Safe Prescribing Research Articles

316 Improving Electronic Prescribing of Mechanical VTE Prophylaxis in General Surgery Patients

Abstract Aim Mechanical VTE prophylaxis forms part of NICE guidance in general surgical patients. Locally, thromboembolic deterrent (TED) stockings are used but not available as a prescription item on the electronic system. They are often prescribed verbally or via noted plans but do not appear on the medication administration record. Importantly, multiple incidents of patient harm through pressure damage have been seen due to poorly checked TEDs. Our aim was to audit and improve safe mechanical VTE prophylaxis prescribing. Method At each cycle, we retrospectively collected data from two weeks of admissions. Data relating to VTE assessment completion, VTE score, TEDs in use, TEDs prescription and LMWH prescription was collected. Our initial intervention consisted of departmental education regarding a work around enabling TEDs to be prescribed as a freehand extra-formulary item. This was reaudited at 12 months. Results All patients in both cycles had VTE assessments completed. TED stocking use increased significantly from 5.1% to 26.4% and prescription of TEDs, when used, increased from 0% to 61.1%. However, documentation regarding daily checks was non-existent. Conclusions Our QIP showed a significant improvement in TEDs use and prescription. However, the intervention is difficult and time consuming. Subsequently from this project, a TEDs stocking item is in the final approval phase for integration into the online prescribing system and will come with associated safety checks built into the nursing medication administration system. Once this is live, we will complete a third cycle to assess uptake and again at 6 months to assess for lasting change.

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty.

BACKGROUNDPatients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines. AIMTo evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA.METHODSWe retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients’ preoperative status using hierarchical Poisson and linear regressions, respectively.RESULTSThere were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15. CONCLUSIONAll patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

A Survey of Medical Residents’ Knowledge, Attitude, and Practice about Drug–Drug Interactions, Shiraz, Iran

Rationale, aims and objectives: Medical residents are among the most important and influential members of the medical team and the level of their knowledge regarding potential drug-drug interactions (DDIs) is a good predictor of the ability to prevent the occurrence of DDIs, as well as safe and rational prescribing in inpatient settings. This survey was designed to evaluate internal medicine and cardiology residents’ knowledge and opinion toward DDIs and to determine different sources of DDI information used by this population. Method: This cross-sectional knowledge attitude practice (KAP) questionnaire study was conducted in Shiraz, Iran. A 25-question questionnaire was designed and completed by 86 internal medicine and cardiology residents. The questions were related to the participants’ demographic information, their practice characteristics, the information sources used by the participants, the residents’ opinion regarding DDIs, and their knowledge regarding the interaction between 8 drug pairs. Results: The results showed that when the participants wanted to learn more about DDIs, most of them used software on mobile or tablet (59.3%). Nearly three-fourths of the participants (73.82%) reported that when a patient was about to be exposed to a potential DDI, they were informed by software on mobile or tablet that the interaction may be present. On average, residents answered 44.03% ± 23.79 of drug pair questions correctly.Conclusion: Our results show insufficient practice skills, as well as relatively poor knowledge concerning the participants’ answers to questions. It seems that further practical training and education are required to enable prescribers to prevent potential DDIs.

TH7.12 Improving electronic prescribing of mechanical VTE prophylaxis in general surgery patients

Abstract Aims Mechanical VTE prophylaxis forms part of NICE guidance in general surgical patients. Locally, thromboembolic deterrent (TED) stockings are used but not available as a prescription item on the electronic system. They are often prescribed verbally or via noted plans but do not appear on the medication administration record. Importantly, multiple incidents of patient harm through pressure damage have been seen due to poorly checked TEDs. Our aim was to audit and improve safe mechanical VTE prophylaxis prescribing. Methods At each cycle, we retrospectively collected data from two weeks of admissions. Data relating to VTE assessment completion, VTE score, TEDs in use, TEDs prescription and LMWH prescription was collected. Our initial intervention consisted of departmental education regarding a work around enabling TEDs to be prescribed as a freehand extra-formulary item. This was reaudited at 12 months. Results All patients in both cycles had VTE assessments completed. TED stocking use increased significantly from 5.1% to 26.4% and prescription of TEDs, when used, increased from 0% to 61.1%. However, documentation regarding daily checks was non-existent. Conclusions Our QIP showed a significant improvement in TEDs use and prescription. However, the intervention is difficult and time consuming. Subsequently from this project, a TEDs stocking item is in the final approval phase for integration into the online prescribing system and will come with associated safety checks built into the nursing medication administration system. Once this is live, we will complete a third cycle to assess uptake and again at 6 months to assess for lasting change.

Multi-label classification of symptom terms from free-text bilingual adverse drug reaction reports using natural language processing

Allergic reactions to medication range from mild to severe or even life-threatening. Proper documentation of patient allergy information is critical for safe prescription, avoiding drug interactions, and reducing healthcare costs. Allergy information is regularly obtained during the medical interview, but is often poorly documented in electronic health records (EHRs). While many EHRs allow for structured adverse drug reaction (ADR) reporting, a free-text entry is still common. The resulting information is neither interoperable nor easily reusable for other applications, such as clinical decision support systems and prescription alerts. Current approaches require pharmacists to review and code ADRs documented by healthcare professionals. Recently, the effectiveness of machine algorithms in natural language processing (NLP) has been widely demonstrated. Our study aims to develop and evaluate different NLP algorithms that can encode unstructured ADRs stored in EHRs into institutional symptom terms. Our dataset consists of 79,712 pharmacist-reviewed drug allergy records. We evaluated three NLP techniques: Naive Bayes-Support Vector Machine (NB-SVM), Universal Language Model Fine-tuning (ULMFiT), and Bidirectional Encoder Representations from Transformers (BERT). We tested different general-domain pre-trained BERT models, including mBERT, XLM-RoBERTa, and WanchanBERTa, as well as our domain-specific AllergyRoBERTa, which was pre-trained from scratch on our corpus. Overall, BERT models had the highest performance. NB-SVM outperformed ULMFiT and BERT for several symptom terms that are not frequently coded. The ensemble model achieved an exact match ratio of 95.33%, a F1 score of 98.88%, and a mean average precision of 97.07% for the 36 most frequently coded symptom terms. The model was then further developed into a symptom term suggestion system and achieved a Krippendorff's alpha agreement coefficient of 0.7081 in prospective testing with pharmacists. Some degree of automation could both accelerate the availability of allergy information and reduce the efforts for human coding.

Pharmacotherapeutics of aprepitant and pregabalin in neuropathic pain and refractory pruritus in a patient diagnosed with a cutaneous T-cell lymphoma

Background/Aims Palliative care nurse specialists are required to have a high level of knowledge and expertise in the management of complex symptoms. As a result of patient complexity, clinicians are often faced with advising on multiple drug regimes. This often requires clinical nurse specialists to have knowledge of pharmacotherapeutics to ensure safe and rational prescribing. In the form of a case study, the author has critically discussed the use of aprepitant and pregabalin in the management of neuropathic pain and refractory pruritus in a patient diagnosed with a cutaneous T cell lymphoma. These drugs are not routinely prescribed together and therefore the author has explored potential pharmacokinetic interactions. Case presentation The case presented a 49-year-old lady with an advanced metastatic cutaneous T-cell lymphoma with failed remission despite extensive oncological treatment. She was referrd to the to hospital specialist palliative care team for treatment of refractory pruritus and neuropathic pain. Conclusion Aprepitant is considered an effective anti-pruritic agent that is normally well tolerated; however, careful consideration must be taken because of extensive drug interactions. Caution is also required in patients with hepatic impairment. Pregabalin is often used in specialist palliative care for the management of neuropathic pain because of its efficacy and ease of titration. Caution must be taken in prescribing in patients with renal impairment. As pregabalin is not bound to plasma proteins nor metabolised by the liver, the risk of pharmacokinetic interaction with aprepitant is minimal. As both drugs cross the blood brain-barrier, clinicians must monitor for adverse central nervous system activity. This case study highlights the importance of pharmacotherapeutics in ensuring safe and rational prescribing, with the need to continue to integrate this knowledge into future practice as nurse prescribers.

Association of Higher-Dose Fluoroquinolone Therapy With Serious Adverse Events in Older Adults With Advanced Chronic Kidney Disease

Population-based data are needed to inform the safe prescribing of fluoroquinolone antibiotics to patients with advanced chronic kidney disease (CKD). To quantify the 14-day risk of a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event in patients with advanced CKD newly prescribed a fluoroquinolone at a higher vs a lower dose. This population-based cohort study in Ontario, Canada (January 1, 2008, to March 17, 2020) used linked health care data to identify new users of fluoroquinolone antibiotics. Participants included adults 66 years or older with advanced CKD (an estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2 but not receiving dialysis). Data analysis was performed from January 1 to April 30, 2021. A new prescription for a higher-dose fluoroquinolone (ciprofloxacin, 501-1000 mg/d; levofloxacin, 501-750 mg/d; or norfloxacin, 401-800 mg/d) vs a lower-dose fluoroquinolone (ciprofloxacin, 500 mg/d; levofloxacin, 250-500 mg/d; or norfloxacin, 400 mg/d). The primary outcome was the 14-day risk of a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event. Secondary outcomes included a hospital visit with sepsis, retinal detachment or other tendinopathies, all-cause hospitalization, all-cause mortality, and sudden cardiac death. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on baseline health. Weighted risk ratios and risk differences were obtained using modified Poisson regression and binomial regression, respectively. Of 11 917 patients (median age, 83 years [IQR, 77-89 years]; 7438 women [62.4%]; median eGFR, 25 [IQR, 21-28] mL/min/1.73 m2) included in the analysis, 5482 (46.0%) received a higher-dose and 6435 (54.0%) received a lower-dose fluoroquinolone. After weighting, the primary composite outcome-a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event-occurred in 68 of 5482 patients (1.2%) treated with a higher-dose fluoroquinolone and in 47 of 5516 (0.9%) treated with a lower-dose fluoroquinolone (weighted risk ratio, 1.45 [95% CI, 1.01-2.08]; weighted risk difference, 0.39% [95% CI, 0.01%-0.76%]). The risk of sepsis, retinal detachment, all-cause hospitalization, all-cause mortality, and sudden cardiac death did not differ significantly between groups. These findings suggest that older patients with advanced CKD who were prescribed a fluoroquinolone at a higher-than-recommended dose were significantly more likely to experience the composite outcome of a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event, although the absolute risk of these events was less than 2%.

Post-COVID-19 Pulmonary Hypertension: How it May Physiologically Affect Exercise Training

Abstract: Exercise training is paramount in improving aerobic capacity, lung function, reducing the symptoms of dyspnea, and reconditioning the lean skeletal muscles. Many literature and guidelines have advocated the importance of exercise intervention in addressing the secondary impairment to post covid-19 infection, including home-based therapy and telerehabilitation. Pulmonary hyperten-sion (PH) was previously thought to be contraindicated by exercise training; however, exercise was later found to be beneficial and relatively safe in chronic PH. However, there is a lack of high-quality evidence on the safety and effectiveness of exercise training in post-COVID-19 infected in-dividuals with PH. Pulmonary hypertension has been documented to be one of the post-COVID-19 complications. PH occurred due to COVID-19 infection should be carefully considered before sub-jecting them to exercise training, especially in home-based therapy. This article aims to discuss the differing etiological factor, pathophysiological backgrounds, and the possible disease long-term outcomes that may compromise the safety of exercise training in post-COVID-19 patients compli-cated with PH. By understanding the risk of developing PH, risk assessment and stratification can be explicitly outlined for a safe exercise prescription through proper patient selections. Any possible complications can be anticipated; hence, proper preventive strategies can be instituted.

Barriers to and facilitators of opioid prescribing by dentists in the United States: A qualitative study

BackgroundDentists in the United States frequently prescribe opioids for dental-related pain, although evidence shows superior efficacy of nonopioids for pain management. A national sample of US dentists was interviewed to understand the barriers and facilitators to opioid prescribing. MethodsSemistructured one-on-one telephone interviews were conducted with dentists sampled from the 6 regions of The National Dental Practice-Based Research Network. Responses were coded into the domains of the Capability, Opportunity and Motivation Model of Behavior. Potential behavior change interventions were identified for targeted themes. ResultsSeventy-three interviews were qualitatively analyzed. Most of those interviewed were general dentists (86.3%) and on average (SD) were in practice for 24.3 (13.0) years. Ten themes were identified within the Capability, Opportunity and Motivation Model of Behavior. Dentists’ knowledge of opioid risk, ability to identify substance use disorder behavior, and capability of communicating pain management plans to patients or following clinic policies or state and federal regulations were linked with judicious opioid prescribing. Dentists reported prescribing opioids if they determined clinical necessity or feared negative consequences for refusing to prescribe opioids. ConclusionsDentists’ opioid decision making is influenced by a range of real-world practice experiences and patient and clinic factors. Education and training that target dentists’ knowledge gaps and changes in dentists’ practice environment can encourage effective communication of pain management strategies with patients and prescribing of nonopioids as first-line analgesics while conserving opioid use. Practical ImplicationsIdentified knowledge gaps in dentistry can be targets for education, clinical guidelines, and policy interventions to ensure safe and appropriate prescribing of opioids.

Impact of Policy Interventions on Oxycodone Prescribing in Queensland, Australia: An Uncontrolled Interrupted Time Series Study.

IntroductionOpioid prescribing rates are continuing to increase in Australia in line with prescribing rates seen internationally. Prescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact.ObjectiveThe aim of this study was to assess the impact of state and national policy interventions on changes to oxycodone 5 mg discharge prescriptions in public hospitals using electronic prescribing in Queensland, Australia by evaluating the proportion of oxycodone 5 mg discharge prescriptions written for ≤ 10 tablets across the study period.MethodThis research utilised a retrospective uncontrolled interrupted time-series design and was undertaken at 12 public hospitals using electronic prescribing from December 2018 to February 2021. The study analysed the impact of two sequential policy interventions that limited the recommended quantity of oxycodone 5 mg on discharge for all hospitalised patients. The first state-wide policy came into effect on 19 September 2019 and the second national policy came into effect on 1 June 2020.ResultsOver the 27-month period, there were 110,728 discharge prescriptions written in the 12 Queensland hospitals for oxycodone 5 mg. During the baseline period, approximately 50.7% (95% CI 49.5–51.8) of all oxycodone 5 mg prescriptions were from tablet quantities of ≤ 10 tablets. After the implementation of the state-wide policy, the proportion increased by 9% (95% CI 7.4–10.7; p = 0.001). The implementation of the national policy increased the proportion of oxycodone 5 mg prescriptions written for ≤10 tablets by 9.8% (95% CI 8.1–11.5; p < 0.001).ConclusionsRestrictive prescribing policies at a state and national level may have resulted in decreased quantities of oxycodone 5 mg prescriptions provided on discharge from public hospitals using electronic prescribing in Queensland, Australia. Despite these positive results, continued multi-faceted policy efforts and individual tailored interventions are necessary to ensure safe and judicious opioid prescribing.

Older Persons Complex Care Nurse Practitioner model to reduce hospital readmissions: A pilot study

BackgroundPeople aged over 65 years are associated with increased numbers of co-morbidities, higher health care needs, an increased risk of fragmented care and are four times more likely to be hospitalised than those under 65 years. Nurse Practitioners (NP) working with older populations improved screening, clinical outcomes, patient satisfaction and provision of equal or better care for chronically ill patients. AimTo evaluate the effectiveness of the NP within the Older Persons Complex Care service to reduce hospital readmission rates in older complex patients. MethodsA pre and post pilot study using a retrospective clinical audit of medical records of patients referred to the NP service from January 2018 to April 2019 was undertaken. All patients reviewed by the NP were eligible for inclusion in the study and only those patients reviewed by the NP were included. FindingsSeventy seven patients were referred during the reporting period. Ages ranged from 64 to 98 years, and many co-morbidities were reported; minimum of two and maximum of 15 highlighting the complexity of the cohort. Management included education (100%), diagnostics (62%), medication changes (61%) and referrals (49%). DiscussionPatients managed within the service had reduced hospitalisations and many medications were ceased, reduced or titrated by the NP. Education was a key component of care. ConclusionThe value of NPs in the provision of care to older persons with complex, chronic diseases was highlighted with the potential to reduce readmissions, improve quality use of medicines and safe prescribing.

Safe prescribing and withdrawal of dependence‐forming medicines

NICE has recently published a guideline on the safe prescribing and withdrawal of medicines associated with dependence or withdrawal symptoms (NG215), including benzodiazepines, Z‐drugs, opioids, gabapentinoids and antidepressants. This article summarises the guidance, which recommends a supportive and collaborative approach.

A call to action for anticoagulation stewardship

A call to action for anticoagulation stewardship

Analysis of pediatric opioid analgesics prescribed in a large pediatric hospital over a 5-year period

Objective: In this study, we aim to look at opioid prescription patterns in a large pediatric hospital with an emphasis on opioid potency as measured by morphine milligram equivalents (MMEs) to understand physician response to safe prescribing regulations and new research on opioid use in pediatrics.Design: Analgesic prescriptions in a pediatric hospital in California from 2012 to 2016 were included. Prescriptions that contained any type of opioid medication were analyzed total MME in each prescription, and medication prescribed. The MME for each opioid was assigned to the prescription and presented as mean ± standard deviation (SD). Statistical analysis was performed by using IBM SPSS statistics version 25.Setting: A pediatric hospital in California.Participants: All pediatric patients receiving analgesic prescriptions from a single institution between 2012 and 2016.Main outcome measure: Relative frequency of different opioid medications prescribed.Results: Of the 14,194 total opioid prescriptions, hydrocodone (11,247), codeine (2,117), and tramadol (411) were most prescribed. The relative frequency of opioid prescription decreased from 2012 to 2016 due to the decreased prescription of hydrocodone and codeine. Despite the decreased relative frequency of opioid prescription, the mean MME of prescribed opioids increased.Conclusion: The study demonstrated that recent efforts to limit pediatric exposure to opioids have been effective. However, recommendations limiting the use of weak opioids (codeine and tramadol) have caused an increase in average prescribed opioid potency. This may be a contributing factor to the overall increase in opioid-related pediatric hospitalizations. Revision of prescription guidelines for hydrocodone (MME = 1) may protect pediatric patients from unnecessary opioid exposure.

The Complexity of Psychotropic Medication Prescription and Treating Trauma Among Youth in Foster Care: Perspectives from the Lived Experience.

Youth in the US foster care system are disproportionately prescribed antipsychotic and psychotropic medication compared to youth not involved with foster care. Research on the relationship between experiences of trauma, mental health symptoms, evidence-based treatment, and safe psychotropic prescribing practices for youth in foster care is limited. We explored stakeholders' perspectives of the relationship between psychotropic medications and trauma informed care (TIC) for youth in foster care. We conducted semi-structured individual and group interviews with foster caregivers, caseworkers, prescribing clinicians, and alumni of the foster care system. Data were recorded and transcribed verbatim, and analyzed using a directed content analysis approach. Five themes emerged across and within stakeholder groups: (1) acknowledging trauma; (2) role of psychotropic medication; (3) psychosocial resources; (4) additional supports; and, (5) training and education. Stakeholders identified TIC as an important component of mental health services for youth in foster care. There was not consensus around the role of psychotropic medication in treating trauma; however, most stakeholders felt that it was overused. Respondents suggested including additional supportive team members to help guide youth through the mental health treatment system, and emphasized the importance of support from individuals with common lived experiences. Results demonstrate the need for a system that emphasizes trauma-sensitive clinical interactions and psychosocial supports. Improving training and education for stakeholders, and providing additional sources of support for youth in foster care, could help better identify and treat the effects of trauma and the safe pharmacotherapy for youth in foster care.

A pharmacovigilance study of terbinafine indication and liver enzyme elevation

To the Editor: Terbinafine is a commonly administered oral and topical antifungal medication. Terbinafine oral treatment regimens are based on the site of infection; nail infections often require a 6 to 12-week treatment schedule, but non-nail (ie, skin or hair) infections can usually be treated for 2 to 6 weeks. While it is commonly regarded that terbinafine-induced liver injury occurs within 30 days,1Maxfield L, Preuss CV, Bermudez R. Terbinafine. [Updated 2021 Aug 31]. In: StatPearls [Internet]. StatPearls Publishing; 2022 January. Accessed July 14, 2022. https://www.ncbi.nlm.nih.gov/books/NBK545218/Google Scholar we hypothesize that indications necessitating longer treatment durations are more likely associated with liver injury/liver enzyme elevation (LEE) events. To analyze this question, we computed a reporting odds ratios (ROR) using drug-event reports extracted from both the FDA Adverse Drug Event Reporting System (FAERS) and Canada Vigilance Adverse Reaction Online (CVARO) databases. It is important to highlight that one of the limitations of these commonly used databases is that the data entered by physicians or pharmaceutical companies is not corroborated or confirmed independently. Raw database files were downloaded from: https://fis.fda.gov/extensions/FPD-QDE-FAERS/FPD-QDE-FAERS.html (USA) and https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/adverse-reaction-database/canada-vigilance-online-database-data-extract.html. The FAERS database included reports logged between January 1, 2014, and December 31, 2020. The CVARO database included all publicly available reports from 1965 to September 2021 inclusively. To capture all terbinafine-associated drug reports, we searched both databases using “%terbinafine%” and “%lamisil%” (% represents a wildcard modifier) terms. Additionally, we made sure to exclude topical terbinafine preparations from the search results. Adverse events are encoded in both databases using MedDRA’s list of accepted terminologies. There was a total of 21,034 and 3913 oral terbinafine-associated adverse drug reaction reports in both the FAERS and CVARO databases, respectively. Notably, 247 (FAERS) and 125 (CVARO) of these reports were related to LEE events. Unfortunately, the degree of LEE (eg, 2-fold vs. 100-fold) or its clinical significance is not detailed in the databases. Furthermore, details on other possible interacting medications that patients might be taking are not available from these sources. Following data extraction, the ROR, a classically accepted method of signal generation for common adverse drug reactions in pharmacovigilance studies, was computed.2Rothman K.J. Lanes S. Sacks S.T. The reporting odds ratio and its advantages over the proportional reporting ratio.Pharmacoepidemiol Drug Saf. 2004; 13: 519-523https://doi.org/10.1002/pds.1001Google Scholar, 3Sakaeda T. Tamon A. Kadoyama K. Okuno Y. Data mining of the public version of the FDA adverse event reporting system.Int J Med Sci. 2013; 10: 796-803https://doi.org/10.7150/ijms.6048Google Scholar Table I demonstrates the RORs for terbinafine and LEE events and is further stratified by indication. Isoniazid, a well-known hepatotoxic agent, was used as a comparator to better contextualize the magnitude of terbinafine-LEE associated RORs.Table IROR for terbinafine-LEE reports according to indicationVariables assessedFAERS ROR (CI)CVARO ROR (CI)Terbinafine-LEE ReportsNon-Onychomycosis1.71 (1.07-2.72)1.51 (0.37-6.09)Terbinafine-LEE ReportsNail Infections4.58 (3.84-5.46)4.51 (2.64-7.68)Isoniazid-LEE Reports5.35 (5.06-5.67)5.51 (5.00-6.07)RORs are listed for terbinafine and onychomycosis and non-onychomycosis indications. In brackets are each ROR’s confidence intervals. FDA adverse event reporting system and Canada Vigilance Adverse Reaction Online RORs are listed in their respective columns.CVARO, Canada Vigilance Adverse Reaction Online; FAERS, FDA Adverse Drug Event Reporting System; LEE, liver enzyme elevation; ROR, reporting odds ratio. Open table in a new tab RORs are listed for terbinafine and onychomycosis and non-onychomycosis indications. In brackets are each ROR’s confidence intervals. FDA adverse event reporting system and Canada Vigilance Adverse Reaction Online RORs are listed in their respective columns. CVARO, Canada Vigilance Adverse Reaction Online; FAERS, FDA Adverse Drug Event Reporting System; LEE, liver enzyme elevation; ROR, reporting odds ratio. Terbinafine-LEE RORs were more than 2-fold higher for onychomycosis versus non-onychomycosis (ie, skin and nail) infections in both FAERS and CVARO databases (Table I, Supplementary Table I, available via Mendeley at https://doi.org/10.17632/n8pkb4tzyz.1). Additionally, onychomycosis-indicated LEE RORs more closely approximated isoniazid-LEE RORs compared with non-onychomycosis-LEE RORs in both databases, possibly suggesting a greater likelihood of LEE and liver injury with longer terbinafine use. Our analysis suggests a possible relationship between liver injury and longer usage of terbinafine, which is comparable to that of isoniazid, where older patients undergo monthly blood tests to evaluate for this idiosyncratic event.4Gray E.L. Goldberg H.F. Baseline abnormal liver function tests are more important than age in the development of isoniazid-induced hepatoxicity for patients receiving preventive therapy for latent tuberculosis infection.Intern Med J. 2016; 46: 281-287https://doi.org/10.1111/imj.12979Google Scholar As a result, we emphasize the importance of further investigating this potentially duration-sensitive adverse drug reaction, assessing its clinical significance and impact on patients to better direct clinicians in the safe prescribing of terbinafine in populations at higher risk of liver-related injuries and complications. None disclosed.

Assessment of Drug prescription Pattern in pregnancy in A Tertiary Care Hospital: A Prospective Study

Pregnancy is a special physiological condition and managing medical conditions during pregnancy is a challenge due to the teratogenic potential of many drugs. This cross-sectional prospective study was conducted for a period of 6 months to describe the prescription pattern and risk categorization of drugs among pregnant inpatients in a tertiary care hospital. Pregnant inpatients of OBG ward in any trimester who were prescribed with at least one drug were included. Demographic details and list of prescribed drugs were collected from medical records of patients. The drugs prescribed were grouped according to their pharmacological classes and US FDA pregnancy risk classification. Prescription pattern was assessed using WHO core prescribing indicators. A total of 951 drugs comprising 34 different drugs were prescribed for 420 pregnant women. The average number of drugs prescribed per encounter was 2.3 ± 0.9 (SD). Anti- anemic/vitamin and mineral supplements (288, 30.3%), followed by antibiotics (142, 14.93%) and antihypertensive drugs (127, 13.35%) were the most commonly prescribed classes of drugs. As per FDA Drug Risk Category, most of prescribed drugs belonged to category B (42.26%) and category A (32.9%) followed by category C (17%), category D (1.05%) and category X (0.84%). It was found that the overall prescription pattern of drugs among pregnant inpatients was safe and rational since the majority of prescribed drugs fell under category A and B pregnancy. Continuous drug utilization evaluation in this population and interaction of clinical pharmacist with healthcare team is crucial to have rational and safe prescription of drugs among hospitalized pregnant women.&#x0D;

The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial

BackgroundThe CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record. MethodsTeladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private Commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1–7% absolute differences in antibiotic prescribing among groups. DiscussionFindings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use.ClinicalTrials.gov: NCT05138874.

Factors Associated With Safe Prescription Opioid Disposal After Surgery in Adolescents

IntroductionUnused prescription opioids contribute to diversion, unintended exposure, and poisonings in adolescents. Factors associated with safe prescription opioid disposal for adolescents undergoing surgery are unknown. MethodsParents of adolescents (13-20 y) undergoing surgery associated with an opioid prescription were enrolled preoperatively. Parents completed a baseline survey measuring sociodemographics and family history of substance abuse and two postoperative surveys capturing opioid use and disposal at 30 and 90 d. Safe disposal was defined as returning opioids to a healthcare facility, pharmacy, take-back event, or a police station. Factors associated with safe opioid disposal were assessed using bivariate analysis. ResultsOf 119 parent-adolescent dyads, 90 (76%) reported unused opioids after surgery. The majority of parents reporting unused opioids completed the surveys in English (80%), although many (44%) spoke another language at home. Most reported income levels <$60,000 (54%), did not attend college (69%), and had adequate health literacy (66%). Most parents (78%) did not report safe opioid disposal. Safe opioid disposal was associated with younger patient age, (median 14 y, IQR 13-16.5 versus median 15.5 y, IQR 14-17, P = 0.031), fewer days taking opioids (median 5, IQR 2-6 versus median 7, IQR 4-14, P = 0.048), and more leftover pills (median 20, IQR 10-35 versus median 10, IQR 5-22, P = 0.008). ConclusionsMost parents fail to safely dispose of unused opioids after their adolescent’s surgery. Younger patient age, shorter duration of opioid use, and higher number of unused pills were associated with safe disposal. Interventions to optimize prescribing and educate parents about safe opioid disposal are warranted.

Characterizing opioid prescribing to adolescents at time of discharge from a pediatric hospital over a five-year period

PurposeTo characterize opioid prescribing over a 5-year period to adolescents upon discharge from one urban pediatric medical center. Design and methodsA retrospective cross-sectional analysis of 4354 adolescents discharged with a pain medication after an admission of ≤5 days between January 2015 and December 2019 was performed. Two outcome groups, based on the analgesics prescribed at discharge, were compared: those discharged with a prescription for a non-opioid only and those discharged with an opioid prescription. The association between year of discharge and receipt of opioid, while adjusting for relevant demographic and clinical characteristics, was also explored. ResultsApproximately 64% of the sample was discharged with an opioid prescription. Of those, the median daily dosage was 45.0 morphine milligram equivalents (MME) [IQR: 32.4, 45.0]. Year of discharge was associated with decreased odds of receiving an opioid when adjusting for age, race, sex, insurance, pain scores, opioid exposure during hospitalization, length of stay, and undergoing surgery. The odds of being discharged with an opioid decreased each year by 29% (Adjusted Odds Ratio [AOR] = 0.71, CI:0.68–0.73). Concurrently, the proportion of patients discharged with nonopioid pain medication increased from 25% of adolescent patients in 2015 to 50% in 2019. ConclusionsOverall, opioid prescribing to adolescents at time of discharge decreased over time in our sample. Practice implicationsWhile prescribing has decreased opioid analgesics are dispensed to young patients. Risk of opioid use disorder and overdose is rare in this population, but adolescence is good opportunity for nursing to promote safe prescribing and analgesic use.