CASE 1: LR, a 43-year-old man, is complaining of mouth sores and receding gum lines. He has been using chewing tobacco for the past 20 years and asks if there is a way to quit. LR's medical history includes alcohol abuse, though he is now sober; hypertension; and major depressive disorder. His conditions are stable, as he takes fluoxetine 40 mg daily and losartan 50 mg daily. LR has been receiving behavioral therapy to help quit but says he needs additional assistance. He asks if there are medications that can help him. 

What should the pharmacist recommend?

ANSWER: 
A systematic review completed by the Cochrane Library presented data from 34 different randomized trials on treatment for smokeless tobacco. The results showed that neither nicotine gum nor the patch increased abstinence. However, behavioral interventions, nicotine lozenges, and varenicline showed some benefit.1 Varenicline showed the highest rates of long-term nicotine abstinence, with rates up to 34% versus a placebo.1 Nicotine lozenges may not be the best choice for LR, given his dental complaints. Although he has a history of alcohol abuse and psychiatric illness, both conditions appear stable. Therefore, varenicline can be tried. The pharmacist should counsel LR about the possible adverse effects of varenicline, including nausea and worsening of his mood. Nicotine withdrawal symptoms should also be discussed. The pharmacist should reinforce LR's abstinence, as alcohol use is not recommended while on varenicline, encourage him to continue with behavioral therapy, and follow up with his primary care provider routinely.

REFERENCE
Ebbert JO, Elrashidi MY, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev. 2015;2015(10):CD004306. doi:10.1002/14651858.CD004306.pub5



CASE 2: SP is a 68-year-old woman who was discharged 3 weeks ago from the hospital with newly diagnosed nonvalvular atrial fibrillation. An ambulatory care pharmacist is assessing her medications posthospitalization. SP's medical history also includes gastroesophageal reflux disease, hypertension, macular degeneration, and obesity. Upon discharge, she was prescribed warfarin for stroke prevention. SP's medications include amlodipine 10 mg daily, omeprazole 20 mg daily, OTC calcium supplements, and warfarin 5 mg daily per the international normalized ratio (INR). She expresses concern because, given her macular degeneration, she is unable to drive and does not think she will be able to come in for monthly INR monitoring. SP asks if there are alternatives to warfarin that may be suitable for her. 

How should the pharmacist respond?

ANSWER: Guidelines for nonvalvular AF recommend direct-acting oral anticoagulants (DOACs) over warfarin when possible. Apixaban and rivaroxaban are most commonly used in practice. Compared with warfarin, rivaroxaban was noninferior for stroke prevention but was associated with a lower risk of intracranial and fatal bleeding.1 In another study that compared apixaban with warfarin, apixaban demonstrated lower rates of all-cause mortality, bleeding, and stroke.2 No prospective, randomized trials have compared the 2 DOACs, but a recent retrospective cohort study did compare their efficacy and safety. Apixaban was found to have fewer rates of gastrointestinal bleeding, intracranial hemorrhage, stroke, and systemic emboli.3 Additionally, rivaroxaban is listed on the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medical Use in Older Adults as potentially inappropriate in older adults because of the increased risk of bleeding. SP can likely benefit from apixaban 5 mg twice daily to lower her risk of stroke.

REFERENCE
  1. Avezum A, Lopes RD, Schulte PJ, et al. Apixaban in comparison with warfarin in patients with atrial fibrillation and valvular heart disease: findings from the aixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (ARISTOTLE) trial. Circulation. 2015;132(8):624-632. doi:10.1161/CIRCULATIONAHA.114.014807
  2. Bansilal S, Bloomgarden Z, Halperin JL, et al; ROCKET AF Steering Committee and Investigators. Efficacy and safety of rivaroxaban in patients with diabetes and nonvalvular atrial fibrillation: the rivaroxaban once-daily, oral, direct factor xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF trial). Am Heart J. 2015;170(4):675-682.e8. doi:10.1016/j.ahj.2015.07.006
  3. Fralick M, Colacci M, Schneeweiss S, Huybrechts KF, Lin KJ, Gagne JJ. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. 2020;172(7):463-473. doi:10.7326/M19-2522
 
Nicholas Rioux is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

Stefanie C. Nigro, PharmD, BCACP, CDE, is an associate clinical professor at the University of Connecticut School of Pharmacy.