[The role of anti-ulcerative drugs in treatment and prevention of gastropathies induced by nonsteroidal anti-inflammatory drugs]

Nonsteroidal anti-inflammatory drugs (NSAIDs) as effective agents for the relief of pain and inflammation are among the most widely prescribed drugs. Unfortunately, their benefits especially for patients with osteoarthritis and other chronic musculoskeletal conditions, are accompanied by well established toxicity. A significant percentage of NSAIDs users experience some type of gastrointestinal adverse events, ranging from manageable dyspepsia to clinically important complications (gastrointestinal bleeding, ulcer perforation, obstruction). In an attempt to reduce the incidence of NSAID-induced gastropathy, the following approaches have been proposed: avoidance of NSAIDs or minimising their dosage, selecting NSAID known to cause less damage and coprescription of various agents. Patients who require NSAIDs therapy should be assessed for factors that increase risk of gastrointestinal damage. In high risk patients, use of misoprostol, which reduces even serious gastrointestinal complications, or proton pump inhibitors, whose efficacy in preventing gastroduodenal ulcers due to NSAIDs exposure has been demonstrated in large clinical trials, is possible to use. The first step in the treatment of NSAID-associated ulcers lies in discontinuation of NSAIDs therapy. If NSAIDs cannot be withdrawn, an antisecretory therapy should be initiated. Proton pump inhibitors appear to be the most effective at healing NSAID-related ulcers among whose with continuous NSAIDs therapy. Another therapeutic option in the management of NSAID-gastropathy is to use specific cyclooxygenase-2 inhibitors. However, the clinical experience with these agents is still limited and further surveillance to resolve this issue as well as e.g. the role of Helicobacter pylori infection in NSAID-induced gastrointestinal injury are needed.

[Comparison of utilization of cardiovascular drugs in the Czech Republic and in Wales]

AIM

To compare and describe the trends in the consumption of selected groups of cardiovascular drugs in several districts of the Czech Republic and counties of Wales in the period of 1997-2000.

METHODS

A retrospective analysis of prescription data from General Medical Insurance Company (three districts in the Czech Republic) and data from the Health Solutions Wales (3 counties of Wales). The data were analyzed during seven half-year intervals from January 1997 till June 2000. The authors investigated the consumption of antihypertensives, diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, hypolipidemic drugs, digoxin and acetylsalicylic acid classified according to ATC classification. The drug consumption was expressed at defined daily doses (DDD) and standardized per 1,000 insured individuals and day for the Czech districts and per 1,000 inhabitants and day for the Welsh counties (DID).

RESULTS

The total consumption of the cardiovascular drugs under study in the last half-year of the investigated period of time (1/00) proved to be highest in CZ2 (40.2 DID), the value being by 40% higher than in CZ1 (348.6 DID) and by 11% higher than in CZ3 (386.9% DID). The rates of consumption in the Welsh counties during this period of time were 338.8 DID (W1), 307.9 DID (W2) and 298.0 DID (W3), respectively. Diuretics proved to be used at the highest rate in both countries. The consumption of thiazides and loop diuretics in the Czech districts during 1/00 represented 67.6% and 16.7% of the all diuretic consumption on the average, whereas the corresponding values in Wales were 42.3% for thiazide preparations and 46.7% for the loop diuretics. An increase in the consumption of new drugs such as ACE inhibitors, calcium channel blockers of 2nd generation and statins was noted in both countries. The statins represented 33.5% of total prescription of hypolipidemic drugs in the Czech districts, whereas their consumption in the Welsh districts represented 88.1% consumption of these drugs.

CONCLUSION

The most significant differences were found in the consumption of diuretics and hypolipidemic drugs. The results of consumption studies could highlight the differences in drug utilization and thereby stimulate discussion on optimization of drug selection.

[Characteristics of patients with osteopenia treated with glucocorticoids at the Osteoporosis Clinic of the Medical Faculty Hospital in Hradec Kralove]

One-hundred-ninety-seven osteopenic or osteoporotic patients registered at the University hospital osteology outpatient clinic during 1995-1999 and exposed to glucocorticoids were included in the cohort. Prevalence of glucocorticoid treatment (of all patients) was 12.4%. The patients diagnosed with rheumatoid arthritis showed the greatest reduction in bone density (average T-score = -2.70), fractures were most frequently recorded in patients suffering from asthma or lupus erythematodes.

[Use of a health insurance company database for study of theoretical exposure to hypolipidemic agents]

OBJECTIVE

The objective of the investigation was to analyze theoretical exposures to hypolipidaemics in patients treated chronically with these drugs, using the database of the health insurance company.

INVESTIGATED GROUP

From the database (with information on age, sex of the insured person, the number of packages and the type of hypolipidemic and year of issue of the prescription) of subjects insured at the Employees Health Insurance Skoda Mladá Boleslav comprising some 100,000 insured subjects in 1994-2000. Patients with long-term (more than one year) hypolipidaemic treatment were selected in years from 1995 to 1999. The group increased every year. In 1995 it comprised 668 cases in 1999, 2396 subjects.

METHOD

The consumption of hypolipidaemics was expressed in defined daily doses (DDD). The authors investigated the ratio of chronically treated patients and the proportion of the following groups of patients according to their annual consumption in 1995-1999: group of of drug "vacation" (0 DDD) and the group with a low (< 121.7 DDD), medium (< 243.3 & > 121.7 DDD) and optimal (> 243.3 DDD) consumption of hypolipidaemics and their relationship to sex and age. For statistical ealuation software SPSS 10.1 was used.

RESULTS

In the course of the investigation among the insured subjects the statin consumption increased 76 times and the consumption of fibrates 5 times. The ratio of consumption of resin derivatives and of nicotinic acid was negligible. The size of the group of subjects treated with hypolipidaemics for longer than one year increased from 0.8% in 1995 to 2.2% of the database. The average age increased from 55 to 59 years. The ratio of seniors (> or = 65 years) increased in the course of the investigation and reached 33% in 1999 of all members of the investigated group. The mean annual consumption of hypolipidaemics increased significantly as compared with 1995 and the interannual increase as compared with the previous year was statistically significant in 1997 and 1999. In 1999 it was 237 DDD/per consumer. A lower consumption was recorded in women and in seniors. Drug "vacations" were recorded in 6% of the insured subjects of the group and the frequency did not change significantly in the course of the investigation and no relationship with age and sex was found. A low exposure according to DDD was found in 20%, medium exposure in about 40% and optimal exposure in only one third of the subjects of the investigated group.

CONCLUSION

The authors developed a method which makes it possible, when individual data of the health insurance company are available, to investigate the theoretical exposure to hypolipidaemics in insured subjects treated on a long-term basis with these drugs. The authors provided evidence that analysis of the database of the health insurance company can provide certain signals for further pharmacoepidemiological research and for application in a defined medical discipline. Some of the insured subjects are exposed to smaller doses than theoretically assumed. It is necessary to extend the investigation so that the results will better reflect the population of patients and prescribing physicians. Complete evaluation of cases with a low exposure from the aspect of morbidity and drug compliance will be also essential.

[Monitoring utilization of hypolipemic agents using an insurance company database]

Databases of health insurance companies can provide information on the motion of a drug in the society. The present paper examines several databases of health insurance companies and analyzes the development of the consumption of hypolipidemic agents in 1994 through 1998. So-called evaluation databases making it impossible to identify a particular patient and the prescribing physician were prepared for the evaluation. They were obtained from the VZP central health insurance office, VZP district health insurance offices in Hradec Králové and Kladno, and the Zamĕstnanecká pojistovna Skoda (Employees Health Insurance Company Skoda). It was not necessary to blind the data in the first cohort, in the second one it was carried out by shortening the identification numbers, and in others by introducing artificial identification codes. The consumption was expressed in DDD and in the relative representation in the group. The consumption of the principal groups of hypolipidemic agents (fibrates, statins, sequestrants of bile acids, and derivatives of nicotinic acid) and the individual medicinal substances was evaluated. Relative values of consumption were obtained by calculation to the magnitude of the denominator--the number of the insured, or the number of patients to whom a hypolipidemic agent was prescribed. The consumption was on the increase in all three databases, in four years increasing from approx. 0.4-4DDD/1000 of the insured/day to 16-24DDD/1000 of the insured/day. At the beginning, the main share in the consumption of hypolipidemic agents was represented by fibrates, approx. 90%, but in four years this share decreased to only 60%, whereas in the period under study the share of statins increased up to 30%. Databases of health insurance companies do not significantly differ in the consumption of hypolipidemic agents, which may give evidence of their validity. In the course of the study, an increase in the consumption of hypolipidemic agents, primarily statins, was found. The shift in the consumption of statins corresponds with the available information about the evidence of their therapeutic effectiveness. The average consumption per one patient does not reach 1DDD, which is a signal that probably very few patients receive long-term treatment and that new patients emerge during the year.

[Cross-sectional study of choice of drug therapy in the acute phase of treatment in acute myocardial infarct--part 1]

INTRODUCTION

Treatment of acute myocardial infarction is undergoing changes. In the treatment of acute myocardial infarction in particular the following proved useful: thrombolysis, administration of anti-aggregating drugs, beta-blockers and inhibitors of angiotensin converting enzyme. An decisive part is played by the interval between the onset of symptoms and the beginning of hospital treatment.

OBJECTIVE

To describe treatment of patients hospitalized at intensive care units for acute myocardial infarctions. Investigate differences between faculty and other hospitals.

METHOD

The authors investigated by means of questionaires in a prospective study during the first three months in 1996 all patients who were hospitalized on account of acute myocardial infarction. The investigation was implemented in seven intensive care units of faculty hospitals and in nine intensive care units of hospitals and information on diagnosis, pharmacotherapy and results of therapy were assembled. During the first 24 hours of treatment more detailed information was procured.

RESULTS

Antiaggregants were used in 88%, nitrates in 77.8%, thrombolytics, beta-blockers and and ACE inhibitors in ca 30% patients. Percutaneous transluminal coronary angioplasty was used in ca 7% patients.

CONCLUSIONS

The authors describe treatment of the acute stage of myocardial infarction. In faculty hospitals in 1996 thrombolysis, percutaneous transluminal coronary angioplasty, beta-blockers and nitrates by the i.v. route were used more frequently.

[Prognosis for the development of Czech pharmaceutical services]

On the basis of a survey of opinions of Czech pharmaceutical experts a prognosis of some changes in the pharmaceutical service in the Czech Republic was made by means of Delphi method. It has been confirmed that the use of this method is suitable for this purpose. It has followed from the answers of the experts that implementation of most innovations in the pharmaceutical service will take place at the beginning of the new century. Most of them believe in rapid introduction of computer technology into pharmacies and limitation of the assortment sold in pharmacies. A decrease in extemporaneous preparation below 5% and an establishment of fixed prices of pharmaceuticals for the final consumer are considered possible. Preparation of infusion mixtures exclusively in pharmacies and introduction of the one-dose system is considered as a long-term task.

European drug information centres--survey of activities

A questionnaire survey of European drug information centres (DICs) was conducted. DICs mentioned in the ESCP directories and other sources were identified and contacted. Information on basic characteristics was obtained: affiliation, the scope of activities, employees, question-answer service characteristics, information sources and the economic aspects of the DICs' work. Information from 84 DICs was analysed (return rate = 71.3%). DICs are mainly affiliated to hospitals (68%), rather rarely with faculties of pharmacy (6%) or with faculties of medicine (8.3%). Activities of DICs mainly include: question-answer service (98%), issue of bulletins (68%), participation in P&T committees (63%), tuition (61%) and drug-use evaluation (52%). Pharmacists, 1-2 full- or part-time, are the most frequent employees working in the DICs. When the question-answer service was analysed, it was found that 56% of the DICs are open only to the health-care professionals and 43% provide a service to the lay public. Questions are mainly concerned with the side effects, indication/therapeutic use and the dosage of the drugs. The majority of DICs (91%) document their activities, very often on a computer database. Quality assurance is provided by almost 75% of DICs, usually by a review (58%) or a feed-back questionnaire (32%). Information sources listed as most frequently used include Martindale--The Extrapharmacopeia, journals such as Lancet, Medline and Micromedex databases. DICs are usually financially supported by the organizations to whom they are affiliated. Fees are charged, for special activities, by 9.5% of DICs.

Lung diffusion estimated by oxygen and carbon monoxide

The study was objected to the comparison of the results of lung diffusion estimated by oxygen to those of routinely used single breath carbon monoxide method. The method described is based on the analysis of the speed of response of arterial partial oxygen pressure (paO2) to increasing inspiratory fraction of oxygen (Fi). The transcutaneous oximetry was used to follow paO2 by means of transcutaneous oxygen pressure (ptCO2). The study was performed on 35 patients of both sexes with interstitial lung involvement with normal or only slightly decreased FVC and FEV1. The close correlation between the results of both methods was proved (r = 0.848, p < 0.0001).

[Analysis of the activities of the Information Service of the National Institute for Drug Control]

An analysis was carried out concerning the questions regarding drug information solved by the information service section of the State Institute for Drug Control (SUKL) in 1992-1995. A rapid decrease in the number of questions was observed during the period under study. This trend was mainly caused by a decline in questions regarding the availability of drugs in the market. Questions were posed in a similar ratio by physicians and pharmacists predominantly from Prague and surrounding areas. Questions from other categories of health-care professionals and the lay public are in minority. Most questions focus on the characteristic of the drug and its availability. AISLP, Martindale and Rote Liste serve as the principal information sources.

Distribution of fenofibric acid in lipoprotein fractions of patients

The antidyslipidemic agent fenofibrate (procetofen) is hydrolysed in vivo to its main active metabolite--fenofibric (procetofenic) acid. This metabolite is usually determined in pharmacokinetic studies, because plasma concentrations of fenofibrate are practically undetectable. Presented study is focussed on the distribution of fenofibric acid into lipoprotein (VLDL, LDL, IDL and HDL) fractions of human and (for comparison) minipig blood plasma, which has not been studied yet. In order to obtain more accurate results, a new HPLC method based on the use of newly synthetized internal standards was developed. Four homologues of fenofibric acid prepared have identical chromophoric part of their molecules and hence the same UV spectra as fenofibric acid. From this point of view, these standards are more suitable for determination of fenofibric acid than the formerly used ones--naproxen or bezafibrate. Fenofibric acid levels in the high density lipoprotein fraction has been shown to be significantly higher (in both human and minipig plasma) than in the other lipoprotein fractions. This fact may be explained by higher affinity of the fenofibric acid to proteins constituting major part of the high density lipoprotein fraction.

Monitoring of TPN consumption at the University Teaching Hospital in Hradec Králové

To standardize studies on the utilization and consumption of drugs, the World Health Organization recommends the use of the Anatomical Therapeutic Chemical (ATC) classification system, using the defined daily dose (DDD value) as a technical unit of measurement of drug consumption. DDD values of total parenteral nutrition have not been established yet. In our descriptive study the methodology by E. Frankfort et al. (1993) is used. This methodology allows the calculation of both the total number of DDD values for TPN and the number of DDD values for the individual substances. Suggested DDD values and consumption of total parenteral nutrition by E. Frankfort et al. (1994) were compared with the values at the Teaching Hospital in Hradec Králové. During 3 months 142 patients administered only TPN were included in the study. The following data from every patient were collected: sex, age, the main diagnosis, composition of TPN each day and duration of this administration. The mean PDD value for carbohydrates was 200 +/- 41 g, for fat emulsion 77 +/- 27 g and for amino acids 93 +/- 16 g. The difference between our and Frankfort's results were found.

[Development of resistance and utilization of fluoroquinolones in a university hospital]

The results of a retrospective study in the Faculty Hospital, Hradec Králové (FHHK) show a steep increase in the consumption of fluoroquinolones in the course of six years. Since 1989, when 360 defined daily doses (DDD) were administered, the consumption increased to 2,825 DDDs in 1992 and 52,162 DDDs in 1995. At the same time, resistance to ofloxacine and ciprofloxacine was increased many times in some bacterial species isolated from patients admitted to FHHK. In the strains Pseudomonas aeruginosa, resistance to ofloxacine increased from 3% to 38% in 1995, in Serratia marcescens from 13% in 1992 to 30% in 1995. A marked increase was observed also in Acinetobacter calcoaceticus. In the naturally highly sensitive species E. coli and Klebsiella pneumoniae no increase in resistance has been observed yet, in Enterobacter cloaceae resistance slightly increased (from 0% in 1992 to 7% in 1995). Due to the fact that in FHHK fluoroquinolones take the first place in the consumption of antibiotics at present, an increase in resistance can be expected also in these bacteria in the future. Investigation of changes in resistance due to the consumption of fluoro-quinolones is a suitable model of a pharmacoepidemiological study (DUE-Drug Utilisation Evaluation) as the relationship of the consumption of a drug and its effect can be observed practically since the introduction of fluoroquinolones into the market.

Drug information centre--analysis of activities of a regional centre

Description and evaluation of a drug information centre's (DIC) professional activities one year after establishment are summarized. The aims of the centre are: to evaluate which problem areas are frequently requested, how frequently and by whom; which information sources are the most appropriate for the service and the approximate cost of such a service. We received 80 questions during the first 8 months. The questions were mainly asked by hospital physicians (32.5%) and pharmacists (32.5%), other health-care professionals were a minority; the scopes of most frequently asked questions include general properties of active substances (12.2%), contents of particular preparations (21%), dosage (11%), side effects (21%) and indications/contraindications (15%). Cost of the service included variable (mainly phone and mail charges, copy and print of the documents) and fixed costs (cost of software and salary of the staff).

Analysis of pharmacotherapy of hypertension in out-patients

In the present pilot study an attempt was made to evaluate the usefulness of results obtained about the treatment of patients suffering from high blood pressure for a pharmacoepidemiological study of the therapeutic value of antihypertensive agents. Data from 90 hypertensive patients were used in the present retrospective-prospective study. These patients all attended an out-patient clinic located in one of the East-Bohemian districts that are participating in the MONICA programme. Instead of the analysis of the population data, regular blood pressure measurements, plasma glucose levels, and total cholesterol concentrations were measured and analysed. The consumption of various antihypertensive drugs in this study was similar to that found in larger studies performed in other health districts of the Czech Republic. Diuretics were the drugs most frequently prescribed for hypertensive patients. General practitioners rarely prescribed calcium channel blockers and angiotensin-converting enzyme inhibitors in 1990 and 1991. The metabolic effects of antihypertensive drugs, mostly diuretics, were not significantly evident. The most frequent occurrence of non-compensated blood pressure was recorded for the treatments with Trimecryton and methyldopa. However, the validity of these findings should be tested in a larger group of hypertensic patients.

Pharmacokinetic parameters of verapamil and its active metabolite norverapamil in patients with hepatopathy

Verapamil (CAS 52-53-9) is a calcium channel blocker with a vasodilatatory effect. Because of its significant first-pass effect, verapamil might be advantageous in the treatment of portal hypertension. It does not produce any excessive systemic effects, provided the doses are suitably adjusted. A decision was made to examine the pharmacokinetic parameters, independent of compartmental analysis of verapamil and its active metabolite norverapamil, in patients with portal hypertension. Their biological half-lives of the terminal phase were significantly prolonged as compared with the control group. However, no statistically significant differences were found in the values of tmax and Cmax. The calculated pharmacokinetic parameters of norverapamil were not significantly different from those of verapamil, except for the tmax of norverapamil, which was significantly longer in patients suffering from portal hypertension as compared with verapamil. The ratio of areas under the plasma concentration-time curve (AUC) of verapamil and norverapamil was comparable in both groups of patients. No relationship between the changes in the pharmacokinetic parameters and the extent of hepatic insufficiency was observed.

Hyperparathyroidism after kidney transplantation: a retrospective case controlled study

We studied retrospectively patients with hyperparathyroidism after successful renal allotransplantation. Since 1972, 1119 transplantations have been performed in our department, and 534 patients survive with functioning grafts. Hyperparathyroidism requiring parathyroidectomy developed in 32 (5.9%). The frequency of interventions increased markedly after introduction of cyclosporine A treatment in our unit. The time between transplantation and parathyroidectomy was 22.5 months (SD 16.5, range 1-82 months). The age of the patients was 49.0 years (SD 10.5, range 17-63 years); the group consisted of 16 female and 16 male patients. All patients but two (no measurement performed) repeatedly exhibited high serum parathormone and calcium levels and therefore underwent surgery. In comparison to a control group, matched for time of transplantation, age, sex, and cause of renal failure, the patients with hyperparathyroidism had longer dialysis treatment (54.2 months, range 9-132 vs 26.9 months, range 1-72) and exhibited lower phosphate concentrations in the early posttransplantation period. Before surgery, serum chemistry was different for hyperparathyroid and control subjects: serum calcium 2.80 +/- 0.23 mmol/l vs 2.48 +/- 0.13 mmol/l and alkaline phosphatase 157.4 +/- 92.0 U/l vs 85.2 +/- 51.5, respectively. We did not see any influence of oral phosphate binders, calcium supplementation, or vitamin D treatment on the development of parathyroid gland hyperactivity during dialysis treatment. Serum creatinine concentration did not change after parathyroidectomy. In four patients, long-term calcium supplementation after surgery was necessary.

Netilmicin in the neonate: population pharmacokinetic analysis and dosing recommendations

Netilmicin pharmacokinetics were studied in neonates of 27 to 42 weeks' gestational age and 0.8 to 5.0 kg body weight in their first 2 weeks of life by the population pharmacokinetic approach. The data were best described by a two-compartment model. Clearance depends on body weight, gestational age, and postnatal age. Volume of distribution of the central and peripheral compartments was also related to body weight. Including these patient characteristics in the population pharmacokinetic regression model resulted in a marked reduction of the unexplained interindividual variability. This enabled us to derive dosage recommendations that result in peak and average concentrations within the desired range for 95% of the neonates with gestational age above 31 weeks, thus avoiding the need for individual drug-level monitoring in a well-defined large group of patients. Only for infants with gestational age less than 31 weeks who are less than 6 days old is individual dose adjustment based on serum concentration measurements required.

[Serum levels and urinary excretion of amino acids during high intensity physical exertion in healthy men]

The authors investigated the effect of a physical load on a bicycle ergometer on serum concentrations and urinary excretion of 19 amino acids. The initial load of 1 W/kg was increased after 5-minute intervals by 10-20 W to achieve the maximum after 50 minutes exercise. During the last 2-3 minutes of the maximal load a spiroergometric examination was made. The serum alanine concentration increased under these conditions significantly from 474 +/- 133 to 739 +/- 171 mumol/l (p less than 0.001), while the serum threonine concentration declined significantly from 155 +/- 39 to 143 +/- 37 mumol/l (p less than 0.05). Urinary excretion and renal clearance of amino acids declined significantly (p less than 0.05-0.001). The authors found a significant correlation between the drop of the urinary excretion and the rise of serum concentration of alanine (p less than 0.05). The drop of the urinary alanine excretion can contribute to its elevated serum concentration. The fractional amino acid excretions did not decline and the decline of amino acid and creatinine clearances was more or less proportional. The authors conclude that the decline of amino acid excretion is directly associated with a drop of glomerular filtration. The revealed, correlations between the drop of gin, lys, pala, thr and Na excretion suggest that the sodium transport through the nephron can influence the transport of these amino acids.

Nonlinear kinetics of propafenone metabolites in healthy man

The pharmacokinetics of oral and i.v. propafenone and its major metabolites have been investigated in 8 healthy subjects. The total body clearance of propafenone was 963 ml/min, the terminal half-life 198 min and its absolute bioavailability was 15.5%. The two active metabolites (5-hydroxypropafenone and N-depropylpropafenone) showed non-linear kinetics in that both the dose-corrected area under the serum concentration-time curve and the amount excreted in the urine were larger after oral dosing. This resulted in considerably higher serum concentrations of the metabolites despite comparable serum concentrations of the parent compound. Thus, the concentration-effect relationship in the same patient may differ after oral and intravenous doses if concentrations of the active metabolite(s) are not taken into consideration. Although the mechanism of the nonlinearity is not clear, the data indicate that it may be due to saturable biliary excretion of the metabolites.