Pharmacogenomics pharmacogenetics image

by Leah Samera, PharmD Candidate, Class of 2018

As with most things, when it comes selecting a drug regimen for the treatment of chronic disease, one size does not fit all. If you take medications, you may have wondered why that is the case. One reason is because of pharmacogenomics.

Pharmacogenomics refers to “the entire spectrum of genes that interact to determine drug efficacy and safety.” In practice, many people may use the terms pharmacogenomics and pharmacogenetics interchangeably.

Pharmacogenetics, however, also refers to variants of one gene that affect drug response. The study of both pharmacogenomics and pharmacogenetics can help to optimize drug therapy and minimize drug toxicity based on an individual’s genetic profile.

What is a gene?

A gene is a series of codons that specify a particular protein. Genetic variation may result in altered protein sequence and function or in altered protein levels. This is significant, because these proteins can have an effect on how your body interacts with medications.

How do pharmacogenomic variations affect drug response?

The impact of pharmacogenomic variations on drug response have traditionally been divided into four categories:

  1. Those that affect drug pharmacokinetics. Pharmacokinetics refers to how a medication moves through a person’s body, i.e., how the drug is absorbed, distributed, metabolized, and eliminated.  An example of a genetic variation that affects pharmacokinetics is one in which drug metabolism is altered, subsequently affecting plasma concentration.
  2. Those that effect on pharmacodynamics. Pharmacodynamics refers to a person’s therapeutic response to a medication; this depends on a medication’s affinity and activity at its site of action. An example of a genetic variation that affects pharmacodynamics is one in which binding of a drug to its receptor is reduced, thereby decreasing therapeutic efficacy.
  3. Those that affect idiosyncratic reactions. An idiosyncratic reaction is an adverse reaction to a medication that is both rare and unpredictable. An example of a genetic variation that affects idiosyncratic reactions is one in which the likelihood of a hypersensitivity reaction to a certain drug is increased.
  4. Those that affect disease pathogenesis or severity and response to specific therapies. Pathogenesis refers to the origination and development of a disease. An example of a genetic variation that affects pathogenesis is a specific molecular defect related to the development of certain malignancies for which there are targeted therapies.

How can the study of pharmacogenomics help to optimize your drug therapy and minimize side effects?

Organizations like 23andMe allow people to “access, understand, and benefit” from the study of pharmacogenomics. With their simple home-based saliva collection kits, all you have to do is order their Health + Ancestry service; register, and spit into, the provided tube; and mail the kit back to their lab via the pre-paid package. Next, their lab extracts, processes, and analyzes the DNA from the cells in your saliva. Within 6 to 8 weeks, you get an email notifying you that you can view your results in your online account and discover what your DNA says about you. By sharing those results with your healthcare providers, they then can use that information to ensure that you get the most benefit from your medications while minimizing the risk of side effects.

References:

  1. Cavallari LH, Lam Y. Pharmacogenetics. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; . http://accesspharmacy.mhmedical.com.ezproxy4.library.arizona.edu/content.aspx?bookid=1861&sectionid=146077703. Accessed September 12, 2017.
  2. Roden DM. Pharmacogenetics. In: Brunton LL, Knollmann BC, Hilal-Dandan R. eds. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics, 13e New York, NY: McGraw-Hill; . http://accesspharmacy.mhmedical.com.ezproxy4.library.arizona.edu/content.aspx?bookid=2189&sectionid=167889559. Accessed September 12, 2017.
  3. Tantisira K, Weiss ST. Overview of pharmacogenomics. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 13, 2017.
  4. Our Mission. 23andMe.com. https://mediacenter.23andme.com. Accessed September 13, 2017.
  5. How it works. 23andMe.com. https://www.23andme.com/howitworks. Accessed September 13, 2017.
  6. Our science. 23andMe.com. https://www.23andme.com/genetic-science. Accessed September 13, 2017.

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Pharmacist help manage epilepsy drugs

by Jenny Bingham, PharmD

Choosing the correct medication to treat epilepsy is a multifaceted process. Pharmacists can have a huge impact on the patient’s therapeutic response as a valued member of the healthcare team. 1

Medications used to treat seizures are called anti-epileptic drugs. Pharmacists review reams of information to ensure medication safety and suitability. The three primary concepts involved in this evaluation include:

  1. Pharmacogenetics – the role of genetic differences on an individual’s response to a drug.
  2. Pharmacokinetics – how a drug moves through the body.
  3. Pharmacodynamics – an individual’s therapeutic response to a drug.

It is important to assess for drug interactions

When medications interact with one another it is called a drug-drug interaction. Medications can enhance the effects of another drug (agonize). They can also block the effects of another drug (antagonize).

Monitoring for kidney or liver function

Medications are either metabolized in the liver or kidneys. If an individual has impaired organ function or damage, it changes how the body responds to that drug. Some medications, like Carbamazepine and Phenytoin may have more of an impact than Gabapentin.

Medications that are metabolized in the liver have an affinity for certain enzymes:

  • If a medication induces a particular enzyme, it can increase the body’s metabolism of it. The result is decreased serum concentration levels, or decreased effects.
  • If a medication inhibits, it can decrease the body’s metabolism of it. The result is an increased serum concentration level. Individuals might experience increased side effects when this happens.

What to expect for the duration of treatment

The goals of treating seizures are:

  1. Improve the patients quality of life; and,
  2. Decrease seizure frequency.

An individual’s type of seizure and previous medical history dictate how long they must take anti-epileptic drug. Patients should only make changes to their medication as directed by their provider.

In general, there is no one size fits all approach to treating seizures. However, pharmacists can prevent medication-related issues by performing a comprehensive safety evaluation as a member of the healthcare team.

References:

  1. Koshy S. Role of pharmacists in the management of patients with epilepsy. Int J Pharm Pract. 2012 Feb; 20 (1):65-8.
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noacs - warfarin alternatives

by Kali Schweitzer, PharmD candidate 2018
University of Arizona College of Pharmacy

Not so long ago, a diagnosis of atrial fibrillation (AFib), deep vein thrombosis (DVT), or pulmonary embolism (PE) meant that a prescription for the blood thinner, warfarin (Coumadin), was likely coming your way. In recent years, multiple other blood thinners have become available, and you may have wondered if any of them could be right for you.

What are NOACs?

The NOACs, or novel oral anticoagulants, are a new breed of blood thinner that have arrived on the market within the last ten years. This class of medications includes:

How are NOACs Different from Warfarin?

Multiple clinical trials comparing these alternative warfarin medications have all shown that the NOACs are just as effective as warfarin, and that they have a similar (or lower) risk of bleeding. Warfarin has been around for decades and has been proven to be both safe and effective at preventing blood clots, but it’s no secret that it has its problems. Here are some key differences to note when comparing the newer anticoagulants with warfarin and when deciding what is right for you:

  1. Warfarin requires frequent trips to the lab to have your INR (international normalized ratio) checked. Also referred to as PT time, Prothrombin time is a blood test that measures how long it takes blood to clot, or how well the medication is working. You may potentially need to change your dose to increase or decrease the clotting time. NOACs do not require lab monitoring or frequent dose changes.
  2. NOACs do not have the high potential to interact with food or other medications like warfarin does, meaning there are fewer restrictions. This means no more worrying about how much salad you can eat on a day-to-day basis, or if you are allowed to have that glass of grapefruit juice in the morning. It is still recommended, however, to check with your doctor or pharmacist before starting any new medications, as there are still some medications that may increase your risk of bleeding when taken with the NOACs.
  3. NOACs begin working quickly, while warfarin may take up to a week to start working. Because of this, patients with a DVT or PE starting warfarin may require “bridge” therapy with heparin or enoxaparin (other fast acting blood thinners) to prevent clots while waiting for the warfarin to take effect. This “bridge” therapy is not necessary with the NOACs.
  4. Unlike warfarin, not all of the NOACs have a reliable reversal agent if you were to begin bleeding. With warfarin, if your INR becomes too high or if you are having signs of bleeding, you may be given vitamin K, or phytonadione, to reverse its effects. Currently, Pradaxa is the only NOAC that has an approved reversal agent, called Praxbind (idarucizumab). While bleeding is rare while on the NOACs, the lack of reversal agent is something to keep in mind when deciding which medication may be right for you.
  5. NOACs may not be appropriate if you have decreased kidney and/or liver function. Your doctor will review your labs and information to determine if your kidneys/liver are functioning well enough for you to take one of these medications.

The recent approval of the NOACs has provided prescribers and patients with more options to choose from when a blood thinner is necessary. Because these medications are still relatively new, there is a lot left to learn about their use and limitations, so they may not be appropriate for everyone. It is always important to discuss any questions or concerns with your doctor when starting any of these medications or when switching from one to another.

 

References

Leung LLK, Direct oral anticoagulants and parenteral direct thrombin inhibitors: Dosing and adverse effects. In: UpToDate, Mannucci PM (Ed.), UpToDate, Waltham, MA.

Hanley CM, Kowey PR. Are the novel anticoagulants better than warfarin for patients with atrial fibrillation? Journal of Thoracic Disease. 2015;7(2):165-171. doi:10.3978/j.issn.2072-1439.2015.01.23.


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Savings card vs. savings coupon image scriptsave wellrx

What’s in a name and why does it matter?

Although many patients tend to think of the ScriptSave WellRx program as a coupon for their meds, your free prescription savings card is actually a lot more powerful.

In addition to the obvious differences, like the fact that you would normally only get to use a regular coupon for one transaction (related to just one very specific product, as stated on the face of the coupon), there are some additional and very important features that make for big differences between an Rx discount card (like ScriptSave WellRx) and a coupon.

Here are a couple of important things to keep in mind. Understanding these differences will also help to explain why an insurance provider can’t allow you use the ScriptSave discount in addition to their own reduced rates, or why a pharmaceutical manufacturer won’t allow you to apply their copay savings program together with our low prices.

  • A regular coupon works by lowering the end-price of a product, cutting it by the exact amount shown on the coupon. The coupon has a fixed value, and the retailer will subtract that fixed value from the current sales price. For example, the regular coupon might say, “Take $5 off the price of XYZ.” When this happens, the savvy consumer might decide to shop around in order to find the store that sells this product for the very lowest price…THEN s/he will receive an additional $5 off that lowest price upon surrendering the coupon.
  • In contrast, what we do with the ScriptSave WellRx program is to negotiate lower final costs for each specific medication. We don’t negotiate a fixed coupon value. Instead, we negotiate a final discounted price. This is a subtle but important difference. With our program we’re saying, “We can get you a specific medication for a negotiated final price of $X.” This being the case, if the patient can find a pharmacy that will fill their prescription for a final out-of-pocket cost that’s lower than our negotiated price (perhaps as a result of the drug being on a low copay list with their insurer), they may not want to use their Rx discount card for that particular medication. Meanwhile, the same patient may have a second prescription that’s not covered by insurance and where the ScriptSave out-of-pocket cost is the lowest discounted price available…in which case one script gets filled with ScriptSave and the other does not.

Can it be used with insurance, Medicare, Medicaid, etc.?

Here’s another example to help illustrate. We’ll start by laying out three basic pricing options for filling a prescription at a given pharmacy…

  1. An insurance policy (including Medicare and Medicaid) includes a list of drugs (known as the Formulary) for which covered patients will pay a predetermined negotiated rate.
  2. Similar to the prescription drug formulary at an insurance company, the contracts that ScriptSave has negotiated with its pharmacy partners also result in pre-determined out-of-pocket costs. These rates are available to ANY patient who chooses to pay cash.
  3. At the same time, a generic drug list at a retail pharmacy shows the final prices for certain drugs at that pharmacy.

Of the three pricing options listed above, a patient is free to choose the price that makes the most sense for each of the prescriptions they are filling. However, this is a one-or-other choice. There’s simply no way to “stack/combine” the savings from an insurance payer together with the savings from a cash discount card, because the prices being offered under each option are contractually agreed and final.

Another way to put this is to say that, in the world of a regular coupon, the value of the coupon is always the same no matter which store it gets redeemed it at. Therefore, the final out-of-pocket cost for any product that has a coupon will vary based on how much the store is selling the product for in the first place. Meanwhile, an Rx savings card like the ScriptSave WellRx card will deliver a fixed final out-of-pocket cost (and so it’s the value of the discount that changes with every prescription being filled, relative to the original cash price for the drug in question).

In short, prescription savings programs are NOT coupons. While it might be easy to think of them in this way (and you may even hear us refer to them as such), it’s important to keep the differences in mind. Furthermore, you’ll want to choose your savings program based on its reputation and relationship with pharmacies … because it’s these relationships that matter when it comes time for the pharmacist to honor the savings card or mobile app.

As part of the Medical Security Card Company and ScriptSave suite of pharmacy programs, the ScriptSave WellRx program boasts well over 20 years (founded in 1994) of history and relationships with our pharmacy partners. We believe this helps make ScriptSave WellRx second-to-none.


Download the free WellRx app from the iOS app store or the Google Play Store,
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If you’re struggling to afford your medications,
visit www.WellRx.com to compare the cash price at pharmacies near you.
You may find prices lower than your insurance co-pay!

Behavioral health medications for anxiety or depression - image

Jenny Bingham, PharmD
University of Arizona College of Pharmacy

There are a number of mental conditions that shape mood and behavior. Any condition that affects a person’s thinking, feeling or mood, falls into a medical classification of Behavioral Health.  Such conditions may affect someone’s ability to relate to others, or maintain reasonable function every day. Each person may have different experiences, even if they have the same diagnosis as someone else.

Depression is the most common behavioral health condition in the general population1. Without treatment, depression can lead to decreased quality of life2, increased suicidal thoughts, and overall worsened health outcomes. The most common method of treating depression is to target serotonin and how the body uses it.  Serotonin regulates mood and ultimately is what makes you feel happy. When we have low serotonin levels, you can feel depressed or anxious. Antidepressants each have their own unique mechanism of action that are specific to certain neurotransmitters in the brain.

Anxiety can affect our ability to function due to excessive worry. Without treatment, anxiety can also lead to a worsened quality of life and can even be debilitating for some patients3. Anxiolytics are the medication class used to treat anxiety. The most common method of treating anxiety is to target serotonin and/or norepinephrine.  Norepinephrine is responsible for motor action, cognition, the body’s alert system, and feeling energetic.  When we have low norepinephrine, it is harder to cope with every day stressors and things that are beyond our control.

How do these medications work?  

These medications are often classified as reuptake inhibitors. They target the neurotransmitters serotonin and norepinephrine, to name a few.  Medications prevent the body from recycling these neurotransmitters. By preventing them from being recycled too soon, it allows the body a better chance to use them to improve mood and/or relieve anxiety.

What can you do to make them work better for you?

We know that the body needs certain building blocks to make serotonin and norepinephrine. An important concept to remember is that no matter how many medications are prescribes to treat these conditions, they don’t stand a chance at being effective without the right precursors; an interesting concept in today’s world. The majority with these conditions take more than one medication.

Step 1: What is your protein source?

The greatest building blocks for serotonin are things that you might already have in your kitchen.

Complete proteins are the main precursor for tryptophan, which is later turned into serotonin. You might think that tryptophan only comes from turkey on Thanksgiving, but did you know that you can also get it from eating beef, venison, buffalo, pork, fish, shellfish, cheese, cottage cheese, milk, yogurt, and eggs? 

The building blocks for norepinephrine are also found in your kitchen.

In addition to eating complete proteins, it’s also important to eat incomplete proteins as well. You can find these in nuts, grains, beans, legumes, and soy.

Step 2: What else is included on your meal plan?

When we think about serotonin building blocks, key vitamins play an important role as well.

  • Vitamin B6. Great nutritional sources of this vitamin are found in whole grains, vegetables, and nuts.
  • Vitamin B12. This vitamin is found in meats, fish, liver, and milk.
  • Folic acid and Vitamin D3 are often found in fortified foods.
  • Omega-3 Fatty Acids are found in fish, dairy, and grains.

Step 3: Don’t forget about your supplements and vitamins.

Over-the-counter supplements can help you fulfill your dietary need of the vitamins mentioned above. But, there is a caveat.  Did you know that you can actually take “too much” of a vitamin? When in doubt always review your supplements and medications with your pharmacist for safe use.

As a patient, take comfort knowing that you can control how well your medications work for you. You are the rate limiting factor in the equation. These simple modifications can make a world of difference with managing depression and anxiety. After all, the best investment you’ll ever make is in yourself.

References:

  1. Kessler RC, Ormel J, Petukhova M, et al. Development of lifetime comorbidity in the World Health Organization world mental health surveys. Arch Gen Psychiatry 2011; 68:90.
  2. Daly EJ, Trivedi MH, Wisniewski SR, et al. Health-related quality of life in depression: a STAR*D report. Ann Clin Psychiatry 2010; 22:43. 
  3. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617.

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transitions of care home health image

“It all started with pain radiating down my left arm. It was hard to breathe and I was short of breath. I knew something was wrong and called 911. I was rushed to the hospital. I remember the sirens, but they slowly faded away. Then I woke up. There was a man in a white coat telling me that I’d had a heart attack. He handed me some medicine bottles and prescriptions. Before you know it, I was discharged and on my way home.”

This was how Nancy described her heart attack. After several days in the hospital,  Nancy was discharged home, and now has to take four new medications every day. That can add up to a lot of out-of-pocket expense.

This scenario happens all too often, and through an unfortunate set of events, Nancy was re-admitted into the hospital just three weeks later.

Moving Through the Healthcare System

Transition of Care (TOC) is the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.1 This definition by The Centers for Medicare & Medicaid Services (CMS) describes the process of a patient navigating the health care system and the unfortunate, but common reality that gaps in care develop between the hospital and outpatient setting.

A Growing Healthcare Need

This area of healthcare is expanding and becoming more important to help reduce readmission rates and the cost of healthcare. Pharmacists are expanding their roles by providing TOC services to patients newly diagnosed with specific conditions and/or a flare-up of a chronic condition or disease. Quite often will a patient’s medication therapy change upon admittance to a hospital and then at discharge from the hospital. They may be prescribed new medications after a hospital stay. The goal is to ensure the continuity of care for patient and help fill the gap, by:

  • Providing education about a condition
  • Monitoring a condition
  • Helping patients understand their medication.

Why Transition of Care Matters

Helping patients understand their prescription medications allows them to get the most benefit from them, and, to understand why it is important to take their medications as prescribed. Helping patients save on prescription medication costs is what ScriptSave WellRx does.

It is not just pharmacists that are expanding into this role, but other health care professionals like nurses, doctors, and case managers, too. It takes a care team effort and patient-centric approach to ensure that each patient is getting the best, high-quality care available.

 

References:

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/8_Transition_of_Care_Summary.pdf


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Role of vitamin d and statin induced muscle pain

by James Ketterer, PharmD

Statins are a class of drugs used to lower cholesterol and decrease the risk of cardiovascular events. They work by inhibiting an enzyme from completing an early step in the body’s process of synthesizing cholesterol. Statins are among the most commonly prescribed medications in the country. Approximately 1-2% of patients on statins report experiencing muscle pain. This pain can present itself in a variety of ways but most often results in flu-like aches and pains. The muscles may feel stiff or sore like the feeling after working out. This usually effects the larger muscles of the body such as parts of the back or thighs. This side effect is often responsible for patients discontinuing the use of these drugs.

Does Vitamin D Play a Role in Statin-induced Muscle Pain?

Do statins cause muscle pain? The exact cause of this phenomenon is not completely understood, but many researchers have hypothesized that vitamin D levels may play a role. Vitamin D is mainly produced in the skin from sun exposure. However, this source is not active. The liver and kidneys are responsible for activating the vitamin D which then plays a role in facilitating intestinal absorption of essential nutrients as well as balancing bone health homeostasis. Vitamin D deficiencies often present with similar muscle pain as those found as a side effect in statins.

Some researchers have theorized that statins could reduce vitamin D levels because certain types of cholesterol carry vitamin D and when the cholesterol is reduced, less vitamin D could be transported. On the other hand, many have theorized that since both vitamin D and statins are metabolized by the same enzyme in the liver, the use of statins could delay metabolism of vitamin D, thus increasing levels in the blood.

Muscle Pain in Clinical Trials

Clinical trials and various other studies and reports have yielded mixed results on muscle pain in statin users with low compared to high levels of vitamin D. A large analysis of these trials showed that more studies resulted in statin users having higher levels of vitamin D on average. One retrospective study divided statin users into 4 groups, 1 being the lowest vitamin D levels and 4 being the highest. Group 1 was 1.21 times more likely to develop muscle pain than group 4. Another study showed statin users with vitamin D levels of less than 15 ng/mL were 1.9 times more likely to experience muscle pain compared with non-statin users. The statin users with higher levels of vitamin D did not have higher risk for muscle pain compared with non-statin users.

When a patient experiences what is believed to be the side effect of a drug, they are often taken off of the drug to see if the symptoms resolve. If they do resolve, sometimes the patient is started back on the drug to see if the symptoms return. This a referred to as a “rechallenge”. One chart review showed that returning vitamin D levels to a sufficient level before a rechallenge in statin users who had experienced muscle pain, increased their tolerability to statins.

Do Vitamin D Supplements Help Reduce Statin-induced Muscle Pain?

Some studies have given vitamin D supplements to statin users experiencing muscle pain. While these studies were uncontrolled, they did show improvement in muscle pain in nearly 90% of patients.

These are just a few of the examples of research looking at the correlation between stain use and vitamin D levels as a possible cause of muscle pain. While nothing is definitive at this point, patients on statins that are experiencing muscle pain may want to explore vitamin D supplementation as a possible resolution plan. The benefits of statins are well documented in patients with heart risks. Any side effects should be attempted to be overcome before giving up on the statin and assuming it is the cause.

References:

Gregory, Philip J. ” Vitamin D and Statin-Related Myalgia”. Medscape. 2017. Web. 10 Mar. 2017.

Simvastatin.  Micromedex Solutions.  Truven Health Analytics, Inc. Ann Arbor, MI.  Available at: http://www.micromedexsolutions.com.  Accessed March 20, 2017.


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ScriptSave WellRx - Statins and Liver Damage

by: James Ketterer, PharmD Candidate
University of Arizona College of Pharmacy

If your doctor has said you have high cholesterol, it’s likely that you’ve heard or read about about the potential side effects of statin drugs and their impact on liver.

Doctors often prescribe statins for people with high cholesterol levels to lower their total cholesterol and reduce their risk of a heart attack or stroke. While statins are highly effective, they have been linked to muscle pain, digestive problems and mental fuzziness in some people and may rarely cause liver damage.

Cholesterol and triglycerides are lipids (fats) that are stored in the body and serve as a source of energy. Lipids, together with proteins and carbohydrates, are the main components of living cells. When lipid levels in the bloodstream are too high or low, this condition is called dyslipidemia. The most common types of dyslipidemia are:

  • High levels of low-density lipoprotein (LDL or “bad”) cholesterol
  • Low levels of high-density lipoprotein (HDL or “good”) cholesterol
  • High levels of triglycerides

You may have heard stories of people who have experienced devastating liver damage from their use of drugs like atorvastatin (Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor). Less than 3% of patients on statins report muscle pain while less than 0.5% report rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood).

Recently, the risk of statin-induced liver injury has become a hot topic, since this class of drugs is metabolized by enzymes in the liver. Liver injury has a broad definition, but generally includes, at minimum, highly elevated liver enzymes which are directly correlated with liver function and often a precursor to various liver diseases.

Statin Studies

While studies on the safety of these drugs have included thousands of patients, it’s difficult to determine if something like liver injury is one of the side effects of statin drugs, or happening for some other reason. Drug-induced side effects are more commonly identified after a drug hits the market and patients and physicians begin reporting problem cases to the drug manufacturers.

There have been a few studies around the world that have looked at drug-induced liver injury. A study in Iceland identified 96 patients with drug-induced liver injury. Three of those 96 were due to statins (1 with simvastatin and 2 with atorvastatin). During the trial, over 27,000 people were treated with simvastatin and over 7,000 with atorvastatin. That means that 1 out of 27,000 people on simvastatin and 1 out of 3,500 people on atorvastatin had drug-induced liver injury in Iceland over that 2 year period. Of all statins, simvastatin and atorvastatin are responsible for most reported incidents of liver damage, but this is likely just due to the fact that they are prescribed the most.

The Spanish Hepatotoxicity Registry identified 858 cases of drug-induce liver injury. Of those cases they attributed 47 (5.5%) of them to statin use. The total number of patients on statins was not available.

One of the latest studies from the USA ran from 2004 to 2014, examining drug-induced liver injury identified 1188 cases. They determined that about 2% could be contributed to statin use.

A Swedish study compared the reported statin-induced liver injuries to the total number of statin users (based on sales) and found that 1.2 people experience liver injury due to statins per 100,000 users of statins.

A Rare Occurrence

Outside of these large studies, there have been case reports of patients experiencing liver injury following an increase in dosage of their statins. These are few and far between, and are corrected by decreasing or discontinuing the medication. Some of these patients have been restarted on statins and experienced the same liver problems, confirming the drug as the cause. People that experience statin induced liver injury have a generally positive prognosis. These injuries are usually short-term and reversible. One study of interest that looked at 298 patients whom had experienced drug-induced liver injury and found that only 7 of them had any signs of liver problems one year later.

While there’s a lot of information on the safety of statins in the media, the truth is that side effects of statin drugs, including livery injury, are very rare. That’s not to say that they don’t occur, but rather that the benefits in patients with cardiovascular risk, even those with underlying liver problems, substantially outweigh the potential risks.

 

References

Björnsson, Einar S. “Hepatotoxicity Of Statins And Other Lipid-Lowering Agents”. Medscape. N.p., 2017. Web. 9 Mar. 2017.

Simvastatin.  Micromedex Solutions.  Truven Health Analytics, Inc. Ann Arbor, MI.  Available at: http://www.micromedexsolutions.com.  Accessed March 2, 2017.

 

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ScriptSave WellRx - Heliobactor Pylori stress image

Heliobacter pylori Eradication and Antibiotics

by: Derek Matlock
Pharm.D. Candidate 2017
Washington State University

Heliobacter pylori is a bacteria highly prevalent worldwide and is closely linked to duodenal ulcers (which affect the upper section of your small intestine), gastric ulcers, and peptic ulcer disease. It is also linked to an increased risk of developing gastric cancer in an infected person. Despite being more common in developing countries with poor socioeconomic conditions, the American College of Gastroenterology states that 30-40% of the U.S. population is infected with H. pylori, putting them at risk for conditions such as peptic ulcer disease — which affects the stomach lining — and gastric cancer.

Anitbiotics for Ulcers?

Numerous research studies and testing have not only supported these correlations, but they have also demonstrated the benefits of eradication using medications, specifically antibiotics, for patients suffering from complications of H. pylori.

Prior to the discovery of H. pylori, lifestyle factors such as smoking, eating spicy and acidic foods, and stress, were considered the major causes of ulcers. Thus, the main treatment choices were popular acid suppressing medications such as ranitidine (Zantac®) or omeprazole (Prilosec®). These medications can help improve ulcer-related pain and symptoms, and might even heal the ulcer, but they do not treat the underlying H. pylori infection. Without treating the infection, symptoms and complications are likely to reappear.

Triple Therapy for Ulcers

After the discovery of the bacteria causing these conditions, appropriate antibiotics have been able to eliminate the infection in the majority of individuals, thus resolving the infection and its complications. The following antibiotic regimens are being used, and the triple therapy is the most common.

  1. Triple therapy: Omeprazole 20 mg twice daily + Clarithromycin 500 mg twice daily + Amoxicillin 1,000 mg twice daily or Metronidazole 500 mg twice daily
  2. Concomitant quadruple therapy: Omeprazole 20 mg twice daily + Clarithromycin 500 mg twice daily + Amoxicillin 1,000 mg twice daily + Metronidazole 500 mg twice daily
  3. Bismuth quadruple therapy: Omeprazole 20 mg twice daily + Bismuth subsalicylate 262 mg four times daily + Tetracycline 500 mg four times daily + Metronidazole 250 mg four times daily

Although the triple therapy remains an effective choice, a preference for quadruple therapies may soon become more common, as the risk for patients to fail treatment due to antibiotic resistance becomes a growing concern in the science community.

As the United States prevalence of H. pylori continues to decline, the resistance to antibiotics, specifically Clarithromycin, makes the infection more difficult to treat. As a patient, it is essential to inform your doctor about any recent antibiotics you may have taken, as this may help in the selection of a better treatment option.

References:

  1. American College of Gastroenterology Guideline on the Management of Heliobacter pylori Infection
  2. CDC: Heliobacter pylori Fact Sheet for HCPs
  3. Medscape: Heliobacter pylori Infection
  4. WebMD: What is H. Pylori?

 

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generic aspirin tablets

by: Rick Lasica, BS
University of Arizona College of Pharmacy PharmD Candidate, Class of 2017

Many people take aspirin occasionally to provide relief from various conditions (e.g. pain, inflammation, fever, headaches), but what about taking a low-dose aspirin every day for prevention reasons? As with all medications, aspirin poses various benefits and risks that need to be taken into consideration before you start taking it. Studies have shown that certain individuals would benefit the most from taking a low-dose aspirin and others shouldn’t take it at all.

Why Take Low Dose Aspirin?

Our bodies make cells called platelets, which help stop us from bleeding uncontrollably. In order to stop this unnecessary bleeding, a blood clot is formed. In this case, the blood clot is beneficial, but sometimes blood clots are formed when they aren’t needed, which have the potential to lead to a heart attack or stroke. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) commonly referred to as a “blood thinner” because it stops platelets from working together to form a blood clot.

Even though aspirin has many potential benefits, it also has many side effects, some serious, that might occur. Most importantly, it can increase your risk of bleeding, both inside and outside of your body. This might be noticed through your gums bleeding while brushing your teeth, any unexplained bruising on your body, or black/tarry stools. Other side effects that might occur are ringing in the ears, nausea/vomiting, dizziness, or yellowing of the eyes/skin.

The United States Preventive Services Task Force (USPSTF) recommends that people aged 50-59 years with an increased risk of heart problems who have never had a heart attack or stroke in the past would likely benefit from taking a daily low-dose aspirin in order to help reduce the chance of one from happening. Also, people who have had a heart attack or stroke are at an increased risk of having another one, and would likely benefit from it as well.

However, you should never start taking aspirin, or any medication, before talking with your physician or pharmacist about it. They will make an assessment of your condition and weigh the benefits and risks of you taking it and make the ultimate decision of whether or not you should take it as part of your daily regimen. Certain people should not take aspirin if they have had any serious bleeding events, are on certain medications, have a high fall risk, or have specific medical conditions. So, next time you interact with your doctor or pharmacist, ask them if they think it is appropriate for you to take a daily low-dose aspirin.

References:

  1. United States Preventive Services Task Force Recommendations on Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer
  2. WebMD: Aspirin
  3. FDA: Safe Daily Use of Aspirin

 

Have questions? Ask a Pharmacist!

We want to make sure you have the information you need to safely
use your prescription drugs. Connect with a pharmacist at SinfoniaRx
who can help with non-emergency prescription questions
about drug interactions, and other medication-related questions.


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www.WellRx.com.

Compare prescription drug prices at more than
62,000 pharmacies nationwide.

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