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Marshall T, Taverner T, Freidoony L. Medicalising diagnoses and treatment preferences: a retrospective cohort study of throat-related consultations in electronic primary care records. BJGP Open 2023; 7:BJGPO.2023.0056. [PMID: 37429635 DOI: 10.3399/bjgpo.2023.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/21/2023] [Accepted: 07/06/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Rather than first diagnosing and then deciding on treatment, GPs may intuitively decide on treatment and justify this through choice of diagnosis. AIM To investigate the relationship between choice of a medicalising diagnosis and antibiotic treatment for throat-related consultations. DESIGN & SETTING A retrospective cohort study in a large database of UK electronic primary care records between 1 January 2010 and 1 January 2020. METHOD All first throat-related consultations were included, categorised as either pharyngitis/tonsillitis or sore throat. The outcome was any antibiotic prescription on the consultation date. GP-level random effects on prescribing and on diagnosis were estimated in a series of mixed-effects regression models, including age, sex, weekday, month, and clinician characteristics as fixed effects. GPs were grouped into quintiles by antibiotic prescribing propensity, and described the proportion of patients they diagnosed with pharyngitis/tonsillitis or sore throat in each quintile. RESULTS The analysis dataset included 393 590 throat-related consultations with 6881 staff. Diagnosis of pharyngitis/tonsillitis was strongly associated with antibiotic prescribing (adjusted odds ratio = 13.41, 95% confidence interval = 12.8 to 14.04). GP random effect accounted for 18% of variation in prescribing and for 26% of variation in diagnosis. GPs in the lowest quintile of antibiotic prescribing propensity diagnosed pharyngitis/tonsillitis on 31% of occasions, compared with 55% in the highest quintile. CONCLUSION There is substantial variation among GPs in diagnosis and treatment of throat-related problems. Preference for a medicalising diagnosis is associated with a preference for antibiotics, suggesting a common propensity to both diagnose and treat.
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Affiliation(s)
- Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tom Taverner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Leila Freidoony
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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2
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Ngwenya S, Simin J, Brusselaers N. Maintenance Proton Pump Inhibitor Use Associated with Increased All-Cause and Cause-Specific Mortality in Sweden. Dig Dis Sci 2023; 68:2252-2263. [PMID: 36629968 DOI: 10.1007/s10620-023-07820-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/31/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Proton pump inhibitor (PPI) use has increased over the last decades and has been associated with multiple adverse events and potentially even overall survival. AIMS We aimed to investigate the association between proton pump inhibitor maintenance use and all-cause and cause-specific mortality, addressing confounding by indication and duration of use. METHODS This Swedish population-based cohort study included all adult (N = 935,236) PPI and histamine-2 receptor antagonist maintenance users (≥ 180 days use) during 2005-2014. Standardised mortality ratios (SMRs) and 95% confidence intervals were calculated for all-cause and cause-specific mortality comparing the risk among PPI/H2RA users to that of the Swedish background population, stratified by age, sex, calendar period, indication and duration of use. Multivariable Poisson regression models were used to compare PPI use to H2RA use, expressed as incidence rate ratios and 95% confidence intervals. RESULTS PPI and histamine-2 receptor antagonist use were associated with an increased risk of all-cause mortality (SMR = 1.35; 1.34-1.36; SMR = 1.31; 1.27-1.36, respectively). The highest SMRs were found in the youngest age groups. In direct comparison, PPI use showed a higher mortality risk than histamine-2 receptor antagonist use (incidence rate ratios = 1.42; 1.38-1.46). PPIs were related to increased cancer (SMR = 1.21; 1.20-1.22), and cardiovascular mortality (SMR = 1.36; 1.35-1.37). Increased SMRs were observed for most indications. Longer duration of use was associated with a higher mortality among PPI users but not among histamine-2 receptor antagonist users. CONCLUSION Maintenance PPI use was associated with an increased risk of all-cause and cause-specific mortality, and the risk increased with prolonged duration.
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Affiliation(s)
- Sharon Ngwenya
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Biomedicum A8, Solnavägen 9, 171 65, Stockholm, Sweden.,Department of Family Medicine and Population Health, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Johanna Simin
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Biomedicum A8, Solnavägen 9, 171 65, Stockholm, Sweden
| | - Nele Brusselaers
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Biomedicum A8, Solnavägen 9, 171 65, Stockholm, Sweden. .,Department of Family Medicine and Population Health, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium. .,Department of Head and Skin, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Centre for Translational Microbiome Research, Solnavägen 9, 171 76, Stockholm, Sweden.
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3
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Müskens JL, van Dulmen SA, Wiersma T, Burgers JS, Hek K, Westert GP, Kool RB. Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study. Br J Gen Pract 2022; 72:e369-e377. [PMID: 35314429 PMCID: PMC8966784 DOI: 10.3399/bjgp.2021.0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/31/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown. AIM To assess the prevalence of low-value pharmaceutical care among Dutch GPs. DESIGN AND SETTING Retrospective cohort study using data from patient records. METHOD The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription. RESULTS Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001). CONCLUSION The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.
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Affiliation(s)
- Joris Ljm Müskens
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | | | - Jako S Burgers
- Department of General Practice, School CAPHRI, Maastricht University, Maastricht; senior consultant, Dutch College of General Practitioners, Utrecht
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht
| | - Gert P Westert
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
| | - Rudolf B Kool
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
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Rachamin Y, Jäger L, Meier R, Grischott T, Senn O, Burgstaller JM, Markun S. Prescription Rates, Polypharmacy and Prescriber Variability in Swiss General Practice—A Cross-Sectional Database Study. Front Pharmacol 2022; 13:832994. [PMID: 35237170 PMCID: PMC8884695 DOI: 10.3389/fphar.2022.832994] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose: The frequency of medication prescribing and polypharmacy has increased in recent years in different settings, including Swiss general practice. We aimed to describe patient age- and sex-specific rates of polypharmacy and of prescriptions of the most frequent medication classes, and to explore practitioner variability in prescribing. Methods: Retrospective cross-sectional study based on anonymized electronic medical records data of 111 811 adult patients presenting to 116 Swiss general practitioners in 2019. We used mixed-effects regression analyses to assess the association of patient age and sex with polypharmacy (≥5 medications) and with the prescription of specific medication classes (second level of the Anatomical Therapeutic Chemical Classification System). Practitioner variability was quantified in terms of the random effects distributions. Results: The prevalence of polypharmacy increased with age from 6.4% among patients aged 18–40 years to 19.7% (41–64 years), 45.3% (65–80 years), and 64.6% (81–92 years), and was higher in women than in men, particularly at younger ages. The most frequently prescribed medication classes were antiinflammatory and antirheumatic products (21.6% of patients), agents acting on the renin-angiotensin system (19.9%), analgesics (18.7%), and drugs for acid related disorders (18.3%). Men were more often prescribed agents targeting the cardiovascular system, whereas most other medications were more often prescribed to women. The highest practitioner variabilities were observed for vitamins, for antiinflammatory and antirheumatic products, and for mineral supplements. Conclusion: Based on practitioner variability, prevalence, and risk potential, antiinflammatory drugs and polypharmacy in older patients appear to be the most pressing issues in current drug prescribing routines.
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5
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Okoro RN, Abdullahi K, Dayar DA. Assessment of proton-pump inhibitor use at a tertiary teaching hospital in Nigeria. MEDICINE ACCESS @ POINT OF CARE 2021; 5:23992026211062729. [PMID: 36204491 PMCID: PMC9413602 DOI: 10.1177/23992026211062729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Proton-pump inhibitor (PPI) is a widely used medication class globally. Because of its good safety profile, there is a huge likelihood of inappropriate use. Objectives: To determine the prevalence of PPI use and indications, describe its pattern of usage, and identify factors associated with inappropriate prescriptions at a federal tertiary teaching hospital in Maiduguri, Nigeria. Methods: PPI prescriptions were retrospectively assessed in the General Outpatients’ Department (GOPD) and Gastroenterology Unit (GITU) of a teaching hospital. Relevant data for the study were extracted from the patients’ medical records. Chi-square or Fisher’s exact tests where appropriate were used to identify factors associated with inappropriate PPI prescriptions. A p < 0.05 was considered to be significant. Results: PPIs were prescribed to 73.3% (220/300) of patients, while inappropriate prescriptions were noted in 91.4% (201/220) of these patients. Epigastric pain (49.5%) was the most common PPI indication, while omeprazole was the highest prescribed (53.4%). Nearly all inpatients (98.2%), those with epigastric pain (95.7%), and patients who were prescribed intravenous PPIs had more inappropriate PPI prescriptions compared to others. Conclusion: This study revealed a high prevalence of PPI use and inappropriate prescriptions at the study hospital. As a result, these findings highlight the importance PPI-based stewardship program at the study hospital.
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Affiliation(s)
- Roland Nnaemeka Okoro
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Maiduguri, Maiduguri, Nigeria
| | - Kasim Abdullahi
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Maiduguri, Maiduguri, Nigeria
| | - Dauda Ayuba Dayar
- Gastroenterology Unit, Department of Internal Medicine, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
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Survey-Based Analysis of Current Trends for Prescribing Gastrointestinal Protectants among Small-Animal General Practitioners in Portugal. Vet Sci 2021; 8:vetsci8050070. [PMID: 33922570 PMCID: PMC8146071 DOI: 10.3390/vetsci8050070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/15/2021] [Accepted: 04/21/2021] [Indexed: 12/13/2022] Open
Abstract
In both human and veterinary healthcare, gastrointestinal protectants (GIPs) are considered a staple of clinical practice in that they are prescribed by general practitioners (GPs) and specialists alike. Concerning GIP use, overprescription of proton pump inhibitors (PPIs) has become a growing concern among human healthcare providers. This trend has also been documented within veterinary practice, prompting the American College of Veterinary Internal Medicine (ACVIM) to publish a consensus statement in 2018 concerning evidence-based indications for GIP use. This observational cross-sectional study evaluated self-reported prescribing protocols among Portuguese GPs to determine whether there is adherence to the consensus guidelines. Respondents were Portuguese GPs recruited by social media posts in veterinarian online forums. Data were collected from 124 respondents concerning their GIPs of choice and their rationales for prescribing them. Data were mined for prescription patterns and protocols. Among GIPs, PPIs were prescribed more often. Rationales for use included gastrointestinal ulceration and erosion (GUE), prophylactic management of nonerosive gastritis, pancreatitis, reflux esophagitis, and steroid-induced ulceration. Once-daily administration of PPIs was the most frequent dosing regime among respondents. Ninety-six percent of PPI prescribers advocated that the drug be administered either shortly before or at mealtime. Forty-nine percent of respondents supported long-term use of PPIs. Fifty-nine percent of respondents acknowledged discontinuing PPIs abruptly. This study supports that Portuguese GPs commonly prescribe GIPs in accordance with ACVIM recommendations to medically manage GUE. However, misuse of GIPs does occur, and they have been prescribed where their therapeutic value is debatable. Educational strategies should target GPs in an effort to reduce GIP misuse.
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Carter M, Chapman S, Watson MC. Multiplicity and complexity: a qualitative exploration of influences on prescribing in UK general practice. BMJ Open 2021; 11:e041460. [PMID: 33431490 PMCID: PMC7802664 DOI: 10.1136/bmjopen-2020-041460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Despite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general practice could inform strategies to promote evidence-based prescribing. This study explored (1) current influences on prescribing in general practice and (2) the possibility that general practice-based pharmacists (PBPs) may contribute to greater engagement with evidence-based prescribing. DESIGN Semistructured, telephone interviews and a focus group were conducted, audio-recorded and transcribed verbatim. Thematic analysis was undertaken. PARTICIPANTS General practice prescribers: general practitioners (GPs), PBPs, nurses.Key informants: individuals within the National Health Service (NHS) with responsibility for influencing, monitoring and measuring general practice prescribing. SETTING General practices and NHS organisations in England. RESULTS Interviews with 17 prescribers (GPs (n=6), PBPs (n=6), nurses (n=5)) and 6 key informants, and one focus group with five key informants were undertaken between November 2018 and April 2019. Determinants operating at individual, practice and societal levels impacted prescribing and guideline use. Prescribers' professional backgrounds, for example, nursing, pharmacy, patient populations and patient pressure were perceived as substantial influences, as well as media portrayal and public perceptions of medicines.Prescribers identified practice-level determinants of prescribing, including practice culture and shared beliefs. Key informants tended to emphasise higher-level influences, including NHS policies, availability of support and advice from secondary care and generic challenges associated with medicines use, for example, multimorbidity.Participants expressed mixed views about the potential of PBPs to promote evidence-based prescribing in general practice. CONCLUSION Prescribing in UK general practice is influenced by multiple intersecting factors. Strategies to promote evidence-based prescribing should target modifiable influences at practice and individual levels. Customising strategies for medical and non-medical prescribers may maximise their effectiveness.
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Affiliation(s)
- Mary Carter
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Sarah Chapman
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Margaret C Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
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8
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Olsen JK, Lykkegaard J, Hansen MP, Waldorff FB, Lous J, Andersen MK. Prescription of antibiotics to children with acute otitis media in Danish general practice. BMC FAMILY PRACTICE 2020; 21:177. [PMID: 32854621 PMCID: PMC7457240 DOI: 10.1186/s12875-020-01248-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022]
Abstract
Background Acute otitis media (AOM) is a common and most often self-limiting infection in childhood, usually managed in general practice. Even though antibiotics are only recommended when certain diagnostic and clinical criteria are met a high antibiotic prescription rate is observed. The study’s objective was to analyse associations between patient- and general practitioner (GP) characteristics and antibiotic prescribing for children with AOM in an effort to explain the high antibiotic prescribing rates. Methods All general practices in the Northern, Southern and Central regions of Denmark were invited to record symptoms, examinations, findings and antibiotic treatment for all children ≤7 years of age diagnosed with AOM during a four-week winter period in 2017/2018. Associations were analysed by means of multivariate logistic regressions. The study design was cross-sectional. Results GPs from 60 general practices diagnosed 278 children with AOM of whom 207 (74%) were prescribed antibiotics, most often penicillin V (60%). About half of the children had tympanometry performed. Antibiotic prescribing rates varied considerably between practices (0–100%). Antibiotic prescribing was associated with fever (odds ratio (OR) 3.69 95% confidence interval (CI) 1.93–7.05), purulent ear secretion (OR 2.35 95% CI 1.01–5.50) and poor general condition (OR 3.12 95% CI 1.31–7.46), and the practice’s antibiotic prescribing rate to other patients with symptoms of an acute respiratory tract infection (OR 2.85 CI 95% 1.07–7.60) and specifically to other children with AOM (OR 4.15 CI 95% 1.82–9.47). Conclusion GPs’ antibiotic prescribing rates for children with AOM vary considerably even considering the of signs, symptoms, request for antibiotics, and use of tympanometry. Interventions to reduce overprescribing should be targeted high-prescribing practices.
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Affiliation(s)
- Jonas K Olsen
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark.
| | - Jesper Lykkegaard
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark.,Audit Project Odense, Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Malene Plejdrup Hansen
- Audit Project Odense, Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark.,Center for General Practice at Aalborg University, Aalborg, Denmark
| | - Frans B Waldorff
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark
| | - Jørgen Lous
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark
| | - Merethe K Andersen
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark.,Audit Project Odense, Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
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Russo V, Orlando V, Monetti VM, Galimberti F, Casula M, Olmastroni E, Tragni E, Menditto E. Geographical Variation in Medication Prescriptions: A Multiregional Drug-Utilization Study. Front Pharmacol 2020; 11:418. [PMID: 32536861 PMCID: PMC7269055 DOI: 10.3389/fphar.2020.00418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/19/2020] [Indexed: 11/13/2022] Open
Abstract
Background Studies have emphasized the importance of geographical factors and general practitioner (GP) characteristics in influencing drug prescriptions. Objectives To: (i) ascertain the prevalence rate (PR) of use of drugs in six therapeutic categories used for chronic conditions; (ii) assess how geographical characteristics and GP characteristics may influence drug prescribing. Methods This study is part of the EDU.RE.DRUG Project, a national collaborative project founded by Italian Medicine Agency (AIFA). Cross-sectional analyses were undertaken employing the pharmacy-claim databases of four local health units (LHUs) located in two Italian regions: Lombardy and Campania. Six drug categories were evaluated: proton-pump inhibitors; antibiotics; respiratory-system drugs; statins; agents acting on the renin−angiotensin system; psychoanaleptic drugs. The PR was estimated according to drug categories at the LHU level. A linear multivariate regression analysis was undertaken to evaluate the association between the PR and geographical area, age and sex of GPs, number of patients, and percentage of patients aged >65 per GP. Results LHUs in Campania showed a PR that was significantly higher than that in Lombardy. Antibiotics showed the highest PR in all the LHUs assessed, ranging from 32.5% in Lecco (Lombardy) to 59.7% in Naples-2 (Campania). Multivariate linear regression analysis confirmed the association of the PR with geographical area for all drug categories. Being located in Campania increased the possibility of receiving a drug prescription from the categories considered, with estimates more marked for antibiotics, proton-pump-inhibitors, and respiratory-system drugs. Conclusions This study provides information about the PR of medications used for treating common and costly conditions in Italy and highlighted a significant geographical variation. These insights could help to develop area-specific strategies to optimize prescribing behavior.
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Affiliation(s)
- Veronica Russo
- Department of Pharmacy, University of Naples Federico II, Naples, Italy.,CIRFF-Center of Pharmacoeconomics and Drug Utilization Research, University of Naples Federico II, Naples, Italy
| | - Valentina Orlando
- Department of Pharmacy, University of Naples Federico II, Naples, Italy.,CIRFF-Center of Pharmacoeconomics and Drug Utilization Research, University of Naples Federico II, Naples, Italy
| | - Valeria Marina Monetti
- Department of Pharmacy, University of Naples Federico II, Naples, Italy.,CIRFF-Center of Pharmacoeconomics and Drug Utilization Research, University of Naples Federico II, Naples, Italy
| | - Federica Galimberti
- Centro Interuniversitario di Epidemiologia e Farmacologia Preventiva, Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
| | - Manuela Casula
- Centro Interuniversitario di Epidemiologia e Farmacologia Preventiva, Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy.,MultiMedica (IRCCS), Milan, Italy
| | - Elena Olmastroni
- Centro Interuniversitario di Epidemiologia e Farmacologia Preventiva, Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
| | - Elena Tragni
- Centro Interuniversitario di Epidemiologia e Farmacologia Preventiva, Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
| | - Enrica Menditto
- Department of Pharmacy, University of Naples Federico II, Naples, Italy.,CIRFF-Center of Pharmacoeconomics and Drug Utilization Research, University of Naples Federico II, Naples, Italy
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10
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Kovacevic T, Kovacevic SV, Stanetic M, Kovacevic P, Miljkovic B. Impact of pharmacist's intervention on decreasing erlotinib interactions in the treatment of lung cancer patients in low resource settings. J Oncol Pharm Pract 2020; 27:350-358. [PMID: 32349642 DOI: 10.1177/1078155220921545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study aimed to demonstrate that having clinical pharmacist as a member of oncology team in low and middle income countries might lead to significant reduction in the number of erlotinib interactions in the treatment of non-small cell lung cancer patients. METHODS A group of 44 patients was labeled as intervention group and they were analyzed prospectively in the period from 1 January 2017 to 1 May 2018 during clinical pharmacist's participation in regular weekly multidisciplinary oncology team meetings. The control group consisted of 44 out of 110 patients treated with erlotinib before the involvement of a clinical pharmacist in oncology team, match paired with 44 patients in intervention group. RESULTS Clinically significant interactions were identified in two-thirds of studied patients (57 out of 88). Most drug interactions, 38%, potentially result in decrease of serum concentration of erlotinib. Clinical pharmacist provided therapy modification suggestions for 32 out of 44 (72.72%) patients in the intervention group, most of which were accepted by doctors. In the intervention group, there were significantly less clinically significant interactions compared to the control group (10 versus 24, p = 0.002). Progression-free survival was significantly longer in the pharmacist's intervention group (p = 0.001). CONCLUSIONS Clinical pharmacist's intervention led to significant decrease in erlotinib interactions which may result in treatment optimization of lung cancer patients.
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Affiliation(s)
- Tijana Kovacevic
- Pharmacy Department, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina.,Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Sandra Vezmar Kovacevic
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Mirko Stanetic
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina.,Lung Disease Clinic, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Pedja Kovacevic
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina.,Medical Intensive Care Unit, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Branislava Miljkovic
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
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11
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Fahlén Bergh C, Toivanen S, Johnell K, Calissendorff J, Skov J, Falhammar H, Nathanson D, Lindh JD, Mannheimer B. Factors of importance for discontinuation of thiazides associated with hyponatremia in Sweden: A population-based register study. Pharmacoepidemiol Drug Saf 2020; 29:77-83. [PMID: 31730289 DOI: 10.1002/pds.4922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 08/08/2019] [Accepted: 10/20/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE In a patient with clinically significant hyponatremia without other clear causes, thiazide treatment should be replaced with another drug. Data describing to which extent this is being done are scarce. The aim of this study was to investigate sociodemographic and socioeconomic factors that may be of importance for the withdrawal of thiazide diuretics in patients hospitalized due to hyponatremia. METHODS The study population was sampled from a case-control study investigating individuals hospitalized with a main diagnosis of hyponatremia. For every case, four matched controls were included. In the present study, cases (n = 5204) and controls (n = 7425) that had been dispensed a thiazide diuretic prior to index date were identified and followed onward regarding further dispensations. To investigate the influence of socioeconomic and sociodemographic factors, multiple logistic regression was used. RESULTS The crude prevalence of thiazide withdrawal for cases and controls was 71.9% and 10.8%, respectively. Thiazide diuretics were more often withdrawn in medium-sized towns (adjusted OR, 1.52; 95% CI, 1.21-1.90) and rural areas (aOR, 1.81; 95% CI, 1.40-2.34) compared with metropolitan areas and less so among divorced (aOR, 0.72; 95% CI, 0.53-0.97). However, education, employment status, income, age, country of birth, and gender did not influence withdrawal of thiazides among patients with hyponatremia. CONCLUSIONS Thiazide diuretics were discontinued in almost three out of four patients hospitalized due to hyponatremia. Educational, income, gender, and most other sociodemographic and socioeconomic factors were not associated with withdrawal of thiazides.
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Affiliation(s)
- Cecilia Fahlén Bergh
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Section of Diabetes and Endocrinology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Susanna Toivanen
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - David Nathanson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Section of Diabetes and Endocrinology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
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12
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Jarbøl DE, Lykkegaard J, Hansen JM, Munck A, Haastrup PF. Prescribing of proton-pump inhibitors: auditing the management and reasons for prescribing in Danish general practice. Fam Pract 2019; 36:758-764. [PMID: 31165863 DOI: 10.1093/fampra/cmz025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Prescribing of proton-pump inhibitors has substantially increased. Information from clinical settings is warranted to gain insight into reasons for prescribing. AIM To investigate Danish General Practitioners' management and reasons for prescribing of proton-pump inhibitors and to identify areas for quality improvement. METHODS All general practitioners in the Region of Southern Denmark and their staff were invited to participate in a 4-week audit on all contacts with patients prescribed proton-pump inhibitors. For each contact, patient characteristics, treatment duration, dose and causes of treatment, previous gastroscopy, Helicobacter pylori test, and decision about future treatment were recorded. RESULTS A total of 51 general practitioners and 47 staff members sampled information about 1101 and 741 patients, respectively. Proton-pump inhibitors had been taken for more than 2 years in 58% of the cases, and 64% of the patients used it daily. Treatment was based on an appropriate reason in three of the four patients, most often due to acid-related symptoms. No gastroscopy had been performed in 46% of the patients, and one of four had had a consultation with the general practitioner regarding proton-pump inhibitor within the last year. CONCLUSION Most patients treated with proton-pump inhibitors are treated daily, on a long-term basis, and due to symptoms. Few consultations led to alterations in treatment, and only 25% of patients had a consultation regarding proton-pump inhibitor treatment with their general practitioner within the last year. Substantial variability between general practitioners with regard to management was detected.
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Affiliation(s)
- Dorte E Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Sønderborg, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Sønderborg, Denmark.,Audit Project Odense, Research Unit of General Practice, Odense, Denmark
| | | | - Anders Munck
- Audit Project Odense, Research Unit of General Practice, Odense, Denmark
| | - Peter F Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Sønderborg, Denmark
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13
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Krause O, Glaubitz S, Hager K, Schleef T, Wiese B, Junius-Walker U. Post-discharge adjustment of medication in geriatric patients : A prospective cohort study. Z Gerontol Geriatr 2019; 53:663-670. [PMID: 31440831 DOI: 10.1007/s00391-019-01601-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/05/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Little is known to what extent general practitioners (GP) change hospital discharge medications in older patients. OBJECTIVE This prospective cohort study aimed to analyze medication changes at the interface between hospital and community in terms of quality, quantity and type of drugs. METHODS A total of 121 out of 248 consecutively enrolled patients admitted to an acute geriatric hospital unit participated in the study. Medication regimens were recorded at admission and discharge and 4 weeks after hospital discharge the general practitioners in charge were contacted to provide the current medication charts. Changes in the extent of polypharmacy, in the type of drugs using anatomical therapeutic chemical classification (ATC) codes and potentially inappropriate medications (PIM) were analyzed. RESULTS Medication charts could be obtained for 98 participants in primary care. Only 21% of these patients remained on the original discharge medication. Overall, the average number of medications rose from hospital admission (6.58 SD ± 3.45) to discharge (6.96 SD ± 3.49) and again post-discharge in general practice (7.22 SD ± 3.68). The rates of patients on excessive polypharmacy (≥10 drugs) and on PIM were only temporarily reduced during hospital stay. The GPs stopped anti-infective drugs (ATC-J) and prescribed more antirheumatic drugs (ATC-M). Although no significant net changes occurred in other ATC groups, a substantial number of drugs were interchanged regarding the subgroups. CONCLUSION The study found that GPs extensively adjusted geriatric discharge medications. Whereas some changes may be necessary due to alterations in patients' state of health, a thorough communication between hospital doctors and GPs may level off different prescribing cultures and contribute to consistency in medication across sectors.
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Affiliation(s)
- Olaf Krause
- Center for Medicine of the Elderly, DIAKOVERE Henriettenstift, Schwemannstr. 19, 30559, Hannover, Germany. .,Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Stefanie Glaubitz
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Department of Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Klaus Hager
- Center for Medicine of the Elderly, DIAKOVERE Henriettenstift, Schwemannstr. 19, 30559, Hannover, Germany
| | - Tanja Schleef
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Ulrike Junius-Walker
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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14
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Luetzenberg FS, Jiang N. Practice patterns of reflux medication prescriptions in otolaryngology compared to other specialties. Laryngoscope 2019; 130:321-327. [DOI: 10.1002/lary.27916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/04/2019] [Accepted: 02/19/2019] [Indexed: 12/26/2022]
Affiliation(s)
| | - Nancy Jiang
- and the Head and Neck Surgery Department, Kaiser Permanente Oakland Medical Group Oakland California U.S.A
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15
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McDowell RD, Bennett K, Moriarty F, Clarke S, Barry M, Fahey T. Prescriber Variation in Relation to Prescribing Trends within the Preferred Drugs Initiative in Ireland (2012-2015): An Interrupted Time-Series Study Using Latent Curve Models. Med Decis Making 2019; 39:278-293. [PMID: 30741086 DOI: 10.1177/0272989x18818165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine the impact of the Preferred Drugs Initiative (PDI), an Irish health policy aimed at reducing prescribing variation. DESIGN Interrupted time series spanning 2012 to 2015. SETTING Health Service Executive pharmacy claims data for General Medical Services (GMS) patients, approximately 40% of the Irish population. PARTICIPANTS Prescribers issuing preferred drug group items to GMS adults before and after PDI guidelines. PRIMARY OUTCOME The percentage coverage of PDI medications within each drug class per calendar quarter per prescriber. METHODS Latent curve models with structured residuals (LCM-SRs) were used to model coverage of the preferred drugs over time. The number of GMS adults receiving medication and the percentage who were 65 years and older at the start of the study were included as covariates. RESULTS In the quarter following PDI guidelines, coverage of the preferred drugs increased most in absolute terms for proton pump inhibitors (PPIs) (1.50% [SE 0.15], P < 0.001) and selective and norepinephrine reuptake inhibitors (SNRIs) (1.17% [SE 0.26], P < 0.001). Variation between prescribers remained relatively unchanged and increased for urology medications. Prescribers who increased coverage of the preferred PPI also increased coverage of the preferred statin immediately following guidelines (correlation 0.47 [SE 0.13], P < 0.001). Where guidelines were disseminated simultaneously, coverage of one preferred drug did not significantly predict coverage of the other preferred drug in the next calendar quarter. Prescribing of preferred drugs was not moderated by prescriber-level factors. CONCLUSIONS Modest changes in prescribing of the preferred drugs have been observed over the course of the PDI. However, the guidelines have had little impact in reducing variation between prescribers. Further strategies may be necessary to reduce variation in clinical practice and enhance patient care.
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Affiliation(s)
- Ronald D McDowell
- Health Research Board (HRB) Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin 2, Ireland.,Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Frank Moriarty
- Health Research Board (HRB) Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin 2, Ireland
| | - Sarah Clarke
- Health Service Executive Medicines Management Programme, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
| | - Michael Barry
- National Centre for Pharmacoeconomics, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
| | - Tom Fahey
- Health Research Board (HRB) Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin 2, Ireland
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Bucholc M, O’Kane M, Ashe S, Wong-Lin K. Prescriptive variability of drugs by general practitioners. PLoS One 2018; 13:e0189599. [PMID: 29462143 PMCID: PMC5819764 DOI: 10.1371/journal.pone.0189599] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022] Open
Abstract
Prescription drug spending is growing faster than any other sector of healthcare. However, very little is known about patterns of prescribing and cost of prescribing between general practices. In this study, we examined variation in prescription rates and prescription costs through time for 55 GP surgeries in Northern Ireland Western Health and Social Care Trust. Temporal changes in variability of prescribing rates and costs were assessed using the Mann–Kendall test. Outlier practices contributing to between practice variation in prescribing rates were identified with the interquartile range outlier detection method. The relationship between rates and cost of prescribing was explored with Spearman's statistics. The differences in variability and mean number of prescribing rates associated with the practice setting and socioeconomic deprivation were tested using t-test and F-test respectively. The largest between-practice difference in prescribing rates was observed for Apr-Jun 2015, with the number of prescriptions ranging from 3.34 to 8.36 per patient. We showed that practices with outlier prescribing rates greatly contributed to between-practice variability. The largest difference in prescribing costs was reported for Apr-Jun 2014, with the prescription cost per patient ranging from £26.4 to £64.5. In addition, the temporal changes in variability of prescribing rates and costs were shown to undergo an upward trend. We demonstrated that practice setting and socio-economic deprivation accounted for some of the between-practice variation in prescribing. Rural practices had higher between practice variability than urban practices at all time points. Practices situated in more deprived areas had higher prescribing rates but lower variability than those located in less deprived areas. Further analysis is recommended to assess if variation in prescribing can be explained by demographic characteristics of patient population and practice features. Identification of other factors contributing to prescribing variability can help us better address potential inappropriateness of prescribing.
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Affiliation(s)
- Magda Bucholc
- Intelligent Systems Research Centre, University of Ulster, Magee Campus, Londonderry, Northern Ireland, United Kingdom
- * E-mail:
| | - Maurice O’Kane
- Altnagelvin Area Hospital, Western Health and Social Care Trust, Glenshane Road, Londonderry, Northern Ireland, United Kingdom
| | - Siobhan Ashe
- Altnagelvin Area Hospital, Western Health and Social Care Trust, Glenshane Road, Londonderry, Northern Ireland, United Kingdom
| | - KongFatt Wong-Lin
- Intelligent Systems Research Centre, University of Ulster, Magee Campus, Londonderry, Northern Ireland, United Kingdom
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Abstract
This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.
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Abstract
Treatment with proton-pump inhibitors (PPIs) might be associated with neuropsychological side effects. We examined the association between use of PPIs and depressive symptoms in an elderly population. Mood was assessed by the 30-item Geriatric Depression Scale (GDS) in all 344 inhabitants of Tuscania (Italy) aged 75 years and over, without exclusion criteria; depression was defined by a GDS score ≥11. Use of PPIs was associated with a higher GDS score in linear regression analysis (B = 2.43; 95% CI = 0.49-4.38; p = 0.014) after adjusting; also, use of PPIs was associated with increased adjusted probability of depression in logistic regression (OR = 2.38; 95% CI = 1.02-5.58; p = 0.045). Higher PPIs dosages were associated with increased probability of depression (p for trend = 0.014). This association was independent of the diagnosis of peptic disease, as well as the use of antidepressant medications. No association was found between use of H2-blockers or antacids and the GDS score. Calculation of the population attributable risk indicated that 14% of depression cases could be avoided by withdrawal of PPIs. Use of PPIs might represent a frequent cause of depression in older populations; thus, mood should be routinely assessed in elderly patients on PPIs.
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From Harmful Treatment to Secondary Gain: Adverse Event Reporting in Dyspepsia and Gastroparesis. Dig Dis Sci 2017; 62:2999-3013. [PMID: 28577245 DOI: 10.1007/s10620-017-4633-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/24/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Medical management of gastroparesis and functional dyspepsia remains difficult with several recent trials showing limited or no benefit. If treatment comes with only marginal improvements, concerns about adverse events become more relevant. We therefore examined the type and outcomes of side effects submitted to a public repository. METHODS We searched the Federal Adverse Event Reporting System for reports associated with the treatment of dyspepsia or gastroparesis. Demographic data, medications used and implicated, side effects, and outcomes were abstracted for the years 2004-2015. RESULTS Acid-suppressive agents and prokinetics were the most commonly listed medications with a stronger emphasis on prokinetics in gastroparesis. Submissions related to metoclopramide by far exceeded reports about other agents and mostly described tardive dyskinesia or other neurological concerns. They peaked around 2012, driven by submissions through legal workers. Most reports about metoclopramide described short-term use to prevent or treat nausea and vomiting. Concerns about acid-suppressive medications increased over time and spanned a wide spectrum of potential problems, including osteoporosis, worsening renal function, or cardiac events. CONCLUSION Despite biasing factors, such as pending legal action, the voluntary repository of adverse events provides insight into current medical practice and its associated risk. Knowing about common and uncommon, but potentially serious risks may enable patients and providers to decide on effective and safe management strategies.
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