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

Consumer perception of the community pharmacist and community pharmacy services in Malta

Objectives: We aimed to determine the perception of Maltese consumers of the community pharmacist and of the services offered from community pharmacies. Method: A self-administered questionnaire was developed and psychometrically evaluated. Fifty community pharmacies were chosen by stratified random sampling and the questionnaire was distributed to 500 consumers, 10 from each pharmacy, selected by convenience sampling. Descriptive statistics were undertaken. Key findings: The majority of the consumers were very or fairly satisfied with various pharmacist characteristics, such as pharmacist efficiency when dealing with requests (95%), provision of instructions on how to take medications (94%), pharmacist discretion (91%), professional pharmacist–consumer relationship (90%), provision of explanations on how medications work (86%) and pharmacist knowledge and ability to answer questions (81%). They were least satisfied with the privacy in the pharmacy (69%). Consumers were in favour of the evolution of pharmacist professional services, namely the community pharmacist liaising with primary and secondary care-based physicians (91%), provision of diagnostic testing (87%) and extended opening hours (83%). Conclusions: Maltese consumers have a positive overall perception of community pharmacists and of the services offered from community pharmacies. They were in favour of the development of extended professional services.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

Serum digoxin concentrations : a retrospective analysis

The use of digoxin is limited by its narrow therapeutic index. American and European guidelines for the management of heart failure and atrial fibrillation recommend targeting a serum digoxin concentration (SDC) between 0.5 and 0.9ng/ml. The aim of the study was to retrospectively analyse SDCs and to assess compliance to the SDC target range recommended in the guidelines. SDCs recorded at the hospital Pathology laboratory between January 2008 and December 2017 were analysed according to gender, age, origin of request, specialty of referring physician and reason for request, and were compared to the SDC target range. Serum potassium (K+) levels and estimated glomerular filtration rate (eGFR) were analysed for SDCs recorded in 2017. A total of 19,065 SDCs from 6,107 patients (65% female, mean age 78 ± 11 years) were analysed. Mean SDC was 1.31 ± 1.01ng/ml (range 0.9ng/ml (66.76 ± 36.43) and ≥ 2.0ng/ml (64.39 ± 34.23) compared to patients with SDC ≤ 0.9ng/ml (73.84 ± 35.21mL/min/1.73m²). The mean SDC observed was higher than the upper limit of the recommended target SDC range. Further investigation to establish the clinical significance of the observed SDC findings on patient outcomes is warranted.peer-reviewe

Antiplatelet and anticoagulant therapy for non-ST-elevation acute coronary syndromes in a general hospital

Aim: To audit compliance with the 2011 European Society of Cardiology (ESC) guidelines for prescribing antiplatelet and anticoagulant therapy in patients diagnosed with non-ST-elevation acute coronary syndromes (NSTE-ACS). Methods: Five-month audit at Cardiac Catheterisation Suite, Mater Dei Hospital, Malta. A data collection form for inpatients diagnosed with NSTE-ACS was developed, psychometrically evaluated and completed for each patient by the investigator. Comparative analysis to assess whether these patients were being managed according to the guidelines was undertaken. Results: 165 patients were recruited; 73% were male, 37% were between 66 and 75 years and 44% were active smokers. The most common risk factors for cardiovascular disease in these patients were hypertension (27%), dyslipidemia and obesity (both 16%). 41% of the patients underwent a percutaneous coronary intervention, either ad hoc (34%) or elective (7%). Compliance to guidelines for prescription of aspirin and clopidogrel 300mg loading dose was 95% and 88% respectively. Compliance to guidelines for prescription of aspirin and clopidogrel 75mg daily maintenance dose was 97% and 96% respectively. Compliance to guidelines for prescription of proton pump inhibitors (PPIs) in patients receiving dual antiplatelet therapy (DAPT) was only 19%; 81% of the patients were prescribed omeprazole against guideline recommendations. Compliance to guidelines for prescription of anticoagulation therapy was 95% with respect to prescription of heparin treatment in combination with DAPT. Compliance to guidelines for prescription of enoxaparin was 81%. Compliance to guidelines for other antiplatelet and anticoagulant drugs recommended in the guidelines, including ticagrelor, prasugrel, glycoprotein IIb/IIIa receptor antagonists, fondaparinux and bivalirudin, was not measured. Conclusions: Prescription of antiplatelet and anticoagulant therapy for NSTE-ACS in Malta is predominantly in accordance with ESC guidelines. Alternative antiplatelet and anticoagulant drugs and PPIs should be included in the Maltese hospital formulary to improve NSTE-ACS management in line with guideline recommendations.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

Palliative care in cancer patients

In palliative care - the holistic care of patients with advanced disease - managing pain and other symptoms is crucial. This article describes a study aimed at developing pharmacist intervention within a local provider's care programme.peer-reviewe

CYP2C19 genetic polymorphisms in Maltese patients on clopidogrel therapy

Introduction and Aims: The prevalence of CYP2C19 genetic polymorphisms in the Maltese population is not reported. The aims were to determine CYP2C19 *2 and *17 allele frequencies and CYP2C19 genotype distribution in a cohort of Maltese patients on clopidogrel and to compare observed frequencies of the CYP2C19 *2 allele and *2/*2 genotype to other populations bordering the Mediterranean Sea. Methods: Genotyping for the CYP2C19 *2 and *17 alleles in Maltese patients on clopidogrel was performed using TaqMan® drug metabolism assays. The frequency of both alleles and six genotypes (*1/*1, *1/*2, *2/*2, *1/*17, *17/*17, *2/*17) were determined. Observed frequencies of the CYP2C19 *2 allele and *2/*2 genotype were compared to fourteen populations bordering the Mediterranean Sea (p>0.05 indicated similar prevalence) Results: Frequencies of the CYP2C19 *2 and *17 alleles in the 244 patients genotyped were 12.3% and 15.4% respectively. CYP2C19 genotype distribution was: *1/*1 (52.1%), *1/*17 (22.5%), *1/*2 (18.0%), 2/*17 (6.6%), *17/*17 (0.8%) and *2/*2 (0). Prevalence of the *2 allele in the Maltese cohort was similar to all fourteen populations bordering the Mediterranean Sea, while prevalence of *2/*2 was similar to Egyptian, Moroccan, Southern French, Slovenian, Turkish and Tunisian populations (p>0.05). Conclusions: This study provides an indication of the prevalence of CYP2C19 polymorphisms in Maltese patients. The high percentage of patients with CYP2C19 IM or UM phenotype demonstrates that CYP2C19 genotyping could aid clinicians to individualise treatment with clopidogrel and other drugs metabolised by the CYP2C19 enzyme.peer-reviewe

CYP2C19*2 allele carrier status and coronary in-stent restenosis : is there an association?

Background and objective: The CYP2C19*2 allele is associated with reduced clopidogrel bioactivation, increasing the risk of complications after percutaneous coronary intervention (PCI), particularly stent thrombosis. Recently published data suggests that CYP2C19*2 allele carriers have a higher risk for in-stent restenosis (ISR) after endovascular treatment. Very few studies have investigated the relationship between CYP2C19*2 and coronary ISR, with no significant association reported. The objective of this study was to assess the relationship between CYP2C19*2 allele carrier status and coronary ISR. Methods: Patients with previous PCI with stenting and who were scheduled for elective PCI after coronary angiogram were recruited from the cardiac catheterization suite over a 12-month period. The angiography report of each patient was perused to identify patients requiring PCI due to ISR. For patients with angiography-confirmed ISR, date of previous PCI to the restenosed stent was noted. CYP2C19*2 genotyping was undertaken using a TaqMan® Drug Metabolism assay. The association between CYP2C19*2 allele carrier status and incidence of coronary ISR within 1 year was assessed using Fisher’s exact test (p < 0.05 significance) and by calculating the odds ratio (OR) with a 95% confidence interval (CI). Results: Of the 82 patients with previous PCI, 29 (35.4%) had angiography-confirmed ISR (12 carriers, 17 noncarriers of CYP2C19*2). In 13 (44.8%) of these patients, the restenosed stent was deployed within 1 year and the patients were on clopidogrel therapy at the time of repeat PCI (8 carriers, 5 non-carriers of CYP2C19*2). The association between CYP2C19*2 allele carrier status and ISR within 1 year was not statistically significant (Fisher’s exact p = 0.067; OR: 4.80, 95% CI: 0.98–23.54, p = 0.053). Conclusions: Despite a higher proportion of CYP2C19*2 allele carriers exhibiting ISR within 1 year compared to non-carriers, the association was not statistically significant. This result may be attributed to the small sample size, and larger prospective studies are recommended to further assess this association.peer-reviewe