Economic burden of respiratory syncytial and parainfluenza viruses in children of upper-middle-income countries: a systematic review

OBJECTIVE

To identify and assess the current evidence available about the costs of managing hospitalized pediatric patients diagnosed with Respiratory Syncytial Virus (RSV) and Parainfluenza Virus Type 3 (PIV3) in upper-middle-income countries.

METHODS

The authors conducted a systematic review across seven key databases from database inception to July 2022. Costs extracted were converted into 2022 International Dollars using the Purchasing Power Parity-adjusted. PROSPERO identifier: CRD42020225757.

RESULTS

No eligible study for PIV3 was recovered. For RSV, cost analysis and COI studies were performed for populations in Colombia, China, Malaysia, and Mexico. Comparing the total economic impact, the lowest cost per patient at the pediatric ward was observed in Malaysia ($ 347.60), while the highest was in Colombia ($ 709.66). On the other hand, at pediatric ICU, the lowest cost was observed in China ($ 1068.26), while the highest was in Mexico ($ 3815.56). Although there is no consensus on the major cost driver, all included studies described that the medications (treatment) consumed over 30% of the total cost. A high rate of inappropriate prescription drugs was observed.

CONCLUSION

The present study highlighted how RSV infection represents a substantial economic burden to health care systems and to society. The findings of the included studies suggest a possible association between baseline risk status and expenditures. Moreover, it was observed that an important amount of the cost is destinated to treatments that have no evidence or support in most clinical practice guidelines.

Use of Antidepressants and the Risk of Upper Gastrointestinal Tract Bleeding: A Case-control Study

PURPOSE

To investigate the association between the use of antidepressants and the risk of upper gastrointestinal tract bleeding (UGIB).

METHODS

A Case-control study was conducted in a Brazilian hospital complex. Cases were defined as patients with a diagnosis of UGIB and controls as patients admitted for reasons unrelated to gastrointestinal bleeding, gastric concerns, or complications associated with low-dose aspirin (LDA) or nonsteroidal anti-inflammatory drugs (NSAIDs) use. Sociodemographic and clinical data, comorbidities, drug therapy in use (long-term use and self-medication), and lifestyle habits were recorded through face-to-face interviews. Two groups were defined: use of antidepressants in general and use of antidepressants according to their affinity for serotonin transporters. The presence of synergism between the concomitant use of antidepressants and LDA or NSAIDs on the risk of UGIB was also explored.

FINDINGS

A total of 906 participants were recruited (200 in the case group and 706 in the control group). The use of antidepressants was not associated with the risk of UGIB (odds ratio [OR] = 1.503; 95% CI, 0.78-2.88) or the use of antidepressants with high affinity for serotonin receptors (OR = 1.983; 95% CI, 0.81-4.85). An increased risk of UGIB was observed in concomitant users of antidepressants and LDA (OR = 5.489; 95% CI, 1.60-18.81) or NSAIDs (OR = 18.286; 95% CI, 3.18-105.29). Despite the lack of significance, the use of antidepressants appears to be a positive modifier of UGIB risk in LDA and NSAID users.

IMPLICATIONS

These findings indicate an increased risk of UGIB in concomitant users of antidepressants and LDA or NSAIDs, suggesting the need to monitor antidepressant users, especially those most likely to develop UGIB. In addition, further studies with larger sample sizes are needed to confirm these findings.

Hospitalization costs of coronaviruses diseases in upper-middle-income countries: A systematic review

Background

COVID-19, SARS and MERS are diseases that present an important health burden worldwide. This situation demands resource allocation to the healthcare system, affecting especially middle- and low-income countries. Thus, identifying the main cost drivers is relevant to optimize patient care and resource allocation.

Objective

To systematically identify and summarize the current status of knowledge on direct medical hospitalization costs of SARS, MERS, or COVID-19 in Upper-Middle-Income Countries.

Methods

We conducted a systematic review across seven key databases (PubMed, EMBASE, BVS Portal, CINAHL, CRD library, MedRxiv and Research Square) from database inception to February 2021. Costs extracted were converted into 2021 International Dollars using the Purchasing Power Parity-adjusted. The assessment of quality was based on the protocol by the BMJ and CHEERS. PROSPERO 2020: CRD42020225757.

Results

No eligible study about SARS or MERS was recovered. For COVID-19, five studies presented cost analysis performed in Brazil, China, Iran, and Turkey. Regarding total direct medical costs, the lowest cost per patient at ward was observed in Turkey ($900.08), while the highest in Brazil ($5,093.38). At ICU, the lowest was in Turkey ($2,984.78), while the highest was in China ($52,432.87). Service care was the most expressive (58% to 88%) cost driver of COVID-19 patients at ward. At ICU, there was no consensus between service care (54% to 87%) and treatment (72% to 81%) as key burdens of total cost.

Conclusion

Our findings elucidate the importance of COVID-19 on health-economic outcomes. The marked heterogeneity among studies leaded to substantially different results and made challenging the comparison of data to estimate pooled results for single countries or regions. Further studies concerning cost estimates from standardized analysis may provide clearer data for a more substantial analysis. This may help care providers and policy makers to organize care for patients in the most efficient way.

A comprehensive look at explicit screening tools for potentially inappropriate medication: A systematic scoping review

OBJECTIVE

To map explicit screening tools to identify potentially inappropriate medication (PIMs), and the characteristics and limitations of these tools. Including PIMs-interactions, therapeutic alternatives and the clinical management of PIMs.

METHODS

A systematic scoping review was conducted in PubMed and Scopus (until May 2021). The number of PIMs listed as essential drugs was identified in Model List of Essential Medicines by the World Health Organization (WHO) and National List of Essential Medicines (Brazil). In addition to reporting the therapeutic alternatives and clinical management proposed by explicit screening tools to identify PIMs, we suggested our own alternatives for the PIMs most frequently reported.

RESULTS

Fifty-eight tools reported 614 PIMs and 747 PIMs-interactions. Limited overlap between the tools was observed: 123 (69.1%) of 178 therapeutic alternatives proposed by the tools were considered inappropriate by other tools, and 222 (36.1%) of the 614 PIMs identified were named as being inappropriate only once. Only 21 tools were developed by a Delphi panel technique associated with systematic review. The PIMs listed as essential medication in Brazil and by the WHO were 30.6% and 23.3% of the total reported, respectively. For the most-cited PIMs, such as non-steroidal anti-inflammatory drugs, tricyclic antidepressants and benzodiazepines, we suggested the use of non-opioid and opioid analgesics; agomelatine, bupropion or moclobemide; and melatonin, respectively.

CONCLUSIONS

The next stages in the development of explicit screening tools to identify PIMs include achieving more consensus between them and improving their applicability across countries. Further, it is recommended that tools include PIMs risks and advice on therapeutic alternatives.

Extemporaneous Compounding: A Possible Trigger Tool to Detect potentially health incidents

BACKGROUND

Extemporaneous compounding (EC) involves preparation of a therapeutic product to a specific-patient need. However, there is a potential relation between this procedure and the occurrence of health incidents (HI). The use of triggers tool increases HI identification.

OBJECTIVE

This study assessed the performance of EC as trigger to detect potentially health incidents arising from this procedure.

METHOD

A one-month observational and cross-sectional study was performed in internal medicine ward and intensive care unit of medium-sized hospital. Data collection was carried out in 5 stages: all triggered patients with dysphagia or enteral feeding tube with prescription of EC were included; it was observed all EC executed in standardized drugs prescribed; the procedure was compared with the hospital guide and scientific literature; HI monitoring and their evaluation using WHO and NCC MERP algorithms; a search for pharmaceutical alternatives (PA) that would avoid the observed EC.

RESULTS

197 patients were recruited. Almost half of them were triggered by EC from 84 standardized drugs. 48 patients met inclusion criteria. It was identified 28 adverse drug reactions, 01 therapeutic ineffectiveness and 29 medication errors. EC as trigger tool showed a PPV value of 0.38. Finally, only 24 drugs have PA available in the market, that could avoid one third of all observed EC.

CONCLUSION

It was possible to detect potentially HI in one of two patients with enteral feeding tube using EC as trigger tool. The use of EC as a trigger tool contributes to identify potentially HI arising from drugs, which have not gotten pharmaceutical alternatives to be administered via enteral feeding tube.

EPIDEMIOLOGICAL PROFILE OF PATIENTS WITH NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING SECONDARY TO PEPTIC DISEASE IN A TERTIARY REFERRAL BRAZILIAN HOSPITAL

BACKGROUND

Non-variceal upper gastrointestinal bleeding (NVUGIB) secondary to peptic ulcer disease is a medical digestive emergency and could be one of the most serious adverse drug reactions.

OBJECTIVE

To identify the frequency of diagnosis of NVUGIB secondary to peptic ulcer disease.

METHODS

Prospective and epidemiological study conducted in a tertiary referral Brazilian hospital, from July 2016 to December 2019. Upper gastrointestinal endoscopies (UGE) reports were evaluated daily. The diagnosis of NVUGIB secondary to peptic ulcer disease was defined through endoscopic findings of peptic ulcer and erosive gastric lesions, and clinical symptoms. The frequency of diagnosis of NVUGIB secondary to peptic ulcer disease was estimated through the ratio between the number of patients diagnosed and the number of patients underwent UGE in the same period.

RESULTS

A total of 2,779 endoscopic reports (2,503 patients) were evaluated, and 178 patients were eligible. The total frequency of diagnosis of NVUGIB secondary to peptic ulcer disease was 7.1%. The annual frequency of diagnosis between 2017 and 2019 ranged from 9.3% to 5.7%. Most patients were men (72.8%); self-declared white (71.8%); older people (56.7%); and, had no familiar or personal history of gastrointestinal diseases (60.1%). 90% of the patients had a peptic ulcer and melena (62.8%). Patients made chronic use of low-dose aspirin (29.3%), other antiplatelet agents (21.9%) and, oral anticoagulants (11.2%); and non-steroidal anti-inflammatories use in the week a prior to the onset of clinical symptoms (25.8%).

CONCLUSION

Seven in every 100 patients admitted and underwent UGE in a tertiary hospital were diagnosed with NVUGIB secondary to peptic ulcer disease.

Genetic Variants in PTGS1 and NOS3 Genes Increase the Risk of Upper Gastrointestinal Bleeding: A Case-Control Study

Objective: To assess the association between PTGS1 and NOS3 variant alleles and the risk to develop upper gastrointestinal bleeding (UGIB) secondary to complicated peptic disease. Methods: A case-control study was conducted in a Brazilian complex hospital from July 2016 to March 2020. Case: Patients with UGIB diagnosis. Control: Patients admitted for surgery not related to gastrointestinal disorders. Variables: UGIB (outcome), genetic variants in PTGS1 and NOS3 genes (independent), and sex, age, schooling, ethnicity, previous history of gastrointestinal disorders, Helicobacter pylori serology, comorbidity, drug therapy, and lifestyle (confounding). The single-nucleotide polymorphisms (SNPs) of the PTSG1 gene (rs1330344, rs3842787, rs10306114, and rs5788) and NOS3 gene (rs2070744 and rs1799983) were determined using the real-time polymerase chain reaction. Helicobacter pylori serology was determined through the chemiluminescence technique. Logistic regression models were built and deviations of allelic frequencies from Hardy-Weinberg equilibrium were verified. Results: 200 cases and 706 controls were recruited. Carriers of the AG genotype of rs10306114 (OR: 2.55, CI 95%: 1.13-5.76) and CA + AA genotypes of rs5788 (OR: 2.53, CI 95%: 1.14-5.59) were associated with an increased risk for the UGIB development. In nonsteroidal anti-inflammatory drugs (NSAIDs) users, the six variants evaluated modified the magnitude of the risk of UGIB, whereas in low-dose aspirin (LDA) users, an increased risk of UGIB was observed for four of them (rs1330344, rs10306114, rs2070744, and rs1799983). Personal ulcer history (p-value: < 0.001); Helicobacter pylori infection (p-value: < 0.011); NSAIDs, LDA, and oral anticoagulant use (p-value: < 0.001); and alcohol intake (p-value: < 0.001) were also identified as independent risk factors for UGIB. Conclusion: This study presents two unprecedented analyses within the scope of the UGIB (rs10306114 and rs2070744), and our findings showing an increased risk of UGIB in the presence of the genetic variants rs10306114 and rs5788, regardless of the drug exposure. Besides, the presence of the evaluated variants might modify the magnitude of the risk of UGIB in LDA/NSAIDs users. Therefore, our data suggest the need for a personalized therapy and drug use monitoring in order to promote patient safety.

Genetic polymorphisms associated with upper gastrointestinal bleeding: a systematic review

Non-variceal upper gastrointestinal bleeding (non-variceal UGIB) is a frequent and severe adverse drug reaction. Idiosyncratic responses due to genetic susceptibility to non-variceal UGIB has been suggested. A systematic review was conducted to assess the association between genetic polymorphisms and non-variceal UGIB. Twenty-one publications and 7134 participants were included. Thirteen studies evaluated genetic polymorphism in patients exposed to non-steroidal anti-inflammatory drugs, low-dose aspirin, and warfarin. Eight studies present at least one methodological problem. Only six studies clearly defined that the outcome evaluated was non-variceal UGIB. Genetic polymorphisms involved in platelet activation and aggregation, angiogenesis, inflammatory process, and drug metabolism were associated with risk of non-variceal UGIB (NOS3, COX-1; COX-2; PLA2G7; GP1BA; GRS; IL1RN; F13A1; CDKN2B-AS1; DPP6; TBXA2R; TNF-alpha; VKORC1; CYP2C9; and AGT). Further well-designed studies are needed (e.g., clear restriction to non-variceal UGIB; proper selection of participants; and adjustment of confounding factors) to provide strong evidence for pharmacogenetic and personalized medicine.

Risk factors associated with drug therapy among elderly people with Alzheimer's disease: a cross-sectional study

BACKGROUND

Improving knowledge and establishing strategies and policies for better patient safety are worldwide priorities.

OBJECTIVE

To evaluate drug safety among elderly people with Alzheimer's disease (AD).

DESIGN AND SETTING

Cross-sectional study among elderly people within the National AD Assistance Protocol (PCDTDA/MS) who were living in the municipality of Araraquara, Brazil, in 2017.

METHODS

Through interviews conducted with relatives/caregivers of elderly people with diagnoses of AD, the following variables were evaluated: comorbidities, drug therapy used, use of potentially inappropriate medications for the elderly (PIMs), presence of potentially inappropriate interactions (PIIs) and medication regimen complexity index. Factors associated with AD severity were also evaluated. Multivariate and simple logistic regressions were applied.

RESULTS

143 elderly people enrolled in PCDTDA/MS were analyzed. The majority were women (67.1%); assisted only through the public healthcare system (75.5%); polymedicated (57.4%); using at least one PIM (63.6%); presenting at least one PII (63.6%); and under drug therapy of low to medium complexity (92.2%). No semi-annual monitoring of the effectiveness of PCDTDA/MS drugs was identified. The proportion using AD drug therapy at daily doses differing from those recommended by the World Health Organization was 75.6%. However, these doses were not associated with drug risk.

CONCLUSION

The data from this study raise the hypothesis that use of polypharmacy might show a correlation with severity of AD. The drug safety risk may be associated with comorbidities of the metabolic syndrome, anxiety and off-label use of PIMs, such as risperidone and quetiapine, and benzodiazepines (i.e. clonazepam and flunitrazepam).

Monitoring compliance with Clinical Protocol and Therapeutic Guidelines for Alzheimer's disease

Dementia is a chronic neurodegenerative disease and Alzheimer’s disease (AD) is the most prevalent type.

Harmonization of Pharmacovigilance Regulation in Brazil: Opportunities to Improve Risk Communication

Brazilian pharmacovigilance regulations involve 3 spheres: health services, Marketing Authorization Holders (MAHs), and sanitary agency. Drug tolerability began to be effectively assessed in Brazil after the founding of the National Agency of Sanitary Surveillance, which developed the Sentinel Network Project. The objective of the Sentinel Network Project is to increase the adverse drug reaction (ADR) reporting rate by health care professionals in the hospital setting. Pharmacovigilance practices became mandatory for MAHs, and patient tolerability issues were considered in drug policy in Brazil only as recently as 2000. However, despite recent events, the regulatory advancements in pharmacovigilance in Brazil are only equivalent to international practices (ie, those of the European Union). The pharmacovigilance system in the European Union integrates the national authorities, the European Commission, and the European Medicines Agency, which is responsible for the scientific evaluation, supervision, and safety monitoring of medicines for human and veterinary use in the European Union. Furthermore, ADR patient reporting is included in the new EU pharmacovigilance regulations. Numerous possible ways are available to improve the Brazilian pharmacovigilance system, mainly through regulations of biosimilar, nanotechnology, and veterinary medicines or by training health care professionals and patients to report nonserious cases and quality deviations. It is necessary to encourage and develop strategies for decentralizing pharmacovigilance actions in the whole country, as is common practice in several EU countries. Motivating and considering ADR reports by patients and improving feedback and audit practices in health care services and MAHs are also necessary measures. With the inclusion of Brazil as a member of the International Conference of Harmonization, significant changes in pharmacovigilance regulation are expected; these updates, which will consider international standards, will improve signal detection and risk communication.

Assessment of the adherence to and costs of the prophylaxis protocol for venous thromboembolism

OBJECTIVES

Evaluate adherence to the therapeutic prophylaxis protocol for venous thromboembolism (VTE) as well as the costs of this practice.

METHODS

A descriptive and cross-sectional study was conducted at a State General Hospital in Brazil through reports of drug dispensions, prescriptions and risk stratification of patients. Adherence to the VTE prophylaxis protocol was monitored. The tests for VTE diagnosis measured the adherence to therapeutic prophylaxis treatment, and the purchase prices of the drugs went into the calculation of drug therapy costs. The level of adherence to prescriptions for VTE prophylaxis in the hospital was classified as "adherence", "non-adherence" and "justified non-adherence" when compared with the protocol.

RESULTS

Protocol adherence was observed for 50 (30.9%) patients, and non-adherence was observed for 63 (38.9%) patients, generating an additional cost of $180.40/month. Justified non-adherence in 49 (30.2%) patients generated $514.71/month in savings due to a reduction in the number of daily administrations of unfractionated heparin while still providing an effective method for preventing VTE. Twenty-six patients stratified as having medium to high risk of VTE who did not receive prophylaxis were identified, generating $154.41 in savings. However, these data should be evaluated with caution since the risks and outcomes associated with not preventing VTE outweigh the economy achieved from not prescribing a drug when a patient needs it. The only case of VTE identified during the study period was related to justified non-adherence to the protocol.

CONCLUSION

The protocol is based on scientific evidence that describes an effective therapy to prevent VTE. However, the protocol should be updated because the justifications for non-adherence are based on scientific evidence, and this justified non-adherence generates savings and yields effective disease prevention.

Safety assessment of omeprazole use: a review

BACKGROUND

Risks regarding hospital admission due to adverse drug reactions and drug interactions from use of omeprazole have been reported. The question guiding the present review was "Which adverse events occur in patients using omeprazole in a Food and Drug Administration-approved and/or off-label manner?" It was also proposed to evaluate the safety of use of omeprazole.

DESIGN AND SETTING

Qualitative narrative review with critical evaluation, in a public university.

METHODS

The PubMed, SCOPUS, LILACS, SciELO, EMBASE and EBSCO databases were searched on July 31, 2018. Studies evaluating adverse events were screened.

RESULTS

72 articles were included, among which 58 reported on adverse drug events (47, adverse drug reactions; 5, drug interactions; and 6, situations of ineffectiveness). 28 adverse drug reactions not described in compendia and drug leaflets were described in these studies: myocardial infarction (6); stroke (2); spontaneous abortion (1); proliferative changes (1); chills (1); heart failure (1); thrombosis (2); and dementia (1), among others. Severe adverse reactions, for instance cardiac problems, Steven-Johnson syndrome and proliferative changes, were identified. The antiplatelet effects of drugs such as clopidogrel, in patients who underwent heart-related surgery, increased the risk of developing cardiac problems, such as cardiovascular death, myocardial infarction and stroke. In newly transplanted patients, decreased absorption of mycophenolate mofetil occurred, thus leading to rejection of transplanted organs.

CONCLUSION

Use of omeprazole should be monitored primarily in patients with heart disorders using antiplatelet agents concomitantly, and in newly transplanted patients using mycophenolic acid, in order to avoid serious adverse reactions.

Drug administration adjustments for elderly patients with dysphagia: A case report

An elderly patient, aged 76 years, diagnosed with dysphagia, depression, hypothyroidism, Alzheimer's disease and mild cognitive deficit, was identified with sertraline and levothyroxine- drug-related problems. Medication Therapy Management (MTM) was used to adjust therapy to the patient's needs by macerating sertraline tablets and solubilizing them in 10-30 mL of orange juice. The patient was advised to take levothyroxine after fasting. Six months later, pharmaceutical follow-up identified an increase in the Mini-Mental State Exam score from 22 to 26 and a decrease in the Clinical Dementia Rating (CDR) scale score from 1.0 to 0.5 in conjunction with mood and physical improvements, as well as a significant decrease in aggressiveness and agitation. Cognitive deficit may be a result of poor drug administration procedures, leading to drug ineffectiveness. Optimizing levothyroxine and sertraline administration, based on knowledge of their physicochemical properties, improves their clinical effectiveness, including the cognition of patients with Alzheimer's disease and dysphagia.

Medication dispensing as an opportunity for patient counseling and approach to drug-related problems

ABSTRACT The objective was to describe and evaluate a model of drug dispensing developed and implemented in a community pharmacy in Brazil. This was a descriptive, observational, quasi-experimental study performed in the period between 21 January 2013 and 20 April 2013. The model was evaluated and described in terms of three parameters: structure, process and outcome. The description and assessment of each parameter was performed as follows: (I) Structure: profile of patients, pharmacist's professional profile, physical facility, informational material; (II) Process: drug-related problems, pharmaceutical interventions performed, results of pharmaceutical interventions; (III) Outcome: patient knowledge of medications. Dispensing service improved patient knowledge of medications (p < 0.05), which was associated with pharmacotherapy complexity (p < 0.05). The main problems identified were related to lack of patient knowledge regarding their medication (52.9%). Pharmaceutical interventions were mostly performed directly to the patients (86.3%) by verbal (95.4%) and written (68.2%) information, and most of the problems were completely solved (62.7%). The medicine dispensing model was able to identify and solve drug-related problems and promote an improvement in patient knowledge about medication.

Knowledge and conduct of pharmacists for dispensing of drugs in community pharmacies: a cross-sectional study

The objective of the study was to evaluate the knowledge of pharmacists and check their conduct in relation to dispensing of drugs. This is a cross-sectional study performed in four municipalities from South and Southeast of Brazil, which are reference in health national scenario and concentrate 73.6% of national economic activity. Pharmacists who works in community pharmacies were invited to answer a questionnaire prepared by the authors of this study and validated. The main outcome measured was the pharmaceutical knowledge, rated according to the number of correct answers on that questionnaire prepared by the researchers, and professional conduct in relation to dispensing of drugs. The data collection occurred from September to December 2012 and the information obtained were tabulated in duplicate by two independent researchers for later analysis. 486 community pharmacies were visited but only 112 professionals participated in the study. Among the participants, 78.6% (n = 88) did not have adequate knowledge to perform the dispensing of drugs, despite this same number of pharmacists claiming to have participated in conferences and courses after graduation. The main sources of information on drugs used by participants have a low level of scientific evidence. The performance of non-employment related tasks reduces the time available for the care of medication users. In addition, the indiscriminate sale of antimicrobials and the sale of products other than health, mischaracterize the role of the pharmacist in the community pharmacy. There are gaps in the knowledge of professionals, limiting the satisfactory completion of dispensing of drugs. In addition, the excess of other duties and inadequate professional conduct compromise the promotion of the rational use of drugs.

Safety assessment of essential medicines for elderly people: a bibliographic survey

Certain medicines are considered potentially inappropriate (PIM) for elderly people as they increase the risk of adverse drug events (ADE) and because safer alternative therapies are available on the market. In this context, in order to identify the instruments that assess the quality of medical prescriptions for elderly and to determine which drugs are considered PIM, a bibliographic survey was conducted in PUBMED, LILACS and PAHO databases, in February and March/2010. The search strategy included the use of health descriptors and a manual search in the references cited by selected papers. During the period of data collection, 15 instruments were identified. In 2012, with the publication of the update of Beers criteria, this instrument was included in the study. We identified 163 PIM of 25 therapeutic classes, of which 125 (76.7%) are marketed in Brazil. Of these, 31 (24.8%) are essential medicines (RENAME 2012), of which 13 have safer therapeutic equivalents and 19 (15.2%) are over-the-counter drugs. Data suggest the need for inclusion of safer alternatives for the elderly in the national list of essential medicines and the pharmaceutical care for early detection of ADE in this age group, in order to contribute to the safe use of medicines.

Possible adverse drug events leading to hospital admission in a Brazilian teaching hospital

OBJECTIVES

Drug safety problems can lead to hospital admission. In Brazil, the prevalence of hospitalization due to adverse drug events is unknown. This study aims to estimate the prevalence of hospitalization due to adverse drug events and to identify the drugs, the adverse drug events, and the risk factors associated with hospital admissions.

METHOD

A cross-sectional study was performed in the internal medicine ward of a teaching hospital in São Paulo State, Brazil, from August to December 2008. All patients aged ≥18 years with a length of stay ≥24 hours were interviewed about the drugs used prior to hospital admission and their symptoms/complaints/causes of hospitalization.

RESULTS

In total, 248 patients were considered eligible. The prevalence of hospitalization due to potential adverse drug events in the ward was 46.4%. Overprescribed drugs and those indicated for prophylactic treatments were frequently associated with possible adverse drug events. Frequently reported symptoms were breathlessness (15.2%), fatigue (12.3%), and chest pain (9.0%). Polypharmacy was a risk factor for the occurrence of possible adverse drug events.

CONCLUSION

Possible adverse drug events led to hospitalization in a high-complexity hospital, mainly in polymedicated patients. The clinical outcomes of adverse drug events are nonspecific, which delays treatment, hinders causality analysis, and contributes to the underreporting of cases.

Safety assessment of potentially inappropriate medications use in older people and the factors associated with hospital admission

PURPOSE

Potentially Inappropriate Medications (PIM) use in elderly people may be responsible for the development of Adverse Drug Reaction (ADR) which, when severe, leads to hospital admissions.

OBJECTIVES

to estimate the prevalence of elderly who had used PIM before being admitted to hospital admission and to identify the risk factors and the hospitalizations related to ADR arising from PIM.

METHODS

A descriptive and cross-sectional study was performed in the internal medicine ward of a teaching hospital (Brazil), in 2008. With the aid of a validated form, patients aged ≥ 60 years, with length of hospital stay ≥ 24 hours, were interviewed about drugs taken prior to the hospital admission and the complaints/reasons for hospitalization.

RESULTS

19.1% (59/308) of older patients had taken PIM before hospital admission and in 4.9%; there were a causal relation between the PIM taken and the complaint reported. PIM responsible for admissions were: amiodarone, amitriptyline, cimetidine, clonidine, diazepam, digoxin, estrogen, fluoxetine, lorazepam, short-acting nifedipine and propranolol. 47.0% of the clinical manifestations of PIM-related ADR were: dizziness, fatigue, digoxin toxicity and erythema. Only polypharmacy was detected as a risk factor for the occurrence of ADR of PIM (p = 0.02).

CONCLUSION

PIM use in elderly people is not a risk factor for ADR-related hospital admission. Probably, severe ADR, which lead to hospitalizations of older people, can be explained by idiosyncratic response or the predisposition of these patients to develop adverse drug events, whether or not drugs are classed as PIM.

Contribuição do uso de medicamentos para a admissão hospitalar

As Reações Adversas a Medicamentos (RAM) podem ser responsáveis por 2,4% a 11,5% das admissões hospitalares. O estudo objetivou conhecer o perfil demográfico dos pacientes internados por possíveis RAM, identificar os medicamentos e as queixas mais freqüentemente relacionadas e estimar a incidência de admissão hospitalar pelo uso de medicamentos. Durante um mês, os pacientes internados em um hospital geral foram entrevistados quanto ao uso de medicamentos antes da internação e as queixas que o levaram ao hospital; as informações foram analisadas, usando-se a base de dados MICROMEDEX® e outras bases oficiais. Observou-se que as admissões por uso de medicamentos ocorreram predominantemente em idosos [47,5% (66/139)] e mulheres [62% (87/139)]. Os medicamentos mais freqüentes foram: omeprazol (16), analgésicos (31), antihipertensivos (31), sinvastatina (7) e formoterol (6); e normalmente os sintomas associados foram do sistema digestório (20,5%), circulatório (20,2%), respiratório (18,2%) e SNC (13,9%). Estima-se que em 15,5% (139/897) das internações, possivelmente, a razão foi o uso de medicamentos. Os dados sugerem medidas de prevenção, como o acompanhamento farmacoterapêutico dos pacientes no âmbito da assistência primária à saúde, principalmente aos idosos, aos portadores de doenças crônicas e aos polimedicados, além da orientação farmacêutica na compra e dispensação de medicamentos, principalmente os isentos de prescrição.

Influence of the legislation on the advertisement of psychoactive medications in Brazil

OBJECTIVE

The regulations on the advertisement of medications aim to encourage and promote an improved health care and the rational use of medications. The objective of this paper is to evaluate the influence of three regulations on the advertisement of medications: the "Export act", published in the United States in 1986; the "WHO's Criteria", published in 1988, and the Resolution 102/2000 of the Collegiate Board of Directors of the ANVISA (Agência Nacional de Vigilância Sanitária- Brazilian Sanitary Surveillance Agency), on the advertisement of psychoactive medications.

METHOD

We collected advertisements that were published in Brazilian psychiatric journals before and after the regulations were established. The contents of the advertisements were analyzed according to a program created based on the regulation's demands.

RESULTS

In the 118 analyzed issues there were 199 different advertisements on 85 psychotropic drugs. We observed that, regardless the studied medication, the information about restrictions of use, such as adverse drug reactions, interactions, contraindications, warnings and precautions, does not appear very often, and when it does, its print sizes were smaller than that of the information favoring the use, such as indication, presentation and dosage. After the publication of the regulations, only 38.2% of the advertisements had all the essential technical information, and 35.3% were irregular in some way.

CONCLUSION

The data suggest that there was very little influence of the regulations on the advertisement of psychotropic drugs in Brazil. Consequently, other control measures are necessary in addition to the regulations.