Adherence to chronic medication in older populations: application of a common protocol among three European cohorts

The European Drug-Drug Interaction (EuroDDI) Study Protocol: A Cross-Country Comparison of Drug-Drug Interaction Prevalence in the Older Community-Dwelling Population

BACKGROUND

Drug-drug interactions (DDIs), highly prevalent amongst the elderly, can lead to avoidable medication-related harm. Cardiovascular and central nervous system (CNS) drugs are commonly implicated. To date, there is no consensus on how to measure DDIs, making comparisons across countries challenging.

OBJECTIVE

To (i) establish a common data model (CDM) to measure DDI prevalence in the older (aged ≥ 70 years) community-dwelling population of three European countries and (ii) compare and describe cardiovascular and CNS DDI prevalence rates across these countries.

METHODS

This cross-country study will apply a harmonised method of DDI identification and analysis using the WHO ATC classification system and national pharmacy claims data from three European countries (Ireland, Italy, Spain). Patients aged ≥ 70 years dispensed ≥ 2 medications during 2016 will be identified from each country's national database. 'Severe' cardiovascular and CNS DDIs (i.e., may result in a life-threatening event/permanent detrimental effect) will be identified using the British National Formulary and Stockley's Drug Interactions. Two separate lists of 'severe' DDIs, per medications reimbursed, will be applied to each database: (i) DDIs relevant to each individual country and (ii) DDIs relevant to all three countries. DDIs will be defined as co-dispensed (same day) and concomitantly (±7 days) dispensed.

RESULTS

Descriptive statistics, including DDI prevalence and 95% confidence intervals, will be reported for each country. Prevalence will be pooled and compared across countries using random effects models and meta-regression, where feasible.

CONCLUSION

The EuroDDI study will develop a harmonised method to measure and compare DDI prevalence across health-related databases in Europe.

Initiation of lipid-lowering therapy as primary prevention of cardiovascular disease in the elderly

AIMS

This study aimed to analyse the initiation adherence phase to lipid-lowering therapy for primary prevention of cardiovascular disease in a Spanish population aged 70 years or older. The secondary objective was to identify the determinants of initiation and early discontinuation.

METHODS

This was an observational study conducted in the CArdiovascular Risk factors for HEalth Service research (CARhES) cohort. People aged 70 and older with a first prescription of a lipid-lowering drug and without a previous major adverse cardiovascular event (MACE) were selected (2018-2021). Data on sociodemographics, clinical conditions, drugs and use of health services were collected from clinical and administrative electronic databases. The study population was classified into: non-initiation, early discontinuation (i.e., discontinuation after the first dispensing) and initiation with more than one dispensing. Their characteristics were compared. Determinants of initiation and early discontinuation were explored.

RESULTS

Among the 15 019 people studied, 80.2% initiated the medication, 11.2% showed an early discontinuation and 8.6% were non-initiators. An older age or conditions such as dementia, diabetes or depression reduced the likelihood of initiation, while obesity and a high pharmacological burden increased it. People over 90 years of age or those prescribed a statin in combination were more likely to have an early discontinuation.

CONCLUSIONS

Non-initiation and early discontinuation are common among older people prescribed lipid-lowering drugs as primary prevention of cardiovascular disease for the first time. The presence of chronic pathologies other than cardiovascular ones should be considered when assessing whether or not to prescribe these drugs in the elderly.

A real-world analysis of pharmacotherapy adherence and the factors influencing it in Serbia: a nationwide, population-based, cross-sectional study

Introduction

Monitoring the pharmacotherapy adherence in society is crucial for identifying occurance and causes of potential inadequate use of drugs and inform providers about the need for better customer counceling. It is necessary component of the strategic planning of the quality of healthcare services. This population- based study aimed to assess the medication intake adherence in the Republic of Serbia and the individual factors and health system variables influencing its pattern.

Methods

We applied a cross-sectional approach to study medication intake adherence using a secondary analysis of the latest 2019 Serbian National Health Survey data. The statistical modeling of the pharmacotherapy adherence incorporated sociodemographic data, self-reported disease, and lifestyle behavior.

Results

In 2019, in the representative sample of 12,066 adults in Serbia, requiring prescribed medicine, 49.8% did comply with the prescribed drugs, and 50.2% do not. Participants who adhered to prescribed medication were significantly (p < 0.001) older (62.4 ± 14 years), predominantly female (55.3%), had secondary education (48.5%), resided in southern and eastern parts of Serbia (55.5%), and belonged to the lowest income quintile (21.4%). The participants most often take prescribed drugs for hypertension (64.1%) and lower back pain (30.5%), while around 20% take medication for coronary disease, diabetes mellitus, and high blood cholesterol. About 85-92% of participants with financial or general difficulties using prescribed medication.

Conclusion

There is poor medication intake adherence to prescribed medication in Serbia. Gender, age, and region determine the adherence. Also, health-related and healthcare system-related factors impact the use of prescribed medication. Study findings can inform planning the counceling interventions in the target groups where improving medication adherence is necessary, as well as to enhance training of healthcare providers about pharmacotherapy adherence.

Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

Italian Translation and Validation of the Original ABC Taxonomy for Medication Adherence

Medication adherence represents a complex and multifaceted process. Standardized terminology is essential to enable a reproducible process in various languages. The study's aim was to translate and adapt the original Ascertaining Barriers for Compliance (ABC) Taxonomy on medication adherence, first proposed in 2012, into Italian language. The study was carried out according to the Preferred Methods for Translation of the ABC Taxonomy for Medication Adherence adopted by the ESPACOMP. Key steps included: (1) a systematic literature review using PubMed and Embase according to the PRISMA Guidelines to identify published Italian terms and definitions, and Italian adherence experts; (2) a forward translation of terms and definitions; (3) panelists' selection; (4) a three-round Delphi survey. From the systematic review, 19 studies allowed detection of 4 terms, 4 definitions and 767 Italian experts. To these, Italian ESPACOMP members and experts though snowball sampling were added. The identified Italian adherence experts received the Delphi questionnaire. The Italian ABC Taxonomy was achieved after three rounds of Delphi survey by reaching at least a moderate consensus on unambiguous naming and definition of medication adherence-related terms. The Taxonomy is intended to be used in research, academic, and professional fields in order to harmonize adherence terminology and avoid confusion in comparing research findings.

Factors Associated with Adherence to Treatment in Patients with HIV and Diabetes Mellitus

We aim to identify the factors that influence the therapeutic adherence of subjects with chronic disease. The design followed in this work was empirical, not experimental, and cross-sectional with a correlational objective. The sample consisted of a total of 400 subjects (199 patients with HIV and 201 patients with diabetes mellitus). The instruments applied for data collection were a sociodemographic data questionnaire, the 4-item Morisky Medication Adherence Scale (MMAS-4) and the Coping Strategies Questionnaire. In the group of subjects with HIV, that the use of emotional coping strategies was related to lower adherence to treatment. On the other hand, in the group of subjects with diabetes mellitus, the variable related to compliance with treatment was the duration of illness. Therefore, the predictive factors of adherence to treatment were different in each chronic pathology. In the group of subjects with diabetes mellitus, this variable was related to the duration of the disease. In the group of subjects with HIV, the type of coping strategy used predicted adherence to treatment. As a result of these results, it is possible to develop health programmes to promote, from nursing consultations to adherence to treatment of patients with HIV and diabetes mellitus.

Study of Adherence Level and the Relationship Between Treatment Adherence, and Superstitious Thinking Related to Health Issues Among Chronic Disease Patients in Southern Jordan: Cross-Sectional Study

BACKGROUND

For disease management, numerous drugs are prescribed. However, long-term treatment adherence is still unsatisfactory. Culture influences beliefs regarding medication, particularly irrational ideas that affect treatment adherence. The Middle East, notably Jordan, is affected by a lack of awareness of these attitudes with regard to treatment adherence.

OBJECTIVE

Investigating the adherence level among patients with chronic diseases in southern Jordan. To determine whether certain demographic traits, different disease factors, and superstitions have any impact on treatment adherence.

PATIENTS AND METHODS

A cross-sectional study that assessed treatment adherence and superstitious thinking-related health issues were conducted among chronic disease patients who had reviewed intrinsic medicine clinics at the Karak governmental hospital.

RESULTS

For 314 participants, treatment adherence was categorized into three levels low-adherent patients made up 27.7% highly-adherent patients made up 49.4%, and the remaining adhered at a medium level. Treatment non-adherence was more common in the elderly and female, according to the chi-square analysis. Additionally, the classification of superstitious beliefs into three categories revealed that different percentages of the study population held low superstitious beliefs 21%, medium superstitions 54.1% and high superstitions 24.8% beliefs. The chi-square analysis revealed that the elderly, female, and low-educated patient groups were the highest in superstitious thinking. Multiple regression analysis revealed that educational level and superstitious thinking explained 0.223 of the treatment adherence variances. Treatment adherence is positively influenced by educational level β (0.244) value, but superstitious thinking is negatively influenced by β (-0.302) value.

CONCLUSION

In conclusion, about half of the participants highly adhered. The results of the multiple-regression analysis indicate that superstition and education were two variables that impacted treatment adherence in this study. While superstitious beliefs lead to lower treatment adherence, education has the opposite effect. Finally, it is recommended to promote patient education to reduce superstitious beliefs, improve medication adherence.

Adherence to antidiabetic treatment among patients managed in primary care centres in Spain: the INTENSE study

AIMS

To determine the degree and factors related to non-insulin antidiabetic drug (NIAD) adherence in people with type 2 diabetes mellitus (DM2) treated in primary carecentres in Spain.

METHODS

We did a cross-sectional study. During the study visit, variables related todifferent clinical characteristics, Adherence to Refills and Medications Scale Spanishversion (ARMS-e) and usage of NIAD were collected. We estimated the adherence toNIADs using the proportion of days covered (PDC) equation.

RESULTS

In total, 515 participants were included in the study. The mean PDC ratio was70.6 ( ± 28.9), and 50.5% (260) were classified as good adherent (PDC ≥80). Good adherence was highest among users of metformin (67.3%) and lowest among the participants using thiazolidinedione (0.8%). The score for ARMS-e was higher in the poor adherence group. In the multivariable analysis, HbA1c and the use of GLP1-RA or SGLT-2i were negatively associated with good adherence (odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.54, 0.82, OR: 0.20, 95%CI: 0.08, 0.46; OR: 0.56, 95%CI: 0.35, 0.89, respectively).

CONCLUSIONS

Adherence to NIADs observed in our study is far from optimal. HbA1c and ARMS-e items could be used as adherence indicators to encourage treatment changes to improve T2DM control.

Patterns of statin adherence in primary cardiovascular disease prevention during the pandemic

Background: Study of medication adherence patterns can help identify patients who would benefit from effective interventions to improve adherence. Objectives: To identify and compare groups of statin users based on their adherence patterns before and during the COVID-19 pandemic, to characterize the profile of users in each group, and to analyze predictors of distinct adherence patterns. Methods: Participants of the CARhES (CArdiovascular Risk factors for HEalth Services research) cohort, comprising individuals aged >16 years, residing in Aragón (Spain), with hypertension, diabetes mellitus and/or dyslipidemia, took part in this observational longitudinal study. Individuals who began statin therapy during January-June 2019 were selected and followed up until June 2021. Those with a cardiovascular event before or during follow-up were excluded. Data were obtained from healthcare system data sources. Statin treatment adherence during the implementation phase was estimated bimonthly using the Continuous Medication Availability (CMA9) function in the AdhereR package. Group-based trajectory models were developed to group statin users according to their adherence pattern during July 2019-June 2021. Group characteristics were compared and predictors of each adherence pattern were analyzed using multinomial logistic regression. Results: Of 15,332 new statin users, 30.8% had a mean CMA9 ≥80% for the entire study period. Four distinct adherence patterns were identified: high adherence (37.2% of the study population); poor adherence (35.6%); occasional use (14.9%); and gradual decline (12.3%). The latter two groups included users who showed a change in adherence (increase or decrease) during the pandemic emergence. Users with suboptimal adherence were likely to be younger, not pensioners, not institutionalized, with low morbidity burden and a low number of comorbidities. Female sex and switching between statins of different intensity increased the likelihood of belonging to the occasional use group, in which improved adherence coincided with the pandemic. Conclusion: We identified four distinct adherence patterns in a population of new statin users; two of them modified their adherence during the pandemic. Characterization of these groups could enable more effective distribution of resources in future similar crisis and the routine implementation of patient-centered interventions to improve medication adherence.

Uncontrolled blood pressure and contributing factors among patients with hypertension at outpatient care of Bedele General Hospital, Southwest Ethiopia: A cross-sectional study

Objective

This study aimed to assess uncontrolled blood pressure and contributing factors among patients with hypertension.

Methods

Hospital-based cross-sectional study was conducted from January to April 2021 at Bedele General Hospital. Data were collected using the semi-structured questionnaire. All patients with hypertension were included using consecutive sampling technique unless ineligible. EpiData 4.4.2 was used for data entry, and SPSS 24.0 was employed for analysis. Binary logistic regression analysis was performed to identify factors associated with uncontrolled blood pressure.

Results

A total of 219 patients with hypertension were included in the study. About 60.3% of participants were male. The mean age of the study participants was 48.54 ± 12.93 years. The prevalence of uncontrolled blood pressure among the study participants was 56.2%. The factors significantly associated with uncontrolled blood pressure were age >60 years (adjusted prevalence ratio = 4.42; 95% confidence interval = (1.71, 11.46); p = 0.002) and the presence of comorbidity (adjusted prevalence ratio = 2.16; 95% confidence interval = (1.22, 3.82); p = 0.008).

Conclusion

More than half of the study participants had uncontrolled blood pressure. Older age and comorbidity were the predictors of uncontrolled blood pressure. Attaining controlled blood pressure is important to avoid consequences of high blood pressure. So, healthcare provider should focus on achieving target blood pressure goal.

The Role of Pharmaceutical Compounding in Promoting Medication Adherence

Pharmaceutical compounding is an important component of pharmacy practice despite its low prevalence. Several therapeutic needs can be met by a compounded medicine such as dosing adjusted for pediatric patients, special drug combinations, medicines for patients allergic to a given excipient, and medicines for orphan drugs not provided by the pharmaceutical industry. Examples of such applications are provided in this review. Adherence to medication is a critical public health issue as nonadherence to pharmacotherapy has been associated with adverse outcomes and higher costs of patient care. Adherence to therapy represents a key factor in the reduction in morbidity and mortality and optimization of the use of financial resources. The role of pharmaceutical compounding in promoting medication adherence is underexploited. The customization might represent a positive reinforcement of the initiation of the treatment, while implementation and persistence might also be favored in a pharmacy setting. However, studies addressing the influence of compounding in adherence promotion are lacking in the literature. The results of such studies could support health policies including proper regulatory framework, pharmacist training, and information to health care practitioners.

Trends in the Prevalence of Chronic Medication Use Within Children in Israel Between 2010 and 2019: Protocol for a Retrospective Cohort Study

Background

Prescription of psychostimulants has significantly increased in most countries worldwide for both preschool and school-aged children. Understanding the trends of chronic medication use among children in different age groups and from different sociodemographic backgrounds is essential. It is essential to distinguish between selected therapy areas to help decision-makers evaluate not only the relevant expected medication costs but also the specific services related to these areas.

Objective

This study will analyze differences in trends regarding medications considered psychobehavioral treatments and medications considered nonpsychobehavioral treatments and will identify risk factors and predictors for chronic medication use among children.

Methods

This is a retrospective study. Data will be extracted from the Clalit Health Services data warehouse. For each year between 2010 and 2019, there are approximately 1,500,000 children aged 0-18 years. All medication classes will be identified using the Anatomical Therapeutic Chemical code. A time-trend analysis will be performed to investigate if there is a significant difference between the trends of children’s psychobehavioral and nonpsychobehavioral medication prescriptions. A logistic regression combined with machine learning models will be developed to identify variables that may increase the risk for specific chronic medication types and identify children likely to get such treatment.

Results

The project was funded in 2019. Data analysis is currently underway, and the results are expected to be submitted for publication in 2022. Understanding trends regarding medications considered psychobehavioral treatments and medications considered nonpsychobehavioral treatments will support the identification of risk factors and predictors for chronic medication use among children.

Conclusions

Analyzing the response of the patient (and their parents or caregivers) population over time will hopefully help improve policies for prescriptions and follow-up of chronic treatments in children.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36756

Agarwood-The Fragrant Molecules of a Wounded Tree

Agarwood, popularly known as oudh or gaharu, is a fragrant resinous wood of high commercial value, traded worldwide and primarily used for its distinctive fragrance in incense, perfumes, and medicine. This fragrant wood is created when Aquilaria trees are wounded and infected by fungi, producing resin as a defense mechanism. The depletion of natural agarwood caused by overharvesting amidst increasing demand has caused this fragrant defensive resin of endangered Aquilaria to become a rare and valuable commodity. Given that instances of natural infection are quite low, artificial induction, including biological inoculation, is being conducted to induce agarwood formation. A long-term investigation could unravel insights contributing toward Aquilaria being sustainably cultivated. This review will look at the different methods of induction, including physical, chemical, and biological, and compare the production, yield, and quality of such treatments with naturally formed agarwood. Pharmaceutical properties and medicinal benefits of fragrance-associated compounds such as chromones and terpenoids are also discussed.

'You need to be healthy to be sick': exploring older people's experiences with medication packaging at home

BACKGROUND

the ageing global population is living longer with complex health conditions addressed by multiple medications. Little is known about how older people manage these medications and associated packaging at home.

OBJECTIVES

to explore how older people manage the use of multiple medication and associated packaging in their process of self-care.

METHODS

fifteen older, home-dwelling participants (mean age = 76.2 years) participated in this study. All participants used three or more daily medications and resided in Southern Sweden. Data were collected using photographs and written diaries completed by each participant over seven consecutive days, complemented by researcher-led interviews. Interviews and diary data were analysed using thematic analysis.

RESULTS

six major themes emerged and are discussed: systematic organisation of medication, design of medication packaging, design of tablets, ease of package opening, emotional response to the need for medication, and environmental waste.

CONCLUSION

packaging plays an important role in protecting products and enabling easy storage, product longevity and transportation. Medication packaging is no exception. However, the design of medication packaging poses challenges for older people managing medications for their chronic health conditions at home. There is a need to facilitate the systematic management of multiple medications, especially for new medication regimes or changes in treatment. Design of both packaging and medication should be consistent for older users to avoid potential errors; difficulties opening packaging can potentially hinder adherence to treatment. This study highlights the need for patient-centred solutions and involvement of older people in a co-design process for medication and packaging design.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial

AIMS

Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge.

METHODS

We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group.

RESULTS

For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (P_interaction  = .085). In total, 77.0% of the patients had at least one MRP post-discharge.

CONCLUSIONS

Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

Electronic Health Records As a Platform for Audiological Research: Data Validity, Patient Characteristics, and Hearing-Aid Use Persistence Among 731,213 U.S. Veterans

OBJECTIVES

This article presents a summary of audiological, general health, and hearing aid (HA) outcome data in a large sample of U.S. Veterans receiving HAs. The current article also provides the foundation for a series of papers that will explore relationships between a wide range of factors and HA outcomes.

DESIGN

The patient sample is all (n = 731,213) patients for whom HAs were ordered between April 2012 and October 2014 through the U.S. Veterans Health Administration Remote Order Entry System. For these patients, Veterans Affairs electronic health records (EHRs) stored in various databases provided data on demographics, received diagnostic and procedure codes (2007 to 2017), audiometry, self-reported outcomes up to 6 months postfitting, and HA battery orders (to 2017). Data cleaning and preparation was carried out and is discussed with reference to insights that provide potential value to other researchers pursuing similar studies. HA battery order data over time was used to derive a measure of long-term HA use persistence. Descriptive statistics were used to characterize the sample, comparative analyses against other data supported basic validity assessment, and bivariate analyses probed novel associations between patient characteristics and HA use persistence at 2 years postfitting.

RESULTS

Following extensive cleaning and data preparation, the data show plausible characteristics on diverse metrics and exhibit adequate validity based on comparisons with other published data. Further, rates of HA use persistence are favorable when compared against therapy persistence data for other major chronic conditions. The data also show that the presence of certain comorbid conditions (Parkinson's disease, diabetes, arthritis, and visual impairment) are associated with significantly lower HA use persistence, as are prior inpatient admissions (especially among new HA recipients), and that increasing levels of multimorbidity, in general, are associated with decreasing HA use persistence. This is all despite the fact that deriving relevant audiological care-process variables from the available records was not straightforward, especially concerning the definition of the date of HA fitting, and the use of battery ordering data to determine long-term HA use persistence.

CONCLUSIONS

We have shown that utilizing EHRs in audiology has the potential to provide novel insights into clinical practice patterns, audiologic outcomes, and relations between factors pertaining to hearing and to other health conditions in clinical populations, despite the potential pitfalls regarding the lack of control over the variables available and limitations on how the data are entered. We thus conclude that research using EHRs has the potential to be an integral supplement to population-based and epidemiologic research in the field of audiology.

Persistence as a Robust Indicator of Medication Adherence-Related Quality and Performance

Medication adherence is a priority for health systems worldwide and is widely recognised as a key component of quality of care for disease management. Adherence-related indicators were rarely explicitly included in national health policy agendas. One barrier is the lack of standardised adherence terminology and of routine measures of adherence in clinical practice. This paper discusses the possibility of developing adherence-related performance indicators highlighting the value of measuring persistence as a robust indicator of quality of care. To standardise adherence and persistence-related terminology allowing for benchmarking of adherence strategies, the European Ascertaining Barriers for Compliance (ABC) project proposed a Taxonomy of Adherence in 2012 consisting of three components: initiation, implementation, discontinuation. Persistence, which immediately precedes discontinuation, is a key element of taxonomy, which could capture adherence chronology allowing the examination of patterns of medication-taking behaviour. Advances in eHealth and Information Communication Technology (ICT) could play a major role in providing necessary structures to develop persistence indicators. We propose measuring persistence as an informative and pragmatic measure of medication-taking behaviour. Our view is to develop quality and performance indicators of persistence, which requires investing in ICT solutions enabling healthcare providers to review complete information on patients' medication-taking patterns, as well as clinical and health outcomes.

Drug-utilisation profiles and COVID-19

Coronavirus disease 2019 (COVID-19) has substantially challenged healthcare systems worldwide. By investigating population characteristics and prescribing profiles, it is possible to generate hypotheses about the associations between specific drug-utilisation profiles and susceptibility to COVID-19 infection. A retrospective drug-utilisation study was carried out using routinely collected information from a healthcare database in Campania (Southern Italy). We aimed to discover the prevalence of drug utilisation (monotherapy and polytherapy) in COVID-19 versus non-COVID-19 patients in Campania (~ 6 million inhabitants). The study cohort comprised 1532 individuals who tested positive for COVID-19. Drugs were grouped according to the Anatomical Therapeutic Chemical (ATC) classification system. We noted higher prevalence rates of the use of drugs in the ATC categories C01, B01 and M04, which was probably linked to related comorbidities (i.e., cardiovascular and metabolic). Nevertheless, the prevalence of the use of drugs acting on the renin-angiotensin system, such as antihypertensive drugs, was not higher in COVID-19 patients than in non-COVID-19 patients after adjustments for age and sex. These results highlight the need for further case-control studies to define the effects of medications and comorbidities on susceptibility to and associated mortality from COVID-19.

Comparing the Predictive Effects of Patient Medication Adherence Indices in Electronic Health Record and Claims-Based Risk Stratification Models

Multiple indices are available to measure medication adherence behaviors. Medication adherence measures, however, have rarely been extracted from electronic health records (EHRs) for population-level risk predictions. This study assessed the value of medication adherence indices in improving predictive models of cost and hospitalization. This study included a 2-year retrospective cohort of patients younger than age 65 years with linked EHR and insurance claims data. Three medication adherence measures were calculated: medication regimen complexity index (MRCI), medication possession ratio (MPR), and prescription fill rate (PFR). The authors examined the effects of adding these measures to 3 predictive models of utilization: a demographics model, a conventional model (Charlson index), and an advanced diagnosis-based model. Models were trained using EHR and claims data. The study population had an overall MRCI, MPR, and PFR of 14.6 ± 17.8, .624 ± .310, and .810 ± .270, respectively. Adding MRCI and MPR to the demographic and the morbidity models using claims data improved forecasting of next-year hospitalization substantially (eg, AUC of the demographic model increased from .605 to .656 using MRCI). Nonetheless, such boosting effects were attenuated for the advanced diagnosis-based models. Although EHR models performed inferior to claims models, adding adherence indices improved EHR model performances at a larger scale (eg, adding MRCI increased AUC by 4.4% for the Charlson model using EHR data compared to 3.8% using claims). This study shows that medication adherence measures can modestly improve EHR- and claims-derived predictive models of cost and hospitalization in non-elderly patients; however, the improvements are minimal for advanced diagnosis-based models.

Development and validation of a clinical risk score to predict the risk of SARS-CoV-2 infection from administrative data: A population-based cohort study from Italy

BACKGROUND

The novel coronavirus (SARS-CoV-2) pandemic spread rapidly worldwide increasing exponentially in Italy. To date, there is lack of studies describing clinical characteristics of the people at high risk of infection. Hence, we aimed (i) to identify clinical predictors of SARS-CoV-2 infection risk, (ii) to develop and validate a score predicting SARS-CoV-2 infection risk, and (iii) to compare it with unspecific scores.

METHODS

Retrospective case-control study using administrative health-related database was carried out in Southern Italy (Campania region) among beneficiaries of Regional Health Service aged over than 30 years. For each person with SARS-CoV-2 confirmed infection (case), up to five controls were randomly matched for gender, age and municipality of residence. Odds ratios and 90% confidence intervals for associations between candidate predictors and risk of infection were estimated by means of conditional logistic regression. SARS-CoV-2 Infection Score (SIS) was developed by generating a total aggregate score obtained from assignment of a weight at each selected covariate using coefficients estimated from the model. Finally, the score was categorized by assigning increasing values from 1 to 4. Discriminant power was used to compare SIS performance with that of other comorbidity scores.

RESULTS

Subjects suffering from diabetes, anaemias, Parkinson's disease, mental disorders, cardiovascular and inflammatory bowel and kidney diseases showed increased risk of SARS-CoV-2 infection. Similar estimates were recorded for men and women and younger and older than 65 years. Fifteen conditions significantly contributed to the SIS. As SIS value increases, risk progressively increases, being odds of SARS-CoV-2 infection among people with the highest SIS value (SIS = 4) 1.74 times higher than those unaffected by any SIS contributing conditions (SIS = 1).

CONCLUSION

Conditions and diseases making people more vulnerable to SARS-CoV-2 infection were identified by the current study. Our results support decision-makers in identifying high-risk people and adopting of preventive measures to minimize the spread of further epidemic waves.

Effect of patient and treatment factors on persistence with antihypertensive treatment: A population-based study

Purpose

To analyze patterns of antihypertensive drug use among new users in a Southern European population, and identify patient- and treatment-related factors that influence persistence.

Methods

This is a retrospective observational study of new antihypertensive drug users aged ≥40 years in Aragón, Spain. Information on antihypertensive drugs (2014–2016) prescribed and dispensed at pharmacies via the public health system were collected from a regional electronic population-based pharmacy database. Persistence was assessed using the gap method. Kaplan-Meier and Cox regression analyses were conducted to analyze patterns of use and factors that influence persistence.

Results

The 25,582 new antihypertensive drug users in Aragón during the study period were prescribed antihypertensive drugs in monotherapy (73.3%), fixed combination (13.9%), free combination (9.1%), or other (3.7%). One in five received antihypertensive drugs within 15 days of the prescription date, but not after. During the first year of follow-up, 38.6% of the study population remained persistent. The likelihood of treatment discontinuation was higher for participants who were male, aged ≥80 years, and received an antihypertensive drug in monotherapy compared with fixed combination.

Conclusion

Overall persistence with antihypertensive therapy was poor, and was influenced by the sex, age and type of therapy. Fixed combinations appear to be a good choice for initial therapy, especially in patients with a higher risk of discontinuation. Nonetheless, adverse drug effects and the patient’s preferences and clinical profile should be taken into account.

New Male Users of Lipid-Lowering Drugs for Primary Prevention of Cardiovascular Disease: The Impact of Treatment Persistence on Morbimortality. A Longitudinal Study

The objective of this study was to analyse persistence to lipid-lowering drug use for primary prevention of cardiovascular disease (CVD) in a new users cohort, to explore all-cause and cardiovascular related morbidity, comorbidity and mortality in this group and, finally, to study the relationship between persistence and morbimortality. We selected subjects who started lipid-lowering treatment for primary prevention of CVD between 1 January 2010 and 31 December 2017 (N = 1424), and classified them as treatment-persistent or -nonpersistent. Bivariate analyses were performed to compare sociodemographic and clinical variables, morbimortality and time to event between groups. The association between morbidities was explored using comorbidity network analysis. The effect of persistence was analysed using logistic regression and Cox survival analyses. Only 38.7% of users were persistent with treatment. Persistent and nonpersistent users had similar sociodemographic and clinical profiles, although differed in age, smoking status, and glycemia. Comorbidity networks revealed that the number of co-occurring diagnoses was higher in nonpersistent than persistent users. Adjusted analyses indicated a protective effect of treatment persistence, especially against major adverse cardiovascular events (MACE), but this effect was not statistically significant. Observational studies are crucial to characterize real-world effectiveness.

The Need to Develop Standard Measures of Patient Adherence for Big Data: Viewpoint

Despite half a century of dedicated studies, medication adherence remains far from perfect, with many patients not taking their medications as prescribed. The magnitude of this problem is rising, jeopardizing the effectiveness of evidence-based therapies. An important reason for this is the unprecedented demographic change at the beginning of the 21st century. Aging leads to multimorbidity and complex therapeutic regimens that create a fertile ground for nonadherence. As this scenario is a global problem, it needs a worldwide answer. Could this answer be provided, given the new opportunities created by the digitization of health care? Daily, health-related information is being collected in electronic health records, pharmacy dispensing databases, health insurance systems, and national health system records. These big data repositories offer a unique chance to study adherence both retrospectively and prospectively at the population level, as well as its related factors. In order to make full use of this opportunity, there is a need to develop standardized measures of adherence, which can be applied globally to big data and will inform scientific research, clinical practice, and public health. These standardized measures may also enable a better understanding of the relationship between adherence and clinical outcomes, and allow for fair benchmarking of the effectiveness and cost-effectiveness of adherence-targeting interventions. Unfortunately, despite this obvious need, such standards are still lacking. Therefore, the aim of this paper is to call for a consensus on global standards for measuring adherence with big data. More specifically, sound standards of formatting and analyzing big data are needed in order to assess, uniformly present, and compare patterns of medication adherence across studies. Wide use of these standards may improve adherence and make health care systems more effective and sustainable.

Geographical Variation in Medication Prescriptions: A Multiregional Drug-Utilization Study

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.

Gender Differences in Medication Use: A Drug Utilization Study Based on Real World Data

A gender-specific drug utilization study was performed in the Campania region, Southern Italy. Data were based on outpatient drug prescriptions collected from administrative databases. The study population included all patients with at least one drug prescription in 2018. Prevalence was used as a measure to estimate the degree of exposure to drugs. A total of 3,899,360 patients were treated with at least one drug (54.2% females). The number of prescriptions was higher in females than males (55.6% vs. 44.4%). Females recorded higher prevalence for the majority of therapeutic groups (ATC II-anatomical therapeutic chemical), as well as for anti-inflammatory and antirheumatic products drugs (M01) (25.6% vs. 18.7%, risk ratio (RR): 0.73), beta blocking agents (C07) (14.5% vs. 11.6%, RR: 0.80), psychoanaleptics (N06) (7.1% vs. 3.7%, RR: 0.52), and antianemic preparations (B03) (2.8% vs. 6.7%, RR: 0.4). Higher prevalence was identified for males only for drugs used in diabetes (A10) (6.8% vs. 6.2%, RR: 1.1), particularly for biguanides (A10BA). Conversely, treatment duration was longer among males, explaining the higher mean cost per treated patient. This real-world study showed substantial gender differences in terms of medication use and duration of treatment and costs. These results are relevant to promoting and supporting the emerging role of precision and personalized medicine.

Initial Therapy, Regimen Change, and Persistence in a Spanish Cohort of Newly Treated Type 2 Diabetes Patients: A Retrospective, Observational Study Using Real-World Data

The World Health Organization considers the non-adherence to medication a significant issue with global impact, especially in chronic conditions such as type 2 diabetes. We aim to study antidiabetic treatment initiation, add-on, treatment switching, and medication persistence. We conducted an observational study on 4247 individuals initiating antidiabetic treatment between 2013 and 2014 in the EpiChron Cohort (Spain). We used Cox regression models to estimate the likelihood of non-persistence after a one-year follow-up, expressed as hazard ratios (HRs). Metformin was the most frequently used first-line antidiabetic (80% of cases); combination treatment was the second most common treatment in adults aged 40-79 years, while dipeptidyl peptidase-4 inhibitors were the second most common in individuals in their 80s and over, and in patients with renal disease. Individuals initiated on metformin were less likely to present addition and switching events compared with any other antidiabetic. Almost 70% of individuals initiated on monotherapy were persistent. Subjects aged 40 and over (HR 0.53-0.63), living in rural (HR 0.79) or more deprived areas (HR 0.77-0.82), or receiving polypharmacy (HR 0.84), were less likely to show discontinuation. Our findings could help identify the population at risk of discontinuation, and offer them closer monitoring for proper integrated management to improve prognosis and health outcomes.

Managing Allergic Rhinitis in the Pharmacy: An ARIA Guide for Implementation in Practice

The paradigm of how we manage allergic rhinitis is shifting with a growing understanding that it is a complex process, requiring a coordinated effort from healthcare providers and patients. Pharmacists are key members of these integrated care pathways resolving medication-related problems, optimizing regimens, improving adherence and recommending therapies while establishing liaisons between patients and physicians. Community pharmacists are the most accessible healthcare professionals to the public and allergic rhinitis is one of the most common diseases managed by pharmacists. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines developed over the past 20 years have improved the care of allergic rhinitis patients through an evidence-based, integrated care approach. In this paper, we propose an integrated approach to allergic rhinitis management in community pharmacy following the 2019 ARIA in the pharmacy guidelines.

Relationship between symptom burden, medication adherence and spiritual well-being in patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

To investigate the relationship between symptom burden, medication adherence and spiritual well-being in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

The relationship between spirituality and medication adherence has been investigated in different chronic conditions. However, the relationship between symptom burden, medication adherence and spiritual well-being in patients with COPD has not been explored.

DESIGN

A descriptive correlational study design was adopted.

METHODS

A total of 112 patients with COPD were included in the study. Data were collected using the COPD Assessment Test (CAT), the Adherence to Refills and Medications Scale-7 (ARMS-7) and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp). The data were analysed using descriptive and correlational statistics. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) Checklist was used.

RESULTS

The CAT score was significantly higher in patients on long-term oxygen therapy and those who had more than three comorbid conditions (p < .05). The mean score of ARMS-7 was significantly associated with age (p < .05). Current smokers had higher ARMS-7 and lower FACIT-Sp scores (p < .001). The FACIT-Sp score was negatively and moderately associated with the CAT and ARMS-7 scores (p < .001).

CONCLUSION

This study concluded that individuals with higher spiritual well-being had lower symptom burden and higher medication adherence. The need for long-term oxygen therapy and a high number of comorbid conditions were associated with increased symptom burden. Current smokers had lower spiritual well-being and medication adherence.

RELEVANCE TO CLINICAL PRACTICE

Spiritual well-being should be evaluated when assessing symptom burden and medication adherence in clinical practice. In addition, further studies examining the causal relationship between symptom burden, spiritual well-being and medication adherence in different populations are warranted.

In Vitro Characterization, Modelling, and Antioxidant Properties of Polyphenon-60 from Green Tea in Eudragit S100-2 Chitosan Microspheres

Eudragit S100-coated chitosan microspheres (S100Ch) are proposed as a new oral delivery system for green tea polyphenon-60 (PP60). PP60 is a mixture of polyphenolic compounds, known for its active role in decreasing oxidative stress and metabolic risk factors involved in diabetes and in other chronic diseases. Chitosan-PP60 microspheres prepared by an emulsion cross-linking method were coated with Eudragit S100 to ensure the release of PP60 in the terminal ileum. Different core–coat ratios of Eudragit and chitosan were tested. Optimized chitosan microspheres were obtained with a chitosan:PP60 ratio of 8:1 (Ch-PP60_8:1), rotation speed of 1500 rpm, and surfactant concentration of 1.0% (m/v) achieving a mean size of 7.16 µm. Their coating with the enteric polymer (S100Ch-PP60) increased the mean size significantly (51.4 µm). The in vitro modified-release of PP60 from S100Ch-PP60 was confirmed in simulated gastrointestinal conditions. Mathematical fitting models were used to characterize the release mechanism showing that both Ch-PP60_8:1 and S100Ch-PP60 fitted the Korsmeyers–Peppas model. The antioxidant activity of PP60 was kept in glutaraldehyde-crosslinked chitosan microspheres before and after their coating, showing an IC₅₀ of 212.3 µg/mL and 154.4 µg/mL, respectively. The potential of chitosan microspheres for the delivery of catechins was illustrated, with limited risk of cytotoxicity as shown in Caco-2 cell lines using the 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. The beneficial effects of green tea and its derivatives in the management of metabolic disorders can be exploited using mucoadhesive chitosan microspheres coated with enteric polymers for colonic delivery.

An Updated Overview on Nanonutraceuticals: Focus on Nanoprebiotics and Nanoprobiotics

Over the last few years, the application of nanotechnology to nutraceuticals has been rapidly growing due to its ability to enhance the bioavailability of the loaded active ingredients, resulting in improved therapeutic/nutraceutical outcomes. The focus of this work is nanoprebiotics and nanoprobiotics, terms which stand for the loading of a set of compounds (e.g., prebiotics, probiotics, and synbiotics) in nanoparticles that work as absorption enhancers in the gastrointestinal tract. In this manuscript, the main features of prebiotics and probiotics are highlighted, together with the discussion of emerging applications of nanotechnologies in their formulation. Current research strategies are also discussed, in particular the promising use of nanofibers for the delivery of probiotics. Synbiotic-based nanoparticles represent an innovative trend within this area of interest. As only few experimental studies on nanoprebiotics and nanoprobiotics are available in the scientific literature, research on this prominent field is needed, covering effectiveness, bioavailability, and safety aspects.

Nanopharmaceutics: Part II-Production Scales and Clinically Compliant Production Methods

Due the implementation of nanotechnologies in the pharmaceutical industry over the last few decades, new type of cutting-edge formulations-nanopharmaceutics-have been proposed. These comprise pharmaceutical products at the nanoscale, developed from different types of materials with the purpose to, e.g., overcome solubility problems of poorly water-soluble drugs, the pharmacokinetic and pharmacodynamic profiles of known drugs but also of new biomolecules, to modify the release profile of loaded compounds, or to decrease the risk of toxicity by providing site-specific delivery reducing the systemic distribution and thus adverse side effects. To succeed with the development of a nanopharmaceutical formulation, it is first necessary to analyze the type of drug which is to be encapsulated, select the type matrix to load it (e.g., polymers, lipids, polysaccharides, proteins, metals), followed by the production procedure. Together these elements have to be compatible with the administration route. To be launched onto the market, the selected production method has to be scaled-up, and quality assurance implemented for the product to reach clinical trials, during which in vivo performance is evaluated. Regulatory issues concerning nanopharmaceutics still require expertise for harmonizing legislation and a clear understanding of clinically compliant production methods. The first part of this study addressing "Nanopharmaceutics: Part I-Clinical trials legislation and Good Manufacturing Practices (GMP) of nanotherapeutics in the EU" has been published in Pharmaceutics. This second part complements the study with the discussion about the production scales and clinically compliant production methods of nanopharmaceutics.

Nanopharmaceutics: Part I-Clinical Trials Legislation and Good Manufacturing Practices (GMP) of Nanotherapeutics in the EU

The latest advances in pharmaceutical technology are leading to the development of cutting edged approaches to produce what is now known as the “Holy Grail” of medicine—nanopharmaceutics. Over the latest decade, the pharmaceutical industry has made important contributions to the scale up of these new products. To ensure their quality, efficacy, and safety for human use, clinical trials are mandatory. Yet, regulation regarding nanopharmaceuticals is still limited with a set of guidelines being recently released with respect to compliance with quality and safety. For the coming years, updates on regulatory issues about nanopharmaceuticals and their use in clinical settings are expected. The use of nanopharmaceuticals in clinical trials depends on the approval of the production methods and assurance of the quality of the final product by implementation and verification of the good manufacturing practices (GMP). This review addresses the available legislation on nanopharmaceuticals within the European Union (EU), the GMP that should be followed for their production, and the current challenges encountered in clinical trials of these new formulations. The singular properties of nanopharmaceuticals over their bulk counterparts are associated with their size, matrix composition, and surface properties. To understand their relevance, four main clinical trial guidelines, namely, for intravenous iron-based nanopharmaceuticals, liposomal-based nanopharmaceuticals, block copolymer micelle-based nanopharmaceuticals, and related to surface coating requirements, are described here.

Lignans: Quantitative Analysis of the Research Literature

The current study provides a comprehensive overview and analysis of the lignan literature. Data for the current study were extracted from the electronic Web of Science Core Collection database via the search string TOPIC = ("lignan*") and processed by the VOSviewer software. The search yielded 10,742 publications. The ratio of original articles to reviews was 14.6:1. Over 80% of the analyzed papers have been published since the year 2000 and nearly 50% since the year 2010. Many of the publications were focused on pharmacology, chemistry, and plant sciences. The United States and Asian countries, such as China, Japan, South Korea, and India, were the most productive producers of lignan publications. Among the 5 most productive institutions was the University of Helsinki in Finland, the country that ranked 9^th. Nineteen journals collectively published 3,607 lignan publications and were considered as core journals. Their impact factor did not correlate with the proportion of uncited papers. Highly cited publications usually mentioned phytoestrogen, isoflavone, daidzein, enterodiol, enterolactone, equol, genistein, and isoflavonoid. Cancer (e.g., breast cancer), cardiovascular disease, and antioxidation were the major themes. Clinical trials were estimated to contribute to 0.2-1.1% of the analyzed body of literature, so more of them should be conducted in the future to substantiate the beneficial effects and optimal dose of lignan intake in humans. Moreover, researchers can refer to these findings for future research directions and collaborations.

Sucupira Oil-Loaded Nanostructured Lipid Carriers (NLC): Lipid Screening, Factorial Design, Release Profile, and Cytotoxicity

Essential oils are odorant liquid oily products consisting of a complex mixture of volatile compounds obtained from a plant raw material. They have been increasingly proven to act as potential natural agents in the treatment of several human conditions, including diabetes mellitus (DM). DM is a metabolic disorder characterized by chronic hyperglycemia closely related to carbohydrate, protein and fat metabolism disturbances. In order to explore novel approaches for the management of DM our group proposes the encapsulation of sucupira essential oil, obtained from the fruits of the Brazilian plants of the genus Pterodon, in nanostructured lipid carriers (NLCs), a second generation of lipid nanoparticles which act as new controlled drug delivery system (DDS). Encapsulation was performed by hot high-pressure homogenization (HPH) technique and the samples were then analyzed by dynamic light scattering (DLS) for mean average size and polydispersity index (PI) and by electrophoretic light scattering (ELS) for zeta potential (ZP), immediately after production and after 24 h of storage at 4 °C. An optimal sucupira-loaded NLC was found to consist of 0.5% (m/V) sucupira oil, 4.5% (m/V) of Kollivax^® GMS II and 1.425% (m/V) of TPGS (formulation no. 6) characterized by a mean particle size ranging from 148.1 ± 0.9815 nm (0 h) to 159.3 ± 9.539 nm (at 24 h), a PI from 0.274 ± 0.029 (0 h) to 0.305 ± 0.028 (24 h) and a ZP from −0.00236 ± 0.147 mV (at 0 h) to 0.125 ± 0.162 (at 24 h). The encapsulation efficiency and loading capacity were 99.98% and 9.6%, respectively. The optimized formulation followed a modified release profile fitting the first order kinetics, over a period of 8 h. In vitro cytotoxicity studies were performed against Caco-2 cell lines, for which the cell viability above 90% confirmed the non-cytotoxic profile of both blank and sucupira oil-loaded NLC.

Drug Utilization Pattern of Antibiotics: The Role of Age, Sex and Municipalities in Determining Variation

Purpose

The purpose was to analyze drug prescription and antibiotic use by age and sex in Italy’s Campania Region, and to estimate the distribution of prescription rates in children (≤14 years old), adults (between 15 and 65 years old), and older adults (≥65 years old) at a municipality level.

Methods

This was a retrospective analysis of pharmacy records in Campania (Southern Italy), in 2016. Difference in antibiotic prescriptions in different age groups was assessed by prevalence rates. Age-adjusted prevalence rates were categorized into quintiles and mapped by the patient’s municipality of residence. Relationship between prevalence rates for the different age groups was estimated using the non-parametric Spearman rank correlation test.

Results

There were 2,738,118 were patients with at least one antibiotic prescription. Antibiotics prescription was higher in children aged <5 years and in the older adults aged >70 years. Prevalence rate distribution was different among municipalities in all age groups. A positive correlation between the rank distribution of prevalence rates at municipality level was identified for children and adults (rs=0.56; P<0.01), adults and the older adults (rs=0.79; P<0.01), and children and the older adults (rs=0.46; P<0.01). Among the studied age groups, the most prescribed antibiotic class was penicillin (except the older adults aged ≥85 years) ranging from 45% in children to 27.2% in the older adults. Fluoroquinolones were the least prescribed antibiotic class, ranging from 0.2% in children to 30.2% in the older adults.

Conclusion

A considerably high use of antibiotic drugs has been detected in Campania Region, with values exceeding the regional and national average. Prescriptions at municipal level differ from one age group to another. Antibiotic use is often unjustified, and to decrease the number of prescriptions and improve their appropriateness, several measures at territorial level are recommended.

Multiple Cell Signalling Pathways of Human Proinsulin C-Peptide in Vasculopathy Protection

A major hallmark of diabetes is a constant high blood glucose level (hyperglycaemia), resulting in endothelial dysfunction. Transient or prolonged hyperglycemia can cause diabetic vasculopathy, a secondary systemic damage. C-Peptide is a product of cleavage of proinsulin by a serine protease that occurs within the pancreatic β-cells, being secreted in similar amounts as insulin. The biological activity of human C-peptide is instrumental in the prevention of diabetic neuropathy, nephropathy and other vascular complications. The main feature of type 1 diabetes mellitus is the lack of insulin and of C-peptide, but the progressive β-cell loss is also observed in later stage of type 2 diabetes mellitus. C-peptide has multifaceted effects in animals and diabetic patients due to the activation of multiple cell signalling pathways, highlighting p38 mitogen-activated protein kinase and extracellular signal-regulated kinase ½, Akt, as well as endothelial nitric oxide production. Recent works highlight the role of C-peptide in the prevention and amelioration of diabetes and also in organ-specific complications. Benefits of C-peptide in microangiopathy and vasculopathy have been shown through conservation of vascular function, and also in the prevention of endothelial cell death, microvascular permeability, neointima formation, and in vascular inflammation. Improvement of microvascular blood flow by replacing a physiological amount of C-peptide, in several tissues of diabetic animals and humans, mainly in nerve tissue, myocardium, skeletal muscle, and kidney has been described. A review of the multiple cell signalling pathways of human proinsulin C-peptide in vasculopathy protection is proposed, where the approaches to move beyond the state of the art in the development of innovative and effective therapeutic options of diabetic neuropathy and nephropathy are discussed.

New Nanotechnologies for the Treatment and Repair of Skin Burns Infections

Burn wounds are highly debilitating injuries, with significant morbidity and mortality rates worldwide. In association with the damage of the skin integrity, the risk of infection is increased, posing an obstacle to healing and potentially leading to sepsis. Another limitation against healing is associated with antibiotic resistance mainly due to the use of systemic antibiotics for the treatment of localized infections. Nanotechnology has been successful in finding strategies to incorporate antibiotics in nanoparticles for the treatment of local wounds, thereby avoiding the systemic exposure to the drug. This review focuses on the most recent advances on the use of nanoparticles in wound dressing formulations and in tissue engineering for the treatment of burn wound infections.

Patient Centric Pharmaceutical Drug Product Design-The Impact on Medication Adherence

Medication adherence is a growing concern for public health and poor adherence to therapy has been associated with poor health outcomes and higher costs for patients. Interventions for improving adherence need to consider the characteristics of the individual therapeutic regimens according to the needs of the patients. In particular, geriatric and paediatric populations as well as dermatological patients have special needs/preferences that should be considered when designing drug products. Patient Centric Drug Product Pharmaceutical Design (PCDPD) offers the opportunity to meet the needs and preferences of patients. Packaging, orodispersible formulations, fixed dose combinations products, multiparticulate formulations, topical formulations and 3D printing are of particular relevance in a PCDPD process. These will be addressed in this review as well as their impact on medication adherence.

Nanoparticle Delivery Systems in the Treatment of Diabetes Complications

Diabetes mellitus, an incurable metabolic disease, is characterized by changes in the homeostasis of blood sugar levels, being the subcutaneous injection of insulin the first line treatment. This administration route is however associated with limited patient's compliance, due to the risk of pain, discomfort and local infection. Nanoparticles have been proposed as insulin carriers to make possible the administration of the peptide via friendlier pathways without the need of injection, i.e., via oral or nasal routes. Nanoparticles stand for particles in the nanometer range that can be obtained from different materials (e.g., polysaccharides, synthetic polymers, lipid) and are commonly used with the aim to improve the physicochemical stability of the loaded drug and thereby its bioavailability. This review discusses the use of different types of nanoparticles (e.g., polymeric and lipid nanoparticles, liposomes, dendrimers, niosomes, micelles, nanoemulsions and also drug nanosuspensions) for improved delivery of different oral hypoglycemic agents in comparison to conventional therapies.

Transferrin-Conjugated Docetaxel-PLGA Nanoparticles for Tumor Targeting: Influence on MCF-7 Cell Cycle

Targeted drug delivery systems are commonly used to improve the therapeutic index of anti-cancer drugs by increasing their selectivity and reducing systemic distribution and toxicity. Ligand-conjugated nanoparticles (NPs) can be effectively applied for active chemotherapeutic targeting to overexpressed receptors of tumor cells. In this study, transferrin (Tf) was successfully conjugated with poly-l-lactic-co-glycolic acid (PLGA) using ethylene diamine confirmed by NMR, for the loading of docetaxel trihydrate (DCT) into PLGA nanoparticles (NPs). The DCT-loaded Tf-conjugated PLGA NPs were produced by an emulsion-solvent evaporation technique, and a 3² full factorial design was used to optimize the nanoparticle formulations. The DCT-loaded Tf-conjugated PLGA NPs were characterized by FTIR spectroscopy, differential scanning calorimetry, powder X-ray diffraction (PXRD), TEM, particle size, and zeta potential analysis. In vitro release kinetics confirmed that release of DCT from the designed formulations followed a zero-order kinetics and a diffusion controlled non-Fickian release profile. The DCT-loaded Tf-conjugated PLGA NPs were evaluated in vitro in MCF-7 cells for bioactivity assessment. Cytotoxicity studies confirmed that the Tf-conjugated PLGA NPs were more active than the non-conjugated counterparts. Cell uptake studies re-confirmed the ligand-mediated active targeting of the formulated NPs. From the cell cycle analysis, the anti-cancer activity of DCT-loaded Tf-conjugated PLGA NPs was shown to occur by arresting the G₂/M phase.

Human health-related properties of chromones: an overview

Natural compounds occurring throughout the world are scientifically and practically valuable because of their unique and beneficial properties to control a wide range of disorders in the human body. Chromones are attracting increasing attention as novel therapeutic agents due to their effective bioactivities for human health. Accordingly, the present overview article was designed to scan the biological and pharmacological performance of chromones, including their anti-inflammatory, anticancer, anti-oxidant, and anti-microbial activities.

Sirtuins and SIRT6 in Carcinogenesis and in Diet

Sirtuins are a highly conserved family of nicotinamide adenine dinucleotide (NAD)-dependent protein lysine modifying enzymes. They are key regulators for a wide variety of cellular and physiological processes such as cell proliferation, differentiation, DNA damage and stress response, genome stability, cell survival, metabolism, energy homeostasis, organ development and aging. Aging is one of the major risk factors of cancer, as many of the physiological mechanisms and pathologies associated with the aging process also contribute to tumor initiation, growth and/or metastasis. This review focuses on one the mammalian sirtuins, SIRT6, which has emerged as an important regulator of longevity and appears to have multiple biochemical functions that interfere with tumor development and may be useful in cancer prevention and for site-specific treatment. The recent evidence of the role of SIRT6 in carcinogenesis is also discussed, focusing on the potential use of SIRT6 modulators in cancer nanomedicine.

Factors Associated With Medication Adherence In Elderly Retired Outpatients In São Paulo, Brazil

OBJECTIVE

To evaluate medication adherence and associated socioeconomic factors in elderly Brazilians.

METHODOLOGY

This observational study was conducted with 159 elderly retired in an outpatient clinic in the city of São Paulo. Treatment adherence was assessed with the questions from the Morisky Green Levine Medication Adherence Questionnaire, and medications were classified using the Anatomical Therapeutic Chemical system. Statistical tests and adjusted Poisson regression models were used to analyze variables.

RESULTS

The study population was mostly female (67.5%), had an average age of, and took an average of 6.5 medications per day. The most commonly used drugs were agents acting on the renin-angiotensin system (67.9%), statins (62.3%), antithrombotic agents (48.4%), and biguanides (37.1%) for the treatment of hypertension (76.7%), dyslipidemia (54.1%), and diabetes (47.8%). The rate of adherence was below 60% in the groups of participants that were analyzed except for the high household income category, which had a rate of 75.8%.

CONCLUSION

Medication adherence among the elderly was low in all categories except for the high household income category, a relevant finding that will help to understand medication adherence patterns in elderly Brazilians.

Treatment Patterns of Diabetes in Italy: A Population-Based Study

Background: The steady increase in type 2 diabetes prevalence and the availability of new antidiabetic drugs (AD) have risen the use of these drugs with a change in the patterns of specific drug utilization. The complexity of this treatment is due to successive treatment initiation, switching and addition in order to maintain glycaemic control. The aim of this study was to describe the utilization patterns of ADs at initiation, treatment addition, and switching profiles and to measure factors influencing persistence to therapy.

Methods: Retrospective observational study. Data were retrieved from the Campania Regional Database for Medication Consumption. Population consisted of patients receiving at least one prescription of ADs between January 1 and December 31, 2016. We calculated time to treatment switching or add-on as median number of days and interquartile range (IQR). Persistence rates were estimated using the Kaplan–Meier method. We used Cox regression models to estimate the likelihood of non-persistence over 1 year of follow-up. Hazard ratios and 95% confidence intervals were calculated.

Results: Of 14,679 patients, 86.9% started with monotherapy and 13.1% with combination therapy. Most common initial treatment was metformin in both monotherapy and combination therapy. First-line prescription of sulfonylurea was observed in 6.9% of patients aged 60–79 years and in 10.8% of patients aged ≥80 years. Patients starting with metformin showed fewer treatment modifications (10.4%) compared to patients initiating with sulfonylureas (35.2%). Newer ADs were utilized during treatment progression. Patients who initiated with sulfonylurea were approximately 70% more likely to discontinue treatment compared to those initiated on metformin. Oldest age group (≥80 years) was more likely to be non-persistent, and likelihood of non-persistence was highest in polymedicated patients. Patients changing therapy were more likely to be persistent.

Conclusions: Our results show that treatment of T2D in Italy is consistent with clinical guidelines. Even if newer ADs were utilized during disease progression, they seem not to be preferred in patients with a higher comorbidity score, although these patients could benefit from this kind of treatment. Our study highlights patients’ characteristics that might help identify those who would benefit from counselling from their health-care practitioner on better AD usage.

Prescribing pattern of antihypertensive drugs in two European cohorts: a population-based database study

Background: Antihypertensive drugs play a crucial role in reducing cardiovascular morbidity and mortality. Variability in prescribing patterns constitutes a major challenge for current healthcare systems. This study aimed to compare patterns of use of antihypertensives in general practice in two southern European populations. Methods: Observational study. Data on antihypertensive drugs consumption in primary care setting (2016) were obtained from pharmacy refill records in Campania (Italy) and Aragon (Spain). Prescribing rates and the number of defined daily doses [DDD/1,000 inhabitants/day (DID)] were calculated, and the Drug Utilization 90% (DU90%) approach used to reveal differences in prescribing patterns in both regions. Results: Antihypertensive prescribing rates in Campania and Aragon were 250.8 (95%CI: 250.2-251.3) and 201.7 (95%CI: 200.9-202.5) users/1,000 inhabitants/year. Overall consumption was of 310.1 and 256.8 DID, respectively. Spanish users, especially women and the elderly, consumed a greater volume of diuretics. Conversely, other therapeutic subgroups were more consumed in Campania. However, the most prescribed subgroups accounted for comparable proportions of the total consumption in each region. Conclusions: Both prescribing rates and intensity of antihypertensive use were higher in Campania. Pharmacy refill records in cross-country comparisons allow to know the factors influencing variability in prescribing habits with a view to improving prescribing quality.