No abstract

Background: Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF). Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. Methods: The Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction (EPIC-HF) trial randomized patients with HFrEF from a diverse health system to usual care versus patient-activation tools—a 3-minute video and 1-page checklist—delivered electronically 1 week prior, 3 days prior and 24 hours prior to a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in HFrEF prescribing. The primary endpoint was the percent of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days, compared to usual care during the same period. Results: EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient-activation tools and 145 were controls. Median age was 65 years, 29% female, 11% black, 7% Hispanic, median ejection fraction 32%. Pre-clinic data revealed significant GDMT opportunities, with no patients on target doses of beta-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days later, 49.0% in the intervention and 29.7% in control experienced an initiation or intensification of their GDMT (p=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths, and no significant differences in hospitalization or emergency department visits at 30 days between groups. Conclusions: A patient-activation tool delivered electronically prior to a cardiology clinic visit improved clinician intensification of GDMT. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT03334188

PHEN/TPM is a new, once-daily, controlled-release, combination weight-loss product approved as an adjunct to diet and exercise for chronic weight management of obese or overweight patients with weight-related comorbidities. PHEN/TPM is modestly effective and a viable option for patients interested in losing weight, although long-term safety data are lacking.

Background: Irritable bowel syndrome (IBS) is a complex syndrome that is difficult to manage. Here we present the evidence supporting medication treatments for specific IBS symptoms, discuss evidence-based management of IBS with medications including dose regimens and adverse effects and review progress on research for new IBS treatments. Summary: Currently, there is evidence to support improvements in specific IBS symptoms following treatment with loperamide, psyllium, bran, lubiprostone, linaclotide, amitriptyline, trimipramine, desipramine, citalopram, fluoxetine, paroxetine, dicyclomine, peppermint oil, rifaximin, ketotifen, pregabalin, gabapentin and octreotide and there are many new medications being investigated for the treatment of IBS. Key Message: Of the medications with demonstrated improvements for IBS symptoms, rifaximin, lubiprostone, linaclotide, fiber supplementation and peppermint oil have the most reliable evidence supporting their use for the treatment of IBS. Onset of efficacy for the various medications has been noted to be as early as 6 days after initiation; however, the efficacy of most medications was not assessed prospectively at predefined periods. Additional studies of currently available and new medications are ongoing and are needed to better define their place in therapy and expand therapeutic options for the treatment of IBS. The most promising new medications for IBS include a variety of novel pharmacologic approaches, most notably the dual μ-opioid receptor agonist and δ-opioid antagonist, JNJ-27018966.