Treatment and prevention of influenza in geriatric patients

INTRODUCTION

Older adults are the most vulnerable population to the effects of influenza. These patients have age-related characteristics that make response to both infection and therapeutics different than younger patients.

AREAS COVERED

Influenza vaccination and antiviral therapy are the foundational approaches to preventing and treating influenza in geriatric patients. Older adults should receive one of the three enhanced vaccines before influenza season beings. There are five antivirals used in influenza. Geriatric patients have been under-enrolled in antiviral studies but have been included in small numbers. Oseltamivir has the most abundant evidence, including in the hospital and long-term care (LTC) facilities, and the strongest evidence for reducing mortality and complications. Peramivir offers the shortest time for symptom alleviation, while baloxavir is best tolerated.

EXPERT OPINION

Oseltamivir has the most versatility in preventing and treating influenza in geriatric patients. Parenteral peramivir and zanamivir are second-line alternatives for complicated influenza when oseltamivir cannot be used. Single-dose peramivir and baloxavir are attractive alternatives to oseltamivir in uncomplicated influenza but will not increase in utilization until more evidence is available regarding mortality and complications, particularly in hospitalized and LTC patients. More studies, including comparative trials, are required to elucidate the role in therapy for each therapeutic in the geriatric population.

Lumacaftor/ivacaftor, a novel agent for the treatment of cystic fibrosis patients who are homozygous for the F580del CFTR mutation

INTRODUCTION

Cystic Fibrosis (CF) is an autosomal recessive disease affecting up to 90,000 people worldwide. Approximately 73% of patients are homozygous for the F508del cystic fibrosis transmembrane conductance regulator [CFTR] mutation. Traditionally treatment has only included supportive care. Therefore, there is a need for safe and effective novel therapies targeting the underlying molecular defects seen with CF. Areas covered: In 2016, the Food and Drug Administration and the European Commission approved LUM/IVA (Orkambi), a CFTR modulator that includes both a CFTR corrector and potentiator, for CF patients homozygous for the F508del CFTR mutation. This article reviews the pharmacologic features, clinical efficacy, and safety of LUM/IVA and summarize the available pre-clinical and clinical data of LUM/IVA use. Expert commentary: LUM/IVA showed modest, but significant improvements from baseline in percent predicted FEV₁ (ppFEV₁) as well as a reduction in pulmonary exacerbations by 35% It was shown to be safe for short- and long-term use. Currently, LUM/IVA is the only oral agent in its class available and represents a milestone the development of therapies for the management of CF. Nonetheless, pharmacoeconomic data are necessary to justify its high cost before is use becomes standard of care.

Impact of the Joint Commission Pneumonia Core Measure on Antibiotic Use and Selection for Community-Acquired Pneumonia in the Emergency Room

Background

Prior to 2012, The Joint Commission (TJC) pneumonia core measure (PN-5) required antibiotic administration for suspected community-acquired pneumonia (CAP) within 6 hours of arrival to the emergency room (ER). In 2012, TJC issued PN-6 requiring antibiotic administration within 24 hours of presentation. Though PN-6 was anticipated to reduce overuse and inappropriate antibiotic use and improve appropriate antibiotic selection, the impact of PN-5 and PN-6 on optimizing care for CAP in the ER remains unknown.

Objective

To investigate the impact of TJC pneumonia core measures on antibiotic use in the ER for suspected CAP.

Methods

In this single-center study, medical records of patients 18 years old and older diagnosed with CAP in the ER during 2011 (PN-5) and 2012 (PN-6) and admitted for 1 day or longer were reviewed. Exclusion criteria included criteria for health care–associated pneumonia. Comparisons between groups were performed using descriptive statistics and contingency table analysis with chi-square or Fisher exact tests for categorical variables and t tests for continuous variables. Statistical analyses were performed using Microsoft Excel 2010 and SAS version 9.4.

Results

Antibiotic use was comparable between PN-5 and PN-6. Approximately half of patients in each group received an appropriate empiric CAP regimen (52% vs 54%; P = .807). Among inappropriate regimens, the most common reason was use of a beta-lactam alone (69% vs 83%; P = .26). More patients had an ultimate diagnosis of CAP with PN-6 (78% vs 86%; P = .3).

Conclusion

Changes in pneumonia core measure requirements did not have a significant impact on appropriate antibiotic use in the ER.

Instruments for evaluating medication use and prescribing in older adults

OBJECTIVE

To describe primarily implicit instruments for assessing medication use in older adults.

DATA SOURCES

Literature was identified via PubMed (1966-2014) and Google Scholar using the following search terms: geriatric/medication use, implicit criteria, inappropriate medication use, inappropriate prescribing, older adults/medication use, and polypharmacy. Reference citations from identified publications were also reviewed.

STUDY SELECTION

All articles in English identified from data sources were evaluated. Instruments applicable to pharmacy and multiple medication classes were included. We excluded instruments developed for a single medication or medication class, for a single condition or disease state, as primarily an academic instrument, using primarily explicit criteria, for use primarily by health care practitioners other than pharmacists, or for regulatory purposes.

DATA SYNTHESIS

Seven instruments were reviewed by evaluating characteristics, components of prescribing and medication use addressed, and settings in which they have been evaluated and validated. Screening Medications in the Older Drug User (SMOG) is a six-question instrument developed specifically for community pharmacists. The Medication Appropriateness Index (MAI); Assess, Review, Minimize, Optimize, Reassess (ARMOR) tool; and Tool to Improve Medications in the Elderly via Review (TIMER) are more comprehensive instruments, but they require clinical judgment and are time intensive. Assessing Care of Vulnerable Elders-3 (ACOVE-3) and the Good Palliative-Geriatric Practice Algorithm (GPGPA) are useful in determining need for medication continuation in older adults who are closer to the end of life. The Assessment of Underutilization (AOU) is an implicit tool to guide medication initiation.

CONCLUSION

Each instrument is unique in design, which may be beneficial in some pharmacy practice settings and present barriers in others. The use of multiple instruments may be necessary to optimize therapy in this vulnerable patient population.

Acute iodine toxicity from a suspected oral methamphetamine ingestion

BACKGROUND

Iodine is a naturally occurring element commercially available alone or in a multitude of products. Iodine crystals and iodine tincture are used in the production of methamphetamine. Although rarely fatal, iodine toxicity from oral ingestion can produce distressing gastrointestinal symptoms and systemic symptoms, such as hypotension and tachycardia, from subsequent hypovolemia.

OBJECTIVE

The objective of this case report is to describe a case of iodine toxicity from suspected oral methamphetamine ingestion.

CASE REPORT

A male in his early 20’s presented with gastrointestinal symptoms, chills, fever, tachycardia, and tachypnea after orally ingesting a substance suspected to be methamphetamine. The patient had elevated levels of serum creatinine, liver function tests, and bands on arrival, which returned to within normal limits by day 4 of admission. Based on the patient’s narrow anion gap, halogen levels were ordered on day 3 and indicated iodine toxicity. This is thought to be the first documented case of iodine toxicity secondary to suspected oral methamphetamine abuse.

CONCLUSION

Considering that the incidence of methamphetamine abuse is expected to continue to rise, clinicians should be aware of potential iodine toxicity in a patient with a history of methamphetamine abuse.

Provision of clinical pharmacist services for individuals with chronic hepatitis C viral infection: Joint Opinion of the GI/Liver/Nutrition and Infectious Diseases Practice and Research Networks of the American College of Clinical Pharmacy

The objective of this opinion paper was to identify and describe potential clinical pharmacists' services for the prevention and management of patients infected with the hepatitis C virus (HCV). The goals of this paper are to guide the establishment and development of pharmacy services for patients infected with HCV and to highlight HCV research and educational opportunities. Recommendations were based on the following: a review of published data on clinical pharmacist involvement in the treatment and management of HCV-infected patients; a consensus of clinical pharmacists who provide direct patient care to HCV-infected patients and practice in different pharmacy models, including community-based and academic settings; and a review of published guidelines and literature focusing on the treatment and management of HCV infections. The recommendations provided in this opinion paper define the areas of clinical pharmacist involvement and clinical pharmacy practice in the treatment and management of patients with HCV. Clinical pharmacists can promote preventive measures and education about reducing HCV transmission, improve medication adherence, assist in monitoring clinical and adverse effects, recommend treatment strategies to minimize adverse effects and drug interactions, and facilitate medication acquisition and logistics that positively improve patient outcomes and reduce the health care system costs.

Sipuleucel-T: a therapeutic cancer vaccine for the treatment of castration- or hormone-refractory prostate cancer

Sipuleucel-T is a therapeutic cancer vaccine approved for the treatment of castration- or hormone-refractory prostate cancer. Through a novel process, it activates the body's own antigen-presenting cells to induce an immune response to prostatic acid phosphatase, a protein found on prostate cancer cells. A treatment course consists of three total infusions spread 2 weeks apart. Throughout all phases of clinical trials, sipuleucel-T has been shown to be safe and well tolerated. Sipuleucel-T has demonstrated an ability to increase overall survival by approximately 4 months when compared with placebo. However, sipuleucel-T has not shown any improvement in affecting patients' time to disease progression.

When one drug affects 2 patients: a review of medication for the management of nonlabor-related pain, sedation, infection, and hypertension in the hospitalized pregnant patient

One of the most difficult challenges health care providers encounter is drug selection for pregnant patients. Drug selection can be complex as efficacy and maternal side effects must be weighed against potential risk to the embryo or fetus. Verification of an individual drug's fetal safety is limited as most evidence is deduced from epidemiologic, prospective cohort, or case-control studies. Medication selection for the pregnant inpatient is a particularly complex task as the illnesses and conditions that require hospitalization mandate different medications, and the risk versus benefit ratio can vary significantly compared to the outpatient setting. Some degree of acute pain is not uncommon among inpatients. Acetaminophen is generally considered the drug of choice in pregnancy for mild to moderate acute pain, while most opioids are thought to be safe for short-term use to manage moderate to severe pain. Providing sedation is particularly challenging as the few options available for the general population are further limited by either known increased risk of congenital malformations or very limited human pregnancy data. Propofol is the only agent recommended for continuous sedation, which has a Food and Drug Administration classification as a pregnancy category B medication. Treatment of infections in hospitalized patients requires balancing the microbiology profile against the fetal risk. Older antimicrobials proven generally safe include beta-lactams, and those with proven fetal risks include tetracyclines. However, little to no information regarding gestational use is available on the newer antimicrobials that are frequently employed to treat resistant infections more commonly found in the inpatient setting. Management of maternal blood pressure is based on the severity of blood pressure elevations and not the hypertensive classification. Agents generally considered safe to use in hypertensive pregnant patients include methyldopa, labetolol, and hydralazine, while angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, hydrochlorothiazide, and atenolol should be avoided.

The treatment of pulmonary Wangiella dermatitidis infection with oral voriconazole

WHAT IS KNOWN AND OBJECTIVE

Wangiella dermatitidis is a darkly pigmented fungus that has been isolated from the soil, dead plant material and areas of high humidity. Infection from the pathogen has not been extensively documented and few published cases report survival. Of the antifungal agents used in previous reports, none has been proven to improve outcomes. Voriconazole is known to have in vitro activity against the organism, but clinical experience for the treatment of W. dermatitidis infection is limited. The objective of this case report is to describe the use of voriconazole for the treatment of W. dermatitidis infection.

CASE SUMMARY

An 86-year-old American woman with a past medical history significant only for mild dementia is successfully treated for pulmonary W. dermatitidis infection using oral voriconazole monotherapy with minimal adverse effects.

WHAT IS NEW AND CONCLUSION

Voriconazole appears to be effective as monotherapy for the treatment of pulmonary W. dermatitidis infections. A minimum of 3-4 months of antifungal treatment should be given. Adverse effects with prolonged voriconazole use do not appear to be a barrier to treatment.

Tolvaptan: a vasopressin antagonist for the management of euvolemic and hypervolemic hyponatremia

Tolvaptan is a new vasopressin antagonist developed for the treatment of hypervolemic or euvolemic hyponatremia. It has greater affinity for the V(2) receptor than native vasopressin or any other vasopressin antagonist. Blockade of the V(2) receptor induces solute-free water excretion without affecting normal electrolyte excretion. The pharmacokinetics and pharmacodynamics of tolvaptan are suitable for once-daily dosing. Throughout all phases of clinical studies, it was shown to be safe for short- and long-term use. Tolvaptan effectively increases serum sodium levels in patients with heart failure, cirrhosis and syndrome of inappropriate secretion of antidiuretic hormone. In patients hospitalized owing to heart failure, tolvaptan decreased bodyweight, increased urine output and improved dyspnea compared with placebo. However, tolvaptan has not proven to be beneficial for the long-term management of heart failure. Currently, tolvaptan is the only oral agent in its class available in the USA and Europe.