Jan. 5, 2009
 Prescriber's Practice Pearl from Prescriber's Letter

 Practice Pearl - January 2009

     There's new debate about which antihypertensives are best for treating high blood pressure.
     Current guidelines recommend thiazides first for most patients. These improve outcomes...are usually well-tolerated...and inexpensive.
     But now results of the big "ACCOMPLISH" study could change this.
     It shows that some patients do better on an ACE inhibitor plus calcium channel blocker...than on an ACE inhibitor plus thiazide... despite good BP control with both regimens.
     In fact, treating about 135 HIGH-risk patients for one year with benazepril and amlodipine prevents one more cardiovascular event than with benazepril and hydrochlorothiazide.
     Experts are debating whether the thiazide makes a difference. Hydrochlorothiazide is less potent and shorter-acting than chlorthalidone. Chlorthalidone has the most evidence of improved outcomes.
     Until we know more, continue to use either thiazide first for most patients with UNCOMPLICATED hypertension.
     But feel comfortable using a calcium channel blocker, ACE inhibitor, or ARB first-line also...especially for patients with coexisting conditions.
     For example, use ACE inhibitors or ARBs for patients with diabetes...and beta-blockers after an MI.
     Start with TWO drugs for patients who are more than 20 mmHg above their systolic, or 10 mmHg above diastolic, goal.
     Consider using combo products to simplify regimens. But keep in mind that these are harder to titrate and sometimes cost more.
     Aim for a BP less than 140/90 for most patients...and less than 130/80 for those with coronary artery disease, diabetes, or kidney disease.

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 Prescriber's Letter: January 2009; Vol: 16, No. 1
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INTRODUCTION
which antihypertensives are best for treating high blood pressure
read this article
CARDIOLOGY
reports saying that angiotensin receptor blockers (ARBs) don't work for heart failure
treating depression in patients with coronary artery disease or after an MI
DIABETES
Is there a maximum dose for Lantus and other insulins
NEUROLOGY / PSYCHIATRY
If you prescribe Effexor XR, you'll get calls to substitute with a new once-a-day extended-release venlafaxine tablet
new caution about using phenytoin (Dilantin, etc) or fosphenytoin (Cerebyx) in certain patients of Asian descent
SUPPLEMENTS
Ginkgo is NOT likely to prevent dementia
antioxidant and other vitamin supplements DON'T decrease the risk of prostate cancer
PAIN
Buprenorphine tablets (Subutex, Suboxone) are now being used more for treating PAIN
PEDIATRICS
The arrival of Flo-Pred and Veripred 20 will raise more questions about how to select an oral prednisolone product
RESPIRATORY / ALLERGY
new warnings, again, about using inhaled long-acting beta-agonists (Serevent, etc) for asthma
STATINS
controversy over whether statins can CAUSE diabetes
OPHTHALMOLOGY
drugs that require eye exams to rule out adverse effects on the eyes
GASTROENTEROLOGY
Stronger warnings about kidney problems are leading to a recall of Fleet Phospho-soda and some other oral sodium phosphate solutions
DERMATOLOGY
new topical acne treatment called Aczone (dapsone) gel
CME QUESTIONS
January 2009 CME Questions

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