Top Killers and Top Prescriptions: an In-Depth Look at Today's Pharmacology

Home , Simvastatin

Top Killers and Top Prescriptions Objectives Top Killers and Top Prescriptions: Upon completion of this session, the participant should be able to: An In-depth Look at 1. Identify major causes of death among men and women Today’s Pharmacology in the United States.

Thomas W. Barkley Jr., DSN, ACNP-BC 2. Recognize some of the most common Professor of Nursing pharmacotherapeutic agents recommended for select Director of Graduate and Nurse Practitioner Programs men’s and women’s health problems. California State University, Los Angeles and 3. State at least one strategy to improve clinical practice President, Barkley & Associates as a result of heightened awareness of top killers and top prescriptions in the United States. www.NPcourses.com

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Topical Outline Leading Causes of Death – All Males

I. Men’s and Women’s Major Causes of Death 1. Heart Disease 2. Cancer II. Most Commonly Prescribed Drugs in the U.S. 3. Unintentional Injuries 4. Stroke III. Correlates of Top Killers and Top Prescriptions 5. Chronic lower respiratory IV. Top Prescriptions and Drug Safety disease 6. Diabetes V. Top Prescriptions and Revenue Generation 7. Influenza and pneumonia 8. Suicide 9. Kidney disease 10. Alzheimer’s Disease

Top Killers and Top Prescriptions Leading Causes of Death – All Females

1. Heart Disease 2. Cancer 3. Stroke 4. Chronic lower Leading Causes of Death: respiratory disease What’s Common? 5. Alzheimer’s Disease 6. Unintentional Injuries 8. Influenza and pneumonia 9. Kidney disease 10. Sepsis

#1 Heart Disease What are the most commonly prescribed drugs in the U.S.? # 2 Cancer

#3 CVA

Top 20 Most Prescribed Drugs in the U.S. Top 20 Most Prescribed Drugs in the U.S.

#1 Hydrocodone + #6 Metformin Acetaminophen • 52 million prescriptions • 128.2 million prescriptions #7 Atorvastatin #2 Simvastatin • 51 million prescriptions • 83 prescriptions #8 Amlodipine #3 Lisinopril • 50.9 million prescriptions • 81.3 prescriptions #9 Amoxicillin #4 Levothyroxine • 49.2 million prescriptions • 66 million prescriptions #10 Hydrocholorothiazide #5 Azithromycin • 47.1 million prescriptions • 53.8 million prescriptions

Top 20 Most Prescribed Drugs in the U.S. Top 20 Most Prescribed Drugs in the U.S.

#11 Omeprazole or #16 Escitalopram Lansoprazole • 29.9 million prescriptions • 45.4 million prescriptions #17 Montelukast #12 Alprazolam • 28.8 million prescriptions • 44.4 million prescriptions #18 Clopidogrel #13 Furosemide • 28.7 million prescriptions • 42.8 million prescriptions #19 Warfarin #14 Metoprolol • 22 million prescriptions • 40.5 million prescriptions #20 Fluticasone/Salmeterol #15 Atenolol • 19.9 million prescriptions • 38.6 million prescriptions

#1 Hydrocodone + #11 Omeprazole (Prilosec) Acetaminophen (Lortab) Lansoprazole (Prevacid) #2 Simvastatin (Zocor) #12 Alprazolam (Xanax) Indications for the Most Commonly #3 Lisinopril (Prinivil) #13 Furosemide (Lasix) Prescribed Drugs #4 Levothyroxine (Synthroid) #14 Metoprolol (Lopressor) #5 Azithromycin (Zithromax) #15 Atenolol (Tenormin) #6 Metformin (Glucophage) #16 Escitalopram (Lexapro) #7 Atorvastatin (Lipitor) #17 Montelukast (Singulair) #8 Amlodipine (Norvasc) #18 Clopidogrel (Plavix) #9 Amoxicillin (Amoxil) #19 Warfarin (Coumadin) #10 Hydrocholorothiazide #20 Fluticasone/Salmeterol (Advair Diskus)

Most Commonly Prescribed Drugs: Indications

Cardiovascular Lisinopril, Simvastatin, Atorvastatin, Amlodipine, Clopidogrel, Hydrochlorothiazide, Atenolol, How many of the 20 most commonly Metoprolol, Furosemide, Warfarin Gastrointestinal prescribed drugs target the leading 10 Omeprazole causes of death? Central Nervous System Hydrocodone/APAP, Alprazolam, Escitalopram Respiratory Montelukast, Salmeterol/Fluticasone Endocrine Levothyroxine, Metformin Anti-infectives Amoxicillin, Azithromycin ©2010 Barkley & Associates ©2010 Barkley & Associates

Most Commonly Prescribed Drugs in the U.S. Most Commonly Prescribed Drugs in the U.S.

#1 Hydrocodone + #11 Omeprazole (Prilosec) #1 Hydrocodone + #11 Omeprazole (Prilosec) Acetaminophen (Lortab) Lansoprazole (Prevacid) Acetaminophen (Lortab) Lansoprazole (Prevacid) #2 Simvastatin (Zocor) #12 Alprazolam (Xanax) #2 Simvastatin (Zocor)* #12 Alprazolam (Xanax) #3 Lisinopril (Prinivil) #13 Furosemide (Lasix) #3 Lisinopril (Prinivil)* #13 Furosemide (Lasix)* #4 Levothyroxine (Synthroid) #14 Metoprolol (Lopressor) #4 Levothyroxine (Synthroid) #14 Metoprolol (Lopressor)* #5 Azithromycin (Zithromax) #15 Atenolol (Tenormin) #5 Azithromycin (Zithromax)* #15 Atenolol (Tenormin)* #6 Metformin (Glucophage) #16 Escitalopram (Lexapro) #6 Metformin (Glucophage)* #16 Escitalopram (Lexapro) #7 Atorvastatin (Lipitor) #17 Montelukast (Singulair) #7 Atorvastatin (Lipitor)* #17 Montelukast (Singulair)* #8 Amlodipine (Norvasc) #18 Clopidogrel (Plavix) #8 Amlodipine (Norvasc)* #18 Clopidogrel (Plavix)* #9 Amoxicillin (Amoxil) #19 Warfarin (Coumadin) #9 Amoxicillin (Amoxil)* #19 Warfarin (Coumadin)* #10 Hydrocholorothiazide #20 Fluticasone/Salmeterol #10 Hydrocholorothiazide* #20 Fluticasone/Salmeterol (Advair Diskus) (Advair Diskus)*

A Closer Look: # 1 Killer of Men and Women: Top Killers and Top Prescriptions Heart Disease

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Men, Women, and Heart Disease Lipid Levels In the United States:  When should cholesterol  Every 20 seconds, someone has screening begin? an MI  What indices should be  1.5 million/year initially tested?  ~ 500,000 deaths  Every 34 seconds, someone dies  Total Cholesterol of heart disease • Desirable: < 200 mg/dL  Overall, more women than men  Triglycerides (VLDLs) die of heart disease each year • < 150 mg/dL  For men < 65 years of age, 3 x  HDL more men than women die from • > 40 mg/dL heart disease  LDLs • < 100mg/dL: Optimal • [Consider values: < 130? < 100? < 70?]

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Physiology Review: HMG-CoA Reductase Statins • Cholesterol: manufactured in the liver by a series of > 25 metabolic • Statins also decrease apolipoprotein B-100 synthesis, steps resulting in decreases in VLDLs • HMG-CoA reductase serves as the primary regulatory site for cholesterol biosynthesis Other Statin Benefits: • Normally, this enzyme is controlled through negative feedback:  Promote plaque stability by cholesterol removal and • High levels of LDL will shut down production of HMG-CoA reductase, thus decreased calcification turning off the cholesterol pathway  Decreased inflammation • Statins act by inhibiting HMG-CoA reductase, which results in less  Improvement of endothelial function cholesterol biosynthesis  Decreased risk of atrial fibrillation • They increase the number of LDL receptors on hepatocytes causing a  Decreased risk of thrombosis by decreasing platelet removal of LDLs from blood aggregation and thrombin formation

 Monitor LFTs HMG-CoA Reductase Comments • Most patients will experience an  but still WNL Inhibitors • Ask about myalgias (Produce the most rapid  in LDL-C)  Myositis • Atorvastatin (Lipitor) #7 • MOA: • Mild injury may present as muscle weakness or tenderness, local or diffuse • Fluvastatin (Lescol) • Inhibit cholesterol synthesis in liver   LDL-C in the serum • Incidence: 1-5% of patients • Lovastatin (Pravachol) • Rarely, may progress to myositis with elevated creatine kinase (CK) • Up-regulate LDL receptors Check for CK levels 10 times the ULN: > 10 = discontinue the statin • Rosuvastatin (Crestor) leading to  catabolic clearance of • Simvastatin (Zocor) #2 serum LDL-C  Rhabdomyolysis • Modest ↑ HDL-C, ↓ triglycerides • Fatal rhabdo seen in < 0.15 cases/1 million prescriptions • ↓ C-reactive protein • Rosuvastatin has the highest risk

 Risk/Benefit Ratio: Still swings in favor of using a statin!

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Latest on the Statins

• The FDA (2010) approved rosuvastatin (Crestor) for: 1. Men > 50 and women > 60 2. + Elevated CRP levels # 2 Killer in Men and Women: 3. + Another CV risk factor (e.g., HTN, low HDL, smoking, and family history) Cancer

**Interesting note: High LDLs are not on the list…  ½ of all MIs and CVAs happen in people with low or normal LDLs  Not sure if all statins will work the same…we shall see

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Most Common Types of Cancer

Women 1. Breast 2. Lung 3. Colorectal

Men 1. Prostate 2. Lung 3. Colorectal

©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions Cancer in Men Cancer in Women Digital Rectal Exams (DREs) Pap Smears • Beginning at age 40 • By the age of 21 or ~ 3 years after first intercourse (which ever comes first) Prostate Surface Antigen (PSAs) • Beginning at age 50 • Earlier if: Breast Cancer Screening • African American • Regular mammograms recommended • Positive Family History starting at age 40 Colonoscopy • Beginning at age 50 Colonoscopy • Beginning at age 50

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Top Unintentional Injuries Causes:

Motor vehicle crashes # 3 Killer of Men and #6 Killer of Women: Poisoning Unintentional Injuries Falls Suffocation Unspecified Drowning Fire/burn Others

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Alcoholism/Drug Abuse = CAGE

C = Cut down? #4 Killer of Men and #3 Killer of Women: A = Annoyed? CVA G = Guilty? E = Eye-opener?

Drugs for Hypertension • Primary/Essential • 95%; onset usually < 55 years of age

• Secondary • 5%; secondary to known causes

• Exacerbating factors: smoking, obesity, alcohol intake, use of NSAIDS, etc.

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Principles of Drug Therapy for Hypertension Hypertension Classifications 1. When small doses work, higher doses do not always work better. Normal: < 120 and < 80 • Inappropriate high doses may increase adverse effects • Adjust dosage based on patient’s actual clinical response Pre-hypertension: 120-139 or 80-89 2. Especially with the elderly, start low and go slow Hypertension: 3. Try to select an antihypertensive with 24 hour activity with at Stage 1 140-159 or 90-99 least 40% of activity in the last 12 hours • Persistent, smooth muscle BP control Stage 2 > 160 or > 100 • Provides improved adherence and less rebound with missed dose

4. Consider at bedtime dosing, rather than a.m. dosing to protect against the a.m. catecholamine surge

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Principles of Drug Therapy for Hypertension – continued Drugs for Hypertension: Diuretics 5. Select drug-drug interactions that not only offer additive Potassium- Thiazide and Loop/High-Ceiling efficacy, but also decrease the toxicity of one or both drugs Sparing Agents Thiazide-Like Agents Agents • ACEI + thiazide = Opposite effect on serum K+

6. Seek instances in which a single drug can positively impact • Amiloride (Midamor) • Benzthiazide (Aquatab) • Bumetanide (Bumex) more than one indication • Spironolactone • Chlorothiaze (Diuril) • Furosemide (Lasix) #13 (Aldactone) • Clonidine to ↓ BP and ↓ symptoms in patients undergoing withdrawal • Chlorthalidone (Hygroton) • Torsemide (Demadex) from alcohol, nicotine and opiates • Triamterene • Hydrochlorothiazide • Alpha blockers to ↓ BP and treat BPH (Dyrenium) (Hydrodiuril) #10 7. First, choose the class of drug, then choose within the class • Indapamide (Lozol) • But, do not assume that drugs within a class are interchangeable • Metolazone (Diulo) • Polythiazide (Renese) 8. View claims of ‘receptor selectivity’ with caution; significance • Trichlormethiazide may be influenced by drug concentration, receptors and/or (Diurese) disease state ©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions Drugs for Hypertension: Drugs for Hypertension: ACE Inhibitors Calcium Channel Blockers ACE Inhibitors • Renin is an enzyme secreted when BP drops Notes: Selective CCB: For blood or when there is a ↓in Na flowing through the • Not used as monotherapy vessels • Benzapril (Lotensin) kidney tubules • Captopril (Capoten) • Amilodipine (Norvasc) • Vasoconstriction by ACE ⁭↑ BP by ↑ PVR • Elderly and African • Enalopril (Vasotec) Americans respond well • Felodipine (Plendil) • Fosinopril (Monopril) • H2O retention results from enhanced Na • Nicardipine (Cardene) reabsorption (Angiotensin II stimulates • Lisinopril (Prinivil) #3 aldosterone secretion) • Relax arterial muscle and ↓ • Nifedipine (Procardia, Adalat) PVR at low doses • Moexipril (Univasc) • Perindopril (Aceon) • Inhibits degredation of bradykinin (potent Non-selective: For both blood vasodilator) • May cause edema, • Quinapril (Accupril) vessels and heart hypotension, tachycardia, • Ramipril (Altace) • SE: cough, postural hypotension, dizziness, headache • Diltiazem (Cardizem) hyperkalemia, angioedema, drug-drug • Trandolapril (Mavik) reactions • Isradipine (DynaCirc) (Nisocor) • *ACEI = standard of care for mild to severe • Nisoldipine HTN • Verapamil (Calan, Isoptin) ©2010 Barkley & Associates ©2010 Barkley & Associates

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Drugs for Hypertension: Drugs for Hypertension – Angiotensin II Receptor Blockers Adrenergic Antagonists

Angiotensin II Receptor • Block the effect of Beta-Adrenergic Comments Blockers angiotensin II by binding to Antagonists angio II receptors • Candesartan (Atacand) • Atenolol (Tenormin) #15 Used to treat: • Eprosartan (Teveten) • HTN, Angina, Arrythmias, HF, Post-MI • No effect on bradykinin • Bisoprolol (Zebeta) • Irbesartan (Avapro) • Metoprolol (Toprol, • Effects: ↓ HR, ↓ contractility, ↓ CO, ↓ BP • Losartan (Cozaar) • Used with diuretics for Lopressor) #14 • ADR: bronchoconstriction (wheezing), • Olmesartan medoxomil maximal effect • Propranolol (Inderal) rebound HTN if discontinued abruptly, masks (Benicar) signs/symptoms of hypoglycemia, may (Betimol, others) • Telmisartan (Micardis) • Timolol cause erectile dysfunction • May cause dizziness, • Large first-pass effect • Valsartan (Diovan) orthostatic hypotension, facial edema

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Drugs for Hypertension – Drugs for Hypertension – Adrenergic Antagonists Adrenergic Antagonists Alpha1-Adrenergic Comments Alpha2-Adrenergic Agonists Comments Antagonists • Clonidine (Catapres) • Clonidine stimulates alpha-2 • Doxazosin (Cardura) • Block sympathetic receptors in • Guanabenz (Witensin) receptors in the CNS (↓ sympathetic arterioles  arterial/venous vasodilators (Monopress) flow  ↓ NE release) • Prazosin • Methyldopa (Aldomet) • Good for mild to moderate HTN • Cause vasodilation, ↓ HR, ↓ BP, ↓ • Terazosin (Hytrin) • Less effective than diuretics CO • Used in combination treatment • May cause rebound HTN if • Causes 1st does syncope: remain in discontinued abruptly office for 30 minutes! • Sedation, dry mouth, constipation, • May cause ↓ libido and erectile edema dysfunction in men • *Clonidine: preferred drug for rapid • First used for BPH ↓ BP

©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions Drugs for Hypertension – Drugs for Hypertension – Adrenergic Antagonists Adrenergic Antagonists

Alpha1-And Beta-Blockers (Centrally Acting) Adrenergic Neuron Blockers Comments (Peripherally Acting) • Carteolol (Cartrol, Ocupress) • Guanadrel (Hylorel) • Inhibits the synthesis or • Labetalol (Trandate, Normodyne) • Guanethidine (Ismelin) release of NE in sympathetic neurons • Reserpine (Serpasil) • ↓ PVR with little or no change in CO • Sedation, depression, ↑ motility and nasal stuffiness • *Rarely prescribed

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Drugs for Hypertension – Antihypertensives: Effects of Serum Lipids Adrenergic Antagonists Thiazides: Direct-Acting Vasodilators Comments • ⁭ ↑ LDLs, ⁭ ↑ triglycerides • Diazoxide (Hyperstat) • Potential to cause serious adverse effects • Hydralazine (Apresoline) • Produce reflex tachycardia Beta blockers: • Minoxidil (Loniten) • Heart works harder, BP ↑ • ⁭↑ triglycerides, ↓ HDLs • Nitroprusside (Nipride) • Concurrent BB therapy may counter reflex tachycardia • May cause Na and H2O retention  ⁭ Alpha-1 blockers: blood volume and ↑BP (diuretic can • ↓ LDLs, ↓ triglycerides, ↑ HDLs counter) • Nipride: DOC for HTN emergency • Metabolized to cyanide ACEI and CCBs: no effect

Top Killers and Top Prescriptions Top Killers and Top Prescriptions

COPD (Chronic Bronchitis and Emphysema) #5 Killer of Men and #4 Killer of Women: Chronic Lower Respiratory Diseases Chronic Bronchitis • Excessive secretion of bronchial mucus – 3 months or more – 2 consecutive years

Emphysema • Abnormal permanent enlargement of air spaces distal to the terminal bronchiole

• Patients usually have features of both!!

Generic Name Brand Name 1. Anticholinergics Ipratropium bromide Atrovent (short-acting) 2. Beta-2 agonists Tiotropium bromide Spiriva (long-acting) Anticholinergic and 3. Corticosteroids Short-acting Beta2- Agonist Combination Ipratropium bromide Combivent, DuoNeb and albuterol sulfate

Top Killers and Top Prescriptions Top Killers and Top Prescriptions

Beta 2 Agonists Beta2-Agonists and Corticosteroid Combinations Generic Name Brand Name Generic Name Brand Name

albuterol (short-acting) Proventil, Ventolin HFA Long-acting Beta2-Agonists and Anticholinergic Brand Name arformoterol tartrate (long-acting) Brovana Combinations Salmeterol xinafoate and Advair Diskus formoterol (long-acting) Foradil, Perforomist fluticasone propionate #20

levalbuterol (short-acting) Xopenex Formoterol and budesonide Symbicort

metaproterenol sulfate (short-acting) Alupent Short-acting Beta2-Agonist and Anticholinergic pirbuterol acetate (short-acting) Maxair Combination salmeterol xinafoate (long-acting) Serevent Albuterol sulfate and Combivent, DuoNeb ipratropium bromide terbutaline sulfate (short-acting)

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Corticosteroids for COPD COPD Corticosteroids – continued

Inhaled Form/Generic Brand Name Pill/liquid (oral forms) Name Generic Name Brand Name Beclomethasone QVAR 40, QVAR dipropionate Methylprednisolone Medrol, Solu-Medrol Budesonide 80Pulmicort Turbuhaler, Pulmicort Flexhaler, Rhinocort Prednisolone Prelone Flunisolide AeroBid Prednisone Deltasone Fluticasone propionate Flovent Diskus, Flovent HFA Mometasone furoate Asmanex Twisthaler

Triamcinolone acetonide Azmacort

#6 Killer of Men and #7 Killer of Women: Diabetes

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Metabolic Syndrome Oral Hypoglycemics

1. Waist circumference 4. FBG > 100 Sulfonylureas Comments: • > 40 inches in men (First Generation) • > 35 inches in women 5. HDL • Acetohexamide (Dimelor, • Older agents Dymelor) < 40 in men • Stimulate the pancreas to release 2. BP > 130/85 more insulin < 50 in women • Chlorpropamide (Diabinese, Novopropamide) • Sulfonylureas, as a class, offer the • Tolazamide (Tolamide, potential for the most adverse effects, 3. Triglyceridees > 150 Tolinase) particularly hypoglycemia • Tolbutamide (Orinase) • SE: weight gain, GI distress, hepatosplenomegaly

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Oral Hypoglycemics – continued Oral Hypoglycemics – continued

Sulfonylureas Comments: Biguanide Comments: Alpha- Comments: Glucosidase (Second Generation) • ↓ gluconeogenesis • Metformin Inhibitors (Glucophage, • Glimepiride (Amaryl) • Most widely prescribed • Reduce insulin Glucophage XR, resistance • Acarbose • Bind to • Stimulate the pancreas to release Fortamet, • Glipizide (Glucotrol) • No hypoglycemia or (Precose) disaccharidases more insulin Glumetza, more readily than • Glyburide (DiaBeta, Riomet) #6 weight gain • Miglitol Micronase, Glynase) • Good adjunct to (Glyset) sucrose, so less sulfonylureas glucose is • Standard of care absorbed by the upon the diagnosis of gut Type II DM • Monitor for lactic acidosis

Thiazolidinediones Comments: Agent Comments: “TZDs” • Exenatide • Injectable that mimics the effects of incretins (signal the • “Glitazones” (Byetta) pancreas to ↑ insulin secretion and the liver to stop • Pioglitazone (Actos) producing glucagon) • Decrease gluconeogenesis • Rosiglitazone (Avandia) • May cause significant N, V & D • Contraindicated in heart failure because these may promote fluid retention • Sitagliptin • First of a new drug class, dipeptidyl peptidase-4 (DD-4 Meglitinides Comments: (Januvia) inhibitors); DD-4 enzyme breaks down incretins Nateglinide (Starlix) • Non-sulfonylurea insulin release • Pramlintide • New injectable for Type 1 and 2 DM stimulators – rapidly absorbed from the Repaglinide (Prandin) (Symlin) • Resembles human amylin, a hormone produced by the intestine and mimic rapid acting insulin pancreas after meals that helps the body regulate blood • Again, have shorter durations than glucose sulfonylureas • Slows the absorption of glucose and inhibits the action of glucagon • ↓ blood glucose and promotes weight loss ©2010 Barkley & Associates ©2010 Barkley & Associates

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Hypoglycemics – continued Insulin Preparations

Combination Agents Insulin Analogs Comments: • Humalog: rapid onset • Glipizide/Metformin (Metaglip) • Insulin Aspart (NovoLog) • Lantus: prolonged duration • Glyburide/Metformin (Glucovance) • Insulin Glargine (Lantus) • Rosiglitazone/Glimepride (Avandaryl) • Insulin Lispro (Humalog) • Pioglitazone/Metformin (ACTOplus met) • Rosiglitazone/Metformin (Avandamet)

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Influenza and Pneumonia

• Pneumonia and influenza: 7th most common cause of death • The most common cause of death from infectious diseases #7 Killer in Men and #8 Killer in Women: Influenza and Pneumonia  1.5 x more men than women die of the flu and pneumonia

©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions More Health Promotion… Vaccination Considerations in Men and Women  Influenza vaccine – annually

INFLUENZA:  Tetanus – every 10 years Pandemics and What’s Next?  Hepatitis A?

 Hepatitis B?

 Zostavax – age 60; perhaps 50?

 Pneumococcal vaccine – age 65

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Community Acquired Pneumonia Update: Community-Acquired Pneumonia • Acute lung tissue infection (at least 2 new symptoms)

Classic Presentations • Fever and/or hypothermia Severity Indicators • Rigors and/or diaphoresis Latest Guidelines • Sputum production or color change • Cough • Chest pain • Dyspnea

• Abnormal chest exam and/or new infiltrate by CXR

• No other exposure (hospitalization or nursing home) in 2 weeks prior to symptom onset

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Community Acquired Pneumonia

• > 85 year of age: at least 1/20 hospitalized each year

• More common in winter months Pneumonia: Inpatient or Outpatient? • Inpatient mortality: 2-30% (~14%)

• Outpatient mortality: <1%

• Chest PE: not sensitive or specific to ascertain diagnosis

Pneumonia Severity Index Calculator: About. December 2003. Agency for Healthcare Research and Quality. Rockville, MD. http://pda.ahrq.gov/psiabout.htm

Top Killers and Top Prescriptions Top Killers and Top Prescriptions

IDSA/ATS Community Acquired Pneumonia Guidelines

Mandell, L.A., Wunderink, R.G., Anzueto, A., Bartlett, J.G., Campbell, G.D., Dean, N.C., et al. (2007). Infectious diseases society of America/American thoracic society consensus guidelines on the management of community- acquired pneumonia in adults. Clinical Infectious Diseases, 44, S27-72.

Top Killers and Top Prescriptions Top Killers and Top Prescriptions CAP-Empirical treatment: IDSA/ATS CAP-Empirical treatment: IDSA/ATS Consensus Guidelines Consensus Guidelines

• Outpatient treatment: • Outpatient treatment: • Patients > 60 years and/or with co-morbid conditions, • Previously healthy, no antibiotics in 3 months: immunosuppresion or antibiotics within 3 months: • Select a different class

• Macrolide (1st choice) such as azithromycin (Zithromax), • *Respiratory fluoroquinolone: moxifloxacin, gemifloxacin, clarithromycin (Biaxin) or erythromycin or levofloxacin (750 mg)

Or • *ß-lactam PLUS a macrolide

• Doxycycline (*Above regimens also for inpatient, non-ICU use) ______• For macrolide-resistant Streptococcus penumoniae in regions with high-rates (>25%) of infection: • For patients without co-morbidities: consider above regimen

©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions CAP-Empirical treatment: IDSA/ATS CAP-Empirical treatment: IDSA/ATS Consensus Guidelines Consensus Guidelines • For Pseudomonas, consider: • Inpatient treatment, ICU: ______• An antipneumococcal, antipseudonomal ß-lactam (piperacillin- tazobactam, cefepime, imipenem or meropenem) + either • ß-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) ciprofloxacin or levofloxacin OR PLUS • The above ß-lactam + an aminoglycoside and azithromycin OR • The above ß-lactam + an aminoglycoside and an antipneumococcal • Azithromycin OR fluoroqinolone • A respiratory fluoroquinolone (for PCN-allergic patients, substitute aztreonam for above ß-lactam) ______• For penicillin allergy: • If CA-MRSA suspected: add vancomycin or linezolid • Respiratory fluoroquinolone + aztreonam

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Suicide  Men have ~ 4 x higher suicide rate than women  Greatest risk: #8 Killer in Men: • Adolescents and young males Suicide • White males > 45 years of age • Elderly men > 75 years of age (9-12 x higher than women)

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Overall Methods of Suicide Suicide: Depression

 Antidepressants: 4th Top Cash- Generating Drug Class in the Suicide by: Males Females United States

Firearms 57% 32%  Escitalopram (#16) Black Box Warning: Increased risk of Suffocation 23% 20% suicidal ideation and behavior in children and young adults Poisoning 13% 38%  FDA-mandated black box warning statements: • Patient Medication Guide (MedGuide) given to patients to advise them of the risks and precautions that can be taken is appropriate

©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions Chronic Kidney Disease Non-modifiable Risk Most Common Causes: Factors: 1. Diabetes #9 Killer in Men and Women: • Age 2. Hypertension Kidney Disease • Race Other Contributing • Male Gender Factors: • Positive Family History • Nephrotoxicity • NSAIDS • Long term antibiotic use

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Alzheimer’s Disease Pathophysiology Review:

• Most common cause of dementia #10 Killer in Men and #5 Killer in Women: Alzheimer’s Disease • Etiology is unknown; but patients lose ability to perform tasks that require acetylcholine (Ach) as the transmitter

• Ach is the a major NT within the hippocampus (responsible for learning and memory)

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Treating Alzheimer’s Disease: Alzheimer’s Disease – continued Acetylcholinesterase Inhibitors • Classic Findings: 1. Multiple cognitive defects characterized by both Select Examples: memory impairment and one or more of the following: 1. Donepezil hydrochloride (Aricept)  Aphasia (difficulty with speech)  Apraxia (inability to perform a previously learned task) 2. Tacrine (Cognex)  Agnosia (inability to recognize an object) Associated with hepatotoxicity  Inability to plan, organize, sequence and make abstract differences 3. Rivastigmine (Exelon) *Most ALL have Associated with weight loss GI side effects: • Treatment: • Nausea • Acetylcholinesterase inhibitors 4. Galantamine (Reminyl) • Vomiting (Parasympathomimetics) • Diarrhea

Top Prescriptions and Top Prescriptions: Drug Safety Black Box Warnings?

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Most Prescribed Drugs Most Commonly Prescribed Drugs in the U.S. and Black Box Warnings* #1 Hydrocodone + #11 Omeprazole (Prilosec) #1 Hydrocodone + #11 Omeprazole (Prilosec) Acetaminophen (Lortab) Lansoprazole (Prevacid) Acetaminophen (Lortab) Lansoprazole (Prevacid) #2 Simvastatin (Zocor) #12 Alprazolam (Xanax) #2 Simvastatin (Zocor) #12 Alprazolam (Xanax) #3 Lisinopril (Prinivil) #13 Furosemide (Lasix) #3 Lisinopril (Prinivil)* #13 Furosemide (Lasix)* #4 Levothyroxine (Synthroid) #14 Metoprolol (Lopressor) #4 Levothyroxine (Synthroid)* #14 Metoprolol (Lopressor)* #5 Azithromycin (Zithromax) #15 Atenolol (Tenormin) #5 Azithromycin (Zithromax) #15 Atenolol (Tenormin)* #6 Metformin (Glucophage) #16 Escitalopram (Lexapro) #6 Metformin (Glucophage)* #16 Escitalopram (Lexapro)* #7 Atorvastatin (Lipitor) #17 Montelukast (Singulair) #7 Atorvastatin (Lipitor) #17 Montelukast (Singulair) #8 Amlodipine (Norvasc) #18 Clopidogrel (Plavix) #8 Amlodipine (Norvasc) #18 Clopidogrel (Plavix) #9 Amoxicillin (Amoxil) #19 Warfarin (Coumadin) #9 Amoxicillin (Amoxil) #19 Warfarin (Coumadin)* #10 Hydrocholorothiazide #20 Fluticasone/Salmeterol #10 Hydrocholorothiazide #20 Fluticasone/Salmeterol (Advair Diskus) (Advair Diskus)*

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Most Prescribed Drugs Most Prescribed Drugs and Black Box Warnings and Black Box Warnings #3 Lisinopril #16 Escitalopram Can cause injury to the developing fetus in the 2nd and 3rd trimester; contraindicated in pregnancy For suicidal ideation in children and young adults age 18-24; Not approved for use in children < 12 years of age; #4 Levothyroxine Dispense FDA medication guide with prescription Ineffective and potentially toxic for weight reduction; High doses may cause toxic effects with other anorectic drugs; Watch in CV disease #19 Warfarin #6 Metformin Increased risk of fatal bleeds Lactic acidosis may result; Watch in patients with CHF or other CV problems #20 Salmeterol #13 Furosemide Increased risk of asthma-related deaths In excessive doses, may cause profound diuresis and electrolyte disturbances #14 Metoprolol & #15 Atenolol Do not discontinue abruptly due to tachycardia, HTN, and ischemia

©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions Aligning Money and Top Prescriptions • Top prescribed drugs are not necessarily the top revenue-generating drugs

Aligning Money and Top Prescriptions • Niche drugs are very, very expensive: • Drugs for cancer • Drugs for MS • Drugs for HIV/AIDS • Any new popular-use drug that has not yet gone generic

• Top revenue-generating drugs include….

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Top Revenue Generating Drugs by SALES Top Revenue Generating Drugs by CLASS

#1 Anti-psychotics 1. Atorvastatin (Lipitor)* 6. Montelukast (Singulair)* • $14.6 billion in sales/year • Top-selling as far as $$ are 2. Esomeprazole (Nexium) concerned: NOT for numbers of 7. Etanercept (Enbrel) prescriptions written 3. Clopidogrel (Plavix)* 8. Pioglitazone (Actos) #2 Acid Reflux Drugs 4. Fluticasone/Salmeterol • $13.6 billion in sales/year (Advair Discus)* 9. Lansoprazole (Prevacid)* #3 Lipid Lowering Drugs 5. Quetiapine (Seroquel) • $13.6 billion in sales/year, but less than GI drugs because 10.Pegfilgrastim (Neulasta) many of these went generic • #1 class of drugs in terms of prescriptions written

#4 Antidepressants * = Top 20 Most Prescribed List • $9.9 billion in sales/year

Top Killers and Top Prescriptions Top Killers and Top Prescriptions Staying on Top of the Top Prescriptions

• Institute for Safe Medication Practices • FDA MedWatch • Medscape Need Additional Pharmacology CEU Credits? • Medical literature: Evidence-based research • Nurse Practitioners’ Prescribing Reference • Pharmaceutical Executive • Popular press • Scholarly internet sources • Business sources

©2010 Barkley & Associates ©2010 Barkley & Associates Top Killers and Top Prescriptions Top Killers and Top Prescriptions Barkley & Associates www.NPcourses.com www.NPcourses.com Online Pharmacology Updates: 1. An Evidence-based Blitz 2. Exploring the Top 20 Drugs! 3. What’s Hot and What to Watch! 4. PSYCHOpharmacology 5. Prescribing Controlled Substances

6. Top Pediatric Prescriptions (coming in 2011)

7. Top Drugs in Acute Care (coming in 2011)

Barkley & Associates is approved as a provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners: AANP Provider Number 081018. ©2010 Barkley & Associates ©2010 Barkley & Associates

Top Killers and Top Prescriptions

~ THANK YOU ~

P.O. Box 69901 West Hollywood, CA 90069 866.938.5557