BackgroundIn some regions, the pharmaceutical services at nursing homes are held by pharmacists from hospitals in the public network.PurposeTo determine the impact of medicines reconciliation on the prevalence of potentially inappropriate medicines (PIMs) in institutionalised elderly patients and to analyse the most frequently PIMs prescribed.Material and methodsRetrospective non-experimental study conducted between December 2014 and February 2015 at four nursing homes: two in which medicines reconciliation was performed and two others where it was not.The prevalence of PIMs prescribed at the residences in which reconciliation was carried out was compared with the prescription at residences in which it was not. PIM frequency was analysed according to the list of drugs to be avoided in older adults (65 years old or older) included in the 2012 Beers criteria.ResultsA total of 521 patients with a mean age of 83 years were included, 224 at nursing homes where reconciliation was conducted and 297 at residences in which it was not. In the first group of residences, there were 142 (63.4%) patients with inappropriate prescriptions compared with 203 (68.3%) in the other group. At homes where medicines reconciliation was carried out, the total number of prescriptions was 2182, and 239 (10.9%) were PIMs. In the other group of patients, the total number of prescriptions was 2849, and 12.8% (365) were inadequate (p < 0.05 vs reconciliation). The total number of different prescribed specialties which were inadequate for patients was 59 for patients in the medicines reconciliation group and 83 in the other group. For comparison of independent proportions, Epidat software version 3.1 was used.The most frequently prescribed PIMs in the reconciliation group were lorazepam, bromazepam, alprazolam, zolpidem and quetiapine, and in the other group of patients, lorazepam, zolpidem, haloperidol, alprazolam and clorazepate dipotassium.ConclusionThe results of this study show a high prevalence of PIMs in institutionalised elderly patients, although residences with a medicines reconciliation programme had a lower percentage of elderly patients with PIMs and fewer inappropriate prescriptions. The total number of different inadequate specialties was also lower.Regarding PIMs, lorazepam, zolpidem and alprazolam were among the five most commonly prescribed in both groups.References and/or AcknowledgementsBeers Criteria UpdateNo conflict of interest.
BackgroundDiabetes mellitus type 2 (DM2) is a chronic disease with major impact on morbidity and mortality and the use of health resources.PurposeTo analyse the evolution of consumption of antidiabetic drugs from 2001 to 2014. To study the variations in admissions due to lower extremity amputations from 2007 to 2013.Material and methodsDescriptive study of the use of antidiabetic drugs between 2001 and 2014. Field of study: two tertiary hospitals and their reference areas, the target population consisting of 675 000 people. Prescriptions under the National Health System coverage were studied. The unit of measure was defined daily doses (DDD) per 1000 inhabitants per day (DHD), using the anatomical therapeutic chemical (ATC)/DDD classification (2006). Hospitalisation data were collected from the hospital dat base. For statistical comparisons, the Student’s t test was used.ResultsDuring the study period, consumption of insulins was maintained from 17.9 DHD to 18.3 DHD but oral agents increased from 41.3 DHD to 52.7 DHD. Consumption of sulfonylureas was gradually reduced from 30.1 DHD to 16.4 DHD but metformin (alone) usage increased from 4.3 DHD to 23.7 DHD, being the most consumed agent in 2014 (45% of consumption). Oral combinations were introduced in 2004 (0.1 DHD) and were the third most consumed group in 2014 (6.5 DHD). Consumption of dipeptidyl peptidase-4 inhibitors (since 2008) and ‘other hypoglycaemic agents’ increased from 0.3 DHD (2008) to 3.8 DHD and from 1.4 DHD to 2 DHD, respectively. On the other hand, the use of thiazolidinediones (since 2004) and alpha-glucosidase inhibitors was reduced from 0.7 DHD (2004) to 0.1 DHD and from 4.5 DHD to 0.2 DHD, respectively. The number of admissions due to lower extremity amputations from 2007 to 2013 was 94, 111, 145, 140, 125, 66 and 72, respectively. The number of amputations decreased significantly from 2008 to 2011 vs. 2013 (p < 0.05).ConclusionMetformin (alone) remains the drug of choice in treating DM2.Increased consumption of oral combinations could reflect more patients in more advanced stages of disease who do not respond to monotherapy.To associate the decrease in admissions due to lower extremity amputations with a higher consumption of oral antidiabetic drugs, more studies are needed.No conflict of interest.
BackgroundTo ensure the effectiveness and/or avoid the toxicity of drugs with narrow therapeutic and/or renal elimination margins, it is essential to adjust the dose according to glomerular filtration rate (GFR). To collaborate in such patient care activities, a growing number of acute care hospitals have pharmacists participating in ambulatory care clinics and hospital based home healthcare services.PurposeTo assess the adequacy of medicines prescribed in our health district in patients with decreased GFR.Material and methodsThis was a retrospective observational study. Field of study: two tertiary hospitals and their reference areas. The target population consisted of 666 000 people. Study population: patients with a serum creatinine (SC) determination in our health district in February 2016. Inclusion criteria: >18 years with GFR <45 mL/min/1.73m2. Exclusion criteria: patients whose characteristics made them unsuitable to use the CKD-EPI formula to calculate GFR. GFR was calculated from the SC provided by the laboratory. Through the electronic medical records, prescribed doses of the medications that needed dosage adjustment were recorded. Correct doses according to GFR of these medications were also recorded. Data on prescription changes made by the primary care physicians (GP) were collected. ATC groups were studied. Adequacy of the prescriptions was calculated as: (prescriptions adjusted correctly according to GFR)/(total number of prescriptions susceptible to modification).Results116 patients (76.7% women) with a mean age of 80.8 years were included. 73.3% of patients had GFR ( mL/min/1.73m2) between 30 and 44; 24.1% between 15 and 29 and 2.6% <15. 52.6% of patients had prescriptions suitable for adjustment (93 prescriptions in total), but only 11.8% (11) of the prescriptions were modified by the corresponding GP. The ATC groups that needed adjustment more frequently were A10A (25.8%), A10B (23.65%) and B01A (10.75%). Only 10.75% of prescriptions were adequate.ConclusionThe adequacy of medicines prescribed in our health district in patients with decreased GFR was very low. More than half of patients with a GFR <45 mL/min/1.73m2 needed adjustment in at least one of their medications, as very few prescriptions were adjusted by their corresponding GP.No conflict of interest
BackgroundThe digoxin range conventionally used (0.8–2.0 ng/mL) may be suitable for patients with atrial fibrillation (AF), although a lower range is preferable for patients with congestive heart failure (CHF) (0.5–1.0 ng/mL).PurposeTo study if digoxin is monitored correctly and according to recent evidence.Material and methodsA retrospective study was conducted between January and June 2016. Field of study: two tertiary hospitals and their reference areas (the population consisted of 666 000 people). Adult patients with analytical determinations of digoxin during the study period were included. Digoxin concentrations were studied in blood samples of patients with CHF and/or AF. The percentage of patients with inappropriate levels of digoxin according to recent evidence was detected. Results were statistically interpreted. A descriptive analysis was conducted, followed by a χ2 test to calculate the differences between all variables. The possible influence of age (younger or older than 75 years) and sex were also analysed.ResultsA total of 102 analytical determinations in 95 patients were studied. 50% of the determinations in blood (51) showed inappropriate levels of digoxin. The number of inappropriate levels of digoxin was significantly higher in the group of patients >75 years of age (p=0.0481). However, no significant differences were found according to sex (p=0.903). 21.6% (22) of the analytical determinations showed blood digoxin levels above the range (>2 ng/mL for AF and >1 ng/mL for CHF). 28.4% (29) of patients had blood digoxin levels below the range (<0.8 ng/mL for AF and <0.5 ng/mL for CHF).ConclusionThe high number of determinations not within the range may indicate that in many cases healthcare professionals are not aware of the appropriate range of digoxin for each pathology. The elderly population had higher percentages of inappropriate blood digoxin concentrations, being more likely to have digoxin levels above the range. Thus therapeutic drug monitoring of digoxin in blood is not being used as often as it should, implying poor control of patients treated with digoxin.No conflict of interest
BackgroundInternational guidelines have embraced the use of non-vitamin K oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation. However, there is controversy regarding the risk of bleeding of NOACs compared with vitamin K antagonists.PurposeTo analyse the evolution of consumption of oral anticoagulants (OACs) (2008–2015) and the economic impact of the recently marketed NOACs. To study major bleedings (intracranial haemorrhage (ICH) and gastrointestinal (GI) bleeding) experienced by our patients (2012–2015).Material and methodsThis was an observational descriptive study. Field of study: two tertiary hospitals and their reference areas. The target population consisted of 666 000 people. Patients with an acenocoumarol, warfarin, dabigatran, rivaroxaban or apixaban prescription, under the National Health System coverage, were studied. The unit of measure was defined daily doses (DDD) per 1000 inhabitants per day (DHD), using the ATC/DDD classification (2006). The number of patients who experienced ICH or GI bleeding associated with OACs prescriptions was studied.Results24 498 patients were included with a mean age of 76.7 years. During the study period, DHD increased by 88.9%; from 6.3 (2008) to 11.8 (2015). DHD values in 2015 were: 6.6 acenocoumarol; 0.6 warfarin; 2.7 dabigatran; 1.3 rivaroxaban; and 0.6 apixaban. In 2015, 91.4% of patients were treated with acenocoumarol (12 370) and warfarin (848); the other 8.6% were treated with NOACs (dabigatran 480, rivaroxaban 494 and apixaban 267). The number of patients treated with OACs increased by 44.6% during the study period, but the total expense increased by 573.8% from €232 650 (2008) to €1 567 675 (2015).Between 2012 and 2015, the number of patients with major bleeding was, respectively, 146, 136, 128 and 121. Associated with NOACs: 2, 8, 10 and 12, respectively. In 2015, 0.7% of patients with NOACs experienced major bleeding versus 0.6% of patients treated with warfarin and acenocoumarol. The percentage for each treatment was: 0.6% acenocoumarol; 0.4% warfarin; 1.2% dabigatran; 0.5% rivaroxaban; and 0% apixaban.ConclusionConsumption of OACs has increased notably. However, overall expenditure on oral anticoagulant medications has grown, particularly due to the introduction of NOACs into the market, even though our data did not show a favourable safety profile with respect to bleeding.No conflict of interest
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