Drug-Drug Interactions With Over-The-Counter Medicines: Mind the Unprescribed

Polypharmacy in Older Patients with Multimorbidity: The Agreement Between Patient and General Practitioner-Reported Drugs Observed in a Pilot cRCT

Polypharmacy (≥5 drugs) increases the risk of discrepancies between patient- and general practitioner (GP)-reported drugs, leading to adverse outcomes. This explorative analysis assesses the agreement between patient- and GP-reported drugs under the influence of a paper-based patient portfolio in a pilot cluster randomized controlled trial (cRCT). Complete data were available for 68 patients aged 65 or older (26 were female), with multimorbidity, polypharmacy, and at least one hospitalization in the past year. Agreement was assessed for drug name and strength level. Differences between the intervention and control group (IG/CG) and comparisons between two time points (six-month interval) stratified according to gender were analyzed using Wilcoxon and Mann-Whitney U tests (α = 5%). To evaluate the reasons for discrepancies, the agreement of active pharmaceutical ingredients (APIs) and anatomical therapeutic chemical (ATC) groups was analyzed. At baseline, the agreement was 72.1% for the IG and 73.9% for the CG. Inclusion of the reported drug strength reduced the agreement in both groups (IG 66.7%, CG 60.0%). Agreement for the IG decreased statistically significantly after six months (-5.4%). ATC groups B, C, and H had the highest agreement, while N, R, and Z had the lowest. Large discrepancies in the drugs reported, due to the APIs and the corresponding ATC group, were observed.

Advertisements for prescription-free drugs and dietary supplements in the Deutsche Apotheker Zeitung (German Pharmacist Journal)

The Deutsche Apotheker Zeitung (DAZ, German Pharmacist Journal) is an independent pharmaceutical newspaper focusing on science and practice, mainly for the profession of pharmacist. In this study, drug advertising in the DAZ was analysed. To our knowledge, there is little scientific data available on drug advertising in professional journals. We assumed that professional journals provide particularly good background information on the advertised drugs because they are targeted to specialists. All non-prescription medicines and preparations that fall under the Medicines Advertising Law (Heilmittelwerbegesetz, HWG) were studied. The Medicines Advertising Law regulates the legal procedure for advertising medicinal products in Germany. The 167 product advertisements from the 52 issues of 2021 were analysed and checked for compliance with the Medicines Advertising Law. We identified significant deficiencies in compliance with the legislation. These included the lack of mandatory information required by the Medicines Advertising Law, for example the indication of adverse drug reactions and the listing of contraindications. There are very few peer-reviewed references on the efficacy of the advertised preparations. A scientific validation was carried out using the PubMed database, with the result that scientific information was available only for 1/3 of the advertisements. In addition, the appearance and target groups as well as social structures, images and feelings conveyed by the advertising were analysed. This study provides insights into the mechanisms of drug advertising in professional journals, which have not yet been researched to any great extent. Even in professional journals, pharmacological evidence plays a much smaller role than marketing, psychology and traditional social values. It seems that drug manufacturers deliberately ignore the German Medicines Advertising Law to advertise their products in the best possible way. Stricter legal controls should be put in place to prevent this practice and protect consumers from misinformation. This will increase drug safety.

Public Awareness and Practice Regarding Over-the-Counter Medications: A Cross-Sectional Study in Al-Ahsa, Saudi Arabia

Background Pharmaceuticals classified as over-the-counter (OTC) medications are also known as self-medications, in which drugs are sold directly to customers without a valid prescription. According to the World Health Organization, self-medication refers to taking medication for ailments that one has self-diagnosed. The public viewed OTC medications as safer, more effective, and beneficial, but misuse can lead to other health issues. Therefore, this study aimed to assess awareness and practices regarding OTC medications. Methodology The study employed a cross-sectional design involving the public residing in Al-Ahsa in eastern Saudi Arabia. The study setting was primary health centers (PHCs) in Al-Ahsa. Four PHCs were chosen by the cluster sampling method. One PHC from each of the four health clusters (northern, southern, middle, and eastern) was selected and a total of 326 people were chosen by simple random sampling from those four PHCs. Data were collected through a structured self-administered questionnaire. Descriptive and inferential statistics such as mean, standard deviation, chi-square, and correlation analyses were used to analyze the results. Results  The mean age of the participants was 38.26 ± 9.73 years. The overall mean knowledge score regarding OTC medications was 14.21 (SD = 3.3). About 39 (11.96%) of the participants had adequate knowledge, 184 (56.44%) had moderately adequate knowledge, and 103 (31.6%) had inadequate knowledge about the safety of using OTC medications. The overall mean score of practices was 20.7 ± 4.42. The chi-square test results showed a significant (p < 0.01) association between the level of knowledge and age, occupation, nationality, and marital status. Additionally, a positive linear relationship (r=+.386) was found between knowledge and practices regarding OTC medications. Conclusion In conclusion, many people in the present study had moderate knowledge and good practices regarding OTC medications. To protect the public from harm, there is an urgent need for more concrete regulatory control over OTC drugs and self-medication. So, it is recommended to create awareness about the proper use of OTC medications.

Drug advertising in the German free-of-charge health magazine Apotheken Umschau (Pharmacy review): a critical analysis

In Germany, the Apotheken Umschau (Pharmacy review) is a very popular health magazine for lay people, which is available free of charge in pharmacies. In this study, drug advertising in the Apotheken Umschau was critically analyzed. To our knowledge, studies on drug advertisements in such magazines are scarce. For the analyses, a total of 123 different advertisements from all 48 issues of Apotheken Umschau in 2020 and 2021 were compared. Since 2021 is the first year that was completely characterized by the COVID-19 pandemic, it was thus also possible to work out pandemic effects. More preparations from the categories immune system, eyes and sleep were advertised in 2021. Accordingly, typical complaints home office workers were addressed. Advertisements provided only very modest scientific information, if at all. The Therapeutic Products Advertising Act (Medicines Advertising Law; Heilmittelwerbegesetz (HWG)) provides regulations regarding the handling of drug advertising. However, in various categories, we noted substantial deficiencies of the advertisements to comply to regulations, e.g. the disclosure of adverse effects and omission of the mandatory statement "For risks and adverse effects, read the package insert and ask your doctor or pharmacist (Für Risiken und Nebenwirkungen fragen Sie Ihren Arzt oder Apotheker oder lesen Sie die Packungsbeilage)". Fifty-one of the 123 advertisements featured females to appeal particularly to this target group. Furthermore, a homogeneous ethnic (Caucasian) picture and a traditional image of German society were presented although this clearly deviates from reality. In conclusion, this study provides insights into the yet poorly studied mechanisms of drug advertisement for lay people. Pharmacological evidence plays a much smaller role than psychology, marketing and traditional societal models. It appears that drug companies intentionally use the "grey area" of the Medicines Advertising Law to optimally promote their products and ignore mandatory statements. This practice must be stopped by stricter legal control to protect the consumer from misinformation. In this way, drug safety will be increased.

Analysis of Drugs Prescribed to Elderly Patients in a Tertiary Health Care Center in Raipur, Central India: An Observational Study

Background Most elderly patients suffer from multiple diseases and are on multiple drugs for treatment. Polypharmacy in the elderly, physiological changes with old age, changes in the pharmacokinetics and pharmacodynamic effects of many drugs, and newer drug prescription trends for diseases like diabetes and cardiovascular disease make drug prescribing in the elderly more difficult. There are many chances of drug-drug interactions with easily available over-the-counter (OTC) medications. To prevent the irrational use of drugs in the elderly, there is a need for prescription analysis studies. Prescription analysis studies will help in finding errors in prescriptions and also change trends in the use of medication among the elderly. Methodology This cross-sectional observation study was conducted on 234 elderly patients to investigate medicine use patterns among the geriatric patients attending the Medicine Outpatient Department in a tertiary care teaching hospital. Drug data were collected from the study participants after obtaining written informed consent and analysed, including demographic details, personal history, disease history, and details of the drug, including the generic name of the drug, dose and duration of therapy, and prescription pattern. The proportions of drugs prescribed for different diseases were analysed. Also, the drugs were analysed as per their pharmacological profiles. Results and interpretation A total of 1298 drug prescriptions were analysed in this study. Of the total participants, 60.26% were male, 35% were unemployed, 53% were retired, and 27% were taking OTC herbal medications. Most of the patients included in this study were suffering from diabetes, hypertension, and other comorbidities. Telmisartan and telmisartan in combination with other drugs were the most commonly encountered prescription drugs, i.e., 24% among the cardiovascular drugs. Aspirin and statins alone or in combination were the most commonly encountered prescriptions, i.e., 27.88% of the drugs used for prophylaxis of cardiovascular diseases. Conclusion This study showed a prescription pattern for the elderly and highlighted precautions to be taken with some of the prescribed drugs. As polypharmacy is observed with elderly prescriptions, possible drug interactions must be taken into account. Regular prescription analysis of drugs prescribed to the elderly will help in the appropriate and rational use of drugs.

Discrepancies in patients' medication lists from pharmacies in Sweden: an interview study before the implementation of the Swedish National Medication List

BACKGROUND

Discrepancies in medication lists are common and can contribute to drug-related problems. This study was performed before the implementation of the National Medication List in Sweden, an intervention expected to improve the accuracy of medication lists.

AIM

The aim of the study was to examine the number and type of discrepancies in the medication list from pharmacies in Sweden. The secondary aim was to describe the information sources Swedish patients used as their medication lists and how confident they were with the information.

METHOD

Structured interviews were conducted with patients at 13 community pharmacies in Sweden during the period October 5, 2020, to April 16, 2021. The printed medication list was reviewed together with the patient to identify any discrepancies and missing information.

RESULTS

A total of 327 patients were included in the study (response rate 51%). The printed medication list from pharmacies was the most common information source for patients to know which medications to use. Two thirds (n  =  215) of the patients had at least one discrepancy among their prescriptions and 32% (n  =  106) were missing at least one prescription medication. Among all prescriptions (n  =  2567) 10% (n  =  264) were non-current prescriptions, 9% (n  =  238) were duplicates and 3% (n  =  88) had the wrong dose. The proportion of prescriptions with discrepancies differed between drug-groups.

CONCLUSION

The discrepancies described in this study can have serious consequences, and results provide a baseline for studies after the implementation of the National Medication List.

Unprescribed and unnoticed: Retrospective chart review of adverse events of interactions between antidepressants and over-the-counter drugs

Aim: To systematically evaluate prevalence and clinical characteristics of adverse effects of antidepressants and OTC drugs interactions in a retrospective chart review.

Methodology: Dataset of 1,145 registered adverse events were evaluated. Reports were selected for further analysis if pharmacoepidemiological avaluation indicated the presence of high probability of a causal relationship between antidepressants and OTC interaction and the occurrence of side effect. Following variables were extracted from the records: sex, age, medical comorbidities, antidepressant and other concomitant medications, clinical consequences ant the possible interaction mechanisms.

Results: 368 showed causal relationship with the simultaneous use of antidepressant with another drug. 15 adverse events (4%) were related to the use of OTC medicine, particularly omeprazole, diphenhydramine, Japanese ginkgo biloba, ibuprofen, diclofenac and sildenafil. All of the analysed side effects were categorized as the result of pharmacokinetic interactions. Here we report identified OTC drugs with corresponding antidepressants and clinical manifestations of DDI. Omeprazole: agomelatine (nausea, abnormal dreams), fluoxetine (extrapyramidal symptoms, paresthesias), sertraline (vertigo, yawning), escitalopram (oral vesiculation). Diphenhydramine: sertraline (diaphoresis, insomnia, vertigo), paroxetine (pruritus, headache), duloxetine (oropharyngeal pain). Japanese ginkgo biloba: citalopram (bradycardia), trazodone (vertigo, taste pervesion), mianserine (restless legs syndrome). Diclofenac: escitalopram (oral vesiculation), and fluoxetine (restless legs syndrome). Ibuprofen: agomelatine (anxiety and nausea), sertraline and omeprazole (QTc prolongation). Sildenafil: fluoxetine (genital oedema) and sertraline (myocardial infarction).

Conclusion: The use of OTC drugs by the patients should be monitored. Pharmacokinetic interactions between nonprescribed medicines and antidepressants may increase concentration and severity of side effects of latter ones.

Screening for severe drug-drug interactions in patients with multiple sclerosis: A comparison of three drug interaction databases

Background: Patients with multiple sclerosis (MS) often undergo complex treatment regimens, resulting in an increased risk of polypharmacy and potential drug-drug interactions (pDDIs). Drug interaction databases are useful for identifying pDDIs to support safer medication use. Objective: To compare three different screening tools regarding the detection and classification of pDDIs in a cohort of MS patients. Furthermore, we aimed at ascertaining sociodemographic and clinical factors that are associated with the occurrence of severe pDDIs. Methods: The databases Stockley's, Drugs.com and MediQ were used to identify pDDIs by screening the medication schedules of 627 patients. We determined the overlap of the identified pDDIs and the level of agreement in pDDI severity ratings between the three databases. Logistic regression analyses were conducted to determine patient risk factors of having a severe pDDI. Results: The most different pDDIs were identified using MediQ (n = 1,161), followed by Drugs.com (n = 923) and Stockley's (n = 706). The proportion of pDDIs classified as severe was much higher for Stockley's (37.4%) than for Drugs.com (14.4%) and MediQ (0.9%). Overall, 1,684 different pDDIs were identified by at least one database, of which 318 pDDIs (18.9%) were detected with all three databases. Only 55 pDDIs (3.3%) have been reported with the same severity level across all databases. A total of 336 pDDIs were classified as severe (271 pDDIs by one database, 59 by two databases and 6 by three databases). Stockley's and Drugs.com revealed 47 and 23 severe pDDIs, respectively, that were not included in the other databases. At least one severe pDDI was found for 35.2% of the patients. The most common severe pDDI was the combination of acetylsalicylic acid with enoxaparin, and citalopram was the drug most frequently involved in different severe pDDIs. The strongest predictors of having a severe pDDI were a greater number of drugs taken, an older age, living alone, a higher number of comorbidities and a lower educational level. Conclusions: The information on pDDIs are heterogeneous between the databases examined. More than one resource should be used in clinical practice to evaluate pDDIs. Regular medication reviews and exchange of information between treating physicians can help avoid severe pDDIs.