NSAID-avoidance education in community pharmacies for patients at high risk for acute kidney injury, upstate New York, 2011

Evaluation of the knowledge, practices, and attitudes of community pharmacists towards adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs): a cross-sectional study

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used over-the-counter medications for the treatment of pain, fever, and inflammation. Gastrointestinal problems and renal complications are the most frequently observed adverse effects associated with NSAID usage. Therefore, this study aims to evaluate the levels of knowledge, attitude, and practice regarding the adverse effects of non-prescription NSAIDs among community pharmacists in Egypt.

METHODS

A 4-month cross-sectional survey, including licenced community pharmacists in Egypt, was conducted. The anonymous Google Forms survey was accompanied by a cover letter explaining its purpose. The survey link was sent to 2000 verified community pharmacist email addresses with clear instructions to complete and submit the questionnaire within 3 weeks. Descriptive and inferential statistical analyses were conducted using IBM-SPSS version 26. The means of variables were compared using analysis of variance test. Pearson correlation was employed to assess the level of linear association between the overall knowledge, practice, and attitude scores. P-value ≤ 0.05 was considered statistically significant.

RESULTS

Approximately 80% of community pharmacists in Egypt exhibit moderate-to-good knowledge regarding the adverse effects of NSAIDs. Additionally, 60.6% of them demonstrated a positive attitude and 80.9% showed moderate-to-good practice scores towards preventing such adverse effects. The education level was the only demographic factor with significant effects on the NSAIDs-related knowledge, practice, and attitude scores. Community pharmacists primarily rely on internet sources for knowledge updates. Additionally, there was a significant positive linear correlation between knowledge and attitude (r = 0.384, P < 0.001), knowledge and practice (r = 0.178, P < 0.001), and between attitude and practice (r = 0.311, P < 0.001) among the participants.

CONCLUSION

Community pharmacists have a vital responsibility to perform screenings, assess patient risk elements, and share knowledge to guarantee the appropriate and safe utilisation of NSAIDs. Given that internet sources are presently the most accessible and used sources of information, governmental directions should prioritise the establishment and enhancement of freely accessible drug information sources for community pharmacists. Further research is necessary to assess the effectiveness of counselling and appropriate guidance provided by community pharmacies in promoting safe and proper drug usage.

A Patient Safety Educational Tool for Patients With Chronic Kidney Disease: Development and Usability Study

Background

Chronic kidney disease (CKD) is a health condition that threatens patient safety; however, few interventions provide patient-centered education about kidney-specific safety hazards.

Objective

We sought to develop and test the usability of a mobile tablet–based educational tool designed to promote patient awareness of relevant safety topics in CKD.

Methods

We used plain language principles to develop content for the educational tool, targeting four patient-actionable safety objectives that are relevant for individuals with CKD. These four objectives included avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs); hypoglycemia awareness (among individuals with diabetes); temporary cessation of certain medications during acute volume depletion to prevent acute kidney injury (ie, “sick day protocol”); and contrast dye risk awareness. Our teaching strategies optimized human-computer interaction and content retention using audio, animation, and clinical vignettes to reinforce themes. For example, using a vignette of a patient with CKD with pain and pictures of common NSAIDs, participants were asked “Which of the following pain medicines are safe for Mr. Smith to take for his belly pain?” Assessment methods consisted of preknowledge and postknowledge surveys, with provision of correct responses and explanations. Usability testing of the tablet-based tool was performed among 12 patients with any stage of CKD, and program tasks were rated upon completion as no error, noncritical error (self-corrected), or critical error (needing assistance).

Results

The 12 participants in this usability study were predominantly 65 years of age or older (n=7, 58%) and female (n=7, 58%); all participants owned a mobile device and used it daily. Among the 725 total tasks that the participants completed, there were 31 noncritical errors (4.3%) and 15 critical errors (2.1%); 1 participant accounted for 30 of the total errors. Of the 12 participants, 10 (83%) easily completed 90% or more of their tasks. Most participants rated the use of the tablet as very easy (n=7, 58%), the activity length as “just right” (rather than too long or too short) (n=10, 83%), and the use of clinical vignettes as helpful (n=10, 83%); all participants stated that they would recommend this activity to others. The median rating of the activity was 8 on a scale of 1 to 10 (where 10 is best). We incorporated all participant recommendations into the final version of the educational tool.

Conclusions

A tablet-based patient safety educational tool is acceptable and usable by individuals with CKD. Future studies leveraging iterations of this educational tool will explore its impact on health outcomes in this high-risk population.

Frequency of nonaspirin NSAID-relevant coexisting medical conditions in the primary-care setting: a retrospective database review

BACKGROUND

Coexisting medical conditions and concomitant medications contribute to treatment challenges primary-care professionals (PCPs) face daily. The current study assessed the extent and distribution of nonaspirin NSAID-relevant coexisting medical conditions of interest (CMCOI) in patients visiting PCPs.

METHODS

This retrospective database review analyzed data from three large health-care claim databases to identify the frequency of nonaspirin NSAID-relevant CMCOI among adults aged ≥18 years with a PCP visit in 2013. Claim databases employed were the Truven Health MarketScan® Commercial Claims and Encounters database, representative of the privately insured (PI) population; Truven Health MarketScan Multi-State Medicaid, representative of the Medicaid population (Medicaid); and Truven MarketScan Medicare Supplemental, representative of the Medicare population with employer-based supplemental Medicare insurance (Medicare-Supplement). Nonaspirin NSAID-relevant CMCOI, asthma, cardiovascular risk factors, gastrointestinal bleeding risk factors, and renal insufficiency were chosen based on US NSAID over-the-counter Drug Facts label warnings. Frequency of CMCOI was determined for those without and with a musculoskeletal diagnosis.

RESULTS

In each database, ≥19% (19.0% PI, 29.9% Medicaid, 33.6% Medicare-Supplement) had a musculoskeletal diagnosis. A greater proportion of individuals with a musculoskeletal diagnosis had one or more CMCOI compared with those without a musculoskeletal diagnosis (61.3% vs 50.4% PI, 78.1% vs 66.8% Medicaid, 87.1% vs 82.3% Medicare-Supplement). The frequency of one or more CMCOI increased with age in each database. Across databases among CMCOI, cardiovascular risk factors were most common, followed by gastrointestinal bleeding risk factors, and proportions were higher among those with a musculoskeletal diagnosis.

CONCLUSION

These data confirm the high frequency of nonaspirin NSAID-relevant CMCOI among patients presenting to PCPs for musculoskeletal diagnosis, as well as among older patients. These analyses reinforce the critical role health-care professionals can play in identifying patients with nonaspirin NSAID-relevant CMCOI, providing those patients with ongoing guidance on appropriate choice and use of over-the-counter analgesics, and educating patients about the impact aging, health status, concomitant conditions, and medicines have on selection of all medicines, including analgesics.

Need for a Judicious Use of Nonsteroidal Anti-inflammatory Drugs to Avoid Community-Acquired Acute Kidney Injury

Millions of Americans use over-the-counter analgesics on a daily basis, and nearly 100 million nonsteroidal anti-inflammatory drug (NSAID) prescriptions are filled per year. In high-risk patients, these medications can disrupt kidney hemodynamics and precipitate community-acquired acute kidney injury (CA-AKI). The risk of NSAID-associated CA-AKI increases 3- to 5-fold in patients taking renin-angiotensin system inhibitors and diuretics concurrently. CA-AKI increases the risk of developing chronic kidney disease (CKD) or accelerating progression of pre-existing CKD. Importantly, many cases of NSAID-induced CA-AKI may be avoided by identifying high-risk patients and providing patient and provider education on when to avoid these medications and minimize risk.

Evaluation of community pharmacists' roles in screening and communication of risks about non-steroidal anti-inflammatory drugs in Thailand

AimThis study aimed to explore community pharmacists' roles on screening for risk factors, providing safety information-related non-steroidal anti-inflammatory drugs (NSAIDs) to patients. BACKGROUND: NSAIDs are widely dispensed without a prescription from pharmacies in Thailand, while they are frequently reported as causing adverse events. METHODS: Self-administered questionnaires were distributed to all accredited pharmacies in Thailand, inviting the main pharmacist in each pharmacy to participate in this study.FindingsOut of 406 questionnaires distributed, 159 were returned (39.2%). Almost all pharmacists claimed to engage in NSAID dispensing practice, but not all of them provided relevant good practice, such as, screening for risk factors (56.3-95.5%), communication on adverse drug reactions (ADRs) (36.9-63.2%) and ADR management (58.9-79.7%), history of gastrointestinal (GI) problems was frequently mentioned for screening, but many pharmacists did not screen for history of NSAID use (24.7-35.5%), older age (45.2-48.9%), concomitant drug (63.7%), and problems of cardiovascular (24.1%), renal (34.9-43.3%), and liver systems (60.3-61.0%). Male pharmacists were significantly less likely to inform users of non-selective NSAIDs about ADRs [odds ratio (OR) 0.44], while provision of information about selective NSAID ADRs was higher among pharmacy owners (OR 2.28), pharmacies with more pharmacists (OR 3.18), and lower in pharmacies with assistants (OR 0.41). Screening for risk factors, and risk communication about NSAIDs were not generally conducted in Thai accredited community pharmacists, nor were NSAID complications fully communicated. Promoting of community pharmacists' roles in NSAID dispensing should give priority to improving, especially in high-risk patients for taking NSAIDs.

Evaluation of a pharmacogenetic educational toolkit for community pharmacists

AIM

Over the past several decades, the roles and services of community pharmacists have expanded beyond traditional medical dispensation and compounding, and include health services such as vaccinations, and clinical testing and screening. Incorporating pharmacogenetic (PGx) testing into the menu of pharmacy services is logical and feasible; however, few pharmacists have experience with PGx testing, and few educational resources about PGx are available to support the uptake of PGx testing in community pharmacies.

METHODS

We developed a toolkit of four resources to assist pharmacists to provide PGx testing. We conducted a survey of pharmacists in North Carolina to evaluate each component of the toolkit and the toolkit as a whole.

RESULTS

A total of 380 respondents completed the evaluation of one or more toolkit components (344 evaluated all four components and the overall toolkit). Most respondents (84%) have never ordered or used PGx test results. Though the usability of the toolkit overall was below average (65.1 on a range of 0-100), individual components were perceived as useful and more than 75% of pharmacists reported that they would use the toolkit components when offering testing, with the result summary sheet receiving the highest score (4.01 out of 5). Open-text comments highlighted the need for more patient-friendly language and formatting.

CONCLUSION

The majority of pharmacist respondents scored the components of the toolkit favorably. The next steps will be to revise and assess use of the toolkit in community pharmacy settings.

Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care

Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD.

The risks and benefits of patients temporarily discontinuing medications in the event of an intercurrent illness: a systematic review protocol

BACKGROUND

Acute kidney injury (AKI) is common and often leads to significant morbidity and/or death. The development of AKI, or complications associated with it, may be due to use of certain medications in at-risk patients experiencing an intercurrent illness. Implicated drugs include diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), metformin and sulfonylureas. Expert consensus opinion (and clinical guidelines) recommend considering discontinuation of diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, NSAIDs, metformin and sulfonylureas in the event of an intercurrent illness to prevent AKI onset or reduce severity or complications. However, the evidence base for these recommendations is very limited. This systematic review aims to address the available evidence for the temporary discontinuation of diuretics, ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors, non-steroidal anti-inflammatories and metformin and sulfonylureas for those at risk of AKI or with newly diagnosed AKI.

METHODS/DESIGN

Randomised controlled trials; non-randomised trials; cohort studies; case-control studies; interrupted time series studies; and before-and-after studies featuring adults aged 18 and over in any setting currently taking diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, NSAIDs and metformin; experiencing an intercurrent illness; or undergoing a radiological/surgical procedure (planned or unplanned) will be searched for. Relevant trial registers and systematic review databases will be searched. Systematic reviews will be assessed for methodological quality using the ROBIS tool, trials will be assessed using the Cochrane risk of bias tool, and observational studies will be assessed using the ACROBAT-NRS tool. If sufficient studies assessing similar populations, study type, settings and outcomes are found, then a formal meta-analysis will be performed to estimate summary measures of effect. If not, a narrative synthesis will be adopted.

DISCUSSION

This review will synthesise evidence for the efficacy of discontinuing diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, NSAIDs, metformin or sulfonylureas to prevent or delay onset of AKI or associated complications. Results will provide guidance on efficacy and safety of this strategy and potentially help to develop an intervention to test the best mechanism of guiding medication discontinuation in at-risk populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015023210.