the american journal for nurse...

MARCH/APRIL 2012VOL. 16 NO. 3/4

The American Journalfor Nurse Practitioners

T H E O F F I C I A L J O U R N A L F O R N U R S E P R A C T I T I O N E R SA Peer-Reviewed Journal

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PRIMARY CAREAdvances in the Treatment ofPatients with Hemophilia

ISSUES INPHARMACOTHERAPYLong-distance Caregiving

PRIMARY CAREManagement Strategies for

Statin Intolerance

ORAL CAREOral Effects of

Methamphetamine Use

Clinical Challenges In…

The Pearson

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2 � THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS MARCH/APRIL 2012 VOL. 16 NO. 3/4

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VOL. 16 NO. 3/4 MARCH/APRIL 2012 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS � 3

Dear Colleagues:With the political process in full swing, no matter which side you support, it is appropriatethat we focus on the legislative agenda and the work that needs to be done to make thesweeping changes needed in our healthcare system. It is our belief that nurse practitionersare and will continue to be major providers of primary care all over this country.To help NPs keep track of where we are in terms of meeting Americans’ healthcare needs,we are pleased inform you that The Pearson Report 2012, the annual state-by-state nation-al overview of nurse practitioner legislation and healthcare issues, by Linda J. Pearson,DNSc, FPMHNP-BC, FAANP, is now up on our website. Readers can log on towebNPonline.com and click on Visit the Pearson Report online to get all the details. Wehope that you will use the data compiled by Linda Pearson to help your state legislatorsunderstand and appreciate the key role that NPs play as healthcare providers across theU.S. As President Obama says, “This is our time.”This March/April issue of The American Journal for Nurse Practitioners features articlesentitled Advances in the Treatment of Patients with Hemophilia, by Angela Y. Lambing;Statin Intolerance: Management Strategies, by Kristine Anne Scordo; and Identifying andTreating the Oral Effects of Methamphetamine Use, by Emily R. Holt and Deborah CarlWolf. The issue also includes contributions from our regular columnists:

• Issues in Pharmacotherapy: Long-distance Caregiving: Challenges and Tips forSuccess, by Mary Ann E. Zagaria. This column includes a 2-page patient handout,“Tips and Resources for Long-distance Caregiving,” that readers can photocopy anddistribute to patients who may be serving as long-distance caregivers; and

• Promoting the NP Profession: Meaningful Use of the Electronic Health Record, byTom Bartol

Happy Spring!

E D I T O R I A L A D V I S O R Y B O A R DIvy M. Alexander, PhD, C-ANPAssociate Professor and Director,Adult, Family, Gerontological, andWomen’s Health Primary Care Specialty

Coordinator, WHNP and ANP TracksYale UniversityNew Haven, Connecticut

Carolyn Buppert, JD, NPLaw Office of Carolyn Buppert, P.C.Bethesda, Maryland

Patricia A. Burns, PhD, RN, FAANProfessor, Dean, University of South FloridaCollege of Nursing, Tampa, Florida

Winifred Carson-Smith, Esq.CarsonCompany, LLCWashington, District of Columbia

M. Katherine Crabtree, DNSc, FAAN, APRN-BCProfessor, School of Nursing at University of PortlandPortland, Oregon

Linda Dominguez, CNP, BSN, WHNPAssistant Medical DirectorPlanned Parenthood of New MexicoAlbuquerque, New Mexico

Edward P. Gruber, PhD, RN, ARNPAssistant Dean and Clinical ProfessorGraduate Nursing ProgramIntercollegiate College of NursingWashington State University College of NursingSpokane, Washington

Thomasine D. Guberski, PhD, CRNPAssociate ProfessorUniversity of Maryland School of NursingBaltimore, Maryland

Doreen C. Harper, PhD, RN, FAANDean and ProfessorUniversity of Alabama at BirminghamBirmingham, Alabama

Jean E. Johnson, PhD, RN, FAANSenior Associate Dean forHealth Sciences Program

The George Washington UniversityWashington, District of Columbia

Mary Knudtson, DNSc, NP, FAANExecutive Director Student HealthUCSC Health CenterUniversity of CaliforniaSanta Cruz, California

Nancy Rudner Lugo, DrPH, NPPresident, Health Action Workplace Health PromotionOrlando, Florida

Lucy Marion, PhD, RN, FAANDean and Professor, School of NursingMedical College of GeorgiaAugusta, Georgia

Carolyn Montoya, MSN, CPNPCoordinator FNP ConcentrationUniversity of New MexicoAlbuquerque, New Mexico

Beth Moran, RN, CNPPrivate Practice, Women’s HealthSag Harbor, New York

Donna G. Nativio, PhD, CRNP, FAANAssociate ProfessorDirector of Adult, Family, and PediatricNurse Practitioner Programs

Director of Doctorate of Nursing PracticeUniversity of Pittsburgh School of NursingPittsburgh, Pennsylvania

Eileen T. O’Grady, PhD, RN, NPPolicy LiaisonAmerican College of Nurse PractitionersPolicy Editor, NP CommunicationsMcLean, Virginia

SusanWysocki, WHNP-BC, FAANPPresidentiWomansHealthWashington, District of Columbia

Phyllis Arn Zimmer, MN, ARNP, FAANPresident, Nurse Practitioner Healthcare FoundationFaculty, FNP ProgramUniversity of Washington School of NursingPartner, FnP Associates, LLPSeattle, Washington

F R O M T H E E D I T O R I A L C O - D I R E C T O R S

Donna R. HodnickiPhD, FNP-BC, FAAN

Charlene M. HansonEdD, FNP-BC, FAAN

The American Journal forNurse Practitioners wel-comes your input. Pleasesend your comments,ideas, and suggestions byphone, fax, or email toDory Greene, ExecutiveEditor (phone, 908-903-0230; fax, 908-903-0231;email, [email protected]); or to NP Com-munications, LLC (phone,732-641-2113; fax, 732-641-2116; website, www.webNPonline.com).

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The American Journal for Nurse PractitionersThe American Journal for Nurse Practitioners™ is published byNP Communications, LLC. It is indexed in CINAHL. Contents of thearticles are determined by the authors and do not reflect the views oropinions of the publisher or advertisers.©2012 NP Communications, LLC

The American Journal for Nurse Practitioners is offered free of charge to alllicensed nurse practitioners.Annual paid subscriptions to The American Journal for NursePractitioners are also available at $59 (US) per year. To receive a paid sub-scription, send name, address, and speciality, along with a check for $59,to NP Communications, LLC, 5 Jefferson Court, Monroe Township, NJ08831.

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Publisher Louise K. Young

CEO George R. Young

Columnists Tom Bartol, NP, CDECarolyn Buppert, JD, NPLoretta C. Ford, RN, PNP, EdDSusan Kellogg-Spadt, PhD, CRNPDonna G. Nativio, PhD, PNP, FAANLinda J. Pearson, DNSc, MSN, APRN-BC, FAANPNancy Rudner Lugo, DrPH, NPMary Ann E. Zagaria, PharmD, MS, RPh, CGP

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VOL. 16 NO. 3/4 MARCH/APRIL 2012

Clinical Challenges In….PRIMARY CAREAdvances in the Treatment of Patients with Hemophilia ................................................ 6

Statin Intolerance: Management Strategies ...................................................................... 20

ORAL CAREIdentifying and Treating the Oral Effects of Methamphetamine Use ........................ 25

Other Features…Issues in Pharmacotherapy: Long-distance Caregiving:Challenges and Tips for Success.................................................................................... 15Issues in Pharmacotherapy: Tips and Resources forLong-distance Caregiving (Patient Handout)................................................................ 17Patient Page: Using insulin to treat your diabetes: what it means to you................ 19Promoting the NP Profession:Meaningful Use of the Electronic Health Record ...... 32

Please visit www.webNPonline.com to subscribe to all publications


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Advances in the Treatment ofPatients with Hemophilia:Understanding the Importance ofComprehensive Care and of the NP Role

Angela Y. Lambing, MSN, RNCS, NP

Purpose: Advances in treatment and a comprehensive care approach have transformed congenital hemophiliainto a manageable chronic disease with life expectancy, mortality rates, and quality of life similar to those of thegeneral male population. Improved treatments have facilitated better management of patients with congenitalhemophilia complicated by coagulation factor inhibitors. This review highlights clinical challenges in the man-agement of adult and elderly males with hemophilia and female carriers of hemophilia, emphasizing the impor-tance of effective coordination of care by specialized hemophilia treatment centers (HTCs) and the role of thenurse practitioner (NP) as patients encounter multiple specialists for care management.

Data sources: To complete this review, a search ofEnglish-language publications was conductedusing MEDLINE and CINAHL databases (1966-2011).

Conclusion: The complexities of managingadults with hemophilia have substantiallyincreased with the onset of age-related diseases,long-standing viral infections, use of contraindi-cated medications and therapies that can increasebleeding risk, and inhibitor development. Coor-dinating care with a local HTC is imperativewhen managing these patients because theyrequire treatment within multiple specialty areas.

Implications for practice: Adults with hemo-philia who are experiencing bleeding-relatedcomplications may be seen by NPs in primarycare and in multiple-specialty areas. Recognitionof the special needs and challenges confrontingthese patients can vastly improve healthcarecoordination.

PRIMARY CARE

IntroductionHemophilia is a serious bleedingdisorder characterized by sponta-neous bleeding episodes and jointdestruction due to an inherited X-linked deficiency of coagulationfactor VIII (hemophilia A) or factorIX (hemophilia B). Individualswith congenital hemophilia areclassified according to residualplasma activity levels of factor VIIIor factor IX, and not by the clinicalexpression or severity of bleedingsymptoms.1 Residual factor VIII/factor IX plasma activity levels of6%-50% are defined as mildhemophilia, those of 1%-5% repre-sent moderate hemophilia, andthose of <1% indicate severehemophilia.1,2 Levels that are 50%-150% of normal are consideredhemostatic.1,2 Approximately one-third of hemophilia cases occurwithout a family history and aredue to spontaneous mutations.1

Modern hemophilia treatmentconsists of factor replacement ther-apy with exogenous factor VIII orfactor IX to boost blood levels tohemostatic levels—that is, ≥50% ofnormal factor VIII or factor IX lev-els.1 Although hemophilia is con-sidered a bleeding disorder affectingmen, female genetic carriers ofhemophilia also have an increasedbleeding tendency despite havingplasma levels of factor VIII or factorIX that are typically in the upperlevel of the mild deficiency range.3

With advances in treatmentoptions and a comprehensive caremodel based on specializedhemophilia treatment centers(HTCs), congenital hemophilia hasbeen transformed into a manage-able chronic disease.4 Increased lifeexpectancy, decreased mortality,and improved quality of life (QoL)represent favorable outcomes forthe general male hemophilia popu-

lation.5 However, as this populationages, an ever-increasing number ofindividuals are presenting with age-related chronic illnesses similar tothose in the aging non-hemophiliapopulation, including diabetes mel-litus (DM), cardiovascular disease(CVD), renal disease, and autoim-mune rheumatic diseases.6-8

Long-standing hemophilia-re-lated co-morbidities compoundedby one or more age-related diseasespresent nurse practitioners (NPs)with a unique set of challengeswhen managing adult and elderlypatients with hemophilia.5,7 Man-agement of these patients is furthercomplicated by the presence of per-sistent infection by hepatitis C virus(HCV) or human immunodeficien-cy virus (HIV), the adverse effects ofantiviral therapies for HCV or HIVinfection, and unmanaged poly-pharmacy for hemophilia-relatedhealth problems such as jointpain.9,10 Nurse practitioners, whomay be the first healthcare profes-sionals (HCPs) to see adults withhemophilia or female hemophiliacarriers, must be able to under-stand the importance of coordi-nating these patients’ specific careneeds.5,6,11

This review article provides up-to-date information regarding theclinical challenges posed by adultand elderly male patients withhemophilia and by female carriersof hemophilia. In addition, thisarticle focuses on the importance ofthe collaboration of NPs with col-leagues at specialized HTCs to coor-dinate care and optimize outcomesfor these patients. A directory of USHTCs can be found at https://www2a.cdc.gov/ncbddd/htcweb/Dir_Report/Dir_Search.asp, and adirectory of non-US HTCs can befound at www.wfh.org/index.asp?lang=EN.

Literature SearchA search of the NP literaturerevealed few, if any, peer-reviewed,evidence-based review articlesdescribing advances in hemophiliatreatment and care, the impact ofthese advances on life expectancyor age-related illnesses, or thebleeding-related health problemsof female hemophilia carriers. Tocomplete this review, a search ofEnglish-language publications wasconducted through MEDLINE andCINAHL databases (1966-2011).Each search consisted of thesespecific keywords and phrases orcombinations thereof: congenitalhemophilia, treatment advances, age-related co-morbidities, hepatitis C,human immunodeficiency virus, anti-retroviral therapy, factor inhibitors,comprehensive care, coordination ofcare, adult hemophilia, hemophiliacarriers, life expectancy, mortality rate,and nursing, nursing management, ornurse practitioner.

Historical Overview of theAdvancements of Treatment andCare for Patients with HemophiliaFew treatment options existed foryoung men with hemophilia priorto the late 20th century, makingtheir care palliative at best.4,9,12

Morbidity and mortality were highbecause of a lack of treatmentoptions, and death typically oc-curred at a young age as a result ofcatastrophic bleeding (eg, intracere-bral hemorrhage at age ≤20 years;Table 1).6 The discovery that trans-fusion of whole blood, plasma, orplasma precipitates shortened clot-ting time in patients with hemo-philia led to the first realbreakthrough for the managementof bleeding episodes.13-15 Thisadvancement was followed by thediscovery that cryoprecipitate frompooled human plasma was an


enriched source of coagulation fac-tor VIII, a finding that eventually ledto the earliest use of factor VIIIreplacement therapy in the 1960sand 1970s (Figure).13 Increasingproduction and availability of earlyplasma-derived factor replacementconcentrates improved treatmentaccess and provided the means toquicker hemostasis with dimin-ished limb- and life-threateningbleeding events.16 During this time,mortality rates began to decline, lifeexpectancy increased, and QoLimproved for young men withhemophilia.4,6

Other notable advances inhemophilia treatment after 1950(Figure) included (1) the develop-ment of the first prothrombin com-plex concentrates from humanplasma (1970s) and the use ofrecombinant DNA technology to

synthesize activated factor VII(1990s) as bypass therapies forpatients with poorly controlledbleeding due to inhibitory antibod-ies to factor VIII and factor IX thatrendered standard factor replace-ment therapy ineffective, (2) use ofdesmopressin, an analog of argi-nine vasopressin (1970s) that stim-ulates release of endogenous factorVIII and its protective co-factor vonWillebrand factor, and (3) theestablishment of federally fundedspecialized centers (1970s) for com-prehensive care and treatment ofhemophilia and other inheritedbleeding disorders.12,16

In the late 1970s and early1980s, plasma-derived cryoprecipi-tate and first-generation factor con-centrates were found to becontaminated with HCV and/orHIV.9,14,17 As a result, transmission of

these blood-borne viruses becamean epidemic within the hemophiliapopulation and reversed earlier pos-itive trends for life expectancy(Table 1).6,16 In addition, hemophil-ia was associated with a stigma thathad an adverse psychosocial effecton patients.18 Prior to 1985, HCVinfection occurred in 98% ofpatients given plasma-derived factorconcentrates and in 66% of thosetreated with cryoprecipitate; morethan 50% of all patients treatedwith plasma-derived concentratesor cryoprecipitates were co-infectedwith HIV.19,20 In the United Statesbetween 1978 and 1986, approxi-mately 90% of patients withhemophilia treated with plasma-derived factor concentrates for fre-quent bleeding became infected byHIV.21 Both HCV and HIV infectionsbecame leading causes of morbidity


PRIMARY CARE

LIFE EXPECTANCY AMONG INDIVIDUALS WITH SEVERE HEMOPHILIA ANDIMPACT OF HIV/AIDS*TABLE 1

Life expectancy (years)

Severe General maleReference/study Population Calendar period n HIV status‡ hemophilia population17Larson 1985 Sweden 1831-1920 948† NA 11 –

1961-1980 NA 57 7614Ikkala et al 1982 Finland 1930-1949 163 NA 7.8 –

1970-1979 NA 25.5 –15Plug et al 2006 The Netherlands 1972-1985 386 NA 63 71

1985-1992 NA 61 741992-2001 NA 59 76

HIV– 70 7634Rosendaal et al 1989 The Netherlands 1973-1986 717 NA 66 7413Darby et al 2007 United Kingdom 1977-1998 2706 HIV– 63 7852Chorba et al 2001 United States 1979-1982 2254† NA 55† –

1987-1990 NA 41† –1995-1998 NA 46† –

HIV+ 33† –HIV– 72† –

53Walder & Julian 1998 Canada 1980-1995 2450 NA 47.4 –1980-1995 HIV+ 44 –1980-1995 HIV– 73 –

54Triemstra et al 1995 The Netherlands 1986-1992 381 NA 61 74

*Adapted with permission from Dolan et al.6 †Number includes all disease severities—mild, moderate and severe. ‡NA, not available (HIV statusunknown—licensed HIV screening tests were not available until after 1985); HIV–, HIV status negative; HIV+, HIV status positive; –, no data provided inreport.

and mortality until effective antivi-ral therapies and plasma productswith viral inactivator processesbecame available in the late 1990s(Figure).4,9,10,15-17 New health threatsemerged in patients with hemophil-ia during the 1990s, includingmetabolic- and cardiac-relatedadverse events from long-termexposure to antiviral therapy andend-stage organ failure and carcino-ma linked to HCV and HIV infec-tions (Table 2).9,15,16,20

Recombinant protein technolo-gy was established in the 1990s tocommercially produce third- andfourth-generation synthetic factorVIII and factor IX concentrates. Thistechnology eliminated the risk forblood-borne viral transmission. Asa result, life expectancy for individu-als with severe hemophilia is

approaching that for the generalmale population (Table 1).4,9,16

Advances in the treatment ofhemophilia in the first and seconddecades of the 21st century culmi-nated with the development ofrecombinant factor protein thera-pies. Current research into genetherapy technology could perma-nently correct factor deficiencies.22

Improvement in the pharmacoki-netic properties and formulationsof factor proteins and inhibitorbypassing agents holds majorpromise for enhancing the healthstatus and longevity of patients withhemophilia (Figure).22 Among thebenefits of an extended duration ofreplacement factor activity relatedto a longer plasma half-life is adecrease in the frequency of factorreplacement infusions or injections

needed to achieve or maintainhemostasis, which may improvepatient compliance with replace-ment regimens.

Prophylactic factor replace-ment initiated early in life andcontinued through adulthood isrecognized as the best treatmentstrategy for minimizing health andpsychosocial problems (eg, physi-cal disability, emotional strain,and anxiety) that are a major bur-den to adult and elderly individu-als with hemophilia, as comparedwith older individuals in the gen-eral population.23 The use of pro-phylactic factor replacement toprevent bleeding in patients withsevere hemophilia A and B and thedevelopment of immune toleranceinduction for eradicating antibodyinhibitors against factor VIII or


FIGURE. Historical Overview of Advances in Treatment and Care for Patients with HemophiliaThe timeline summarizes the major advances and complications associated with the treatment of hemophilia prior to 1950 through 2010. Improvements inhemophilia care have been the result of changes in recombinant protein technology, successful strategies for combating key complications due to blood-borne viraltransmission, the introduction of emerging improvements in current procoagulant molecules, the discovery of novel orally bioavailable procoagulant molecules,and, currently, the prospect of a cure with gene therapy.

*Information compiled from Lillicrap16 (2009) for an updated historical timeline highlighting the major milestones in hemophilia research and treatment; Mannucci4 (2008) for an overview of key recent advancesachieved in hemophilia treatment, including the treatment of HIV/AIDS and hepatitis C virus, as well as treatment strategies for factor inhibitors; and Pierce et al22 (2007) for an overview of therapeutic manage-ment of hemophilia using bioengineered clotting factors, novel delivery technologies, and gene therapy as a potential cure for hemophilia.

factor IX, which were pioneered byNilsson and co-workers, representtwo of the most importantadvances in hemophilia treat-ment.12,24-26 Bio-engineering meth-ods have been used to introducestrategic molecular changes torecombinant factor proteins thatprolong plasma availability andactivity as well as reduce theirimmunogenicity, thereby mitigat-ing inhibitory antibody develop-ment that can impair effectivecontrol of bleeding by factorreplacement therapy and diminishQoL. Recent technological advancesthat have increased the efficiency ofrecombinant factor protein pro-duction, as well as the emergingdevelopment of procoagulantagents that can be orally adminis-tered, promise to greatly expandpatient access and improve adher-ence to prophylactic therapeuticregimens.22

Challenges to Managing an AgingHemophilia PopulationThe primary consequence of theadvances in hemophilia treatmentover the past several decades hasbeen a steady and significant demo-graphic shift toward a hemophiliapopulation that is living longer andbeginning to experience typical age-related illnesses (Table 2).10 Co-existing health conditions in agingpatients with hemophilia can bemore problematic than those inyounger patients.

The prevalence of hemophilicarthropathy is as high as 95% inindividuals with severe hemophiliawho were born prior to 1960.26 Thiscondition, which results in progres-sive joint damage and disability, hasoccurred as a result of untreatedjoint bleeds (older individuals withhemophilia did not have access tomodern factor replacement concen-trates).27 The prevalence of progres-

sive disabling joint disease is higherin adult patients with hemophiliawith inhibitors than in those with-out inhibitors.28 Patients typicallypresent with four or more arthro-pathic joints, limited range ofmotion, and chronic pain and stiff-ness, which limits their physicalactivity and contributes to signifi-cant weight gain.27

Management of pain is difficultin this population because the useof nonsteroidal anti-inflammatorydrugs (NSAIDs), often the drug ofchoice for arthritis pain and stiff-ness, increases bleeding risk.29,30

NSAIDs are contraindicated inpatients with hemophilia, but, asthis population ages, instances mayarise in which pain relief is needed.Non-pharmacologic options forpain relief include cryotherapy,hydrotherapy, electrotherapy, acu-puncture, and relaxation tech-niques.29,30 Moderate to severe pain


PRIMARY CARE

HEALTH PROBLEMS AND CO-MORBID CONDITIONS IN AGING INDIVIDUALSWITH HEMOPHILIA*TABLE 2

*Adapted with permission from Mauser-Bunschoten et al.10

Related to Hemophilia� Progressive arthropathy, mobilitylimitation, pain and stiffness

� Chronic hepatitis C (HCV)infection and HCV-related liverdisease

� HIV infection/AIDS

� Side effects of antiviral therapy(interferon/ribavirin) for HCVinfection

� Side effects of highly activeantiretroviral therapy (HAART) forHIV/AIDS

� Factor inhibitor development

Related to Aging� Metabolic disease (diabetes,hypertension, dyslipidemia)

� Cancer and cancer-relatedinterventions such aschemotherapy, surgery, andradiation

� Cardiovascular disease

� Obesity

� Renal disease

� Dental hygiene and toothextraction

� Osteoporosis and osteopenia(fractures, falls)

Related to Both HemophiliaStatus and Aging� Psychosocial problems

� Quality of life

� Sexual problems

may require use of opioid anal-gesics; however, these agents canhave serious long-term side effects,including drug dependence. Formanagement of chronic severepain, patient referral to a pain spe-cialist or clinic is appropriate.29,30

Long-term acetaminophen use forpain may be contraindicated insome individuals with hemophiliabecause of concomitant HCV-relat-ed liver disease. Increased bodyweight, along with limited physicalactivity and pain in older patientswith hemophilia, not only worsensdamage to weight-bearing joints,but also enhances the risk formetabolic and cardiovascular co-morbidities associated with aging.31

Nurse practitioners should consultthe nearest HTC to determine thebest treatment options for theirpatients with arthropathic pain.

In adults with hemophilia, un-treated or undertreated age-relatedco-morbidities such as CVD, DM,hypertension (HTN), renal disease,and autoimmune rheumatic disor-ders (Table 2) may lead to accelerat-ed end-stage failure of vital organssuch as the heart, liver, andkidneys.5,6,11 In addition, in patientswith hemophilia, a strong associa-tion has been found between HTNand HIV infection and betweenHTN and acute and chronic renaldisease.32 In patients with hemo-philia who have concomitant HIVinfection and HTN, progression ofrenal insufficiency to end-stagerenal disease requiring dialysis canbe complicated because of the abso-lute need for achievement of anappropriate balance between anti-coagulation and hemostasis duringblood filtration.33 Careful consider-ation is given to the use of anymed-ications or other treatments thatmay potentially impair renal func-tion in patients with hemophilia,which could worsen existing renal

disease and escalate the need fordialysis.

Patients with hemophilia arecurrently more likely to die of can-cer, ischemic heart disease, or bacte-rial infection than of bleeding-related complications.6,13 Surgeryand diagnostic invasive proceduresin patients with hemophilia under-going cancer care and treatmentcan significantly increase bleedingrisk, and require close coordinationwith the HTC. Whether the risk forCVD in the current generation ofpatients with hemophilia isincreased is uncertain because ofsparse data from longitudinal clini-cal studies in older generations.6

Nevertheless, the risk for acutecoronary syndromes and atrial fib-rillation appears to be approachingthat of older adults withouthemophilia in the general popula-tion.13,15,34,35 The likelihood of devel-oping CVD has increased primarilybecause of rising incidences ofHTN, smoking, and DM in theseindividuals.31,34,36 Use of daily low-dose aspirin to prevent thrombosismay be indicated despite its usualcontraindication in patients withhemophilia; discussion with theHTC is recommended to balancerisk versus benefit. Nurse practi-tioners’ collaboration with cardiol-ogy specialists and with the HTC isneeded to evaluate patients on anindividual basis to prevent andmanage coronary artery disease.

Coagulation Factor InhibitorsInhibitors or neutralizing alloanti-bodies directed against coagulantfactor proteins may develop in20%-30% of patients with severehemophilia A (defined as <1% ofnormal factor VIII plasma levels)and in fewer than 5% of patientswith severe hemophilia B (definedas <1% of normal factor IX plasmalevels) after repeated administra-

tion of factor VIII or IX concen-trates to arrest bleeding.37 Develop-ment of inhibitors, which may bedifficult to eradicate, occurs morefrequently in children withhemophilia than in adults withhemophilia. Prospective analysisof factor VIII inhibitor incidencethroughout the lifespan of morethan 2500 patients with severehemophilia A showed a bimodal,age-adjusted incidence that washighest in children <5 years of age(64.29/1000 treatment years) andin individuals aged ≥60 years(10.49/1000 treatment years).38

Known risk factors for inhibitordevelopment include occurrenceat young age, positive family histo-ry, nonwhite ethnicity, mutationsin the factor VIII gene, and inten-sive factor VIII replacement thera-py regardless of age and diseaseseverity.39-41 Presence of inhibitorsis a serious complication thathampers the routine and effectiveuse of factor replacement concen-trates to control bleeding, therebyincreasing the risk for uncontrol-lable or catastrophic bleeding, dis-ability, and premature death.42

Adult and elderly patients withmild hemophilia who may beunaware of their risk for bleedingcan present unexpectedly withconsiderable bleeding problems asa result of major surgery or inva-sive procedures performed for seri-ous age-related chronic illnesses ortrauma.10,43 Bleeding problems canarise as a result of the develop-ment of inhibitors after postopera-tive or post-traumatic use ofintensive factor VIII or factor IXreplacement therapy.42 In the pres-ence of persistent inhibitors, mildbleeding can become severe anduncontrollable.10,43

Inhibitors can pose a seriousbleeding threat to older adultpatientswhoundergo recommended


screenings and diagnostic proce-dures such as colonoscopy, cathe-terizations, and biopsies for cancerand other age-related illnesses; andfor those who require majorsurgery or highly invasive interven-tional procedures such as laparo-scopic surgery.5,6,7,10,11,44 Procedures inpatients with hemophilia andinhibitors require administrationof bypassing agents such as recom-binant activated factor VII or plas-ma-derived activated prothrombincomplex concentrate before, dur-ing, and after the procedure toensure adequate hemostatic cover-age and prevention of postopera-tive bleeding.5,6,7,11,33,45 If an inhibitorhas been identified, the HTC/hematology team must be closelyinvolved in determining appropri-ate therapeutic strategies and inter-ventions for hemostasis andinhibitor eradication.

Bleeding Complications in FemaleCarriers of HemophiliaBleeding symptoms occur with amuch higher incidence and intensi-ty in female carriers than previouslythought, and bleeding tendency infemale carriers seems to correlatewith the type of genetic mutationthey carry and the severity ofhemophilia in their male offspringand male relatives.3 Bleeding ten-dency in female carriers is frequent-ly overlooked, and seems to beinfluenced by age, presence of age-related co-morbidities, and bloodgroup type.3,46 Bleeding risk infemale carriers is particularlyincreased during menstrual cyclesand childbirth.3,47,48

Adult female hemophilia carri-ers contend with the effects of ageand age-related co-morbidities onbleeding tendency, which mayincrease their risk for obstetric andgynecologic complications.3,48 These

womenmay present withmenorrha-gia, menometrorrhagia, or dysmen-orrhea,48 and they may have a10%-22% incidence of primary andsecondary postpartum hemorrhage.47

In addition, they may experienceincreased bleeding after minor surgi-cal and dental procedures, as well aslife-threatening hemorrhage afterinjury or invasive procedures. Alltreatments and medical/dental pro-cedures must be coordinated withthe HTC. A recent study by Renaultand co-workers49 showed that manyhemophilia A carriers received inap-propriate care, had poor relation-ships with their HCPs, and hadnegative emotional and behavioralresponses, which significantly com-plicated their management.

Coordination and Delivery ofComprehensive Hemophilia CareThe current standard of care forhemophilia, based on moderntreatment advances, has trans-formed the lives of patients withhemophilia to the extent that theycan expect a near-normal life ex-pectancy and improved QoL. In-creased life expectancy means thatmost patients with hemophilia willnow be living long enough to devel-op age-related chronic illnesses suchas DM, HTN, CVD, renal disease,and cancer, which complicate ongo-ing hemophilia-related health prob-lems and treatment.10 A primaryconcern is lack of coordinationamong various healthcare specialiststhat may result in delayed receipt ofhealthcare services, increased bleed-ing risk, unmanaged polypharmacy,and decreased patient well-beingand QoL.11 Healthcare systems andHCPs must adapt to the demo-graphic shift to older patients withhemophilia by taking a more com-prehensive approach, providingappropriate services not only for

effective management of bleeding,orthopedic problems, and infec-tion-related problems, but also formanagement of age-related chronicillness.6,7

The hemophilia community hasrecognized the need to re-evaluatethe model for providing compre-hensive care that has existed formore than 40 years in specializedHTCs. Hemophilia treatment cen-ters are now successfully aligningadvances in treatment within amultidisciplinary team approachfocused on treatment and preven-tion of bleeds, long-term manage-ment of hemophilic arthropathyand other musculoskeletal compli-cations, management of inhibitordevelopment and infectious com-plications, and provision of psy-chosocial support and educationfor patients.12 The model has suc-ceeded in lowering rates of hospital-ization and mortality comparedwith those for patients not treatedin HTCs.50,51

The comprehensive care modeloriginally embodied in HTCs waspredicated on the needs of childrenand adolescents and is outdated;current HTCs are shifting their focustoward meeting the needs of anaging adult population withhemophilia.9 An HTC is best suitedto serve this purpose because long-standing relationships with patientsalready exist; multidisciplinaryteams are highly experienced inproviding continuity of patient care;and collaboration with surgical andmedical subspecialists, includingcardiologists, oncologists, nephrol-ogists, and obstetrician/gyne-cologists, may be available only atlarge medical centers affiliated withan HTC.7,11

Several overarching needs ofpatients with hemophilia, whichare expanding as these patients age,can be fulfilled by HTCs offering


PRIMARY CARE

expanded care and services.7,11 TheseHTCs can provide or oversee:1.Appropriate coagulation factorreplacement regimens for pre-vention and control of bleed-ing episodes during:a. major and minor surgery.b. invasive screening or diag-nostic procedures (eg,colonoscopy) or invasiveinterventions (eg, cardiaccatheterization, angioplasty,coronary artery stenting,renal dialysis).

c. invasive procedures relatedto cancer treatment regi-mens, as indicated.

2.Management of multiple med-ications (ie, polypharmacy):a. agents used to treat arthro-pathic pain and inflamma-tion (ie, aspirin or otherNSAIDs and acetaminophen);

b. antiviral therapy;c. antiplatelet therapy: use ofdaily aspirin or clopidogrelfor thromboprophylaxismust be carefully balancedwith hemostatic coverage;

d. agents used to treat age-relat-ed disorders (eg, DM, HTN,dyslipidemia).

3.Monitoring and eradication ofinhibitors in those treated inten-sively with factor concentrates.

4.Comprehensive screening andlaboratory assessments for gen-eral health maintenance.

5. Institution of lifestyle behav-iors to promote health andwellness to mitigate risks forage-related illness.

6.Psychosocial and emotionalsupport to implement advancecare planning for chronic illness.

Attending to these vital patientneeds requires closer collaborationamong NPs, the HTC team, andsubspecialists to tightly coordinatecare for optimizing outcomes for

patients with hemophilia and age-related co-morbidities.

ConclusionBecause of the major advancesachieved in hemophilia treatmentover the past 30 years, NPs as front-line HCPs in many primary careand specialty areas, includinghematology, are increasingly likelyto encounter and care for adult andelderly men with hemophilia. Im-provements in life expectancy andhealth-related QoL tied to thesetreatment advances have set thestage for a substantial impact on NPpractice and decision making asmore patients with hemophiliabegin to develop age-related illness-es—the downside of improved lifeexpectancy. As a result of this demo-graphic shift in the hemophiliapopulation, the current compre-hensive model of hemophilia careis being re-evaluated and revised toprovide expanded delivery ofhealthcare services and better conti-nuity of care to meet the needs ofincreasing numbers of adult andelderly men with hemophilia.Expanded research opportunitiesthat include the older hemophiliapopulation are needed to provideevidence-based guidelines for thetreatment of this population.

Nurse practitioners need to beaware of practice challenges infemale genetic carriers of hemo-philia. These women are atincreased risk for serious bleedingand bleeding-related complica-tions. Management of these carrierscan be extremely complex becauseof uncontrolled gynecologic bleed-ing, postpartum hemorrhage, andthe high risk for life-threateninglabor and delivery of an infantwith severe hemophilia. Care forhemophilia carriers must be coor-dinated with high-risk obstetrics/gynecology specialists.

Nurse practitioners in primarycare or in specialties must workeffectively alongside the multidisci-plinary HTC team to optimizepatient care and management forindividuals with long-standinghemophilia who present with age-related co-morbidities, cancer,adverse effects associated with per-sistent HCV or HIV infection,and/or complications arising fromlong-term antiviral therapy expo-sure. Evidence-based, standardizedtreatment protocols do not exist,and individual patient treatmentresponses can be variable andunpredictable. Therefore, NPs needto be aware of current treatmentoptions and of contraindicationsagainst use of certain therapies thatcould increase bleeding risk.Hemophilia treatment centers canguide treatment, and NPs can indi-vidualize therapies for bothhemophilia-related and age-relatedco-morbidities in consultation withHTC experts and specialists. Withan increased awareness for HTCs tobroaden the scope of comprehen-sive care for patients withhemophilia, particularly for thosewith age-related co-morbidities,NPs will play a pivotal role in man-aging and coordinating care forthese patients. �

Angela Y. Lambing is the NursePractitioner Coordinator for the Hemo-philia & Thrombosis Treatment Centerin the Department of Hematology andOncology, Henry Ford Health System,Detroit, Michigan. The author reportsthat she serves on the Speakers' Bureaufor Novartis and CSL Behring and is amember of the Nurse Advisory Board forBaxter Health Care, Pfizer, NovoNordisk, CSL Behring, and Biogen Idec.

AcknowledgmentThis manuscript was prepared witheditorial assistance by Jeffrey M.



Palmer, PhD, ETHOS Health Com-munications, Newtown, Penn-sylvania, and with financialassistance from Novo Nordisk, Inc.,Princeton, New Jersey, in compli-ance with international GoodPublication Practice guidelines.

References1. den Uijl IE, Fischer K, Van Der Bom JG, et al.Clinical outcome of moderate haemophilia com-pared with severe and mild haemophilia.Haemophilia. 2009;15(1):83-90.

2. Venkateswaran L, Wilimas JA, Jones DJ, Nuss R.Mild hemophilia in children: prevalence, complica-tions, and treatment. J Pediatr Hematol Oncol.1998;20(1):32-35.

3. Miesbach W, Alesci S, Geisen C, Oldenburg J.Association between phenotype and genotype incarriers of haemophilia A. Haemophilia. 2011;17(2):246-251.

4. Mannucci PM. Back to the future: a recent histo-ry of haemophilia treatment. Haemophilia. 2008;14suppl 3:10-18.

5. Konkle BA. Clinical challenges within the aginghemophilia population. Thromb Res. 2011;127suppl 1:S10-S13.

6. Dolan G, Hermans C, Klamroth R, et al.Challenges and controversies in haemophilia carein adulthood.Haemophilia. 2009;15 suppl 1:20-27.

7. Lambing A, Kachalsky E. The new age ofhaemophilia.Haemophilia. 2009;15(6):1330-1331.

8. Miesbach W, Alesci S, Krekeler S, Seifried E.Comorbidities and bleeding pattern in elderlyhaemophilia A patients. Haemophilia.2009;15(4):894-899.

9. Oldenburg J, Dolan G, Lemm G. Haemophiliacare then, now and in the future. Haemophilia.2009;15 suppl 1:2-7.

10. Mauser-Bunschoten EP, Fransen Van De PutteDE, Schutgens RE. Co-morbidity in the ageinghaemophilia patient: the down side of increasedlife expectancy.Haemophilia. 2009;15(4):853-863.

11. Franchini M, Mannucci PM. Co-morbiditiesand quality of life in elderly persons withhaemophilia. Br J Haematol. 2010;148(4):522-533.

12.Manco-Johnson MJ. Advances in the care andtreatment of children with hemophilia. Adv Pediatr.2010;57(1):287-294.

13.Darby SC, Kan SW, Spooner RJ, et al. Mortalityrates, life expectancy, and causes of death in peoplewith hemophilia A or B in the United Kingdomwho were not infected with HIV. Blood.2007;110(3):815-825.

14. Ikkala E, Helske T, Myllyla G, et al. Changes inthe life expectancy of patients with severehaemophilia A in Finland in 1930-79. Br JHaematol. 1982;52(1):7-12.

15.Plug I, Van Der Bom JG, Peters M, et al.Mortality and causes of death in patients withhemophilia, 1992-2001: a prospective cohort study.J Thromb Haemost. 2006;4(3):510-516.

16.Lillicrap D. Advancing research for inheritedbleeding disorders. Hemophilia World. 2009;16(3):4-5.

17.Larsson SA. Life expectancy of Swedishhaemophiliacs, 1831-1980. Br J Haematol. 1985;59(4):593-602.

18.Golden J, Conroy RM, O'Dwyer AM, et al.Illness-related stigma, mood and adjustment to ill-ness in persons with hepatitis C. Soc Sci Med.2006;63(12):3188-3198.

19.Mannucci PM. Clinical evaluation of viral safetyof coagulation factor VIII and IX concentrates. VoxSang. 1993;64(4):197-203.

20.Posthouwer D, Makris M, Yee TT, et al.Progression to end-stage liver disease in patientswith inherited bleeding disorders and hepatitis C:an international, multicenter cohort study. Blood.2007;109(9):3667-3671.

21. EysterME. Coping with theHIV epidemic 1982-2007: 25-year outcomes of the HersheyHaemophilia Cohort. Haemophilia. 2008;14(4):697-702.

22.Pierce GF, Lillicrap D, Pipe SW, VandendriesscheT. Gene therapy, bioengineered clotting factors andnovel technologies for hemophilia treatment. JThromb Haemost. 2007;5(5):901-906.

23.Coppola A, Cerbone AM, Mancuso G, et al.Confronting the psychological burden ofhaemophilia.Haemophilia. 2011;17(1):21-27.

24.Manco-Johnson MJ, Abshire TC, Shapiro AD, etal. Prophylaxis versus episodic treatment to preventjoint disease in boys with severe hemophilia. NEngl J Med. 2007;357(6):535-544.

25.Mannucci PM. Hemophilia: treatment optionsin the twenty-first century. J Thromb Haemost.2003;1(7):1349-1355.

26.Mannucci PM. The future of hemophilia treat-ment.Haematologica. 2004;89(7):774-776.

27.Siboni SM, Mannucci PM, Gringeri A, et al.Health status and quality of life of elderly personswith severe hemophilia born before the advent ofmodern replacement therapy. J Thromb Haemost.2009;7(5):780-786.

28.Leissinger CA. Prevention of bleeds inhemophilia patients with inhibitors: emerging dataand clinical direction. Am J Hematol. 2004;77(2):187-193.

29.WitkopM, Lambing A, Divine G, et al. A nation-al study of pain in the bleeding disorders commu-nity: a description of haemophilia pain.Haemophilia. Dec 16 2011.

30.Witkop M, Lambing A, Kachalsky E, et al.Assessment of acute and persistent pain manage-ment in patients with haemophilia. Haemophilia.2011;17(4):612-619.

31. Hofstede FG, Fijnvandraat K, Plug I, et al.Obesity: a new disaster for haemophilic patients? Anationwide survey. Haemophilia. 2008;14(5):1035-1038.

32.Kulkarni R, Soucie JM, Evatt B. Renal diseaseamong males with haemophilia. Haemophilia.2003;9(6):703-710.

33.Lambing A, Kuriakose P, Lanzon J, Kachalsky E.Dialysis in the haemophilia patient: a practicalapproach to care.Haemophilia. 2009;15(1):33-42.

34.Rosendaal FR, Varekamp I, Smit C, et al.Mortality and causes of death in Dutch haemophil-iacs, 1973-86. Br J Haematol. 1989;71(1):71-76.

35.Tuinenburg A, Mauser-Bunschoten EP, VerhaarMC, et al. Cardiovascular disease in patients withhemophilia. J Thromb Haemost. 2009;7(2):247-254.

36.Kulkarni R, Soucie JM, Evatt BL. Prevalence andrisk factors for heart disease among males withhemophilia. Am J Hematol. 2005;79(1):36-42.

37.Wight J, Paisley S. The epidemiology ofinhibitors in haemophilia A: a systematic review.Haemophilia. 2003;9(4):418-435.

38.Hay CR, Palmer B, Chalmers E, et al. Incidenceof factor VIII inhibitors throughout life in severehemophilia A in the United Kindgom. Blood.2011;117(23):6367-6370.

39.Astermark J, Altisent C, Batorova A, et al. Non-genetic risk factors and the development ofinhibitors in haemophilia: a comprehensive reviewand consensus report. Haemophilia. 2010;16(5):747-766.

40.Gouw SC, van den Berg HM. The multifactorialetiology of inhibitor development in hemophilia:genetics and environment. Semin Thromb Hemost.2009;35(8):723-734.

41. Gouw SC, van der Bom JG, Marijke van denBerg H. Treatment-related risk factors of inhibitordevelopment in previously untreated patients withhemophilia A: the CANAL cohort study. Blood.2007;109(11):4648-4654.

42.Hay CR, LudlamCA, Colvin BT, et al. Factor VIIIinhibitors in mild and moderate-severityhaemophilia A. UK Haemophilia Centre DirectorsOrganisation. Thromb Haemost. 1998;79(4):762-766.

43.Peerlinck K, Jacquemin M. Mild haemophilia: adisease with many faces and many unexpected pit-falls.Haemophilia. 2010;16 suppl 5:100-106.

44.Franchini M, Salvagno GL, Lippi G. Inhibitorsin mild/moderate haemophilia A: an update.Thromb Haemost. 2006;96(2):113-118.

45.Lambing A, Kachalsky E, Kuriakose P. Livertransplantation in the haemophilia patient.2011;17(5):e981-e984.

46.Sousa NC, Anicchino-Bizzacchi JM, LocatelliMF, et al. The relationship between ABO groupsand subgroups, factor VIII and von Willebrand fac-tor.Haematologica. 2007;92(2):236-239.

47.Knol HM, Voskuilen MA, Holterman F, et al.Reproductive choices and obstetrical experience inDutch carriers of haemophilia A and B.Haemophilia. 2011;17(2):233-236.

48.Winikoff R, Lee C. Hemophilia carrier statusand counseling the symptomatic and asymptomat-ic adolescent. J Pediatr Adolesc Gynecol. 2010;23(6suppl):S43-S47.

49.Renault NK, Howell RE, Robinson KS, GreerWL. Qualitative assessment of the emotional andbehavioural responses of haemophilia A carriers tonegative experiences in their medical care.Haemophilia. 2011;17(2):237-245.

50.Bolton-Maggs PH. Optimal haemophilia careversus the reality. Br J Haematol. 2006;132(6):671-682.

51. Evatt BL, Black C, Batorova A, et al. Com-prehensive care for haemophilia around the world.Haemophilia. 2004;10 suppl 4:9-13.

52.Chorba TL, Holman RC, Clarke MJ, Evatt BL.Effects of HIV infection on age and cause of deathfor persons with hemophilia A in the United States.Am J Hematol. 2001;66(4):229-240.

53.Walker IR, Julian JA. Causes of death inCanadians with haemophilia 1980-1995.Association of Hemophilia Clinic Directors ofCanada.Haemophilia. 1998;4(5):714-720.

54.Triemstra M, Rosendaal FR, Smit C, et al.Mortality in patients with hemophilia. Changes ina Dutch population from 1986 to 1992 and 1973to 1986. Ann Intern Med. 1995;123(11):823-827.

PRIMARY CARE

The burden of caregiving forsenior/chronically ill family mem-bers can be overwhelming.Caregivers commonly experience aspectrum of emotions, includingfrustration, anger, fear, guilt, andshame.1,2 Caregiver burden cancause fatigue and insomnia. In addi-tion, caregiving is associated withstress that can increase one's risk forinfectious disease, depressive symp-toms, and chronic illness such asdiabetes, heart disease, and cancer.2,3

Stresses and burdens are magnifiedwhen caring for seniors (personsaged ≥65 years) with a chronic con-dition such as stroke, Alzheimer’sdisease, or metastatic cancer.4

Similarly, when seniors themselves arethe caregivers for a chronically illloved one, the added emotionalstrain they experience is an indepen-dent risk factor for mortality.3

Nurse practitioners need to rou-tinely assess family caregivers forstress-related health risks.5 In addi-tion, NPs need to recognize that per-sons who care for a loved one from adistance face different, and some-times even greater, stresses and chal-lenges, including maintainingregular communication with theloved one, arranging for an on-sitecaregiver, and assessing conditionsin a home located many miles

away. NPs can further assist care-givers and patients by providingtips and resources for effectivelong-distance caregiving. Thiscolumn focuses on key areas ofconcern forNPs, including pharma-cotherapy appropriateness inseniors and guidance for theirpatients, and for caregivers, includ-ing steps for effective caregiving,potential warning signs of dementiaand depression in their loved ones,keeping an up-to-date-medicationlist, and helpful safety measures. Anaccompanying Tips and Resourcesfor Long-distance Caregiving tear-out sheet can be photocopied andgiven to patients who may be, orwill be, faced with these challengesas they care for loved ones.

Visiting a Loved OneEffective use of time during a visitwith a loved one requires plan-ning.6 Caregivers can use this timeto perform tasks around the home(eg, changing light bulbs, repairingloose handrails,), taking the patientto appointments, or just spendingtime together.7 Visiting is an oppor-tune time to determine whether theloved one may be showing signs ofdementia, depression, or physicalimpairments (eg, neglected house-work, poor personal hygiene).7 The

presence of scorched pots suggeststhat an individual may be forgettingabout food cooking on the stove.7

Unexplained weight loss may signaldifficulty cooking, loss of taste orsmell, or underlying conditions suchas malnutrition, dementia, depres-sion, or cancer.7 A visit is a good timefor the long-distance caregiver toassess the patient for pain (see PainAssessment section and Tips andResources tearout sheet).

Pain AssessmentNurse practitioners can raise care-givers’ awareness of the indicatorsof pain or possible pain to assistwith the care of their loved ones(also see Tips and Resources).Whether pain is treated by over-the-counter or prescription medi-cation, NPs can emphasize theneed for ongoing pain assessmentand monitoring so that an appro-priate, effective, and safe treatmentplan can be instituted and main-tained as long as necessary. Thisconcept applies whether treatmentis for acute or persistent pain. NPsare encouraged to review theAmerican Geriatrics Society’s AGSClinical Practice Guideline: Phar-macological Management of Per-sistent Pain in Older Persons (seereference 8).8


I S S U E S I N P H A R M A C O T H E R A P Y

LONG-DISTANCECAREGIVING:Challenges andTips for Success

Mary Ann E. Zagaria, PharmD, MS, RPh, CGP


ISSUES IN PHARMACOTHERAPY

Preventing FallsFalls are the leading cause of injurydeath for seniors in the U.S.9 NPsshould inform caregivers that oneof every three seniors experiences afall each year and that certain risksin the home (eg, dark hallways,throw rugs or runners in walkways)contribute to about 50% of allhome-related falls.9 Certain behav-iors are also risky (eg, walkingaround the home in slippers orsocks, standing up too quicklyfrom a seated or prone position).9

NPs can provide caregivers with aFalls Prevention Home SafetyCheck List, which addresses everyroom in the house (see Tips andResources). This checklist may becompleted by the patient and thecaregiver by telephone or during avisit, or by a neighbor or health-care provider. Use of the checklisthelps identify risks so that patientsand caregivers can make specificmodifications in and around thehome and reduce the risk for falls.Many of these measures are simpleand require minimal cost.

Medication: Keeping Safeand Up-to-datePotentially Inappropriate Medica-tions (PIMs)—Although evidenceshows poor outcomes related to useof PIMs in seniors, these medica-tions continue to be prescribed. Arecently published guideline, theAGS Updated Beers Criteria forPotentially Inappropriate Medica-tion Use in Older Adults (oftencalled simply the Beers List) is avail-able online (see reference 10).10 NPscan review this document to famil-iarize themselves with PIMs toavoid in vulnerable seniors.Medication List—One exam-

ple of a medication list template,My Medicine List (see Tips andResources), was developed by theAmerican Society of Health-System

Pharmacists (ASHP). This listincludes “the name of what youtake, how much you take, what itlooks like, how you take it, youstarted taking this on:, you will stoptaking this on:, why you take it, whotold me to use it.” The list isdesigned to be carried with thepatient at all times—it can be fold-ed and kept in a wallet or purse—soit is available when needed. TheASHP resource includes full instruc-tions for “How to Use My MedicineList,” including how to fill it outappropriately and completely.

Consulting with a pharmacistwho works specifically withseniors, such as a senior care phar-macist or a consultant pharmacist,or who is specially credentialed ingeriatric pharmacy, such as a certi-fied geriatric pharmacist or CGP,may help ascertain the appropriate-ness, effectiveness, and safety of thepatient's drug regimen as a wholeand further identify, resolve, andprevent medication-related prob-lems (see Additional Resources).

Hospice, Palliative Care,and RespiteKnowledgeable and compassion-ate persons can help patients andcaregivers navigate options for hos-pice, palliative care, caring for aseriously ill child, respite, and griefcounseling. These persons can pro-vide answers to questions on end-of-life issues, state-specific advancedirectives, and contact informationfor community services. Becausesome patients are unfamiliar withor have misconceptions aboutthese services, NPs can broach anddiscuss the topic, and guide andrefer patients and caregivers toappropriate service providers asneeded (see Tips and Resources).

ConclusionNurse practitioners need to be on

the lookout for patients who areserving as long-distance caregiversfor elderly/infirm loved ones. Theburdens and stresses of thisresponsibility can take their toll onthese patients’ well-being. In addi-tion to providing for these long-distance caregivers’ healthcareneeds, NPs can guide and referthem by providing tips for successand resources for advice and ser-vices (see Tips and Resources andAdditional Resources).

Dr. Zagaria is a Senior CareConsultant Pharmacist and Presidentof MZ Associates, Inc., in Norwich,NY (www.mzassociatesinc.com).

References1. Cora VL. Helping family caregivers of olderadults with dementia. ElderCare. 2006;6(1):1-4.2. Zagaria M. Family caregiving: seniors continueto receive and deliver care. US Pharm. 2006;12:23-29.3. National Family Caregiver Support Program,http://www.aoa.gov/AoA_programs/HCLTC/Caregiver/index.aspx4. McMillan SC, Small BJ, Weitzner M, et al.Impact of coping skills intervention with familycaregivers of hospice patients with cancer: a ran-domized clinical trial. Cancer. 2006;106:214-222.5. Who's Caring for the Caregivers? AARPUnveilsNew Report on Trends in Support for FamilyCaregivers. Consumer-Directed Services forCaregivers Take Hold in States. March 16, 2006.http://www.aarp.org/about-aarp/press-center/info-2006/caring_for_caregivers.html6. Mayoclinic.com. Caregiving: Tips for Long-dis-tance Caregivers. July 09, 2010. http://www.mayoclinic.com/health/caregiving/MY012667. Aging parents: 7 warning signs of health prob-lems. http://www.mayoclinic.com/health/aging-parents/HA000828. American Geriatrics Society. AGS ClinicalPractice Guideline: Pharmacological Managementof Persistent Pain in Older Persons. 2012. http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/persistent_pain_executive_summary

9. Minnesota Safety Council Fall PreventionHome Safety Checklist. 2004. http://www.minnesotasafetycouncil.org/seniorsafe/fallcheck.pdf

10. American Geriatrics Society. AGS UpdatedBeers Criteria for Potentially InappropriateMedication Use in Older Adults. 2012.http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012

11. Beers MH, Jones TV, Berkwits M, et al, eds. TheMerck Manual of Health and Aging. WhitehouseStation, NJ: Merck Research Laboratories;2004:165-183.


Options for Long-distance Caregiving6

Elements of long-distance caregiving for your loved one include:� Provision of full or supplemental financial support;� Coordination of services (eg, home care; household help;

transitioning to a rehabilitation, assisted-living, or nursingfacility);

� Provision of emotional support to a primary/on-site caregiver;� Management of medical bills or records; and� Periodic visits that may or may not provide for respite for a

primary caregiver.Extent of the involvement may vary over time as needs change.

Tips for Effective Long-distance Caregiving2,6,11

� Get organized. Schedule a family meeting. Plan foremergencies.

� Research your loved one’s illness and treatment on rep-utable websites such as mayoclinic.com and webmd.com.

� Keep in touch with your loved one's healthcare practitioners.� Use technology (eg, email, webcams) to facilitate communi-

cation; schedule a regular time for telephone calls.� Identify a person who can visit your loved one regularly; ask

his or her friends for help.� Arrange for a meal program service (eg, Meals on Wheels).� Provide a personal emergency response system (medical

alert device); install a home security system.� Seek professional help in addition to a primary care practi-

tioner (eg, geriatric care manager, home-care professional,senior care pharmacist, certified geriatric pharmacist; seeAdditional Resources).

� Use leave of absence where applicable (Family MedicalLeave Act).

� Keep copies of advance directives handy (eg, living will,healthcare proxy, durable power of attorney for health care).

Eldercare LocatorA public service of the US Administration on Aging, EldercareLocator lists services for seniors and their families in your commu-nity. Search by zip code, city/state, or topic or by calling 800-677-1116 or by logging on to http:// www.eldercare.gov/Eldercare.NET/Public/Index.aspx.

Current Medication ListMy Medicine List, available at http://www.wapatientsafety. org/my-medicine-list, helps patients and caregivers keep track of prescrip-tion and over-the-counter (OTC) medications, including vitaminsand herbal preparations. This list, which contains full instructionsfor use, can be shown to any healthcare practitioner. Similarforms, including different language versions, are available athttp://www.wapatientsafety.org/my-medicine-list/examples.

Visiting Your Loved One� Inquire about what is needed before visiting (eg, tasks, items,

repairs).� Schedule appointments (NP, doctor, dentist, diagnostic tests)

during your visit.� Look for signs of problems with managing daily tasks, driving

(see Older drivers in Additional Resources), eating, groom-ing, bill-paying, and risks for falls (see Preventing Falls in thissection). Ask friends/neighbors about any noticeable behav-ioral changes, health problems, or safety concerns (seeAging parents: 7 warning signs of health problems inAdditional Resources).

� Inquire about pain (see Relieving Pain in this section).� Enjoy quality time together (eg, walking, movie-watching,

playing cards, relaxing).

Preventing FallsEach year in the United States, one of three seniors experiences afall; some of them sustain serious injury or die. See the MinnesotaSafety Council’s Fall Prevention Home Safety Checklist, availableat http://www.minnesotasafetycouncil.org/seniorsafe/fallcheck.pdf.

Relieving PainAsk your loved one to “Please rate your worst pain over the last5 days on a zero to ten scale, with zero being no pain and ten asthe worst pain you can imagine.” Indicators of Pain or PossiblePain include:

� Nonverbal sounds: crying, whining, gasping, moaning, orgroaning;

� Vocal complaints of pain: “That hurts!” “Ouch! "Stop!”;� Facial expressions: grimaces, winces, wrinkled forehead,

furrowed brow, clenched teeth or jaw; and� Protective body movements or postures: bracing, guarding,

rubbing or massaging a body part/area, clutching or holdinga body part during movement.

Providing Hospice and Palliative CareCaring Connections, a program of the National Hospice andPalliative Care Organization, is a national consumer and commu-nity engagement initiative that provides free resources and infor-mation to help people make decisions about end-of-life care andservices before a crisis. Get help with understanding hospice andpalliative care services, talking to your healthcare practitioner aboutpain or illness, discussing end-of-life wishes, preparing state-spe-cific advance directives, paying for long-term care, caring for a seri-ously ill child, and grief counseling. Call the HelpLine at800-658-8898 (multilingual line, 877-658-8896) or log on tohttp://www.caringinfo.org/i4a/pages/index.cfm?pageid=3401.

Tips and Resources forLong-distance Caregiving

uuuuuuuuuuuuuuuuuuu

Providing Respite� Respite for the Patient or Loved One May Include: Medical or

social adult day care; a short-term stay in a nursing home orassisted living facility; home health aide or home health com-panion; private duty nurse

� Respite for the Caregiver May Include: Short break forappointments, shopping, attending religious services; oppor-tunity to nap, bathe, or visit a friend; longer break for a vaca-tion. For more information on respite for caregivers, log on tohttp://www.caringinfo.org/i4a/pages/index.cfm?pageid=3340.

Caregiver SupportWhen caregiving, feelings of guilt, isolation, helplessness, orresentment may be overwhelming. If so, consider joining a sup-port group for caregivers in your area through the FamilyCaregiver Support Program in your state. Contact your local AreaAgency on Aging (AAA) through the Eldercare Locator, 800-677-1116 or log on to Caring for the Caregiver at http://www.pbs.org/wgbh/caringforyourparents/handbook/caringcaregiver/supportgroups.html?printme=true.

Mail Carrier Alert ProgramIn some areas of the country, mail carriers or utility workers aretrained to spot signs of trouble, such as accumulated mail or trash,and report concerns to an agency that will check on your lovedone. The US Postal Service and the National Association of LetterCarriers (NALC), in collaboration with local non-profits, may beable to help. Contact the local post office or NALC branch office,or ask your mail carrier for information.

Additional ResourcesLong-Distance Caregiving

� Mayo Clinic: Caregiving: Tips for long-distance caregivers.http://www.mayoclinic.com/health/caregiving/ MY01266

� AARP: Obstacles to Long-Distance Caregiving: Caring foryour loved one from far away. http://www.aarp.org/relationships/caregiving-resource-center/info-09-2010/pc_obstacles_to_long_distance_caregiving. html

� Alzheimer's Association: Long-Distance Caregiving.http://www.alz.org/living_with_alzheimers_long_distance_caregiving.asp

National Caregivers Library Checklists & FormsHousing, Money and Insurance, Physical and Emotional Health,Planning and Assessment, Record Keeping and Legal Matters,End of Life Issues. http://www.caregiverslibrary.org/caregivers-resources/grp-checklists-forms.aspx

Alternatives to Nursing Home CareMedicare: http://www.medicare.gov/nursing/alternatives.asp

Additional Senior Care Resources� Mayo Clinic:Aging parents: 7 warning signs of health prob-

lems. http://www.mayoclinic.com/health/aging-parents/HA00082

� National Institute on Aging� Older drivers. http://www.nia.nih.gov/health/publication/

older-drivers� There's no place like home - for growing old. http://www.

nia.nih.gov/health/publication/theres-no-place-home-growing-old

� Forgetfulness: Knowing when to ask for help. http://www.nia.nih.gov/health/publication/forgetfulness-knowing-when-ask-help

Websites for Healthcare Professionals� Geriatric Care Manager (GCM):A health and human ser-

vices specialist who acts as a guide, advocate, and resourcefor families caring for older relatives and persons with disabil-ities. GCMs are trained in any of several fields related to caremanagement, including nursing, gerontology, social work, orpsychology. Find a GCM on the website by zip code, city,state. http://www.caremanager.org/

� Senior Care Pharmacist: This healthcare professional hasspecialized training in seniors' medication-related needs andprovides a comprehensive consultation that includes a one-on-one review of medications. Log onto the AmericanSociety of Consultant Pharmacists website to:� Find out What Can a Senior Care Pharmacist Do for You?

https://www.ascp.com/what-can-senior-care-pharmacist-do-you

� Find a Senior Care Pharmacist: https://www.ascp.com/find-senior-care-pharmacist

� Certified Geriatric Pharmacist: This healthcare profession-al has advanced knowledge and skills in geriatric pharma-ceutical care and can advise about medication therapyneeds, which may help reduce the risks for adverse effects.Log onto the Commission for Certification in GeriatricPharmacy website to:� Answer the question Why Should Your Pharmacist be

“Geriatric” Certified?http://www.ccgp.org/consumer/index.htm

� Locate a Board Certified Geriatric Pharmacist Near You:http://www.ccgp.org/consumer/locate.htm

Home Care ServicesNational Association for Home Care & Hospice:AgencyLocator by state and zip code. http://www.nahcagencylocator.com/


Tips and Resources for Long-distance Caregiving

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tatins, also known as HMG-CoA reductase inhibitors,reduce low-density lipoproteincholesterol (LDL-C) levels and

decrease cardiovascular disease(CVD)-related morbidity and mor-tality.1 However, not all patients forwhom statins are prescribed cantolerate these medications. Themost common manifestation ofstatin intolerance is myalgia with-out associated creatine kinase (CK)elevations. Serious statin-relatedmuscle toxicity is rare, with reportsof myopathy in 5 patients/100,000person-years and rhabdomyolysisin 1.6 patients per 100,000 person-years.2 Although the incidence ofstatin-related myalgia in random-ized clinical trials (RCTs) rangesfrom 1.5% to 3.0%,2 in clinicalpractice, up to 10% of statin usersreport muscle pain.3,4 This differ-ence may be partly related to thepopulations studied in RCTs.Patients with risk factors for statinintolerance, such as those with

The number of prescriptions for statin medications continues to rise. Although these lipid-lower-ing medications have been shown to reduce cardiovascular disease-related morbidity and mortal-ity, they can have unpleasant, intolerable, or dangerous muscle-related side effects in somepatients. Although serious side effects are rare, 1 in 10 statin users experiences myalgias. As aresult, nurse practitioners must be able to identify patients at risk for statin-related muscle prob-lems and implement management strategies to minimize these side effects. In this article, theauthor discusses risk factors for statin intolerance and interventions to manage this problem.


Statin Intolerance:Management StrategiesKristine Anne Scordo, PhD, RN, FAANP, ACNP-BC

PRIMARY CARE

S

renal or hepatic impairment andthose with a history of statin intol-erance, are often excluded fromthese trials.5

Although complaints of muscleaches commonly occur within 1month after initiation of statin ther-apy or after an increase in doselevel, muscle-related symptomsmay occur after 6 months of thera-py.4 The exact mechanism underly-ing statin-associated myopathy isunclear but may involve coenzymeQ10 depletion, altered excitation–contraction coupling, decreased cel-lular membrane fluidity, and/oraltered Ca++ modulation.6 Withincreasing use of statin therapy, NPsneed to understand patient andtreatment-related risk factors forstatin intolerance, along with diag-nostic and management strategiesfor statin-related muscle problems.

Defining and IdentifyingStatin IntoleranceStatin-related muscle problemsinclude myalgias, myopathy,myositis, and rhabdomyolysis(Table 1).5,7,8 Myalgias, the mostcommon manifestation of statinintolerance, present as aches, pain,cramping, tenderness, soreness,stiffness, heaviness, or weakness ofthe muscles at rest or with physicalexertion or both. Pain is often sym-metrical, involves large musclegroups—most often, the lowerextremities—and is usually inter-mittent, lasting several minutes toseveral hours.4,8 Statin-relatedmyalgias may interfere with theperformance of activities of dailyliving, including one's job.4

Nurse practitioners need tonote any patient reports of mildmuscle symptoms. Unless NPsinquire about muscle discomfort,even mild discomfort, somepatients may not mention it,

believing that they have overexert-ed themselves or that the discom-fort is normal for their age. NPsneed to take a careful history eachtime statin users are seen in follow-up, and ask about any changes inexercise tolerance or musclestrength. At the same time, NPsneed to be aware that frequentinquiries of this nature may promptthe perception of muscle symptomsin suggestible individuals.8

Risk Factors for Statin IntoleranceThe first step in preventing statin-induced muscle problem is to rec-ognize patients at risk and to usecaution when prescribing theseagents. Patients at an increased riskfor statin-related muscle problemsinclude those who present with apersonal or family history of myal-gias while on lipid-modifying ther-

apy, those who have had CK eleva-tions in the past, and those whohave undiagnosed or undertreatedhypothyroidism, vitamin D defi-ciency, alcoholism, or low bodymass index (Table 2).3,4,9,10 Becauseof physiologic changes related toadvancing age (eg, declines in renaland hepatic function), along withfragility and a decrease in leanbody mass, older adults (ie, those>65 years of age) are at particularrisk.4

Polypharmacy increases the riskfor adverse drug interactions viacytochrome P (CYP) 450 isoenzymes(especially CYP3A4) or glucuronida-tion pathways.9,11 Lovastatin, sim-vastatin, and, to a lesser extent,atorvastatin, undergo metabolism byCYP3A4 isoenzyme, creating thepotential for drug interactions withmany medications. By contrast,


MUSCLE PROBLEMS RELATED TO STATIN USE5,7,8TABLE 1

Term Definition

Myalgia Muscle aches or weakness without associated CK elevation

Myopathy Muscle pain or soreness accompanied by a CK >10 times ULN

Myositis Muscle inflammation with or without CK elevation

Rhabdomyolysis Breakdown of muscle fibers resulting in release of muscle fibercontents (myoglobin) into the bloodstream and, after filtering by thekidneys, into the urine. Associated with significant CK elevations(usually >10 times ULN). May lead to acute tubular necrosis orkidney failure.

CK, creatine kinase; ULN, upper limit of normal.

RISK FACTORS FOR STATIN-RELATED MUSCLE PROBLEMS4,9,10TABLE 2

� Alcohol abuse

� Older age

� Hypothyroidism

� Low body mass index

� Personal or family history of myalgiaswhile on lipid-modifying therapy

� Polypharmacy

� Previous history of creatine kinaseelevations

� Renal and/or hepatic dysfunction

� Vitamin D deficiency


PRIMARY CARE

pravastatin, rosuvastatin, andpitavastatin do not undergo signifi-cant metabolism via CYP3A4.Gemfibrozil, when combined withatorvastatin or simvastatin, canresult in increased active forms ofthese statins and is responsible formost cases of statin-induced rhab-domyolysis.12 Other clinically im-portant drug interactions occurwhen statins metabolized by theCYP3A4 isoenzyme are combinedwith medications that are sub-strates or potent inhibitors of thisenzyme. These medications includecyclosporine, amiodarone, azoleantifungals, macrolide antibiotics,protease inhibitors, and non-dihy-dropyridine calcium channelblockers such as verapamil and dil-tiazem.9,11-13 Large quantities ofgrapefruit juice can interact withstatins metabolized by the CYP34Aenzyme.13

When prescribing short-termantibiotics or antifungals that mayinhibit statin metabolism, NPs askpatients to suspend statin use dur-ing this period of time. Low-dosestatins that are not major CYP3Ainhibitors (eg, lovastatin, rosuva-statin) are preferable for patientson cyclosporine, amiodarone, orprotease inhibitors.14 When statinsneed to be switched because ofcost constraints or changes ininsurance coverage, a washout peri-od—the duration of which isbased on the half-life of the drug—is needed to terminate the effectsof the current statin prior to start-ing the next statin. This strategyavoids possible additive effects ofthe two statins, which could leadto muscle symptoms.

Management Strategies forStatin IntolerancePrior to initiation of a statin, NPsobtain patients’ baseline liver

enzyme levels and thyroid-stimu-lating hormone (TSH) level. Ifpatients are at risk for vitamin Dinsufficiency or if NPs suspect thatpatients may be deficient (eg, thosewith depression, myalgias, andfatigue), NPs order a serum25(OH)D level.15 Low levels of vita-min D or abnormal TSH levels aretreated prior to statin initiation.Measurement of baseline CK levelsis recommended in patients atincreased risk formyopathy—that is,in patients with renal or hepatic dys-function or in those using medica-tions that might alter statinmetabolism.8 Routinemonitoring ofCK levels is not advocated in asymp-tomatic patients.8 CK levels are mea-sured in symptomatic patients inorder to determine the severity ofmuscle damage and to aid in deci-sions about discontinuing statintherapy.8 CK elevations >10 timesthe upper limit of normal that aresecondary to statin therapy requirediscontinuation of the statin, withfollow-up measurements of CK lev-els to confirm that these levels have

decreased. Table 3 summarizesmanagement strategies for patientswith statin intolerance.4,9,10

For patients who have intolera-ble muscle symptoms, the statin isdiscontinued regardless of CK lev-els until the patient is asymp-tomatic. Statin cessation results insymptom reversal, usually within afew weeks.8 After this time, thesame statin or a different statinmay be initiated at a lower doseand/or taken less frequently, withclose follow-up for recurrence ofsymptoms. Studies have demon-strated the efficacy of alternate-day,3-times-weekly, and lesser-frequen-cy dosing regimens for statins.1,16-20

For example, patients who reportmuscle symptoms secondary todaily statin use may be started on astatin 1-2 days a week, with dosingincreased over the course of a fewweeks to 3 times weekly, depend-ing on tolerance. To determine theappropriateness of the dose andfrequency, lipid and liver enzymeanalyses are repeated in about 12weeks.14

MANAGEMENT STRATEGIES FOR PATIENTS WITH STATIN-RELATED MUSCLE PROBLEMS4,9,10TABLE 3

� Begin or intensify lifestyle modifications including diet and exercise

� Identify and treat underlying thyroid disorders

� Identify and treat vitamin D deficiency

� Decrease statin dose

� Add coenzyme Q10 (100-200 mg/day)

� Verify potential drug–drug interactions

� Discontinue statin and rechallenge in a few weeks with same or different statin at a lowerdose and/or dosing frequency

� Increase dose and dosing frequency according to patient tolerance

� Change class of lipid-lowering agent (eg, ezetimibe alone or in combination withcolesevelam)

� Change to red yeast rice (1200-2400 mg/day); monitor lipid profile and liver enzyme andadjust dosage accordingly

Although the effectiveness ofprophylactic therapy with coen-zyme Q10 is not well studied,some evidence suggests thatadding 100-200 mg/day may be ofbenefit in decreasing myalgiaseverity.21,22 One method is to begincoenzyme Q10 daily for a fewweeks prior to initiating the statinand then starting the statin andcontinuing the Q10 at full or halfstrength, depending on patients’symptoms.

Patients at high risk for CVDevents—particularly those withdiabetes mellitus or metabolic syn-drome—and patients with mixedhyperlipidemia often require com-bination lipid-lowering therapy.Many of these patients have lowlevels of high-density lipoproteincholesterol, increased triglyceride(TG) levels, and increased totalcholesterol levels. Depending onpatient-specific treatment goalsand hyperlipidemic profiles, com-bination therapies with fibrates,fenofibrates, ezetimibe, bile acidsequestrants, omega 3 fatty acids(OM3FAs), and/or nicotinic acidmay be used.23-25 Although allfibrates can cause CK elevationsand myopathy when used in com-bination with statins, the risk isgreater with gemfibrozil than withfenofibrate.21 Cases of myalgia havebeen reported with concomitantadministration of nicotinic acid(niacin) and statins (mainly lova-statin).23 The combined use ofstatins with Lovaza (an OM3FAavailable by prescription), ezeti-mibe, and bile acid sequestrantshas not been associated with majoradverse events.24

To reduce the risk for treatment-associated muscle problems, NPscan start patients on one agentbefore moving to combination ther-apy. For example, patients withhypertriglyceridemia can try fenofi-

brate, nicotinic acid, or an OM3FA(along with disease managementand lifestyle changes). After checkingpatients' lipid profile and liverenzyme levels in 8-12 weeks—assuming that TG levels havedeclined but that a greater lipid-low-ering effect is needed—NPs can adda statin, preferably one that is not amajor inhibitor of the CYP450enzyme pathway. Follow-up lipidand liver profiles are done as needed.For patients at high risk for CVDwhorequire further reductions in LDL-C,addition of ezetimibe, as opposed todoubling the dose of the statin, mayprovide substantial reductions inLDL-Cwith a decreased risk formus-cle problems.24

For patients unable to toleratestatins, red rice yeast preparationsmay provide an effective alterna-tive for lipid lowering.18,26-29 Areduction in LDL-C of 21% hasbeen noted.27 Red rice yeast is apopular dietary supplement thatcontains naturally occurring HMG-CoA reductase inhibitors, includ-ing monacolin K (also known asmevinolin or lovastatin).30 As withother dietary supplements, FDAapproval is not required for red riceyeast preparations; therefore, prod-ucts may contain unlabeled ingre-dients. For instance, some productscontain citrinin, a mycotoxin thatmay cause renal failure.30 Also,manufacturing processes lack con-sistency, so the amount of mevino-lin varies with preparations. Thesuggested dosage is two 600-mgcapsules twice a day. One prepara-tion that provides 13.5 total mona-colins is Xuezhikang at a dosage of1.2 g/day. As with other statins,myopathy can occur with red yeastrice. Although rare, hepatitis hasbeen reported.31 NPs monitorpatients’ lipid profiles and liverfunction in a manner similar tothat with statin therapy.

ConclusionStatins can reduce CVD-relatedmorbidity and mortality inpatients at risk for CVD. Althoughserious side effects of statin therapyare rare, they do occur. As a conse-quence, NPs need to be able to rec-ognize patients at risk forstatin-related muscle problemsand implement managementstrategies that will minimize theseside effects. �

Kristine Anne Scordo is a professor,an acute care nurse practitioner, anddirector of the Acute Care NursePractitioner Program at WrightState University in Dayton, Ohio.The author states that she does nothave a financial interest in or otherrelationship with any commercialproduct named in this article.

References1. Cannon CP, Steinberg BA, Murphy SA, et al.Meta-analysis of cardiovascular outcome trialscomparing intensive versus moderate statin thera-py. J Am Coll Cardiol. 2006;48(3):438-445.

2. Law M, Rudnicka A. Statin safety: a systematicreview. Am J Cardiol. 2006;17;97(suppl 8A):52C-60C.

3. Jacobson TA. Toward “pain-free” statin pre-scribing: clinical algorithm for diagnosis and man-agement of myalgia. Mayo Clin Proc. 2008;83(6):687-700.

4. Bruckert E, Hayem G, Dejager S, et al. Mild tomoderate muscular symptoms with high-dosagestatin therapy in hyperlipidemic patients—thePRIMO study. Cardiovasc Drugs Ther. 2005;19(6):403-414.

5. McKenney JK, Davidson M, Jacobson T,Guyton J. Final conclusions and recommendationsof the National Lipid Association Statin SafetyAssessment Task Force. Am J Cardiol. 2006;17:97(suppl 8A):89C-94C.

6. Baker K, Tarnopolsky M. Statin myopathies:pathophysiologic and clinical perspectives. ClinInvest Med. 2001;24(5):258-272.

7. Pasternak RC, Smith SC Jr, Bairey-Merz CN, etal. ACC/AHA/NHLBI clinical advisory on the useand safety of statins. J Am Coll Cardiol. 2002;40(3):567-572.

8. Thompson PD, Clarkson PM, Rosenson RS;National Lipid Association Statin Safety Task ForceMuscle Safety Expert Panel. An assessment of statinsafety by muscle experts. Am J Cardiol. 2006;97(8A):69C-76C.


9. Bottorff MB. Statin safety and drug interac-tions: clinical implications. Am J Cardiol. 2006;97(8A):27C-31C.

10. Goldstein MR. Myopathy, statins, and vitaminD deficiency. Am J Cardiol. 2007;100(8):1328.

11. Bellosta S, Paoletti R, Corsini A. Safety ofstatins: focus on clinical pharmacokinetics anddrug interactions. Circulation. 2004;109(23 suppl1): III50-III57.

12. Thompson PD, Clarkson P, Karas RH. Statin-associated myopathy. JAMA. 2003;289(13):1681-1690.

13. Greenblatt DJ. Update on drug interactionswith grapefruit juice: an evidence-based review.Pharmacy Times. 2010;76(1):95-105.

14. Scordo K. Treating antiretroviral induced dys-lipidemia in the HIV-infected adult patient: a focuson dyslipidemia medications. Nurse Pract. 2010;35(7):32-37.

15. Droste L, Holmes C, Hernandez JF, MahdjoubiM. Diagnosis and management of vitamin D defi-ciency in adults. Am J Nurse Pract. 2010;14(7/8):25-32.

16. Backes JM, Moriarty PM, Ruisinger JF, GibsonCA. Effects of once weekly rosuvastatin amongpatients with a prior statin intolerance. Am JCardiol. 2007;100(3):554-555.

17. Ruisinger JF, Backes JM, Gibson CA, MoriartyPM. Once-a-week rosuvastatin (2.5 to 20 mg) in

patients with a previous statin intolerance. Am JCardiol. 2009;103(3):393-394.

18. Halbert SC, French B, Gordon RY, et al.Tolerability of red yeast rice (2,400 mg twice daily)versus pravastatin (20 mg twice daily) in patientswith previous statin intolerance. Am J Cardiol.2010;105(2):198-204.

19. Brudi P, Reckless JP, Henry DP, et al. Efficacy ofezetimibe/simvastatin 10/40mg compared to dou-bling the dose of low-, medium- and high- potencystatin monotherapy in patients with a recent coro-nary event. Cardiology. 2009;113(2):89-97.

20. Degreef LE, Opdam FL, Teepe-Twiss IM, et al.The tolerability and efficacy of low-dose simvas-tatin in statin-intolerant patients. Eur J Intern Med.2010;21(4):293-296.

21. Young JM, Florkowski CM, Molyneux SL, et al.Effect of coenzyme Q10 supplementation on sim-vastatin-induced myalgia. Am J Cardiol. 2007;100(9):1400-1403.

22. Caso G, Kelly P, McNurlan MA, Lawson WE.Effect of coenzyme q10 on myopathic symptomsin patients treated with statins. Am J Cardiol.2007;99(10):1409-1412.

23. Franssen R, Vergeer M, Stroes ES, Kastelein JJ.Combination statin-fibrate therapy: safety aspects.Diabetes Obes Metab. 2009;11(2):89-94.

24. Ballantyne CM, Corsini A, DavidsonMH, et al.Risk for myopathy with statin therapy in high-risk

patients. Arch Intern Med. 2003;163(5):553-564.

25. Barter P, Ginsberg HN. Effectiveness of com-bined statin plus omega-3 fatty acid therapy formixed dyslipidemia. Am J Cardiology. 2008;102(8):1040-1045.

26. Ong HT, Cheah JS. Statin alternatives or justplacebo: an objective review of omega-3, red yeastrice and garlic in cardiovascular therapeutics. ChinMed J (Engl). 2008;121(16):1588-1594.

27. Venero CV, Venero JU, Worthan D, ThompsonP. Lipid lowering efficacy of red yeast rice in a pop-ulation intolerant to statins. Am J Cardiol. 2010;105(5):664-666.

28. Yang NC, Chou CW, Chen CY, et al. Combinednattokinase with red yeast rice but not nattokinasealone has potent effects on blood lipids in humansubjects with hyperlipidemia. Asia Pac J Clin Nutr.2009;18(3):310-317.

29. Zhaopiny L, Seeram NP, Lee R, et al. Plasmaclearance of lovastatin versus Chinese red yeast ricein healthy volunteers. J Altern Compliment Med.2005;11(6):1031-1038.

30. Red yeast rice. Med Lett Drugs Ther. 2009;51(1320):71-72.

31. Heber D, Lembertas A, Lu QY, et al. Analysis ofnine proprietary Chinese red yeast rice dietary sup-plements: implications of variability in chemicalprofile and contents. J Altern Complement Med.2001;7(2):133-139.

PRIMARY CARE

Feosol Ad

ethamphetamine is a ScheduleII, highly addictive syntheticstimulant that initially

increases the level of the neuro-

transmitter dopamine in thebrain.1,2 Dopamine is involved inpleasure, reward, motivation, andmotor function.2 Continued use of

methamphetamine depresses dopa-mine levels, leading to physical con-ditions such as neuromusculardysfunction mimicking Parkinson’sdisease and psychological condi-tions such as depression.3 Personsaddicted to methamphetaminemay require an increased amountof the drug to experience the samelevel of euphoria as that initiallyperceived with a lower dose.Closely related to amphetamine,methamphetamine has effects thatlast longer and are more harmful tothe body; higher levels of the drugcan enter and remain in the brainfor extended periods of time.1,3,4

Medical use of metham-phetamine dates back to 1887,when this agent was used as a nasaldecongestant.3 Methamphetamineis currently available by prescrip-tion to treat narcolepsy and atten-tion deficit disorder (ADD).4

Although most methamphetaminein the United States is manufac-tured by pharmaceutical compa-nies in large-scale laboratories, thedrug is also made by inexperienced


Identifying and Treating the OralEffects of Methamphetamine UseEmily R. Holt, RDH, MHA, CDA and Deborah Carl Wolf, RDH, MEd

ORAL CARE

Methamphetamine use is a major problem in the United States, with serious general and oralhealth consequences. Adverse oral ramifications of methamphetamine use include xerostomia,rampant caries, periodontal disease, and infection. Oral infections can lead to serious systemiccomplications. Many individuals seek care from primary care practitioners, including nursepractitioners, for relief of methamphetamine-related oral problems. The authors discuss the NProle in providing diagnostic, therapeutic, and referral services to address the oral effects ofmethamphetamine use.

M


PRIMARY CARE

laypersons in small concealed lab-oratories.4 These individuals derivemethamphetamine from over-the-counter (OTC) cold and sinus medi-cations containing ephedrine orpseudoephedrine, or from stimu-lants used to treat ADD, obesity, ornarcolepsy, including methylphen-idate (Ritalin), dextroamphetamine/amphetamine (Adderall), and dex-troamphetamine (Dexedrine).3

According to the Office ofNational Drug Control Policy,methamphetamine is known bymore than 100 street names; someof the more commonly usednames aremeth, crank, bikers' coffee,speed, ice, chalk, crystal, fire, rock,and yaba.6 The name of the drugmay indicate whether it containsmethamphetamine only, orwhether it is combined withanother chemical or drug.Combinations include coffee andmethamphetamine powder, knownas bikers' coffee, and methamphet-amine/MDMA/sildenafil (Viagra),known as party and play or PNP.6

The street name of the drug mayalso indicate its form (ie, pill, pow-der, or crystal).

Profile of a Methamphetamine UserMethamphetamine use in theUnited States is widespread.According to the most recent state-level prevalence data from theNational Survey on Drug Use andHealth (NSDUH), compiled from2004 through 2007, the highestrate of methamphetamine use is inWestern and Midwestern states.7

The number of past-year users inthe United States declined by near-ly half between 2007 and 2008,from 1,343,000 to 850,000.5

Although this trend suggests thatmethamphetamine use is decreas-ing, the severity of the problemsnoticed in people who use the drughas not changed. Overall use ofillicit drugs is highest in personsaged 18-25 years.5 National datashow that about 0.2% of personsin this age range used metham-phetamine in 2008,5 again withhigher rates of use in Western andMidwestern states.7

The rate of methamphetamineuse is similar among males andfemales,5 but from a racial stand-point, most methamphetamine

users are Caucasian or NativeAmerican.8 According to the 2008NSDUH, education level does notaffect whether or not a person usesillicit drugs.5 However, unem-ployed individuals are twice aslikely to use illicit drugs as thosewho are employed part time or fulltime.5 An increase of metham-phetamine use has been seen inhomosexual males in urban set-tings because of the drug’s abilityto boost libido and sexualendurance.9

In addition to its effects on sexdrive and performance, metham-phetamine is used to producedesirable effects such as intensepleasure, increased wakefulness,increased physical activity, anddecreased appetite.1 Persons likelyto seek these sensations/behaviorsthrough drug use include thosewho work multiple jobs, truckdrivers, women characterized as“supermoms,” college students,and persons in high-stress jobs.10Many people use illicit drugs sim-ply for the thrill of the high.

General Health Effects ofMethamphetamineTable 1 lists the physical and behav-ioral complications—divided intoimmediate effects and extendedeffects—resulting from metham-phetamine use.1,3,9,11 If a person hasnot used methamphetamine with-in the previous 12-hour period, theimmediate effects would not bereadily noticeable at a clinical visit;however, NPs need to be alert forextended effects of the drug. Inaddition, some patients may pre-sent with methamphetamine with-drawal symptoms (eg, mooddisturbances, violent behavior, anxi-ety, insomnia) that usually last 7-10days.1,11 Because paying attention toone's health and physical appear-

HEALTH COMPLICATIONS FROM METHAMPHETAMINE USE1,3,9,11TABLE 1

Immediate EffectsIncreased heart rate

Irregular heart beat

Increased blood pressure

Increased respirations

Increased body temperature

Perspiration

Dilated pupils

Rapid speech

Confusion

Paranoia

Extended EffectsAbrupt weight loss

Decreased interest in personal appearance

Formication skin lesions

Memory loss

Psychosis

Depression

Suicidal behavior

Dyskinesia similar to Parkinson’s disease

Cardiovascular complications

erholt

Sticky Note

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Sticky Note

should be eg. instead of eg, ?


ance becomes a low priority formethamphetamine users, NPs needto observewhether a patient exhibitssooner-than-expected decline in anyarea. Because of methampheta-mine-related cognitive impairment,users may skip appointments orfail to comply with healthcarerecommendations.9

The skin of chronic metham-phetamine users ages rapidly,appearing thinner than usual andsagging prematurely.3 In addition,users may experience formica-tion—a sensation of insects crawl-ing on or under the skin—leadingto compulsive scratching and sub-sequent formation of skin lesions.9

Furthermore, methamphetamineusers are at risk for acute andchronic cardiovascular complica-tions, including acute coronarysyndrome, acute aortic dissection,sudden cardiac death, coronaryheart disease, and cardiomyopa-thy.11 Users can contract infectiousdiseases such as HIV infection andhepatitis when sharing contami-nated needles or participating inrisky sexual behaviors.1

Damage to the Oral CavityAdverse oral effects in metham-phetamine users include xerosto-mia (dry mouth), rampant caries(“meth mouth”), and periodontaldisease.3 These effects are due large-ly to blood vessel damage, poordiet, and inadequate oral hygiene.

Methamphetamine-related ele-vations in blood pressure causeblood vessels in the mouth todeteriorate, leading to a decreasedblood supply.3 Without a properblood supply, the salivary glandsatrophy and display decreasedoutput, resulting in a dry oral envi-ronment. (This drug-inducedxerostomia mimics the oralchanges experienced by personswho have received radiation thera-

py to the head and neck regions.)Without proper salivary flow, de-mineralization of the enameloccurs in the presence of bacteriaand a pH level of ≤5.5. The initialstages of demineralization are seenin the whitest enamel adjacent tothe large areas of caries in Figure 1.

Demineralized enamel canremineralize and be structurallysound from repeated exposure tofluoride, or it can transition intothe next stage of the caries processthrough repeated acid attacks. Thisprocess continues for several rea-sons. To combat xerostomia,methamphetamine users consumelarge quantities of sucrose-contain-ing beverages. The combination ofdecreased saliva, low pH, high bac-terial counts due to poor oralhygiene, and high sucrose intakemake the perfect environment forthe formation of the most notice-able oral feature of metham-phetamine use—”meth mouth”(Figure 1).

Meth mouth is manifested byrampant caries that destroy thecrowns of the teeth. Loss of enamel

typically begins in the posteriorregion of the mouth and movestoward the anterior teeth with pro-longed methamphetamine use.The smooth surfaces first affectedby caries are near the gingivalline.12 Without intervention, theentire clinical crown of the toothwill be consumed by caries.Fractures of the remaining crownmay result from the increased ten-dency to clench or grind teethwhile using methamphetamines.12

The weakened tooth structure fromrampant caries causes teeth to bemore susceptible to fracturing nearthe gingival/tooth junction, lead-ing to retained root tips in thegingiva. If this damage is leftuntreated, dental abscesses maydevelop, resulting in pain,swelling, and possibly the fatalspread of infection to the brain.

Another side effect of metham-phetamine use is a decrease inappetite, often resulting in dramat-ic weight loss. The process of eatingis further compromised when anindividual has difficulty swallow-ing because of decreased salivary

FIGURE 1. “Meth Mouth” and Severe Periodontal Disease

Courtesy of Stephen Wagner, DDS

output. The combined result of theinhibitory effect of the drug on theappetite and the decrease in salivato enable swallowing is anincreased risk for anorexia.

Poor oral hygiene, a result ofneglect of the oral cavity, can leadnot only to meth mouth but alsoto periodontal disease, which is abacterial infection of the tissuessurrounding the teeth, includingthe gingiva, bone, periodontal liga-ment, and cementum. Periodontaldisease is classified into two forms,gingivitis (inflammation of thegum tissue) and periodontitis(inflammation of the ligamentsand bones that support the teeth),the latter of which is irreversible.Signs of periodontal diseaseinclude erythema and edema,recession of gingival tissues, loss ofalveolar bone, and tooth mobility(Figure 2). Maintenance and repairof periodontal tissues require prop-er blood flow to provide the oxygenand nutrients necessary for tissueregeneration. Methamphetamineuse damages blood vessels and hin-ders adequate blood flow, whichallows for rapid progression of peri-odontal disease.3

Another oral complication aris-ing from methamphetamine use isthe development of oral infectionsrelated to a lowered immuneresponse. This diminished im-mune response occurs as a result ofdamage that methamphetamineinflicts on the cardiovascular, pul-monary, hepatic, dermatologic,and central nervous systems, aswell as of the changes in dietaryhabits and associated diseases thatdevelop following initiation ofmethamphetamine use.3 Candidaalbicans can cause oral candidiasiswhen normal checks and balancesare eliminated because of xerosto-mia. Candidiasis can be varied inappearance, but the most common

form manifests as an ulceration ofmucosal tissues following removalof a white pseudomembrane. Thispainful and debilitating conditioninterferes with normal oral func-tions and prevents adequate oralcare.

Caring for Methamphetamine UsersWithin their scope of practice, NPsprovide diagnosis, treatment, andcounseling for the health-relatedcomplications of methampheta-mine use, including those relatedto the oral cavity. NPs need toknow the options available for pro-viding palliative and preventiveoral care, as well as knowing whento refer patients to a dental practi-tioner. NPs can provide palliativecare for oral pain, caries, periodon-tal disease and related conditions,and mucosal irritations or ulcera-tions until a dental practitioner canbe accessed.Performing an Oral Eval-

uation—Many health conditions,including those associated withmethamphetamine use, first mani-fest in the oral cavity. An oral

examination begins with a hands-free light source, which allows clin-icians to manipulate the patient'soral tissues. All tissues within theoral cavity are examined, includingthe most posterior sections of thetongue, the sides of the tongue,and the floor of the mouth. Gauzeis used to retract the tongue duringthe examination. Identification ofcertain lesions requires furtherevaluation by a physician or den-tist. Table 2 lists online resourcesthat review the performance of anoral examination.Oral Treatment Options—Dis-

comfort related to mucosal irrita-tions and ulcerations can often bealleviated with the use of OTC gels,pastes, and rinses (eg, Rincinol,Orabase, Oragel, Gly-Oxide). Ahomemade version of an analgesicoral rinse consists of equal parts ofbismuth subsalicylate (eg, Kao-pectate) and diphenhydramine(eg, Benadryl). NPs can offer a pre-scription pain-relieving mouth gel,such as Gelclair, to relieve oral dis-comfort. Prescribing opioids aspain relievers is avoided because of


PRIMARY CARE

FIGURE 2. Moderate Inflammation of Gingival Tissues

Courtesy of Stephen Wagner, DDS

the tendency of these agents to beaddicting in vulnerable individuals.In addition, NPs must be awarethat some methamphetamine userswill deceptively seek opioids toembellish the “high.” Nonsteroidalanti-inflammatory drugs are effec-tive if taken at the appropriatedosage. Antibiotics may berequired to treat dental abscesses.Candida infections are treated withan antifungal medication such asnystatin.

Approaches to treating xerosto-mia include stimulation of salivaproduction and use of saliva sub-stitutes (Table 3). Saliva produc-tion can be stimulated through theuse of pharmaceuticals, the use ofsugar-free mints or gum, or theconsumption of crunchy foods.Medications designed to increasesaliva production include pilo-carpine (Salagen) and cevimeline(Evoxax). OTC xerostomia prod-ucts include gels, pastes, rinses,mints, gum, and ointments.

Preventive care focuses oninterrupting the demineralizationprocess in the enamel before itprogresses to the rampant cariesseen in Figure 1. Fluoride is anintegral component. In addition toprescribing fluoride gels, pastes, orrinses, some NPs are allowed (asper regulations in their state) toapply sodium fluoride varnish toteeth. Fluoride varnish has proper-ties that make it an attractiveoption for remineralizing enamel;extended contact with the teethallows for continued release of flu-oride into the enamel. Most fluo-ride varnish products are packagedin unit-dose containers thatinclude an applicator brush and asmall well filled with the white-to-yellow colored varnish. It is impor-tant to maintain a dry field whileapplying a thin layer of the varnishto the teeth with the brush applica-

tor—generally not a concernbecause xerostomia is likely pre-sent in methamphetamine users.Patients are instructed to refrainfrom brushing the teeth until thefollowing day.

Patient EducationNutritional counseling includes adiscussion of eliminating sourcesof sucrose in the diet and replacingsucrose-containing beverages withwater, not sugar-free sodas. Thelow pH levels found in all sodascontribute to erosion of the enam-el. Methamphetamine users whohave evidence of periodontal dis-

ease are instructed to consumefoods rich in vitamin C, protein,iron, zinc, and copper to aid inhealing.13 Table 4 lists foods rich inthese nutrient sources.13 To reducethe severity of periodontal inflam-mation and the likelihood thatincipient demineralization willtransition into meth mouth, NPsreview proper brushing and floss-ing techniques. Basic recommen-dations include brushing teethtwice daily with a soft-bristledbrush to prevent abrasive damageto the gingival tissues, flossingonce daily to remove plaque fromthe sides of the teeth, and using an


XEROSTOMIA THERAPIESTABLE 3

Saliva SubstitutesRinse: Oasis

Sprays: Optimoist, MouthKote

Gel: Biotene Oral Balance

Methods of Increasing Saliva ProductionMedications: pilocarpine, cevimeline

Sugar-free gum, mints, candy

Eating crunchy foods

FOOD SOURCES FOR PERIODONTAL HEALING13TABLE 4

Vitamin C Grapefruit, oranges, strawberries, tomatoes, kiwi fruit, bell peppers, broccoli,cauliflower, kale

Protein Meat, cow’s milk, eggs, fish, legumes, peas, beans, grains

Copper Liver, whole grains, nuts, legumes, vegetables, fruits

Zinc Liver, beef, lamb, venison, pumpkin seeds, yogurt, green peas

Iron Clams, oysters, organ meats, fortified cereal, white beans, soybeans, pumpkin

ORAL EXAMINATION RESOURCESTABLE 2

Resource WebsiteJournal of the American http://jada.ada.org/cgi/content/full/132/suppl_1/36SDental Association

Medscape http://emedicine.medscape.com/article/1080850-overview

Family Practice Notebook http://www.fpnotebook.com/ENT/Exam/OrlExm.htm


PRIMARY CARE

antimicrobial mouth rinse once ortwice a day, depending on theseverity of gingival inflammation.Instructions for proper brushingand flossing are found on theAmerican Dental Hygienists’ Asso-ciation’s web page at http://adha.org/oralhealth/index.html.

Antimicrobial rinses may beincorporated into patients' dailyroutine to reduce gingival inflam-mation seen in periodontal dis-ease. These rinses are availableOTC or by prescription, dependingon the antimicrobial strength of therinse and its substantivity (abilityto be retained by the tissues). NPsneed to consider the alcohol con-tent in a mouth rinse before recom-mending its use in a patient with anaddiction. Sunstar manufactures analcohol-free prescription mouthrinse containing 0.12% chlorhexi-dine gluconate, which has the high-est level of substantivity of anyrinse on the market. Chlorhexidinegluconate also aids in arresting pro-gression of carious lesions in enam-el. Crest Pro-Health rinse, an OTCoption, is alcohol free and containsa high level of cetylpyridiniumchloride, making it a suitablechoice for reducing inflammation.This product has a moderate levelof substantivity.

ReferralsIf the treatment required to repairdamage to the oral cavity is beyondan NP's scope of practice, patientsare referred to a dental profession-al. Although prevention of furtherdamage is the ultimate goal formethamphetamine users, manypatients will ultimately lose teethbecause of their rampant cariesand periodontal disease. Dentalabscesses may be treated with rootcanal therapy or extraction andmay require antibiotic therapybefore dental treatment can occur.

A general dentist can provide mosttreatment for teeth, periodontaltissues, and mucosal tissues dam-aged by methamphetamine use.Complex cases may require theexpertise of an oral surgeon.

Nurse practitioners may haveongoing contact with patientsreferred elsewhere because of thepatients' other health complica-tions accompanying metham-phetamine use. Patients need to beclosely monitored to prevent pro-gression of oral and systemic dis-eases and to identify early signs ofrelapse. Because of the damage tothe oral cavity from metham-phetamine use, patients areadvised to see a dental professional3-4 times a year. Those with addic-tion problems are referred to sub-stance abuse centers and mentalhealth facilities for comprehensivecare. Information is available at theSubstance Abuse & Mental HealthServices Administration website athttp://findtreatment.samhsa.gov/about.htm. This organization pro-vides a referral helpline—1-800-662-HELP—and English- andSpanish-speaking individuals.

ConclusionAlthough statistics indicate thatmethamphetamine use in theUnited States is declining, thelong-term health effects continueto manifest themselves in currentand prior users. These individualslikely require palliative, definitive,and preventive care from medicaland dental professionals. NPs whosee patients with methamphet-amine-related damage provide notonly holistic care, but also muchneeded oral care, to a populationthat frequently lacks access to den-tal care. �

Emily R. Holt and Deborah Carl Wolfare both assistant professors of dental

hygiene at the University of SouthernIndiana in Evansville. The authorsstate that they do not have a financialinterest in or other relationship withany commercial product named in thisarticle.

References1. National Institutes of Health. NationalInstitute on Drug Abuse. Methamphetamine. 2011.http://www.drugabuse.gov/DrugPages/Methamphetamine.html

2. National Institutes of Health. NIDA InfoFacts:Methamphetamine. http://drugabuse.gov/infofacts/methamphetamine.html. Revised March 2010.

3. Kelsch NB. Methamphetamine Abuse—OralImplications and Care. www.ineedce.com. Updated2012. http://www.ineedce.com/courses.aspx

4. Volkow N. Research Report. Methamphet-amine Abuse and Addiction. http://www.nida.nih.gov/researchreports/methamph/methamph.html. Updated 2006.

5. Department of Health and Human Services,Substance Abuse and Mental Health ServicesAdministration (SAMHSA), Office of AppliedStudies (OAS). Results from the 2008 NationalSurvey on Drug Use and Health: NationalFindings. Rockville, MD; 2009. http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf

6. Office of National Drug Control Policy. StreetTerms: Drugs and the Drug Trade: Metham-phetamine. 2012. http://www.whitehousedrugpolicy.gov/streetterms/By Type.asp?intTypeID=14.

7. Department of Health and Human Services,Substance Abuse and Mental Health ServicesAdministration (SAMHSA), Office of AppliedStudies (OAS). Results from the 2007 NationalSurvey on Drug Use and Health: NationalFindings. Rockville, MD; 2008. http://www.oas.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm

8. Meth Resources.gov. Use Rates. http://www.methresources.gov/use.html

9. The Rural Center for AIDS/STD Prevention, ajoint project of Indiana University, University ofColorado, and University of Kentucky,. RuralMethamphetamine Use and HIV/STD Risk FactSheet. Updated 2006. http://www.indiana.edu/~aids/factsheets/factsheets18.pdf

10. Scofield JC. Gravity of methamphetamineaddiction.Dimens Dent Hygiene. 2007;5(3):16-18.

11. Cruickshank CC, Dyer KR. A review of the clin-ical pharmacology of methamphetamine.Addiction. 2009;104(7):1085-1099.

12. Frese P, Kunselman B, McClure E, Schierling J.Methamphetamine: implications for the dentalhygienist. Access. 2006;20(9):16-22.

13. Nield-Gehrig JS, Willman DE. Foundations ofPeriodontics for the Dental Hygienist. 3rd ed.Philadelphia, PA: Lippincott Williams & Wilkins;2011.

erholt

Sticky Note

should be plural (routines)

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From large health centers to ruralpractices, electronic health records(EHRs) are everywhere. EHR use isthe new way of documentinghealth care delivery, yet it alsochanges the way we practice. At themost basic level, a computer isadded to the clinician–patientencounter. Some aspects of EHRuse can make care more efficient.No longer must we search the clin-ic for a chart when a phone callcomes in. No longer must we waitfor dictations to be transcribed. Inmy case, no longer must anyone tryto decipher my handwriting!

Now the US government is ask-ing us to put EHRs to meaningfuluse. Clinic administrators knowwhat this term means—not its lit-eral definition, but, rather, how ittranslates into dollars. To adminis-trators, meeting meaningful useobjectives can translate into$44,000 (through Medicare) and$63,750 (through Medicaid) ofadditional revenue per clinicianover the next 10 years.1 Cliniciansare encouraged not only to imple-ment an EHR system, but also touse it in ways that improve patientcare. Sure, the concept is great, butsometimes it may not fully capture

the true spirit of meaningful use.The American Recovery and

Reinvestment Act of 2009 estab-lished specific components ofmeaningful EHR use. According tothe Centers for Medicare &Medicaid Services (CMS), mean-ingful use means that providersneed to show they're using certifiedEHR technology in ways that canbe measured significantly in quali-ty and in quantity.2 A total of 15core objectives and 5 of 10 addi-tional objectives must be met in aspecified time period to receiveincentives. Yet, as I see some ofthese objectives implemented, Istart to wonder. Use of EHRstreamlines the recording andretrieval of information and gener-ates good-looking reports repletewith data. From a patient-care per-spective, however, I think that weclinicians must have our own defi-nition of meaningful use. For me,it means continuity of care. If noth-ing else, the EHR depicts what hap-pened during specific patientencounters so that I can read aboutthem months later and recall whathappened at each visit.

Electronic health recordsenable us to check boxes or select

items from drop-down menus; inthe past, we wrote notes or dictateda narrative. The purpose of thecheck boxes is to simplify dataentry and help us meet codingrequirements for documentation.But do the check boxes give a truepicture of what is happening withthe patient?

Exhibit A, a computer-generat-ed narrative, is based on the boxes Ichecked in the history template.Within these constraints, I had dif-ficulty painting a true picture ofwhat was happening with thispatient, so I typed Exhibit B. Bothdescribe the same patient visit.Both are adequate from a codingperspective and meet criteria need-ed to bill for the visit. But whichdescription is more meaningful?Which one paints a clearer picture?Which one would be more useful ifthe patient returned to the office 2weeks later and I (or you) wantedto review what happened? Whichrecord, the EHR or the writtendescription, enables us to makemore meaningful use of it?

Another challenge with EHRs isto personalize patients' records.With paper charts, I used a coversheet with information that helped


P R O M O T I N G T H E N P P R O F E S S I O N

Meaningful Useof the ElectronicHealth Record

Tom Bartol, NP

me get to know my patients andremember the important details oftheir lives. The cover sheet includ-ed their occupation, partner’sname, children’s names, pet’sname, hobbies, and points of inter-

est about them. Checked boxessimply don't capture the person. Iskip the boxes and the pick-listsand write in the names of the part-ner and the children, including theyears in which the kids were bornso I know their ages. I add com-ments about patients' occupationsand hobbies—all free-texted in. If Iam going to see a patient whom Idon’t remember well, I take a quicklook at his or her social history toremind myself.

The plan template can becomegeneric too. For the EHR to bemeaningful and useful, we need toembellish it. We may choose anassessment from the list such as719.46, Pain in Lower Leg Joint.

This assessment, like many others,begs for more detail. I clarify it byadding specifics such as “R kneepain for 2 months.” As I write outmy care plan, I describe my deci-sion-making process, includingwhich entities I've excluded andwhy. My plan of care is written tohelp me, or whoever else might seethis patient, at follow-up. I includetest results such as the A1c for apatient with diabetes, and showhow this value has changed since

the last measurement. I record myplans for the next visit. Theseefforts may take a few extra min-utes, but they can save time whenthe patient returns 3 months later.Finally, I write my patient-specificrecommendations. Instead ofchecking a box indicating that Ieducated the patient about exer-cise, I write that she has agreed totry to use her exercise bike for 5minutes a day before supper. WhenI see her in follow-up, I can reviewthe plan from the past visit andhave a clear idea of what needs tobe done at the current visit.

Accessing and retrieving infor-mation is key to making the EHRuseful. Paper reports and resultscoming to our office still need tobe “filed” in the EHR. Thesereports may be diagnostic images,consultations, or lab results fromanother site. How do we index thisinformation for later use? Thisinformation can be scanned in, butI have found that looking back atpast reports can be overwhelming.The reports are there, but they maybe difficult to read on the computerscreen. It’s not as simple as flippingthrough pages in a paper chart. Weneed to try to find ways to helpindex this information. Again, thiseffort may take an extra minute todo, but it can save us a lot of time inthe future. We don’t “thin” the EHRsas we used to with paper records.Over the years, these scanned docu-ment files may be so thick andunwieldy that we may not be able tofind information we need. In myEHR system, I have been able toenter a summary of reports in a pastmedical history diagnostic historytemplate. This can guide me to theappropriate report for further refer-ence if needed.

We base much of what we doon assessed risk, which depends inlarge part on family history. We


CC: Back pain. Onset: 1 week ago. Duration: more than 1 hour. Severitylevel is 9. The problem is fluctuating. Location: right (back). There isradiation. The pain is aching, dull, piercing, sharp, and throbbing.Context: there was an injury. Trauma occurred at home, 1 week 3 daysago on 02/05/2008. The pain is aggravated by bending, climbing anddescending stairs, lifting, movement, pushing, and sitting. The pain isrelieved by heat, massage, OTC medicines: naproxen sodium, and rest.Associated symptoms include bruising, decreased mobility, difficultygoing to sleep, and night-time awakening. Pertinent negatives includeinstability, limping, locking, numbness, popping, spasms, swelling,tingling in the arms and legs, tenderness and weakness. Handdominance: right.

CC: Back pain. Pt was walking to barn 10 days ago with a 2.5-galloncontainer and slipped on ice, went airborne, and landed on the containeron R side of back. Said it knocked the wind out of him. He was able toget up and carry the container to the barn but had shallow breaths. Amassage therapist friend did some massage with some type of ointmentand the pain improved. Used ice initially, then heat, which helped initially.Pt has taken naproxen bid, which helps. Pain flared up again yesterday.Can't sleep well due to pain. Still can't take a deep breath due to pain.Sneezing and coughing also cause pain. Pain is improving some. ROS:neg for hemoptysis and SOB, neg for hematuria.

Exhibit A

Exhibit B

screen for a family history ofdiseases such as heart disease,cancer, or diabetes and we treatto various goals accordingly.On paper charts, family historywas on the first page. Now it isburied among the templates.With many EHR systems, it’seasy to add a positive familyhistory—you just check boxesfor which family membershave which diseases. But thefact that a box hasn’t beenchecked may mean simply thatno one has asked about it, notthat the history is negative. Sobe sure to mark pertinent nega-tive family histories in a mean-ingful way. Family history is soimportant that CMS will beincluding it in the Tier 2 mean-ingful use criteria.

Electronic health records arestill quite new. Although theyhave obvious utility and bene-

fits, let’s not get overly boggeddown on the government’s crite-ria for EHRs' meaningful use.Talk to your colleagues at meet-ings to find out how they'reusing their EHR systems. EHRsare with us to stay. We must besure to use them in a meaning-ful way for our patients, who are,after all, at the center of what wedo. The records we create eachday are reflections of the care weprovide.

References1. Blumenthal D, Tavenner M. The "meaning-ful use" regulation for electronic healthrecords. N Engl J Med. 2010;363(6):501-504.

2. Centers for Medicare & Medicaid Services.The Official Web Site for the Medicare andMedicaid Electronic Health Records (EHR)Incentive Programs. March 1, 2012. https://www.cms.gov/EHRIncentive Programs/

Tom Bartol can be reached [email protected].

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