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2001. Volume 5. Number 1. The National Asthma Education Prevention Program (NAEPP II) Guidelines for the Treatment of Asthma: Implications for the Pharmacist (Manuscript Updated December 2000) 146-000-01-001-H01 (Expires February 7, 2004)	0.25	Abstract	Article
2000. Volume 4. Number 5. Tales of Migraine: Migraine Overview from a Clinician's Perspective 146-000-00-012-H01 (Expires October 26, 2003)	0.2	Abstract	Article
2000. Volume 4. Number 4. Primer on Disease Management 146-000-00-011-H04 (Expires September 24, 2003)	0.2	Abstract	Article
2000. Volume 4. Number 3. A Primer and Update of Basic Cardiac Electrophysiology and Antiarrhythmic Agents 146-000-00-005-H01 (Expires July 25, 2003)	0.2	Abstract	Article
2000. Volume 4. Number 2. Diagnosis and Therapeutic Management of Depression: An Update in the Use of Selective Serotonin Reuptake Inhibitors (SSRIs) 146-000-00-004-H01 (Expires June 15, 2003)	0.2	Abstract	Article
2000. Volume 4. Number 1. Update on the Management of Common Musculoskeletal Conditions: Osteoarthritis, Rheumatoid Arthritis, and Fibromyalgia 146-000-00-003-H01 (Expires March 14, 2003)	0.2	Abstract	Article
1999. Volume 3. Number 8. Schizophrenia, Part I: Etiology and Pathophysiology 146-000-99-008-H04 (Expires December 14, 2002)	0.2	Abstract	Article
1999. Volume 3. Number 7. Herbals and other Dietary Supplements in the United States - Part I - Dietary Supplement Regulations: Impact on Pharmacy. This is a CE program on law. 146-000-99-007-H03 (Expires November 14, 2002)	0.2	Abstract	Article
1999. Volume 3. Number 6. Update on Adult Immunization 146-000-99-006-H01 (Expires October 14, 2002)	0.2	Abstract	Article
1999. Volume 3. Number 5. Potassium Channel Blocking Agents and Atrial Tachyarrhythmias 146-000-99-005-H01 (Expires September 14, 2002)	0.2	Abstract	Article
1999. Volume 3. Number 4. Primer on Type 2 Diabetes Mellitus 146-000-99-004-H01 (Expires August 14, 2002)	0.2	Abstract	Article
1999. Volume 3. Number 3. Emerging Roles of Low-molecular-weight Heparin Derivatives in Anticoagulation 146-000-99-003-H01 (Expires June 14, 2002)	0.2	Abstract	Article
1999. Volume 3. Number 2. Lyme Disease and other Co-transmitted Tick-borne Agents 146-000-99-002-H04 (Expires April 30, 2002)	0.2	Abstract	Article
1999. Volume 3. Number 1. Vancomycin-resistant Enterococcus: Implications for Pharmacy 146-000-99-001-H01 (Expires April 14, 2002)	0.2	Abstract	Article
1998. Volume 2. Number 5. Pharmacotherapeutic Management of Chronic Heart Failure 146-000-98-005-H01 (Expires December 14, 2001)	0.2	Abstract	Article
1998. Volume 2. Number 4. Adverse Drug Reactions and Events: What, Why, and How? 146-000-98-004-H04 (Expires July 31, 2001)	0.2	Abstract	Article
1998. Volume 2. Number 3. An Update on the Diagnosis and Management of Peptic Ulcer Disease 146-000-98-003-H01 (Expires July 9, 2001)	0.2	Abstract	Article
1998. Volume 2. Number 2. Update on Alzheimer's Disease 146-000-98-002-H01 (Expired and discontinued February 28, 2001)
1998. Volume 2. Number 1. The National Asthma Education Prevention Program (NAEPP II) Guidelines for the Treatment of Asthma: Implications for the Pharmacist 146-000-98-001-H01 (Expired and discontinued December 29, 2000)
1997. Volume 1. Number 2. The Current Management of Hyperlipidemia 146-000-97-011-H01 (Expired and discontinued May 31, 2000)
1997. Volume 1. Number 1. Disease Management: Looking at the Big Picture 146-000-97-010-H04 (Expired and discontinued February 15, 2000)

The National Asthma Education Prevention Program (NAEPP II) Guidelines for the Treatment of Asthma: Implications for the Pharmacist (Manuscript Updated December 2000) 146-000-01-001-H01

Abstract:The National Asthma Education and Prevention Program (NAEPP II) Expert Panel II Report updated its recommendations for the monitoring and treatment of asthma in February 1997. This article updates the pharmacy practitioner on significant changes from the first panel report published in September 1991. The Report identifies 4 components that are important for effective asthma management: 1) assessment and monitoring, 2) environmental control, 3) comprehensive pharmacologic therapy, and 4) patient education.

All patients should perform daily home peak flow monitoring with moderate-to-severe persistent asthma to detect the onset of acute asthma exacerbations. Peak flow monitoring may also be useful in other asthma patients to establish their personal best peak expiratory flow rate (PEFR), assess efficacy of changes in chronic medications, and identify asthma triggers. Patients with moderate to severe asthma or a history of severe asthma exacerbations should also have a written asthma care plan that specifies their chronic medications and recommendations for acute management of asthma exacerbations based on peak flow readings and asthma symptoms.

The patient in conjunction with health care professionals should identify goals for asthma therapy. Management of all patients with asthma should include environmental or trigger control and a short-acting beta agonist for acute asthma symptoms. Patients with mild, persistent asthma should also receive an anti-inflammatory agent to minimize the potential for the development of chronic lung impairment.

Patients with asthma require asthma education that is "integrated, systematic, and tailored to individual patient needs." Content should include information regarding the disease, monitoring, and treatment of asthma and environmental control of asthma triggers. Pharmacists can be important providers of asthma education and can also verify a patient's understanding and expand on information provided by other health care professionals. Ways pharmacists can implement the NAEPP II Guidelines into their practice are discussed.

Tales of Migraine: Migraine Overview from a Clinician's Perspective 146-000-00-012-H01

Abstract: In spite of advances in migraine and headache therapy in the last decade, migraine remains underrecognized and undertreated. This may be explained, in part, by the heterogeneity of presentation of migraine and, in part, by an unfamiliarity of the pathophysiology and chronic nature of this condition. Migraine may progress in frequency and severity and may transform into a very frequent or daily headache, particularly with comorbidities such as depression or with excessive analgesic use and analgesic "rebound." Migraine as a primary headache disorder must be differentiated, particularly when progressive, from secondary headache because of intracranial or systemic disease. The treatment of migraine can be complex, as this involves consideration of preventive medications and nonpharmacologic therapies when headaches become frequent and disabling. Many headache-abortive therapies, particularly ergot derivatives, have been successful in the past, and remain important options for migraine, although triptan medications have revolutionized migraine abortive therapy. The proper use of these and other therapies would alleviate not only discomfort but the significant disability associated with migraine.

Primer on Disease Management 146-000-00-011-H04

Abstract:Since its introduction in the mid-1990s, disease management (DM) has often been a misused and much abused phrase. Nonetheless, DM can best be described as an evaluative approach to health care delivery that attempts to improve outcomes for patients with a specific disease while optimizing the overall use of health care resources. DM differs from traditional health care delivery in many ways, but, most noticeably, DM offers a broader perspective of the health care provided. Numerous organizations, including pharmacy benefit management companies, managed care organizations, pharmaceutical manufacturers, employers, and others, can have roles to play in DM programs, but a direct patient-provider relationship is a prerequisite for DM to be successful. Key components of DM programs include the following: a continuum of care perspective, focus on patient health-related outcomes, optimization of economic outcomes, use of clinical practice guidelines, focus on chronic diseases, implementation of continuous quality improvement, integrated health databases, feedback to health care providers, and an expanded role of pharmacists in drug therapy monitoring. The 8 primary steps to implementing a DM program are explained as well as the primary aspects of DM program evaluation. While DM has captured the attention of most health care organizations, the lack of rigorous evaluations of DM programs and the continued use of component management have prevented DM from being universally implemented with success.

A Primer and Update of Basic Cardiac Electrophysiology and Antiarrhythmic Agents 146-000-00-005-H01

Abstract:Developing an adequate comprehension of arrhythmias and antiarrhythmic agents (AAAs) requires a basic knowledge of cardiac electrophysiology. Most clinicians find the understanding of arrhythmia and AAAs difficult. There are approximately 60 medications that directly affect cardiac electrophysiology. Additionally, there are several other non-cardiac medications that may affect the cardiac rhythm indirectly. The goal of this article is to present an understandable discussion of basic cardiac electrophysiology and a review of selected AAAs.

Diagnosis and Therapeutic Management of Depression: An Update in the Use of Selective Serotonin Reuptake Inhibitors (SSRIs)--146-000-00-004-H01

Abstract: Major depression is a very common disorder in the United States. Although effective treatment has been available for almost 40 years, it often goes underdiagnosed and, consequently, undertreated. It has been estimated that the annual cost of depression in the United States totals approximately $43 billion. This figure includes the direct costs of medications and physician visits as well as indirect costs, such as loss of productivity in the workplace. Therefore, it is important to recognize the signs and symptoms of depression in order to treat the disease. The discovery of selective serotonin reuptake inhibitors (SSRIs) has had a major impact on the therapeutic management of depression. Five SSRIs are currently available in the United States market: citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline. This review will focus on the recognition and diagnosis of depression as well as a comparison of the available SSRIs. The SSRIs have made an impact in the treatment of depression because of their favorable side effect profile, tolerability, and relative safety in overdose. Although the SSRIs have, essentially, the same pharmacology, their chemical structures are slightly different; thus, they differ slightly in their side effect profiles as well as their interactions with other medications. The selection of the appropriate SSRI should be based on the patient’s symptoms of depression, concurrent medications (to avoid any potential drug interactions), and side effect profile. Depression is one of the most costly disorders in the United States, and diagnosis is the first step in treatment. Education of the public as well as healthcare providers is the key to the treatment of depression. Once diagnosed, SSRIs can be used effectively to treat depression.

Update on the Management of Common Musculoskeletal Conditions: Osteoarthritis, Rheumatoid Arthritis, and Fibromyalgia--146-000-00-003-H01

Abstract: Musculoskeletal conditions affect over 40 million people in the United States. The 3 most common are osteoarthritis, rheumatoid arthritis, and fibromyalgia. Osteoarthritis is the most common form of all musculoskeletal conditions affecting more than 20 million people in the United States. Rheumatoid arthritis and fibromyalgia are not as common, but have a significant impact on a patient's quality of life and physical functioning. The exact etiologies of these conditions are not well understood, but research on these topics is providing important information about the pathophysiology of these diseases. Currently, therapy is aimed at reducing the pain and other symptoms associated with these conditions. Non-pharmacologic therapies play an important role in the treatment of these disorders including weight loss, exercise, and physical therapy. Pharmacologic therapy is aimed at pain relief and, in the case of rheumatoid arthritis, disease modification. In addition to therapies that have been available for years, new therapies with fewer side effects and more specific mechanisms of action are being studied and released. Pharmacists should become familiar with these therapies to help patients achieve optimal treatment outcomes.

Schizophrenia, Part I: Etiology and Pathophysiology-146-000-99-008-H04

Abstract: There are over 3 million diagnosed cases of schizophrenia in the United States, and 100,000 new cases are diagnosed each year. Schizophrenia is considered to be a chronic disorder and is the most common psychosis. The course of the disease is highly variable, but typically there is a progressive, downward course characterized by deterioration of function and a lifelong need for care and treatment. In many instances, the individual suffering from schizophrenia will proceed through the following phases: prodromal phase, followed by an active phase, and ending in a residual phase. The diagnosis of schizophrenia is made according to the criteria set forth in Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). Delusions and hallucinations are the hallmark symptoms of the disease. Schizophrenia is considered to be a group of disorders commonly divided into the following subtypes: catatonic, disorganized, paranoid, undifferentiated, and residual. The symptoms of the disorder are categorized into positive (presence of an abnormal behavior) and negative (absence of a normal behavior) symptoms. The life expectancy of schizophrenics is 20% shorter than the general population. The etiology is complex and overlapping and includes theories involving neurochemical alternations (most especially of dopamine), genetic contributions, as well as various environmental risk factors (viral, perinatal complications). There is obviously an underlying pathophysiology that leads to the varying clinical subtypes of schizophrenia.

HERBALS AND OTHER DIETARY SUPPLEMENTS IN THE UNITED STATES-Part I-Dietary Supplement Regulations: Impact on Pharmacy. This is a CE program on law. -146-000-99-007-H03

Abstract: Sales of herbal and other dietary supplements have increased sharply in recent years in the United States (U.S.) A 1997 survey of the U.S. herbal markets estimated that 60 million adults (one-third of the adult population) used herbal supplements. Under the Dietary Supplement Health and Education Act of 1994 (DSHEA), dietary supplements are sold as "foods" to be used to supplement the diet. These products are not regulated as nonprescription drugs, or Over-the-Counters (OTCs), and manufacturers do not need Food and Drug Administration (FDA) approval for safety and efficacy prior to marketing dietary supplements. The goal of Part I of this continuing education series is to discuss the issues and controversies surrounding the recent explosion in the use of alternative medicine and dietary supplements. After completing this article, the practicing pharmacist should have a greater understanding of current regulations of dietary supplements, the potential quality assurance problems that may be associated with these products, and how this impacts the practice of pharmacy.

Update on Adult Immunization-146-000-99-006-H01

Abstract: Vaccine-preventable diseases of adults represent a continued source of morbidity and mortality in the United States. Safe and effective vaccines are available for these infections, but they are poorly used. The available vaccines include the pneumococcal, influenza, hepatitis B, hepatitis A, varicella, measles-mumps-rubella, and tetanus-diphtheria vaccines. Among these, the pneumococcal, influenza, and hepatitis B vaccines have the greatest potential for public health benefit. Approximately 50,000 to 70,000 persons die each year in the United States from pneumococcal infection, influenza, and hepatitis B, compared with fewer than 500 children who die from diseases targeted by childhood immunizations. Adult immunization does not receive the same emphasis as the childhood immunization, in spite of deaths from vaccine-preventable diseases occurring predominantly in adults. Reasons for low vaccination rates in adults include a limited perception of the significance of vaccine-preventable diseases by healthcare providers and the public, lingering doubts regarding vaccine efficacy and safety, uncertainty regarding specific recommendations, misconceptions about vaccine contraindications, lack of adult immunization programs, and inadequate reimbursement. Adult immunization should rank among our nation's highest health priorities. Improved vaccine use will require the development and promotion of formalized adult immunization systems as well as sustained efforts to educate both healthcare providers and the public.

Potassium Channel Blocking Agents and Atrial Tachyarrhythmias-146-000-99-005-H01

Abstract: Epidemiologic studies have shown a high incidence of atrial fibrillation/flutter (AFF) in the elderly population. If left untreated, this type of atrial tachyarrhythmia can lead to the development of ischemic events, heart failure, cardiomyopathy, stroke, or syncope. These secondary complications will increase the comorbid conditions in an already fragile population susceptible to decompensation. Therefore, one priority is to restore sinus rhythm early in the process.

Sinus rhythm can be restored either electrically or pharmacologically. Electrical cardioversion requires general anesthesia and a lengthy pre- per- and postcardioversion anticoagulation period, which can become costly, especially in this time of cost-containment restraint. Pharmacologic cardioversion represents an attractive alternative. Among the current, commercially available antiarrhythmic agents, we chose to focus on the therapeutic use of the class III potassium channel blocker agents, such as sotalol, amiodarone, ibutilide, and dofetilide for managing AFF. They have proven to be more tolerable and efficacious in converting AFF back to sinus rhythm as well as maintaining the sinus rhythm for as long as 5 years' postsuccessful conversion. However, the drug choice must be individualized for each patient based on his clinical status and risk factors. By far, the class III antiarrhythmic drugs were more efficacious in converting AFF to sinus rhythm and preventing the recurrence of AFF than the other agents from class I, II, or IV. The proarrhythmic events, such as polymorphic ventricular tachycardia or torsades de pointes, remain a potential risk and require careful monitoring.

Other strategies are also currently under investigation, namely the approach to control the ventricular responses pharmacologically in association with anticoagulation therapy, the surgical procedure maze, the catheter ablation technique, the newer mode of pacing, and the implantable devices.

Primer on Type 2 Diabetes Mellitus-146-000-99-004-H01

Abstract: Ninety percent of diabetics are classified as diabetes mellitus Type 2 (DM-2), most of them over age 65. DM-2 involves both insulin resistance and a relative deficiency of insulin to achieve glycemic control. New guidelines in the classification and diagnosis of diabetes have been established, which may increase the number of newly diagnosed diabetics. The terms, insulin-dependent diabetes (IDDM) and non—insulin-dependent diabetes (NIDDM) have been eliminated because they describe the therapy for the disease rather than the underlying physiology. The fasting plasma glucose (FPG) levels for diagnosing diabetes have been lowered from 140 mg/dl to 126 mg/dl.

Many new oral agents have become available to treat DM-2 since the early 1990s. Sulfonylureas; bedtime insulin, daytime sulfonylurea (BIDS); metformin; troglitazone; repaglinide; and the a-glucosidase inhibitors will be reviewed. The agents have different mechanisms of action, contraindications, and side effect profiles.

With the advent of new oral medications for DM-2 and a large, elderly population with altered pharmacokinetics and pharmacodynamics, pharmacists play an increasing role in appropriate drug selection and appropriate management of DM-2. Diabetes education will be a reimbursable service with new Medicare policies. However, currently, there are no guidelines promulgated as who these providers of diabetes education are. Points for counseling can include medications, pathophysiology, complications, hypoglycemia and treatment, hyperglycemia, foot care, diet, exercise, and appropriate goals of therapy. Pharmacists can be instrumental in providing this education.

Emerging Roles of Low-molecular-weight Heparin Derivatives in Anticoagulation-146-000-99-003-H01

Abstract: Venous thromboembolism is a common problem affecting approximately two million Americans annually. It has been estimated to result in 300,000 to 600,000 hospitalizations in the United States each year. Unfortunately, more patients die each year with pulmonary emboli resulting from venous thromboembolism than American women from breast cancer.

Deep vein thrombosis commonly develops in the lower extremities and is associated with advanced age, prior venous thromboembolism, hypercoagulable states, cancer, trauma, and surgery. It can become a chronic health problem with potential for recurrence, development of the postphlebitic syndrome, and impaired mobility of the affected limbs. Venous ultrasonography is a commonly used diagnostic test to rapidly identify symptomatic patients.

Low-molecular-weight heparins (LMWHs) are an addition to the prophylactic and treatment options of venous thromboembolism. They display favorable pharmacokinetic profiles over unfractionated heparin and offer once or twice daily dosing convenience using the subcutaneous route. They have been evaluated in a variety of clinical conditions associated with venous thromboembolism and have similar or greater efficacy than unfractionated heparin. LMWHs require minimal monitoring and have a lower incidence of heparin-induced thrombocytopenia. The rates of bleeding complications with these agents are similar or slightly lower than unfractionated heparin. Although LMWHs are more expensive than conventional unfractionated heparin, the overall savings with potentially earlier discharge from the hospital and less monitoring may override the higher drug acquisition costs.

Lyme Disease and other Co-transmitted Tick-borne Agents--146-000-99-002-H04

Abstract: Lyme disease is the most prevalent tick-borne disease in the United States. The disease caused by Borrelia burgdorferi (B. burgdorferi) is characterized as chronic with multiorgan involvement. Disease manifestations can range from asymptomatic to chronic rheumatologic and neurologic symptoms or, rarely, death. Because of the protean characteristics of the clinical manifestations diagnosis is difficult. Diagnosis is usually performed using a combination of clinical presentations and patient history. The ability of the tick to transmit Lyme disease is confined to those molts beyond the larval stage, with the nymph associated with most of the transmission of the disease agent to humans. Since there is essentially no transovarial transmission of the Lyme disease agent in the tick, reservoir hosts are essential for maintenance of the spirochete in nature. The principle reservoir for the spirochete is the white-footed mouse.

In addition to Lyme disease, the clinical picture associated with tick-borne diseases is further complicated by the coinfection of the white-footed mouse with Ehrlichia and/or Babesia. Human granulocytic ehrlichiosis is characterized as having an acute onset with symptoms that can resemble toxic shock syndrome, requiring the hospitalization of approximately 60% of infected individuals. Babesiosis is a malarial-like illness with an insidious onset and the ability to recrudesce. The peak season for all three diseases mirrors that of the tick population (i.e., spring and summer).

Among the emerging and reemerging agents of infectious diseases are the agents of zoonoses including Borrelia burgdorferi (B. burgdorferi), Ehrlichia species (sp.), and Babesia. Because each of these agents has caused the incidence of disease to have increased sharply, what is also of concern is that they are transmitted by the same ticks (i.e., deer ticks, western black-legged ticks, and the lone star tick). The implication of this is that the clinician must maintain an index of suspicion when a patient presents with clinical symptoms associated with a tick bite. There may be the need to treat for multiple etiologic agents, which range from an obligate intracellular pathogen (ehrlichia) to a eucaryotic protozoal parasite (babesia), in addition to the free-living spirochetal agent that causes Lyme disease. This review will cover each of these agents of tick-borne disease.

Vancomycin-resistant Enterococcus: Implications for Pharmacy--146-000-99-001-H01

Abstract:Vancomycin-resistant enterococci (VRE) have emerged as a significant problem in the healthcare system. Normal flora inhabiting the human intestinal tract, enterococci have increasingly been isolated as pathogens, now being the second most common cause of nosocomial (hospital-acquired) infections. This high prevalence is exacerbated because many of these organisms are beginning to exhibit resistance to vancomycin, as well as many other antibiotics.

For over 40 years vancomycin has been the gold standard for the treatment of gram-positive infections. During this time the overuse of other antibiotics has exerted selective pressure, which has facilitated the development of organisms resistant to these agents. The resultant multidrug-resistant VRE is extremely difficult to treat in most cases, requiring development of patient-specific treatment plans, often involving multiple antibiotics.

Prevention, early detection, and control of this organism make the greatest impact in treating VRE. To facilitate this process, the Centers for Disease Control (CDC) have published extensive guidelines for the prevention and control of VRE.

The possibility of further VRE emergence or even the transfer of this resistance to other organisms, such as Staphylococcus aureus (S. aureus), is of great clinical concern. This paper will focus on the two most important implications for today's healthcare pharmacist:

• Strategies of antibiotic use to hinder the further development of VRE
• Various treatment options for the medical management of this organism

Pharmacotherapeutic Management of Chronic Heart Failure --146-000-98-005-H01

Abstract: Congestive Heart Failure (CHF) is a chronic, progressive disease associated with high rates of morbidity and mortality. It affects approximately five million Americans, and its associated healthcare costs are continuing to rise. CHF often results from an initial injury to the myocardial tissue, leading to decreased myocardial contractility, stroke volume, and cardiac output. Early on, compensatory mechanisms, such as the release of endogenous catecholamines and angiotensin II, attempt to maintain adequate cardiac output. When compensatory mechanisms fail, clinical symptoms of heart failure ensue. Left ventricular CHF can be secondary to either systolic or diastolic dysfunction and can be acute or chronic in nature. Clinical signs and symptoms are similar; therefore, diagnosis should be based on objective findings obtained from echocardiography or radionuclide ventriculography. Pharmacotherapeutic management of systolic and diastolic chronic CHF differs, emphasizing the importance of an adequate diagnosis before initiating therapy. Current agents available for treating CHF include angiotensin-converting enzyme inhibitors, angiotensin II antagonists, diuretics, digoxin, beta-adrenergic blocking agents (beta blockers), calcium channel blockers, vasodilators, and nitrates. Appropriate selection of these agents should be based on the type of heart failure, safety and efficacy profile, and available clinical outcomes data.

Adverse Drug Reactions and Events: What, Why, and How?--146-000-98-004-H04

Abstract: For many years the prevention, documentation, and reporting of adverse drug reactions (ADRs) have been an important part of the pharmacist's practice. Recently, healthcare has expanded beyond simple ADR reporting to encompass more inclusive concepts such as drug misadventuring, medication-related problems, and/or adverse drug events (ADEs). The primary impetus behind this expansion is the growing realization that deleterious consequences, which may be associated with medication use (or misuse), extend beyond adverse reactions and may include therapeutic appropriateness, errors, compliance, and other problems that result in suboptimal outcomes.

The recent resurgence of interest in this topic has been driven by a number of factors in the healthcare environment. There are both regulatory and professional standards for the reporting of ADEs. Furthermore, the high incidence and costs associated with these events have caused increased focus on the subject. Another contributing factor is the increasing recognition of the need for extensive post-marketing surveillance for adverse events, especially to detect those adverse reactions that occur infrequently and/or in those new agents whose approval has been expedited. A possible last factor in the rediscovery of this subject has been the continued evolution and implementation of pharmaceutical care in multiple practice settings.

An Update on the Diagnosis and Management of Peptic Ulcer Disease --146-000-98-003-H01

Abstract: The relationship of H. pylori to peptic ulcer disease (PUD) has been known for over a decade. Virtually all H. pylori-positive patients have antral gastritis.1 Nearly all duodenal ulcer patients and 80%of gastric ulcer patients whose ulcers are not NSAID-induced are H. pylori-positive.1 Yet, some ulcer patients continue to be treated with acid-lowering therapy alone. Though acid-lowering drugs play an important role in the treatment of H. pylori infection, multiple-drug treatment regimens must be used to eradicate H. pylori. Therefore, pharmacists need to focus on patient compliance, increased incidence of adverse events and drug interactions as well as efficacy, antibiotic resistance, and cost. Endoscopy, although invasive and costly, is an accurate way to detect H. pylori infection and visualize the GI tract. Newer methods of detecting H. pylori infection are fast, non-invasive, accurate, inexpensive and simple to perform. Whole blood or serology tests can be used for initial screening of patients. Urea breath tests can be used to verify eradication of H. pylori infection after initial treatment. Since ulcer patients have a high incidence of H. pylori infection, several questions remain. Should symptomatic patients with or without a past history of PUD be empirically treated with antibiotics? Should asymptomatic patients with a history of PUD be tested for H. pylori infection and treated if positive? Selection of the optimal medication regimen to treat H. pylori infection continues to be problematic for physicians. Since the optimal regimen that combines high eradication rates with low side effects, short treatment duration, low cost, and minimal recurrence has yet to be discovered, it seems that proton pump inhibitor (PPI) triple therapies offer the most advantages in treating H. pylori-related ulcer disease.