Treatment of diabetic peripheral neuropathy: a review

Abstract Objectives This review surveys current pharmacotherapies available for the treatment of diabetic peripheral neuropathy (DPN), emphasising their mechanisms of action. Methods A comprehensive literature review focusing on the ‘pharmacotherapy and treatment of diabetic peripheral neuropathy’ was conducted. The Database of International Pharmaceutical Abstracts, EMBASE, PubMed, OVID, Scopus, Google and Google Scholar were searched, and reference lists of relevant articles were also included. Key findings Diabetic peripheral neuropathy is often inadequately treated, and the role of improving glycaemic control specifically in type-2 diabetes remains unclear. It is crucial to explore the mechanisms of action and effectiveness of available therapies. Major international clinical guidelines for the management of DPN recommend several symptomatic treatments. First-line therapies include tricyclic antidepressants, serotonin–noradrenaline reuptake inhibitors, and anticonvulsants that act on calcium channels. Other therapies include opioids and topical agents such as capsaicin and lidocaine. The objectives of this paper are to review current guidelines for the pharmacological management of DPN and to discuss research relevant to the further development of pharmacological recommendations for the treatment of diabetic neuropathy. Summary Diabetic neuropathy is a highly prevalent, disabling condition, the management of which is associated with significant costs. Evidence supports the use of specific anticonvulsants and antidepressants for pain management in patients with diabetic peripheral neuropathy. All current guidelines advise a personalised approach with a low-dose start that is tailored to the maximum response having the least side effects or adverse events

Impact of pharmaceutical care on health outcomes in patients with COPD

Background Chronic obstructive pulmonary disease (COPD) treatment goals are often not achieved despite the availability of many effective treatments. Furthermore, clinical pharmacist interventions to improve clinical and humanistic outcomes in COPD patients have not yet been explored and few randomized controlled trials have been reported to evaluate the impact of pharmaceutical care on health outcomes in patients with COPD. Objective The aimof the present studywas to evaluate the impact of pharmaceutical care intervention,with a strong focus on self-management, on a range of clinical and humanistic outcomes in patients with COPD. Setting Outpatient COPD Clinic at the Royal Medical Services Hospital. Method In a randomised, controlled, prospective clinical trial, a total of 133 COPD patients were randomly assigned to intervention or control group. A structured education about COPD and management of its symptoms was delivered by the clinical pharmacist for patients in the intervention group. Patientswere followed up at 6 months during a scheduled visit. Effectiveness of the intervention was assessed in terms of improvement in health-related quality of life,medication adherence, disease knowledge and healthcare utilization. Data collected at baseline and at the 6 month assessment was coded and entered into SPSS software version 17 for statistical analysis. A P value of\0.05 was considered statistically significant. Main outcome measure The primary outcome measure was health-related quality of life improvement. All other data collected including healthcare utilization, COPD knowledge and medication adherence formed secondary outcome measures. Results A total of 66 patients were randomized to the intervention group and 67 patients were randomized to the control group. Although the current study failed to illustrate significant improvement in health-related quality of life parameters, the results indicated significant improvements in COPD knowledge (P\0.001), medication adherence (P\0.05), medication beliefs (P\ 0.01) and significant reduction in hospital admission rates (P\0.05) in intervention patients when compared with control group patients at the end of the study. Conclusion The enhanced patient outcomes as a result of the pharmaceutical care programme in the present study demonstrate the value of an enhanced clinical pharmacy service in achieving the desired health outcomes for patients with COPD

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

Evaluation of hypertension knowledge among hypertensive and non-hypertensive adults: a crosssectional study from Palestine

Hypertension is one of the leading causes of morbidity and mortality worldwide and significantly contributes to the burden of non-communicable diseases especially in low and middle income countries like Palestine. The current study aimed to evaluate the level of knowledge on hypertension among the Palestinian hypertensive and non-hypertensive adults in the West Bank. The study was conducted in a cross-sectional design in Hebron, Ramallah, Nablus, and Tulkarm directorates in the West Bank. Convenient proportional sample from each directorate was selected with a total of 1200 subjects from all directorates. The participants were interviewed face to face for data collection using a previously validated hypertension knowledge level scale questionnaire (HK-LS) that included (among others) selfreported lifestyle, medication and clinical history questions. The questionnaire had 22 questions where a new continuous variable (score) was developed ranged from 0-22. In our study, the participants had an adequate level of knowledge regarding hypertension and they showed a good understanding of the main concepts (definition, medical treatment, lifestyle, diet, complications). The mean score for hypertensive and non-hypertensive participants were 18.22 and 16.74 respectively. This indicates that those with hypertension have superior knowledge amongst the two groups. Hypertensive participants’ results were related to some socio-demographic factors including city, age, educational level, and physician visit. On the other hand, non-hypertensive participants’ scores were associated with age, gender, marital status, smoking status, educational level, and physician visit. Knowledge of hypertension among the general population was acceptable and those with hypertension showed a higher level of knowledge in comparison to those without hypertension. There should be more focus on educational programs that help improve the knowledge about hypertension in the general population. There should also be an emphasis on the importance of the physicians’ role in the awareness and education of the patients.ACKNOWLEDGEMENTS The authors would like to thank all participants in this study for their cooperation and understanding. Funding Non

Pharmacovigilance and Adverse Drug Reactions Reporting Process in West-Bank, Palestine

Active national pharmacovigilance programmes are needed to monitor adverse drug reaction (ADR) data in local populations. The objective of this study was to describe the knowledge, experiences, attitudes and perceived barriers to reporting of suspected ADRs by community and hospital pharmacists in West Bank, Palestine. Between December 2014 and March 2015 we conducted a survey about the knowledge and attitude of pharmacists (n = 270) using a face-to-face questionnaire. The questionnaire consisted of questions about the sociodemographic characteristics of the pharmacists, their knowledge of pharmacovigilance and their attitudes towards ADR reporting. Main outcomes measured: The majority of the pharmacists (62.6%) worked in the community pharmacies and more females responded to the questionnaire than males (59% vs 41%). only 11.9% could conceptually or actually define ‘pharmacovigilance’ correctly while one quarter of the respondent pharmacist (24.9%) could define ADR correctly. The hospital clinical pharmacists defined ‘pharmacovigilance’ correctly with higher significance (P<0.001) when compared with community pharmacists. Only 12.2% had ever reported an ADR. The majority of these reports (85%) done by the hospital pharmacists (p<0.0001). The main reasons that discourage the pharmacists from reporting ADRs were ‘‘no enough information available from the patient (76.7%)’’, and ‘‘they did not know how to report (66.7%)’’. The majority of the respondents (92.0%) felt that reporting ADR was their duty and (82%) participants were interested in participating in the National Pharmacovigilance Programme in Palestine. The results show that Palestinian pharmacists have poor knowledge about pharmacovigilance. There is an urgent need for educational programs to train them about pharmacovigilance and ADR reporting scheme

Knowledge, attitudes, and practices of community pharmacists toward the management of acne vulgaris in Palestine: a cross-sectional study

Background Acne vulgaris (AV) is a common dermatological disease affecting almost 85% of teenagers. Patients with AV usually present at community pharmacies during the early stages of their disease. Aim The aim of this study was to assess community pharmacists’ knowledge, attitudes, and practice toward AV management in West Bank in Palestine. Methods This study was a cross-sectional questionnaire-based study. The questionnaire included four sections: 1) demographic, 2) knowledge, 3) attitude and practice items related causes, and 4) treatment options and counseling during management of patients with AV. A convenience sampling method was implemented in this study. Parametric and non-parametric tests were used to compare different issues as appropriate. P < 0.05 were considered significant. Result A total of 270 community pharmacists were interviewed, and more than half (54.1%) were males. The study revealed that community pharmacists had an inadequate level of knowledge on management of AV; only 7.7% had high levels of knowledge. Pharmacists have positive attitude regarding AV management, but inadequate knowledge was reflected on their treatment practices; only 10% of participants independently dealt with AV without referral. Pharmacists with a low level of knowledge showed five times more referrals than those with a high level of knowledge (OR: 5.3; P < 0.001), and those with a bachelor degree showed three times more referrals than postgraduates (OR: 3.3; P < 0.001). Conclusion There is a demand to update dermatological knowledge of community pharmacists and encourage them to attend structured training programs about the management of AV.Funding source: None

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

Assessment of the inhalation technique and adherence to therapy and their effect on disease control in outpatients with asthma

Objectives The objective of this study was to assess correct use of inhaler devices, adherence to inhaler corticosteroid treatment and their effects on asthma control. Methods This study was a prospective, single-centre, observational study conducted between July and February 2016 at Al-Makased Hospital, respiratory outpatient clinic. Inhaler technique of asthma patients using pressurized metered-dose inhalers or dry powder inhalers (Turbuhaler (TH) and Accuhaler DiskusTM (ACC)) were assessed against published inhaler technique checklists. Asthma control variables measured using Asthma Control Test (maximum 25, higher score corresponding to better asthma control) were assessed, and adherence to asthma medications was assessed by Morisky adherence scale. Key findings Two hundred and twenty patients were recruited in the study. The mean age was 42.3 15.2 years and 59.1% were male. One hundred and seventeen (53.2%) were using TH, 60 (27.3%) were using ACC and 43(19.5%) were using MDIs. Only 22 (10%) were smoker and only 48 (21.8%) patients were their asthma controlled (ACT score >20). The devices were used correctly by 79.1% of patients using MDI, 69% of ACC and 55.6% of TH users (P > 0.001). The most common improper step was ‘forceful inhalation’ (65.4%) made by the MDI users, ‘Not exhaling to residual volume’ (58.7%) made by ACC users and ‘Not inhaling deeply enough’ (52.2%) made by TH users. Multivariate analysis showed that the likelihood of having controlled asthma was significantly higher in those with correct inhaler techniques (OR 2.3; 95% CI: 1.08–4.77; P = 0.028), high adherence to medications (OR 2.37; 95% CI: 1.05–4.92; P = 0.03) and having a higher level of education (OR 2.58; 95% CI: 1.19–3.63; P = 0.018). Conclusions It was found that asthma control was better among correct users. Repetitive training about using devices may contribute improving inhaler technique.This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

Necessity and concerns about lipid-lowering medical treatments and risk factors for non-adherence: A cross-sectional study in Palestine

Aims: Strong evidence indicates that drugs reduce blood lipids and improve cardiovascular end-points, leading to their wide usage. However, the success of these drugs can be affected by poor patient's adherence to prescribed medication. This study aimed to evaluate medication adherence in patients with dyslipidaemia in association with patient beliefs about medicines. Methods: The study was conducted from January 2019 to July 2019 at the middle governmental primary healthcare clinics in Ramallah and Bethlehem cities, and used a cross-sectional design. Adherence was determined using the 4-item Morisky medication adherence scale, while beliefs were determined using the Beliefs about Medicines Questionnaire. Results: Of 220 patients, 185 agreed to participate in the study, resulting in a response rate of 84.1%. Of the participants, 106 (57.3%) were men, and almost half (88, 46.5%) were ≥56 years. Medication non-adherence was high (47.6%), but a majority (65.5%) reported believing their treatment to be necessary for their continued good health. Accordingly, the mean necessity score (17.3, SD 3.7) significantly outweighed (P < .001) the mean concerns score (14.0, SD 3.5). Multivariate regression demonstrated four variables to be significantly correlated with non-adherence: illiterate (OR = 2.52; CI: 0.9-4.3; P = .03), polypharmacy (OR = 3.18; CI: 1.9-5.7; P = .007), having comorbidity (OR = 3.10; CI: 2.2-4.6; P = .005) and having concerns about side effects (OR = 2.89; CI: 1.1-4.6, P = .04). Conclusion: Non-adherence among patients taking lipid-lowering agents was high despite most holding positive beliefs regarding medication necessity. This may be due to concern also being high. Physicians should identify and target high-risk patients and individualise their treatment plans in order to achieve adequate control of dyslipidaemia.We thank all workers at health clinics at Ramallah and Bethlehem who helped in finishing this study and also we thank the participants who willingly accepted to share for the purpose of this study

Pharmaceutical care for adult asthma patients: A controlled intervention one‐year follow‐up study

Asthma is a clinical problem with social, psychological and economic burdens. To improve patient disease management, different education programmes have been developed. Challenges in asthma management may be partially attributed to nonadherence or improper use of inhalers. This study aimed to implement and assess hospital‐based pharmaceutical care services for asthmatic patients. A 12‐month, single‐ centre, randomized, controlled study was initiated in asthmatic adult patients who had been divided into either a control or intervention group. Patients in the control group received the usual care, and patients in the intervention group received patient counselling per study protocol that covered asthma knowledge, control, adherence to treatment and inhalation techniques. The main variables compared measurements at baseline with those at 6 and 12 months. A total of 192 patients completed the study protocol: 90 in the control group and 102 in the intervention group. The control group included 90 patients, and the intervention group included 102 patients. Over the course of the 12‐month follow‐up period, a significant difference was observed between intervention and control groups with respect to asthma control (38.2% vs 10.0%; P < .001), mean correct inhalation technique (confidence interval [CI]: 8.1, 7.8‐8.5 vs CI: 6.1; 5.6‐6.6; P = .01) and good medication adherence (60.7% vs 50.0%, P = .02). There were 34% and 25% decreases in emergency room visits and hospital admissions, respectively, in the intervention group compared to the control group. This study emphasizes the importance of patient counselling in asthma management and the significant contribution that the pharmacist's intervention can have on asthma control