Inappropriate Drug Combinations Research Articles

INDENTIFIKASI PERMASALAHAN TERKAIT PENGOBATAN PADA PASIEN DISLIPIDEMIA KOMORBID DIABETES MELITUS DENGAN TERAPI STATIN DI SALAH SATU RUMAH SAKIT KOTA BANDUNG TAHUN 2023

ABSTRACT Dyslipidemia and type II diabetes mellitus (DM) can occur simultaneously and can mutually worsen the patient's condition. The complexity of treatment in patients with such comorbidities potentially increases the risk of treatment-related problems. This study aims to determine the demographics of patients with type II DM comorbid dyslipidemia in one of the hospitals in Bandung City in 2023 and describe the incidence of treatment problems. This descriptive study reviewed 92 patient medical records that met the research criteria. The classification method for identifying problems related to treatment refers to Basger et al. 2015. The results showed that patients with type II DM comorbid dyslipidemia on statin therapy were dominated by women (55.43%) and elderly (59.78%). The most frequent incidence of treatment-related problems was in the subcategory of inappropriate drug combinations. There were 78 cases resulting in increased therapeutic effect and the most common was related to the prescription of lansoprazole with atorvastatin; 55 cases of interactions resulting in reduced therapeutic effect, of which the most common was related to the prescription of clopidogrel with atorvastatin. There were 4 cases that resulted in hypersensitivity reactions involving allopurinol and antihypertensive drugs. It can be concluded that clinical pharmacists intervene in reviewing patient care by considering the risks and benefits of such a combination for the patient.

Drug-related problems (DRPs) in hypertensive patients at Karsa Husada Batu Hospital, East Java, Indonesia: Evaluation based on drug selection

Background: Hypertension significantly contributes to premature deaths globally. Drug selection has a vital role in the success of hypertension treatment, but incorrect selection could promote Drug-related problems (DRPs). Objective: This study evaluates DRPs based on the drug selection of inpatient hypertensive patients at Karsa Husada Batu Hospital, which is located in East Java, Indonesia. Method: This study was an observational study with a retrospective research design. The cases of DRPs were classified using the Pharmaceutical Care Network Europe (PCNE) DRP classification tool V9.1. This was total sampling research with the population of medical records of patients with hypertension without complications who were hospitalised at Karsa Husada Batu Hospital in 2018-2021. Result: This study involved 66 patients’ medical records. The DRPs of the drug selection occurred in 47 patients (71.21%), including 15 cases of drug use that did not comply with guidelines, 34 cases without indication for the drug used, 51 cases of improper combination of drugs, nine cases of inexact duplication of the therapeutic group, and 31 cases of no adequate drug for existing indication. Conclusion: Inappropriate drug combinations are the primary cause of DRPs based on drug selection, and there are no cases in which too many drugs are prescribed for an indication.

ANALISIS BIAYA DAN RASIONALITAS TERAPI PARU OBSTRUKTIF KRONIK DI RSU ANWAR MEDIKA SIDOARJO

COPD is the main cause of death, and is currently the fifth cause of death in the world. COPD patients experience decreased capacity for quality of life, physical disability and increased costs of living. In COPD patients, the use of more than one drug therapy and long-term use can carry the risk of drug-related problems. The aim is to analyze the costs and rationality of treating COPD exacerbations. The research design was retrospective to determine the costs and description of therapy for COPD patients at RSU Anwar Medika Sidoarjo. The variables are real costs, INA-CBGs rates, severity and treatment therapy. The research sample was inpatients with BPJS insurance who were diagnosed with COPD attacks at RSU Anwar Medika Sidoarjo for January 2019-December 2021, using the total sampling method. The data collection by observing research materials including medical records. Data analysis is descriptive for data analysis and the incidence of drug-related problems (MTO), and the Mann-Whitney test to determine significant differences between real hospital costs and INA CBG'S inpatient rates. The number of respondents involved was 81 people. The highest components of direct costs incurred by COPD patients during hospitalization are hotel room costs and the cost of consumable medical materials. There was no difference in real costs compared to the rates INA-CBG's (p=0.158). The total incidence of MTO that occurred was 83 cases consisting of inappropriate drug selection (19.27%), drugs without indications (66.26%), inappropriate drug combinations (4.81%), indications without drugs (2 .40%), too many drugs for same indication (7.22%).

Efficacy of administrative intervention for neurosurgical patients with off-label use of alprostadil lipid microsphere

As an adjuvant drug, alprostadil lipid microsphere injection (Lipo-PGE1) is one of the best-selling drugs in China in recent years. However, the off-label use of Lipo-PGE1 is very common. This study aimed to investigate the use of Lipo-PGE1 and evaluate the clinical effects and economic benefits after administrative intervention on inappropriate use of Lipo-PGE1 in neurosurgical patients in a Chinese tertiary hospital. Administrative interventions were implemented from January to December 2018 by reducing the procurement volume of Lipo-PGE1, judging the rationality of medical records, and establishing reward and punishment mechanisms. Administrative interventions significantly decreased prescription rate (49.98% vs 22.49%), utilization (22,311 DDDs vs 8334 DDDs), drug use density (43.52 DDDs/TID vs 15.84 DDDs/TID), total expenditure (3.58 million RMB vs 1.30 million RMB), and average expenditure (2025.04 RMB vs 1466.49 RMB) of Lipo-PGE1. To our delight, these intervention effects were maintained or even better in the 1-year post-intervention period. Moreover, in the intervention and post-intervention phases, the Lipo-PGE1 use for no indications as well as inappropriate drug dose, frequency, menstruum type, combination, and contraindication were markedly reduced. Besides, the mean costs (P < 0.001), and mean duration (P < 0.001) of Lipo-PGE1 were also obviously decreased. The administrative intervention obviously reduced the off-label use of Lipo-PGE1. However, there still remains a number of inappropriate uses of Lipo-PGE1. To further improve the rational use of Lipo-PGE1, combination of administrative intervention and real-time clinical pharmacists intervention should be implemented.

Polypharmacy in Australian Veterans with Post-traumatic Stress Disorder upon Admission to a Mental Health Facility: A Retrospective Chart Review.

ObjectivePolypharmacy increases the risk of adverse drug events and drug–drug interactions, and contributes to falls, hospital admissions, morbidity and mortality. Veterans with post-traumatic stress disorder often have psychological and physical comorbidities, increasing the likelihood of general and psychotropic polypharmacy. This study investigates the prevalence of general and psychotropic polypharmacy in inpatient veterans with post-traumatic stress disorder, and illustrates potential risks associated with polypharmacy in this population.MethodsMedical records of 219 veterans admitted to a mental health facility for post-traumatic stress disorder management were retrospectively reviewed. Medication lists on admission were extracted and coded according to Anatomical Therapeutic Chemical Classification classes. The prevalence of general (five or more total medications), psychotropic (two or more N-code medications), and sedative (two or more medications with sedating effects) polypharmacy and Drug Burden Index were calculated. Class combinations were reported, and associations between demographic characteristics and polypharmacy were determined.ResultsMean age was 62.5 (± 14.6) years. In addition to post-traumatic stress disorder, 90.9% had a diagnosis of at least one other psychiatric condition, and 96.8% had a diagnosis of at least one non-psychiatric medical condition. The prevalence of general polypharmacy was 76.7%, psychotropic polypharmacy was 79.9% and sedative polypharmacy was 75.3%. Drug Burden Index scores ranged from 0 to 8.2, with 66.2% of participants scoring ≥ 1.ConclusionsThis cohort of inpatient veterans with post-traumatic stress disorder had a high prevalence of general, psychotropic and sedative polypharmacy, and were at high risk for drug-related adverse events. This highlights the importance of increasing awareness of polypharmacy and potentially inappropriate drug combinations, and the need for improved medication review by prescribers.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40801-022-00298-3.

Angiogenesis Inhibition in Prostate Cancer: An Update

Prostate cancer (PCa), like all other solid tumors, relies on angiogenesis for growth, progression, and the dissemination of tumor cells to other parts of the body. Despite data from in vitro and in vivo preclinical studies, as well as human specimen studies indicating the crucial role played by angiogenesis in PCa, angiogenesis inhibition in clinical settings has not shown significant benefits to patients, thus challenging the inclusion and usefulness of antiangiogenic agents for the treatment of PCa. However, one of the apparent reasons why these antiangiogenic agents failed to meet expectations in PCa can be due to the choice of the antiangiogenic agents, because the majority of these drugs target vascular endothelial growth factor-A (VEGFA) and its receptors. The other relevant causes might be inappropriate drug combinations, the duration of treatment, and the method of endpoint determination. In this review, we will first discuss the role of angiogenesis in PCa growth and progression. We will then summarize the different angiogenic growth factors that influence PCa growth dynamics and review the outcomes of clinical trials conducted with antiangiogenic agents in PCa patients and, finally, critically assess the current status and fate of antiangiogenic therapy in this disease.

Inappropriate drug use in the elderly outpatient population in a West-African metropolitan community .

Most studies investigating drug use patterns in the elderly have evaluated the prescribers' behavior with little focus on the target population who consume the drugs. This is a community-based study to evaluate drug use patterns in the elderly, a special population because of the high risk of adverse drug reactions including drug hypersensitivity syndrome, which is associated with a higher mortality in this population. A house-to-house survey was carried out, and drug use was determined by interviewing respondents using a questionnaire. The study population included adults aged 60 years and above. A total of 270 respondents were interviewed. The majority (88.1%) had at least one chronic medical disorder. Hypertension was the most common disease. Multimorbidity and polypharmacy were uncommon in this population. Approximately half (46.4%) of the respondents with chronic diseases were either not on treatment (14.5%) or were on inappropriate drugs and/or drug combinations (31.9%). Of these, 5.1% were on potentially inappropriate medications judging from the Beers Criteria. Inappropriate drug combinations observed in this study included an inappropriate drug for the disease diagnosed, inadvertent use of two different brands of the same drug as two drugs, combining two drugs from the same class, or inappropriate drug class combination among hypertensive patients. Aspirin was the most commonly used drug, some hypertensive patients were taking aspirin without being on concomitant antihypertensive drugs. Contrary to reports of polypharmacy, inappropriate drug combinations and a high rate of aspirin use were prominent in the population studied. .

Use of renal risk drugs in a nation-wide Polish older adult population: an analysis of PolSenior database

BackgroundNumerous medications should be avoided, or require dose adjustment in subjects with impaired kidney function. We aimed to assess the prevalence of potentially inappropriate use of renal risk drugs in a nation-wide, community-dwelling Polish older adult population.MethodsWe analysed regular intake of 38 medications that should be avoided, requiring dose modification, increase the risk of pre-renal kidney injury, or may cause potassium retention in subjects with moderately to severely impaired renal function in the PolSenior data base (N = 4514, mean age 76 ± 11 yrs). Kidney function was assessed with short Modification of Diet in Renal Disease formula estimated glomerular filtration rate (sMDRD) and Cockcroft-Gault creatinine clearance (CC).ResultsThere were 855 (19%) individuals with sMDRD < 60 ml/min/1.73m2, and 1734 (38%) with CC < 60 ml/min. Among drugs that should be avoided, spironolactone (20.4% of patients as classified by sMDRD and 17.5% by CC), non-steroidal anti-inflammatory drugs (13.4 and 11.3%), hydrochlorothiazide (11.1 and 11.0%), and metformin (6.9 and 8.2%) were most frequently used. The most frequently used drugs requiring dose modification were piracetam (13.9% by sMDRD, and 11.9% by CC), digoxin (8.3 and 8.8%), and gliclazide (6.8 and 5.9%). Classification of a drug use as ‘appropriate’ or ‘inappropriate’ was discordant depending on the method of kidney function assessment (sMDRD or CC) in up to 30%.Subgroups with sMDRD < 60 ml/min/1.73m2 and with CC < 60 ml/min were taking ≥2 drugs increasing the risk of pre-renal kidney injury more frequently than individuals with better kidney function (46.6 vs. 23.1 and 33.0% vs. 24.4%, respectively).There were 24.7% of individuals with sMDRD < 60 ml/min/1.73m2 and 18.0% with CC < 60 ml/min taking 2 or more drugs increasing serum potassium level. The proportion of subjects with hyperkalaemia increased with the number of such drugs.ConclusionsUse of drugs that should be avoided or require dose adjustment due to renal impairment, and potentially inappropriate drug combinations is a common problem in older adults in Poland. Assessment of kidney function with sMDRD may result in overlooking of requirements for dose adjustment formulated based on creatinine clearance.Trial registrationNot applicable.

EVALUATION OF DRUG THERAPY PROBLEMS IN ASTHMA PATIENTS RECEIVING CARE IN TWO HOSPITALS IN SOUTH-EASTERN NIGERIA

Objective: To evaluate drug therapy problems in asthma patients visiting a secondary and tertiary hospital in South-Eastern Nigeria.Methods: This study was a retrospective, cross-sectional analyses of the medical records of adult asthmatic patients receiving care in two hospitals in Enugu State, within a 15-year period. The Pharmaceutical Network Care Europe (PCNE) tool version 6.2 was used to assess drug therapy problems. The IBM Statistical Product for Services Solution (SPSS) version 20.0 was used for analysis. For all results, P ≤ 0.05 was considered statistically significant.Results: Majority of the patients were below 60 y old (81.2%); female (68.8%) and were on more than two drugs (95.3%). Majority of the identified drug therapy problems (DTPs) were adverse reactions (65.7%). The inappropriate drug combination was the major cause of DTPs (65.6%). Only about 23.4% of the intervention outcomes were known. University of Nigeria Teaching Hospital (UNTH) had more interventions (35.9%) than Medical Centre (8.0%) (χ2 = 6.323; df = 1; **P = 0.012); and more of the outcomes of their interventions known (38.5%) compared to Medical Centre (0.0%) (χ2 = 12.559; df = 1; **P ˂ 0.001).Conclusion: Adverse reactions and inappropriate drug selection were the major identified DTPs and major cause of DTPs, respectively. Most DTPs had no interventions. The documented interventions included stopping of the drugs, change of drugs or dosage, change of instructions for use and starting of new drugs. Most interventions had unknown outcomes. UNTH had more interventions with known outcomes than the University of Nigeria Medical Centre.

Identifikasi Drug Related Problems (DRPs) Pada Pasien Pediatri Pneumonia Komunitas di Instalasi Rawat Inap RSD Madani Provinsi Sulawesi Tengah

Drug Related Problems (DRPs) are events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes. DRPs may occur in the treatment of various diseases such as community acquired pneumonia (CAP). This study aims to determine the percentage of DRPs in pediatric inpatients with CAP. This is a descriptive and observational study design with prospective data conducted in November 2015 until February 2016 at Madani Hospital, Central Sulawesi. The results obtained from 28 patients showed that incidences of DRPs categories of inappropriate drug is 1 event (1,7%), inappropriate drug combination 35 events (58,3%), drugs dose too low 18 events (30%), drugs dose too high 6 events (10%), and no indication for drug 0 event (0%).

English

A ten year (2006 &ndash; 2015) retrospective study was conducted using records from the case files of patients handled at the Usmanu Danfodiyo University Veterinary Teaching Hospital (UDUVTH) in order to ascertain the pattern and problems associated with drug prescriptions in the management of diseases presented to the hospital. The results obtained show that, a total number of 622 patients comprising cattle (4.80%), goats (16.9%), sheep (33%), birds (11.3%), horses (1.1%), dogs (28.6%), cats (2.9%), rabbits (0.8%) and others (0.3%) were presented. Of the total number of 622, 537 (86.2%) received various medicaments ranging from antibacterial drugs (39.1%), anthelmintics (18.1%), acaricides (4.4%), haemoparasiticides (1.3%), antidiarrhoic (2.5%) and analgesic (4.3%). Other drugs dispensed were dietary supplements/vitamins (17.7%), fluids/electrolytes (2,5%), anticoccidialsm (3.7%) and unspecific agents (5.8%) in retrospective study of drug use and prescription pattern at the UDUVTH, Sokoto. 20% of the drugs were given by oral route of administration while parenteral and topical routes constitute 74.2 and 10.3%, respectively. The route of administration of 4% of the medications was not specified. Multiple drug therapy overwhelmed the practice with 80.41% while inappropriate prescription and drug combination was 1.03% of all the drugs used over the study period. The study revealed that antibacterials and anthelmintics are the most widely used drugs and parenteral route of drug administration and polytherapy were the dominant practice in the hospital. Key words: Retrospective study, prescription pattern, UDUVTH, Sokoto, North-western Nigeria.

Anticholinergic Drug Burden in Persons with Dementia Taking a Cholinesterase Inhibitor: The Effect of Multiple Physicians.

ObjectivesTo explore the association between the number of physicians providing care and anticholinergic drug burden in older persons newly initiated on cholinesterase inhibitor therapy for the management of dementia.DesignPopulation‐based cross‐sectional study.SettingCommunity and long‐term care, Ontario, Canada.ParticipantsCommunity‐dwelling (n = 79,067, mean age 81.0, 60.8% female) and long‐term care residing (n = 12,113, mean age 84.3, 67.2% female) older adults (≥66) newly dispensed cholinesterase inhibitor drug therapy.MeasurementsAnticholinergic drug burden in the prior year measured using the Anticholinergic Risk Scale.ResultsCommunity‐dwelling participants had seen an average of eight different physicians in the prior year. The odds of high anticholinergic drug burden (Anticholinergic Risk Scale score ≥ 2) were 24% higher for every five additional physicians providing care to individuals in the prior year (adjusted odds ratio = 1.24, 95% confidence interval = 1.21–1.26). Female sex, low‐income status, previous hospitalization, and higher comorbidity score were also associated with high anticholinergic drug burden. Long‐term care facility residents had seen an average of 10 different physicians in the prior year. After a sensitivity analysis, the association between high anticholinergic burden and number of physicians was no longer statistically significant in the long‐term care group.ConclusionIn older adults newly started on cholinesterase inhibitor drug therapy, greater number of physicians providing care was associated with higher anticholinergic drug burden scores. Given the potential risks of anticholinergic drug use, improved communication among physicians and an anticholinergic medication review before prescribing a new drug are important strategies to improve prescribing quality.

The prevalence of duloxetine in medico-legal death investigations in Victoria, Australia (2009–2012)

The drug duloxetine (Cymbalta®) is a newer antidepressant which has been available in Australia since 2008. Duloxetine is a serotonin and noradrenaline reuptake inhibitor (SNRI), which is associated with adverse effects in the first 6 weeks of therapy, including tachycardia and worsening symptoms in people with advanced heart failure. It is also associated with serotonin toxicity in combination with certain drugs. Few reports have been published in the toxicology literature regarding duloxetine and its prevalence in coroners’ cases. This study documents the prevalence of duloxetine in coronial cases between 2009 and 2012 and seeks to better understand the role of duloxetine in deaths where concomitant use with other drugs may cause adverse outcomes. Duloxetine was analyzed in blood specimens taken for the purpose of assisting the pathologist in determining a cause of death and analyzed using a validated LC–MS/MS method employed for overnight screening. There were 34 cases where duloxetine was detected of which 19 were attributed to drug toxicity. The median femoral blood concentration in the cohort was 0.14mg/L (range 0.01–1.42mg/L). Many deaths involved the concomitant use of numerous other medications; up to 13 other drugs were co-detected in a case. Over half of the deaths were attributed to fatal combined drug toxicity. SSRIs and venlafaxine that may have increased the risk of serotonin toxicity in combination with duloxetine were detected in five cases. Metoclopramide, contraindicated with duloxetine use, was detected in two cases. NSAIDs (n=11), antipsychotics (n=15) and benzodiazepines (n=14) were also commonly co-detected. Heart disease was observed in over 40% of the cohort, mostly in the form of coronary artery disease or cardiomegaly. Death involving duloxetine alone was uncommon (n=4); however with certain comorbidities and co-administered drugs, the risk of a fatal event is increased, particularly in the setting of other pro-serotonergic agents. In deaths where duloxetine is detected and the cause of death is believed to be natural or unascertained, it is essential that other serotonin drugs or inappropriate drug combinations be examined for their possible contribution to death.

Placebo-controlled trial of quetiapine for sleep disturbance in AD

Quetiapine is a novelantipsychotic, approved for the treQuetiapine is a novelantipsychotic, approved for the treatment of schizophrenia and bipolardisorder. Quetiapine is also used off-label for the treatment ofneuropsychiatric symptoms of dementia patients, including sleep disturbance. Studies have shown that quetiapine promotes nighttime sleep recorded bywrist-actigraphy in patients with depression (6). No sleep-promoting drug ornon-pharmacologic intervention has been shown to be highly effective inpatients with dementia. This pilot study was designed to investigate theeffects of quetiapine on sleep disturbance (nighttime awaklenings) in patientswith MCI or dementia. Quetiapine is also used off-label for the treatment of neuropsychiatricsymptoms of dementia patients, including sleep disturbance. Studies have shownthat quetiapine promotes nighttime sleep recorded by wrist-actigraphy inpatients with depression (6). No sleep-promoting drug or non-pharmacologicintervention has been shown to be highly effective in patients with dementia. This pilot study was designed to investigate the effects of quetiapine on sleepdisturbance (nighttime awaklenings) in patients with MCI or dementia. Study drug was administeredonce daily at bedtime for 1-week placebo run-in (baseline), followed by an6-week quetiapine titration. Quetiapine was started at 25 mg with a fixed doseescalation to 50 mg at week 2. The PI (C. Singer) then followed a flexibleweekly titration in 25 mg increments, to a maximum dose of 200 mg. Placebo andactive drug were administered in identical appearing 25 mg tablets. Subjectstook 5 tablets at bedtime, including a 100 mg tablet and four 25 mg tablets inappropriate placebo-active drug combinations to achieve the scheduled dose. Primary outcomes wereactigraph-scored nighttime sleep and awakenings. Wrist-actigraphs were worn24/7 throughout the trial. Night total sleep time (NTST) was defined as theaverage minutes of sleep in the twelve-hour 20:00 to 08:00 period during eachtreatment condition. Subjective response was assessed by the Sleep DisordersInventory (SDI) and Clinical Global Impression of Change (CGI-C). Fourteen subjects were enrolled. Analyzable data were available for 12 subjects. Wrist-Actigraphy Nighttime sleep (NTST) increased during quetiapine treatment (weeks 1-5) versus placebo baseline. Wake time after sleep onset or WASO wassignificantly reduced at weeks 3 (75 mg; p value = 0.030) and 5 (116 mg; pvalue = 0.018). Sleep DisordersInventory (SDI) Caregivers andsubjects were blind to treatment and dose. Caregiver rating of sleepdisturbances by SDI significantlyimproved at week 5 (p value = 0.004). Mini Mental State Exam (MMSE). General cognition asmeasured by MMSE did not change. Clinical GlobalImpressions - Change. No changewas reported in about half of the patients but, at week 5, all patients werejudged to have improved (11% marked improvement (1/9), 44% moderate improvement (4/9), and 22% minimal improvement (2/9)). Note this rating was by the PI whowas not blinded. Tolerability Quetiapine was generally well tolerated with thisconservative dose titration. There was one serious adverse event (SAE) that was “possibly drug related”: (Frequent falls in a subject with a history of falls). There was another SAE, non-drug related, that led to drop out during theplacebo week. Quetiapine appears toincrease nighttime sleep and to reduce the number of nighttime awakenings inpatients with either dementia or MCI. The effect size was very large ascompared to sedative hypnotics trials in young and old insomnia patients. Theimprovement was seen in both objective and subjective measures. The data show atrend towards a dose response curve. These results need to beconfirmed by a larger, randomized trial. Subsequent studies will need toconfirm efficacy and dosing. However, a study with bipolar disorders I and II (21-76 yrs) found a significant effect in depressed patients (300 -800 mg) relative to controls.

Führt die Implementierung von offenem Benchmarking in datengestützten Qualitätszirkeln zur Verbesserung der hausärztlichen Versorgung bei Arzneimittelinteraktion und Asthma bronchiale?

The purpose of this cluster-randomised controlled trial was to evaluate the efficacy of quality circles (QCs) working either with general data-based feedback or with an open benchmark within the field of asthma care and drug-drug interactions.Twelve QCs, involving 96 general practitioners from 85 practices, were randomised. Six QCs worked with traditional anonymous feedback and six with an open benchmark. Two QC meetings supported with feedback reports were held covering the topics "drug-drug interactions" and "asthma"; in both cases discussions were guided by a trained moderator. Outcome measures included health-related quality of life and patient satisfaction with treatment, asthma severity and number of potentially inappropriate drug combinations as well as the general practitioners' satisfaction in relation to the performance of the QC.A significant improvement in the treatment of asthma was observed in both trial arms. However, there was only a slight improvement regarding inappropriate drug combinations. There were no relevant differences between the group with open benchmark (B-QC) and traditional quality circles (T-QC). The physicians' satisfaction with the QC performance was significantly higher in the T-QCs.General practitioners seem to take a critical perspective about open benchmarking in quality circles. Caution should be used when implementing benchmarking in a quality circle as it did not improve healthcare when compared to the traditional procedure with anonymised comparisons.

Deaths involving contraindicated and inappropriate combinations of serotonergic drugs

In the Australian state of Victoria, all fatalities that were recorded from 2002 through to 2008 involving the use of certain serotonin active drugs (tramadol, venlafaxine, fluoxetine, sertraline, citalopram and paroxetine), were reviewed to assess the incidence of contraindicated or ill advised drug combinations. More than 1,000 were identified of which 326 cases formed the basis of this study. These cases involved contraindicated or inappropriate drug combinations that can lead to adverse drug reactions (ADRs) and subsequent fatal toxicity. Of these, 46% were drug-related, 35% were a result of natural disease and 13% were classified as external injury cases. The remaining cases were those where the cause of death (COD) was unascertained. Tramadol was the most common drug, usually detected alongside a serotonergic antidepressant (in 20% of cases). Twenty-five (8%) cases involved contraindicated drug combinations while the remainder (301 cases, 92%) involved drug combinations that are associated with adverse interactions ranging from minor to major severity. Of these 326 cases, the Coroner determined 166 cases (51%) to be acts of intentional self-harm or drug misuse, with the remainder unascertained or attributed to natural disease. Very few post-mortem reports and Coroners' findings made mention of possible ADRs when such combinations were actually present. The majority of cases comprising contraindicated drug combinations involved the combined use of five drugs (24%) at the time of death. A combination of three to five drugs was most common in cases involving inadvisable drug combinations. Combined drug toxicity was the most common COD, with heart disease the most common co-morbidity.

Personal digital assistant with a barcode reader—A medical decision support system for nurses in home care

Introduction Inappropriate medication among elderly people increases the risk of adverse drug–drug interactions, drug-related falls and hospital admissions. In order to prevent these effects it is necessary to obtain a profile of the patients’ medication. A personal digital assistant (PDA) can be used as a medical decision support system (MDSS) to obtain a profile of the patients’ medication and to check for inappropriate drugs and drug combinations, and to reduce medication errors. Aim The aim of the present study was to evaluate nurses’ experiences of using a MDSS in a PDA with a barcode reader, in order to obtain profiles of the patients’ medication, regarding drug–drug interactions, therapeutic duplications, and warnings for drugs unsuitable for elderly in home care. Methods The LIFe-reader ® is a MDSS in a PDA with a barcode reader. By scanning the drug packages in the patients’ home, the LIFe-reader ® obtained profiles of the patients’ medication and checked for drug–drug interactions, therapeutic duplications and warnings for drugs unsuitable for elderly people. The LIFe-reader ® also contained, e.g. drug information and medical reference works. Nurses ( n = 15) used the LIFe-reader ® for five weeks during their nursing home care practice assignment. The nurses answered questionnaires about the content and functions of the LIFe-reader ® before, during and after the nursing home care practice assignment, and were interviewed in focus groups. Descriptive statistics were used and content analysis was applied for qualitative data. Results By using the LIFe-reader ®, the majority of the nurses found it easy to obtain profiles of the patients’ medication and check for drug–drug interactions, therapeutic duplications and warnings for drugs unsuitable for elderly people. Most nurses regarded the LIFe-reader ® to reduce drug-related risks of falling, and some thought it could reduce the drug-related admissions to hospitals. The scanning function was described as easy and time saving, although not always possible to use. The LIFe-reader ® was regarded as a useful and user-friendly MDSS, but more content and functions were requested. Conclusions We found that the LIFe-reader ® has the potential to be a useful and user-friendly MDSS for nurses in home care when obtaining profiles of the patients’ medication regarding drug–drug interactions, therapeutic duplications and warnings for drugs unsuitable for elderly. A regular scanning of the patients’ drugs in their home might support nurses and general practitioners (GPs) in reducing the inappropriate use of drugs. If the LIFe-reader ® should be used in a larger scale among nurses, more content and functions are necessary.

The Cost and Incidence of Prescribing Errors Among Privately Insured HIV Patients

With the rapid growth in the volume of HIV-related studies that address drug interactions, appropriate medication regimens, and when and how to alter drug regimens, it is challenging for physicians to stay informed. Physicians require knowledge about all drugs taken by HIV patients in order to assess accurately the benefits and risks of various drug combinations. To examine the cost and frequency of antiretroviral prescribing errors among a sample of privately insured patients with HIV disease. Data were obtained from the MarketScan Commercial Claims and Encounter Database created by the Medstat Group Inc. The MarketScan database contains claims data for inpatient care, outpatient care, physician services and prescription drugs in benefit plans sponsored by >50 large employers in the US. This study compared data from the 1999-2000 MarketScan database with those from the 2005 MarketScan database. The 2005 MarketScan database includes 12,226 HIV enrollees who received antiretroviral drugs. This study compared the claims experience of HIV patients who filled a prescription for a drug combination that is not recommended by the US Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents with the claims experience of patients who did not receive such a prescription. In the 1999-2000 database the most common inappropriate drug combination involved the co-administration of a protease inhibitor (PI) and the lipid-lowering drug simvastatin, and 1% of patients experienced this type of error. In the 2005 database, only 0.4% of patients (46 of 12,226) experienced an inappropriate combination of simvastatin and a PI while 5.3% of patients (644 of 12,226) received atazanavir and tenofovir without ritonavir (referred to herein as 'boosting errors'). Patients who experienced a boosting error incurred higher annual costs than patients who took ritonavir along with tenofovir and atazanavir ($US 20,927 vs $US 16,704). Because atazanavir was approved by the US FDA in June 2003, medication errors involving atazanavir were not relevant in 1999 and 2000. Overall, it was found that HIV patients were three times as likely to experience an inappropriate drug combination in 2005 than they were in either 1999 or 2000 (5.9% vs 1.9%), and that this increase is attributable to boosting errors. In addition, the prevalence rate of HIV in the 2005 MarketScan database was almost triple that in the 1999 MarketScan database (0.14% vs 0.05%). This study indicates that those who provide care to HIV patients must be vigilant in their efforts to provide patients with a drug therapy regimen that minimizes the chance of an adverse reaction and maximizes the potential to control viral replication.

Population-based severity, onset and type of drug-drug interactions in prescriptions

Inappropriate drug combinations occur frequently and may lead to serious adverse events. In Iran, drug overdose and interactions are relatively common but rarely reported and are mainly derived from admitted subjects. The aim of this study was to determine the prevalence of possible drug-drug interactions via a population database survey in Mashhad, Iran. In this survey all prescriptions paid by insurance companies in the period 21rst March 2006 to 20th March 2008 were studied retrospectively. Data were gathered from the Division of Rational Use Drug, Food and Drug Vice Chancellor of Mashhad University of Medical Sciences, Iran. Drug interactions were categorized based on severity, onset and dynamic/kinetic nature. Incidence was calculated based on the number of interactions/1000 prescriptions. In total 11,562,808 prescriptions were studied, among which 5% showed interactions. Two hundred and four types of potential interactions were detected. Belladonna, phenytoin sodium, cimetidine, propranolol hydrochloride, gentamicin, acetylsalicylic acid (ASA), Antacid, theophylline and carbamazepine were the most common medications. Among them, 54% showed dynamic and 34% kinetic interactions, 11% were categorized to be both and 76% displayed rapid-onset interactions. Moderate interactions were the most dominant (70%) phenomenon. Dynamic and kinetic interactions significantly differed with respect to the onset of interactions (P < 0.001). A rather different pattern of drug-drug interaction exists in Iran, highlighting the need for a nationwide program on related education and a stronger focus on severe and rapid-onset interactions. Further studies warrant the need to explore high-risk patients.

Drug-Drug Interactions Associated with Length of Stay and Cost of Hospitalization

To evaluate the prevalence of drug-drug interactions (DDI) in prescriptions of hospitalized patients and to identify risk factors associated. A retrospective cross-sectional analysis of prescription data and medical records from a public hospital in Brazil was conducted to identify potential DDI. An inappropriate drug combination was identified and classified with a standard drug interaction source. The main diagnoses were classified with Charlson Comorbidity Index (CCI). Sex, age, polypharmacy and length of stay, among other variables, were correlated with the frequency of potential DDI. The study included 589 patients and 3,585 prescriptions. Thirty-seven percent of the patients were exposed to at least one potential interaction during their stay in the hospital. The most frequent interacting pair was Digoxin+Furosemide (11%). In univariate analysis, several variables were associated with DDI, including sex, age, number of prescribed drugs, length and cost of hospitalization and CCI. Multivariate analysis showed that the adjusted odds of being prescribed a potential DDI among patients in polypharmacy was almost five-fold that of patients taking less than five drugs. Further, length of stay, CCI and cost of hospitalization were independently associated with DDI. Analysis of prescription data found that a substantial number of potential DDI were identified. Results of this study indicate that DDI is associated with number of prescribed drugs, increased duration of stay in the hospital and cost, which suggest that DDI are a significant clinical and economic problem. Potential damage to patients could be avoided.