Cardiovascular System Drugs Research Articles

Study on drug related hospital admissions in a tertiary care hospital in South India

Background and objectives Accidental and intentional poisonings or drug overdoses constitute a significant source of aggregate morbidity, mortality, and health care expenditure. Studies evaluating drug related hospitalization have estimated that approximately 5–10% of all hospital admissions are drug related. The present study was carried out to investigate type, nature and incidence of drug related admissions in our hospital settings. Method A hospital based retrospective study was conducted in 575 cases of drug related admissions. The case records of patients admitted in various clinical departments of Amrita Institute of Medical Sciences (AIMS) Hospital during last 8 years (January 2002–December 2009) were collected and analyzed. Results During the retrospective study, the total number of drug related cases reported were 575. Out of these, 35.5% cases were induced by central nervous system (CNS) drugs, 19.8% were by cardiovascular system (CVS) drugs, 12.3% were by NSAIDs, 11.3% were by antibiotics and 9.9% were by anticoagulants, 11.3% by other drugs which includes hormones, cytotoxic drugs, hypolipidemics, etc. Four hundred and forty cases were admitted to emergency department. Common drug related problems resulting in hospital visits were due to intentional, accidental and overdose. The incidence of drug related hospital admissions was found to be 0.20%. Conclusion The most of the accidental and suicidal cases were reported are by CNS drugs. Psychiatric patients intentionally taking medicines as suicidal attempt and as a part of their illness. As drug related problems are so significant, increased awareness and enhanced collaborative efforts among patients, physicians, pharmacists and caregivers within community and hospital have the potential to minimize the impact of this problem.

Recent Patents on Oral Combination Drug Delivery and Formulations

Oral combination drug delivery systems have been proven to be highly beneficial and vital in the treatment of several dreadful diseases such as cancer, HIV (AIDS) and tuberculosis. Further, pharmaceutical companies have often explored the strategy of combination drug therapy for treating diseases such as diabetes (Type 2), cardiovascular diseases, central nervous system (CNS) disorders, and for treating several other microbial infections. Patenting combination drug delivery systems and formulations has been proven to be very beneficial for the sustainment and growth of pharmaceutical industry. Several pharmaceutical companies have explored this opportunity in extending the life cycle of their blockbuster molecules, and providing additional sources of revenues when the new chemical entity (NCE) discovery is scarce. The article reviews some recent combination formulation patents and patent publications, particularly the US patents and patent applications, relevant to oral delivery of pharmaceuticals. Examples of some oral combination products on the US and worldwide market are presented. Patents and patent applications on combination oral formulations relevant to analgesics (including anti-inflammatory and antipyretics), cardiovascular system (CVS) products, antibacterial and antiviral, and central nervous system (CNS) products are briefly discussed.

Principal Component Analysis of HPLC Retention Data and Molecular Modeling Structural Parameters of Cardiovascular System Drugs in View of Their Pharmacological Activity

Evaluation of relationships between molecular modeling structural parameters and high-performance liquid chromatography (HPLC) retention data of 11 cardiovascular system drugs by principal component analysis (PCA) in relation to their pharmacological activity was performed. The six retention data parameters were determined on three different HPLC columns (Nucleosil C18 AB with octadecylsilica stationary phase, IAM PC C10/C3 with chemically bounded phosphatidylcholine, and Nucleosil 100-5 OH with chemically bounded propanodiole), and using isocratically acetonitrile: Britton-Robinson buffer as the mobile phase. Additionally, molecular modeling studies were performed with the use of HyperChem software and MM+ molecular mechanics with the semi-empirical AM1 method deriving 20 structural descriptors. Factor analysis obtained with the use of various sets of parameters: structural parameters, HPLC retention data, and all 26 considered parameters, led to the extraction of two main factors. The first principal component (factor 1) accounted for 44–57% of the variance in the data. The second principal component (factor 2) explained 29–33% of data variance. Moreover, the total data variance explained by the first two factors was at the level of 73–90%. More importantly, the PCA analysis of the HPLC retention data and structural parameters allows the segregation of circulatory system drugs according to their pharmacological (cardiovascular) properties as shown by the distribution of the individual drugs on the plane determined by the two principal components (factors 1 and 2).

Exploring Differences in Drug Doses Between Japan and Western Countries

Japan is unique among Asian countries in that it requires inclusion of substantial domestic clinical trial data in new drug application data packages. Some question the need for this and call for globalization of approved doses. The current study examines international differences in maximum daily dose of drugs approved in Japan between 2001 and 2007, and for all cardiovascular system (CVS) and central nervous system (CNS) drugs marketed in Japan. For 32% of the drugs approved in Japan between 2001 and 2007, the maximum recommended dose in the United States was > or =2 times higher than the maximum dose approved in Japan. Dose differences were rare for antitumor and antiviral drugs and also for priority-review and orphan drugs. Of all the price-listed CVS drugs currently available in Japan, 65% had maximum doses that were > or =2 times higher in the Netherlands than in Japan; similarly, 57% of the drugs had maximum doses that were > or =2 times higher in the United States than in Japan. For CNS drugs, these figures were 32% (the Netherlands) and 29% (United States). These results underscore the necessity to carry out quantitative analyses to determine the causes of these differences.

Intervenciones farmacoterapéuticas realizadas mediante un programa de prescripción electrónica en una unidad de medicina interna

IntroductionThe objective of this article is to describe the drug-related interventions made in the prescriptions with a computerized order entry system and to determine their frequency and clinical relevance in order to propose improvement actions. Material and methodObservational descriptive study. Drug-related interventions made in the inpatient's prescriptions of an Internal Medicine unit from January to May of 2007 were analyzed and recorded. The frequency of the intervention causes and of the drugs involved was determined. The clinical significance and impact of the recommendations were also determined. ResultsA total of 441 interventions were recorded, 0.73 per patient. The most frequent was the proposal of intravenous to oral conversion (45%), mainly with acetaminophen (63%) and protons pump inhibitors (24%). This was followed by replacement of drugs not included in the guide (15% of interventions), mainly involving cardiovascular and central nervous system drugs (23% each one). Educational actions proposed included a campaign to promote intravenous to oral conversion and a program involving therapeutic equivalent replacement. The most clinically significant interventions were due to dosage errors, therapeutic duplicities, off label medications and adverse events. A proposal was made to include a new module in the medical order entry system that alerts on the established maximum doses for each drug, and new protocols for the treatment of certain conditions. Sixty percent of the interventions achieved an improvement in efficiency. DiscussionWe conclude that drug therapy intervention analysis can identify items that can be improved, set educational actions for physicians and new protocols for certain conditions. Innovative actions can be introduced into the medical order entry system in order to improve drug safety.

Prescription Audit carried out at the Pharmacy Practice Centre of the University of Nairobi between June and November 2004

A retrospective descriptive study was carried out from June to November 2004 in a retail pharmacy situated at the School of Pharmacy, University of Nairobi within the Kenyatta National Hospital complex. The objective was to evaluate prescribing habits and to determine the frequency of prescribing of commonly used drug classes in a hospital. The average number of drugs per prescription was 2.20  1.16. The prevalence of prescribing was 28.6% anti-infective drugs, 21.1% musculoskeletal agents, 16.6% respiratory system drugs, 8.1% cardiovascular system drugs, 7.2% central nervous system drugs, 7.1% gastrointestinal system drugs, 4.3% minerals and vitamins, 2.1% ear, nose and throat drugs, 1.1% endocrine drugs, 2% skin preparations, 0.9% anticancer drugs and 0.74% eye preparations. The prescribing habits evaluated were compared to the legal requirements in Kenya and to recommended international practice. The information gathered may serve as a basis for rational use of drugs. Keywords: keyword; keyword; keyword East and Central African Journal of Pharmaceutical Sciences Vol. 10 (2) 2007: pp. 50-54

Have newer cardiovascular drugs reduced hospitalization? Evidence from longitudinal country‐level data on 20 OECD countries, 1995–2003

This study examines the effect of changes in the vintage distribution of cardiovascular system drugs on hospitalization and mortality due to cardiovascular disease using longitudinal country-level data. The vintage of a drug is the first year in which it was marketed anywhere in the world. We use annual data on the utilization of over 1100 cardiovascular drugs (active ingredients) in 20 OECD countries during the period 1995-2003. Countries with larger increases in the share of cardiovascular drug doses that contained post-1995 ingredients had smaller increases in the cardiovascular disease hospital discharge rate, controlling for the quantity of cardiovascular medications consumed per person, the use of other medical innovations (computed tomography scanners and magnetic resonance imaging units), potential risk factors (average consumption of calories, tobacco, and alcohol), and demographic variables (population size and age structure, income, and educational attainment). The estimates also indicate that the use of newer cardiovascular drugs has reduced the average length of stay and the age-adjusted cardiovascular mortality rate, but not the number of potential years of life lost due to cardiovascular disease before age 70 per 100,000 population. The estimates indicate that if drug vintage had not increased during 1995-2004, hospitalization and mortality would have been higher in 2004. We estimate that per capita expenditure on cardiovascular hospital stays would have been 70% ($89) higher in 2004 had drug vintage not increased during 1995-2004. Per capita expenditure on cardiovascular drugs would have been lower in 2004 had drug vintage not increased during 1995-2004. However, our estimate of the increase in expenditure on cardiovascular hospital stays is about 3.7 times as large as our estimate of the reduction in per capita expenditure for cardiovascular drugs that would have occurred ($24).

DRUG POISONING IN SLOVENIA

BACKGROUND The Slovenian Register of Intoxications managed by the Poison Control Centre at LjubljanaUniversity Medical Centre was established in 2001. It offers a continuous review ofpoisoning in Slovenia. Our aim was to study the epidemiology of acute drug poisoning inadult patients admitted to hospitals in Slovenia. METHODS We analyzed the data of reported acutely poisoned patients older than 16 years who weretreated in hospitals in Slovenia between 2001 and 2005. RESULTS A total of 1,838 adult acutely poisoned patients were reported to the Register of Intoxicationsbetween 2001 and 2005, of whom 1,234 (67 %) were poisoned by drugs. 67 % ofpatients poisoned by drugs were women and 76 % of patients ingested drugs at home 85 % of patients ingested drugs in suicide attempts. Anxyolytics, hypnotics, sedatives, antipsychoticsand antidepressants represented 68 % of all ingested drugs due to self-poisoning.Drugs for the musculo-skeletal system and drugs for the cardiovascular system followedpoisoning by these drugs. There were 6 benzodiazepines and related drugs betweenthe 10 most commonly ingested drugs due to self-poisoning. The most common signs ofacute drug poisoning were somnolence and coma (75 %). A gastric lavage was performedin 64 % of patients, active charcoal was given to 73 % of patients and 35 % of patients weretreated with an antidote. CONCLUSIONS Poisoning by drugs for the nervous system, particularly benzodiazepines, is the most commonform of poisoning by drugs in Slovenia. It would be necessary to report all acutelypoisoned patients to the Register of Intoxications, since we need data about all poisoningin Slovenia to improve their prophylaxis and treatment

Profile of drug utilization in the elderly living in Porto Alegre, Brazil.

The elderly population is one of the most rapidly increasing populations in the world. Physiological alterations induced by the aging process make these individuals more susceptible to chronic diseases and, consequently, to increased drug utilization. To describe the profile of drug utilization in the elderly living in Porto Alegre, RS, Brazil. An observational and cross-sectional population-based study to investigate the characteristics of the population, sources of information and types of drugs used by the elderly was performed. Four hundred and eighty patients were recruited from data supplied by the City Hall of Porto Alegre. The elderly were interviewed individually during the period from January to May 2006 by trained interviewers. A validated pharmacotherapy questionnaire was used for data collection and data were tabulated and analyzed by the SPSS 11.5 computer program. Of the 480 patients interviewed, 13.8% did not use any medication. Cardiovascular system drugs represented the pharmacological class most used by the elderly (64.0%). When ill, 71.9% of these individuals visited the doctor, while 36.9% self-medicated. For the majority (50.2%), drugs were identified by their labels. Only 41.2% of the elderly understood medical prescriptions and 68.3% of the patients studied obtained the necessary information for the appropriate use of therapy from their doctors. The present study suggests that a pharmaceutical care program for the treatment, prevention, and use of medications may provide a higher efficiency to elderly drug therapy.

Survey of Forged Prescriptions to Investigate Risk of Psychoactive Medications Abuse in France

To describe patterns of drug diversion from 2001 to 2004 in France and to define different profiles of forged prescriptions. Data from a national cross sectional survey carried out each year since 2001 were analysed. A national network of community pharmacies is requested to collect suspect prescriptions during two periods each year in May and November. Data included were date, age and sex of the patient, type of prescription form, drugs and criteria of suspicion. Between 2001 and 2004, a sample of 1710 abnormal prescription forms were analysed. These concerned women in 54% of cases. The average age of those sampled was 47 years. Sixty-one percent of the 597 varieties of medication belonged to the anatomic therapeutic chemical (ATC) nervous system class. The most frequently involved drugs were benzodiazepines and benzodiazepine analogues (flunitrazepam, zolpidem) or opioids (buprenorphine, morphine). Multiple correspondence analysis underlined two opposite profiles for suspicious prescriptions: (i) specific prescription forms for scheduled drugs presented by men aged <45 years involving drugs for the nervous system and presenting the criteria of stolen, falsified and abnormal prescriptions; and (ii) prescription forms presented by women aged >45 years involving cardiovascular and muscular-skeletal system drugs, presenting the criteria of alteration to the prescription. Analysis of data collected from community pharmacies in the OSIAP (Ordonnances Suspectes Indicateur d'Abus et de Pharmacodépendance) survey gives information about patterns of diversion of medication in France. This system is able to evaluate the impact of measures implemented in order to decrease the misuse of drugs and able to identify new patterns of drug diversion. Identification of profiles of suspicious 'prescription forms' could help pharmacists to better identify abnormal prescriptions. A European project has recently been implemented to extend this kind of survey to other countries in Europe.

QRAR models for cardiovascular system drugs using biopartitioning micellar chromatography

The capability of biopartitioning micellar chromatography (BMC) to describe and estimate pharmacological parameters of cardiovascular system drugs has been studied. The retention of cardiovascular system drugs was studied using different pH of Brij-35 as micellar mobile phase in modified C 18 stationary phase. Quantitative retention–activity relationships (QRAR) in BMC were investigated for these compounds. An adequate correlation between the retention factors (log k) and the toxicity (LD 50) of cardiovascular system drugs was obtained.

Drugs and falls in community-dwelling older people: a national veterans study

Objective: The aim of this study was to identify which specific medications within recognized major problematic drug categories that increase risk of falling were prescribed to veterans before their out-patient treatment for a fall. Methods: This was a retrospective, cross-sectional national secondary outpatient data analysis with an age- and sex-matched comparison group. The setting was the national Veterans Health Administration (VHA) ambulatory health care system in fiscal year (FY) 2004. The study population was VHA patients aged ≥65 years who had fall-related outpatient clinical health care encounters in FY 2004 (as indicated by diagnostic codes) and who received ≥1 outpatient medication during the study period. The age- and sex-matched comparison group consisted of an equal number of patients with nonspecific chest pain. The percentage of patients in each group receiving medications (at the time of the outpatient encounter) that affect the cardiovascular system (CVS), central nervous system (CNS), or musculoskeletal system (MSS) was compared with Bonferrom-adjusted P values. Results: The study sample consisted of 20,551 patients; the comparison group included the same number of patients. More patients with fall-coded encounters used CNS drugs than those with nonspecific chest pain (42.05% vs 29.29%). Also, within the CNS category, more patients with fall-coded encounters used antiparkinsonian medications (3.67% vs 1.32%), Alzheimer's disease medications (ie, cholinesterase inhibitors [5.40% vs 2.35%]), anticonvulsants/barbiturates (8.95% vs 5.18%), antidepressants (22.50% vs 14.16%), antipsychotics (4.68% vs 2.01%), opioid analgesics and narcotics (11.21% vs 9.09%), and benzodiazepines (7.60% vs 5.96%) (all, P < 0.002). More patients with nonspecific chest pain received CVS drugs compared with the fall-coded group (69.13% vs 63.07%; P < 0.002). Within the CVS category, more patients in the nonspecific chest pain group received angiotensin-II receptor antagonists, angiotensin-converting enzyme inhibitors, β-blockers, calcium channel blockers, vasodilators, diuretics, and antiarrhythmics (all, P < 0.002). No differences were noted between groups in the MSS category, except for NSAIDs, which more patients in the nonspecific chest pain group used than in the fall-coded group (6.44% vs 5.63%; P < 0.002). Conclusion: In this study, subjects with a health care encounter for a fall (as indicated by diagnostic code) were prescribed significantly more CNS-category medications than subjects in the age- and sex-matched comparison group.

Outcome of acute idiosyncratic drug-induced liver injury: Long-term follow-up in a hepatotoxicity registry

A chronic adverse reaction may occur in some instances of drug-induced liver injury (DILI), even despite drug cessation. In our study, we obtained records from a Spanish registry and evaluated cases of DILI with biochemical evidence of long-term damage. Chronic outcome was defined as a persistent biochemical abnormality of hepatocellular pattern of damage more than 3 months after drug withdrawal or more than 6 months after cholestatic/mixed damage. Data on 28 patients with a chronic clinical evolution (mean follow-up 20 months) between November 1995 and October 2005 were retrieved (18 female; overall mean age 55 yr) and accounted for 5.7% of total idiosyncratic DILI cases (n = 493) submitted to the registry. The main drug classes were cardiovascular and central nervous system (28.5% and 25%, respectively), which, in contrast, represented only 9.8% and 13%, respectively, of all DILI cases. The most frequent causative drugs were amoxicillin-clavulanate (4 of 69 cases), bentazepam (3 of 7 cases), atorvastatin (2 of 7 cases), and captopril (2 of 5 cases). Patients with cholestatic/mixed injury (18 of 194 cases [9%]) were more prone to chronicity than patients with hepatocellular injury (10 of 240 cases; P < .031). In the case of chronic hepatocellular injury, 3 patients progressed to cirrhosis and 2 to chronic hepatitis. In the cholestatic/mixed group, liver biopsy indicated cirrhosis in 1 patient and ductal lesions in 3 patients. In conclusion, cholestatic/mixed type of damage is more prone to become chronic while, in the hepatocellular pattern, the severity is greater. Cardiovascular and central nervous system drugs are the main groups leading to chronic liver damage.

Drug administration errors and their determinants in pediatric in-patients

. To quantify the type and frequency of drug administration errors to pediatric in-patients and to identify associated factors. Prospective direct-observation study of drug administration errors from April 2002 to March 2003. Four clinical units in a pediatric teaching hospital. Twelve observers accompanied nurses giving medications and witnessed the preparation and administration of all drugs to all patients on all weekday mornings. None. Discrepancies between physicians' orders and actual drug administration. During the 1719 observed administrations to 336 patients by 485 nurses, 538 administration errors were detected, involving timing (36%), route (19%), dosage (15%), unordered drug (10%), or form (8% form). These errors occurred for 467 (27%) of the 1719 administrations. Intravenous drugs (OR = 0.28; CI = 0.16-0.49; versus miscellaneous) were associated with fewer errors. Error rates were higher for cardiovascular (OR = 3.38; CI = 1.24-9.27; versus miscellaneous) and central nervous system drugs (OR = 2.65; CI = 1.06-6.59; versus miscellaneous); unspecified dispensing system (OR = 2.06; CI = 1.29-3.29; versus store in the unit); non-intravenous non-oral administration (OR = 4.44; CI = 1.81-10.88; versus oral administration); preparation by the pharmacy (OR = 1.66; CI = 1.10-2.51); and administration by a hospital pool nurse, temporary staffing agency nurse, or nurse intern (OR = 1.67; CI = 1.04-2.68; versus registered full-time nurse). Each additional management procedure in the patient increased the risk of error (OR = 1.22; CI = 1.01-1.48). The risk factors identified in our study should prove useful for designing preventive strategies, thereby improving the quality of care.

Drug development and use in the elderly: search for the right dose and dosing regimen

Across the globe over the last few decades, there has been a remarkable increase in the proportion of the population which is elderly, and this trend is set to continue. Data from 10 countries that accounted for about 55% of the world population of 6079 million in the year 2000 provide an overview of this significant shift in demography. Table 1 summarizes the projections for the next 25 years. Hitherto, increases in life expectancy have been most obvious in the affluent countries; however, improvements in public health and disease control are also leading to increases in life expectancy in the less affluent countries. As a result of relatively larger increases in life expectancy at birth, significant shifts in demography are also expected in countries that are at present economically less affluent. The number of elderly people in the world is therefore expected to continue to increase for some considerable time. Interestingly, the most dramatic increases in the proportion of the population who are elderly are anticipated in countries where total populations are projected to decrease (such as Japan, Germany and Italy). Table 1 Age-related demography in 2000 and projected changes in 10 major countries The 2001 population census of the UK revealed that since the census of 1951, the proportion of elderly population above 65 years and 85 years has increased from 16% and 0.4% respectively to 21% and 1.9%, respectively. These changes in demography will have significant effects on the economics generally as well as on the provisions for healthcare. Cardiovascular and neurological diseases and cancers are the most prevalent in the elderly. These three groups of diseases account for about 54% of the total burden of disease in Europe in terms of disability adjusted life years. Of the total gross Hospital and Community Health Services expenditure of £31.9 billion in the year 2001–2002 in the UK, 13% was expended on people aged 65–74 years, 16% on those aged 75–84 years and 10% for people aged 85 years or more. Furthermore, about 55% of the community prescriptions during 2001 in the UK were dispensed for the elderly. Cardiovascular and psychoactive drugs accounted for more than 40% of these prescriptions. In view of many age-related changes in the pharmacokinetics and pharmacodynamics of a drug, the safe and effective prescribing of medicines in the elderly will continue to present a major challenge. This review provides an overview of the issues relevant to development and clinical use of drugs in the elderly population, with particular reference to determining the right dosage and dose regimen and the regulatory requirements that facilitate this process. It also examines whether, as a result of advancing age per se, the dosing regimens in the elderly and the frail elderly might be different from those in the non-elderly.

General practitioner prescribing patterns in Babol city, Islamic Republic of Iran

To determine patterns of prescribing in Iranian primary care, we analysed 4000 randomly selected prescriptions from 52 general practitioners (GPs) in Babol city during 1999-2000. The mean number of drugs prescribed per encounter was 4.4 +/- 1.7, with 98% prescribed by generic name. The most commonly prescribed items were non-steroidal anti-inflammatory drugs (62.9% of encounters) and antibiotics (61.9%), followed by central nervous system drugs, gastrointestinal tract drugs, corticosteroids, vitamins and cardiovascular system drugs respectively. Injections were prescribed in 58.0% of encounters. Female and male doctors had significantly different antibiotic prescribing patterns. Our study confirms the tendency of GPs to overprescribe.

Geriatric drug therapy and healthcare utilization in the United kingdom.

To describe the use of prescription drug therapy, especially polypharmacy, in an elderly general population; to relate that use to age, gender, and different types of healthcare utilization; and to investigate the influence of selection of different time windows on the result of the quantity as well as the categories of drugs used. Data on a sample of 5000 patients aged 65-90 years in 1996 were derived from the General Practice Research Database (GPRD). The population covered by GPRD is broadly representative of the UK population treated in general practice. Drug use was assessed using 2 time windows - current use of individual drugs on a random day (index date) and 1 month following the index date. Healthcare utilization was analyzed by use of information on visits to general practitioners (GPs), hospitalizations, and referrals to specialists. Women used more drugs than men; however, the prevalence of polypharmacy, defined as concomitant use of > or =5 drugs, was similar in both genders. The most frequently used therapeutic groups were cardiovascular, central nervous, and gastrointestinal system drugs. Almost 80% of both women and men visited a GP at least once a year. Overall, women used more ambulatory care services and men were hospitalized more often. Use of random date compared with 1-month period resulted in a significant underestimation of the amount of drugs used for acute conditions and, consequently, the risk of polypharmacy. The overall results confirm the findings in earlier studies suggesting that the GPRD might be a useful tool in further studies on prescription drug use among elderly persons. More information on the appropriateness of drug use is needed to prevent overuse as well as underuse of medications among the elderly.

An investigation into antidiabetic medication prescribing in South Africa.

The number of people with diabetes in Africa is expected to triple in the next 15 years, which will have a significant impact on the prescribing and use of antidiabetic medication. The primary aim of this study was to investigate the prescribing patterns of antidiabetic medication that are used on a chronic basis in South Africa. Prescribing data of 1100 diabetic patients were retrospectively analysed over a 1-year period. The average age of patients was 53.2 years (SD = 16.4 years), with more male than female patients. The oral antidiabetic drugs accounted for 67.4% of all the antidiabetic products prescribed, with the sulphonylureas the most frequently prescribed antidiabetic therapeutic subgroup. Glicazide was the single most frequently prescribed oral antidiabetic drug, accounting for 38.2% of all oral agents. Biphasic insulin was the most frequently prescribed class of insulin. Fifty-seven patients were using insulin as well as one or more oral antidiabetic drugs. Cardiovascular system drugs, nervous system drugs and drugs acting on the alimentary tract and metabolism together accounted for more than half of the drugs that were prescribed concurrently with antidiabetic medication. Further research on the prescribing of antidiabetic medication should be conducted focusing on the qualitative aspects of treatment and treatment costs as well as studies on antidiabetic treatment in the public health sector.

Medication use by the driving population.

This study investigated patterns of medicine use among Spanish drivers. The study was conducted in the fall of 1993 on 1500 drivers aged over 16, all of whom completed accordingly and then returned the questionnaires. Among those surveyed, 45.1% had used drugs at least once in the previous year, while 17.3% of drivers surveyed were using medicines chronically. Chronic users, the majority of whom were female and belonging to the older age group, were using an average of two drugs. Central nervous system drugs (21.7%), respiratory system drugs (19.2%), cardiovascular system drugs (14.9%) and alimentary tract drugs (14.3%) were the most frequent groups of medication used. Of those surveyed 76.5% who took drugs regularly had never been warned by health professionals about the effects of the medication use on driving skills. The study shows both how often drivers use medication as well as the need to inform patients and drivers about the effect of medication on driving performance.

Drug-induced hepatotoxicity: Lee WM. N Engl J Med 1995;333:1118–27

Pharmaceutical preparations, but also herbal products and dietary supplements, are emerging contributors to severe forms of liver disease, with hepatotoxicity ranking as the most frequent cause for acute liver failure. Although acetaminophen intoxication is still the reason for many severe cases of druginduced liver injury, the bulk of hepatic reactions to drugs are idiosyncratic. Indeed, the rarity of this serious adverse event prevents its detection in clinical trials. Therefore, in order to collect reliable data, prospective post-marketing studies are needed, especially with commonly used drugs that have been shown to be associated with drug-induced liver injury. Recently, different databases have described acetaminophen, antibiotics, nonsteroidal anti-inflammatory drugs, and anticonvulsants as being associated with drug-induced liver injury. Clinical presentations of drug-induced liver injury include predominantly a hepatocellular type of damage, yet cholestatic and mixed types are also common, the determinants of the type of damage induced by a given drug being poorly understood. Recent analysis of pooled data has underlined the influence of older age in the cholestatic/mixed expression of the liver injury, as well as the independent association of female gender, older age, aspartate aminotransferase levels/hepatocellular type of damage and high bilirubin levels with the risk of fulminant liver failure/death. In the long-term (proving the patient survives to the initial episode) cholestatic mixed type of damage is more prone to become chronic, while in the hepatocellular pattern the severity is greater, with further likelihood of evolution to cirrhosis. Cardiovascular and central nervous system drugs have been found to be the main groups leading to chronic liver damage. The diagnosis of hepatotoxicity remains a difficult task because of the lack of reliable markers for use in general clinical practice. To incriminate any given drug in an episode of liver dysfunction is a step-by-step process that requires a high degree of suspicion, compatible chronology, awareness of the drug’s hepatotoxic potential, the exclusion of alternative causes of liver damage, and the ability to detect the presence of subtle data that favors a toxic etiology. This process is time-consuming and the final result is frequently inaccurate. Diagnostic algorithms may add consistency to the diagnostic process by translating the suspicion into a quantitative score. Such scales are useful since they provide,