Commentary

Jun 26, 2017

Among Medicare recipients, from 2000 to 2010, there was a whopping 83-fold increase (that’s an 8300% increase!) in the number of blood tests performed to determine their vitamin D status.1 What could possibly cause such a dramatic increase?  While the aging U.S. population is at a higher risk for fractures and falls and may benefit from vitamin D supplementation, it is unlikely that this is the main driver of this phenomenon.  A more likely explanation is the fascination...

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Jun 10, 2017

Whether – or not - to continue anticoagulation therapy to prevent venous thromboembolism (VTE) after the initial acute treatment period requires shared decision making.  The risks and benefits are patient and situation-specific.  Numerous factors need to be considered. And the risks and benefits change over time. The EINSTEIN CHOICE study provides some important new insights to help inform this decision.1

 

Tens of thousands die from venous thromboembolism (VTE)...

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Apr 14, 2017

More than 15 million Americans have coronary heart disease and most should be taking aspirin daily.1  Given aspirin’s ubiquity in cardiovascular medicine and patients’ pill boxes, it is shocking that there are still so many unanswered questions about aspirin use.  Which dose and dosage forms should be prescribed?  How common is aspirin resistance?  What is the relationship between platelet inhibition and clinical outcomes?

 

The notion of aspirin “resistance” is...

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Mar 24, 2017

Many patients with atrial fibrillation (AF) received triple antithrombotic therapy after undergoing a percutaneous coronary intervention (PCI) and receiving cardiac stent. Triple therapy consists of warfarin plus dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor and low-dose aspirin. But is triple therapy the best approach? This practice, while widely employed, is not entirely evidence-based. It’s actually the result of combining two evidence-based strategies – one to...

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Mar 13, 2017

Could automated, web-based cognitive behavioral therapy (CBT) replace flesh-and-blood healthcare practitioners?  Can computers deliver healthcare at lower cost and similar quality to face-to-face interactions with humans? Several web-based CBT programs have been developed and are now being marketed directly to consumers.  But do they actually work?

 

According to results of the America Insomnia Survey, up to 50% of adults in the U.S. experience difficulty sleeping. Of those,...

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Feb 24, 2017

Hypertension affects more than 70% of patients with type 2 diabetes mellitus and further increases the risk of cardiovascular disease in this high risk population.1 While renin angiotensin system (RAS) blockers are clearly indicated in patients with heart failure, chronic kidney disease with proteinuria, and coronary artery disease (CAD), experts have come to different conclusions regarding their role as initial antihypertensive therapy for patients with diabetes (See Table 1)....

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Feb 9, 2017

About 5 million Americans are currently living with heart failure (HF) and an astounding 24-42% of them also suffer from depression.1,2 One meta-analysis found a greater than 2-fold risk of death in patients with HF and comorbid depression.  Depressed patients with HF are more likely to be hospitalized, seek care from emergency rooms, and rack up big bills.3  Not surprisingly, patients with HF and depression have a much lower quality of life when compared to HF patients...

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Jan 25, 2017

Critically evaluating the primary literature and applying the information to patient care is vital to ensuring optimal patient outcomes.  Unfortunately, the foundational knowledge and skills that most of us acquire during our formal education and post-graduate training programs are unlikely to fully prepare us for the challenges and intricacies of interpreting the evolving methods used in clinical drug studies today.  Like the development of any skill, it requires practice and refinement...

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Jan 13, 2017

Pharmacotherapy for diabetes management has expanded in recent years with several new drug classes. Beyond lowering A1c, some medications show promise for reducing cardiovascular risk.1-2 Current guidelines recommend several options for patients who have not reached their goal A1c on metformin monotherapy including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) or basal insulin.3  However, if basal insulin is chosen as the first add-on treatment with...

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Dec 29, 2016

When you reach a certain age, bowel cleansing becomes a necessary poison.  Colorectal cancer is the third most common type of cancer in the United States with an estimated 95,270 new colon and 39,220 new rectal cancer diagnoses for 2016. More importantly, colorectal cancer (CRC) is the second most common cause of cancer-related mortality in the United States. Screening is imperative because the early stages of CRC are often asymptomatic1 and when combined...

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Dec 6, 2016

A mom recieves a prescription for an oral clindamycin solution for her daughter.  The instructions: “give one teaspoon by mouth three times daily for 10 days.”  The mom is given a medicine cup marked with “mLs”  and “tsp” on the side.  Five days later she returns complaining that she ran out of medicine.  After a brief interview, you determine that she has been giving her daughter one “cupful” instead of one “teaspoon.”

 

This brief case vignette is all too common.  Children...

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Nov 11, 2016

Approximately one in three patients with diabetes in the United States have chronic kidney disease (CKD).1 As CKD is progressive and irreversible, the goal is to slow its progression.  In addition to controlling blood pressure and blood glucose, clinical practice guidelines recommend the use of angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs).2 However, these agents are contraindicated in patients who develop intolerance or...

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Nov 7, 2016

From 2000–2010, opioid overdose was the fastest growing cause of death in the United States.1 In 2014, opioids were implicated in 61% of all drug overdose deaths, killing 28,647 Americans.2 Forty states have passed legislation recognizing pharmacists as front-line providers for overdose prevention by allowing standing orders for naloxone.3 Unfortunately, many pharmacists are not well prepared to fully participate in opioid harm reduction efforts due to a lack...

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Sep 29, 2016

A recent paper published in Diabetes Care proposes a new classification system for diabetes that challenges our existing paradigm and has significant implications for our treatment approach to diabetes.1  Here are eleven key takeaway points that every practitioner should know about the proposed beta-cell centric classification schema:

 

Background:

 

...
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Sep 15, 2016

Primary prevention is rooted at the foundation of public health by promoting interventions to decrease healthcare utilization and disease burden.  Cardiovascular disease (CVD) remains the leading cause of death not only in the United States but worldwide — causing 18 million global deaths annually and estimated to increase to 23 million by 2030.1,2 Stroke is the third leading cause of death in the United States but the second leading cause worldwide.1,2 Heart disease...

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Sep 2, 2016

Cardiovascular disease is the leading cause of morbidity and mortality in patients with type 2 diabetes.1 While many medications effectively treat the hyperglycemia and microvascular complications associated with diabetes, there has been a recent focus on medications that not only lower blood glucose but mitigate the risk of cardiovascular events.1  The need for more data regarding the macrovascular safety of antidiabetic drugs entered the spotlight in 2008 when the FDA...

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Aug 16, 2016

Persons diagnosed with a psychiatric disorder consume nearly half of all cigarettes smoked in the United States!  Moreover, they are at higher risk for premature death, especially from vascular disease and cancer.1  Smoking cessation efforts are paramount in this population but often more challenging. Clinical practice guidelines firmly endorse pharmacotherapy — combined with cognitive behavioral therapy — be offered to all patients willing to quit smoking.2 Seven first...

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Jul 17, 2016

We're all aware that there is an obesity epidemic and its linked to dozens of health problems.1  But nothing we've done so far — public awareness campaigns, changes in school lunch programs, and approving new drugs for weight loss — has halted this epidemic.  Although the rate of obesity in kids age 2 to 19 has plateaued around 17%, it continues to climb in young adults and most of us keep packing on the pounds as we get older!2

 

For patients with obesity...

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Jun 17, 2016

The list of regimens for Helicobacter pylori eradication is longer than ever.  In recent years, American and European guidelines have recommended clarithromycin-based triple therapy or bismuth-containing quadruple therapy for primary treatment of H. pylori infection (Table 1).1,2  However, increasing resistance to these regimens has forced us to consider alternative treatments, including but not limited to: the addition of probiotics, use of sequential regimens,...

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Jun 3, 2016

Resistant hypertension (RH) is frequently encountered in primary care practice and often presents a significant clinical challenge because limited evidence-based guidance exists.1 RH is a major cause of cardiovascular disease and death, and has been associated with a 50% increased risk of myocardial infarction, stroke, congestive heart failure, and chronic kidney disease when compared to patients without RH.2,3   The American Heart Association defines RH as uncontrolled...

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May 20, 2016

Could a nutritional supplement be the “magic bullet” in heart failure therapy?  Coenzyme Q10 (CoQ10), or ubiquinone, is an electron carrier in mitochondria and plays a key role in ATP synthesis. It is also thought to have antioxidant effects and may stabilize LDL molecules. All of which would, theoretically, help the failing heart.1-3

 

Previous studies using CoQ10 in HF have suggested it may, indeed, have clinical benefits.4-6 Several meta-analyses have...

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May 6, 2016

“Slip! Slop! Slap! And Wrap!®”, the slogan created by the American Cancer Society is a catchphrase intended to attract the public’s attention, raise awareness of the dangers of ultraviolet (UV) radiation, and promote prevention against skin cancer.1 By slipping on a shirt, slopping on sunscreen, slapping on a hat, and wrapping on sunglasses, the organization reminds the public to take measures to protect themselves against all types of skin...

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Apr 22, 2016

After cardiovascular (CV) safety concerns emerged with rosiglitazone use, the Food and Drug Administration (FDA) now requires outcome studies to be performed for all new diabetes medications.1-3  Naturally, we’d prefer to use medications to treat diabetes that actually reduce CV risk – but, at a minimum, they shouldn’t be harmful.  The first CV safety study (ELIXA) for a drug in the glucagon-like peptide 1-receptor agonist (GLP-1 RA) class – lixisenatide - was recently...

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Apr 8, 2016

Managing behavioral health in persons with dementia is an enormous and growing problem. Today more than 5.3 million Americans are living with Alzheimer’s disease (AD) and that number is expected to increase by 30% by 2025.1 Most patients with AD have challenging neuropsychiatric symptoms such as agitation. These symptoms are distressing and often overwhelming for caregivers often resulting in institutionalization and increased healthcare utilization.1 Several...

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Mar 25, 2016

A 76 year-old male with a past medical history of hypertension, diabetes, and atrial fibrillation on warfarin management is undergoing elective surgery that requires warfarin to be held. The patient’s CHADS2 score is 3 with no history of stroke. Should this patient be bridged with low molecular weight heparin (LMWH)? For over two decades LMWHs have been routinely used to provide therapeutic coverage in patients who must temporarily stop warfarin.1 Current guidelines...

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