Drug Topics - October 22, 2007 - (Page H10)

10HSE DRUG TOPICS OCTOBER 22, 2007 www.drugtopics.com Ending/reversing weight gain 45-year-old man, F.H., with Type 2 diabetes and chronic obstructive pulmonary disease (COPD), is in for his six-month checkup in your managed care organization. He has gained 40 lb. since his last visit (height= 5’7” and weight=282 lb.). Despite this, his blood pressure=124/69 and his A1c=6.5, although his recent blood sugar levels are running high. F.H. takes prednisone 35 mg daily, lisinopril 10 mg daily, hydrochlorothiazide 12.5 mg daily, mometasone furoate (Asmanex, Schering) one puff daily, montelukast 10 mg (Singulair, Merck) at bedtime, nebulized albuterol/ipratropium every six hours as needed, and Novolin 70/30 (Novo Nordisk) in the morning and afternoon. His doctor has repeatedly tried to taper prednisone, but F.H. always complains he can’t breathe. F.H. previously failed theophylline and formoterol (Foradil, Novartis). His physician is considering whether exenatide (Byetta, Amylin/Lilly) would help F.H. lose weight. Do you agree? A I effect on weight compared with insulin. However, t is true exenatide has been shown to have a favorable F.H. weighs 282 lb. (135 lb. over ideal body weight); therefore the potential weight loss (10 lb. to 15 lb.) resulting from a switch is unlikely to have a substantial impact on his overall health. I always hesitate to recommend drug therapy to treat a side effect. The weight gain is possibly a result of his chronic prednisone therapy, although F.H. should be worked up for other causes of weight gain, such as heart failure. The real issue is that F.H. has very severe COPD that needs to be managed appropriately. I recommend starting tiotropium (Spiriva, Boehringer Ingelheim/Pfizer) or salmeterol (Serevent, GlaxoSmithKline) alone or in combination. I would also question his formoterol failure. Was this simply a matter of nonadherence or poor inhaler technique? The importance of adherence and proper technique needs to be stressed to F.H. and evaluated periodically by a healthcare professional. Chronic oxygen therapy could also be considered. Once appropriate therapy is started, a prednisone taper should again be attempted. Chronic treatment with systemic steroids is not recommended for COPD patients. F.H. would benefit from an exercise training program to help maintain lung function and improve COPD symptoms as well as encourage weight loss. Danny McNatty, Pharm.D., BCPS Assistant Professor, Pharmacy Practice Midwestern University College of Pharmacy-Glendale, Ariz. Yes, exenatide would help F.H. lose weight; however, weight loss could be achieved by simply tapering/discontinuing prednisone—oral steroids lead to weight gain, hyperglycemia, plus other adverse effects. Chronic oral corticosteroids should be avoided in COPD patients given the unfavorable benefit-to-risk ratio, so taper and discontinue prednisone. To aid discontinuation of prednisone, use a combination of scheduled long-acting bronchodilators—tiotropium, one inhalation daily, plus salmeterol or formoterol— and discontinue ipratropium via nebulizer. Discontinue mometasone (no data in Global Initiative for Chronic Obstructive Pulmonary Disease Guidelines). Switch to salmeterol/fluticasone (Advair Diskus, GlaxoSmithKline), one inhalation twice daily, or formoterol/budesonide (Symbicort Turbuhaler, AstraZeneca), two inhalations twice daily. F.H. previously failed formoterol; however, combining different bronchodilator classes with a corticosteroid improves lung function more than individual agents. Prescribe smoking cessation if he uses tobacco; reduce risk factors: tobacco smoke, occupational dusts and chemicals, and smoke from home cooking or heating fuels. Check spirometry and start pulmonary rehabilitation. Check for respiratory failure and right-sided heart failure. Also, check arterial blood gases to see if oxygen is warranted and check for infectious exacerbation of COPD to see if antibiotics are indicated. Check for possible GERD that may be worsening breathing as some pulmonary medications (e.g., albuterol) can reduce lower esophageal sphincter pressure. Suggest influenza and pneumococcal vaccination, if applicable, and perform osteoporosis evaluation secondary to chronic systemic corticosteroid use. Later, consider discontinuing montelukast unless F.H. has asthma or allergic rhinitis (leukotriene modifiers haven’t been adequately tested in COPD). Prescribe exercise and nutrition counseling for weight loss. Consider exenatide (if CrCl >30 ml/min) if stopping prednisone and weight loss interventions fail after a few months. Lower insulin dose by 50% if exenatide is added. During prednisone taper, F.H. should monitor hypoglycemia/hyperglycemia multiple times daily. Diabetes could be better controlled with a peakless insulin combined with rapid-acting insulin, i.e., insulin glargine (Lantus, Sanofi-Aventis) plus insulin lispro (Humalog, Lilly). Kristine E. Keplar, Pharm.D. Clinical Pharmacist St. Anthony’s Memorial Hospital Effingham, Ill. Adjunct Associate Professor Butler University, Indianapolis http://www.drugtopics.com

Table of Contents Feed for the Digital Edition of Drug Topics - October 22, 2007

Drug Topics - October 22, 2007 Contents Latebreakers Legislative Victory Builds Momentum for Pharmacy Month Letters Health-System Edition R.Ph.s Brace for Payment Denial for Hospital-Acquired Conditions Topical Human Thrombin Helps Arrest Bleeding FDA Panels Fail to Set Target Levels for Renal Patients’ Hemoglobin Warning Letters Raise Patient Safety Concerns for Fentora Ending/Reversing Weight Gain Man Given Fatal Drug Overdose at Staten Island Hospital Pharmacists Playing More Important Role in Dialysis Treatment AHA President R.Ph.'s Here's How You Can Increase Your Value Premier Launches Comprehensive Quality Improvement Project FDA Approves Dexrazoxane for Treatment of Extravasation New Federal, State Reforms to Ease Disaster Relief Kinks 150 Years of American Pharmacy Ten Tips for MTM Success Independent Superstars: The Ones to Watch The New Dynamic Duo A Parkinson's Disease Primer Classified New Products Advertisers Index Viewpoint

Drug Topics - October 22, 2007

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.