%) and accessed the Internet for information about them (64%). Younger, female respondents were more likely to take NHPs.

Discussion

Patients appear to be comfortable foregoing education from health care professionals about the benefits and risks of NHPs. Patients' comfort with self-prescribing NHPs seems to stem from a perception of general efficacy and quality with little to no concern about harm and appears to be strongly influenced by lay sources of information.

Conclusion

Most respondents take 1 or more NHPs, preferring to use NHPs over prescription medications for minor and chronic health concerns seemingly based on a perception of safety and quality.

Prevention and management of statin adverse effects: A practical approach for pharmacists

Statin-associated adverse effects, primarily muscle-related symptoms, occur in up to approximately one-third of patients in clinical practice. Recently, a Canadian Consensus Working Group outlined 6 key principles to assess and manage patients with goal-inhibiting statin intolerance, defined as a syndrome characterized by symptoms or biomarker abnormalities that prevent the long-term use of and adherence to indicated statin therapy, which includes a trial of at least 2 statins and precludes reversible causes of statin adverse effects. These principles ensure patients are appropriately receiving a statin and aware of both the benefits and risks of therapy. As well, they address factors that may increase the risk of statin-associated myopathy. A thorough assessment of patients' clinical and laboratory history should be performed in any patient presenting with muscle symptoms on statin therapy, followed by a systematic dechallenge/rechallenge approach. In practice, most patients with statin intolerance due to muscle symptoms will be able to tolerate another statin. This is of particular importance because of the relative paucity of compelling evidence demonstrating a cardiovascular benefit with nonstatin therapies. Pharmacists are ideally situated to provide patient education, recommend changes to therapy and monitor patients with goal-inhibiting statin intolerance.

Do the Benefits of Electronic Cigarettes Outweigh the Risks?

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Effect of Glucagon-like Peptide-1 Receptor Agonists on All-cause Mortality and Cardiovascular Outcomes: A Meta-analysis

BACKGROUND

Cardiovascular disease is the leading cause of death in patients with type 2 diabetes.

OBJECTIVE

To assess the impact of glucagon-like peptide-1 receptor agonist (GLP1RA) therapy, compared to placebo, on clinically relevant outcomes including all-cause mortality, cardiovascular mortality, nonfatal myocardial infarction (MI), nonfatal stroke, and hospitalizations for heart failure, in patients with type 2 diabetes.

METHODS

EMBASE, MEDLINE, and CENTRAL were searched (inception to September 2016) for randomized, double-blind, placebo-controlled trials of at least one year in duration that compared any GLP1RA to placebo in patients with type 2 diabetes. Both authors independently completed the literature search, data extraction, and risk of bias assessment. For each outcome, a Risk Ratio (RR) and 95% Confidence Interval (CI) were calculated using a Mantel-Haenszel random effects model.

RESULTS

Eight trials (three albiglutide, two lixisenatide, two liraglutide, one semaglutide) consisting of 21,135 patients were included. Most patients had, or were at high risk for, cardiovascular disease. Follow- up ranged from 1-3.8 years. Trials contributing the majority of data were deemed to have a low risk of bias. The risk of all-cause mortality was lowered by 11% in patients receiving a GLP1RA (RR 0.89, 95% CI 0.81-0.99). There was no statistically significant difference between groups with respect to cardiovascular death, nonfatal MI, nonfatal stroke, or hospitalizations for heart failure.

CONCLUSION

GLP1RA therapy when compared to placebo reduced all-cause mortality in high cardiovascular risk patients with type 2 diabetes. They did not impact cardiovascular mortality, nonfatal MI, nonfatal stroke, or heart failure hospitalizations.