Evidence-based drug therapy in the management of heart failure

This article provides an update on the drug treatment for heart failure (HF) mostly based on the recent clinical guidelines issued by the National Institute of Clinical Excellence (NICE).1 New high quality evidence from randomised controlled trials has resulted in greater value being given to the use of beta-blockers (BBs) and to the use of the hydralazine-nitrate combination. The importance of monitoring laboratory and clinical parameters to ensure safe and effective drug treatment is also highlighted.peer-reviewe

An update on the management of hypertension

This article provides an update on the management of hypertension mostly based on the recent clinical guidelines issued by the National Institute of Clinical Excellence (NICE). Key points being highlighted are the importance of assessment of the cardiovascular disease (CVD) risk and the fact that beta-blockers (BBs) are no longer considered as appropriate first-line agents (in the absence of other indications for beta-blockade). The importance of fully involving patients in treatment decisions on an on-going basis is also emphasised.peer-reviewe

Benzodiazepines and older people

There is a high prevalence of benzodiazepine use among elderly persons despite the fact that this sector of the population is particularly susceptible to the adverse effects of these medicines. Short half-life benzodiazepines are usually preferred for chronic use in older adults because they do not accumulate in the body, although they have a higher potential for dependence and are more strongly associated with withdrawal symptoms. A review of the literature confirms that benzodiazepines should be prescribed with caution, at low doses and for short periods.peer-reviewe

Evidence-based management of chronic heart failure

Throughout the past 10 to 15 years, the therapeutic approach to heart failure has undergone considerable change. Current treatment not only concerns symptomatic improvement, but increasingly focuses on the prevention of disease progression and on reducing mortality. The understanding and acceptance of the need to prescribe therapies proven to be effective in large controlled trials is vital for the provision of optimal treatment for heart failure patients.peer-reviewe

Selection of medication in hospitalised elderly patients with Angina Pectoris

Objective: To evaluate medication changes in hospitalised elderly patients diagnosed with angina pectoris and to compare the selection of medication with evidence-based treatment guidelines. Design: Review of medical notes and patient interview. Setting: St. Luke's Hospital, Malta; January - May 2001. Subjects: 226 patients, aged 60 years or over, with a history of chronic stable angina and a discharge diagnosis of angina. Main outcome measures: Prevalence of use of antiplatelet agents, lipid lowering agents, beta-blockers, calcium channel blockers, nitrates, potassium channel openers and cellular anti-ischaemic agents; presence of co-morbidities, concurrent medication and adverse effects. Results: Prior to discharge, 77% of patients were receiving antiplatelet agents and 27% were receiving lipid lowering agents. The most frequent anti-ischaemic agents used were nitrates (97%) and second-generation dihydropyridine calcium channel blockers (59%). Beta-blockers were used in 31% of patients and non-dihydropyridine calcium channel blockers were used in 4% of patients. Potassium channel openers (nicorandil) and cellular anti-ischaemic agents (trimetazidine) were used in 5% and 19% of patients respectively. Of patients discharged on a single anti-ischaemic agent, 96% were prescribed nitrates, while 64% of those on two agents were prescribed nitrates and dihydropyridine calcium channel blockers. Beta-blockers, nicorandil and trimetazidine were generally used in conjunction with at least two other antiischaemic agents. The major medication changes involved the addition, or increase in dose, of amlodipine and isosorbide dinitrate. The major determinants affecting choice of medication were age and co-morbidities. Conclusion: Medication selection for chronic stable angina was not in accordance with treatment guidelines.peer-reviewe

Community pharmacist perception of supplementary prescribing

Objective: To determine the perception of Maltese community pharmacists regarding supplementary prescribing. Method: A self-administered questionnaire was developed, tested for validity and reliability and distributed to 50 community pharmacists selected by stratified random sampling. Statistical analysis was undertaken using Microsoft® Excel® XP and the BioMedical Data Package (BMDP) software. Key Findings: Cronbach’s alpha correlation coefficient for the questionnaire was 0.8191. Forty-six pharmacists responded to the questionnaire. Twentythree pharmacists were in favour of supplementary prescribing for a variety of conditions predominantly gastro-oesophageal reflux disease and asthma (both 19 pharmacists). Pharmacists (20) envisaged the introduction of supplementary prescribing by forming liaisons with general practitioners. Conclusion: The initial response to the concept of pharmacist prescribing is encouraging. Community pharmacy in Malta will need to make changes in order to provide such services to patients.peer-reviewe

Clinical pharmacist implementation of a medication assessment tool for long-term management of atrial fibrillation in older persons

Background: Optimisation of drug therapy is important in the older population and may be facilitated by medication assessment tools (MATs). Objective: The purpose of the study was to evaluate whether appropriateness of drug therapy and clinical pharmacist intervention documentation improved following implementation of a previously developed MAT for the long-term management of atrial fibrillation (MAT-AF). Methods: Adherence to MAT-AF review criteria and clinical pharmacist intervention documentation was assessed by the researcher pre-MAT implementation in 150 patients aged ≥60 years admitted to a rehabilitation hospital with a diagnosis of atrial fibrillation. MAT-AF was introduced as a clinical tool in the hospital for identification of pharmaceutical care issues in atrial fibrillation patients. Adherence to MAT-AF and pharmacist intervention documentation were assessed by the researcher post-MAT implementation for a further 150 patients with the same inclusion criteria. Logistic regression analysis and measurement of odds ratio was used to identify differences in adherence to MAT-AF pre- and post-MAT implementation. The differences between two population proportions z-test was used to compare pharmacist intervention documentation pre- and post-MAT implementation. Results: Adherence to MAT-AF criteria increased from 70.9% pre-implementation to 89.6% post-implementation. MAT-AF implementation resulted in a significant improvement in prescription of anticoagulant therapy (OR 4.07, p<0.001) and monitoring of laboratory parameters for digoxin (OR 10.40, p<0.001). Clinical pharmacist intervention documentation improved significantly post-implementation of MAT-AF (z-score 20.249, p<0.001). Conclusions: Implementation of MAT-AF within an interdisciplinary health care team significantly improved the appropriateness of drug therapy and pharmacist intervention documentation in older patients with atrial fibrillation.peer-reviewe

Assessing appropriateness of drug therapy in older persons : development and application of a medication assessment tool for long-term management of atrial fibrillation

Background: Atrial fibrillation (AF) is highly prevalent in older persons and is associated with considerable morbidity and mortality. Assessing appropriateness of drug therapy in AF may be facilitated by application of medication assessment tools (MATs). Objective: To develop, psychometrically evaluate and apply an innovative MAT for the long-term management of AF with particular relevance to older persons. Methods: Key recommendations from clinical practice guidelines for the long-term management of AF were selected and review criteria defining appropriate drug therapy were constructed as a ‘qualifying statement’ followed by a ‘standard’. The developed MAT was given the designation MAT-AF. An application guide was compiled where justifications for non-adherence were specified. Content validity was tested by an expert group using a three-round Delphi process. Inter- and intra-observer reliability testing was conducted with agreement expressed by Cohen’s kappa and application time measured to assess feasibility. MAT-AF was applied to 150 patients with a diagnosis of AF admitted to a rehabilitation hospital. Results: MAT-AF consists of 15 criteria sectioned into antithrombotic, rate control and rhythm control therapy. Content validity was demonstrated for all criteria. Reliability was confirmed with kappa values of 0.84 and 0.91 for inter- and intra-observer agreements. Mean application time for the two observers was 3.9 and 2.4 minutes, which decreased significantly in the second application conducted after a four-week interval (p<0.001). Overall adherence to applicable criteria was 59.8%. Non-adherence was evident for prescription of anticoagulation in patients with a CHA2DS2VASc score ≥1 (29.5%). Monitoring of laboratory parameters for digoxin was suboptimal. Ophthalmic and pulmonary monitoring and patient counselling regarding amiodarone therapy could not be assessed since relevant records were not readily available. Conclusion: MAT-AF application highlighted key aspects which need to be addressed to improve patient care.peer-reviewe

Time and motion study for pharmacists’ activities in a geriatric hospital

Objectives: This study aimed to identify and quantify activities undertaken by pharmacists in a geriatric hospital. Methods: A data collection form was developed, validated and tested for applicability and practicality. Pharmacist activities were organised into three categories: Clinical, Administration and Others. Clinical activities incorporated patient discharge, patient admission, checking the ward controlled drugs record book, emergency trolley and patient medication trolley, prescription monitoring, ward round, discussion with health care professionals, and other professional activities; Administration activities included checking the ward medication stock and medication order; Others included break and inactive time. Observers conducted 6000 min of direct observation using a time and motion technique and observed the work activities of three pharmacists on three wards. Data were analysed using Microsoft Excel 2007 and SPSS version 16.0. Descriptive statistics were carried out. Key findings: The time dedicated to Clinical activities was 3636 min (60.60%), Administration activities 1646 min (27.43%) and Others 718 min (11.97%). When considering total time in minutes for Clinical and Administration activities, ward round (1348 min), medication order (1255 min), patient discharge (723 min) and prescription monitoring (562 min) occupied most of the pharmacists’ time. Ward round activities were subdivided into: patient profiling (545 min), actual ward round (668 min) and conference (135 min). Conclusions: The time and motion study indicated that the pharmacists’ time is mainly allocated to clinical activities. However, there is still a large proportion of time taken up by administrative activities, which can be conducted by non-pharmacist personnel, allowing more time to be directed to patient care.peer-reviewe

A short survey about drug deprescribing

AIM: The main purpose of the survey is to discover practices about deprescribing of potentially inappropriate polypharmacy among doctors working within the Department of Geriatric Medicine in Malta.METHODS: An online questionnaire was distributed via electronic mail to all doctors more senior than foundation year 1 working within the mentioned department between August and September 2021.RESULTS: A response rate of 54% was obtained. Just over half of the participants admitted to deprescribe at every opportunity, with psychiatric medications being mostly deprescribed. One of the commonest reasons for deprescribing included medication not indicated. Lack of knowledge about the reason for prescription and being prescribed by others were primary barriers to deprescribing. The role of a clinical pharmacist and need for a guideline was reflected in the results.CONCLUSION: The importance of deprescribing is appreciated by many doctors working in geriatrics in Malta, but there is still room for improvement.peer-reviewe