Management of Helicobacter pylori eradication--the influence of structured counselling and follow-up

Comparison of vonoprazan-based dual therapy with vonoprazan-based bismuth quadruple therapy for treatment-naive patients with Helicobacter pylori infection: A propensity score matching analysis

Vonoprazan, a novel acid suppressant and the first potassium-competitive acid blocker, has the potential to enhance the eradication rate of Helicobacter pylori due to its robust acid-suppressing capacity. This study aimed to compare the efficacy of vonoprazan-based dual therapy (vonoprazan-amoxicillin, VA) with vonoprazan-based bismuth quadruple therapy (VBQT) as a first-line treatment for H pylori infection. This retrospective single-center non-inferiority study was conducted in China. Treatment-naive H pylori-positive patients aged 18 to 80 received one of the 2 treatment regimens at our center. The VA group received vonoprazan 20 mg twice daily and amoxicillin 1000 mg 3 times daily for 14 days, whereas the VBQT group received vonoprazan 20 mg, amoxicillin 1000 mg, clarithromycin 500 mg, and bismuth potassium citrate 220 mg twice daily for 14 days. The eradication rate was evaluated 4 to 6 weeks after treatment using the carbon-13/14 urea breath test. Propensity score matching was used to analyze eradication rates, adverse events (AEs), and patient compliance between the 2 groups. Initially, 501 patients were included, and after propensity score analysis, 156 patients were selected for the study. Intention-to-treat analysis showed eradication rates of 87.2% (95% CI, 79.8-94.6%) for the VA group and 79.5% (95% CI, 70.5-88.4%) for the VBQT group (P = .195). Per-protocol analysis demonstrated rates of 94.4% (95% CI, 89.2-99.7%) for the VA group and 96.8% (95% CI, 92.4-100%) for the VBQT group (P = .507). Non-inferiority was confirmed between the 2 groups, with P values < .025. The VA group showed a lower rate of AEs (10.3% vs 17.9%, P = .250) compared to the VBQT group. There were no significant differences in patient compliance between the 2 groups. In treatment-naive patients with H pylori infection, both the 14-day VA and VBQT regimens demonstrated comparable efficacy, with excellent eradication rates. Moreover, due to reduced antibiotic usage, lower rate of AEs, and lower costs, VA dual therapy should be prioritized.

Clarifying varied Helicobacter pylori eradication therapies: A comprehensive review

Current global variations exist in Helicobacter pylori (H. pylori) eradication regimens. Triple therapy (TT), bismuth quadruple therapy (BQT), and high-dose dual therapy (HDDT) currently represent the predominant regimens. These regimens diverge in terms of treatment duration, the utilization of susceptibility testing, acid-inhibiting drug administration, and patient education. We conducted a comprehensive systematic literature review on these H. pylori treatment regimens. Our review aims to provide standardized treatment recommendations for H. pylori, reducing the risk of amalgamating findings from diverse eradication regimens. Recent research suggests that the optimal treatment duration for TT and BQT may be 14 and 10 days, respectively. Selecting the appropriate treatment duration for HDDT should rely on regional research evidence, and 14 days may be the optimal duration. The incorporation of susceptibility testing in TT is of paramount importance. In the case of BQT, the absence of susceptibility testing may be considered as an option, contingent upon cost and availability, and should be determined based on local antibiotic resistance patterns and the efficacy of empirical regimens. The type and dosage of acid-inhibiting drug would affect the efficacy of these regimens. Acid-inhibiting drugs should be selected and applied reasonably according to the population and therapies. Adequate patient education plays a pivotal role in the eradication of H. pylori. In regions with accessible local research evidence, the 10-day empirical BQT regimen may be considered a preferred choice for H. pylori eradication.

EFFECT OF PHARMACIST COUNSELING ON PATIENT MEDICATION COMPLIANCE AND HELICOBACTER PYLORI ERADICATION AMONG JORDANIAN OUTPATIENTS

BACKGROUND

To examine the impact of pharmacist counseling and follow-up on patient's medication compliance and Helicobacter Pylori (H. pylori) eradication and evaluate the efficiency of an eradication regimen consisting of Clarithromycin 500 mg, Amoxicillin 1 g, and Lansoprazole 30 mg, twice daily for 14 days.

METHODS

Two hundred patients undergoing endoscopy and positive rapid urease tests were included in the present study. Patients were randomly divided into two groups: an intervention group (n=100) and a control group (n=100). The intervention patients obtained their medications from the hospital pharmacist and received sufficient counseling and follow-up. On the other hand, the control patients received their medications from another hospital pharmacist and went through the routine hospital procedure without good counseling and follow-up.

RESULTS

The intervention resulted in a statistically significant improvement in outpatient compliance with medication (45.0% vs 27.5%; P<0.05) and eradication of H. pylori (28.5% vs 42.5%; P<0.05) among those patients.

CONCLUSION

This study reflects the importance of pharmacist counseling and patient compliance to medication, as the patients who received pharmacist counseling exhibited perfect compliance to medication, which led to the successful eradication of H. pylori.

Treatment strategies and pharmacist-led medication management for Helicobacter pylori infection

Half of the world's population is Helicobacter pylori carrier. Updated guidelines and consensus have been issued across regions with the main aim of reducing social transmission and increasing H. pylori eradication rate. Although alternative therapies including traditional Chinese medicine and probiotics have also been used to improve H. pylori eradication rate in clinical practice, current mainstream treatment is still dependent on triple and quadruple therapies that includes antibacterial agents (e.g., amoxicillin and furazolidone) and proton pump inhibitor. Researches also assessed the eradication rate of optimized high-dose dual therapy in treating H. pylori infection. With the increase of antibiotic resistance rate, the treatment strategies for H. pylori infection are constantly adjusted and improved. Besides, low medication compliance is another key influencing factor for H. pylori treatment failure. Emerging studies indicate that pharmacists' intervention and new pharmaceutical care methods can enhance patient medication compliance, reduce adverse drug reactions, and improve H. pylori eradication rate. The purpose of this review is to summarize the advances in treating H. pylori infection and highlight the necessity of developing novel strategies to cope with the increasing challenges and to achieve personalized medication. Also, this review attaches great importance to pharmacists in optimizing H. pylori treatment outcomes as a routine part of therapy.

Improving Syrian refugees' knowledge of medications and adherence following a randomized control trial assessing the effect of a medication management review service

BACKGROUND

Syrian refugees living in Jordan have many chronic conditions and use many medications. Pharmacists delivering the Medication Management Review (MMR) service can have a role in improving this growing global refugees' problem.

OBJECTIVES

To assess the effect of the MMR service on adherence to treatment therapy and knowledge of chronic medications for Syrian refugees residing in Jordan.

METHODS

This randomized intervention control single-blinded study was conducted in Jordan. Syrian refugees were recruited and randomized into intervention and control groups. Two home visits were delivered to each participant, at baseline and three months later. All participants completed questionnaires regarding adherence and knowledge. As a part of the MMR service, treatment-related problems (TRPs) were recognized for all patients; recommendations to resolve these TRPs were only delivered to intervention group refugees' physicians; TRPs were corrected. At follow-up, TRPs assessment, adherence and medication knowledge were assessed for all refugee participants.

RESULTS

Participants (n = 106; intervention n = 53, control n = 53) had a number of medications and diagnosed chronic diseases of 5.8 ± 2.1 and 2.97 ± 1.16 per participant respectively. A significant improvement in the adherence and knowledge scores were noted in the intervention (P < 0.001 for both) but not the control group (P = 0.229, P = 0.07 respectively).

CONCLUSION

The MMR service can significantly improve refugees' TRPs, adherence to therapy and knowledge of chronic medications. If this approach was extended to the large scale, many refugees in need would be able to access a quality essential health-care service; a step towards achieving universal health coverage.

TRIAL REGISTRATION

Registry: ClinicalTrials.gov Identifier: NCT04554810.

Does technology-enhanced communication improve Helicobacter pylori eradication outcomes?-A meta-analysis

BACKGROUND

Helicobacter pylori (H. pylori) is a highly prevalent organism that can induce an inflammatory state in the upper gastrointestinal tract and lead to complications such as peptic ulcer and gastric cancer. The treatment regime is complicated, and mild-to-moderate adverse effects are common, making patient compliance a key determinant of successful eradication. One attractive strategy is to leverage on technology-enhanced communication (TEC) strategies. However, the current data on the efficacy of TEC modalities in improving H. pylori eradication are limited. This is the first meta-analysis evaluating its effectiveness to the best of our knowledge. Thus, it is essential to evaluate the current body of evidence to learn the impact of TEC initiatives.

METHODS

A literature search was done on PubMed, World of Science, and Embase. A total of 9 studies variably reported on compliance rate, eradication rate, adverse effect rate, symptom relief, patient satisfaction, treatment cost, patient disease awareness, and follow-up rates.

RESULTS

This meta-analysis showed that TEC initiatives significantly improve patient compliance (OR 4.52, 95% CI 2.09 - 9.77, p < .01) and eradication rate (OR 1.98, 95% CI 1.34 - 2.93, p < .01) but not adverse effect rate (OR 0.65, 95% CI [0.27 - 1.57], p = .34). Due to the small number of studies and population sample, patient satisfaction, symptom relief, treatment costs, disease awareness, and follow-up rates were assessed qualitatively.

CONCLUSION

TEC initiatives effectively improve compliance to the H. pylori eradication regime and increase the eradication rate.

Effects of enhanced education for patients with the Helicobacter pylori infection: A systematic review and meta-analysis

BACKGROUND

Helicobacter pylori (H. pylori) infections are of serious concern due to the associated risk of gastric cancer. However, many patients have poor medication and therapy compliance, which makes it difficult to eradicate their infections. This points to the need for stronger educational interventions aimed at enhancing compliance, thus increasing the potential for treatment success. As such, this study conducted a meta-analysis to clarify the effects of enhanced patient education (EPE) programs for H. pylori.

MATERIALS AND METHODS

We searched electronic databases (PubMed, EMBASE, Web of Science, and Cochrane Library) for randomized controlled trials (RCTs) on health education for patients infected with H. pylori from inception to June 2021. The primary outcome was the eradication rate of H. pylori, while the secondary outcomes included the incidence of individual adverse symptoms, treatment compliance, clinical symptom remission after treatment, and patient satisfaction. We used the fixed or random-effects model to pool the risk ratio (RR), with 95% confidence interval. We also conducted sensitivity and subgroup analyses.

RESULTS

Our search returned seven relevant studies across a total of 1,433 patients. Compared with controls, EPE was significantly associated with improved H. pylori eradication rates (RR = 1.16, 95%CI: 1.04-1.29, p = 0.006) and patient compliance (RR = 1.48, 95%CI: 1.14-1.93, p = 0.003). A subgroup analysis also showed that EPE benefits were consistent across patients with different eradication programs, WeChat intervention plans, and intervention frequencies (p < 0.05). However, there were no significant differences in the total adverse effects, common side effects (diarrhea, nausea, abdominal pain, taste disorder, and skin rash), or discontinuation rate (p > 0.05).

CONCLUSIONS

Patient education is inexpensive, safe, and convenient. In this context, our findings suggest that enhanced educational interventions have positive effects on both the H. pylori eradication rate and adherence among infected patients, and thus constitute promising complements to clinical treatment regimens.

Helicobacter pylori diagnosis and therapy in the era of antimicrobial stewardship

The diagnosis and therapy of Helicobacter pylori infection have undergone major changes based on the use the principles of antimicrobial stewardship and increased availability of susceptibility profiling. H. pylori gastritis now recognized as an infectious disease, as such there is no placebo response allowing outcome to be assessed in relation to the theoretically obtainable cure rate of 100%. The recent recognition of H. pylori as an infectious disease has changed the focus to therapies optimized to reliably achieve high cure rates. Increasing antimicrobial resistance has also led to restriction of clarithromycin, levofloxacin, or metronidazole to susceptibility-based therapies. Covid-19 resulted in the almost universal availability of polymerase chain reaction testing in hospitals which can be repurposed to utilize readily available kits to provide rapid and inexpensive detection of clarithromycin resistance. In the United States, major diagnostic laboratories now offer H. pylori culture and susceptibility testing and American Molecular Laboratories offers next-generation sequencing susceptibility profiling of gastric biopsies or stools for the six commonly used antibiotics without need for endoscopy. Current treatment recommendations include (a) only use therapies that are reliably highly effective locally, (b) always perform a test-of-cure, and (c) use that data to confirm local effectiveness and share the results to inform the community regarding which therapies are effective and which are not. Empiric therapy should be restricted to those proven highly effective locally. The most common choices are 14-day bismuth quadruple therapy and rifabutin triple therapy. Prior guidelines and treatment recommendations should only be used if proven locally highly effective.

Comparison of tailored Helicobacter pylori eradication versus modified bismuth quadruple therapy in Korea: a randomized controlled trial

OBJECTIVES

We aimed to compare the success rate, adverse drug events, and cost-effectiveness of tailored Helicobacter pylori eradication and modified bismuth-containing quadruple therapy.

METHODS

The diagnosis of H. pylori infection was randomly based on either rapid urease test (RUT) or dual priming oligonucleotide (DPO)-based multiplex polymerase chain reaction (PCR) in 1:1 ratio. According to the presence of point mutations that cause clarithromycin resistance, patients in the tailored therapy (TT) group received standard triple therapy or classic bismuth quadruple therapy. Patients with positive RUT results received 40 mg pantoprazole, 1000 mg amoxicillin, 750 mg metronidazole, and 600 mg bismuth subcitrate twice daily for 14 days (PAM-B therapy).

RESULTS

Between the TT (n = 141) and PAM-B groups (n = 141), H. pylori eradication rate did not differ significantly according to intention-to-treat (TT: 80.9% vs. PAM-B: 85.8%, P = 0.262), modified intention-to-treat (TT: 89.1% vs. PAM-B: 91.0%, P = 0.606), and per-protocol (TT: 89.0% vs. PAM-B: 93.5%, P = 0.198) analyses. The average cost for successful eradication was higher in the TT group than in the PAM-B group ($340.7 vs. $263.9 per patient).

CONCLUSION

PAM-B therapy exhibits similar efficacy and improved cost-effectiveness compared to TT based on the results of DPO-PCR tests.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov identifier is NCT05002595.

Are physicians ready to comply with the guidelines for diagnosis and management of Helicobacter pylori-associated diseases: the survey results 2020–2021

Objective: To assess compliance of physicians with diagnostic and management guidelines for H. pylori-associated diseases with a question-naire-based survey.

Materials and methods: We conducted an anonymous voluntary online survey of 775 physicians of the following specialties: internal medicine 459 (59.2%), gastroenterology 279 (36%), and endoscopy 34 (4.4%). The respondents expressed their level of agreement with the questionnaire items as follows: 0 – I do not know, 1 – disagree, 2 – partially agree, and 3 – fully agree.

Results: 613 (79.4%) of the physicians fully agreed to diagnose and treat H. pylori in patients with chronic atrophic gastritis, 602 (78.0%) in the 1 st degree relatives of gastric cancer patients, 525 (68.0%) in patients with chronic superficial gastritis, 423 (54.8%) in peptic ulcer at remission, and 336 (43.4%) in those with dyspepsia syndrome. The physicians were equally compliant with eradication therapy in the patients, for whom long term use of proton pump inhibitors (PPI) or non-steroid anti-inflammatory drugs (NSAID) is being planned (386 (50.0%) and 397 (51.4%), respectively). Internists were less compliant with diagnosis and management of H. pylori in patients taking both PPI (χ2 = 66.525, p = 0.004) and NSAID (χ2 = 103.354, p = 0.003). Among the primary diagnostic tools for H. pylori the physicians preferred 13/14С-urease breath test (545 physicians, or 70.6%) and gastric bioptate morphology (574, or 74.4%), and among the control diagnostic methods they chose fаeces analyses (enzyme-linked immunosorbent assay and polymerase chain reaction). The respondents considered bismuth-enhanced standard triple therapy with clarithromycin to be the most effective regimen for the 1 st line eradication therapy (606, 78.5%). To increase the efficacy of eradication therapy, the physicians were more prone to administer esomeprazole or rabeprazole (70.6%), bismuth-based agents (79.4%), than to use rebamipid (35%), probiotics (44.9%) and/or to double PPI doses (44.2%). The respondents expressed their concerns with low patient compliance to treatment (59.4%) and limited diagnostic capabilities (49.4%).

Conclusion: Physician's compliance with the guidelines on diagnosis and management of H. pylori-associated diseases is adequate and might depend on both their awareness and availability of the proposed diagnostic and therapeutic methods.

Efficacy and Safety of Modified Dual Therapy as the First-line Regimen for the Treatment of Helicobacter pylori Infection: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

In an era of antibiotic resistance, modified dual therapy has been paid much attention because of simple drug composition and low resistance of amoxicillin. However, its eradication rate as a first-line regimen remains controversial. This study is to evaluate the efficacy and safety of modified dual therapy for the initial treatment of Helicobacter pylori (H. pylori) infection compared with mainstream first-line therapies.

METHODS

PubMed, the Cochrane Library, and Embase were searched for randomized clinical trials evaluating the efficacy and safety of modified dual therapy as the initial treatment for H. pylori eradication compared with guideline-recommended first-line therapies. A meta-analysis was conducted using Review Manager 5.3 and dichotomous data were estimated by the risk ratio (RR) with the 95% confidence interval (CI). We also performed subgroup analysis according to control groups and studies with antibiotic susceptibility tests.

RESULTS

Eight studies including 1672 patients with H. pylori infection met the selection criteria and were assessed. The meta-analysis demonstrated that modified dual therapy achieved similar efficacy [85.83% vs. 86.77%, RR 0.99 (95% CI, 0.95-1.03), intention-to-treat analysis; 89.53% vs. 90.45%, RR 0.99 (95% CI, 0.96-1.02), per-protocol analysis] and compliance [95.77% vs. 95.56%, RR 1.00 (95% CI, 0.98-1.02)] compared with recommended first-line regimens. In addition, there were no significant differences in comparing the eradication rate of modified dual therapy with clarithromycin triple therapy, bismuth quadruple therapy, and concomitant therapy, respectively. Subgroup analysis based on the studies with antibiotic susceptibility tests also confirmed a similar efficacy. However, modified dual therapy showed fewer adverse effects [8.70% vs. 22.38%, RR 0.39 (95% CI, 0.28-0.54)], with a significant difference (P<0.00001).

CONCLUSION

Modified dual therapy achieved equal efficacy and compliance compared with recommended first-line regimens for H. pylori infection, and generally modified dual therapy showed fewer side effects.

Drug-Related Problems on a Palliative Care Unit

Pharmacotherapy is essential in palliative medicine. Besides potential benefits, pharmacotherapy also poses potential risks that need to be minimized for patient safety. Pharmacists can play an important role in identifying, solving, and avoiding drug-related problems (DRPs). The aim of this study was to evaluate pharmaceutical interventions on safety of drug therapy in patients in an inpatient palliative care unit. All patients admitted to a palliative care unit over a 12-month period were screened for eligibility (ie, life expectancy >4 weeks). To identify and assess DRPs, patients' pharmacotherapy was evaluated by a pharmacist according to various aspects (eg, drug selection, dose selection, or treatment duration according to the Pharmaceutical Care Network Europe classification for DRPs). During the 12-month period, 41 patients were included. Patients received a median of 11 (range, 1-22) different drugs. Overall, 207 DRPs were documented (median 5 DRPs/patient). After recording a DRP, the pharmacist directly intervened 290 times in order to solve the DRP, which was successful in 181/207 (88%). Clinically relevant DRPs are common in palliative medicine. The systematic assessment can support therapy decisions. This can result in optimized drug therapy, subsequently having a positive effect on symptom control and quality of life.

Two Different 1-Week Quadruple Therapies Given Back-to-Back Consecutive Therapy for Difficult-to-Treat Helicobacter pylori Infection: A Pilot Study

INTRODUCTION

We aim to evaluate the efficacy of 2 different 1-week quadruple therapies given back-to-back consecutive therapy in patients with difficult-to-treat Helicobacter pylori infection.

METHODS

Patients with proven H. pylori infection were recruited after >3 failed standard quadruple eradication. They received consecutive therapy consisting of esomeprazole 40 mg or rabeprazole 20 mg twice daily, amoxicillin 1,000 mg twice daily, tetracycline 500 mg 4 times daily, and furazolidone 100 mg 3 times daily for the first 7 days, followed by colloidal bismuth pectin 200 mg twice daily in place of furazolidone 100 mg for another 7 days. Eradication rates, treatment-emergent adverse events (TEAEs), and compliance were assessed.

RESULTS

Sixty-five patients were enrolled. The mean number of previous eradications was 3.6 (range: 3-7). The intention-to-treat and per-protocol eradication rates were 90.8% (59/65) and 95.1% (58/61). In total, 23.4% (15/64) of patients experienced drug-related TEAEs. No serious adverse events were observed. None of the patients required treatment for TEAEs, and 95.3% (61/64) showed good compliance. Overall, 51 patients (78.5%) were with the available antimicrobial susceptibility testing results. The resistance rates to clarithromycin, metronidazole, levofloxacin, and amoxicillin were 60.8% (31/51), 100% (51/51), 70.6% (36/51), and 2.0% (1/51), respectively. No resistance was detected to either furazolidone or tetracycline. However, in 54.9% of patients (28/51), H. pylori was resistant to 3 antibiotics (metronidazole, levofloxacin, and clarithromycin).

DISCUSSION

Consecutive therapy, including amoxicillin, tetracycline, and furazolidone, achieved a good eradication rate (>90%), with desirable compliance and tolerability in difficult-to-treat H. pylori infection.

A High-Throughput Metabolic Microarray Assay Reveals Antibacterial Effects of Black and Red Raspberries and Blackberries against Helicobacter pylori Infection

Helicobacter pylori infection is commonly treated with a combination of antibiotics and proton pump inhibitors. However, since H. pylori is becoming increasingly resistant to standard antibiotic regimens, novel treatment strategies are needed. Previous studies have demonstrated that black and red berries may have antibacterial properties. Therefore, we analyzed the antibacterial effects of black and red raspberries and blackberries on H. pylori. Freeze-dried powders and organic extracts from black and red raspberries and blackberries were prepared, and high-performance liquid chromatography was used to measure the concentrations of anthocyanins, which are considered the major active ingredients. To monitor antibiotic effects of the berry preparations on H. pylori, a high-throughput metabolic growth assay based on the Biolog system was developed and validated with the antibiotic metronidazole. Biocompatibility was analyzed using human gastric organoids. All berry preparations tested had significant bactericidal effects in vitro, with MIC₉₀ values ranging from 0.49 to 4.17%. Antimicrobial activity was higher for extracts than powders and appeared to be independent of the anthocyanin concentration. Importantly, human gastric epithelial cell viability was not negatively impacted by black raspberry extract applied at the concentration required for complete bacterial growth inhibition. Our data suggest that black and red raspberry and blackberry extracts may have potential applications in the treatment and prevention of H. pylori infection but differ widely in their MICs. Moreover, we demonstrate that the Biolog metabolic assay is suitable for high-throughput antimicrobial susceptibility screening of H. pylori.

Pharmacist-Managed Helicobacter pylori Treatment Service Within a Gastroenterology Clinic: Workflow and Real-World Experiences

BACKGROUND

Treatment eradication rates of Helicobacter pylori, a gastrointestinal infection, are 70% to 90% in clinical studies but lower in real-world settings. Potential barriers include multidrug regimen complexity or prescribing/administration errors. A pharmacist-managed H pylori treatment service was implemented to address these barriers and optimize treatment outcomes. The clinical pharmacist provided 2 services: (1) treatment education and monitoring for treatment-naïve patients and (2) treatment initiation, education, and monitoring for treatment-experienced patients.

OBJECTIVE

We aimed to evaluate the impact of a pharmacist-managed H pylori treatment service within a gastroenterology clinic.

METHODS

We conducted a retrospective observational cohort study of all patients referred to and seen in the pharmacist-managed H pylori treatment service from July 10, 2019, to December 31, 2020. Patient demographics, prior treatment history, course(s) of treatment prescribed, frequency of follow-ups, and outcomes posttreatment were collected.

RESULTS

The clinical pharmacist managed 60 referrals for 55 unique patients over a mean of 5 ± 2 visits. Five patients failed H pylori treatment and were re-referred. Identified barriers included prescribing/dispensing and administration errors. Posttreatment, 38 referrals tested for H pylori eradication, of which 100% of treatment-naïve patients and 69% of treatment-experienced patients were cured, and 13 (22%) referrals were lost to follow-up.

CONCLUSION AND RELEVANCE

This study described and assessed the impact of a pharmacist-managed H pylori treatment service in a gastroenterology clinic, in which various barriers were effectively addressed to optimize treatment outcomes. Future studies should focus on long-term outcome, impact on health care costs, and patient satisfaction with this service.

Development of a multivariable model to predict medication non-adherence risk factor for patients with acute coronary syndrome

Objective

The aim of this study was to develop a risk prediction model for non-adherence to prescribed medication based on self-reported risk factors in patients with the acute coronary syndrome (ACS).

Methods

This is a prospective follow-up cohort study of 210 patients with ACS at a tertiary hospital in Al Ain city in the United Arab Emirates. Patients with ACS in the electronic registry who were discharged from the hospital but continued to attend outpatient clinics and were prescribed evidence-based medications were identified and interviewed. Univariate and multivariate logistic regression models were constructed and used as appropriate. SPSS V24 was used for data analysis.

Key findings

A final predictive model of eight variables was developed for ACS medication non-adherence. The significant predicted risk factors identified in the final model with their odds ratios (ORs) and confidence intervals (CIs) were as follows: poor knowledge of prescribed medications (OR = 1.81; CI = 1.032–3.34; P = 0.010), five or more prescribed medicines (OR = 4.97; CI = 1.98–2.49; P = 0.007), more than twice daily dosing regimen (OR = 2.21; CI = 1.04–4.67; P = 0.039), unpleasant side-effects (OR = 2.97; CI = 1.98–2.49; P = 0.007), patients believed that side-effects were the cause of health problems (OR = 4.28; CI = 1.78–10.39; P = 0.001), patients undertaking regular exercise (OR = 2.14; CI = 1.06–4.32; P = 0.035), and comorbid diabetes (OR = 1.97; CI = 1.00–3.87; P = 0.049).

Conclusion

This study indicates poor knowledge, polypharmacy and comorbidity as risk factors associated with medication non-adherence among patients with ACS. Identification of predictors of non-adherence and strategies has the potential to reduce non-adherence dramatically.

General practitioner practice-based pharmacist input to medicines optimisation in the UK: pragmatic, multicenter, randomised, controlled trial

BACKGROUND

Changing demographics across the UK has led to general practitioners (GPs) managing increasing numbers of older patients with multi-morbidity and resultant polypharmacy. Through government led initiatives within the National Health Service, an increasing number of GP practices employ pharmacist support. The purpose of this study is to evaluate the impact of a medicines optimisation intervention, delivered by GP practice-based pharmacists, to patients at risk of medication-related problems (MRPs), on patient outcomes and healthcare costs.

METHODS

A multi-centre, randomised (normal care or pharmacist supplemented care) study in four regions of the UK, involving patients (n = 356) from eight GP practices, with a 6-month follow-up period. Participants were adult patients who were at risk of MRPs.

RESULTS

Median number of MRPs per intervention patient were reduced at the third assessment, i.e. 3 to 0.5 (p < 0.001) in patients who received the full intervention schedule. Medication Appropriateness Index (MAI) scores were reduced (medications more appropriate) for the intervention group, but not for control group patients (8 [4-13] to 5 [0-11] vs 8 [3-13] to 7 [3-12], respectively; p = 0.001). Using the intention-to-treat (ITT) approach, the number of telephone consultations in intervention group patients was reduced and different from the control group (1 [0-3] to 1 [0-2] vs 1 [0-2] to 1 [0-3], p = 0.020). No significant differences between groups were, however, found in unplanned hospital admissions, length of hospital stay, number of A&E attendances or outpatient visits. The mean overall healthcare cost per intervention patient fell from £1041.7 ± 1446.7 to £859.1 ± 1235.2 (p = 0.032). Cost utility analysis showed an incremental cost per patient of - £229.0 (95% CI - 594.6, 128.2) and a mean QALY gained of 0.024 (95% CI - 0.021 to 0.065), i.e. indicative of a health status gain at a reduced cost (2016/2017).

CONCLUSION

The pharmacist service was effective in reducing MRPs, inappropriateness of medications and telephone consultations in general practice in a cost-effective manner.

TRIAL REGISTRATION

ClinicalTrials.Gov, NCT03241498. Registered 7 August 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03241498.

Application of a semi-automatic, intensive follow-up for improving efficacy and adherence of Helicobacter pylori eradication therapy: A randomized controlled trial

A complete understanding and good adherence are crucial for successful Helicobacter pylori eradication. Proper frequency of reminders might be helpful to both doctors and patients to maintain adherence during treatment. The study was to evaluate the influence of an intensive follow-up system based on a clinical database on H. pylori eradication therapy. A total of 196 eligible patients were equally and randomly divided into an intensive follow-up group and a control group. Both groups were administered bismuth-containing quadruple therapy for 14 days. Patients in the intensive follow-up group were informed of pre-treatment, including the duration and potential adverse events. Subsequently, they received telephone follow-ups on days 3 and 14 and 3 days before the urea breath test (UBT). The time points were automatically reminded by a follow-up system in the established clinical database. The control group was only informed of pre-treatment information. UBT was performed 4 weeks after treatment in both groups to assess the presence of H. pylori. The eradication rate, patient compliance, and adverse events were calculated and compared. The H. pylori eradication rates of the intensive follow-up and control groups were 94.7% (90/95, 95% CI: 90%-99%) and 92.9% (78/84, 95% CI: 87%-98%), respectively, by PP analysis (p = 0.601), and 91.8% (90/98, 95% CI: 86%-97%) and 81.6% (80/98, 95% CI: 74%-89%) by ITT analysis (p = 0.035). Adverse events occurred in 9 intensive follow-up group patients and 12 in the control group. Adherence was 96.9% (95/98) in the intensive follow-up group and 85.7% (84/98) in the control group. Semi-automatic intensive follow-up contributed to a higher eradication rate and adherence to H. pylori treatment.

Persistent Helicobacter pylori Infection: An Insight to the Limitations of Current Clinical Practice

The discovery of the pathological role of Helicobacter pylori in various disease states, such as peptic ulcer disease (PUD) and Mucosa Associated Lymphoid Tissue (MALT) lymphoma, was ground-breaking in the field of gastroenterology. Given the potentially dire clinical implications of chronic H. pylori infection, it is important to achieve complete eradication. More importantly, the rising prevalence of H. pylori antimicrobial resistance, similar to other pathogens world-wide, is of particular concern. Despite evidence supporting the growing threat of antimicrobial resistance, clinically, it is also important to survey just how much of the failed treatment is truly a reflection of resistance versus poor treatment adherence. In this report, we detail the case of a 64-year-old female who was previously given six treatment courses for persistent H. pylori infection. Successful eradication was achieved with rifabutin triple therapy consisting of high-dose amoxicillin and strict adherence monitoring by a clinical pharmacist. This case highlights the importance of patient education, medication reconciliation, and close monitoring to ensure successful treatment of persistent H. pylori infection.

Pharmacist Interventions to Improve Specialty Medication Adherence: Study Protocol for a Randomized Controlled Trial

BACKGROUND

The effectiveness of specialty medications in complicated clinical conditions depends on adherence to therapy. However, specialty medications pose unique barriers to adherence.

OBJECTIVE

This study aims to determine whether pharmacist interventions improve specialty medication adherence.

METHODS

This is a single-center, pragmatic, randomized controlled trial ongoing since 10 May 2019 at an integrated health system specialty pharmacy. This study evaluates usual care compared with usual care plus patient-tailored adherence interventions. Study design and procedures were informed by focus groups with patients and specialty pharmacists. Patients at Vanderbilt Specialty Pharmacy with a proportion of days covered (PDC) < 90% in the previous 4 months are identified by a daily query of the electronic pharmacy database. A pharmacist reviews these patients' electronic health records to identify and exclude ineligible patients. Eligible patients are randomized evenly to the control or intervention arm and stratified by historical clinic nonadherence rates. Patients randomized to the intervention arm undergo a baseline assessment to clarify reasons for nonadherence and subsequently receive patient-tailored interventions based on their specific reasons. Interventions and follow-up are provided at the discretion of the intervening pharmacist. The primary outcome is PDC calculated at 8 months post-enrollment. Enrollment of 438 participants will provide 90% power to detect a 5% difference in PDC between the two arms within each nonadherence risk stratum.

DISCUSSION

This trial will evaluate the effect of patient-tailored interventions on specialty medication adherence and will inform how often and why patients are misidentified as nonadherent.

REGISTRATION

The trial was deemed a quality improvement initiative by the Vanderbilt University Institutional Review Board. It was registered in ClinicalTrials.gov (NCT03709277) on 17 October 2018.

Amoxicillin or tetracycline in bismuth-containing quadruple therapy as first-line treatment for Helicobacter pylori infection

AIM

To compare the efficacy and safety between modified quadruple- and bismuth-containing quadruple therapy as first-line eradication regimen for Helicobacter pylori infection.

METHODS

This study was a multicenter, randomized-controlled, non-inferiority trial. Subjects endoscopically diagnosed with H. pylori infection were randomly allocated to receive modified quadruple- (rabeprazole 20 mg bid, amoxicillin 1 g bid, metronidazole 500 mg tid, bismuth subcitrate 300 mg qid [elemental bismuth 480 mg]; PAMB) or bismuth-containing quadruple therapy (rabeprazole 20 mg bid, bismuth subcitrate 300 mg qid, metronidazole 500 mg tid, tetracycline 500 mg qid; PBMT) for 14 days. Rates of eradication success and adverse events were investigated. Antibiotic resistance was determined using the agar dilution and DNA sequencing of the clarithromycin resistance point mutations in the 23 S rRNA gene of H. pylori.

RESULTS

In total, 233 participants were randomized, 27 were lost to follow-up, and four violated the protocol. Both regimens showed an acceptable eradication rate in the intention-to-treat (PAMB: 87.2% vs. PBMT: 82.8%, P = .37), modified intention-to-treat (96.2% vs. 96%, P > .99), and per-protocol (96.2% vs. 96.9%, P > .99) analyses. Non-inferiority in the eradication success between PAMB and PBMT was confirmed. The amoxicillin-, metronidazole-, tetracycline-, clarithromycin-, and levofloxacin-resistance rates were 8.3, 40, 9.4, 23.5, and 42.2%, respectively. Antimicrobial resistance did not significantly affect the efficacy of either therapy. Overall compliance was 98.1%. Adverse events were not significantly different between the two therapies.

CONCLUSION

Modified quadruple therapy comprising rabeprazole, amoxicillin, metronidazole, and bismuth is an effective first-line treatment for the H. pylori infection in regions with high clarithromycin and metronidazole resistance.

Risk factors for hospital readmission of patients with heart failure: A cohort study

Aim:

The aim of this study was to develop a risk factor model for hospital readmission in patients with heart failure.

Background:

Identification of risk factors and predictors of readmission to hospital in patients with heart failure is very crucial for improved clinical outcomes.

Objective:

The objective of the current study was to investigate and delineate the risk factors that may be implicated in putting a patient at greater risk of readmission due to uncontrolled heart failure.

Materials and Methods:

This is a prospective follow-up cohort study of 170 patients with heart failure at a tertiary hospital in Al Ain city in the United Arab Emirates. We have developed a risk factor model based on the recommendations of validated published data. We have used univariate and multivariate logistic regression analyses on structured steps based on the published data. The main outcome was the risk factors for readmission to hospital due to heart failure.

Results:

A final predictive model (10 variables) was produced for unplanned readmission of patients with heart failure. The risk factors identified in the final model with their odds ratios (ORs) and confidence intervals (CIs) were as follows: four or more prescribed medicines (OR = 4.13; CI = 3.5–4.1; P = 0.003), more than twice daily dosing regimen (OR = 2.34; CI = 1.0–5.0; P = 0.023), poor knowledge of prescribed medications (OR = 4.24; CI = 1.213–14.781; P = 0.006), diabetes mellitus (OR = 3.78; CI = 1.6–8.7; P = 0.006), edema (OR = 2.64; CI = 1.2–5.6; P = 0.011), being house bound (OR = 2.77; CI = 1.2–6.2; P = 0.014), and being prescribed diuretics (OR = 3.69; CI = 1.4–9.2; P = 0.042).

Conclusion:

The specificity of the developed risk prediction model was 82.2%, the sensitivity was 74.3%, and the overall accuracy was 72.9%. The model can be emulated in population with similar characteristics to prevent early readmission of patient with heart failure.

Self-reported adverse drug effects and associated factors among H. pylori infected patients on standard triple therapy: Prospective follow up study

Background

One of the most common reasons for poor medication adherence and associated treatment failure of triple therapy is adverse drug effect (ADEs) of medications.

Objective

Assessment of ADEs and associated factors during H. pylori eradication therapy.

Method

Consented H. pylori positive adult outpatients on standard triple therapy (proton pump inhibitor, amoxicillin and clarithromycin) were involved in this facility based follow up study from May 2016 to April 2018 at Bahir Dar city in Ethiopia. Pre-developed questionnaire and formats were used to collect sociodemographic, medical information, and patient practice data before, during, and after therapy. Bivariate and backward stepwise multivariate logistic regression was used to analyze data. P-value < 0.05 at 95%CI was considered as significant.

Result

A total of 421 patients were involved in the study. Almost 80% of the patients were urban residents. Mean (±SD) age and body weight of patients were 30.63 (± 10.74) years and 56.79 (± 10.17) kg, respectively. ADE was reported from 26.1% of the patients and of all the reported ADEs, more than 85% was manifested with gastrointestinal symptoms which include gastrointestinal discomfort(39.1%), nausea (13.6%), constipation(12.7%), diarrhea(12.9%) and anorexia(10%). Determinants of self-reported ADEs among patients in the present study were body mass index above 25 (AOR: 2.55; 95%CI (1.21–5.38), p = 0.014), duration of acid-pepsin disorder more than 3weeks (AOR: 3.57; 95%CI (1.63–7.81), p = 0.001), pain feeling during long interval between meals (AOR: 2.14; 95%CI (1.19–3.84), p = 0.011), and residence in urban area (AOR: 1.95; 95% CI (1.04–3.67), p = 0.038).

Conclusion

Significant proportion of patients reported ADEs which commonly manifested with gastrointestinal symptoms. Consideration of patients’ body mass index, duration of the disorder, period of the day when patients feel pain, and patients’ area of residence could help to reduce ADEs experienced during H. pylori eradication therapy.

Clinical background factors affecting outcomes of Helicobacter pylori eradication therapy in primary care

OBJECTIVE

Few studies have reported the influence of clinical background factors on the outcome of Helicobacter pylori eradication therapy in primary care practice. We aimed to determine which clinical background factors influence the outcome of eradication therapy in a primary care setting.

METHODS

This was a retrospective study of patients who received H pylori eradication therapy at Higashiohmi City Gamo Medical Center, Shiga, Japan, from January 2012 to December 2015. We investigated clinical background factors associated with success, failure, and self-interruption of H pylori eradication therapy: patients' age, gender, first- or second-line treatment, reasons for receiving gastroenterological endoscopic examination, method of drug administration, and attending physicians' age and their specialties.

RESULTS

There were 369 patients (208 females, 161 male), with a mean age of 59 years (range 30-88 years). The middle-aged group (50-69 years) was associated with successful eradication therapy compared with the young group (30-49 years). The elderly group (>70 years) was associated with eradication therapy failure compared with the middle-aged group. The young group was associated with self-interruption of eradication therapy. There was a marginally significant association between male patients and self-interruption. Older attending physicians (>50 years) were also associated with failure compared with younger physicians. There was no difference in outcome of eradication therapy between generalists and gastroenterology specialists.

CONCLUSION

We have identified clinical factors associated with success, failure, and self-interruption of H pylori eradication therapy in a primary care setting.

Twice daily short-message-based re-education could improve Helicobacter pylori eradication rate in young population: A prospective randomized controlled study

BACKGROUND

To investigate the effects of twice daily short-message-based re-education (SMRE) before taking medicine for Helicobacter pylori (H pylori) eradication.

MATERIALS AND METHODS

Treatment-naive patients with H pylori infection were prescribed 14-day quadruple regimen consisting of lansoprazole 30 mg, colloidal bismuth pectin 200 mg, amoxicillin 1000 mg, and clarithromycin 500 mg twice daily. Patients were randomly allocated to SMRE group or control group. Patients in control group received oral and written instructions at outpatient clinic. In contrast, patients in the SMRE group received extra short messages including dosage and time of administration twice daily. Successful H pylori eradication was assessed using the ¹³ C-urea breath test 6 weeks after treatment. The compliance, adverse events, and patient satisfaction were also analyzed.

RESULTS

A total of 310 patients were enrolled in the intention-to-treat (ITT) and 283 in the per-protocol (PP) analysis. For young patients, the eradication rates were significantly higher in SMRE group than those in control group in PP analysis (88.6% vs 71.2%, P = 0.036), while for patients of all age groups, the eradication rate improvements were not statistically significant. The eradication rates in SMRE group and control group were 74.2% and 67.7% (P = 0.211) in ITT analysis and 82.1% and 73.4% (P = 0.078) in PP analysis, respectively. The compliance in SMRE group was significantly better than that in control group (84.8% vs 72.8%, P = 0.011).

CONCLUSIONS

Twice daily SMRE could improve the eradication rate in young population, as well as the compliance with treatment during H pylori eradication.

Cost-effectiveness of a tailored Helicobacter pylori eradication strategy based on the presence of a 23S ribosomal RNA point mutation that causes clarithromycin resistance in Korean patients

BACKGROUND AND AIM

The Helicobacter pylori eradication rate using conventional triple therapy has decreased due to clarithromycin (CAM) resistance in H. pylori. Recently, dual priming oligonucleotide (DPO)-based multiplex polymerase chain reaction (PCR) can be used to detect H. pylori and point mutations in the 23S ribosomal RNA gene causing CAM resistance. This study aimed to evaluate the success rate and cost-effectiveness of tailored H. pylori eradication using DPO-PCR.

METHODS

The H. pylori-positive patients diagnosed by a rapid urease test or DPO-PCR were enrolled from a single academic hospital. The patients with positive rapid urease test results received a CAM-based triple regimen. In the tailored therapy group that underwent DPO-PCR testing, patients with A2142G and/or A2143G point mutations were treated with a bismuth-containing quadruple regimen. The cost-effectiveness of H. pylori eradication success was evaluated according to the average cost per patient and the incremental cost-effectiveness ratio.

RESULTS

A total of 243 patients were allocated to the triple therapy group and 124 patients to the tailored therapy group. The first-line eradication rate of H. pylori was significantly higher in the tailored therapy group than in the conventional triple therapy group (92.7% vs 76.5%, P < 0.001). The average costs per patient for tailored therapy were $307.37 and $299.59 for first-line and second-line treatments, respectively. Compared with triple therapy, the incremental cost-effectiveness ratios of tailored therapy were $3.96 and -$3.81 per patient for first-line and second-line treatments, respectively.

CONCLUSION

In Korea, tailored H. pylori eradication using DPO-PCR may be more cost-effective than conventional triple therapy.

Patterns of Narcotic Prescribing by Orthopedic Surgeons for Medicare Patients

In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.

Levofloxacin or Clarithromycin-based quadruple regimens: what is the best alternative as first-line treatment for Helicobacter pylori eradication in a country with high resistance rates for both antibiotics?

BACKGROUND

Helicobacter pylori eradication rates in Portugal are declining, due to increased resistance of this bacterium to antimicrobial agents, especially Clarithromycin. Quadruple Levofloxacin-containing regimens could be an option for first-line treatment, but its efficacy should be evaluated as fluoroquinolone resistance is rapidly increasing. Our aim was to compare the efficacy of Clarithromycin and Levofloxacin-based sequential quadruple therapies as first-line treatment options and determine factors associated with treatment failure.

METHODS

A total of 200 Helicobacter pylori infected patients were retrospectively included (female 57.5%; average age: 53.2 ± 15.7) and received either 10-day sequential therapy (Proton-Pump Inhibitor + Amoxicillin 1 g bid for 5 days and Proton-Pump Inhibitor + Clarithromycin 500 mg + Metronidazole/Tinidazole 500 mg bid/tid in the following 5 days; group A) or a 10-day modified sequential therapy with Levofloxacin 500 mg id instead of Clarithromycin (group B). Eradication was confirmed with urea breath test. Variables that could influence success rate were analyzed.

RESULTS

There were no differences between groups in terms of gender, age, smoking habits and indications for treatment. The eradication rate obtained with Clarithromycin-based sequential treatment was significantly higher than with Levofloxacin-based therapy (90%, CI95%: 84-96% vs. 79%, CI95%: 71-87%, p = 0.001). Using full-dose proton-pump inhibitor and high-dose Metronidazole in group A, and full-dose proton-pump inhibitor and prescription from a Gastroenterologist in group B were associated with eradication success.

CONCLUSIONS

Ten-day Levofloxacin-based sequential treatment achieved inadequate efficacy rate (<80%) and should not be adopted as first-line therapy. Standard sequential therapy showed significantly better results in this naïve population. Using full-dose proton-pump inhibitor and higher doses of Metronidazole is essential to achieve such results.

Evaluation of the types and frequency of drug-related problems and the association with gender in patients with chronic diseases attending a primary health care center in Jordan

BACKGROUND

Drug-related problems (DRPs) can be defined as any event that is drug related that results in harm or in providing less than optimum medical care to patients. The aim of this study is to determine the types and frequency of each type of DRP in selected outpatient settings in Jordan, with emphasis on gender as a grouping variable.

METHODS

This study was a non-randomized controlled trial, carried out over 3 days, at Alsarih Medical Health Center in the north of Jordan. Clinical pharmacists conducting the research interviewed a randomly selected population, assessed their DRPs, proposed appropriate clinical interventions to physicians and provided appropriate patient counseling.

RESULTS

The study included a total of 258 patients (mean age 54.4±12.1; male ratio 37.6%). The most frequently encountered DRPs in our study were patients' need for counseling and education (83.8%), and life style modifications (80%). This study also revealed that 71.8% of patients required additional and/or more frequent monitoring, and 53% of patients had untreated conditions that required pharmacological and/or non-pharmacological interventions. Gender did not affect the frequency of DRPs among patients.

CONCLUSION

Certain types of DRPs are the most common among outpatient settings. Therefore, measures should be taken to specifically tackle these types of DRPs.

Randomized clinical trial comparing 10-day sequential, 7-day concomitant and 7-day standard triple therapies for Helicobacter pylori eradication

OBJECTIVES

To compare triple therapy with sequential and concomitant therapies directly in a head-to-head comparison in Helicobacter pylori-infected patients.

DESIGN

Patients were allocated randomly as follows: a triple therapy with esomeprazole (20 mg), amoxicillin (1000 mg) and clarithromycin (500 mg) twice daily for 7 days; a sequential therapy with 5 days of esomeprazole (20 mg) and amoxicillin (1000 mg) twice daily, followed by 5 days of esomeprazole (20 mg), clarithromycin (500 mg) and metronidazole (400 mg) twice daily; or a concomitant therapy consisting of esomeprazole (20 mg), amoxicillin (1000 mg), clarithromycin (500 mg) and metronidazole (400 mg) twice daily for 7 days.

RESULTS

A total of 356 consecutive patients were included. The eradication rates for the triple, sequential and concomitant therapies were 83.6% [95% confidence interval (CI) 76.9-90.4%], 94.2% (95% CI 90.0-98.4%) and 91.7% (95% CI 86.7-96.6%), respectively, in the intention-to-treat population. The differences were significant only between triple and sequential therapies (P=0.01). The primary resistance rates to amoxicillin, clarithromycin and metronidazole were 0.6, 10.5 and 25.9%, respectively. Concomitant therapy was significantly better than triple therapy in cases with clarithromycin resistance (P=0.01).

CONCLUSION

Ten-day sequential therapy was significantly better than 7-day triple therapy in a clinical setting with low rates of clarithromycin and dual resistance. Concomitant therapy was significantly better than standard triple therapy in the subgroup of patients with clarithromycin-resistant strains.

Bismuth, lansoprazole, amoxicillin and metronidazole or clarithromycin as first-line Helicobacter pylori therapy

OBJECTIVE

To evaluate the efficacy and tolerability of replacing tetracycline with amoxicillin in bismuth quadruple therapy.

DESIGN

Subjects who were infected with Helicobacter pylori and naïve to treatment were randomly (1:1) assigned to receive a 14-day modified bismuth quadruple therapy: lansoprazole 30 mg, amoxicillin 1 g, bismuth potassium citrate 220 mg (elemental bismuth), twice a day with metronidazole 400 mg four times a day (metronidazole group) or clarithromycin 500 mg twice a day (clarithromycin group). Six weeks after treatment, H. pylori eradication was assessed by 13C-urea breath test. Antimicrobial susceptibility was assessed by the twofold agar dilution method. This was a non-inferiority trial.

RESULTS

Two hundred and fifteen subjects were randomised. Metronidazole and clarithromycin containing regimens achieved high cure rates: 94 of 97 (96.9%, 95% CI 93.5% to 100%) and 93 of 98 (94.9%, 95% CI 90.5% to 99.3%) by per-protocol and 88.9% (95% CI 83.0% to 94.8%) and 88.8% (95% CI 82.8% to 94.8%) by intention-to-treat, respectively. Amoxicillin, metronidazole and clarithromycin resistance rates were 1.5%, 45.5% and 26.5%, respectively. Only clarithromycin resistance reduced treatment success (e.g., susceptible 98.6%, resistant 76.9%, p=0.001). Adverse events were more common in the metronidazole group.

CONCLUSIONS

These results suggest that amoxicillin can substitute for tetracycline in modified 14 day bismuth quadruple therapy as first-line treatment and still overcome metronidazole resistance in areas with high prevalence of metronidazole and clarithromycin resistance. Using clarithromycin instead of metronidazole was only effective in the presence of susceptible strains.

TRIAL REGISTRATION NUMBER

NCT02175901.

Effects of daily telephone-based re-education before taking medicine on Helicobacter pylori eradication: A prospective single-center study from China

AIM: To investigate the effects of daily telephone-based re-education (TRE) before taking medicine for the eradication of Helicobacter pylori (H. pylori) on the compliance and the eradication rate in a Chinese patient population.

METHODS: A prospective, physician-blinded, randomized, controlled clinical study was conducted. The patients were randomly assigned to receive TRE every day before taking medicine (TRE group) or no TRE (control group). The patients in the TRE group received regular instructions before taking medicine for the eradication of H. pylori during the entire course of treatment through telephone calls. The patients in the control group received detailed instructions at the time of seeing a doctor for the guidance. The primary outcome was the H. pylori eradication rate after treatment. The secondary outcomes included the clinical remissions after treatment, adverse events, compliance, and patients’ satisfaction.

RESULTS: A total of 140 patients were randomized, 70 to the TRE group and 70 to the control group. As the primary outcome, the H. pylori eradication rates in the TRE and control groups were 62.7% and 71.2% in per protocol analysis (P = 0.230), and 52.9% and 52.9% in intention-to-treat analysis (P = 0.567), respectively. As the secondary outcomes, there were no significant differences in the patients’ satisfaction between the two groups (good, 79.7% vs 76.9%; fair, 13.6% vs 19.2%; poor, 6.7% vs 3.9%, for the TRE group and control group, respectively; P > 0.05 for all); the rates of adverse effects were 15.2% and 63.5% in the TRE and control groups, respectively (P < 0.001); the compliance rates in the TRE and control groups were 85.7% and 74.3%, respectively (P = 0.069).

CONCLUSION: Daily TRE before taking medicine had no significant impact on the patients’ compliance, satisfaction, or H. pylori eradication, but reduced the rate of adverse events.

How to Effectively Use Bismuth Quadruple Therapy: The Good, the Bad, and the Ugly

Bismuth triple therapy was the first effective Helicobacter pylori eradication therapy. The addition of a proton pump inhibitor helped overcome metronidazole resistance. Its primary indication is penicillin allergy or when clarithromycin and metronidazole resistance are both common. Resistance to the primary first-line therapy have centered on complexity and difficulties with compliance. Understanding regional differences in effectiveness remains unexplained because of the lack of studies including susceptibility testing and adherence data. We discuss regimen variations including substitutions of doxycycline, amoxicillin, and twice a day therapy and provide suggestions regarding what is needed to rationally and effectively use bismuth quadruple therapy.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

The economics of medicines optimization: policy developments, remaining challenges and research priorities

BACKGROUND

This review scopes the evidence on the effectiveness and cost-effectiveness of interventions to improve suboptimal use of medicines in order to determine the evidence gaps and help inform research priorities.

SOURCES OF DATA

Systematic searches of the National Health Service (NHS) Economic Evaluation Database, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects.

AREAS OF AGREEMENT

The majority of the studies evaluated interventions to improve adherence, inappropriate prescribing and prescribing errors.

AREAS OF CONTROVERSY

Interventions tend to be specific to a particular stage of the pathway and/or to a particular disease and have mostly been evaluated for their effect on intermediate or process outcomes.

GROWING POINTS

Medicines optimization offers an opportunity to improve health outcomes and efficiency of healthcare.

AREAS TIMELY FOR DEVELOPING RESEARCH

The available evidence is insufficient to assess the effectiveness and cost-effectiveness of interventions to address suboptimal medicine use in the UK NHS. Decision modelling, evidence synthesis and elicitation have the potential to address the evidence gaps and help prioritize research.

A win for the patient: Direct patient notification improves treatment rates of active Helicobacter pylori infection

BACKGROUND

Current international guidelines recommend the commencement of effective eradication therapy as soon as active Helicobacter pylori (H. pylori) infection is confirmed. At our institution, all positive Campylobacter-like Organism (CLO) test results were automatically communicated to general practitioners (GPs) via a standardised letter, which also advised the commencement of eradication therapy. Despite this endeavour, a clinical audit conducted in 2011 demonstrated that only 66 per cent of confirmed H. pylori-positive South Auckland patients received eradication treatment and only 83 per cent of these patients received treatment within one month.

AIMS

Improve the timely initiation of H. pylori eradication therapy through direct patient notification.

METHOD

A prospective clinical audit of 109 consecutive outpatients with a positive CLO test identified at gastroscopy. In addition to standard general practitioner notification, patients were also directly notified of their positive CLO test result via a standardised letter, which provided information about H. pylori and its disease associations as well as advising patients to seek consultation with their GP to commence eradication therapy. Dispensing data was examined using Test Safe electronic records to determine the total uptake and timing of treatment compared to data from a preliminary 2011 audit.

RESULTS

Ninety-five per cent of H. pylori-positive patients received standard triple therapy; therefore, treatment of active H. pylori infection was significantly higher when patients were directly notified in addition to standard GP notification, when compared to GP notification alone (95 per cent vs 66 per cent, p<0.001). All patients who received eradication therapy did so within one month of notification, a significant improvement compared to data from the previous audit in 2011 (100 per cent vs. 83 per cent, p<0.001).

CONCLUSION

Direct patient notification using a standardised letter is a simple and economical strategy that significantly improves the timely initiation of eradication therapy for active H. pylori infection. This has since been integrated into standard practice at our District Health Board (DHB).

Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review

Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.

Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review

Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.

The problem of Helicobacter pylori resistance to antibiotics: a systematic review in Latin America

OBJECTIVES

Latin America has a high prevalence of Helicobacter pylori infection and associated diseases, including gastric cancer. Antibiotic therapy can eradicate the bacterial infection and decrease associated morbidity and mortality. To tailor recommendations for optimal treatments, we summarized published literature and calculated region- and country-specific prevalences of antibiotic resistance.

METHODS

Searches of PubMed and regional databases for observational studies evaluating H. pylori antibiotic resistance yielded a total of 59 independent studies (56 in adults, 2 in children, and 1 in both groups) published up to October 2013 regarding H. pylori isolates collected between 1988 and 2011. Study-specific prevalences of primary resistance to commonly prescribed antibiotics were summarized using random-effects models. Between-study heterogeneity was assessed by meta-regression. As a sensitivity analysis, we extended our research to studies of patients with prior H. pylori-eradication therapy.

RESULTS

Summary prevalences of antimicrobial primary resistance among adults varied by antibiotic, including 12% for clarithromycin (n=35 studies), 53% for metronidazole (n=34), 4% for amoxicillin (n=28), 6% for tetracycline (n=20), 3% for furazolidone (n=6), 15% for fluoroquinolones (n=5), and 8% for dual clarithromycin and metronidazole (n=10). Resistance prevalence varied significantly by country, but not by year of sample collection. Analyses including studies of patients with prior therapy yielded similar estimates. Pediatric reports were too few to be summarized by meta-analysis.

CONCLUSIONS

Resistance to first-line anti-H. pylori antibiotics is high in Latin American populations. In some countries, the empirical use of clarithromycin without susceptibility testing may not be appropriate. These findings stress the need for appropriate surveillance programs, improved antimicrobial regulations, and increased public awareness.

Levofloxacin and proton pump inhibitor-based triple therapy versus standard triple first-line therapy for Helicobacter pylori eradication

BACKGROUND

Standard triple therapy for Helicobacter pylori infection fails in up to one quarter of patients. Levofloxacin-based triple therapy may be more efficacious.

OBJECTIVE

The aim of this paper was to compare levofloxacin and proton pump inhibitor-based triple therapy with standard triple therapy for H. pylori infection.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar, and Ovid were systematically searched to identify randomized controlled trials comparing levofloxacin and proton pump inhibitor-based therapy with standard triple therapy in treatment-naive patients with H. pylori infection until August 2013.

RESULTS

Ten randomized controlled trials involving 2676 patients (1357 in the levofloxacin group and 1319 in the control group) met the inclusion criteria. The pooled odds ratio by intention-to-treat analysis and by per protocol analysis in the levofloxacin regimen versus standard regimen was 1.28 [95% confidence interval (CI): 0.88-1.85] and 1.23 (95% CI: 0.82-1.84) by the random effects model, respectively. There was no statistical significance of the incidence of total side effects between the groups, but levofloxacin-based therapy was associated with a significant reduction in the incidence of taste disturbance compared with standard third therapy.

CONCLUSION

Levofloxacin-based therapy was as safe and effective as triple therapy for H. pylori infection and could be considered as an additional treatment option. However, more rigorous research is required to accurately assess the role of levofloxacin in eradicating H. pylori infection.

Rational Helicobacter pylori therapy: evidence-based medicine rather than medicine-based evidence

Data are available such that choice of Helicobacter pylori therapy for an individual patient can be reliably predicted. Here, treatment success is defined as a cure rate of 90% or greater. Treatment outcome in a population or a patient can be calculated based on the effectiveness of a regimen for infections with susceptible and with resistant strains coupled with the knowledge of the prevalence of resistance (ie, based on formal measurement, clinical experience, or both). We provide the formula for predicting outcome and we illustrate the calculations. Because clarithromycin-containing triple therapy and 10-day sequential therapy are now only effective in special populations, they are considered obsolete; neither should continue to be used as empiric therapies (ie, 7- and 14-day triple therapies fail when clarithromycin resistance exceeds 5% and 15%, respectively, and 10-day sequential therapy fails when metronidazole resistance exceeds 20%). Therapy should be individualized based on prior history and whether the patient is in a high-risk group for resistance. The preferred choices for Western countries are 14-day concomitant therapy, 14-day bismuth quadruple therapy, and 14-day hybrid sequential-concomitant therapy. We also provide details regarding the successful use of fluoroquinolone-, rifabutin-, and furazolidone-containing therapies. Finally, we provide recommendations for the efficient development (ie, identification and optimization) of new regimens, as well as how to prevent or minimize failures. The trial-and-error approach for identifying and testing regimens frequently resulted in poor treatment success. The described approach allows outcome to be predicted and should simplify treatment and drug development.

A mobile phone text message program to measure oral antibiotic use and provide feedback on adherence to patients discharged from the emergency department

OBJECTIVES

Nonadherence to prescribed medications impairs therapeutic benefits. The authors measured the ability of an automated text messaging (short message service [SMS]) system to improve adherence to postdischarge antibiotic prescriptions.

METHODS

This was a randomized controlled trial in an urban emergency department (ED) with an annual census of 65,000. A convenience sample of adult patients being discharged with a prescription for oral antibiotics was enrolled. Participants received either a daily SMS query about prescription pickup, and then dosage taken, with educational feedback based on their responses (intervention), or the usual printed discharge instructions (control). A standardized phone follow-up interview was used on the day after the intended completion date to determine antibiotic adherence: 1) the participant filled prescription within 24 hours of discharge and 2) no antibiotic pills were left on the day after intended completion of prescription.

RESULTS

Of the 200 patients who agreed to participate, follow-up was completed in 144 (72%). From the 144, 26% (95% confidence interval [CI] = 19% to 34%) failed to fill their discharge prescriptions during the first 24 hours, and 37% (95% CI = 29% to 45%) had pills left over, resulting in 49% (95% CI = 40% to 57%) nonadherent patients. There were no differences in adherence between intervention participants and controls (57% vs. 45%; p = 0.1). African American race, greater than twice-daily dosing, and self-identifying as expecting to have difficulty filling or taking antibiotics at baseline were associated with nonadherence.

CONCLUSIONS

Almost one-half (49%) of our patients do not adhere to antibiotic prescriptions after ED discharge. Future work should improve the design and deployment of SMS interventions to optimize their effect on improving adherence to medication after ED discharge.

Improving compliance with helicobacter pylori eradication therapy: when and how?

Compliance with therapy is the single most important factor in Helicobacter pylori (H. pylori) eradication. Poorer levels of compliance with therapy are associated with significantly lower levels of eradication. Numerous factors can contribute to achieving good levels of compliance. These include the complexity and duration of treatment. It is also important that the physician is motivated to ensure eradication is confirmed and the patient is sufficiently informed to empower him or her to achieve high levels of compliance. Compliance is also contingent on medication regimes that are simple, safe, tolerable and efficacious. The opportunity to improve compliance exists at every point of contact between the patient and the medical services. Experts and opinion leaders in the field can play a role by ensuring that physicians are educated and motivated enough to encourage and support compliance with H. pylori eradication therapy. Both patients and physicians need to be aware of the importance of the bacterium in causing disease. The importance of the doctor-patient relationship is paramount. Pragmatic strategies that may be of assistance may come in the form of polypills, combined Blister Packs, adjuvant therapies and modified release compounds. Colleagues such as pharmacists and nurse specialists can also play an important role and should be actively engaged. Structured aftercare and follow up offers the best chance for ensuring compliance and subsequent eradication of the H. pylori pathogen.

Treatment of Helicobacter pylori infection 2010

It is accepted that the success of Helicobacter pylori eradication treatment using standard triple therapy is declining. Resistance, particularly to clarithromycin, has been shown in numerous countries to be rising to a level where the use of standard triple therapy in its current form may no longer be justified. The two major factors influencing resistance are prior exposure to the antibiotic and compliance with therapy. Regimes based on bismuth and levofloxacin, which had previously been mainly second-line options, are now emerging as superior first-line options. Trials of sequential and concomitant therapies are also showing the usefulness of these treatments in different populations. Options for third and subsequent line therapies include furazolidone and rifabutin-based regimes. Susceptibility testing should be performed to maintain accurate data on resistance levels, and has also clinical utility in difficult to eradicate cases. None of these, however, will be successful unless compliance is improved upon. If compliance is assured and eradication confirmation pursued, it has been repeatedly illustrated that near full eradication is achievable.

The modified sequential treatment regimen containing levofloxacin for Helicobacter pylori eradication in Turkey

BACKGROUND

Eradication rates of Helicobacter pylori have declined to unacceptable levels in recent years. New and effective treatment options are warranted both as a first and second line treatment.

AIM

To test an effectiveness of modified sequential therapy with levofloxacin for H. pylori eradication in Turkey.

MATERIAL AND METHODS

Helicobacter pylori infected dyspeptic patients were included to the study. Subjects were treated with modified sequential therapy consisting of rabeprazole 20 mg b.i.d. and amoxicillin 1 g b.i.d., for 7 days followed by rabeprazole 20 mg b.i.d, levofloxacin 500 mg q.d. and metronidazole 500 mg b.i.d for the remaining 7 days.

RESULTS

Sixty-three treatment naive patients and 37 previous treatment failures were enrolled to the study (59 F, 41 M, age: 21-80 years). There was five drop out. Helicobacter pylori eradication was achieved in 80 patients, intention-to-treat (ITT): 80% (95% CI: 71-87%) and per-protocol (PP): 84.2% (95% CI: 75-91%), totally. In treatment naive patients ITT and PP eradication rates were 82.5% (95% CI: 71-91%), and 86.7% (95% CI: 75-94%), respectively. As a second line treatment eradication was successful in ITT 75.7%.(95% CI: 59-88%), and PP 80% (95% CI: 63-92%).Mild side effects were reported by 8 patients (8.4%).

CONCLUSIONS

Sequential therapy using "rabeprazole and amoxicillin 7 days followed by rabeprazole, metronidazole and levofloxacin for 7 days" is a new regimen with acceptable eradication rates in naïve patients in Turkey. Further modifications in the dose or duration of this new sequential therapy might increase its effectiveness as both first and second line treatment.

Treatment of Helicobacter pylori infection

This article aims to examine current best practice in the field reference to first-line, second-line, rescue and emerging treatment regimens for Helicobacter pylori eradication. The recommended first-line treatment in published guidelines in Europe and North American is proton pump inhibitor combined with amoxicillin and clarithromycin being the favoured regimen. Rates of eradication with this regimen however are falling alarmingly due to a combination of antibiotic resistance and poor compliance with therapy. Bismuth based quadruple therapies and levofloxacin based regimes have been shown to be effective second line regimens. Third-line options include regimes based on rifabutin or furazolidone, but susceptibility testing is the most rational option here, but is currently not used widely enough. Sequential therapy is promising but needs further study and validation outside of Italy. Although the success of first line treatments is falling, if compliance is good and a clear treatment paradigm adhered to, almost universal eradication rates can still be achieved. If compliance is not achievable, the problem of antibiotic resistance will continue to beset any combination of drugs used for H. pylori eradication.

Written information about individual medicines for consumers

BACKGROUND

Medicines are the most common intervention in most health services. As with all treatments, those taking medicines need sufficient information: to enable them to take and use the medicines effectively, to understand the potential harms and benefits, and to allow them to make an informed decision about taking them. Written medicines information, such as a leaflet or provided via the Internet, is an intervention that may meet these purposes.

OBJECTIVES

To assess the effects of providing written information about individual medicines on relevant patient outcomes (knowledge, attitudes, behaviours and health outcomes) in relation to prescribed and over-the-counter medicines.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, The Cochrane Library, PsycINFO and other databases to March 2007. We handsearched five journals' tables of contents, and the reference lists of included studies, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of medicine users, comparing written medicines information with no written medicines information; or trials that compared two or more styles of written medicines information. We only included trials that measured a knowledge, attitudinal or behavioural outcome. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data relating to the interventions, methods of the trials, and outcome measures; and reconciled differences by discussion. Heterogeneity of interventions and outcomes measured meant that data synthesis was not possible. The results are presented in narrative and tabular format.

MAIN RESULTS

We included 25 RCTs involving 4788 participants. Six of twelve trials showed that written information significantly improved knowledge about a medicine, compared with no written information. The inability to combine results means we cannot conclude whether written information was effective for increasing knowledge. The results for attitudinal and behavioural outcomes were mixed. No studies showed an adverse effect of medicines information.

AUTHORS' CONCLUSIONS

The combined evidence was not strong enough to say whether written medicines information is effective in changing knowledge, attitudes and behaviours related to medicine taking. There is some evidence that written information can improve knowledge. The trials were generally of poor quality, which reduces confidence in the results. Trials examining the effects of written information need to be better designed and use consistent and validated outcome measures. Trials should evaluate internet-based medicines information. It is imperative that written medicines information be based on best practice for its information design and content, which could improve its effectiveness in helping people to use medicines appropriately.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.