Particulate steroids in axial spinal blockade and the increasing role of patient consent: Les grains de sable dans l’engrenage

The complexity of modern medical practice is such that it is very unlikely that on any single issue we can give a definitive answer in any circumstance, and in our view the medical debate as to the use of particulate corticosteroid medicines in axial spinal blockade is one such argument. The medical discussion of the use of particulate corticosteroids has to be set against the uncertain risk and benefits of axial spinal procedures in which the drugs are utilised, and in which the most likely catastrophic complication may occur with their use, and then, as the law now demands, involve the patient in the relevant consenting issues

Impact of smoking status on the efficacy of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review

Objectives: Inhaled corticosteroids (ICS) reduce exacerbation rates and the decline in lung function in people with chronic obstructive pulmonary disease (COPD). There is evidence that smoking causes ‘steroid resistance’ and thus reduces the effect of ICS. This systematic review aimed to investigate the effect of smoking on efficacy of ICS in COPD in terms of lung function and exacerbation rates.Design: Systematic reviewData Sources: An electronic database search of PubMed, Ovid Medline, Ovid Embase and Cochrane Library (Jan 2000-Jan 2020).Eligibility criteria: Fully published RCTs, in the English language, evaluating the use of ICS in COPD adults that stratified the participants by smoking status. Trials that included participants with asthma, lung cancer and pneumonia were excluded. The primary outcome measures were changes in lung function and yearly exacerbation rates. Data extraction and synthesis: Two independent reviewers extracted data and assessed risk of bias using the Cochrane Collaboration’s tool. Results: Eight studies were identified. Five trials (17,999 participants) recorded change in forced expiratory volume (FEV1) from baseline to up to 30 months after starting treatment. Heavier smokers (>36 pack years) using ICS had a greater decline in FEV1 that ranged from -22ml to -75ml in comparison to lighter smokers. Ex-smokers using ICS had a lesser decline in FEV1 that was +8ml to +110ml in comparison to current smokers. Three trials (21,270 participants) recorded difference in COPD exacerbation rates at 52 weeks. The rate ratios favoured more exacerbations in ICS users who were current or heavier smokers than those who were ex- or lighter smokers (0.81 to 0.99 versus 0.92 to 1.29).Conclusions: In COPD, heavier or current smokers do not gain the same benefit from ICS use on lung function and exacerbation rates as lighter or ex-smokers do, however effects may not be clinically important

Prescription opioids: regional variation and socioeconomic status: evidence from primary care in England

Background: This study aimed to quantify dispensed opioid prescriptions among primary care practices throughout England and investigate its association with socioeconomic status (SES).Methods: This cross-sectional study used publicly available data in 2015, including practice-level dispensing data and characteristics of registrants from the United Kingdom (UK) National Health Service Digital, and Index of Multiple Deprivation (IMD) data from Department of Communities and Local Government. Practices in England which had opioid prescriptions that could be assigned a defined daily dose (DDD) in the claim-based dispensing database were included. The total amount of dispensed opioid prescriptions (DDD/1000 registrants/day) was calculated for each practice. The association between dispensed opioid prescriptions and IMD was analyzed by multi-level regression and adjusted for registrants' characteristics and the clustered effect of Clinical Commissioning Groups. Subgroup analysis was conducted for practices in London, Birmingham, Manchester and Newcastle.Results: Of the 7856 included practices in England, the median and interquartile range (IQR) of prescription opioids dispensed was 36.9 (IQR: 23.1, 52.5) DDD/1000 registrants/day. The median opioid utilization (DDD/1000 registrants/day) amongst practices varied between Manchester (53.1; IQR: 36.8, 71.4), Newcastle (48.9; IQR: 38.8, 60.1), Birmingham (35.3; IQR: 23.1, 49.4) and London (13.9; IQR: 8.1, 18.8). Lower SES, increased prevalence of patients aged more than 65 years, female gender, smoking, obesity and depression were significantly associated with increased dispensed opioid prescriptions. For every decrease in IMD decile (lower SES), there was a significant increase of opioid utilization by 1.0 (95% confidence interval: 0.89, 1.2, P less than 0.001) DDD/1000 registrants/day.Conclusion: There was a variation in prescription opioids dispensed among practices from Northern and Eastern England to Southern England. A significant association between increased opioid prescriptions and greater deprivation at a population level was observed. Further longitudinal studies using individual patient data are needed to validate this association and identify the potential mechanisms

Evidence-based clinical practice guidelines on the management of pain in older people – a summary report

Objective:The objective of this study is to develop an update of the evidence-based guidelines for the management of pain in older people.Design:Review of evidence since 2010 using a systematic and consensus approach is performed.Results:Recognition of the type of pain and routine assessment of pain should inform the use of specific environmental, behavioural and pharmacological interventions. Individualised care plans and analgesic protocols for specific clinical situations, patients and health care settings can be developed from these guidelines.Conclusion:Management of pain must be considered as an important component of the health care provided to all people, regardless of their chronological age or severity of illness. By clearly outlining areas where evidence is not available, these guidelines may also stimulate further research. To use the recommended therapeutic approaches, clinicians must be familiar with adverse effects of treatment and the potential for drug interactions

Current Use of Analgesics and the Risk of Falls in people with Knee Osteoarthritis: A Population-based Cohort Study Using Primary Care and Hospital Records

ObjectiveTo examine the association between the current use of analgesics and the risk of falls in people with knee osteoarthritis (KOA).MethodsA retrospective cohort study using data from the UK Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics data. People diagnosed with KOA in England between 2000 and 2014 were included. The studied analgesic classes were antidepressants, antiepileptic drugs (AEDs), opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. Cox Proportional Hazards model was used to estimate the risk of fall with current use of analgesics within one year of KOA diagnosis, reported as Hazard Ratio (HR) with 95% Confidence Intervals (CI).ResultsThis study included 57,383 patients (mean age [SD] 67.0 [12.8] years, 59.3% were female); 44,010 (76.7%) were prescribed analgesics at least once within one year of KOA diagnosis. Within the first six months of KOA diagnosis, the reported HR (95%CI) were 1.46 (1.20, 1.78), 1.40 (0.91, 2.16), 2.40 (2.01, 2.85), 1.72 (1.43, 2.07), 1.98 (1.68, 2.33), while between 6 and 12 months after KOA diagnosis, the HR (95%CI) were 2.68 (2.14, 3.36), 2.22 (1.70, 2.91), 1.96 (1.70, 2.26), 1.47 (1.21, 1.78), 1.92 (1.63, 2.26) for antidepressants, AEDs, opioids, NSAIDs and paracetamol, respectively and adjusted for important potential confounders.ConclusionThe current use of analgesics was associated with an increased risk of falls within one year of KOA diagnosis. These findings identify people with KOA who use analgesics as a priority for fall prevention programs/interventions, in an effort to optimise safety of analgesics in this population

“Application of five different strategies to define a cohort of patients with knee osteoarthritis in a large primary care database”

BackgroundElectronic health records (EHR) are frequently used for epidemiological research including drug utilisation studies in a defined population such as the population with knee osteoarthritis (KOA). We sought to describe the process of defining a cohort of patients with KOA from a large UK primary care database and estimate the annual incidence of diagnosed KOA between 2000 and 2015.MethodThis was a retrospective study using data from the clinical practice research datalink (CPRD). CPRD is a large primary care longitudinal electronic medical records’ database that contains anonymous records of patients from general practices across United Kingdom. Five different cohort definition strategies were applied including symptoms-based or diagnosis-based strategies or a combination of both. To validate results, the annual incidence of KOA was estimated and compared to published data.ResultsThe study defined 898,690 patients when symptoms-based strategy was applied, 137,541 patients when diagnosis based and 83,294 when a combination of both strategies were applied. The final cohort was defined using a diagnosis-based strategy that avoided overestimation (with symptoms-based definition) or underestimation (with a combination of symptoms and diagnosis). The incidence of KOA ranged from 1.33 per 1000 CPRD registrants in 2000, 1.76 in 2008 and 1.45 patients in 2015.ConclusionThis study logically/sensibly defined a cohort of patients with diagnosed KOA through the application of several strategies. This was an essential step to avoid subsequent over or underestimation of the prevalence of drug utilisation and the associated adverse clinical outcomes within primary care patients with KAO

Analgesic Utilisation in People with Knee Osteoarthritis: A Population‐ Based Study Using Primary Care Data

PurposeOsteoarthritis (OA) is a chronic painful condition that often affects large joints such as the knee. Treatment guidelines recommend paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids. Antidepressants and Anti-epileptic drugs (AEDs) are commonly prescribed for chronic non-cancer pain conditions including OA, as an off-label use. This study describes analgesic utilisation in patients with knee OA at population-level using standard pharmaco-epidemiological methods.MethodThis was a cross-sectional study between 2000 and 2014 using data from the UK Clinical Practice Research Datalink (CPRD). The use of antidepressants, AEDs, opioids, NSAIDs and paracetamol was studied in adults with knee OA using the following measures: annual number of prescriptions, Defined Daily Doses (DDD), oral morphine equivalent dose (OMEQ) and days’ supply.ResultsIn total, there were 8,944,381 prescriptions prescribed for 117,637 patients with knee OA during the 15-year period. There was a steady increase in the prescribing of all drug classes, except for NSAIDs, over the study period. Opioids were the most prevalent class prescribed in every study year. Tramadol was the most commonly prescribed opioid, with the number of DDD increasing from 0.11 to 0.71 DDDs per 1000 registrants in 2000 and 2014, respectively. The largest increase in prescribing was for AEDs, where the number of prescriptions increased from 2 to 11 per 1000 CPRD registrants.ConclusionThere was an overall increase in the prescribing of analgesics apart from NSAIDs. Opioids were the most frequently prescribed class however, the greatest increase in prescribing between 2000 and 2014, was observed in AEDs

Logic model for opioid safety in chronic non-malignant pain management, an in-depth qualitative study

Background Opioids are commonly used for the management of chronic non-malignant pain in Pakistan; but there is a lack of literature around precursors or motivators in the use of opioids.Aim The study holistically explored factors contributing towards the unsafe use of opioids and identifies strategies to over- come them.Method Exploratory qualitative methods using interviews, focus groups and non-participant observational case studies were used. Interviews and focus groups were carried out face-to-face as well as virtually and observations were conducted in com- munity pharmacies in Islamabad and Khyber Pukhtoon Khuwa province, Pakistan. Data were collected from 4 stakeholder groups; pharmacy policy makers (n=11), people with chronic non-malignant pain (n=14), doctors (n=31) and community pharmacists (n = 36) by purposive critical case sampling method. Data were analysed inductively using reflexive thematic analy- sis and then deductively mapped to a social ecological framework. Non-participant observations were analysed using a cross case synthesis using explanation building technique. Data from all three methods were triangulated to develop a logic model. Results Identified factors at macro (regulation), meso (social perceptions of pain and opioids) and micro levels (uncontrolled pain, self-medication, health literacy) and strategies are presented holistically and were used to develop a logic model for the prevention and mitigation of factors currently causing unsafe use of opioids.Conclusion The study provides an in-depth view of factors contributing towards diversion of pharmaceutical opioids and can help guide national and international policy makers in their future initiatives to promote safe use of opioids in the manage- ment of chronic non-malignant pain in Pakistan

Rapid acting fentanyl formulations in breakthrough pain in cancer: drug selection by means of the System of Objectified Judgement Analysis

Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient

Role of pharmacists in optimising opioid therapy for chronic non-malignant pain; A systematic review

BackgroundOpioid optimisation is a global issue in Chronic Non-malignant Pain (CNMP) management.ObjectiveThis systematic review aims to assess the effectiveness of interventions delivered by pharmacists in outpatient clinical settings, community pharmacies and primary care services in optimising opioid therapy for people with CNMP and to explore stakeholders’ opinions about role of pharmacists in optimising opioid therapy.MethodsWe conducted searches in PubMed, CINAHL, Psych Info, EMBASE, ISI Web of Science and Conference Proceedings and International Pharmaceutical Abstracts. All studies where pharmacists in outpatient clinical settings, community pharmacies and patient care services helped in optimisation of opioids in the treatment of CNMP as individuals or part of a team were included. Authors followed the 27-item PRISMA guidelines and the review was registered in PROSPERO. All authors were involved in screening and selection of studies and included studies between January 1990–June 2020. Studies not published in English language and participants with cancer pain were excluded. All the included studies were descriptively synthesized.ResultsFourteen studies were included in the final data synthesis of this review and the total number of participants in all studies was 1175. Interventions by pharmacists were successful in decreasing opioid dose in 4 studies and improved patient opioid safety in 5 studies. Stakeholders considered that the role of pharmacists in optimisation of opioid therapy for people with CNMP can be promising and should be further developed.ConclusionThis systematic review gives an overview of pharmacist intervention feasibility, stakeholders’ opinions and possible benefits on opioid optimisation in people with CNMP in outpatient clinical settings, community pharmacies and primary care settings. However, further research is warranted, which can guide the development of new policies and guidelines for the utilisation of pharmacists to promote opioid safety in people using prescription opioids for CNMP management