Utility of proton pump inhibitors in the treatment of gastrointestinal hemorrhage

Proton pump inhibitors inhibit gastric acid secretion thereby promoting the healing of peptic ulcers and decreasing the occurrence of gastrointestinal bleeding. An intravenous formulation of the PPI pantoprazole is now available in the United States. Some clinicians have prescribed this product after endoscopic hemostasis of acute upper gastrointestinal hemorrhage to prevent recurrence. Historically, the evidence is weak for the use of histamine H2-receptor antagonists in this role. Fifteen original studies on the use of intravenous proton pump inhibitors in this setting are reviewed. The evidence for their efficacy is similarly weak and does not justify the increased cost of their use in this setting. Larger, more definitive studies on proton pump inhibitors are needed to clarify their role in the control of acute upper gastrointestinal hemorrhage.

[Therapeutic interchange of drugs not included in the hospitaĺs pharmacotherapeutic guide: a quality program]

BACKGROUND

Standardised substitution of those drugs not included in the hospitaĺs formulary constitutes one of several methods used to improve therapeutic efficiency, due to reduction of variability in pharmaceutical practice and prevention of potential medication errors.

OBJECTIVES

To evaluate quality of drug substitution procedures in those drugs not included in the hospital's formulary.

METHODS

Assessment study in a surgical hospital with 314 beds, using structural, process and outcome criteria from 1998 to 2002.

RESULTS

Compliance degree for structure, process and outcome criteria were 100, 89 and 35%, respectively, while the established standards were 100%. Prevalence values for patients with substituted medication, increased from 2.9 (95%CI, 2.4-3.6) in 1998 to 11.1% (95%CI, 10.2-12.1) in 2002. Non-substituted drugs annual cost decreased from 20,199 in 1998 to 12,356 Euro in 2002. Drug substitution made by the pharmacist had an acceptance degree of 82.5%. No interchange errors were found in 126 replaced drugs.

CONCLUSIONS

The development of quality programs to improve drug prescription adherence to the hospitaĺs formulary, specially those that promote therapeutic interchange under the Pharmacy Committee guidance, are helpful strategies to make a proficient management of patients pharmacotherapy.

An animal model with relevance to schizophrenia: sex-dependent cognitive deficits in osteogenic disorder-Shionogi rats induced by glutathione synthesis and dopamine uptake inhibition during development

Low glutathione levels have been observed in the prefrontal cortex and the cerebrospinal fluid of schizophrenic patients, possibly enhancing the cerebral susceptibility to oxidative stress. We used osteogenic disorder Shionogi mutant rats, which constitute an adequate model of the human redox regulation because both are unable to synthesize ascorbic acid. To study the long-term consequences of a glutathione deficit, we treated developing rats with L-buthionine-(S,R)-sulfoximine (BSO), an inhibitor of glutathione synthesis, and later investigated their behavior until adulthood. Moreover, some rats were treated with the dopamine uptake inhibitor GBR 12909 in order to elevate dopamine extracellular levels, thereby mimicking the dopamine hyperactivity proposed to be involved in schizophrenia. BSO and GBR 12909 alone or in combination minimally affected the development of spontaneous alternation or basic sensory and motor skills. A major effect of BSO alone or in combination with GBR 12909 was the induction of cataracts in both sexes, whereas GBR 12909 induced an elevation of body weight in females only. Sex and age-dependent effects of the treatments were observed in a test of object recognition. At postnatal day 65, whereas male rats treated with both BSO and GBR 12909 failed to discriminate between familiar and novel objects, females were not affected. At postnatal day 94, male object recognition capacity was diminished by BSO and GBR 12909 alone or in combination, whereas females were only affected by the combination of both drugs. Inhibition of brain glutathione synthesis and dopamine uptake in developing rats induce long-term cognitive deficits occurring in adulthood. Males are affected earlier and more intensively than females, at least concerning object recognition. The present study suggests that the low glutathione levels observed in schizophrenic patients may participate in the development of some of their cognitive deficits.

Quality use of medicines in aged-care facilities in Australia

Medication-related problems are most commonly reported in elderly patients. It is for this reason that the development of services supporting appropriate medication management in the elderly is paramount; particularly for those living in residential care facilities. In 1991, Australia had very limited services supporting the quality use of medicines for residents of aged-care facilities. Over 11 years, from 1991-2002, the range of services has expanded considerably. Federally funded medication review services are now available, with over 80% of residents provided with the service. Medication advisory committees, in accordance with national practice guidelines, have been established in many facilities to address issues concerning medication management. Fifty percent of Australian's pharmacies are registered to provide services, with over 10% of the country's pharmacists accredited to provide the service. National practice guidelines for medication management in aged-care facilities have been incorporated into accreditation standards for aged-care facilities, further integrating activity into the wider health system. The environment was created for these activities through the formation of the Pharmaceutical Health and Rational Use of Medicines (PHARM) Committee, an expert advisory committee, and the Australian Pharmaceutical Advisory Council (APAC), a representative council. Both groups had responsibility for advising the Federal Minister of Health. They both identified medication misadventure in residential aged care as a priority issue and through their recommendations the Government devoted funds to the development of best practice guidelines and research activity. Clinical pharmacy services in nursing-home and hostel settings were found to reduce the use of benzodiazepines, laxatives, NSAIDs and antacids leading to cost savings to the health system. Dose-administration aids were found to reduce error rates during medication administration, and the alteration of medications for administration to residents was found to be common practice and potentially problematic. Research in the Australian setting demonstrating effectiveness, as measured by changes in medication use or health outcomes, as well as actual or potential cost savings has been a critical success factor. In addition, prioritisation by government advisory committees, inquiries and policy documents, have assisted in the development of services from ideas in 1991 to nationally funded realities in 2002.

Look beyond budgets to the broader benefits

The success of researchers in developing innovative and effective medicines has produced a healthier and older population, as well as an observable shift in expenditure towards pharmaceuticals. In contrast to drug expenditures, patented drug prices have actually shown an average annual decrease of 0.5% since 1988. While we agree cost-effectiveness evaluation is a useful input into the decision-making process of drug benefit managers, it is but one consideration, and it is imperative that governments look beyond drug budgets to the broader benefits of innovative drug therapy to Canadians, both economically and clinically. The lead paper makes a number of suggestions regarding clinical trials that would lead to an increased demand on the developers of innovative medicines, all of which would raise the development costs of drugs while reducing the spectrum of available agents. This commentary argues that focusing greater attention on ensuring the appropriate use of medicines, with less concentration on restricting Canadians' access to effective drugs available in other countries, will yield the greatest benefits to the health of our population. Patient health management is a strategy that deserves a closer look to achieve this goal.

[Identification and analysis of errors in prescription, preparation and administration of drugs in intensive care, medicine and surgery at the University Hospital Center of Tours]

OBJECTIVE

Within the framework of a project to establish "the safety of drug use and the prevention of iatrogenic risks", the pharmaceutical team conducted a review on the errors in drug prescription in order to implicate the medical professionals in its development. In collaboration with the medical teams, the pharmacy organised a series of therapeutic surveys aimed at quantifying and qualifying the errors related to the prescription, preparation and administration of medicinal products.

METHODS

A prospective survey was conducted in three types of care units (Medicine, surgical intensive care and paediatric vascular surgery) over a 30-day period in each unit. A resident pharmacist studied the preparations and administration of drugs and compared them to the prescriptions and recommendations of in the literature. The investigator also conducted the pharmaceutical analysis of the prescriptions (dose, drug interactions, administration timetable...). The clinical impact of the errors on the patient were scored 0 (none) to 3 (lethal) by a duo composed of an external physician and the resident physician in charge of the study on site.

RESULTS

Among the 3,023 drugs prescribed, the error rate was of 0.04 [0.033; 0.047], 44% of which scored 2. The errors in preparation or administration were of 0.134 [0.117; 0.151] among the 1,632 drug administrations observed, 19% of which scored 2. Regarding errors in prescription and administration, no significant difference was revealed between the three units [p > 0.09].

DISCUSSION

This study enhanced the awareness of the nursing and medical staff and the hospital management with regards to the reality of medical errors. Our data were comparable to the results of other studies published elsewhere.

Impact of a multidisciplinary approach to the control of antibiotic prescription in a general hospital

We examined the impact of a rational antibiotic prescription programme based on a multidisciplinary consultative approach in a 600-bed hospital. The programme involved four measures: (1). drawing up of a local prescribing consensus with all prescribers; (2). a restricted prescriptions policy for the most expensive antibiotics; (3.assessment of the prescription of these antibiotics by regular audits; and (4). institutional training and information for prescribers. The impact of the programme was assessed by comparing actual prescriptions with the criteria of the local consensus, compliance with the restrictive prescription policy, changes in the average daily cost of antibiotic therapy per inpatient and changes in the local ecology of methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae producing extended-spectrum beta-lactamases (EPESB) and ceftazidime-resistant Pseudomonas species (CRP). Using a participatory consensual approach, 182 reference recommendations were established (104 for adults, 78 for children), corresponding to 85% of the clinical settings encountered in the hospital. Six audits, conducted since June 1997, show that the rate of unjustified prescriptions first fell significantly (from 6 to 0%, P<0.001), then increased significantly (from 0 to 3%, P<0.05) before stabilizing at 3%. The cost of antimicrobials per inpatient day fell significantly (from US dollars 13.8 in 1997 to US dollars 11 in 2000, P<0.001). The prevalence of MRSA and CRP remained stable, while that of EPESB fell significantly (P<0.001). This multidisciplinary consultative approach thus reduced antibiotic costs, contributed to infection control, and improved the quality of antibiotic prescription.

The successful introduction of a programme to reduce the use of i.v. ciprofloxacin in hospital

The effectiveness of a programme to reduce the use of i.v. ciprofloxacin was assessed. i.v. ciprofloxacin was removed from ward stock and discussion occurred regarding appropriate use of the drug. Six months later, a factsheet containing recommendations was distributed to all medical staff and a requirement for justification before prescription was introduced. The programme reduced expenditure on i.v. ciprofloxacin to 34% of original levels. Savings of > 36,000 pounds sterling were made for two consecutive years. A sustained reduction in the use of i.v. ciprofloxacin was obtained by a combination of education and restriction.