Community Practice

A 63-year-old Hispanic man, P.C., seen in your diabetes clinic, is complaining of burning and aching in his legs and feet. His current daily drugs include glipizide ER (Glucotrol XL, Pfizer) 10 mg, pioglitazone (Actos, Takeda) 45 mg, metformin ER (Glucophage XR, Bristol-Myers Squibb) 500 mg, escitalopram (Lexapro, Forest) 10 mg, atorvastatin (Lipitor, Pfizer) 40 mg, ezetimibe (Zetia, Merck/ Schering-Plough) 10 mg , aspirin 325 mg, and ramipril 10 mg. Although his current fasting blood glucose is 100, his A1c=9. Upon questioning him, you find he has not been taking his medicine regularly since he lost his job and insurance last spring. What do you recommend?

The 2006 World Congress of Cardiology (WCC) was host to more than 25,000 cardiologists this year. Noteworthy among the thousands of presentations were several large-scale drug trials, most of which evaluated agents affecting the renin-angiotensin system (RAS).

From pills to patches, from implants to Plan B going OTC, women have more contraceptives to choose from today than ever before.

One year ago, Howard Brooker, R.Ph., in Glenside, Pa., went where few pharmacists have gone before. He and partner Adam Shubbar, R.Ph., opened Adams Discount Pharmacy, a no-insurance pharmacy selling generics at a significant markdown. "It was a little scary at first, going off into uncharted territory," said Brooker. "But it's been fantastic. Business has never been better, I've never been happier."

New evidence indicates that traditional diuretics may be more harmful than beneficial for heart failure patients, while some drugs currently contraindicated could be beneficial. These nuggets and more were presented at the Heart Failure Society of America's 10th annual meeting in Seattle last month.

Closing the only pharmacy in Holly Ridge, a small town in eastern North Carolina, was not an easy decision for Randy Spainhour. The 58-year-old pharmacist knew that the closest pharmacy was 15 miles away and that it would put a big strain on many of his customers. "I felt I had no choice," he insisted. "It was either that or going bankrupt."

Invasive fungal infections will have less of a fighting chance now that a new antifungal has been approved by the Food & Drug Administration. Posaconazole (Noxafil, Schering-Plough), available as an oral suspension, is indicated for the prophylaxis of invasive Aspergillus and Candida infections in patients 13 years of age and older who are immunocompromised, such as hematopoietic stem cell transplant recipients with graft-versus-host disease or those with hematologic malignancies with prolonged neutropenia from chemotherapy.

If you want to understand the immediate impact of Wal-Mart's recent announcement that it will charge only $4 per prescription for nearly 300 generic drugs, just ask Nick Patel, R.Ph. Patel's West Coast Pharmacy, Tampa, Fla., is located one block from a Wal-Mart location and suddenly finds itself at the epicenter of a new healthcare debate. "I've had people come in with the list," Patel reported to Drug Topics. "But so far, I haven't lost any customers." Like many in the industry-especially those in the Tampa area-Patel is watching closely to see what happens next.

A new era is coming for the Medicaid program-one that will spare the state and federal governments from overpaying for drugs and provide more pricing transparency to all parties involved.

Hoping to stem a new season of confusion over Medicare's Part D prescription drug benefit, the Centers for Medicare & Medicaid Services is asking pharmacists to prepare patients for the upcoming enrollment period.

The Medicare Modernization Act (MMA) set minimum federal standards for prescription drug coverage. Plans wanting to participate in the program could offer the standard benefit or a variation that was approved as actuarially equivalent by CMS. Most plans elected to modify the standard design with their own formularies and combination of enhanced benefits. Each plan sought the right combination of premium level, benefit package, formulary structure, and tiered co-pays that they believed would attract and keep an acceptable share of the market while generating a profit to the plan.

Picture this: A patient who is taking the blood-thinning medication Coumadin (warfarin sodium, Bristol-Myers Squibb) visits his community pharmacy to have his blood checked. The pharmacist makes sure his dosage is correct and that his blood isn't getting too thin or too thick.

Mail-order pharmacies may not always provide the lowest costs for employers, despite conventional wisdom to the contrary, according to Michael Johnsrud, associate director of the Center for Pharmacoeconomic Studies at the University of Texas at Austin College of Pharmacy.

For the fifth consecutive year, consumer satisfaction with pharmacies has risen, according to the 2006 Pharmacy Satisfaction Digest. Ninety-eight percent of respondents reported that they were either highly satisfied or satisfied with their pharmacy, up from 95% in 2002. Moreover, the number of respondents indicating that they were highly satisfied rose to 58%, a gain of 5% over the 2005 results and 13% higher than the 2002 results.

When Gov. Jon Corzine recently signed the New Jersey Prescription Drug Retail Price Registry bill into law, he hailed it as a "significant step toward making health care more affordable." The law creates a database of prices for the 150 most common prescription drugs. Consumers will be able to access the database via a toll-free telephone number or search it on-line. Despite the Governor's optimism, however, many pharmacists doubt the law will have much impact on either pharmacists or consumers.

With conflicting statements from the Food & Drug Administration, Centers for Medicare & Medicaid Services, and a Federal District Court judge, the definition and legality of pharmacy compounding once again seems headed to the Supreme Court or Congress for sorting out.

With dramatic demographic shifts under way in this country, pharmacies should tailor their marketing to multiethnic groups.

All symptomatic patients with HIV disease should begin antiretroviral therapy right away, according to new guidelines published by the International AIDS Society-USA and presented at the International AIDS Conference held in August in Toronto. Based on several new developments, the revision marks the seventh time since 1996 that the organization has updated its recommendations for HIV treatment.

Sometimes the best defense is a good offense. While many pharmacists have been vocal critics of the role of pharmacy benefit managers and the growing use of mail-order pharmacies, much of the focus has been on passing legislation to protect pharmacists or restrict PBMs. Taking a different approach, the Georgia Academy of Independent Pharmacy (AIP) has developed a multitiered plan to compete directly with the PBMs.

In the past, pharmacists played a somewhat limited role in the care and treatment of brain cancer. But all that is changing.

Almost 70% of minor surgeries are now performed in surgical centers, physicians' offices, and hospital outpatient departments. Procedures including cardiac catheterizations and colonoscopies can be done using sedatives such as midazolam and fentanyl instead of general anesthesia.

A 28-year-old African-American man with sickle cell disease, B.B., will be admitted to your hospital to undergo a hip replacement. B.B. has a significant chronic pain problem and uses a regular schedule of controlled-release oxycodone 60 mg every 12 hours plus oral transmucosal fentanyl 400 mcg (Actiq, Cephalon) for breakthrough pain crises (less than two doses per day). He is controlled at a pain level of 2; he also takes hydroxyurea 2,000 mg/day. The surgeon asks you about dealing with B.B.'s pain medications in preparation for surgery. Should drugs be held, decreased, or continued as usual?

The American Society of Clinical Oncology (ASCO) recently updated its guidelines for the use of hematopoietic colony-stimulating factors (CSFs). The 2005 update committee unanimously agreed that the reduction in febrile neutropenia (FN) was an important clinical outcome that justified the use of CSFs, regardless of impact on other factors, when the risk of FN was approximately 20% and no other equally effective regimen that did not require CSFs was available. The first guidelines were published in 1994, and they were updated in 1996, 1997, 2000, and, most recently, 2005.

Can society countenance paying $161,000 a year for treating one cancer patient, as was estimated for one new drug? And again and again for many patients? If newer agents cost 500 times the older ones, can we cover them? What if, due to new agents, some cancers become more like other chronic diseases, where expensive treatment continues for a lifetime?

An incident that tied a compounded drug solution to three deaths and eight acute illnesses has captured the attention of both the media and the many pharmacists who regularly compound critical care drug products for hospital use.

Tom Kellenberger wants to do for pharmacy what Expedia, Orbitz, and Travelocity have done for travel: Blow the market wide-open. In late May, the Wisconsin pharmacist flipped the switch on BidRx (www.bidrx.com), an on-line marketplace for prescription drugs, over-the-counter products, and pharmacy services.

After 11 years in business on Main Street in Aspen, Colo., Rodney Diffendaffer, R.Ph., knows too well that the struggle between community pharmacists and the mail-order industry is heating up, with generics fueling the fire. "They get to sell three months of drugs at what comes close to my one-month price," he said. "I'm not allowed to sell a three-month supply. It's not a level playing field. Never has been."

Sometimes the best defense is a good offense. While many pharmacists have been vocal critics of the role of pharmacy benefit managers and the growing use of mail-order pharmacies, much of the focus has been on passing legislation to protect pharmacists or restrict PBMs. Taking a different approach, the Georgia Academy of Independent Pharmacy (AIP) has developed a multitiered plan to compete directly with the PBMs.

While electronic prescriptions offer many benefits over handwritten orders, some independent pharmacies still balk at adopting this new technology. Some say learning the new technology will pose an obstacle, while others are concerned about verification of who is sending the electronic Rx, as well as the additional costs associated with e-prescribing.