Community Pharmacist and Family Medicine Collaboration for Pre-Visit Planning for Shared Patients Receiving Chronic Care Management Services

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients' medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the CP. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations. CCM billing provided a mechanism for CPs to receive revenue for their services.

Assessment of postgraduate skin lesion education among Iowa family physicians

Background:

Family medicine physicians play a pivotal role in the prevention and early detection of skin cancer. Our objective was to evaluate how family physicians believe their postgraduate training in skin cancer screening and prevention has prepared them for independent practice and to assess the need for enhanced skin lesion teaching in a family medicine residency setting.

Methods:

A descriptive, cross-sectional survey investigating provider demographics, confidence in providing dermatological care, residency training, current medical practice, and skin cancer prevention beliefs was mailed to all family medicine physicians in the state of Iowa as listed in the Iowa Academy of Family Physicians annual directory in 2006 (N = 1069).

Results:

A total of 575 family medicine physicians completed the survey for an overall response rate of 53.8%. Overall, family medicine physicians reported feeling confident in their ability to diagnose skin lesions (83.2%), differentiate between benign and malignant lesions (85.3%), and perform a biopsy of a lesion (94.3%). Only 65% of surveyed physicians felt that their residency program adequately trained them in diagnosing skin lesions and 65.7% of physicians agree that they could have benefited from additional training on skin lesions during residency training. Nearly 90% of clinicians surveyed believe that skin cancer screenings are the standard of care; however, only 51.8% perform skin cancer screening examinations during adult health maintenance visits more than 75% of the time. The primary reason listed by respondents who said they do not routinely perform skin cancer screenings was inadequate time (68.2%).

Conclusion:

Family medicine physicians in the state of Iowa are confident in evaluating skin lesions. However, they reported a need for additional enhanced, targeted skin lesion education in family medicine residency training programs. Physicians believe that skin cancer screening examination is the standard of care, but find that inadequate time increasingly hinders skin cancer screening during routine health maintenance examinations.

Administration of Direct Oral Anticoagulants Through Enteral Feeding Tubes

Objective: To review literature regarding direct oral anticoagulants (DOACs) and determine their viability of administration in solution or via enteral tubes. Data Sources: MEDLINE literature searches identified articles published 2007-present using MeSH terms: factor Xa inhibitors, antithrombins, biological availability, and enteral nutrition. Package inserts were included. Manufacturers were asked to provide literature. Study Selection and Data Extraction: We included studies emphasizing bioavailability or enteral administration. Data Synthesis: Dabigatran and edoxaban package inserts recommend against altering the dosage form, and against enteral administration. One rivaroxaban study was identified. Given with food, enteral administration was comparable to the oral tablet. The mean AUC (0.889, 90% CI 86.12-91.84%) was within the equivalency margins; however Cmax (0.820, 90% CI 78.84-85.86%) was slightly below the 80% threshold. One apixaban study was identified. They showed bioequivalence between oral and enteral administration in different vehicles, but decreased bioavailability when crushed tablets were given along with nutritional support. AUC and Cmax were 32% and 19% lower, respectively, when apixaban solution was given via nasogastric (NG) tube with nutritional supplement versus oral administration of solution. Conclusions: Dabigatran capsules should not be altered, due to large variations in drug exposure. Rivaroxaban can be given as oral solution or via NG tube. Larger doses must be given with nutritional supplementation and enteral tubes must not be distal to the stomach. Apixaban can be given as oral solution or via nasogastric or gastric tube on an empty stomach. Food impairs bioavailability of the crushed tablets. There are insufficient data to recommend enteral administration of edoxaban and the package insert recommends against altering tablets.

Fatal Aspiration Pneumonia during Transition from Donepezil to Rivastigmine

OBJECTIVE:

To report a case of fatal aspiration pneumonia in a patient shortly after initiation of rivastigmine and discontinuation of donepezil, with no washout period between therapies.

CASE SUMMARY:

An 83-year-old white man presented to the emergency department in respiratory distress (O2 saturation 70%; RR 44 breaths/min) secondary to aspiration. He had started rivastigmine 1.5 mg twice daily that same day. The patient had been previously treated with donepezil 10 mg/d, and there was no washout period. He was intubated due to worsening respiratory status and was transferred to the cardiac care unit. He then became hypotensive and required dopamine and fluid support. Brief bronchoscopy revealed food particles in the lower airways and bile-stained secretions. Intubation was notable for the large amount of secretions. The patient died approximately 27 hours after presentation to the emergency department. Blood and sputum cultures were subsequently positive for Haemophilus influenzae.

DISCUSSION:

Cholinesterase (ChE) inhibitors approved for treatment of Alzheimer disease are associated with nausea and vomiting in a sizable percentage of patients, ranging from 5% to 31% in clinical trials. Most of these adverse events occur during the initiation/titration phase of therapy. An additive risk of adverse events may be expected with coadministration of ChE inhibitors or cholinergic agents or, potentially, with an inadequate washout period between such agents. Review of MEDLINE (1966–July 2002) and International Pharmaceutical Abstracts (1970–July 2002) failed to identify any previous reports of aspiration with rivastigmine or donepezil.

CONCLUSIONS:

A washout period should be considered when switching between ChE inhibitors to minimize the risk of vomiting and aspiration.

Inclusion of salt form on prescription medication labeling as a source of patient confusion: a pilot study

Background:

It has been estimated that 10,000 patient injuries occur in the US annually due to confusion involving drug names. An unexplored source of patient misunderstandings may be medication salt forms.

Objective:

The objective of this study was to assess patient knowledge and comprehension regarding the salt forms of medications as a potential source of medication errors.

Methods:

A 12 item questionnaire which assessed patient knowledge of medication names on prescription labels was administered to a convenience sample of patients presenting to a family practice clinic. Descriptive statistics were calculated and multivariate analyses were performed.

Results:

There were 308 responses. Overall, 41% of patients agreed they find their medication names confusing. Participants correctly answered to salt form questions between 12.1% and 56.9% of the time. Taking more prescription medications and higher education level were positively associated with providing more correct answers to 3 medication salt form knowledge questions, while age was negatively associated.

Conclusions:

Patient misconceptions about medication salt forms are common. These findings support recommendations to standardize the inclusion or exclusion of salt forms. Increasing patient education is another possible approach to reducing confusion.

An open-label, pragmatic, randomized controlled clinical trial to evaluate the comparative effectiveness of daptomycin versus vancomycin for the treatment of complicated skin and skin structure infection

Background

Treatment of complicated skin and skin structure infection (cSSSI) places a tremendous burden on the health care system. Understanding relative resource utilization associated with different antimicrobials is important for decision making by patients, health care providers, and payers.

Methods

The authors conducted an open-label, pragmatic, randomized (1:1) clinical study (N = 250) to compare the effectiveness of daptomycin with that of vancomycin for treatment of patients hospitalized with cSSSI caused by suspected or documented methicillin-resistant Staphylococcus aureus infection. The primary study end point was infection-related length of stay (IRLOS). Secondary end points included health care resource utilization, cost, clinical response, and patient-reported outcomes. Patient assessments were performed daily until the end of antibiotic therapy or until hospital discharge, and at 14 days and 30 days after discharge.

Results

No difference was found for IRLOS, total LOS, and total inpatient cost between cohorts. Hospital LOS contributed 85.9 % to the total hospitalization cost, compared with 6.4 % for drug costs. Daptomycin showed a nonsignificant trend toward a higher clinical success rate, compared with vancomycin, at treatment days 2 and 3. In the multivariate analyses, vancomycin was associated with a lower likelihood of day 2 clinical success (odds ratio [OR] = 0.498, 95 % confidence interval [CI], 0.249–0.997; P < 0.05).

Conclusion

This study did not provide conclusive evidence of the superiority of one treatment over the other in terms of clinical, economic, or patient outcomes. The data suggest that physician and patient preference, rather than drug acquisition cost, should be the primary driver of initial antibiotic selection for hospitalized patients with cSSSI.

Trial registration

ClinicalTrials.gov: NCT01419184 (Date: August 16, 2011)

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1261-9) contains supplementary material, which is available to authorized users.

Investigation of Simulated Pharmacist Decision Making Involving Prescriptions With a High Probability of Causing Patient Harm

Background: Medication errors pose a significant risk to patients, resulting in morbidity, mortality, and unnecessary health care utilization. Pharmacists, using their professional judgment, have an important role as a final check for identifying and resolving these problems. Little is known, however, about pharmacist perspectives and experiences with dispensing or withholding potentially dangerous prescriptions. Objectives: To (a) evaluate the extent to which pharmacists would not dispense a likely harmful prescription which has been confirmed by the prescriber and (b) assess pharmacist attitudes and experiences with dispensing likely harmful prescriptions. Methods: An anonymous, self-administered, 25-item survey was emailed to members of a state pharmacy association and a pharmacy college alumni list. A series of static prescription vignettes (1 reasonable and 4 likely dangerous doses) were presented and asked if they would fill each prescriber-confirmed prescription. Pharmacists also were asked a series of Likert-type, open-ended, multiple choice, and demographic items regarding their professional experiences and role perceptions. Results: There were 497 usable responses. Three of the 4 dangerous prescriptions were withheld by the majority of pharmacists (sumatriptan as the exception). No demographic variable was universally associated with filling dangerous vignette prescriptions; rather, there were vignette-specific differences. The majority of pharmacists reported refusing to fill a potentially harmful prescription during their career. Conclusions: There appears to be meaningful variation in how pharmacists react when presented with likely harmful prescriptions. More research is needed to better understand this role, its determinants, and the potential effects on patient safety.

Severe rhabdomyolysis and acute renal failure secondary to concomitant use of simvastatin, amiodarone, and atazanavir

OBJECTIVE

To report a case of a severe interaction between simvastatin, amiodarone, and atazanavir resulting in rhabdomyolysis and acute renal failure.

BACKGROUND

A 72-year-old white man with underlying human immunodeficiency virus, atrial fibrillation, coronary artery disease, and hyperlipidemia presented with generalized pain, fatigue, and dark orange urine for 3 days. The patient was taking 80 mg simvastatin at bedtime (initiated 27 days earlier); amiodarone at a dose of 400 mg daily for 7 days, then 200 mg daily (initiated 19 days earlier); and 400 mg atazanavir daily (initiated at least 2 years previously). Laboratory evaluation revealed 66,680 U/L creatine kinase, 93 mg/dL blood urea nitrogen, 4.6 mg/dL creatinine, 1579 U/L aspartate aminotransferase, and 738 U/L alanine aminotransferase. Simvastatin, amiodarone, and the patient's human immunodeficiency virus medications were all temporarily discontinued and the patient was given forced alkaline diuresis and started on dialysis. Nine days later the patient's creatine kinase had dropped to 1695 U/L and creatinine was 3.3 mg/dL. The patient was discharged and continued outpatient dialysis for 1 month until his renal function recovered.

DISCUSSION

The risk of rhabdomyolysis is increased in the presence of concomitant drugs that inhibit simvastatin metabolism. Simvastatin is metabolized by CYP3A4. Amiodarone and atazanavir are recognized CYP3A4 inhibitors.

CONCLUSIONS

Pharmacokinetic differences in statins are an important consideration for assessing the risk of potential drug interactions. In patients requiring the concurrent use of statins and CYP3A4 inhibitors, pravastatin, fluvastatin, and rosuvastatin carry the lowest risk of drug interactions; atorvastatin carries moderate risk, whereas simvastatin and lovastatin have the highest risk and should be avoided in patients taking concomitant CYP3A4 inhibitors.

Adherence to clinical practice guidelines for 7 chronic conditions in long-term-care patients who received pharmacist disease management services versus traditional drug regimen review

BACKGROUND

Numerous studies have shown that adherence to published clinical practice guidelines (CPGs) reduces disease morbidity and mortality. However, few benchmarks exist that demonstrate the rate of adherence to CPGs in patients in long-term-care facilities (LTCFs).

OBJECTIVE

To evaluate CPG adherence in patients in LTCFs who received consultation from pharmacists who emphasize disease state management (DSM) compared with patients in other LTCFs who received traditional drug regimen review (DRR).

METHODS

A retrospective chart review was conducted in November 2005 for 107 patients who received DSM services in 2 LTCFs and 304 patients who received DRR services in 4 LTCFs for the service period ending September 30, 2005. Chart review was conducted on all patients included in the current census as of September 1, 2005; residents were excluded from the analysis if they were discharged or deceased between September 1, 2005, and the date of chart review. CPG adherence was evaluated for the following 7 conditions: diabetes, coronary artery disease (CAD), stroke, heart failure (HF), hypertension, hyperlipidemia, and osteoporosis. In addition, the 6 most recent pharmacist recommendations for each patient were classified according to disease state.

RESULTS

Adherence to CPGs was significantly better (all P <0.05) in patients receiving DSM services for the following performance measures for 4 of the 7 disease states: (1) diabetes: antiplatelet or warfarin use or contraindication for use (hypersensitivity or history of serious bleeding event), 89.7% for DSM services versus 71.0% for DRR services, and glycosylated hemoglobin (HbA1c) 0.05). The mean number of pharmacist recommendations per patient per month was greater in DSM facilities (0.76) compared with DRR facilities (0.23, P <0.001). Pharmacists who provided DSM consultant services were more likely to make a recommendation to improve DSM (51.6%) than were pharmacists in the comparison facilities who provided traditional DRR services (31.7%, P <0.001).

CONCLUSION

This self-evaluation of the provision of pharmacist consultant services that focus on disease management in addition to DRR found a higher rate of adherence to clinical practice guidelines for 4 of 7 common chronic disease states in long-term-care patients compared with patients who received only traditional DRR services.

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

Background

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

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

Methods

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

Setting. Two family medicine outpatient clinics in Iowa.

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

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

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

Results

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

Conclusion

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

Antimuscarinic Intoxication Resulting from the Ingestion of Moonflower Seeds

OBJECTIVE:

To report a case in which ingestion of moonflower seeds resulted in antimuscarinic intoxication.

CASE SUMMARY:

An 18-year-old man was found at a local convenience store hallucinating and incoherent. Upon presentation to the emergency department, his signs and symptoms included tachycardia, confusion, dilated pupils, and dry, flushed, hot skin. He was admitted to the intensive care unit. Hallucinations and symptoms resolved within 36–48 hours after hospitalization. The patient then reported that he had ingested moonflower seeds. He recovered and was released 4 days after admission.

DISCUSSION:

Based on the patient's description and clinical presentation, the moonflower seeds were believed to be Datura inoxia. This species of plant is similar to jimson weed, or Datura stramonium. These plants are known to contain high concentrations of anticholinergic substances; ingestion can result in anticholinergic intoxication. Signs and symptoms that commonly occur include hallucinations, tachycardia, dilated pupils, and disorientation. In our patient, use of the Naranjo probability scale indicated a possible relationship between the moonflower seed ingestion and the patient's signs and symptoms.

CONCLUSIONS:

Ingestion of the Datura species can result in severe toxicity. Each plant varies in the concentrations of alkaloid substances. For this reason, it is very important for individuals to become educated on the toxicities and potential risks associated with recreational use of these plants.

Oral Antivirals for the Acute Treatment of Recurrent Herpes Labialis

OBJECTIVE

To evaluate the use and benefit of oral antivirals in the acute treatment of episodic, recurrent herpes labialis.

DATA SOURCES

A literature search was performed in MEDLINE (1966—August 2003) using acyclovir, famciclovir, valacyclovir, cold sores, herpes labialis, and HSV-1 as search terms.

DATA SYNTHESIS

We reviewed 5 placebo-controlled and 2 comparative studies evaluating oral antivirals for acute treatment of recurrent herpes labialis. No studies directly compared different antivirals. Studies discussing the efficacy of antivirals for chronic suppression of herpes simplex virus-1 infection were not included.

CONCLUSIONS

Treatment with oral antivirals decreases the duration of lesion episodes and pain by approximately one day; however, the antivirals do not abort lesions from developing. Clinical implications of these results appear relatively modest.

Analgesic efficacy of calcitonin for vertebral fracture pain

OBJECTIVE

To evaluate the analgesic efficacy of calcitonin for treating the pain of vertebral fractures associated with osteoporosis.

DATA SOURCES

Searches of MEDLINE (1966-July 2002), Cochrane Library, International Pharmaceutical Abstracts (1977-July 2002), and an extensive manual review of journals were performed using the key search terms calcitonin, analgesic, osteoporosis, vertebral fracture, and pain.

STUDY SELECTION AND DATA EXTRACTION

All articles identified from the data sources were evaluated and all information deemed relevant was included for this review.

DATA SYNTHESIS

Fractures, especially vertebral fractures, are a common complication of osteoporosis, leading to significant pain. Calcitonin has been studied for its analgesic properties. Fourteen double-blind, placebo-controlled trials that evaluated the analgesic efficacy of calcitonin for osteoporosis-related vertebral fracture pain were identified and reviewed. Thirteen of these studies demonstrated statistically significant improvement in pain or function in calcitonin-treated patients.

CONCLUSIONS

Calcitonin has proven efficacy in acute pain associated with osteoporosis-related vertebral fractures. Analgesic effects are seen with intranasal, parenteral, and rectal administration. Future studies comparing calcitonin with other commonly used analgesics are needed to more clearly define its place in therapy.

Achieving the best outcome in treatment of depression

Combined treatment with psychotherapy or psychiatric consult and drug therapy has shown better response in several studies than either therapy alone. Although not proven by clinical trials, selecting a medication by matching its side-effect profile to patient characteristics is supported by case reports and likely enhances compliance. Patients who do not improve with initial therapy often benefit from being switched to another class of antidepressants, or having a drug from another class added to their therapy.

Diabetes management quality improvement in a family practice residency program

BACKGROUND

Diabetes is a devastating chronic disease. Although optimal diabetes control reduces chronic complications, actual provision of diabetes care frequently falls short of accepted guidelines. We wanted to determine whether locally developed diabetes care initiatives can result in improvements in the provision of diabetes care.

METHODS

This study was a retrospective cohort analysis using Medicare claims and chart abstraction data to ascertain diabetes care indicator utilization rates at the Northeast Iowa Family Practice Clinic (NEIFPC), which serves as the training site for the Northeast Iowa Family Practice Residency Program. Diabetic patients receiving care at the NEIFPC during 1996, 1997, and 1998 were included. Diabetes care rates are compared with those of other Iowa practices. Diabetes initiatives included chart audits, glycosylated hemoglobin (HbA1c) measurement reminder cards, educational symposia, an endocrinology outreach clinic, resident elective rotations, diabetes flow sheet utilization, pharmacist interface, and nursing foot-examination preparations. The primary outcome was the utilization rate of accepted diabetes care indicators.

RESULTS

Diabetic patients at NEIFPC had greater utilization of diabetes care indicators than did patients of Iowa collaborators in 1997 and 1998. NEIFPC patients had HbA1c levels measured more frequently in 1997 and 1998 (84% and 88%, respectively) than did patients of Iowa collaborators (49% and 41%, respectively) (P < .001). The mean 1997 and 1998 HbA1c levels of 7.32% and 7.25%, respectively, are impressive compared with that of Iowa collaborators (8.83% and 8.36%) (P < .001) and other published data (8.5%-10%). The percentage of NEIFPC patients with good glycemic control (HbA1c < 8%) was 75%, compared with the reported 50% of all US patients.

CONCLUSIONS

Our findings suggest that multimodal diabetes care quality improvement initiatives, applied longitudinally, can result in significant improvements in the provision and documentation of diabetes care.

Torsades de pointes associated with chlorpromazine: case report and review of associated ventricular arrhythmias

PURPOSE

To present a case of chlorpromazine-associated torsades de pointes, review established cases of ventricular arrhythmias associated with chlorpromazine, and describe the proarrhythmic characteristics of this drug.

DATA SOURCES

Articles identified through a search of MEDLINE and IDIS from January 1966-November 2000 and thorough review of the article bibliographies. Patient cases also were identified from a search of the Food and Drug Administration's Adverse Event Reporting System database (November 1997-March 2001). Cases involving intentional overdoses of chlorpromazine were excluded.

RESULTS

In addition to the case reported herein, 12 cases of documented, chlorpromazine-associated ventricular arrhythmias were identified; five had characteristic features of torsades de pointes. Chlorpromazine delayed repolarization and produced electrocardiographic abnormalities; although, whether chlorpromazine induced torsades de pointes through a mechanism of early afterdepolarizations is unclear. Similar to other instances of drug-induced torsades de pointes, concurrent factors such as electrolyte deficiencies may place the patient at increased risk for arrhythmia.

CONCLUSIONS

Chlorpromazine can delay repolarization and produce electrocardiographic abnormalities. These can result infrequently in ventricular arrhythmias and torsades de pointes, particularly in patients with confounding factors.

Sudden cardiac death with clozapine and sertraline combination

OBJECTIVE

To report a case of sudden cardiac death in a patient receiving combination therapy with clozapine and sertraline.

CASE SUMMARY

A 26-year-old white man was discovered dead at his residence. His medical history included chronic paranoid schizophrenia, obsessive-compulsive disorder, major depressive disorder, obstructive sleep apnea, and akathisia. He had no prior history of cardiovascular disease. His medication regimen included clozapine 100 mg twice daily (started 4 y prior to his death), risperidone 3 mg twice daily, sertraline 200 mg once daily, atenolol 50 mg twice daily, and lorazepam 0.5 mg four times daily. Autopsy and toxicology studies revealed cardiomegaly suggestive of idiopathic cardiomyopathy, single-vessel coronary artery disease, sertraline and clozapine blood concentrations in the expected range, undetectable lorazepam and risperidone blood concentrations, obesity, and moderate fatty changes to the liver. The most likely cause of death was sudden cardiac death due to acute cardiac arrhythmia.

DISCUSSION

Clozapine is structurally similar to the tricyclic antidepressants, which have type 1 A antiarrhythmic properties. Case reports have described electrocardiographic abnomalities, cardiomyopathy, and fatal myocarditis associated with its use. Unexplained death in patients on clozapine therapy has also been reported. Sertraline appears to have less cardiac effect; however, one report has observed clinically significant QT prolongation during sertraline therapy.

CONCLUSIONS

Clozapine-induced cardiomyopathy and cardiac arrhythmia from clozapine and/or sertraline use may have contributed to this man's death.

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.

Thrombolytic-associated cholesterol emboli syndrome: case report and literature review

Thrombolytics can cause cholesterol embolization syndrome (CES). This adverse effect has received less attention than other risks of thrombolytic therapy, such as systemic bleeding and hemorrhage, with only sporadic reports of CES in the literature. Risk factors have not been consistently identified and emphasized; therefore, occurrence of CES after thrombolysis remains difficult to predict, it results in substantial morbidity and mortality, and it lacks effective pharmacologic treatment. Heightened awareness of the disorder can aid in its correct identification and reporting.

Zolpidem: a nonbenzodiazepine hypnotic for treatment of insomnia

The pharmacology, pharmacokinetics, and clinical efficacy of zolpidem tartrate, a new hypnotic agent, are described. Zolpidem belongs to the imidazopyridine class. It exhibits high-affinity binding at a benzodiazepine-receptor subtype that is located in the cerebellum and cerebral cortex but not in the spinal cord or peripheral tissues. It decreases sleep latency and increases total sleep time and sleep efficiency without affecting sleep architecture. Zolpidem tartrate is absorbed rapidly. Bioavailability is 67% after oral doses of 5-20 mg. Pharmacokinetics show age-related and sex-related variations. The disposition of zolpidem is reduced in hepatically and renally impaired patients. Clinical studies have shown effectiveness of zolpidem in increasing sleep time and decreasing sleep latency. It has demonstrated efficacy equal to that of benzodiazepines without causing rebound insomnia or withdrawal effects. Comparative trials have found zolpidem as effective as flunitrazepam, flurazepam, and triazolam. The optimum dose of zolpidem tartrate is 10 mg at bedtime; 5 mg for elderly patients. Adverse reactions to zolpidem are dose-related and have primarily CNS and gastro-intestinal manifestations. Zolpidem exhibits similar efficacy to the benzodiazepines in the treatment of insomnia. Zolpidem's advantages over benzodiazepines are that it does not lead to tolerance, withdrawal phenomena, or REM rebound; however, for short-term, as-needed use, these advantages are not relevant.