Acetaminophen Overuse in the Ohio Medicaid Population

Drug-induced liver injury in older adults

Drug-induced liver injury (DILI) is an important cause of hospitalisation and of medication deregistration. In old age, susceptibility to DILI is affected by changes in physiology and increased interindividual variability, compounded by an increased prevalence of disease and the frailty syndrome. While dose-related or predictable DILI reactions are often detected in preclinical trials, the occurrence of rare hypersensitivity or idiosyncratic reactions cannot be reliably predicted from preclinical studies or even by clinical trials. The limited participation of older adults in clinical trials means that the susceptibility of this population to DILI is largely unknown. Vigilance during clinical trials and postmarketing surveillance must be universally practised. A systematic approach should be taken to determine not only which medicines are hepatotoxic and should be removed from the market, but also the hepatotoxicity risks from marketed drugs to consumers with different characteristics, many of whom are older people.

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool

OBJECTIVE

The Leapfrog CPOE evaluation tool has been promoted as a means of monitoring computerized physician order entry (CPOE). We sought to determine the relationship between Leapfrog scores and the rates of preventable adverse drug events (ADE) and potential ADE.

MATERIALS AND METHODS

A cross-sectional study of 1000 adult admissions in five community hospitals from October 1, 2008 to September 30, 2010 was performed. Observed rates of preventable ADE and potential ADE were compared with scores reported by the Leapfrog CPOE evaluation tool. The primary outcome was the rate of preventable ADE and the secondary outcome was the composite rate of preventable ADE and potential ADE.

RESULTS

Leapfrog performance scores were highly related to the primary outcome. A 43% relative reduction in the rate of preventable ADE was predicted for every 5% increase in Leapfrog scores (rate ratio 0.57; 95% CI 0.37 to 0.88). In absolute terms, four fewer preventable ADE per 100 admissions were predicted for every 5% increase in overall Leapfrog scores (rate difference -4.2; 95% CI -7.4 to -1.1). A statistically significant relationship between Leapfrog scores and the secondary outcome, however, was not detected.

DISCUSSION

Our findings support the use of the Leapfrog tool as a means of evaluating and monitoring CPOE performance after implementation, as addressed by current certification standards.

CONCLUSIONS

Scores from the Leapfrog CPOE evaluation tool closely relate to actual rates of preventable ADE. Leapfrog testing may alert providers to potential vulnerabilities and highlight areas for further improvement.

Prescription-acquired acetaminophen use and potential overuse patterns: 2001-2008

BACKGROUND

Food and Drug Administration advisory committees recently made some recommendations to address acetaminophen (APAP)-related toxicity.

OBJECTIVES

To study the proportion of APAP users potentially consuming APAP over the currently recommended dosage (4 g/day) and a toxic dosage (10 g/day). To explore the impact of substituting the APAP strength in combination prescriptions to 325 mg on potential APAP overuse patterns.

METHODS

Using the 2001-2008 pharmacy claims from IMS LifeLink Health Plans, APAP potential maximum daily dose (PMDD), potential cumulative dose, and potential average daily dose (PADD) were calculated annually for APAP users. The proportion of users with potential APAP use above 4 g/day and 10 g/day are reported. Analyses were repeated by substituting the maximum APAP strength in combination prescriptions to 325 mg. Ordinary least squares regression was used to detect linear trends in APAP use/overuse.

RESULTS

790 188 of 2 656 161 study subjects were prescribed APAP in one or more years from 2001 to 2008. 32.62% and 26.84% of the adult APAP users had a PMDD > 4 gm/day in 2001 and 2008 while 1.88% and 3.17% had a PMDD > 10 gm/day. If the maximum APAP strength in combination prescriptions was 325 mg, the proportion of APAP users with PMDD > 4 g would be 14.08% in 2001 and 13.67% in 2008, whereas the proportion of those with PMDD > 10 g would be 0.21% and 2.30%, respectively.

CONCLUSION

About one in four APAP users have a PMDD > 4 g/day, whereas 2-3% have a PMDD > 10 g based exclusively on prescription data, which is concerning. These proportions could reduce by over half if the maximum APAP strength in combination prescriptions is 325 mg. Additional monitoring of opioid prescription-patterns, physician and pharmacist cognizance in prescribing APAP-containing combination products, and dose-reduction strategies should be considered to reduce APAP overuse.

Evaluation of the community pharmacist's behavior towards a prescription of antidiabetic and antiasthma drugs

OBJECTIVE

The objective of this study is to assess the performance of community pharmacist towards antidiabetic and antiasthma prescriptions, and also to assess the lack of information provided by community pharmacists regarding patient counseling and missing data, using a simulated patient technique.

METHODS

A prescription including antidiabetic and antiasthma drugs was used by simulated patient to assess community pharmacist's performance in 194 pharmacies. A performance assessment sheet was used to measure the patient counseling process. A quantitative descriptive and comparative analysis was done for the collected data. Pearson chi-square test (crosstabs) was used with a level of significance 95%).

RESULTS

The analysis of the 194 pharmacies visited revealed that most of the pharmacists were male (61%), Arabs (35%) and Indians (55%) with some other nationalities. The dispensing time in the pharmacy ranged between 2 to 10 minutes. Spending time with patients was not affected by gender (p-value 0.087), slightly affected by nationality (p-value 0.04), and highly affected by age (p-value 0.002) leaning towards older pharmacists who spent more time with patients than younger pharmacists. Most pharmacists (90%) started preparing the prescription once they received the prescription with no actual prescription screening. fifty five percent of the pharmacists asked about the duration of the treatment after preparing the prescription. ninety six percent did not counsel patients about diet, exercise and lifestyle changes. Less than 40% asked if the prescription was intended to be used for the same patient.

CONCLUSION

This study recommends that health authorities consider follow up plans in order to ensure the best pharmaceutical care is provided by community pharmacies.

COX-2 selective inhibitors in the treatment of osteoarthritis

OBJECTIVES

To assess the efficacy of cyclooxygenase-2 selective inhibitors (coxibs) in osteoarthritis (OA) and their gastrointestinal, cardiovascular, renovascular, and hepatic side effects compared with traditional nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen.

METHODS

Bibliographic database searches for randomized controlled trials, meta-analyses, and literature reviews.

RESULTS

Coxibs are comparable to traditional NSAIDs, providing moderate benefit for OA patients in pain and function versus placebo. NSAIDs, including coxibs, are superior to acetaminophen for OA, particularly in patients with moderate to severe pain. Coxibs decrease gastroduodenal ulcers (74% relative risk reduction) and ulcer complications (61% reduction) versus traditional NSAIDs. Meta-analysis of randomized trials indicates that coxibs increase the risk of myocardial infarctions approximately twofold versus placebo and versus naproxen, but do not increase the risk versus nonnaproxen NSAIDs. NSAIDs, including coxibs, commonly cause fluid retention and increase blood pressure and uncommonly induce congestive heart failure or significant renal dysfunction; risk factors include advanced age, hypertension, and heart or kidney disease. NSAIDs are a rare cause of clinical hepatotoxicity (<1 liver-related death per 100,000 NSAID users in clinical studies). Increased rates of aminotransferase elevations occur with rofecoxib (2%) and high-dose lumiracoxib (3%), and postmarketing cases of clinical liver injury with lumiracoxib have been reported recently.

CONCLUSIONS

Coxibs are as effective as traditional NSAIDs and superior to acetaminophen for the treatment of OA. Coxibs cause fewer gastrointestinal complications than traditional NSAIDs. Coxibs increase cardiovascular risk versus placebo and naproxen-but probably not versus nonnaproxen NSAIDs. Blood pressure commonly increases after initiation of selective or nonselective NSAIDs, especially in hypertensive patients.

Refill non-adherence to repeat prescriptions leads to treatment gaps or to high extra costs

OBJECTIVE

To determine the nature and extent of undersupply and the economic consequences of oversupply of medication among non-adherent patients.

METHODS

This study used copies of repeat prescriptions (= multiple dispensations), collected during 1 week in 2002 at 16 Swedish community pharmacies. For patients with a refill adherence below 80%, treatment gaps were defined as the number of days they had no drug available. The cost of drug oversupply (i.e., refill adherence > 120%) was calculated from the prices of the drug packages dispensed.

RESULTS

The number of collected repeat prescriptions was 3,636. The median of treatment gaps among patients with a refill adherence below 80% was 53 days per 90-100 days treatment period and the corresponding median for oversupply was 40 days. The cost of oversupply for exempt patients (i.e., patients who have paid 1,800 SEK (Euro 196; US$ 243) per year for medicines) was 32,000 SEK (Euro 3,500; US$ 4,300) higher than for non-exempt patients. An extrapolation to all Sweden indicates that exemption from charges leads to an additional oversupply of about 142 million SEK (Euro 15 million; US$ 19 million) per year above that of non-exempt patients.

CONCLUSION

Both undersupply and oversupply of prescribed medicines are common in Sweden. Patients with a refill adherence below 80% seem to have less than half of the prescribed treatment available. Oversupply or drug stockpiling occurs more frequently among exempt than among non-exempt patients, and this oversupply leads to high unnecessary costs.

Knowledge of appropriate acetaminophen doses and potential toxicities in an adult clinic population

OBJECTIVE

To evaluate the knowledge of appropriate doses and potential toxicities of acetaminophen and assess the ability to recognize products containing acetaminophen in an adult outpatient setting.

DESIGN

Cross-sectional, prospective study.

SETTING

University adult general internal medicine (AGIM) clinic.

PATIENTS

104 adult patients presenting to the clinic over consecutive weekdays in December 2003.

INTERVENTIONS

Three-page, written questionnaire.

MAIN OUTCOME MEASURES

Ability of patients to identify maximum daily doses and potential toxicities of acetaminophen and recognize products that contain acetaminophen.

RESULTS

A large percentage of participants (68.3%) reported pain on a daily or weekly basis, and 78.9% reported use of acetaminophen in the past 6 months. Only 2 patients correctly identified the maximum daily dose of regular acetaminophen, and just 3 correctly identified the maximum dose of extra-strength acetaminophen. Furthermore, 28 patients were unsure of the maximum dose of either product. Approximately 63% of participants either had not received or were unsure whether information on the possible danger of high doses of acetaminophen had been previously provided to them. When asked to identify potential problems associated with high doses of acetaminophen, 43.3% of patients noted the liver would be affected. The majority of the patients (71.2%) recognized Tylenol as containing acetaminophen, but fewer than 15% correctly identified Vicodin, Darvocet, Tylox, Percocet, and Lorcet as containing acetaminophen.

CONCLUSION

Although nearly 80% of this AGIM population reported recent acetaminophen use, their knowledge of the maximum daily acetaminophen doses and potential toxicities associated with higher doses was poor and appeared to be independent of education level, age, and race. This indicates a need for educational efforts to all patients receiving acetaminophen-containing products, especially since the ability to recognize multi-ingredient products containing acetaminophen was likewise poor.