A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care

Background: Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.<p></p> Methods: We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.<p></p> Findings: We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.<p></p> Interpretation: Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population

Personalized medicine : the impact on chemistry

An effective strategy for personalized medicine requires a major conceptual change in the development and application of therapeutics. In this article, we argue that further advances in this field should be made with reference to another conceptual shift, that of network pharmacology. We examine the intersection of personalized medicine and network pharmacology to identify strategies for the development of personalized therapies that are fully informed by network pharmacology concepts. This provides a framework for discussion of the impact personalized medicine will have on chemistry in terms of drug discovery, formulation and delivery, the adaptations and changes in ideology required and the contribution chemistry is already making. New ways of conceptualizing chemistry’s relationship with medicine will lead to new approaches to drug discovery and hold promise of delivering safer and more effective therapies

Management of type 2 diabetes mellitus for general practitioners

A 55-year-old Asian man presents with a history of intense thirst, polyuria, blurring of vision and weight loss over a period of several weeks. He is obese with a waist circumference of 110 cm and a body mass index (BMI) of 32 kg/m2. His blood pressure is 170/110 mmHg. Laboratory investigations indicate the following: random blood glucose 13.6 mmol/l, haemoglobin A1c (HbA1c) 9.5%, total serum cholesterol 6.8 mmol/l, low-density lipoprotein (LDL) cholesterol 3.5 mmol/l, high-density lipoprotein (HDL) cholesterol 0.7 mmol/l, triglycerides 3.2 mmol/l, and serum creatinine normal. His urine shows glycosuria and microalbuminuria. What would be your approach to this patient’s management?Keywords: type 2 diabetes mellitus, management, general practitioners, lifestyle intervention

Behavioural Interventions for Obese Adults with Additional Risk Factors for Morbidity : Systematic Review of Effects on Behaviour, Weight and Disease Risk Factors

Peer reviewedPostprin

Concordance of gout management with European League against Rheumatism recommendations in hospital practice

Aim: To assess the concordance of gout management with the European League Against Rheumatism (EULAR) gout recommendations in hospital practice. Methods: This was a retrospective review of case notes of patients presenting to rheumatology outpatients between June and December 2009 under the care of 2 consultant rheumatologists. Data collected consisted of demographics, time lag to specialist referral, comorbidities, details about acute and recurrent attacks, lifestyle advice and use of urate lowering therapies. Documented management was assessed for concordance with the EULAR recommendations. Results: Thirty consecutive patients (27 males, 3 females) attending Rheumatology clinic at Mater Dei Hospital were recruited. Mean age at the time of survey was 59.4 ± 10.7 years, while mean age at diagnosis was 51.1 ± 14 years. Documentation of lifestyle advice was recorded for alcohol reduction (83%), weight loss (43%), diet (13%), and exercise (13%). Adequate control of comorbidities was attained in hyperlipidaemia (71%), diabetes mellitus (55%) and hypertension (30%). Advice about smoking cessation was given to 37%. Uric acid levels below target were achieved in 47%. The mean uric acid level at time of survey was 379 ± 146 μmol/l. This was significantly less than that at presentation (p=0.001). Conclusions: Current treatment of gout is poorly concordant with many of the EULAR recommendations. Documentation of lifestyle modifications advice is infrequent except for alcohol reduction. A significant number of patents on allopurinol still have hyperuricaemia implying that more aggressive management is required to improve standard of care. A proforma has been developed to make and help sustain the necessary improvements.peer-reviewe

Essential steps in primary care management of older people with Type 2 diabetes: an executive summary on behalf of the European geriatric medicine society (EuGMS) and the European diabetes working party for older people (EDWPOP) collaboration

We present an executive summary of a guideline for management of type 2 diabetes mellitus in primary care written by the European Geriatric Medicine Society, the European Diabetes Working Party for Older People with contributions from primary care practitioners and participation of a patient’s advocate. This consensus document relies where possible on evidence-based recommendations and expert opinions in the fields where evidences are lacking. The full text includes 4 parts: a general strategy based on comprehensive assessment to enhance quality and individualised care plan, treatments decision guidance, management of complications, and care in case of special conditions. Screening for frailty and cognitive impairment is recommended as well as a comprehensive assessment all health conditions are concerned, including end of life situations. The full text is available online at the following address: essential_steps_inprimary_care_in_older_people_with_diabetes_-_EuGMS-EDWPOP___3_.pdf

Healthy ageing in Europe: prioritizing interventions to improve health literacy

Background: Health literacy (HL) is low for 40-50% of the population in developed nations, and is strongly linked to many undesirable health outcomes. Older adults are particularly at risk. The Intervention Research on Health Literacy in Ageing populations project systematically created a large inventory of HL interventions targeting adults age 50+, to support practical production of policy and practice guidelines for promoting health literacy in European populations. Methods: We comprehensively surveyed international scientific literature, grey literature and other sources (published 2003+) for implemented HL interventions that involved older adults. Studies were screened for eligibility criteria and further selected for aspects important in European public health policy, including priority diseases, risk factors and vulnerable target groups. Interventions were prioritised using a multiple criteria tool to select final interventions that also featured strong evidence of efficacy and a broad range of strategies. Results: From nearly 7000 written summaries, 1097 met inclusion criteria, of which 233 were chosen for scoring and ranking. Of these, 7 had the highest multi-criteria scores. Eight more articles were selected based on rounded criteria including a high multi-criteria score as well as elements of innovation. Final selections were 18 articles describing 15 programmes, which feature strong evidence of efficacy among important diseases or risk factors and vulnerable groups, or that had success with elements of innovation were identified. Most programmes tried to increase skills in communication, self-management and understanding healthcare or lifestyle choices. Conclusions: These programmes have multiple positive attributes which could be used as guidance for developing innovative intervention programmes to trial on European older adults. They provide evidence of efficacy in addressing high priority diseases and risk factors

Chapter 11: The approach to achieving glycaemic control

The Society for Endocrinology, Metabolism and Diabetes of South Africa Type 2 Diabetes Guidelines Expert Committee.Chapter 11. The approach to achieving glycaemic control in 2017 SEMDSA Guideline for the Management of Type 2 Diabetes Guideline Committee. JEMDSA 2017; 21(1)(Supplement 1): S51-5