Mortality among patients due to adverse drug reactions that lead to hospitalization: a meta-analysis

How much time do emergency department physicians spend on medication-related tasks? A time- and-motion study

BACKGROUND

Medication-related problems are an important cause of emergency department (ED) visits, and medication errors are reported in up to 60% of ED patients. Procedures such as medication reconciliation and medication review can identify and prevent medication-related problems and medication errors. However, this work is often time-consuming. In EDs without pharmacists, medication reconciliation is the physician's responsibility, in addition to the primary assignments of examining and diagnosing the patient. The aim of this study was to identify how much time ED physicians spend on medication-related tasks when no pharmacists are present in the EDs.

METHODS

An observational time-and-motion study of physicians in three EDs in Northern Norway was conducted using Work Observation Method by Activity Timing (WOMBAT) to collect and time-stamp data. Observations were conducted in predefined two-hour observation sessions with a 1:1 relationship between observer and participant, during Monday to Friday between 8 am and 8 pm, from November 2020 to October 2021.

RESULTS

In total, 386 h of observations were collected during 225 observation sessions. A total of 8.7% of the physicians' work time was spent on medication-related tasks, of which most time was spent on oral communication about medications with other physicians (3.0%) and medication-related documentation (3.2%). Physicians spent 2.2 min per hour on medication reconciliation tasks, which includes retrieving medication-related information directly from the patient, reading/retrieving written medication-related information, and medication-related documentation. Physicians spent 85.6% of the observed time on non-medication-related clinical or administrative tasks, and the remaining time was spent standby or moving between tasks.

CONCLUSION

In three Norwegian EDs, physicians spent 8.7% of their work time on medication-related tasks, and 85.6% on other clinical or administrative tasks. Physicians spent 2.2 min per hour on tasks related to medication reconciliation. We worry that patient safety related tasks in the EDs receive little attention. Allocating dedicated resources like pharmacists to contribute with medication-related tasks could benefit both physicians and patients.

A prospective intervention study to identify drug-related emergency department visits comparing a standard care group and a pharmaceutical care group

BACKGROUND AND IMPORTANCE

Adverse drug reactions impose a major burden. Those adverse drug reactions might lead to hospitalization but are often not correctly identified in the emergency department (ED). Clinical pharmacists, although not routinely implemented, can help identify adverse drug reactions.

OBJECTIVE

The primary objective was to examine the drug association of ED visits in a pharmaceutical group with a clinical pharmacist integrated in the ED team compared with a standard group without additional support.

DESIGN/SETTING/PARTICIPANTS

This prospective intervention study was performed in the ED of a tertiary care university hospital in Leipzig, Germany. Patients who were ≥50 years old were included. From 1 March 2020 to May 31, 2020 patients were enrolled in the standard group. From 1 March 2021 to 31 May 2021, the pharmaceutical group was enrolled. The clinical pharmacist supported the ED team with patient´s detailed medication history and medication analysis. In both groups, patients were evaluated whether their ED visit was drug-related.

OUTCOME MEASURES AND ANALYSIS

The number of identified drug-related ED presentations were compared between the two groups. Interventions performed on adverse drug reaction management, causative drugs and patient characteristics were evaluated.

MAIN RESULTS

A total of 798 patients were enrolled in the standard group and 827 patients in the pharmaceutical group. Patients whose ED visit was drug-related had a median age of 77 years [(Q25-Q75) 63.5-83.5] and took 7 [(Q25-Q75) 5-8] drugs in standard group. In the pharmaceutical group median age was 78 years [(Q25-Q75) 66-83] and number of drugs taken was 9 [(Q25-Q75) 5.25-11]. 31 (3.9%) drug-related ED visits were identified in the standard group compared to 104 (12.6%) in the pharmaceutical group (OR 3.56; 95% CI 2.35-5.38). An intervention on the patient's pharmacotherapy was performed in 16 drug-related ED visits in standard group compared to 77 in the pharmaceutical group.

CONCLUSION

In this study the implementation of a clinical pharmacist was associated with improved identification of drug-related ED visits. Discontinuations of causal medications and dose reductions were significantly higher in the pharmaceutical group compared to the standard care group.

Adverse clinical outcomes associated with drug-related hospitalizations in people with dementia

BACKGROUND

This study aimed to determine the clinical impact associated with adverse drug reactions (ADRs) in patients with dementia.

RESEARCH DESIGN AND METHODS

This case-control, propensity score-matched study utilized administrative data of people with dementia admitted to major public hospitals in Tasmania, Australia, from July 2010 to December 2019.

RESULTS

Acute renal failure constituted the most common ADR. The length of hospital stay was greater for people with an ADR index admission, versus non-ADR index admission (median [IQR]: 9 [4-18] versus 6 [2-12]; p < 0.001). In-hospital mortality and combined in-hospital and post-hospital mortality within 30, 60 and 90 days were higher for those whose index admission was ADR-related (in-hospital: HR 1.40, 95% CI 1.11-1.77, p-value <0.001; 30 days: HR 1.25, 95% CI 1.05-1.49, p-value <0.001; 60 days: HR 1.27, 95% CI 1.08-1.49, p-value <0.001; 90 days: HR 1.29, 95% CI 1.10-1.50, p-value <0.001). Subsequent ADR admission within 30, 60 and 90 days of index discharge was 9 to 10 times greater for people with dementia (30 days: OR 10.0, 95% CI 6.04-16.8, p-value <0.001; 60 days: OR 8.96, 95% CI 5.57-14.4, p-value <0.001; 90 days: OR 9.31, 95% CI 5.79-14.9, p-value <0.001).

CONCLUSION

Safe prescribing and vigilant monitoring of ADRs is pivotal to mitigate adverse outcomes in people with dementia.

Costs associated with adverse drug reactions in an older population admitted to hospital: a prospective cohort study

PURPOSE

This study examines healthcare costs associated with adverse drug reactions (ADR) in an older population admitted acutely to an Irish tertiary hospital.

METHODS

Prospective cohort study involving older persons admitted to hospital with and without an ADR. Data was collected at baseline, during hospitalisation and post-discharge. Participants provided information on healthcare resource use three months before admission (baseline) and three months after discharge (follow-up). For each healthcare resource, unit costs were derived and applied. The average cost (standard deviation (SD)) associated with the hospital admission for the ADR and non-ADR are presented. In addition, baseline and follow-up care costs were compared using difference-in-difference analysis and presented with 95% confidence intervals (CI). Costs by preventability and severity of ADR are also presented.

RESULTS

A total of n = 230 participants were included (n = 93 ADR and n = 137 without ADR). The average cost associated with hospital admission for an ADR was €9538 (SD €10442) and €9828 (SD €11770) for non-ADR. The additional follow-up costs (difference-in-difference) associated with the ADR was estimated at €2047 (95% CI: -€889 to €4983). The mean incremental follow-up cost of definite preventable ADRs was estimated at €1648 (95% CI: -€4310 to €7605), possible preventable ADRs €2259 (95 CI: -€1194 to €5712) and unavoidable ADRs €1757 (95% CI: -€3377 to €6890). The mean incremental follow-up cost associated with moderate severe ADRs was estimated at €1922 (95% CI: -€1088 to €4932) and €3580 (95% CI: -€4898 to €12,058) for severe ADRs.  CONCLUSION: ADRs leading to hospital admission are associated with modest incremental healthcare costs during and three months after admission. Severe and possibly preventable ADRs were associated with higher costs.

Hospitalisations Related to Adverse Drug Reactions in Switzerland in 2012-2019: Characteristics, In-Hospital Mortality, and Spontaneous Reporting Rate

INTRODUCTION

Adverse drug reactions (ADRs) contribute to morbidity, and serious ADRs may cause hospitalisation and death. This study characterises and quantifies ADR-related hospitalisations and subsequent in-hospital deaths, and estimates the spontaneous reporting rate to regulatory authorities in Switzerland, where healthcare professionals are legally obliged to report ADRs.

METHODS

This retrospective cohort study from 2012 to 2019 analysed nationwide data from the Federal Statistical Office. ICD-10 coding rules identified ADR-related hospitalisations. To estimate the reporting rate, individual case safety reports (ICSRs) collected in the Swiss spontaneous reporting system during the same period were considered.

RESULTS

Among 11,240,562 inpatients, 256,550 (2.3%) were admitted for ADRs, 132,320 (51.6%) were female, 120,405 (46.9%) were aged ≥ 65 (median of three comorbidities, interquartile range [IQR] 2-4), and 16,754 (6.5%) were children/teenagers (0 comorbidities, IQR 0-1). Frequent comorbidities were hypertension (89,938 [35.1%]), fluid/electrolyte disorders (54,447 [21.2%]), renal failure (45,866 [17.9%]), cardiac arrhythmias (37,906 [14.8%]), and depression (35,759 [13.9%]). Physicians initiated 113,028 (44.1%) of hospital referrals, and patients/relatives 73,494 (28.6%). Frequently ADR-affected were the digestive system (48,219 [18.8%], e.g. noninfective gastroenteritis and colitis), the genitourinary system (39,727 [15.5%], e.g. acute renal failure), and the mental/behavioural state (39,578 [15.4%], e.g. opioid dependence). In-hospital mortality was 2.2% (5669). Since ICSRs indicated 14,109 hospitalisations and 700 in-hospital deaths, estimated reporting rates were 5% and 12%, respectively.

CONCLUSIONS

This 8-year observation in Switzerland revealed that 2.3%, or roughly 32,000 admissions per year, were caused by ADRs. The majority of ADR-related admissions were not reported to the regulatory authorities, despite legal obligations.

Critical Assessment of Phenotyping Cocktails for Clinical Use in an African Context

Interethnic and interindividual variability in in vivo cytochrome P450 (CYP450)-dependent metabolism and altered drug absorption via expressed transport channels such as P-glycoprotein (P-gp) contribute to the adverse drug reactions, drug-drug interaction and therapeutic failure seen in clinical practice. A cost-effective phenotyping approach could be advantageous in providing real-time information on in vivo phenotypes to assist clinicians with individualized drug therapy, especially in resource-constrained countries such as South Africa. A number of phenotyping cocktails have been developed and the aim of this study was to critically assess the feasibility of their use in a South African context. A literature search on library databases (including AccessMedicine, BMJ, ClinicalKey, MEDLINE (Ovid), PubMed, Scopus and TOXLINE) was limited to in vivo cocktails used in the human population to phenotype phase I metabolism and/or P-gp transport. The study found that the implementation of phenotyping in clinical practice is currently limited by multiple administration routes, the varying availability of probe drugs, therapeutic doses eliciting side effects, the interaction between probe drugs and extensive sampling procedures. Analytical challenges include complicated sample workup or extraction assays and impractical analytical procedures with low detection limits, analyte sensitivity and specificity. It was concluded that a single time point, non-invasive capillary sampling, combined with a low-dose probe drug cocktail, to simultaneously quantify in vivo drug and metabolite concentrations, would enhance the feasibility and cost-effectiveness of routine phenotyping in clinical practice; however, future research is needed to establish whether the quantitative bioanalysis of drugs in a capillary whole-blood matrix correlates with that of the standard plasma/serum matrixes used as a reference in the current clinical environment.

Epidemiological investigation of emergency infusion adverse drug reactions in Nanjing, China: a prospective cross-sectional study

OBJECTIVE

Little is known about the morbidity and mortality of infusion Adverse drug reactions (ADRs) in the emergency department. We sought to evaluate the epidemiology of emergency infusion ADRs.

MATERIALS AND METHODS

This was a prospective study of infusion ADRs in the emergency infusion unit (EIU) of a tertiary hospital from 1 January 20201 January 2020, to 31 December 2021w31 December 2021. Emergency infusion ADRs were identified as intravenous drug-related ADRs that the causality was determined using the Naranjo algorithm. The incidence, severity and preventability of these ADRs were assessed using other standard criteria.

RESULTS

A total of 327 ADRs were recorded for 320 participants, antibiotics were the class of drugs most commonly involved, and 76.15% of ADRs occurred within the first hour. The most common symptoms observed were skin manifestations, accounting for 46.04% of ADRs. Mild reactions accounted for 85.32% based on the Hartwig and Siegel scale. In 89.30% of the reports, the ADRs were evaluated as not preventable based on the modified Schumock and Thornton scale. The causality and severity of ADRs were related to Charlson Comorbidity Index score and age (P < 0.05).

CONCLUSION

This epidemiological study described the pattern of emergency infusion ADRs in East China in detail. These findings may be useful to compare patterns among different centers.

Patterns of adverse drug reactions in Jordan: a retrospective analysis of the National Pharmacovigilance Data Registry (2015-2021)

BACKGROUND

Post-marketing surveillance of drugs is a cornerstone of pharmacovigilance. This study was conducted to characterize patterns of adverse drug reactions (ADRs) reported in Jordan.

RESEARCH DESIGN AND METHODS

ADR reports submitted to the pharmacovigilance database of the Jordan Food and Drug Administration during 2015-2021 were retrospectively analyzed. The most commonly reported drugs, drug classes, ADRs, and ADRs consequences were explored. Logistic regression identified possible predictors of reporting serious ADRs.

RESULTS

A total of 2744 ADR reports were included, among which 28.4% were classified as serious. An annual increase in ADR reporting was observed. The most commonly implicated drug classes were antineoplastic and immunomodulating agents (24.0%), anti-infectives for systemic use (14.2%), and alimentary tract and metabolism (12.1%). Covid-19 vaccination was the most reported drug (22.8%). Fatigue (6.3%), injection site pain (6.1%), and headache (6.0%) were the top three common ADRs. Among ADRs with outcome information, 4.7% were fatal. Patient's age and intravenous medication use largely predicted reporting serious ADRs.

CONCLUSIONS

This study provides contemporary insights into the post-marketing surveillance of drugs in Jordan. The findings are foundational for future studies exploring drug-ADRs causality relationships. Efforts that promote pharmacovigilance concepts should be sustained and enhanced at the national level.

STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: uptake and clinical impact

INTRODUCTION

STOPP/START criteria for potentially inappropriate medications (PIMs, STOPP) and potential prescribing omissions (PPOs, START) have gained considerable interest and traction since they were first published in 2008. This review focuses on their uptake and impact in various clinical settings.

AREAS COVERED

STOPP/START criteria, now in their third iteration, are explicit criteria designed to facilitate detection of common and clinically important PIMs and PPOs during routine medication review in any clinical setting. We examine the influence of the criteria, particularly in clinical trials that focused on their impact on clinically relevant endpoints.

EXPERT OPINION

STOPP/START criteria are widely used in several countries within Europe and beyond for medication review and audit. As a discreet intervention, the criteria have been tested in several single-center and two large-scale multi-center clinical trials. The single-center trials indicate that STOPP/START criteria reduce polypharmacy, inappropriate prescribing, ADRs (adverse drug reactions), medication cost and falls. In contrast, the SENATOR and OPERAM multicentre trials did not demonstrate significant reduction in ADRs, all-cause mortality, drug-related hospital readmissions, nor any improvement in quality-of-life. Further clinical trials are required to examine whether STOPP/START criteria as an intervention can deliver significant clinical benefit in a reproducible manner in various clinical settings.

Bupropion Mediated Effects on Depression, Attention Deficit Hyperactivity Disorder, and Smoking Cessation

Bupropion had been in use since the late 1980s as an unconventional treatment for depression. Unlike other antidepressants, bupropion has no serotonergic activity and inhibits the reuptake of norepinephrine and dopamine. The drug has been used to treat depression, Attention Deficit Hyperactivity Disorder (ADHD), and smoking cessation. This investigation reviews the pharmacokinetic and pharmacodynamic effects of bupropion and its mechanisms of action and interactions with other drugs. We evaluated the efficacy of major on and off-label uses of bupropion, focusing on the indications, benefits, and adverse effects. Our review demonstrates that bupropion is superior to placebo and non-inferior to SSRIs such as escitalopram in treating major depressive disorder. More research is needed to determine positive patient-centered outcomes such as increases in quality of life. In the case of ADHD, the evidence for efficacy is mixed with poorly conducted randomized clinical trials, small sample sizes, and a lack of long-term assessments. The same is true in the case of bipolar disorder in which there is still limited and controversial data available on bupropion's safety and efficacy. In the case of smoking cessation, bupropion is found to be an effective anti-smoking drug with synergistic benefits when used as a combination therapy. We conclude that bupropion has the potential to provide benefit for a subset of patients who do not tolerate other typical antidepressants or anti-smoking therapies or for those whose treatment goals align with bupropion's unique side effect profile, such as smokers who wish to quit and lose weight. Additional research is needed to determine the drug's full clinical potential, particularly in the areas of adolescent depression and combination therapy with varenicline or dextromethorphan. Clinicians should use this review to understand the varied uses of the drug and identify the situations and patient populations in which bupropion can lend its greatest benefit.

Patient perceptions and experiences with medication-related activities in the emergency department: a qualitative study

BACKGROUND

Emergency department (ED) pharmacists reduce medication errors and improve quality of medication use. Patient perceptions and experiences with ED pharmacists have not been studied. The aim of this study was to explore patients' perceptions of and experiences with medication-related activities in the ED, with and without an ED pharmacist present.

METHODS

We conducted 24 semistructured individual interviews with patients admitted to one ED in Norway, 12 before and 12 during an intervention, where pharmacists performed medication-related tasks close to patients and in collaboration with ED staff. Interviews were transcribed and analysed applying thematic analysis.

RESULTS

From our five developed themes, we identified that: (1) Our informants had low awareness and few expectations of the ED pharmacist, both with and without the pharmacist present. However, they were positive to the ED pharmacist. (2) Our informants expressed a variation of trust in the healthcare system, healthcare professionals and electronic systems, though the majority expressed a high level of trust. They believed that their medication list was automatically updated and assumed to get the correct medication. (3) Some informants felt responsible to have an overview of their medication use, while others expressed low interest in taking responsibility regarding their medication. (4) Some informants did not want involvement from healthcare professionals in medication administration, while others expressed no problems with giving up control. (5) Medication information was important for all informants to feel confident in medication use, but the need for information differed.

CONCLUSION

Despite being positive to pharmacists, it did not seem important to our informants who performed the medication-related tasks, as long as they received the help they needed. The degree of trust, responsibility, control and information varied among ED patients. These dimensions can be applied by healthcare professionals to tailor medication-related activities to patients' individual needs.

Impact of suspected adverse drug reactions on mortality and length of hospital stay in the hospitalised patients: a meta-analysis

PURPOSE

To estimate the risk of mortality and length of stay in hospitalised patients who have experienced suspected adverse drug reactions (ADRs) as compared to patients who did not experience suspected ADRs.

METHODS

A systematic literature search was conducted on databases for observational and randomised controlled studies conducted in any inpatient setting that reported deaths and/or length of hospital stay in patients who had suspected ADRs and did not have suspected ADRs during hospitalisation. PRISMA guidelines were strictly followed during the review. The methodological quality of included studies was assessed using a tool designed by Smyth et al. for the studies of adverse drug reactions. The meta-analytic summary of all-cause mortality was estimated using odds ratio-OR (95% CI) and length of stay using mean difference-MD (95% CI). Both outcomes were pooled using a random effect model (DerSimonian and Laird method). Subgroup and meta-regression were performed based on study variables: study design, age group, study ward, study region, types of suspected ADRs (ADR_Ad-suspected ADRs that lead to hospitalisation and ADR_In-suspected ADRs that occur following hospitalisation), study duration, sample size and study period. The statistical analysis was conducted through the 'Review manager software version 5.4.1 and JASP (Version 0.14.1)'.

RESULTS

After screening 475 relevant articles, 55 studies were included in this meta-analysis. Patients having suspected ADRs had reported significantly higher odds of all-cause mortality [OR: 1.50 (95% CI: 1.21-1.86; I² = 100%) than those patients who did not have suspected ADRs during hospitalisation. Study wards, types of suspected ADRs and sample size were observed as significant predictors of all-cause mortality (p < 0.05). Patients having suspected ADRs had reported significantly higher mean difference in hospital stay [MD: 3.98 (95% CI: 2.91, 5.05; I² = 99%) than those patients who did not have suspected ADRs during hospitalisation. Types of suspected ADRs and study periods were observed as significant predictors of length of stay (p < 0.05).

CONCLUSION

Suspected ADRs significantly increase the risk of mortality and length of stay in hospitalised patients.

SYSTEMATIC REVIEW REGISTRATION

CRD42020176320.

Physicians’ Knowledge, Altitudes, and Perceived Barriers of Inappropriate Prescribing for Older Patients in Shanghai, China

Background: Inappropriate medication use is common around the world, particularly among older patients, and, despite potentially being preventable, often leads to adverse clinical and economic outcomes. However, there is a dearth of information regarding this prominent issue in China.

Objectives: To evaluate the extent to which the physician can correctly identify potentially inappropriate medication (PIM) in older patients and to understand physicians’ attitudes towards improving PIM knowledge.

Methods: An online, cross-sectional survey was conducted anonymously among practicing physicians in China from November through December 2020. Knowledge of PIM was accessed using seven clinical vignettes covering a wide variety of therapeutic areas. Source of information and perceived barriers regarding PIM were also evaluated. We performed the ordinary least square regression analysis to understand the potential factors related to physicians’ knowledge of PIM.

Results: A total of 597 study participants were included in the analysis. More than half of them had never heard of any screening tool for PIMs (n = 328, 54.9%) and the most frequently acknowledged tool was the China PIM Criteria (n = 259, 43.4%). For the seven clinical vignettes testing physicians’ knowledge on the medications that should be generally avoided in older patients, the mean score was 2.91 points out of 7 (SD: 1.32), with the median score of three points (IQR: 2–4). Only one-third of the respondents were feeling confident when prescribing for older patients (n = 255, 35.08%). Package inserts have been used as the major source of PIM information (always, n = 177, 29.65%; frequently, n = 286, 47.91%). Perceived barriers to appropriate prescribing include polypharmacy (n = 460, 77.05%), lack of formal education on prescribing for the older patients (n = 428, 71.69%).

Conclusion: In this online survey evaluating physicians’ ability to detect PIM for older patients, approximately 40% of PIM were recognized, suggesting an insufficient level of knowledge about appropriate prescribing.

A systematic review on the cost effectiveness of pharmacogenomics in developing countries: implementation challenges

The major challenges that delay the implementation of pharmacogenomics based clinical practice in the developing countries, primarily the low- and middle-income countries need to be recognized. This review was conducted to systematically review evidence of the cost-effectiveness for the conduct of pharmacogenomics testing in the developing countries. Studies that evaluated the cost-effectiveness of pharmacogenomics testing in the developing countries as defined by the United Nations were included in this study. Twenty-seven articles met the criteria. Pharmacogenomics effectiveness were evaluated for drugs used in the treatment of cancers, cardiovascular diseases and severe cutaneous adverse reactions in gout and epilepsy. Most studies had reported pharmacogenomics testing to be cost-effective (cancers, cardiovascular diseases, and tuberculosis) and economic models were evaluated from multiple perspectives, different cost categories and time horizons. Additionally, most studies used a single gene, rather than a gene panel for the pharmacogenomics testing. Genotyping cost and frequency of risk alleles in the populations influence the cost-effectiveness outcome. Further studies are warranted to examine the clinical and economic validity of pharmacogenomics testing in the developing countries.

Ten-year trends in adverse drug reaction–related hospitalizations among people with dementia

Aim:

Trends in the incidence of adverse drug reaction (ADR)–related hospitalizations have been studied in the general population, but not specifically in people with dementia. This study aimed to investigate trends in the incidence of ADR-related hospitalizations among people with dementia, and identify the most commonly implicated drugs and diagnoses in these admissions.

Methods:

This study utilized the administrative data of all adults admitted to the four major public hospitals of Tasmania, Australia, with a primary or secondary diagnosis of dementia from July 2010 to December 2019. ADR-related hospitalizations were identified by using diagnosis-based and external cause codes. The Cochran–Armitage test was used to examine trends in the incidence of ADR-related hospitalizations.

Results:

Of the 7552 people with dementia admitted to the hospital at least once within the study period, 1775 (23.5%) experienced at least one ADR-related hospitalization. The estimated annual incidence of ADR-related hospitalizations increased 18% (1484–1760 per 100,000 population with dementia, p for trend <0.05) from 2010 to 2019. For those ADR-related admissions with a drug code recorded, 19.3% were due to antithrombotics and 11.5% to antihypertensives. The most frequent ADR-related admission diagnoses were renal diseases (72.9%). Length of hospital stay and in-hospital mortality were both significantly greater for ADR-related, relative to non-ADR-related, admissions (median 7 versus 5 days and 11% versus 6.7%, respectively; p < 0.001).

Conclusion:

The annual incidence of ADR-related hospitalizations in people with dementia increased between 2010 and 2019. Antithrombotics were the most commonly implicated drug class. The ADR-related hospitalizations were associated with increased length of stay and greater mortality.

Plain Language Summary

Adverse drug reaction–related hospitalizations among people with dementia

Introduction:

This study aimed to investigate trends in hospitalizations associated with medication problems among people with dementia, and identify the most commonly implicated drugs and diagnoses in these admissions.

Methods:

This study utilized the administrative data of all adults admitted to the four major public hospitals of Tasmania, Australia, with dementia from July 2010 to December 2019.

Results:

The annual incidence of hospitalizations associated with medication problems among people with dementia increased nearly 20% over 10 years. The length of hospital stay and in-hospital mortality were significantly greater for hospitalizations related to medication problems.

Conclusion:

The incidence of hospitalizations associated with medication problems in people with dementia increased between 2010 and 2019.

Drug-Related Deaths in China: An Analysis of a Spontaneous Reporting System

Background: Adverse drug reactions with an outcome of death represent the most serious consequences and are inherently important for pharmacovigilance. The nature and characteristics of drug-related deaths are to a large extent unknown in the Chinese population. This study aims to characterize drug-related deaths by analysis of individual case safety reports (ICSRs) with an outcome of death in China.

Methods: The characteristics of death ICSRs were analyzed by descriptive statistics of a large multi-provincial pharmacovigilance database in China.

Results: There were 1,731 ICSRs with an outcome of death, representing 0.95% of all serious cases and 0.05% of all reported ICSRs. Most death ICSRs (78.57%) were reported by medical institutions. Only 16.00% of death ICSRs were reported by manufacturers or distributors. The reporting rate of death ICSRs in the age group of 0–4 years was significantly higher than patients aged 5–64 years. Patients aged over 64 years had the highest reporting rate of death ICSRs. Male patients generally had a higher reporting rate of death ICSRs than female patients. However, the reporting rate of female patients exceeded that of male patients in the age group of 20–34 years. Among 3,861 drugs implicated, ceftriaxone sodium with 146 (3.78%) records of death ranked first. Dexamethasone with 131 (3.39%) records of death ranked second. Qingkailing, an injectable traditional Chinese medicine with 75 (1.94%) records of death, ranked the fifth most frequently implicated medicine.

Conclusion: Young children and elderly patients have a higher risk of drug-related deaths than patients aged 5–64 years. Female patients generally have a lower risk of drug-related deaths than male patients. However, female patients of reproductive age (aged 20–34 years) have a higher risk of drug-related deaths than male patients, hinting that physiological changes and drug uses for child bearing, giving birth, or birth control may significantly increase the risk of death for female patients aged 20–34 years. This paper suggests more research on the safe use of drugs for young children, elderly patients, and female patients of reproductive ages. Pharmacovigilance databases can be valuable resources for comprehensive understanding of drug-related problems.

Fatal Events Associated with Adverse Drug Reactions in the Korean National Pharmacovigilance Database

Adverse drug reactions (ADRs) pose a global public health threat, substantially contributing to death. Due to the relative paucity of clinical evidence regarding fatal ADRs, this study was performed to characterize the epidemiology of fatal ADRs in Korea. This was a retrospective, cross-sectional analysis of ADR cases reported to the Korea Adverse Event Reporting System from 2010 to 2019. All ADRs were coded using the World Health Organization-Adverse Reaction Terminology system and classified as either fatal or non-fatal events. Logistic regression was performed to identify factors associated with fatal events. Among 289,756 ADR records, 629 fatal events (0.2%) occurred. The most common causative agent of fatal ADRs was antibacterials (20.3%), followed by antimycobacterials (5.4%), analgesics (4.0%), and contrast media (1.9%). Among antimicrobials, vancomycin was most frequently implicated without significantly increasing the risk of fatal events. The risk for fatal ADRs was significantly increased with male sex; advanced age; polypharmacy; piperacillin/β-lactamase inhibitor; cefotetan; ceftriaxone; combination antimycobacterial therapy consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol; morphine; and iopromide (reporting odds ratio > 1, p < 0.05 for all). Although fatal ADRs are uncommon (<1%) in Korea, they are primarily caused by commonly used medications including antibiotics, analgesics, and contrast media.

Serious adverse drug reactions in sub-Saharan Africa in the era of antiretroviral treatment: A systematic review

We aimed to summarize and describe the burden of serious adverse drug reactions (ADRs) in sub-Saharan Africa (SSA) in the era of antiretroviral therapy. We searched Medline, CINAHL, Africa-Wide Information, Scopus, and Web of Science, without language restriction up to March 2021. We hand-searched reference lists, conference abstracts, and dissertation databases. We included studies reporting proportions of admissions attributed to ADRs, admissions prolonged by ADRs, or in-hospital deaths attributed to ADRs. Two reviewers independently screened the studies, reviewed the study quality using a previously published tool, and extracted the data. We tested for heterogeneity using I2 -statistics and summarized the study results using medians and interquartile ranges. Subgroup analyses summarized the results by study quality, setting, methodology, and population. From 1005 unique references identified, we included 15 studies. Median study quality was 7/10; heterogeneity was very high. Median [IQR] proportion of admissions attributed to ADRs was 4.8% [1.5% to 7.0%] (14 studies) and 6.4% [4.0% to 8.4%] in nine active surveillance studies in adults. Two pediatric studies reported the proportion of admissions prolonged by ADRs (0.29% and 0.99%). Three studies reported the proportion of in-hospital deaths attributed to ADRs (2.5%, 13%, and 16%). Antiretroviral and antituberculosis drugs were often implicated in serious ADRs. Evidence of the burden of serious ADRs in SSA is patchy and heterogeneous. A few high-quality studies suggest that the burden is considerable, and that it reflects the regional impact of the HIV pandemic. Further characterization of this burden is required, ideally in studies of standardized methodology.

Drug-related deaths among inpatients: a meta-analysis

PURPOSE

To estimate the prevalence of drug-related deaths with regard to total hospital mortality and to explore the heterogeneity in its estimation through subgroup analysis, univariate and multivariate analysis.

METHODS

Two investigators independently searched the PubMed and Google Scholar databases with appropriate key terms to identify observational and randomised studies assessing drug-related problems. The prevalence of drug-related deaths was estimated using a double arcsine method. The heterogeneity was explored through subgroup and univariate analysis for the following study characteristics: study design, age group, study ward, study region, types of drug-related problems, study duration, sample size and study period. The study variables showing significant effects were further explored through a multivariable regression model. The percentage of preventable drug-related deaths was explored as a secondary objective.

RESULTS

Of the 480 full-text articles assessed, 23 studies satisfying the selection criteria were included. The mean percentage of drug-related deaths was 5.6% (95% CI: 3.8-7.6%; I² = 96%). The univariable analysis showed study design (regression coefficient: 4.31) and study wards (regression coefficient: - 6.37) as heterogeneity modifiers. In the multivariable model, only the study ward was considered a significant predictor of drug-related deaths (regression coefficient: - 5.78; p = 0.04). The mean percentage of preventable drug-related deaths was 45.2% (95% CI: 33.6-57.0%; I² = 60%).

CONCLUSION

Drug-related problems are an important cause of mortality. The variability in its estimation could be explained by admission wards.

Drug-Related Deaths in a Tertiary Hospital: Characteristics of Spontaneously Reported Cases and Comparison to Cases Detected from a Retrospective Study

Drug-related deaths (DRDs) are a common cause of hospital death. Pharmacovigilance, either as spontaneous reporting or active surveillance, plays a key role in the detection and reporting of suspected adverse drug reactions (ADRs). We conducted a retrospective analysis of all DRDs spontaneously reported to a pharmacovigilance program of a tertiary hospital, by health care professionals. We compared these results to those of a previous retrospective study conducted in the same hospital from the hospital's mortality registry. From 1460 spontaneous reported ADRs in a 10-year period, 73 (5%) were DRDs. The median age of DRD was 75 years (range 1 month-94) and 60.3% were men. The most frequent DRDs were hemorrhages (41.1%), followed by infections (17.8%). The most frequently involved drugs were anticoagulants and/or antithrombotic (30%), and antineoplastics (26.3%). When comparing both studies, spontaneous reporting detected more type B reactions (p < 0.001) and hospital-acquired DRD (p < 0.001); the number of concomitant drugs was higher (p = 0.0035); and the kind of ADR were different. The combination of several methods is mandatory to detect, assess, understand, and design strategies to prevent ADRs in a hospital setting, to ensure patient safety.

Qualitative Study of Community Pharmacists' and General Practitioners' Views toward Pharmacovigilance in Lithuania

Lithuania is the leader in pharmacovigilance among the three Baltic countries. However, comparisons with other European countries are difficult because the reported number of adverse drug reactions (ADRs) in Lithuania is too low to rely on in terms of the annual use of medicines by the population over the year. The aim of this study was to explore challenges related to the understanding and practices of general practitioners and community pharmacists in reporting ADRs in Lithuania. The qualitative study approach of face-to-face interviews was used. All interviews were recorded, transcribed verbatim, and thematically analyzed. Twelve interviews with general practitioners and community pharmacists were conducted from March 2020 through December 2020. All participants had a basic knowledge of pharmacovigilance, but only four participants reported ADRs to the interviewer. Six main barriers regarding ADR reporting were identified, and appropriate interventions were suggested. The importance of collaboration between physicians and pharmacists was highlighted, and the need for guidelines supporting collaboration was expressed. Medications are becoming more complex, and comprehensive medication management is key for the optimization of patient outcomes. Our results reveal the need to improve and innovate the current pharmacovigilance system at all levels, starting from education for pharmacy and healthcare students and continuing through the development of ADR procedures.

CYP2B6 Functional Variability in Drug Metabolism and Exposure Across Populations-Implication for Drug Safety, Dosing, and Individualized Therapy

Adverse drug reactions (ADRs) are one of the major causes of morbidity and mortality worldwide. It is well-known that individual genetic make-up is one of the causative factors of ADRs. Approximately 14 million single nucleotide polymorphisms (SNPs) are distributed throughout the entire human genome and every patient has a distinct genetic make-up which influences their response to drug therapy. Cytochrome P450 2B6 (CYP2B6) is involved in the metabolism of antiretroviral, antimalarial, anticancer, and antidepressant drugs. These drug classes are commonly in use worldwide and face specific population variability in side effects and dosing. Parts of this variability may be caused by single nucleotide polymorphisms (SNPs) in the CYP2B6 gene that are associated with altered protein expression and catalytic function. Population variability in the CYP2B6 gene leads to changes in drug metabolism which may result in adverse drug reactions or therapeutic failure. So far more than 30 non-synonymous variants in CYP2B6 gene have been reported. The occurrence of these variants show intra and interpopulation variability, thus affecting drug efficacy at individual and population level. Differences in disease conditions and affordability of drug therapy further explain why some individuals or populations are more exposed to CYP2B6 pharmacogenomics associated ADRs than others. Variabilities in drug efficacy associated with the pharmacogenomics of CYP2B6 have been reported in various populations. The aim of this review is to highlight reports from various ethnicities that emphasize on the relationship between CYP2B6 pharmacogenomics variability and the occurrence of adverse drug reactions. In vitro and in vivo studies evaluating the catalytic activity of CYP2B6 variants using various substrates will also be discussed. While implementation of pharmacogenomic testing for personalized drug therapy has made big progress, less data on pharmacogenetics of drug safety has been gained in terms of CYP2B6 substrates. Therefore, reviewing the existing evidence on population variability in CYP2B6 and ADR risk profiles suggests that, in addition to other factors, the knowledge on pharmacogenomics of CYP2B6 in patient treatment may be useful for the development of personalized medicine with regards to genotype-based prescription.

Drug-related challenges following primary total hip and knee arthroplasty

We aimed to characterize the in-hospital analgesic use among total hip or knee arthroplasty (THA or TKA) patients, and to identify possible drug-related challenges. We identified 15 263 patients operated with a THA or TKA between 1 January 2012 and 30 April 2016. The prevalence of analgesic users and patients with potential clinically relevant drug-drug interactions (DDIs), along with the prevalence of readmission among patients with vs. without a DDI, were calculated. A DDI was defined as the combination of (A) a diuretic, an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker, and an non-steroidal anti-inflammatory Drug (NSAID); (B) warfarin and an NSAID; and (C) a benzodiazepine or a benzodiazepine-related drug and an opioid. The prevalence of analgesics administered in THA and TKA patients was 99.3% and 99.1% for paracetamol and 93.8% and 98.8% for opioids, respectively. The prevalence of patients who received interaction A, B or C was 8.4%, 2.5% and 40.7%, respectively. Patients with vs. without a DDI had a higher prevalence of 30-day readmission. In conclusion, most THA and TKA patients were administered paracetamol or opioids. The prevalence of 30-day readmission was higher in patients with than in patients without a potential clinically relevant DDI.

An Evaluation of Postmarketing Reports with an Outcome of Death in the US FDA Adverse Event Reporting System

INTRODUCTION

Adverse reactions with an outcome of death are inherently important for pharmacovigilance organizations to evaluate. Prior efforts to systematically evaluate individual case safety reports (ICSRs) with an outcome of death have been limited to high-level summaries.

OBJECTIVE

The aim of this study was to characterize ICSRs with an outcome of death contained in the US FDA Adverse Event Reporting System (FAERS) database.

METHODS

All ICSRs received through 31 December 2017 reporting an outcome of death were characterized by patient demographics, suspect product(s), adverse events, and reporter type. Using the ICSR's narrative and reporter information, we classified ICSRs by source to include those from industry-sponsored programs, poison control centers, specialty pharmacies, and litigation. Additionally, a random sample of ICSRs was evaluated for completeness of structured data fields and manually reviewed for the availability of key information in the narrative (i.e. cause of death, medical history, and causality assessment).

RESULTS

Overall, 1,053,716 ICSRs with a death outcome were received in the study period. Ten medications treating conditions for malignancies, pain, and kidney disease accounted for nearly 20% of all fatal ICSRs. ICSRs originating from industry-sponsored programs, poison control centers, litigation, and specialty pharmacies accounted for 14%, 6.5%, 5.0%, and 3.3% of all fatal ICSRs, respectively. ICSRs in which the only adverse event coded was 'death' were more likely to be missing structured data and less likely to include key information in the narrative.

CONCLUSION

Understanding the origins and characteristics of ICSRs with an outcome of death supports meaningful evaluations and interpretations of FAERS data. A wide variability in ICSR quality exists, even in those reports with the most serious outcome.

Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study

With the increase in prevalence of cardiovascular diseases, multimorbidity, and medical progress, oral antithrombotic (AT) combinations are increasingly prescribed. The aims of this study were to estimate the incidence of oral AT combinations, their appropriateness (defined as indications compliant with guidelines), and the related risk of major bleeding (i.e., leading to hospitalization) or death, among new users. We conducted a 5-year historical cohort study, using the French national healthcare database, including all individuals ≥ 45 years old with a first delivery of oral ATs between 1 January 2013 and 31 December 2017. The cumulative incidence of oral AT combinations was estimated with the Fine and Gray method, taking into account the competitive risk of death. We compared the cumulative incidence of major bleeding according to the type of oral AT treatment initiated at study entry (monotherapy or oral AT combinations). During the study period, 22,220 individuals were included (mean (SD) age 68 (12) years). The cumulative incidence of oral AT combinations at 5 years was 27.8% (95% confidence interval (CI) 26.8–28.9). Overall, 64% of any oral AT combinations did not comply with guidelines. The cumulative incidence of major bleeding and death in the whole cohort at 5 years was 4.1% (95% CI 3.7–4.6) and 10.8% (95% CI 10.1–11.6), respectively. Risk of major bleeding increased among individuals with oral AT combinations versus oral AT monotherapy at study entry (subdistribution hazard ratio sHR: 2.16 (1.01–4.63)); with no difference in terms of death. The use of oral AT combinations among oral AT users is frequent, often inappropriately prescribed, and associated with an increased risk of major bleeding.

Estimation of adverse drug reaction reporting in Iran: Correction for underreporting

PROPOSE

Underreporting of Adverse Drug Reactions (ADRs) reduces the sensitivity of pharmacovigilance systems. We described ADR reporting and its trend from 1999 to 2017 and estimated the ADR underreporting in the Iranian Pharmacovigilance Center.

METHODS

We expressed the number of ADR reporting per inhabitants and admissions and their possible trends. Finally, ADR underreporting percentages were estimated by three approaches: prospective studies, literature review, stratification of the country; and the trend of the proportion of ADR per inhabitants was corrected.

RESULTS

The proportion of ADR reporting was 15.3 per 100 000 inhabitants (95% CI: 15.2, 15.8) and 10.0 per 100 000 admissions (95% CI: 9.8, 10.2) in 2017, and its trend was increasing with 16.3% average change per annum during 19 years. The median of estimated percentages of underreporting was 76.0% (IQR: 64.32-81.35). After the correction, the mean proportion of ADR reporting for 19 years reached from 5.87 to 10.33 per 100 000 inhabitants.

CONCLUSIONS

The trend of ADRs reporting has been increasing over the 19 years but is still low. This study showed a considerable underreporting of ADR, and about one of four detected ADRs were reported to the pharmacovigilance center from 1999 to 2017.

Fatal adverse drug reactions: A worldwide perspective in the World Health Organization pharmacovigilance database

AIMS

Adverse drug reactions (ADRs) are important causes of death. However, the main involved drugs are relatively unknown. The present study was performed to characterise death-related drugs recorded in a large pharmacovigilance database during the last 10 years.

METHODS

A retrospective analysis of VigiBase, the World Health Organization pharmacovigilance database, was performed investigating fatal ADRs registered between 1 January 2010 and 31 December 2019 in male and female patients aged ≥18 years and reported by physicians. Analyses were descriptive investigating age, sex and suspected drugs. Differences in reporting according to sex, age and continents were investigated using disproportionality analysis with calculation of reporting odds ratio and its 95% confidence interval.

RESULTS

Among the 23 millions ADRs recorded in VigiBase, 3 250 967 were included with 43 685 fatal. They were reported mainly in patients older than 75 years. The 3 most frequently involved drug classes were antineoplastic/immunomodulating drugs followed by nervous system and cardiac drugs. The top 3 individual drugs were denosumab, lenalidomide and thalidomide with marked differences according to age, sex, continents and countries. The risk of reporting fatal ADRs was higher in males, in the Americas and in patients ≥65 years.

CONCLUSION

Fatal ADRs registered in a large pharmacovigilance database during the last 10 years correspond to just over 1% of the total number of ADRs. They occurred more in males, after 65 years and with antineoplastic/immunomodulating drugs in general. Our study also highlighted, for the first time, important differences in fatal ADRs between continents and countries.

Analysis of fatal adverse drug events recorded in several Italian emergency departments (the MEREAFaPS study)

Fatal Adverse Events (FADEs) are a major public health problem, and some FADEs could be preventable. The aim of the present study is to describe the frequency, the drugs involved and the preventability in the FADEs collected through the MEREAFaPS Study between 2012 and 2018. All cases including the outcome "death" have been examined. We excluded cases with vaccine-related ADEs, overdose or suicide, and ADEs occurred during the hospitalisation. Two trained assessors evaluated all cases fulfilling the inclusion criteria. ADEs' preventability was evaluated applying the Schumock and Thornton algorithm. During the study period, we observed 429 cases of death, 92 of which were excluded. The remaining 337 cases involved 187 women and 150 men, with a mean age of 79 and of 77 years, respectively. For each report, the suspected drugs and concomitant ones were 1.26 and 4.20, respectively. Anticoagulants and antiplatelet agents account for more than 40% of FADE cases and the most frequent reactions are haemorrhages (37.5%). The 25% of the FADEs were preventable. This study confirms that FADEs are still a relevant clinical occurrence, and are often caused by widely used old drugs associated with adverse events. The death of one in four patients was preventable. Further efforts should be done to improve the appropriateness of the therapy, especially in older patients who are treated with anticoagulants.

Adverse event rates associated with oral anticoagulant treatment early versus later after hospital discharge in older adults: a retrospective population-based cohort study

BACKGROUND

Oral anticoagulants are commonly used high-risk medications, but little is known about their safety in transition from hospital to home. Our objective was to measure the rates of hemorrhage and thromboembolic events among older adults receiving oral anticoagulant treatment early after hospital discharge compared to later.

METHODS

We conducted a retrospective population-based cohort study among Ontario residents aged 66 years or more who started, continued or resumed oral anticoagulant therapy at hospital discharge between September 2010 and March 2015. We calculated the rates of hemorrhage and thromboembolic events requiring hospital admission or an emergency department visit over a 1-year follow-up period, stratified by the first 30 days after discharge and the remainder of the year. We used multivariable regression models, adjusting for covariates, to estimate the effect of sex, prevalent versus incident use, and switching anticoagulants on events.

RESULTS

A total of 123 139 patients (68 408 women [55.6%]; mean age 78.2 yr) were included. About one-quarter (32 563 [26.4%]) had a Charlson Comorbidity Index score of 2 or higher. The rates of hemorrhage and thromboembolic events per 100 person-years were highest during the first 30 days after hospital discharge (25.8, 95% CI 24.8-26.8 and 19.3, 95% CI 18.4-20.2, respectively), falling to 15.7 (95% CI 15.3-16.1) and 6.9 (95% CI 6.6-7.1), respectively, during the subsequent 11 months. Multivariable analysis showed that patients whose anticoagulant was switched in hospital and men had more hemorrhages and thromboembolic events in follow-up.

INTERPRETATION

The first few weeks following hospital discharge represent a very high-risk period for adverse events related to oral anticoagulant treatment among older adults. The results support an intervention trial addressing anticoagulation management in the early postdischarge period.

Integrating disease and drug-related phenotypes for improved identification of pharmacogenomic variants

Aim: To improve the identification and interpretation of pharmacogenetic variants through the integration of disease and drug-related traits. Materials & methods: We hypothesized that integrating genome-wide disease and pharmacogenomic data may drive new insights into drug toxicity and response by identifying shared genetic architecture. Pleiotropic variants were identified using a methodological framework incorporating colocalization analysis. Results: Using genome-wide association studies summary statistics from the UK Biobank, European Bioinformatics Institute genome-wide association studies catalog and the Pharmacogenomics Research Network, we validated pleiotropy at the ABCG2 locus between allopurinol response and gout and identified novel pleiotropy between antihypertensive-induced new-onset diabetes, Crohn's disease and inflammatory bowel disease at the IL18RAP/SLC9A4 locus. Conclusion: New mechanistic insights and genetic loci can be uncovered by identifying pleiotropy between disease and drug-related traits.

Nephrotoxin Stewardship

Drugs are the third leading cause of acute kidney injury (AKI) in critically ill patients. Nephrotoxin stewardship ensures a structured and consistent approach to safe medication use and prevention of patient harm. Comprehensive nephrotoxin stewardship requires coordinated patient care management strategies for safe medication use, ensuring kidney health, and avoiding unnecessary costs to improve the use of nephrotoxins, renally eliminated drugs, and kidney disease treatments. Implementing nephrotoxin stewardship reduces medication errors and adverse drug events, prevents or reduces severity of drug-associated AKI, prevents progression to or worsening of chronic kidney disease, and alleviates financial burden on the health care system.

A cell-based high-throughput screen identifies drugs that cause bleeding disorders by off-targeting the vitamin K cycle

Drug-induced bleeding disorders contribute to substantial morbidity and mortality. Antithrombotic agents that cause unintended bleeding of obvious cause are relatively easy to control. However, the mechanisms of most drug-induced bleeding disorders are poorly understood, which makes intervention more difficult. As most bleeding disorders are associated with the dysfunction of coagulation factors, we adapted our recently established cell-based assay to identify drugs that affect the biosynthesis of active vitamin K-dependent (VKD) coagulation factors with possible adverse off-target results. The National Institutes of Health (NIH) Clinical Collection (NCC) library containing 727 drugs was screened, and 9 drugs were identified, including the most commonly prescribed anticoagulant warfarin. Bleeding complications associated with most of these drugs have been clinically reported, but the pathogenic mechanisms remain unclear. Further characterization of the 9 top-hit drugs on the inhibition of VKD carboxylation suggests that warfarin, lansoprazole, and nitazoxanide mainly target vitamin K epoxide reductase (VKOR), whereas idebenone, clofazimine, and AM404 mainly target vitamin K reductase (VKR) in vitamin K redox cycling. The other 3 drugs mainly affect vitamin K availability within the cells. The molecular mechanisms underlying the inactivation of VKOR and VKR by these drugs are clarified. Results from both cell-based and animal model studies suggest that the anticoagulation effect of drugs that target VKOR, but not VKR, can be rescued by the administration of vitamin K. These findings provide insights into the prevention and management of drug-induced bleeding disorders. The established cell-based, high-throughput screening approach provides a powerful tool for identifying new vitamin K antagonists that function as anticoagulants.

Undergraduate and postgraduate pharmacovigilance education: A proposal for appropriate curriculum content

BACKGROUND

Adverse drug reactions (ADRs) are common, often preventable, and a leading cause of morbidity and mortality. Pharmacovigilance (PV) involves detection, assessment, understanding, and prevention of adverse effects or any other drug-related problem. Education of healthcare professionals (HCPs) involved in drug prescription, dispensing and administration is essential to help prevent and mitigate both ADRs and medication errors and has to be focused on 3 pivotal aspects: •Awareness: All medicines can produce adverse effects. ADRs should always be considered as part of the differential diagnosis if any new adverse condition, symptoms or signs appear after a drug administration or during or after pharmacological treatment. •Knowledge: HCPs must have a sound understanding of the most frequently prescribed drugs and over-the-counter medications, factors that make patients more likely to benefit or more susceptible to harm, as well as of causes of medication errors. •Reporting: HCPs should know how to report ADRs and the role of reporting on regulatory aspects and scientific knowledge. Undergraduate curricula must provide, at a minimum, sufficient skills that warrant the appropriate and safe prescription/dispensing/administration of medications in clinical practice, focusing both on therapeutic effects and prevention of harm. Clinical appraisal skills must include ADRs as differential diagnosis, taking accurate medication history, basic individual causality assessment, identification and proper management of ADRs, and informing patients of possible ADRs. Postgraduate periodic PV training should be mandatory as part of continuing education. Specialised postgraduate education should include advanced contents.

The safety of oral anticoagulants registry (SOAR): A national, ED-based study of the evaluation and management of bleeding and bleeding concerns due to the use of oral anticoagulants

OBJECTIVE

The Safety of Oral Anticoagulants Registry (SOAR) was designed to describe the evaluation and management of patients with oral anticoagulant (OAC)-related major bleeding or bleeding concerns who present to the emergency department (ED) with acute illness or injury. Patients in the ED are increasingly taking anticoagulants, which can cause bleeding-related complications as well as impact the acute management of related or unrelated clinical issues that prompt presentation. Modifications of emergency evaluation and management due to anticoagulation have not previously been studied.

METHODS

This was a multicenter observational in-hospital study of patients who were judged to be experiencing an active OAC effect and had (a) an obvious bleeding event or (b) were deemed at risk for serious bleeding spontaneously, after injury, or during an indicated invasive procedure. Diagnostic testing, therapies employed, and clinical outcomes were collected.

RESULTS

Thirty-one US hospitals contributed data to SOAR. Of 1513 subjects, acute hemorrhage (AH) qualified 78%, while 22% had a bleeding concern (BC). Warfarin was the index OAC in 37.3%, dabigatran in 13.3%, and an anti-Factor X_a in 49.4%. The most common sites of AH were gastrointestinal (51.0%) and intracranial (26.8%). In warfarin-treated patients, the mean (IQR) presenting INR was 3.1 (2.2, 4.8) in AH patients and 3.9 (2.4, 7.2) in BC patients. Three-fifths of SOAR patients were treated with factor repletion or specific reversal agents, and those patients had a longer length of stay. In addition, seven (0.76%) of the treated patients experienced an in-hospital thrombotic complication; two of these seven died on the index admission, both of fatal pulmonary embolism. Vitamin K was used and dosed inconsistently in both warfarin and NOAC cohorts.

CONCLUSION

Care of anticoagulated patients in the acute care setting is inconsistent, reflecting the diversity of presentation. As the prevalence of OAC use increases with the aging of the US population, further study and targeted educational efforts are needed to drive more evidence-based care of these patients.

Potential drug-drug interactions associated with clinical and laboratory findings at hospital admission

Background Drug-drug interactions represent one of the causes of adverse therapy outcomes through deteriorated efficacy or safety. However, the true extent of harm related to drug-drug interactions is not well established due to a lack of recognition and understanding. Objective The aim of this study was to investigate the association of potential drug-drug interactions with patients variables recorded at admission. Setting A cross-sectional correlation study was performed on the Cardiology ward of the University Clinical Hospital Center in Belgrade, Serbia. Method Data were retrospectively obtained from medical records and LexiInteract was used as the screening tool for potential drug-drug interactions. Main outcome measure Clinical and laboratory parameters recorded at the patients admission. Results A total of 351 patient records entered the analysis, with the mean age of 70 ± 10 years. The prevalence of potentially relevant drug-drug interactions was 61% (N = 213). After controlling for patient characteristics, nine potential drug-drug interactions were significantly associated with laboratory values outside the range and five potential drug-drug interactions with inadequate clinical parameter values. Potential drug-drug interactions were associated with abnormalities in blood count, metabolic parameters, electrolyte imbalance and renal function parameters. Association with inadequate control of systolic, diastolic blood pressure, as well as heart rhythm was also shown. Conclusion Drug-drug interactions were associated with patients clinical and laboratory findings. Our findings may assist in the identification of patients with increased likelihood of suboptimal therapy outcomes. Generating evidence through post-marketing drug-drug interactions research would lead to improvement in clinical decision-support systems, increased effectiveness and utilization in everyday clinical practice.

Analysis of spontaneous reporting of suspected adverse drug reactions for non-analgesic over-the-counter drugs from 2008 to 2017

BACKGROUND

Adverse drug reaction (ADR) reporting practices by health care professionals remain poor. Over-the-counter (OTC) drugs are perceived as safe; however, they can also cause ADRs. The objective of this study was to analyze ADR reporting for OTC drugs in a 10-year period, in order to evaluate frequency of ADRs, population that ADRs most affect and reporters of ADRs of OTC drugs in Croatia.

METHODS

Spontaneously reported ADRs of non-analgesic OTC drugs, collected from January 2008 to December 2017 were analyzed. Data was obtained from Agency for Medicinal Products and Medical Devices of Croatia (HALMED).

RESULTS

There were 547 ADRs of OTC drugs reported in total and an increase in number of reports through the years was observed. Pharmacists reported 45.4% of all ADRs, and were most frequent reporters (p < 0.001). In 2017 majority of reports, 62 (49.2%), were obtained from consumers. ADRs were most frequently observed in patients aged 70 years and older (15% of ADRs). Five percent of all reports were accidental exposures among children.

CONCLUSIONS

Pharmacists most frequently reported ADRs of OTC drugs and consumers' awareness of ADR reporting has risen. Other health care professionals (e.g., nurses and dentists) must be offered proper education in order to improve reporting practice of ADRs. Health care professionals should address concerns about OTC drug safety in elderly and children.

Why maximum tolerated dose?

A long-established approach to the pharmacological treatment of disease has been to start low and go slow. However, clinicians often prescribe up to maximum tolerated dose (MTD), especially when treating acute and more severe disease, without evidence to show that MTD is more likely to improve outcomes. Cardiovascular guidelines for some indications advocate MTD even in prevention, for example hypercholesterolaemia, without compelling evidence of better outcomes. This review explores the origins and potential problems of prescribing medications at MTD. Oral effective dose 50 (ED50) may be a useful guide for balancing efficacy and safety.

Physician's Knowledge of Appropriate Prescribing for the Elderly-A Survey Among Family and Internal Medicine Physicians in Nigeria

Background: Prescription and use of inappropriate medications have been identified as a major cause of morbidity among the elderly. Several screening tools have been developed to identify inappropriate medications prescribed for elderly patients. There is dearth of information about the knowledge of Nigerian physicians regarding these screening tools and appropriate prescribing for the elderly in general. The primary objective of this study was to assess the knowledge of Nigerian physicians about these screening tools and appropriate prescribing of medications for the elderly.

Methods: The study was a cross-sectional questionnaire-based study conducted among physicians working in Family Medicine and Internal Medicine departments of four tertiary health care facilities in Nigeria. The questionnaire consisted of sections on general characteristics of respondents and their knowledge of four selected screening tools for inappropriate medications in the elderly. Ten clinical vignettes representing different therapeutic areas (using the best option type questions) about medicine use in the elderly were included with a score of 1 and 0 for correct and wrong answers, respectively. The knowledge of respondents was classified as (total score, over 10): poor (score, < 5), average (score, 5-6), and good (score, 7-10).

Results: One hundred and five physicians returned completed questionnaires. Twenty percent of respondents knew about Beers criteria, whereas 15.6% were familiar with the STOPP criteria. Majority (83; 84.7%) of the respondents were confident of their ability to prescribeappropriately for elderly patients. The mean knowledge score was 5.3 ± 2.0 with 32 (30.5%), 41 (39%), and 32 (30.5%) having low, average, and good scores, respectively. The association between the knowledge score, duration of practice, and seniority was statistically significant (OR, 3.6, p = .004 and OR, 3; p = .012), respectively.

Conclusion: There are significant gaps in the knowledge of Nigerian physicians about screening tools for inappropriate medications. There is a need for stakeholders involved in the care of elderly Nigerian patients to develop new strategies to improve services being offered. These may include introduction of modules on appropriate prescribing in the curriculum of undergraduate and postgraduate medical education and the routine use of some screening tools for inappropriate medications in daily clinical practice.