Real-world Prescribing Research Articles

Dosage Prediction in Pediatric Medication Leveraging Prescription Big Data

Rational use of medicines is of great importance in pediatric clinical medication. As the pharmacokinetics and pharmacodynamics of the pediatric group is highly dynamic, it is a great challenge to determine the rational dosage for pediatric patients. Traditional clinical decision support systems for dosage guidance largely rely on manual collection of medication information, which usually suffers from incomplete and missing evidences for the pediatric group. In this paper, we propose a data-driven approach to accurately predict pediatric medication dosages by leveraging prescription big data. More specifically, we first identify two relevant factors of pediatric medication dosage, i.e., the physiology factors including patients' body weight and age group, and the indication factors that affect clinical dosage patterns. We then extract the corresponding physiology and indication features, and propose a hybrid-learning-based method to adaptively integrate the two sets of heterogeneous features into a model for accurate pediatric dosage prediction. We evaluate our method on real-world prescription datasets from two tertiary children's hospitals. Results show that our method predicts pediatric medication dosages with an accuracy above 81.3%, and consistently outperforms other baselines.

Improved Dosing and Administration of Rivaroxaban when Prescribed by a Cardiologist.

This retrospective study assessed real-world prescribing and patient adherence to dietary requirements during use of rivaroxaban in 116 patients with AF. Associations between prescriber specialty and the correct dosing and administration were assessed using the Chi-Square test. Most rivaroxaban prescriptions were ordered by cardiologists (50.9%). Sixty-nine patients (59.5%) were taking the right dose at the correct time with an adequate meal. Of the 47 (40.5%) taking rivaroxaban incorrectly, 39 (33.6%) had not been administered an adequate meal and eight (6.9%) were not prescribed the correct dose. Compared with other prescribers, patients were most likely to be taking the correct dose and administration when prescribed by cardiologists (72.9% versus 45.6%; p=0.003). Patients were least likely to be taking the correct dose and administration when prescribed by primary care providers (44.4% versus 69.0%; p=0.009). This difference was driven by patients who did not take the treatment with an adequate meal. Inappropriate prescribing, administration and non-adherence to DOACs can have devastating consequences. This highlights the importance of formal systematic education of patients prescribed DOACs across the whole health system. Future studies are warranted to explore the impact of non-adherence to rivaroxaban dietary requirements on clinical outcomes.

Evidence synthesis, practice guidelines and real-world prescriptions of new generation antidepressants in the treatment of depression: a protocol for cumulative network meta-analyses and meta-epidemiological study

IntroductionDepressive disorders are the most common, burdensome and costly mental disorders. Their treatments have developed through the past decades and we now have more than a dozen new generation antidepressants,...

Studying additive interaction in a healthcare database: Case study of NSAIDs, cardiovascular profiles, and acute myocardial infarction.

PurposeThere are clinical trial data on risk of acute myocardial infarction (MI) with nonsteroidal anti-inflammatory drugs (NSAIDs) in patients at increased cardiovascular (CV) risk requiring chronic daily treatment. This study investigated whether risks of acute MI with real-world prescription NSAIDs, such as low-dose or intermittent use, vary according to an individual’s CV profile.MethodsNested case-control analyses were carried out on an administrative health cohort from Quebec, Canada by randomly selecting 10 controls per case matched on age ± 1 year, sex, and month and year of cohort entry. We measured the additive joint effects on acute MI of current NSAID use and presence of hypertension, coronary heart disease (CHD), history of previous MI, or concomitant use of cardioprotective aspirin. The endpoint was the relative excess risk due to interaction (RERI). To verify the robustness of interaction findings, we performed sensitivity analyses with varying specifications of NSAID exposure-related variables.ResultsThe cohort consisted of 233 816 elderly individuals, including 21 256 acute MI cases. For hypertension, CHD, and previous MI, we identified additive interactions on MI risk with some but not all NSAIDs, which also depended on the definition of NSAID exposure. Hypertension was sub-additive with naproxen but not with the other NSAIDs. Celecoxib and CHD were sub-additive in the primary analysis only (modelling NSAID dose on index date or up to 7 days before–best-fitting base model) whereas celecoxib and rofecoxib were super-additive with a history of previous MI in the secondary analysis only (modelling NSAID use on index date). For cardioprotective aspirin we found no evidence for an additive interaction with any of the NSAIDs.ConclusionsAlternative specifications of NSAID exposure concurred in finding that concomitant use of cardioprotective aspirin does not attenuate the risks of acute MI with NSAIDs. However we were unable to demonstrate consistent interactions between an individual’s cardiovascular comorbidities and NSAID-associated acute MI. Our study highlights challenges of studying additive interactions in a healthcare database and underscores the need for sensitivity analyses.

Physicians' Perspectives on Cost, Safety, and Perceived Efficacy Determine Aminosalicylate Use in Crohn's Disease.

Aminosalicylates are the most commonly prescribed therapy in Crohn's disease (CD), despite uncertainty in the evidence to support their efficacy. To examine physicians' perspectives on aminosalicylate use for CD and explore the discordance between clinical practice and the evidence base. A qualitative interview study was performed amongst physicians with at least 4 years of independent experience in managing CD patients. Semi-structured telephone interviews were conducted using an exploratory interview guide. Interview transcripts were thematically analyzed to elucidate concepts pertaining to treatment strategies for CD, motivations for prescribing aminosalicylates, perceived benefits and harms of aminosalicylate use, and the relationship between the evidence and real-world prescribing practices. A representative sample of thirty physicians from four different countries and multiple practice environments (university/teaching hospitals, public practice, private/community practice, and subspecialty gastroenterology clinics) participated. Nearly all physicians (93.3%, 28/30) reported prescribing aminosalicylates for CD. Aminosalicylates were endorsed as first-line therapy for mild CD by nearly half of participants (13/30, 43.3%). A favorable safety profile, possible efficacy in mild colonic CD, and patient reluctance to step-up to other therapies were primary motivators for aminosalicylate use. Almost half of respondents (46.7%) expressed that the evidence informing aminosalicylate efficacy in CD differed substantially from their own clinical experience. Physicians' beliefs about efficacy in subgroups of CD patients, safety, and patient preferences primarily motivate aminosalicylate prescription in CD. There is a lack of confidence in published clinical trials, and a desire for more robust evidence to inform 5-ASA use in CD.

Association of the adoption of immune checkpoint inhibitor therapy (ICT) with prevalence of tumor mutation burden (TMB) in sixteen cancer types.

e18557 Background: Tumor Mutation Burden (TMB) is an emerging biomarker for response to immune checkpoint inhibitor therapy (ICT). PDL1 is still the only companion diagnostic test for ICT. We sought to examine the relationship between the use of ICT based on real world prescription data relative to key FDA approval dates to TMB prevalence data based on whole exome sequencing (WES). Methods: Treatment plans submitted through a proprietary web-based application to obtain automated precertification for first, second, and third line therapies for 16 tumor types were retrospectively reviewed for ICT use before and after key ICT approval dates. These usage rates were then compared to the frequency of high TMB in respective tumor types as determined by a retrospective analysis of data from a commercial DNA tumor:normal and RNAseq platform where 992 samples were identified with paired DNA(WGS or WES)/RNAseq NGS. “High” vs “low” mutation burden was assigned with a threshold of 200 non-synonymous mutations. Results: High TMB frequency ranged between 5%(ovary)-52%(melanoma). ICT usage ranged between 0%-2%(melanoma) from 2011 through 2014, 0%-56%(melanoma) between 2015 and May 2017, and 0%-66%(melanoma) from May 2017 to February 2018. The rate of ICT usage increased by more than 15% since 2015 in head and neck, kidney, liver, lung, and melanoma. However, in kidney, liver, and melanoma, the usage rates since May 2017 are 18%, 10%, and 13% greater than the frequency of high TMB in those tissue types. Conversely, usage rates are 11-23% lower than high TMB frequency in bladder, breast, colon, lung, rectal, and uterine cancer. Conclusions: In this retrospective analysis using WES data to evaluate the correlation of high TMB frequency tumor types and ICT use, we found ICT use increased across most tumor types after 2014. However, the rate of use is lower than the prevalence of high TMB in many cancers (including lung). As ICT therapy is associated with better quality of life and equal to better overall survival than chemotherapy, more aggressive identification of prospective ICT patients through NGS exome assessment of TMB could be warranted.

PCV60 - Cost-Effectiveness Of Rivaroxaban Compared With Real-World Treatment For Stroke Prevention In Non-Valvular Atrial Fibrillation In China

To evaluate the cost-effectiveness of rivaroxaban over real-world treatment prescribing scenario (i.e. 23% of patients receiving warfarin, 57% of patients receiving aspirin, or 20% of patients receiving no treatment in a cohort of warfarin-eligible patients) for stroke prevention in non-valvular atrial fibrillation (NVAF) patients in China. A Markov model was designed from a payer’s perspective to evaluate the costs and quality-adjusted life years (QALYs) of NVAF patients treated with rivaroxaban or real-world prescribing. Clinical data were from ROCKET AF trial or network meta-analysis to estimate the transition probabilities. Data on Chinese health resource use, unit costs and utility parameters were collected from previously published literature. The time horizon was set at patients’ lifetime and a 3-month cycle length was used in the model. All costs were expressed as the 2017 USD (exchange rate, 1 USD = 6.67 Chinese Yuan) with future costs discounted at 5% per year. One-way sensitivity analyses and probability sensitivity analyses were undertaken to further assess the uncertainty of the cost-effectiveness results of rivaroxaban over real-world treatment. Rivaroxaban therapy resulted in the gain of 6.90 QALYs, with the total lifetime costs USD 17,269. And the real-world prescribing mixture resulted in 6.43 QALYs, with the costs USD 8,157. The ICER of rivaroxaban was USD 19,563 per QALY versus the real-world treatment. Sensitivity analysis indicated that the result was most sensitive to relative risk (RR) of stroke for rivaroxaban and rivaroxaban would be cost-effective, assuming a willingness-to-pay threshold of USD 24,279 per QALY. It demonstrates that rivaroxaban therapy is a cost-effective alternative to real-world treatment for stroke prevention of NVAF patients in China.

Prescribing patterns for FOLFIRINOX in the real world.

463 Background: FOLFIRINOX therapy is associated with improved outcome in patients with gastrointestinal cancers. The regimen can be associated with significant toxicity and empiric dose modifications are often used. We analyzed 1) real-world prescribing patterns of FOLFIRINOX and 2) toxicity of therapy. Methods: Patients undergoing FOLFIRINOX chemotherapy at an academic, NCI-Designated Comprehensive Cancer Center were identified and electronic medical records reviewed. Patients who received at least one dose of FOLFIRINOX were included. Chemotherapy dose, growth factor use and toxicity data was abstracted for the first 8 weeks. ‘Standard FOLFIRNOX’ was defined as the regimen utilized by Conroy et al (NEJM 2011). Any empiric reduction/withholding of drug dose for cycle 1 was classified as ‘modified FOLFIRINOX’. Bivariate analysis was performed on the data. Results: There were 111 patients seen between 5/2011-3/2017 and 94% had pancreatic cancer. Age range was 29-87 years and 52% were female. 59% received ‘modified FOLFIRINOX’ and 20% received empiric growth factors. Line of therapy for standard vs modified respectively was 71.1% vs 45.5% for 1st, 17.8% vs 36.4% for 2nd, and 11.1% vs 18.2% for beyond 2nd (p = 0.03). Patients with ‘modified FOLFIRINOX’ were more likely to have metastatic disease (p = 0.01), have received second line or beyond, and higher ECOG score (p = 0.03). Patients with ‘modified FOLFIRINOX’ had a trend toward fewer treatment-related ED visits or hospitalization vs ‘standard FOLFIRINOX’ (27.2% vs 42.2% p = 0.10) and fewer treatment delays (25.8% vs 42.2% p = 0.07). Conclusions: In the real world setting, a majority of patients on FOLFIRINOX receive empiric dose modifications. Although modified dose did not translate to a significant difference in ED visits, hospitalizations or treatment delays, there was a trend toward fewer events.

Medication use in adults with attention deficit/hyperactivity disorder in a commercially-insured population in the United States

Objective: To examine real-world prescription medication usage among commercially-insured adults with attention deficit/hyperactivity disorder (ADHD) in the US.Methods: Adults with ADHD who received ≥1 ADHD medication during 2013 were identified from a large US claims database. Combination therapy was defined as an overlap of ≥30 days between the index (first treatment ≥30 days in 2013) and another medication(s). Patients were classified into six groups: long-acting (LA) monotherapy, short-acting (SA) monotherapy, LA + LA, SA + SA, LA + SA, and >2 therapies. Analyses compared baseline characteristics by regimen, ranked combination regimens, and estimated daily average consumption (DACON) for monotherapy users.Results: Of 206,443 adults with ADHD (mean age = 32.9 years; 51.6% female), 56.9% used LA monotherapy, 30.7% SA monotherapy, and 12.5% used combination therapies (LA + SA: 10.3%; LA + LA: 1.3%; SA + SA: 0.4%; >2 therapies: 0.5%). Extended-release mixed amphetamine salts (MAS-XR, 39.2%) and lisdexamfetamine (LDX, 31.5%) were the most common LA monotherapies. Nearly all SA monotherapy patients received immediate-release mixed amphetamine salts (MAS-IR; 81.7%). The top three therapies among combination categories were: (a) LA + LA: branded MAS-XR + generic MAS-XR (13.7%), LDX + generic MAS-XR (10.8%), LDX + guanfacine ER (10.7%); (b) SA + SA: generic MAS-IR + clonidine IR (33.5%), generic MAS-IR + generic MPH SA (17.9%), branded MAS-IR + generic MAS-IR (11.1%); (c) LA + SA: generic MAS-XR+/-IR (39.2%), LDX + generic MAS-IR (16.7%), LA + SA generic MPH (12.6%). Among monotherapy users, DACON was 1.2 ± 0.6 (LA) and 2.1 ± 0.9 (SA) tablets.Conclusions: There is significant treatment heterogeneity among US adults with ADHD. A sizable proportion of patients received monotherapies at above the recommended dosages or combination therapies, suggesting existing single-tablet regimens may not meet patients’ needs.

Treatment choices for the glycaemic management of patients with type 2 diabetes and chronic kidney disease: Analysis of the SAIL patient linked dataset

AimsChronic kidney disease (CKD) is common in type 2 diabetes and limits the treatment choices for glycaemic control. Our aim was to examine real-world prescribing for managing hyperglycaemia in the presence of CKD. MethodsThe SAIL (Secure Anonymised Information Linkage) databank was used to examine prescribing during the period from the 1st of January to 30th December 2014. CKD was defined as:- none or mild CKD, eGFR ≥60mL/min/1.73m2; moderate CKD eGFR <60mL/min/1.73m2; and severe CKD eGFR <30mL/min/1.73m2 or requiring dialysis. ResultsWe identified 9585 subjects who received any form of glucose lowering therapy (8363 had no/mild CKD; 1137 moderate CKD; 85 severe CKD). There was a linear association between insulin use and CKD severity with approximately 54% of those with severe CKD receiving insulin. Sulphonylureas use did not differ among the CKD groups and was approximately 40%. Metformin showed a linear decrease across the groups, however approximately 21% in the severe CKD group received metformin. The use of dipeptidyl peptidase 4 inhibitors (DPP-4i) was approximately 20% and did not differ among groups. The DPP-4 inhibitor choice was:- 1% vildagliptin, 9% saxagliptin, 58% sitagliptin, and 32% linaglitpin. With respect to sitagliptin and saxagliptin, 72% and 62% received an inappropriately high dose in the setting of CKD. ConclusionsWe observed that a considerable proportion of patients with type 2 diabetes and CKD were receiving metformin and non dose-adjusted DPP-4 inhibitors. Careful consideration of medication use and dosaging is required in the setting of CKD and type 2 diabetes.

Real-world prescribing patterns of long-acting benzodiazepines for elderly Koreans in 2013 .

We aimed to estimate the prevalence of prescriptions to long-acting benzodiazepines (BZDs) among elderly outpatients in Korea in 2013 and analyze the factors that led to inappropriate prescription practices. Using the Korea Health Insurance Review and Assessment Service-National Patients Sample database in 2013, we estimated the pattern of BZD prescription among elderly outpatients. BZDs were categorized as long-acting (half-life (T_1/2) ≥20hours) or short-acting (T_1/2 <20hours). In addition, we investigated the pattern of BZD prescription for populations defined according to patient, healthcare provider, and geographic characteristics. Multivariate logistic regression analysis was performed to estimate odds ratios and 95% confidence intervals and identify predictors of long-acting BZD use. Overall, 58,056 elderly patients (38,910 females, 67%) received at least 1 BZD prescription. The total number of BZD prescriptions was 78,843, of which long-acting BZD prescriptions accounted for 44.7%. Diazepam was the most frequently prescribed BZD (39.7%). Long-acting BZDs were most frequently prescribed in the primary-care setting and were relatively frequently prescribed in rural areas. Of the patients prescribed long-acting BZDs, 435 (3.5%) had chronic obstructive pulmonary disease. Long-acting BZD use varied across different medical institutions (p < 0.05). A decrease in long-acting BZD use was identified relative to data from previous studies. However, BZDs continued to be used, and their use should be further limited in the primary-care setting and in rural areas. The results of this study may provide fundamental data for further review of BZD utilization. .

Real-world prescribing patterns in acute myeloid leukemia in the United States.

e18524 Background: The effective treatment of patients with acute myeloid leukemia (AML) remains a challenge in clinical practice. This analysis describes the patient characteristics and real-world use of AML treatments in the United States for patients on high- and low-intensity treatment. Methods: Data from the Adelphi AML Disease-Specific Programme, a real-world, cross-sectional survey conducted between February–May 2015, were analysed. A total of 61 hematologist/hem-oncologists, across academic, non-academic and office-based practice locations, provided data on 457 AML patients. Patient characteristics were derived from physician-completed patient record forms where each physician was asked to provide treatment details, including the treatment intensity, for each line of therapy. Results: A total of 91% (n = 415) of patients included in this analysis were previously untreated for AML. Patients had a mean age of 60 years and been diagnosed with AML for a median of 5.0 months. At first-line induction therapy, over half (53%; n = 241) of the patients were initiated on a high-intensity treatment, the most common regimen being cytarabine plus anthracycline (61%; n = 147). The remaining 47% (n = 216) of patients received a low-intensity induction therapy such as low dose cytarabine monotherapy (28%, n = 61), azacitidine monotherapy (25%, n = 54), or decitabine monotherapy (21%, n = 45). Over half (55%, n = 62) of patients suited to high intensity treatment went on to receive cytarabine monotherapy during the consolidation phase of their first-line treatment. Conclusions: According to treating physicians, the large majority of patients receive traditional, well-established therapies at first-line induction for AML. Whilst cytarabine combinations dominate the high-intensity treatment setting, the hypomethylating agents, azacitidine and decitabine, are frequently used for those more suited to low-intensity treatment.

Mo1820 - Real-World Prescription Drug Utilization and Costs of Biological Therapies in Inflammatory Bowel Disease

Mo1820 - Real-World Prescription Drug Utilization and Costs of Biological Therapies in Inflammatory Bowel Disease

基于耦合关系的医生用药异常分析

近些年来，医患关系受到广泛关注。如何准确地挖掘异常用药是制约医生和缓减医患关系的关键。本文提出了一种检测医生用药异常的总体框架。该框架集成处方数据的耦合相似度度量和变色龙聚类算法，并分为三个阶段，定性分析，定量分析和异常检测。在真实处方数据上进行了充分的实验，实验验证了该框架能够有效地检测出医生用药异常。 In recent years, the doctor-patient relationship has received extensive attention. How to exactly mine the abnormal use of drugs is the vital to constrain doctors and relieve the doctor-patient relationship. This paper presents a general framework for detecting the abnormal use of drugs. The framework integrates coupled similarity and Chameleon clustering algorithm, and consists of three stages, qualitative analysis, quantitative analysis and abnormal detection. We conduct extensive experiments on real-world prescription data. The experiments evaluate that the framework can efficiently detect abnormal use of drugs.

Current drugs for weight loss

Current drugs for weight loss

National trends in alcohol pharmacotherapy: Findings from an Australian claims database

BackgroundAlthough the efficacy of alcohol pharmacotherapy has been widely investigated, little is known about real-world prescription patterns. Population-based dispensing data can provide an understanding of prescription patterns and characteristics of treatment in nonexperimental settings. MethodsA retrospective cohort study of patients (aged 15–84) treated with acamprosate or naltrexone between July 2009 and June 2013 was conducted using dispensing claims from the Australian Pharmaceutical benefits Scheme Database. Only individuals with prescriptions from September 2009 onwards were included. ResultsWe identified 61,904 individuals (40% female, 32% in 35–44 age bracket,) with a total number of 198,247 dispensings. There were 23,452 naltrexone-treated and 38,452 acamprosate-treated patients. For naltrexone, 42% of initial dispenses were followed by a second dispense with only 25% receiving at least 3 months of treatment. For acamprosate, 28% of dispenses were followed by a third dispense with only 15% receiving at least 3 months of treatment. Patients in older age groups were more likely to be dispensed a repeat script than those in younger age groups (e.g., for the 75–84 vs 15–24 age bracket OR’s=2.27 and 2.98 for naltrexone and acamprosate respectively). ConclusionCurrent national guidelines in Australia recommend alcohol pharmacotherapy for a minimum period of 3 months yet only 15–25% are receive this duration of treatment. Naltrexone-treated patients were more likely to return for a second and third dispense than acamprosate-treated patients. Prevalence and prescribing patterns change with age.

Acute Rhinosinusitis: Prescription Patterns in a Real-World Setting.

Understand real-world prescription patterns for patients presenting with a first diagnosis of ARS and evaluate adherence to published medical guidelines. Retrospective administrative database analysis. US-based outpatient settings. From a US claims database (MarketScan), 99,033 patients were identified with acute rhinosinusitis (ARS) in 2012 ("index"), with a complete medical and prescription history for 12 months preindex and 18 months postindex and no diagnoses of asthma or chronic rhinosinusitis. Of these, a random 10,000-patient sample was generated matched for age and sex to the initial cohort. Prescriptions and procedures at index, as well as complications up to 12 months postindex, were analyzed. Nearly 90% of all patients received a prescription at index. Antibiotics were prescribed for 84.8% patients, followed by antitussives (16.2% for adults, 6.2% for pediatrics), nasal corticosteroids (15.5% adults, 7.5% for pediatrics), and systemic corticosteroids (10.3% for adults, 5.5% for pediatrics), with 49% adults and 29% children receiving >1 medication at first visit. Macrolides were the most frequently prescribed antibiotics (35.6% adults, 28.6% pediatrics), followed by amoxicillin/clavulanate and amoxicillin. Within 12 months of index, 3 patients presented with meningitis and 3 with orbital cellulitis. Significant variability in ARS treatment was observed, highlighting the need for heightened awareness of existing guidelines.

Prescription et surveillance d’antipsychotiques chez les patients âgés souffrant de schizophrénie : pratiques des psychiatres et leurs déterminants

ObjectiveAdvancing age entails specific treatment modalities for patients with schizophrenia. The choice of appropriate antipsychotic therapy (AP) and the monitoring of treatment is a major challenge. However, little is known about the real-world prescribing practices of psychiatrists for elderly schizophrenia patients. The aim of this study was to assess prescribing practices and treatment monitoring in elderly schizophrenia patients and whether socio-professional psychiatrists’ characteristics are related to their practices. MethodsWe contacted by mail 190 psychiatrists to take part in an observational survey of their AP prescribing practices for elderly (aged over 65) schizophrenia patients. ResultsThe response rate was 44.2%, and of the psychiatrists who replied 75% were treating elderly schizophrenia patients. A second-generation AP (SGAP) was prescribed as first-line of treatment by 87.7% of the psychiatrists. The most frequently used SGAPs were risperidone and olanzapine (respectively preferred by 54.4% and 19.3% of the psychiatrists taking part). At the beginning of treatment, 91.1% of the psychiatrists prescribed a lower dose than for middle-aged patients. Of the psychiatrists taking part, 64.9% prescribed monotherapy; and among these psychiatrists, 65% cited insufficient control of the disease as the reason for their choice, while 48.7% of those who elected not to prescribe combined AP did so in order to limit the side-effects. Of the psychiatrists taking part, 54.4% prescribed long-acting injectable AP (LAAP); better therapeutic compliance and alliance was the main argument in the choice of LAAP given by the psychiatrists taking part who prescribed the drug, whereas the absence of indications and problems of tolerance were arguments against for those who did not. “Personal experience” emerged as the governing factor in the choice of AP. The AP side-effect profile was the main criterion of choice of the AP agent for 3.5% of the psychiatrists taking part, and the most frequently chosen secondary criterion (29.8%). Monitoring of treatment was partly performed according to professional recommendations: pre-treatment and post-prescription assessments of waist circumference and ophthalmological monitoring were very infrequent (8.8 to 18.5%) as were pre-treatment and early post-prescription assessments of prolactinaemia (14.8 to 20.4%); long-term cardiac monitoring was infrequent (43.9%). The psychiatrists taking part whose first-line drug was SGAP were more familiar with professional recommendations than those who prescribed first generation antipsychotic (FGA) drugs (72% as against 14.3%, P=0.006). Of the psychiatrists taking part in the study, 64.9% reported they commonly use professional recommendations. Psychiatrists who declared they commonly use professional recommendations measured pulse rate and blood pressure significantly more often over the long-term than those who did not (74.3% as against 41.2%, P=0.0315). They also measured waist circumference over the long-term significantly more often than psychiatrists who did not commonly use professional recommendations (22.9% as against 0%, P=0.0420). Psychiatrists treating more than ten of these patients yearly measured significantly more often over the long-term pulse rate and blood pressure than those treating fewer patients (80% as against 50%, P=0.0399). Over the long-term monitoring, psychiatrists with a larger number of elderly schizophrenia patients in their care also performed more often fasting blood glucose test, lipid profile and referral for cardiac consultation with ECG (respectively, 95.5% as against 70.8%, P=0.0489; 90.9% as against 58.3%, P=0.0182; 81.8% as against 29.2%, P<0.0001). ConclusionsThe results of this survey need to be confirmed in a larger population sample. The antipsychotic prescribing practices were broadly in agreement with current recommendations except for the tolerance profile which was not the first element taken into account in the choice of the AP agent. Some clinical and paraclinical medical examinations were carried out infrequently, in particular cardiac monitoring over the long-term, which is essential in this elderly patient population. One important element to emerge from our results was that common use of professional recommendations is associated with better monitoring.

Comorbidities and pharmacotherapies in patients with Gaucher disease type 1: The potential for drug-drug interactions.

Clinical care for patients with rare diseases may be complicated by comorbidities. Administration of medications to treat comorbidities may elicit potentially harmful drug-drug interactions (DDIs). Genetic background may also influence DDI occurrence. We investigated the range of comorbid conditions in patients with Gaucher disease type I (GD1), the pharmacotherapies prescribed and the potential for DDI with enzyme replacement and substrate reduction therapies and additional medications, specifically cytochrome P450 (CYP) metabolizing medications. A literature review examined comorbid conditions and pharmacotherapies reported in GD1. Analysis of two national databases reported real-world prescription practices in patients with GD1 (Germany, N=87; US, N=374). Prescribed drugs were assessed for known interactions with isoenzymes from the hepatic CYP enzyme family. The literature reported GD1 symptomatology and comorbid conditions in broad agreement with the known clinical picture. German patients received 86 different medications whereas US patients received 329 different medications. An average of 3.2 medications (Germany) and 7 medications (US) per patient were prescribed. Moderate/strong inhibitors of CYP isoenzymes were prescribed to 20% and 57% of patients in the US and Germany, respectively. This study describes the extensive number of comorbid conditions and drugs prescribed to patients with GD1, and the importance of determining CYP isoenzyme interaction to reduce DDI risk.

Psychopharmacological treatment of 1650 in-patients with acute mania-data from the AMSP study

BackgroundSeveral studies have analyzed prescription patterns for bipolar disorder, but few have for acute mania. Treatment strategies in this complex domain change over time and do not always follow evidence-based guidelines. MethodsPrescription data of in-patients suffering from acute mania in the time period from 2005 to 2012 were obtained from the database of the Drug Safety Program in Psychiatry (Institut für Arzneimittelsicherheit in der Psychiatrie; AMSP). Data were collected on two index dates per year. Changes over time were analyzed comparing the time periods 2005/06 and 2011/12. ResultsAmong 1650 patients (mean ±SD; age: 48.9±14.91 years; 53.1% females) 54.1% received anticonvulsants, 74.5% second-generation antipsychotics (SGAs), 17.8% first-generation antipsychotics (FGAs), 29.1% lithium, 44.1% benzodiazepines and 14.5% antidepressants. Prescription of SGAs increased from 70% to 79% (p=0.005), while prescription of FGAs and anticonvulsants decreased from 19% to 13% (p<0.05) and 59% to 46% (p<0.001), respectively. Only 30% of patients received monotherapy with one mood stabilizer. We observed an impact of gender, age and psychotic symptoms on treatment strategy. 36.8% of the women≤40 years received valproate. LimitationsFollow-up data are missing and no differentiation between acute and maintenance treatments could be made due to the cross-sectional design. Additionally, our findings do not necessarily translate to outpatients or to other countries. ConclusionsCombination therapies represent standard clinical practice. Though many results reflect clinical necessity, the high number of antidepressant prescriptions or valproate use in women of child-bearing age should be judged critically. Further prospective studies should focus on real-world prescription practice in acute mania to evaluate efficacy and safety of common practice.This paper is dedicated to Prof. Dr. Hanns Hippius on the occasion of his 90th birthday.