Active methodology and blended learning: An experience in pharmaceutical care

BACKGROUND AND PURPOSE

The aim of this study was to analyze the implementation of an active methodology in a blended model of education in the teaching-learning processes of students enrolled in two disciplines: Pharmaceutical Care I and Pharmaceutical Care II, both part of the undergraduate Bachelor of Pharmacy program at the Federal University of Paraná.

EDUCATIONAL ACTIVITY AND SETTING

The study design was quasi-experimental, prospective, comparative, following a pre/posttest format, where Pharmaceutical Care classes were the intervention. Identical pre- and post-intervention tests were designed based on Anderson and Krathwohl's (2001) revision of Bloom's taxonomy, and according to the three levels of the cognitive domain: remember and understand; apply and analyze; evaluate and create.

FINDINGS

Participants were 133 students enrolled in the two Pharmaceutical Care classes. A significant difference between pre- and posttest results was observed, showing an increase in students' performance in the applied tests at all cognitive levels. This is the first study of its kind involving Pharmaceutical Care and Blended Learning.

DISCUSSION AND SUMMARY

By comparing the results of the diagnostic and summative assessments based on Bloom's taxonomy at all levels of the cognitive domain, positive results were observed regarding the students' performance in the two disciplines (Pharmaceutical Care I and II).

Development of the Brazilian brief version of the Diabetes Quality of Life Measure (DQOL-Brazil-8)

OBJECTIVE

To provide for Brazil, through the selection of items of the Brazilian version of the Diabetes Quality of Life Measure (DQOL-Brazil), a concise instrument.

METHODS

This is a cross-sectional study in which the DQOL-Brazil was administered to 150 type 1 diabetic patients and 146 type 2 diabetic patients. The items of the instrument were selected according to the analysis of the principal components and Spearman's correlations with treatment satisfaction, glycated hemoglobin level, and Nottingham Health Profile.

RESULTS

From a total of 44 items, only 8 were selected to compose the summary instrument (DQOL-Brazil-8). The DQOL-Brazil-8 presented Spearman's correlation of 0.873 with the DQOL-Brazil and a Cronbach's alpha coefficient of 0.702.

CONCLUSION

The Brazilian health professionals now have a brief tool for a fast application that preserves the best features of the full DQOL-Brazil.

Systematic review and meta-analysis of the efficacy and safety of amfepramone and mazindol as a monotherapy for the treatment of obese or overweight patients

The aim of this study was to evaluate efficacy and safety of amfepramone, fenproporex and mazindol as a monotherapy for the treatment of obese or overweight patients. A systematic review of primary studies was conducted, followed by a direct meta-analysis (random effect) and mixed treatment comparison. Medline and other databases were searched. Heterogeneity was explored through I2 associated with a p-value. Of 739 identified publications, 25 were included in the meta-analysis. The global evaluation of Cochrane resulted in 19 studies with a high level of bias and six with unclear risk. Due to the lack of information in primary studies, direct meta-analyses were conducted only for amfepramone and mazindol. Compared to placebo, amfepramone resulted in higher weight loss in the short-term (<180 days; mean difference (MD) -1.281 kg; p<0.05; I2: 0.0%; p=0.379) and long-term (≥180 days; MD -6.518 kg; p<0.05; I2: 0.0%; p=0.719). Only studies with long-term follow up reported efficacy in terms of abdominal circumference and 5-10% weight reduction. These results corroborated the finding that the efficacy of amfepramone is greater than that of placebo. Treatment with mazindol showed greater short-term weight loss than that with placebo (MD -1.721 kg; p<0.05; I2: 0.9%; p=0.388). However, metabolic outcomes were poorly described, preventing a meta-analysis. A mixed treatment comparison corroborated the direct meta-analysis. Considering the high level of risk of bias and the absence of important published outcomes for anti-obesity therapy assessments, this study found that the evaluated drugs showed poor evidence of efficacy in the treatment of overweight and obese patients. Robust safety data were not identified to suggest changes in their regulatory status.

Diethylpropion and mazindol: An end to the discussion?

Summary Antiobesity pharmacotherapy remains the main point of disagreement among both scientists and regulators. This is probably due to small sample sizes, high levels of heterogeneity, and low methodological quality. For many years, Brazil was one of the largest consumers of appetite suppressants worldwide, with evidence of irrational use of this drug class. Therefore, the country was the scene of a debate that divided the Brazilian Health Surveillance Agency (Anvisa - Agência Nacional de Vigilância Sanitária) and medical societies over the maintenance record of diethylpropion, mazindol and fenproporex. In this context, this commentary presents new arguments to contribute to the discussion, as well as recommendations for future studies.

Comparing medication adherence tools scores and number of controlled diseases among low literacy patients discharged from a Brazilian cardiology ward

Background Adherence to prescribed drug therapy is associated with lower rates of cardiovascular causes of death. In view of the relevance for public health, it is important to understand the relation between medication adherence tools' scores, especially in low literacy patients discharged from a cardiology ward. Objectives We aimed to assess: (a) the association between number of controlled clinical conditions and adherence tools scores, and (b) the correlation between the scores of three instruments to assess adherence. Methods We conducted a prospective study and included patients discharged from a specialized cardiovascular ward in Brazil. The results of the Beliefs about Medicines questionnaire (BMQ), the Adherence to Refills and Medication Scale (ARMS) and the MedTake test were compared. Results Of 53 included patients, most of them were elderly, and did not complete primary school. On average, there were six health conditions per patient, where two of them were not controlled. ARMS was the only tool that was associated with number of controlled health conditions (r = -0.312, p < 0.05). Moreover, ARMS (average score 15.6 ± 3.4) had significant correlation with MEDTAKE (r = 0.535, p < 0.01) and BMQ (r = 0.38, p < 0.01). BMQ and MEDTAKE were also positively correlated (r = 0.311, p < 0.05). Conclusions Clinically, higher ARMS scores (>12) suggest assumed non-adherence. It is also negatively correlated with the number of controlled clinical conditions in low literacy elderlies with cardiovascular diseases.

Analysis of the discrepancies identified during medication reconciliation on patient admission in cardiology units: a descriptive study

Objectives:

this observational study aimed to describe the discrepancies identified during medication reconciliation on patient admission to cardiology units in a large hospital.

Methods:

the medication history of patients was collected within 48 hours after admission, and intentional and unintentional discrepancies were classified as omission, duplication, dose, frequency, timing, and route of drug administration.

Results:

most of the patients evaluated were women (58.0%) with a mean age of 59 years, and 75.5% of the patients had a Charlson comorbidity index score between 1 and 3. Of the 117 discrepancies found, 50.4% were unintentional. Of these, 61.0% involved omission, 18.6% involved dosage, 18.6% involved timing, and 1.7% involved the route of drug administration.

Conclusion:

this study revealed a high prevalence of discrepancies, most of which were related to omissions, and 50% were unintentional. These results reveal the number of drugs that are not reincorporated into the treatment of patients, which can have important clinical consequences.

Quantitative genotoxicity assays for analysis of medicinal plants: A systematic review

ETHNOPHARMACOLOGICAL RELEVANCE

Medicinal plants are known to contain numerous biologically active compounds, and although they have proven pharmacological properties, they can cause harm, including DNA damage.

AIM OF THE STUDY

Review the literature to evaluate the genotoxicity risk of medicinal plants, explore the genotoxicity assays most used and compare these to the current legal requirements.

MATERIAL AND METHODS

A quantitative systematic review of the literature, using the keywords "medicinal plants", "genotoxicity" and "mutagenicity", was undertakenQ to identify the types of assays most used to assess genotoxicity, and to evaluate the genotoxicity potential of medicinal plant extracts.

RESULTS

The database searches retrieved 2289 records, 458 of which met the inclusion criteria. Evaluation of the selected articles showed a total of 24 different assays used for an assessment of medicinal plant extract genotoxicity. More than a quarter of those studies (28.4%) reported positive results for genotoxicity.

CONCLUSIONS

This review demonstrates that a range of genotoxicity assay methods are used to evaluate the genotoxicity potential of medicinal plant extracts. The most used methods are those recommended by regulatory agencies. However, based on the current findings, in order to conduct a thorough study concerning the possible genotoxic effects of a medicinal plant, we indicate that it is important always to include bacterial and mammalian tests, with at least one in vivo assay. Also, these tests should be capable of detecting outcomes that include mutation induction, clastogenic and aneugenic effects, and structural chromosome abnormalities. In addition, the considerable rate of positive results detected in this analysis further supports the relevance of assessing the genotoxicity potential of medicinal plants.

Review of the efficacy and safety of over-the-counter medicine

<p>Over-the-counter medicines are available without prescription because of their safety and effectiveness, to treat minor ailments and symptoms. The objective of the study was to analyze the availability and quality of systematic reviews published about nonprescription medicines, identifying the groups for which there are gaps in evidence. We identified published articles through the Cochrane Database of Systematic Review and MEDLINE, from the start of the database until May 2012, using the search terms "nonprescription drugs," "over the counter," and "OTC." We searched for articles that describe systematic reviews addressing the efficacy and safety of drugs dispensed without a prescription, according to the lists published by the Association of the European Self-Medication Industry and in Brazil, in the clinical conditions listed in Groups and Specified Therapeutic Indications. We included 49 articles, 18 articles were of moderate quality and 31 of high quality. Of the studies, 74.5% demonstrated efficacy in favor of the use of drugs evaluated. Of the 24 studies that evaluated safety, 21% showed evidence unfavorable to the drug. Overall, the evidence found in the studies included in the overview is favorable to the use of the drugs evaluated. However, there are gaps in evidence for some therapy groups.</p>

Clinical correlation between a point-of-care testing system and laboratory automation for lipid profile

BACKGROUND

We evaluated the clinical correlation between the CardioChek PA analyzer and a clinical laboratory reference method to use for screening program purposes.

METHODS

Fasting blood samples were collected on 516 patients (age 20-85 y). One venous sample was collected using a serum tube for the evaluation on a COBAS reference analyzer. A second venous sample was collected in a lithium heparin tube and was evaluated on the CardioChek PA analyzer (CCPA venous). A fingerstick sample (CCPA fingerstick) was evaluated only on the CardioChek PA analyzer. Linear regression analyses were performed for each measured analyte, total cholesterol, HDL-cholesterol and triglycerides.

RESULTS

The correlation between the CCPA fingerstick and CCPA venous was extremely high for HDL-C and triglycerides, and good for total cholesterol. Our results demonstrated a good clinical agreement for total cholesterol, HDL-C and triglycerides between 97.7% and 94.6% in the comparison of the CCPA to the reference analyzer.

CONCLUSIONS

We identified the pre-analytic phase as an important step to guarantee the quality of results and indicate that the CardioChek PA is a reliable lipid point-of-care testing system that can be used for the application of clinical screening anywhere.

Efficacy and safety of biologics in the treatment of moderate to severe psoriasis: a comprehensive meta-analysis of randomized controlled trials

We conducted a systematic review and metaanalysis of randomized placebo-controlled trials in moderate-to-severe psoriasis treated with biological agents, with a follow-up of 10-14 weeks. Overall, 41 studies, with mean Jadad score of 4.4, and 15,586 patients were included. For the efficacy outcomes PASI 50, 75 and 90 our findings are not conclusive to point what biological agent has the greatest response in short term follow-up. There were no statistical differences between placebo and biologics for the occurrence of infections and serious adverse events. Ustekinumab 45 mg showed lower withdrawal due to adverse events compared with the placebo. Based on data available up to now, it is not possible to determine which biological agent is the best for PASI 50, 75 or 90 after 10-14 weeks of treatment. At the same follow-up, overall safety seems to be the same for all biological agents and Ustekinumab 45 mg the most well tolerated drug. To better understand efficacy and safety, indirect meta-analysis comparing drug-to-drug is required since randomized placebo-controlled trials may not be feasible.

Proportion of Brazilian diabetes patients that achieve treatment goals: implications for better quality of care

BACKGROUND

Diabetes and its complications are substantial causes of morbidity and mortality, and caused approximately 5.1 million deaths worldwide in 2013. Early detection and treatment of diabetes complications can prevent their progression.

OBJECT

This study compared the proportions of patients with type 1 and 2 diabetes mellitus (T1DM and T2DM, respectively) who achieved the goals of good clinical control.

METHODS

Adults and elderly patients with T1DM and T2DM at a public outpatient endocrinology service in Brazil were retrospectively evaluated between 2012 and 2013. Clinical and socio demographic data were obtained from medical records and evaluated in accordance with the Brazilian Diabetes Society Guidelines. Care process measures, outcomes indicators, and supporting process measures were evaluated.

RESULTS

A total of 1031 records were analyzed: 29 and 71 % of patients had T1DM and T2DM, respectively. T2DM patients had significantly higher BMI than T1DM patients (overweight and obesity in 85.1 vs. 47.5 %, p < 0.01). The follow-up periods for diabetes and number of clinical visits to the endocrinology service were significantly greater among T1DM patients than T2DM patients (p < 0.01). However, T2DM patients required significantly more other (i.e., non-endocrinological) healthcare services (p < 0.01). HbA1c was significantly lower in T2DM patients (p < 0.01). Moreover, blood pressure and triglycerides were significantly higher in T2DM patients (p < 0.01), whereas total cholesterol and low-density lipoprotein were significantly lower in T2DM patients (p < 0.01). Only 0.5 % of the patients achieved all targets, and 1.1 % did not achieve any.

CONCLUSIONS

The achievement of goals of good clinical practice varies among the parameters evaluated. Almost no patients achieved all targets. Many patients are overweight and do not achieve targets for HbA1c, lipid profile, or blood pressure control.

Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review

Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.

Analysis of clinical pharmacist interventions in a tertiary teaching hospital in Brazil

Objective:

To analyze the clinical pharmacist interventions performed during the review of prescription orders of the Adult Intensive Care, Cardiologic Intensive Care, and Clinical Cardiology Units of a large tertiary teaching hospital in Brazil.

Methods:

The analysis took place daily with the following parameters: dose, rate of administration, presentation and/or dosage form, presence of inappropriate/unnecessary drugs, necessity of additional medication, more proper alternative therapies, presence of relevant drug interactions, inconsistencies in prescription orders, physical-chemical incompatibilities/solution stability. From this evaluation, the drug therapy problems were classified, as well as the resulting clinical interventions.

Results:

During the study, a total of 6,438 drug orders were assessed and 933 interventions were performed. The most prevalent drug therapy problems involved ranitidine (28.44%), enoxaparin (13.76%), and meropenem (8.26%). The acceptability of the interventions was 76.32%. The most common problem found was related to dose, representing 46.73% of the total.

Conclusion:

Our study showed that up to 14.6% of the prescriptions reviewed had some drug therapy problem and the pharmacist interventions have promoted positive changes in seven to ten of these prescriptions.

Insulin analogues versus human insulin in type 1 diabetes: direct and indirect meta-analyses of efficacy and safety

All patients with Diabetes Mellitus (DM) receive insulin therapy. In this study, we evaluated the efficacy, safety and tolerability of human insulin and insulin analogues. We performed a systematic review of the literature and a meta-analysis according to the Cochrane Collaboration methodology. In the absence of clinical studies comparing insulins, we performed a mixed treatment comparison to establish the differences between the active treatments. We included studies published from 1995 to 2010. HbA1c results, episodes of hypoglycemia and nocturnal hypoglycemia data were extracted and analyzed. Thirty-five randomized clinical trials were selected after examining the abstract and a full text review. These studies included 4,206 patients who received long-acting insulin analogues and 5,733 patients who received short-acting insulin analogues. Pooled data regarding efficacy indicated no significant differences in HbA1c values between glargine or detemir (once daily) and NPH insulin. However, a twice-daily dose of detemir produced differences in HbA1c values that favored detemir (-0.14% [95% CI: -0.21 to -0.08]; p<0.0001; I²=0%). Direct and indirect comparisons are consistent and show that there were no significant differences between human insulin and insulin analogues in efficacy or safety. Our results indicate that long- and short-acting insulin analogues offer few clinical advantages over conventional human insulin.

Economic evaluation of treatments for chronic hepatitis B

The aim of this study was to conduct a cost-utility study of adefovir, entecavir, interferon alpha, pegylated interferon alpha, lamivudine and tenofovir for chronic hepatitis B in the context of Brazilian Public Health Care System. A systematic review was carried out for efficacy and safety. Another review was performed to collect utility data and transition probabilities between health states. A Markov model was developed in a time horizon of 40 years with annual cycles for three groups of: HBeAg positive, HBeAg negative, and all patients. These strategies were compared to a fourth group that received no treatment. Discount rates of 5% were applied and sensitivity analyses were performed. Tenofovir offered the best cost-utility ratio for the three evaluated models: U$397, U$385 and U$384 (per QALY, respectively, for HBeAg positive, negative, and all patients). All other strategies were completely dominated because they showed higher costs and lower effectiveness than tenofovir. The sequence of cost-utility in the three models was: tenofovir, entecavir, lamivudine, adefovir, telbivudine, pegylated interferon alpha, and interferon alpha. In the sensitivity analysis, adefovir showed lower cost-utility than telbivudine in some situations. The study has some limitations, primarily related to the creation of scenarios and modeling. In this study, tenofovir presented the best cost-utility ratio. The results obtained in this study will be valuable in decision-making and in the review of the clinical protocol, mainly involving the allocation of available resources for health care.

Análise de Custo-Utilidade do Tratamento Adjuvante de Câncer de Cólon Estádio III (Dukes C)

Introdução: O aumento do repasse financeiro ao tratamento adjuvante de câncer de cólon estádio III nos hospitais integrantes do Sistema Único de Saúde permite a utilização de quimioterápicos anteriormente não empregados. Entretanto, não há estudos farmacoeconômicos que norteiem gestores quanto a escolha da terapia. Objetivo: Avaliar a relação custo utilidade das terapias adjuvantes Fluorouracil/Leucovorin (5FU/LV, Mayo Clinic Regimen) versus Capecitabina e 5FU/LV versus Fluorouracil/Leucovorin/Oxaliplatina (FLOX) para câncer de cólon em estádio III na perspectiva de um hospital público no Brasil. Método: Dados de eficácia foram extraídos da literatura e custos a partir do Sistema de Informação Hospitalar da referida instituição. Utilizou-se uma modelagem de Markov com dez ciclos de seis meses com quatro estados de saúde: terapia com antineoplásico, livre de doença, recidiva e morte. A taxa de desconto aplicada foi de 5%. Os custos foram expressos em Real (R$) e o desfecho em meses de vida ajustados pela qualidade (QALM). Realizou-se análise de sensibilidade univariada. Resultados: Capecitabina e FLO X proporcionam 0,33 e 1,75 QALM a mais que 5FU/LV, respectivamente. A comparação Capecitabina e 5FU/LV mostrou relação custo efetividade incremental (RCEI) de R$13.585,64/QALM, enquanto a comparação FLO X e 5FU/LV RCEI de R$1.007,92/QALM. A análise de sensibilidade sugere resultados robustos. Conclusão: O custo de aquisição da Capecitabina inviabiliza o uso em pacientes com câncer de cólon estádio III na perspectiva avaliada. O custo incremental de FLOX está compreendido pelo repasse financeiro do SUS, favorecendo sua incorporacao como terapia adjuvante de câncer de cólon estádio III pelo hospital aos indivíduos elegíveis para esse protocolo.  

Efficacy, safety and tolerability of using abatacept for the treatment of rheumatoid arthritis

The objective is to provide an update on the clinical efficacy, safety and tolerability of the use of abatacept for treating rheumatoid arthritis. A systematic review (up to June 2011) followed by meta-analyses was performed. Randomized controlled clinical trials comparing abatacept at a dose of 10 mg/kg with a placebo, both with concomitant methotrexate, were used. Only high- or moderate-quality studies were included. The efficacy was evaluated based on changes in the ACR, DAS and HAQ; safety was assessed based on serious adverse events, serious infections, malignancies and deaths; tolerability was evaluated based on the withdrawals due to adverse events, serious adverse events and lack of efficacy. All these parameters were evaluated within one year of treatment. Nine studies met the inclusion criteria, comprising 4,219 patients. For all of the efficacy parameters, the abatacept group had better results than the placebo group, except in the case of HAQ improvement >0.3, which presented no statistically significant difference. None of the safety parameters presented a significant difference between the groups. The tolerability parameters were also similar between groups, with the exception of withdrawals due to lack of efficacy. For this criterion, the abatacept group presented favorably compared to the control group. Abatacept showed a higher efficacy compared to placebo without significant differences between the abatacept and control group in terms of safety.

Efficacy and safety of topical antifungals in the treatment of dermatomycosis: a systematic review

The analysis of comparative efficacy and safety of topical antifungals in the literature is restricted to the treatment of tinea pedis and onychomycosis. Therefore our objective was to evaluate and compare the efficacy and safety of topical antifungals used in the treatment of dermatomycosis, we performed a comprehensive search for randomized controlled trials (RCTs) in the following databases: Medline, Cochrane Central Register of Controlled Trials, EMBASE, Lilacs and International Pharmaceutical Abstracts, we identified studies that compared the use of topical antifungals with other antifungals or with placebo published up to July 2010 in English, Spanish or Portuguese. The quality of reporting was assessed according to the Jadad scale; only studies with a score of 3 or more were included. The outcomes evaluated were mycological cure at the end of treatment, sustained cure, occurrence of adverse events and tolerability, including withdrawals due to adverse events. A total of 104 RCTs satisfied the inclusion criteria, containing a total of 135 comparisons, with 55 out of 120 possible comparisons among the 16 drugs evaluated. Pooled data on efficacy showed that all the antifungals were better than placebo. There were no significant differences among antifungal classes. No differences were found in safety or tolerability in any direct comparison. Sensitivity analysis indicated the robustness of the findings. Our results indicate the clear superiority of topical antifungals over placebo but that there is no consistent difference among classes. Mixed treatment comparisons are necessary to rank antifungals, as direct comparisons among many of them are lacking.

Efficacy of topical antifungal drugs in different dermatomycoses: a systematic review with meta-analysis

OBJECTIVE

To evaluate and compare the efficacy of topical antifungal drugs applied to the treatment of each dermatomycosis.

METHODS

A systematic review of randomized clinical trials, published in Portuguese, Spanish and English until July 2010, which compared the use of azole and allylamine antifungal drugs among themselves and with placebo in the treatment of cutaneous candidiasis and T. versicolor, T. pedis, T. cruris and T. corporis was performed. The efficacy outcomes evaluated were mycological cure at the end of treatment and sustained cure.

RESULTS

Of the 4,424 studies initially identified, 49 met the selection criteria and were included in the meta-analyses. The grouped efficacy data evidenced the superiority of antifungal drugs compared to placebo, regardless of the dermatomycosis under evaluation, with odds ratio values ranging from 2.05 (95% CI 1.18-3.54) to 67.53 (95% CI 11.43-398.86). Allylamines were better than azoles only for the outcome sustained cure (OR 0.52 [95% CI 0.31-0.89]).

CONCLUSION

There is consistent evidence of the superiority of antifungal drugs over the use of placebo, and placebo-controlled studies are no longer justifiable. Allylamines maintain the mycological cure for longer periods compared to azole drugs. Given the significant cost difference among the classes, pharmacoeconomic analyses should be performed.

Profile of users of anticytokines offered by the health care system in the state of Paraná for the treatment of rheumatoid arthritis

INTRODUCTION

The Brazilian Unified Health Care System (SUS) offers treatment for patients with RA through federal funding (Ministry of Health) and state co-financing. The Clinical Protocol and Therapeutic Guidelines for the treatment of rheumatoid arthritis describe the therapeutic regimen for the disease, including the anticytokines adalimumab, etanercept or infliximab.

OBJECTIVES

The aim of this study was to evaluate the profile of registered users of those anticytokines, biologics registered in the Information System of the Pharmaceutical Assistance Specialized Division, managed by the Paraná State Drug Center.

METHODS

A cross-sectional study regarding data from March 2010 was conducted. Based on dispensation data, information regarding the following variables were collected: age; gender; regional health care centers; International Classification of Diseases (ICD); and drug dispensed. In addition, the monthly cost with anticytokines for the SUS was calculated.

RESULTS

In the state of Paraná, 923 patients on anticytokines were identified, 40%, 44% and 16% of whom receiving adalimumab, etanercept and infliximab, respectively. This generated a monthly cost of R$3,403,195.59. Regarding the ICD, the distribution of patients was as follows: 55% had ICD M05.8; 27%, ICD M06.0; 9%, ICD M6.8; 8%, ICD M5.0; and 1% had other ICDs related to the disease. The regional health care centers of the state of Paraná with the largest number of patients on anticytokines were in the following municipalities: Ponta Grossa; Cornélio Procópio; Londrina; Cianorte; Maringá; Irati; and Campo Mourão.

CONCLUSION

This study assessed the distribution and profile of users of anticytokines for the rheumatoid arthritis treatment covered by the SUS in the state of Paraná, in March 2010.

Revisiting the efficacy of long-acting insulin analogues on adults with type 1 diabetes using mixed-treatment comparisons

AIM

To perform a network meta-analysis between long-acting insulin analogues (glargine and detemir) and Neutral Protamine Hagedorn (NPH) insulin on adults with type 1 diabetes.

METHODS

A systematic review of the literature was conducted according to the Cochrane Collaboration guidelines. The search for randomized controlled trials was performed in process databases, conferences and "gray literature" by 1995.

RESULTS

We found 1051 citations comparing glargine or detemir with human insulin and 187 comparing long-acting insulin analogues. Data on Glycated Hemoglobin (HbA1c), hypoglycemia episodes, nocturnal hypoglycemia and withdrawal were meta-analyzed. After review, 8 studies comparing glargine and 9 comparing detemir with NPH and 2 comparing glargine with detemir were considered relevant. Were included 1508 patients that received glargine, 2698 detemir and 2654 NPH insulin. Efficacy data showed no significant differences in HbA1c change between glargine or detemir (once daily) and NPH insulin. Twice-daily regimen of detemir caused a difference in HbA1c that favored detemir (-0.14% [95% CI -0.21 to -0.08]). Direct comparisons showed no significant differences between glargine and detemir in safety or HbA1c mean change.

CONCLUSION

The long-acting insulin analogues offer little to no clinical advantages over NPH insulin, and there is no significant difference in the efficacy and safety.

Quality of life in hypertensive patients and concurrent validity of Minichal-Brazil

BACKGROUND

Health-Related Quality of Life Questionnaires (HRQOL) are humanistic outcome measure instruments both in clinical and in pharmacoeconomic studies. However, they should have their psychometric parameters evaluated so as to reflect the individual subjective assessment of quality of life.

OBJECTIVES

To describe the quality of life profile of hypertensive patients and to assess the concurrent validity of the Minichal-Brazil instrument by comparing it to the generic World Health Organization's (WHO) assessment instrument known as WHOQOL-Bref.

METHODS

A total of 191 adult patients (72.8% females) with hypertension were interviewed. Approximately one third of these patients had their hypertension controlled. The mean HRQOL as measured by the total Minichal score was 69.7 (SD = 19.2; 95%CI from 66.9 to 72.4); the "mental status" domain and "somatic manifestations" domain scores were 69.1 (95%CI from 66.1 to 72.2), and 69.9 (95%CI from 66.5 to 73.2), respectively. The means for the WHOQOL-Bref instrument were: in the "physical" domain = 61.5 (95%CI from 59.0 to 64.1); in the "psychological" domain = 65.7 (95%CI from 63.2 to 68.2); in the "social" domain = 72.3 (95%CI from 70.0 to 74.5); and in the "environment" domain = 59.7 (95%CI from 57.7 to 61.7).

RESULTS

Minichal significantly correlated (p<0.001) with WHOQOL-Bref as regards all its domains, except for the "environment" domain, which did not correlate with the "somatic manifestations" domain.

CONCLUSION

Minichal-Brazil proved to be a useful tool in the assessment of HRQOL in hypertensive patients.

Instrumentos para avaliação da farmacoterapia do idoso: uma revisão

O envelhecimento é definido, no contexto cronológico, como sendo a partir de 60 anos nos países em desenvolvimento como o Brasil e a partir de 65 anos nos países desenvolvidos. Estudos mostram que, em termos absolutos, o Brasil será o 6º país com a maior população idosa do mundo até o ano de 2025. Este dado se torna preocupante quando se percebe que os profissionais da área da saúde não estão preparados para atender essa demanda. São os idosos as pessoas que possuem maior número de diagnósticos e de uso de medicamentos; assim, a possibilidade do surgimento de problemas relacionados aos medicamentos é superior quando comparada à de pessoas jovens. Portanto, há necessidade de profissionais com conhecimento sobre as alterações fisiológicas e farmacológicas que ocorrem nos idosos, bem como sobre o uso de medicamentos por este grupo, a fim de avaliar a terapia prescrita e, quando necessário, sugerir alterações para otimização do tratamento. O farmacêutico pode ser este profissional. Este artigo traz uma revisão de alguns instrumentos de avaliação da farmacoterapia do idoso e os disponibiliza para que os profissionais possam utilizá-los durante o processo de acompanhamento destes pacientes.

[Economic evaluation of pharmacotherapeutic follow-up in type 2 diabetes mellitus patients in community pharmacies]

OBJECTIVE

Assess economics results of Pharmacotherapeutic Follow-up (PF) in patients with diabetes mellitus type 2 in community pharmacies from additional Health system.

METHODS

In a prospective clinic study, 161 patients were divided into two groups, of which only one group received PF for 12 months. From the results, we calculated data of effectiveness and costs. The primary endpoint was the economic evaluation PF by using an indicator of effectiveness (changes in glycated hemoglobin), which was related to the costs of pharmaceutical care. Secondary endpoints were values of blood pressure, waist circumference and body mass index of patients, also related to costs of pharmaceutical care.

RESULTS

A real reduction of 1.3% of HbA1 was observed in the PF group, in comparison to control group. The annual cost of the reduction in 1% in HbA1 values in the PF group patients was $45.15. This feature to improve the control of type 2 diabetic patients can be implemented with annual investments of about $225.76 per patient, using PF and monitoring of blood glucose test.

CONCLUSIONS

It is possible to reduce the HbA1 values to desired levels by using PF. This can be considered an additional resource for the attainment of metabolic control, resulting in this study a cost of $37.62 per patient, per year, to reduce 1% in the HbA1 values.

Effect of a Pharmaceutical Care Program on quality of life and satisfaction with pharmacy services in patients with type 2 diabetes mellitus

The aim is to evaluate the humanistic outcomes in type 2 diabetic patients by the adoption of pharmacotherapy follow-up in community pharmacies. Controlled, non-randomized, 12-months trial; n=161 patients distributed into control and intervention groups; 6 community pharmacies involved, all in the Curitiba city region, in the state of Paraná were used. The health-related quality of life (HRQoL) and the satisfaction index were determined using both the DQOL assessment tool, which measures HRQoL, and the satisfaction evaluation tool (QSSF). Interventions on 119 negative therapeutic outcomes were done (2.3/patient [SD=1.6]); the most commonly found problems were related to ineffectiveness of pharmacotherapy (68.1%). The Intervention-Group showed a significant improvement in HRQoL compared with the Control Group (0.08 vs -0.01, respectively; p=0.036). Satisfaction and impact domains presented the most significant improvement (0.13 vs 0.00 [p=0.030] and 0.07 vs -0.04 [p=0.033], respectively). After adjusting for baseline variables, the difference in improvement scores between groups on the QSSF was attributed to the allocation of patients in the intervention group. Pharmacotherapy follow-up of type 2 diabetic patients in community pharmacies can improve the HRQoL and satisfaction of patients.

A systematic review and meta-analysis of the efficacy and safety of adalimumab for treating rheumatoid arthritis

Adalimumab (ADA) is a monoclonal antibody. Published studies indicate that its use in patients with rheumatoid arthritis can be efficient in providing long-term benefits. The aim of this study is to evaluate the efficacy and safety of ADA for treating rheumatoid arthritis. A systematic review was performed to search for randomized clinical trials that compare subcutaneous doses of ADA 20 mg weekly or 40 mg every other week with placebo, with or without concomitant methotrexate. Only studies of moderate or high quality were included. A meta-analysis was conducted to assess the efficacy (based in changes of American College of Rheumatology ACR criteria) and the safety (based in serious adverse events, serious infections, malignancy and deaths) of ADA use. Withdrawals due to adverse events or lack of efficacy were also evaluated. Eight studies met the inclusion criteria, comprising 2,692 patients. In the efficacy meta-analysis, a greater number of ADA-treated patients relative to those in placebo group achieved ACR20, ACR50 and ACR70 values from 6 months to 2 years of treatment. For safety results, there were no statistically significant differences between the groups. Withdrawals due to adverse events were higher in ADA group relative to the placebo group, and withdrawals due to the lack of efficacy were higher in placebo group relative to the ADA-treated group. This meta-analysis shows a higher efficacy of ADA relative to placebo, but clinicians should be careful regarding adverse events in ADA-treated patients.

Satisfação dos usuários com serviços da farmácia: tradução e validação do Pharmacy Services Questionnaire para o Brasil

Este estudo teve por objetivo traduzir e validar para o português o Pharmacy Services Questionnaire (PSQ). O instrumento possui 20 questões que medem a satisfação dos usuários com serviços da farmácia, organizadas em dois domínios. Utiliza uma escala de respostas Likert de 1 (ruim) a 5 (excelente). O Questionário de Satisfação com os Serviços da Farmácia (QSSF) foi aplicado a 137 diabéticos entre 31 e 89 anos (60,6% mulheres), clientes de farmácias privadas, em sua maioria usuários de serviços públicos de saúde (65,7%), com baixa escolaridade (67,9% até ensino fundamental) e utilizando em média 4,3 medicamentos por pessoa. O escore geral na população estudada foi de 3,6 [DP = 1,1 (IC95%: 3,4-3,8)]. Após análise fatorial, os domínios "exposição agradável" e "manejo da terapia" incluíram 8 e 12 itens, respectivamente, e se correlacionaram significativamente entre si (r = 0,92; p < 0,001) e com o escore geral. O instrumento obteve um a de Cronbach de 0,98 para o escore geral. Os domínios exposição agradável e manejo da terapia mostraram um a de 0,941 e 0,980. O QSSF apresenta aspectos de confiabilidade e validade adequados para sua utilização.

Translation and validation into Portuguese language of the medication regimen complexity index

BACKGROUND

The complexity of pharmacotherapy is a result of a multiplicity of prescribed regimen factors, including the number of different drugs in the regimen, the number of dosage units per dose, the total number of prescribed doses per day and administration instructions. The Medication Regimen Complexity Index (MRCI) is a specific, reliable and valid tool used to measure the complexity of pharmacotherapy, originally developed in English language.

OBJECTIVE

Transcultural translation and validation of this tool into Brazilian Portuguese.

METHODS

A cross-sectional study was developed with 95 type-2 diabetes patients, receiving multiple medications. The validation process included translation into Portuguese, back-translation and pre-test of the tool, creating a new version called the Pharmacotherapy Complexity Index (PCI). The psychometric parameters were assessed, including convergent validity, discriminant validity and reliability (interclass and test-retest correlation).

RESULTS

The complexity of pharmacotherapy measured by the MRCI-Brazil had an average score of 15.7 points (SD=8.36). MRCI-Brazil showed significant correlation with the number of medications (r=0.86; p<0.001) and age of patients (r=0.28, p=0.005). Interrater reliability analysis found an intra-class correlation (ICC) of 0.99 (p<0.001) and test-retest correlation was of 0.997 (p<0.001).

CONCLUSION

The results have shown that the Brazilian version of the MRCI presents adequate validity and reliability, and may be useful in clinical practice and research involving the analysis of the drug regimen complexity.

Tradução para o português e validação do instrumento Diabetes Quality of Life Measure (DQOL-Brasil)

OBJETIVO: Avaliar as propriedades psicométricas da versão brasileira do questionário de medida da qualidade de vida em diabetes (DQOL). MÉTODOS: O DQOL foi traduzido ao português segundo protocolo e aplicado em 121 indivíduos (56,2% mulheres), com tempo diagnóstico médio de diabetes melito tipo 2 de 8,1 ± 7,13 anos e na faixa etária de 32 a 89 anos. RESULTADOS: O instrumento apresentou consistência interna total (alfa de Cronbach = 0,92). Todas as questões apresentaram correlação positiva (p < 0,01) com seus domínios e com o escore geral do questionário, exceto as questões 18 e 35, que requereram exclusão da versão traduzida. O instrumento foi capaz de diferenciar pacientes com HbA1c acima e abaixo de 9% (p = 0,01). CONCLUSÃO: O DQOL-Brasil apresenta aspectos de confiabilidade e validade adequados para sua utilização em pacientes adultos com diabetes tipo 2.

Pharmaceutical care in community pharmacies: practice and research in Brazil

OBJECTIVE

To discuss the provision of pharmaceutical services and pharmaceutical care in Brazil.

FINDINGS

Professional training and pharmaceutical services are undergoing a period of restructuring in Brazil, including the adoption of incentives for pharmaceutical care. Some important national measures include the rational use of medications, evidence-based medicine, and pharmacovigilance. A new and more generalist pharmacy curriculum is being implemented and tailored for the Brazilian Public Health System; recently, the Brazilian government has provided resources for pharmaceutical care research.

DISCUSSION

A proposal for national consensus in Brazilian pharmaceutical care was published in 2002. The components of this proposal include drug dispensing, counseling, health education, symptoms advice, and pharmacotherapy follow-up. Pharmacy practice is currently focused on drug dispensing and logistic aspects of drug distribution. Professionals are satisfied with patients' confidence in being counseled by pharmacists and reveal interest in extending their role in patient care. Most pharmacy customers were originally unaware of the term "pharmaceutical care"; however, following an explanation, they showed an interest in this service. Furthermore, over 50% stated that they would pay for this service. Despite these initiatives, numerous barriers to the development of pharmaceutical care remain, the main ones being the commercial objective of most pharmacies that sell medications and the insufficient training of professionals. Although government-owned pharmacies also distribute medications, they do not meet all of the needs of the population and lack sufficient pharmacists.

CONCLUSIONS

Several actions are required to stimulate the implementation and development of pharmaceutical care and services in Brazil. Recent research incentives in pharmaceutical care and reorientation of pharmacy education will contribute to this development.