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SHANDS July/August 2004 at the University of Florida Drugs & Therapy B ◆ U ◆ L ◆ L ◆ E ◆ T ◆ I ◆ N

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SHANDS July/August 2004 at the University of Florida Drugs & Therapy B ◆ U ◆ L ◆ L ◆ E ◆ T ◆ I ◆ N Volume 18, Number 7 SHANDS July/August 2004 at the University of Florida Drugs & Therapy B ◆ U ◆ L ◆ L ◆ E ◆ T ◆ I ◆ N FORMULARY UPDATE DRUG INFORMATION FORUM The Pharmacy and Therapeutics NSAIDS + ASA = CONFUSION Committee met June 15, 2004. 3 drugs were added in the Formu- atients are seeing advertisements on platelets and prevents the binding lary and 3 drugs were deleted and P promoting the use of acetamino- of aspirin to platelets.1 This led to the designated not available. phen instead of traditional nonsteroi- recommendation that aspirin should be dal anti-inflammatory drugs (NSAIDs), given before administering ibuprofen. like ibuprofen, when they are taking It also led to observational studies that ◆ ADDED low-dose aspirin for the prevention of suggest that chronic use of ibuprofen cardiovascular events. The premise of (and possibly other NSAIDs) may Extended-Release Divalproex ® these warnings is that traditional decrease the effectiveness of low-dose Sodium (Depakote ER by Abbott NSAIDs could negate the beneficial aspirin.2-3 However, a recently done Pharmaceuticals) cardiovascular effects of low dose case-control study showed that the Rimantadine (Flumadine® by aspirin. The advertisements suggest combination of aspirin and ibuprofen Forest Pharmaceuticals) that acetaminophen is the preferable did not increase the incidence of analgesic because it has fewer drug myocardial infarctions.4 Tiotropium (Spiriva® by interactions. Intermittent use of ibuprofen (and Boehringer Ingelheim/Pfizer) ◆ other NSAIDs) has not been shown to alter the cardiovascular protective ◆ DELETED Is acetaminophen effects of low-dose aspirin. Chronic use Bacitracin + Polymyxin B preferable to traditional of ibuprofen alone (without aspirin) may Topical Powder (Polysporin® NSAIDs in patients taking be cardioprotective compared with Topical Powder by Pfizer)* nothing. However, if there is concern aspirin? Are COX-2 that ibuprofen decreases aspirin’s Clotrimazole Vaginal Tablets inhibitors preferable to effectiveness, acetaminophen is a (Femcare® by Schering Plough)* traditional NSAIDs when good option for chronic pain. Salsalate (Disalcid®)* Acetaminophen at doses of less than acetaminophen does not or equal to 4 grams per day (eg, 500 mg 4 times a day) is a first-line agent for *Nonformulary and Not Available work? Does low-dose mild to moderate joint pain associated aspirin cancel the lower with osteoarthritis. It is a first-line Tiotropium is a quaternary gastrointestinal effects of therapy because it is inexpensive, has ammonium derivative that is few adverse effects, and does not have structurally related to ipratropium. COX-2 inhibitors? many drug interactions. Patients treated It acts as an anticholinergic bron- with acetaminophen do not have to chodilator and is indicated for the What is the science behind these worry about mitigating the cardio- maintenance treatment of chronic warnings? Is acetaminophen prefer- protective benefits of low-dose aspirin. obstructive pulmonary disease able to traditional NSAIDs in patients Unfortunately, acetaminophen may (COPD). Although similar to taking aspirin? Are COX-2 inhibitors not provide sufficient pain relief. Many ipratropium, tiotropium possesses preferable to traditional NSAIDs when patients have already tried over-the- a unique pharmacodynamic profile acetaminophen does not work? Does counter acetaminophen before seeking allowing for once daily administra- low-dose aspirin cancel the lower gastro- medical attention and it did not pro- tion. The improved dosing schedule intestinal effects of COX-2 inhibitors? vide adequate relief. Also, many is a major advantage over ipratro- These are all related questions received patients find it difficult to adhere pium, which requires dosing up to 6 by the Drug Information & Pharmacy to the 4-times-a-day dosage. times daily. Tiotropium is the first Resource Center. This article will (continued on page 4) anticholinergic drug approved for summarize what we know about these COPD-associated bronchospasm issues…and what we do not know. ◆ since the approval of ipratropium ASA and Traditional NSAIDs INSIDE THIS ISSUE in 1986. Concern about the use of traditional In clinical trials, tiotropium ◆ Prescribing patterns NSAIDs with low-dose aspirin can demonstrated superior sustained be traced to a study that shows that ◆ Alcohol (continued on next page) ibuprofen binds to the COX-1 receptor Formulary update, from page 1 by which valproic acid exerts its Rimantadine has shown superior effects on pulmonary function tests anticonvulsant activity is unclear. It is efficacy to placebo and comparable compared to ipratropium. Tiotro- believed that its anticonvulsant efficacy to amantadine. Symptomatic pium reduced beta-agonist use, the activity results from inhibition of and virological improvements are number of COPD exacerbations, the GABA (gamma-amino-butyric acid), an the efficacy markers used in trials. time to exacerbation, the overall inhibitory neurotransmitter. Treatment appears to reduce the number of hospitalizations, and Depakote® ER has labeled indica- duration of symptoms by approxi- number of days spent in the hospital tions for the treatment of seizures in mately 1 day. when compared to ipratropium. adults and children at least 10 years Rimantadine has a significantly Significant increases in broncho- old and for the prophylaxis of migraine better adverse effect profile than dilation, dyspnea, and health-related headaches. The advantage of Depa- amantadine. Amantadine is associ- quality of life scores were seen with kote® ER is a simplified dosing ated with severe gastrointestinal tiotropium versus twice-daily sal- regimen. The manufacturer’s claims and central nervous system adverse meterol use. However, tiotropium of more stable serum concentrations effects, especially in the elderly. has not been shown to reduce the have not been shown to translate into These effects occur less frequently number of exacerbations or hospital- meaningful differences in clinical with the use of rimantadine. izations compared with salmeterol. outcomes. Salsalate is a traditional nonste- The recommended dosage of Conversion from the regular release roidal anti-inflammatory drug tiotropium is the inhalation of one Depakote® to Depakote® ER requires (NSAID) that lacks antipyretic 18-mcg capsule once daily using the approximately a 20% increase in dose. properties. Salsalate has not been HandiHaler® device. The most For example, 1750 mg of regular dispensed in over a year and, commonly reported adverse effect release Depakote® is equivalent to therefore, was deleted from the with tiotropium use in clinical trials 2000 mg of Depakote® ER. Formulary. Other available NSAIDS was dry mouth, followed by other Depakote® ER has a black box include: aspirin, ibuprofen, in- anticholinergic effects (ie, constipa- warning for hepatotoxicity, teratoge- domethacin, and naproxen. tion, increased heart rate, blurred nicity, and pancreatitis. Administra- The manufacturer of clotrimazole vision, glaucoma, urinary difficulty, tion of Depakote® ER is contraindi- vaginal tablets discontinued their and urinary retention). cated in patients with hepatic disease production in 1999. Thus, it was Depakote® ER is a once-daily or significant hepatic dysfunction. deleted from the Formulary. version of valproic acid. Valproic Rimantadine belongs to the Clotrimazole vaginal cream (eg, acid is available in several different adamantane class of antiviral agents. Mycelex®-G) is an alternative formulations. Divalproex sodium It has activity against influenza A therapy. (Depakote®) was introduced as a viruses but not influenza B viruses. Bacitracin and Polymyxin B sustained-release formulation of Rimantadine is FDA approved for Topical Powder (Polysporin®) is a valproic acid that allowed for twice- the treatment of influenza A in adults topical anti-infective. It has been daily dosing. The extended-release and for the prophylaxis of influenza A removed from the Formulary version of divalproex (Depakote® ER) in children at least 1 year of age. because of low utilization. Alterna- was developed to permit once-daily However, the American Academy of tives to this product include neomy- administration. Valproic acid is also Pediatrics recommends rimantadine be cin-bacitracin-polymyxin (Neo- available as a liquid, as Depakote used in the treatment of influenza A in sporin®) ointment, mupirocin Sprinkles®, and for intravenous children. Rimantadine is dosed at 100 (Bactroban®) cream or ointment, administration. mg twice a day for adults and children and bacitracin ointment. Similar to other antiepileptic over 10 years of age. by Wendy D. Smith, PharmD medications, the exact mechanism PRESCRIBING Tracking physicians’ prescribing patterns: If HIPAA protects patients, then who protects physicians? hen prescriptions are dispensed the quantity, the location where the environment. Prescription databases Win community pharmacies, an prescription was filled, and most are extremely useful in analyzing enormous database is created. When surprisingly, the identity of the patterns of utilization. a patient brings a prescription to be physician writing the prescription. The pharmaceutical industry uses filled, the pharmacist attempts to This process leaves the switch the IMS prescription information to submit an electronic claim for payment companies in possession of a huge define marketing targets for their sales by the patient’s insurer. The informa- amount of data. Unknown to most force, a practice known as “detailing.” tion
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