Obesity association with antidiabetic drugs’ prescription among patients with type 2 diabetes mellitus: a systematic review and meta-analysis

Introduction

Type 2 diabetes mellitus (T2DM) is a chronic disease of persistent elevation in blood glucose level. Several antidiabetic drugs (ADDs) with different features are currently available for T2DM management (1). The selection of appropriate ADDs is crucial for preventing/attenuating diabetes-related complications(1). All guidelines agreed on metformin to be an initial therapy for patients diagnosed with T2DM, yet the selection of an intensifying therapy or alternative initial therapy are lacking any agreements (1). Consequently, the selection of ADDs could be linked to multiple factors (2). Since obesity is a risk factor for T2DM and ADDs have variable effect on body weight, obesity is an important factor that could be associated with ADDs’ selection.

Aim

This systematic review (SR) and meta-analysis (MA) aimed to overview and quantify obesity association with the selection of ADDs among type 2 diabetic patients.

Methods

A systematic literature search was conducted on multiple databases. Eligible studies were selected based on the following inclusion criteria: quantitative observational studies, evaluated obesity association with ADDs’ prescription, in outpatient setting, and published in English over the period of Jan/2009-April/2021. Studies on other types of diabetes, about switching therapy, or published before 2009 were excluded. The following items were extracted from identified articles: study details as author, year, and method, participants’ characteristics as age and gender, type of investigated ADDs, comparison group, and stage of treatment, as well as type of analysis test. Extracted data was synthesized quantitively utilising a three-level MA approach as some studies reported more than one effect-size because of examining multiple ADDs. It was based on odds ratio and 95%confidence interval.

Results

A total of 21 studies evaluated the association of obesity with ADDs’ prescription was identified. All except one were included in the MA which contributed to a total of 66 effect sizes from all investigated ADDs. The pooled estimate of obesity association with the prescription of ADDs including all groups was 1.19[0.85 -1.67]. A subgroup analysis showed a significant difference according to the type of ADDs (p< .0001). A positive significant association was found with glucagon-Like peptide receptor agonist (GLP1-RA), sodium glucose transporter 2 inhibitors (SGLT2-I), and metformin prescriptions (pooled estimate: 2.35 [1.54-3.59], 1.89[1.33-2.68], and 1.22[1.08-1.37], respectively). Whereas a negative significant association was found with sulfonylurea prescription (pooled estimate: 0.76 [0.62-0.93]). The pooled estimate of thiazolidinedione, dipeptidyl-peptidase 4 inhibitors, and insulin showed a non-significant association with obesity. None of the investigated variables showed significant influence on the overall result including stage of treatment and quality of study (p >0.05).

Conclusion

Obesity is an important factor influencing ADDs’ prescription. Patients with higher weight were more likely to get ADDs with weight losing or neutral effect as GLP1-RA, SGLT2-I, and metformin. This reflects some adherence of clinical practice to the variability in drugs’ features as indicated from the consistent findings of obesity as a factor affecting ADDs’ selection with the weight effect of ADDs. Yet, further studies are required because of limited number of studies examined each antidiabetic group.

References

1. American Diabetes A. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S98-S110.

2. Wilkinson S, Douglas I, Stirnadel-Farrant H, Fogarty D, Pokrajac A, Smeeth L, et al. Changing use of antidiabetic drugs in the UK: trends in prescribing 2000-2017. BMJ Open. 2018;8(7):e022768.

A national initiative to promote public involvement in medicine safety in Scotland: the use of a population survey to identify candidate behaviours for intervention development

Introduction

Medicines are the most commonly used healthcare intervention (1). Every medicine has benefits and harms. One of the five objectives of the WHO Global Patient Safety campaign, Medication Without Harm, is to “empower patients, families and their carers to become actively involved and engaged in treatment or care decisions, ask questions, spot errors and effectively manage their medications” (2). Effective strategies are needed to promote greater public involvement in the safe and effective use of medicines.

Aim

The aim of this study was to explore the prevalence of public behaviour in terms of information-/advice-seeking about medicines in general, newly prescribed medicines, and pain management including their use of oral, over-the-counter (OTC) analgesics. The survey also included exploration of self-reported behaviour regarding their use of pharmacies and OTC analgesics.

Methods

A cross-sectional online survey of 1000 adults (aged >16years) in Scotland was undertaken in collaboration with Ipsos MORI. The content was informed by a multi-stakeholder prioritisation event (held in November 2019) and supplemented with information from earlier studies, including national surveys using Citizen Panels. The following themes were included in the questionnaire:

The data were input online by respondents then cleaned and weighted by Ipsos Mori using random iterative method (RIM) weighting to the known offline population proportions for age, gender, region and working status. All data were analysed and presented using descriptive statistics.

Results

Most respondents (78%, n=777) had used a pharmacy in the previous 12 months to obtain a prescription medicine and slightly fewer (61%, n=610) to obtain an OTC medicine. Low levels of information- and advice-seeking were reported especially on receipt of new prescription medicines.

Few (5%) respondents ‘always’ discussed their new prescription medicine with pharmacy staff and 29% reported ‘never’ engaging in this behaviour. Older people (> 35 years) were less likely to engage in this behaviour. Up to 65% of respondents reported ‘always’ engaging with specific aspects of the appropriate use of OTC analgesics e.g. appropriate dose.

Potentially unsafe behaviours were identified with medicine disposal. Nearly one third (29%) of respondents considered waste bin disposal to be of low or no harm, and 19% considered disposal of medicines via the toilet/sink to be of low/no harm.

Conclusion

Despite the extensive use of pharmacies, low levels of information-/advice-seeking were reported especially on receipt of new prescription medicines. Potentially unsafe behaviours were also identified with medicine use and disposal. The key determinants of these behaviours will be explored in more detail and theory-based interventions will be developed and tested to evaluate their effect.

Respondent opinion (positively or negatively) regarding their perceptions regarding community pharmacies and/or pharmacy personnel could have been influenced by the increased use and/or awareness of community pharmacy services due to the pandemic.

References

(1) National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE Guidelines [NG5]. 2015. https://www.nice.org.uk/guidance/ng5 (accessed 13/10/2021).

(2) Medication without harm - Global patient safety challenge on medication safety. Geneva: World Health Organization, 2017. Licence: CCBY-NC-SA3.0IGO.

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

BACKGROUND

Antimicrobial stewardship (AMS) programmes optimize antimicrobial use and address antimicrobial resistance. Pharmacists are often key agents of these programmes. The effectiveness of hospital-based AMS interventions when they are led by pharmacists, however, has not previously been reported.

AIM

To evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use for hospital inpatients.

METHODS

Standard systematic review methods were used. The search strategies and databases used in a previous Cochrane review were applied. Studies that reported pharmacist-led AMS interventions were included. Narrative synthesis was used to report the findings. PRISMA guidelines were followed.

FINDINGS

From 6971 records retrieved and screened, 52 full-text articles were included. Most studies were undertaken in teaching hospitals (N = 45) and many were conducted in North America (N = 27). Most interventions targeted junior or ward physicians and lasted between one and six months. All studies evaluated educational interventions often in combination with other interventions and reported improvements 'in compliance with target AMS practice'. Greater compliance was achieved with multiple interventions. Pharmacist-led interventions reduced the duration of antimicrobial therapy without increasing mortality. No consistency of evidence was achieved in relation to interventions and reduced duration of hospital stay, nor infections due to antimicrobial resistance or occurrence of Clostridium difficile.

CONCLUSION

This is the first systematic review to evaluate the effectiveness of pharmacist-led AMS interventions in hospital inpatients. Education-based interventions were effective in increasing guideline compliance and reducing duration of antimicrobial therapy. Future hospital-based AMS programmes should consider the involvement of pharmacists to deliver and promote AMS interventions and programmes.

A systematic review of pharmacist-led audit and feedback interventions to influence prescribing behaviour in general practice settings

Introduction

Audit and Feedback (A&F) involves measuring data about practice, comparing it with clinical guidelines, professional standards or peer performance, and then feeding back the data to individuals/groups of health professionals to encourage change in practice (if required). A 2012 Cochrane review (1) found A&F was effective in changing health professionals’ behaviour and suggested that the person who delivers the A&F intervention influences its effect. Increasingly, pharmacists work in general practice and often have responsibility for medication review and repeat prescriptions. The effectiveness of pharmacist-led A&F in influencing prescribing behaviour is uncertain.

Aim

This secondary analysis from an ongoing update of the original Cochrane review aims to identify and describe pharmacist-led A&F interventions and evaluate their impact on prescribing behaviour in general practice compared with no intervention.

Methods

This sub-review is registered with PROSPERO: CRD42020194355 and complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (2). For the updated Cochrane review, the Cochrane Effective Practice and Organization of Care Group searched MEDLINE (1946 to present), EMBASE, CINAHL and Cochrane Library (March 2019) to identify randomised trials featuring A&F interventions. For this sub-review, authors screened titles and abstracts (May 2020) to identify trials involving pharmacist-led A&F interventions in primary care, extracted data, and assessed risk of bias (RoB) in eligible studies. Review results are summarised descriptively. Heterogeneity will be assessed and a random-effects meta-analysis is planned. Publication bias for selected outcomes and the certainty of the body of evidence will be evaluated and presented. Sub-group analyses will be conducted.

Results

Titles and abstracts of 295 studies identified for inclusion in the Cochrane A&F review update were screened. Eleven studies (all cluster-randomised trials) conducted in 9 countries (Denmark, Italy, Netherlands, Norway, Republic of Ireland, UK, Australia, Malaysia, USA) were identified for inclusion (Figure 1). Six studies had low RoB, two had high risk due to dissimilarities between trial arms at baseline and/or insufficient detail about randomisation, and three studies had unclear RoB. Studies examined the effect of A&F on prescribing for specific conditions (e.g. hypertension), medications (e.g. antibiotics), populations (e.g. patients >70), and prescribing errors (e.g. inappropriate dose). The pharmacist delivering A&F was a colleague of intervention participants in five studies. Pharmacists’ levels of skill and experience varied; seven studies reported details of pharmacist training undertaken for trial purposes. A&F interventions in nine studies demonstrated changes in prescribing, including reductions in errors or inappropriate prescribing according to the study aims and smaller increases in unwanted prescribing compared with the control group. Data analyses are ongoing (results will be available for the conference).

Conclusion

The preliminary results demonstrate the effectiveness of pharmacist-led A&F interventions in different countries and health systems with influencing prescribing practice to align more closely with guidance. Studies measured different prescribing behaviours; meta-analysis is unlikely to include all 11 studies. Further detailed analysis including feedback format/content/frequency and pharmacist skill level/experience, work-base (external/internal to recipients), will examine the impact of specific features on intervention effectiveness.

References

1. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012(6):CD000259.

2. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.