Whats New in The Medicine Cabinet

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Whats New in The Medicine Cabinet

• Mike Spieker, M.D.Naval Hospital Bremerton

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• 10 chronic
• Chronic illness
• 2x lost days
• 3,025 lost per employee/yr

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Sleep

• Benzodiazipines
• Anti-histamines
• Non-Benzos
• Melatonin receptor agonists.
• GABA
• Others

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• ZZZ
• AM
• BIEN

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ZZZZZZs II

• Eszopiclone
• Duration 8 hr
• No tolerance
• Cancer risk?
• Aftertaste

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Sleep

• Ambien CR
• To increase sleep duration
• Dual release
• Lasts about 7-8 hours
• Same drug as Ambien BUT it got FDA approval for
  long-term use

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The Big O

• Rozerem
• Melatonin agonist
• Fall asleep, not stay asleep
• Hypnotic effect not impressive
• Not Schedule II
• Cheapest retail
• Fluvoxamine

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Indiplon

• Immediate CR
• GABA receptor
• NDA submitted
• 50 decrease in LSO
• 50 min increase in sTST

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Sleep V Cost
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30 day supply
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• Benadryl 2.50
• Elavil 21
• Trazodone 12
• Halcion 20
• Restoril 22

AWP 30 days
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• Go to sleep/wake at same time
• Avoid caffeine late in the day
• Watch your diet.
• Exercise regularly.
• Create relaxing bedtime routine
• Get out of bed if not sleeping.

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Insomnia Differential

• Depression
• Restless legs

www.sleepfoundation.org
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Insomnia 780.52
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• Ropinirole
• Dopamine agonist
• 1 mg /day
• No head-head trials
• 2 retail .68 DoD

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Table 3 NNTs for RLS treatments
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Cholesterol

• Crestor
• Pitavastatin -Zomaril
• Niaspan
• Omega 3 Fatty Acids
• Behavior

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Omega 3s

• Salmon, tuna, halibut, herring
• Flax seed and nuts
• Walnuts, almonds, pecans
• Omacor - Prescription

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Womens Health

• Calcium / Vit D
• Fosamax D
• Boniva
• DepoProvera SQ
• Evra

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Battle of the Bones
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Among healthy postmenopausal women, calcium
with vitamin D supplementation resulted in a
small but significant improvement in hip bone
density, did not significantly reduce hip
fracture, and increased the risk of kidney
stones.
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• What are my risk factors for osteoporosis?
• What can I do to prevent osteoporosis?
• Am I getting enough calcium and vitamin D?
• What is a bone mineral density test?
• How is a bone mineral density test done? How long
  does it take? How much does it cost?
• Should I get a bone mineral density test? What
  should I wear and where do I get tested?
• What is a T-score? What does it tell us about my
  bone mass and risk for fracture?
• Do I have osteopenia (thinning bones) or
  osteoporosis?
• Im already taking calcium and vitamin D. Are
  other treatments available?

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Coolest Pill
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• Monthly and daily are equi-efficacious
• Increases bone density without GI
• 52 Risk Reduction
• Absolute RR lt 5
• Cost 950-1000/yr
• 60 minutes PC

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975
950
1066
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Numbers Needed to Treat

• Estimates the number of patients requiring
  therapy for X time to prevent one event.

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Relative Risk Reduction - RRR
ARR 4.9
NNT 1/ARR 1/.049 20.4
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So..

• To prevent one vertebral fracture, we would
  have to
• treat 20 women
• Asymptomatic
• postmenopausal
• for 3 years
• direct cost of 58,140

Bandolier
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Depo Provera SQ 104 PL 12-5

• Contraception endometriosis
• 30 less hormone
• Bone loss risk gt 2 years
• Wt gain 3.5 first year

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• 2-3x risk of clots
• 60 more estrogen exposure than BCP
• BCP higher peak but Evra higher overall
• No proof
• Dont cut in ½
• Which risk?
• BCP 1/200K
• Evra 2-3/200k
• Pregnancy 26/200K

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• The risk of dying from a pregnancy related
  complication (1/2 of all pregnancies are
  unplanned) is higher than for ALL causes of death
  associated with all contraceptive use.

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DIABETES WARS
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Diabetes

• Exubra
• Symlin
• Byetta
• Insulin Detamir
• Pargluva
• Sitagliptin

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Exubera

• 5 million Americans use insulin
• Tested in both DM I and II
• 2 years 3500 patients
• Difference in A1c less than 0.5 versus injected
• Rapid onset
• Pulmonary ?

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Exubera

• Meal time only
• Patients prefer
• Smokers NO
• Inhaler concerns
• Cough
• PFT
• Insulin Antibody

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Symlin (pramlintide)

• New Class - Amlyinomimetic
• Injectable cannot mix with insulin
• Reduces fluctuations
• No weight gain
• Hypoglycemia, esp. with type I
• Reduce insulin dose on initiation

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Byetta (exenatide)

• First incretin mimetic
• Glucagon-like peptide-1, or GLP-1 hormone
• Lowers after-meal and fasting glucose
• Not for use with insulin
• Hypoglycemia 14-36 with sulfonylurea
• Wholesale 147/187
• Weight loss

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Pargluva (muraglitazar)

• FDA - Approvable
• New class glitazars
• Type II DM
• Activation of the PPARs
• Decreases plasma glucose
• Decreases FFA
• Decreases Triglycerides
• Increases HDL
• JAMA Cleveland Clinic

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Levemir

• Ultra-long acting insulin detemir
• BID dosing may be necessary
• Phase III trials
• Seeking approval in pediatrics

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Sitagliptin

• Dipeptidyl peptidase IV inhibitor
• Phase II trials success
• .6 - .8 reduction in A1c
• Low wt gain
• GI side effect, low hypoglycemia

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Vaccines

• Proquad
• Rotavirus
• Adacel
• Boostrix

• Cervarix
• Gardasil
• Zostavax

http//www.hhs.gov/nvpo/meetings/jun2003/zhou.ppt
1
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ProQuad

• MMR Varicella
• 12 m to 12 yrs
• 99 conversion
• No ACIP recs
• Side effects
• Fever, rash similar
• Less pain at site

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Rotavirus

• US 2.7 million infections
• 70,000 hospitalizations
• 20-70 deaths
• RotaShield
• RotaTeq
• Genetic engineered
• 3 dose, liquid
• 5 strains
• 98 effective

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Boostrix

• Diptheria, pertussis, tetanus
• Pertussis on rise
• 1/3 cases in age gt 10
• Approved for age 10 - 18
• ACIP age 11-12

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Adacel

• Tetanus, diphtheria and pertussis
• Active booster - adults
• Single dose
• Ages 11- 64
• Adverse similar to Td

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Zostavax

• ½ of 85 yr olds
• Shingles Prevention Study
• 5 yr study 3 yrs average
• 38,500 patients, gt 60 yr
• 51 RRR 1.8 ARR
• NNT 55 shingles
• NNT 344 for PNH
• 200/wk Valtrex

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Menactra

• Meningococcus
• ACIP 11-12 year olds
• Replace menomune will last longer than 3-5
  years
• applied for approval for use in children 2 to 10
  years

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Cervical Cancer

• Second most common cancer
• 270,000 deaths annually
• US
• 1 million new infections
• 20 million infected
• 3,900 deaths
• 6 BILLION

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Cervarix vs. Gardasil

• Fast track 12/05
• HPV 16 18 AND
• Genital wart 6,11
• 0,2 6 months
• NNT 250 _at_ 17 months

• Submit in 2006
• HPV 16 18
• 70 of cancers
• 0, 1, 6 month

Estimated cost 300
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Antibiotics

• Tygacil
• New class Glyclcyclines
• Cost 90/d
• LevaPak - levofloxacin
• ZMax
• Single dose
• CAP and ABS

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Drugs Off Patent

• Ambien - 2006
• Fosamax - 2008
• Zocor June 06
• Zoloft 2006
• Pravachol April 06
• Norvasc July 06
• Lipitor - 2009
• Zofran Dec 06

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Justsay No!
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• Campral
• Acomplia
• Champix
• Varenicline
• Commit

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• Paxil fetal heart defects
• Crestor - rhabdomyolosis
• Depo-Provera bone loss
• Elidel and Protopic - lymphoma
• NSAIDS MI
• Strattera suicide
• ADHD meds Sudden death
• Salmeterol asthma attack

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Congratulations Stealers!
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