The scientific basis of rational prescribing. A guide to precision clinical pharmacology based on the WHO 6-step method

Activities of clinical pharmacologists across Europe: A survey by the European association of clinical pharmacology and therapeutics

PURPOSE

In order to explore clinical pharmacology and therapeutics (CPT) teaching and practices across continental Europe, the European Association of Clinical Pharmacology and Therapeutics (EACPT) made a survey in 2022 amongst its 27 affiliated societies.

METHODS

The survey was made available online to EACPT representatives, and 47 filled-in questionnaires were received from 25 countries (one to five per country), representing all geographic areas of Europe.

RESULTS

Clinical pharmacologists (CPs) spend 25%, 30%, 15%, and 25% of their time in teaching, hospital activities, committees, and research, respectively, with large variations across and within countries. CPT courses are given at Schools of Medicine in all the countries except one, mostly organized and taught by medical doctors (MDs). In Central, Western, and Southern Europe, the teachers may have medicine or pharmacy training. Therapeutic drug monitoring and pharmacovigilance were the hospital activities most frequently reported, and clinical/forensic toxicology, rounds of visits, and pharmacogenetics the least. Two-thirds of the panel think CPs should be MDs. However, the transversal nature of CPT was underlined, with patients/diseases and drugs as gravity centres, thus calling for the complementary skills of MDs and PharmDs. Besides, most respondents reported that clinical pharmacists in their country are involved in rounds of visits, pharmacovigilance, TDM, and/or pharmacogenetic testing and that collaborations with them would be beneficial.

CONCLUSION

CPT comes with a plurality of backgrounds and activities, all required to embrace the different pathologies and the whole lifecycle of medicinal products, but all of them being rarely performed in any given country. The willingness to use common CPT teaching material and prescribing exams at the European level is a good sign of increasing harmonisation of our discipline Europewide.

Polypharmacy and precision medicine

Precision medicine is an approach to maximise the effectiveness of disease treatment and prevention and minimise harm from medications by considering relevant demographic, clinical, genomic and environmental factors in making treatment decisions. Precision medicine is complex, even for decisions about single drugs for single diseases, as it requires expert consideration of multiple measurable factors that affect pharmacokinetics and pharmacodynamics, and many patient-specific variables. Given the increasing number of patients with multiple conditions and medications, there is a need to apply lessons learned from precision medicine in monotherapy and single disease management to optimise polypharmacy. However, precision medicine for optimisation of polypharmacy is particularly challenging because of the vast number of interacting factors that influence drug use and response. In this narrative review, we aim to provide and apply the latest research findings to achieve precision medicine in the context of polypharmacy. Specifically, this review aims to (1) summarise challenges in achieving precision medicine specific to polypharmacy; (2) synthesise the current approaches to precision medicine in polypharmacy; (3) provide a summary of the literature in the field of prediction of unknown drug-drug interactions (DDI) and (4) propose a novel approach to provide precision medicine for patients with polypharmacy. For our proposed model to be implemented in routine clinical practice, a comprehensive intervention bundle needs to be integrated into the electronic medical record using bioinformatic approaches on a wide range of data to predict the effects of polypharmacy regimens on an individual. In addition, clinicians need to be trained to interpret the results of data from sources including pharmacogenomic testing, DDI prediction and physiological-pharmacokinetic-pharmacodynamic modelling to inform their medication reviews. Future studies are needed to evaluate the efficacy of this model and to test generalisability so that it can be implemented at scale, aiming to improve outcomes in people with polypharmacy.

Cooling spray or lidocaine spray and needle insertion pain in hemodialysis patients: an open-label cross-over randomized clinical trial

BACKGROUND

The needle insertion pain to perform hemodialysis is the main challenge and a common problem that requires pain management techniques for patients' comfort.

AIM

This study aimed to compare the effects of cooling and lidocaine sprays on needle insertion pain in hemodialysis patients.

METHODS

In this randomized cross-over clinical trial study, the hemodialysis patients were selected through convenience sampling according to inclusion criteria and randomly assigned to three intervention groups using the block randomization method. Each patient received three interventions in a cross-over design: Cooling spray or 10% lidocaine spray or placebo spray. There was a 2-week wash-out time between each intervention. The pain score was measured four times for each patient by the Numerical Rating Scale.

RESULTS

Forty-one hemodialysis patients were included. The results showed a significant interaction between time and group (p < 0.05), so only observations of time 1 with adjustment for baseline values were used to evaluate the effect of the intervention. Patients receiving cooling spray reported 2.29 less pain score on average compared to placebo (B=-2.29, 95% CI: -4.17 to -0.43; p < 0.05); Also, patients receiving cooling spray reported a 1.61 lower pain score than those receiving lidocaine spray, but this difference was not statistically significant (95% CI: -0.26 to 3.48; p > 0.05).

CONCLUSION

The cooling spray was effective in reducing the needle insertion pain. Although it was impossible to compare the pain scores at different times and following different interventions, the present study results can help supplement the existing knowledge regarding cooling and lidocaine sprays.

Frailty in older adults with heart disease

BACKGROUND

Heart failure prevalence will double in the next 40 years and affects more than 10% of persons over the age of 70 years in an age-dependent manner. Frailty is an age-associated clinical syndrome defined as a decrease in physiological reserve in situations of stress, such as operations, infections and acute illness based on a state of higher vulnerability. The prevalence is up to 74% in older individuals over the age of 80 years or those over 70 years old with a high burden of comorbidities and chronic diseases. This geriatric syndrome is associated with a worse clinical outcome and higher morbidity and mortality in acute and chronic disease than in age-matched cohorts without this syndrome.

METHODS

In this brief review, the scientific evidence of appropriate tools for diagnosis of frailty in heart failure patients is addressed. Heart failure management in this special group of patients requires a holistic care planning presented here in accordance with pathophysiologic particularities. A literature search in PubMed using the terms "heart failure" and "frailty" was carried out and a further search in the references based on the findings.

CONCLUSION

The diagnosis of frailty should influence the intensity of further diagnostic investigations and medical treatment based on the personal wishes of the patient, reduced organ reserves and general prognosis. The prognosis of heart failure patients remains poor, partially due to the intertwining with frailty. A clear statement for the use of an appropriate diagnostic tool for frailty and heart failure and specific therapeutic recommendations are presented based on clinical evidence.

Polypharmacy in elderly people

Polypharmacy characterizes ongoing prescription of multiple medications in a patient. Following the demographic change and growing number of elderly patients, polypharmacy is of major concern due to the associated risks and even mortality. Many causes made this geriatric syndrome more common in the past decade. First, the management of comorbidities is often lacking in disease-specific guidelines. Second, multimorbidity is rising due to the ageing population. Third, deprescribing methods are sparse, and results are conflicting. This mini review integrates the effects of polypharmacy on mortality and morbidity, the causes and confounders of polypharmacy, and presents a practical stepwise manual of deprescribing. The work is based on a literature search for randomized control trials and reviews in English and German from 2015 onwards in the PubMed database, with integration of relevant citations as a result of this search.

Pharmacological Management of Pattern Hair Loss

Pattern hair loss (PHL) is a condition that worsens with time and the only way it can be slowed down is with pharmacological intervention. Pharmacological treatments for PHL, from an evidenced-based perspective with respect to safety and efficacy, are limited to only two drugs, minoxidil and finasteride. However, there are a host of drugs being used, off-label with limited evidence. This article attempts to review the literature on this topic, and the authors add to this, with their experience of over two decades on incorporating pharmacologic treatments along with hair transplantation in their management of PHL.