Appropriateness of timing of drug administration in electronic prescriptions

Circadian Regulation of Endocrine Fibroblast Growth Factors on Systemic Energy Metabolism

The circadian clock is an endogenous biochemical timing system that coordinates the physiology and behavior of organisms to earth's ∼24-hour circadian day/night cycle. The central circadian clock synchronized by environmental cues hierarchically entrains peripheral clocks throughout the body. The circadian system modulates a wide variety of metabolic signaling pathways to maintain whole-body metabolic homeostasis in mammals under changing environmental conditions. Endocrine fibroblast growth factors (FGFs), namely FGF15/19, FGF21, and FGF23, play an important role in regulating systemic metabolism of bile acids, lipids, glucose, proteins, and minerals. Recent evidence indicates that endocrine FGFs function as nutrient sensors that mediate multifactorial interactions between peripheral clocks and energy homeostasis by regulating the expression of metabolic enzymes and hormones. Circadian disruption induced by environmental stressors or genetic ablation is associated with metabolic dysfunction and diurnal disturbances in FGF signaling pathways that contribute to the pathogenesis of metabolic diseases. Time-restricted feeding strengthens the circadian pattern of metabolic signals to improve metabolic health and prevent against metabolic diseases. Chronotherapy, the strategic timing of medication administration to maximize beneficial effects and minimize toxic effects, can provide novel insights into linking biologic rhythms to drug metabolism and toxicity within the therapeutical regimens of diseases. Here we review the circadian regulation of endocrine FGF signaling in whole-body metabolism and the potential effect of circadian dysfunction on the pathogenesis and development of metabolic diseases. We also discuss the potential of chrononutrition and chronotherapy for informing the development of timing interventions with endocrine FGFs to optimize whole-body metabolism in humans. SIGNIFICANCE STATEMENT: The circadian timing system governs physiological, metabolic, and behavioral functions in living organisms. The endocrine fibroblast growth factor (FGF) family (FGF15/19, FGF21, and FGF23) plays an important role in regulating energy and mineral metabolism. Endocrine FGFs function as nutrient sensors that mediate multifactorial interactions between circadian clocks and metabolic homeostasis. Chronic disruption of circadian rhythms increases the risk of metabolic diseases. Chronological interventions such as chrononutrition and chronotherapy provide insights into linking biological rhythms to disease prevention and treatment.

Timing of Administration: For Commonly-Prescribed Medicines in Australia

Chronotherapy involves the administration of medication in coordination with the body's circadian rhythms to maximise therapeutic effectiveness and minimise/avoid adverse effects. The aim of this study is to investigate the "time of administration" recommendations on chronotherapy for commonly-prescribed medicines in Australia. This study also aimed to explore the quality of information on the timing of administration presented in drug information sources, such as consumer medicine information (CMI) and approved product information (PI). Databases were searched for original research studies reporting on the impact of "time of administration" of the 30 most commonly-prescribed medicines in Australia for 2014. Further, time of administration recommendations from drug information sources were compared to the evidence from chronotherapy trials. Our search revealed 27 research studies, matching the inclusion and exclusion criteria. In 56% (n = 15) of the research studies, the therapeutic effect of the medicine varied with the time of administration, i.e., supported chronotherapy. For some medicines (e.g., simvastatin), circadian-based optimal administration time was evident in the information sources. Overall, dedicated studies on the timing of administration of medicines are sparse, and more studies are required. As it stands, information provision to consumers and health professionals about the optimal "time" to take medications lags behind emerging evidence.

Chronotherapy in practice: the perspective of the community pharmacist

BACKGROUND

Optimising the time of drug administration in alignment with circadian rhythms to enhance the clinical effect or minimise/avoid adverse effects is referred to as chronotherapy. Pharmacists have a key role in providing medicine related information, including counselling about the optimal time for medication administration. Where applicable, the principles of chronotherapy should underlie this aspect of medication counselling. Despite significant developments in the science of chronotherapy for specific pharmacological treatments, the perspective of pharmacists about their understanding and application of these principles in practice has not been explored.

OBJECTIVE

To explore community pharmacist's viewpoints about and experience with the application of chronotherapy principles in practice.

SETTING

Community pharmacies within metropolitan Sydney in New South Wales, Australia.

METHODS

Semi-structured, face to face interviews with a convenience sample of community pharmacists were conducted. All interviews were audio-recorded, transcribed verbatim and thematically analyzed using a 'grounded theory' approach, given the novelty of this area. Main outcome measure Community pharmacists' awareness, current practice and future practice support requirements about the principles of chronotherapy.

RESULTS

Twenty-five semi-structured interviews were conducted. Most participants reported encountering cases where clinical decision making about suggesting appropriate times of drug administration to patients was needed. Their approach was mainly pragmatic rather than based on theoretical principles of circadian variation in drug disposition or on current or emerging evidence; thus there was an evidence practice chasm in some cases. However, most participants believed they have an important role to play in counselling patients about optimal administration times and were willing to enact such roles or acquire skills/competence in this area.

CONCLUSION

Community pharmacists contribute to the safe and effective use of medications in providing the patients with information on optimal timing of drug administration during counselling. Further education, practical training and access to information may help pharmacists in translating principles of chronotherapy into the practice.

Education Intervention on Chronotherapy for Final-Year Pharmacy Students

Chronotherapy involves altering the timing of medication administration in coordination with the body's circadian rhythms to improve the overall control of disease and to minimise treatment side effects. Training on chronotherapy requires students to map different topics learnt in earlier years of their professional degree and apply these concepts clinically. This requires strategic educational design. Therefore, the aim of the study was to develop, implement and evaluate an educational intervention focusing on the application of chronotherapy for final-year undergraduate pharmacy students. An educational intervention utilizing multiple learning strategies for enhancing chronotherapy related awareness was designed and implemented in the final year undergraduate pharmacy cohort at the University of Sydney Australia (2013). A custom-designed questionnaire measuring awareness about (13 items scored 0 or 1), and attitudes (12 items scored on a Likert scale of 1-5) towards chronotherapy was administered pre and post intervention to evaluate its impact. The pre-intervention mean total awareness and attitude scores were 6.5 ± 2.0 (score range 0-13) and 47.4 ± 6.9 (score range 12-60) respectively. The mean total post-intervention scores were significantly higher for total awareness (10.1 ± 1.9) and attitude (54.0 ± 6.0). Carefully designed educational interventions utilising pedagogic principles for pharmacy students can improve awareness of and enhance positive attitudes toward pharmacists' roles in optimizing drug therapy using chronotherapy.

A novel multilayered multidisk oral tablet for chronotherapeutic drug delivery

A Multilayered Multidisk Tablet (MLMDT) comprising two drug-loaded disks enveloped by three drug-free barrier layers was developed for use in chronotherapeutic disorders, employing two model drugs, theophylline and diltiazem HCl. The MLMDT was designed to achieve two pulses of drug release separated by a lag phase. The polymer disk comprised hydroxyethylcellulose (HEC) and ethylcellulose (EC) granulated using an aqueous dispersion of EC. The polymeric barrier layers constituted a combination of pectin/Avicel (PBL) (1st barrier layer) and hydroxypropylmethylcellulose (HPMC) (HBL1 and HBL2) as the 2nd and 3rd barrier layers, respectively. Sodium bicarbonate was incorporated into the diltiazem-containing formulation for delayed drug release. Erosion and swelling studies confirmed the manner in which the drug was released with theophylline formulations exhibiting a maximum swelling of 97% and diltiazem containing formulations with a maximum swelling of 119%. FTIR spectra displayed no interactions between drugs and polymers. Molecular mechanics simulations were undertaken to predict the possible orientation of the polymer morphologies most likely affecting the MLMDT performance. The MLMDT provided two pulses of drug release, separated by a lag phase, and additionally it displayed desirable friability, hardness, and uniformity of mass indicating a stable formulation that may be a desirable candidate for chronotherapeutic drug delivery.

Timing is important in medication administration: a timely review of chronotherapy research

BACKGROUND

Chronotherapy involves altering the timing of medication administration to improve the overall control of a disease and to minimise treatment side-effects, and is an emerging concept in the field of therapeutics.

AIM

The aim of this review is to conduct an in-depth analysis of the recent literature in order to identify and evaluate the evidence base for drug chronotherapy.

METHOD

A literature search was conducted in three databases (Medline, Embase, International Pharmaceutical Abstracts) using the search terms "Chronotherapy", "Chronopharmacology", "Chronopharmacokinetics", "Chronopharmacodynamics", "Chronoefficacy", "Chronoformulation", "Morning and Evening", "Morning and Bedtime" and their combinations. The selection criteria for the inclusion of articles in the review included currency (years 2008-Aug 2011), publication in English language, studies done in Humans and non-review articles that pertained to 'drug' therapy.

RESULTS

Our search revealed a total of 192 journal articles, of which 41 articles were selected for review. The specific hypothesis for the effectiveness of chronotherapy that was tested in these 41 studies was chronoeffectiveness (n = 34), followed by chronopharmacokinetics (n = 5), chronomodulation (n = 3) and chronopharmacodynamics (n = 2). The findings from two-thirds (n = 27) of the reviewed studies, support the notion of chronotherapy.

CONCLUSION

The review presents the scope of chronotherapy in drug utilization. We believe that the knowledge of chronotherapy is growing and the current research for chronotherapy is promisingly in the conceptualization or early experimental phase. Going forward, chronotherapy studies should also explore genetic, gender and age related differences. Preliminary screening of new drugs for chronotherapeutic potential may be a way of enhancing quality use of medicines.