Appropriate antibiotic prescribing in bronchitis
Antibiotics are often inappropriately prescribed for adults with acute bronchitis. Clinical guidelines for treating adults with no co-morbidity do not indicate treatment with antibiotics.
Acute bronchitis consistently ranks among the top 10 conditions diagnosed in the retail health setting. Most cases of bronchitis have a viral etiology — respiratory syncytial virus, adenovirus, influenza and parainfluenza being most common.
Despite the fact that the vast majority of acute bronchitis cases (i.e., more than 90%) have a nonbacterial cause, antibiotics are prescribed 65% to 85% of the time. Inappropriate antibiotic treatment of adults with acute bronchitis is of clinical concern, especially since misuse and overuse of antibiotics lead to antibiotic drug resistance. Because so many of our patients come to us with symptoms related to bronchitis and other upper respiratory complaints, it is imperative that the retail clinician review and understand the Centers for Disease Control and Prevention guidelines on antibiotic use in upper
The evaluation of adults with an acute cough illness or with presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out pneumonia. In the healthy, non-elderly adult, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds. Routine antibiotic treatment of uncomplicated bronchitis is not recommended, regardless of duration of cough. Chronic bronchitis (i.e., cough with mucus most days for at least three months a year for at least two years) is more common among smokers.
Patient education, while it sometimes presents difficulty, is of utmost importance. While patients are often eager for a quick fix, and clinicians are stressed for time in patient encounters, it is important to take a moment to explain to each patient the expected course of the illness (i.e., two to eight weeks) and provide empathy around the fact that although the patient is likely feeling quite ill, antibiotics will not alter the course of
Pharmacists seek federal recognition
The month of March came in like a lion, indeed, but not because of the weather. The month began with a roar as a group of the largest and most influential pharmacy associations and chains came together to form the Patient Access to Pharmacists’ Care Coalition, or PAPCC, in an effort to secure formal federal recognition of pharmacists as healthcare providers.
As discussed in this column in the November 2013 issue, provider status for pharmacists is an issue that gained huge momentum over the past year, particularly when in October 2013, California Gov. Jerry Brown signed the state’s pharmacist provider status into law, enabling pharmacists to be paid for their patient care services. The formation of PAPCC was motivated by the need to get the Federal government to buy into the idea that care by pharmacists improves outcomes for patients and lowers healthcare costs, as numerous studies have already shown.
Nine major associations, including the American Association of Colleges of Pharmacy (AACP), American Pharmacists Association (APhA), American Society of Consultant Pharmacists (ASCP), American Society of Health-System Pharmacists (ASHP), Food Marketing Institute (FMI), International Academy of Compounding Pharmacists (IACP), National Alliance of State Pharmacy Associations (NASPA), National Association of Chain Drug Stores (NACDS) and National Community Pharmacists Association (NCPA) are part of the Patient Access to Pharmacists’ Care Coalition. In addition, numerous pharmacies and wholesalers have signed on, including Albertson’s, AmerisourceBergen, Bi-Lo, Cardinal Health, CVS Caremark, Rite Aid, Safeway and Walgreens, among others.
“What do we want? Recognition! When do we want it? As soon as possible!”
PAPCC will head the effort to push for a federal legislative proposal, enabling patient access to and reimbursement for Medicare Part B services by pharmacists in medically underserved communities. Because pharmacists were not originally included in Medicare Part B, beneficiaries have limited access to pharmacists’ services on an outpatient basis. And due to the omission of pharmacists under Medicare, state and private plans also have failed to include pharmacists as providers, or to compensate them. PAPCC’s goal is to change that.
“This group will be knocking on the doors of Congress to ensure that pharmacists are formally recognized for their work as healthcare providers under federal law,” wrote APhA EVP and CEO, Thomas Menighan, on his weekly blog. “As we gain federal recognition, it will be easier for pharmacists to provide the critical care that our patients rely on, which will reduce system costs, improve patient outcomes and expand professional opportunities for pharmacists.”
On his blog on the ASHP website, ASHP CEO Paul Abramowitz wrote that “the proposal also will establish a mechanism to pay for pharmacist provider services as a percentage of the current physician fee schedule, or pursuant to pharmacists’ specific codes as part of that schedule.”
In conjunction with the development of PAPCC, and as part of its annual meeting at the end of March, APhA is launching a new marketing campaign — Pharmacists Provide Care. The campaign is designed to raise awareness of the value of pharmacists and the care they provide to their patients in order to gain support for pharmacist provider status. More information on the campaign and on PAPCC will be released at APhA’s annual meeting at the end of March.
As PAPCC gears up toward its goal of getting bills introduced into Congress — like H.R. 4190, which would allow pharmacists to work to their full capability by providing underserved patients in the Medicare program with services not currently available to them — it seeks support from pharmacists on the national, state and local levels. According to Abramowitz, “As federal advocacy takes place, it will be equally, if not more important, for pharmacists and their partners in the stakeholder community at the state and local level to take an assertive stance and leading role in persuading their elected officials in Washington to support provider status for pharmacists under Medicare Part B.” Menighan agreed that “there will be numerous opportunities to lend your voice and contribute to this cause,” but in the meantime, educational materials, resources and tools are available at Pharmacist.com/ProviderStatusRecognition.
Blood-based biomarkers may predict cognitive impairment associated with Alzheimer’s disease
Early-stage Alzheimer’s disease, or AD, increasingly is the target of drug development efforts, but there are very few tools that measure the cognitive function of patients with the condition before the onset of dementia. Experts have concluded that it is best to treat patients prior to changes in cognition, before the symptoms of neurodegeneration appear. As a result, scientists have turned to biomarkers to provide some indication of whether AD is likely to develop.
Although cognitive capacity may not be measured easily before AD has caused significant neuronal damage, there now is a simple blood test that may predict whether a healthy person is likely to develop mild cognitive impairment or AD within a two- to three-year time frame with more than 90% accuracy.
The researchers behind the test — led by Howard Federoff, M.D., EVP health sciences at Georgetown University Medical Center — enrolled 525 healthy participants ages 70 years or older into a five-year observational study. Federoff and colleagues determined there were 74 participants who displayed signs of preclinical AD after testing participants for memory performance. Then the researchers compared the blood plasma biomarker levels of 53 of those 74 participants showing signs of cognitive impairment with those of 53 participants who were cognitively healthy.
The researchers determined that a set of 10 phospholipids predicted “phenoconversion” to the cognitive functional impairment that is the hallmark of AD. “This biomarker panel, reflecting cell membrane integrity, may be sensitive to early neurodegeneration of preclinical Alzheimer’s disease,” Mark Mapstone, M.D., wrote in a letter published in Nature Medicine.
The lower level of 10 lipids in the blood in the study subjects who went on to develop functional impairment might reflect the breakdown of neural cell membranes, the researchers hypothesized.
There are already tests in existence that measure cognitive function, but these rely on the examination of cerebrospinal fluid or brain imaging scans, and involve testing methods that are considered both expensive and complicated. A test that uses blood samples may be much cheaper and more practical in terms of widespread use, although the study researchers admit that the results need to be validated on a much larger scale for any definitive conclusions to be made.
This begs the question: How will patients change their behavior if they are found to have signs of the biomarkers associated with AD? There are currently no suitable disease-modifying therapies to treat AD, so having the knowledge of a predisposition for the condition may not be quite so helpful. However, knowledge of this risk could allow patients to enroll in experimental clinical trials, and could help scientists better understand the etiology of AD.
Although beta amyloid has been thought to be a promising therapeutic target for AD, many of the drugs that have been developed with the belief that reducing the amount of amyloid in the brain halts disease progression have failed in clinical trials.