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

The impact of the internet on the practice of general practitioners and community pharmacists in Northern Ireland

Objective The objective of this study was to gain an insight into the use of the internet for practice-related purposes by community pharmacists and general practitioners (GPs) in Northern Ireland, and to gather information about their experiences relating to patients and the internet. Method A postal questionnaire survey of all community pharmacies (n=522) and all GPs practising in Northern Ireland (n=1081). Results A total of 542 completed questionnaires were returned, giving an overall response rate of 34%. The majority of respondents had access to the internet in their workplace, and approximately 60% of respondents in each profession accessed health-related websites on up to five occasions per week. Of those who did not access health-related websites, lack of time was the main reason cited. The most popular sites for both professions were online journals. Significant differences were found in the activities undertaken by the two professions whilst online. Significantly more GPs than community pharmacists reported searching for disease-related (non-drug) information, using web-based disease management tools or reading online journal articles. Few respondents reported recommending websites to patients, although significantly more GPs than pharmacists did so. Significantly more pharmacists had been approached or felt challenged by patients who had downloaded information from the internet. GPs were more likely to communicate with colleagues about patients by email but neither profession reported frequent correspondence with patients by email. Conclusions Both professions used the internet regularly as a source of health-related information and both had to deal with 'internet-informed', (or sometimes misinformed) patients. Community pharmacists were more likely to feel challenged by these patients and GPs sometimes had to deal with unnecessarily worried patients or patients with unrealistic expectations. Both professions will have to change working practices to accommodate the impact of the internet. This will have significant future training implications

Extent and nature of unlicensed and off-label medicine use in hospitalized children in Palestine

Objective of the study To determine the extent and nature of unlicensed/off-label prescribing patterns in hospitalised children in Palestine. Setting Four paediatric wards in two public health system hospitals in Palestine [Caritas children’s hospital (Medical and neonatal intensive care units) and Rafidia general hospital (Medical and surgical units)]. Method A prospective survey of drugs administered to infants and children \18 years old was carried out over a five-week period in the four paediatric wards. Main outcome measure Drug-licensing status of all prescriptions was determined according to the Palestinian Registered Product List and the Physician’s Desk Reference. Results Overall, 917 drug prescriptions were administered to 387children. Of all drug prescriptions, 528 (57.5%) were licensed for use in children; 65 (7.1%) were unlicensed; and 324 (35.3%) were used off-label. Of all children, 49.6% received off-label prescriptions, 10.1% received unlicensed medications and 8.2% received both. Seventy-two percent of off-label drugs and 66% of unlicensed drugs were prescribed for children \2 years. Multivariate analysis showed that patients who were admitted to the neonatal intensive care unit and infants aged 0–1 years were most likely to receive a greater number of off-label or unlicensed medications (OR 1.80; 95% CI 1.03–3.59 and OR 1.99; 95% CI 0.88–3.73, respectively). Conclusion The present findings confirmed the elevated prevalence of unlicensed and off-label paediatric drugs use in Palestine and strongly support the need to perform well designed clinical studies in children.The authors wish to thank Dr Chris Cardwell, Department of Epidemiology and Public Health, Queen’s University Belfast, for his statistical support, Nursing & administrative staff at the Caritas and Rafidia hospitals. The Daniel Turnberg UK/Middle East Travel Fellowship for financial support is acknowledge

The impact of the internet on the practice of general practitioners and community pharmacists in Northern Ireland

Objective The objective of this study was to gain an insight into the use of the internet for practice-related purposes by community pharmacists and general practitioners (GPs) in Northern Ireland, and to gather information about their experiences relating to patients and the internet. Method A postal questionnaire survey of all community pharmacies (n=522) and all GPs practising in Northern Ireland (n=1081). Results A total of 542 completed questionnaires were returned, giving an overall response rate of 34%. The majority of respondents had access to the internet in their workplace, and approximately 60% of respondents in each profession accessed health-related websites on up to five occasions per week. Of those who did not access health-related websites, lack of time was the main reason cited. The most popular sites for both professions were online journals. Significant differences were found in the activities undertaken by the two professions whilst online. Significantly more GPs than community pharmacists reported searching for disease-related (non-drug) information, using web-based disease management tools or reading online journal articles. Few respondents reported recommending websites to patients, although significantly more GPs than pharmacists did so. Significantly more pharmacists had been approached or felt challenged by patients who had downloaded information from the internet. GPs were more likely to communicate with colleagues about patients by email but neither profession reported frequent correspondence with patients by email. Conclusions Both professions used the internet regularly as a source of health-related information and both had to deal with 'internet-informed', (or sometimes misinformed) patients. Community pharmacists were more likely to feel challenged by these patients and GPs sometimes had to deal with unnecessarily worried patients or patients with unrealistic expectations. Both professions will have to change working practices to accommodate the impact of the internet. This will have significant future training implications

Pharmacogenetics and the print media:what is the public told?

Background: Pharmacogenetics is a rapidly growing field that aims to identify the genes that influence drug response. This science can be used as a powerful tool to tailor drug treatment to the genetic makeup of individuals. The present study explores the coverage of the topic of pharmacogenetics and its potential benefit in personalised medicine by the UK newsprint media. Methods: The LexisNexis database was used to identify and retrieve full text articles from the 10 highest circulation national daily newspapers and their Sunday equivalents in the UK. Content analysis of newspaper articles which referenced pharmacogenetic testing was carried out. A second researcher coded a random sample (21%) of newspaper articles to establish the inter-rater reliability of coding. Results: Of the 256 articles captured by the search terms, 96 articles (with pharmacogenetics as a major component) met the study inclusion criteria. The majority of articles over-stated the benefits of pharmacogenetic testing while paying less attention to the associated risks. Overall beneficial effects were mentioned 5.3 times more frequently than risks (p < 0.001). The most common illnesses for which pharmacogenetically based personalised medicine was discussed were cancer, cardiovascular disease and CNS diseases. Only 13% of newspaper articles that cited a specific scientific study mentioned this link in the article. There was a positive correlation between the size of the article and both the number of benefits and risks stated (P < 0.01). Conclusion: More comprehensive coverage of the area of personalised medicine within the print media is needed to inform public debate on the inclusion of pharmacogentic testing in routine practice

Public perceptions of coronary events risk factors: a discrete choice experiment

Objectives: To assess public perceptions of coronary heart disease (CHD) risk factors. Design: Discrete choice experiment questionnaire. Setting: Six provincial centres in Northern Ireland. Participants: 1000 adults of the general public in Northern Ireland. Primary and secondary outcomes: The general public's perception of CHD risk factors. The effect of having risk factor(s) on that perception. Results: Two multinomial logit models were created. One was a basic model (no heterogeneity permitted), while the other permitted heterogeneity based on respondents' characteristics. In both models individuals with very high cholesterol were perceived to be at the highest risk of having a coronary event. Respondents who reported having high cholesterol perceived the risk contribution of very high cholesterol to be greater than those who reported having normal cholesterol. Similar findings were observed with blood pressure and smoking. Respondents who were male and older perceived the contribution of age and gender to be lower than respondents who were female and younger. Conclusions: Respondents with different risk factors perceived such factors differently. These divergent perceptions of CHD risk factors could be a barrier to behavioural change. This brings into focus the need for more tailored health promotion campaigns to tackle CHD

Potential risk factors for medication non-adherence in patients with chronic obstructive pulmonary disease (COPD)

Aims To investigate the effect of a range of demographic and psychosocial variables on medication adherence in chronic obstructive pulmonary disease (COPD) patients managed in a secondary care setting. Methods A total of 173 patients with a confirmed diagnosis of COPD, recruited from an outpatient clinic in Northern Ireland, participated in the study. Data collection was carried out via face-to-face interviews and through review of patients’ medical charts. Social and demographic variables, co-morbidity, self-reported drug adherence (Morisky scale), Hospital Anxiety and Depression (HAD) scale, COPD knowledge, Health Belief Model (HBM) and self-efficacy scales were determined for each patient. Results Participants were aged 67±9.7 (mean ± SD) years, 56 % female and took a mean (SD) of 8.2±3.4 drugs. Low adherence with medications was present in 29.5 % of the patients. Demographic variables (gender, age, marital status, living arrangements and occupation) were not associated with adherence. A range of clinical and psychosocial variables, on the other hand, were found to be associated with medication adherence, i.e. beliefs regarding medication effectiveness, severity of COPD, smoking status, presence of co-morbid illness, depressed mood, self-efficacy, perceived susceptibility and perceived barriers within the HBM (p<0.05). Logistic regression analysis showed that perceived ineffectiveness of medication, presence of co-morbid illness, depressed mood and perceived barriers were independently associated with medication non-adherence in the study (P<0.05). Conclusions Adherence in COPD patients is influenced more by patients’ perception of their health and medication effectiveness, the presence of depressed mood and comorbid illness than by demographic factors or disease severity

A novel dried blood spot-LCMS method for the quantification of methotrexate polyglutamates as a potential marker for methotrexate use in children

Objective: Development and validation of a selective and sensitive LCMS method for the determination of methotrexate polyglutamates in dried blood spots (DBS). Methods: DBS samples [spiked or patient samples] were prepared by applying blood to Guthrie cards which was then dried at room temperature. The method utilised 6-mm disks punched from the DBS samples (equivalent to approximately 12 μl of whole blood). The simple treatment procedure was based on protein precipitation using perchloric acid followed by solid phase extraction using MAX cartridges. The extracted sample was chromatographed using a reversed phase system involving an Atlantis T3-C18 column (3 μm, 2.1x150 mm) preceded by Atlantis guard column of matching chemistry. Analytes were subjected to LCMS analysis using positive electrospray ionization. Key Results: The method was linear over the range 5-400 nmol/L. The limits of detection and quantification were 1.6 and 5 nmol/L for individual polyglutamates and 1.5 and 4.5 nmol/L for total polyglutamates, respectively. The method has been applied successfully to the determination of DBS finger-prick samples from 47 paediatric patients and results confirmed with concentrations measured in matched RBC samples using conventional HPLC-UV technique. Conclusions and Clinical Relevance: The methodology has a potential for application in a range of clinical studies (e.g. pharmacokinetic evaluations or medication adherence assessment) since it is minimally invasive and easy to perform, potentially allowing parents to take blood samples at home. The feasibility of using DBS sampling can be of major value for future clinical trials or clinical care in paediatric rheumatology. © 2014 Hawwa et al

Methotrexate polyglutamates as a potential marker of adherence to long-term therapy in children with juvenile idiopathic arthritis and juvenile dermatomyositis:an observational, cross-sectional study

Introduction: Methotrexate (MTX) is a cornerstone of treatment in a wide variety of inflammatory conditions, including juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM). However, owing to its narrow therapeutic index and the considerable interpatient variability in clinical response, monitoring of adherence to MTX is important. The present study demonstrates the feasibility of using methotrexate polyglutamates (MTXPGs) as a biomarker to measure adherence to MTX treatment in children with JIA and JDM. Methods: Data were collected prospectively from a cohort of 48 children (median age 11.5 years) who received oral or subcutaneous (SC) MTX therapy for JIA or JDM. Dried blood spot samples were obtained from children by finger pick at the clinic or via self- or parent-led sampling at home, and they were analysed to determine the variability in MTXPG concentrations and assess adherence to MTX therapy. Results: Wide fluctuations in MTXPG total concentrations (>2.0-fold variations) were found in 17 patients receiving stable weekly doses of MTX, which is indicative of nonadherence or partial adherence to MTX therapy. Age (P = 0.026) and route of administration (P = 0.005) were the most important predictors of nonadherence to MTX treatment. In addition, the study showed that MTX dose and route of administration were significantly associated with variations in the distribution of MTXPG subtypes. Higher doses and SC administration of MTX produced higher levels of total MTXPGs and selective accumulation of longer-chain MTXPGs (P < 0.001 and P < 0.0001, respectively). Conclusions: Nonadherence to MTX therapy is a significant problem in children with JIA and JDM. The present study suggests that patients with inadequate adherence and/or intolerance to oral MTX may benefit from SC administration of the drug. The clinical utility of MTXPG levels to monitor and optimise adherence to MTX in children has been demonstrated. Trial registration: ISRCTN Registry identifier: ISRCTN93945409. Registered 2 December 2011

Quantitative analysis of methyl and propyl parabens in neonatal DBS using LC-MS/MS

AIM: Excipients are used to overcome the chemical, physical and microbiological challenges posed by developing formulated medicines. Both methyl and propyl paraben are commonly used in pediatric liquid formulations. There is no data on systemic exposure to parabens in neonates. The European Study of Neonatal Exposure to Excipients project has investigated this. Results & methodology: DBS sampling was used to collect opportunistic blood samples. Parabens were extracted from the DBS and analyzed using a validated LC-MS/MS assay. DISCUSSION & CONCLUSION: The above assay was applied to analyze neonatal DBS samples. The blood concentrations of parabens in neonates confirm systemic exposure to parabens following administration of routine medicines