Prescriber's letterより

有名なprescriber's letter。

You'll see two new protease inhibitors for hepatitis C, Incivek (telaprevir) and Victrelis (boceprevir).
That's right...protease inhibitors for hep C.
These are "game changers." They lead to much higher cure rates and shortened treatment duration. They're ADDED to pegylated interferon and ribavirin for genotype 1 hep C. なるほど。
They can also help patients who didn't respond to previous therapy.これは有り難い。
But Incivek and Victrelis cost $26,500 to $49,000...and they're challenging to use. For example, Incivek can cause itching and rash...and Victrelis can cause severe anemia. すでに、Pegasys + ribavirinだけでneutropeniaとか貧血とか色々大問題があるのに。それは困るだろうね。
Plus these hep C protease inhibitors interact with a laundry list of drugs...just like HIV protease inhibitors (ritonavir, etc).
If you have a patient on one of these new hep C drugs, don't add simvastatin, lovastatin, triazolam, alfuzosin, rifampin, and others.
Remember that women of childbearing age on ribavirin must use TWO reliable contraceptives since ribavirin causes birth defects.
Now keep in mind the new twist...Incivek and Victrelis can make hormonal contraceptives less effective. Advise these women to use two barrier contraceptives instead.これは、、、えーっっと、コンドーム&ダイアフラムを両方同時に使うってことかな?ダイアフラムなんて今時使っている人も少ないよね。私も授業で習ったけど一回の処方してないし。ピル使えないのは辛いね。
Emphasize adherence with Incivek and Victrelis...very high adherence is needed for them to be effective and to limit resistance.HIVの薬と一緒ね。
See our PL Detail-Document, Victrelis and Incivek for Hepatitis C, for their dose regimens, adverse effects, and drug interactions.

You'll hear debate over which long-acting bronchodilator to use first-line for COPD.
Guidelines suggest either tiotropium (Spiriva) or a long-acting beta-agonist (salmeterol, formoterol) for persistent symptoms.
Both types of bronchodilators improve COPD symptoms...but tiotropium seems to work better to prevent exacerbations.
One more exacerbation can be prevented for every 25 patients treated for one year with tiotropium instead of salmeterol.
Tiotropium is given just once daily...compared to twice daily with salmeterol or formoterol. But tiotropium costs about $250/month...compared to $180/month for salmeterol or formoterol. 確かに、高いから処方しても患者さんがそれを使ってくれない。。。という問題は、経験したことがある。だから結局Advairになっちゃったり。
And there's no proof that any of them reduce mortality.
Lean toward tiotropium first if cost isn't a problem...especially for patients with heart disease. Beta-agonists might exacerbate heart failure...or reduce the efficacy of beta-blockers.
Be careful about using tiotropium in men with benign prostatic hyperplasia...due to possible urinary retention.  これ、忘れてた〜 気をつけなければ。
Combine tiotropium and a long-acting beta-agonist if needed. Watch for Arcapta (indacaterol) next will be the first once-daily long-acting beta-agonist.
Save inhaled steroids or steroid/beta-agonist combos (Advair, etc) for more severe COPD or frequent exacerbations. Explain that inhaled steroids are linked to a higher risk of pneumonia and fractures. そうそう。


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