Current Knowledge about Providing Drug-Drug Interaction Services for Patients-A Scoping Review

Exploring the need for a clinical decision support system for deprescribing - A qualitative interview study

Background

Deprescribing (i.e., the process of discontinuing an inappropriate medication) requires time, knowledge, and care, but there is a lack of education, support, and guidelines for this important clinical task. A clinical decision support system (CDSS) aims to influence the quality of care by combining structured medical knowledge with patient-specific information to generate recommendations.

Objective

The objective was to examine the need to develop a CDSS for drug deprescribing. Furthermore, this study aimed to examine the obstacles to deprescribing and potential users' requirements for a CDSS for deprescribing.

Methods

The qualitative design consisted of semistructured interviews with physicians (n = 10) in Sweden from different disciplines, including geriatrics, primary care and internal medicine. The interviews were conducted using a predefined guide containing multiple questions about any challenges related to deprescribing and the perceived need for a CDSS. A qualitative content analysis was performed to analyse the empirical data.

Results

The interviews provided several aspects of the difficulty of deprescribing medicines. The structure and usability of the CDSS knowledge database in clinical practice needs to be ensured from the outset. Physicians needs fast, simple and up-to-date information filtered, summarized and synthesized from reliable sources. The information should preferably be integrated into pre-existing electronic health record.

Conclusion

There is a need to develop a CDSS for deprescribing. There is little, if any, guidelines or support for deprescribing, which is regarded as a large obstacle. The current findings contribute to further knowledge regarding the perspective of physicians when deprescribing medication.

Challenges and barriers to physician decision-making for prescribing and deprescribing among patients with multimorbidity in eastern China's primary care settings: a qualitative study

OBJECTIVES

Patients with multimorbidity have an increased risk of medication-related problems. Physicians face the dilemmas of multimorbidity management with multiple medications in primary care settings. We aimed to investigate the experiences and perceptions of primary care physicians (PCPs) regarding their decision-making processes in prescribing and deprescribing medications for patients with multimorbidity, and identify the challenges and barriers they face.

DESIGN

From 5 October 2023 to 27 January 2024, this qualitative study was conducted through semi-structured interviews that encouraged in-depth exploration of the participants' experiences and perspectives. The interviews were audio-recorded, transcribed verbatim, and independently coded by two investigators. Themes were developed using a conventional content analysis approach.

SETTING

12 community health centers and 8 township health centers across four regions in eastern China were included.

PARTICIPANTS

26 PCPs from 20 primary care institutions in eastern China were interviewed through purposive sampling, representing a mix of urban and rural healthcare settings.

RESULTS

Of the 26 participants in this study, 14 (53.8%) were women, and the mean age was 36.3 years old. When prescribing and stopping medications for patients with multimorbidity, they often encounter complex challenges. These challenges stemmed from three key areas: (1) difficulties in identifying drug-disease and drug-drug interactions; (2) cognitive biases in medication benefit-risk evaluation and (3) heavy treatment burden. The challenges were further compounded by multiple barriers, including clinical inertia among physicians, patient resistance to medication changes, inadequate decision support and training, and time constraints in clinical consultation.

CONCLUSIONS

The complexity of prescribing and deprescribing decisions faced by PCPs in treating patients with multimorbidity in China is influenced by interconnected factors related to physicians, patients, technology and working environment. Future research could develop and evaluate implementation strategies to address specific challenges and barriers to allow PCPs to make effective medication decisions for patients with multimorbidity.

Managing drug therapy-related problems and assessment of chronic diabetic wounds

Type 2 diabetes mellitus (T2DM), responsible for most diabetes cases recorded worldwide, increases the risk of chronic wounds and amputation. Patients with T2DM appear to be more susceptible to delayed wound healing due to their treatment adherence. This review explores the specifics of polypharmacy, side effects, possible drug interactions and the importance of medication adherence for therapeutic efficacy. We discuss the effects of anti-diabetes medications on wound healing as well as the role that biofilms and microbial infections play in diabetic wounds. Inconsistent use of medications can lead to poor glycaemic control, which negatively affects the healing process of diabetic foot ulcers. Managing chronic wounds represents a substantial portion of healthcare expenditures. Biofilm-associated infections are difficult for the immune system to treat and respond inconsistently to antibiotics as these infections are slow growing and persistent. Additionally, we emphasize the critical role pharmacists play in enhancing patient adherence and optimizing diabetes treatment by offering comprehensive coverage of drugs associated with problems related to pharmacological therapy in type 2 diabetes.

Deciphering the Intricate Interplay in the Framework of Antibiotic-Drug Interactions: A Narrative Review

Drug interactions are a significant and integral part of the concept of medication-related adverse events, whether referring to potential interactions or those currently observed in real-world conditions. The high global consumption of antibiotics and their pharmacokinetic and pharmacodynamic mechanisms make antibiotic-drug interactions a key element that requires continuous study due to their clinical relevance. In the present work, the current state of knowledge on antibiotic-drug interactions, which are less studied than other drug-drug interactions despite their frequent use in acute settings, has been consolidated and updated. The focus was on the interactions of the commonly used antibiotics in clinical practice, on the characteristics of the geriatric population susceptible to interactions, and on the impact of online drug interaction checkers. Additionally, strategies for optimizing the management of these interactions, including spacing out administrations, monitoring, or avoiding certain combinations, are suggested. Sustained research and careful monitoring are critical for improving antibiotic safety and efficacy, especially in susceptible populations, to enhance precision in managing antibiotic-drug interactions.

Potentially harmful drug-drug interactions in the therapeutic regimens of persons with spinal cord injury

OBJECTIVES

Individuals with spinal cord injury deal with multiple health complications that require them to use many medications. The purpose of this paper was to find the most common potentially harmful drug-drug interactions (DDIs) in therapeutic regimens of persons with spinal cord injury, and the risk factors associated with it. We further highlight the relevance of each of the DDIs specific to spinal cord injury population.

DESIGN

Observational design and cross-sectional analysis.

SETTING

Community; Canada.

PARTICIPANTS

Individuals with spinal cord injury (n = 108).

MAIN OUTCOME MEASURES/ANALYSIS

The main outcome was the presence of one or more potential DDIs that can lead to an adverse outcome. All the reported drugs were classified as per the World Health Organization's Anatomical Therapeutic Chemical Classification system. Twenty potential DDIs were selected for the analysis based on the most common medications prescribed to people with spinal cord injury and severity of clinical consequences. The medication lists of study participants were analyzed for selected DDIs.

RESULTS

Among the 20 potential DDIs analyzed in our sample, the top 3 prevalent DDIs were Opioids + Skeletal Muscle Relaxants, Opioids + Gabapentinoids, and Benzodiazepines + ≥ 2 other central nervous system (CNS)-active drugs. Of the total sample of 108 respondents, 31 participants (29%) were identified with having at least one potential DDI. The risk of having a potential DDI was highly associated with polypharmacy, though no associations were found between the presence of a drug interaction and age, sex, level of injury, time since injury, or cause of injury among the study sample.

CONCLUSION

Almost three out of ten individuals with spinal cord injury were at risk of having a potentially harmful drug interaction. Clinical and communication tools are needed that facilitate identification and elimination of harmful drug combinations in the therapeutic regimens of patients with spinal cord injury.

Clinical Pharmacist-Led Interventions for Improving Breast Cancer Management-A Scoping Review

Breast cancer is the leading cause of cancer-related death in women worldwide and the fifth most common cause of cancer death overall. Most women with breast cancer have a good prognosis if the cancer is detected at an early stage and the patients have access to the appropriate treatment and disease management. This study aims to evaluate the impact of pharmacist-led interventions on breast cancer management and health outcomes. A literature review was carried out through the scientific databases PubMed, Scopus, and Web of Science using predefined keywords. Only full-text original articles written in English that investigated the role of the pharmacist in the management of breast cancer were included in the final analysis. No publication date limits were set. A total of 1625 articles were retrieved from the electronic databases, of which 14 met the inclusion criteria. The current scoping review consists of different study types, including randomized controlled trials, cross-sectional studies, pre-post studies, retrospective cohort studies, quality improvement projects, case-control studies, and one pharmacoeconomic study. Pharmacists commonly provided the following interventions: consultations regarding chemotherapy treatment, risk assessment and patient education, adverse drug reactions and drug-drug interactions detection, and adherence assessment. This scoping review highlights the beneficial effects of the involvement of pharmacists in breast cancer management, such as better quality of life, reduced drug interaction risk, greater adherence rates, and improved patient knowledge. This confirms the importance of including the pharmacist in the oncology team caring for patients with breast cancer.

Avapritinib Carries the Risk of Drug Interaction via Inhibition of UDP-Glucuronyltransferase (UGT) 1A1

BACKGROUND

Avapritinib is the only drug for adult patients with PDGFRA exon 18 mutated unresectable or metastatic gastrointestinal stromal tumor (GIST). Although avapritinib has been approved by the FDA for four years, little is known about the risk of drug-drug interactions (DDIs) via UDP-glucuronyltransferases (UGTs) inhibition.

OBJECTIVE

The aim of the present study was to systematically evaluate the inhibitory effects of avapritinib against UGTs and to quantitatively estimate its potential DDIs risk in vivo.

METHODS

Recombinant human UGTs were employed to catalyze the glucuronidation of substrates in a range of concentrations of avapritinib. The kinetics analysis was performed to evaluate the inhibition types of avapritinib against UGTs. The quantitative prediction of DDIs was done using in vitro-in vivo extrapolation (IVIVE).

RESULTS

Avapritinib had a potent competitive inhibitory effect on UGT1A1. Quantitative prediction results showed that avapritinib administered at clinical doses might result in a 14.85% increase in area under the curve (AUC) of drugs primarily cleared by UGT1A1. Moreover, the Rgut value was calculated to be 18.44.

CONCLUSION

Avapritinib has the potential to cause intestinal DDIs via the inhibition of UGT1A1. Additional attention should be paid when avapritinib is coadministered with UGT1A1 substrates.

Indirect and Direct 65+ Patient Reporting of Non-Steroidal Anti-Inflammatory Drug-Induced Adverse Drug Reactions as a Source of Information on Polypharmacy and Polypharmacy-Related Risk

Background and Objectives: Non-steroidal anti-inflammatory drugs (NSAIDs), which have anti-inflammatory and analgesic properties, are commonly used in the treatment of various, particularly frequent, as well as chronic, conditions in older patients. Due to common polypragmasia in these patients and a high risk of adverse drug reactions (ADRs) and drug interactions, pain management poses a therapeutic challenge. This study describes the importance of ADR reports in the identification of polypharmacy and the ensuing interactions. Materials and Methods: Both healthcare professionals (HPs) and non-healthcare professionals (non-HPs) reports collected in the EudraVigilance database of NSAIDs, including most commonly co-reported medications and reported reactions, were analysed and differences between HPs and non-HPs reports were identified. Results: In the analysed period and group, non-HPs reported more reactions but indicated fewer drugs as suspect or concomitant. The outcomes of our analysis indicate more HP engagement and more detailed reports of serious ADRs when compared to non-serious individual case safety reports (ICSRs) by non-HPs, which appeared more detailed. Such reactions as kidney failure and increased risk of bleeding are known adverse reactions to NSAIDs and common symptoms of their interactions, which were described in the available literature. They were much more frequently reported by HPs than by non-HPs. Non-HPs more frequently reported reactions that may have been considered less significant by HPs. Conclusions: The differences between healthcare professionals' (HPs) and non-healthcare professionals' (non-HPs) reports may result from the fact that the reports from patients and their caregivers require a professional medical diagnosis based on symptoms described by the patient or additional diagnostic tests. This means that when appropriately classified, medically verified, and statistically analysed, the data may provide new evidence for the risks of medication use or drug interactions.

Clinical relevance of potential self-medication drug interactions in antineoplastic and immune-modulating therapy among online pharmacy customers

Background

Modern oral antineoplastic and immune-modulating drugs offer an array of therapeutic advantages, and yet pose challenges in daily use for patients, physicians and pharmacists. In contrast to intravenous administration, these drugs are not subject to direct medical control. Recently, we have seen a huge rise in sales of non-prescription over-the-counter (OTC) medicines via the internet without any advice from a healthcare professional.

Objectives

The aim of this study was to investigate whether the risk of known potential drug-drug interactions between modern oral antineoplastic and immune-modulating drugs and OTC drugs differs between sales in traditional community pharmacies versus online pharmacies.

Design

Real-life sales data from community and online pharmacies were used as basis for the analysis.

Methods

We determined the most frequently purchased antineoplastic and immune-modulating drug-substances in 14 local community pharmacies within the Munich area, Germany and identified the OTC substance groups that could potentially cause interactions with oncological therapies. Using sales data from 11 local community pharmacies and three online pharmacies, we investigated whether OTC purchases differed between the two sales channels.

Results

We identified 10 relevant OTC substance classes and detected significant variations in patients' preferred sales channels between the drug classes. Certain OTC drugs, which seem to be bought more often over the internet, pose risks during antineoplastic and immune-modulating therapy.

Conclusion

Patients should therefore be proactively made aware of the corresponding risks in order not to jeopardize the activity of the antineoplastic and immune-modulating drugs and thus the success of their therapy.

Pharmaceutical Care Within Community Pharmacies: Tools Availability and Pharmacists' Views, Wad-Medani, Sudan

Background

Pharmaceutical Care (PhC) services within community pharmacies (CPs) have become a vital issue in many developed countries.

Purpose

This study assessed the availability of PhC tools and pharmacists' views towards PhC services within CPs in Sudan.

Methods

A cross-sectional study was conducted from December 2019 to August 2020 using a pretested self-administered questionnaire. The participants were 120 community pharmacists.

Results

Fifty-eight percent of respondents used to work in pharmacies near homes rather than within the marketplace. The study revealed that the overall tool availability of the assessed components and items was only 25% (Counselling areas 3%, Records 5%, Pharmacist identity 3%, Pharmacy phones 15%, Medical devices 38%, and Staff 29%). The result of pharmacists' views towards the PhC concept, roles, and responsibilities showed a high level of agreement, at 88%, with a statistically insignificant difference between participants.

Conclusion

Tools available within CPs were lower than required. However, pharmacists' views showed a high agreement level towards PhC concept roles and responsibilities. Community pharmacists, academic sectors, and regulatory authorities must start initiatives to improve the provision of PhC tools for better patient care service delivery.

Screening for severe drug-drug interactions in patients with multiple sclerosis: A comparison of three drug interaction databases

Background: Patients with multiple sclerosis (MS) often undergo complex treatment regimens, resulting in an increased risk of polypharmacy and potential drug-drug interactions (pDDIs). Drug interaction databases are useful for identifying pDDIs to support safer medication use. Objective: To compare three different screening tools regarding the detection and classification of pDDIs in a cohort of MS patients. Furthermore, we aimed at ascertaining sociodemographic and clinical factors that are associated with the occurrence of severe pDDIs. Methods: The databases Stockley's, Drugs.com and MediQ were used to identify pDDIs by screening the medication schedules of 627 patients. We determined the overlap of the identified pDDIs and the level of agreement in pDDI severity ratings between the three databases. Logistic regression analyses were conducted to determine patient risk factors of having a severe pDDI. Results: The most different pDDIs were identified using MediQ (n = 1,161), followed by Drugs.com (n = 923) and Stockley's (n = 706). The proportion of pDDIs classified as severe was much higher for Stockley's (37.4%) than for Drugs.com (14.4%) and MediQ (0.9%). Overall, 1,684 different pDDIs were identified by at least one database, of which 318 pDDIs (18.9%) were detected with all three databases. Only 55 pDDIs (3.3%) have been reported with the same severity level across all databases. A total of 336 pDDIs were classified as severe (271 pDDIs by one database, 59 by two databases and 6 by three databases). Stockley's and Drugs.com revealed 47 and 23 severe pDDIs, respectively, that were not included in the other databases. At least one severe pDDI was found for 35.2% of the patients. The most common severe pDDI was the combination of acetylsalicylic acid with enoxaparin, and citalopram was the drug most frequently involved in different severe pDDIs. The strongest predictors of having a severe pDDI were a greater number of drugs taken, an older age, living alone, a higher number of comorbidities and a lower educational level. Conclusions: The information on pDDIs are heterogeneous between the databases examined. More than one resource should be used in clinical practice to evaluate pDDIs. Regular medication reviews and exchange of information between treating physicians can help avoid severe pDDIs.

Mobile Health Apps Providing Information on Drugs for Adult Emergency Care: Systematic Search on App Stores and Content Analysis

Background

Drug-referencing apps are among the most frequently used by emergency health professionals. To date, no study has analyzed the quantity and quality of apps that provide information on emergency drugs.

Objective

This study aimed to identify apps designed to assist emergency professionals in managing drugs and to describe and analyze their characteristics.

Methods

We performed an observational, cross-sectional, descriptive study of apps that provide information on drugs for adult emergency care. The iOS and Android platforms were searched in February 2021. The apps were independently evaluated by 2 hospital clinical pharmacists. We analyzed developer affiliation, cost, updates, user ratings, and number of downloads. We also evaluated the main topic (emergency drugs or emergency medicine), the number of drugs described, the inclusion of bibliographic references, and the presence of the following drug information: commercial presentations, usual dosage, dose adjustment for renal failure, mechanism of action, therapeutic indications, contraindications, interactions with other medicinal products, use in pregnancy and breastfeeding, adverse reactions, method of preparation and administration, stability data, incompatibilities, identification of high-alert medications, positioning in treatment algorithms, information about medication reconciliation, and cost.

Results

Overall, 49 apps were identified. Of these 49 apps, 32 (65%) were found on both digital platforms; 11 (22%) were available only for Android, and 6 (12%) were available only for iOS. In total, 41% (20/49) of the apps required payment (ranging from €0.59 [US $0.64] to €179.99 [US $196.10]) and 22% (11/49) of the apps were developed by non–health care professionals. The mean weighted user rating was 4.023 of 5 (SD 0.71). Overall, 45% (22/49) of the apps focused on emergency drugs, and 55% (27/49) focused on emergency medicine. More than half (29/47, 62%) did not include bibliographic references or had not been updated for more than a year (29/49, 59%). The median number of drugs was 66 (range 4 to >5000). Contraindications (26/47, 55%) and adverse reactions (24/47, 51%) were found in only half of the apps. Less than half of the apps addressed dose adjustment for renal failure (15/47, 32%), interactions (10/47, 21%), and use during pregnancy and breastfeeding (15/47, 32%). Only 6% (3/47) identified high-alert medications, and 2% (1/47) included information about medication reconciliation. Health-related developer, main topic, and greater amount of drug information were not statistically associated with higher user ratings (P=.99, P=.09, and P=.31, respectively).

Conclusions

We provide a comprehensive review of apps with information on emergency drugs for adults. Information on authorship, drug characteristics, and bibliographic references is frequently scarce; therefore, we propose recommendations to consider when developing an app of these characteristics. Future efforts should be made to increase the regulation of drug-referencing apps and to conduct a more frequent and documented review of their clinical content.