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New Drugs in the Long-Term Care Setting, Part 1

May 1, 2002
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A look at new agents for cholesterol, diabetes, infection andmental disorders By James W. Cooper, RPH, PhD, Clinical Editor
New Drugs in the Long-Term Care Setting, Part 1 A quick look at the benefits, uses and abuses of some recent candidates for LTC formularies B y James W. Cooper, RPH, PhD, Clinical Editor Lost in all the current debate over PPS, RUGs and prescription drug coverage is the fact that the pharmaceutical industry continues to make progress in developing new products for the long-term care market. Some have real potential for improving the well-being and quality of life of many residents. In this article and its next part in a future issue, I will explore these new agents, contrast their benefits with those of older agents and discuss the potential benefits of adding them to long-term care formularies. In this issue we will discuss drugs for decreasing cholesterol (hypolipidemics), managing diabetes (anti-diabetics), treating infection (anti-infectives) and addressing mental health problems (psychotropics).

While up to 70% of nursing facility residents have been shown to have hyperlipidemia that should be treated, there is increasing evidence that very few residents who might benefit from hypo-lipidemics actually receive appropriate therapy or reach consensus goals. These goals, for individuals with a history of target organ damage such as angina, myocardial infarction, stroke or diabetes, are levels of LDL cholesterol 40. There is also evidence for the cholesterol-lowering drugs called statins (Lipitor, Lescol, Mevacor, Pravachol and Zocor) that, when started in middle to later middle-age years, they reduce the risk of dementia, type 2 diabetes and osteoporosis.

There are some precautions. Hypo-lipidemic myopathy (meaning, in general, muscle aches and damage) is still a problem with the statins when used with the drugs Lopid, Tricor and Lipidil, and especially with niacin. This myopathy might also be seen with Mevacor and Zocor when erythromycin, Biaxin, Nizoral, Sporanox, cyclosporine, Ser-zone, protease inhibitors (for AIDS) or grapefruit juice are used with them. Pravachol and Lescol are the statins least affected by these drug-drug interactions.

The most potent statin yet developed, Crestor, is due to be released this year.

Antidiabetic Agents
Lantus is a newer insulin form that, unlike other regular or extended-release insulins, is meant to be given once a day at bedtime only. It is critical that this product not be delivered intravenously or mixed with other insulins. Patients on once-daily NPH insulin or Ultralente can be switched to the same dose of Lantus. Patients and caregivers should be warned that Lantus might sting more than NPH or other insulins because it is more acidic. They should also be told that Lantus is clear, not cloudy-which might be confusing, as prior diabetic teaching has emphasized that the NPH and Ultralente insulins are cloudy.

Starlix is a new, very-short-acting oral insulin stimulator for patients with type 2 diabetes (the most common form of diabetes in the elderly). It is meant to be given with meals that are consumed-in other words, if residents skip a meal, they should skip the pill. Starlix and a similar product called Prandin might have a unique use, i.e., for failure of other antidiabetic drugs, such as Micronase/Glynase, Diabeta or Glucotrol, when their maximal doses are reached and fasting glucose is no longer reduced appropriately.

Other medications for the diabetic. Evidence has shown that the heart drugs called ACE inhibitors and angiotensin receptor blockers (ARBs) spare insulin and preserve heart and kidney function. ACE inhibitors include Lotensin, captopril, enalapril, Monopril, Prinivil/Zestril, Univasc, Aceon, Accupril, Altace and Mavik. The ARBs are Atacand, Teveten, Avapro, Cozaar, Micardis and Diovan.

Metformin (Glucophage) is most useful as an insulin-sparing agent in younger type 2 diabetics, as long as their kidney function is adequate (creatinine clearance [CrCl] not less than 50 to 60 ml/min) and they do not have class II or higher congestive heart failure (CHF). Unfortunately, the average CrCl of most elderly LTC residents is 40 ml/min or less, and one-third or more have CHF. Recent studies have shown that prescribers do not take either CrCl or CHF into account when using metformin. When advanced CHF or reduced CrCl is present, there is a much greater risk of lactic acidosis, which can be fatal in 20% or more of cases.

Actos and Avandia are secondary insulin-sparing drugs. They routinely cause fluid retention and might exacerbate CHF, but they can still be useful if HgA1c-a measure of blood glucose control over the previous 90 to 120 days-drops. A simple way to anticipate the fluid retention is to weigh the resident on Actos or Avandia daily for the first two weeks, then every other week throughout therapy. A five-pound or more weight gain or worsening foot swelling (pedal edema) should be reported to the prescriber to prevent acute pulmonary edema and hospital admission for CHF. The patient most likely to have new or worsened CHF is the patient using insulin. It might be most prudent to avoid Actos or Avandia in any patient requiring insulin.

Precose and Glyset are also insulin-sparing agents with a modest effect on HgA1c, but they require careful titration because of their excessive flatulence and laxative effect.