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INTRODUCTION
Diabetes mellitus affects over 2 million Canadians. Type 2 diabetes accounts for 90% of these cases, and its incidence is increasing dramatically. Complications include cardiovascular disease, stroke, hypertension, dyslipidemia, nephropathy, neuropathy, and retinopathy. Diabetes and its complications cost the Canadian health care system an estimated $13.2 billion every year.
Practice Spotlight: Collaborative Patient Care
26 Nov2010
The stroke rehabilitation team at the Toronto Rehabilitation Institute provides a multidisciplinary, team- based, patient-focused, collaborative approach to patient care. Barb Coulston, a pharmacist, and Cynthia White- head, a physician, have worked closely together for 6 years as part of this team.
- In: Health
- Tags: Practice Spotlight
A major limitation of this study was the impossibility of determining whether symptoms of toxicity were due to interactions between a prescription drug and digoxin or between a herbal supplement and digoxin. The numerous medications and supplements used and the variety of dosages and regimens confound the assessment of clinical effects due to herb-digoxin interactions. Since it is difficult to assess the efficacy of digoxin by means of a survey, this study focused on the safety aspects of digoxin use and emphasized herb-digoxin interactions that might lead to toxic effects. Although having an interviewer administer the survey might have led to bias and disinclination of patients to fully disclose their use of supplements, this approach was deemed appropriate to ensure the accuracy and completeness of data collection. Read the rest of this entry »
Among the patients surveyed, there was no difference in the prevalence of herbal supplement use between those reporting and those denying symptoms potentially related to digoxin toxicity. Although the lack of a difference may be attributable to the fact that only a few patients were using herbal supplements purported to interact with digoxin, the general use of herbal supplements did not appear to compromise the safety of digox- in therapy in the population studied. Since monitoring of digoxin level was rare (such that more than 70% of patients had undergone no digoxin monitoring in the past year), the effects of herbal supplements that might interfere with digoxin assays were difficult to assess. Furthermore, using patient-reported symptoms as an outcome limits specificity. Read the rest of this entry »
Previous research on the frequency of use of alternative medications has focused on the general public or on cardiac patients in general. In this study, we examined the use of nonprescription medications within a specific subpopulation, patients who were taking digoxin. Because both dietary supplements (herbal and nonherbal) and OTC medications are commonly used, they were considered collectively as nonprescription medications in this study. To further distinguish the use of herbal supplements, nonherbal supplements (e.g., vitamins and minerals) were grouped with OTC medications in subsequent analysis. Since digoxin has a narrow therapeutic window and is subject to various drug-drug and herb-drug interactions that might increase the risk of toxic effects, the use of nonprescription medications in this patient population is of particular concern. In fact, several recent articles have reviewed interactions involving herbal products and cardiovascular drugs, highlighting the importance of this issue.
Use of Prescription Medications
The mean number (± standard deviation) of prescription medications, including digoxin, taken during the month before the survey was 7.6 ± 2.8, and the number of concurrent prescription medications ranged from 1 to 17. Almost 90% of the patients (152 or 88.4%) had been exposed to one or more medications with the potential to influence digoxin therapy. The most common concurrent prescription medications of any type were furosemide, spironolactone, carvedilol, and amiodarone; the most common prescription medications with potential interactions with digoxin were also furosemide, spironolactone, carvedilol, and amiodarone (see also Table 3).
Patient CharacteristicsOf the 447 potential participants identified in the chart review, 143 could not be contacted, and 132 were excluded for various reasons: declined to participate in the study, were excluded by their doctors, lacked sufficient proficiency in English, were no longer taking digoxin, had died, were in poor health, or were deaf. A total of 172 patients were enrolled for the study in person (n = 33, 19.2%) or by phone (n = 139, 80.8%) between June 2001 and November 2003. Participants’ demographic characteristics, including digoxin use and concurrent illnesses, are summarized in Table 1. As expected, the most common indications for digoxin therapy were heart failure and/or atrial fibrillation (a total of 143 patients, 83.1%). Despite their digoxin therapy, most patients (151 or 87.8%) had experienced symptoms commonly associated with heart failure and/or atrial fibrillation in the month before the survey, including light-headedness, dizziness, loss of consciousness, heart palpitations, shortness of breath, fatigue, coughing, lung congestion, and swelling in the legs or ankles. Eighteen (10.5%) of the patients were unsure of the reason for digoxin therapy. Impaired renal function, thyroid disorder, and acute diarrhea were the relevant concurrent disorders most commonly reported. Twelve of the patients reported having cancer, but none had undergone chemotherapy in the month or year before the study. Only 47 (27.3%) of the patients had undergone testing for serum digoxin level in the past year.