PRECEPTOR TODAY TM
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Early SpringApril 2011
In This Issue
 
 
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What's Going On at SJC SO

 

 

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SAVE THE DATE

May 17th

CE PROGRAM

 Combating Health Disparities SurroundingHeart Disease in Women

6-8PM 

AT 

SJC SCHOOL OF PHARMACY

XL CENTER

held in conjunction with the  Connecticut Society of Health System Pharmacists

Visit their website by clicking on the above link for more details and to register.

 

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-Heart of Hartford

The faculty took part in 2 sessions of blood pressure screenings and handed out information pertaining to women's heart health. These sessions are part of the grant received by the SOP.

 

-John Parisi RPh, attended the APhA Convention in Seattle, acting as a delegate for Connecticut and representing the school. He was also named to the Ambulatory Care section of the Board of Specialty Pharmacy.

 

-In March, Associate Professor Maria Summa participated in college-wide health disparities program presented by the Saint Joseph College Department of Nursing, the Saint Joseph College Weekend Program for Adult Learners, and the Connecticut Multicultural Health Partnership.  

-



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COMING SOON


The experiential part of our curriculum begins early in September so if you have not signed up to be a preceptor and are interested, please contact
jparisi@sjc.edu
John Parisi RPh
Director of Experiential Education
860.231.5874

 


Quick Links


If you would like a tour of the School, call Heather Dery at ::
(860) 231-5542

We love to show off our beautiful facility.

 or
John Parisi RPh
at
860.231.5874
Greetings!

 

Welcome to our latest edition of PRECEPTOR TODAY from the Department of Experiential Education for you, the Adjunct Faculty who provides precepting for our students. Things are getting exciting around the School of Pharmacy. In the first week of August, our first class will arrive for an orientation session and will begin classes in Mid August. Faculty and staff are putting the finishing touches on lesson plans and coordinating their lessons with the Experiential Education department. This will insure that the material taught in the classroom will be reinforced by their IPPEs (Introductory Pharmacy Education Experiences). We at the School understand that a lecture not supported with "active learning" activities is not very effective. The workbook that our students and you will work with details each week's activities, making it clear to you and the student as to what is expected. As a preceptor, you will receive a copy before the semester begins. The student will also have a copy for grading purposes.  This issue features an article on hypertension and its treatment written by faculty member Natalie Dearing PharmD. and  an introduction to the Chair, Department of Pharmacy Practice and Administration. Some of you have met Bruce when he has traveled with me visiting some of our sites. He is in the process at this time of heading the search for several more faculty placements so if you are or know of someone who is interested in the academia side of our profession, contact Bruce a the school or check the various websites listing open positions. 

Watch for an announcement of an upcoming Free CE program about Active Learning and how it is being used at SJC. 

 

INFORMATION TO HELP WHEN PROVIDING MTM
Occasionally, the newsletter will feature an article on an area of drug therapy that will be helpful in providing MTM. The following article was written by  Natalie Dearing, Pharm.D., R. Ph., Assistant Professor, Department of Pharmacy Practice and Administration. 

 natalie dearing

Overview of Hypertension: Diagnosis and Treatment

Hypertension (HTN) is defined as either a systolic blood pressure>140 mmHg or diastolic blood pressure >90 mmHg or both; and is often diagnosed by two or more elevated blood pressure readings.1 According the Joint National Committee (JNC-7) hypertension can be classified according to table 1.

 

Table 1: JNC-7 Classification of Blood Pressure

BP classification

Systolic BP (SBP) mmHg

Diastolic BP (DBP) mmHg

Normal

<120 mmHg

<80 mmHg

Pre-Hypertension

120 - 139 mmHg

80 - 90 mmHg

Stage 1 Hypertension

140 - 159 mmHg

90 - 99 mmHg

Stage-2 Hypertension

≥ 160 mmHg

 ≥ 100 mmHg

 

According to JNC-7, thiazide-type diuretics are considered the first-line drug/choice for the treatment of stage-1 hypertension.1 The evidence supporting this recommendation are the results of the Veterans Affairs Cooperative Trial (1967), which showed that HTN patients treated with thiazide-type diuretics had a significant reduction in cardiovascular events, including stroke, congestive heart disease, and heart failure as compared to placebo.1,2 The ALLHAT study (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), which involved more than 40,000 hypertensive individuals, showed that there were no differences in the primary CHD outcome or mortality between the thiazide-type diuretic, chlorthalidone; the ACE-I, lisinopril; or the CCB, amlodipine.1,3

 

It is these results, in addition to numerous other antihypertensive trials, low drug cost, and favorable tolerability that make low-dose diuretics the preferred first line of treatment for many patients with hypertension1-3 It is important to note, however, that the American Heart Association recently published new hypertension guidelines, stating that any of the following: thiazide-type diuretic, ACE-I, ARB, or CCB can be used as first line therapy in patients with stage-1 hypertension. The committee goes on to state that patients presenting with stage-2 hypertension should be started on a combination of antihypertensive medications. Lastly, the American Heart Association states that beta-blockers are no longer recommended as first line drug choice and should be reserved for patients with compelling indications.4

 

Emerging Literature: Are Chlorthalidone and HCTZ Really Different?

Historically, most clinicians believe that the benefits seen with chlorthalidone can be applied to all thiazide diuretics. However, evidence is raising concerns regarding therapeutic interchange.

 

In 1990, the Multiple Risk Factor Intervention Trail Research Group (MRFIT), published results from a 10.5 year retrospective study that showed favorable mortality and morbidity trends in patients treated with chlorthalidone, but not in patients treated with HCTZ.5 The findings support that of the ALLHAT study, which showed that chlorthalidone was associated with fewer cardiovascular events including stroke and heart failure. Unlike chlorthalidone, however, low-dose HCTZ has yet to be proven effective at reducing cardiovascular morbidity and mortality when used alone in patients with hypertension.3,5-8 In fact, the Second Australian National Blood Pressure Study (ANBP2) found that HCTZ alone was inferior to an ACE inhibitor at reducing combined mortality and morbidity in men but not in women.9

 

Moreover, a number of studies comparing HCTZ to other types of antihypertensive agents tended to show favorability for the other agent.10-13A literature review conducted by Carter etal. in 2004 not only showed the lack of evidence supporting interchangeability of chlorthalidone and HCTZ, but that these two drugs actually differ greatly in their pharmacokinetic and pharmacodynamic properties (Table 2).11

 

Table 2: Pharmacokinetic/Pharmacodynamic

Drug

Onset (h)

Peak (h)

Half-life (h)

Duration (h)

HCTZ

2

4-6

6-9

(single dose)

 

8-15

(long-term dosing)

 

12

(single dose)

 

16-24

(long-term dosing)

Chlorthalidone

2-3

2-6

40

(single dose)

 

45-60

(long-term dosing)

24-48

(single dose)

 

48-72

(long-term dosing)

 

A randomized, single-blinded, cross-over study, conducted by Ernst et al. in 2006 showed that patients treated with chlorthalidone 25mg had a greater reduction in 24hr systolic ambulatory blood pressure (BP) at 8 weeks as compared to 50mg of HCTZ. The authors attributed the overall reduction in systolic BP to a significantly greater reduction in the nocturnal BP in patients treated with chlorthalidone (Figure 2). Results from this study suggested that chlorthalidone is twice as potent as HCTZ in reducing 24 hour ambulatory BP. The observation was attributed to the longer duration of action of chlorthalidone.10

 

 

 Due to its pharmacokinetic properties, researchers have suggested twice daily dosing for HCTZ. However, previous clinical trials addressing the administration of HCTZ have shown that twice daily dosing offers no additional benefit in its ability to lower BP.14-16 For example, a randomized, double-blinded, cross-over study conducted by Allen et al. showed twice daily dosage did not improve BP reduction (130/84 mmHg) as compared to once daily dosing (131/85 mmHg); p = 0.22.14 In addition, twice daily dosing could be associated with more adverse reactions.

 

Clinical Impact: Are changes in Pharmacologic Treatment Warranted?

While there are no forthcoming clinical trials comparing HCTZ and chlorthalidone, the above evidence suggests that chlorthalidone and HCTZ are not interchangeable and that the clinical differences between them merits considering chlorthalidone in preference to HCTZ for the treatment of uncomplicated hypertension. Evidence supports a starting dosage of 12.5mg per day increased to a maximum of 25mg per day. It is important to note, however, that even low dosages of chlorthalidone (or HCTZ) can significantly lower serum potassium, placing the patient at a higher risk for cardiac arrest.17 Accordingly, when initiating chlorthalidone (or HCTZ) serum potassium should be routinely monitored.

 

Although chlorthalidone may be considered the preferred diuretic for monotherapy in patients with uncomplicated hypertension, fixed-dose combination products containing HCTZ should not be discredited. Several clinical trials have shown that antihypertensive efficacy is increased when another agent is paired with HCTZ.3,5-8 Moreover, when paired with a potassium-sparing agent the risk for thiazide-induced hypokalemia significantly decreases. In a randomized, open-label, two-period study HCTZ + triamterene was found to be as effective as HCTZ + potassium supplementation (40 mmol/day) in restoring potassium levels in patients with HCTZ-induced hypokalemia.18 Lastly, fixed-dose combinations have several advantages such as increased patient adherence (reduced pill burden), decreased cost (one prescription versus two), and reduced incidence of adverse side effects.19

 

References:

1.     Chobanian AV, Bakris Gl, Black HR, et al. The seventh report of the Joint National Committee n Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC-7 report. Hypertension. 2003;42:1206-1252.

2.     Veterans Administration Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension. JAMA 1970;213:1143-1152.

3.     ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major Outcomes in high-risk hypertensive patients randomized to angiotension-converting enzyme inhibitor or calcium channel blocker vs diuretic: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trail (ALLHAT). JAMA. 2002;288:2981-2997

4.     American Heart Association Guidelines. <http://www.americanheart.org/presenter.jhtml?identifier=3004556.>

5.     Multiple Risk Factor Intervention Trail Research Group. Mortality after 10 years for hypertensive participants in the Multiple Risk Factor Intervention Trail. Circulation. 1990;82:1616-1628.

6.     Hypertensive Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program: I-reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242:2562-2571.

7.     SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255-3264.

8.     Neaton JD, Grimm RH Jr, Prineas RJ, Stamler J, et al. Treatment of Mild Hypertension Study: final results - Treatment of Mild Hypertension Study Research Group. JAMA 1993;270:713-724.

9.     Wing LM, Reid CM, Ryan P, et al. A comparison of outcomes with angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly. N Engl of Med. 2003;348:583-592

10.   Ernst ME, Carter BL, Goerdt CJ, et al. Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure. Hypertension. 2006;47:352-358.

11.   Cater BL, Ernst ME, Cohen JD. Hydrochlorothiazide versus chlorthalidone: evidence supporting their interchangeability. Hypertension. 2004;43:4-9.

12.   Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl of Med. 2008; 359:2417-2428.

13.   Schmieder RE, Philipp T, Guerediaga J, et al. Long-term antihypertensive efficacy and safety of the oral direct renin inhibitor aliksiern: a 12 month randomized, double-blind comparator trail with hydrochlorothiazide. Circulation. 2009; 119:417-425.

14.   Allen JH, McKenney JM, Stratton MA, Link K. Antihypertensive effect of hydrochlorthiazide administered once or twice daily. Clin Pharm. 1982;1:239-243

15.   De Plaen JF, Vander Elst R, et al. Penbutolol or hydrochlorothiazide on office and ambulatory blood pressure in mild to moderate essential hypertension. Br J Clini Pharmacol. 1989;12:215-221.

16.   Lutterodt A, Nattel S, McLeod PJ. Duration of antihypertensive effects of a single daily dose of hydrochlorothiazide. Clin Pharmacol Ther. 1980;27:324-327.

17.   Siscovick DS, Raghuanthan TE, Psaty BM, et al. Diuretic therapy for hypertension and the risk of primary cardiac arrest. N. Engl J Med. 1194;330:1852-1857.

18.   Schnapr H, Freis E, et al. Potassium Restoration in Hypertensive Patients Made Hypokalemiz by HCTZ. Arch Intern Med. 1989;149:2677-2681.

19.   WHO expert committee on specifications for pharmaceutical preparations. Thirty-ninth Report. http://apps.who.int/prequal/info_general/documents/TRS929/WHO_TRS_929_annex5FDCs.pdf.

  20.   Boulet AP, Chockalingam A, et al. Treatment of mild-to-moderate hypertension: comparison between a calcium-channel    blocker and a potassium-sparing diuretic. J Cardiovasc Pharmacol. 1991;18(9):S45-50.

  21.   Trenkwalder P, Plaschke M, et al. Felodipine or Hydrochlorothiazide/triamterene for Treatment of Hypertension in the  Elderly: Effects on blood pressure, hypertensive heart disease, metabolic and hormonal parameters. Blood Pressure    1996;5:154-163.  


MEET OUR STAFF

Bruce Edgren, Pharm.D., R.Ph.
Chair and Associate Professor, Department of Pharmacy Practice and Administration
Saint Joseph College School of Pharmacy

Bruce Edgren, Pharm.D., RPhIn his position as Chair, Department of Pharmacy Practice and Administration, Dr. Edgren is responsible for the provision of the practice-based educational component of the Saint Joseph College Doctor of Pharmacy Program. He will use his broad base of experience to create a unique program for Saint Joseph College doctoral students.

Dr. Edgren comes to Saint Joseph College from Maple & Main Consulting, LLC in Farmington, CT, a private consulting firm he founded that provided expertise for the pharmaceutical industry and pharmacy benefit companies.

Dr. Edgren received his Bachelors and Doctor of Pharmacy degrees from the University of Minnesota. His academic appointments include Assistant Professor of Clinical Practice at Ferris State University in Michigan where he was the Michigan State University site director for the experiential portion of the FSU pharmacy program and an Assistant Professor in the MSU School of Medicine. He then joined the clinical staff at Sparrow Hospital (Mich.) and continued teaching FSU students as an Assistant Clinical Professor in the areas of Critical Care Pediatrics and Neonatal Intensive Care.

Dr. Edgren also served as Assistant Clinical Professor with the University of Minnesota at both St. Paul Children's Hospital and the Minneapolis Children's Medical Center. While there he served as assistant director for clinical services and initiated residency and research fellowship positions. Over 100 Pharm.D. residents and fellows received their clinical training under his direction.

Dr. Edgren's experience in the managed care era included his leadership position as at an early Pharmacy Benefit Manager (PBM), Diversified Pharmaceutical Services (DPS), where as a director of Outcomes Management he led a team of 33 professionals. His team used medical claims data as a way of mapping illness progression then related it back to Rx claims, then the only on-line claims source in healthcare. SmithKline Beecham (now Glaxo SmithKline) purchased DPS, and Dr. Edgren and his team developed both the product and market for the Health Care Management (HCM) division of SB. He won several performance awards and remained a sought-after speaker. During this time Dr. Edgren was the recipient of the Hallie Bruce Lecture Award from the MSHP in recognition of outstanding clinical practice.

Dr. Edgren has authored many articles, including a chapter on Drug Utilization Review/Drug Use Evaluation in Managed Competition in Managed Care Pharmacy, Principles and Practice.

Dr. Edgren maintains active memberships in ASHP, AMCP, ACCP, APhA and CPA. He is president of the Farmington Field Club, a recreational and charitable organization.