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He X, Ji J, Pei Z, Luo Z, Fang S, Liu X, Lei Y, Yan H, Guo L. Anxiety and depression status in patients with idiopathic pulmonary fibrosis and outcomes of nintedanib treatment: an observational study. Ann Med 2024; 56:2323097. [PMID: 38581666 PMCID: PMC11000612 DOI: 10.1080/07853890.2024.2323097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/21/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Anxiety and depression are common comorbidities in idiopathic pulmonary fibrosis (IPF) that impair health-related quality of life. However, there is a lack of studies focusing on the mental disorder of IPF after antifibrotic treatment and their related predictive factors. METHODS Patients with an initial diagnosis of IPF were enrolled. Data on demographics, lung function, Generalized Anxiety Disorder-7 (GAD-7) Scale, Patient Health Questionnaire 9 (PHQ-9), Patient Health Questionnaire-15 (PHQ-15), and St. George's Respiratory Questionnaire total score(SGRQ-T) were collected. Changes in anxiety, depression, somatic symptoms, and quality of life scores before and after nintedanib treatment were compared, and the related predictive factors were analyzed. RESULTS A total of 56 patients with a first diagnosis of IPF were enrolled, with 42 and 35 patients suffering from anxiety and depression, respectively. The GAD-7, PHQ-9, PHQ-15, and SGRQ scores were higher in the anxiety and depression groups. SGRQ total score (SGRQ-T) [OR = 1.075, 95%CI= (1.011, 1.142)] was an independent predictor of IPF combined with anxiety (p < 0.05); SGRQ-T [OR = 1.080, 95%CI= (1.001, 1.167)] was also an independent predictor of IPF combined with depression (p < 0.05). After treatment, GAD-7, PHQ-9, PHQ-15, and SGRQ scores decreased (p < 0.05). ΔSGRQ-T significantly affected ΔGAD-7 (β = 0.376, p = 0.009) and ΔPHQ-9 (β = 0.329, p = 0.022). CONCLUSION Anxiety and depression in IPF patients are closely related to somatic symptoms, pulmonary function, and quality of life. The SGRQ-T score is of great value for assessing anxiety and depression in patients with IPF. Short-term treatment with nintedanib antifibrotic therapy can alleviate anxiety and depression in IPF patients.
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Affiliation(s)
- Xing He
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
- Department of Pulmonary and Critical Care Medicine, Cheng Du Qing Cheng Mt. Hospital, Chongzhou City, Chengdu, Sichuan Province, China
| | - Jiaqi Ji
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Zongmin Pei
- Department of Psychosomatic Medicine, Chengdu Seventh People's Hospital (Affiliated Cancer Hospital of Chengdu Medical College), Chengdu, Sichuan Province, China
| | - Zeli Luo
- Department of Critical Care Medicine, Wenjiang District People's Hospital, Chengdu, Sichuan Province, China
| | - Siyu Fang
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Xiaoqin Liu
- Department of Pulmonary and Critical Care Medicine, Cheng Du Qing Cheng Mt. Hospital, Chongzhou City, Chengdu, Sichuan Province, China
| | - Yan Lei
- Department of Pulmonary and Critical Care Medicine, Cheng Du Qing Cheng Mt. Hospital, Chongzhou City, Chengdu, Sichuan Province, China
| | - Haiying Yan
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
- Department of Pulmonary and Critical Care Medicine, Cheng Du Qing Cheng Mt. Hospital, Chongzhou City, Chengdu, Sichuan Province, China
| | - Lu Guo
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
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Inoue Y, Wells AU, Song JW, Xu Z, Kitamura H, Suda T, Okamoto M, Müller H, Coeck C, Rohr KB, Kolb M, Brown KK. Nintedanib in Asian patients with progressive fibrosing interstitial lung diseases: Results from the INBUILD trial. Respirology 2023; 28:465-474. [PMID: 36642509 DOI: 10.1111/resp.14452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 12/19/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVE In the INBUILD trial in patients with progressive fibrosing interstitial lung diseases (ILDs), nintedanib reduced the rate of decline in forced vital capacity (FVC) with an adverse event profile characterized mainly by gastrointestinal events. We analysed the effects of nintedanib in the subset of Asian subjects. METHODS Subjects with fibrosing ILDs other than idiopathic pulmonary fibrosis who had shown progression of ILD at any time within the prior 24 months despite management deemed appropriate in clinical practice were randomized to receive nintedanib or placebo. We analysed the rate of decline in FVC (ml/year) over 52 weeks in all Asian subjects and in Asian subjects with a usual interstitial pneumonia (UIP)-like fibrotic pattern on high-resolution computed tomography (HRCT). RESULTS One hundred sixty-four subjects in the INBUILD trial were of Asian race. The rate of decline in FVC (ml/year) over 52 weeks in this subgroup was -116.8 in the nintedanib group and -207.9 in the placebo group (difference: 91.0 [95% CI: 8.1, 173.9]; nominal p = 0.03). In Asian subjects with a UIP-like fibrotic pattern on HRCT, the rate of decline in FVC (ml/year) over 52 weeks was -130.1 in the nintedanib group and -224.2 in the placebo group (difference: 94.1 [5.5, 182.7]; nominal p = 0.04). Adverse events led to treatment discontinuation in 19.0% of the nintedanib group and 13.8% of the placebo group. CONCLUSION In Asian patients with progressive fibrosing ILDs, nintedanib reduced the rate of decline in FVC with adverse events that were manageable for most patients.
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Affiliation(s)
- Yoshikazu Inoue
- Clinical Research Centre, National Hospital Organization Kinki-Chuo Chest Medical Centre, Osaka, Japan
| | - Athol U Wells
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and National Heart and Lung Institute, Imperial College, London, UK
| | - Jin Woo Song
- University of Ulsan College of Medicine, Asan Medical Center, Pulmonary and Critical Care Medicine, Seoul, South Korea
| | - Zuojun Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Kanazawa-ku, Yokohama, Japan
| | - Takafumi Suda
- Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masaki Okamoto
- Department of Internal Medicine, Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Heiko Müller
- Biostatistics and Data Sciences, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Carl Coeck
- TA Inflammation Medicine, Boehringer Ingelheim SComm., Brussels, Belgium
| | - Klaus B Rohr
- Biostatistics and Data Sciences, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martin Kolb
- Department of Medicine, McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
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Aronson KI, Suzuki A. Health Related Quality of Life in Interstitial Lung Disease: Can We Use the Same Concepts Around the World? Front Med (Lausanne) 2021; 8:745908. [PMID: 34692737 PMCID: PMC8526733 DOI: 10.3389/fmed.2021.745908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/31/2021] [Indexed: 01/17/2023] Open
Abstract
Health-Related Quality of Life (HRQOL) is increasingly viewed as an important patient-centered outcome by leading health organizations, clinicians, and patients alike. This is especially true in the interstitial lung disease community where patients often struggle with progressive and debilitating disease with few therapeutic options. In order to test the effectiveness of new pharmacologic therapies and non-pharmacologic interventions globally in ILD, this will require expansion of clinical research studies to a multinational level and HRQOL will be an important endpoint to many. In order to successfully expand trials across multiple nations and compare the results of studies between different communities we must recognize that there are differences in the concepts of HRQOL across the world and have strategies to address these differences. In this review, we will describe the different global influences on HRQOL both generally and in the context of ILD, discuss the processes of linguistic translation and cross-cultural adaptation of HRQOL Patient Reported Outcome Measures (PROMs), and highlight the gaps and opportunities for improving HRQOL measurement in ILD across the world.
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Affiliation(s)
- Kerri I. Aronson
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Atsushi Suzuki
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Huang TH, Kuo CW, Chen CW, Tseng YL, Wu CL, Lin SH. Baseline plasma KL-6 level predicts adverse outcomes in patients with idiopathic pulmonary fibrosis receiving nintedanib: a retrospective real-world cohort study. BMC Pulm Med 2021; 21:165. [PMID: 33992083 PMCID: PMC8126113 DOI: 10.1186/s12890-021-01530-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background Nintedanib is effective for treating idiopathic pulmonary fibrosis (IPF), but some patients may exhibit a suboptimal response and develop on-treatment acute exacerbation (AE-IPF), hepatic injury, or mortality. It remains unclear which patients are at risk for these adverse outcomes.
Methods We analysed the demographic and clinical data, baseline plasma levels of Krebs von den Lungen-6 (KL-6) and surfactant protein A (SPA), and longitudinal clinical courses of a real-world cohort of IPF patients who received nintedanib ≥ 14 days between March 2017 and December 2020. Cox proportional-hazards regression, subdistribution hazards regression, and sensitivity analyses were performed to investigate the association between baseline predictors and AE-IPF, mortality, and nintedanib-related hepatic injury. The relationship between baseline predictors and pulmonary function decline was determined. Results Fifty-seven patients were included, of whom 24 (42%) developed hepatic injury, 20 (35%) had AE-IPF, and 16 (28%) died on-treatment. A baseline plasma KL-6 level ≥ 2.5 ng/mL, and diffusion capacity for carbon monoxide (DLCO) < 55% predicted, were associated with increased risk of hepatic injury (adjusted hazard ratio [aHR] was 3.46; 95% CI 1.13–10.60; p = 0.029 for KL-6, and 6.05; 95% CI 1.89–19.32; p = 0.002 for DLCO). Both factors also predicted severe and recurrent hepatic injury. Patients with baseline KL-6 ≥ 2.5 ng/mL also had a higher risk of AE-IPF (aHR 4.52; 95% CI 1.63–12.55; p = 0.004). For on-treatment mortality, baseline KL-6 ≥ 3.5 ng/mL and SPA ≥ 600 pg/mL were significant predictors (aHR 5.39; 95% CI 1.16–24.97; p = 0.031 for KL-6, and aHR 12.28; 95% CI 2.06–73.05; p = 0.006 for SPA). Results from subdistribution hazard regression and sensitivity analyses supported these findings. Patients with elevated baseline plasma KL-6 levels also exhibited a trend towards faster pulmonary function decline. Conclusions For patients with IPF who are receiving nintedanib, we have identified baseline predictors, in particular plasma KL-6 levels, for the risk of adverse outcomes. Patients with these predictors may require close monitoring for unfavourable responses during treatment. Our findings also support the prognostic role of molecular markers like KL-6 and may contribute to future formulation of more individualized therapeutic strategies for IPF. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01530-6.
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Affiliation(s)
- Tang-Hsiu Huang
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Wei Kuo
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chian-Wei Chen
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chao-Liang Wu
- Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Jouneau S, Crestani B, Thibault R, Lederlin M, Vernhet L, Valenzuela C, Wijsenbeek M, Kreuter M, Stansen W, Quaresma M, Cottin V. Analysis of body mass index, weight loss and progression of idiopathic pulmonary fibrosis. Respir Res 2020; 21:312. [PMID: 33239000 PMCID: PMC7690188 DOI: 10.1186/s12931-020-01528-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 10/01/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Nintedanib is an approved therapy for idiopathic pulmonary fibrosis (IPF). Some patients treated with nintedanib experience weight loss. Exploratory data suggest that low body mass index or weight loss are associated with worse outcomes in patients with IPF. We investigated whether BMI at baseline or weight loss over 52 weeks was associated with FVC decline, or influenced the effect of nintedanib, in patients with IPF. METHODS Using pooled data from the two INPULSIS trials, we analysed the rate of decline in FVC (mL/yr) over 52 weeks in patients treated with nintedanib and placebo in subgroups by baseline BMI (< 25; ≥25 to < 30; ≥30 kg/m2) and by weight loss over 52 weeks (≤5; > 5%) using random coefficient regression. RESULTS In the placebo group, the mean rate of FVC decline over 52 weeks was numerically greater in patients with lower baseline BMI (- 283.3 [SE 22.4], - 207.9 [20.9] and - 104.5 [21.4] in patients with BMI < 25 kg/m2, ≥25 to < 30 kg/m2 and ≥ 30 kg/m2, respectively). Nintedanib reduced the rate of FVC decline versus placebo in all subgroups by BMI, with a consistent treatment effect across subgroups (interaction p = 0.31). In the placebo group, the mean rate of FVC decline was numerically greater in patients with > 5% than ≤5% weight loss over 52 weeks (- 312.7 [SE 32.2] versus - 199.5 [SE 14.4] mL/year). Nintedanib reduced the rate of FVC decline versus placebo in both subgroups by weight loss, with a greater treatment effect in patients with > 5% weight loss (interaction p = 0.0008). The adverse event profile of nintedanib was similar across subgroups. CONCLUSIONS In patients with IPF, lower BMI and weight loss may be associated with faster decline in FVC. Nintedanib reduces the rate of FVC decline both in patients who lose weight on treatment and those who do not. TRIAL REGISTRATION ClinicalTrials.gov ; Nos. NCT01335464 and NCT01335477 ; URL: www.clinicaltrials.gov .
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Affiliation(s)
- Stéphane Jouneau
- Department of Respiratory Medicine, Competences Centre for Rare Pulmonary Diseases, Pontchaillou Hospital, CHU Rennes, univ Rennes, Rennes 1 University, Rennes, France.
| | - Bruno Crestani
- Université de Paris, Inserm U1152, APHP, Hôpital Bichat, Centre de reference constitutif pour les maladies pulmonaires rares, Paris, France
| | - Ronan Thibault
- INRA, Inserm, Univ Rennes, Nutrition Metabolisms and Cancer, NuMeCan, Unité de Nutrition, CHU Rennes, Rennes, France
| | - Mathieu Lederlin
- Department of Radiology, CHU Rennes, univ Rennes, Rennes, France
| | - Laurent Vernhet
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Claudia Valenzuela
- Pulmonology Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Marlies Wijsenbeek
- Department of Respiratory Medicine, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Care Medicine, Thoraxklinik, University of Heidelberg, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Wibke Stansen
- Boehringer Ingelheim GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Vincent Cottin
- Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Claude Bernard University Lyon 1, Lyon, France
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Cox IA, Borchers Arriagada N, de Graaff B, Corte TJ, Glaspole I, Lartey S, Walters EH, Palmer AJ. Health-related quality of life of patients with idiopathic pulmonary fibrosis: a systematic review and meta-analysis. Eur Respir Rev 2020; 29:29/158/200154. [PMID: 33153990 DOI: 10.1183/16000617.0154-2020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/03/2020] [Indexed: 02/07/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in persons 50 years and older. Through a comprehensive review of available studies, we aimed to assess health-related quality of life (HRQoL) of people living with IPF and the instruments used in this assessment.Searches were conducted up to May, 2020. Quality appraisal and data extraction were performed using pre-designed forms. Narrative synthesis approach was used to report results of the systematic review and a random effects model was used for the meta-analysis. A leave-one-out sensitivity analysis was performed, and a trim and fill method was used to assess publication bias.The review included 134 studies. The most used instruments to measure HRQoL were St George's Respiratory Questionnaire (SGRQ), Short Form 36 (SF36) and EuroQoL (EQ5D). Standardised mean scores (95% confidence interval) for these instruments were as follows: SGRQ total score: 44.72 (42.21-47.22); SF36 physical component score (PCS): 37.00 (34.74-39.26) SF36 mental component score (MCS): 50.18 (48.41-51.95); King's Brief Interstitial Lung Disease questionnaire total score: 58.38 (55.26-61.51); and EQ5D utility: 0.73 (0.68-0.79). Analysis of standardised means for both SGRQ and SF36 demonstrated worse scores in physical health domains as compared to mental health domains.This systematic review confirms that IPF negatively affected HRQoL, mostly impacting the physical health domains. This study also demonstrated that a diverse number of instruments are used to evaluate HRQoL. In view of this diversity, a standardised approach to measurement of HRQoL for IPF is important to ensure that comparisons made are reliable.
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Affiliation(s)
- Ingrid A Cox
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia.,Centre of Research Excellence for Pulmonary Fibrosis, Royal Prince Alfred Hospital, Camperdown, Australia
| | | | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia.,Centre of Research Excellence for Pulmonary Fibrosis, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Tamera J Corte
- Centre of Research Excellence for Pulmonary Fibrosis, Royal Prince Alfred Hospital, Camperdown, Australia.,Central Clinical School, The University of Sydney, Camperdown, Australia.,Dept of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Ian Glaspole
- Centre of Research Excellence for Pulmonary Fibrosis, Royal Prince Alfred Hospital, Camperdown, Australia.,Alfred Hospital, Melbourne, Australia.,Monash University, Melbourne, Australia
| | - Stella Lartey
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
| | - E Haydn Walters
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia.,Centre of Research Excellence for Pulmonary Fibrosis, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia .,Centre of Research Excellence for Pulmonary Fibrosis, Royal Prince Alfred Hospital, Camperdown, Australia.,Centre for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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Abstract
Objective: Provide information for pharmacists on idiopathic pulmonary fibrosis (IPF) and its treatment. Study Selection and Data Extraction: All articles with data from randomized controlled trials of nintedanib or pirfenidone were reviewed. Data Synthesis: IPF is a progressive and ultimately fatal interstitial lung disease characterized by decline in lung function and worsening dyspnea. It is uncommon and mainly occurs in individuals aged >60 years, particularly men with a history of smoking. Nintedanib and pirfenidone were approved in the United States for the treatment of IPF in 2014 and received conditional recommendations in the 2015 American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Association treatment guidelines. These drugs slow the progression of IPF by reducing the rate of decline in lung function. Their adverse event profile is characterized mainly by gastrointestinal events, which can be managed through dose adjustment and symptom management. Management of IPF should also include smoking cessation, vaccinations, and supportive care such as patient education, pulmonary rehabilitation, and the use of supplemental oxygen as well as optimizing the management of comorbidities. Relevance to Patient Care and Clinical Practice: This review provides clinical pharmacists with information on the course of IPF, what can be expected of current treatments, and how to help patients manage their drug therapy. Conclusions: IPF is a progressive disease, but treatments are available that can slow the progression of the disease. Clinical pharmacists can play an important role in the care of patients with IPF through patient education, monitoring medication compliance and safety, ensuring drugs for comorbidities are optimized, and preventive strategies such as immunizations.
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Affiliation(s)
- Roy Pleasants
- The University of North Carolina at Chapel Hill, NC, USA.,Durham Veterans Administration Medical Center, Durham, NC, USA
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