Five must reads for pharmacists short on time!

One of the reasons I became a pharmacist was the constant evolution of the profession. Medical and pharmaceutical knowledge is advancing all the time, and the opportunity to keep learning throughout my career is a major source of fulfillment for me. From the development of innovative drugs to the publication of studies with new data on treatment efficacy and safety, not to mention the release of updated guidelines for pharmacy practice, there are countless opportunities for pharmacists to learn.

Of course, even the most enthusiastic pharmacist could never keep up with the constant stream of new publications on pharmacotherapy. What's more, our ever-expanding responsibilities require us to juggle more and more clinical and administrative tasks. Unsurprisingly, it can be hard to find the time to read the latest guidelines, reports, etc.

At Vigilance Santé, a large part of our day is devoted to keeping abreast of the latest information and reading a wide variety of articles.

So I thought it would be interesting to share with you publications on five subjects that have captured my attention in recent months.

1. Medical eligibility criteria for contraceptive use
2. Major depressive disorder in adults
3. Drugs and the risk of QT interval prolongation
4. Myocardial infarction with no obstructive coronary artery disease (MINOCA) 
5. Osteoporosis 

1. Medical eligibility criteria for contraceptive use

As pharmacists, we are regularly asked to advise our patients on the different contraceptive methods that are available. However, it can sometimes be difficult to make sense of the many precautions that apply to hormonal products. Recently, the US Centers for Disease Control and Prevention (CDC) published the 2024 update to their recommendations on medical eligibility criteria for contraceptive use.

In this comprehensive document, the CDC classifies the conditions affecting eligibility for the use of each contraceptive method into one of four categories, based on the risks and benefits of the method. The categories are defined as follows:

Notable updates to the criteria include the addition of new contraceptive methods (e.g., new formulations of progestin-only contraceptive pills) and recommendations for people with chronic kidney disease. The recommendations for a number of medical conditions have also been revised, including postpartum, postabortion, obesity, surgery, and a history or active episode of thrombosis, to name but a few.

A summary chart with classifications for over sixty medical conditions is also available and may be useful to keep on hand for quick reference during consultations.

2. Major depressive disorder in adults

The 2023 update to the Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults has several additions compared to the 2016 version. The updated guidelines have been online for a few months and appear in the September 2024 issue of The Canadian Journal of Psychiatry.

The guidelines are based on a literature review focusing on meta-analyses and systematic reviews published between January 1, 2015, and May 31, 2023, and are presented in a question-and-answer format organized around eight themes:

1. What are Important Issues for Assessment and Diagnosis?
2. What are the Principles for Depression Management?
3. How are Treatments Selected?
4. What is the Role of Digital Health Interventions (DHIs)?
5. How is Treatment Monitored?
6. What Should be Done When a Patient is Better?
7. What Should be Done When a Patient is not Better?
8. When Should Neuromodulation Treatments be Used?

The updates include additional recommendations on digital health interventions (DHIs). Thanks to their accessibility, healthcare technologies such as mobile applications are increasingly popular among patients. Therefore the CANMAT expert group proposes several factors to consider when evaluating these technologies to ensure their optimal use.

The guidelines also address suggested strategies for inadequate response. Of particular note are recommendations on treatment substitution and adjuvant therapies, which have been updated according to the latest data.

For podcast fans, Dr. Raymond Lam, co-first author of the 2023 guidelines and Executive Chairman of CANMAT, was interviewed by Dr. David Gratzer on the podcast Quick Takes: A Podcast by Physicians, for Physicians. You can listen to the episode on the web or via your preferred podcast app (e.g., Apple Podcasts).

3. Drugs and the risk of QT interval prolongation

This resource is not a guideline, but rather a list of drugs posing some risk of QT interval prolongation and/or torsades de pointe. In my opinion, this tool deserves to be better known.

Developed based on systematic analyses done by a committee of experts, the QT Drugs List is available via AZCERT's CredibleMeds platform. Each drug on the list is assigned a risk category according to whether it poses a known, possible, or conditional risk of torsades de pointes. Note that this reference is frequently updated. At the time of writing, the most recent update was made on August 8, 2024.

Other resources available on the CredibleMeds platform include a Drugs to Avoid list for people with congenital long QT syndrome and a section on clinical factors associated with prolonged QTc interval and/or torsades de pointes. A free online account is required to access these documents.

Vigilance Santé is proud to rely on its partnership with AZCERT and its team of experts to provide users with the tools they need to practise their profession. In fact, the data on QT interval prolongation and torsades de pointes used by RxVigilance come from this organization.

4. Myocardial infarction with no obstructive coronary artery disease [MINOCA]

Since the Canadian Cardiovascular Society frequently issues guidelines on a variety of topics related to cardiovascular health, it was difficult to choose just one article to recommend. For instance, the organization's 2024 guidelines on antiplatelet therapy and hypertrophic cardiomyopathy are packed with information relevant to pharmacy practice.

However, I've chosen to highlight a clinical practice update on myocardial infarction with no obstructive coronary artery disease (MINOCA), jointly developed by the Canadian Cardiovascular Society (CCS) and the Canadian Women's Heart Health Alliance (CWHHA). I was particularly interested in this topic because MINOCA is a condition that many health care professionals are still unfamiliar with, but which nevertheless accounts for 6% to 15% of acute coronary syndromes.

Mainly affecting women, this disease is defined as myocardial infarction without significant coronary artery stenosis (i.e., > 50% on coronary angiography). Nonischemic causes of myocardial injury (e.g., myocarditis, Takotsubo) must be ruled out when diagnosing MINOCA.

MINOCA has many possible causes. Around two-thirds of cases have atherosclerotic causes (e.g., plaque rupture or erosion). There are also nonatherosclerotic causes of MINOCA, such as epicardial coronary vasospasm, thromboembolism, spontaneous coronary artery dissection (SCAD), and coronary microvascular dysfunction (CMD).

The CCS/CWHHA practice guide also addresses the pharmacological management of MINOCA. As MINOCA can be caused by a number of conditions, treatments must be tailored to the underlying cause.

Details of this clinical practice update, as well as several other relevant guides, can be found in the Canadian Cardiovascular Society's collection of clinical practice guidelines and updates.

5. Osteoporosis

Despite being published almost a year ago, in October 2023, the updated clinical practice guidelines for osteoporosis management and fracture prevention in Canada are worth a look, as several changes have been made since the 2010 version.

Additions include recommendations on physical activity, diet, fracture risk assessment, and pharmacological interventions. Here are a few examples:

• Calcium supplements are not suggested for fracture prevention in people who eat a varied, calcium-rich diet and meet Health Canada's recommended dietary allowance (RDA). Also, the authors suggest meeting Health Canada's RDA for vitamin D, while noting that a daily supplement of 400 IU is often necessary to do so. For informational purposes, the following table shows Health Canada's recommended dietary allowances of calcium and vitamin D for adults over age 50. 
  
  

• For people on bisphosphonates, an initial therapy duration of 3 to 6 years is recommended. A number of factors, such as a history of fractures and the presence of risk factors for accelerated bone loss, must be considered when selecting the initial duration of treatment.
• Recommendations on the use of romosozumab, an anabolic treatment brought to market in recent years, have also been added in this update.

Given Canada's aging population, I feel that this update is particularly relevant and offers health care professionals additional tools to help patients improve bone health.

A desire to go further

In this article, my aim was not to take a complete inventory of recent updates, but rather to share a selection of suggestions that could enhance your practice.

Of course, this is just a sample of the many resources published or reviewed in recent months. I hope that some of the publications that I've shared have piqued your curiosity and prompted you to explore them further, whether during a bit of downtime between consultations (if those still exist!) or on a rainy day off.

In the meantime, rest assured that our team will continue to scrutinize a wide range of resources to bring you high-quality tools designed to support you in your day-to-day work.