What is The Value of Diet and Exercise in Patients With Diabetes?

Citation: The Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013; 369: 145-54.

Category: Diabetes
Original commentary found in iForumRx.com, written by: By Danielle Hebel, PharmD and Erica Pearce, PharmD, BCPS

Today, I read this Article posted in iForumRx: “Looking AHEAD to less diet and exercise for patients with diabetes?

This article points out that intensive lifestyle interventions (7% weight loss and increase physical activity 175 min/week) does not impact CV morbidity and mortality or lower CV risk; however, it does have positive outcomes on A1C, HDL, LDL, and mean SBP.  In addition, it can lower the risk of urinary incontinence, sleep apnea, and depression, as well as improve quality of life and physical functioning.

Patients in this study were not poorly controlled with their DM as we see in practice. Perhaps in patients who are poorly controlled, intensive lifestyle interventions may lower their CV risk. This commentary questions whether weight loss and exercise should be recommended to all patients with DM. I would say YES; while, weight loss (for patients who are obese) and exercise may not truly show decrease in CV risk, it can still bring other benefits and it does not cause harm; therefore if the pt is able to exercise I would recommend it.

~Livia

Β-Blockers And Hypertension: Where Are The Data?

Citation: Parker ED, Margolis KL, Trower NK, et al. Comparative Effectiveness of 2 β-Blockers in Hypertensive Patients. Arch Intern Med 2012: 172: 1406-12.
Category: Hypertension
Original commentary found in iForumRx.com, written by: Jenna M. Siskey, PharmD, Adraine L. Lyles, PharmD, BCPS, and Dave L. Dixon, PharmD, BCPS

Commentary Written By: Livia Macedo, PharmD

This study compares both B-blockers atenolol and metoprolol tartrate in patients without compelling indications. Compelling indications in which B-blocker therapy is recommended includes heart failure with reduce ejection fraction, acute myocardial infarction, high coronary disease risk, and diabetes. Currently, in JNC 7, B-blockers are recommended as second line in these patients, after a thiazide diuretic, and equally recommended as ACEI, angiotensin II receptor blockers, and calcium channel blockers. However, the 2007 American Heart Association recommends B-blockers as 3rd or 4th line for the treatment of hypertension in these patients. The results of the study by Parker, et al. showed there was no difference between atenolol and metoprolol tartrate in reducing MI, HF, stroke, or cardiovascular event in patients with hypertension without compelling indications. I personally would recommend B-blockers as a 3rd or 4th line in patients with hypertension without compelling indications. I would first recommend thiazide diuretic, ACEI or ARB, and CCB. Then, if needed would recommend a B-blocker such as atenolol rather than metoprolol tartrate because of its once daily dosing; and would recommend metoprolol tartrate as an alternative option if atenolol is not appropriate for the patient. What would you do?

Check out iForumRx for the more details on this article at http://www.iforumrx.org/

Dosing Blood Pressure Medications At Bedtime: Improve Outcomes?

Citation: Hermida RC, Ayala DE, Mojon A, and Fernandez JR. Influence of Time of Day of Blood Pressure- Lowering Treatment on Cardiovascular Risk in Hypertensive Patients with Type 2 Diabetes. Diabetes Care. 2011; 34: 1270-76.
Category: Diabetes, Hypertension
Original commentary found in iForumRx.com, written by: Joshua W. Fleming, Pharm.D. and Patricia A. Ross, Pharm.D., BCPS

Commentary Written By: Livia Macedo, PharmD

This study commented how dosing blood pressure medications at bedtime might reduce risk of cardiovascular events, specifically in patients who are “non-dippers”. I learned that the term non-dippers is used when referred to patients who don’t normally have a 10% drop in blood pressure overnight. This non-dipping blood pressure pattern has been associated with a higher risk of cardiovascular events. The authors from the original study claim that by moving 1 or more blood pressure medication to bedtime will not only decrease nocturnal blood pressure, but will also decrease cardiovascular events and increase event free survival. However, Fleming, et al. points out several limitations associated with this study. The study is not specific with regards to what classes of blood pressure medications should be moved to bedtime. Dose adjustments and baseline blood pressure medication are not reported. In addition, this study was conducted only in one center in Spain, and may not be generalizable in locations with a more diverse population. These factors make it challenging to replicate this study in other settings. Although, this study has limitations, I think it can still be applicable in practice as an alternative option for patients who are non-dippers with uncontrolled nocturnal and awakening blood pressure, and are consistently adherent to their medications. In this situations, I think it would be okay to recommend to take one of their blood pressure medications at bedtime (definitely not a diuretic though, due to inconvenience for the patient), and monitor for improvement in their nocturnal and morning blood pressure. Definitely encourage adherence as most important. I don’t think it would be a good idea to ask patients who are currently non-adherent to their medication to take one blood pressure medication at bedtime, because that would make their medication regimen more complex, and increase likelihood of them missing doses, which could potentially worsen their clinical outcome. What are your thoughts? Would you consider recommending  a blood pressure medications at bedtime? If so, which class of blood pressure medications?

Check out iForumRx for the more details on this article at http://www.iforumrx.org/

Is Tiotropium Appropriate For Uncontrolled Asthma?

Citation:  Kerstjens HAM, Engel M, Dahl R et. al. Tiotropium in Asthma Poorly Controlled with Standard Combination Therapy.  N Engl J Med 2012; 367:1198-1207.

Moderator: Roshni Patel, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident

Panelists:  Mona Tsoukleris, Pharm.D. and Dennis Williams, Pharm.D.

Category: Ambulatory Care

Commentary Written By: Livia Macedo, PharmD

I read about the study discussion posted on Feb 18 by Dr. Patel “Tiotropium in asthma poorly controlled with standard combination therapy”.  This study was a two replicate randomized, double-blind, placebo-controlled trial which included patients (N=912) of age 18-75 years with asthma for >5 years diagnosed before age 40, lifelong nonsmokers or people who had a smoking history of fewer than 10 pack years with no smoking in the year before enrollment.  They excluded patients with COPD, serious coexisting illness, and concurrent use of anticholinergic bronchodilators. The study compared the effect on lung function and exacerbations of adding tiotropium 5 mcg or placebo, both delivered by a soft-mist inhaler once daily for 48 weeks. The results of this study showed that the addition of tiotropium to ICS and LABA therapy reduced the risk for exacerbations and improved lung function.  However the study presented with some limitations. Patients included in this study could have mixed asthma and COPD. To ensure these patients had solely asthma, they should have included patients from a different age group of 18-35 instead. In addition, this study was sponsored by the product’s manufacturer, which could have led to study bias. This agent may be a therapeutic option for patients with mixed asthma and COPD.  I think more research is needed at this time to determine whether this agent is a treatment option for patients solely with asthma. What are your thoughts? When would you consider the use of tiotropium?

Check out iForumRx for the more details on this article at http://www.iforumrx.org/