Oral Prescription Research Articles

Community Pharmacists' Knowledge, Willingness, and Readiness to Prescribe Oral Contraceptives in Saudi Arabia.

Background: The role of community pharmacists (CPs) in various healthcare settings is well documented in the literature including providing safe and easy access to medications. Oral contraceptives (OCPs) are the most frequently used method of terminating unwanted pregnancies worldwide. Objective: This study aims to evaluate the Community pharmacist’s knowledge, willingness, and readiness to prescribe OCPs in Saudi communities in Saudi Arabia. Methods: This is across sectional, self-administered questionnaire-based study conducted between May and November 2021 in the central region of Saudi Arabia. The results were presented as frequencies and percentages. Chi-square tests were used to sort significant association between groups. Results: Out of 368 CPs who got the questionnaire, 347 completed (94.3%). Most of CPs were be-tween the ages of 25 and 35, with 76.9% working in chain pharmacies. Of the surveyed CPs, 45.5% had >24 months of experience in community pharmacies. 41.8% of them prescribed more than six prescriptions for OCPs/week. The patients’ safety (77.2%), physician’s resistance (54.5%), and CPs objection based on religious purposes (36.9%) and lack of time (29.7%) were the most commonly cited barriers among CPs. CPs who worked in chain pharmacies were significantly too busy (p = 0.038) to prescribe OCPs. Also, community pharmacists with experience of more than two years significantly agreed not to prescribe OCPs due to religious convictions (p = 0.009). Conclusion: The current study revealed that most of the CPs were knowledgeable about OCPs. Additionally, most of them were likely to prescribe oral contraceptives. We further suggest overcoming the barriers associated with contraceptives among CPs and providing sufficient training to improve the oral contraceptive prescriptions in CPs is needed.

Correlates of unscheduled and emergency clinical contact in a cohort of patients treated for psychosis

Psychosis has the highest economic burden among mental disorders worldwide. Our retrospective chart-based review aimed to identify factors that predict unscheduled clinical contact for patients with psychosis attending an outpatient psychiatry clinic. Participants consisted of patients with a primary diagnosis of a psychotic disorder being followed for one consistent calendar year at the clinic. The primary outcome was the frequency of unscheduled and emergency clinical contact (phone-based nursing services, visits to the emergency department, or hospitalizations to the inpatient psychiatry ward) as a reflection of psychiatric morbidity and level of care need. The sample consisted of 331 patients, mostly diagnosed with schizophrenia (43.5%) or schizoaffective disorder (30.8%). Logistic regression analyses showed that participants who used any emergency service were significantly more likely to be females, to have comorbid obsessive-compulsive disorder, and to be prescribed two or more antipsychotics. In conclusion, individuals with psychosis following on an outpatient basis might require emergency health services at a point during their treatment. A small minority seems to require unscheduled clinical contact, and an even smaller number will require admission. Early identification of those more likely to require more frequent or intensive care can help organize services more effectively. • Individuals with psychosis might require emergency health services during treatment. • In one year follow-up, 49.9% of participants used at least one unscheduled service. • Females, schizoaffective diagnosis, and comorbid OCD increased unscheduled services. • Oral antipsychotic prescription and polypharmacy increased unscheduled services.

FACTORS ASSOCIATED WITH SWITCHING FROM INJECTABLE TO ORAL DISEASE MODIFYING AGENTS AMONG PATIENTS WITH MULTIPLE SCLEROSIS

BackgroundSince the introduction of oral disease-modifying agents (DMA) in 2010, the treatment options for multiple sclerosis (MS) have changed significantly. There is limited information regarding the factors associated with switching to oral DMA among prevalent injectable DMA users. ObjectiveThis study evaluated the factors associated with switching to oral DMAs among prevalent injectable DMA users with MS. MethodsA retrospective observational cohort study using the TriNetX electronic medical records (EMR) data was conducted among patients with MS. The study included prevalent injectable DMA users with at least two injectable DMA (interferon beta-1a, interferon beta-1b, peginterferon beta-1a, or glatiramer acetate) prescription records within 6 months between September 2010 and May 2018. The second injectable DMA prescription date was considered as the index date. Switching was defined as any oral DMA prescription record (fingolimod, dimethyl fumarate, or teriflunomide) within 12 months after the index date. Patients with any infusion DMA prescription after the first injectable DMA prescription, and those less than 18 years of age were excluded from the study. The Andersen Behavioral Model was used as the conceptual framework to identify predisposing, enabling, and need factors measured during the 1-year baseline period before the index date. A multivariable logistic regression model was used to examine the predisposing (age, sex, race, and ethnicity), enabling (time-period), and need factors (comorbidities, MS symptoms, MS-related medication, and healthcare utilization) associated with switching from injectable to oral DMAs. ResultsAmong 2,943 prevalent injectable users included in this study, 8.09% (n=238) patients switched to oral DMAs. Patients who switched to oral DMAs were primarily younger adults aged 18-44 years (64.29%), females (82.77%), had sensory and visual symptoms, and had corticosteroid utilization during the one-year look-back period compared to non-switchers. Results from multivariable logistic regression model revealed that middle-aged adults (45-64 years, adjusted odds ratio [aOR]: 0.43, 95% Confidence Interval [CI]: 0.32-0.58), old adults (≥65 years, aOR: 0.30, 95% CI: 0.13-0.66) and men (aOR: 0.67, 95% CI: 0.47-0.96) were associated with decreased odds of switching to oral DMAs. Presence of MS-related sensory symptoms (aOR: 1.52, 95% CI: 1.07-2.16), visual symptoms (aOR: 1.59, 95% CI: 1.10-2.31), and corticosteroids usage (aOR: 1.44, 95% CI: 1.04-1.98) were associated with increased odds of switching to oral DMAs. ConclusionThe study found that about one in twelve prevalent injectable DMA users switched to oral DMA. Both demographic and clinical factors were associated with switching to oral DMAs. Further research is needed to evaluate the outcomes of switching to inform treatment decisions for MS management.

Impact of Empirical Antibiotic Therapy on Outcomes of Outpatient Urinary Tract Infection Due to Nonsusceptible Enterobacterales.

ABSTRACTResistance to oral antibiotics commonly used to treat outpatient urinary tract infections (UTIs) is increasing, but the implications of empirical treatment of resistant pathogens are not well described. Using an electronic records database, we reviewed the outcomes of patients >18 years of age who developed an outpatient UTI and had an outpatient urine culture result showing a member of the order Enterobacterales along with prescription data for an oral antibiotic filled on the day before, day of, or day after the culture was collected. Linear probability models were used to estimate partial effects of select clinical and demographic variables on the composite outcome. In all, 4,792 patients had 5,587 oral antibiotic prescriptions. Of 5,395 evaluable episodes, 22% of patients received an antibiotic to which the pathogen was resistant in vitro, and those patients were almost twice as likely to require a second prescription (34% versus 19%) or be hospitalized (15% versus 8%) within 28 days of the initial prescription fill compared to patients who received an antibiotic to which the pathogen was susceptible. Approximately 1% of Enterobacterales isolates were resistant to all commonly available classes of oral antibiotics. A greater risk of treatment failure was seen in patients over 60 years of age, patients with diabetes mellitus, men, and those treated with an antibiotic when prior culture identified an organism resistant to that class. The increasing resistance among members of Enterobacterales responsible for outpatient UTIs is limiting the effectiveness of empirical treatment with existing antibiotics, and consequently, outpatients with UTI are more likely to require additional courses of therapy or be hospitalized.IMPORTANCE Resistance rates for bacteria that cause urinary tract infections (UTIs) have increased dramatically. Regional rates of resistance to commonly prescribed antibiotics now exceed 20%, which is the threshold at which the Infectious Diseases Society of America recommends therapy be guided by culture. Our goals were to describe outcomes for outpatients with UTIs caused by bacteria resistant to empirically chosen antibiotics and to create a simple stratification schema for clinicians to identify UTI patients at increased risk of treatment failure due to antibiotic mismatch. These data are relevant to clinicians, given how common uncomplicated UTIs are, and highlight the need for clinicians to understand local resistance rates and the importance of culture-guided treatment, especially in vulnerable patients. These findings also showed that 1% of bacteria were resistant to all major classes of oral antibiotics, underscoring the need for new antibiotics to treat patients with UTIs due to resistant bacteria.

Oral antithrombotic prescription patterns among hospitalized adult patients with non-valvular atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Oral anticoagulant (OAC) therapy reduces stroke risk in patients with atrial fibrillation. Despite extensive recommendations regarding the use of non-vitamin K antagonist oral anticoagulants (NOACs), available data shows that they remain underutilized. Additionally, data on OAC prescription patterns in relation to stroke and bleeding risk scores are scarce; more so in low to middle income countries. The aim of this study was to describe the antithrombotic prescription patterns among Filipino patients with non-valvular AF. Methods This retrospective, cross-sectional study included adult patients with non-valvular AF admitted from January to December 2019 in a single center. The antithrombotic therapy prescribed was reviewed for patterns according to the CHA2DS2-VASc and HAS-BLED risk scores. Creatinine clearance was also calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to determine the dose appropriateness of prescribed NOACs. Results We reviewed the records of 503 patients, and 302 were included in the study. Of these, 143 (47.35%), 61 (20.19%), 78 (25.83%) and 20 (6.62%) patients were on anticoagulant therapy alone, antiplatelet therapy alone, combination therapy, and no therapy, respectively. A total of 210 (69.54%) patients were prescribed with NOACs, of which 52.8% were dosed appropriately and 41.43% were underdosed. Among patients with high stroke risk but with low bleeding risk, only 39.63% were prescribed with an appropriately dosed NOAC. Thirty-three percent were given an underdosed NOAC while 16.28% received only antiplatelets and 4.65% received no antithrombotic therapy. Patients with low bleeding risk accounted for the majority of NOAC underdosage rates. Furthermore, 59 (20.48%) patients were prescribed with antiplatelets alone despite being stratified as having a high stroke risk. Warfarin use was also documented in 11 (3.64%) patients. Although accounting for only a minority, overdosed NOACs were observed among patients with high bleeding risk. Conclusion Over two-thirds of the patients with non-valvular AF were initiated on NOACs but only one-half received the appropriate dose. Rivaroxaban monotherapy or in combination with clopidogrel were the most frequently used agents. Antiplatelet therapy and underdosed NOACs constituted one-half of the antithrombotic therapy prescribed in high risk patients. The prescription patterns observed show that although the rate of NOAC use was high, a significant proportion of patients were still given suboptimal antithrombotic treatment. Abstract Figure. Baseline characteristics Abstract Figure. Antothrombotic therapy

Medications to manage cancer-associated anorexia/cachexia syndrome (CACS) in patients with advanced gastrointestinal (GI) cancer.

658 Background: Patients with advanced GI cancer have a high prevalence of CACS. Medications used for CACS have limited efficacy, unwanted side effects, and high costs. We sought to describe the prescribing patterns of medications for CACS in patients with advanced GI cancer. Methods: We identified patients with advanced GI cancer (primary pancreatic, gastric, colorectal, and hepatobiliary) treated at the UM Fairview Medical Center, Minneapolis, MN from 2011-2019. We extracted sociodemographics, clinicopathological data (e.g. body mass index [BMI]), other treatments (e.g. nutrition referral), and prescriber specialty (e.g. oncology). The primary outcome was medication use for CACS: outpatient oral prescription of ≥7 days of megestrol, dronabinol, mirtazapine, olanzapine, or cyproheptadine as any formulation (e.g., tablet, solution) on a scheduled basis. Since medications can have overlapping indications, we clarified prescription indication through chart review if needed. We excluded dexamethasone given extremely non-specific use. Results: We identified 974 patients with advanced GI cancer (45.9 % women, 84.2% White, 4.7% Black, median age 65 years, 36.8% pancreatic cancer, median overall survival 212 days). Of these, 265 (27.2%) patients received at least 1 prescription for CACS (Table). There were 736 unique prescriptions (41.8% dronabinol, 26.9% mirtazapine, 22.4% olanzapine, 8.4% megestrol and 0.4% cyproheptadine). Brand-name formulations comprised 2.7% prescriptions. Most prescriptions were provided by oncologists (67.1%), followed by primary care practitioners (20.3%), and palliative care (6.0%). The median times from advanced cancer diagnosis to first prescription, and from last prescription to death were 73 and 50 days respectively. The median BMI (kg/m2) and serum albumin (g/dL) at time of first prescription were 24.3 (range 11.8-51.1) and 2.5 (range 0.7-4.5) respectively. Conclusions: Almost 1/3rd of patients with advanced GI cancers received medications for CACS. Prescribing was primarily driven by oncologists, and was common in the last weeks of life. Our findings can guide interventions to optimize CACS care by reducing reflexive medication prescribing for CACS, while underscoring the need to develop better pharmacologic and non-pharmacologic CACS treatments.[Table: see text]

Disruptions in Care for Medicare Beneficiaries With Severe Mental Illness During the COVID-19 Pandemic

Little is known about changes in care for individuals with severe mental illness during the COVID-19 pandemic. To examine changes in mental health care during the pandemic and the use of telemedicine in outpatient care among Medicare beneficiaries with severe mental illness. This population-based cohort study included Medicare beneficiaries (age ≥18 years) diagnosed with schizophrenia and schizophrenia-related disorders or bipolar I disorder. Care patterns during January to September 2020 for a cohort defined in 2019 were compared with those during January to September 2019 for a cohort defined in 2018. Start of COVID-19 pandemic in the United States, defined as week 12 of 2020. Use of mental health-related outpatient visits, emergency department visits, inpatient care, and oral prescription fills for antipsychotics and mood stabilizers during 4-week intervals. Multivariable logistic regression analyses examined whether the pandemic was associated with differential changes in outpatient care across patient characteristics. The 2019 cohort of 686 214 individuals included 389 245 (53.8%) women, 114 073 (15.8%) Black and 526 301 (72.8%) White individuals, and 477 353 individuals (66.0%) younger than 65 years; the 2020 cohort of 723 045 individuals included 367 140 (53.5%) women, 106 699 (15.6%) Black and 497 885 (72.6%) White individuals, and 442 645 individuals (64.5%) younger than 65 years. Compared with 2019, there were large decreases during the pandemic's first month (calendar weeks 12-15) in individuals with outpatient visits (265 169 [36.7%] vs 200 590 [29.2%]; 20.3% decrease), with antipsychotic and mood stabilizer medication prescription fills (216 468 [29.9%] vs 163 796 [23.9%]; 20.3% decrease), with emergency department visits (12 383 [1.7%] vs 8503 [1.2%]; 27.7% decrease), and with hospital admissions (11 564 [1.6%] vs 7912 [1.2%]; 27.9% decrease). By weeks 32 to 35 of 2020, utilization rebounded but remained lower than in 2019, ranging from a relative decrease of 2.5% (outpatient visits) to 12.9% (admissions). During the full pandemic period (weeks 12-39) in 2020, 1 556 403 of 2 743 553 outpatient visits (56.7%) were provided via telemedicine. In multivariable analyses, outpatient visit use during weeks 12 to 25 of 2020 was lower among those with disability (odds ratio, 0.95; 95% CI, 0.93-0.96), and during weeks 26 to 39 of 2020, it was lower among Black vs non-Hispanic White individuals (OR, 0.97; 95% CI, 0.95-0.99) and those with dual Medicaid eligibility (OR, 0.96; 95% CI, 0.95-0.98). In this cohort study, despite greater use of telemedicine, individuals with severe mental illness experienced large disruptions in care early in the pandemic. These narrowed but persisted through September 2020. Disruptions were greater for several disadvantaged populations.

Risk of serious COVID-19 outcomes among adults with asthma in Scotland: a national incident cohort study

SummaryBackgroundThere is considerable uncertainty over whether adults with asthma should be offered booster vaccines against SARS-CoV-2 and, if so, who should be prioritised for booster vaccination. We were asked by the UK's Joint Commission on Vaccination and Immunisation to undertake an urgent analysis to identify which adults with asthma were at an increased risk of serious COVID-19 outcomes to inform deliberations on booster COVID-19 vaccines.MethodsThis national incident cohort study was done in all adults in Scotland aged 18 years and older who were included in the linked dataset of Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II). We used data from EAVE II to investigate the risk of COVID-19 hospitalisation and the composite outcome of intensive care unit (ICU) admission or death from COVID-19 among adults with asthma. A Cox proportional hazard model was used to derive adjusted hazard ratios (HRs) and 95% CIs for the association between asthma and COVID-19 hospital admission and ICU admission or death, stratified by markers of history of an asthma attack defined by either oral corticosteroid prescription (prednisolone, prednisone, and dexamethasone) in the 2 years before March 1, 2020, or hospitalisation for asthma before March 1, 2020. Analyses were adjusted for age, sex, socioeconomic status, comorbidity, previous hospitalisation, and vaccine status.FindingsBetween March 1, 2020, and July 27, 2021, 561 279 (12·7%) of 4 421 663 adults in Scotland had clinician-diagnosed-and-recorded-asthma. Among adults with asthma, 39 253 (7·0%) had confirmed SARS-CoV-2 infections, of whom 4828 (12·3%) were admitted to hospital for COVID-19 (among them, an estimated 600 [12·4%] might have been due to nosocomial infections). Adults with asthma were found to be at an increased risk of COVID-19 hospital admission (adjusted HR 1·27, 95% CI 1·23–1·32) compared with those without asthma. When using oral corticosteroid prescribing in the preceding 2 years as a marker for history of an asthma attack, the adjusted HR was 1·54 (95% CI 1·46–1·61) for those with three or more prescribed courses of oral corticosteroids, 1·37 (1·26–1·48) for those with two prescribed courses, 1·30 (1·23–1·37) for those with one prescribed course, and 1·15 (1·11–1·21) for those without any courses, compared with those aged 18 years or older without asthma. Adults with asthma were found to be at an increased risk of COVID-19 ICU admission or death compared with those without asthma (adjusted HR 1·13, 95 % CI 1·05–1·22). The adjusted HR was 1·44 (95% CI 1·31–1·58) for those with three or more prescribed courses of oral corticosteroids, 1·27 (1·09–1·48) for those with two prescribed courses, 1·04 (0·93–1·16) for those with one prescribed course, and 1·06 (0·97–1·17) for those without any course, compared with adults without asthma.InterpretationAdults with asthma who have required two or more courses of oral corticosteroids in the previous 2 years or a hospital admission for asthma before March 1, 2020, are at increased risk of both COVID-19 hospitalisation and ICU admission or death. Patients with a recent asthma attack should be considered a priority group for booster COVID-19 vaccines.FundingUK Research and Innovation (Medical Research Council), Research and Innovation Industrial Strategy Challenge Fund, Health Data Research UK, and Scottish Government.

Appropriateness of Antibiotic Prescribing in Patients Discharged From a Community Hospital Emergency Department

IMPORTANCE: Every year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. PURPOSE: The purpose of this study was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. ENDPOINTS: The primary objective was to determine the overall percent of appropriate antibiotic prescriptions for patients discharged from the ED. Secondary objectives included the following: identify reasons for inappropriateness categorized by antibiotic selection, dose, duration, and allergies; identify the most common antibiotics prescribed inappropriately as well as the most common disease states that led to inappropriate prescribing of antibiotics; and analyze prescribing trends based on provider type and time of day the prescription was written. STUDY DESIGN AND METHODS: Patients eligible for inclusion were adults age 18 and older who presented to the ED during four chosen weeks in 2019 and who were discharged with oral antibiotics. Extracted electronic health record data was reviewed to identify the discharge diagnosis for each patient that meets the inclusion criteria. Pertinent information gathered from the patients’ medical records along with a validated antimicrobial assessment tool were utilized to determine the level of appropriateness of the prescribed antibiotic regimens. RESULTS: A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis. Overall, medical residents prescribed the highest percent of appropriate regimens, and the time of day that had the highest percent of appropriate prescriptions was third shift (11 p.m. to 7 a.m.). CONCLUSION AND RELEVANCE: Almost half of all the nonoptimal antibiotic regimens had an excessive duration. Targeted local education efforts and future clinical decision support can facilitate appropriate prescribing of discharge antibiotics from the ED, ultimately improving antimicrobial stewardship within the community.

Antibiotics prior to age 2 years have limited association with preschool growth trajectory.

Background:Prior studies of early antibiotic use and growth have shown mixed results, primarily on cross-sectional outcomes. This study examined the effect of oral antibiotics before age 24 months on growth trajectory at age 2–5 years.Methods:We captured oral antibiotic prescriptions and anthropometrics from electronic health records through PCORnet, for children with ≥1 height and weight at 0–12 months of age, ≥1 at 12–30 months, and ≥2 between 25 and 72 months. Prescriptions were grouped into episodes by time and by antimicrobial spectrum. Longitudinal rate regression was used to assess differences in growth rate from 25 to 72 months of age. Models were adjusted for sex, race/ethnicity, steroid use, diagnosed asthma, complex chronic conditions, and infections.Results:430,376 children from 29 health U.S. systems were included, with 58% receiving antibiotics before 24 months. Exposure to any antibiotic was associated with an average 0.7% (95% CI 0.5, 0.9, p < 0.0001) greater rate of weight gain, corresponding to 0.05 kg additional weight. The estimated effect was slightly greater for narrow-spectrum (0.8% [0.6, 1.1]) than broad-spectrum (0.6% [0.3, 0.8], p < 0.0001) drugs. There was a small dose response relationship between the number of antibiotic episodes and weight gain.Conclusion:Oral antibiotic use prior to 24 months of age was associated with very small changes in average growth rate at ages 2–5 years. The small effect size is unlikely to affect individual prescribing decisions, though it may reflect a biologic effect that can combine with others.

Trajectories of Nutritional Parameters Before and After Prescribed Oral Nutritional Supplements: A Longitudinal Cohort Study of Patients With Chronic Kidney Disease Not Requiring Dialysis

Background:The association between oral nutritional supplement use and nutritional parameters among patients with nondialysis chronic kidney disease (CKD-ND) with or at high risk of undernutrition/protein-energy wasting has not been previously studied. The definition of patient subgroups most likely to benefit from oral nutritional supplementation (ONS) is also an area where more research is needed.Objective:To assess nutritional parameter trajectories among patients with CKD-ND prescribed oral nutritional supplements in British Columbia, and to compare trajectories by nutritional phenotype.Design:Longitudinal cohort study, pre-post design.Setting:Multidisciplinary CKD clinics across British Columbia.Patients:A total of 3957 adult patients with CKD-ND, who entered multidisciplinary CKD clinics during 2010 to 2019, met criteria for oral nutritional supplement prescription based on dietitian assessment, and received ≥1 oral nutritional supplement prescription.Measurements:Longitudinal nutritional parameters, including body mass index (BMI), serum albumin, serum bicarbonate, serum phosphate, and neutrophil-to-lymphocyte ratio (NLR).Methods:Using linear mixed models, slopes for nutritional and inflammation parameters were assessed in the 2-year periods before and after the first oral nutritional supplement prescription. Hierarchical cluster analysis was applied to identify nutritional phenotypes using baseline data, and slope analysis was repeated by cluster.Results:In the pre-oral-nutritional-supplement period, declines in BMI (−0.87 kg/m2/year, 95% confidence interval [CI]: −0.99 to −0.75), albumin (−1.11 g/L/year, 95% CI: −1.27 to −0.95), and bicarbonate (−0.49 mmol/L/year; 95% CI: −0.59 to −0.39), and increases in NLR (+0.79/year; 95% CI: 0.60 to 0.98) and phosphate (+0.05 mmol/L/year; 95% CI: 0.04 to 0.06) were observed. Following oral nutritional supplement prescription, there were statistically significant increases in BMI slope (+0.91 kg/m2/year, P < .0001), albumin slope (+0.82 g/L/year, P < .0001), and phosphate slope (+0.02 mmol/L/year, P = .005), as well as a decline in NLR slope of −0.55/year (P < .0001). There was no significant change in bicarbonate slope. Cluster analysis identified 5 distinct phenotypes. The cluster with the highest mean baseline NLR and lowest mean BMI demonstrated the greatest number of improvements in nutritional parameter slopes in the post-oral-nutritional-supplement period.Limitations:Possibility of residual confounding. Data on dietary intake, muscle mass, and nutritional scoring systems were not available in the registry.Conclusions:Among patients with CKD-ND prescribed oral nutritional supplements, there were improvements in nutrition/inflammation parameters over time following the first ONS prescription. The heterogeneity in response to ONS by cluster subgroup suggests an individualized approach to nutritional management may be beneficial.

Impact of a pharmacy department-wide transitions-of-care program on inappropriate oral antibiotic prescribing at hospital discharge.

To evaluate oral antibiotic prescribing for common infections at hospital discharge before and after implementation of a pharmacist-driven transitions-of-care (TOC) program. Single-center before-and-after study. Acute-care, academic, community hospital in Santa Barbara, California. Eligible adult patients prescribed oral antibiotics at hospital discharge for community-acquired pneumonia, skin and soft-tissue infections, and urinary tract infections between September 2019 and December 2019 (preimplementation period) and between March 2021 and May 2021 (postimplementation period). Antimicrobial stewardship-initiated, department-wide, TOC program requiring all clinical pharmacists to review discharge antibiotic prescriptions in real time. In total, 260 antibiotic prescriptions were assessed for appropriateness: 140 before implementation and 120 after implementation. After implementation, the number of prescriptions considered inappropriate significantly decreased by 18% (52% vs 34%; P = .005). Inappropriate rates decreased in all assessment categories: dosing (15% vs 2%; P < .001), treatment duration (42% vs 31%; P = .08), antibiotic selection based on infection type or microbiology (8% vs 4%; P = .33), and antibiotics not indicated (16% vs 10%; P = .18). Median total antibiotic days decreased by 1 day after implementation (10 days vs 9 days; P = .67), and 30-day readmission rates were similar between both phases. A real-time, pharmacist-driven, TOC program for oral antibiotic prescriptions had a significant impact in reducing inappropriate prescribing of antibiotics at hospital discharge for common infections. Incorporating discharge antibiotic prescription review into pharmacist daily workflow may be a sustainable approach to outpatient antimicrobial stewardship in a setting with limited resources.

Changes in intravenous and oral antimicrobial prescriptions during the coronavirus disease 2019 (COVID-19) pandemic: an experience at a tertiary-care center.

Antimicrobial use during the coronavirus disease 2019 (COVID-19) pandemic at a tertiary-care center was analyzed using interrupted time-series analysis. Among intravenous antimicrobials, the use of azithromycin and third-generation cephalosporins significantly decreased during the current pandemic. Similarly, the use of oral antimicrobials, including azithromycin and fluoroquinolones, also decreased.

Real-world Treatment Patterns, Outcomes, and Healthcare Resource Utilization in Newly Treated Korean Patients With Asthma: A Retrospective Cohort Study.

PurposeAlthough asthma treatment guidelines recommend regular inhaled medication, real-world treatment patterns and outcomes in South Korea have not been examined. We examined real-world treatment patterns and outcomes among patients treated for asthma in South Korea.MethodsThis retrospective cohort study utilized data from the South Korean National Health Insurance database (2013–2016). Newly treated patients with asthma aged ≥18 years without history of chronic obstructive pulmonary disease were included. Initial and maintenance medication prescriptions were examined. Treatment discontinuation and switch were described. Asthma exacerbation rates, poor asthma control, and healthcare resource utilization (HRU) were compared between maintenance treatment groups (inhaled versus oral) using adjusted incidence rate ratios (aIRR) and hazard ratios (aHR).ResultsOverall, 1,054,707 patients initiated any asthma medication; 37,868 patients initiated inhaled (n = 9,983, 26.4%) or oral (n = 27,885, 73.6%) maintenance medication. More patients initiating inhaled versus oral asthma medication discontinued treatment within 12 months (94.4% vs. 86.3%; P < 0.0001). Patients treated with inhaled and oral medication switched treatment (2.5% and 2.3%; P = 0.4160, respectively). Patients initiating inhaled medication had significantly lower rates of asthma exacerbation (aIRR, 0.52; 95% CI, 0.39–0.69), lack of asthma control (aHR, 0.55; 95% CI, 0.48–0.62; P < 0.0001), all-cause and asthma-related HRU versus oral medication.ConclusionsDespite current asthma guidelines, more patients in South Korea were prescribed oral than inhaled medications, resulting in suboptimal asthma management and increased HRU. This study highlights the need to reduce oral corticosteroid prescriptions for optimized treatment in asthma management.

Telemedicine in epilepsy management during the coronavirus disease 2019 pandemic.

BackgroundTelemedicine has spread rapidly during the coronavirus disease 2019 (COVID‐19) pandemic and shown its usefulness, particularly for patients with epilepsy, compared to face‐to‐face visits. We sought to evaluate the clinical features of patients with childhood onset epilepsy associated with consultations by telephone call during the COVID‐19 pandemic.MethodsWe retrospectively investigated the medical records of patients with childhood onset epilepsy who visited an outpatient clinic in Saitama Children's Medical Center, Saitama, Japan, from 1 March 2020 to 30 September 2020. To find the clinical features of patients who utilized telemedicine consultation (by telephone call), we divided the patients into the telemedicine group and the face‐to‐face group. We then reviewed the clinical features. Telemedicine consultation was not implemented for new patients.ResultsWe enrolled 776 outpatients in total, and 294 patients (37.9%) utilized telemedicine consultations. The total number of visits was 2,299 and the total number of telemedicine consultations was 373 (16.2%). No clinical feature was associated with telemedicine consultations except for age at onset of epilepsy. The number of oral antiepileptic drugs prescriptions decreased in 23 of 776 (3.0%) of the patients who did not experience seizure deterioration, including status epilepticus, or who visited the emergency room.ConclusionTelemedicine consultations were successfully utilized for epilepsy treatment at our outpatient clinic, regardless of epilepsy type, etiology, seizure frequency, comorbidities, and patients' residential areas. Thus, telemedicine by telephone call may be a useful resource in the management of patients with childhood onset epilepsy during the pandemic.

Nefopam prescribing preferences in French hospitals: results of a survey.

Introductionnefopam is a non-opioid, centrally-acting analgesic, frequently prescribed in France for acute pain and postoperatively. Only intravenous (IV) formulation is available, however the off-label oral use is frequent in surgical and medical patients. There is no data on the actual in-hospital prescription preferences in French physicians regarding nefopam. We wish to identify nefopam prescription habits for acute and chronic pain among hospital physicians.Methodsan online survey was sent to physicians via professional emails. Frequency of prescription, indication, preferred and prescribed administration route, dose regimen, and personal perception of the nefopam tolerance and efficiency were examined.Resultsa total of 527 responses were analysed. Nefopam was mostly prescribed by senior hospital physicians, for acute pain, orally (85%), 20 mg/6h with 120 mg maximal daily dose. For chronic pain, the oral administration was more frequent. More than half of prescribers considered the efficacy of the oral route was similar to intravenous, and better tolerated compared to intravenous administration. Forty-eight percent of responders would change their prescription attitude in case of oral route approval of nefopam.Conclusionoral prescription of intravenous formulation of nefopam is frequent, especially for acute pain, and has the same dose and regimen pattern as for intravenous route. Prescribers consider oral nefopam efficient and safe for patients. Regulatory actions regarding the oral nefopam prescription authorization and duration of such prescription are needed.

Accuracy of Oral Liquid Measuring Devices Used Among Caregivers at Hospital Dungun

Oral liquid medications are common type of dosage form prescribed to children. Caregiver responsible to choose appropriate measuring device to measure intended dose and minimize dosing error. Objectives of this study were 1) To identify types of measuring devices used at home; 2) To determine dose error deviation across all the measuring devices. This cross-sectional study involved caregivers visiting outpatient pharmacy with oral liquid prescription that fulfilled inclusion and exclusion criteria. The caregivers were instructed to measure 4.8ml and 15.0ml liquid by using suitable devices provided, which were 4 types of syringes and 2 types of dosing cups. The measured liquid was read by investigator and any dose error deviation was calculated and reported as percentages. Data was analyzed descriptively using SPSS version 21. Out of 120 caregivers involved, 60% were female (n=72), aged between 31-40 years old (49.1%, n=59), and employed (62.5%, n=75). 82 caregivers (68.3%) received secondary education level. Most caregivers use standardized measuring devices at home, particularly syringes and dosing cups. For smaller dose, less dose error was detected if using syringe (13.3%) as compared to dosing cup (39.3%); while for larger dose, both syringe and dosing cups are acceptable (11.7% and 7.4% respectively). Syringe shows less dose error as compared to dosing cup for smaller dose. Pharmacist should participate in decision making of choosing right measuring device to improve accuracy of medication administration.

Persistence With and Adherence to Paliperidone Palmitate Once-Monthly Injection for Schizophrenia Treatment in China and Japan

Objective: To describe persistence with and adherence to paliperidone palmitate once-monthly injection (PP1M) compared to oral second-generation antipsychotics (SGAs) in patients with schizophrenia in real-world settings in China and Japan.Methods: Patients with a schizophrenia diagnosis (ICD-10: F20.x) who received oral or injectable antipsychotics from study start (China: January 1, 2012; Japan: January 1, 2014) until December 31, 2017, were enrolled in this retrospective cohort study. The first PP1M or oral SGA prescription date during the study period was defined as the index date. Eligible patients were followed up for up to 1 year after the index date. Persistence was measured from the index date until discontinuation or reaching 1 year. Adherence was assessed by calculating the proportion of days covered (PDC). Multivariable regression models were used to adjust for potential confounders.Results: The study cohorts comprised 44,266 patients from Japan and 7,564 and 5,189 patients, respectively, from 2 hospitals in China. The PP1M group showed consistently lower risk of discontinuation; adjusted hazard ratios and 95% CIs were 0.75 (0.72-0.90) (Japan), and 0.76 (0.68-0.84) and 0.65 (0.56-0.76) (China) compared to oral SGAs. The PP1M group also showed better adherence; adjusted odds ratios and 95% CIs were 1.61 (1.22-2.11) (Japan), and 1.92 (1.53-2.41) and 2.25 (1.58-3.23) (China).Conclusions: Persistence and adherence were significantly higher in PP1M users than in oral SGAs users across 3 databases comprising patients in 2 countries in Asia.

Nutritional Status, Nutritional Phenotypes, and Oral Nutritional Supplement Prescription Patterns Among Patients With Non-Dialysis Chronic Kidney Disease in British Columbia

Management of protein-energy wasting and undernutrition with oral nutritional supplements (ONS) has not been systematically studied in the non-dialysis chronic kidney disease (CKD-ND) population. We aimed to describe nutritional status, identify phenotypes of patients prescribed ONS, and evaluate ONS prescription patterns among CKD-ND patients in British Columbia. This observational study assessed adult CKD-ND patients who entered multidisciplinary CKD clinics during 2013-2018 in British Columbia. Descriptive statistics were used to describe baseline nutrition and inflammation parameters among patients prescribed ONS versus patients not prescribed ONS within 1year of clinic entry. Hierarchical clustering method with consensus clustering was applied to identify phenotypes of patients prescribed ONS. Multivariable logistic regression was used to assess the associations between ONS prescription and health region/dietitian full-time equivalents per 1,000 CKD patients. Of 15,859 CKD-ND patients, 9% of patients entering CKD clinics were prescribed ONS within 1year of clinic entry, and these patients demonstrated lower baseline estimated glomerular filtration rate, body mass index (BMI), serum albumin, bicarbonate, as well as greater age, serum phosphate, and neutrophil-to-lymphocyte ratio compared with those not receiving ONS. Cluster analysis revealed 5 phenotypes of ONS users: cluster 1 had the highest mean neutrophil-to-lymphocyte ratio; cluster 2 had the lowest mean albumin; cluster 3 had the lowest mean BMI; cluster 4 had the highest mean BMI; and cluster 5 had the lowest mean bicarbonate. There was regional variability in ONS prescription, and an odds ratio for ONS prescription of 1.32 (95% confidence interval 1.16-1.50) for every 1-unit increase in dietitian full-time equivalents per 1,000 patients. Over 3years of follow-up, overall ONS use among CKD-ND patients remained stable. This study demonstrates appropriate prescribing of ONS to patients with suboptimal nutritional status, although regional variation exists. Patients receiving ONS represent a heterogenous group with phenotypes reflecting several clinical and biochemical features of the protein-energy wasting syndrome. These findings will assist with updating ONS policy, planning quality improvement initiatives, and informing dietitian resource allocation.

P-P14 A multi-centre retrospective cohort study exploring weight loss and nutritional interventions in severe acute pancreatitis

Abstract Background Acute pancreatitis is among the most common acute gastrointestinal diseases. Severe acute pancreatitis (SAP) develops in up to 20% of patients and is associated with increased morbidity and mortality. Patients may have long and complex hospital admissions; nutritional support is a cornerstone of management. Due to increased metabolic demands and development of pancreatic exocrine insufficiency (PEI) patients frequently endure excessive weight loss. There has been little research into the effect of SAP on nutritional status and necessary nutritional interventions. This project aimed to characterise weight loss in SAP, routes of feeding, and PEI - including pancreatic enzyme replacement therapy (PERT). Methods Participating centres were recruited via the Nutrition Interest group of PSGBI and were required to retrospectively recruit 5-10 consecutive patients admitted following January 1st 2018 using a predefined data collection tool. Inclusion criteria included; age ≥18 years and diagnosed SAP of any aetiology (defined by organ failure of &amp;gt; 48hrs). The exclusion criterion was where death occurred during hospital admission. Data were collected regarding, weight changes, anthropometric measures, nutritional interventions used, PERT administration and diabetic status, including insulin use. All analyses were performed with IBM SPSS 22 (IBM Corp. Armonk, NY), with p &amp;lt; 0.05 considered statistically significant. Results 34 patients (22 male) from five centres met the inclusion criteria and were included in data analysis. Most common aetiologies were gallstones (13/34) and alcohol (11/34). A mean weight reduction of 12.6% (SD ± 10.77) (p &amp;lt; 0.001) was observed. Multivariate analyses showed that higher premorbid weight (p = 0.02) and PERT administration with tube feeding (p = 0.005) were associated with weight loss. Most patients (29/34) received tube feeding; mean duration 56.8 (SD ± 58.29) days. There was a significant increase in patients with diabetes requiring insulin therapy from admission (n = 3) to discharge (n = 9) (p = 0.03). Most (29/31) patients required oral PERT prescription on discharge. Conclusions Patients with SAP lost significant weight during the course of their illness despite aggressive, extended nutritional support and the correction of PEI with PERT. The significant increase in insulin dependence among patients with diabetes, and the number of patients requiring PERT on discharge, reflects the destructive effect SAP has on pancreatic function. These multicentre findings could be used as a baseline for determining effectiveness of nutritional interventions in SAP and may provide a basis for further prospective research in this area.