RESUMEN
OBJECTIVE: The aim of this study is to describe recommendations made by clinical pharmacists when co-managing hypertension with physicians. SETTING: Two family medicine clinics at a major teaching hospital in the mid-western United States. METHOD: This report details the specific recommendations made by pharmacists during a prospective randomized controlled clinical trial. Patients with uncontrolled hypertension were enrolled in a 9-month intensive pharmacist-physician co-management study. Clinical pharmacists saw patients at baseline, 2, 4, 6, and 8 month visits. Optional visits were allowed between required visits. MAIN OUTCOME MEASURE: For this analysis, pharmacist recommendations were grouped. Physician acceptance of the pharmacists' recommendations was also evaluated. RESULTS: Data from 101 patients were included and analyzed in this study. Changes in drug therapy were recommended 267 times for these 101 patients. Most recommendations for a change in treatment involved adding a new antihypertensive medication (46.4%) or increasing a dose (33.3%). The majority of pharmacist recommendations to modify drug therapy were made at the baseline visit (41.6%), with 76.8% of recommendations made by the 2 month visit. Physicians accepted and implemented 95.9% of the 267 pharmacist recommendations to modify drug therapy. Pharmacists recommended no change in the treatment plan 361 times, most often because the patient's blood pressure (BP) had achieved the goal. Average BP decreased from 153.1+/-10.0/84.9+/-12.0 mmHg (average+/-SD) at baseline to 124.2+/-9.7/74.7+/-9.6 mmHg (P<0.001) at the end of 9 months, with 89.1% (P<0.001) of patients reaching their BP goal. CONCLUSION: Pharmacist recommendations for alterations in drug therapy generally occurred early in the course of the study and were largely to intensify therapy through higher dosages or additional medications. Pharmacist-physician co-management of BP is effective at reducing BP and improving BP control rates.
Asunto(s)
Antihipertensivos/uso terapéutico , Hipertensión/tratamiento farmacológico , Grupo de Atención al Paciente , Farmacéuticos , Servicio de Farmacia en Hospital , Médicos , Adulto , Anciano , Anciano de 80 o más Años , Antihipertensivos/administración & dosificación , Femenino , Hospitales de Enseñanza , Humanos , Relaciones Interprofesionales , Masculino , Persona de Mediana Edad , Rol Profesional , Estudios Prospectivos , Estados UnidosRESUMEN
STUDY OBJECTIVE: To explore reasons for discrepancies between findings from case reports and those from a meta-analysis of randomized controlled trials regarding the association between beta-adrenergic blockers and depression. DESIGN: Systematic review. DATA SOURCE: PubMed/MEDLINE database. MEASUREMENTS AND MAIN RESULTS: We reviewed 24 published case reports showing an association between beta-blockers and depression and eight randomized controlled trials included in a meta-analysis of the adverse effects of these drugs. We abstracted the beta-blocker taken, patients' age and sex, diagnoses, history of depression, type of depressive symptoms reported, and method and timing of the assessment of depression. Naranjo criteria were used to evaluate the strength of evidence from each case report for a possible association between beta-blockers and depression. Twelve case reports had a Naranjo score of 5 or more (suggesting a likely causal relationship), nine of which involved propranolol. In all nine, depression began soon after treatment, and in four, the patient had a history of depression. Three randomized controlled trials assessed propranolol. Depression rates in the control groups of these studies differed substantially from each other (0-40%, p<0.0001). In only one randomized controlled trial did investigators assess depression systematically; they evaluated depression after 1 year of treatment and eliminated patients who had previously been prescribed an antidepressant. CONCLUSION: A criterion standard to assess the true relationship between beta-blockers and depression is lacking. Factors such as the lack of systematic assessment of depression, the timing of assessments, and the selection of patients may have reduced the ability of researchers in the randomized controlled trials to detect depression as an adverse effect. Evidence from case reports should be carefully considered when relevant randomized controlled trials have not been adequately designed to detect adverse effects.
Asunto(s)
Antagonistas Adrenérgicos beta/efectos adversos , Trastorno Depresivo/inducido químicamente , Propranolol/efectos adversos , Adulto , Trastorno Depresivo/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
Low-dose thiazide-type diuretics are recommended as initial therapy for most hypertensive patients. Chlorthalidone has significantly reduced stroke and cardiovascular end points in several landmark trials; however, hydrochlorothiazide remains favored in practice. Most clinicians assume that the drugs are interchangeable, but their antihypertensive effects at lower doses have not been directly compared. We conducted a randomized, single-blinded, 8-week active treatment, crossover study comparing chlorthalidone 12.5 mg/day (force-titrated to 25 mg/day) and hydrochlorothiazide 25 mg/day (force-titrated to 50 mg/day) in untreated hypertensive patients. The main outcome, 24-hour ambulatory blood pressure (BP) monitoring, was assessed at baseline and week 8, along with standard office BP readings every 2 weeks. Thirty patients completed the first active treatment period, whereas 24 patients completed both. An order-drug-time interaction was observed with chlorthalidone; therefore, data from only the first active treatment period was considered. Week 8 ambulatory BPs indicated a greater reduction from baseline in systolic BP with chlorthalidone 25 mg/day compared with hydrochlorothiazide 50 mg/day (24-hour mean = -12.4+/-1.8 mm Hg versus -7.4+/-1.7 mm Hg; P=0.054; nighttime mean = -13.5+/-1.9 mm Hg versus -6.4+/-1.8 mm Hg; P=0.009). Office systolic BP reduction was lower at week 2 for chlorthalidone 12.5 mg/day versus hydrochlorothiazide 25 mg/day (-15.7+/-2.2 mm Hg versus -4.5+/-2.1 mm Hg; P=0.001); however, by week 8, reductions were statistically similar (-17.1+/-3.7 versus -10.8+/-3.5; P=0.84). Within recommended doses, chlorthalidone is more effective in lowering systolic BPs than hydrochlorothiazide, as evidenced by 24-hour ambulatory BPs. These differences were not apparent with office BP measurements.