Disgruntled Dan's Pharmacy Podcast

Episode #3: The new GLP-1 kid on the block - Semaglutide!

Disgruntled Dan’s Conclusions:
Semaglutide reduces the risk of nonfatal stroke (NNT 97 for 2.1 years), new or worsening nephropathy (NNT 43 over 2.1 years), and revascularization. Yes – there was a reduction in the composite MACE outcomes, but this was primarily driven by the results from nonfatal strokes.
Use with caution in patients that currently have retinopathies – Semaglutide may worsen and/or cause retinopathies and the exact cause is currently unknown.
Once weekly dosing – convenient for the patient.
Start low and go slow, it is a once weekly injection. Due to the long half life it is recommended you start at 0.25mg x 4 weeks THEN 0.5mg x 4 weeks THEN increase to max dose of 1mg.
Cost ~$700 for a 4-6 week supply without insurance.
It is a new drug. We do not have much experience with it. So I am always cautiously optimistic but I will generally choose options that we have a bit more real world data with before jumping to this. In reality it comes down to that patient sitting in front of you. Remember to keep it patient centred!
References
Marso, S. P. et al. Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N. Engl. J. Med. 375, 1834–1844 (2016).
Fda, Cder & buckmans. Non-Inferiority Clinical Trials to Establish Effectiveness Guidance for Industry. (2016).
Sorli, C. et al. Efficacy and safety of once-weekly semaglutide monotherapy versus placebo in patients with type 2 diabetes (SUSTAIN 1): a double-blind, randomised, placebo-controlled, parallel-group, multinational, multicentre phase 3a trial. lancet. Diabetes Endocrinol. 5, 251–260 (2017).
Dungan, K. & DeSantis, A. Glucagon-like peptide-1 receptor agonists for the treatment of type 2 diabetes mellitus - UpToDate. Available at: https://www.uptodate.com/contents/glucagon-like-peptide-1-receptor-agonists-for-the-treatment-of-type-2-diabetes-mellitus?search=glp 1&source=search_result&selectedTitle=1~106&usage_type=default&display_rank=1. (Accessed: 6th May 2018)
Guyatt, G., Rennie, D., Meade, M. & Cook, D. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed | JAMAevidence | McGraw-Hill Medical. Available at: https://jamaevidence.mhmedical.com/Book.aspx?bookId=847. (Accessed: 6th May 2018)

Episode #2: Pharmacist Awareness Month - The evidence for your family Pharmacist?

Disgruntled Dan’s Conclusions:
Pharmacists in Alberta, Canada have one of the most advanced scopes of practice in the world. With this scope of practice pharmacists can proactively, and systematically identify, and manage patients with uncontrolled diabetes, HTN, and those at an increased risk of CV disease.
The ability to independently assess and prescribe allows pharmacists to help ease the burden of care on physicians and other healthcare providers and strengthen interprofessional care. This has the potential to increase efficiencies and provide substantial cost savings within our healthcare system.
As one of the most accessible healthcare providers, there is an opportunity for pharmacists to develop new and innovative practices that can enhance patient care! I hope to continue seeing the scope of practice here in Alberta being adopted and built upon in other jurisdictions worldwide!
References
Marra, C., Johnston, K., Santschi, V. & Tsuyuki, R. T. Cost-effectiveness of pharmacist care for managing hypertension in Canada. Can. Pharm. J. / Rev. des Pharm. du Canada 171516351770110 (2017). doi:10.1177/1715163517701109
Tsuyuki, R. T., Jones, C. A., Hemmelgarn, B. & Hamarneh, Y. N. Al. The Alberta Vascular Risk Reduction Community Pharmacy Project: R x EACH. (2013).
Tsuyuki, R. T. et al. Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the CommunityCLINICAL PERSPECTIVE. Circulation 132, 93–100 (2015).
Al Hamarneh, Y. N., Charrois, T., Lewanczuk, R. & Tsuyuki, R. T. Pharmacist intervention for glycaemic control in the community (the RxING study). BMJ Open 3, e003154 (2013).
Al Hamarneh, Y. N., Sauriol, L. & Tsuyuki, R. T. After the diabetes care trial ends, now what? A 1-year follow-up of the RxING study. BMJ Open 5, e008152 (2015).

Episode #1: Shingrix - Too good to be true?

Disgruntled Dan's Conclusions 
1) Shingrix – Reduces the incidence of Herpes Zoster Infections RRR of 97%; NNT of 36 over 3.7 years
-Are the results too good to be true?
-No long-term efficacy data yet....
2) Shingrix – Requires 2 intramuscular injections spaced 2-6 months apart
-Adherence may be an issue - will one dose be effective? 
-Second dose can still be given outside of the 2-6 month window without restarting the series 
3) As per the Advisory Committee on Immunization Practices it is safe to provide the Shingrix vaccine to those previously immunized with Zostavax – space a minimum of 8 weeks apart.
-Can provide the flu vaccine simultaneously with Shingrix 
4) No contraindication to providing Shingrix to the immunocompromised. 
-Trials have been completed in HIV infected and haematopoietic stem cell transplant recipients and thus far have been shown to be safe but the clinical efficacy in these patient populations is yet to be evaluated.
5) Cost 
-Shingrix ~$150/injection - ~$300 per series
-Zostavax ~200+/injection
 
References 
1) Morrison, V.A. et al. Long-term Persistence of Zoster Vaccine Efficacy. Clin. Infect. Dis. 60, 900–909 (2015).
2) Schmader, K. E. et al. Persistence of the Efficacy of Zoster Vaccine in the Shingles Prevention Study and the Short-Term Persistence Substudy. Clin. Infect. Dis. 55, 1320–1328 (2012).
3) Oxman, M. N. et al. A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. N. Engl. J. Med. 352, 2271–2284 (2005).
4) Cunningham, A. L. et al. Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older. N. Engl. J. Med. 375, 1019–1032 (2016).
5) Grupping, K. et al. Immunogenicity and Safety of the HZ/su Adjuvanted Herpes Zoster Subunit Vaccine in Adults Previously Vaccinated With a Live Attenuated Herpes Zoster Vaccine. J. Infect. Dis. 216, 1343–1351 (2017).
6) Lal, H. et al. Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults. N. Engl. J. Med. 372, 2087–2096 (2015).
7) Bharucha, T., Ming, D. & Breuer, J. A critical appraisal of ‘Shingrix’, a novel herpes zoster subunit vaccine (HZ/Su or GSK1437173A) for varicella zoster virus. Hum. Vaccin. Immunother. 13, 1789–1797 (2017).
8) GSK. Product Monograph: Shingrix. (2017).
9) Albrecht, M., Hirsch, M. & Mitty, J. Vaccination for the prevention of shingles (herpes zoster) - UpToDate. (2017). Available at: https://www.uptodate.com/contents/vaccination-for-the-prevention-of-shingles-herpes-zoster?search=shingles&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4. (Accessed: 19th February 2018)
10) Keilly, J., et al. Rx Files:A Summary Herpes Zoster Vaccine (ZOSTAVAX).
11) Canada. National Advisory Committee on Immunization & Public Health Agency of Canada. An advisory committee statement (ACS) - National Advisory Committee on Immunization (NACI) : update on the use of herpes zoster vaccine

Disgruntled Dan - The Introduction