Changes In Prescribing Research Articles

Association between anticholinergic drug prescription changes and rehabilitation outcome in post-acute hip fractured patients

Purpose: To follow changes in anticholinergic drug prescriptions throughout hip fractured patients’ rehabilitation; to assess whether a change in anticholinergic burden affects rehabilitation outcome.Methods: Retrospective study of 869 hip fractured patients admitted between January 2011 to October 2015, performed in a post-acute geriatric rehabilitation center. The Anticholinergic Cognitive Burden Scale quantified the anticholinergic burden. Main outcome measures: Functional Independence Measure, motor Functional Independence Measure, Montebello Rehabilitation Factor Score on motor Functional Independence Measure and length of stay. Multiple linear regression analysis tested for independent association between admission anticholinergic burden and anticholinergic burden change during rehabilitation, and rehabilitation outcomes.Results: One hundred and sixty two (18.7%) patients were prescribed additional anticholinergic medications upon discharge; 76 (8.7%) were prescribed fewer. Patients with high admission anticholinergic burden presented with a significantly higher rate of higher education, less likely to reside at home, less independent pre-fracture, exhibited a significantly lower admission and discharge Functional Independence Measure score, a lower Functional Independence Measure score change and a lower Montebello Rehabilitation Factor Score. Admission anticholinergic burden, but not changes in anticholinergic burden during rehabilitation, was found to be independently associated with rehabilitation outcome (discharge FIM score).Conclusions: High admission anticholinergic burden is associated with lower functional ability in hip fractured patients. Changes in anticholinergic drug prescription during rehabilitation were not associated with rehabilitation outcomes.Implications for rehabilitationClinicians should make an effort to reduce AC drug use in hip fractured patients on admission to post-acute rehabilitation.AC burden should be carefully monitored throughout the rehabilitation period and reduced whenever possible.When functional ability does not improve as expected, AC burden should be considered as an intervening factor.

Prevalence of Pharmacogenomic Evidence for the ADME Genes Related to Commonly Used Drugs

BackgroundPharmacogenomics (PGx) is the study of genetic differences in multiple genes that influence the variability in drug response (efficacy and toxicity). The advantages of PGx application include optimization of patient therapy outcomes, improved drug alternatives and decreased healthcare costs. Genes related to absorption, distribution, metabolism and elimination (ADME) are susceptible to genetic polymorphisms and may influence the pharmacokinetic behavior of the medications. Clinical Pharmacogenetics Implementation Consortium (CPIC®) is a platform that advances the PGx practice by developing evidence‐based guidelines. The purpose of the present study was to analyze the involvement of ADME genes in the CPIC practice guidelines for the drugs for the fifteen most prevalent disease states in the United States.MethodsThe study analyzed for the drugs with ADME biomarkers genes (phase I drug metabolizing enzymes, phase II drug metabolizing enzymes and transporters) and level of evidence (A, B, C, D) in the CPIC database. CPIC evidence level A means a strong or moderate PGx intervention is recommended, whereas level B means a discretionary PGx action is recommended. For level C or level D no prescription changes are required due to either variable or very little PGx evidence available at this time. The fifteen most prevalent disease states in the United States were derived from the National Vital Statistics Reports of Centers for Disease Control and Prevention (CDC). The inclusion criteria consisted of drugs used in the treatment of most prevalent diseases as per the CDC reports and CPIC PGx evidence levels available on the CPIC website (www.cpicpgx.org). The exclusion criterion consisted of drugs that did not have CPIC level of evidence. The ADME gene‐related drugs were sorted out by CPIC level of evidence, number of prescriptions dispensed (ClinCalc database; www.Clincalc.com), and disease state. Data were organized and graphically analyzed using Microsoft Excel software.ResultsA total of 123 drugs related to ADME genes were identified from the CPIC database and levels of evidence were profiled. In general, a larger number of drugs are affected by the phase 1 enzyme PGx with a total of 49 drugs than the phase 2 enzyme or transporter PGx. Among the CPIC level of evidences, level D had the most drugs with a total of 55. CYP2D6 (n=25) had the most prevalence in CPIC level of evidence. The CPIC PGx evidence levels for genes‐related to phase I drug metabolizing enzymes were: level A 15 (31%), level B 17 (35%), level C 10 (20%) and level D 7 (14%). The evidence for phase II drug metabolizing enzymes were classified as: level A 3 (7%), level B 0 (0%), level C 6 (15%) and level D 32 (78%). The genes for transporters were found as: level A 1 (3%), level B 3 (9%), level C 13 (39%) and level D 16 (49%). The CPIC level A, C, and D had the most evidence for the drugs related to cancer, whereas CPIC level B had the most evidence for the drugs related depression.ConclusionThe PGx intervention by the biomedical and clinical professionals through the knowledge of ADME‐gene related CPIC PGx guidelines for drugs will ensure patient safety, potentially minimize healthcare cost and facilitate new drug development in a targeted manner. Oncology and depression are the disease conditions with most drugs affected by ADME gene PGx.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

High-risk medications in older patients with trauma: a cross-sectional study of risk mitigation

The Beers Criteria for Potentially Inappropriate Medication Use inOlder Adults is a framework that can assess the nature of high-risk medication use. The objective of this study was to use the Beers Criteria to assess the prevalence and nature of polypharmacy, the magnitude of medication changes during the hospital stay and the impact of Beers Criteria medications on outcomes in older patients with trauma. We used the Alberta Trauma Registry to conduct a retrospective review of patients aged 65 years or older with major trauma (Injury Severity Score ≥ 12) who were admitted to a level 1 trauma centre between January 2013 and December 2014. We analyzed changes in medication prescriptions during the hospital stay using descriptive statistics and assessed the association between Beers Criteria medications and relevant outcomes using multivariable regression analysis. There was no significant change in the number of Beers Criteria medications prescribed before and after admission. The adjusted odds ratio for 30-day mortality for each additional Beers Criteria medication prescribed was 2.02 (95% confidence interval [CI] 1.16–3.51) versus 1.24 (95% CI 1.04–1.59) for each additional medication of any type. The corresponding adjusted incidence rate ratios for length of stay were 1.15 (95% CI 1.03–1.30) versus 1.05 (95% CI 1.01–1.10). Beers Criteria medications were not discontinued during trauma admissions. Using the Beers Criteria as a process indicator for quality improvement in trauma care may provide interdisciplinary trauma teams an opportunity to audit patient medications and stop potentially harmful medications in a vulnerable population.

Remote Automated Peritoneal Dialysis Management in Colombia

Remote Automated Peritoneal Dialysis Management in Colombia

Implications of the Parenteral Opioid Shortage for Prescription Patterns and Pain Control Among Hospitalized Patients With Cancer Referred to Palliative Care

The recent parenteral opioid shortage (POS) has potential implications for cancer-related pain management in hospitalized patients. This study compared changes in opioid prescriptions and clinically improved pain (CIP) among patients treated by an inpatient palliative care (PC) team before and after our institution first reported the POS. A cohort study of 386 eligible patients with cancer treated at a comprehensive cancer center 1 month before and after the announcement of the POS. We reviewed data from electronic health records, including patient demographics, opioid type, route of administration, and dose. Board-certified palliative care specialists assessed CIP at follow-up day 1. The announcement of the POS by the institution's pharmacy and therapeutics committee on February 8, 2018. The primary outcome was to measure the change in opioid prescription patterns of physicians, and the secondary outcome was to measure the proportion of patients who achieved CIP before and after announcement of the POS. Of 386 eligible patients, 196 were men (51%), 270 were white (70%), and the median age was 58 years (interquartile range, 46-67 years). Parenteral opioids were prescribed less frequently by the referring oncology teams after the POS (56 of 314 [18%]) vs before the POS (109 of 311 [35%]) (P < .001). The PC team also prescribed fewer parenteral opioids after the POS (96 of 336 [29%]) vs before the POS (159 of 338 [47%]) (P < .001). After the POS (vs before the POS), significantly fewer patients achieved CIP on follow-up day 1 (119 [62%] vs 144 [75%] of 193; P = .01). Multivariate analysis showed that before the POS, patients had an 89% higher chance of achieving CIP on follow-up day 1 (odds ratio, 1.89; 95% CI, 1.22-2.94; P = .005). There was a significant change in opioid prescription patterns associated with the POS. Furthermore, after the POS, fewer patients achieved CIP. These factors have potential implications for patient satisfaction and hospital length of stay.

The effect of blood flow rate on dialysis recovery time in patients undergoing maintenance hemodialysis: A prospective, parallel-group, randomized controlled trial.

A majority of patients with end-stage renal disease (ESRD) on in-center hemodialysis (HD) require several hours to recover from an HD session. Patients and caregivers identify fatigue as a high priority for improvement. However, evidence for practical interventions to improve recovery time from conventional in-center HD is lacking. The effect of blood flow rate reduction on dialysis recovery time (DRT) is unknown. Multicenter, single-blinded, randomized, parallel-design controlled trial of blood flow rate reduction vs. usual care. One-hundred two patients with ESRD undergoing maintenance HD in 18 centers with baseline DRT of greater than 6 hours were included as subjects. The intervention was a blood flow rate reduction of 100 mL/min, to a minimum of 300 mL/min. The primary outcome was the between-group difference in change in DRT. Secondary outcomes were changes in London Evaluation of Illness (LEVIL) survey responses from baseline. Baseline median DRT was 720 (IQR 360-1013) minutes in controls and 720 (IQR 360-1106) minutes in the intervention group. DRT decreased in both groups. Mean change from baseline (95% confidence interval) at Week 4 in the study was -324 (-473, -175) minutes in the control group and -120 (-329, 90) minutes in the intervention group. The change from baseline was more profound in the control group (P = 0.05). Secondary outcomes of measures of quality of life reported on the LEVIL survey showed more improvement in patients' feelings of general well-being in the control group (P = 0.01). Differences between groups in pain, feeling washed out or drained, sleep quality, shortness of breath, and appetite were not statistically significant. Blood flow rate reduction did not improve DRT over usual care. Though more work needs to be done to address patient-reported fatigue, a significant positive impact may not be achieved without substantial changes in dialysis prescription.

Longitudinal Experience with Remote Monitoring for Automated Peritoneal Dialysis Patients

Background: Peritoneal dialysis (PD) is an ideal model for testing remote monitoring (RM). In this study, we evaluated the RM application longitudinally in stable patients undergoing automated PD (APD). Methods: This was an observational study, comparing outcomes in patients with (current patients) and without (historical data) exposure of RM. We analyzed cost-effectiveness of RM-APD measuring the number of night alarms, number of hospital visits, direct and indirect costs. Results: Changes in APD prescription were almost double in the case group (RM) compared to the control group (p = 0.0005). The need for in-person visits and nocturnal alarms was significantly less in RM-APD than in traditional APD (p = 0.01 and p = 0.002, respectively). The distance traveled by patients in the case of RM-APD was reduced by 1,134 km with a time saving of 1,554 min for patients. The overall cost reduction for the PD center in terms of time/nurse and time/physician was 2,647 and 3,673 min, respectively. All these advantages were obtained in the presence of an improved technique survival with a significant reduction of dropouts. All patients found that it is easy to use the RM system and were satisfied with the high level of interaction with the care team and with the possibility of timely resolving technical problems. Conclusion: These data confirm the long-term benefits of RM applied to APD. RM-APD is cost-effective; it allows early detection and resolution of problems, improved treatment compliance, reduction of patient’s access to hospital center for technical and clinical complications with consequent savings, and improved patient’s quality of life.

Impact of Parenteral Opioid Shortage on Opioid Prescriptions Among Patients Seen by the Palliative Care Team of a Comprehensive Cancer Center (FR440D)

•Measure the impact of parenteral opioid shortage on the opioid prescriptions by the inpatient palliative care (PC).•Compare the pain control of patients before and after parenteral opioid shortage (POS). Recent POS has the potential to impact cancer pain management in hospitalized patients. This study aims to compare changes in the opioid prescriptions by the inpatient PC team before and after the institution first reported the POS. We reviewed and compared the electronic health records of 386 consecutive eligible consultations seen by the inpatient PC team equally in 1 month before and after the announcement of POS on February 8, 2018. The eligibility criteria include (1) cancer diagnosis, (2) ≥18 years of age, (3) taking opioid medication at the time of consultation, and (4) having at least two consecutive visits with the PC team. Patient demographics, cancer type, opioid type, route, and dose defined as the morphine equivalent daily dose were assessed. Pain control was assessed based on the documentation for each follow-up by the PC team. After POS, parenteral opioids (patient-controlled analgesia, and intravenous breakthrough) were less used by the referring oncology teams [before POS 109/311 (35%) vs. after POS 56/311 (18%) (P=<.001)], while non-parenteral opioids (extended release, transdermal, and oral breakthrough) were more used [before POS 202/311 (65%) vs. after POS 258/311 (82%) P=<.001]. Similar changes associated with POS were indicated by the PC team [parenteral opioids 159/338 (47%) vs. 96/338 (29%) (P=<.001); non-parenteral opioids 179/338 (53%) and 240/228 (71%)]. At first PC follow-up, significantly less proportion of patients achieved better pain control after POS [119/193 (62%) vs. 144/193 (75%) (P=.006)]. However, at the second PC follow-up, the proportion of pain improvement was similar in both cohorts. There is a significant change in opioid routes associated with POS. POS was associated with worse analgesia.

Aripiprazole induced myopia - case report and literature review: Aripiprazole induced myopia.

Aripiprazole is an antipsychotic used in the treatment of different disorders. The most common side effects are dizziness, insomnia, akathisia, activation, nausea and vomiting. Ophthalmologic side effects are rare. We report a case of myopia induced by aripiprazole. Case study and literature review on aripiprazole-induced myopia. a 21-year-old male, with a first psychotic episode, developed myopia two weeks after initiating aripiprazole 20 mg/day. The symptoms of blurred vision were solved eight to ten days after switching to paliperidone. To date, seven cases of aripiprazole-induced myopia were reported in literature, all of them related to the oral formulation. in the present case, as seen in seven previously reported cases, the patient presented with myopia after the initiation of aripiprazol and the problem was solved after discontinuation of the drug. Apparently, this effect is not dose dependent, since the eight patients described were medicated with different dosages, from 3 to 20 mg per day. The onset of the symptoms was within a month, from three to thirty days, and the resolution after discontinuation was reported to be from three to fourteen days. Psychiatrists and ophthalmologists should be alert to the possibility of aripiprazole-induced myopia. When an ophthalmologist detects this problem, the patient should be referred to his psychiatrist to proceed with the prescription changes.

Effects of Pregnancy and Delivery Methods on Change in Ankylosing Spondylitis Treatment Using the Korean Health Insurance Review and Assessment Service Claims Database

BackgroundWomen with ankylosing spondylitis (AS) show a higher rate of cesarean section (CS) compared with healthy women. In this study, we determined the effects of pregnancy and delivery methods on AS worsening by analyzing prescription patterns.MethodsThe subjects were women with AS aged 20–49 years listed in the Korean Health Insurance Review and Assessment Service claims database. Change in treatment was defined as change in prescriptions 1–2 years before delivery or 1 year after delivery. We compared change in prescriptions between AS women with delivery or without delivery (1:1 matched). Moreover, we evaluated change in prescriptions according to delivery method among AS women with delivery.ResultsA total of 6,821 women with AS were included. Women in the delivery group (n = 996) were younger and showed less drug use and lower comorbidity rates than those in the no delivery group. Change in prescriptions did not differ between the delivery and no delivery groups (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.56–1.05). Furthermore, the overall change in prescriptions did not significantly differ between vaginal delivery (VD) and CS (OR, 0.72; 95% CI, 0.45–1.14).ConclusionThe rate of change in prescriptions was comparable between AS patients with and without delivery. There was no association between the method of delivery and change in prescription. Therefore, pregnancy and VD may not be the factors associated with AS worsening.

A Survey on the Prescription Changes and the Reduction in Medical Expenses by Prescription Proposals on Renal Function Evaluation by Community Pharmacists

A Survey on the Prescription Changes and the Reduction in Medical Expenses by Prescription Proposals on Renal Function Evaluation by Community Pharmacists

Generic Drug Policy and Suboxone to Treat Opioid Use Disorder.

Despite some improvements in access to evidence-based medications for opioid use disorder, treatment rates remain low at under a quarter of those with need. High costs for brand name products in these medication markets have limited the volume of drugs purchased, particularly through public health insurance and grant programs. Brand firm anti-competitive practices around the leading buprenorphine product Suboxone - including product hops, citizen petitions and Risk Evaluation and Mitigation Strategy abuses - helped to maintain high prices by extending brand exclusivity periods and hindering generic drug entry. Remedies to address costly anti-competitive activities include adoption of the proposed CREATES Act and modernization of the Hatch-Waxman Act by the Congress, and implementation of substantive modifications to the Food and Drug Administration citizen petition filing procedures. Given the persistence of these abuses, prescriptive changes are favorable to the procedural and clarifying steps thus far favored by the federal government. Extrapolating from the 37% price declines attributable to generic entry for buprenorphine tablets in 2011, our calculations suggest that implementing these remedies to facilitate generic competition with Suboxone film would have resulted in savings of approximately $703 million overall and $203 million to Medicaid in 2017.

Changing trends in anti-psychotic prescription pattern in Pakistan.

Background and Objective:This study was designed to identify the changing trends in Anti-psychotic prescription pattern in Pakistan. It was part of the research project Research on East Asian Psychotropic Prescription Pattern (REAP) carried out to identify the prescription patterns of schizophrenic patients in different countries located in Asia.Our objective was to assess the trend and change of psychotropic drug prescriptions for patients with schizophrenia.Methods:The design of the study was quantitative and of descriptive epidemiology. This study was carried out from 30th March 2017. Data was collected on a unified protocol by the Psychiatrists from Pakistan. Three (3) centers i.e., Lahore, Karachi and Islamabad provided the data. Indoor and outdoor cases with Schizophrenia were recruited. A web based recording system for collection of data done at Taipei Taiwan, and statistical analysis was performed and transferred to all participating centers including Pakistan.Results:The main findings of the study were that majority of the patients were prescribed antipsychotic poly pharmacy drug. It was also found that Anxiolytics, anti-depressants and Anti-parkinsonian drugs were also co-prescribed.Conclusion:It was concluded that antipsychotic poly pharmacy along with Anxiolytics, anti-depressants and Anti-parkinsonian drugs were prescribed to patients with schizophrenia in Pakistan.

Mitohormesis in muscle cells: a morphological, molecular, and proteomic approach

Low-level oxidative stress induces an adaptive response commonly defined as hormesis; this type of stress is often related to reactive oxygen species (ROS) originating from the mitochondrial respiratory chain (mitochondrial hormesis or mitohormesis). The accumulation of transient low doses of ROS either through chronic physical activity or caloric restriction influences signaling from the mitochondrial compartment to the cell, reduces glucose metabolism, induces mitochondrial metabolism, increases stress resistance and ultimately, increases lifespan. Mitochondrial formation of presumably harmful levels (chronic and/or excessive) of ROS within skeletal muscle has been observed in insulin resistance of obese subjects, type 2 diabetes mellitus, as well as in impaired muscle function associated with normal aging. Advances in mitochondrial bioimaging combined with mitochondrial biochemistry and proteome research have broadened our knowledge of specific cellular signaling and other related functions of the mitochondrial behavior. In this review, we describe mitochondrial remodeling in response to different degrees of oxidative insults induced in vitro in myocytes and in vivo in skeletal muscle, focusing on the potential application of a combined morphological and biochemical approach. The use of such technologies could yield benefits for our overall understanding of physiology for biotechnological research related to drug design, physical activity prescription and significant lifestyle changes.

Actividad física y nutrición en la educación médica

Noncommunicable diseases (NCDs) are the leading cause of death worldwide (70%). In Colombia, 178,000 people per year (73%) die from NCDs. Bad practices in lifestyles, especially physical inactivity, overfeeding and smoking leading to NCDs. In Colombia, overweight has increased in the entire population: 56.5% in adults aged 18 to 65 years and the percentage of people who meet the physical activity recommendations is only 51.3% in adults. Physicians and in general health professionals have a fundamental role to help patients and their families in the construction of a healthy lifestyle. The subject of physical activity and nutrition must be compulsory part of the curricula of health careers. For nutrition, instruction is recommended centered on 4 axes: basic nutrition, nutritional assessment, nutritional intervention and dietary treatment of disease. In physical activity it is recommended that the intervention focuses on four aspects: physical activity and fitness cardiorespiratory assessment, exercise prescription, counseling and behavioral change strategies and health of medical personnel. The experience of the authors is shown with the sports medicine and exercise program of the School of Medicine and Health Sciences of the Universidad del Rosario

Factors underlying the changing of antibiotics in a paediatric intensive care unit in Pietermaritzburg, KwaZulu-Natal

Background. Antibiotics are among the most commonly used drugs in a paediatric intensive care unit (PICU). Despite guidelines and protocols for the use of antibiotics, inappropriate use may contribute to an increase in antibiotic resistance. The factors behind changes in antibiotic prescriptions in the PICU at Grey’s Hospital are unknown. Objective. To establish the frequency, process and rationale behind antibiotic prescription changes in the PICU. Methods. A retrospective descriptive study of all eligible patients admitted to the PICU during a 6-month period. Results. Three-quarters of patients admitted to the PICU received antibiotics during their stay. The antibiotic prescription was changed in 80 (58%) of the138 patients, with most changes (63.4%) occurring within 3 days of admission. Patients younger than 1 year and those who were malnourished accounted for 57% of the changes. The majority (65%) of the changes entailed the escalation of antibiotics and 89% of these were empiric therapy. De-escalation accounted for 35% of the changes. The rationale for a prescription change was not documented in 80% of cases. Conclusion. Antibiotic use in this PICU and changes to prescriptions were common. Changes were generally made on an empirical basis soon after admission and were more likely to occur in young malnourished children and patients admitted for a medical reason or surgical emergency.

Impact of community pharmacist intervention on concurrent benzodiazepine and opioid prescribing patterns

Objectives(1) To evaluate the number of opioid/benzodiazepine (BZD) prescription changes resulting from pharmacist communication to prescriber(s); (2) to determine the number of patients on concurrent opioid/BZD therapy from single versus multiple prescribers; (3) to compare the number of opioid/BZD prescription changes resulting from communication when a single versus multiple prescribers was involved in a patient’s care; and (4) to compare the number of opioid/BZD prescription changes resulting from communication via fax versus the Kansas Health Information Network (KHIN) direct messaging feature. MethodsProspective study conducted at 13 community pharmacies, including patients 18 years of age or older simultaneously filling opioid and BZD prescriptions within 90 days before October 2017. Prescribers received faxed or KHIN communication proposing evidence-based prescription changes to opioid/BZD agents. Prescription changes were evaluated weekly for 3 months after the initial intervention. Descriptive statistics assessed demographics and the number and types of prescription changes. Spearman rho correlations compared prescription changes and number of prescriptions to number of prescribers; a priori alpha was set at 0.05. ResultsA total of 137 prescribers and 121 patients were included. Ninety-nine prescribers were contacted via fax and 38 via KHIN. After 4 weeks, 34 recommendations were received: 20 responses (59%) indicated rejection of recommendations, 5 (15%) approved BZD taper/discontinuation, 3 (9%) deferred changes until a patient visit, 2 (6%) approved opioid taper/discontinuation, 2 (6%) prescribed naloxone, and 2 (6%) withdrew from the patient’s care. Three months after communication, 35 prescription changes were noted: 22 (63%) opioid/BZD agent tapers/discontinuation, 14 (26%) opioid/BZD dose increases, and 2 (6%) naloxone prescriptions. There was positive correlation between the number of tapered/discontinued agents and the number of prescribers involved in a patient’s care (P = 0.046). ConclusionA faxed pharmacist intervention may help to reduce opioid/BZD coprescribing, especially when multiple providers are involved in a patient’s care.

Impact of parenteral opioid shortage on opioid prescriptions among patients seen by the palliative care team of a comprehensive cancer center.

201 Background: Recent parenteral opioid shortage (POS) has the potential to impact cancer pain management in hospitalized patients. This study aims to compare changes in the opioid prescriptions by the inpatient palliative care (PC) team before and after the institution first reported the POS. Methods: We reviewed and compared the electronic health records of 386 consecutive eligible consultations seen by the inpatient PC team equally in one month before and after the announcement of POS on February 8, 2018. The eligibility criteria include (1) cancer diagnosis, (2) ≥18 years of age, (3) taking opioid medication at the time of consultation, and (4) having at least two consecutive visits with the PC team. Patient demographics, cancer type, opioid type, route, and dose defined as the morphine equivalent daily dose were assessed. Results: POS was associated with less use of parenteral opioids (patient controlled analgesia, and intravenous breakthrough) and more use of non-parenteral opioids (extended release, transdermal, and oral breakthrough) by the referring oncology teams, and PC team (P≤.001) (Table 1). At first PC follow-up, significantly less proportion of patients achieved better pain control after POS [119/193 (62%) versus 144/193 (75%) (P=.006)] However, at second PC follow-up, the proportion of pain improvement was similar in both cohorts. Conclusions: There is a significant change in opioid routes associated with POS. POS was associated with worse analgesia. More research is needed to better understand the impact of POS on cancer pain management.[Table: see text]

Impact of EU risk assessment process and administrative regulations for manufacturers of combined hormonal contraceptive prescribing. An analysis of developments in Germany and the implications

Objective: Combined hormonal contraceptives (CHC) exhibit differing risks for cardiovascular and thrombotic events (VTE). A European referral process confirmed higher VTE risks for 3rd generation gestagens and drospirenone. CHC are now grouped in risk classes (RC) I, II, and III, with RC III having a higher risk than RC I and X (risk not yet known). Marketing authorization holders were obliged to implement pharmacovigilance measures and risk minimization measures including changes of prescribing information. The study assessed whether these activities induced changes in prescription patterns.Methods: German prescription data for 1.1 million women below 20 years of age were used to analyze the effects of interventions and potential influence factors using logistic regression. Descriptive statistics were calculated for prescriptions for 3.3 million women from January 2011 to March 2016.Results: Shares of RC I and RC X recipients rose substantially over the observation period, while RC III recipient share showed a steady decrease. The referral induced a slightly faster decrease in RC III and increase in RC X. The implementation of pharmacovigilance measures manifested no additional effect.Conclusion: The decrease in RC III share already observed before the referral process can be explained with pre-existing discussions around CHC. The effect attributable to the referral was statistically significant, although very small. While evidence for a connection between interventions and prescription change is only indirect, the study shows that routine data are suitable for impact analyses, and monitoring prescribing patterns can be recommended as feedback after regulatory or political interventions. This is being followed up.

Effect of a computerized decision support system on potentially inappropriate medication prescriptions for elderly patients in Thailand

The prescription of potentially inappropriate medication (PIM) is a global issue associated with increased adverse drug events, mortality, and health care expenditure. Computerized decision support system (CDSS) for the detection of PIM is a novel alert system in Thailand for reducing PIM prescriptions. The aim of this study was to evaluate the effect of a CDSS on PIM prescriptions for elderly patients in Thai community hospitals. The study design comprised two phases with a duration of 12months each: pre-CDSS implementation (October 2015-March 2016) and post-CDSS implementation (October 2016-March 2017). Medical services and prescription claims data from four hospitals were used to calculate the prevalence of PIM prescriptions among elderly patients aged 60years and older. Chi-square tests were used to analyse changes in PIM prescriptions across hospitals post CDSS. The overall prevalence of PIM prescriptions post-CDSS implementation significantly decreased from 87.7% to 74.4%. The severity of mild and moderate PIMs was significantly reduced from 71.9% to 49.0% and from 64.5% to 48.7%, respectively. All hospitals had only one severe PIM, which was hyoscine. It was reduced from 4.7% to 1.5%, but the change was not significant (P=0.74). The proportion of frequently prescribed PIMs in all PIM levels was significantly decreased, regardless of existing alternative medications. Specific CDSS for PIM in community hospital setting was associated with a reduction of PIM prescription in elderly patients. This CDSS can change physician's prescription behaviour to avoid inappropriate medications.