Inappropriate Dosing Research Articles

Phenotypes of Patients with Direct Oral Anticoagulant (DOAC) Underdosing in Atrial Fibrillation: Results from the ARENA Registry.

Oral anticoagulation in patients with atrial fibrillation is crucial to prevent thrombus formation in the heart, a major cause of ischemic stroke. The appropriate dose of direct oral anticoagulants (DOAC) - either standard or reduced dose - must be chosen individually in accordance with defined patient characteristics. However, a significant proportion of patients receive inappropriately low DOAC doses (underdosing). With a novel medication-based approach, this study aims to facilitate the identification of patients at risk of DOAC underdosing. The prospective ARENA registry is a multi-centre study on patients with atrial fibrillation in Germany. Patients gave detailed information on medication, including over-the-counter preparations. Medication data were grouped according to the Anatomical Therapeutic Chemical (ATC) classification. In a bivariate analysis, the characteristics of patients on an appropriate versus inappropriate dose were compared (n = 866). To further evaluate variables for their association with underdosing, a model based on ATC third level medication data complemented with dose-adjustment criteria and validated clinical scores in all patients with complete information was built (n = 504). In 15% of patients, an inappropriately low dose was found. The number of DOAC drug interactions, concomitant antiplatelet therapy and the total drug count were the most important predictors of DOAC underdosing. Mineral supplements and better health-related quality of life (HrQoL) were predictive of correct DOAC dosing, among others. Medication-related data showed to be predictive of DOAC underdosing. Clinicians should check for inappropriately reduced DOAC doses, especially in patients undergoing antiplatelet therapy, polypharmacy and reduced HrQoL. NCT02978248; date of registration: 30 November 2016.

Inappropriate Prescribing of Nirmatrelvir/Ritonavir in Solid Organ Transplantation With COVID-19 Infection: A Multicenter Retrospective Study

BackgroundNirmatrelvir-ritonavir (NR) has demonstrated effectiveness in halting the progression to severe coronavirus disease 2019 (COVID-19) among solid organ transplant recipients (SOTRs) infected with Severe Acute Respiratory Syndrome Coronavirus 2. However, it has a wide range of interactions, especially with immunosuppressants. The study aimed to comprehensively evaluate the Inappropriate prescribing of NR and immunosuppressants in SOTRs with COVID-19, while also highlighting the essential aspects. MethodsWe included hospitalized SOTRs who received NR at five tertiary hospitals between December 2022 and June 2023, and evaluated their prescription. ResultsA total of 211 patients were enrolled, of which 205 did not meet all criteria for appropriate prescribing (97.16%). Inappropriateness primarily stemmed from starting treatment more than 5 days after symptom onset (87.68%), followed by application in severe-to-critical cases of COVID-19 (52.13%), the inappropriate dosages based on renal function (47.87%). Contraindications encompassed 17.06% of patients with severe renal impairment and 5.69% with contraindicated drug interactions. Inappropriate resumption of immunosuppressants accounted for a larger proportion than inappropriate discontinuation or dose adjustment (30.16% vs 8.99%). More than one-third of patients neglected to monitor concentrations. About 8% experienced abnormal high concentrations. ConclusionInappropriate prescribing of NR is widespread among hospitalized SOTRs. Adjusting doses based on patients’ renal function and paying attention to concurrent use of immunosuppressive drugs are crucial, and therapeutic drug monitoring is necessary. Clinical practitioners should enhance their vigilance and attention.

Determinants of Inappropriate Dosing of Direct Oral Anticoagulants in Non-Valvular Atrial Fibrillation in a Low-Income Country

Determinants of Inappropriate Dosing of Direct Oral Anticoagulants in Non-Valvular Atrial Fibrillation in a Low-Income Country

Treatment appropriateness of direct oral anticoagulants in patients with atrial fibrillation for stroke prevention: A real-world prospective study.

Inappropriate use of direct oral anticoagulants (DOACs) is common, affecting up to 30% of atrial fibrillation (AF) population receiving treatment for stroke prevention. This study assessed appropriateness of anticoagulation in anticoagulation-naive AF patients treated with DOACs during a 12-month prospective follow-up. This prospective cohort study included all anticoagulation-naive AF patients referred for anticoagulation for stroke prevention at a tertiary cardiovascular center. Participants were prospectively followed through phone call interviews by a dedicated nurse at 1, 3, 6, 9, and 12 months after enrollment. Of 403 anticoagulation-naive AF patients, rivaroxaban was prescribed for 325 patients (80.7%) and apixaban for 78 (19.3%). Inappropriate therapy was observed in 23% (76/325) and 46% (36/78) of patients treated with rivaroxaban and apixaban, respectively. Undertreatment was predominant scenario for both drugs, detected in 78.5% (78/112) of patients treated inappropriately, and was more frequently observed with apixaban versus rivaroxaban (44.8% vs 16.3%). During 12 months, inappropriate treatment was corrected in only 13% of all patients. The multivariate regression model identified creatinine clearance ≤ 49 mL/min (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.12 to 4.21), female sex (OR, 1.81; 95% CI, 1.11 to 2.97), and age ≥ 80 years (OR, 1.85; 95% CI, 1.22 to 2.83) as independent covariates associated with inappropriate dosing. Inappropriate therapy with DOACs for stroke prevention in patients with AF is common, and the dosage were corrected in few patients during the 12-month follow-up. Our findings highlight the persistent lack of knowledge regarding appropriate DOAC dosage and need for continuous education.

Evaluating pediatric antimicrobial dosing of β-lactam antibiotics for upper respiratory tract infections in emergency and primary care settings.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Pediatric prescribing is often weight and indication specific and has been associated with high rates of error. The aim of this study was to evaluate outpatient β-lactam suspension dosing practices for pediatric upper respiratory tract infections (URIs), to characterize the rate of error and to describe common error types. This retrospective cohort study was conducted at a community health system with 2 emergency departments and 20 outpatient family medicine practices. Pediatric patients treated from these settings with oral suspension formulations of amoxicillin, amoxicillin/clavulanate, cefdinir, or cephalexin for streptococcal pharyngitis or otitis media between June 1, 2020, and May 31, 2023, were eligible for inclusion. Doses were evaluated against indication-specific best-practice guidelines and assessed for guideline concordance. Of the 200 patients evaluated, 100 were treated for streptococcal pharyngitis and 100 were treated for otitis media. Of the prescribed β-lactam doses, 32% were discordant with best-practice guideline recommendations. Dosing errors were more common for pharyngitis than for otitis media (47% vs 17%; P < 0.001). Overdosing was the most frequently observed error in pharyngitis prescriptions (93.6% of errors) and most commonly occurred in patients weighing more than the 20-kg weight associated with the dosing maximum (80.9% of overdosing errors). All patients receiving an inappropriate dose for otitis media were underdosed. Outpatient pediatric dosing errors for URI indications are common among both emergency medicine and family medicine prescribers. Patients weighing over the weight corresponding to the dosing maximum are at highest risk for error. Antimicrobial stewardship interventions targeting the point of prescribing are urgently needed to provide safe dosing practices for pediatric patients.

An audit of the adherence to dosing and therapeutic monitoring of intravenous vancomycin in accordance with the trust’s antimicrobial guidelines

Abstract Introduction Inappropriate vancomycin dosing and monitoring have compromised patient safety, causing acute kidney injury and prolonged hospital stays. Misuse of antibiotics, like vancomycin, accelerates resistance, a global health threat. Following guidelines can prevent harm and curb the emergence of vancomycin-resistant enterococci and resistant Staphylococcus aureus1. Aim To assess the level of adherence to trust guidelines for the dosing and monitoring of intravenous vancomycin. Audit Standards Standard 1: Patients prescribed intravenous vancomycin should have documented indication Standard 2: Patients prescribed intravenous vancomycin should have correct loading dose Standard 3: Patients prescribed intravenous vancomycin should have correct maintenance dose Standard 4: Patients prescribed intravenous vancomycin should have trough levels taken at the right time Standard 5: Patients prescribed intravenous vancomycin should have doses accurately adjusted against trough level Results: Standard 6: Patients prescribed intravenous vancomycin should have all prescribed doses administered (i.e. no missed doses). Standard 7: Vancomycin prescriptions should be screened by a pharmacist. Methods This audit was approved by both the Trust Clinical Audit Committee and the Antimicrobial Stewardship Group. A retrospective audit using data extracted from EPMA. The data collected included: indication documented (Yes/No), correct loading dose? (Yes/No), missed doses? (Yes/No), correct maintenance dose? (Yes/No), correct first sampling? (Yes/No), correct subsequent sampling? (Yes/No), correct dose adjustments based on levels? (Yes/No) and prescription screened by a pharmacist? (Yes/No). Data was input into Microsoft Excel for analysis. The period covered was 01/12/2022 to 31/05/2023. Ethics approval was not required, as clinical audits do not require ethical review. The inclusion criterion was adult patients prescribed intravenous vancomycin. The exclusion criteria were patients in maternity, labour, and renal wards, due to different guidelines and ITU due to no EPMA. The population size was 243; sample size (n) =150 ensuring a 95% confidence level. Results In total, 150 patient drug charts were analysed, of which 96 % had their vancomycin indication documented. 65.3% of patients had the correct loading dose, 64.7% had the correct maintenance dose. 32.23% had the initial trough level done at the right time and 35% had correct subsequent trough levels measured. 44% had correct dose adjustments based on their trough levels and 57.33% had their prescriptions screened by a pharmacist. Discussion and conclusion None of the target compliance rates were met, highlighting significant issues with vancomycin dosing and therapeutic monitoring within the trust. Therapeutic drug monitoring (TDM) is crucial to ensure optimal patient outcomes2. Audit findings have been shared with the wider multidisciplinary team, education on TDM has taken place with junior pharmacists and digital prompts on EPMA have been included to help improve adherence. A limitation of this audit is its retrospective nature, useful for trend analysis but not for identifying causes. A prospective audit was not feasible due to staffing pressures. Conducting clinical audits are an important tool for assessing and ensuring safe clinical practice.

Adopting a model of antimicrobial stewardship program to anti-tubercular treatment stewardship: A single-centre experience from a private tertiary care hospital in South India.

Tuberculosis (TB) remains a significant public health challenge in Low- and Middle-Income Countries (LMIC). Inappropriate use of Anti-Tubercular Treatment (ATT) undermines treatment efficacy and could contribute to drug resistance. While antimicrobial stewardship programs (AMSP) are well established, anti-tubercular treatment stewardship programs (ATTSP) in private hospitals do not have an established model. An AMSP model in a private tertiary care hospital in South India was repurposed to monitor the prescription appropriateness of ATT. A multidisciplinary team evaluated the ATT prescription appropriateness among inpatients over a one-year period with the 4R's criteria: Right Indication, Right Drug, Right Dose, and Right Frequency. The ATTSP team filed recommendations for inappropriate prescriptions to the primary clinical care team, and compliance to the recommendations was documented within 48 hours. During the study period, 172 ATT prescriptions were evaluated. Inappropriate dose and drug prescriptions were found in 16% and 7%, respectively. The primary clinical care teams complied with 83% of the recommendations within 48 hours. The potential impact of implementing the ATTSP model nationwide was assessed using published data, suggesting that the opportunities to correct inappropriate prescriptions could reach a quarter million. The study provides a proof of concept that an ATTSP can be successfully implemented in a TB endemic, resource-constrained setting. Extrapolation for implementing ATTSP across the country has the potential for huge public health benefits.

Predictors and Outcomes of Inappropriate Dosing of Direct Oral Anticoagulants in Patients Receiving Transcatheter Aortic Valve Implantation.

Direct oral anticoagulant (DOAC) dose adjustment is based on age, renal function, and body weight. There is a paucity of data describing the factors associated with the prescription of inappropriate dosage and their impact on clinical outcomes among patients receiving transcatheter aortic valve implantation (TAVI). In a single-center study, 432 patients who were on long-term DOAC therapy and underwent TAVI between 2015 and 2022 were included. We analyzed the predictors and outcomes of inappropriate dosing of DOACs; namely apixaban, dabigatran, edoxaban, and rivaroxaban. A composite endpoint, including all-cause mortality, life-threatening/major bleeding, stroke, peripheral thromboembolic complications, or myocardial infarction, was assessed after 1 year. In this TAVI cohort, inappropriate DOAC dosing was observed in 20.6% of patients. Inappropriate DOAC dosage was related to female gender (adj. odds ratio [OR] 2.72, 95% confidence interval [CI] 1.64-4.51, p < 0.001) as well as lower estimated glomerular filtration rate (eGFR) (adj. OR 0.99, 95% CI 0.98-1.00, p = 0.019), and to the administration of non-rivaroxaban DOACs (adj. OR 0.28, 95% CI 0.16-0.50, p < 0.001). After 1 year, patients on both appropriate and inappropriate DOAC dosage exhibited comparable rates of the composite endpoint (OR 0.88, 95% CI 0.53-1.46, p = 0.622). Old age (adj. OR 1.05, 95% CI 1.01-1.10, p = 0.018) as well as anemia (adj. OR 0.86, 95% CI 0.75-0.99, p = 0.031) emerged as independent predictors of the composite endpoint. In this TAVI cohort, female gender and renal insufficiency were associated with inappropriate DOAC dosage, whereas rivaroxaban was linked to appropriate dosing. Inadequate DOAC dosage did not translate into a worse outcome in our TAVI population. Prospective Segeberg TAVI Registry (ClinicalTrials.gov identifier: NCT03192774).

Unveiling pharmacogenomics: insights from Portuguese pharmacists on quaternary prevention

Abstract Background Public health genomics recognises the potential of genomic knowledge for enhancing population health. Adverse drug reactions (ADR) and lack of efficacy have significant clinical and economic burdens, which can be mitigated by pharmacogenomics (PGx) testing. Pharmacists can play a vital role in facilitating the implementation of PGx into routine clinical care. This will promote quaternary prevention, to protect individuals from medical intervention that can cause more harm than good. Objectives To assess attitudes, opinions, expectations, practices, and concerns of Portuguese pharmacists regarding PGx implementation. Methods An observational cross-sectional web-based survey was developed based on literature review, adapted to the national context, and validated in a focus group. The target population were adults residing in Portugal with a degree in Pharmaceutical Sciences or equivalent, with convenience sampling. Descriptive statistics were performed. Results From 303 participants, 98% believe that PGx is an important area of pharmaceutical sciences and 97% indicate that PGx should be included in continuing education. Almost all (99%) anticipate that PGx implementation will prevent the administration of ineffective drugs and inappropriate doses, 98% expect PGx will reduce ADR. Major concerns are related with direct-to-consumer sale of PGx tests via internet (78%) and unauthorized access to test results (91%). Currently, 25% are familiar with reliable sources of information on PGx, but only 11% feel qualified to recommend PGx testing, and 10% have analysed PGx reports. Conclusions There are positive opinions and expectations regarding the potential benefits of PGx tests. However, there are regulatory concerns and lack of readiness for immediate application. Pharmacists express interest in learning more about PGx, highlighting the need for continuous education and training to integrate it effectively into routine pharmaceutical practice. Key messages • Pharmacists recognize the benefits of PGx implementation for quaternary prevention. • Regulatory concerns and readiness gaps in PGx emphasise a need for training and life-long education of pharmacists.

Extended Spectrum β-Lactamase: Tackling Antibiotic Resistance and Overcoming Treatment Challenges

Antibiotics, also known as antibacterials, kill or inhibit bacterial growth but are ineffective against viruses, fungi, or parasites, often leading to misuse. They are categorized by molecular structure, mode of action, and spectrum of activity. Antimicrobial Resistance (AMR) occurs when pathogens no longer respond to antimicrobial drugs, arising naturally or through acquisition. Resistance mechanisms include enzymatic (most common), genetic and physical. Bacteria produce various β-lactamases, such as Extended Spectrum β-lactamases (ESBLs), AmpC enzymes, and carbapenemase to exert resistance to Beta-Lactam (βL) class of antibiotics. ESBL families include TEM, SHV, and CTX-M, with E. coli being the most prevalent host. Any Gram-Negative Bacteria (GNB) can be an ESBL producer, but most common ones are the Enterobacteriaceae including Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca and Proteus mirabilis. ESBL-producing Enterobacteriaceae (ESBL-E) resist penicillin, aztreonam, and cephalosporins except cephamycins and carbapenems, posing a significant public health risk. Genetic resistance mechanisms involve random mutations and horizontal gene transfer through either of the following processes namely conjugation, transformation, transduction. Physical mechanisms include efflux pump production and decreased porin channels. In some microbiological laboratories, ESBL production are often not determined, rather resistance based on MIC values to third generation Cephalosporins are considered as resistance due to ESBL production. Antibiotic use in agriculture and medicine has increased Multi-drug resistant (MDR) ESBL-producing E. coli and evidenced in retail meat and among meat shop employees. Community-acquired ESBL-E infections are a growing concern, with hospital transmission primarily occurring among patients sharing rooms with ESBL carriers. Empirical and definitive therapies for ESBL-E infections must be adjusted based on Antibiotic Susceptibility Testing (AST). The MERINO trial identified urinary tract infections as the most common source of ESBL-E bacteremia, with E. coli being predominant. For critically ill patients with non-urinary tract infections, Meropenem or Imipenem-cilastatin are recommended. For uncomplicated UTIs, Nitrofurantoin, Cotrimoxazole, and Piperacillin-Tazobactam (Pip-Taz) are effective, while Cotrimoxazole, Fluoroquinolones, and Ceftolozane-tazobactam are suitable for complicated UTIs. New β-lactamase inhibitors like avibactam, vaborbactam, and relebactam are promising for treatment. Misuse of antibiotics, such as inappropriate dosing and duration, contributes to AMR, a growing global challenge. Deaths from AMR, estimated at 1.27 million in 2019, could reach 10 million by 2050. ESBLs drive the use of broad-spectrum antibiotics, accelerating resistance development. Inadequate therapy exacerbates infections, leading to prolonged hospital stays, complications, and increased mortality. Balancing new drug development with resistance emergence is crucial to combat AMR.

Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation undergoing percutaneous coronary intervention

Abstract Background Underdose (inappropriate low-dose) of direct oral anticoagulants (DOAC) is sometimes prescribed due to concerns of bleeding risk in patients with atrial fibrillation (AF). In AF patients with coronary artery disease requiring percutaneous coronary intervention (PCI), careful treatment is required to prevent bleeding events because of intensive antithrombotic therapy with a combination of oral anticoagulants and antiplatelet agents. Purpose The purpose of this study was to investigate the prevalence of underdose of DOAC and its impact on clinical outcomes in AF patients with coronary artery disease undergoing PCI. Methods This multicenter observational cohort study enrolled patients with AF on DOAC undergoing PCI between January 2015 and March 2021 at 15 institutions. Appropriateness of DOAC dose was determined according to the manufacturer's labeling recommendations in Japan. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE), all-cause mortality, ischemic stroke, and major bleeding events, were evaluated. Results Of 630 patients enrolled, 168 patients (26.7%) received underdose, 227 (36.0%) received appropriate low-dose, 213 (33.8%) received appropriate standard-dose, and 22 (3.5%) received overdose. Because of the extremely small number of patients in the overdose group, the primary analysis of the present study was a comparison between the underdose group (n=168) and the appropriate dose group (appropriate low-dose and standard-dose groups) (n=440). Although the incidence of MACE, all-cause mortality, and major bleeding events was not significantly different between the 2 groups (log-rank p=0.872, p=0.170, and p=0.725), ischemic stroke more frequently occurred in the underdose group compared with the appropriate dose group (log-rank p=0.010) (Figure 1). The multivariable Cox regression analysis determined underdose of DOAC as an independent predictor for ischemic stroke (adjusted HR 3.288, 95% CI: 1.189-9.088, p=0.022). Conclusions Compared with appropriate dose of DOAC, underdose was associated with a higher incidence of ischemic stroke, despite no significant difference in MACE, all-cause mortality, and major bleeding events, in AF patients undergoing PCI.Figure 1

PROFIL PENGOBATAN KEMOTERAPI PADA PASIEN KANKER PAYUDARA DI RUMAH SAKIT UMUM DAERAH KOTA BOGOR PADA TAHUN 2022

Breast cancer is cancer that starts in the breast tissue, which consists of milk-producing glands (lobules) and ducts that connect the lobules to the nipple. One of the efforts to reduce the morbidity rate of breast cancer is chemotherapy. Chemotherapy involves the use of cytostatic drugs aimed at stopping the growth and spread of cancer cells. The purpose of this study was to determine the pattern of drug use and evaluation of drug use in breast cancer patients. The study was conducted observational with retrospective data collection. The research was conducted from May to June 2023. The number of samples was 96 samples with the method of purposive sampling technique using the slovin formula, the data were analyzed qualitatively. The results of the chemotherapy treatment profile using single therapy 9 patients (9.38%), combination therapy 87 patients (90.63%) with a combination chemotherapy regimen of Epirubicin and Cyclophosphamide followed by Paclitaxel as many as 50 patients (57.47%). Evaluation of appropriate patient (98.96%), appropriate indication (100%), appropriate drug (100%), appropriate dose (19.79%), inappropriate dose (20.83%), under dose (34.48%), over dose (25%).

Silent inactivation of asparaginase in Japan: results of the prospective ALL-ASP19 trial.

Silent inactivation (SI) of L-asparaginase (ASP) is a phenomenon by which a neutralizing antibody for ASP (AAA) decreases ASP activity (ASA) in patients without a clinical allergy to ASP. Acute lymphoblastic leukemia (ALL) has a poor prognosis in patients with SI. Therefore, measurement of ASA levels, not AAA levels, is needed to identify patients with SI. We herein report the results of the prospective clinical trial ALL-ASP19, the first study in Japan to measure ASA and AAA to identify patients with SI. A total of 110 newly diagnosed ALL patients were enrolled, and ASA levels were measured three times during ALL treatment. Besides the 12 patients who discontinued the study, 32 were excluded due to inappropriate frequency and timing of ASA measurements and inappropriate ASP dosing. The remaining 66 patients were analyzed, and 3 patients with SI (4.5%) were identified. The incidence of SI is lower in Japan than in other countries. AAA was detected in all patients with SI, but four of the seven patients with AAA did not develop SI. Clinical characteristics did not significantly differ between patients with and without SI. Therefore, ASA levels must be measured to identify patients receiving insufficient ASP treatment.

Prevalence and Risk Factors of Inappropriate Drug Dosing among Older Adults with Dementia or Cognitive Impairment and Renal Impairment: A Systematic Review

Background: Potentially inappropriate medication prescribing is prevalent and well studied in older adults. However, limited data are available on inappropriate drug dosing in those with dementia or cognitive impairment and renal impairment. Objectives: We aimed to examine the prevalence of, and factors associated with, inappropriate drug dosing in older patients with dementia or cognitive impairment and renal impairment. Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and the Cochrane Handbook for Systematic Reviews of Interventions. We searched Medline, Embase, CINAHL, and PubMed for studies on inappropriate drug dosing in older patients with dementia or cognitive impairment and renal impairment, published from 1 January 2000 to 31 August 2024, with English language restriction following the PICOS search strategy. Two reviewers independently screened all titles and abstracts, extracted data from included studies, and undertook quality assessment using the Joanna Briggs Institute (JBI) tool. Descriptive statistics were used to summarise and present findings. Results: In total, eight retrospective cohort studies were included. Of the total number of patients with dementia who had renal impairment (n = 5250), there were 2695 patients (51.3%; range: 0–60%) who had inappropriate drug dosing. Drugs commonly prescribed in inappropriate doses in patients with dementia who had renal impairment included memantine, baclofen, nonsteroidal anti-inflammatory drugs (NSAIDs), metformin, digoxin, morphine, and allopurinol. The studies did not identify statistically significant risk factors for inappropriate drug dosing. Conclusions: Inappropriate drug dosing among older adults with dementia or cognitive impairment and renal impairment appears to occur frequently. While our findings should be interpreted with caution owing to the small number of studies and substantial heterogeneity, proactive prevention, recognition, and management of inappropriate drug dosing in this population is warranted.

Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation at a tertiary care hospital in Thailand

BackgroundAppropriate dosing of direct oral anticoagulants (DOACs) has been associated with clinical efficacy and safety. Several studies have shown that DOAC dosing are often inconsistent with guideline recommendations. Little is known about this issue in Thailand. This study aimed to evaluate the appropriateness of DOAC dosing in Thai hospitalized patients with atrial fibrillation (AF). MethodThis was a retrospective descriptive study conducted on hospitalized patients at Rajavithi Hospital, a tertiary care hospital in Thailand. Inpatients diagnosed with AF and treated with DOACs between February 2021 and February 2023 were enrolled in the study. The appropriate dosing of DOACs was assessed according to the recommendation of the 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation (EHRA). Descriptive statistics were used to analyze the data; median (interquartile range) for continuous variables, and numbers and percentages for categorical variables. ResultsA total of 120 patients with AF were evaluated for dosing. The patients received rivaroxaban in 47 cases (39.2 %), apixaban in 32 cases (26.7 %), edoxaban in 31 cases (25.8 %), and dabigatran in 10 cases (8.3 %). Most of the patients were elderly, with a median age of 77.5 (68–84) years. Females were predominant (57.5 %). Our findings indicate that the prevalence of appropriate dosing of DOACs was 63.3 %. However, approximately one-third of patients received inappropriate dosing, with 24 (20.0 %) being overdosed, and 20 (16.7 %) being underdosed. The highest overdosing and underdosing rates were seen in dabigatran (90.0 %) and apixaban (21.9 %), respectively. ConclusionInappropriate dosing of DOACs according to the 2021 EHRA recommendations was high in 36.7 %, with overdosing mostly occurring in 20.0 %. The high number of inappropriate dosing highlights the need for implementation of optimal strategies to select the appropriate dose of DOACs in Thai hospitalized patients with AF.

Prevalence of inappropriate antibiotic doses among pediatric patients of inpatient, outpatient, and emergency care units in Bangladesh: A cross-sectional study.

The heterogeneous pediatric populations, their physiological differences, along with the necessity of performing additional dose calculation, make the pediatric population more vulnerable to the incidences of inappropriate antibiotic doses. This study was conducted to examine and evaluate the appropriateness of antibiotic doses. A cross-sectional study with a quantitative approach was conducted in three hospitals located in Savar from January 06, 2021 to October 17, 2022. This study had used a convenient sampling method to collect 405 filled prescription orders from heterogeneous pediatric patients prescribed by physicians from emergency, inpatient, and outpatient care units of various clinical settings. The Harriet Lane Handbook was used as reference to investigate inappropriate doses of antibiotics. Subsequently, all analyses were conducted using the RStudio 1.3.959 software. Binary logistic regression was used to assess the risk of inappropriate antibiotic prescription in pediatrics. The overall prevalence of inappropriate antibiotic dosing in pediatrics was 335 out of 545 (61.5%). Overdosing (36.3%) and oral antibiotic prescriptions (64%) were more common than underdosing (20.4%) and parenteral antibiotics (36%). The majority (230 out of 405, 56.8%) of pediatric patients had prescriptions with inappropriate antibiotic doses, with prevalence rates of 33.8% for inpatients, 86.7% for outpatients, and 50% for emergency pediatrics. The results also indicated that pediatric patients in outdoor and emergency care units, infants, toddlers, and early childhood, those prescribed two antibiotics simultaneously, and those receiving parenteral antibiotics, were less likely to have inappropriate antibiotic dosages in their prescriptions. This study demonstrated that about one out of every two prescriptions had inappropriate antibiotic doses; in particular, prescriptions containing only one antibiotic exhibited a substantial proportion of inappropriate antibiotic doses. Inappropriate antibiotic doses may result in therapeutic failure, patient harm, and antibiotic resistance. Good clinical pharmacy practice and careful adherence to pediatric dosing standards may minimize inappropriate antibiotic doses.

Realities of opioid and gabapentinoid deprescribing in socioeconomically disadvantaged communities: qualitative evaluation.

Opioid and gabapentinoid prescribing has increased substantially in recent years despite having limited effectiveness in treating chronic primary pain. This is concerning with the prescribing rates and adverse effects of these medications being higher in more socioeconomically disadvantaged groups. Guidance for prescribing and deprescribing these medications exists but the understanding of how deprescribing is operationalised especially in areas of socio-economic disadvantage is limited. To explore primary healthcare professionals' views and experiences of designing and implementing an intervention to reduce opioid and gabapentinoid prescribing. A qualitative evaluation, using participant observation and semi-structured interviews with primary healthcare professionals working in practices serving areas of substantial socio-economic disadvantage. Interviewees were purposively recruited with subsequent snowballing with participant observation of the peer-support meetings. Interviews transcripts and notes from the participant observation were inductively coded and thematically analysed. Thirteen healthcare professionals from five practices were interviewed. Person-centred care with shared decision-making was strived for which was time consuming due to the complexity of the problem and patients. Where shared-decision making was not possible due to patient refusal or non-engagement, risk was used to determine the appropriate action. This work involved an emotional toll on staff and patients but was at times conversely easier and more rewarding than expected. Ultimately, demedicalising pain with a culture change is required to ensure patients are not prescribed these medications for inappropriate reasons or doses. This study demonstrates key operational aspects to consider when undertaking opioid and gabapentinoid deprescribing in primary care.

Implementation and Evaluation of Clinical Decision Support for Apixaban Dosing in a Community Teaching Hospital.

This study aimed to describe and evaluate the transition from a specialty service-based prospective order approval system to a computerized clinical decision support (CCDS) tool for apixaban dosing at a community teaching hospital. The primary objective was to assess the impact of the transition on the appropriateness of apixaban prescribing. A CCDS tool for apixaban dosing was developed and implemented using interprofessional collaboration. A retrospective chart review was conducted for apixaban orders placed before (preimplementation) and after (postimplementation) the CCDS transition. The primary outcome was the percent change in inappropriate apixaban orders, with secondary outcomes exploring percent change of apixaban orders with inappropriate dosing in different patient groups and indications per package insert. Fifty orders were assessed in both arms, with 8% of orders preimplementation and 10% postimplementation deemed inappropriate. After accounting for questionable orders, overall appropriateness of prescribing was 88% preimplementation and 84% postimplementation ( P = 0.7). Challenges with implementation of CCDS included working with available information technology resources and facilitating acceptance of a new ordering process. The implementation of a CCDS tool for apixaban dosing at a community teaching hospital demonstrated comparable rates of appropriateness to the previous specialty service-based approval process. While the transition streamlined resources and improved efficiency, ongoing efforts are needed to address specific dosing challenges. Future research should explore the sustainability and generalizability of CCDS tools in diverse healthcare settings.

Rational Use of Proton Pump Inhibitors among Patients Admitted in a Tertiary Care Hospital

Background: The prevalent usage of proton pump inhibitors (PPIs) is a testament to the effectiveness of this class of medications, but it also introduces risk associated with inappropriate prescriptive and consumptive practices. Because of the negative effect of incorrect usage and overdose of PPIs, it is very important for physicians to only prescribe these drugs when needed. However, recent studies showed some concerns about long-term PPIs consumption. The rational prescription of medications is vital to ensuring the optimal use of medical resources, providing effective therapy and minimizing adverse drug reactions. Methods: This observational study was conducted in the department of Pharmacology and therapeutics, Sylhet M.A.G. Osmani medical college, Sylhet, in collaboration with the department of Medicine, Surgery, Gastroenterology, Obstetrics and gynaecology, Sylhet M.A.G. Osmani medical college hospital, Sylhet, from July 2022 to June 2023. The sample size for this study was 600. Usage of PPIs was considered to be appropriate on the basis NICE guidelines and recommendations by Scarpignato et al. (2016) committees on behalf of three Italian scientific societies. Result: For 600 PPIs prescriptions, total 705 case sheets were reviewed. The mean age of the study patients was 42.94±17.16 years. Female were found more 359(59.8%) than male 241(40.2%). Out of 600 patients, based on the indications of PPI usage, 287 (47.8%) of prescriptions were found appropriate, whereas inappropriate prescriptions were found in 313 (52.2%) cases. Out of 287 patients who were prescribed PPIs in an appropriate indication, 175 (61%) patients were given PPIs in an appropriate dose, whereas inappropriate dose was found in 112 (39%) of patients. Again, among 175 patients who were prescribed PPIs for appropriate dose, 24 (13.7%) patients were given PPIs in an appropriate frequency, whereas inappropriate frequency was found in 151 (86.3%) of patients. Finally, 24/600 (4%) patients were prescribed in an appropriate indication with an appropriate dose and frequency, whereas inappropriate prescription were found in 576/600 (96%) patients. PPIs were used as prophylaxis for NSAIDs in highest number 147(51.2%) of patients. Oral was the most common 348(58%) route of prescribing PPIs. Omeprazole was the highest 577(96.2%) prescribed PPIs. Conclusion: Based on this study result, it could be concluded that in most of the patients PPIs prescriptions were not following appropriate indications, dose and frequency recommended by reference guidelines. Like any other drugs, PPIs should be prescribed for a clear indication, the minimum dose needed for the expected effect and medication halted when no longer necessary upon re-evaluation.

LEVERAGING LEAN SIX SIGMA TECHNIQUES FOR ACCELERATED ON-SITE CASTING: FACTORS AND STRATEGIES

In the construction industry, issues such as excessive waste, rising costs, and strained relationships are prevalent. A pressing matter of plunged casting time during mass concreting activities has engulfed numerous construction contracting firms around the world. The increased time of concrete utilization not only risks the commencement of the heat of hydration but also initiates the setting time of concrete. The use of admixtures has often been a boon to curb this situation but human errors are almost impossible to escape from as inappropriate dosage of the admixtures can result in changing the properties of the concrete, affects the quality and pumping ability, which ultimately reducing the speed of casting and elapsed schedules. Other factors on site, though minor, vastly affect the pumping efficiency and causes considerable delays in the casting which not only affects the schedules but also causes time overrun and affects the productivity at site. The focus of this study is to address the issues encountered at the site that directly affect the speed of on-site casting and corrective actions.