Adherence to monitoring of patients treated with amiodarone: a nationwide study

Objective

The aim of this study was to assess the adherence to monitoring guidelines regarding amiodarone treatment.

Methods

This is a retrospective cohort study of data recorded in Clalit Health Services, the largest healthcare organization in Israel. Included were individuals aged >18 years; who were prescribed amiodarone and had a documented purchase of this drug, for a minimum of 200 consecutive days; and who had less than a 100-day gap between two consecutive purchases during 2013-2021. Adherence was assessed to testing for thyroid, liver function, and electrolytes, as determined by the performance of a test every 6 months.

Results

The study included 24,094 individuals (mean age: 75 years, 53% male). The median follow-up was 2.3 years (total 73,727 person-years). The proportions of patients who performed baseline tests were: 43.4% for thyroid function, 58.3% for electrolytes, 48.6% for liver function, 20.6% for chest X-rays, and 14.9% for electrocardiograms. Adherence rates to semiannual monitoring of thyroid function, liver function, and electrolyte tests were: 70.4%, 79.4%, and 88.3%, respectively. In a multivariable analysis, the factors associated with higher adherence were male sex; older age; the presence of thyroid abnormalities, renal failure, and hypertension; and more frequent visits to the primary care physician.

Conclusions

In our country, adherence is low to monitoring risk factors for adverse effects of amiodarone therapy, especially prior to treatment initiation. Patient and primary care physicians should be educated about the importance of monitoring, particularly prior to initiation of amiodarone treatment.

Compliance with the north American Society of Pacing and Electrophysiology guidelines on amiodarone monitoring in Riyadh, Saudi Arabia: a retrospective charts review study

Background

Amiodarone is known for its efficacy as an antiarrhythmic agent; however, its extensive side-effect profile requires careful selection of patients and frequent monitoring. The purpose of this study was to evaluate the performance of the baseline tests before initiating amiodarone therapy and the on-going monitoring based on the North American Society of Pacing and Electrophysiology guidelines recommendations.

Methods

A retrospective descriptive charts review study included all patients who are 18 years of age and older and were started on oral amiodarone with a primary diagnosis of any type of cardiac arrhythmia from January 2016 to December 2018 in King Abdualziz Medical City, Riyadh, Saudi Arabia. The medical charts were reviewed and evaluated based on the performance of the recommended baseline and follow-up of chest X-ray (CXR), liver function test (LFT), thyroid function test (TFT) and electrocardiogram (ECG). The continuous variables were analyzed and presented as mean ± SD and the categorical variables were presented as percentages.

Results

Over the study period, 143 eligible participants on amiodarone therapy were included, with an average of 165 ± 207 days on amiodarone. Of patients, 36.4% had the entire recommended baseline assessments before initiating amiodarone. Our results indicated optimal compliance rates to the baseline tests of CXR (79.7%), LFT (79.7%) and ECG (86.7%). However, there was a lower compliance rate to TFT recommendations (40.6%). The compliance rate to the guideline recommendations related to the follow-up tests was minimal. On-going monitoring performance rates were 47.6% of CXR, 49% of LFT, 54.5% of ECG and 22.4% of TFT.

Conclusion

The compliance with the guideline recommendations related to amiodarone baseline assessments was optimal for all the baseline tests, except for TFT. However, the proportion of patients who received all the recommended baseline assessments was minimal. In addition, the performance of on-going monitoring was suboptimal for all the follow-up tests. Improvements could be made by establishing a local protocol for amiodarone monitoring and pharmacists participating in amiodarone therapy assessments.

A real-world cohort study on the quality of potassium and creatinine monitoring during initiation of mineralocorticoid receptor antagonists in patients with heart failure

Aims

Clinical heart failure (HF) guidelines recommend monitoring of creatinine and potassium throughout the initial weeks of mineralocorticoid receptor antagonists (MRAs) therapy. We here assessed the extent to which this occurs in our health care.

Methods and results

Observational study in 2007-2010 HF patients starting MRA therapy in Stockholm, Sweden. Outcomes included potassium and creatinine laboratory testing before MRA initiation and in the early (Days 1-10) and extended (Days 11-90) post-initiation periods. Exclusion criteria considered death/hospitalization within 90 days, and lack of a second MRA dispense. Of 4036 HF patients starting on MRA, 45% were initiated from a hospital, 24% from a primary care centre, and 30% from other private centres. Overall, 89% underwent pre-initiation testing, being more common among hospital (97%) than for primary care (74%) initiations. Only 24% were adequately monitored in all three recommended intervals, being again more frequent following hospital (33%) than private (21%) or primary care (17%) initiations. In multivariable analyses, adequate monitoring was more likely for hospital [odds ratio (OR) 2.85, 95% confidence interval (95% CI) 2.34-3.56] initiations, and for patients with chronic kidney disease (OR 1.79, 95% CI 1.30-2.43) and concomitant use of angiotensin-converting enzyme (OR 1.27, 95% CI 1.05-1.52), angiotensin receptor blockers (OR 1.19, 95% CI 1.01-1.40) or beta-blockers (OR 1.65, 95% CI 1.22-2.26). Age, sex, and prescribing centre explained a small portion of adequate monitoring (c-statistic 0.63). Addition of comorbidities and medications improved prediction marginally (c-statistic 0.65).

Conclusion

Although serum potassium and creatinine monitoring before MRA initiation for HF is frequent, rates of post-initiation monitoring remain suboptimal, especially among primary care centres.

Design and implementation of population-based specialty care programs

PURPOSE

The development, implementation, and scaling of 3 population-based specialty care programs in a large integrated healthcare system are reviewed, and the role of clinical pharmacy services in ensuring safe, effective, and affordable care is highlighted.

SUMMARY

The Kaiser Permanente (KP) integrated healthcare delivery model allows for rapid development and expansion of innovative population management programs involving pharmacy services. Clinical pharmacists have assumed integral roles in improving the safety and effectiveness of high-complexity, high-cost care for specialty populations. These roles require an appropriate practice scope and are supported by an advanced electronic health record with disease registries and electronic surveillance tools for care-gap identification. The 3 specialty population programs described were implemented to address variation or unrecognized gaps in care for at-risk specialty populations. The Home Phototherapy Program has leveraged internal partnerships with clinical pharmacists to improve access to cost-effective nonpharmacologic interventions for psoriasis and other skin disorders. The Multiple Sclerosis Care Program has incorporated clinical pharmacists into neurology care in order to apply clinical guidelines in a systematic manner. The KP SureNet program has used clinical pharmacists and data analytics to identify opportunities to prevent drug-related adverse outcomes and ensure timely follow-up.

CONCLUSION

Specialty care programs improve quality, cost outcomes, and the patient experience by appropriating resources to provide systematic and targeted care to high-risk patients. KP leverages an integration of people, processes, and technology to develop and scale population-based specialty care.

Adherence to guidelines in monitoring amiodarone-induced thyroid dysfunction

RATIONALE, AIMS AND OBJECTIVES

Baseline thyroid function testing and regular follow-up of thyroid function under amiodarone usage was recommended by guidelines. Little is known about the status of amiodarone monitoring in real-world clinical care in Taiwan. The objective was to determine the rate of thyroid monitoring and to assess the clinical and physicians' characteristics associated with adequate monitoring in a tertiary referral centre for arrhythmia.

METHODS

We reviewed the medical records of patients receiving amiodarone during the period 2008-2009 at Taipei Veterans General Hospital. The rate of baseline and follow-up thyroid function monitoring during amiodarone therapy were calculated. Factors associated with guideline adherence to monitoring were analysed.

RESULTS

Among the 1319 enrolled cases, 36.4% (n = 480) underwent baseline thyroid function testing and 1.1% (n = 15) received measurement of anti-thyroid peroxidase antibody before amiodarone initiation. Regular follow up of thyroid function under amiodarone usage occurred in only 8.6% (n = 114) of cases. Baseline thyroid function was more likely to be present in patients of younger age (P < 0.001), female sex (P = 0.01), and in those who received amiodarone therapy from cardiologists (P < 0.001) or electrophysiologists (P < 0.001) with fewer years of service (P < 0.001). Upon multivariate analysis, only physicians' expertise (cardiologist versus non-cardiologist, OR = 5.67, 95% CI: 2.44-13.16) and years of service (OR = 0.97, 95% CI: 0.95-0.998) were significantly associated with adequate thyroid monitoring.

CONCLUSIONS

The rate of thyroid monitoring with amiodarone therapy had been suboptimal. Strategies to enhance guideline adherence are needed.

Characterization of Mineralocorticoid Receptor Antagonist Therapy Initiation in High-Risk Patients With Heart Failure

BACKGROUND

Heart failure guidelines recommend routine monitoring of serum potassium, and renal function in patients treated with a mineralocorticoid receptor antagonist (MRA). How these recommendations are implemented in high-risk patients or according to setting of drug initiation is poorly characterized.

METHODS AND RESULTS

We conducted a retrospective cohort study of Medicare beneficiaries linked to laboratory data in 10 states with prevalent heart failure as of July 1, 2011, and incident MRA use between May 1 and September 30, 2011. Outcomes included laboratory testing before MRA initiation and in the early (days 1-10) and extended (days 11-90) post-initiation periods, based on setting of drug initiation and the presence of renal insufficiency. Additional outcomes included abnormal laboratory results and adverse events proximate to MRA initiation. Of 10 443 Medicare beneficiaries with heart failure started on an MRA, 19.7% were initiated during a hospitalization. Appropriate follow-up laboratory testing across all time periods occurred in 25.2% of patients with inpatient initiation compared with 2.8% of patients begun as an outpatient. Patients with chronic kidney disease had higher rates of both hyperkalemia and acute kidney failure in the early (1.3% and 2.7%, respectively) and extended (5.6% and 9.8%, respectively) post-initiation periods compared with those without chronic kidney disease.

CONCLUSIONS

Patients initiated on MRA therapy as an outpatient had extremely poor rates of guideline indicated follow-up laboratory monitoring after drug initiation. In particular, patients with chronic kidney disease are at high risk for adverse events after MRA initiation. Quality improvement initiatives focused on systems to improve appropriate laboratory monitoring are needed.

2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis

BACKGROUND

Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition.

METHODS

The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group.

RESULTS

Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded.

CONCLUSIONS

One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Pharmaceutical services as a tool to improve outcomes in patients with cardiovascular diseases

Despite the presence of effective and safe pharmacotherapy, and availability of multidimensional non-pharmacological treatment, the overall rate of major adverse cardiovascular outcomes remains still unsatisfactory. The clinical pharmacy activities and pharmaceutical care available in the community pharmacy settings have a significant impact on outcomes in cardiovascular patients, e.g. adherence, the level of blood pressure, total cholesterol or patients' health literacy. Pharmaceutical care in patients diagnosed with cardiovascular diseases remains beneficial both to the patients and the entire health care system. However, the prediction of results of pharmacists' interventions is particularly difficult and random. Many factors contribute to outcomes of community pharmacy services, e.g. time spent with the patients or quality of communication between patients and healthcare professionals. The most important issue in delivering effective pharmaceutical care is to develop an evidence-based model. Globally, the development of interprofessional collaboration between physicians and pharmacists, and preparing more sophisticated pharmacoeconomics analyses in the scope of pharmaceutical care are the next step in the improvement of advanced pharmaceutical services. Further research, particularly based on real data on this highly interesting topic is needed and recommended.

Effectiveness of Pharmacist-Led Amiodarone Monitoring Services on Improving Adherence to Amiodarone Monitoring Recommendations: A Systematic Review

Amiodarone remains the mostly frequently used antiarrhythmic in clinical practice and is most often used to maintain normal sinus rhythm in patients with atrial fibrillation who have failed a rate control strategy. Amiodarone has superior efficacy over other antiarrhythmics, a lower risk of torsade de pointes, and a better cardiovascular safety profile in patients with structural heart disease. However, amiodarone is associated with notable noncardiac toxicities affecting the thyroid, lungs, eyes, liver, and central nervous system. Since 2000, clinicians have been advised to follow amiodarone monitoring guidelines provided by the Heart Rhythm Society. Adherence to these recommendations in clinical practice, however, is suboptimal. Pharmacists play a major role in ensuring the safe and effective use of medications, particularly high-risk medications such as amiodarone. This qualitative review details the evidence supporting the role of pharmacist-led amiodarone monitoring services (AMS) in improving adherence to amiodarone monitoring guidelines and identifying adverse effects. Five studies were identified, and, overall, these programs had a favorable impact on improving adherence to guideline-recommended monitoring standards for amiodarone. The available evidence is limited by the significant variations in study designs and outcome definitions, lack of patient randomization, and limited generalizability. Nevertheless, available studies suggest that pharmacist-led AMS may improve adherence to recommended monitoring guidelines and identification of amiodarone-related adverse effects. Further study is warranted to demonstrate whether these services impact the overall quality of care provided to patients receiving amiodarone, which may justify broader implementation.