Focused Jurisdictional Scan of Glomerulonephritis Medication Access in Canada: A Program Report

Purpose of Program

Glomerulonephritis (GN) is a group of rare kidney diseases that is increasingly being managed with higher cost immunosuppressive (IS) agents in Canada. Ontario Health's Ontario Renal Network (ORN) oversees the management and delivery of GN services in the province. Stakeholder surveys previously conducted by ORN identified that both clinicians and patients do not perceive access to GN medications as comprehensive or timely. The program conducted a focused jurisdictional scan among 7 provinces to inform ORN initiatives to improve access to GN medications. Specifically, the program examined clinician experience with GN access, public drug coverage criteria, and timelines for public coverage for select IS agents (ie, tacrolimus, cyclosporine, mycophenolate mofetil [MMF], mycophenolate sodium, rituximab, and eculizumab) used to manage GN in adults who live in Canada.

Methods

For the selected IS agents, a focused jurisdictional scan on medication access was conducted by ORN in 2018 and updated in July 2022. Information was obtained by searching the gray literature and/or credible online sources for public funding policies and eligibility criteria. Findings were supplemented by personal communications with provincial drug programs and consulting GN clinical experts from 7 provinces (ie, Alberta, British Columbia, Saskatchewan, Manitoba, Ontario, Nova Scotia, and Quebec).

Key Findings

Clinicians from different provinces prescribe IS agents similarly for GN indications, despite distinctions in public drug funding policies. While patients can obtain public funding for many IS agents, for GN, most provinces rely on case-by-case review processes. In addition, provinces can vary in their funding criteria and which IS agents are listed on the public formulary. For IS agents that require prior authorization or case-by-case review, timelines vary by province with decisions taking a few days to weeks. British Columbia, with a GN-specific drug formulary, had the most integrated and efficient system for patients and prescribers.

Limitations

This scan primarily relied on publicly available information for drug coverage criteria and clinician experience with access in their province. Since this scan was conducted, public drug coverage criteria and/or application processes may have changed.

Implications

While patients in most provinces have similar needs and nephrologists similar prescribing patterns, gaps still exist for publicly funded GN medications. Interprovincial differences in the drugs funded, funding criteria, and application process may affect timely and equitable access to GN medications across Canada. Given the rarity of GN, a pan-Canadian funding approach may be warranted to improve the current state.

The Efficacy and Safety of Megestrol Acetate in Protein-Energy Wasting due to Chronic Kidney Disease: A Systematic Review

OBJECTIVE

To assess the efficacy and safety of oral megestrol acetate (MA) in the management of protein-energy wasting in patients with chronic kidney disease (CKD).

DESIGN

A systematic review of English published literature from 1970 until April 1, 2014.

SUBJECTS

All adult patients with CKD including both dialysis and non-dialysis-dependent.

INTERVENTION

Oral MA.

MAIN OUTCOME MEASURE

Efficacy outcomes included changes in body weight, serum albumin, and appetite. Safety outcomes examined included adverse events (AEs) and deaths.

RESULTS

A total of 9 studies met the inclusion criteria. No data on MA in non-dialysis CKD patients were available. Statistically significant increases in body weight (range 1.5-5 kg) were reported in 6 trials. Statistically significant increases in albumin (range of 0.22 g/dL-0.52 g/dL) were observed in 5 trials. Improved appetite was observed in 7 trials. All trials were limited by small sample sizes (range 9-32 subjects), short duration (range 8-24 weeks), a high degree of bias, and absence of clinical outcomes such as quality of life or hospitalizations. Forty-seven AEs were reported and included overhydration/excessive fluid gain, diarrhea, hyperglycemia, excessive weight gain, suppressed cortisol levels, thrombophlebitis, nausea/vomiting, confusion/hallucinations, vaginal bleeding, headache/dizziness, and elevated lactate dehydrogenase. There were 26 discontinuations due to death.

CONCLUSION

The current evidence for treatment with MA in patients receiving dialysis is sparse with few high-quality trials. The safety of using MA beyond 24 weeks is unknown, and use of MA is associated with significant AEs. At this time, oral MA should be used with significant caution, and only when other treatment options are unavailable.

Cost analysis of an intravenous to subcutaneous epoetin α conversion

BACKGROUND/AIMS

A cost analysis of a conversion from intravenous (IV) to subcutaneous (SC) epoetin α in patients receiving chronic in-center hemodialysis (HD).

METHODS

This retrospective analysis compared epoetin α drug costs during a 6-month period of IV usage (July to December 2010, period 1) to a 6-month period of SC usage (July to December 2011, period 2) in four large in-center HD units. Data were collected from quarterly counts of HD patients receiving epoetin α and monthly inventory billing records.

RESULTS

622 HD patients who received IV epoetin α (period 1) were compared to 609 HD patients who received SC epoetin α (period 2). A 12.6% decrease in dose was observed. The average weekly cost of epoetin α was USD 173.02 per patient during the IV period versus USD 151.20 per patient during the SC period. This equated to a yearly cost savings of USD 1,135 per patient with SC epoetin α.

CONCLUSION

The switch from IV to SC epoetin α was successfully implemented in all four centers and realized significant cost savings.

New models of chronic kidney disease care including pharmacists: improving medication reconciliation and medication management

PURPOSE OF REVIEW

Patients with chronic kidney disease (CKD) are complex, have many medication-related problems (MRPs) and high rates of medication nonadherence, and are less adherent to some medications than patients with higher levels of kidney function. Nonadherence in CKD patients increases the odds of uncontrolled hypertension, which can increase the risk of CKD progression. This review discusses reasons for gaps in medication-related care for CKD patients, pharmacy services to reduce these gaps and successful models that incorporate pharmacist care.

RECENT FINDINGS

Pharmacists are currently being trained to deliver patient-centred care, including identification and management of MRPs and helping patients overcome barriers to improve medication adherence. A growing body of evidence indicates that pharmacist services for CKD patients, including medication reconciliation and medication therapy management, positively affect clinical and cost outcomes, including lower rates of decline in glomerular filtration rates, reduced mortality and fewer hospitalizations and hospital days, but more robust research is needed. Team-based models including pharmacists exist today and are being studied in a wide range of innovative care and reimbursement models.

SUMMARY

Opportunities are growing to include pharmacists as integral members of CKD and dialysis healthcare teams to reduce MRPs, increase medication adherence and improve patient outcomes.

Iron replacement and supplementation in patients with chronic kidney disease

Interest in optimizing iron management in the treatment of anemia of CKD is growing due to concerns that high doses of ESAs may have deleterious effects and the high cost of ESAs in comparison to iron therapy. International guidelines have defined iron targets for this patient population, but there are some unanswered questions with respect to long-term use of iron, such as the maximum TSAT or ferritin concentration and concerns with oxidative stress. Large head-to-head safety studies of the different i.v. iron preparations have not been performed to date and current safety data rely on small studies and spontaneous adverse event reporting. Interprofessional management of anemia, including iron therapy, has shown beneficial effects and should be encouraged.

Sodium thiosulfate-based treatment in calcific uremic arteriolopathy: a consecutive case series

BACKGROUND

Calcific uremic arteriolopathy (CUA) is a rare complication in end stage renal disease with high mortality. Numerous case reports and one case series of 3 patients report the benefit of sodium thiosulfate (STS) for treatment of CUA. The purpose of this evaluation was to examine the response to a STS-based treatment approach in patients with CUA with 1 year follow up.

METHODS

A retrospective case series of 6 consecutive patients from Manitoba, Canada who met predefined diagnostic criteria for CUA and received STS between 2006 and 2008 were included. STS responders were defined as improvement in at least one of the following three parameters: pain severity, wound size and diagnostic imaging/radiography. Mortality, STS dose, duration, adverse events and cost were also collected.

RESULTS

Four patients were classified as responders. The 2 responders who survived at 1 year of follow-up demonstrated an improvement in all 3 parameters examined including an improvement in their follow-up diagnostic imaging results within the first 4 - 6 weeks of STS treatment. At 1 year of follow-up, 3 patients died.

CONCLUSION

Using an STS-based multifaceted treatment approach for CUA, 4 patients responded but 3 of 6 patients died within 1 year. Further larger prospective studies are needed to delineate STS responders from non-responders.

Reduced drug costs from switching hemodialysis patients from epoetin alfa in multidose vials to pre-filled syringes

OBJECTIVE

We sought to evaluate epoetin alfa drug costs in hemodialysis (HD) patients after a province-wide switch from multidose vials (MDV) to prefilled syringes (PFS).

METHODS

A retrospective study of epoetin alfa drug costs and estimated doses based on these costs during a six-month period of MDV usage (2007) were compared to a PFS usage period (2008). Data were collected from quarterly counts of HD patients receiving epoetin alfa in the Manitoba Renal Program (MRP) and monthly inventory billing records.

RESULTS

756 patients who received epoetin alfa MDV were compared to 799 patients who received epoetin alfa PFS. Average weekly dose calculated from drug costs was 13,282 units (MDV) versus 11,689 units (PFS). Average weekly costs were $195.71 (MDV) versus $183.23 (PFS). This translated to an estimated $12.48 per patient per week in savings ($518,519 annual savings across the Manitoba Renal Program).

CONCLUSION

The switch from epoetin alfa MDV to epoetin alfa PFS realized cost savings, likely as a result of reduced drug wastage.

Pharmacotherapeutic options for the treatment of depression in patients with chronic kidney disease

Depressive disorders occur in up to one-third of patients with chronic kidney disease CKD). First-line pharmacologic treatments include selective serotonin reuptake inhibitors and second generation agents, such as bupropion, mirtazapine, and venlafaxine. Although very little research has been conducted on the use of antidepressants in CKD, health care providers should be aware of renal dose adjustments for these agents, drug interactions, and potential adverse effects. This article reviews the epidemiology and significance of depression in patients with CKD and discusses drug therapy options for treatment of depression in this patient population.

Are CSN and NKF-K/DOQI mineral metabolism guidelines for hemodialysis patients achievable? Results from a provincial renal program

BACKGROUND

The calcium, phosphorus, and parathyroid hormone targets recommended by the Canadian Society of Nephrology (CSN) encompass a wider range of values as compared to the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines. We sought to compare mineral metabolism parameters within the Manitoba Renal Program (MRP) to the CSN and NKF-K/DOQI guidelines. Medication use was also examined.

METHODS

All hemodialysis patients in Manitoba were evaluated. Values for serum albumin, phosphorus, calcium, intact parathyroid hormone (PTH) and pertinent medications were collected.

RESULTS

Five hundred and forty-six patients were included in the analysis. Fifty-three per cent to 81% of MRP patients met individual CSN targets. However, only 26% of patients achieved all targets, despite high usage of phosphate (85.5% calcium carbonate, 16.1% sevelamer, 1.3% aluminum) and PTH-lowering drug therapies (30.2% calcitriol, 2.7% cinacalcet).

CONCLUSION

Only a small proportion of patients were able to achieve all three CSN mineral metabolism targets simultaneously. The majority of outliers presented with hyperphosphatemia or hypoparathyroidism.

Oral calcitriol versus oral alfacalcidol for the treatment of secondary hyperparathyroidism in patients receiving hemodialysis: a randomized, crossover trial

BACKGROUND

Secondary hyperparathyroidism is a common complication in patients with chronic kidney disease and treatment with vitamin D analogues is a mainstay of therapy. Although oral calcitriol and alfacalcidol are used extensively in Canada, there is little published data comparing equal doses of these agents.

OBJECTIVES

To compare the effect of equal doses of oral calcitriol and alfacalcidol on intact parathyroid hormone concentrations (iPTH) in the treatment of secondary hyperparathyroidism due to chronic kidney disease. Secondary endpoints included serum 1,25-dihydroxyvitamin D3, calcium and phosphate concentrations, achievement of target iPTH concentrations, and need for phosphate binder dose increases.

METHODS

Five adult hemodialysis subjects who were naA ve to vitamin D analogues and had iPTH concentrations > or = 20 pmol/L were enrolled in a prospective, randomized 16-week crossover pilot study. Subjects were randomized to either oral calcitriol or oral alfacalcidol 0.75 mcg three times weekly for six weeks. After a four-week washout period, patients were crossed over to the alternate drug for six weeks.

RESULTS

Oral calcitriol significantly suppressed iPTH after six weeks of therapy (p=0.003), while no significant change in iPTH was observed with oral alfacalcidol.

CONCLUSIONS

This small randomized crossover study provides preliminary evidence that equal doses of oral alfacalcidol and calcitriol may demonstrate differences in iPTH suppression during the first six weeks in dialysis patients treated for secondary hyperparathyroidism. Further comparative trials are required to confirm this finding and to determine whether important differences in parathyroid hormone suppression exist between oral calcitriol and alfacalcidol beyond the six-week period. Key words: Vitamin D analogues, alfacalcidol, calcitriol, secondary hyperparathyroidism, renal dialysis.

Conversion from epoetin alfa to darbepoetin alfa within the Manitoba Renal Program: evaluation of dose ratios

We sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for patients with anemia of chronic kidney disease (CKD) in a large provincial renal program. Hemodialysis (HD), peritoneal dialysis (PD) and pre-dialysis patients with CKD were included. Laboratory parameters and darbepoetin alfa doses were compared to epoetin alfa doses (same route). In 2005, 857 patients received darbepoetin alfa and were compared to 746 patients who received epoetin alfa in 2003-2004. Mean dose conversion ratios were 12,939 IU, 53.1 microg, 244:1 for HD; 9,273 IU, 41.8 microg, 222:1 for PD; and 5,516 IU, 25.2 microg and 219:1 for CKD patients. The mean hemoglobin and iron parameters were within K/DOQI targets on both drugs. Conversion ratios in HD, PD and CKD patients using erythropoietic therapies was greater than 200:1 with both intravenous and subcutaneous dosing. Renal programs across Canada should consider dosage conversion ratios in addition to drug acquisition costs when considering a formulary decision about erythropoiesis stimulating agents.

Erythropoietin dose requirements when converting from subcutaneous to intravenous administration among patients on hemodialysis

BACKGROUND

The optimal route for administration of exogenous erythropoietin remains controversial, particularly after the increased incidence in pure red cell aplasia. In Canada, the majority of hemodialysis units have converted to the intravenous route for administration of erythropoietin to potentially decrease the risk of pure red cell aplasia.

OBJECTIVE

To compare the difference in the weight-adjusted, weekly erythropoietin dose (units/kg/wk) administered by the subcutaneous compared with the intravenous route in a chronic hemodialysis population followed for 12 months.

METHODS

This prospective cohort study recruited patients receiving subcutaneous erythropoietin for at least 3 months while undergoing dialysis in a tertiary care hemodialysis program. Participants were switched to intravenous erythropoietin, and the average weekly dose was recorded at 1, 2, 3, 6, and 12 months. Anemia management and hemoglobin, iron, and delivered dialysis dose targets remained constant throughout the study.

RESULTS

The erythropoietin dose increased by 24.5 units/kg/wk (95% CI 12.7 to 36.3; p < 0.001), representing a 20.2% increase (95% CI 10.5% to 29.9%; p < 0.001) 12 months after conversion from the subcutaneous to intravenous route of administration. Both patients with and without residual renal function at baseline required a significant increase in the intravenous dose.

CONCLUSIONS

A 20.2% increase in erythropoietin dose was required to maintain hemoglobin targets between 11 and 12 g/dL after conversion from a subcutaneous to intravenous formulation. Healthcare funding agencies need to reexamine the cost benefit of using intravenous erythropoietin in the hemodialysis population with a low incidence of pure red cell aplasia.

Assessment of a fax document for transfer of medication information to family physicians and community pharmacists caring for hemodialysis outpatients

BACKGROUND

Studies have clearly identified the outpatient dialysis population as one that is at high risk for drug-related problems. The objective of this study was to evaluate whether a fax document was useful for community pharmacies and family physicians to notify these health care providers that their patient was receiving hemodialysis, to update medication and allergy records, provide dosing information on antibiotics and drugs to avoid, facilitate communication from the hemodialysis unit, and to decide if this was a worthwhile project to continue on an on-going basis.

METHODS

Fax documents were sent to community pharmacists and family physicians of 70 hemodialysis patients from two different hemodialysis satellite units. The fax document consisted of a brief cover letter with contact numbers, a copy of the patient's medication and allergy list, a table of appropriate antibiotic doses and medications to avoid in dialysis, and a survey to evaluate this project's usefulness. Fisher's exact test was used to determine whether there were any significant differences between the family physician and community pharmacist responses.

RESULTS

The survey response rate was 37%. Ninety-five per cent (20/21) of family physicians and 81% (22/27) of community pharmacists who responded to the survey would use the medication profile to update their records. Ninety-five per cent of family physicians and 93% of community pharmacies thought the fax document was an improvement in communication from the dialysis unit. Ninety per cent of family physicians and 85% of community pharmacies thought that the fax document was a worthwhile project for the dialysis unit to continue. No significant differences were found between family physician and community pharmacist responses.

CONCLUSIONS

Implementation of a fax document for the transfer of medication information to family physicians and community pharmacists caring for hemodialysis patients aids in updating medication and allergy profiles, improves communication fom the dialysis unit and is considered a worthwhile project to continue on an ongoing basis.

Impact of Pharmacist Intervention on Osteoporosis Treatment after Fragility Fracture

Objective and Background:

The objective of this study was to evaluate whether increasing patient, nurse, and family physician awareness about osteoporosis had an effect on post-discharge initiation of osteoporosis treatment after fragility fracture. A recent study had found that less than 20% of patients with osteoporosis who were treated in hospital for bone fracture received subsequent investigation and treatment of their osteoporosis.

Methods:

The subjects consisted of a historical cohort of 33 patients and a prospective intervention group of 33 patients admitted to a community hospital with a diagnosis of fragility fracture. Data were analyzed for 28 patients in the historical control group and 27 patients in the intervention group. All patients in the latter group gave verbal consent to discuss risk factors and treatment options for osteoporosis. Subjects were included if they were at least 50 years of age and had been admitted to hospital because of hip, wrist, or ankle fracture. Patients were excluded if they had traumatic fractures or fractures related to cancer and if they had dementia or Alzheimer's disease. Patients in the intervention group received education from the pharmacist about osteoporosis. Patients in both groups received a follow-up phone assessment six months after the initial hospital admission. The main outcome measures were number of patients who received bone mineral density (BMD) tests and the number for whom osteoporosis treatment was initiated.

Results:

No significant difference was observed between the groups in terms of the number of BMD tests ordered ( p = 0.49), however, significantly more patients in the pharmacist intervention group had started treatment for osteoporosis at six months after the fragility fracture ( p = 0.001).

Conclusions:

When pharmacists provided education about osteoporosis to patients and nurses and provided information about osteoporosis to family physicians, the proportion of patients receiving treatment for osteoporosis after a fragility fracture was significantly greater than when such information was not provided.

Factors influencing erythropoietin compliance in peritoneal dialysis patients

BACKGROUND

Peritoneal dialysis patients who manage their own therapy with subcutaneous erythropoietin (EPO) may be at risk for noncompliance. The objectives of this study were to examine the rate of noncompliance and to investigate the factors that are associated with patient noncompliance with the prescribed EPO regimen.

METHODS

A multiple-choice questionnaire was mailed to eligible patients, and a review of pharmacy records was conducted for EPO dates of refill. Noncompliance was defined as less than 90% use of the prescribed dose either by pharmacy record review or missed injections on the questionnaire.

RESULTS

Of 55 eligible patients, 54 completed the questionnaire. The overall rate of noncompliance was 35%. Patients who were noncompliant were younger (P = 0.005), had fewer comorbidities (P = 0.050), had been on EPO therapy longer (P = 0.011), were more likely to have completed postsecondary education (P = 0.011), and were more likely to admit to missed peritoneal dialysis exchanges (P = 0.011). On multiple regression analysis, the independent predictors of noncompliance, in order of importance, were missing dialysis exchanges, completion of postsecondary education, and younger age.

CONCLUSION

These findings suggest that noncompliance with EPO injections is relatively common among peritoneal dialysis patients. The independent predictors of noncompliance were missing dialysis exchanges, completion of postsecondary education, and younger age. Further studies are needed to determine if specific interventions targeting this group of patients can affect compliance.

Desensitization protocols for vancomycin hypersensitivity

OBJECTIVE

To discuss the pathophysiology of vancomycin-induced immediate hypersensitivity reactions, review the process of vancomycin desensitization, and provide specific directions for ordering and preparing rapid and slow desensitization protocols.

DATA SOURCES

A MEDLINE search (1966-February 2001) of English-language literature pertaining to vancomycin desensitization and hypersensitivity reactions was performed. Tertiary sources were also used.

DATA EXTRACTION

Published clinical studies and case reports.

DATA SYNTHESIS

The pathophysiology of vancomycin-induced hypersensitivity reactions is discussed along with the procedure of vancomycin desensitization. Desensitization should be considered in Red Man syndrome (RMS) that does not respond to the usual treatment measures, and in vancomycin-induced anaphylaxis. Rapid desensitization is preferred as it is effective in the majority of patients and enables therapeutic dosing of vancomycin within 24 hours. In patients who fail rapid desensitization, a slow desensitization protocol may be tried.

CONCLUSIONS

Vancomycin-induced immediate hypersensitivity reactions include RMS and anaphylaxis. Vancomycin desensitization should be considered for severe RMS reactions not responding to usual measures and in anaphylactic reactions to vancomycin, when substitution of another antbiotic is not feasible.

The pharmacokinetics of subcutaneous enoxaparin in end-stage renal disease

STUDY OBJECTIVE

To evaluate the pharmacokinetics of enoxaparin in end-stage renal disease (ESRD), and determine if dosage reduction is necessary to maintain antifactor Xa activity concentrations within the therapeutic range.

DESIGN

Prospective, single-dose pharmacokinetic study.

SETTING

University-affiliated general clinical research center.

PATIENTS

Eight nonthrombosed patients with ESRD requiring hemodialysis.

INTERVENTION

All subjects received a single dose of enoxaparin sodium 1 mg/kg subcutaneously and had serial plasma antifactor Xa activity concentrations measured over 24 hours.

MEASUREMENTS AND MAIN RESULTS

The pharmacokinetics of enoxaparin were determined from plasma antifactor Xa activity concentrations, and various multiple-dose regimens were simulated. After administration of the drug, total body clearance was 14.6 ml/minute and there was a 2-fold prolongation in antifactor Xa activity half-life compared with values reported in healthy subjects. All other pharmacokinetic parameters were similar to those in healthy subjects and patients with chronic renal insufficiency. An accumulation ratio of 1.6 was estimated for a dosing interval of every 12 hours based on single-dose pharmacokinetics. When various therapeutic regimens were simulated to predict average steady-state antifactor Xa activity, standard enoxaparin dosages of 1 mg/kg subcutaneously every 12 hours and 1.5 mg/kg every 24 hours resulted in average steady-state concentrations within the therapeutic range.

CONCLUSIONS

Based on antifactor Xa activity, ESRD has little effect on the pharmacokinetics of enoxaparin, and dosing adjustments are unnecessary.

Evaluation and management of drug-induced thrombocytopenia in the acutely ill patient

The numerous drugs to which the acutely ill are exposed place these patients at a significant risk of developing drug-induced thrombocytopenia. Such patients tend to have preexisting hemostatic defects that place them at additional risk of complications as a result of the drug-induced thrombocytopenia. The clinical challenge is to provide rapid identification and removal of the offending agent before clinically significant bleeding or, in the case of heparin, thrombosis results. Drug-induced thrombocytopenic disorders can be classified into three mechanisms: bone marrow suppression, immune-mediated destruction, and platelet aggregation. Clinical characteristics, preliminary laboratory findings, and drug history specific to the mechanisms can assist clinicians in rapidly isolating the causative drug.

Amiloride for the prevention of amphotericin B-induced hypokalemia and hypomagnesemia

OBJECTIVE

To review the published clinical data assessing the role of amiloride in the prevention of amphotericin B (AmB)induced electrolyte disorders.

DATA SOURCES

A MEDLINE search (January 1966-April 1999) of English-language literature pertaining to AmB, amiloride, potassium, and magnesium was performed. Tertiary sources were also used.

DATA EXTRACTION

In vivo and in vitro human and animal data and case reports were included due to the lack of published clinical trials.

DATA SYNTHESIS

AmB administration can result in severe hypokalemia and hypomagnesemia requiring chronic supplementation. In one prospective, controlled study of hypokalemia with AmB administration, patients receiving concomitant amiloride had significantly greater potassium concentrations (p < 0.01) and required significantly less potassium supplementation (p < 0.001). Amiloride may also reduce the amount of magnesium supplementation required by sparing elimination through the kidneys.

CONCLUSIONS

Amiloride may be considered for the prevention of AmB-induced hypokalemia and hypomagnesemia, especially in patients at high risk for complications resulting from these electrolyte disorders. Further studies are needed to assess concomitant use of other potassium-sparing diuretics and AmB.

Pharmacotherapy of dyslipidemia in postmenopausal women: weighing the evidence

In the United States, coronary heart disease (CHD) is the leading cause of death in women. The incidence of CHD rises dramatically in women following menopause, which can be partially attributed to a more atherogenic lipoprotein profile. For years, observational and epidemiological data have suggested that estrogen and progesterone therapy reduced CHD end points. However, the first prospective trial that evaluated hormone replacement therapy (HRT) for secondary CHD prevention demonstrated no positive cardiovascular benefit of HRT compared with placebo. In interventional studies, the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA)reductase inhibitors significantly reduced CHD outcomes in postmenopausal women, and these agents have emerged as the drugs of choice for primary and secondary CHD prevention. The selective estrogen receptor modulators (SERMs) may have a role in CHD prevention, but long-term clinical trials evaluating end points are needed. An evidence-based approach is necessary when deciding the appropriate pharmacotherapy of dyslipidemia in postmenopausal women.