Discharge Information About Adverse Drug Reactions Indicates Lower Self-Reported Adverse Drug Reactions and Fewer Concerns in Patients After Percutaneous Coronary Intervention

AIM

There are discrepancies between the information patients desire about adverse drug reactions (ADRs) and the information they receive from healthcare providers; this is an impediment to shared decision-making. This study aimed to establish whether patients received information about ADRs resulting from prescribed pharmacotherapy, before hospital discharge, after percutaneous coronary intervention (PCI) and to determine whether receiving information about ADRs was associated with incidence of self-reported ADRs or concerns related to prescribed pharmacotherapy.

METHODS

CONCARDPCI, a prospective multicentre cohort study including 3,417 consecutive patients after PCI, was conducted at seven high-volume referral PCI centres in two Nordic countries. Clinical data were collected from patients' medical records and national quality registries. Patient-reported outcome measures were registered 2 months (T1), 6 months (T2), and 12 months (T3) after discharge. Covariate-adjusted logistic regression yielded adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

At discharge, 38% of participants had been informed about potential ADRs. For these patients, the incidence of self-reported ADRs was significantly lower at T1 (aOR 0.61, 95% CI 0.50-0.74; p<0.001), T2 (aOR 0.60, 95% CI 0.49-0.74; p<0.001), and T3 (aOR 0.57, 95% CI 0.46-0.71; p<0.001). Those who were not informed reported higher levels of concern about prescribed pharmacotherapy at all measuring points (p<0.001 for all comparisons). Those living alone (aOR 0.73, 95% CI 0.57-0.92; p=0.008), who were female (aOR 0.57, 95% CI 0.44-0.72; p<0.001), and with three or more versus no comorbidities (aOR 0.61, 95% CI 0.44-0.84; p=0.002) were less likely to receive information.

CONCLUSION

A substantial proportion of patients were not informed about potential ADRs from prescribed pharmacotherapy after PCI. Patients informed about ADRs had lower incidences of self-reported ADRs and fewer concerns about prescribed pharmacotherapy.

Self-perceived learning outcomes of virtual and in-person academic detailing among general practitioners in Norway

Self-perceived learning outcomes of virtual academic detailing (AD) are poorly studied. We compared self-perceived learning outcomes of virtual and in-person AD among general practitioners (GPs). GPs from the Western region of Norway received a questionnaire before and after AD concerning rational pharmacotherapy of migraine in the autumn 2022. Five statements addressing specific knowledge and two statements addressing general knowledge and skills in pharmacotherapy of migraine were rated in both questionnaires. A 7-point Likert scale ranging from 1: Strongly disagree to 7: Strongly agree was applied to all the statements. Histograms that showed the difference in the mean composite scores before and after AD were used to compare learning outcomes of virtual and in-person AD. Positive self-perceived learning outcomes were observed among 80%-88% of the GPs. No significant differences between virtual and in-person AD were observed.

Nurses as adverse drug reaction reporting advocates

Adverse drug reactions (ADRs) is a challenge in modern healthcare, particularly given the increasing complexity of drug therapy, an ageing population, rising multimorbidity, and a high patient turnover. The core activity of detecting potential ADRs over the last half century has been spontaneous reporting systems. A recent Norwegian regulation commits healthcare professionals other than physicians and dentists to report serious ADRs. In this discussion paper, we share our preliminary experience with a training programme using nurses as ADR advocates to stimulate ADR reporting among the clinical staff in a hospital department.

Healthcare professionals' information need related to antiseizure medication use in breastfeeding patients with epilepsy. Retrospective analysis of enquiries to Norwegian medicines information and pharmacovigilance centers

Background

Safety information of antiseizure medication (ASM) during breastfeeding is scarce and conflicting. We aimed to identify characteristic traits of safety concerns among healthcare professionals by reviewing enquiries to the Norwegian Regional Medicines Information and Pharmacovigilance Centres (RELIS).

Method

Enquiries related to breastfeeding, epilepsy, and ASM identified by their ATC-numbers were retrieved from the RELIS database of question-and-answer pairs (QAPs) by combining indexed and Boolean database searches and manual inspection. 112 QAPs were analyzed retrospectively using descriptive statistics.

Results

Hospital-employed physicians and nurses were puzzled by ambiguous or conflicting drug information advice and called for general information about the compatibility of an ASM with breastfeeding, mainly related to lamotrigine and levetiracetam. Other enquiries were related to co-medication with other drugs, mainly antidepressants. Half of the enquiries were posed after birth, 12 of these motivated by suspected adverse events in the infants.

Conclusion

Healthcare professionals with acknowledged high competence in the topic were uncertain about the prevailing safety information of ASM during breastfeeding. The fear to harm the infant may lead to the decision not to recommend breastfeeding. Future information strategies should aim to reach these professions, and support their information need on this topic.

Identifying target areas of medicines information efforts to pregnant and breastfeeding women by reviewing questions to SafeMotherMedicine: A Norwegian web-based public medicines information service

BACKGROUND

Online information about safety of medications during pregnancy and breastfeeding is shown to be conflicting, resulting in anxiety and abstaining from use. The aim of this study was to characterize questions to SafeMotherMedicine, a web-based medicines information service for pregnant and breastfeeding women, to identify target areas that could guide subsequent development of medicines information directed at pregnant and breastfeeding women.

METHODS

The SafeMotherMedicine database contains all questions received through the web-based service and their corresponding answers. A retrospective database analysis of questions received from January 2016 to September 2018 was performed, using descriptive statistics.

RESULTS

A total of 11 618 questions were received including 5 985 questions (51.5%) concerning pregnancy, 4 878 questions (42.0%) concerning breastfeeding, and 755 questions (6.5%) concerning both conditions. The medications in question represented all therapeutic groups with paracetamol (7.0%), ibuprofen (4.1%), cetirizine (3.3%), desloratadine (3.2%) and meclizine (2.8%) being the top five. The 20 medications most frequently asked about for either pregnancy, breastfeeding or both pregnancy and breastfeeding, constituted half of all questions and were used to identify target areas. These included both symptomatic relief of common complaints, such as pain, nausea, and rhinitis, as well as treatment of chronic conditions such as allergy, psychiatric disorders, and asthma. Analysis of a subset of questions showed that most of these questions were asked before use of medications in a current pregnancy (49%) or during breastfeeding (72%). The questions concerned use of medications in all stages of pregnancy and breastfeeding. For 81.6% of the questions concerning pregnancy, and for 84.2% of the questions concerning breastfeeding, information of no or low risk for the foetus or the breastfed infant was provided by SafeMotherMedicine.

CONCLUSIONS

We found that target areas for medicines information directed at pregnant and breastfeeding women included both symptomatic relief of common complaints as well as treatment of chronic conditions. The questions concerned a wide range of medications and involved use in all stages of pregnancy and breastfeeding. Our findings indicate that developing medicines information addressing the identified target areas will meet the information need for a large proportion of this patient group.

Perceptions of generic medicines and medication adherence after percutaneous coronary intervention: a prospective multicentre cohort study

OBJECTIVE

To determine patient perceptions of generic medicines 2 and 6 months after percutaneous coronary intervention (PCI), and to determine whether these perceptions moderate medication adherence.

DESIGN

Prospective multicentre cohort study with repeated measures of perceptions of generic medicines and medication adherence.

SETTING

The CONCARD^PCI study conducted at seven large referral PCI centres in Norway and Denmark between June 2017 and May 2020.

PARTICIPANTS

A total of 3417 adults (78% men), using both generic and brand name medicines, with a mean age of 66 years (SD 11) who underwent PCI were followed up 2 and 6 months after discharge from hospital.

MAIN OUTCOME MEASURES

Perceptions of generic medicines were the main outcome. The secondary outcome was medication adherence.

RESULTS

Perceptions of generic medicines were significantly more negative at 2 than at 6 months (1.10, 95% CI 0.41 to 1.79, p=0.002). Female sex (-4.21, 95% CI -6.75 to -1.71, p=0.001), older age (-0.12, 95% CI -0.23 to -0.02, p=0.020), lower education level (overall p<0.001), ethnicity (overall p=0.002), Norwegian nationality (10.27, 95% CI 8.19 to 12.40, p<0.001) and reduced self-reported health status (0.19, 95% CI 0.09 to 0.41, p=0.003) were significantly associated with negative perceptions of generic medicines. There was no evidence to suggest that perceptions of generic medicines moderate the association between sociodemographic and clinical variables and medication adherence (p≥0.077 for all covariates). Moreover, self-reported medication adherence was high, with 99% scoring at or above the Medication Adherence Report Scale midpoint at both time points. There were no substantial correlations between negative perceptions of generic medicines and medication non-adherence at 2 months (r=0.041, 95% CI 0.002 to 0.081, p=0.037) or 6 months (r=0.038, 95% CI -0.005 to 0.081, p=0.057).

CONCLUSIONS

Mistrust and uncertainty about the safety and efficacy of generic medicines remains in a sizeable proportion of patients after PCI. This applies especially to those of lower socioeconomic status, older age, female sex, immigrants and those with poorer mental health. However, this study demonstrated a shift towards more positive perceptions of generic medicines in the longer term.

Serum or Plasma for Quantification of Direct Oral Anticoagulants?

BACKGROUND

Direct oral anticoagulants are increasingly replacing vitamin K antagonists for prevention of stroke in patients with atrial fibrillation, partly owing to the lack of a need for routine monitoring. Therapeutic drug monitoring may still be warranted under certain circumstances. It is generally assumed that serum and plasma can be interchangeably used for this purpose. The aim of this study was to investigate possible differences between the serum, citrate-plasma, and ethylenediaminetetraacetic acid (EDTA)-plasma concentrations of apixaban and rivaroxaban in a larger patient group and their relation to factor X measurements.

METHODS

Plasma and serum samples were drawn during the same venipuncture from patients treated with apixaban or rivaroxaban. Drug levels were measured using ultrahigh-performance liquid chromatography combined with tandem mass spectrometry. Three sample matrices were obtained from 8 healthy volunteers for measurement of factor X antigen and activity.

RESULTS

Mean concentrations of apixaban and rivaroxaban were 16.8% and 36.6% higher in serum than in citrate-plasma, respectively (both P < 0.001). The corresponding differences in serum versus EDTA-plasma were 4.5% for apixaban and 13.1% for rivaroxaban (both P < 0.001). Factor X antigen measurements in citrate-plasma, EDTA-plasma, serum with clot activator, and serum without additives yielded comparable results, and factor X activity was significantly higher in serum than in plasma.

CONCLUSIONS

Apixaban and rivaroxaban concentrations were significantly higher in serum than in plasma. The difference was more pronounced with rivaroxaban and was larger between serum and citrate-plasma than between serum and EDTA-plasma. Higher factor X activity in serum may explain the observed concentration differences. The choice of matrix is, thus, important when interpreting therapeutic drug monitoring results and in research involving analyses of direct oral anticoagulants. The authors recommend citrate-plasma as the preferred matrix.

The possibility of hypersensitivity myocarditis following COVID-19 vaccines: Implications for contrast echocardiography

Response to the comments by Kounis and colleagues on our recent article “Incidence, clinical presentation and management of myocarditis following mRNA-based Covid-19 vaccines: A brief report”, published in Cardiology. We focus on the pharmacological aspects of hypersensitivity myocarditis related to mRNA-based COVID-19 vaccines, which is believed to be caused by the excipient polyethylene glycol (PEG), and show a clinically relevant association between anaphylactic reactions to mRNA-based COVID-19 vaccines and ultrasound contrast agents (UCA). We include hitherto unpublished observations on the frequency of anaphylactic reactions to UCAs.

A Patient With Sepsis-Induced Multiorgan Failure and Increasing Serum Methadone Concentration: A Case Study

ABSTRACT

The authors describe a patient with substance use disorder admitted to the hospital with septic shock and multiorgan failure, in whom the serum concentration of methadone kept increasing despite discontinuation of the drug. Therapeutic drug monitoring was performed to monitor the methadone serum concentration during treatment of the underlying diseases.

Quetiapine, Misuse and Dependency: A Case-Series of Questions to a Norwegian Network of Drug Information Centers

Purpose

The second-generation antipsychotic quetiapine has been associated with misuse and dependency. We aimed to review questions to the Norwegian network of drug information centers concerning this potential drug safety problem.

Methods

We conducted a Boolean search in the database of the Regional Medicines Information and Pharmacovigilance Centres in Norway (RELIS) combining the indexed categories “quetiapine” and “adverse drug reaction” with the text words “misuse” or “dependency”. Question–answer pairs (Q/As) in the full-text, searchable RELIS database were defined as cases. Cases were analyzed for drug safety issues linked to use of quetiapine, including off-label use, polypharmacy and other patient risk factors.

Results

The search resulted in 54 cases. Forty-six cases (85%) were patient-related, and a majority came from physicians working in hospitals. Twenty-nine cases (54%) concerned patients with a history of addiction, 14 cases (26%) had polypharmacy, and off-label use of quetiapine for insomnia was identified in 14 of the cases (26%). Only three of the cases included a specific question about patient dependency of quetiapine, and these cases were all associated with insomnia.

Conclusion

We conclude that our case series from the Norwegian network of drug information centres reflects that quetiapine frequently involves clinical narratives of a history of addiction, polypharmacy or insomnia (off-label use). However, the case series did not reveal new information about the drug’s addictive potential.

Acute Myocardial Injury in a Patient with Attention Deficit Hyperactivity Disorder and History of Substance Abuse: A Multimodality Imaging Point of View

Both cannabis and amphetamine are the most commonly used illegal substances worldwide and are associated with a number of adverse cardiovascular effects including transient coronary vasospasm. Here, we present the case of a 39-year-old male admitted to our institution with a 6-h history of severe chest pain and ST-segment elevation on the ECG. Coronary angiography on admission showed normal coronary arteries. The patient had a 14-year history of substance abuse, primarily amphetamine and cannabis, and was prescribed lisdexamfetamin (Aduvanz^®) for attention deficit hyperactivity disorder (ADHD) for the past 2 years. A cardiac magnetic resonance (CMR) the following day showed widely distributed focal lesions of late gadolinium enhancement in mid- and sub-epicardial myocardium in the anterior, lateral and inferior walls, suggestive of chronic fibrotic lesions. There was no sign of acute myocardial edema. No viral cause was identified during a thorough investigation, including negative SARS-COV-2 and endomyocardial biopsy. Substance-abuse-induced coronary vasospasm leading to ST-segment elevation, myocardial damage with a rise and fall of cardiac TnT, as well as a slightly reduced left ventricular ejection fraction (48%) and regional wall motion abnormalities on echocardiography, was the most likely diagnosis.

Review of Questions Concerning Clinical Drug Interactions in ADHD Treatment From Physicians in Norway

Pharmacological treatment of attention deficit hyperactivity disorder (ADHD) is challenging due to a wide age span among patients, risk of reduced adherence, and comorbidities like psychiatric disorders and drug addiction. Drugs used for ADHD are associated with risk of interactions and adverse drug reactions due to their potent pharmacological effect. In this brief report we aimed to describe real-world problem areas concerning interactions in pharmacotherapy of ADHD. We reviewed questions to a Norwegian drug information center from physicians concerning drug-drug interactions involving ADHD drugs in the last 10-year period. Questions were retrieved by a combination of indexed and Boolean database searches, in addition to manual inspection. ADHD drugs and interacting drugs were defined according to the Anatomical Therapeutic Chemical (ATC) classification system. Interactions were classified by use of Stockley’s Interactions Checker (SIC). Answers were examined with regard to whether the advice from the drug information center was more restrictive, similar or more liberal than SIC when assessing drug combinations. We retrieved 61 questions that included assessment of 96 drug combinations, and found 33 potential interactions according to SIC. Methylphenidate was involved in more than 50% of the interactions, and interacting drugs were in nearly 70% of the cases from ATC-group N (Nervous system) with antidepressants most frequently involved. Seventy percent of the interactions were pharmacodynamic, and interactions were frequently described as potentially severe although they were based on theoretical evidence. All the 33 interactions could be handled with monitoring or adjusting dose or with informative measures, and none was contraindicated according to SIC. More than 90% of the questions came from physicians in hospitals or outpatient specialist practice, and questions mainly concerned adults. In 75% of the drug combinations that involved ADHD drugs, we found similar advice from SIC and the drug information center. Our results suggest that future drug information efforts in ADHD treatment to clinicians, including specialists in the field, should focus on psychotropic interactions.

Perception of prescribing factors and purchase statistics of non-steroidal anti-inflammatory drugs in an orthopedic clinic

Objectives

Nonsteroidal anti-inflammatory drugs (NSAIDS) are associated with concern of adverse drug reactions (ADRS) including gastrointestinal, cardiovascular, renal, and musculoskeletal. Non-selective and selective NSAIDS are proposed to differ with regard to their potential to cause ADRS. The aim of this pilot study was to compare perception of prescribing factors and purchase statistics of NSAIDS among physicians in a Norwegian orthopedic clinic.

Results

Forty-five (55%) of 82 invited physicians from the orthopedic clinic participated anonymous in a survey in February 2017. Effect and ADRS were rated as the most important factors for prescribing of NSAIDS. The participants were equally concerned about specific ADRS for prescription of non-selective and selective NSAIDS irrespective of type of ADR. They were generally more concerned about cardiovascular, gastrointestinal and renal ADRS than musculoskeletal. Purchase statistics from 2015 and 2016 showed that celecoxib, a selective NSAID, dominated in the orthopedic clinic. The discrepancy between perception of prescribing factors and purchase statistics of NSAIDS was possibly explained by a high degree of conformity to clinic guidelines. Our preliminary results indicate that perception of prescribing factors of NSAIDS among orthopedics should be surveyed in multicenter or multinational studies.

The Possibility of Therapeutic Drug Monitoring of the Most Important Interactions in Nursing Homes

Background

Therapeutic drug monitoring is a relevant tool in drug treatment of elderly patients. The aim of this study was to assess the possibility of therapeutic drug monitoring of the most important potential interactions in nursing homes.

Methods

A material of prescribed drugs to 446 patients in three nursing homes in Bergen, Norway from a single day in March 2016 was analysed. Clinically relevant drug interactions (pharmacodynamic or pharmacokinetic) were identified and classified with Stockley`s Interaction Alerts. The most important interaction among several in each patient were ranked by recommended action > severity > evidence according to Stockley`s. The possibility of therapeutic drug monitoring of drug combinations involved in the most important interactions was retrieved from a database of all laboratories performing clinical pharmacology in Norway (the Pharmacology Portal).

Results

Two or more drugs were used by 443 (99.3%) of 446 patients. Three-hundred and eighty-four patients (86.1%) had > 1 interaction. About 95% of the most important interactions were pharmacodynamic. In 280 (72.9%) of these interactions, Stockley`s recommended adjust dose or monitoring. Among the 384 most important interactions, 93% involved one drug and 41% involved two drugs available for therapeutic drug monitoring.

Conclusion

In this pilot study, therapeutic drug monitoring was possible in the majority of the most important interactions in Norwegian nursing homes. This option is of importance since adjust dose or monitoring were frequently recommended actions associated with these interactions.

SafeMotherMedicine: Aiming to Increase Women's Empowerment in Use of Medications During Pregnancy and Breastfeeding

Purpose

Approximately 80% of pregnant women use medications. There is a need for evidence based medicines information that provide realistic risk estimates as pregnant and breastfeeding women tend to overestimate the risk of medications. The purpose of this paper is to describe the development and future perspectives of an innovative medicines information service aiming to increase empowerment among pregnant and breastfeeding women.

Description

SafeMotherMedicine (SMM) (www.tryggmammamedisin.no) is a Norwegian medicines information service for pregnant and breastfeeding women. Established in 2011, the service was initially web-based only, in contrast to most teratology information services that at the time mainly operated using telephone and/or e-mail.

Assessment

During the last eight years, SMM has provided close to 30,000 answers promoting appropriate medication use among pregnant and breastfeeding women. SMM launched a telephone-service in 2016, however, the annual number of questions received through the web-based service continues to increase.

Conclusion

The service seems to have fulfilled a previously unmet need of evidence-based, individually tailored information about medications to pregnant and breastfeeding women in Norway. SMM empowers the women to make informed decisions regarding medication use in pregnancy and breastfeeding, thus contributing to person-centred medicine. The web-based design of the service may represent the pregnant and breastfeeding women’s preferred way of communication.

Intracellular Cytidine Deaminase Regulates Gemcitabine Metabolism in Pancreatic Cancer Cell Lines

Cytidine deaminase (CDA) is a determinant of in vivo gemcitabine elimination kinetics and cellular toxicity. The impact of CDA activity in pancreatic ductal adenocarcinoma (PDAC) cell lines has not been elucidated. We hypothesized that CDA regulates gemcitabine flux through its inactivation and activation pathways in PDAC cell lines. Three PDAC cell lines (BxPC-3, MIA PaCa-2, and PANC-1) were incubated with 10 or 100 µM gemcitabine for 60 minutes or 24 hours, with or without tetrahydrouridine, a CDA inhibitor. Extracellular inactive gemcitabine metabolite (dFdU) and intracellular active metabolite (dFdCTP) were quantified with liquid chromatography tandem mass spectrometry. Cellular expression of CDA was assessed with real-time PCR and Western blot. Gemcitabine conversion to dFdU was extensive in BxPC-3 and low in MIA PaCa-2 and PANC-1, in accordance with their respective CDA expression levels. CDA inhibition was associated with low or undetectable dFdU in all three cell lines. After 24 hours gemcitabine incubation, dFdCTP was highest in MIA PaCa-2 and lowest in BxPC-3. CDA inhibition resulted in a profound dFdCTP increase in BxPC-3 but not in MIA PaCa-2 or PANC-1. dFdCTP concentrations were not higher after exposure to 100 versus 10 µM gemcitabine when CDA activities were low (MIA PaCa-2 and PANC-1) or inhibited (BxPC-3). The results suggest a regulatory role of CDA for gemcitabine activation in PDAC cells but within limits related to the capacity in the activation pathway in the cell lines. SIGNIFICANCE STATEMENT: The importance of cytidine deaminase (CDA) for cellular gemcitabine toxicity, linking a lower activity to higher toxicity, is well described. An underlying assumption is that CDA, by inactivating gemcitabine, limits the amount available for the intracellular activation pathway. Our study is the first to illustrate this regulatory role of CDA in pancreatic ductal adenocarcinoma cell lines by quantifying intracellular and extracellular gemcitabine metabolite concentrations.

Rethinking rehabilitation after percutaneous coronary intervention: a protocol of a multicentre cohort study on continuity of care, health literacy, adherence and costs at all care levels (the CONCARDPCI)

INTRODUCTION

Percutaneous coronary intervention (PCI) aims to provide instant relief of symptoms, and improve functional capacity and prognosis in patients with coronary artery disease. Although patients may experience a quick recovery, continuity of care from hospital to home can be challenging. Within a short time span, patients must adjust their lifestyle, incorporate medications and acquire new support. Thus, CONCARD^PCI will identify bottlenecks in the patient journey from a patient perspective to lay the groundwork for integrated, coherent pathways with innovative modes of healthcare delivery. The main objective of the CONCARD^PCI is to investigate (1) continuity of care, (2) health literacy and self-management, (3) adherence to treatment, and (4) healthcare utilisation and costs, and to determine associations with future short and long-term health outcomes in patients after PCI.

METHODS AND ANALYSIS

This prospective multicentre cohort study organised in four thematic projects plans to include 3000 patients. All patients undergoing PCI at seven large PCI centres based in two Nordic countries are prospectively screened for eligibility and included in a cohort with a 1-year follow-up period including data collection of patient-reported outcomes (PRO) and a further 10-year follow-up for adverse events. In addition to PROs, data are collected from patient medical records and national compulsory registries.

ETHICS AND DISSEMINATION

Approval has been granted by the Norwegian Regional Committee for Ethics in Medical Research in Western Norway (REK 2015/57), and the Data Protection Agency in the Zealand region (REG-145-2017). Findings will be disseminated widely through peer-reviewed publications and to patients through patient organisations.

TRIAL REGISTRATION NUMBER

NCT03810612.

Ultrasound- and Microbubble-Assisted Gemcitabine Delivery to Pancreatic Cancer Cells

Pancreatic ductal adenocarcinoma (PDAC) is a major cause of cancer death worldwide. Poor drug delivery to tumours is thought to limit chemotherapeutic treatment efficacy. Sonoporation combines ultrasound (US) and microbubbles to increase the permeability of cell membranes. We assessed gemcitabine uptake combined with sonoporation in vitro in three PDAC cell lines (BxPC-3, MIA PaCa-2 and PANC-1). Cells were cultured in hypoxic bioreactors, while gemcitabine incubation ± sonoporation was conducted in cells with operational or inhibited nucleoside membrane transporters. Intracellular active metabolite (dFdCTP), extracellular gemcitabine, and inactive metabolite (dFdU) concentrations were measured with liquid chromatography tandem mass spectrometry. Sonoporation with increasing US intensities resulted in decreasing extracellular gemcitabine concentrations in all three cell lines with inhibited membrane transporters. In cells with inhibited membrane transporters, without sonoporation, dFdCTP concentrations were reduced down to 10% of baseline. Sonoporation partially restored gemcitabine uptake in these cells, as indicated by a moderate increase in dFdCTP concentrations (up to 37% of baseline) in MIA PaCa-2 and PANC-1. In BxPC-3, gemcitabine was effectively inactivated to dFdU, which might represent a protective mechanism against dFdCTP accumulation in these cells. Intracellular dFdCTP concentrations did not change significantly following sonoporation in any of the cell lines with operational membrane transporters, indicating that the gemcitabine activation pathway may have been saturated with the drug. Sonoporation allowed a moderate increase in gemcitabine transmembrane uptake in all three cell lines, but pre-existing nucleoside transporters were the major determinants of gemcitabine uptake and retention.

Analysis of consensus among drug interaction databases with regard to combinations of psychotropics

Drug interaction databases are important tools in today's clinical decision support. However, there is great variation with regard to classification and presentation of interactions among databases. The present study aimed to investigate consensus among databases with regard to combinations of psychotropics. A database integrated in Norwegian computerised clinical decision support systems and three international recommended subscription databases were compared. Combinations of psychotropics (two or more) prescribed to patients 65 years or older on a single day from three nursing homes in Bergen, Norway 16 years apart (2000 and 2016) were studied. The databases were compared in a common analysis with the following questions: interaction (no, not contraindicated or contraindicated), type (pharmacodynamic or pharmacokinetic), the total number of interactions, and the first ranked interaction among several in each patient. Consensus among the four drug interaction databases was associated with pharmacokinetic interactions involving mainly older psychotropics in the common analysis. The qualities that best characterised interactions with consensus was primarily the evidence including a description of manageability. There was a surprising lack of consensus with regard to contraindicated interactions, even when older psychotropics were involved. Lack of consensus decreased with the number of psychotropics in the combinations. This was mainly because the highest ranked interactions in the respective databases involved different drugs. We propose evidence and manageability as core factors when ranking and presenting interactions in clinical decision support.

Norwegian drug information centres strongly promote person-centred and personalised medicine: a brief report on the achievements and strategy

The Norwegian network of drug information centres (RELIS) has achievements in person-centred and personalised medicine. RELIS receive questions from physicians, pharmacists, nurses and other health professionals and provide decision support in all aspects of pharmacotherapy. Questions associated with person-centred medicine often include problems with unrealistic risk perception and poor adherence among patients. Questions associated with personalised medicine frequently concern comorbidity, biomarkers and pharmacogenetics. The questions frequently include a mix of problems related to health and disease care. The RELIS staff addresses each question in a problem-oriented approach with expertise in pharmacology and skills in searching and critical evaluation of the literature. A written answer can describe decision support concerning patient empowerment, further diagnostics and preferences in pharmacotherapy including advice with regard to choice of drug and dose to a patient. Links to online resources and attached references for further reading are often included in the answers. The question-answer service is documented in a full-text, searchable question-answer database. Additional drug information activities towards clinicians and patients, and a multi-professional staff with pharmacists and clinical pharmacologists, are important elements in RELIS drug information strategy, and it is essentially relevant to predictive, preventive and personalised medicine (PPPM).

Drug information centres and their provision of decision support: The Scandinavian experience

WHAT IS KNOWN AND OBJECTIVE

Appraisal of drug information centres (DICs) is mainly by word of mouth communication and surveys of overall user satisfaction. Efforts to study the impact of this type of informatics and decision support systematically are generally lacking within the healthcare system.

COMMENT

Scandinavian DICs question-answering databases are relevant sources for identifying recurring problems in pharmacotherapy, including drug safety questions, and for re-use of previous answers. Recent studies in this setting have shown that high-quality answers demand easily accessible literature sources, skills in literature search and critical assessment of the retrieved documentation. Furthermore, patient-specific advice in clinical cases presented within a requested time frame is appraised by clinicians.

WHAT IS NEW AND CONCLUSIONS

Effective decision support by Scandinavian DICs depends on skills among staff and technological resources. Our experience could motivate further studies investigating methods and evaluating the impact of DICs in the healthcare system.

Rituximab Serum Concentrations and Anti-Rituximab Antibodies During B-Cell Depletion Therapy for Myalgic Encephalopathy/Chronic Fatigue Syndrome

PURPOSE

Previous Phase II trials indicated clinical benefit from B-cell depletion using the monoclonal anti-CD20 antibody rituximab in patients with myalgic encephalopathy/chronic fatigue syndrome (ME/CFS). The association between rituximab serum concentrations and the effect and clinical relevance of antidrug antibodies (ADAs) against rituximab in ME/CFS is unknown. We retrospectively measured rituximab concentrations and ADAs in serum samples from patients included in an open-label Phase II trial with maintenance rituximab treatment (KTS-2-2010) to investigate possible associations with clinical improvement and clinical and biochemical data.

METHODS

Patients with ME/CFS fulfilling the Canadian criteria received rituximab (500 mg/m²) infusions: 2 infusions 2 weeks apart (induction), followed by maintenance treatment at 3, 6, 10, and 15 months. The measured rituximab concentrations and ADAs in serum samples included 23 of 28 patients from the trial.

FINDINGS

There were no significant differences in mean serum rituximab concentrations between 14 patients experiencing clinical improvement versus 9 patients with no improvement. Female patients had higher mean serum rituximab concentrations than male patients at 3 months (P = 0.05). There was a significant negative correlation between B-cell numbers in peripheral blood at baseline and rituximab serum concentration at 3 months (r = -0.47; P = 0.03). None of the patients had ADAs at any time point.

IMPLICATIONS

Clinical improvement of patients with ME/CFS in the KTS-2-2010 trial was not related to rituximab serum concentrations or ADAs. This finding is also in line with a recent randomized trial questioning the efficacy of rituximab in ME/CFS. Rituximab concentrations and ADAs still offer supplemental information when interpreting the results of these trials.

Challenges adhering to a medication regimen following first-time percutaneous coronary intervention: A patient perspective

BACKGROUND

Percutaneous coronary intervention is the most common therapeutic intervention for patients with narrowed coronary arteries due to coronary artery disease. Although it is known that patients with coronary artery disease often do not adhere to their medication regimen, little is known about what patients undergoing percutaneous coronary interventions find challenging in adhering to their medication regimen after hospital discharge.

OBJECTIVES

To explore patients' experiences in adhering to medications following early post-discharge after first-time percutaneous coronary intervention.

DESIGN

An abductive qualitative approach was used to conduct in-depth interviews of patients undergoing first-time percutaneous coronary intervention.

SETTINGS

Participants were recruited from a single tertiary university hospital, which services a large geographical area in western Norway. Patients fulfilling the inclusion criteria were identified through the Norwegian Registry for Invasive Cardiology.

PARTICIPANTS

Participants were patients aged 18 years or older who had their first percutaneous coronary intervention six to nine months earlier, were living at home at the time of study inclusion, and were prescribed dual antiplatelet therapy. Patients who were cognitively impaired, had previously undergone cardiac surgery, and/or were prescribed anticoagulation therapy with warfarin or novel oral anticoagulants were excluded. Purposeful sampling was used to include patients of different gender, age, and geographic settings. Twenty-two patients (12 men) were interviewed between December 2016 and April 2017.

METHODS

Face-to-face semi-structured interviews were conducted, guided by a set of predetermined open-ended questions to gather patient experiences on factors relating to medication adherence or non-adherence. Transcribed interviews were analysed by qualitative content analysis.

FINDINGS

Patients failed to adhere to their medication regimen for several reasons; intentional and unintentional reasons, multifaceted side effects from heart medications, scepticism towards generic drugs, lack of information regarding seriousness of disease after percutaneous coronary intervention, psychological impact of living with coronary artery disease, and these interacted. There were patients who felt that the medication information they received from physicians and nurses was uninformative and inadequate. Side effects from heart medications were common, ranging from minor ones to more disabling side effects, such as severe muscle and joint pain and fatigue. Patients found well established medication taking routines and aids to be necessary, and these improved adherence.

CONCLUSION

Patients undergoing first-time percutaneous coronary intervention face multiple, interacting challenges in trying to adhere to prescribed medications following discharge. This study highlights the need for a more structured follow-up care in order to improve medication adherence and to maximise their self-care abilities.

Use of References in Responses from Scandinavian Drug Information Centres

Background: The aim of this study was to compare use of references in responses from Scandinavian drug information centres (DICs). Methods: Six different fictitious drug-related queries were sent to each of seven Scandinavian DICs. The six queries concerned adverse effects, pharmacokinetics, pregnancy, complementary medicine, polypharmacy, and breast feeding. References in the responses were categorised into five types of drug information sources: primary (original studies), secondary (reviews), tertiary (drug monographs, handbooks, etc.), DIC database, or personal communication. Results: Two hundred and forty-four references were used in the 42 responses. The mean number of references varied from 3.0 to 10.6 for the six queries. The largest difference between centres with regard to number of references used (range 1⁻17) was found for the query on complementary medicine. In total, 124 references (50.8%) were tertiary, and only 10 of the 42 responses (23.8%) did not have any tertiary references included. Complementary medicine, breast feeding, and pregnancy were query types associated with relatively frequent use of primary references. Use of DIC database was not uncommon, but personal communications were seldom used. Conclusions: Scandinavian DICs differ substantially in number and type of references to identical drug-related queries. Tertiary sources are mainly preferred irrespective of type of query.

Physicians' questions concerning drug use among older patients: experience from Norwegian drug information centres (RELIS) in the period 2010-2015

Questions from physicians to regional medicines information and pharmacovigilance centres in Norway (RELIS) concerning older patients were described. Question-answer pairs (QAPs) from the RELIS database indexed with the category "older", and concerning individual patients from the period 01 Jan 2010 to 31 Dec 2015, were analysed. Two-hundred and eight QAPs categorized with "older" were retrieved from a total of 16 710 in the study period, and 122 of 208 QAPs fulfilled the inclusion criteria. The most common categories of drugs in question (n = 228) according to the ATC system were N: Nervous system (30.3%) and C: Cardiovascular system (23.7%). Questions from physicians (n = 122) were most frequently about adverse effects (41.8%) and treatment (39.3%). The majority of questions to RELIS concerning older patients came from general practice (GP). The results suggest drug information efforts to GPs in care of older patients with regard to psychopharmacology and cardiovascular pharmacology.

Analysis of questions about use of drugs in breastfeeding to Norwegian drug information centres

Background

Health professionals may advise women to either stop breastfeeding or drug treatment due to restrictive advice in drug monographs. Regional medicines information and pharmacovigilance centres in Norway (RELIS) provide free and industry-independent answers to questions about drugs and breastfeeding documented in a full-text, searchable database (RELIS database). We used the RELIS database to describe which health care practitioners sought information about medication safety in lactation, most common drugs involved, advice provided and which resources were used to provide the advice.

Methods

A random selection of 100 question-answer pairs (QAPs) from the RELIS database indexed with “BREASTFEEDING” in the period from January 2011 to December 2015 was analysed. Inclusion criteria were queries from health professionals about drugs. Questions about herbal supplements and other exposures not classified as drugs were excluded. The QAPs were manually analysed for compatibility of one or several drugs with breastfeeding, health care profession and workplace of enquirer in addition to advice and search strategy used.

Results

In the 100 QAPs there were enquires about 152 drugs. Seventy-four questions concerned a single drug, but the number of drugs evaluated varied between 1 and 16. Fifty-nine questions were from physicians, 34 from nurses or midwives, two from pharmacists and two from other health professionals. Questions from physicians contained 93 drug evaluations (61%), nurses or midwives 47 (31%) and pharmacists seven (5%). The most frequent categories of drugs were antidepressants, antiepileptics and immunosuppressants. The most asked about drugs were lamotrigine, codeine, quetiapine and escitalopram. Fifty-nine percent of the drugs were deemed safe while breastfeeding, 16% if precautions were taken and 12% not recommended. Thirty-nine percent of the drug evaluations used an advanced literature search strategy, and this was significantly (p < 0.05) more likely when the enquirer was a physician.

Conclusions

This analysis of questions to Norwegian medicines information centres about medicine use in breastfeeding indicates the need for communication about safety of drugs affecting the nervous system, primarily to medical doctors and midwives. In the majority of cases the medicine information centre can reassure about the safety of breastfeeding while taking a drug.

Electronic supplementary material

The online version of this article (10.1186/s13006-017-0143-8) contains supplementary material, which is available to authorized users.

Quality assessment of structure and language elements of written responses given by seven Scandinavian drug information centres

PURPOSE

The aim of this study was to identify structure and language elements affecting the quality of responses from Scandinavian drug information centres (DICs).

METHODS

Six different fictitious drug-related queries were sent to each of seven Scandinavian DICs. The centres were blinded for which queries were part of the study. The responses were assessed qualitatively by six clinical pharmacologists (internal experts) and six general practitioners (GPs, external experts). In addition, linguistic aspects of the responses were evaluated by a plain language expert.

RESULTS

The quality of responses was generally judged as satisfactory to good. Presenting specific advice and conclusions were considered to improve the quality of the responses. However, small nuances in language formulations could affect the individual judgments of the experts, e.g. on whether or not advice was given. Some experts preferred the use of primary sources to the use of secondary and tertiary sources. Both internal and external experts criticised the use of abbreviations, professional terminology and study findings that was left unexplained. The plain language expert emphasised the importance of defining and explaining pharmacological terms to ensure that enquirers understand the response as intended. In addition, more use of active voice and less compressed text structure would be desirable.

CONCLUSIONS

This evaluation of responses to DIC queries may give some indications on how to improve written responses on drug-related queries with respect to language and text structure. Giving specific advice and precise conclusions and avoiding too compressed language and non-standard abbreviations may aid to reach this goal.

Risk perception regarding drug use in pregnancy

Pregnant women, but also physicians, have unrealistically high perceptions of teratogenic drug effects. This may result in suboptimal treatment of disease and even influence decisions of whether to continue pregnancy. To attain more realistic teratogenic risk perceptions, several factors that influence this issue should be considered, and these are further discussed in this Clinical Opinion. Importantly, drug use may have several benefits, both for the pregnant woman's health and to avoid negative fetal effects of untreated maternal disease. A greater focus on this aspect may act to balance risk perceptions. Furthermore, both pregnant women and physicians need access to drug information sources that provide realistic risk estimates to increase confidence in appropriate drug use and prescribing. We suggest that access to decision support and individually tailored information provided by drug information centers may contribute to this goal.

A human clinical trial using ultrasound and microbubbles to enhance gemcitabine treatment of inoperable pancreatic cancer

BACKGROUND

The primary aim of our study was to evaluate the safety and potential toxicity of gemcitabine combined with microbubbles under sonication in inoperable pancreatic cancer patients. The secondary aim was to evaluate a novel image-guided microbubble-based therapy, based on commercially available technology, towards improving chemotherapeutic efficacy, preserving patient performance status, and prolonging survival.

METHODS

Ten patients were enrolled and treated in this Phase I clinical trial. Gemcitabine was infused intravenously over 30min. Subsequently, patients were treated using a commercial clinical ultrasound scanner for 31.5min. SonoVue® was injected intravenously (0.5ml followed by 5ml saline every 3.5min) during the ultrasound treatment with the aim of inducing sonoporation, thus enhancing therapeutic efficacy.

RESULTS

The combined therapeutic regimen did not induce any additional toxicity or increased frequency of side effects when compared to gemcitabine chemotherapy alone (historical controls). Combination treated patients (n=10) tolerated an increased number of gemcitabine cycles compared with historical controls (n=63 patients; average of 8.3±6.0cycles, versus 13.8±5.6cycles, p=0.008, unpaired t-test). In five patients, the maximum tumour diameter was decreased from the first to last treatment. The median survival in our patients (n=10) was also increased from 8.9months to 17.6months (p=0.011).

CONCLUSIONS

It is possible to combine ultrasound, microbubbles, and chemotherapy in a clinical setting using commercially available equipment with no additional toxicities. This combined treatment may improve the clinical efficacy of gemcitabine, prolong the quality of life, and extend survival in patients with pancreatic ductal adenocarcinoma.

Relationship Between Time Consumption and Quality of Responses to Drug-related Queries: A Study From Seven Drug Information Centers in Scandinavia

PURPOSE

The aims of this study were to assess the quality of responses produced by drug information centers (DICs) in Scandinavia, and to study the association between time consumption processing queries and the quality of the responses.

METHODS

We posed six identical drug-related queries to seven DICs in Scandinavia, and the time consumption required for processing them was estimated. Clinical pharmacologists (internal experts) and general practitioners (external experts) reviewed responses individually. We used mixed model linear regression analyses to study the associations between time consumption on one hand and the summarized quality scores and the overall impression of the responses on the other hand.

FINDINGS

Both expert groups generally assessed the quality of the responses as "satisfactory" to "good." A few responses were criticized for being poorly synthesized and less relevant, of which none were quality-assured using co-signatures. For external experts, an increase in time consumption was statistically significantly associated with a decrease in common quality score (change in score, -0.20 per hour of work; 95% CI, -0.33 to -0.06; P = 0.004), and overall impression (change in score, -0.05 per hour of work; 95% CI, -0.08 to -0.01; P = 0.005). No such associations were found for the internal experts' assessment.

IMPLICATIONS

To our knowledge, this is the first study of the association between time consumption and quality of responses to drug-related queries in DICs. The quality of responses were in general good, but time consumption and quality were only weakly associated in this setting.

Drug Information Services Today: Current Role and Future Perspectives in Rational Drug Therapy

Polypharmacy and complex drug treatment regimens are becoming increasingly common, which may lead to adverse drug reactions, drug interactions, medication nonadherence, and increasing costs and thus challenge the rational use of drugs. At the same time, the accessibility of drug information increases, and health care professionals may have limited opportunities and capabilities to search and critically evaluate drug information. Clinicians have reported difficulties in searching the best evidence and translating study findings into clinically meaningful information applicable to specific patients. Consequently, it remains a challenge to ensure the rational use of drugs in the years to come. Drug information centers (DICs) have been established to promote the rational use of drugs. One of the most important tasks of DICs is the question and answer services for health care professionals posing drug-related questions. DICs staffed by pharmacists and clinical pharmacologists hold expertise in searching for drug information and critical evaluation of the literature. The uniqueness in this service lies not only in the identification and interpretation of the scientific literature but also in the adaptation of the findings into specific clinical situations and the discussion of possible solutions with the enquirer. Thus, DICs could provide valuable decision support to the clinic. Taking into account the increasing number of possible drug-related questions that will arise today and in the future, the DICs will remain highly relevant in the years to come. However, the DICs must follow the developments in health information technology to disseminate relevant, unbiased drug information to old and new users of the service. Moreover, the DICs are important tools to counterbalance the drug information published by the pharmaceutical industry.

Cross-reactivity of the CEDIA buprenorphine assay in drugs-of-abuse screening: influence of dose and metabolites of opioids

PURPOSE

The cloned enzyme donor immunoassay (CEDIA) for buprenorphine is applied for both urine drugs-of-abuse screening and compliance monitoring. Sensitivity, specificity, and optimal cutoff of this assay have differed between studies. This may indicate that cross-reactivity has to be taken into account during assay evaluation. We therefore investigated the performance of the CEDIA buprenorphine assay for use in our patient population and explored the impact of cross-reactivity on assay accuracy.

METHODS

The CEDIA buprenorphine assay and high-performance liquid chromatography-tandem mass spectrometry were employed to analyze drugs-of-abuse in urine samples from a healthy drug-naïve male volunteer after intake of two tablets of a prescription drug containing 400 mg paracetamol +30 mg codeine phosphate, and in urine samples (n=2,272) from drug-addicted patients. Receiver operating characteristic analyses were performed to express the diagnostic accuracy of the CEDIA buprenorphine assay.

RESULTS

CEDIA buprenorphine was positive in one urine sample from the drug-naïve person after intake of the prescription drug. Twenty-five (1.1%) of the patient urine samples were positive for buprenorphine by CEDIA, but negative by high-performance liquid chromatography-tandem mass spectrometry. Codeine, morphine, and their respective metabolites were prevalent in samples that were false positive for buprenorphine. The specificity of the CEDIA buprenorphine assay increased to 99.7% when the cutoff was increased from 5 ng/mL to 10 ng/mL.

CONCLUSION

Intake of a therapeutic dose of codeine can yield a false-positive CEDIA buprenorphine result. Additive effects from metabolites of codeine contribute to cross-reactivity in concentrations much lower than listed in the manufacturer's cross-reactivity guide. Raising the cutoff from 5 ng/mL to 10 ng/mL increased the diagnostic accuracy. Clinicians should be informed about the risk of false-positive results with the CEDIA buprenorphine assay.

Liquid chromatography/tandem mass spectrometry method for simultaneous quantification of eight endogenous nucleotides and the intracellular gemcitabine metabolite dFdCTP in human peripheral blood mononuclear cells

Quantification of endogenous nucleotides is of interest for investigation of numerous cellular biochemical processes, such as energy metabolism and signal transduction, and may also be applied in cancer and antiretroviral therapies in which nucleoside analogues are used. For these purposes we developed and validated a sensitive and high accuracy ion-pair liquid chromatography tandem mass spectrometry (IP LC-MS/MS) method for simultaneous quantification of eight endogenous nucleotides (ATP, CTP, GTP, UTP, dATP, dCTP, dGTP, dTTP) and 2',2'-difluoro-2'-deoxycytidine triphosphate (dFdCTP), an intracellular metabolite of the nucleoside analogue gemcitabine. The assay was validated using 200μL aliquots of peripheral blood mononuclear cell (20×10(6)cells/ml, 4×10(6)cells) extracts, pretreated with activated charcoal and spiked with unlabeled nucleotides, deoxynucleotides and dFdCTP. Analytes were extracted by simple precipitation with cold 60% methanol containing isotope labeled internal standards and separated on a porous graphitic carbon column. For method validation, the concentration ranges were: 0.125-20.8pmol injected for deoxynucleotides, 0.25-312.5pmol injected for dFdCTP and 5-3200pmol injected for nucleotides. The highest coefficients of variation (CV) were 12.1% for within run assay and 11.4% for between run assay, both representing the precision at the lowest analyte concentrations. The method was applied to monitor dFdCTP and changes in endogenous nucleotides in patients who were receiving gemcitabine infusions.

Factors associated with time consumption when answering drug-related queries to Scandinavian drug information centres: a multi-centre study

PURPOSE

There is little research-based documentation on the services provided by drug information centres (DICs). The aim of this multi-centre study was to explore for the first time the factors associated with time consumption when answering drug-related queries at eight different but comparable DICs.

METHODS

During an 8-week period, staff members at eight Scandinavian DICs recorded the number of minutes during which they responded to queries. Mixed model linear regression analyses were used to explore the factors associated with time consumption when answering queries.

RESULTS

The mean time consumption per query was 178 min (range 4-2540 min). The mean time consumed per query increased by 28 (95 % confidence interval (CI) 23 to 33, p < 0.001) min higher for queries for which there was a lack of documentation and 139 (95 % CI 74 to 203, p < 0.001) min higher when conflicting information was present in the literature. Staff members with less than 1 year of experience consumed a mean of 91 more minutes (95 % CI 32 to 150, p = 0.003) per query than staff members with more than 2 years of experience.

CONCLUSIONS

This study demonstrates the large variation in time consumed answering queries posed to Scandinavian DICs. The results highlight the need for highly competent staff members and easy access to drug information sources. Further studies are required to explore the association between time consumption and response quality.

Myocardial injury in a 41-year-old male treated with methylphenidate: a case report

Background

Elevated cardiac troponin levels are consistent with the diagnosis of an acute coronary syndrome, but may also represent adverse drug reactions. Psychostimulating drugs raise both blood pressure and heart rate, and case reports of sudden death, stroke, and myocardial infarction have led to regulatory and public concern about the cardiovascular safety of these drugs.

Case presentation

We present a case where a 41-year-old Norwegian male with radiating chest pain, elevated troponins, and supraventricular tachycardia was hospitalized. Tentative diagnosis was acute coronary syndrome. Percutaneous coronary angiography, but not cardiac magnetic resonance imaging, was performed and medical antiplatelet treatment started. Because of an attention deficit/hyperactivity disorder the patient had recently increased his dose of methylphenidate, but still within the therapeutic dose range. Apart from venlafaxine, also in a therapeutic dose, the patient took no other drugs. An acute coronary syndrome was excluded during hospitalization, and a drug effect was suspected.

Conclusions

When interpreting troponin results it is important to take into account the context of the patient’s clinical presentation, including the possibility of adverse drug reactions. The adverse drug reaction could include a combination of vasospasm and/or increased oxygen demand due to tachycardia. This case should be borne in mind before a diagnosis of myocardial infarction is given, or a decision to perform invasive coronary angiography is made in patients that use methylphenidate or related substances. Cardiac magnetic resonance imaging could be of diagnostic value in such cases.

Joint medicine-information and pharmacovigilance services could improve detection and communication about drug-safety problems

Background

RELIS is a Norwegian network of four regional medicine-information and pharmacovigilance centers where pharmacists and clinical pharmacologists provide feedback to health care professionals in spontaneous drug-related questions and adverse drug-reaction (ADR) reports published in a question–answer pair (QAP) database (the RELIS database) and the Norwegian ADR database, respectively.

Objective

To describe the potential of RELIS’s dual service to improve detection and communication of drug-safety problems.

Materials and methods

We searched the RELIS database for QAPs about ADRs with use of the Norwegian ADR database as a reference. We also searched the Norwegian ADR database for reports that used the RELIS database as a reference. Both searches were limited to the years 2003–2012. We then selected the example of pregabalin and drug abuse after the marketing of Lyrica in Norway in September 2004 to illustrate RELIS’s potential to detect new drug-safety information through a limited number of QAPs and ADR reports.

Results

A total of 5,427 (26%) of 21,071 QAPs in the RELIS database concerned ADRs. QAPs from this database were used as references in 791 (4%) of a total of 22,090 reports in the Norwegian ADR database. The Norwegian ADR database was used as a reference in 363 (7%) of 5,427 QAPs that concerned ADRs. Between September 2004 and September 2008, RELIS received eleven questions and 13 ADR reports about suspicion of Lyrica (pregabalin) and different aspects of abuse.

Conclusion

RELIS processes data through two databases that facilitate communication about ADRs. Our service also has the potential to detect new drug-safety problems with a limited number of questions and ADR reports.

Diazoxide protects against doxorubicin-induced cardiotoxicity in the rat

AIM

Chemotherapy with doxorubicin is limited by cardiotoxicity. Free radical generation and mitochondrial dysfunction are thought to contribute to doxorubicin-induced cardiac failure. In this study we wanted to investigate if opening of mitochondrial KATP-channels by diazoxide is protective against doxorubicin cardiotoxicity, and if 5-hydroxydecanoate (5-HD), a selective mitochondrial KATP-channel antagonist, abolished any protection by this intervention.

METHODS

Wistar rats were divided into 7 groups (n = 6) and followed for 10 days with 5 intervention groups including the following treatments: (1) Diazoxide and doxorubicin, (2) diazoxide and 5-hydroxydecanoate (5-HD), (3) 5-HD and doxorubicin, (4) diazoxide and saline and (5) 5-HD and saline. On day 1, 3, 5 and 7 the animals received intraperitoneal (i.p.) injections with 10 mg/kg diazoxide and/or 40 mg/kg 5-HD, 30 minutes before i.p. injections with 3.0 mg/kg doxorubicin. One control group received only saline injections and the other control group received saline 30 minutes prior to 3.0 mg/kg doxorubicin. On day 10 the hearts were excised and Langendorff-perfused. Cardiac function was assessed by an intraventricular balloon and biochemical effects by release of hydrogen peroxide (H2O2) and troponin-T (TnT) in effluate from the isolated hearts, and by myocardial content of doxorubicin.

RESULTS

Doxorubicin treatment produced a significant loss in left ventricular developed pressure (LVDP) (p < 0.05) and an increase in both H2O2 and TnT release in effluate (p < 0.05). Diazoxide significantly attenuated the decrease in LVDP (p < 0.05) and abolished the increased release of H2O2 and TnT (p < 0.05). 5-HD abolished the effects of pretreatment with diazoxide, and these effects were not associated with reduced myocardial accumulation of doxorubicin.

CONCLUSIONS

Pretreatment with diazoxide attenuates doxorubicin-induced cardiac dysfunction in the rat, measured by physiological indices and TnT and H2O2 in effluate from isolated hearts. The effect could be mediated by opening of mitochondrial KATP-channels, reduced doxorubicin-associated free radical generation and decreased cardiomyocyte damage. Diazoxide represents a promising protective intervention against doxorubicin-induced acute cardiotoxicity.