BACKGROUND: Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist. OBJECTIVE: To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients. DESIGN: Retrospective cohort study. SETTING: Multi-state Medicaid database (Thomson Reuters MarketScan®). PARTICIPANTS: Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed. MAIN MEASURES: Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables. KEY RESULTS: In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63-0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12-3.29). CONCLUSIONS: Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.

BACKGROUND Acne is a common condition for which multiple treatment options are available. The patterns of pharmacotherapy for acne and similar conditions, and the effect of those patterns on cost, are not well characterized. OBJECTIVE This study examined the impacts of patient demographics and medication choices on patients' health status and associated medication costs. METHODS A retrospective cross-sectional study was conducted using the 2007 Medical Expenditure Panel Survey (MEPS) database. Information on patient demographics, health status, medication utilization and medication costs was obtained from the database representing 3,784,816 patients with acne and similar conditions. RESULTS Weighted multiple linear regression analyses indicated that the use of topical retinoids was preferred in combination with other treatments rather than as monotherapy. Oral antibiotics were widely prescribed and their use was associated with a significant decrease in total annual prescription spending. Use of oral retinoids and oral contraceptives increased the annual prescription costs significantly. Increase in annual drug refills was not associated with the improvement in health status. CONCLUSION We observed an association with medication choice for acne and acne-related conditions on medication spending. Pharmacologic treatment of acne significantly adds to acne-related annual healthcare costs compared to non-pharmacologic treatment.

WHAT IS KNOWN AND OBJECTIVE: The complexity and diversity of irritable bowel syndrome's (IBS) presentation make treatment difficult. Although there are reviews and guidelines for treating IBS, they focus on the efficacy of medications for IBS symptoms using high-priority endpoints, leaving those of lower priority largely unreported. Therefore, the aim of this review is to provide a comprehensive evidence-based review of the efficacy of medications to treat IBS symptoms, reported by IBS subtype, including secondary symptom endpoints that are often underreported. METHODS: A review of PubMed for articles published through December 2009 using the keywords:'irritable bowel syndrome','therapeutics','antidiarrhoeals','laxatives','loperamide','dietary fibre','psyllium','calcium polycarbophil','bulking agents','lubiprostone','antidepressant agents, tricyclics' and its representative entities,'serotonin reuptake inhibitors' and its representative entities,'dicyclomine', hyoscyamine','peppermint oil','parasympatholytics' and its representative entities,'rifaximin','pregabalin','gabapentin','clonidine','octreotide','atropine' and 'probiotics' is provided. Placebo-controlled trials were evaluated for the strength of evidence supporting the efficacy of each medication for explicit IBS symptoms. The efficacy of each medication for the symptoms of abdominal pain, bloating, stool form, mucus, urgency, feeling of incomplete evacuation, flatulence, frequency, or borborgymi and overall symptoms are reported by IBS subtype. RESULTS AND DISCUSSION: The literature search identified 58 placebo-controlled trials of the efficacy of medications for treating IBS symptoms, which were critically evaluated and reported. The available studies suggest improvement in various IBS symptoms with loperamide, fibre supplements, lubiprostone, tricyclic antidepressants (TCAs), selective serotonin receptor inhibitors (SSRIs), antispasmotics, rifaximin, pregabalin, gabapentin, clonidine, octreotide and probiotic treatments. WHAT IS NEW AND CONCLUSion: This review is the first to compile the available evidence on the efficacy of the various pharmacological treatments for IBS on the basis of IBS subtype and specific symptoms. This evidence is limited and more well-designed studies are required to better inform therapeutic decision-making in the management of this difficult syndrome.

BACKGROUND:: La Crosse viral encephalitis (LACVE) is associated with residual epilepsy and neurocognitive deficits in survivors. This report summarizes 3 phases of clinical studies of children treated with intravenous (IV) ribavirin (RBV), each one exploring a different phase (I, IIA, IIB) of clinical trial development. METHODS:: In phase I, 7 children with life-threatening LACVE were treated with emergency use RBV using a moderate IV dose (8.33 mg/kg/dose q 8 hours day 1, 5 mg/kg/dose q 8 hours days 2-10). In phase IIA, 12 children with severe LACVE were enrolled: 8 treated with RBV (same dose as phase I) and 4 with placebo. In phase IIB an escalated dose was used (33 mg/kg dose 1, then 16 mg/kg/dose q 6 hours for 4 days, and 8 mg/kg/dose q 8 hours for 3 days). RESULTS:: In a group of 15 children treated in phase I and phase IIA, RBV appeared safe at moderate dose, but based on steady-state RBV levels of 9.3 μM, estimated cerebrospinal fluid levels were less than 20% of the EC50 of RBV for LACVE. At the escalated dose used in phase IIB, adverse events occurred, likely related to RBV, and therefore the trial was discontinued. Nevertheless, valuable pharmacokinetic (PK) and safety data were obtained at moderate dose, with potential treatment implications for other indications. CONCLUSIONS:: Although the results do not support the use of RBV for LACVE, this nevertheless is the largest study of antiviral treatment for LACVE to date and the largest pharmacokinetic analysis of IV RBV in children for any indication.

Health-care providers use computerized provider order entry as a component of the electronic medical record system in conjunction with clinical decision support. An important aspect of clinical decision support is screening of drug-drug interactions including contraindications in the labeling approved by the Food and Drug Administration. Currently, there are inconsistencies between the knowledge databases and the official package labeling for contraindications on drug-drug interactions. Unnecessary warnings can cause alert fatigue among clinicians and potentially influence adoption of true contraindications for drug prescribing. Each institution should evaluate the accuracy and completeness of the knowledge databases used for screening of contraindications on drug-drug interactions.

While laboratory and clinical benefits of hydroxyurea for patients with sickle cell disease (SCD) are well-established, few data describe the extent and implications of non-adherence. We sought to assess adherence to hydroxyurea among patients with SCD and investigate associations between adherence and clinical and economic outcomes. Insurance claims of North Carolina Medicaid enrollees (6/2000-8/2008) with SCD were analyzed. Inclusion criteria included age < 65 years, continuous Medicaid enrollment ≥ 12 months before and following hydroxyurea initiation, and ≥ 2 hydroxyurea prescriptions. Three hundred twelve patients, mean age 21 (± 12.2) years, met inclusion criteria and 35% were adherent, defined as a medication possession ration (MPR) ≥ 0.80; mean MPR was 0.60. In the 12 months following hydroxyurea initiation, adherence was associated with reduced risk of SCD-related hospitalization (hazard ratio [HR]= 0.65, p =.0351), all-cause and SCD-related emergency department visit (HR = 0.72, p =.0388; HR = 0.58, p =.0079, respectively), and vaso-occlusive event (HR = 0.66, p =.0130). Adherence was associated with reductions in health care costs such as all-cause and SCD-related inpatient (-$5,286, p <.0001;-$4,403, p <.0001, respectively), ancillary care (-$1,336, p <.0001;-$836, p <.0001, respectively), vaso-occlusive event-related (-$5,793, p <.0001), and total costs (-$6,529, p <.0001;-$5,329, p <.0001, respectively). Adherence to hydroxyurea among SCD patients appears suboptimal and better adherence is associated with improved clinical and economic outcomes.

BACKGROUND Statin adherence is a serious problem in patients with hyperlipidemia. However, it is not clear whether statin adherence is associated with medical utilization or health-care costs. OBJECTIVE To study statin adherence and assess associated medical utilization and health-care costs in patients with type 2 diabetes, based on a national Medicaid database. METHODS A retrospective claims-based study was conducted using the records of patients with type 2 diabetes with comorbid hyperlipidemia who were continuously enrolled in Medicaid from January 2004 to December 2006. All data were drawn from MarketScan Medicaid Database, including inpatient, outpatient, and drug claims. The eligible patients starting statins in 2005 were followed for 1 year to measure medication use, hospitalization, outpatient visits, emergency department (ED) visits, and health-care costs based on Medicaid medical and drug claims. Adherence was measured by medication possession ratio (MPR). Multiple regression analyses were implemented to assess statin adherence-associated outcomes, including medical utilization (risks for hospitalization and ED visits), all-cause costs, and hyperlipidemia-related medical costs. RESULTS A total of 1705 eligible patients with type 2 diabetes and hyperlipidemia were identified. The average adherence rate to statins (MPR) at 1 year was 0.61, and 37% of the patients (n=624) were adherent to statins (MPR≥0.8). Regression analyses indicated that diabetic patients who were adherent to statins showed lower risks for hospitalization (OR 0.80; 95% CI 0.636 to 0.966) and ED visits (OR 0.71; 95% CI 0.519 to 0.812) and decreased all-cause medical costs by 15%(p<0.05) and hyperlipidemia-related medical costs by 12%(p<0.05). CONCLUSIONS Our study found high prevalence of nonadherence to statins in Medicaid patients with type 2 diabetes. Adherence to statins (MPR≥0.8) was associated with reduced medical utilization and lower medical costs.

A residency requirement has been proposed as a prerequisite for all pharmacists providing direct patient care. This editorial explores the basis for requiring a residency, direct patient care offered by pharmacists with or without a residency, needs to increase interprofessional team-based health care, importance of distinguishing levels of pharmacy practice, role of pharmacy technicians, availability of residency positions, and future of pharmacy residencies. All PharmD graduates should be able to provide a certain level of direct patient care, including medication therapy management services, without completing a residency, and residency programs should be offered for complex levels of direct patient care in all practice settings.