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Powerful Placebos and Notorious Nocebos: Implications for Ambulatory Care

Imagine you have recommended statin therapy to a patient with diabetes. A few weeks later, the patient experiences leg pain and stops it. Was this patient’s leg pain caused by the statin? Or was it a nocebo effect? Muscle symptoms in placebo-controlled trials of statin therapy range from 3-5%, while rates in real-world observational studies are between 15-20%. Ambulatory care pharmacists have an important role in recognizing and managing placebo and nocebo effects. Understanding the placebo effect allows clinicians to harness the power of placebos. Reframing risks during patient education may decrease nocebo effects.

Guest Authors:  Sara Wettergreen, PharmD, BCACP and Joseph Nardolillo, PharmD

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An Incli-ng of Benefit? Efficacy and Safety of Inclisiran for Elevated LDL

Lipid management continues to be an essential component in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD).  For the past decade, clinical practice guidelines have gone back and forth about optimal treatment goals but guidelines all agree that statins should be used as the preferred initial therapy. However, there is still a lack of clarity about the optimal add-on therapies. The newest LDL-lowering therapy is inclisiran, a small interfering RNA (siRNA) that targets the PCSK9 pathway.

Guest Authors:  Joshua O. Holmes, PharmD, MS and Amanda Schartel, PharmD, BCACP

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Will Riva Be Defeated By It’s (Long-Standing) Nemesis, Apixa?

Do we finally have enough evidence to establish a preferred direct-acting oral anticoagulant (DOAC) for stroke prevention in patients with atrial fibrillation? The use of DOACs for a-fib has rapidly increased due to their ease of use and favorable safety profile. The AHA/ACC/HRS and CHEST guidelines now recommend DOACs over warfarin for stroke prevention in a-fib, but do not state a preference for one DOAC over another. Factor Xa inhibitors, specifically apixaban and rivaroxaban, are the most commonly prescribed DOACs suggesting they are preferred by clinicians in real-world practice but is one better than the other?

Guest Authors: Amy D. Robertson, PharmD, BCACP and Michelle Balli, PharmD, BCACP

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Should Bedtime be Med-Time for Hypertension?

Few medications are specifically dosed at night to optimize outcomes. However, antihypertensive medications may soon belong on our patients’ nightstands. It is common practice for patients to take all antihypertensive medications in the morning, but perhaps daytime dosing doesn’t maximize cardiovascular risk reduction? The potential benefits of chronotherapy and its impact on BP and CV outcomes have been investigated since the 1980s. However, current practice guidelines do not explicitly recommend dosing antihypertensive medications at bedtime.

Guest Authors:  Vivian Cheng, PharmD, BCPS and Joseph Saseen, PharmD, BCPS, BCACP

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Let’s COLCOT to the Chase: Colchicine for Secondary Prevention of CV Events

Millions of Americans will have a myocardial infarction in their lifetime and 20% will have a recurrent fatal or non-fatal coronary heart disease event. Several modifiable risk factors, including elevated blood pressure, cholesterol, and glucose as well as tobacco use, can and should be addressed to reduce the risk of recurrent cardiovascular events. Systemic inflammation has also been associated with poor CV outcomes. Is systemic inflammation a modifiable CV risk factor? And if so, should an anti-inflammatory agent be added to the recommend post-MI drug cocktail to reduce the risk of morbidity and mortality?  That's the question that the COLCOT Study attempted to answer.

Guest Authors:  Jessica Wearden, PharmD and Augustus (Rob) Hough, PharmD, BCPS, BCCP

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Age is Just a Number: Discontinue Statins with Care

More than 14 million Americans age 75 years and older face a dilemma. They are at high risk for atherosclerotic cardiovascular disease (ASCVD). On the other hand, older adults are more susceptible to adverse effects associated with statins. Many adults, often in their 60s or early 70s, decide to initiate statin therapy for the primary prevention of ASCVD. However, at some point in a patient’s life, the potential benefits may no longer be so clear … or the risks and costs increase. Unfortunately, there is little information on the potential consequences of stopping statin in patients who are tolerating statins.

Guest Authors:  Maricar Conson, PharmD and W. Cheng Yuet, PharmD, BCACP

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A Cause for a PAUSE: Evaluating a Standardized Perioperative DOAC Management Protocol

One in six patients with atrial fibrillation (AF), or an estimated six million patients worldwide, will require perioperative anticoagulant management this year.  Ambulatory care pharmacists commonly face the scenario where a patient taking a direct oral anticoagulant (DOAC) for AF requires an elective surgery or procedure. Best practices for periprocedural management of DOACs are unclear and current guidelines differ in their recommended approaches. Having a simple, systematic periprocedural DOAC management protocol would be helpful. But would a straightforward protocol that is easily understood by clinicians and patients be safe and effective? The PAUSE study investigators attempt to establish the standard of care.

Guest Authors:  Maggie Faraj, PharmD and Candice Garwood, PharmD, BCPS, BCACP

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Secondary Stroke Prevention in A-Fib: Do DOACs PROSPER in High-Risk Patients?

Several guidelines now recommend direct oral anticoagulants (DOACs) as the preferred anticoagulants for patients with non-valvular atrial fibrillation (a-fib). However, the landmark clinical trials focused largely on the primary prevention of stroke.  Moreover, real-world data using DOACs for secondary prevention is lacking. Many have argued that warfarin might be a better choice in these high-risk patients because it requires routine monitoring and increases the patient’s contact with the healthcare system. Does the choice of anticoagulant make a difference in preventing recurrent stroke?

Guest Authors: Blaire White, PharmD; Amber Cizmic, PharmD, BCACP; and Tish Smith, PharmD, BCACP

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Will Oral Semaglutide PIONEER the Way to Lower Cardiovascular Risk?

Until recently, glucagon-like-peptide-1 (GLP-1) receptor agonists were only available as injectable products. Some clinicians and patients are reluctant to use injectable agents because they require additional patient education and can be intimidating.  If a GLP-1 receptor agonist were available in an oral dose form, it would be welcomed treatment option. But would the cardiovascular safety and benefits of oral GLP-1 receptor agonists be better, similar, or worse than their injectable siblings?

Guest Authors:  Sally Earl, PharmD, BCPS and Megan Supple, PharmD, BCACP

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If Your Heart’s Not into It, Do You Really Need to Take Your Meds?

Dilated cardiomyopathy is the leading cause of sudden cardiac death and heart failure (HF) and the chief indication for cardiac transplantation. However, approximately 40% of patients see a significant improvement in left ventricular ejection fraction and reduction in the left ventricle size over time with pharmacologic treatment. As deprescribing becomes an increasingly important part of our clinical practice, we need more data about how deprescribing impacts outcomes, particularly in chronic diseases such as heart failure.  The recently published TRED-HF is attempted to address this important question: Is the burden of lifelong therapy with medications necessary or worth it in patients with "recovered" dilated cardiomyopathy?

Guest Author:  Jennifer Pruskowski, PharmD, BCPS, BCGP, CPE

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