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Domingues ÍP, Costa MRD. [Update of triggers for detection of adverse drug events in hematologic patients]. CAD SAUDE PUBLICA 2023; 39:e00077923. [PMID: 38126560 PMCID: PMC10740396 DOI: 10.1590/0102-311xpt077923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/10/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
The use of triggers for the active search and detection of adverse drug events (ADEs) has been gaining ground within pharmacovigilance services. Thus, the main objective of the study was to propose a new list of triggers to be used in a center specialized in hematology in Rio de Janeiro, Brazil. The update of the list of triggers consisted of revising the current list, with the exclusion and inclusion of new triggers. To verify the performance of the new list of triggers, a cross-sectional study was conducted in which the new triggers were used to investigate the occurrence of ADEs in patients attended in the emergency unit or hospitalized from January to March 2022. For each suspected ADEs, the patient's profile and adverse drug reactions (ADRs) were characterized regarding causality and severity. The performance of the triggers and their ability to capture ADEs were estimated using the following indicators: frequency of the trigger per 100 medical records, frequency of ADEs per 100 records, and positive predictive value (PPV). To evaluate the overall performance of the proposed new list, the PPV was estimated. A total of 374 prescriptions for triggers were identified in 186 medical records. The most efficient in the detection of possible ADEs were: lidocaine, loperamide, bisacodyl, filgrastim and glycerin clyster. The overall PPV of the new suggested list was 48% versus 10% of the previous list. This study demonstrated the importance of an updated list of triggers for the monitoring of ADEs and improvement of the care provided.
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Affiliation(s)
- Íris Pilegi Domingues
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti, Rio de Janeiro, Brasil
| | - Milene Rangel da Costa
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
- Instituto Nacional de Cardiologia, Rio de Janeiro, Brasil
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Choe S, Lee S, Park CH, Lee JH, Kim HJ, Byeon SJ, Choi JH, Yang HJ, Sim DW, Cho BJ, Koo H, Kang MG, Jeong JB, Choi IY, Kim SH, Kim WJ, Jung JW, Lhee SH, Ko YJ, Park HK, Kang DY, Kim JH. Development and Application of an Active Pharmacovigilance Framework Based on Electronic Healthcare Records from Multiple Centers in Korea. Drug Saf 2023; 46:647-660. [PMID: 37243963 DOI: 10.1007/s40264-023-01296-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION With the availability of retrospective pharmacovigilance data, the common data model (CDM) has been identified as an efficient approach towards anonymized multicenter analysis; however, the establishment of a suitable model for individual medical systems and applications supporting their analysis is a challenge. OBJECTIVE The aim of this study was to construct a specialized Korean CDM (K-CDM) for pharmacovigilance systems based on a clinical scenario to detect adverse drug reactions (ADRs). METHODS De-identified patient records (n = 5,402,129) from 13 institutions were converted to the K-CDM. From 2005 to 2017, 37,698,535 visits, 39,910,849 conditions, 259,594,727 drug exposures, and 30,176,929 procedures were recorded. The K-CDM, which comprises three layers, is compatible with existing models and is potentially adaptable to extended clinical research. Local codes for electronic medical records (EMRs), including diagnosis, drug prescriptions, and procedures, were mapped using standard vocabulary. Distributed queries based on clinical scenarios were developed and applied to K-CDM through decentralized or distributed networks. RESULTS Meta-analysis of drug relative risk ratios from ten institutions revealed that non-steroidal anti-inflammatory drugs (NSAIDs) increased the risk of gastrointestinal hemorrhage by twofold compared with aspirin, and non-vitamin K anticoagulants decreased cerebrovascular bleeding risk by 0.18-fold compared with warfarin. CONCLUSION These results are similar to those from previous studies and are conducive for new research, thereby demonstrating the feasibility of K-CDM for pharmacovigilance. However, the low quality of original EMR data, incomplete mapping, and heterogeneity between institutions reduced the validity of the analysis, thus necessitating continuous calibration among researchers, clinicians, and the government.
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Affiliation(s)
- Seon Choe
- Division of Biomedical Informatics, Systems Biomedical Informatics Research Centre, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Suhyun Lee
- Department of Preventive Medicine, Ulsan University Hospital, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Republic of Korea
| | - Chan Hee Park
- Division of Biomedical Informatics, Systems Biomedical Informatics Research Centre, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jeong Hoon Lee
- Division of Biomedical Informatics, Systems Biomedical Informatics Research Centre, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyo Jung Kim
- Center for Research Resource Standardization, Research Institution for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Sun-Ju Byeon
- Department of Pathology, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Jeong-Hee Choi
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Hyeon-Jong Yang
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Da Woon Sim
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Bum-Joo Cho
- Department of Ophthalmology, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Hoseok Koo
- Department of Internal Medicine, Seoul Paik Hospital, Inje University, Seoul, Republic of Korea
| | - Min-Gyu Kang
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Ji Bong Jeong
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - In Young Choi
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Woo Jin Kim
- Department of Internal Medicine, Kangwon National University College of Medicine, Chuncheon, Republic of Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Sang-Hoon Lhee
- Department of Preventive Medicine, Naeun Hospital, Incheon, Republic of Korea
| | | | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Republic of Korea
| | - Dong Yoon Kang
- Department of Computer Engineering, Gachon University, Seongnam, Republic of Korea.
| | - Ju Han Kim
- Division of Biomedical Informatics, Systems Biomedical Informatics Research Centre, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Alsaleh FM, Naser AY, Alsairafi ZK, Ofori-Asenso R. Hospitalisations related to administration errors of psychotropic drugs: a nationwide retrospective study between 1998 and 2019 in Australia. Front Pharmacol 2023; 14:1149500. [PMID: 37426812 PMCID: PMC10323131 DOI: 10.3389/fphar.2023.1149500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Objectives: Medication administration error occurs when there is a discrepancy between what the patient received or was planned to receive and what the doctor originally intended. The aim of this study was to examine the trends in hospitalisation related to administration errors of psychotropic drugs in Australia. Materials and Methods: This was a secular trend analysis study that examined the hospitalisation pattern for medication administration errors of psychotropic drugs in Australia between 1998 and 2019. Data on medication administration errors of psychotropic drugs was obtained from The National Hospital Morbidity Database. We analysed the variation in hospitalisation rates using the Pearson chi-square test for independence. Results: Hospitalisation rates related to administration errors of psychotropic drugs increased by 8.3% [from 36.22 (95% CI 35.36-37.08) in 1998 to 39.21 (95% CI 38.44-39.98) in 2019 per 100,000 persons, p < 0.05]. Overnight-stay hospital admission patients accounted for 70.3% of the total number of episodes. Rates of same-day hospitalisation increased by 12.3% [from 10.35 (95% CI 9.90-10.81) in 1998 to 11.63 (95% CI 11.21-12.05) in 2019 per 100,000 persons]. Rates of overnight-stay hospital admission increased by 1.8% [from 25.86 (95% CI 25.13-26.59) in 1998 to 26.34 (95% CI 25.71-26.97) in 2019 per 100,000 persons]. Other and unspecified antidepressants (selective serotonin and norepinephrine reuptake inhibitors) were the most common reason for hospitalisation accounting for 36.6% of the total number of hospitalisation episodes. Females accounted for 111,029 hospitalisation episodes, representing 63.2% of all hospitalisation episodes. The age group 20-39 years accounted for nearly half (48.6%) of the total number of episodes. Conclusion: Psychotropic drug administration error is a regular cause of hospitalization in Australia. Hospitalizations usually required overnight stays. The majority of hospitalizations were in persons aged 20-39 years, which is concerning and warrants further investigation. Future studies should examine the risk factors for hospitalization related to psychiatric drug administration errors.
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Affiliation(s)
- Fatemah M. Alsaleh
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Hawalli, Kuwait
| | - Abdallah Y. Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Zahra K. Alsairafi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Hawalli, Kuwait
| | - Richard Ofori-Asenso
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Seo B, Yang MS, Park SY, Park BY, Kim JH, Song WJ, Kwon HS, Chang YS, Cho YS, Kim SH, Kim TB. Incidence and Economic Burden of Adverse Drug Reactions in Hospitalization: A Prospective Study in Korea. J Korean Med Sci 2023; 38:e56. [PMID: 36852852 PMCID: PMC9970790 DOI: 10.3346/jkms.2023.38.e56] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/30/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) are escalating, and their socioeconomic burden is increasing. However, large-scale prospective studies investigating ADRs during hospitalization are rare in Korea. We prospectively investigated the incidence, characteristics, and economic burden of ADRs in hospitalized patients based on electronic medical records (EMRs). METHODS Among patients admitted to three hospitals from October 2016 to October 2017, 5,000 patients were randomly selected and prospectively observed during hospitalization. Research nurses monitored and detected patients who had symptoms, signs, or laboratory findings suspicious for ADRs using an EMR-based detection protocol. Next, allergy and ADR specialists reviewed the medical records to determine the relationship between adverse reactions and drugs. Cases in which a causal relationship was certain, probable/likely, or possible were included in the ADR cases. Clinically meaningful ADR cases or those leading to prolonged hospitalization were defined as significant ADRs. RESULTS ADRs occurred in 510 (10.2%) patients. The mean length of hospital stay was approximately 5 days longer in patients with ADRs. Opioids accounted for the highest percentage of total ADRs. Significant ADRs were observed in 148 (3.0%) patients. Antibiotics accounted for the highest percentage of significant ADRs. Drug hypersensitivity reactions (DHRs) occurred in 88 (1.8%) patients. Antibiotics accounted for the highest percentage of DHRs. The average medical expenses for one day of hospitalization per patient were highest in significant ADRs, followed by non-significant ADRs, and non-ADRs. CONCLUSION ADRs in hospitalized patients are an important clinical issue, resulting in a substantial socioeconomic burden. EMR-based strategy could be a useful tool for ADR monitoring and early detection.
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Affiliation(s)
- Bomi Seo
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Pulmonary, Allergy and Critical Care Medicine, Seongnam Citizens Medical Center, Seongnam, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Bo Young Park
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Hyun Kim
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Woo-Jung Song
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyouk-Soo Kwon
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - You Sook Cho
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Tae-Bum Kim
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Srisuriyachanchai W, Cox AR, Kampichit S, Jarernsiripornkul N. Severity and Management of Adverse Drug Reactions Reported by Patients and Healthcare Professionals: A Cross-Sectional Survey. Int J Environ Res Public Health 2023; 20:3725. [PMID: 36834422 PMCID: PMC9959449 DOI: 10.3390/ijerph20043725] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 06/18/2023]
Abstract
Adverse drug reaction (ADR) severity levels are mainly rated by healthcare professionals (HCPs), but patient ratings are limited. This study aimed to compare patient-rated and pharmacist-rated ADR severity levels and determined methods employed for ADR management and prevention by patients and HCPs. A cross-sectional survey was conducted in outpatients visiting two hospitals. Patients were asked about ADR experiences using a self-administered questionnaire, and additional information was retrieved from the medical records. In total, 617 out of 5594 patients had experienced ADRs (11.0%), but 419 patients were valid (68.0%). Patients commonly reported that their ADR severity level was moderate (39.4%), whereas pharmacists rated the ADRs as mild (52.5%). There was little agreement between patient-rated and pharmacist-rated ADR severity levels (κ = 0.144; p < 0.001). The major method of ADR management by physicians was drug withdrawal (84.7%), while for patients, it was physician consultation (67.5%). The main methods for ADR prevention by patients and HCPs were carrying an allergy card (37.2%) and recording drug allergy history (51.1%), respectively. A higher level of ADR bothersomeness was associated with higher ADR severity levels (p < 0.001). Patients and HCPs rated ADR severity and used ADR management and prevention methods differently. However, patient rating of ADR severity is a potential signal for severe ADR detection of HCPs.
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Affiliation(s)
- Warisara Srisuriyachanchai
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Anthony R. Cox
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sirinya Kampichit
- Department of Pharmacy Service, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Narumol Jarernsiripornkul
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen 40002, Thailand
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Patel TK, Patel PB, Bhalla HL, Dwivedi P, Bajpai V, Kishore S. Impact of suspected adverse drug reactions on mortality and length of hospital stay in the hospitalised patients: a meta-analysis. Eur J Clin Pharmacol 2023; 79:99-116. [PMID: 36399205 DOI: 10.1007/s00228-022-03419-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/05/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To estimate the risk of mortality and length of stay in hospitalised patients who have experienced suspected adverse drug reactions (ADRs) as compared to patients who did not experience suspected ADRs. METHODS A systematic literature search was conducted on databases for observational and randomised controlled studies conducted in any inpatient setting that reported deaths and/or length of hospital stay in patients who had suspected ADRs and did not have suspected ADRs during hospitalisation. PRISMA guidelines were strictly followed during the review. The methodological quality of included studies was assessed using a tool designed by Smyth et al. for the studies of adverse drug reactions. The meta-analytic summary of all-cause mortality was estimated using odds ratio-OR (95% CI) and length of stay using mean difference-MD (95% CI). Both outcomes were pooled using a random effect model (DerSimonian and Laird method). Subgroup and meta-regression were performed based on study variables: study design, age group, study ward, study region, types of suspected ADRs (ADRAd-suspected ADRs that lead to hospitalisation and ADRIn-suspected ADRs that occur following hospitalisation), study duration, sample size and study period. The statistical analysis was conducted through the 'Review manager software version 5.4.1 and JASP (Version 0.14.1)'. RESULTS After screening 475 relevant articles, 55 studies were included in this meta-analysis. Patients having suspected ADRs had reported significantly higher odds of all-cause mortality [OR: 1.50 (95% CI: 1.21-1.86; I2 = 100%) than those patients who did not have suspected ADRs during hospitalisation. Study wards, types of suspected ADRs and sample size were observed as significant predictors of all-cause mortality (p < 0.05). Patients having suspected ADRs had reported significantly higher mean difference in hospital stay [MD: 3.98 (95% CI: 2.91, 5.05; I2 = 99%) than those patients who did not have suspected ADRs during hospitalisation. Types of suspected ADRs and study periods were observed as significant predictors of length of stay (p < 0.05). CONCLUSION Suspected ADRs significantly increase the risk of mortality and length of stay in hospitalised patients. SYSTEMATIC REVIEW REGISTRATION CRD42020176320.
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Affiliation(s)
- Tejas K Patel
- Department of Pharmacology, All India Institute of Medical Sciences, Gorakhpur, 273008, India.
| | - Parvati B Patel
- Department of Pharmacology, GMERS Medical College, Gotri, Vadodara, Gujarat, 390021, India
| | - Hira Lal Bhalla
- Department of Pharmacology, All India Institute of Medical Sciences, Gorakhpur, 273008, India
| | - Priyanka Dwivedi
- Department of Anaesthesiology, All India Institute of Medical Sciences, Gorakhpur, 273008, India
| | - Vijeta Bajpai
- Department of Anaesthesiology, All India Institute of Medical Sciences, Gorakhpur, 273008, India
| | - Surekha Kishore
- All India Institute of Medical Sciences, Gorakhpur, 273008, India
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Gosselt HR, Bazelmans EA, Lieber T, van Hunsel FPAM, Härmark L. Development of a multivariate prediction model to identify individual case safety reports which require clinical review. Pharmacoepidemiol Drug Saf 2022; 31:1300-1307. [PMID: 36251280 DOI: 10.1002/pds.5553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The number of Individual Case Safety Reports (ICSRs) in pharmacovigilance databases are rapidly increasing world-wide. The majority of ICSRs at the Netherlands Pharmacovigilance Centre Lareb is reviewed manually to identify potential signal triggering reports (PSTR) or ICSRs which need further clinical assessment for other reasons. OBJECTIVES To develop a prediction model to identify ICSRs that require clinical review, including PSTRs. Secondly, to identify the most important features of these reports. METHODS All ICSRs (n = 30 424) received by Lareb between October 1, 2017 and February 26, 2021 were included. ICSRs originating from marketing authorisation holders and ICSRs reported on vaccines were excluded. The outcome was defined as PSTR (yes/no), where PSTR 'yes' was defined as an ICSR discussed at a signal detection meeting. Nineteen features were included, concerning structured information on: patients, adverse drug reactions (ADR) or drugs. Data were divided into a training (70%) and test set (30%) using a stratified split to maintain the PSTR/no PSTR ratio. Logistic regression, elastic net logistic regression and eXtreme Gradient Boosting models were trained and tuned on a training set. Random down-sampling of negative controls was applied on the training set to adjust for the imbalanced dataset. Final models were evaluated on the test set. Model performances were assessed using the area under the curve (AUC) with 95% confidence interval of a receiver operating characteristic (ROC), and specificity and precision were assessed at a threshold for perfect sensitivity (100%, to not miss any PSTRs). Feature importance plots were inspected and a selection of features was used to re-train and test model performances with fewer features. RESULTS 1439 (4.7%) of reports were PSTR. All three models performed equally with a highest AUC of 0.75 (0.73-0.77). Despite moderate model performances, specificity (5%) and precision (5%) were low. Most important features were: 'absence of ADR in the Summary of product characteristics', 'ADR reported as serious', 'ADR labelled as an important medical event', 'ADR reported by physician' and 'positive rechallenge'. Model performances were similar when using only nine of the most important features. CONCLUSIONS We developed a prediction model with moderate performances to identify PSTRs with nine commonly available features. Optimisation of the model using more ICSR information (e.g., free text fields) to increase model precision is required before implementation.
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Affiliation(s)
- Helen R Gosselt
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | | | - Thomas Lieber
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | | | - Linda Härmark
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
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Rochanathimoke O, Tragulpiankit P, Turongkaravee S, Jittikoon J, Udomsinprasert W, Chaikledkeaw U. Costs Associated with Adverse Drug Reactions Among HIV/TB Patients in Thailand. Clinicoecon Outcomes Res 2022; 14:587-599. [PMID: 36105845 PMCID: PMC9464632 DOI: 10.2147/ceor.s373489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the direct and indirect costs associated with adverse drug reactions (ADRs) in patients receiving treatment regimens for human immunodeficiency virus (HIV) infection and tuberculosis (TB) in selected Thai hospitals. Patients and Methods This was a retrospective study conducted between October 2014 and September 2019 at three public hospitals in Thailand. Data were obtained from a medical database and spontaneous ADR reporting system of each study site. The out-of-pocket health payments and indirect costs were determined via interviewing. All costs were updated to 2021. Results A total of 432 eligible patients who experienced ADRs due to HIV and TB treatment, and 93 patients were interviewed to determine direct non-medical and indirect costs. The average direct medical cost for ADR was USD 5.65 for mild cases, USD 156.54 for moderate cases, and USD 1,242.45 for severe cases. For direct non-medical costs, the average cost per episode was USD 27.29 in mild ADR, USD 70.86 in moderate ADR and USD 270.66 in severe ADR. The indirect cost incurred in each mild, moderate and severe ADR was USD 41.86, USD 89.34, and USD 552.60, respectively. The Stevens-Johnson syndrome (SJS) had the highest management costs. Conclusion ADRs associated with anti-tuberculosis drugs and antiretroviral drugs seem to have a substantial economic impact from a societal perspective. These findings would be useful for increasing awareness and encouraging early avoidance of ADRs.
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Affiliation(s)
- Onwipa Rochanathimoke
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Pramote Tragulpiankit
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Saowalak Turongkaravee
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Jiraphun Jittikoon
- Department of Biochemistry, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | - Usa Chaikledkeaw
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand.,Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
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Lee FY, Islahudin F, Abdul Gafor AH, Wong HS, Bavanandan S, Mohd Saffian S, Md Redzuan A, Makmor-Bakry M. Adverse Drug Reactions of Antihypertensives and CYP3A5*3 Polymorphism Among Chronic Kidney Disease Patients. Front Pharmacol 2022; 13:848804. [PMID: 35359836 PMCID: PMC8963814 DOI: 10.3389/fphar.2022.848804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/18/2022] [Indexed: 11/21/2022] Open
Abstract
Chronic kidney disease (CKD) patients may be more susceptible to adverse drug reactions (ADRs), given their complex medication regimen and altered physiological state driven by a decline in kidney function. This study aimed to describe the relationship between CYP3A5*3 polymorphism and the ADR of antihypertensive drugs in CKD patients. This retrospective, multi-center, observational cohort study was performed among adult CKD patients with a follow-up period of up to 3 years. ADRs were detected through medical records. CYP3A5*3 genotyping was performed using the direct sequencing method. From the 200 patients recruited in this study, 33 (16.5%) were found to have ADRs related to antihypertensive drugs, with 40 ADRs reported. The most frequent ADR recorded was hyperkalemia (n = 8, 20.0%), followed by bradycardia, hypotension, and dizziness, with 6 cases (15.0%) each. The most common suspected agents were angiotensin II receptor blockers (n = 11, 27.5%), followed by angiotensin-converting enzyme inhibitors (n = 9, 22.5%). The CYP3A5*3 polymorphism was not found to be associated with antihypertensive-related ADR across the genetic models tested, despite adjustment for other possible factors through multiple logistic regression (p > 0.05). After adjusting for possible confounding factors, the factors associated with antihypertensive-related ADR were anemia (adjusted odds ratio [aOR] 5.438, 95% confidence interval [CI]: 2.002, 14.288) and poor medication adherence (aOR 3.512, 95% CI: 1.470, 8.388). In conclusion, the CYP3A5*3 polymorphism was not found to be associated with ADRs related to antihypertensives in CKD patients, which requires further verification by larger studies.
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Affiliation(s)
- Fei Yee Lee
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Clinical Research Centre, Hospital Selayang, Ministry of Health Malaysia, Batu Caves, Malaysia
| | - Farida Islahudin
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- *Correspondence: Farida Islahudin,
| | - Abdul Halim Abdul Gafor
- Nephrology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Hin-Seng Wong
- Clinical Research Centre, Hospital Selayang, Ministry of Health Malaysia, Batu Caves, Malaysia
- Nephrology Department, Hospital Selayang, Ministry of Health Malaysia, Selangor, Malaysia
| | - Sunita Bavanandan
- Nephrology Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Shamin Mohd Saffian
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adyani Md Redzuan
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Makmor-Bakry
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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10
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Asiamah M, Akuffo KO, Nortey P, Donkor N, Danso-Appiah A. Spontaneous reporting of adverse drug reaction among health professionals in Ghana. Arch Public Health 2022; 80:33. [PMID: 35057859 PMCID: PMC8772084 DOI: 10.1186/s13690-021-00783-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 12/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background Spontaneous reporting of adverse drug reactions (ADR) is an effective means of ensuring postmarketing surveillance of drugs, and health professionals play a cardinal role through voluntary reporting of ADR. However, the pharmacovigilance system in Ghana is plagued with under-reporting issues, which is of public health concern. Method A questionnaire-based cross-sectional study involving 268 health professionals at Kpone-Katamanso District was carried out. Data on spontaneous reporting of ADR, demographics of participants, knowledge, and attitudes of professionals towards reporting and factors that may influence ADR reporting were collected. Logistic regression models were used to examine the association of the independent variables with spontaneous reporting of ADR. Result Overall, 77.6% (208) of the 268 respondents had observed ADR; however, only 17.3% of the respondents had ever reported an ADR to the Ghana FDA. Health professionals who had average knowledge on spontaneous reporting of ADR were 51.9%, while 30.3% had good knowledge of spontaneous reporting of ADR. After adjustment on potential confounding variables (Knowledge, Feedback from FDA, Uncertainty about cause of ADR, Severity of ADR), Age (AOR = 2.26, 95%CI = 1.25–4.10), Fear of Legal Consequences (AOR = 0.15, 95%CI = 0.41–0.51), Time Constraint (AOR = 0.3, 95%CI = 0.10–0.91), Pharmacovigilance training (AOR = 18.78, 95%CI = 5.46–64.59) and Unavailability of Reporting form (AOR = 0.28, 95%CI = 0.09–0.88) were found to be significantly associated spontaneous reporting of ADR. Conclusion The proportion of health professionals in the Kpone- Katamanso District who spontaneously reported observed ADR was low though they had average knowledge about ADR reporting. This underscores the need for a policy to be implemented that makes spontaneous reporting of adverse drug reaction mandatory for health professionals.
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11
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Falconer N, Snoswell C, Morris C, Barras M. The right time and place: the need for seven‐day pharmacist service models. Pharmacy Practice and Res 2021. [DOI: 10.1002/jppr.1761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Nazanin Falconer
- School of Pharmacy Pharmacy Australia Centre of Excellence The University of Queensland Brisbane Australia
- Department of Pharmacy Princess Alexandra Hospital Metro South Health Brisbane Australia
- Centre for Health Services Research Faculty of Medicine The University of Queensland The University of Queensland Brisbane Australia
| | - Centaine Snoswell
- Department of Pharmacy Princess Alexandra Hospital Metro South Health Brisbane Australia
- Centre for Health Services Research Faculty of Medicine The University of Queensland The University of Queensland Brisbane Australia
| | - Christopher Morris
- Department of Internal Medicine Princess Alexandra Hospital Metro South Health Brisbane Australia
| | - Michael Barras
- School of Pharmacy Pharmacy Australia Centre of Excellence The University of Queensland Brisbane Australia
- Department of Pharmacy Princess Alexandra Hospital Metro South Health Brisbane Australia
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12
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Johnston JP, Heavner MS, Liu M, Casal GLH, Akgün KM. The Prevalence of Drug-Drug Interactions with Antiretroviral Therapy in Human Immunodeficiency Virus-Infected Patients in the Intensive Care Unit. J Pharm Pract 2021; 36:322-328. [PMID: 34587846 DOI: 10.1177/08971900211035262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Persons living with human immunodeficiency virus (HIV) (PWH) on antiretroviral therapy (ART) are frequently admitted to the intensive care unit (ICU). Persons living with HIV on ART may be at higher risk for potential drug-drug interactions (pDDIs) due to polypharmacy in the ICU. We determined the prevalence of pDDI with ART in critically ill PWH. Objectives: The primary outcome was prevalence of pDDI between ART and ICU medications. Secondary outcomes included pDDI per ICU admission, pDDI severity, ICU, and hospital length of stay (LOS). Methods: A single-center, retrospective cohort evaluating PWH ≥ 18 years old admitted to the ICU for > 24 hours who received ART during ICU admission, between January 2013 and 2015 at a tertiary care hospital in the United States. Each ICU admission was counted as a separate encounter. Medication databases and chart review were used to identify pDDI. Results: We included 77 PWH encounters; mean age was 55 ± 9 years and 65% were male. We identified 208 pDDIs among 53/77 (68.8%), with a mean 4 ± 2 pDDI per ICU admission. Antipsychotics (20%), analgesics (20%), and anti-lipemics (11%) were the most common ICU medications with ART-related pDDI. Of the pDDI, 64% were major, 24% moderate, and 12% contraindicated. Median ICU and hospital LOS were 4 days (IQR: 3-5) and 11 days (IQR: 7-31), respectively. Conclusion: Most PWH had at least one pDDI during ICU admission. Collaborations among pharmacists, intensivists, and infectious disease/HIV specialists to develop effective, actionable strategies, such as electronic health record alerts, could reduce pDDIs for PWH on ART in the ICU.
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Affiliation(s)
- Jackie P Johnston
- Pharmacy Practice and Administration, 15484Rutgers Ernest Mario School of Pharmacy, The State University of New Jersey, Piscataway, NJ, USA.,Department of Pharmacy, 6473St Joseph's University Medical Center, Paterson, NJ, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Michael Liu
- Department of Pharmacy Practice, 471068Touro College of Pharmacy, New York, NY, USA
| | | | - Kathleen M Akgün
- Department of Internal Medicine and General Internal Medicine, 19985VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Internal Medicine, 12228Yale University School of Medicine, New Haven, CT, USA
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13
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Abstract
Idiosyncratic drug reactions (IDRs) range from relatively common, mild reactions to rarer, potentially life-threatening adverse effects that pose significant risks to both human health and successful drug discovery. Most frequently, IDRs target the liver, skin, and blood or bone marrow. Clinical data indicate that most IDRs are mediated by an adaptive immune response against drug-modified proteins, formed when chemically reactive species of a drug bind to self-proteins, making them appear foreign to the immune system. Although much emphasis has been placed on characterizing the clinical presentation of IDRs and noting implicated drugs, limited research has focused on the mechanisms preceding the manifestations of these severe responses. Therefore, we propose that to address the knowledge gap between drug administration and onset of a severe IDR, more research is required to understand IDR-initiating mechanisms; namely, the role of the innate immune response. In this review, we outline the immune processes involved from neoantigen formation to the result of the formation of the immunologic synapse and suggest that this framework be applied to IDR research. Using four drugs associated with severe IDRs as examples (amoxicillin, amodiaquine, clozapine, and nevirapine), we also summarize clinical and animal model data that are supportive of an early innate immune response. Finally, we discuss how understanding the early steps in innate immune activation in the development of an adaptive IDR will be fundamental in risk assessment during drug development. SIGNIFICANCE STATEMENT: Although there is some understanding that certain adaptive immune mechanisms are involved in the development of idiosyncratic drug reactions, the early phase of these immune responses remains largely uncharacterized. The presented framework refocuses the investigation of IDR pathogenesis from severe clinical manifestations to the initiating innate immune mechanisms that, in contrast, may be quite mild or clinically silent. A comprehensive understanding of these early influences on IDR onset is crucial for accurate risk prediction, IDR prevention, and therapeutic intervention.
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Affiliation(s)
- Samantha Christine Sernoskie
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
| | - Alison Jee
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
| | - Jack Paul Uetrecht
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
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14
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Wang L, Shendre A, Chiang CW, Cao W, Ning X, Zhang P, Zhang P, Li L. A pharmacovigilance study of pharmacokinetic drug interactions using a translational informatics discovery approach. Br J Clin Pharmacol 2021; 88:1471-1481. [PMID: 33543792 DOI: 10.1111/bcp.14762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND While the pharmacokinetic (PK) mechanisms for many drug interactions (DDIs) have been established, pharmacovigilance studies related to these PK DDIs are limited. Using a large surveillance database, a translational informatics approach can systematically screen adverse drug events (ADEs) for many DDIs with known PK mechanisms. METHODS We collected a set of substrates and inhibitors related to the cytochrome P450 (CYP) isoforms, as recommended by the United States Food and Drug Administration (FDA) and Drug Interactions Flockhart table™. The FDA's Adverse Events Reporting System (FAERS) was used to obtain ADE reports from 2004 to 2018. The substrate and inhibitor information were used to form PK DDI pairs for each of the CYP isoforms and Medical Dictionary for Regulatory Activities (MedDRA) preferred terms used for ADEs in FAERS. A shrinkage observed-to-expected ratio (Ω) analysis was performed to screen for potential PK DDI and ADE associations. RESULTS We identified 149 CYP substrates and 62 CYP inhibitors from the FDA and Flockhart tables. Using FAERS data, only those DDI-ADE associations were considered that met the disproportionality threshold of Ω > 0 for a CYP substrate when paired with at least two inhibitors. In total, 590 ADEs were associated with 2085 PK DDI pairs and 38 individual substrates, with ADEs overlapping across different CYP substrates. More importantly, we were able to find clinical and experimental evidence for the paclitaxel-clopidogrel interaction associated with peripheral neuropathy in our study. CONCLUSION In this study, we utilized a translational informatics approach to discover potentially novel CYP-related substrate-inhibitor and ADE associations using FAERS. Future clinical, population-based and experimental studies are needed to confirm our findings.
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Affiliation(s)
- Lei Wang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Aditi Shendre
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Chien-Wei Chiang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Weidan Cao
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Xia Ning
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Ping Zhang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Pengyue Zhang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA.,Now at Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lang Li
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
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15
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Ganeshanandan L, Lucas M. Drug Reaction with Eosinophilia and Systemic Symptoms: A Complex Interplay between Drug, T Cells, and Herpesviridae. Int J Mol Sci 2021; 22:1127. [PMID: 33498771 DOI: 10.3390/ijms22031127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 12/14/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, also known as drug induced hypersensitivity (DiHS) syndrome is a severe delayed hypersensitivity reaction with potentially fatal consequences. Whilst recognised as T cell-mediated, our understanding of the immunopathogenesis of this syndrome remains incomplete. Here, we discuss models of DRESS, including the role of human leukocyte antigen (HLA) and how observations derived from new molecular techniques adopted in key studies have informed our mechanism-based understanding of the central role of Herpesviridae reactivation and heterologous immunity in these disorders.
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16
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Monteiro C, Duarte AP, Alves G. Adverse drug reactions in elderly: a five-year review of spontaneous reports to the Portuguese pharmacovigilance system. Expert Opin Drug Saf 2020; 20:109-118. [PMID: 33170742 DOI: 10.1080/14740338.2020.1849137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Adverse drug reactions (ADRs) are responsible for considerable morbidity and mortality in elderly. This study aimed to characterize the ADRs profile in Portuguese elderly patients, thus enhancing ADRs knowledge in this vulnerable population. Methods: All spontaneous ADRs reported to the Portuguese Pharmacovigilance System from 2013 to 2017 were examined. However, considering the aim of this study, ADRs referring to patients aged 65 and over were analyzed in higher detail and compared with those reported in non-elderly adults. Results: Considering the age of 65 years and above, 3692 spontaneous reports of suspected ADRs were analyzed. The suspected ADRs most frequently reported fall within the categories of general disorders and administration site conditions, and skin and subcutaneous tissue complaints. Regarding therapeutic agents, the antineoplastic drugs were the most common involved. Among the 2458 cases of serious ADRs reported, 34.0% led to hospitalization and in 5.8% of them occurred a fatal outcome. The antineoplastic and antithrombotic drugs were the most represented pharmacotherapeutic groups of suspected drugs involved in patient's death (25.0% and 13.6%, respectively). Conclusions: Most of the suspected ADRs were classified as serious. The majority of them were expected, so preventable, highlighting the importance of improving medication use in elderly.
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Affiliation(s)
- Cristina Monteiro
- UFBI - HealthSciences to Health Sciences, University of Beira Interior , Covilhã, Portugal
| | - Ana Paula Duarte
- UFBI - HealthSciences to Health Sciences, University of Beira Interior , Covilhã, Portugal.,CICS-UBI - HealthSciences Research Centre, University of Beira Interior , Covilhã, Portugal
| | - Gilberto Alves
- UFBI - HealthSciences to Health Sciences, University of Beira Interior , Covilhã, Portugal.,CICS-UBI - HealthSciences Research Centre, University of Beira Interior , Covilhã, Portugal
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17
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Sahilu T, Getachew M, Melaku T, Sheleme T. Adverse Drug Events and Contributing Factors Among Hospitalized Adult Patients at Jimma Medical Center, Southwest Ethiopia: A Prospective Observational Study. Curr Ther Res Clin Exp 2020; 93:100611. [PMID: 33296443 PMCID: PMC7689274 DOI: 10.1016/j.curtheres.2020.100611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Adverse drug events (ADEs) are common complications of clinical care resulting in significant morbidity, mortality, and high clinical expenditure. Population-level estimates of inpatient ADEs are limited in Ethiopia. Objective This study aimed to assess the incidence, contributing factors, severity, and preventability of ADEs among hospitalized adult patients at Jimma Medical Center, Ethiopia. Methods A prospective observational study design was conducted among hospitalized adult patients at tertiary hospital in Ethiopia. A structured data collection tool was prepared from relevant literatures for data collection. Data were analyzed using statistical software. Logistic regression was performed to identify factors contributing to ADE occurrence. P values < 0.05 were considered statistically significant. Results A total of 319 patients were included with follow-up period of 5667 person-days. About 50.5% were women. The mean (SD) age of patients was 43 (17.6) years. One hundred sixteen ADEs were identified with the incidence of 36.4 (95% CI, 30.1-43.6) per 100 admissions and 20.5 (95% CI, 16.9-24.6) per 1000 person-days. Antituberculosis agents (adjusted odds ratio [aOR] = 2.52; 95% CI, 1.06-5.98; P = 0.036), disease of the circulatory system (aOR = 2.67; 95% CI, 1.46-4.89; P = 0.001), disease of the digestive system (aOR = 2.84; 95% CI, 1.45-5.57; P = 0.002), being on medication during admission (aOR = 3.09; 95% CI, 1.77-5.41; P < 0.001), and hospital stay more than 2 weeks (aOR = 3.93; 95% CI, 1.39-11.12; P = 0.010) were independent predictors of ADE occurrence. Conclusions One in every 4 patients admitted to the hospital experienced ADEs during their hospital stay. Most ADEs were moderate in severity. About two-thirds of the ADEs identified were deemed probably or definitely preventable. Therefore, it is high time to reinforce large-scale efforts to redesign safer, higher quality health care systems to adequately tackle the problem.
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Affiliation(s)
- Tamiru Sahilu
- Department of Pharmacy, College of Health Science, Assosa University, Assosa, Ethiopia
| | - Mestawet Getachew
- Department of Clinical Pharmacy, School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Tsegaye Melaku
- Department of Clinical Pharmacy, School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Tadesse Sheleme
- Department of Pharmacy, College of Public Health and Medical Science, Mettu University, Metu Zuria, Ethiopia
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18
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Patel PB, Patel TK. Mortality among patients due to adverse drug reactions that occur following hospitalisation: a meta-analysis. Eur J Clin Pharmacol 2019; 75:1293-1307. [PMID: 31183532 DOI: 10.1007/s00228-019-02702-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 05/30/2019] [Indexed: 02/02/2023]
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19
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McCarthy BC, Tuiskula KA, Driscoll TP, Davis AM. Medication errors resulting in harm: Using chargemaster data to determine association with cost of hospitalization and length of stay. Am J Health Syst Pharm 2019; 74:S102-S107. [PMID: 29167147 DOI: 10.2146/ajhp160848] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Results of an analysis of the economic impact of adverse drug events (ADEs) resulting in patient harm on hospitalization costs and length of stay (LOS) are reported. METHODS In a retrospective single-site study, medication errors among patients admitted to an academic medical center during the period April 2014-May 2015 were identified using voluntary event reporting system data and diagnosis codes. Hospitalization cases involving documented ADEs resulting in harm, as defined on a widely used medication error classification index, were matched with control cases by admission period, diagnosis-related group, and patient age and sex. Total hospitalization costs and LOS in the study groups were analyzed using an independent 2-sample Mann-Whitney U test. RESULTS Among 416 hospitalization cases evaluated for inclusion in the study, 242 were matched with 3,279 control cases for analysis. The primary drug classes implicated in the evaluated medication errors included chemotherapy agents (38%), corticosteroids (14%), and opioids (11%). Total hospitalization costs differed significantly (p = 0.044) between patients who experienced ADEs resulting in harm (median, $19,444; interquartile range [IQR], $13,481-$40,580) and those who did not (median, $17,173; IQR, $12,500-$27,125); the former group also had a significantly (p = 0.005) longer median LOS. CONCLUSION Chargemaster data for an academic medical center revealed that the median total hospitalization cost and LOS were significantly greater for hospitalizations during which a harm-causing medication error was recorded versus hospitalizations during which harm-causing medication errors were not recorded.
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Affiliation(s)
| | | | | | - Andrew M Davis
- Section of General Internal Medicine, University of Chicago, Chicago, IL
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20
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Liao PJ, Mao CT, Chen TL, Deng ST, Hsu KH. Factors associated with adverse drug reaction occurrence and prognosis, and their economic impacts in older inpatients in Taiwan: a nested case-control study. BMJ Open 2019; 9:e026771. [PMID: 31079084 PMCID: PMC6530431 DOI: 10.1136/bmjopen-2018-026771] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Older patients are likely to have higher disease complexity and more drug prescriptions of which are associated with a higher incidence of adverse drug reactions (ADR). This study aimed to investigate factors associated with ADR occurrence, prognosis and medical expenses in older inpatients. DESIGN A nested case-control study. SETTING A medical centre located in north Taiwan. PARTICIPANTS 539 reported ADR cases from a patient cohort containing 108 548 older inpatients were collected from 2006 to 2012. There were 1854 non-ADR matched controls; a maximum of 1:5 matched by age, sex and principal diagnosis were collected. EXPOSURE Polypharmacy, the number of drugs prescribed, comorbidities and the admission department were factors associated with ADRs, as well as subsequent poor prognosis, length of stay and medical expenses. PRIMARY AND SECONDARY OUTCOME MEASURES ADR occurrence and poor prognosis (mortality, discharge against medical advice in critical conditions, or admitted to intensive care unit) were the primary outcomes. Additional medical expenses and the length of hospital stay were the secondary outcomes. RESULTS The admission department, number of comorbidities and number of drug prescriptions before ADRs were associated with ADR occurrence among older inpatients. ADR severity was a significant prognostic factor among ADR cases. The multivariate-adjusted OR of 1.63 (95% CI 1.36 to 1.95) for poor prognosis was found as the number of comorbidities increased. Patients prescribed ≥11 drugs including psychoactive drugs showed 2.45-fold (95% CI 1.40 to 4.28) poorer prognosis than other patients. ADRs caused the addition of US$1803.8, US$360.8 and 5.6 days in total medical expenses, drug expenses and length of stay among affected older inpatients, respectively. CONCLUSIONS The number of comorbidities and polypharmacy including the use of psychoactive drugs has significant impacts on ADR occurrence and prognosis among older inpatients. The findings provide clues for future prescription modification and patient's safety improvement in geriatric care.
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Affiliation(s)
- Pei-Ju Liao
- Department of Health Care Administration, Oriental Institute of Technology, New Taipei City, Taiwan
| | - Chien-Tai Mao
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tun-Liang Chen
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shin-Tarng Deng
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kuang-Hung Hsu
- Department of Health Care Management, and Healthy Aging Research Center, Chang Gung University, Tao-Yuan, Taiwan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Urology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Research Center for Food and Cosmetic Safety, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
- Department of Safety, Health and Environmental Engineering, Ming Chi University of Technology, New Taipei City, Taiwan
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21
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Hernández MH, Mestres C, Modamio P, Junyent J, Costa-Tutusaus L, Lastra CF, Mariño EL. Adverse Drug Events in Patients with Dementia and Neuropsychiatric/Behavioral, and Psychological Symptoms, a One-Year Prospective Study. Int J Environ Res Public Health 2019; 16:E934. [PMID: 30875907 PMCID: PMC6466294 DOI: 10.3390/ijerph16060934] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 01/19/2023]
Abstract
Older people usually present with adverse drug events (ADEs) with nonspecific symptoms such as cognitive decline, recurrent falls, reduced mobility, and/or major deterioration. The aims of this study were to assess the ADEs of patients with dementia and presenting neuropsychiatric/behavioral, and psychological symptoms in dementia (BPSD) and to categorize and identify the principal factors that allow to prevent ADEs, and separately ADEs that result in falls. To that end, a one-year prospective study in a psychogeriatric ward (July 2015 to July 2016) was performed. All patients admitted to this ward were eligible for enrolment. Patients who met any of the following criteria were excluded from the study: Patients without cognitive impairment, a length of stay under 7 days, and palliative or previous psychiatric pathology. We included 65 patients (60% women, 84.9 years ± 6.7) with mild to moderate cognitive impairment, moderate to severe functional dependence, and a high prevalence of geriatric syndromes and comorbidity. A total of 87.7% were taking five or more drugs (mean 9.0 ± 3.1). ADEs were identified during the interdisciplinary meeting and the follow up by clinical record. Sixty-eight ADEs (81.5% patients) were identified, of which 73.5% were not related to falls. From these, 80% were related to drugs of the nervous system. The Naranjo algorithm determined that 90% of ADEs were probable. The severity of the ADEs was Category E in 34 patients (68%). The number of preventable ADE according to the Schumork⁻Thornton test was 58%. The main ADE was drowsiness/somnolence (27.7%). ADEs related to falls represented a 26.5%. The balance between effective treatment and safety is complex in these patients. A medication review in interdisciplinary teams is an essential component to optimize safety prevention.
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Affiliation(s)
- Marta H Hernández
- Pharmacy Department, Grup Mutuam, 08024 Barcelona, Spain.
- School of Health Sciences Blanquerna, University Ramon Llull, 08025 Barcelona, Spain.
| | - Conxita Mestres
- School of Health Sciences Blanquerna, University Ramon Llull, 08025 Barcelona, Spain.
| | - Pilar Modamio
- Clinical Pharmacy and Pharmacotherapy Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain.
| | | | - Lluís Costa-Tutusaus
- School of Health Sciences Blanquerna, University Ramon Llull, 08025 Barcelona, Spain.
| | - Cecilia F Lastra
- Clinical Pharmacy and Pharmacotherapy Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain.
| | - Eduardo L Mariño
- Clinical Pharmacy and Pharmacotherapy Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain.
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Raffa RB, Taylor R, Pergolizzi JV. Treating opioid‐induced constipation in patients taking other medications: Avoiding CYP450 drug interactions. J Clin Pharm Ther 2019; 44:361-371. [DOI: 10.1111/jcpt.12812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Robert B. Raffa
- University of Arizona College of Pharmacy Tucson Arizona
- Temple University School of Pharmacy Philadelphia Pennsylvania
- Neumentum Inc Palo Alto California
- The NEMA Research Group Naples Florida
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Fabel PH, Wagner T, Ziegler B, Fleming PA, Davis RE. A sustainable business model for comprehensive medication management in a patient-centered medical home. J Am Pharm Assoc (2003) 2019; 59:285-290. [PMID: 30611660 DOI: 10.1016/j.japh.2018.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 11/02/2018] [Accepted: 11/03/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To develop a sustainable business model for pharmacist-provided comprehensive medication management services in a patient-centered medical home. Secondarily, to evaluate the impact that the pharmacist had on clinical (glycosylated hemoglobin [A1C], low-density lipoprotein [LDL], and blood pressure) and economic (physician productivity and cost avoidance) outcomes. PRACTICE DESCRIPTION This pilot project took place at the Palmetto Primary Care Physicians Trident office in North Charleston, South Carolina, from October 2013 to September 2014. At the time, the practice employed 5 physicians and 2 nurse practitioners and served more than 20,000 patients. PRACTICE INNOVATION The pharmacist targeted patients with diabetes, lipid disorders, hypertension, congestive heart failure, obesity, polypharmacy, and treatment regimen nonadherence for his comprehensive medication management services. The pharmacist was available for immediate consultation or referrals by appointment 5 days per week. Services provided by the pharmacist were billed as medication therapy management or "incident to" physician evaluation and management services codes. EVALUATION Number of patients seen per day, revenue collected from services rendered by the pharmacist, physician productivity and payment, cost avoidance, and health quality metrics (A1C, LDL, and blood pressure) were measured to determine the financial sustainability and clinical impact of the project. RESULTS AND IMPLICATIONS The pharmacist was able to see an average of 11 patients per day, which was 72% of his capacity. The practice collected about $7400 per month for services rendered by the pharmacist. The average daily payment for services rendered by the physicians in the practice increased by 20.6%. More than 70% of uncontrolled patients had an improvement in clinical outcomes, such as A1C, LDL, and blood pressure. CONCLUSION This project demonstrates the sustainable business model for embedding a pharmacist into a patient-centered medical home.
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Park CS, Kang DY, Kang MG, Kim S, Ye YM, Kim SH, Park HK, Park JW, Nam YH, Yang MS, Jee YK, Jung JW, Kim SH, Kim CW, Kim MY, Kim JH, Lee J, Lee JG, Kim SH, La HO, Kim MH, Park SJ, Koh YI, Lee SM, Kwon YE, Jin HJ, Kim HK, Kang HR, Choi JH. Severe Cutaneous Adverse Reactions to Antiepileptic Drugs: A Nationwide Registry-Based Study in Korea. Allergy Asthma Immunol Res 2019; 11:709-722. [PMID: 31332981 PMCID: PMC6658409 DOI: 10.4168/aair.2019.11.5.709] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/25/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) to antiepileptic drug (AED), are rare, but result in significant morbidity and mortality. We investigated the major culprit drugs, clinical characteristics, and clinical course and outcomes of AED-induced SCARs using a nationwide registry in Korea. METHODS A total of 161 patients with AED-induced SCARs from 28 referral hospitals were analyzed. The causative AEDs, clinical characteristics, organ involvements, details of treatment, and outcomes were evaluated. We compared the clinical and laboratory parameters between SJS/TEN and DRESS according to the leading causative drugs. We further determined risk factors for prolonged hospitalization in AED-induced SCARs. RESULTS Carbamazepine and lamotrigine were the most common culprit drugs causing SCARs. Valproic acid and levetiracetam also emerged as the major causative agents. The disease duration and hospital stay in carbamazepine-induced SJS/TEN were shorter than those in other AEDs (P< 0.05, respectively). In younger patients, lamotrigine caused higher incidences of DRESS than other drugs (P= 0.045). Carbamazepine, the most common culprit drug for SCARs, was associated with a favorable outcome related with prolonged hospitalization in SJS (odds ratio, 0.12; 95% confidence interval, 0.02-0.63, P= 0.12), and thrombocytopenia was found to be a risk factor for prolonged hospitalization in DRESS. CONCLUSION This was the first large-scale epidemiological study of AED-induced SCARs in Korea. Valproic acid and levetiracetam were the significant emerging AEDs causing SCARs in addition to the well-known offending AEDs such as carbamazepine and lamotrigine. Carbamazepine was associated with reduced hospitalization, but thrombocytopenia was a risk factor for prolonged hospitalization. Our results suggest that the clinical characteristics and clinical courses of AED-induced SCARs might vary according to the individual AEDs.
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Affiliation(s)
- Chan Sun Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Dong Yoon Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea.,Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Min Gyu Kang
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Sujeong Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Young Min Ye
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Kyung Park
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Jung Won Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hee Nam
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Min Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Koo Jee
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Jae Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sang Hyon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Cheol Woo Kim
- Department of Internal Medicine, Inha University School of Medicine, Seoul, Korea
| | - Mi Yeong Kim
- Department of Internal Medicine, Inje University Pusan Paik Hospital, Busan, Korea
| | - Joo Hee Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Jun Gyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Sang Hyun Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyen O La
- Department of Pharmacology, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Min Hye Kim
- Department of Internal Medicine, Ewha Womans University Hospital, Seoul, Korea
| | - Seoung Ju Park
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Young Il Koh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sang Min Lee
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yong Eun Kwon
- Department of Internal Medicine Chosun University Hospital, Gwangju, Korea
| | - Hyun Jung Jin
- Department of Internal medicine, Medical School of Yeungnam University, Daegu, Korea
| | - Hee Kyoo Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan Korea
| | - Hye Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Jeong Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.,Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chuncheon, Korea.
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Abstract
INTRODUCTION Given that adverse drug effects (ADEs) have led to post-market patient harm and subsequent drug withdrawal, failure of candidate agents in the drug development process, and other negative outcomes, it is essential to attempt to forecast ADEs and other relevant drug-target-effect relationships as early as possible. Current pharmacologic data sources, providing multiple complementary perspectives on the drug-target-effect paradigm, can be integrated to facilitate the inference of relationships between these entities. OBJECTIVE This study aims to identify both existing and unknown relationships between chemicals (C), protein targets (T), and ADEs (E) based on evidence in the literature. MATERIALS AND METHODS Cheminformatics and data mining approaches were employed to integrate and analyze publicly available clinical pharmacology data and literature assertions interrelating drugs, targets, and ADEs. Based on these assertions, a C-T-E relationship knowledge base was developed. Known pairwise relationships between chemicals, targets, and ADEs were collected from several pharmacological and biomedical data sources. These relationships were curated and integrated according to Swanson's paradigm to form C-T-E triangles. Missing C-E edges were then inferred as C-E relationships. RESULTS Unreported associations between drugs, targets, and ADEs were inferred, and inferences were prioritized as testable hypotheses. Several C-E inferences, including testosterone → myocardial infarction, were identified using inferences based on the literature sources published prior to confirmatory case reports. Timestamping approaches confirmed the predictive ability of this inference strategy on a larger scale. CONCLUSIONS The presented workflow, based on free-access databases and an association-based inference scheme, provided novel C-E relationships that have been validated post hoc in case reports. With refinement of prioritization schemes for the generated C-E inferences, this workflow may provide an effective computational method for the early detection of potential drug candidate ADEs that can be followed by targeted experimental investigations.
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Affiliation(s)
- Mary K La
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Alexander Sedykh
- Laboratory for Molecular Modeling, Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
- Sciome LLC, 2 Davis Drive, Research Triangle Park, NC, 27709, USA
| | - Denis Fourches
- Department of Chemistry, North Carolina State University, Raleigh, NC, 27695, USA
| | - Eugene Muratov
- Laboratory for Molecular Modeling, Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Alexander Tropsha
- Laboratory for Molecular Modeling, Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.
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Fricke-Galindo I, Jung-Cook H, LLerena A, López-López M. Pharmacogenetics of adverse reactions to antiepileptic drugs. Neurología (English Edition) 2018. [DOI: 10.1016/j.nrleng.2015.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Patel TK, Patel PB. Mortality among patients due to adverse drug reactions that lead to hospitalization: a meta-analysis. Eur J Clin Pharmacol 2018; 74:819-32. [PMID: 29556685 DOI: 10.1007/s00228-018-2441-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/07/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE The aim of this study was to estimate the prevalence of mortality among patients due to adverse drug reactions that lead to hospitalisation (fatal ADRAd), to explore the heterogeneity in its estimation through subgroup analysis of study characteristics, and to identify system-organ classes involved and causative drugs for fatal ADRAd. METHODS We identified prospective ADRAd-related studies via screening of the PubMed and Google Scholar databases with appropriate key terms. We estimated the prevalence of fatal ADRAd using a double arcsine method and explored heterogeneity using the following study characteristics: age groups, wards, study region, ADR definitions, ADR identification methods, study duration and sample size. We examined patterns of fatal ADRAd and causative drugs. RESULTS Among 312 full-text articles assessed, 49 studies satisfied the selection criteria and were included in the analysis. The mean prevalence of fatal ADRAd was 0.20% (95% CI: 0.13-0.27%; I2 = 93%). The age groups and study wards were the important heterogeneity modifiers. The mean fatal ADRAd prevalence varied from 0.01% in paediatric patients to 0.44% in the elderly. Subgroup analysis showed a higher prevalence of fatal ADRAd in intensive care units, emergency departments, multispecialty wards and whole hospitals. Computer-based monitoring systems in combination with other methods detected higher mortality. Intracranial haemorrhage, renal failure and gastrointestinal bleeding accounted for more than 50% of fatal ADRAdcases. Warfarin, aspirin, renin-angiotensin system (RAS) inhibitors and digoxin accounted for 60% of fatal ADRAd. CONCLUSIONS ADRAd is an important cause of mortality. Strategies targeting the safer use of warfarin, aspirin, RAS inhibitors and digoxin could reduce the large number of fatal ADRAdcases.
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Ribeiro MR, Motta AA, Marcondes-Fonseca LA, Kalil-Filho J, Giavina-Bianchi P. Increase of 10% in the Rate of Adverse Drug Reactions for Each Drug Administered in Hospitalized Patients. Clinics (Sao Paulo) 2018; 73:e185. [PMID: 29451619 PMCID: PMC5784181 DOI: 10.6061/clinics/2018/e185] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/17/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess the risk factors, incidence and severity of adverse drug reactions in in-patients. METHODS This prospective study evaluated 472 patients treated at a teaching hospital in Brazil between 2010 and 2013 by five medical specialties: Internal Medicine, General Surgery, Geriatrics, Neurology, and Clinical Immunology and Allergy. The following variables were assessed: patient age, gender, comorbidities, family history of hypersensitivity, personal and family history of atopy, number of prescribed drugs before and during hospitalization, hospital diagnoses, days of hospitalization. The patients were visited every other day, and medical records were reviewed by the investigators to detect adverse drug reactions. RESULTS There were a total of 94 adverse drug reactions in 75 patients. Most reactions were predictable and of moderate severity. The incidence of adverse drug reactions was 16.2%, and the incidence varied, according to the medical specialty; it was higher in Internal Medicine (30%). Antibiotics were the most commonly involved medication. Chronic renal failure, longer hospital stay, greater number of diagnoses and greater number of medications upon admission were risk factors. For each medication introduced during hospitalization, there was a 10% increase in the rate of adverse drug reaction. In the present study, the probability of observing an adverse drug reaction was 1 in 104 patients per day. CONCLUSIONS Adverse drug reactions are frequent and potentially serious and should be better monitored in patients with chronic renal failure or prolonged hospitalization and especially in those on 'polypharmacy' regimens. The rational use of medications plays an important role in preventing adverse drug reactions.
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Affiliation(s)
- Marisa Rosimeire Ribeiro
- Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, BR
| | - Antonio Abílio Motta
- Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, BR
| | | | - Jorge Kalil-Filho
- Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, BR
| | - Pedro Giavina-Bianchi
- Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, BR
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Vázquez-Alvarez AO, Brennan-Bourdon LM, Rincón-Sánchez AR, Islas-Carbajal MC, Huerta-Olvera SG. Improved drug safety through intensive pharmacovigilance in hospitalized pediatric patients. BMC Pharmacol Toxicol 2017; 18:79. [PMID: 29216902 PMCID: PMC5721683 DOI: 10.1186/s40360-017-0186-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The aim of this study was to detect and analyze Adverse Drug Reactions (ADRs) through Intensive Pharmacovigilance (IPV) in hospitalized pediatric patients to improve drug safety. METHODS A prospective 6-month cross-sectional study was performed in the pediatric service of a regional hospital in Mexico in order to assess hospitalized children from 1 day to 18 years old. The inclusion criteria were: both genders, all hospitalization causes, and at least one prescribed medication (indistinct drug group). Notifications were performed through medical visits, phone calls, or spontaneous reports. ADR suspicions were assessed with severity scales: Naranjo algorithm, Schumock & Thornton and Hartwig and Siegel. RESULTS From a total of 1083 hospital admissions, 19 ADRs were recorded. The average age of patients in years was 7.2 (±5.9). The causality assessment in this study showed that most of the ADRs were probable (68.4%) and 4 certain (8.2%); causality was mainly attributed to antibiotics (AB) and an antiepileptic drug. We found a relationship of AB with ADRs (p < 0.05) with an increased risk at the third day of prescription (p < 0.05). The average severity was level 2 and 21% were classified as "preventable". Lastly, an increase in hospital stay associated with ADRs (p < 0.05) and with concomitant medications (p < 0.05), was also found. The most severe ADRs were hemolysis and toxic epidermal necrolysis. CONCLUSIONS IPV was an effective tool for ADR prevention, detection, and treatment in hospitalized patients. The intensive monitoring approach in pharmacovigilance amplifies ADR detection and this translates into the improvement of drug safety in children.
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Affiliation(s)
- Alan O. Vázquez-Alvarez
- Instituto de Terapéutica Experimental y Clínica (INTEC). Departamento de Fisiología. Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco Mexico
| | | | - Ana Rosa Rincón-Sánchez
- Departamento de Biología Molecular y Genómica. Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco Mexico
| | - María Cristina Islas-Carbajal
- Instituto de Terapéutica Experimental y Clínica (INTEC). Departamento de Fisiología. Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco Mexico
| | - Selene G. Huerta-Olvera
- Departamento de Ciencias Médicas y de la Vida. Centro Universitario de la Ciénega, Universidad de Guadalajara, C.P. 47820 Guadalajara, Jalisco Mexico
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Gyllensten H, Jönsson AK, Hakkarainen KM, Svensson S, Hägg S, Rehnberg C. Comparing Methods for Estimating Direct Costs of Adverse Drug Events. Value Health 2017; 20:1299-1310. [PMID: 29241889 DOI: 10.1016/j.jval.2017.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 05/29/2017] [Accepted: 06/10/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To estimate how direct health care costs resulting from adverse drug events (ADEs) and cost distribution are affected by methodological decisions regarding identification of ADEs, assigning relevant resource use to ADEs, and estimating costs for the assigned resources. METHODS ADEs were identified from medical records and diagnostic codes for a random sample of 4970 Swedish adults during a 3-month study period in 2008 and were assessed for causality. Results were compared for five cost evaluation methods, including different methods for identifying ADEs, assigning resource use to ADEs, and for estimating costs for the assigned resources (resource use method, proportion of registered cost method, unit cost method, diagnostic code method, and main diagnosis method). Different levels of causality for ADEs and ADEs' contribution to health care resource use were considered. RESULTS Using the five methods, the maximum estimated overall direct health care costs resulting from ADEs ranged from Sk10,000 (Sk = Swedish krona; ~€1,500 in 2016 values) using the diagnostic code method to more than Sk3,000,000 (~€414,000) using the unit cost method in our study population. The most conservative definitions for ADEs' contribution to health care resource use and the causality of ADEs resulted in average costs per patient ranging from Sk0 using the diagnostic code method to Sk4066 (~€500) using the unit cost method. CONCLUSIONS The estimated costs resulting from ADEs varied considerably depending on the methodological choices. The results indicate that costs for ADEs need to be identified through medical record review and by using detailed unit cost data.
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Affiliation(s)
- Hanna Gyllensten
- Nordic School of Public Health NHV, Gothenburg, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Anna K Jönsson
- National Board of Forensic Medicine, Department of Forensic Genetics and Forensic Toxicology, Linköping, Sweden
| | - Katja M Hakkarainen
- Nordic School of Public Health NHV, Gothenburg, Sweden; EPID Research, Espoo, Finland
| | | | - Staffan Hägg
- Department of Drug Research/Clinical Pharmacology, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Futurum-Academy for Health and Care, Jönköping County Council, Jönköping, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Abstract
Adverse drug reactions (ADRs) are a significant source of patient morbidity and mortality and represent a major burden to health care systems and drug development. Up to 50% of such reactions are preventable. Although many ADRs can be predicted based on the on-target pharmacologic activity, ADRs arising from drug interactions with off-target receptors are recognized. Off-target ADRs include the immune-mediated ADRs (IM-ADRs) and pharmacologic drug effects. In this review, we discuss what is known about the immunogenetics and pathogenesis of IM-ADRs and the hypothesized role of heterologous immunity in the development of IM-ADRs.
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Affiliation(s)
- Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia
| | - Katie D White
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Celestine Wanjalla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Simon A Mallal
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, 6150 Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Ke CH, Chung WH, Wen YH, Huang YB, Chuang HY, Tain YL, Wang YCL, Wu CC, Hsu CN. Cost-effectiveness Analysis for Genotyping before Allopurinol Treatment to Prevent Severe Cutaneous Adverse Drug Reactions. J Rheumatol 2017; 44:835-843. [PMID: 28365572 DOI: 10.3899/jrheum.151476] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Patients with an HLA-B*58:01 allele have an increased risk of developing severe cutaneous adverse drug reactions (SCAR) when treated with allopurinol. Although one-off pharmacogenetic testing may prevent life-threatening adverse drug reactions, testing prior to allopurinol initiation incurs additional costs. The study objective was to evaluate the cost-effectiveness of HLA-B*58:01 screening compared with using other available urate-lowering agents (ULA). METHODS A decision-analytical model was used to compare direct medical costs and effectiveness [including lifetime saved, quality-adjusted life-yrs (QALY) gained] in treating new patients with the following options: (1) genetic screening followed by allopurinol prescribing for noncarriers of HLA-B*58:01, (2) prescribing benzbromarone without screening, (3) prescribing febuxostat without screening, and (4) prescribing allopurinol without screening. A 1-year time frame and third-party payer perspective were modeled for both the entire cohort (base-case) and for the subgroup of patients with chronic kidney disease (CKD). RESULTS The incremental cost-effectiveness ratio of genetic screening prior to ULA therapy was estimated as New Taiwan (NT) $234,610 (US$7508) per QALY gained in the base-case cohort. For patients with CKD, it was estimated as NT$230,925 (US$7390) per QALY. The study results were sensitive to the probability of benzbromarone/febuxostat-related hypersensitivity, and a negative predicted value of genotyping. CONCLUSION HLA-B*58:01 screening gave good value for money in preventing allopurinol-induced SCAR in patients indicated for ULA therapy. In addition to the costs of genotyping, it is important to monitor ULA safety closely in adopting HLA-B*58:01 screening in practice.
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Affiliation(s)
- Ching-Hua Ke
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - Wen-Hung Chung
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - Yen-Hsia Wen
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - Yaw-Bin Huang
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - Hung-Yi Chuang
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - You-Lin Tain
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - Yu-Ching Lily Wang
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - Cheng-Chih Wu
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital
| | - Chien-Ning Hsu
- From the School of Pharmacy, and Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Department of Pharmacy, Kaohsiung Medical University, Chung-Ho Memorial Hospital; Department of Pediatrics, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,C.H. Ke, MSc, School of Pharmacy, Kaohsiung Medical University; W.H. Chung, MD, PhD, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.H. Wen, PhD, School of Pharmacy, Kaohsiung Medical University; Y.B. Huang, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Chung-Ho Memorial Hospital; H.Y. Chuang, MD, PhD, Department of Public Health and Center of Excellence for Environmental Medicine, Kaohsiung Medical University; Y.L. Tain, MD, PhD, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University; Y.C. Wang, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.C. Wu, MSc, Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital; C.N. Hsu, PhD, School of Pharmacy, Kaohsiung Medical University, and Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital.
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Natanaelsson J, Hakkarainen KM, Hägg S, Andersson Sundell K, Petzold M, Rehnberg C, Jönsson AK, Gyllensten H. Direct and indirect costs for adverse drug events identified in medical records across care levels, and their distribution among payers. Res Social Adm Pharm 2017; 13:1151-8. [PMID: 27894838 DOI: 10.1016/j.sapharm.2016.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/27/2016] [Accepted: 11/18/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adverse drug events (ADEs) cause considerable costs in hospitals. However, little is known about costs caused by ADEs outside hospitals, effects on productivity, and how the costs are distributed among payers. OBJECTIVE To describe the direct and indirect costs caused by ADEs, and their distribution among payers. Furthermore, to describe the distribution of patient out-of-pocket costs and lost productivity caused by ADEs according to socio-economic characteristics. METHOD In a random sample of 5025 adults in a Swedish county, prevalence-based costs for ADEs were calculated. Two different methods were used: 1) based on resource use judged to be caused by ADEs, and 2) as costs attributable to ADEs by comparing costs among individuals with ADEs to costs among matched controls. Payers of costs caused by ADEs were identified in medical records among those with ADEs (n = 596), and costs caused to individual patients were described by socio-economic characteristics. RESULTS Costs for resource use caused by ADEs were €505 per patient with ADEs (95% confidence interval €345-665), of which 38% were indirect costs. Compared to matched controls, the costs attributable to ADEs were €1631, of which €410 were indirect costs. The local health authorities paid 58% of the costs caused by ADEs. Women had higher productivity loss than men (€426 vs. €109, p = 0.018). Out-of-pocket costs displaced a larger proportion of the disposable income among low-income earners than higher income earners (0.7% vs. 0.2%-0.3%). CONCLUSION We used two methods to identify costs for ADEs, both identifying indirect costs as an important component of the overall costs for ADEs. Although the largest payers of costs caused by ADEs were the local health authorities responsible for direct costs, employers and patients costs for lost productivity contributed substantially. Our results indicate inequalities in costs caused by ADEs, by sex and income.
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Schreiber R, Gregoire JA, Shaha JE, Shaha SH. Think time: A novel approach to analysis of clinicians' behavior after reduction of drug-drug interaction alerts. Int J Med Inform 2016; 97:59-67. [PMID: 27919396 DOI: 10.1016/j.ijmedinf.2016.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/12/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Pharmacologic interaction alerting offers the potential for safer medication prescribing, but research reveals persistent concerns regarding alert fatigue. Research studies have tried various strategies to resolve this problem, with low overall success. We examined the effects of targeted alert reduction on clinician behavior in a resource constrained hospital. METHODS A physician and a pharmacy informaticist reduced alert levels of several drug-drug interactions (DDI) that clinicians almost always overrode with approval from and knowledge of the medical staff. This study evaluated the behavioral changes in prescribers and non-prescribers as measured by "think time", a new metric for evaluating the resolution time for an alert, before and after suppression of selected DDI alerts. RESULTS The user-seen DDI alert rate decreased from 9.98% of all orders to 9.20% (p=0.0001) with an overall volume reduction of 10.3%. There was no statistical difference in the reduction of cancelled (-10.00%) vs. proceed orders (-11.07%). Think time decreased overall by 0.61s (p<0.0001). Think time unexpectedly increased for cancelled orders 1.00s which while not statistically significant (p=0.28) is generally thought to be clinically noteworthy. For overrides, think time decreased 0.67s which was significant (p<0.0001). Think time lowered for both prescribers and non-prescribers. Targeted specialists had shorter think times initially, which shortened more than non-targeted specialists. CONCLUSIONS Targeted DDI alert reductions reduce alert burden overall, and increase net efficiency as measured by think time for all prescribers better than for non-prescribers. Think time may increase when cancelling or changing orders in response to DDI alerts vs. a decision to override an alert.
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Affiliation(s)
- Richard Schreiber
- Clinical Informatics, Chief Medical Informatics Officer, Holy Spirit Hospital-A Geisinger Affiliate, 431 North 21st Street, Suite 101, Camp Hill, PA 17011, United States.
| | - Julia A Gregoire
- Medication Information Systems Manager, Holy Spirit Hospital-A Geisinger Affiliate, 503 North 21st Street, Camp Hill, PA 17011, United States.
| | - Jacob E Shaha
- University of Michigan, Graduate School of Engineering & Computer Science, Ann Arbor, MI, United States.
| | - Steven H Shaha
- Center for Public Policy & Administration, Draper, UT, United States.
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Geer M, Koul P, Tanki S, Shah M. Frequency, types, severity, preventability and costs of Adverse Drug Reactions at a tertiary care hospital. J Pharmacol Toxicol Methods 2016; 81:323-34. [DOI: 10.1016/j.vascn.2016.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 04/16/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
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Sledge T, Lonardo N, Simons H, Shipley W. Implementing the Use of Pharmacist Progress Notes in a Surgical ICU. Hosp Pharm 2016; 51:577-84. [PMID: 27559191 DOI: 10.1310/hpj5107-577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Critical care pharmacists are established and valuable members of the critical care team, however there is rarely written evidence of their daily involvement in the patient's electronic medical record (EMR). Documentation in the EMR has the advantage of ensuring a seamless pass-off and provides an opportunity to capture the pharmacist's cognitive and clinical impact in a way that traditional systems of tracking "interventions" fail to do. We investigated implementation of pharmacist progress notes in a surgical intensive care unit (ICU) and their utility in measuring pharmacist activity. METHODS Daily pharmacist progress notes written in a surgical ICU over a period of 2 months were reviewed. Each pharmacist action identified through progress note review was quantified and scored by an independent reviewer using a newly developed scoring system, the clinical impact score (CIS). This was developed as a way to quantify pharmacist actions and to classify those actions by clinical impact. RESULTS Four hundred sixty-two daily pharmacist progress notes were reviewed over a 2-month period. There were 1,055 actions identified that resulted in a therapy change. Four of these actions resulted in the potential avoidance of a sentinel event. Of patients with at least 5 progress notes (n = 44), the majority of pharmacist actions occurred on ICU day 1. CONCLUSION The results of this descriptive study demonstrate that the implementation of daily pharmacist progress notes is feasible in an advanced practice setting, and the pharmacist's contribution to patient care may be obtained through review of this documentation in the patient's medical record. The critical care pharmacist's daily involvement in patient care most commonly results in optimization of pharmacotherapy and avoidance of drug misadventure.
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Abstract
Introduction The growing evidence of the increased frequency and severity of adverse drug events (ADEs), besides the negative impact on patient’s health status, indicates that costs due to ADEs may be steadily rising. Observational studies are an important tool in pharmacovigilance. Despite these studies being more susceptible to bias than experimental designs, they are more competent in assessing ADEs and their associated costs. Objective To identify and characterize the best available evidence on ADE-associated costs. Methods MEDLINE, Cochrane Library, and Embase were searched from 1995 to 2015. Observational studies were included. The methodological quality of selected studies was assessed by Cochrane Collaboration tool for experimental and observational studies. Studies were classified according to the setting analyzed in “ambulatory”, “hospital”, or both. Costs were classified as “direct” and “indirect”. Data were analyzed using descriptive statistics. The total incremental cost per patient with ADE was estimated. Results Twenty-nine (94%) longitudinal observational studies and two (7%) cross-sectional studies were included. Twenty-three (74%) studies were assessed with the highest methodological quality score. The studies were mainly conducted in the US (61%). Twenty (65%) studies evaluated any therapeutic group. Twenty (65%) studies estimated costs of ADEs leading to or prolonging hospitalization. The “direct costs” were evaluated in all studies, whereas only two (7%) also estimated the “indirect costs”. The “direct costs” in ambulatory ranged from €702.21 to €40,273.08, and the in hospital from €943.40 to €7,192.36. Discussion Methodological heterogeneities were identified among the included studies, such as design, type of ADEs, suspected drugs, and type and structure of costs. Despite such discrepancies, the financial burden associated with ADE costs was found to be high. In the light of the present findings, validated methods to measure ADE-associated costs need future research efforts.
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Affiliation(s)
- Francisco Batel Marques
- CHAD - Centre for Health Technology Assessment and Drug Research, AIBILI - Association for Innovation and Biomedical Research on Light and Image; School of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Ana Penedones
- CHAD - Centre for Health Technology Assessment and Drug Research, AIBILI - Association for Innovation and Biomedical Research on Light and Image; School of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Diogo Mendes
- CHAD - Centre for Health Technology Assessment and Drug Research, AIBILI - Association for Innovation and Biomedical Research on Light and Image; School of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Carlos Alves
- CHAD - Centre for Health Technology Assessment and Drug Research, AIBILI - Association for Innovation and Biomedical Research on Light and Image; School of Pharmacy, University of Coimbra, Coimbra, Portugal
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Yasunaga D, Tasaka Y, Murakami S, Tanaka A, Tanaka M, Araki H. Economic contributions of pharmaceutical interventions by pharmacists: a retrospective report in Japan. J Pharm Policy Pract 2016; 10:2. [PMID: 27446592 PMCID: PMC4955163 DOI: 10.1186/s40545-016-0073-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 06/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pharmacists in Japan currently play a key role in patient hospital care. Their responsibilities include filling prescriptions, checking a patient's medication history, and providing appropriate information to other health care workers. More importantly, pharmacists' interventions can also result in reductions in adverse drug reactions (ADRs) and, ultimately, in cost savings. This study aimed to determine the economic value of such interventions at a hospital in Japan. METHODS At a single Japanese hospital, we analyzed 1452 pharmaceutical interventions by pharmacists, including recommending antibiotic dosage regimens, attending ward rounds with multidisciplinary health providers, providing drug information, and reporting ADRs. We classified the interventions into 13 categories. Using data from the PreAVOID Report by the Japanese Society of Hospital Pharmacists, along with previous studies, we estimated the cost savings of the interventions. RESULTS Various savings could be realized through appropriate interventions by hospital pharmacists. Based on the amount paid by the Pharmaceuticals and Medical Devices Agency, we calculated the cost savings associated with preventing serious ADRs as 21,400 USD ($) per case. The cost savings for recommendations related to transvenous antimicrobial therapy amounted to $1900 per patient. Pharmacists' interventions were able to prevent 12 cases of serious ADRs. CONCLUSIONS Determining the economic value of pharmacists' interventions is an important means of appraising the current role of hospital pharmacists. Our evaluation demonstrates the positive economic effects of pharmacists' interventions in a hospital setting.
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Affiliation(s)
- Daiki Yasunaga
- Division of Pharmacy, Ehime University Hospital, Shitsukawa, Toon, Ehime 791-0295 Japan
| | - Yuichi Tasaka
- Division of Pharmacy, Ehime University Hospital, Shitsukawa, Toon, Ehime 791-0295 Japan
| | - Satoshi Murakami
- Division of Pharmacy, Ehime University Hospital, Shitsukawa, Toon, Ehime 791-0295 Japan
| | - Akihiro Tanaka
- Division of Pharmacy, Ehime University Hospital, Shitsukawa, Toon, Ehime 791-0295 Japan
| | - Mamoru Tanaka
- Division of Pharmacy, Ehime University Hospital, Shitsukawa, Toon, Ehime 791-0295 Japan
| | - Hiroaki Araki
- Division of Pharmacy, Ehime University Hospital, Shitsukawa, Toon, Ehime 791-0295 Japan
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Kim KS, Moon A, Kang HJ, Shin HY, Choi YH, Kim HS, Kim SG. Higher plasma bilirubin predicts veno-occlusive disease in early childhood undergoing hematopoietic stem cell transplantation with cyclosporine. World J Transplant 2016; 6:403-410. [PMID: 27358786 PMCID: PMC4919745 DOI: 10.5500/wjt.v6.i2.403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 02/15/2016] [Accepted: 03/18/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To analyze the association between plasma bilirubin levels and veno-occlusive disease (VOD) in non-adult patients undergoing hematopoietic stem cell transplantation (HSCT) during cyclosporine therapy.
METHODS: A total of 123 patients taking cyclosporine were evaluated using an electronic medical system at the Seoul National University Children’s Hospital from the years 2004 through 2011. Patients were grouped by age and analyzed for incidence and type of adverse drug reactions (ADRs) including VOD.
RESULTS: The HSCT patients were divided into three age groups: G#1 ≥ 18; 9 ≤ G#2 ≤ 17; and G#3 ≤ 8 years of age). The majority of transplant donor types were cord blood transplantations. Most prevalent ADRs represented acute graft-vs-host disease (aGVHD) and VOD. Although the incidences of aGVHD did not vary among the groups, the higher frequency ratios of VOD in G#3 suggested that an age of 8 or younger is a risk factor for developing VOD in HSCT patients. After cyclosporine therapy, the trough plasma concentrations of cyclosporine were lower in G#3 than in G#1, indicative of its increased clearance. Moreover, in G#3 only, a maximal total bilirubin level (BILmax) of ≥ 1.4 mg/dL correlated with VOD incidence after cyclosporine therapy.
CONCLUSION: HSCT patients 8 years of age or younger are more at risk for developing VOD, diagnosed as hyperbilirubinemia, tender hepatomegaly, and ascites/weight gain after cyclosporine therapy, which may be represented by a criterion of plasma BILmax being ≥ 1.4 mg/dL, suggestive of more sensitive VOD indication in this age group.
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Leong C, Mamdani MM, Gomes T, Juurlink DN, Macdonald EM, Yogendran M. Antiepileptic use for epilepsy and nonepilepsy disorders: A population-based study (1998-2013). Neurology 2016; 86:939-46. [PMID: 26850976 DOI: 10.1212/wnl.0000000000002446] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/12/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the trends in antiepileptic drug (AED) use among individuals living in Manitoba with and without a history of epilepsy. METHODS Using data obtained from administrative health databases in Manitoba, we assessed the quarterly prevalence of AED use between 1998 and 2013 among individuals with and without a history of epilepsy using cross-sectional time series analysis. RESULTS Over the study period, the number of individuals prescribed AEDs increased more than 3-fold, from 8,883 to 27,246. The prevalence of AED use among patients with epilepsy increased by 3%, from 789.6 per 1,000 in 1998/1999 to 813.9 per 1,000 in 2012/2013 (p < 0.001 after 2006). In contrast, we observed a 210% increase in AED use among patients without epilepsy from 6.8 to 21.1 per 1,000 over the same period (p < 0.001). We observed a 55-fold rise in gabapentin use among patients without a seizure disorder (from 0.2 to 11.1 per 1,000; p < 0.001), while gabapentin use among those with epilepsy increased only 2-fold, from 21.6 to 41.3 per 1,000 (p < 0.001). CONCLUSIONS There has been a marked increase in the prevalence of AED users over the last 15 years, with a large shift towards the use of newer antiepileptic agents (primarily gabapentin) among those without epilepsy. Further research on the effect of these trends on health and economic outcomes will be of interest for clinicians and policymakers.
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Affiliation(s)
- Christine Leong
- From the College of Pharmacy, Faculty of Health Sciences, Apotex Centre (C.L.), and the Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine (M.Y.), University of Manitoba, Winnipeg; Leslie Dan Faculty of Pharmacy (M.M.M., T.G.), University of Toronto; Institute for Clinical Evaluative Sciences (M.M.M., T.G., D.N.J., E.M.M.); Li Ka Shing Knowledge Institute of St. Michael's Hospital (M.M.M.); and Divisions of General Internal Medicine and Clinical Pharmacology (D.N.J.), Sunnybrook, Toronto, Canada.
| | - Muhammad M Mamdani
- From the College of Pharmacy, Faculty of Health Sciences, Apotex Centre (C.L.), and the Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine (M.Y.), University of Manitoba, Winnipeg; Leslie Dan Faculty of Pharmacy (M.M.M., T.G.), University of Toronto; Institute for Clinical Evaluative Sciences (M.M.M., T.G., D.N.J., E.M.M.); Li Ka Shing Knowledge Institute of St. Michael's Hospital (M.M.M.); and Divisions of General Internal Medicine and Clinical Pharmacology (D.N.J.), Sunnybrook, Toronto, Canada
| | - Tara Gomes
- From the College of Pharmacy, Faculty of Health Sciences, Apotex Centre (C.L.), and the Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine (M.Y.), University of Manitoba, Winnipeg; Leslie Dan Faculty of Pharmacy (M.M.M., T.G.), University of Toronto; Institute for Clinical Evaluative Sciences (M.M.M., T.G., D.N.J., E.M.M.); Li Ka Shing Knowledge Institute of St. Michael's Hospital (M.M.M.); and Divisions of General Internal Medicine and Clinical Pharmacology (D.N.J.), Sunnybrook, Toronto, Canada
| | - David N Juurlink
- From the College of Pharmacy, Faculty of Health Sciences, Apotex Centre (C.L.), and the Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine (M.Y.), University of Manitoba, Winnipeg; Leslie Dan Faculty of Pharmacy (M.M.M., T.G.), University of Toronto; Institute for Clinical Evaluative Sciences (M.M.M., T.G., D.N.J., E.M.M.); Li Ka Shing Knowledge Institute of St. Michael's Hospital (M.M.M.); and Divisions of General Internal Medicine and Clinical Pharmacology (D.N.J.), Sunnybrook, Toronto, Canada
| | - Erin M Macdonald
- From the College of Pharmacy, Faculty of Health Sciences, Apotex Centre (C.L.), and the Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine (M.Y.), University of Manitoba, Winnipeg; Leslie Dan Faculty of Pharmacy (M.M.M., T.G.), University of Toronto; Institute for Clinical Evaluative Sciences (M.M.M., T.G., D.N.J., E.M.M.); Li Ka Shing Knowledge Institute of St. Michael's Hospital (M.M.M.); and Divisions of General Internal Medicine and Clinical Pharmacology (D.N.J.), Sunnybrook, Toronto, Canada
| | - Marina Yogendran
- From the College of Pharmacy, Faculty of Health Sciences, Apotex Centre (C.L.), and the Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine (M.Y.), University of Manitoba, Winnipeg; Leslie Dan Faculty of Pharmacy (M.M.M., T.G.), University of Toronto; Institute for Clinical Evaluative Sciences (M.M.M., T.G., D.N.J., E.M.M.); Li Ka Shing Knowledge Institute of St. Michael's Hospital (M.M.M.); and Divisions of General Internal Medicine and Clinical Pharmacology (D.N.J.), Sunnybrook, Toronto, Canada
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White KD, Chung WH, Hung SI, Mallal S, Phillips EJ. Evolving models of the immunopathogenesis of T cell-mediated drug allergy: The role of host, pathogens, and drug response. J Allergy Clin Immunol 2015; 136:219-34; quiz 235. [PMID: 26254049 DOI: 10.1016/j.jaci.2015.05.050] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/11/2015] [Accepted: 05/12/2015] [Indexed: 12/12/2022]
Abstract
Immune-mediated (IM) adverse drug reactions (ADRs) are an underrecognized source of preventable morbidity, mortality, and cost. Increasingly, genetic variation in the HLA loci is associated with risk of severe reactions, highlighting the importance of T-cell immune responses in the mechanisms of both B cell-mediated and primary T cell-mediated IM-ADRs. In this review we summarize the role of host genetics, microbes, and drugs in IM-ADR development; expand on the existing models of IM-ADR pathogenesis to address multiple unexplained observations; discuss the implications of this work in clinical practice today; and describe future applications for preclinical drug toxicity screening, drug design, and development.
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Affiliation(s)
- Katie D White
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Wen-Hung Chung
- Department of Dermatology, Chang Gung Memorial Hospital, Keelung, Taiwan; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shuen-Iu Hung
- Program in Molecular Medicine, Institute of Pharmacology, School of Medicine, Infection and Immunity Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Simon Mallal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia.
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Eshetie TC, Hailemeskel B, Mekonnen N, Paulos G, Mekonnen AB, Girma T. Adverse drug events in hospitalized children at Ethiopian University Hospital: a prospective observational study. BMC Pediatr 2015; 15:83. [PMID: 26173560 PMCID: PMC4502527 DOI: 10.1186/s12887-015-0401-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 07/06/2015] [Indexed: 11/10/2022] Open
Abstract
Background The nature and magnitude of adverse drug events (ADEs) among hospitalized children in low-income countries is not well described. The aim of this study was thus, to assess the incidence and nature of ADEs in hospitalized children at a teaching hospital in Ethiopia. Methods We used prospective observational method to study children that were hospitalized to Jimma University Specialized Hospital between 1 February and 1 May 2011. ADEs were identified using review of treatment charts, interview of patient and care-giver, attendance at ward rounds and/or meetings and voluntary staff reports. Two senior pediatric residents evaluated the severity and preventability of ADEs using preset criteria. Logistic regression analysis was employed to determine predictors of ADEs. Results There were 634 admissions with 6182 patient-days of hospital stay. There were 2072 written medication orders accounting for 35,117 medication doses. Fifty eight ADEs were identified with an incidence of 9.2 per 100 admissions, 1.7 per 1000 medication doses and 9.4 per 1000 patient-days. One-third of ADEs were preventable; 47 % of these were due to errors in the administration stage of medication use process. Regarding the severity of ADEs, 91 % caused temporary harms and 9 % resulted in permanent harm/death. Anti-infective drugs were the most common medications associated with ADEs. The occurrence of ADEs increased with age, length of hospital stay, and use of CNS, endocrine and antihistamine medicines. Conclusion ADEs are common in hospitalized children in low-income settings; however, one-third deemed preventable. A strategy to prevent the occurrence and consequences of ADEs including education of nurses/physicians is of paramount importance. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0401-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tesfahun Chanie Eshetie
- School of Pharmacy, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia.
| | - Bisrat Hailemeskel
- College of Pharmacy, Howard University, 2300 4th Street, N.W, Washington, DC, 20059, USA.
| | - Negussu Mekonnen
- Management Sciences for Health - Ethiopia, P.O Box: 1157, Code 1250, Addis Ababa, Ethiopia.
| | - Getahun Paulos
- School of Pharmacy, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia.
| | | | - Tsinuel Girma
- Department of Pediatrics and Child Health, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia.
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Fricke-Galindo I, Jung-Cook H, LLerena A, López-López M. Pharmacogenetics of adverse reactions to antiepileptic drugs. Neurologia 2015; 33:165-176. [PMID: 25976948 DOI: 10.1016/j.nrl.2015.03.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/30/2014] [Accepted: 03/04/2015] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Adverse drug reactions (ADRs) are a major public health concern and a leading cause of morbidity and mortality in the world. In the case of antiepileptic drugs (AEDs), ADRs constitute a barrier to successful treatment since they decrease treatment adherence and impact patients' quality of life of patients. Pharmacogenetics aims to identify genetic polymorphisms associated with drug safety. This article presents a review of genes coding for drug metabolising enzymes and drug transporters, and HLA system genes that have been linked to AED-induced ADRs. DEVELOPMENT To date, several genetic variations associated with drug safety have been reported: CYP2C9*2 and *3 alleles, which code for enzymes with decreased activity, have been linked to phenytoin (PHT)-induced neurotoxicity; GSTM1 null alleles with hepatotoxicity induced by carbamazepine (CBZ) and valproic acid (VPA); EPHX1 polymorphisms with teratogenesis; ABCC2 genetic variations with CBZ- and VPA-induced neurological ADRs; and HLA alleles (e.g. HLA-B*15:02, -A*31:01, -B*15:11, -C*08:01) with cutaneous ADRs. CONCLUSIONS Published findings show that there are ADRs with a pharmacogenetic basis and a high interethnic variability, which indicates a need for future studies in different populations to gather more useful results for larger number of patients. The search for biomarkers that would allow predicting ADRs to AEDs could improve pharmacotherapy for epilepsy.
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Affiliation(s)
- I Fricke-Galindo
- Programa de Doctorado en Ciencias Biológicas y de la Salud, Universidad Autónoma Metropolitana, Unidad Xochimilco, Coyoacán, México D.F. , México
| | - H Jung-Cook
- Departamento de Neuropsicofarmacología, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Departamento de Farmacia, Universidad Nacional Autónoma de México, Tlalpan, México D.F., México
| | - A LLerena
- CICAB Centro de Investigación Clínica, Complejo Hospitalario Universitario y Facultad de Medicina, Universidad de Extremadura, Servicio Extremeño de Salud, Badajoz, España
| | - M López-López
- Departamento de Sistemas Biológicos, Universidad Autónoma Metropolitana, Unidad Xochimilco, Coyoacán, México D.F., México.
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Martins ACM, Giordani F, Rozenfeld S. Adverse drug events among adult inpatients: a meta-analysis of observational studies. J Clin Pharm Ther 2014; 39:609-20. [PMID: 25219403 DOI: 10.1111/jcpt.12204] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Studies in a number of countries have shown that adverse drug events (ADE) occur frequently among hospital inpatients. The objective of this study was to conduct a systematic review of observational studies of the frequency of ADE in adult inpatients and to examine factors associated with observed heterogeneity in the reported results. METHODS The systematic review included observational studies, which identified and analysed ADE during hospitalization of adult inpatients. The literature search was conducted on MEDLINE, Embase, Lilacs and Google Scholar (January of 2000 to June of 2013). Article selection, quality assessment and information extraction were performed by two of the authors, working independently. Using the random-effects model, the proportion of patients with adverse events was used as an outcome measure. Proportion was estimated for subgroups based on event identification method: stimulated reporting (SR), retrospective monitoring (RM) and prospective monitoring (PM). For the latter group, meta-regression was used to identify sources of heterogeneity in the estimates. RESULTS AND DISCUSSION Twenty-eight articles from the 7550 identified met our inclusion criteria. The articles were heterogeneous in terms of quality, outcome definition and event identification method and in the corresponding descriptions. Of the 28 articles selected, 25 were included in the corresponding quantitative summary: four used SR, six RM and 15 PM, returning incidences of 2·3% (CI 95%: 1·6-4·5), 8·7% (CI 95%: 4·8-15·3) and 21·3% (CI 95%: 15·7-28·3), respectively, and I(2) greater than 95%. There were other sources of heterogeneity, including the use of combined strategies within each subgroup. In the PM subgroup, using multivariate meta-regression model, no variables were found to associate with proportion. WHAT IS NEW AND CONCLUSION Event frequency seems to associate with the event identification method. PM returned the highest estimates. This subgroup used a greater diversity of approaches for event identification and more diverse data sources. Improved recording of information on the event identification method, the characteristics of the events and the conduct of the study would enable more reliable and precise estimates of the frequency of ADE among hospital inpatients.
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Affiliation(s)
- A C M Martins
- National Regulatory Agency for Private Health Insurance/Agência Nacional de Saúde Suplementar, Rio de Janeiro, RJ, Brasil; National School of Public Health/Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
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Taylor R, V Pergolizzi J, Puenpatom RA, Summers KH. Economic implications of potential drug-drug interactions in chronic pain patients. Expert Rev Pharmacoecon Outcomes Res 2014; 13:725-34. [PMID: 24219048 DOI: 10.1586/14737167.2013.851006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic pain patients may be subject to polypharmacy because of long-term pharmacological pain treatment and additional comorbidities. Many chronic pain patients expose themselves to potential drug-drug interactions (DDIs) and these interactions can have unintended and severe consequences. Prevalence and costs associated with DDIs are inconsistent and has led to an inadequate level of awareness among the medical community; therefore, it has become necessary to re-evaluate the rates of DDIs in chronic pain patients. Utilizing medical and prescription claims databases, five studies were conducted to assess the health care utilization of and associated financial payments for patients >18 years with chronic noncancer pain. The studies evaluated drug-drug exposures with the potential to cause DDIs specifically occurring through the CYP450 enzyme system. The studies reported that drug-drug exposures are prevalent, costly and can occur in any age group and that physicians should consider ways to limit their patients' exposure to potential DDIs.
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Affiliation(s)
- Robert Taylor
- NEMA Research, 840 111th Avenue North, Suite 9, Naples 34108-1877, FL, USA
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Chan ALF, Lee HY, Ho CH, Cham TM, Lin SJ. Cost evaluation of adverse drug reactions in hospitalized patients in Taiwan: A prospective, descriptive, observational study. Curr Ther Res Clin Exp 2014; 69:118-29. [PMID: 24692791 DOI: 10.1016/j.curtheres.2008.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/03/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND Adverse drug reactions (AADRs) are a leading cause of morbidity and mortality. In the United States, ADR-related morbidity and mortality costs have been estimated at US $330 billion to US $1130 billion annually. OBJECTIVES The aim of this study was to evaluate the incidence of ADRs in Taiwan, to identify the drug classes that are most commonly related to ADRs, and to determine the direct medical costs to hospitals associated with prolonged hospitalizations due to ADRs. METHODS In this prospective, descriptive, observational study, patients who experienced ADRs during their hospitalization at a Taiwan teaching hospital or who were admitted due to an ADR from January 1, 2002, through December 31, 2004, were included in the study. The patients were identified actively by clinical pharmacists and passively by physicians and nurses who reported ADRs. The World Health Organization (WWHO) definition of ADR severity was adopted, and degrees of probability for each ADR were determined using the Naranjo algorithm. The direct medical costs incurred to the hospital in the treatment of ADRs that prolonged hospitalization were calculated (ie, costs of emergency department [ED] visits, intensive care unit visits, extra days of hospitalization, monitoring and laboratory studies, pharmacist dispensing fees, physician fees, room charges, ED charges). RESULTS During the study period, 43 of the 142,295 hospitalized patients (00.03%)) were admitted because of an ADR. A total of 564 (00.40%)) of the hospitalized patients were verified to have ADRs. Three hundred eighteen of the patients (56.44%) with ADRs were male and the overall mean (SD) age was 66(2) years. The most common drug classes associated with the ADRs were antibiotics (219 patients [38.8% ]), analgesics (62 [11.0%]), and cardiovascular agents (56 [9.9%]). The systems most commonly involved in ADRs were cutaneous (296 patients [52.5%]), hematologic (61 [10.8%]), and cardiovascular (54 [9.66%]). The causes of the ADRs were anaphylactic (464 patients [82.3%]), drug overdose (78 [13.8%]), and drug-drug interactions (22 [3.9%]). Of the ADRs, 474 (884.0%) were idiosyncratic type B reactions (predictable). ADR-related costs, estimated at US $3489/ADR, were mostly due to prolonged length of stay. Based on the WHO definition, of the 564 ADRs, 330 (58.5%) and 40 (7.1%) were classified as moderate and severe, respectively. Two patients died of ADRs associated with allopurinol. CONCLUSION In this hospital, 0.40% of patients were identified as having ADRs that were associated with high direct costs, mostly due to extended hospitalizations.
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Affiliation(s)
- Agnes L F Chan
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan ; Faculty of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Haw Yu Lee
- Department of Family Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chi-Hou Ho
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan
| | - Thau-Ming Cham
- Faculty of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shun Jin Lin
- Faculty of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
Over the past decade, there have been significant advances in our understanding of the immunopathogenesis and pharmacogenomics of severe immunologically-mediated adverse drug reactions. Such T-cell-mediated adverse drug reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), drug-induced liver disease (DILI) and other drug hypersensitivity syndromes have more recently been shown to be mediated through interactions with various class I and II HLA alleles. Key examples have included the associations of HLA-B*15:02 and carbamazepine induced SJS/TEN in Southeast Asian populations and HLA-B*57:01 and abacavir hypersensitivity. HLA-B*57:01 screening to prevent abacavir hypersensitivity exemplifies a successful translational roadmap from pharmacogenomic discovery through to widespread clinical implementation. Ultimately, our increased understanding of the interaction between drugs and the MHC could be used to inform drug design and drive pre-clinical toxicity programs to improve drug safety.
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Affiliation(s)
- Eric Karlin
- Vanderbilt University School of Medicine, 1161-21 St Avenue South, A-2200 Medical Center North, Nashville, TN, 37232-2582, USA
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Bissonnette L, Bergeron MG. Next revolution in the molecular theranostics of infectious diseases: microfabricated systems for personalized medicine. Expert Rev Mol Diagn 2014; 6:433-50. [PMID: 16706745 DOI: 10.1586/14737159.6.3.433] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The molecular diagnosis of infectious diseases is currently going through a revolution sustained by the regulatory approval of amplification tests that have been shown to be equivalent or superior to existing gold standard methods. The recent approval of a microarray system for the pharmacogenomic profiling of cytochrome P450-mediated drug metabolism is paving the way to novel, rapid, sensitive, robust and economical microfabricated systems for point-of-care diagnostics, which are utilized closer and closer to the patient's bedside. These systems will enable the multiparametric genetic evaluation of several medical conditions, including infectious diseases. This forecoming revolution will position molecular theranostics in a broader integrated view of personalized medicine, which exploits genetic information from microbes and human hosts to optimize patient management and disease treatment.
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Affiliation(s)
- Luc Bissonnette
- Département de Biologie Médicale (Microbiologie), Faculté de Médecine, Université Laval, Québec City, Canada.
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Patidar D, Rajput MS, Nirmal NP, Savitri W. Implementation and evaluation of adverse drug reaction monitoring system in a tertiary care teaching hospital in Mumbai, India. Interdiscip Toxicol 2013; 6:41-6. [PMID: 24170978 DOI: 10.2478/intox-2013-0008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 12/12/2012] [Accepted: 01/07/2013] [Indexed: 11/30/2022] Open
Abstract
Adverse drug reactions (ADR) are a significant cause of morbidity and mortality, often identified only post-marketingly. Improvement in current ADR reporting, including utility of underused or innovative methods, is crucial to improve patient safety and public health. Hospital-based monitoring is one of the methods used to collect data about drug prescriptions and adverse events. The aims of this study were to identify the most frequent ADRs recognized by the attending physicians, study their nature, and to target these ADRs in order to take future preventive measures. A prospective study was conducted over a 7-month period in an internal medicine department using stimulated spontaneous reporting for identifying ADRs. Out of the 254 admissions, 32 ADRs in 37 patients (14.56%) were validated from the total of 36 suspected ADRs in 41 patients. Female predominance was noted over males in case of ADRs. Fifty percent of total ADRs occurred due to multiple drug therapy. Dermatological ADRs were found to be the most frequent (68.75%), followed by respiratory, central nervous system and gastrointestinal ADRs. The drugs most frequently involved were antibiotics, anti-tubercular agents, antigout agents, and NSAIDs. The most commonly reported reactions were itching and rashes. Out of the 32 reported ADRs, 50% of the reactions were probable, 46.87% of the reactions were possible and 3.12% of the reactions were definite. The severity assessment done by using the Hartwig and Seigel scale indicated that the majority of ADRs were ‘Mild’ followed by ‘Moderate’ and ‘Severe’ reactions, respectively. Out of all, 75% of ADRs were recovered. The most potent management of ADRs was found to be drug withdrawal. Our study indicated that hospital based monitoring was a good method to detect links between drug exposure and adverse drug reactions. Adequate training regarding pharmacology and optimization of drug therapy might be helpful to reduce ADR morbidity and mortality.
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