Barriers to pharmaceutical care in Iran

<p><strong>Editorial</strong></p

Corticosteroids Administration Following COVID-19-induced Acute Respiratory Distress Syndrome. Is it harmful or Life-saving?

Until now, April 22, 2020, Covid-19 has been confirmed in 2471136 patients and 203 countries and territories with mortality rate over 169000 patients. Right now, there is no definite cure for it and developing treatments including vaccines and antiviral compounds are under evaluations for efficacy. Covid-19 infection can be mild, severe, or even critical. The symptoms may range from fever (the most common symptom), chills, fatigue and cough to decreased arterial oxygen saturation, changes in respiratory rate and dyspnea. The dyspnea in critically patients is more severe. In severe cases, respiratory failure, acute respiratory distress syndrome (ARDS) and septic shock have been reported. Septic shock is also associated with hypoxia and acidosis.&nbsp;ARDS is the most important cause of death in this group of patients. This feature of the disease may be caused by various factors, including inflammatory mediators and cytokine storm. The computed tomography (CT) imaging findings have shown that the lung with ARDS has a ground-glass appearance, in which white fluid-filled patches are seen inside the lung. The fluid inside these patches has a jelly state. Pathological samples obtained from lung tissue also indicate pulmonary damage, obvious destruction of pneumocytes and formation of a hyaluronan membrane, which more emphasized on ARDS occurrence.&nbsp;Cytokine storm caused by Covid-19 infection is a severe immune response. The occurrence of cytokine storm can lead to severe tissue damages. Pre-inflammatory factors are involved in this process and one of them is interleukin 6 (IL-6) which affects different cells. IL-6 performs various functions such as regulating body temperature, increasing the production of acute phase protein and differentiation of B cells. On the other hand, the production of interleukin 1 (IL-1) as an inflammatory mediator will be increased during cytokine storm, as well. IL-1 can cause fever and stimulating the production of hyaluronan which has been seen in fibrosis. Based on studies on SARS-CoV, rapid spread and proliferation of the virus as a result of delayed interferon-1 production and subsequent rapid accumulation of macrophages and monocytes may also be involved in tissue destructions and a similar mechanism might be seen in Covid-19 infection.&nbsp;When there is no proper immune system response, the virus causes extensive tissue damages, especially to organs where ACE2 is most commonly seen, such as the lungs. Therefore, since the lungs are damaged, efforts should be focused on suppressing the inflammation, managing the symptoms and theoretically any compounds that may help this inflammation subside could play an important role in reducing the incidence of ARDS and consequently the mortality rate.&nbsp;The use of corticosteroids in different phases of ARDS has been inconsistent with conflicting results. Corticosteroids exert their anti-inflammatory effects by regulating the signaling pathways on the membrane and inside the cells, stopping pre-inflammatory gene-related processes (genes responsible for producing pre-inflammatory factors). Furthermore, they are able to increase the production of anti-inflammatory mediators such as interleukin 10 (IL-10).&nbsp;Corticosteroids have been investigated in some clinical protocols for evaluation of their effectiveness in reducing inflammatory responses and cytokine storm. According to the guideline of World Health Organization (WHO), systemic corticosteroids should not be routinely used in viral pneumonia except in clinical trials. However, WHO has recommended that these compounds can be used in exacerbations of asthma and COPD, and septic shock, considering each patient's condition and assessing the benefits and risks. This guideline further states that the use of corticosteroids in similar conditions such as influenza may lead to secondary super infections and increase mortality rate. But in another study on SARS-CoV, the use of corticosteroids was associated with improvement in time to survival in severe patients and decrease in mortality rate. Delayed viral clearance is another concern. In a study on patients with MERS-CoV, the use of corticosteroids did not make a significant difference in mortality rate. However, its association with a delay in viral clearance from the lungs of patients was reported.&nbsp;Side effects are another limiting factors for use of corticosteroids in patients with Covid-19. A similar study in patients with SARS-CoV showed that use of higher doses of corticosteroids in such conditions could cause a corticosteroid-induced diabetes, with 36.3% of patients experiencing such complication.&nbsp;The guideline of Surviving Sepsis Campaign for the management of patients with Covid-19 has recommended the use of corticosteroids under the following conditions: 1) in patients with Covid-19 who are suffering from septic shock, the use of corticosteroids (low-dose) are preferred over not using it. The guideline notes that there is no difference in mortality rate and side effects. However, there is weak recommendation that using corticosteroids in these conditions can reduce the time of resolution of shock and ICU and hospital length of staying; 2) In cytokine storm, if the patient has not yet developed ARDS, corticosteroids are recommended in ways other than routine procedures, and if ARDS occurred, the use of these compounds is recommended over not using them. Lesser need of oxygen, improved radiographic findings and reduced length of staying in ICU and hospital are some of the advantages that this guideline has referred to. However, there is just a week recommendation over the use of these compounds in this guideline.&nbsp;Based on what has been discussed, it could be concluded that the use of corticosteroids in the current situation should be limited, since there are no significant benefits over their effectiveness. On the other hand, there is a risk in prolongation of viral clearance and secondary infections and mortality rate. The use of these compounds should be limited to clinical trials to further evaluate their effectiveness in this new found disease. The clinical conditions of patients should be carefully evaluated throughout the studies and close monitoring should be performed while discontinuing these drugs

Optimizing Outpatient Medication Management: The Impact of Clinical Pharmacists on Identifying and Addressing Drug-Related Problems

Medication Therapy Management Services (MTMS) are effective strategies to reduce Drug-Related Problems (DRPs) and associated healthcare costs. Given the high prevalence of DRPs in outpatient settings and the lack of an effective process to detect such problems in Iran, we decided to evaluate the type and number of DRPs identified by clinical pharmacists in a university-affiliated Pharmacotherapy Clinic in Khuzestan province, South of Iran. In this cross-sectional study, 150 eligible outpatients were included. At a university-affiliated pharmacotherapy clinic, pharmacy students took patients' histories and referred them to clinical pharmacists for DRP evaluation and detection. Appropriate interventions were then implemented in collaboration with patients and their healthcare providers to resolve the problems. Approximately 3.56 DRPs per patient were identified during a nine-month study period. The most prevalent DRPs were lack of education or information (32.40% [174/537]), undertreated indications (17.31% [93/537]), and patient compliance (15.27% [82/537]). Clinical pharmacists detected 537 DRPs, implemented 525 interventions, and performed 0.977 interventions per DRP. The provision of information (57.52% [302/525]) and change of therapy (21.71% [114/525]) were the most frequent types of clinical pharmacist interventions. This study revealed deficiencies and limitations in our healthcare services, resulting in a significant prevalence of DRPs. Implementing pharmaceutical care practice models, such as Pharmacotherapy Clinics, where clinical pharmacists integrate their experience and knowledge in a patient-centered manner, is the most effective method for preventing and managing these issue

Interferon beta-1a as a Candidate for COVID-19 Treatment; An Open-Label Single-Arm Clinical Trial

Introduction: Since December 2019, an outbreak of Covid-19 has caused growing concern in multiple countries. Researchers around the world are working to find a treatment or a vaccine for Covid-19 and different treatment approaches have been tested in this regard.&nbsp;Objective: This study was designed and conducted to assess the possible efficacy of Interferon beta-1a as a safe and efficient candidate for Covid-19 treatment.&nbsp;Methods: This is an investigator-initiated, open-label, single-arm clinical trial. Twenty patients with suspected Covid-19, who were admitted to Sina hospital in Tehran, Iran, with moderate to severe symptoms, from 6 to 10 March, 2020, were enrolled. Patients were treated with antiviral and hydroxychloroquine combination therapy, along with subcutaneous Interferon beta-1a for 5 consecutive days. Baseline characteristics and findings during the course of admission and 5 days after discharge were recorded for all the patients.&nbsp;Results: In total, 20 patients with suspected Covid-19 were included in this study, 12 (60%) of which were male. The median (Interquartile (IQ) range) of patients’ age was 55.5 (43-63.5). The most common symptom of the patients at onset of disease was fever. The median (IQ range) of duration of hospital stay was 5.0 (3-6) days. Only 2 cases were admitted to ICU. At the time of follow-up, 15 (94%) patients reported that they generally felt good and had oral tolerance, 1 patient had suffered from dyspnea, 5 patients had suffered from cough, none of them had experienced fever and no case of re-admission or death was reported after discharge.&nbsp;Conclusions: Results of the current study are in favor of using Interferon beta-1a in addition to recommended antiviral treatment in Covid-19 patients

Interferon beta-1a as a Candidate for COVID-19 Treatment; An Open-Label Single-Arm Clinical Trial

Introduction: Since December 2019, an outbreak of Covid-19 has caused growing concern in multiple countries. Researchers around the world are working to find a treatment or a vaccine for Covid-19 and different treatment approaches have been tested in this regard.&nbsp;Objective: This study was designed and conducted to assess the possible efficacy of Interferon beta-1a as a safe and efficient candidate for Covid-19 treatment.&nbsp;Methods: This is an investigator-initiated, open-label, single-arm clinical trial. Twenty patients with suspected Covid-19, who were admitted to Sina hospital in Tehran, Iran, with moderate to severe symptoms, from 6 to 10 March, 2020, were enrolled. Patients were treated with antiviral and hydroxychloroquine combination therapy, along with subcutaneous Interferon beta-1a for 5 consecutive days. Baseline characteristics and findings during the course of admission and 5 days after discharge were recorded for all the patients.&nbsp;Results: In total, 20 patients with suspected Covid-19 were included in this study, 12 (60%) of which were male. The median (Interquartile (IQ) range) of patients’ age was 55.5 (43-63.5). The most common symptom of the patients at onset of disease was fever. The median (IQ range) of duration of hospital stay was 5.0 (3-6) days. Only 2 cases were admitted to ICU. At the time of follow-up, 15 (94%) patients reported that they generally felt good and had oral tolerance, 1 patient had suffered from dyspnea, 5 patients had suffered from cough, none of them had experienced fever and no case of re-admission or death was reported after discharge.&nbsp;Conclusions: Results of the current study are in favor of using Interferon beta-1a in addition to recommended antiviral treatment in Covid-19 patients

Pharmacist-Led Medication Review: Supports for New Role of Pharmacists

In recent decades, by increasing complexity of drug therapy, pharmacists considered as health- care members who can help optimizing drug therapy. We know that medicines do not have the anticipated effects all the times and a vast variability may exist in their behaviors in the body. So, it is very crucial to individualize treatment for every single patient. Nowadays, optimizing drug therapy in patients needs a collaborative interdisciplinary approach to patients care and treatment. Specifically when drug therapy is considered for a condition, pharmacists can enroll as a valuable professional to help for modification of therapy along with other clinicians. Abundant number of studies and reports exist in the literatures which address usefulness of pharmacist engagement in patient care. In this review we have presented some valuable evidences supporting pharmacist role in different clinical settings

Increasing the Number of Adverse Drug Reactions Reporting: the Role of Clinical Pharmacy Residents

Abstract Detection of adverse drug reactions (ADRs) in hospitals provides an important measure of the burden of drug related morbidity on the healthcare system. Spontaneous reporting of ADRs is scare and several obstacles to such reporting have been identified formerly. This study aimed to determine the role of clinical pharmacy residents in ADR reporting within a hospital setting.Clinical pharmacy residents were trained to report all suspected ADRs through ADRreporting yellow cards. The incidence, pattern, seriousness, and preventability of the reported ADRs were analyzed. During the period of 12 months, for 8559 patients, 202 ADR reports were received. The most frequently reported reactions were due to anti-infective agents (38.38%). Rifampin accounted for the highest number of the reported ADRs among anti-infective agents. The gastro-intestinal system was the most frequently affected system (21.56%) of all reactions. Fifty four of the ADRs were reported as serious reactions. Eighteen of the ADRs were classified as preventable. Clinical pharmacy residents involvement in the ADR reporting program could improve the ADR reporting system

Vitamin D Utilization May Improve Military Performance: A Mini-Review

Studies from different regions of the world show that vitamin D deficiency is a common problem across the globe, even in military personnel. Risk factors of this deficiency includes elderly and female population, higher geographical latitudes, winter season, darker skins, low sunlight exposure, diet, and lack of vitamin D supplementation /fortification, although the deficiency in areas with higher sun exposure also has been documented.  We reviewed some of the clinical trials and observations regarding vitamin D deficiency and supplementation. It has been shown that vitamin D deficiency is associated with more acute respiratory tract infections and acute pharyngitis resulting in more days off from training, more bone stress fractures, poor physical performance, and increased risk for suicide. Clinical trials that utilized supplemental vitamin D shows decreased incidence of stress fractures in female navy recruits, lower incidence of influenza A and lower risk of acute respiratory tract infections, and improved bone density during initial military training, although one systematic review found conflicting data in supplementation with vitamin D for the prevention of acute respiratory infection. These data opens a window for supplementation with vitamin D in populated military bases to decrease rate of respiratory infection and to minimize stress fractures for better performances; doses used for these purposes ranges from 300 to 1200 IU per day. Further clinical trials of vitamin D supplementation or dietary fortification for these military purposes should be conducted to determine the optimum dose and duration

Therapeutic Drug Monitoring of Vancomycin Following Critical Care Illnesses: Peak Concentration Determination Maybe Critical

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