Changes In Drug Therapy Research Articles

PSY53 Changes in Concomitant therapy for Weight-related Illness Following Initiation of Weight Loss Pharmacotherapy

Over two-thirds of the US population are overweight or obese. While current pharmacotherapy options for weight loss are limited, new weight loss products have not been approved partly over safety concerns, including some linked to weight-related illnesses such as hypertension. However, very little is known about the association of available weight-loss pharmacotherapy with changes in drug therapy for weight-related illnesses. A retrospective cohort analysis of a deidentified pharmacy claims database evaluated adult patients initiating weight-loss pharmacotherapy (no weight-loss drug prescriptions 6 months prior) between November 1, 2007 – October 31, 2010. Patients with continuous eligibility for 6 months pre- (baseline) and 6 months post- weight-loss drug initiation were evaluated for changes in concomitant drug therapy associated with weight-related illnesses (hypertension, dyslipidemia, type 2 diabetes, anxiety, gastrointestinal disorders, depression, and hypothyroidism). Six-month outcomes included concomitant therapy incidence, and net change (% patients adding ≥1 drug minus % discontinuing ≥1 drug in each illness category) analyzed using t-test (significance at p<0.05). A total of 91,160 patients initiated weight-loss pharmacotherapy: phentermine (N=67,434), sibutramine (N=13,438), orlistat (N=8,047), phendimetrazine (N=4,631), and diethylpropion (N= 4,350); mean±SD age 44±12 years (96%, 18-64 y/o), 82% female. Patients received 1.5±0.8 concomitant weight-related illness drugs at baseline for hypertension (21.6%) depression (14.9%), dyslipidemia (11.5%), hypothyroidism (9.2%), gastrointestinal disorders (9.6%), anxiety (6.7%), and diabetes (5.5%). Incident/net therapy change over 6 months for each illness category: hypertension (3.2%/-6.5%), depression (0/-16.0%), dyslipidemia (1.1%/-12.2%), hypothyroidism (1.2%/+0.7%), gastrointestinal disorders (0.2%/-17.1%), anxiety (1.1%/-19.4%), and diabetes (0.6%/-8.9%). All net changes from baseline are significant (p<0.05), with the exception of hypothyroidism therapy. Concomitant therapy for obesity-related illnesses generally has a low incidence and declines significantly over 6 months after initiating weight-loss pharmacotherapy. Antihypertensive and hypothyroidism therapy appear to follow different patterns, and whether this reflects disease progression, effect of weight-loss therapy, genetics, or other factors warrants further investigation.

148 The assessment of transient loss of consciousness: we're still not asking the right questions

Accurately diagnosing patients with TLOC can be achieved in most cases with a detailed clinical history. We set out to assess how patients were assessed in the setting of a district general hospital (DGH) with 570 beds, receiving an unselected intake via general practice and an A&amp;E. Using the ESC guidelines of 2009 we generated a 22-question study proforma for a retrospective review of the medical records. We identified 322 cases for possible inclusion over a 4 month period. 26 of the case notes were not available to analyse, 8 had insufficient details to identify the relevant patient. Therefore in total 288 notes were reviewed. Inclusion required the TLOC to be complete, of rapid onset and short duration with spontaneous complete recovery. A further 123 patients were therefore excluded. This left 165 data sets (58% male). The age distribution was a typical bimodal distribution with 16% between 10 and 29 years of age and 48% over the age of 70 years. 73% were assessed in A&amp;E, 18% were assessed in the Acute Medical Unit (AMU) and 7% were assessed in rapid access ambulatory clinics. Only 4% of the initial assessments were undertaken by consultants, 12% by a Specialist Registrar (SpR), 21% by a year 1 foundation program (FP1) doctor and the majority was assessed by FP 2 or core medical trainees (CMT). Key diagnostic elements of the history are still being neglected. For example, the symptoms at the onset of the TLOC were documented in only 58% of cases; the recovery symptom profile was reported in only 37%. Only 47% (n=78) of records described a witness account. Within the witness accounts that were recorded, key elements remained un-reported for example skin complexion was only reported in 35% of the 78. The duration of the TLOC was recorded in only 44%, Tongue biting in 27% and the presence or absence of abnormal movements was recorded in only 12% of this 78 patients. The presence or absence of a family history of sudden cardiac death was only reported in 2% cases. The family history of a cardiomyopathy was only recorded in 1% and a family history of TLOC was recorded in 1%. A patient past history of cardiac disease was asked about in 40% of cases while a past history of TLOC was only asked about in 35%. In this majority elderly study population, a recent change in drug therapy was only asked about in 2% of cases. This study highlights that in a DGH environment, the initial assessment of patients with TLOC is undertaken by junior medical staff who often do not document key diagnostically differentiating elements of the history and examination indicating an ongoing lack of adequate training regarding the most appropriate and accurate techniques for differentiating the causes of TLOC.

Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE)

Despite a broad and efficient pharmacological antihypertensive armamentarium, blood pressure (BP) control is suboptimal and heterogeneous throughout Europe. Recent representative data from Switzerland are limited. The goal of the present survey was therefore to assess the actual control rate of high BP in Switzerland in accordance with current guidelines. The influence of risk factors, target organ damage and medication on BP levels and control was also evaluated. A cross-sectional visit-based survey of ambulatory hypertensive patients was performed in 2009 in Switzerland. 281 randomly selected physicians provided data on 5 consecutive hypertensive patients attending their practices for BP follow-up. Data were anonymously collected on demographics, comorbidities and current medication, and BP was recorded. Subsequent modification of pharmacological antihypertensive therapy was assessed. Data from 1376 patients were available. Mean age was 65 ± 12 years, 53.9% were male subjects. 26.4% had complicated hypertension. Overall, BP control (<140/90 mm Hg for uncomplicated and <130/80 mm Hg for complicated hypertension) was achieved in 48.9%. Compared to patients with complicated hypertension, BP control was better in patients with uncomplicated hypertension (59.4% vs. 19.2%, p <0.001). As a monotherapy the most prescribed drug class were angiotensin receptor blockers (ARB, 41%), followed by angiotensin converting enzyme (ACE) inhibitors (21.5%), betablockers (20.8%) and calcium channel blockers (CCB, 10.8%). The most prescribed drug combinations were ARB + diuretic (30.1%) and ACE inhibitors + diuretic (15.3%). 46% were receiving a fixed drug combination. In only 32.7% of patients with uncontrolled hypertension was a change in drug therapy made. This representative survey on treated adult hypertensive patients shows that, compared to earlier reports, the control rate of hypertension has improved in Switzerland for uncomplicated but not for complicated, particularly diabetes-associated hypertension. ARBs and ACE inhibitors are the most prescribed antihypertensive drugs for monotherapy, whereas diuretics and ARBs were the most used for combination therapy.

Nutritional Interventions for Cancer-Induced Cachexia

Cancer-induced cachexia remains a significant cause of morbidity and mortality in cancer treatment. Cancer research and development continues at an aggressive pace and yet a degree of cancer-induced cachexia is experienced by up to 80% of advanced stage cancer patients. Unfortunately, there are no established treatment regimens for this condition. Weight loss and fatigue consistently appear in patient oncologic histories and progress notes. However, few oncologists fully understand the pathologic mechanisms causing cachexia resulting in well-meaning advice to increase caloric intake with minimal results. Our goal is to describe the pathologic basis of cancer-induced cachexia and to detail accompanying metabolic derangements. Understanding the causes of cachexia sheds light on the subsequent need for multi-modality therapy including clinical intervention with specialized nutrition support, drug therapy, lifestyle and diet changes. In addition to nutrition support modalities, practicing oncologists may prescribe medical therapies designed to increase body weight and lean body mass, including megestrol acetate, tetrahydrocannibinol, oxandrolone, and non-steroidal anti-inflammatory drugs. A variety of experimental therapies are also being investigated for cancer-induced cachexia including tumor necrosis factor-alpha inhibitors and ghrelin infusions. We review the available data to support nutrition-oriented interventions in cancer-induced cachexia, including omega-3 fatty acids, amino-acid loading/protein supplementation, parenteral and enteral nutrition support, and food-derived compounds such as curcumin, reservatrol, and pomegranate.

A randomised controlled trial of a pharmaceutical care programme in high-risk diabetic patients in an outpatient clinic

Abstract Objective To determine the impact of a pharmaceutical care programme (PCP) in diabetic patients. Design Randomised controlled study of high-risk diabetic patients. Setting Outpatient clinic at Fremantle hospital (FH), Western Australia. Method Patients over 18 years of age who could communicate freely in English and fulfilled pre-determined criteria for being high-risk for the development of diabetic complications, were randomly assigned to the PCP or control groups in a ratio of 2:1. In the PCP arm, a clinical pharmacist reviewed and monitored all aspects of the patients' drug therapy in collaboration with other health care professionals at six-weekly intervals for six months. The control patients received usual outpatient care. Main outcome measures Glycosylated haemoglobin (HbA1c), quality of life (QOL), patient satisfaction with health care providers and changes in drug therapy during the PCP. Results Seventy-three patients were recruited into the study, of whom 48 (66 per cent) were randomised to the PCP. There were no significant differences between the PCP (cases) and the control groups for demographic variables. The mean (±SD) HbA1c for the cases was 8.4±1.4 per cent at the beginning and 8.2±1.5 per cent at the end of the study period (P&amp;gt;0.05). There was similarly no change in the control group (8.5±1.6 per cent to 8.1±1.6 % P&amp;gt;0.05). There were no significant changes in QOL for cases or controls over the period of the study. During the PCP, there was a significant increase in patient satisfaction with the care provided by the clinical pharmacist (P=0.007) and the provision of drug information (P=0.036). The clinical pharmacist facilitated 39 drug interventions in the 48 cases. A high level of complementary medicine usage was found in the PCP group (16.7 per cent). Conclusions PCPs provide patients with important medication information and result in changes to drug therapy. However, in diabetic patients under specialist care, a six-month PCP did not lead to an improvement in glycaemic control. The role for pharmacist intervention in primary care now needs to be evaluated.

A multidisciplinary approach to improve drug therapy in nursing homes

Management of drug therapy in nursing home patients is challenging due to complex health problems, use of multiple medications, and age-related changes in pharmacokinetics and pharmacodynamics. The objective of this study was, first, to examine the effect of systematic medication reviews conducted by multidisciplinary nursing home teams on prescribing quality and, second, to evaluate if drug therapy changes were maintained over time. Patients in a large nursing home in Oslo, Norway, were prospectively followed during a 1.5-year period. Systematic comprehensive medication reviews were carried out and the identified drug-related problems (DRPs) were discussed at multidisciplinary team meetings. After 3 months, the patients’ drug regimens were reviewed again to evaluate if drug therapy changes were maintained. Altogether, 93 patients were included (89% women, mean age 87 years). In total, 234 DRPs were identified in 82 patients, and 151 drug therapy changes were performed in 73 patients. The most common DRPs were ‘drug treatment without a clear indication’ (37% of all DRPs) and ‘treatment with an inappropriate drug’ (20%). After 3 months, 85 patients (91%) were available for follow-up. In these patients, 133 (88%) of the drug therapy changes were maintained, and the mean number of DRPs had decreased from 2.6 to 1.0 per patient (P < 0.01). We were able to demonstrate that medication reviews conducted by multidisciplinary teams were effective to improve the quality of drug treatment in nursing home patients by significantly reducing both number of drugs and number of DRPs. The large majority of drug therapy changes were maintained after 3 months.

Economic impact of pharmacist-reimbursed drug therapy modification

To determine (1) the frequency of the different types of drug therapy modification claims paid by a pharmacy benefits manager (PBM), (2) PBM cost savings and return on investment (ROI), and (3) patient savings from pharmacist-reimbursed drug therapy modifications. Cross-sectional, retrospective, descriptive study. Midwest United States in 2006. Not applicable; 767 paid therapeutic interchange service claims from the PBM database were analyzed. Descriptive statistics for PBM costs and cost savings to the PBM and to patients were calculated using all prescription fills. ROI calculated by dividing net savings across all fills by net costs. Claims were paid to pharmacists for drug therapy modifications to allow tablet splitting, drug therapy changes, and switching noncovered drugs. Tablet splitting provided the largest cost savings to the PBM, accounting for slightly more than one-third of the claims and representing more than one-half of the prescription fills. Switching drugs not covered provided the largest cost savings to patients. Overall, the PBM saved a mean of $20.31 per prescription fill, and patients saved $14.76 per prescription fill. Mean overall ROI to the PBM was 3.55. Payment for pharmacist interventions can be an economic benefit for both patients and third-party payers. The cost savings for payers likely will dictate the endorsement of pharmacist-reimbursed programs and economic incentives offered to pharmacists and pharmacies.

The Role of Cardiac Rehabilitation in Achieving Optimal Treatment

The clinical practice of European cardiologists is directed by the European Society of Cardiology’s guidelines for several clinical entities, in which ‘optimal medical treatment’ (a specific drug regime and lifestyle measures) for each syndrome is defined. The described pharmacotherapy is composed of several drugs, since the clinical research behind the recommendations is conducted using an ‘on top of’ strategy. For example, an asymptomatic patient after an acute coronary syndrome with normal ventricular function and without residual ischaemia has an indication to take at least four types of tablets per day, which is difficult to understand and to follow long term. The cost of the drugs is sometimes beyond the patient’s means, which also contributes to lower compliance. A clinician’s practice is usually very busy, which means it is almost impossible to perform patient education and promote adherence to drug therapy and lifestyle changes. Cardiac rehabilitation, as proved by the Global Secondary Prevention Strategies to Limit Event Recurrence after Myocardial Infarction (GOSPEL) study, may be considered the best available secondary prevention programme, as it educates patients and promotes adherence to the optimal medical treatment to a greater degree than usual care.

Molecular Response After 3 Months of 1st Line Imatinib Therapy Is Predictive for Treatment Failure and Disease Progression In Patients with Chronic Phase Chronic Myeloid Leukemia - a Follow-up Analysis of the German CML Study IV

AbstractAbstract 360 Introduction:The lack of a sufficient response to first line imatinib treatment has been observed in a substantial proportion of CML patients and has been associated with an inferior survival. Therefore, response criteria have been defined to identify patients with treatment failure. A change of drug therapy to 2nd generation tyrosine kinase inhibitors or allogeneic stem cell transplantation is recommended for this group of patients (European LeukemiaNet, ELN, Baccarani et al., JCO 2009). We sought to evaluate the predictive value of early molecular response landmarks for treatment failure and disease progression to identify patients at risk and to provide a guidance for the interpretation of BCR-ABL levels. Patients and methods:949 patients included into the randomized German CML Study IV and treated with an imatinib based therapy consisting of standard dose imatinib (400 mg/d), high dose imatinib (800 mg/d) and combinations of standard dose imatinib with low dose cytarabine or interferon alpha were evaluable for molecular and cytogenetic analysis. BCR-ABL (IS) was determined by quantitative RT-PCR. The type of BCR-ABL transcript (b2a2, n=424; b3a2, n=464; b2a2 and b3a2, n=148) was defined by multiplex PCR. Patients with atypical BCR-ABL transcripts were excluded from the analysis. Cytogenetic response (CyR) was determined by G-banding metaphase analyses. Treatment failure has been defined according to ELN criteria as a lack of major CyR after 12 months and a lack of complete CyR after 18 months of imatinib treatment, respectively. CyR data were available for 479 pts between 12 and 18 months with a subset of 289 pts evaluable for 3 month molecular response (CyR data after 18 months, n=532; 3 month molecular subset, n=289). Disease progression comprises the incidence of accelerated phase, blast phase and death. Median follow-up for disease progression was 35 months (range 2–85). Fisher's exact test has been performed to evaluate the prognostic significance of 3 month BCR-ABL landmarks for 12 month and 18 month treatment failure. A landmark analysis has been performed for disease progression (logrank test). Results:In 20 of 289 evaluable pts treatment failure has been observed after 12 months, and in 29 of 289 pts after 18 months. 24 of 570 evaluable pts showed a disease progression after a median of 18 months (range 5–71). A stratification into three groups at 3 months reveals a significant difference concerning treatment failure between pts with BCR-ABL levels between 1% and 10% and those with BCR-ABL levels >10%. With regard to disease progression there is a statistical trend. Comparing two groups the 10% BCR-ABL cut-off is highly significant for both, treatment failure and disease progression. Missing the 10% BCR-ABL landmark after 3 months of imatinib treatment defines a poor risk group with a 20.7% risk of treatment failure after 18 months and a 8.1% risk of disease progression (Table). Conclusion:Early assessment of molecular response after 3 months of imatinib therapy allows the identification of a patient cohort with an increased risk of treatment failure and disease progression. [Display omitted] Disclosure:Müller:Novartis Corporation: Honoraria, Research Funding. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Hochhaus:Novartis Corporation: Honoraria, Research Funding.

Effect of Pharmaceutical Care Programs on Glycemic Control in Patients with Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials

Background: Diabetes mellitus is a common disease that has an increasing influence on the health of human beings. While the role of pharmaceutical care (PC) programs in the treatment of patients with diabetes mellitus is well established, there is little research that quantitatively and comprehensively assesses the impact of PC programs on glycemic control in diabetics. Objective: To evaluate the effect of PC programs on glycemic control in patients with diabetes mellitus. Methods: Publications on PC programs and randomized controlled trials (RCTs) of glycemic control were retrieved by searching MEDLINE, Embase, Cochrane, Elsevier, Chinese Biomedicine Database, and Chinese Journal Full-Text Database databases from January 1996 through February 2010. Data were extracted by 2 reviewers independently, based on their correlation with this project, and then evaluated with meta-analysis. The meta-analysis was conducted using STATA version 10.1. Begg-Mazumdar's funnel plot was generated to determine the potential impact of publication bias. Results: Fourteen RCTs, with a total of 1770 patients with diabetes mellitus, were included in this meta-analysis. Pharmacists were involved in all of these PC interventions. The average ± SD study period of included trials was 9.5 ± 4.1 months. Drug counseling, drug therapy management, lifestyles education, self-monitoring, and recommendations of drug therapy changes were the most frequently used interventions. All of the trials reported the reduction of hemoglobin A1c (A1C) as the primary clinical outcome of PC intervention. Compared with the usual-care control groups, the PC intervention groups had significant reduction in A1C levels (weighted mean difference −0.68; 95% CI-1.03 to −0.34; p = 0.000). Conclusions: PC programs delivered separately or in combination by pharmacists and other health professionals can lead to an improvement in glycemic control. The incorporation of PC programs into disease management should be strongly considered.

Urgent Continuous EEG (cEEG) Monitoring Leads to Changes in Treatment in Half of Cases

How Seizure Detection by Continuous Electroencephalographic Monitoring Affects the Prescribing of Antiepileptic Medications. Kilbride RD, Costello DJ, Chiappa KH. Arch Neurol 2009;66(6):723–728. Objectives To assess the effect of continuous electroencephalographic monitoring on the decision to treat seizures in the inpatient setting, particularly in the intensive care unit. Design Retrospective cohort study. Setting Medical and neuroscience intensive care units and neurological wards. Patients Three hundred consecutive nonelective continuous electroencephalographic monitoring studies, performed on 287 individual inpatients over a 27-month period. Main Outcome Measures Epileptiform electroencephalographic abnormalities and changes in antiepileptic drug (AED) therapy based on the electroencephalographic findings. Results The findings from the continuous electroencephalographic monitoring led to a change in AED prescribing in 52% of all studies with initiation of an AED therapy in 14%, modification of AED therapy in 33%, and discontinuation of AED therapy in 5% of all studies. Specifically, the detection of electrographic seizures led to a change in AED therapy in 28% of all studies. Conclusions The findings of continuous electroencephalographic monitoring resulted in a change in AED prescribing during or after half of the studies performed. Most AED changes were made as a result of the detection of electrographic seizures.

Standardisation and outcomes audit: a step forward in surgical oncology

Looking back in time, we appreciate how efforts in basic, translational and clinical research have allowed us to arrive at sophisticated treatment modalities for cancer and results that could not be imagined some decades ago. Along the timeline of cancer management evolution, where profound changes in drug therapy and radiation technology have occurred, surgery has remained –and remains today– the key component of cancer treatment for solid malignancies. The classic aphorism “no surgery, no cure” is still fully valid in the majority of cases. Moreover, it is well known that fl aws in the primary surgical resection of a malignant tumour imprint a negative impact on diseasespecifi c survival that cannot be overcome by complementary cancer therapy delivered at a later time. The surgeon has been identifi ed as a signifi cant prognostic factor in malignant disease [1], and the crucial responsibility of surgeons in the ultimate outcome of their cancer patients cannot be overemphasised.

Geographic variation in drug safety: potentially unsafe prescribing of medications and prescriber responsiveness to safety alerts.

Drug safety issues represent a major cause of morbidity and mortality. Alerting programs are intended to identify patients at potential risk for adverse drug reactions and may provide relevant information to prescribers to support their decision making about clinically appropriate risk reduction. Geographic differences in the incidence of drug safety issues and the responsiveness of prescribers to alerting systems have not been previously studied. To measure geographic differences in the rates of alerting events for potential drug safety issues, communicated to prescribers by mail or fax, and the responsiveness of prescribers to such alerts. All alerts generated by a commercially available drug safety alerting program were evaluated for calendar year 2008 and were classified geographically based on patient residence. Primary study measures were (a) number of alerting events per 1,000 members (i.e., covered beneficiaries of all ages whose plan sponsor was enrolled in the alerting program service), and (b) therapy change rate (defined as the percentage of alerts that were followed by therapy modification consistent with the clinical alert). The program-wide aggregate rate of alerting events across all regions was 128 per 1,000 members, with the state-specific range from 78 to 240. The program-wide aggregate rate of drug therapy change across all regions was 54.0%, with the state-specific range from 48.1% to 59.5%. The rates of potential drug safety issues (alerting events) and the responsiveness of prescribers to drug safety alerts vary considerably by region and state. States with high issue rates and low therapy change rates may require additional prescriber outreach.

Trends in Prescription and Determinants of Persistence to Antihypertensive Therapy

To assess trends in prescriptions, determinants and timing of treatment discontinuation and/or changes in antihypertensive drug therapy in a cohort of hypertensive patients living in Pavia, a city in the north of Italy. The cohort included 61 493 patients aged ≥18 years who received their first antihypertensive drug prescription (monotherapy, fixed or extemporaneous combination) during the period 2003-6. Patients were classified as 'persistent' if 12 months after the beginning of treatment they were still taking a regular therapy (same drug = 'same therapy users', added one or more drugs = 'add-on therapy users', different drug = 'switchers'). Otherwise, they were classified as 'non-persistent' (stopping therapy after the first prescription = 'occasional users'; stopping treatment early = 'stoppers'; taking medicines in an erratic fashion = 'intermittent users'). ACE inhibitors were the most frequently prescribed drugs (22.8%), followed by β-adrenoceptor antagonists (β-blockers) [14.3%], diuretics (13.9%), Ca(2+) antagonists (11.4%) and angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) [9.3%]. After 12 months, persistent patients were only 11.2% (same therapy users 6.7%, switchers 3.2%, add-on therapy users 1.3%). Non-persistent patients were 88.8% (35.3% occasional users, 20.6% stoppers, 32.8% intermittent users). Patient-related predictors of persistence were older age, male sex, concomitant treatment with antidiabetic and hypolipidaemic drugs and previous hospitalizations for cardiovascular events. Highest level of persistence was seen in patients starting with ARBs (18.8%), followed by ACE inhibitors (11.4%), β-blockers (11.0%), Ca(2+) antagonists (10.8%) and diuretics (3.0%). Among ARBs, considering separately monotherapy and fixed-combination therapy, highest level of persistence was observed in patients starting with candesartan, irbesartan, valsartan and telmisartan given in monotherapy, and with valsartan and telmisartan given in fixed-dose combination. Persistence to antihypertensive treatment at 12 months is only 11.2%, being the lowest with diuretics (3.0%) and the highest with ARBs (18.8%).

Management of antihypertensive drugs in three European countries

To compare rates of treatment discontinuation of and changes in initial antihypertensive drug therapy in the natural setting of treatment dispensation of Italy, Sweden and the Netherlands. The cohorts included all the 23 715 (Italy), 20 289 (Sweden), and 5801 (the Netherlands) patients aged 40-70 years who received their first antihypertensive drug prescription from July 1, 2006 to September 30, 2006. Discontinuation was assumed if no antihypertensive drug was issued within 90 days following the end of the latest antihypertensive dispensation. Addition or replacement of the initial medication during the 90-day interval were defined as treatment combination or treatment switching. At 9 months after treatment initiation, the discontinuation rate of any antihypertensive drug was 24%. Compared with Italian patients, the discontinuation rate was significantly lower in Swedish [hazard ratios: 0.52, 95% confidence interval (CI): 0.50-0.54] and Dutch patients (hazard ratio: 0.79, 95% CI: 0.75-0.84). Almost 21 and 16% of patients who started on monotherapy respectively combined with and switched to another antihypertensive drug. Compared with Italian patients, the adjusted hazard rate of combining was lower in Swedish patients (hazard ratio: 0.83, 95% CI: 0.79-0.87). The hazard rate of switching was lower in Swedish and Dutch patients than in Italians (hazard ratios: 0.83, 95% CI: 0.79-0.88 and hazard ratio: 0.77, 95% CI: 0.71-0.84 respectively). Management of hypertension is unsatisfactory worldwide due to a very high rate of treatment discontinuation or insufficient use of proper treatment strategies.

Evaluation of a novel 7‐joint ultrasound score in daily rheumatologic practice: A pilot project

To introduce a new standardized ultrasound score based on 7 joints of the clinically dominant hand and foot (German US7 score) implemented in daily rheumatologic practice. The ultrasound score included the following joints of the clinically dominant hand and foot: wrist, second and third metacarpophalangeal and proximal interphalangeal, and second and fifth metatarsophalangeal joints. Synovitis and synovial/tenosynovial vascularity were scored semiquantitatively (grade 0-3) by gray-scale (GS) and power Doppler (PD) ultrasound. Tenosynovitis and erosions were scored for presence. The scoring range was 0-27 for GS synovitis, 0-39 for PD synovitis, 0-7 for GS tenosynovitis, 0-21 for PD tenosynovitis, and 0-14 for erosions. Patients with arthritis were examined at baseline and after the start or change of disease-modifying antirheumatic drug (DMARD) and/or tumor necrosis factor alpha (TNFalpha) inhibitor therapy 3 and 6 months later. C-reactive protein level, erythrocyte sedimentation rate, rheumatoid factor, anti-cyclic citrullinated peptide, Disease Activity Score in 28 joints (DAS28), and radiographs of the hands and feet were performed. One hundred twenty patients (76% women) with rheumatoid arthritis (91%) and psoriatic arthritis (9%) were enrolled. In 52 cases (43%), erosions were seen in radiography at baseline. Patients received DMARDs (41%), DMARDs plus TNFalpha inhibitors (41%), or TNFalpha inhibitor monotherapy (18%). At baseline, the mean DAS28 was 5.0 and the synovitis scores were 8.1 in GS ultrasound and 3.3 in PD ultrasound. After 6 months of therapy, the DAS28 significantly decreased to 3.6 (Delta = 1.4), and the GS and PD ultrasound scores significantly decreased to 5.5 (-32%) and 2.0 (-39%), respectively. The German US7 score is a viable tool for examining patients with arthritis in daily rheumatologic practice because it significantly reflects therapeutic response.

Medication review and patient counselling at discharge from the hospital by community pharmacists

In 2001, the Association of Amsterdam Community Pharmacists adopted a programme to improve the pharmaceutical care of patients who were discharged from hospital with five or more drug prescriptions. A comprehensive protocol for pharmaceutical care at discharge (IBOM-1) was developed. The aim of the study was to evaluate the initial IBOM protocol and to study the effects of the protocol on drug therapy and patient satisfaction as well as on drug use compliance and mortality. A controlled intervention study involving 37 community pharmacies and 715 of their registered patients who were discharged from a hospital and using at least five prescribed drugs in the years 2001-2003. The intervention included an extensive medication review and drug counselling at the patient's home. Pharmacy intervention activities, changes in medication, discontinuation of drugs prescribed at discharge, mortality, time spent on the intervention activities, and medication cost savings were all evaluated. Patient satisfaction was measured by means of a questionnaire. 379 and 336 patients were enrolled in the intervention and control groups, respectively. The mean number of drugs per patient not dispensed, concomitantly dispensed, or of which the quantity was changed was higher in the intervention group than in the control group (0.70 +/- 1.74 vs. 0.40 +/- 1.43, 0.11 +/- 0.40 vs. 0.038 +/- 0.26, and 0.29 +/- 1.05 vs. 0.097 +/- 0.52, respectively). The mean number of drugs for which the dose or dosage form was changed was similar in both groups. Substitution of brand for generic or vice versa was greater in the intervention group. Changes resulting from a PAIS signal were similar in both groups. The mean number of drugs per patient for which contact was required with the physician or the Pharmacy Hospital Service Desk was higher in the intervention group (0.35 +/- 0.51 vs. 0.16 +/- 0.38). About 40% of home visits resulted in the clearing of redundant drug supplies. The IBOM-1 intervention did not influence discontinuation of drugs prescribed at discharge, nor did it influence mortality. Medication costs were slightly reduced. More patients of intervention pharmacies than of control pharmacies indicated that they were (very) satisfied with the drug counselling by their community pharmacist upon delivery of their discharge medication (87% vs. 50%; chi(2) < 0.001). Structured pharmaceutical care according to the IBOM-1 protocol led to more changes in drug therapy. Home visits resulted in the clearing of redundant home drug supplies. In addition, patients were highly satisfied with the counselling at discharge from hospital by their community pharmacist. Patient counselling at discharge from hospital by pharmacists, therefore, appears to be a meaningful pharmaceutical care activity.

Lifestyle Changes and Blood Pressure Control: A Community‐Based Cross‐Sectional Survey (2006 Ontario Survey on the Prevalence and Control of Hypertension)

To the Editor : We read with interest the Fodor and colleagues1 article in your January issue wherein the authors asserted, in our opinion most erroneously, that “when a comparison is made between drug treatment and lifestyle changes, the outcomes of lifestyle interventions in real life are disappointing.” We would counter that drug therapy is not the only proven method of reducing blood pressure (BP) and most guidelines that recommend lifestyle changes for BP reduction are based on solid efficacy trials, including the Trials of Hypertension Prevention (TOHP), Dietary Approaches to Stop Hypertension (DASH), Prevention of Myocardial Infarction Early Remodeling (PREMIER), and Trial of Nonpharmacologic Interventions in the Elderly (TONE), to mention a few. This is especially true for patients who have stage 1 hypertension. In a recent PREMIER follow-up study, patients assessed 18 months later continued to have reduced BP, demonstrating the effectiveness of lifestyle changes.2 In the TONE trial, a greater percentage (23%) of older adults who received the lifestyle intervention remained normotensive (following medication withdrawal) at the 48-month follow-up than those who received usual care (7%).3 Furthermore, the conclusion that “practicing lifestyle changes did not add a beneficial effect to BP control compared with antihypertensive treatment with medications only” cannot be supported by this data. First, the authors’ comment is based on cross-sectional surveys with a relatively small sample of 733 hypertensive individuals, rather than on studies designed to test the comparative effectiveness of drug therapy vs lifestyle changes on BP control. Second, data were not presented on the actual degree of medication adherence or amount of lifestyle change. Rather, the assessment asked participants “whether they were using any nonpharmacologic and/or lifestyle treatments for BP control.” Although the authors note this limitation, they nevertheless reach beyond the limits of their data to minimize the effectiveness of lifestyle change for BP reduction. That lifestyle changes are difficult to enact is true, but that is also true for adherence to antihypertensive medications. Our studies indicate an adherence rate of 42% to 56% among hypertensive black patients followed in primary care practices,4, 5 similar to rates reported by others.6, 7 Other factors, ignored in this paper, and often in the literature, include clinical uncertainty and physicians’ awareness of evidence-based hypertension treatment guidelines when counseling patients. At the patient level, BP control can be hampered by lack of knowledge about the benefits of healthy lifestyle behaviors on BP reduction, side effects of prescribed medications, and comorbidity.8-10 Such factors also contribute to the often intractable multifactorial nature of BP control. We also take issue with the authors’ assertion that “relying on the effectiveness of lifestyle changes can lead to the postponement of efficacious drug treatment with serious consequences.” No data is presented in this paper to support this assertion, and there are no studies we are aware of that demonstrate “reliance on the effectiveness of lifestyle changes” leads to clinical inertia. Finally, the authors’ focus on the lack of significant between-group differences in BP control diminishes the positive finding that approximately half (42%) of the population reported adopting lifestyle changes in addition to using medications as part of their treatment. This rate is 2-fold higher than the prevalence reported in US adults when examining the 2006 Behavioral Risk Factor Surveillance System dataset (approximately 22% of the sample reported being adherent to heart-healthy behaviors).11 In our work, we have found group-based lifestyle interventions not only improve clinical outcomes such as BP reduction but also provide individuals with the impetus to sustain these interventions in their communities. In summary, we believe significant cardiovascular risk reduction can be achieved through multilevel interventions targeted at potentially reversible adverse lifestyle behaviors such as poor dietary intake and physical inactivity, particularly in high-risk patient populations. Suggestions to the contrary by Fodor and colleagues are simply unsupported.—

How Seizure Detection by Continuous Electroencephalographic Monitoring Affects the Prescribing of Antiepileptic Medications

To assess the effect of continuous electroencephalographic monitoring on the decision to treat seizures in the inpatient setting, particularly in the intensive care unit. Retrospective cohort study. Medical and neuroscience intensive care units and neurological wards. Three hundred consecutive nonelective continuous electroencephalographic monitoring studies, performed on 287 individual inpatients over a 27-month period. Epileptiform electroencephalographic abnormalities and changes in antiepileptic drug (AED) therapy based on the electroencephalographic findings. The findings from the continuous electroencephalographic monitoring led to a change in AED prescribing in 52% of all studies with initiation of an AED therapy in 14%, modification of AED therapy in 33%, and discontinuation of AED therapy in 5% of all studies. Specifically, the detection of electrographic seizures led to a change in AED therapy in 28% of all studies. The findings of continuous electroencephalographic monitoring resulted in a change in AED prescribing during or after half of the studies performed. Most AED changes were made as a result of the detection of electrographic seizures.

Status epilepticus and alcohol abuse: an analysis of 82 status epilepticus admissions.

In 1979-80, 82 cases of grand mal status epilepticus (71 patients, 39 male and 32 female) were admitted to the Casualty Department of Meilahti University Hospital in Helsinki, Finland. The cause of the underlying epilepsy was symptomatic in 43 cases (52.4%) and idiopathic in 19 cases (23.2%). In 6 cases (7.3%), there was a history of alcohol withdrawal seizures, and in 14 cases (17.1%) there was no earlier history of convulsions. Status epilepticus was associated with an acute or progressive cerebral disorder in 14 episodes. These comprised 6 bouts of status with brain tumour, 4 with acute stroke and 4 with brain injury. Alcohol abuse preceded the status in 29 episodes (35.4%), 23 of which occurred in men (53.5% of the male cases). Excessive use of alcohol was the only obvious precipitating factor for status in 16 cases, and in 6 cases the status presented as a prolonged alcohol withdrawal seizure. A change or irregularity of anticonvulsive drug therapy could be documented in 14 cases and an acute infection outside the central nervous system in 7 cases. Intravenous diazepam, used as the only therapy for status epilepticus, was effective in 58 of 78 episodes. In 7 cases of prolonged status, a thiopental sodium anaesthesia proved effective. The total mortality was 4.2%, including 2 deaths from concomitant extracerebral disorders and one late death from brain metastasis.