Adverse drug reactions monitoring: prospects and impending challenges for pharmacovigilance

Pharmacovigilance and Adverse Drug Reactions Reporting: Healthcare Providers' Experiences from Southern Highland Tanzania

Purpose

This exploratory qualitative study aimed to analyze the experiences of healthcare providers (HCPs) in pharmacovigilance (PV) and ADR reporting in the southern highland zone of Tanzania.

Methods

In 2022, an exploratory qualitative case study using in-depth interviews (IDIs) was conducted to explore the experiences of PV and ADR reporting among HCPs (doctors, nurses, and pharmacists). The study was carried out in a zonal referral hospital and a regional referral hospital of the Tanzanian southern highlands zone. Inductive-deductive thematic analysis was adopted for data analysis.

Results

Participants demonstrated adequate knowledge of PV and its related activities including ADR reporting. Knowing the interactions and wrong medication dosage as sources of ADR, signs, and symptoms, stopping the drug, and treating the symptoms following ADR emerged as subthemes linked with adequate knowledge in identifying and managing ADR. Participants perceived reporting ADR as laborious, posing a subjective burden and that not all ADRs needed to be reported. The latter contributed to limited participation in ADR reporting despite that participants were conversant with both physical and online ADR reporting platforms.

Conclusion

Although HCPs are well informed about PV and ADR reporting including the benefits to public health, their involvement in ADR reporting is low. In addition to the ongoing on-the-job training and regular supportive supervision for HCPs to improve the ADR practice, there is still a need to explore other strategies to be used as motives for HCPs to report ADR regularly.

Awareness, Actions, and Predictors of Actions on Adverse Drug Reaction Reporting among Patients Attending a Referral Hospital in Southern Highland Tanzania

Purpose

This study assessed the awareness, actions, and predictors of actions on adverse drug reaction reporting among patients attending a referral hospital in southern highland Tanzania.

Methods

A hospital-based cross-sectional study was conducted from January to August 2022 at Mbeya Zonal Referral Hospital (MZRH) in Mbeya, Tanzania. A total of 792 adult patients with chronic conditions attending outpatient clinics at MZRH were recruited consecutively. A semistructured questionnaire was used to collect demographic characteristics, ADR awareness, and actions when encountering ADR. Data were analyzed using the statistical package for social sciences (SPSS) version 23 and results are summarized using frequency and percentages. Binary logistic regression was used to assess the predictors associated with reporting ADR among patients. P value ≤0.05 was considered statistically significant.

Results

Out of 792, 397 (50.1%) were males and 383 (48.6%) had a primary education level. Only 171 (21.6%) participants previously experienced ADR, and 111 (14.1%) were aware that ADR is an unexpected harm that occurs after medication use. The majority 597 (70.3%) of the participants said will report ADR to healthcare providers, 706 (88.9%) prefer reporting ADR to healthcare providers, and 558 (69.1%) said patients are not aware of the importance of reporting ADR. Patients aged below 65 years of age, unemployed ((AOR (95% CI) = 0.4 (0.18-0.87), self-employed ((AOR (95% CI) = 0.5 (0.32-0.83)), and those who ever encountered ADR ((AOR (95% CI) = 0.1 (0.05-0.11)) were more likely to report the ADR to HCPs compared to the rest.

Conclusions

The majority of patients are not aware of what is ADR and the importance of ADR reporting. Most of the patients prefer to report ADR to healthcare providers. We recommend an awareness campaign to raise awareness of the patients on ADR and other methods of ADR reporting.

Is intravenous magnesium sulphate a suitable adjuvant in postoperative pain management? - A critical and systematic review of methodology in randomized controlled trials

A growing worldwide focus on opioid-free anaesthesia entails multimodal analgesic strategies involving non-opioids such as magnesium sulphate (MgSO4). Several systematic reviews have concluded there is beneficial analgesic effect of MgSO4 administration but do not take considerable heterogeneity among the studies into consideration. Medical literature published until June 2021 was searched in PubMed/Medline, Embase, Central and Web of Science: The final search yielded a total of 5,672 articles. We included only randomised controlled trials assessing the effect of intravenous MgSO4 on opioid consumption and acute postoperative pain when compared to either placebo or standardized analgesic treatment. The primary aim was to compare the homogeneity of essential variables and confounders. A post-hoc meta-analysis demonstrated a reduction in both postoperative morphine consumption (-6.12 mg) and pain score (-12.32 VAS points) in favour of the MgSO4-groups. Data for meta-analysis was missing from 19 studies (45%) on morphine consumption and 29 studies (69%) for pain score, the majority of which reports no effect for either morphine consumption or pain score. The calculated heterogeneity among the included studies was considerable for both outcomes; I 2=91% for morphine consumption and I 2=96% for pain score. Although we found a per se reduction in opioid consumption and pain score, methodological heterogeneity and clinical shortcomings of pre-, intra-, and post anaesthetic data precludes conclusions on clinical importance of intraoperative intravenous MgSO4. In addition, the reduction is likely less than what can be gained from using standardized analgesic treatment.

A drug utilisation pattern in non-dialysis patients of diabetic nephropathy in a government-run tertiary care hospital in South-Asia

OBJECTIVES

The objective of the present study was to evaluate the Drug utilisation pattern in patients of diabetic nephropathy (stage 1-4) in a tertiary care hospital in South-Asia.

METHODS

A cross-sectional observational study was conducted in the nephrology out-patient-department of a tertiary care hospital in South-Asia. WHO core prescribing, dispensing, and patient care indicators were evaluated, and adverse drug reactions (ADRs) encountered by the patients were analysed for causality, severity, preventability, and outcome.

RESULTS

The most commonly prescribed antidiabetics in diabetic nephropathy patients were insulin (17.42%), followed by metformin (4.66%). Current drugs of choice SGLT-2 inhibitors were prescribed in a lesser frequency than expected. Loop diuretics and calcium channel blockers (CCBs) were the preferred antihypertensives. The use of ACE inhibitors (1.26%) and ARBs (3.45%) for hypertension was restricted to Stage 1 and 2 nephropathy. The patients were on 6.47 drugs on average. 30.70% of drugs were prescribed by generic names, 59.07% of the drugs were prescribed from the national essential drugs list and 34.03% of the prescribed drugs were supplied by the hospital. CTCAE grade 1 (68.60%) and grade 2 (22.09%) ADR severity was the highest.

CONCLUSIONS

Prescribing patterns in patients of diabetic nephropathy were adapted from relevant medical evidence, affordability and availability of the drugs. Generic prescribing, availability of drugs and ADR preventability in the hospital have a broad scope for improvement.

Interpretable Drug-to-Drug Network Features for Predicting Adverse Drug Reactions

Recent years have witnessed booming data on drugs and their associated adverse drug reactions (ADRs). It was reported that these ADRs have resulted in a high hospitalisation rate worldwide. Therefore, a tremendous amount of research has been carried out to predict ADRs in the early phases of drug development, with the goal of reducing possible future risks. The pre-clinical and clinical phases of drug research can be time-consuming and cost-ineffective, so academics are looking forward to more extensive data mining and machine learning methods to be applied in this field of study. In this paper, we try to construct a drug-to-drug network based on non-clinical data sources. The network presents underlying relationships between drug pairs according to their common ADRs. Then, multiple node-level and graph-level network features are extracted from this network, e.g., weighted degree centrality, weighted PageRanks, etc. After concatenating the network features to the original drug features, they were fed into seven machine learning models, e.g., logistic regression, random forest, support vector machine, etc., and were compared to the baseline, where there were no network-based features considered. These experiments indicate that all the tested machine-learning methods would benefit from adding these network features. Among all these models, logistic regression (LR) had the highest mean AUROC score (82.1%) across all ADRs tested. Weighted degree centrality and weighted PageRanks were identified to be the most critical network features in the LR classifier. These pieces of evidence strongly indicate that the network approach can be vital in future ADR prediction, and this network-based approach could also be applied to other health informatics datasets.

A taxonomy for community pharmacy patient care services reported in Pharmacist eCare Plans

BACKGROUND

Pharmacies belonging to the Community Pharmacy Enhanced Service Networks (CPESN) are transforming their practices with support of the Flip the Pharmacy initiative. These pharmacies are submitting eCare plans that describe care that they have provided to patients.

OBJECTIVES

The objectives of this study were (1) To develop a taxonomy for services reported by community pharmacies participating in year 1 of the Flip the Pharmacy initiative and (2) to illustrate the use of the taxonomy for hypertension-related services.

METHODS

A retrospective observational study design was used. The analyzed data were extracted from eCare plans submitted by participating pharmacies during the first year of the Flip the Pharmacy initiative (October 1, 2019-September 30, 2020). Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) codes submitted for encounter reason and for procedures were sorted into categories based on similarity of terminology in the SNOMED-CT code labels. All SNOMED-CT codes in the encounter reasons that had blood pressure or hypertension in their labels were mapped to taxonomy categories. Descriptive statistics were calculated for all variables.

RESULTS

A total of 368,297 eCare plans reporting 1,049,061 SNOMED-CT procedures were submitted for 133,210 patients by 526 pharmacies. Seven categories of community pharmacy patient care services were identified: medication synchronization, medication review, monitoring, immunizations, patient education, adherence, and recommendations. Over half of the encounter reasons (63.5%) and procedures (56.2%) were for medication synchronization. Both medication review and monitoring accounted for about 10% of the encounters, and medication review made up over 30% of procedures. A total of 18,307 encounters were related to hypertension. Of these, monitoring was the most frequent, with 11,285 encounters (61.6%) encounters, followed by patient education, with 5173 encounters (28.3%).

CONCLUSION

CPESN pharmacies are delivering a wide range of patient care services. This taxonomy provides a concise way to organize and report services being delivered by community pharmacies.

Assessment of knowledge, practices, and barriers to pharmacovigilance among nurses at a teaching hospital, Ghana: a cross‑sectional study

Background

Pharmacovigilance may be defined as the continuous monitoring of the reaction between a drug agent or combination of drugs a patient took and steps taken to prevent any associated risk. Clinical trials conducted before drug approval cannot uncover every aspect of the health hazards of approved drugs. People with carefully selected characteristics are monitored for the safety and efficacy of the drug; hence, common adverse drug reactions (ADRs) following proper use of the medication can be detected. This calls for continuous monitoring of drugs to report any undocumented ADRs during the clinical trial. The study aimed to assess the knowledge, practice, and barriers to pharmacovigilance among nurses at a teaching hospital.

Methods

The study was a descriptive cross-sectional study, and a stratified sampling technique was used to select 125 nurses within the three units: medical, surgical, and pediatric wards. A structured questionnaire was developed and used for data collection based on the study's objectives and reviewed literature.

Results

The majority (67.2%) of the respondents were females, and 32.8% were males. Most (71.2%) of the nurses had low knowledge of ADR reporting procedures. Also, 84.8% of the nurses knew the purpose of reporting ADRs. The purpose of ADR reporting, as perceived by respondents, was to identify safe drugs (80.8%) and calculate the incidence of ADR (75.2%). Additionally, among the nurses who reported having nursed a patient with ADRs, 52.54% stated they reported the case, while 47.46% did not report it. The most cited reason for not reporting ADRs was that nurses considered the reaction normal and commonly associated with that medicine (35.7%). In comparison, 28.5% of the nurses said they did not know they were supposed to report the adverse drug reaction. There was no statistically significant difference between ranks of nurses, ward, attending in-service training, and pharmacovigilance practice.

Conclusion

In conclusion, nurses in this study had inadequate knowledge of pharmacovigilance and its reporting procedure. The study found that most nurses fear that reporting ADRs may be wrong because most of the nurses in the study did not have any form of pharmacovigilance training.

Exploring the factors and barriers of healthcare professionals in tertiary care hospitals toward pharmacovigilance: a multicenter study from Khyber Pakhtunkhwa, Pakistan

BACKGROUND

Spontaneous Adverse drug reactions (ADRs) reporting is a cornerstone for a successful pharmacovigilance program as under-reporting of ADRs remains a major issue around the globe. The current study aimed to assess the knowledge attitude and practices of health care professionals regarding pharmacovigilance along with barriers and factors to encourage ADR reporting at tertiary care hospitals of Khyber-Pakhtunkhwa, Pakistan.

METHODS

A questionnaire-based cross-sectional survey was conducted, using the convenience sampling method to collect the data from doctors, nurses, and pharmacists working in seven tertiary care hospitals from seven districts of Khyber-Pakhtunkhwa province, Pakistan, between July 2019 and March 2020.

RESULTS

During the study, a total of 830 questionnaires were distributed, out of which 669 were returned (response rate 80.6%). Overall, Healthcare professionals exhibited poor knowledge (79.5%) about ADR reporting and pharmacovigilance however, 73.5% of pharmacists were more knowledgeable as compared to 18.7% doctors and 13.8% nurses (p < .001). Moreover, poor reporting practices were displayed by 95.6% doctors, 94.4% nurses, 94.4 and 75.5% pharmacists (p < .001). However, the majority of healthcare professionals showed an overall positive attitude (94%) toward ADR reporting. The most frequently cited barriers were unavailability of reporting forms (92.5%), absence of a professional environment to discuss ADRs (82.5%), and lack of training (81.8%) whereas, most common factors to encourage ADR reporting were obligatory reporting (85.9%) and provision of ADR management guidelines and training (84.3%). A significant relation was found between the healthcare professionals and their professional status with the overall knowledge, attitude, and practice (KAP) scores (p < .001) whereas a medium, positive correlation was found between the knowledge and practice of pharmacovigilance and ADR reporting by the healthcare professionals (r = 0.321, n = 669, p < .001).

CONCLUSION

There is an overall lack of knowledge and poor reporting practices among health care professionals on ADR reporting and pharmacovigilance. Hence the study suggests that strategies should be devised by all the stakeholders to properly educate and train the healthcare professionals in this area to enhance overall patient safety and safe use of medicines.

J. Khojah H, Susan Dewey R. Spontaneous adverse drug reaction reporting by community pharmacists: preparedness and barriers

Background

Adverse drug reactions (ADRs) are undesired, unintended responses to drugs, and are significantly underreported. Pharmacists are drug experts recognized as custodians of drug safety, who are expected to be prepared for and knowledgeable about ADR reporting.

Objectives

To identify Egyptian community pharmacists’ preparedness for and perceived barriers to spontaneous ADR reporting.

Methods

This cross-sectional study recruited a sample of community pharmacists across Egypt, who were invited to complete a self-administrated questionnaire during April 2020.

Results

A total of 923 pharmacists across Egypt responded to the questionnaire. Most pharmacists were knowledgeable about the definition of ADRs (93.9 %) and indicated they felt reporting ADRs benefits the patients (82.2%). Despite recognizing their public health value, only a small percentage of participants conveyed familiarity with the reporting process for both paper (19.2%) and electronic (30.4%) forms, indeed 56.6% of participants did not remember what the ADR report form looked like. Moreover, 75.4% of respondents said they felt that community pharmacies are not the right place for reporting, with 49% suggesting that reporting was the responsibility of physicians. However, only 32.1% reported having insufficient time being a barrier to ADR reporting.

Conclusions

Community pharmacists in Egypt are not well prepared for spontaneous ADR reporting due to a lack of knowledge about the formal process and not acknowledging their responsibility, although time was not a major barrier. Therefore, this highlights a clear opportunity for improvement likely involving targeted education.

Pharmacovigilance education to healthcare professionals: Will it affect their performance in reporting adverse drug reactions?

AIM

To assess impact of pharmacovigilance (PV) educational program on knowledge, attitude and practice (KAP) of healthcare professionals (HCPs).

METHODS

a prospective study was conducted on HCPs at an Egyptian hospital. The study included: pre-education phase; where KAP questionnaire was administered by HCPs to obtain baseline data, intervention phase; where educational sessions were held by clinical pharmacists and Egyptian PV centre, and post-education phase; where the questionnaire was re-administered by participants 9 months post-receiving educational sessions. The questionnaire comprised five sections: participants' demographics, knowledge, attitude and practice sections and two multiple choice questions asking about the importance of establishment of ADRs monitoring centre, and factors hindering ADRs reporting. Pre-education and post-education data were compared.

RESULTS

From 221 HCPs invited to participate, only 153 filled the pre-education and post-education questionnaires. At baseline, the median (range) of the total KAP score were 1 (0-7), 1 (0-4) and 4 (0-14) for physicians, nurses and pharmacists, respectively. All KAP scores were low for all HCPs at baseline with the pharmacists having significantly higher knowledge and attitude scores compared with physicians, and nurses (P < .001). After education, all scores significantly increased and 13 ADRs were reported by HCPs compared with only 2 at baseline.

CONCLUSION

It was concluded that educational program had a significant impact on enhancing KAP of HCPs towards PV and ADRs reporting.

[Adverse drug reaction notification forms of the pharmacovigilance systems in Brazil and twelve other Latin-American countries: a comparative analysis]

The scope of this study was to assess the forms used to report suspected adverse drug reactions (ADR) to the pharmacovigilance system in Brazil and twelve other Latin-American countries. The study comprised three stages. In the first stage, the forms were attributed a score relating to the presence of critical items to generate ADR notification. In the second stage, the variables of the forms were quantified and classified regarding feasibility to contribute to an appropriate assessment of causality. In the last stage, hierarchical clustering was used to identify similar forms. The Venezuelan form achieved the highest score (18 points). The median number of variables in the forms of each country was 41 [26 (Guatemala) to 95 (Brazil)]. Most of the variables of the form were classified as life-critical and the majority contribute as an alternative explanation to causality assessment. Four clusters were identified (1, 2, 3 and 4). The forms of Brazil and Bolivia formed two distinct groups, 1 and 3 respectively. The results of this study indicate the need to change the forms of the different countries studied or even delete some variables, making them more appropriate for the process of assessment of ADR causality.

Adverse drug reactions at adverse drug reaction monitoring center in Raipur: Analysis of spontaneous reports during 1 year

BACKGROUND:

India is a developing country and adverse drug reactions (ADRs) influence most of the diseases in our population, and monitoring is required due to the paucity of ADRs. The present study was done to analyze the ADRs at the ADR monitoring center (AMC) of tertiary care hospital in Raipur during 1 year.

MATERIALS AND METHODS:

Study of ADR monitoring of outpatient and inpatient was a prospective and observational study carried out between September 2015 and August 2016. The ADRs in the form of Individual Case Safety Report (ICSR) was sent to the Indian database (Vigiflow^®).

RESULTS:

Total ICSRs reported to Vigiflow^® were 232 during 1 year. Among them, 63.79% were found to be nonserious and 36.21% were serious. Nearly 45% of ADRs were implicated only due to antimicrobials, which is highest among all other groups of drugs. A maximum number of ADRs were observed in 31–60 years of age group (52.15%). In causality assessment, the probable cases had a higher incidence (67.24%), followed by possible (27.58%) and certain (4.74%). The frequency of ADR reporting at our AMC was low (0.043%) compared to national average. Our AMC shared 0.35% of total ICSRs, which is insignificant (P < 0.001) compared to the JSS, Mysore and PGIMER, Chandigarh, AMCs, which have shared most of the ICSRs in Vigiflow^®.

CONCLUSIONS:

The frequencies of ADRs reporting in our study are less compared to those reported with other similar studies. Underreporting is a very serious concern in Raipur, and Pharmacovigilance Programme of India must intercede to pick up ADRs across the country.

Characteristics of drugs safety signals that predict safety related product information update

Purpose

Investigation of drug safety signals is one of the major tasks in pharmacovigilance. Among many potential signals identified, only a few reflect adverse drug reactions requiring regulatory actions, such as product information (PI) update. Limited information is available regarding the signal characteristics that might predict PI update following signal evaluation. The objective of this study was to identify signal characteristics associated with PI updates following signal evaluation by the European Medicines Agency Pharmacovigilance Risk Assessment Committee during 2012 to 2016.

Methods

A comparative study was performed based on data from 172 safety signals. Characteristics of signals were extracted from the European Pharmacovigilance Issues Tracking Tool database. Multivariable logistic regression analysis was used to assess the relationship between signal characteristics and the decision to update the PI.

Results

Multivariable logistic regression analysis showed that the presence of evidence in multiple types of data sources (adjusted odds ratio [OR] 7.8 95% CI [1.5, 40.1]); mechanistic plausibility of the drug‐event association (adjusted OR 3.9 95% CI [1.9, 8.0]); seriousness of the event (adjusted OR 4.2 95% CI [1.3, 13.9]); and age of drugs ≤5 years (adjusted OR 3.9 95% CI [1.2, 12.7]) were associated with the decision to change the PI (P < 0.05).

Conclusions

This study identified 4 characteristics of drug safety signals that have shown to be associated with PI changes as outcome of signal evaluation. These characteristics may be used as criteria for selection and prioritization of potential signals that are more likely to necessitate product information updates.

Seguimiento e impacto de la divulgación de cinco alertas sanitarias de medicamentos en Colombia

Objetivo Realizar la notificación y verificar el seguimiento de cinco alertas sanitarias de medicamentos a un grupo de prestadores de salud en Colombia.Métodos Estudio cuasi-experimental, prospectivo, antes y después, sin grupo control, mediante una intervención en médicos prescriptores de ketoconazol, metoclopramida, nimesulida, diacereina, ranelato de estroncio. Se tomó como población universo a los afiliados al régimen contributivo del Sistema de Salud Colombiano en 13 entidades promotoras de salud (EPS) de Colombia. Se identificaron los pacientes que recibían mensualmente estos medicamentos previamente a la alerta. Se realizó una intervención educativa y posteriormente se midió la proporción de cambio en la dispensación.Resultados Se realizaron en total unas 26 actividades diferentes a 500 médicos prescriptores. De un total de 4 121 954 de personas se identificaron 13 979 pacientes mensuales en 2013 que recibían alguno de los cinco medicamentos y se observó una reducción en 1 470 sujetos al mes (-10,5%) para 2014. El medicamento con el que se consiguió la mayor reducción fue ketoconazol (-31,1% de casos), seguido de ranelato de estroncio (-30,3%) y metoclopramida (-8,6%). Para nimesulida (+0,7%) y diacereina (+16,4%) no se obtuvieron resultados favorables.Conclusiones Se mantienen prescripciones potencialmente riesgosas en pacientes de Colombia. Con intervenciones basadas en farmacovigilancia posterior al reporte de alertas por agencias reguladoras sanitarias, se puede disminuir la proporción de pacientes que utilizan estos medicamentos.

Side-effects associated with ketamine use in depression: a systematic review

This is the first systematic review of the safety of ketamine in the treatment of depression after single and repeated doses. We searched MEDLINE, PubMed, PsycINFO, and Cochrane Databases and identified 288 articles, 60 of which met the inclusion criteria. After acute dosing, psychiatric, psychotomimetic, cardiovascular, neurological, and other side-effects were more frequently reported after ketamine treatment than after placebo in patients with depresssion. Our findings suggest a selective reporting bias with limited assessment of long-term use and safety and after repeated dosing, despite these being reported in other patient groups exposed to ketamine (eg, those with chronic pain) and in recreational users. We recommend large-scale clinical trials that include multiple doses of ketamine and long-term follow up to assess the safety of long-term regular use.

Safety reporting through a comprehensive and pragmatic pharmcovigilance process for India and emerging markets: an industry perspective

INTRODUCTION

Pharmacovigilance (PV) deals with the drug-related adverse reactions ensuring patients' safety. Emerging markets of India, South East Asia (SEA), Russia, Latin America (LA), Middle East and North Africa (MENA) have developed their own PV programs. However, under/manual reporting accompanied with lack of awareness regarding adverse drug reactions (ADRs) are major drawbacks that continue to exist due to lack of co-ordination and disparity in the regulatory approach.

AREAS COVERED

Of the 118 studies identified using various databases, 60 were included for the review. The authors discuss the present PV scenario of India, SEA, Russia, LA and MENA, and explain a basic process for uniform PV data input-output across industry, which includes data collection, analysis, processing, causality assessment and data distribution systems.

EXPERT OPINION

As the number of clinical trials conducted are rising in the emerging markets, there is a need to understand and implement a robust PV system, where electronically globalized, evidence based, public health oriented and regulatory compliant PV system is established. This would also improve transparency in system and ensure enhancement in safety data reporting ensuring premature and trouble-free detection of ADRs. It might result in implementing various PV boosting activities, which could yield robust patient safety data from India and emerging markets.