Integrase strand transfer inhibitors (INSTIs) are oral antiretroviral agents used against HIV infection. There are three agents available, including raltegravir, elvitegravir and dolutegravir, some of which are available as combination medications with other antiretroviral drugs. The efficacy and safety of INSTIs in treatment-naïve and experienced HIV-infected patients have been established by multiple studies. Based on the current practice guidelines, INSTI-based regimens are considered as one of the first-line therapies for treatment-naïve HIV-infected patients. There are new INSTIs in development to improve the resistance profile and to decrease the frequency of drug administration.

Clinicians should become familiar with tools to identify delirium in order to initiate treatment and remove mitigating factors early in hospitalization to prevent delirium. Pharmacists are in a unique position to reduce delirium through minimization of medication-related risk factors and development of protocols.

Currently, all second-generation antipsychotics are approved for schizophrenia. Many are also approved for bipolar disorder, with some also approved as adjunctive treatment for depression and autism-related irritability. Second-generation antipsychotics are increasingly being prescribed for indications other than those approved by the Food and Drug Administration, such as in dementia, anxiety, and post-traumatic stress disorder to name a few. Obsessive–compulsive and related disorders are a group of disorders characterized by preoccupation and repetitive behaviors. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, obsessive–compulsive disorder, body dysmorphic disorder, trichotillomania, hoarding disorder, and excoriation, the latter two being newly designated disorders, fall under obsessive–compulsive and related disorders. Due to a lack of well designed clinical studies specifically addressing the use of second-generation antipsychotics in obsessive–compulsive and related disorders, it is unknown whether these agents are clinically beneficial. Current research describing the pathophysiology of these disorders shows the involvement of similar brain regions and neurotransmitters across the five obsessive–compulsive and related disorders. Despite differences in the receptor binding profiles, second-generation antipsychotics share many common pharmacodynamics properties. This review sought to examine all the published reports of second-generation antipsychotics being used in the management of symptoms of the aforementioned diseases and compile evidence for clinicians who encounter patients who are unresponsive to standard treatment.

Purpose Aprepitant and its parenteral formulation fosaprepitant are widely used for the prevention of chemotherapy-induced nausea and vomiting. Aprepitant exerts modest inhibitory effect on CYP3A4 and modest inductive effect on CYP2C9 substrates such as some antineoplastics and multiple other medications. This article is aimed to provide pharmacists and other healthcare professionals with an updated summary of drug-drug interactions of aprepitant/fosaprepitant and implications for clinical practice. Method We reviewed publications reporting drug-drug interactions between aprepitant/fosaprepitant and other medications. Results Coadministration of aprepitant with antineoplastics or opiods may result in significant elevations in the serum levels of the agents metabolized via CYP3A4, with the best documentation for cyclophosphamide, ifosfamide, erlotinib and oxycodone. These alterations did not translate into adverse outcomes and/or necessitate dosing adjustments. The levels of warfarin were significantly decreased by aprepitant requiring prolonged monitoring after discontinuation of aprepitant. Among direct oral anticoagulants, a theoretical interaction between aprepitant and rivaroxaban or apixaban exists. Interactions between aprepitant and quetiapine or diltiazem or sirolimus required dose reductions to avoid adverse outcomes. The intravenous route had a weaker inhibitory effect on CYP3A4 than the oral pathway. Conclusion The evidence on drug interactions of aprepitant with other medications is limited, and the impact on therapeutic outcomes remains to be determined. The intravenous regimen may be a preferred option. As utilization of aprepitant is expanding, practitioners and patients need to be educated about the potential for drug interactions and a need for careful monitoring of patients concurrently receiving aprepitant and CYP2C9 or CYP3A4 substrates, especially those with a narrow therapeutic window.

Atrial fibrillation is a commonly encountered arrhythmia associated with increased risk for thromboembolic events. Anticoagulation is necessary to decrease the risk of ischemic stroke. Traditionally, warfarin has been the only oral pharmacotherapeutic option for long-term anticoagulation in patients with nonvalvular atrial fibrillation (NVAF). Recently, non-vitamin K antagonist oral anticoagulants (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban, have become available as alternatives for warfarin in the prevention of stroke in patients with NVAF. Recently published atrial fibrillation guidelines contain new recommendations for risk stratification tools in determining the need for anticoagulant therapy and incorporate NOAC pharmacotherapy options for stroke prevention in patients with NVAF. NOACs offer several advantages over warfarin, including the elimination of routine laboratory monitoring, fewer drug and food interactions, and rapid therapeutic onset and offset. However, the lack of antidote in the case of serious bleeding and lack of data for long-term use in patient populations at risk for bleeding is problematic. Older adults are at high risk for thromboembolic and bleeding events as a result of anticoagulation and require special consideration when selecting anticoagulant therapy. The risk of drug accumulation and bleeding is concerning in the presence of renal impairment. The objective of this review is to provide the clinician with an update on the use of NOACs for NVAF, focusing on older adults and patients with renal impairment in light of recently published atrial fibrillation guidelines. Available data on using NOACs in coronary artery stenting, cardioversion, and ablation are also reviewed.