Background: The optimal monitoring and follow-up strategy for long-term direct oral anticoagulant (DOAC) therapy has not been established. Historically, at our medical center, DOAC patients were referred to a clinical pharmacy specialist managed anticoagulation clinic (AC) for monitoring via regularly scheduled encounters (face-to-face or telephone). Objective: To determine if implementation of a DOAC Population Management Tool (PMT) designed to identify patients who most likely require clinical review and possibly intervention, would improve the efficacy (interventions per patient) and efficiency (time invested to generate an intervention) of monitoring over AC practices. Methods: The DOAC PMT group included patients flagged as potentially having a dosing issue or history of valve replacement. The AC group included patients who were scheduled for routine DOAC follow-up. The quantity and character of interventions made were prospectively recorded and compared. Results: A total of 399 patients were included. Data were collected for 131 patients identified by the DOAC PMT, resulting in a review of 170 flags with a total of 94 interventions or 0.55 interventions per flag reviewed. For the AC group, 268 patients were evaluated, leading to 53 interventions or 0.20 interventions per patient encounter ( P < 0.001 for comparison). The time to generate an intervention was 16 minutes in the DOAC PMT versus 64 minutes for the AC group. Conclusion and Relevance: A population-based approach to DOAC monitoring represents a more effective and efficient strategy to reduce missed opportunities for interventions between follow-up appointments while also increasing clinic access, particularly for patients who require immediate attention.

A clinical reminder tool developed to quantify and characterize the interventions provided by CPSs found that for every visit with a CPS, approximately one disease-specific intervention and one additional pharmacotherapy intervention were made, independent of those interventions being made by the primary physician or other members of the primary care team.

Despite the wide array of antihypertensive agents and the availability of national guidelines regarding treatment for hypertension, the disease remains uncontrolled in nearly 50% of affected patients. Furthermore, the number of patients with resistant hypertension continues to increase. For patients with resistant hypertension, the American Heart Association has advocated for clinical studies to determine appropriate pharmacologic treatment strategies. One proposed strategy involves ambulatory measurement of plasma renin activity (PRA) to guide the selection of antihypertensive therapy. Patients with low PRA would be prescribed natriuretic volume-mediated therapies (e.g., diuretics and calcium channel blockers), whereas those with high PRA would receive antirenin system therapies (e.g., β-blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers). This review focuses on the principles of PRA-guided therapy, its historical development, alternative approaches to classifying patients into categories of response to antihypertensive agents, and recent data supporting the use of plasma renin activity-guided hypertension management.

• Myopathy occurs in 1.5%-5% of patients in randomized controlled clinical trials with statins. However, observational studies suggest that mylagia may occur in as many as 10% of statin users, but rhabdomyolysis, the life-threatening form of myopathy, is rare.• In 2002, the FDA added a warning to the label of simvastatin (Zocor) that recommended it not be used in doses exceeding 20 mg per day in combination with amiodarone (Pacerone).• In August 2008, the FDA reissued a safety alert regarding the increased risk for myopathy and rhabdomyolysis in patients receiving concomitant amiodarone and simvastatin in doses greater than 20 mg per day, citing 52 cases of rhabdomyolysis reported to the FDA in the Adverse Event Reporting System (AERS) for this drug combination that occurred after warnings to the labels of amiodarone and simvastatin were added in 2002: 26 (50%) were taking simvastatin 80 mg per day, 13 (25%) were taking simvastatin 40 mg per day, 4 (8%) were taking simvastatin 20 mg per day, and 1 patient was taking simvastatin 5 mg per day; 8 patients (15%) were taking an unknown dose of simvastatin. • In the Study of the Effectiveness of Additional Reductions inCholesterol and Homocysteine (SEARCH), 12,064 patients with a previous heart attack were randomized to simvastatin 80 mg per day (n=6,031) or simvastatin 20 mg per day (n=6,033), and the relative risk of definite myopathy or incipient myopathy (defined as "a creatine kinase level that was more than both 3 times the upper limit of the normal range and 5 times the baseline level, plus an alanine aminotransferase level that was more than 1.7 times the baseline value without an elevated alanine aminotransferase level alone at any other visit, irrespective of whether there were muscle symptoms") was 8.8 (95% CI=4.2-18.4) for concomitant simvastatin 80 mg and amiodarone versus simvastatin 80 mg alone.• Observational and pharmacokinetic data suggest that pravastatin may be the safest initial therapeutic alternative to simvastatin in combination with amiodarone. The lack of significant interaction reports with rosuvastatin and amiodarone suggest its potential role as safer than simvastatin in patients who require a highpotency statin in combination with amiodarone. What is already known about this subject

Prophylaxis for venous thromboembolism (VTE) in hospitalized acutely ill medical patients is a well-established practice. Despite the increased use of inpatient prophylaxis, the duration of hospitalization is typically shorter than the duration of VTE prophylaxis provided in clinical trials. In addition, VTE events after hospitalization are not unusual, with most events occurring within 30 days of hospital discharge. Therefore, the 30-day time period postdischarge has been identified as a stage in which patients are still at high risk of developing VTE. Attempts to provide extended prophylaxis with enoxaparin, rivaroxaban, or apixaban in patients with acute medical illness have been met with mixed results. Although some of these agents have reduced the incidence of VTE with extended prophylaxis, all of these agents have also demonstrated a significant increase in major bleeding that seems to offset any potential benefit. A recent trial of a new direct factor Xa inhibitor, betrixaban, demonstrated a reduction in VTE events with extended prophylaxis without significantly increasing the risk of major bleeding. Understanding appropriate patient selection, dosing, and outcomes associated with betrixaban will be important to potentially reducing the continued risk of VTE in patients with acute medical illness.