Opioids and gabapentinoids utilisation and their related-mortality trends in the UK primary care setting, 2010-2019 : a cross-national, population-based comparison study

Background: There is growing concern over the increasing utilisation trends of opioids and gabapentinoids across but there is lack of data assessing and comparing the utilisation trends across the four United Kingdom countries. We assessed/compared opioids and gabapentinoids utilisation trends across the four United Kingdom countries then evaluated the correlation between their utilisation with related mortality. Methods: This repeated cross-national study used Prescription Cost Analysis (PCA) datasets (2010–2019). Opioids and gabapentinoids utilisation were measured using number of items dispensed/1,000 inhabitants and defined daily doses (DDDs)/1,000 inhabitant/day. Number of Opioids and gabapentinoids-related mortality were extracted from the United Kingdom Office for National Statistics (2010–2018). Data were analysed using descriptive statistics including linear trend analysis; correlation between the Opioids and gabapentinoids utilisation and their related mortality using Pearson correlation coefficient. Results: The results illustrated an overall significant increasing trend in the utilisation of opioids (12.5–14%) and gabapentinoids (205–207%) with substantial variations among the four United Kingdom countries. For opioids, Scotland had the highest level of number of items dispensed/1,000 inhabitant (156.6% higher compared to the lowest level in England), whereas in terms of DDD/1,000 inhabitant/day, NI had the highest level. Utilisation trends increased significantly across the four countries ranging from 7.7% in Scotland to 20.5% in NI (p < 0.001). Similarly, for gabapentinoids, there were significant increasing trends ranging from 126.5 to 114.9% in NI to 285.8–299.6% in Wales (p < 0.001) for number of items/1,000 inhabitants and DDD/1,000 inhabitant/day, respectively. Although the utilisation trends levelled off after 2016, this was not translated into comparable reduction in opioids and gabapentinoids-related mortality as the latter continued to increase with the highest level in Scotland (3.5 times more deaths in 2018 compared to England- 280.1 vs. 79.3 deaths/million inhabitants). There were significant moderate-strong positive correlations between opioids and gabapentinoids utilisation trends and their related mortality. Conclusion: The utilisation trends of opioids and gabapentinoids have increased significantly with substantial variations among the four United Kingdom countries. This coincided with significant increase in their related mortality. Our findings support the call for immediate actions including radical changes in official United Kingdom policies on drug use and effective strategies to promote best clinical practice in opioids and gabapentinoids prescribing

A qualitative study on factors influencing the implementation of a Clostridium difficile risk prediction tool in the Scottish secondary care setting

Introduction: Clostridium difficile is the leading cause of hospital acquired diarrhoea, driven by the consumption of 4C antibiotics (co-amoxiclav, clindamycin etc..). In order to support clinicians with the prescription of antibiotic in secondary care, an algorithm to help identify high risk patients to contract Clostridium difficile infection (CDI) has been created. The aim of this study is to identify factors that are influencing the development and implementation of a risk predictive tool for CDI in secondary care. Methods: Four Scottish Podiatrist from Fife were interviewed to gather their perception on CDI, their antibiotic prescription process and whether a CDI tool would support their prescription process. The interviews were inductively analysed in NVivo using the consolidated framework for implementation research to identify factors influencing the development and implementation of the CDI tool. Result: The preliminary interview themes suggests that although Podiatrist in secondary care don’t perceive many cases of CDI, they would like to have risk predictor for CDI for patient’s safety netting purposes. As there isn’t a concrete and accurate electronic health record in secondary care, the CDI tool can’t be implemented into their system, therefore a standalone app or website has to be developed. Conclusion: The next stage is to collaborate with a company to develop a prototype of the CDI tool and test it with secondary care clinicians using case scenarios

Clinical and economic implications of therapeutic switching of Angiotensin receptor blockers to Angiotensin-converting enzyme inhibitors : a population-based study

OBJECTIVE: To evaluate the clinical and cost impact of switching angiotensin receptor blockers (ARBs) to angiotensin-converting enzyme inhibitors (ACEIs) in patients with hypertension. METHODS: This study used the UK Clinical Practice Research Datalink, linking with the Hospital Episode Statistics (April 2006 to March 2012). Adults with hypertension (n = 470) were followed from the first ARB prescription date to the switching date (preswitching period); then from the switching date to the date when study ended, patient left the dataset or died (postswitching period). Patients were divided into ACEIs-combined (n = 369) and ACEIs-monotherapy (n = 101) groups by whether additional antihypertensive drugs were prescribed with ACEIs in the postswitching period. Proportion of days covered (PDC), clinical outcomes and costs were compared between the preswitching and postswitching periods using a multilevel regression. RESULTS: Overall, in the postswitching period, there was a significant increase in the proportion of nonadherence (PDC < 80%) (OR: 2.4; 95% CI: 1.6-3.7), but a significant reduction in mean SBP (mean difference: -2.3; 95 CI: -3.4 to 1.2 mmHg) and mean DBP (mean difference: -1.9; 95% CI: -2.6 to -1.2 mmHg). However, these results were only observed in the ACEIs-combined group. There was no postswitching significant difference in either the incidence of individual or composite hypertension-related complications (OR: 0.9; 95% CI: 0.4-2.0). There was a significant reduction in the overall annual medical cost per patient by £329 (95% CI: -534 to -205). CONCLUSION: Switching of ARBs to ACEIs monotherapy appeared to be clinically effective and a cost-saving strategy. The observed changes in the ACEIs-combined group are assumed to be related to factors other than the ARBs switching

Self medication using antibiotics at community pharmacies in low and middle income countries : a systematic review and meta-analysis

Background: Self medication with antibiotics has become increasingly common in low and middle income countries. It has been identified as a key driver to antimicrobial resistance. Factors contributing to self purchasing of antibiotics include: low socioeconomic status, lack of access to prescribers and weak legislation, among others. Objectives: To establish the extent of antibiotic self-medication in low and middle income countries especially Africa and the impact of potential policies to address this. Methods: Potential studies for inclusion in the review were identified through direct searches on the Cochrane Library, EMBASE, Scopus, University of Strathclyde Library and PubMed. Google Scholar was also used to complement our searches. The search terms used were "self-medication", "non-prescription", 'self-treatment', "antimicrobial", "antimalarial", "antibiotic", "antibacterial" and combining them using Boolean operators. We searched for studies published between January 2007 to March 2018. Study results were summarized narratively for a sub-set of studies where the data on outcomes and methodology varied significantly. The quality of the available evidence about the pre-specified outcomes to support a given intervention was assessed Critical Appraisal Skills Programme (CASP) cross sectional study Checklist. Two reviewers independently assessed study quality; disagreements were resolved by discussion. Results: A total of 64 potentially relevant articles were identified from literature searches. 21 studies were deemed eligible for inclusion. There is a huge variation in the prevalence of self-medication using antibiotics across low and middle income countries. It ranged from a low of 12% in Iran to as high as 93% in Uganda. Data on the type of antibiotics used for self-medication was not commonly reported. Some of the recurrent reasons for self-medication included inaccessible health facilities, long waiting time for consultation, familiarity of patients with symptoms, bad experience with doctors and ambiguous professional boundaries. Conclusions: Generally the prevalence of self medication with antibiotics was high, with variations across countries. Reasons for self medication should be addressed to reduce the prevalence. Policies should be put in place to address these as there was scanty data on this

Prevalence of post-stroke depression in Iranian patients : a systematic review and meta-analysis

Background: Post-stroke depression (PSD) is the most common and important neuropsychiatric outcome of stroke, which can result in longer hospital stay, compromise the effectiveness of rehabilitation, and reduce the patients’ quality of life. However, Iranian studies have reported different and conflicting prevalence rates for PSD. Objective: The present systematic review and meta-analysis aimed to evaluate the overall prevalence of PSD in Iranian patients. Patients and methods: A systematic search was conducted in 2018 for Persian or English articles on PSD, published in the Scientific Information Database (SID), MagIran, PubMed, Scopus, and Web of Science, using the following keywords: Depression, Depressive Disorder, Stroke, Cerebrovascular Disorder, and Iran and all of their possible combinations. Heterogeneity across the studies was evaluated using the Cochran's Q test. According to the heterogeneity results, a random effects model was used to estimate the overall prevalence of PSD. The data were analyzed using the Stata 12 software. Results: In overall, 6 articles with a total sample size of 641 patients were included in the analysis. The overall prevalence of PSD in Iran was 46.9% (95%, CI: 30.1-63.7). In addition, the prevalence of PSD was higher in women (50.4%, 95% CI: 17.9-82.9) than in men (29.5%, 95% CI: 17.2-41.8). According to the results of univariate meta-regression, there was a significant relationship between PSD prevalence and sample size (p = .010). Conclusion: Around half of the stroke patients in Iran suffer from PSD. Given the overlap between neurological symptoms of stroke and depression, efforts should be made to quickly and accurately diagnose depression so that it can be effectively managed with minimum complications

What patient assessment skills do pharmacist independent prescribers require to prescribe immunomodulators in myeloma?

Aim To gain consensus on the patient assessment skills (PAS) required by pharmacist independent prescribers (PIPs) prescribing immunomodulators (IMIDs) in myeloma across National Health Service Scotland. Methods This was a two-phase study which used nominal group technique (NGT) to gain local consensus followed by a two-round eDelphi questionnaire to gain national consensus across all cancer networks. Setting This project was conducted across the three cancer networks within NHS Scotland: South East Scotland Cancer Network (SCAN); West of Scotland Cancer Network (WoSCAN) and North Cancer Alliance (NCA). Subjects Participants were invited from each cancer network (SCAN, WoSCAN and NCA) and included haematology consultants, haematology specialist registrars, haematology advanced nurse practitioners and haematology pharmacists. Results There were five participants in the NGT. Twenty-two out of 31 PAS gained local consensus, seven PAS did not gain consensus and two PAS were deemed irrelevant. There were 12 and 14 participants in round one and two of the eDelphi questionnaire, respectively. Twenty-nine PAS were included in the first-round questionnaire and 21 gained consensus. The remaining eight PAS were included in round two where seven did not achieve consensus and one achieved disagreement consensus. Conclusion This research outlines 21 PAS required for PIPs to prescribe IMIDs for myeloma patients according to haematology specialists in Scotland. Discussion on PAS without consensus showed that the PIPs would have a shared responsibility with the consultant. This work should inform the development of a competency framework to allow training of PIPs in Scotland. Some PAS could be transferrable for PIPs prescribing SACT for other haematological malignancies

An umbrella review and quality assessment of renin-angiotensin system drugs use and Covid-19 outcomes : wat is the quality of the research evidence?

Background: During 2020, an extensive number of reviews were published on the effect of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin-receptor blockers (ARBs) on COVID-19 outcomes, yet the evidence appeared heterogenous. We conducted a meta-analysis and quality assessment of these reviews. Methods: An umbrella review was conducted. Medline, Embase, Scopus, Cochrane library and medRxiv were searched on 1 February 2021. The AMSTAR 2 Critical Appraisal Tool assessed study quality. The Corrected Cover Area (CCA) calculated the degree of study overlap within the reviews. Results: In 2020/21, 47 reviews on this topic were conducted. The overall confidence in the results was most commonly ‘critically low’ (n=22, 44.9%), followed by ‘low’ (n=15, 30.6%) and ‘moderate’ (n=10, 21.3%). A minority (n=15, 31.9%) established a review protocol a priori. The CCA value was 9.2 indicating a moderate degree of study overlap, yet this analysis was complicated by three studies not fully reporting included studies. In total, 168 studies were known to have been included within the reviews. Most (n = 99) were included in three or less reviews, yet one study was included within 37 reviews. Collective evidence indicated good quality evidence on the significant association between ACEIs/ARBs use and reduction in death and death/ICU admission, but poor-quality evidence on reducing severe COVID-19 and increasing hospitalisation. Conclusions: The superfluous research activities are likely related to the collective interest in the topic, and limited development of review protocols a-priori. Despite quality concerns, our findings do support not discontinuing ACEIs/ARBs therapy in patients with COVID-19

An umbrella review and meta-analysis of renin-angiotensin system drugs use and COVID-19 outcomes

Abstract: Background: Despite the availability of extensive literature on the effect of angiotensin‐converting enzyme inhibitors (ACEIs)/angiotensin‐receptor blockers (ARBs) on COVID‐19 outcomes, the evidence is still controversial. We aimed to provide a comprehensive assessment of the effect of ACEIs/ARBs on COVID‐19‐related outcomes by summarising the currently available evidence. Methods: An umbrella review was conducted using Medline (OVID), Embase, Scopus, Cochrane library and medRxiv from inception to 1 February 2021. Systematic reviews with meta‐analysis that evaluated the effect of ACEIs/ARBs on COVID‐19‐related clinical outcomes were eligible. Studies' quality was appraised using the AMSTAR 2 Critical Appraisal Tool. Data were analysed using the random‐effects modelling including several subgroup analyses. Heterogenicity was assessed using I2 statistic. The study protocol was registered in PROSPERO (CRD42021233398) and reported using PRISMA guidelines. Results: Overall, 47 reviews were eligible for inclusion. Out of the nine COVID‐19 outcomes evaluated, there was significant associations between ACEIs/ARBs use and each of death (OR = 0.80, 95%CI = 0.75–0.86; I2 = 51.9%), death/ICU admission as composite outcome (OR = 0.86, 95%CI = 0.80–0.92; I2 = 43.9%), severe COVID‐19 (OR = 0.86, 95%CI = 0.78–0.95; I2 = 68%) and hospitalisation (OR = 1.23, 95%CI = 1.04–1.46; I2 = 76.4%). The significant reduction in death/ICU admission, however, was higher among studies which presented adjusted measure of effects (OR = 0.63, 95%CI = 0.47–0.84) and were of moderate quality (OR = 0.74, 95%CI = 0.63–0.85). Conclusions: Collective evidence from observational studies indicate a good quality evidence on the significant association between ACEIs/ARBs use and reduction in death and death/ICU admission, but poor‐quality evidence on both reducing severe COVID‐19 and increasing hospitalisation. Our findings further support the current recommendations of not discontinuing ACEIs/ARBs therapy in patients with COVID‐19

Appropriateness of antibiotic prescribing and compliance to guidelines at a referral hospital in Kenya : a point prevalence survey

Background: A large proportion of antibiotics globally are prescribed, dispensed or administered irrationally. This is partly due to lack of local guidelines or non-adherence to available antibiotic use guidelines. The irrational use of antibiotics results in wastage of scarce health care resources, increases the risk of adverse drug reactions and increases the potential of development of resistance. This leads to poor health outcomes. Objectives: The aim of the study was to establish whether there was rational or irrational prescribing and adherence to guidelines in one of the referral hospitals in Kenya at a specific point in time. Methods: A point prevalence survey was conducted at a referral hospital in Kenya in April 2017. Stratified proportionate random sampling technique was used to select eligible patients who were on systemic antibiotics. Data was abstracted from the patient medical records into a predesigned patient form. Associations between predictor variables such as socio-demographic factors and outcome variables such as rational prescribing and guideline compliance were determined using Chi square. Stepwise backward binary logistic regression was done to determine the independent predictors of rational antibiotic prescribing and guideline compliance. Statistical significance was set at 95% confidence level and values with p≤0.05 were considered statistically significant. Approval to conduct the study was obtained from the Kenyatta National Hospital/University of Nairobi Research and Ethics Committee. Results: A total of 179 patients were recruited into the study. There was rational prescribing in 33.9% (n=121) of all the 357 antibiotic encounters. The neonatal medical ward had the highest prevalence of rational prescribing (80%, n=12) while the critical care unit had the highest prevalence of irrational prescribing (100%, n=4). The most powerful predictor variables of rational antibiotic prescribing were the department (AOR=0.778, 95% CI=0.640–0.945, p=0.011), a diagnosis of a neonatal infection (AOR=5.992, 95% CI=1.985–18.094, p=0.001), a diagnosis of skin, soft tissue, bone and joint infection (AOR=6.221, 95% CI=2.053–18.847, p=0.001) and a diagnosis of no defined site such as sepsis (AOR=5.540, 95% CI=1.486–20.648, p=0.011). There was guideline compliance in 45.8% (n=82) of the study population. The most powerful predictors of guideline compliance were a diagnosis of a respiratory infection (AOR=7.141, 95% CI=2.950–17.287, p<0.001), a diagnosis of a neonatal infection (AOR=10.603, 95% CI=1.671–67.280, p=0.012) and a diagnosis of a skin, soft tissue, one and joint infections (AOR=5.606, 95% CI=1.730–18.162, p=0.004). Conclusions: Rational prescribing was documented in only a third of all antibiotics prescribed. There was poor compliance to guidelines. Local guidelines were not available for a significant proportion of conditions. International guidelines were used in such scenarios

Development of a risk prediction tool for Clostridium difficile : a Scottish experience

Background: Risk prediction tools in clinical practice are aimed to support clinicians during decision making, facilitate patient education on their health conditions, and identify and initiate preventive approaches. The development and implementation of risk prediction tools can vary depending on the setting and the user it is being implemented for. This study aims to highlight the process of developing a risk prediction tool for Clostridium difficile infection (CDI) in Scotland. Methods: Initially three GPs were recruited for interviews, shadowing and co-design of a CDI prototype. The study focused on gathering GP’s perception of CDI and the usefulness of a CDI tool in supporting their antibiotic prescribing. Subsequently non-medical prescribers from secondary care were interviewed with the same objective. The study process and analysis were guided by the Consolidated Framework for Implementation Research and the Guideline Implementation with Decision Support (GUIDES) checklist. Results: As CDI is not common in primary care, GPs deemed a CDI tool unnecessary; however, higher support for the tool could be achieved with its integration into their prescribing system and providing advice on an action(s) rather than a risk score. Differently in secondary care, clinicians were receptive to having a tool for antibiotic decision making. However, due to patient data being stored in different systems, only a website or mobile app of the CDI tool would be feasible. Conclusion: Despite the initial reticence by GPs for a CDI tool, through the guidance of the implementation frameworks, CDI tools with preferred formats by both cohorts are under development