Therapeutic Debate Paper
Therapeutic Debate Paper
The student pharmacist will choose from a therapeutic debate topic from the list of topics that will be provided. The student pharmacist will research the topic and then, using primary literature, discuss both sides of the argument. The student pharmacist will then determine what they would do, if asked by a physician, for a given patient based on the literature that they researched.
The paper should be written in a debate or position paper format. The paper will be between 4-7 pages, double-spaced, 12-point Times New Roman, one-inch margins. References will be cited using AMA format. All papers will be submitted to Turn-it-in prior to submission. Submissions will include the Turn-it-in report with the submission. Plagiarism, or lack of Turn-it-in report, will result in an automatic 0 for this assignment.
Therapeutic Debate Topics:
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Please chose one (1) question to answer from the list below:
1. What is the best Direct Oral AntiCoagulant (DOAC) to use for a patient with non-valvular atrial fibrillation (CHADS2-VASC=4) that has a CrCl of 20 ml/min?
2. Given that the number one cause of death in ESRD patients is cardiac related, should a patient that has never been on a statin before and has recently started dialysis be place on a statin (Pt is 60 years old).
3. Should the thiazide of choice for a patient with hypertension be hydrochlorothiazide or chlorthalidone?
4. Should we use normal saline or acetylcysteine prior to a procedure that uses contrast dye for a patient that is at increased risk for developing or worsening acute kidney injury?
5. Should patients that have had a recent (within 1 year) drug eluting stent placed plus paroxysmal atrial fibrillation be using triple therapy (dual antiplatelet therapy plus and anticoagulant) or double therapy (one antiplatelet plus an anticoagulant)?
6. Should a patient (CHADS-VASc 5) receiving warfarin for atrial fibrillation be bridged with heparin if holding warfarin prior to a surgical procedure?
7. Should aspirin be used for primary prevention in non-DM patients?
Therapeutic Debate Writing Assignment Scoring Rubric
5-Outstanding
4-Satisfactory
3-Almost There
2-Needs Work
1-Does Not Meet
Grade
Clinical
Background
Clear, well-defined background of the topic and clearly elucidated why there is a clinical controversy in the area.
Clear, well-defined background of the topic and briefly described a clinical controversy in the area.
Very generalized statement on background without much background information that would help my audience understand.
I did not give an explanation on the background of my topic, but I gave some information on it throughout my presentation.
I did not introduce my topic or give any background information to help my audience understand my presentation.
Analysis of literature and overall argument
Described in detail the strengths and limitations of the data being discussed. Argued why some data should be accounted for more heavily than other literature in a convincing way.
Described most of the strengths and limitations of the data being discussed. Provided relevant reasons for viewpoint based on literature.
Described data but did not discuss strengths and weaknesses. Argument was without substantive rationale.
Did not describe basic trial data thoroughly. No mention of study design, number of patients, primary endpoints, or statistical values. Argument was not based on facts.
Primary literature was not used. Argument was not based on supporting facts.
Organization
All arguments were tied to an idea and organized in a logical fashion
Most arguments were clearly tied to an idea and organized in a logical fashion
All arguments were clearly tied to an idea but the organization was sometimes not clear or logical
Arguments were not tied to well to an idea
Arguments were not tied to an idea at all
Writing Skills
No writing errors (complete sentences, correct punctuation, correct word use); well organized; good word choice
Minor (1-4) writing errors (incomplete sentences, incorrect use of words, ungrammatical, poor punctuation, lacks organization, and/or difficult to understand)
Some (5-9) significant writing errors (incomplete sentences, incorrect use of words, ungrammatical, poor punctuation, lacks organization, and/or difficult to understand)
Writing quality significantly interferes with comprehensibility of answer (10+ errors) (incomplete sentences, incorrect use of words, ungrammatical, poor punctuation, lacks organization, and/or difficult to understand)
Writing quality renders answer incomprehensible (incomplete sentences, incorrect use of words, ungrammatical, poor punctuation, lacks organization, and/or difficult to understand)
Use of Primary Literature
> 3 primary literature sources are utilized. The sources represent current opinion on clinical controversy
References are appropriately cited based on AMA style guidelines throughout the document and in the references section
> 3 primary literature sources are utilized. The sources represent some of the current opinion on clinical controversy and/or
some references are appropriately cited based on AMA style guidelines throughout the document and in the references section
< 3 primary literature sources are utilized
Utilized primary literature is outdated and/or does not represent currently accepted clinical consensus.
More than 2 references are not appropriately cited based on AMA guidelines throughout the document
< 2 primary literature sources are utilized
Utilized primary literature is outdated and/or does not represent currently accepted clinical consensus.
More than 3 references are not appropriately cited based on AMA guidelines throughout the document
No appeal to primary literature OR all references are not appropriately cited based on AMA guidelines throughout the document.
Conclusion/
Professionalism
Provided a specific clinical recommendation for a provider in how to proceed. Language used is professional and at the level that a fellow provider would appreciate. No derogatory or condescending statements used.
Provided a specific clinical recommendation for a provider in how to proceed. Language used may not be completely professional and at the level that a fellow provider would appreciate. No derogatory or condescending statements used.
Clinical position is not appropriately justified. Clinical position is not derived from totality of literary evidence. Language used is professional and at the level that a fellow provider would appreciate. No derogatory or condescending statements used.
Clinical position is not appropriately justified. Clinical position is not derived from totality of literary evidence. Language used may not be completely professional and at the level that a fellow provider would appreciate. No derogatory or condescending statements used.
No definitive clinical position was taken OR Language used was unprofessional or not at a level that a fellow provider would appreciate OR Derogatory or condescending statements were used.
Total: / 30 possible points
Therapeutic Debate Practice Session
Rationale: Clinical pharmacists in practice are routinely asked to provide recommendations for pharmacotherapy which fall outside the general purview of therapeutic guidelines. More succinctly, many medication questions arise form scenarios with no definitive answer. This experience is designed to develop critical thinking skills and literary assessment techniques to justify therapeutic recommendations.
Assignment:We will be working through a practice example of formulating a therapeutic debate and deciding on an appropriate option based on the data as a class.
Topic: What is the optimal target blood pressure for older adults to reduce risk of morbidity and mortality?
Background information: Blood pressure targets have been a hot topic recently with new trials potentially showing that treating older adults to lower blood pressure targets may provide morbidity and mortality benefit. Other trials including the newest hypertension guidelines remain more conservative.
Prior to Class/Pre-class assignment:Please research primary literature (including guidelines on the topic) on blood pressure targets for older adults. Please skim/review the articles and pick one to write up a BRIEF synopsis/journal club on the trial, its findings, strengths and weaknesses and turn in prior to class.
In class:We will be splitting the class into two groups. One group will argue for using lower blood pressure targets for older adults and the other group with argue against using lower blood pressure, or rather will be for using the traditional or higher targets for blood pressure for older adults. Last names of A-K will be FOR using lower blood pressure targets and L-Z will be FOR using higher blood pressure targets, or AGAINST using lower blood pressure targets. Keep in mind that sometimes the best way to stage an argument against one position would be to find flaws in the pro or con argument… meaning you would need to look at data on both sides of the debate to be able to discredit or argue for a side.
We will spend the first half of class in groups discussing the articles that you found and then we will discuss the data the second half of class and, hopefully, come to a resolution.
In support Lower target
Sprint
What about it says should do lower target-reduces mortality keeps people alive.
Reduce cardiac events as well. As compared to the higher amount
Sprint-Pros about the trial, strengths std of treatment groups comparable, baseline, cv risk, etc.
Starting blood pressure comparable, pretty good match between the patients. Lower group definitely group
Average age group was our are of interest (older group
Large (10000) sample size
All of that, ok cool sounds good
INVEST Trials, strictly more relaxed systolic BP groups,
Between strict and relaxed marginal cv mortality benefits, compoarring unctonrolled control group.
More controlled gets more moratlity benefits. Big sample size 32000 people showing lower is better
Patients >75 age pts~3000 patients
Similar results, live longer
Jatos . external validity in question due to all of the patients being Japanese. Endpoint were blindided.
HYVET trial lower is better but didn’t discuss how low is too low.
Older adults, why would you not eculde 50
CON: group in support of traditional target.
Meta analysis, Older adults siimilar effect between traditional and strict control in terms of morbidity and mortality
Trials meta analysis 15 included sprint only split it up into two group . 16 even though 16 trials, 10000 in high intensity 33 in the lower more patients.
JATOA trial found the loweing blood prsssure lowering <140 compared to 160 to 160 didn’t had similar rates of morbidity and mortality
2200 pts in each arm of trial
Observational Studies
339887 pts more risk of AKI?CKD with intensive lowering
Failed to ahcive benefit
HYVET
4000 over 80 yo Bp>160/90 treating to goal of 150/90 imprved all cause mortality
Accord
40-79 average age 62
<140 vs <120…..no difference in Primary outcome in MACCE
Increase in adverse effects
For Sprint trials-no nursing home patients, disparity in asprin use between lgroups, lower bp had more pts on asprining lower bp ahad more pts on asprinn…..
6 years of follow up….
Sprint xculued pts with hx stroke and 5- yyears old and dm. .
Greater amount of AKI, and electrolyte abnormalities ….study was terminated early. Why? Pro.
Stopped early 140 people dying
140 group was dying more. Look at the number of heart failre. Heart failure. Groups stat
Heart failure statisitically signicant 0.002- they had to down titrate diuretics on heart failure into the standard trement, reduced their mount of diuretics, bad….changed that a little bit.
Look at which one is really pulling that pullig primary outcome into that range. Hewart failure is part of that.
So
Sprint not external validity. Comobordities, in sample size even though good trial did stop it early. Especially extreme blood pressure. count on sprint trials, for blood patietns.
Paper in AMA style superscript we all have to do it. Haven’t found this yet. Super easy reference manager on library website. Use super easy
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