another successful educational event -...

Page | 1 www.accuscriptspharmacy.com April 2016

Another Successful Educational Event

AccuScripts Pharmacy sponsored and hosted a Lunch & Learn for those who work

with Individuals with Intellectual/Developmental Disabilities (IID). Allisha

Berendts, Licensed Professional Clinical

Counselor and PhD candidate from The Ohio

State University Nisonger Center delivered an

excellent overview of mental health issues in the

IID community and how those present similarly

and differently from the rest of the population.

Attendees from all over northern Ohio were able

to enjoy this event and earn 1 CEU in nursing

and/or Ohio Department of DD training credit.

Evaluations show an excellent response to the

content, speaker and enthusiasm for more similar

topics. Rest assured AccuScripts has heard and

will be offering quality educational programs

like this in the future. As with our pharmacy

operations, your feedback drives our service.

IN THIS ISSUE:

Dementia Incidence in the U.S. 2

Overview of Alzheimer’s Disease 2

Questionable Medication Benefit in

Advanced Dementia 5

Antibiotic Stewardship in LTCF 6

Two Diabetes Drugs have Heart Failure

Risk 7

New FDA Approvals 7


The March 2016 edition of Annals of Long-Term Care reveals from the first study to look at

dementia risk in the U.S. population that there appears to be dementia incidence highest among

African Americans and American Indians and Alaskan natives; intermediate among Latinos,

Pacific Islanders and Caucasians, and lowest among Asian Americans. This information was

published by The Journal of the Alzheimer’s Association and analyzed data from more than

274,000 northern California members of Kaiser Permanente.

The researchers used electronic health records covering patient visits for a 14 year period – from

January of 2000 through December of 2013 – to identify participants diagnosed with dementia as

well as their race and ethnicity. The dementia diagnoses included Alzheimer’s, vascular and

non-specific dementia.

If a U.S. resident remains dementia-free at age 65, the chances of developing dementia over the

course of the remainder of his / her life is still high. 38% African Americans, 35% American

Indians/Alaskan Natives, 32% Latinos, 30% Caucasians, 28% Asian Americans and 25% Pacific

Islanders can still expect to contract some form of dementia during their remaining years.

Heather S Anderson, MD, staff neurologist and associate professor, University of Kansas

Alzheimer’s Disease Center, and Jasvinder Chawla, MD, Chief of Neurology, Hines veterans

Affairs Hospital, Loyola University Medical Center, have just now published an up-to-date

comprehensive overview of the current information available pertaining to Alzheimer’s:

Alzheimer’s is an acquired disorder of cognitive and behavioral impairment, is progressive and

incurable; the disorder develops due to the formation of plaques in the hippocampus which

hinders and eventually destroys functioning of memory, decision-making, learning and thinking

in general. The plaque formation is still an unknown regarding it being a product of the disease

or the causative agent. It is thought that specific regions of the brain (e.g. entorhinal cortex,

hippocampus) probably begin to be affected some 10-20 years before any visible symptoms

appear. A patient with preclinical AD may appear completely normal on physical examination

and mental status testing.

Mild Alzheimer disease can include:

memory loss

confusion about the location of familiar places

increased time required to complete normal, daily tasks

trouble handling money and paying bills

compromised judgement and declining decision-making


loss of spontaneity

mood and personality changes; increased anxiety

Moderate Alzheimer disease:

increasing memory loss and confusion

shortened attention span

problems recognizing familiar people

difficulty with language, reading, writing, math

difficulty organizing thoughts and thinking logically

inability to learn new concepts or cope with new or unexpected situations

restlessness, agitation, anxiety, tearfulness, wandering, especially during the late

afternoon or at night

exhibiting of hallucinations, delusions, suspiciousness or paranoia, irritability

loss of impulse control

having perceptual-motor problems e.g. getting out of a chair, setting the table

Severe Alzheimer disease:

inability to recognize anyone

inability to communicate in any way

showing total loss of sense of self

(usually) weight loss

possible onset of seizures, skin infections, dysphagia

only vocalization becomes groaning, moaning or grunting

increased sleeping, with often times progression to bedridden status

incontinence

eventually, death (which is often the result of other illnesses, frequently aspiration

pneumonia)

Diagnosis:

Clinical exam – the clinical diagnosis is usually made during the mild stage of the disease, using

the above-listed signs/symptoms lumbar puncture (which usually reveals elevated levels of tau

and phosphorylated tau in the CSF and amyloid levels are low – this technique is not

recommended now except in research settings) imaging studies of the brain, especially to

differentiate and rule out potentially treatable causes of progressive cognitive decline e.g. chronic

subdural hematoma, normal-pressure hydrocephalus.

Management of Alzheimer’s Disease:

Front line medications (which only slow the rate of progressive symptoms) which are the

neurotransmitter modulators of acetylcholine and glutamate; currently four such modulators have


been approved and are available on the American market place: Aricept, Exelon, Razadyne and

Namenda.

Other psychoactive medications may be considered to treat the secondary symptoms of AD:

antidepressants

anxiolytics

antiparkinsonian agents

beta blockers

anti-epileptic drugs

neuroleptics (but only when behaviors threaten others, self or property)

Prevention:

No proven modalities, but some epidemiologic studies suggest that the following may be

protective:

physical and mental activity – ongoing

exercise – ongoing

cardiorespiratory fitness – ongoing

(possibly) diet…. the most notable being the Mediterranean diet

Background and risk factors:

Alzheimers is the most prevalent form of dementia in the U.S., affecting over 5.3 million

residents

Extremely costly to the American economy; those with Alzheimer’s aged 65 and over

cost well over 220 billion dollars annually. Approximately 200,000 people younger than

65 with AD constitute the younger demographic.

Currently, an autopsy or brain biopsy is the only way to make a definitive diagnosis of

AD. In clinical practice, the diagnosis is usually made on the basis of the patient’s

history and findings on the Mental Status Examination.

Four different genes (at least) have been definitively associated with AD, and others that

have a probable role have been identified.

The mechanisms by which altered amyloid and tau protein metabolism, inflammation,

oxidative stress and hormonal changes may produce neuronal degeneration in AD are

being elucidated, and rational pharmacologic interventions based on these discoveries are

being developed

The risk factors of obesity, insulin resistance, vascular problems, dyslipidemia,

hypertension (especially midlife), inflammatory markers, Down syndrome, traumatic

brain injury, family history, advancing age, having the APOE 4 genotype and having

decreasing estrogen levels (i.e. being postmenopausal) include many of the risk factors

that place the adult into a mildly compromising situation regarding increasing the odds of

one day presenting with AD.


The cause / etiology of AD is unknown, however, several investigators now believe that

converging environmental and genetic risk factors trigger a pathophysiologic cascade

that, over decades, leads to Alzheimer pathology and dementia.

As we have just reviewed in the ‘Severe Alzheimer disease’ stage of progression, many, if not all

‘advanced dementia’ descriptions would closely parallel this status described in the severe or end

stage of Alzheimer’s. Upon the arrival to this near-end-of-life state, a very important and often

controversial question needs to be asked and assessed: what medications now should be

discontinued and which ones retained? All kinds of factors now will play a role in determining a

decision as to what meds we keep on board and those we don’t. First and foremost would be the

wishes and desires the resident had in mind at an earlier time when cognitive function was intact

(though this specific area of level of care may well not have been documented in the ‘advance

directives’ section of his/her chart). If no such documentation expressly written by the resident

exists, then the medical power of attorney may need to come up with some kind of medication

regimen guidance and relay this to the PCP, nurse practitioner or P.A. But again, an informed

decision on the part of the MPOA may not be at hand, and he / she may actually feel very ill at

ease in making this decision. If the MPOA turns out to be a family member who communicates

regularly with several other family members, this issue may become a hotly contested decision

with emotion often times entering in to the decision-making process rather than informed logic.

We could examine all classes of medications that might be questionable for continuing

administration to the advanced dementia patient, however, this would be an extremely lengthy

project and the continuing or discontinuing of medications may depend on the unique physical

and / or mental status of the resident in question.

The American Geriatrics Society fosters the idea of minimizing or eliminating medications that

do not support the primary goal of healthcare that should have been or presently needs to be

elucidated for the advanced dementia resident. The Choosing Wisely initiative and campaign

which has published “Ten Things Physicians and Patients Should Question” does list two med

classes and a procedure that should generally be excluded in caring for the end stage dementia

resident. They are:

-the cognitive enhancers (Aricept, Exelon, Razadyne, Namenda) with the rule of thumb being:

these should not be prescribed or continued to manage the end-stage dementia patient without

periodic assessment (perhaps at two to three month increments) of a perceived cognitive benefit

the resident is experiencing + assessing that no adverse gastrointestinal effects are present.

Another class of medications Choosing Wisely, Consumer Reports and AMDA discusses is the

statins. All seem to agree that the vast majority of residents > 75 years of age should not be on

statins – there is no clear evidence for older patients that high cholesterol leads to heart disease

and death, and some studies indicate that older people with the lowest cholesterol levels actually


have the highest risk of death. Statins generally are somewhat costly, may induce risk factors

such as memory loss, confusion, nausea, constipation, diarrhea and have negative effects on

skeletal muscles when combined with other medications.

And finally the third ‘don’t’ consists of not recommending percutaneous feeding tubes in

patients with advanced dementia; instead offer oral assisted feedings. Multiple studies have

turned in strong evidence that artificial nutrition does NOT prolong life or improve quality of

life in patients with advanced dementia, nor does it ensure comfort or reduce suffering and may

cause fluid overload, diarrhea, abdominal pain, does not promote human interaction and may

increase the risk of aspiration.

Recent overtures expressed by the Center for Medicare and Medicaid Services (CMS) and the

Center for Disease Control and Prevention (CDC) has resulted in heightened awareness and

stricter enforcement of antibiotic stewardship in extended-care facilities across the United States.

LTC facilities are increasingly being cited for inappropriate antibiotic use. A significant

percentage of antibiotics prescribed in facilities have been found to be unnecessary or

inappropriate. In fact, in skilled nursing facilities, the inappropriate use of antibiotics has a

specific guideline (F-Tag 329 Unnecessary Drugs).

In September 2015, the CDC had a press release that advised all nursing homes to implement the

following core elements to improve antibiotic use: leadership commitment, accountability, drug

expertise, action, tracking, reporting and education. These suggestions come after findings that of

the 4.1 million Americans who reside in nursing homes annually, 70% received antibiotics

F329

Medication Issues of Particular Relevance: All Antibiotics

Indications

Use of antibiotics should be limited to confirmed or suspected bacterial infection

Adverse Consequences

Any antibiotic may cause diarrhea, nausea, vomiting, anorexia and hypersensitivity/allergic

reactions

Antibiotics are non-selective and may result in the eradication of beneficial microorganisms

and the emergence of undesired ones, causing secondary infections such as oral thrust, colitis,

and vaginitis.


during a year and up to 75% of antibiotics are prescribed incorrectly (wrong drug, dose, duration

or reason). The CDC recommendations aim to help nursing homes reduce their inappropriate

antibiotic therapy use to protect residents from the consequences of antibiotic resistant infections

such as C. difficile.

The CDC’s input that is expected to be followed by extended-care facilities and will be

monitored by the various states’ departments of health (who employ long-term care surveyors)

consist of the following:

-healthcare facilities are to direct their health care providers to improve antibiotic use by

prescribing antibiotics correctly. This consists of:

-starting the right antibiotic promptly

-at the right dose

-for the right duration

-reassessing the prescribed antibiotic within 48 hrs based on tests or patient exam

-rechecking prescribing documentation re: dosage, duration and indication

The final guidance mandates the healthcare provider to remain aware and up-to-date regarding

antibiotic resistance patterns within the facility and to oversee that the facility has put into place

an Infection Prevention and Control Officer.

As of April 6, 2016, the U.S. Food and Drug Administration (FDA) has issued a new alert about

the potential for increased heart failure risk in patients taking the D.M.-II medications,

saxagliptin (Onglyza) and alogliptin (Nesina). The bulletin states there may be even a higher

risk for patients taking one of these two drugs who already have cardiovascular or kidney

disease. The notification concludes that clinicians should consider discontinuing medications

containing saxagliptin or alogliptin in patients who develop heart failure and assess the

possibility of changing the medication regimen to a safer glucose-lowering agent. Two related

medications, Tradjenta and Januvia, are not mentioned and remain as AccuScripts Pharmacy’s

preferred DPP-4 inhibitors.

The US Food and Drug Administration has just approved a maintenance drug for adults with

severe asthma who keep having attacks despite treatment with other asthma medications. The

new drug, reslizumab (Cinqair by Teva Pharmaceuticals) is a monoclonal antibody which is

indicated as an adjunct to other asthma drugs for adults (18 and over) whose condition is linked

to elevated eosinophils, a type of white blood cell that can cause airway inflammation. The

FDA estimates that about 5% of all asthmatics have severe and an often uncontrolled version of

the illness despite maximum therapy. Patients receive reslizumab q 4 weeks by I.V. infusion in a


clinical setting prepared to manage anaphylaxis which is one possible adverse outcome from

receiving this medication.

Dalvance (dalbavancin by Allergan) is a new single-dose injection indicated for the treatment of

adult patients with acute bacterial skin and skin structure infections caused by susceptible

isolates of gram positive staph and strep microorganisms and enterococcus faecalis. Dalvance is

to be administered IV as one dose (1500mg) over 30 minutes or as 1000mg X 1 plus 500mg one

week later. A moderately reduced dosage is recommended in patients with reduced renal

clearance (less than 30ml’s/min) who are not on hemodialysis but NO dosage decrease is

necessary for patients on regularly scheduled hemodialysis.

Feels like the pharmacy “right around the corner.”

Our marketing & sales team who both

makes the promises and produces the service:

Denis Holmes, Executive Vice President [email protected]

Craig Baughman, Director of Pharmacy [email protected]

Sarah Partlo, Director of Financial Accounts [email protected]

Matt Lengauer, Director of Customer Service [email protected]

another successful educational event -...

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