Pharmacotherapy
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Erythropoiesis-stimulating agents (ESAs) are approved as an alternative to blood transfusions for treating anemia secondary to chemotherapy in patients with cancer. Recently, ESAs have been a source of controversy and confusion in the oncology community. This began when two European trials-the Breast Cancer Erythropoietin Survival Trial (BEST) and the Advanced Head-and-Neck Cancer Treated with Radiotherapy (ENHANCE) Study-raised safety concerns about decreased overall survival and increased venous thromboembolic events. ⋯ When compared with FDA-approved labeling and professional society guidelines, the NCD revealed differences in ESA initiation, dosage escalation, dosage reduction, and definition of response. These discrepancies have generated confusion among health care providers, who are struggling over whether they can feasibly provide a dual system of care-one for Medicare patients and another for non-Medicare patients-that is evidence based. With this supplement, we hope to educate health care providers on the issues and challenges associated with policy-guided health care when discrepancies exist between the policy and evidence-based practice; offer guidance on implementing the NCD; and highlight the important role of pharmacists in the process.
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To determine whether body mass alters the effectiveness of a fixed-dose infusion of arginine vasopressin. ⋯ Body mass index did not alter the effects of arginine vasopressin on hemodynamic stability or changes in MAP when the drug was administered as a fixed-dose infusion of 0.04 U/minute. Our results do not support weight-based dosing of vasopressin, unlike the dosing for catecholamine vasopressors.
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Increased intracranial pressure after neurologic injury is a clinical challenge that often requires administration of osmotic agents. The most common osmotic agent used for treatment has been mannitol; however, interest has been renewed in using hypertonic saline after neurologic injury, since it is not associated with hypovolemia. The types of procedures or injury for which hypertonic saline has been used are vast, from elective craniotomy for tumor resection to stroke and traumatic brain injury. ⋯ Nonetheless, both animal and clinical data suggest that patients with traumatic brain injury and those with stroke may benefit from hypertonic saline therapy. Since hypertonic saline has a high risk of injury with inappropriate administration and is considered a "high-alert" drug, safety issues surrounding its dispensing and administration must be considered. Randomized outcome trials comparing mannitol with hypertonic saline in various subpopulations of neurologic injury would add valuable information to the literature and provide a basis for establishment of best clinical practices.
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As an integral part of the United States health care delivery system, pharmacists are ideally positioned to provide diabetes mellitus management. In this systematic review, we assessed the effectiveness of diabetes quality improvement strategies delivered by pharmacists in outpatient settings. Five electronic databases were searched for articles published through August 2007. ⋯ Findings from this review are limited by flaws in the study designs, including the high potential for selection bias in the study populations. However, due to the clinical significance of reported improvements in A1C, further trials with pharmacist case managers are warranted. Prospective assessments of the comparable efficacy of pharmacists to improve diabetes outcomes through self-management education and pharmacologic management are recommended.
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Cardiovascular disease is the leading cause of mortality in the United States. In high-risk patients, statin therapy has become the standard of care. ⋯ Results from studies of statin therapy in patients with elevated liver enzyme levels, nonalcoholic fatty liver disease, hepatitis C, cirrhosis, liver transplants, and hepatocellular carcinoma show benefit without increased risk of adverse effects. Thus, based on available evidence, statin therapy should not be withheld in this patient population; however, more robust, prospective clinical trials are needed to confirm the safety and efficacy.