PRN Use Research Articles

30.1 Does Trauma Increase Rates of PRN Use in Inpatient Children

30.1 Does Trauma Increase Rates of PRN Use in Inpatient Children

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study.

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics. Cross-sectional study. All AL residents and select staff in 250 AL communities in 7 states. Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics. Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n= 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n= 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds. The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

Circadian Rhythm Of Pulmonary Artery Pressures In HFpEF Assessed With Cardiomem: Preliminary Results

<h3>Purpose</h3> : Systemic blood pressure is known to display a circadian rhythm in most healthy individuals, characterized by a nocturnal fall and a diurnal rise. Dysregulation of this pattern is associated with higher risk of cardiovascular disease. However, the circadian rhythm in the pulmonary arterial circulation and its impact on cardiovascular disease is less established. The aim of this study is to perform a preliminary investigation of any circadian variations of pulmonary artery (PA) pressures in patients with implanted cardiomem devices. <h3>Methods</h3> : Among 15 subjects with heart failure with preserved ejection fraction (HFpEF) and an implanted cardiomem device who were offered participation in this study, four subjects enrolled. Study participants recorded PA pressure signals three times a day: AM (7-9AM), mid-day (Noon-2PM), and PM (7-9PM). We excluded the readings that were preceded by changes in the diuretic regimen (change in dose and/or prn use of metolazone) within 3 days prior to the reading. <h3>Results</h3> : In the first two subjects (#1 and #2), we identified a "steady trend or slight rise" in PA pressures from morning-to-evening. These subjects had clinical stability (defined as no hospitalizations within the last year or medication changes within last 3-months), and relatively well controlled risk factors (diabetes, hypertension, sleep apnea). In the other two subjects (#3 and #4), we identified a "drop" in PA pressures from morning-to-evening. Subjects #3 and #4 have poorly controlled sleep-disordered breathing and DM, respectively. Both of these disease processes have been implicated in circadian misalignment of systemic BP. <h3>Conclusion</h3> : Based on these preliminary findings, a diurnal rise or steady PA pressures may reflect well-controlled risk factors in HFpEF. However, a nocturnal rise may indicate poorly controlled risk factors like sleep apnea or metabolic syndrome. Future studies are needed to confirm the circadian misalignment and its impact on cardiovascular outcomes.

Implementing an Interdisciplinary Committee to Reduce Psychotropic Drug and Increase Behavioral Intervention Use

In Fiscal Year (FY) 2018, the Butler VA Health Care System’s Psychotropic Medication and Behavior Management Committee was identified as a Veterans Integrated Service Network 4 Best Practice. The goal of this committee is to reduce unnecessary psychotropic medication use and polypharmacy and to increase behavioral intervention implementation among Community Living Center (CLC) Veterans. This committee meets quarterly to review Psychotropic Drug Safety Initiative data, behaviors and behavior care plans, and all psychotropic medications prescribed to Veterans. Psychiatric diagnoses, changes to psychotropic medications, and appropriate behavioral interventions are discussed. Committee members take responsibility for action items in accordance with their discipline; documentation of recommendations are made in quarterly behavioral health assessments in CPRS; and follow-up on action items is completed at twice weekly interdisciplinary treatment team meetings, weekly behavior rounds, and/or as needed. From the first quarter (Q1) of FY16 to Q1 FY20, the Butler VA CLC has seen decreased prescriptions of 2 or more anticholinergics (6.6% to 0.80%), antihistamines (12.5% to 5.9%), benzodiazepines (24.7% to 11.0%), and benzodiazepines or sedative hypnotics (23.2% to 9.0%). While prescription of antipsychotic use has increased (Q1 FY20 = 23.8%), the committee will follow Long Term Care Institute guidelines for gradual dose reductions, behavioral interventions, and as needed psychotropic medication PRN use. This committee provides an interdisciplinary forum to discuss and implement beneficial changes to pharmacological and non-pharmacological interventions among all CLC Veterans. The committee is a valuable process for monitoring and reinforcing best practices that may be easily replicated across VA CLCs nationwide.

Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia.

To understand how acute care nurses make decisions about administering "as-needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD). Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. A qualitative descriptive design was used to explore acute care nurses' decision-making about PRN psychotropic medication administration to PWD. Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed. Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre-emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision-making. These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.

PRN Medication Events in a Forensic Psychiatric Hospital: A Document Analysis of the Prevalence and Reasons

The aim of this study was to describe and explain the prevalence and reasons for as needed medication (pro re nata, PRN) in a forensic psychiatric hospital. We reviewed the documents of 67 long-term inpatients (87% male) over the one-year study period and identified 8626 PRN events. Virtually all of the patients received PRN for physical reasons, just over half for psychiatric reasons, and just over one-third for insomnia. The number of PRN events per patient was unevenly distributed. The prevalence of PRN events for both psychiatric reasons (26%) and insomnia (14%) were associated with the female gender, more severe psychiatric symptoms, and lower daily functioning. Half of the patients did not receive PRN for psychiatric reasons. It is likely that the use of such medication was successfully mitigated with scheduled medication and psychosocial approaches. The high number of PRN events for physical reasons (60%) was not explained by the patient characteristics and urgent research is needed on this aspect. Protracted PRN use should be recognized in clinical practice, and consider more structured solutions to develop PRN protocols and evidence-based care. Future research should examine how PRN is integrated with patients’ regular treatment and non-pharmacological methods.

Presidential Address: Emotion Dysregulation in Children and Adolescents

Presidential Address: Emotion Dysregulation in Children and Adolescents

3.67 Effect of Milieu on Frequency of PRN Medication Use

Managing hospitalized children with aggression is challenging. Our prior study showed that PRN use increased on a children's inpatient unit when the psychiatrist was reduced from full-time to half-time and the behavior modification program (BMP) was discontinued. Subsequently, the psychiatrist was restored to full-time but the BMP was not. The impact of this on the use of PRN agitation medications is presented.

Staff and patient accounts of PRN medication administration and non-pharmacological interventions for anxiety.

Most psychiatric inpatients will receive psychotropic PRN medication during their hospital stay for agitation, anxiety, and/or insomnia. While helpful in some cases, caution is warranted with regard to PRN use due to inherent risks of additional medication; therefore, experts advise that non-pharmacological interventions should be attempted first where indicated. However, research to date highlights that, in practice, non-pharmaceutical approaches are attempted in a minority of cases. While some information is known about the practice of PRN administration and the use of and barriers to implementing non-pharmacological interventions for treating acute psychiatric symptoms, full understanding of this practice is hampered by poor or altogether missing documentation of the process. This study used interviews with patients and staff from two psychiatric hospitals to collect first-person accounts of administering PRN medication for anxiety, thereby addressing the limitations of relying on documented notation found in previous research. Our results indicate that nurses are engaging in non-pharmacological interventions more often than had previously been captured in research. However, the types of strategies suggested are not typically evidence based and further, only happening approximately half the time. The barriers to providing such care are centred on two main beliefs about client choice and efficacy of these non-medical strategies. Implications for research and practice are discussed.

Real-Life Clinical Use of Symbicort® Maintenance and Reliever Therapy for Asthmatic Patients in Korea

The aim of this study was to examine the daily practice patterns of Symbicort® Maintenance and Reliever Therapy (SMART) in Korean asthmatic patients and to analyze clinical signs related to overuse. This study used an observational, multicenter, noninterventional, prospective, uncontrolled design for examining asthmatic patients prescribed SMART to assess the frequency and pattern of Symbicort® usage as a maintenance and reliever medication. The characteristics of patients showing signs of overuse (frequency of inhalation: 8 or more times per day) were also analyzed. Among the 1,518 patients analyzed, 1,292 (85.1%) completed the trial. The number of mean inhalations per day was 2.14±1.15; the number of patients who had at least 1 as needed usage (PRN) inhalation per day was 843 (55.5%); the mean frequency of PRN use was 0.25±0.67 inhalations per day. The number of patients who overused for at least 1 day was 260 (17.1%). In particular, young patients, patients with limited physical activity, and patients with nocturnal symptoms demonstrated high frequency of overuse. The frequency of overuse during SMART was not high in Korean asthmatic patients and the asthma status of follow-up outpatients improved overall. However, there is a need for careful education targeted toward younger patients, patients with limited physical activity, and patients with nocturnal symptoms owing to their tendency to frequently overuse.

Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo, Norway

Objective: We describe the drug-related problems (DRPs) identified during medication reviews (MRs) and the changes in drug utilization after MRs at nursing homes in Oslo, Norway. We explored predictors for the observed changes.Design: Observational before-after study.Setting: Forty-one nursing homes.Intervention: MRs performed by multidisciplinary teams during November 2011 to February 2014.Subjects: In all, 2465 long-term care patients.Main outcome measures: DRPs identified by explicit criteria (STOPP/START and NORGEP) and drug–drug interaction database; interventions to resolve DRPs; drug use changes after MR.Results: A total of 6158 DRPs were identified, an average of 2.6 DRPs/patient, 2.0 for regular and 0.6 for pro re nata (prn) drugs. Of these patients, 17.3% had no DRPs. The remaining 82.7% of the patients had on average 3.0 DRPs/patient. Use of unnecessary drugs (43.5%), excess dosing (12.5%) and lack of monitoring of the drug use (11%) were the most frequent DRPs. Opioids and psychotropic drugs were involved in 34.4% of all DRPs. The mean number of drugs decreased after the MR from 6.8 to 6.3 for regular drugs and from 3.0 to 2.6 for prn drugs. Patients with DRPs experienced a decrease of 1.1 drugs after MR (0.5 for regular and 0.6 for prn drugs). The reduction was most pronounced for the regular use of antipsychotics, antidepressants, hypnotics/sedatives, diuretics, antithrombotic agents, antacid drugs; and for prn use of anxiolytics, opioids, hypnotics/sedatives, metoclopramide and NSAIDs.Conclusion: The medication review resulted in less drug use, especially opioids and psychotropic drugs.

ARE CARE HOME RESIDENTS WITH UNDIAGNOSED DEMENTIA MORE AT RISK OF ANTIPSYCHOTIC OVERUSE?

Antipsychotics are often prescribed in response to agitation in dementia. There is government pressure to reduce use in people with dementia, particularly ‘off-label’ prescribing, due to negative side effects. Clinical guidelines recommend review every three months for people with diagnosed dementia, however there are many residents in care homes with undiagnosed dementia who may not receive regular review. We collected data from the largest prospective clustered cohort study of residents living with dementia or probable dementia in a representative sample of English care homes. Dementia diagnosis status, dementia severity (Clinical Dementia Rating) and agitation data (Cohen-Mansfield Agitation Inventory [CMAI]) were collected during structured interviews. Medication data and PRN administration in the prior 2 weeks were extracted from care records: antipsychotics, anxiolytics, hypnotics, antidepressants, opioids (strong and weak), non-opioids, NSAIDs. Data collected four months after baseline reports length of prescription. Prevalence (95% CIs) of medication prescribing were calculated. We will use regression models to identify factors associated with psychotropic and analgesic use, including agitation subtypes. 86 care homes and 1483 residents were recruited. 13.6% of consented residents did not have a clinical dementia diagnosis but screened positively for probable dementia (Noticeable Problems Checklist). 55.6% (53.0–58.1%) residents were prescribed psychotropics, with 16.7% (14.8–18.7%) of residents prescribed antipsychotics. Of the 248 residents prescribed antipsychotics, 142 (57.3%) received prescriptions for drugs other than Risperidone, the only antipsychotic licensed for use in people with dementia. 40% of residents had clinically significant agitation (CMAI>45). Other drugs, such as antidepressants (prescribed for 39.6% residents) and strong opioids (10.8%) may be used for their sedative effect. Results, including PRN use, will be presented in full at conference. Antipsychotic point prevalence appears similar to national prescribing levels. Reductions in antipsychotic prescribing do not appear to have been sustained. Many residents are prescribed unlicensed antipsychotics to treat agitation. It is vital to understand what factors are associated with use of antipsychotics, and whether those with undiagnosed dementia are more likely to receive antipsychotics, and for a longer, and potentially unsafe, duration.

PO-0153 A Review Of Practice For Prescribing Antiemetics In Paediatric Haematology And Oncology

<h3>Background and aims</h3> In July 2013 the European Medicines Agency reviewed risk-benefit ratios for Metoclopramide following concerns about neurological side-effects including short-term extrapyramidal disorders. Our practice review assesses safety and efficacy of current antiemetic agents in controlling CINV (Chemotherapy induced nausea and vomiting) in a tertiary centre of UK. <h3>Methods</h3> A randomised review of inpatient chemotherapy prescriptions done from paediatric Haemato-Oncology in first 7 days of initiating treatment in Excel format. It included choice of anti-emetics with regards to chemoregimen, compatibility of agents used together, dose, frequency and adverse reactions that might be related to antiemetics. <h3>Results</h3> Number of children assessed in study were 26. A total of 23 prescriptions with Ondansetron, Metoclopramide, Dexamethasone, Hyoscine, Domperidone, Levomepromazine and Aprepitant were assessed. Ondansetron was prescribed in 23 and Metoclopramide in 19 prescriptions. Degree of antiemetic control surrogately assessed by use of PRN antiemetics where Metclopramide and Levomepromazine most commonly used PRN drugs. There were 8 occasions (34%) of multiple dopaminergic antiemetic prescribing. 1 acute dystonic reaction observed in a 9 year old male child on Day 4 during methotrexate clearance. Metoclopramide and Levomepromazine were both administered. <h3>Conclusions</h3> Raising awareness about antiemetic compatibility in prescribing multiple dopaminergic antiemetics. A considerable degree of Metoclopramide use noted for controlling CINV in both regular and PRN use. Developing validated tools to improve antiemetic prescribing efficacy with specialist pharmacology input. <h3>References</h3> Antiemetic medication for prevention and treatment of CINV in childhood, Phillips, Cochrane CCG-Sep’10 Development and validation of pictorial nausea rating scale for children. Pediatrics 2011;127(6)

Characterising the nature of psychotropic medication prescribed in Scottish PICUs

To determine the nature of psychotropic medication routinely prescribed in Scottish PICUs, the medical notes and prescription charts of 75 patients from 10 out of 14 units were consulted. These included 55 males (73%), the majority of whom were detained and had a diagnosis of schizophrenia. There was good conformance with mental health legislation treatment plans (T2/T3 forms) with only five instances of non-conformance identified. Antipsychotics were prescribed to 60 patients (80%) of which olanzapine and zuclopenthixol decanaote were the most common. The average number of regular psychotropic medicines prescribed per patient was two. In total, 14 drugs, encompassing 21 formulations, were prescribed for PRN use. Lorazepam and haloperidol were the most common PRN medicines. 76 PRN prescriptions (32%) had the oral and IM doses written on the same line of the prescription chart and showed no allowance for bioavailability when detailing the maximum dose that could be administered. 16 patients (21%) were prescribed more than one antipsychotic. Seven patients were prescribed high dose therapy, but this increased to 25 when PRN antipsychotics were included. This study provides information about psychotropic medication prescribing in Scottish PICUs and highlights areas where practice is sub-optimal.

Stability of Paracetamol Tablets Repackaged in Dose Administration Aids for prn Use: Implications for Practice

ABSTRACTBackgroundParacetamol tablets are often repackaged into dose administration aids (DAAs) for prn use. Pharmacists have limited information regarding the long‐term stability of prn medicines stored in DAAs for extended periods due to infrequent dosing. According to current guidelines, in the absence of specific data, medicines should not be stored in a DAA for longer than 8 weeks.AimTo determine the physicochemical stability of paracetamol tablets repackaged into DAAs and stored for 12 months.MethodParacetamol (Panamax) tablets were removed from primary packaging, repackaged into DAAs (Multi Dose Webster‐pak) and stored under ambient (25 °C; 60% relative humidity) and accelerated (40 °C; 75% relative humidity) conditions for 12 months. Physical characteristics of the tablets, such as appearance, weight uniformity, thickness, hardness, friability, disintegration and dissolution rates were evaluated at baseline, 3, 6 and 12 months. Chemical stability was confirmed by high performance liquid chromatography.ResultsAll compendial requirements for physical stability were met for tablets stored under ambient and accelerated conditions over the 12‐month period. Chemical stability was confirmed, with paracetamol content in the tablets within the British Pharmacopoeial range of 95% to 105% of the labelled amount.ConclusionThis study provides data on the stability of paracetamol tablets repackaged into DAAs and stored under ambient and accelerated conditions for 12 months. Pharmacists will be able to make risk–benefit assessments and recommend a 12‐month expiry on paracetamol prn DAAs.

Medication Management in Assisted Living

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics.Cross-sectional study.All AL residents and select staff in 250 AL communities in 7 states.Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7 days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics.Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7 days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n = 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n = 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds.The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

Five-Year Trajectories of Long-Term Benzodiazepine Use by Adolescents: Patient, Provider, and Medication Factors

Five-Year Trajectories of Long-Term Benzodiazepine Use by Adolescents: Patient, Provider, and Medication Factors

Identifying unprescribed controlled medication use: a database analysis

Hospitalizations and deaths due to unintentional poisonings have been on the rise over the last decade, primarily due to prescription opioids, sedatives and tranquilizers. The largest increases in numbers of cases and percentage of hospitalizations from 1999-2006 were due to benzodiazepines and methadone, respectively, emphasizing the need to closely monitor patients who are taking these medications.1 Urine drug monitoring is an important tool which provides the clinician with additional information to optimally manage patients requiring treatment with controlled substances. Urine samples tested by Ameritox between the dates of October 1, 2009 and October 1, 2010 were evaluated (using proprietary methodology) to assess the likelihood that patients with chronic pain were taking their medications as prescribed. Overall, there were 922,440 samples tested during this period. Of these, a preliminary analysis was conducted on 2% of the samples (n=17,970) to determine the most common prescription drugs that were present but not recorded on the requisition form. The most common medication categories tested for and detected included benzodiazepines, opiates, opioids and amphetamines. Specifically, oxazepam, alprazolam, diazepam, hydrocodone, oxycodone and morphine were most commonly found. Potential reasons for these findings include clerical errors in the patient chart or on the requisition form, patient confusion about their medications, multiple prescribing physicians, hoarding of older prescription medications for PRN use, or abuse of unprescribed medications. Given the dramatic rise in abuse and misuse of prescription medication, these data emphasize the need for routine urine drug monitoring in patients with chronic pain to determine the likelihood of adherence to prescribed medications, as well as to provide evidence of any additional medications the patient may be ingesting, whether intentional or unintentional. (1. Coben J, American Journal of Preventative Medicine, 2010).

Use of Methadone for Uncontrolled Pain: An Alternative Dosing Regimen

Use of Methadone for Uncontrolled Pain: An Alternative Dosing Regimen

Use of Pro Re Nata Medications in Acute Inpatient Care

Available evidence suggests that the use of 'as needed' (PRN; from the Latin pro re nata: for an occasion that has arisen) medications has remained a standard aspect of treatment in acute inpatient mental health units over a number of years despite lack of evidence from controlled clinical trials. The practice is one in which doctors and nurses are interdependent; that is, while doctors prescribe the medications, professional nurses are the ones who make the clinical decisions to administer them. The aim of the present study was to provide a detailed description of the circumstances surrounding the use of PRN medications across four inpatient units in Sydney. The medical records of all patients admitted for >24h during a 2 month period were retrospectively audited for details regarding prescriptions and administrations of PRN medications. A total of 420 records were reviewed, producing a total of 3868 PRN medication administrations. Ninety-seven per cent of all patients were prescribed PRN medications and 93.8% were prescribed regular medications. The most frequently prescribed medications were second-generation antipsychotics for regular use along with benzodiazepine for PRN use. Nearly 84% of patients received at least one PRN medication during their admission, while patients diagnosed with personality disorder received more PRNs per day. The most common reason for PRN administration was patient agitation. The results indicated poor documentation in the prescription and documentation of PRN administrations. Also, the findings show that a small subset of the patients (5%) received >30% of all PRN medications. PRN medication use has endured as standard practice and the results of the present study are consistent with the reported frequency of use increasing slightly over the years. The combination of second-generation antipsychotics as regular medications and benzodiazepines for PRN medication is consistent with recommended treatment guidelines. The small subset of patients who were overrepresented in the PRN administrations is noteworthy.