Background: Glucocorticosteroids and aminosalicylates, mainly mesalazine (5-ASA), are both standard therapeutics in the treatment of inflammatory bowel disease (IBD) patients. The glucocorticosteroids are highly effective in inducing remission in both ulcerative colitis and Crohn's disease, but their use is limited by the high incidence and the potentially serious nature of adverse events. In an attempt to limit systemic side effects, rapidly metabolized corticosteroids such as budesonide have been introduced. The safety profile of aminosalicylates differs between the formulations. Methods: We summarize the potentialrisks associated with glucocorticosteroid and aminosalicylate therapy in IBDs. Results: The numerous adverse events of glucocorticosteroids, particularly at high doses and prolonged treatment, include opportunistic infections, diabetes mellitus, hypertension, ocular effects (glaucoma and cataracts), psychiatric complications, hypothalamic-pituitary-adrenal axis suppression and increased fracture risk. Partially, these systemic adverse events occur with budesonide, which only has a low systemic exposure. The safety profile of 5-ASA is comparable to placebo and superior to the old aminosalicylate prodrug sulfasalazine, which had a significantly higher incidence of intolerance reactions including allergic rashes. Only in rare cases has nephrotoxicity such as interstitial nephritis been associated with 5-ASA. Conclusion: Considering the toxicity profile of conventional glucocorticosteroids, one primary goal of treatment in IBD should be corticosteroid-free remission. Therapy with budesonide may result in a better safety profile. 5-ASA treatment is usually well tolerated, but with regard to the rare nephrotoxic events, it is advisable to assess renal function before and during treatment with 5-ASA.
PURPOSE: Clinical decision support systems (CDSS) are promoted as powerful screening tools to improve pharmacotherapy. The aim of our study was to evaluate the potential contribution of CDSS to patient management in clinical practice. METHODS: We prospectively analyzed the pharmacotherapy of 100 medical inpatients through the parallel use of three CDSS, namely, Pharmavista, DrugReax, and TheraOpt. After expert discussion that also considered all patient-specific clinical information, we selected apparently relevant alerts, issued suitable recommendations to physicians, and recorded subsequent prescription changes. RESULTS: For 100 patients with a median of eight concomitant drugs, Pharmavista, DrugReax, and TheraOpt generated a total of 53, 362, and 328 interaction alerts, respectively. Among those we identified and forwarded 33 clinically relevant alerts to the attending physician, resulting in 19 prescription changes. Four adverse drug events were associated with interactions. The proportion of clinically relevant alerts among all alerts (positive predictive value) was 5.7, 8.0, and 7.6%, and the sensitivity to detect all 33 relevant alerts was 9.1, 87.9, and 75.8% for Pharmavista, DrugReax and TheraOpt, respectively. TheraOpt recommended 31 dose adjustments, of which we considered 11 to be relevant; three of these were followed by dose reductions. CONCLUSIONS: CDSS are valuable screening tools for medication errors, but only a small fraction of their alerts appear relevant in individual patients. In order to avoid overalerting CDSS should use patient-specific information and management-oriented classifications. Comprehensive information should be displayed on-demand, whereas a limited number of computer-triggered alerts that have management implications in the majority of affected patients should be based on locally customized and supported algorithms. Methods We prospectively analyzed the pharmacotherapy of 100 medical inpatients through the parallel use of the CDSS Pharmavista, DrugReax and TheraOpt. After expert discussion that also considered all patient-specific clinical information we selected apparently relevant alerts, issued according recommendations to physicians and recorded subsequent prescription changes.Results For 100 patients with a median of eight concomitant drugs Pharmavista, DrugReax and TheraOpt generated a total of 53, 362 and 328 interaction alerts, respectively. Among those we identified and forwarded 33 clinically relevant alerts that were followed by 19 according prescription changes. Four adverse drug events were associated with interactions.The proportion of clinically relevant alerts among all alerts (positive predictive value) was 5.7, 8.0 and 7.6%, and the sensitivity to detect all 33 relevant alerts 9.1, 87.9 and 75.8% for Pharmavista, DrugReax and TheraOpt, respectively. TheraOpt recommended 31 dose adjustments, of which we considered 11 as relevant, and three were followed by dose reductions.Conclusions CDSS are valuable screening tools for medication errors, but on...
In a real-world setting, APR rates with ZOL and IBN may be higher than reported in randomised controlled trials and may differ by compound, prior BP exposure, and serum 25(OH)D levels.
Combination therapy with only 50 mg allopurinol and 50 mg azathioprine daily is sufficient, efficacious and safe in most IBD patients with inadequate thiopurine metabolite concentrations to optimize azathioprine-based IBD therapy.
Clinical pharmacologists and pharmacists can play an important role in identifying DRPs among neurology inpatients. Their recommendations for optimising medication-safety are most likely to be accepted for regular prescriptions, prescriptions associated with an adverse drug event and high-risk drug combinations.
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT• Electronic prescribing reduces drug prescription errors and therefore improves patient safety.• Whether electronic prescribing compared with prescribing on paper facilitates the implementation of clinical pharmacologists' recommendations in the care of patients hospitalized with medical problems is not known.WHAT THIS STUDY ADDS• The use of electronic prescriptions when compared with handwritten prescriptions increased the uptake of clinical pharmacologists' recommendations for improving drug safety in hospitalized patients.AIMS To determine whether electronic prescribing facilitates the uptake of clinical pharmacologists' recommendations for improving drug safety in medical inpatients.METHODS Electronic case records and prescription charts (either electronic or paper) of 502 patients hospitalized on medical wards in a large Swiss teaching hospital between January 2009 and January 2010 were studied by four junior and four senior clinical pharmacologists. Drug‐related problems were identified and interventions proposed. The implementation and time delays of these proposed interventions were compared between the patients for whom paper drug charts were used and the patients for whom electronic drug charts were used.RESULTS One hundred and fifty‐eight drug‐related problems in 109 hospital admissions were identified and 145 recommendations were made, of which 51% were implemented. Admissions with an electronic prescription chart (n= 90) were found to have 2.74 times higher odds for implementation of the change than those with a paper prescription chart (n= 53) (95% confidence interval 1.2, 6.3, P= 0.018, adjusted for any dependency introduced by patient, ward or clinical team; follow‐up for two cases missing). The time delay between recommendations being made and their implementation (if any) was minimal (median 1 day) and did not differ between the two groups.CONCLUSIONS Electronic prescribing in this hospital setting was associated with increased implementation of clinical pharmacologists' recommendations for improving drug safety when compared with handwritten prescribing on paper.
BackgroundRising health care costs are a major public health issue. Thus, accurately predicting future costs and understanding which factors contribute to increases in health care expenditures are important. The objective of this project was to predict patients healthcare costs development in the subsequent year and to identify factors contributing to this prediction, with a particular focus on the role of pharmacotherapy.MethodsWe used 2014–2015 Swiss health insurance claims data on 373′264 adult patients to classify individuals’ changes in health care costs. We performed extensive feature generation and developed predictive models using logistic regression, boosted decision trees and neural networks. Based on the decision tree model, we performed a detailed feature importance analysis and subgroup analysis, with an emphasis on drug classes.ResultsThe boosted decision tree model achieved an overall accuracy of 67.6% and an area under the curve-score of 0.74; the neural network and logistic regression models performed 0.4 and 1.9% worse, respectively. Feature engineering played a key role in capturing temporal patterns in the data. The number of features was reduced from 747 to 36 with only a 0.5% loss in the accuracy. In addition to hospitalisation and outpatient physician visits, 6 drug classes and the mode of drug administration were among the most important features. Patient subgroups with a high probability of increase (up to 88%) and decrease (up to 92%) were identified.ConclusionsPharmacotherapy provides important information for predicting cost increases in the total population. Moreover, its relative importance increases in combination with other features, including health care utilisation.
Our data indicate that both TMP and SMX are removed by CVVHDF to a significant degree, and dose reduction of TMP/SMX in CVVHDF bears the risk of underdosing. Given variability in drug exposure in critically ill patients, therapeutic drug monitoring is advisable in anuric or oliguric patients undergoing continuous renal replacement therapy to ensure optimal TMP/SMX dosing.
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