CYP3A activity in severe liver cirrhosis correlates with Child-Pugh and model for end-stage liver disease (MELD) scores

AIMS

Impaired liver function often necessitates drug dose adjustment to avoid excessive drug accumulation and adverse events, but a marker for the extent of the required adjustment is lacking. The aim of this study was to investigate whether Child-Pugh (CP) and model for end-stage liver disease (MELD) scores correlate with drug clearance.

METHODS

Midazolam was used as a CYP3A probe and its pharmacokinetics were analyzed in 24 patients with mild to severe liver cirrhosis (n = 4, 10 and 10 with CP class A, B and C, respectively) and six patients without liver disease.

RESULTS

Both scores correlated well with unbound midazolam clearance (CLu ), unbound midazolam fraction and half-life (all P < 0.01), whereas the unbound steady-state volume of distribution was not significantly changed. In patients with severe liver cirrhosis unbound midazolam clearance was only 14% of controls (CP C: CLu = 843 ± 346 l  h(-1), MELD ≥ 15: CLu = 805 ± 474 l  h(-1), controls: CLu = 5815 ± 2649 l  h(-1), P < 0.01).

CONCLUSION

The correlation with unbound midazolam clearance suggests that either score predicts the metabolic capacity of CYP3A, the most relevant drug metabolizing enzyme subfamily in humans.

Pharmacokinetic interaction of intravenous fentanyl with ketoconazole

Fentanyl is primarily metabolized by CYP3A, but has also been suggested to act as a weak inhibitor of CYP3A. We investigated the influence of CYP3A inhibition by ketoconazole on the pharmacokinetics of intravenously administered fentanyl and the effect of fentanyl on CYP3A activity. A prospective, open-label, randomized, monocentre, crossover study was conducted in 16 healthy volunteers. They received fentanyl alone (5 microgram per kilogram) or fentanyl plus ketoconazole (200 milligram orally B.I.D. over 2 days). Naloxone (2 × 0.2 milligram i.v.) was given simultaneously with fentanyl to mitigate any opioid effect. Midazolam was administered as a CYP3A probe drug. Fentanyl and its metabolites were quantified by LC/MS/MS in blood and urine samples obtained over 24 hour. Exposure of fentanyl (AUC0- ∞ ) was significantly increased to 133% and systemic clearance was reduced to 78% by ketoconazole, norfentanyl formation was significantly delayed and partial metabolic clearance decreased to 18%. Fentanyl had no influence on midazolam exposure and CYP3A activity whereas ketoconazole decreased CYP3A activity to 13%. Although fentanyl N-dealkylation is substantially inhibited by ketoconazole, exposure of fentanyl itself increased by one third only. Clinically fentanyl dosage adjustments may become necessary when ketoconazole or other strong CYP3A inhibitors are given simultaneously. Fentanyl itself does not influence CYP3A activity.

More than just crushing: a prospective pre-post intervention study to reduce drug preparation errors in patients with feeding tubes

WHAT IS KNOWN AND OBJECTIVES

Incorrect drug preparation for patients with feeding tubes can result in harm for the patient and the preparing person. Combined intervention programs are effective tools to reduce such preparation errors. However, to date, intervention programs have been mostly tested in hospitals with computerized physician order entry (CPOE), unit-dose systems, or ward-based clinical pharmacists. Hence, the primary objective of this study was to develop and evaluate an intervention program tailored to hospitals without such preconditions.

METHODS

We conducted a prospective pre-/post-intervention study on a gastroenterological intensive care unit (ICU) and a surgical ward for oral, dental and maxillofacial diseases (surgical ward). During the study periods, observers documented and evaluated drug preparation processes of all peroral drugs for patients with feeding tubes. The primary endpoint was the rate of inappropriately crushed and/or suspended solid peroral drugs in regards to all solid peroral drugs.

RESULTS AND DISCUSSION

Altogether, we evaluated 775 drug preparation processes of solid peroral drugs on the ICU and 975 on the surgical ward. The intervention program significantly reduced incorrect crushing and/or suspending of solid peroral drugs for administration to patients with feeding tubes from 9·8% to 4·2% (P < 0·01) on the ICU and from 5·7% to 1·4% (P < 0·01) on the surgical ward.

WHAT IS NEW AND CONCLUSION

The implementation of the newly developed intervention program significantly reduced the rate of inappropriately prepared solid peroral drugs, suggesting that it is an effective measure to enable safe drug administration for inpatients with feeding tubes.

Impact of an electronic clinical decision support system on workflow in antenatal care: the QUALMAT eCDSS in rural health care facilities in Ghana and Tanzania

BACKGROUND

The implementation of new technology can interrupt established workflows in health care settings. The Quality of Maternal Care (QUALMAT) project has introduced an electronic clinical decision support system (eCDSS) for antenatal care (ANC) and delivery in rural primary health care facilities in Africa.

OBJECTIVE

This study was carried out to investigate the influence of the QUALMAT eCDSS on the workflow of health care workers in rural primary health care facilities in Ghana and Tanzania.

DESIGN

A direct observation, time-and-motion study on ANC processes was conducted using a structured data sheet with predefined major task categories. The duration and sequence of tasks performed during ANC visits were observed, and changes after the implementation of the eCDSS were analyzed.

RESULTS

In 24 QUALMAT study sites, 214 observations of ANC visits (144 in Ghana, 70 in Tanzania) were carried out at baseline and 148 observations (104 in Ghana, 44 in Tanzania) after the software was implemented in 12 of those sites. The median time spent combined for all centers in both countries to provide ANC at baseline was 6.5 min [interquartile range (IQR) =4.0-10.6]. Although the time spent on ANC increased in Tanzania and Ghana after the eCDSS implementation as compared to baseline, overall there was no significant increase in time used for ANC activities (0.51 min, p=0.06 in Ghana; and 0.54 min, p=0.26 in Tanzania) as compared to the control sites without the eCDSS. The percentage of medical history taking in women who had subsequent examinations increased after eCDSS implementation from 58.2% (39/67) to 95.3% (61/64) p<0.001 in Ghana but not in Tanzania [from 65.4% (17/26) to 71.4% (15/21) p=0.70].

CONCLUSIONS

The QUALMAT eCDSS does not increase the time needed for ANC but partly streamlined workflow at sites in Ghana, showing the potential of such a system to influence quality of care positively.

Two techniques to make swallowing pills easier

To evaluate whether 2 techniques (the pop-bottle method for tablets and the lean-forward technique for capsules) ease swallowing of tablets and capsules, we conducted a cross-sectional study including 151 adults of the general German population. Participants swallowed 16 differently shaped placebos, rated their ease of swallowing on an 8-point Likert scale, and swallowed the 2 dosage forms that they had rated most difficult again using the appropriate technique. The pop-bottle method substantially improved swallowing of tablets in 59.7% (169/283) and the lean-forward technique for capsules in 88.6% (31/35). Both techniques were remarkably effective in participants with and without reported difficulties swallowing pills and should be recommended regularly.

Health workers' knowledge of and attitudes towards computer applications in rural African health facilities

Background

The QUALMAT (Quality of Maternal and Prenatal Care: Bridging the Know-do Gap) project has introduced an electronic clinical decision support system (CDSS) for pre-natal and maternal care services in rural primary health facilities in Burkina Faso, Ghana, and Tanzania.

Objective

To report an assessment of health providers’ computer knowledge, experience, and attitudes prior to the implementation of the QUALMAT electronic CDSS.

Design

A cross-sectional study was conducted with providers in 24 QUALMAT project sites. Information was collected using structured questionnaires. Chi-squared tests and one-way ANOVA describe the association between computer knowledge, attitudes, and other factors. Semi-structured interviews and focus groups were conducted to gain further insights.

Results

A total of 108 providers responded, 63% were from Tanzania and 37% from Ghana. The mean age was 37.6 years, and 79% were female. Only 40% had ever used computers, and 29% had prior computer training. About 80% were computer illiterate or beginners. Educational level, age, and years of work experience were significantly associated with computer knowledge (p<0.01). Most (95.3%) had positive attitudes towards computers – average score (±SD) of 37.2 (±4.9). Females had significantly lower scores than males. Interviews and group discussions showed that although most were lacking computer knowledge and experience, they were optimistic about overcoming challenges associated with the introduction of computers in their workplace.

Conclusions

Given the low levels of computer knowledge among rural health workers in Africa, it is important to provide adequate training and support to ensure the successful uptake of electronic CDSSs in these settings. The positive attitudes to computers found in this study underscore that also rural care providers are ready to use such technology.

Trimethoprim-metformin interaction and its genetic modulation by OCT2 and MATE1 transporters

AIMS

Metformin pharmacokinetics depends on the presence and activity of membrane-bound drug transporters and may be affected by transport inhibitors. The aim of this study was to investigate the effects of trimethoprim on metformin pharmacokinetics and genetic modulation by organic cation transporter 2 (OCT2) and multidrug and toxin extrusion 1 (MATE1) polymorphisms.

METHODS

Twenty-four healthy volunteers received metformin 500 mg three times daily for 10 days and trimethoprim 200 mg twice daily from day 5 to 10. Effects of trimethoprim on steady-state metformin pharmacokinetics were analysed.

RESULTS

In the population as a whole, trimethoprim significantly reduced the apparent systemic metformin clearance (CL/F) from 74 to 54 l h(-1) and renal metformin clearance from 31 to 21 l h(-1) , and prolonged half-life from 2.7 to 3.6 h (all P < 0.01). This resulted in an increase in the maximal plasma concentration by 38% and in the area under the plasma concentration-time curve by 37%. In volunteers polymorphic for both OCT2 and MATE1, trimethoprim had no relevant inhibitory effects on metformin kinetics. Trimethoprim was associated with a decrease in creatinine clearance from 133 to 106 ml min(-1) (P < 0.01) and an increase in plasma lactate from 0.94 to 1.2 mmol l(-1) (P = 0.016).

CONCLUSIONS

The extent of inhibition by trimethoprim was moderate, but might be clinically relevant in patients with borderline renal function or high-dose metformin.

Nesting doctoral students in collaborative North-South partnerships for health systems research

BACKGROUND

The European Union (EU) supports North-South Partnerships and collaborative research projects through its Framework Programmes and Horizon 2020. There is limited research on how such projects can be harnessed to provide a structured platform for doctoral level studies as a way of strengthening health system research capacity in sub-Saharan Africa (SSA).

OBJECTIVE

The aim of this study was to explore the challenges of, and facilitating factors for, 'nesting' doctoral students in North-South collaborative research projects. The term nesting refers to the embedding of the processes of recruiting, supervising, and coordinating doctoral students in the overall research plan and processes.

DESIGN

This cross-sectional qualitative study was undertaken by the EU-funded QUALMAT Project. A questionnaire was implemented with doctoral students, supervisors, and country principal investigators (PIs), and content analysis was undertaken.

RESULTS

Completed questionnaires were received from nine doctoral students, six supervisors, and three country PIs (86% responses rate). The doctoral students from SSA described high expectations about the input they would receive (administrative support, equipment, training, supervision). This contrasted with the expectations of the supervisors for proactivity and self-management on the part of the students. The rationale for candidate selection, and understandings of the purpose of the doctoral students in the project were areas of considerable divergence. There were some challenges associated with the use of the country PIs as co-supervisors. Doctoral student progress was at times impeded by delays in the release of funding instalments from the EU. The paper provides a checklist of essential requirements and a set of recommendations for effective nesting of doctoral students in joint North-South projects.

CONCLUSION

There are considerable challenges to the effective nesting of doctoral students within major collaborative research projects. However, ways can be found to overcome them. The nesting process ultimately helped the institutions involved in this example to take better advantage of the opportunities that collaborative projects offer to foster North-South partnerships as a contribution to the strengthening of local research capacity.

Memorandum on the use of information technology to improve medication safety

BACKGROUND

Information technology in health care has a clear potential to improve the quality and efficiency of health care, especially in the area of medication processes. On the other hand, existing studies show possible adverse effects on patient safety when IT for medication-related processes is developed, introduced or used inappropriately.

OBJECTIVES

To summarize definitions and observations on IT usage in pharmacotherapy and to derive recommendations and future research priorities for decision makers and domain experts.

METHODS

This memorandum was developed in a consensus-based iterative process that included workshops and e-mail discussions among 21 experts coordinated by the Drug Information Systems Working Group of the German Society for Medical Informatics, Biometry and Epidemiology (GMDS).

RESULTS

The recommendations address, among other things, a stepwise and comprehensive strategy for IT usage in medication processes, the integration of contextual information for alert generation, the involvement of patients, the semantic integration of information resources, usability and adaptability of IT solutions, and the need for their continuous evaluation.

CONCLUSION

Information technology can help to improve medication safety. However, challenges remain regarding access to information, quality of information, and measurable benefits.

A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care

AIMS AND OBJECTIVES

To prevent medication errors in drug handling in a paediatric ward.

BACKGROUND

One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce.

DESIGN

A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling.

METHODS

After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors.

RESULTS

The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%.

CONCLUSION

Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes.

RELEVANCE TO CLINICAL PRACTICE

Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings.

Gute Verordnungspraxis

Die Arzneimittelverordnung steht am Anfang eines jeden Medikationsprozesses und kann somit gleich zu Beginn über Erfolg oder Misserfolg einer therapeutischen Intervention entscheiden. Eine „gute Verordnung“ zeichnet sich durch die Berücksichtigung von (1) relevanten pharmakokinetischen und pharmakodynamischen Besonderheiten und Komorbiditäten des Patienten sowie (2) evidenzbasierten Leitlinien und (3) dem spezifischen Setting, in dem eine Verordnung ausgestellt wird, aus. Das Setting wird darüber entscheiden, welche weiteren Partner mit welchen Kompetenzen, Bedürfnissen und Anforderungen im nachfolgenden Medikationsprozess beteiligt sein werden. Dazu zählen sowohl Apotheker, die das Arzneimittel abgeben oder den Patienten schulen oder auch Gesundheitspersonal, das das Arzneimittel verabreicht. Letztlich ist aber der Patient selbst oder seine Angehörigen der häufigste Partner in der Arzneimitteltherapie, da er, insbesondere im ambulanten Setting, die Mehrzahl der Arzneimittelanwendungen selbst durchführen wird und dabei durch seine Fertigkeiten und seine Überzeugung ein bestimmtes Arzneimittel (nicht) anzuwenden, den Verlauf der Therapie entscheidend beeinflussen kann. Zum Zeitpunkt der Verordnung ist der Arzt angehalten, all diese in der Zukunft ablaufenden Prozesse zu antizipieren und in seinem Entscheidungsprozess zu berücksichtigen. Er sollte darüber hinaus sicherstellen, dass die Verordnung mit allen relevanten Teilinformationen zur Verabreichung in einer expliziten, unmissverständlichen (leserlichen!) Art und Weise weitergegeben werden. Neben diesen inhaltlichen und formal-inhaltlichen Kriterien treffen insbesondere im ambulanten Versorgungssektor häufig noch formal-gesetzliche Anforderungen zu, die vorgeben, in welcher Art und Weise eine Therapie verordnet werden darf. Eine gute Verordnung ist folglich eine Kunst, die Fallstricke sind häufig – ihre Erkenntnis aber ein erster Schritt zur effektiven Fehlervermeidung in der Praxis.

Gute Verordnungspraxis im ambulanten Sektor – Qualitätsanforderungen an die Rezeptschreibung in Deutschland

Die schriftliche Verordnung von Medikamenten als persönliches Rezept ist eine komplexe ärztliche Tätigkeit mit multiplen landestypischen Fehlerquellen. Verschiedene Rezepttypen (rosa, blaues, grünes, T- und Betäubungsmittelrezepte), Rabattverträge und andere häufig wechselnde erstattungsrelevante Rahmenbedingungen, ein besonders großer Arzneimittelmarkt und die vielfach zwingend erforderliche formale Detailtreue machen die Rezeptschreibung in Deutschland vielschichtig und kompliziert und führen so besonders häufig zu Fehlern. Die erforderlichen Entscheidungsschritte sind in dieser Arbeit algorithmisch dargestellt und können die Basis für eine gezielte Schulung von Ärzten und Studenten in der Rezeptschreibung bilden. Entsprechende Schulungen können die Rezeptqualität zwar unmittelbar verbessern, ändern jedoch nichts an der Komplexität des Vorgangs, weshalb eine Umstellung auf eine konsequente elektronische Rezeptschreibung wirksamer und langfristig wirtschaftlicher ist. Elektronisch unterstützt, ist die Rezeptqualität substanziell besser und der Schulungsaufwand geringer; dadurch wird die Arzneimittelversorgung der Patienten beschleunigt und der Arbeitsaufwand der involvierten Heilberufler minimiert.

Substantially increased sildenafil bioavailability after sublingual administration in children with congenital heart disease: two case reports

INTRODUCTION

Pulmonary hypertension is a progressive disease of diverse origin with devastating consequences in adults as well as in children. The phosphodiesterase 5 inhibitor sildenafil successfully lowers pulmonary vascular resistance. However, because of its poor enteral absorption, resulting in ineffective plasma concentrations, responses in infants and children are often erratic.

CASE PRESENTATIONS

We report the cases of two Caucasian boys, one born at term (case 1) and one aged 2.5 years (case 2), who had structural cardiac and pulmonary defects accompanied by symptomatic pulmonary hypertension. They received sildenafil enterally and sublingually and also intravenously in one of them. Plasma samples were taken at various time points to determine the plasma concentrations of sildenafil and its partially active metabolite. Sildenafil and N-desmethyl sildenafil were quantified using a validated liquid chromatography/mass spectrometry method. Oxygen partial pressure was determined from routine arterial blood gas samples.

CONCLUSION

In agreement with previous observations in adults, we found that sublingual sildenafil was more extensively absorbed in our two pediatric patients. After sublingual administration, sildenafil plasma concentrations increased by 314% to 361% compared to enteral dosing. Concurrently, the metabolic ratio increased, suggesting not only that the overall absorption was enhanced but also that first-pass metabolism was partially bypassed. In case 2, the free fraction of sildenafil was 0.9%, which is considerably less than in adults (4%), suggesting that, in case 2, higher plasma concentration would have been needed to achieve effects similar to those in adults. Sublingual sildenafil appears to be a promising alternative route of administration in children with poor enteral absorption.

Indirect evidence for proton pump inhibitor failure in patients taking them independent of meals

PURPOSE

We investigated the association between conditions of proton pump inhibitor (PPI) treatment failure and food intake in an elderly ambulatory population.

METHODS

Our data originate from a large population-based cohort study. During a home visit done by a trained study physician, patients were asked for each medication to state whether it was taken in relation to a meal (before, concurrently with, and after) or independent of a meal. This information was analyzed for all patients taking a PPI daily and correlated to markers of PPI failure.

RESULTS

Out of 2717 patients participating in a home visit and taking at least one medication, 383 took a PPI daily (14.1%). A PPI intake independent of meals was defined as incorrect and was observed in 64 patients, whereas 319 patients took their PPI in relation to a meal, which was defined as the correct intake. Treatment failure was observed in 10 out of 64 (15.6%) PPI users with incorrect intake and in 18 out of 319 (5.6%) PPI users with correct intake. The risk of treatment failure was threefold higher in patients taking their PPI independent of meals (OR 3.35; 95%CI 1.44-7.76).

CONCLUSION

The higher risk for PPI failure in patients taking PPIs independent of meals suggests that synchronized PPI administration with meals is indeed essential, and better counseling of patients is needed.

What, if all alerts were specific - estimating the potential impact on drug interaction alert burden

PURPOSE

Clinical decision support systems (CDSS) may potentially improve prescribing quality, but are subject to poor user acceptance. Reasons for alert overriding have been identified and counterstrategies have been suggested; however, poor alert specificity, a prominent reason of alert overriding, has not been well addressed. This paper aims at structuring modulators that determine alert specificity and estimating their quantitative impact on alert burden.

METHODS

We developed and summarized optimizing strategies to guarantee the specificity of alerts and applied them to a set of 100 critical and frequent drug interaction (DDI) alerts. Hence, DDI alerts were classified as dynamic, i.e. potentially sensitive to prescription-, co-medication-, or patient-related factors that would change alert severity or render the alert inappropriate compared to static, i.e. always applicable alerts not modulated by cofactors.

RESULTS

Within the subset of 100 critical DDI alerts, only 10 alerts were considered as static and for 7 alerts, relevant factors are not generally available in today's patient charts or their consideration would not impact alert severity. The vast majority, i.e. 83 alerts, might require a decrease in alert severity due to factors related to the prescription (N=13), the co-medication (N=11), individual patient data (N=36), or combinations of them (N=23). Patient-related factors consisted mainly of three lab values, i.e. renal function, potassium, and therapeutic drug monitoring results.

CONCLUSION

This paper outlines how promising the refinement of knowledge bases is in order to increase specificity and decrease alert burden and suggests how to structure knowledge bases to refine DDI alerting.

Inequalities in out-of-pocket payments for health care services among elderly Germans--results of a population-based cross-sectional study

Introduction

In order to limit rising publicly-financed health expenditure, out-of-pocket payments for health care services (OOPP) have been raised in many industrialized countries. However, higher health-related OOPP may burden social subgroups unequally. In Germany, inequalities in OOPP have rarely been analyzed. The aim of this study was to examine OOPP of the German elderly population in the different sectors of the health care system. Socio-economic and morbidity-related determinants of inequalities in OOPP were analyzed.

Methods

This cross-sectional analysis used data of N = 3,124 subjects aged 57 to 84 years from a population-based prospective cohort study (ESTHER study) collected in the Saarland, Germany, from 2008 to 2010. Subjects passed a geriatric assessment, including a questionnaire for health care utilization and OOPP covering a period of three months in the following sectors: inpatient care, outpatient physician and non-physician services, medical supplies, pharmaceuticals, dental prostheses and nursing care. Determinants of OOPP were analyzed by a two-part model. The financial burden of OOPP for certain social subgroups (measured by the OOPP-income-ratio) was investigated by a generalized linear model for the binomial family.

Results

Mean OOPP during three months amounted to €119, with 34% for medical supplies, 22% for dental prostheses, 21% for pharmaceuticals, 17% for outpatient physician and non-physician services, 5% for inpatient care and 1% for nursing care. The two-part model showed a significant positive association between income (square root equivalence scale) and total OOPP. Increasing morbidity was associated with significantly higher total OOPP, and in particular with higher OOPP for pharmaceuticals. Total OOPP amounted to about 3% of disposable income. The generalized linear model for the binomial family showed a significantly lower financial burden for the wealthiest quintile as compared to the poorest one.

Conclusions

This is the first study providing evidence of inequalities in OOPP in the German elderly population. Socio-economic and morbidity-related inequalities in OOPP and the resulting financial burden could be identified. The results of this study may contribute to the discussion about the mechanisms causing the observed inequalities and can thus help decision makers to consider them when adapting future regulations on OOPP.

On the alert: future priorities for alerts in clinical decision support for computerized physician order entry identified from a European workshop

BACKGROUND

Clinical decision support (CDS) for electronic prescribing systems (computerized physician order entry) should help prescribers in the safe and rational use of medicines. However, the best ways to alert users to unsafe or irrational prescribing are uncertain. Specifically, CDS systems may generate too many alerts, producing unwelcome distractions for prescribers, or too few alerts running the risk of overlooking possible harms. Obtaining the right balance of alerting to adequately improve patient safety should be a priority.

METHODS

A workshop funded through the European Regional Development Fund was convened by the University Hospitals Birmingham NHS Foundation Trust to assess current knowledge on alerts in CDS and to reach a consensus on a future research agenda on this topic. Leading European researchers in CDS and alerts in electronic prescribing systems were invited to the workshop.

RESULTS

We identified important knowledge gaps and suggest research priorities including (1) the need to determine the optimal sensitivity and specificity of alerts; (2) whether adaptation to the environment or characteristics of the user may improve alerts; and (3) whether modifying the timing and number of alerts will lead to improvements. We have also discussed the challenges and benefits of using naturalistic or experimental studies in the evaluation of alerts and suggested appropriate outcome measures.

CONCLUSIONS

We have identified critical problems in CDS, which should help to guide priorities in research to evaluate alerts. It is hoped that this will spark the next generation of novel research from which practical steps can be taken to implement changes to CDS systems that will ultimately reduce alert fatigue and improve the design of future systems.

Development of a standardized knowledge base to generate individualized medication plans automatically with drug administration recommendations

AIMS

We aimed to develop a generic knowledge base with drug administration recommendations which allows the generation of a dynamic and comprehensive medication plan and to evaluate its comprehensibility and potential benefit in a qualitative pilot study with patients and physicians.

METHODS

Based on a literature search and previously published medication plans, a prototype was developed and iteratively refined through qualitative evaluation (interviews with patients and focus group discussions with physicians). To develop the recommendations for safe administration of specific drugs we screened the summary of product characteristics (SmPC) of different exemplary brands, allocated the generated advice to groups with brands potentially requiring the same advice, and reviewed these allocations regarding applicability and appropriateness of the recommendations.

RESULTS

For the recommendations, 411 SmPCs of 140 different active ingredients including all available galenic formulations, routes of administrations except infusions, and administration devices were screened. Finally, 515 distinct administration recommendations were included in the database. In 926 different generic groups, 29,879 allocations of brands to general advice, food advice, indications, step-by-step instructions, or combinations thereof were made. Thereby, 27,216 of the preselected allocations (91.1%) were confirmed as appropriate. In total, one third of the German drug market was labelled with information.

CONCLUSIONS

Generic grouping of brands according to their active ingredient and other drug characteristics and allocation of standardized administration recommendations is feasible for a large drug market and can be integrated in a medication plan.

Safeguarding the process of drug administration with an emphasis on electronic support tools

AIMS

The aim of this work is to understand the process of drug administration and identify points in the workflow that resulted in interventions by clinical information systems in order to improve patient safety.

METHODS

To identify a generic way to structure the drug administration process we performed peer-group discussions and supplemented these discussions with a literature search for studies reporting errors in drug administration and strategies for their prevention.

RESULTS

We concluded that the drug administration process might consist of up to 11 sub-steps, which can be grouped into the four sub-processes of preparation, personalization, application and follow-up. Errors in drug handling and administration are diverse and frequent and in many cases not caused by the patient him/herself, but by family members or nurses. Accordingly, different prevention strategies have been set in place with relatively few approaches involving e-health technology.

CONCLUSIONS

A generic structuring of the administration process and particular error-prone sub-steps may facilitate the allocation of prevention strategies and help to identify research gaps.

In-vitro evaluation of chronic alcohol effects on expression of drug-metabolizing and drug-transporting proteins

Objectives

In alcoholics without alcoholic liver disease, boosted drug elimination has been reported. However, mechanistic explanations for this phenomenon remain uncertain. In particular, data on the potential role of drug transporters are sparse.

Methods

Using a well-established in-vitro model for induction of human drug-metabolizing and drug-transporting proteins, we evaluated the potency of ethanol and the major fermentation side-product isopentanol to alter expression and function of these proteins by quantitative real-time polymerase chain reaction, Western blotting and flow cytometry. P-glycoprotein (Pgp)-inhibiting properties of ethanol and isopentanol were investigated via calcein extrusion assay.

Key findings

Ethanol and isopentanol significantly changed expression levels of drug-metabolizing and drug-transporting proteins that normalized within 2 weeks upon withdrawal. Cytochrome P-450 2C19 and Pgp were most strongly induced. Ethanol-induced Pgp at the messenger RNA (mRNA) (twofold to eightfold) and protein level (twofold), but not at the functional level. Both compounds did not inhibit Pgp.

Conclusions

Ethanol is demonstrated to increase mRNA and protein expression of human drug transporters such as Pgp in vitro. Withdrawal of ethanol exposure causes return to non-induced conditions within weeks. Functional consequences of increased Pgp expression in alcoholics need to be evaluated by clinical trials applying selective Pgp substrates such as digoxin.