Marlene Busko

April 07, 2016

CHICAGO, IL — A community-based pharmacist intervention in Alberta, Canada—where authorized pharmacists can prescribe and adjust medications and doses—reduced the estimated risk for cardiovascular events by 21% in 3 months[1].

These benefits were seen in the RxEACH study of 700 high-risk patients who had at least one uncontrolled risk factor (hypertension, hyperglycemia, hyperlipidemia, smoking) and were randomized to usual pharmacist care or a targeted intervention designed to lower CVD risk.

Dr Ross T Tsuyuki (University of Alberta, Edmonton) presented these findings in a clinical research session at the American College of Cardiology (ACC) 2016 Scientific Sessions, and the paper was simultaneously published in the Journal of the American College of Cardiology.

"We think [this] represents a new paradigm of community-based cardiovascular risk reduction," he said, adding that patients like the intervention and stressing that it involves close collaboration their family-care physicians.

"Engaging pharmacists could bring another 450,000 'helping hands' in the United States and Canada to help reduce the burden of cardiovascular disease," according to Tsuyuki and colleagues. "We would encourage policy makers to consider broadening the scope of practice of pharmacists (as in Alberta) and for pharmacists and pharmacy professional organizations to seize these opportunities for the betterment of patient care," they conclude.

Session panelist Dr Allen J Taylor (MedStar Georgetown University Hospital and MedStar Washington Hospital Center, Washington, DC) told heartwire from Medscape that the results have to be interpreted with caution, because risk score calculators such as Framingham are based on long-term exposure to risks, and this was a 3-month study.

Nevertheless, the researchers looked at four risk factors and "were able to make a fair amount of changes across the board, [which] is laudable," he said. "There's a physician shortage, and there's no reason why we can't rely upon the pharmacist as part of the healthcare team to deliver more prevention," according to Taylor.

Frequent Patient Contact, Prescription Tweaking

Dr Ross Tsuyuki

Community pharmacists are accessible, frontline healthcare professionals who often see patients with or at high risk for CVD, and prior studies have shown that this can be effective in managing certain CVD risk factors, Tsuyuki noted.

RxEACH evaluated how a comprehensive, provincewide, pharmacist-delivered intervention designed to improve four risk factors (diabetes, hypertension, hyperlipidemia, and smoking) would affect predicted risk of a CVD event.

In 2014 and 2015, pharmacists in 56 practices in Alberta identified and randomized 723 adults aged 18 and older who had diabetes, chronic kidney disease, cerebrovascular disease, cardiovascular disease, peripheral artery disease, or multiple risk factors and a Framingham risk score >20%.

The patients also had to have at least one uncontrolled risk factor (blood pressure >140/90 mm Hg or >130/80 mm Hg if diabetic, LDL cholesterol >2.0 mmol/L, HbA1c >7%, or current smoker).

The researchers randomized 353 patients to usual care and 370 patients to the intervention. The patients had a mean age of 62, 58% were male, and their mean estimated risk of a CV event was 26%.

"A fair number of patients had diabetes, vascular disease, and coronary heart disease, and a relatively small group [7%] were primary-prevention patients," Tsuyuki noted. Many patients (72%) had poorly controlled blood pressure, 59% had poorly controlled dyslipidemia, 27% were smokers, and 79% of the patients with diabetes had poor glycemic control.

Patients in the intervention group received a medication-therapy-management consultation with their pharmacist, in which the pharmacist measured their blood pressure, waist circumference, height, and weight; ordered laboratory tests to determine HbA1c, lipid levels, and kidney function; and discussed CVD risk factors and their specific CVD risk scores (calculated from risk engines such as the UKPDS, the international score, and the Framingham risk score).

The pharmacists saw the patients in the intervention group every 3 to 4 weeks for 3 months, adjusted medications and doses based on Canadian clinical practice guidelines, and relayed information to the patient's physician after each patient contact. "Pharmacists did adjust doses, but more often they added drugs or discontinued drugs that weren't working," Tsuyuki noted.

At 3 months, the patients' estimated cardiovascular disease risk was virtually unchanged in the usual-care group, but it dropped from 25.5% to 20.5% in the pharmacist-intervention group.

Patients in the intervention group were more likely to achieve guideline-recommended targets for LDL cholesterol (55.5% vs 45.6%), blood pressure (50.9% vs 27.8%), and HbA1c (42.2% vs 24.6%), and more likely to not smoke.

In the intervention group, mean blood pressure decreased from 137/81 mm Hg to 127/77 mm Hg; mean LDL cholesterol decreased from 2.47 mmol/L to 2.07 mmol/L; mean HbA1c dropped from 8.61% to 7.60%; and the number who smoked fell from 26.2% to 19.7%, but these measures remained unchanged in the control group.

Compared with patients in the control group, those in the intervention group had a 0.2-mmol/L greater reduction in LDL cholesterol, a 9.37-mm-Hg greater reduction in systolic blood pressure, a 0.92% greater reduction in HbA1c, and there were 20.2% fewer smokers (all P<0.0001).

Transforming the Interaction at the Pharmacy Window

Panelist Dr Prediman K Shah (Cedars Sinai Medical Center, West Hollywood, CA) wanted to know if all pharmacists in Canada can prescribe medications or change doses. In some places in the United States, there are collaborative drug-therapy management programs with pharmacists and physicians, Tsuyuki noted, but Alberta is the only Canadian province with this broadly expanded scope of pharmacist practice.

That the number of smokers in the intervention group dropped by 20% in 3 months is "really rather remarkable," Taylor noted. The pharmacists "are not just providing pills, they are providing general health advice, and you can only imagine what they could do if they built in things like adherence and monitoring, exercise recommendations, dietary recommendations. . . . It's turning the interaction at a pharmacy window, which used to be to simply sliding a prescription in one direction and pills coming back in the other direction, to an actual healthcare interaction. 'Are you taking your medications? What are your risk factors? What numbers have you achieved?' "

Funding for the RxEACH study was provided by Alberta Health, the Cardiovascular Health and Stroke Strategic Clinical Network of Alberta Health Services, and Merck Canada (for development of the educational materials only). Tsuyuki received investigator-initiated research grants from Merck, Sanofi, and AstraZeneca and is a consultant for Merck; the coauthors have no relevant financial relationships. Taylor reports receiving consultant fees/honoraria from Amgen and Eli Lilly and being on the speaker's bureau of Sanofi.

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