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de Oliveira Costa J, Lin J, Milder TY, Greenfield JR, Day RO, Stocker SL, Neuen BL, Havard A, Pearson SA, Falster MO. Geographic variation in sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide-1 receptor agonist use in people with type 2 diabetes in New South Wales, Australia. Diabetes Obes Metab 2024. [PMID: 38618983 DOI: 10.1111/dom.15597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
AIM Sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) improve glycaemic control and cardio-renal outcomes for people with type 2 diabetes (T2D). However, geographic and socio-economic variation in use is not well understood. METHODS We identified 367 829 New South Wales residents aged ≥40 years who dispensed metformin in 2020 as a proxy for T2D. We estimated the prevalence of use of other glucose-lowering medicines among people with T2D and the prevalence of SGLT2i and GLP-1RA use among people using concomitant T2D therapy (i.e. metformin + another glucose-lowering medicine). We measured the prevalence by small-level geography, stratified by age group, and characterized by remoteness and socio-economic status. RESULTS The prevalence of SGLT2i (29.7%) and GLP-1RA (8.3%) use in people with T2D aged 40-64 increased with geographic remoteness and in areas of greater socio-economic disadvantage, similar to other glucose-lowering medicines. The prevalence of SGLT2i (55.4%) and GLP-1RA (15.4%) among people using concomitant T2D therapy varied across geographic areas, with lower SGLT2i use in more disadvantaged areas and localized areas of high GLP-1RA use (2.5 times the median). Compared with people aged 40-64 years, the prevalence of SGLT2i and GLP-1RA use was lower in older age groups, but with similar patterns of variation across geographic areas. CONCLUSIONS The prevalence of SGLT2i and GLP-1RA use varied by geography, probably reflecting a combination of system- and prescriber-level factors. Socio-economic variation in GLP-1RA use was overshadowed by localized patterns of prescribing. Continued monitoring of variation can help shape interventions to optimize use among people who would benefit the most.
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Affiliation(s)
- Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jialing Lin
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tamara Y Milder
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Alys Havard
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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Michael TJF, Wright DFB, Chan JS, Coleshill MJ, Aslani P, Hughes DA, Day RO, Stocker SL. Patient-Led Urate Self-Monitoring to Improve Clinical Outcomes in People With Gout: A Feasibility Study. ACR Open Rheumatol 2024. [PMID: 38591107 DOI: 10.1002/acr2.11666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/30/2024] [Accepted: 02/24/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVE Self-monitored point-of-care urate-measuring devices are an underexplored strategy to improve adherence to urate-lowering therapy and clinical outcomes in gout. This study observed patient-led urate self-monitoring practice and assessed its influence on allopurinol adherence, urate control, and health-related quality of life. METHODS People with gout (n = 31) and prescribed allopurinol self-monitored their urate concentrations (HumaSens2.0plus) at baseline and thereafter monthly for 12 months (3 months per quarter). Adherence to allopurinol was measured using medication event monitoring technology (Medication Event Monitoring System cap). Time spent below the target urate concentration (<0.36 mmol/L) was determined. Health-related quality of life was measured using a survey (EuroQoL EQ-5D-5L). Gout flares were recorded. Two-tailed Spearman correlation and the Wilcoxon matched-pairs signed-rank test (P < 0.05) were used for statistical comparisons. RESULTS Most participants were male (94%) and had urate concentrations below the target (74%) at baseline. Overall, seven participants demonstrated repeated periods of "missed doses" (two or fewer allopurinol doses missed consecutively) and "drug holidays" (three or more missed doses). Most participants (94%) persisted with allopurinol. Time spent within the target urate concentration increased 1.3-fold (from 79% to 100%; P = 0.346), and the incidence of gout flares decreased 1.6-fold (from 8 to 5; P = 0.25) in the final quarter compared to that in the first quarter of the study. Health-related quality of life was reduced for participants reporting at least one gout flare (median utility values 0.9309 vs 0.9563, P = 0.04). CONCLUSION Patient-led urate self-monitoring may support the maintenance of allopurinol adherence and improve urate control, thus reducing the incidence of gout flares. Further research on patient-led urate self-monitoring in a randomized controlled study is warranted.
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Affiliation(s)
- Toni J F Michael
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | | | - Jian S Chan
- St. Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Matthew J Coleshill
- Black Dog Institute, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - Parisa Aslani
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Dyfrig A Hughes
- School of Medical and Health Sciences, Bangor University, Bangor, United Kingdom
| | - Richard O Day
- St. Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, Australia, and Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Darlinghurst, Australia
| | - Sophie L Stocker
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia, and Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Darlinghurst, Australia
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Milder TY, Stocker SL, Baysari MT, Day RO, Greenfield JR. 'We are somehow fixated on this being a diabetes drug': a qualitative study exploring the views of cardiologists and nephrologists about sodium-glucose cotransporter 2 inhibitor initiation. Intern Med J 2024; 54:559-567. [PMID: 37548317 DOI: 10.1111/imj.16203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are now indicated for heart failure and chronic kidney disease (CKD), irrespective of the presence of diabetes. Hence, cardiologists and nephrologists have an important role in initiating these drugs. AIMS To explore cardiologists' and nephrologists' perspectives regarding initiating SGLT2i and their safety monitoring practices when initiating SGLT2i. METHODS Purposive and snowball approaches were used to recruit participants working in diverse areas in New South Wales, Australia. Semi-structured interviews were conducted with 12 cardiologists and 12 nephrologists. Interviews were conducted until thematic saturation was reached. Emergent themes were identified from transcripts. An iterative general inductive approach was used for data analysis. RESULTS There was a reluctance amongst most non-heart-failure subspecialist cardiologists to initiate SGLT2i. Reasons included the perception of SGLT2i as diabetes drugs, concern about side effects, lack of experience and issues with follow-up. In contrast, nephrologists reported feeling confident to initiate SGLT2i. Nephrologists varied in their opinions about the severity of CKD at which SGLT2i initiation was reasonable and monitoring of renal function following initiation. Government subsidisation was an important factor in the decision to prescribe SGLT2i to people without diabetes. CONCLUSIONS Our findings highlight the complex transition from the perception of SGLT2i as diabetes drugs to cardiometabolic and reno-protective agents. Interdisciplinary collaboration may enable greater confidence amongst specialists to initiate SGLT2i, including in patients with CKD. Additionally, there is a need for clear and detailed guidance about SGLT2i prescription in patients with renal dysfunction and renal function monitoring following SGLT2i initiation.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Melissa T Baysari
- Discipline of Biomedical Informatics and Digital Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, New South Wales, Australia
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Baysari MT, Van Dort BA, Stanceski K, Hargreaves A, Zheng WY, Moran M, Day RO, Li L, Westbrook J, Hilmer SN. Qualitative study of challenges with recruitment of hospitals into a cluster controlled trial of clinical decision support in Australia. BMJ Open 2024; 14:e080610. [PMID: 38479736 PMCID: PMC10936458 DOI: 10.1136/bmjopen-2023-080610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/28/2024] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVE To identify barriers to hospital participation in controlled cluster trials of clinical decision support (CDS) and potential strategies for addressing barriers. DESIGN Qualitative descriptive design comprising semistructured interviews. SETTING Five hospitals in New South Wales and one hospital in Queensland, Australia. PARTICIPANTS Senior hospital staff, including department directors, chief information officers and those working in health informatics teams. RESULTS 20 senior hospital staff took part. Barriers to hospital-level recruitment primarily related to perceptions of risk associated with not implementing CDS as a control site. Perceived risks included reductions in patient safety, reputational risk and increased likelihood that benefits would not be achieved following electronic medical record (EMR) implementation without CDS alerts in place. Senior staff recommended clear communication of trial information to all relevant stakeholders as a key strategy for boosting hospital-level participation in trials. CONCLUSION Hospital participation in controlled cluster trials of CDS is hindered by perceptions that adopting an EMR without CDS is risky for both patients and organisations. The improvements in safety expected to follow CDS implementation makes it challenging and counterintuitive for hospitals to implement EMR without incorporating CDS alerts for the purposes of a research trial. To counteract these barriers, clear communication regarding the evidence base and rationale for a controlled trial is needed.
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Affiliation(s)
- Melissa T Baysari
- Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Bethany Annemarie Van Dort
- Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kristian Stanceski
- Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Wu Yi Zheng
- Black Dog Institute, Randwick, New South Wales, Australia
| | - Maria Moran
- Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- St Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
| | - Sarah N Hilmer
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
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Schulz M, Coleshill MJ, Day RO, Wright DFB, Brett J, Briggs NE, Aung E. Estimation of adherence to urate-lowering therapy in people living with gout using Australia's Pharmaceutical Benefits Scheme and patient-reported dosing. Br J Clin Pharmacol 2024. [PMID: 38382554 DOI: 10.1111/bcp.16016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/04/2024] [Accepted: 01/16/2024] [Indexed: 02/23/2024] Open
Abstract
AIMS The aim of this study was to estimate adherence to urate-lowering therapy (ULT), predominately allopurinol, from Australia's Pharmaceutical Benefits Scheme (PBS) claims database in association with (1) patient-reported doses and (2) World Health Organization's (WHO) defined daily doses (DDD), namely, allopurinol (400 mg/day) or febuxostat (80 mg/day). METHODS Proportion of days covered (PDC) was calculated in 108 Gout App (Gout APP) trial participants with at least two recorded ULT dispensings in an approximately 12-month period before provision of intervention or control apps. Adherence was defined as PDC ≥80%. We measured the correlation between the two methods of calculating PDC using a Wilcoxon signed rank test. Agreement between ULT-taking status (self-reports) and ULT-dispensed status (PBS records) was tested with Cohen's kappa (κ), and positive and negative percent agreement. RESULTS Allopurinol was prescribed in 93.5% of participants taking ULT. Their self-reported mean daily dose (SD) was 291 (167) mg/day. Mean PDC (SD) for allopurinol was 83% (21%) calculated using self-reported dose, and 63% (24%) using WHO's DDD. Sixty-three percent of allopurinol users were identified as adherent (PDC ≥80%) using self-reported dose. There was good agreement between self-reported ULT use and PBS dispensing claims (κ = 0.708, P < .001; positive percent agreement = 90%, negative percent agreement = 82%). CONCLUSIONS Participant-reported allopurinol daily doses, in addition to PBS dispensing claims, may enhance confidence in estimating PDC and adherence compared to using DDD. This approach improves adherence estimations from pharmaceutical claims datasets for medications where daily doses vary between individuals or where there is a wide therapeutic dose range.
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Affiliation(s)
- Marcel Schulz
- St Vincent's Clinical Campus, School of Clinical Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Matthew J Coleshill
- St Vincent's Clinical Campus, School of Clinical Medicine, UNSW Sydney, Sydney, NSW, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- Black Dog Institute, Sydney, NSW, Australia
| | - Richard O Day
- St Vincent's Clinical Campus, School of Clinical Medicine, UNSW Sydney, Sydney, NSW, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | | | - Jonathan Brett
- St Vincent's Clinical Campus, School of Clinical Medicine, UNSW Sydney, Sydney, NSW, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Nancy E Briggs
- Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, Australia
| | - Eindra Aung
- St Vincent's Clinical Campus, School of Clinical Medicine, UNSW Sydney, Sydney, NSW, Australia
- Northern Sydney Local Health District, NSW Health, Sydney, NSW, Australia
- Kolling Institute, Pain Management Research Institute, The University of Sydney, Sydney, NSW, Australia
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Carland JE, Stojanova J, Lau C, Day RO, Marriott DJE. Crying Over Stark Differences: Resource Disparity and Therapeutic Drug Monitoring. Ther Drug Monit 2024:00007691-990000000-00189. [PMID: 38321597 DOI: 10.1097/ftd.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, NSW, Australia
| | - Jana Stojanova
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Cindy Lau
- Department of Pharmacy, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, NSW, Australia
- School of Medical Sciences, UNSW Sydney, NSW, Australia; and
| | - Deborah J E Marriott
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, NSW, Australia
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW
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Yang JJ, Brett J, Sordo A, Reuter SE, Stocker SL, Day RO, Roberts DM, Carland JE. The Influence of a Therapeutic Drug Monitoring Service on Vancomycin-Associated Nephrotoxicity. J Clin Pharmacol 2024; 64:19-29. [PMID: 37779493 DOI: 10.1002/jcph.2363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/29/2023] [Indexed: 10/03/2023]
Abstract
Vancomycin's widespread use as the mainstay antibiotic against methicillin-resistant Staphylococcus aureus infections is complicated by its narrow therapeutic index. Therapeutic drug monitoring using area under the concentration-time curve (AUC)-guided dosing is recommended to optimize therapy and prevent vancomycin-associated nephrotoxicity (VAN). In 2018, a consultative therapeutic drug monitoring Advisory Service (the Service) was piloted at an Australian hospital to enable AUC-guided vancomycin dosing. This study sought to compare the incidence of VAN pre- and post-Service implementation. A 4-year retrospective observational study of intravenous vancomycin therapy (greater than 48 hours) in adults (aged 18 years or older), spanning 3 years before and 1-year after implementation of the Service was undertaken. Nephrotoxicity was defined as an increase in serum creatinine concentrations of 26.5 μmol/L or greater or 50% or more from baseline, on 2 or more consecutive days. Univariate analysis was performed to compare patients before and after implementation, and with and without VAN. Independent factors associated with VAN were identified using a multivariate model. In total, 971 courses of vancomycin therapy, administered to 781 patients, were included: 764 courses (603 patients) before implementation and 207 courses (163 patients) after implementation. The incidence of VAN decreased by 5% after Service implementation (15% before implementation vs 10% after implementation; P = .075). Independent factors associated with VAN were sepsis, heart failure, solid-organ transplant, concomitant piperacillin-tazobactam, and average vancomycin AUC during therapy. In conclusion, there was a nonsignificant trend toward a reduced incidence of VAN after the Service. Larger prospective studies are needed to confirm the efficacy of the Service.
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Affiliation(s)
- Jennifer J Yang
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Jonathan Brett
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Anna Sordo
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
- School of Medical Sciences, UNSW Sydney, Sydney, NSW, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
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Milder TY, Milder DA, Greenfield JR, Day RO. Sodium-Glucose Cotransporter 2 Inhibitor-Associated "Ketoacidosis" Versus "Diabetic Ketoacidosis": The Importance of Accurate Terminology. Drug Saf 2023; 46:1303-1305. [PMID: 37847339 DOI: 10.1007/s40264-023-01358-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, 384 Victoria St, Darlinghurst, Sydney, NSW, 2010, Australia.
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, NSW, Australia.
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia.
| | - David A Milder
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
- Department of Anaesthesia, St. Vincent's Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, 384 Victoria St, Darlinghurst, Sydney, NSW, 2010, Australia
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, NSW, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia
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Abstract
Off-label prescribing refers to prescribing that is not concordant with the indications, doses, routes of administration or patient groups included in the Australian approved product information. Off-label prescribing is common, especially for vulnerable patient groups who tend to be excluded from clinical trials, such as children and pregnant women. There may be increased risk of prescriber liability if the patient experiences an adverse event following off-label prescription, particularly when supporting evidence or guidelines are lacking. There may be additional costs to the patient if the medicine is not subsidised for the off-label indication. Prescribers should ensure patients are aware when a medicine is being prescribed off label, and informed of potential benefits and harms. Alternative pathways for approval of new indications, doses and patient groups may reduce the need for off-label prescribing.
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Affiliation(s)
- Richard O Day
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney
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Ferreira GE, Zadro J, Jones C, Ayre J, Lin C, Richards B, Needs C, Abdel Shaheed C, McLachlan A, Day RO, Maher C. General practitioners' decision-making process to prescribe pain medicines for low back pain: a qualitative study. BMJ Open 2023; 13:e074380. [PMID: 37899160 PMCID: PMC10619041 DOI: 10.1136/bmjopen-2023-074380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Pain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines. OBJECTIVES The aim of this study was to investigate what influences GPs' decision to prescribe pain medicines for LBP. DESIGN Qualitative study with in-depth interviews. SETTING Australian primary care. PARTICIPANTS We interviewed 25 GPs practising in Australia experienced in managing LBP (mean (SD) age 53.4 (9.1) years, mean (SD) years of experience: 24.6 (9.3), 36% female). GPs were provided three vignettes describing common LBP presentations (acute exacerbation of chronic LBP, subacute sciatica and chronic LBP) and were asked to think aloud how they would manage the cases described in the vignettes. DATA ANALYSIS We summarised GP's choices of pain medicines for each vignette using content analysis and used framework analysis to investigate factors that affected GP's decision-making. RESULTS GPs more commonly prescribed opioid analgesics. Anticonvulsants and antidepressants were also commonly prescribed depending on the presentation described in the vignette. GP participants made decisions about what pain medicines to prescribe for LBP largely based on previous experiences, including their own personal experiences of LBP, rather than guidelines. The choice of pain medicine was influenced by a range of clinical factors, more commonly the patient's pathoanatomical diagnosis. While many adhered to principles of judicious use of pain medicines, polypharmacy scenarios were also common. Concerns about drug-seeking behaviour, adverse effects, stigma around opioid analgesics and pressure from regulators also shaped their decision-making process. CONCLUSIONS We identified several aspects of decision-making that help explain the current profile of pain medicines prescribed for LBP by GPs. Themes identified by our study could inform future implementation strategies to improve the quality use of medicines for LBP.
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Affiliation(s)
- Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Joshua Zadro
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Caitlin Jones
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Julie Ayre
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bethan Richards
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher Needs
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard O Day
- St Vincent's Clinical School, Department of Clinical Pharmacology & Toxicology, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Stefani M, Musgrave K, Sevastos J, Penny M, Day RO, Roberts DM. Optimizing the dosing of vancomycin in patients receiving intermittent haemodialysis with low-flux filters, and the potential impact of dosing software. Nephrology (Carlton) 2023; 28:534-539. [PMID: 37394830 DOI: 10.1111/nep.14198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 07/04/2023]
Abstract
AIM Iterative approaches to vancomycin dosing (e.g., dosing when trough concentrations <15-20 mg/L) can be inadequate. Computer-guided dosing may be superior but has not been evaluated in patients with kidney failure receiving replacement therapy. We evaluated vancomycin concentrations using a hospital protocol and a pharmacokinetic software. We measured vancomycin clearance by the FX8 low-flux filter because data are absent. METHODS We retrospectively reviewed records of adults with kidney failure requiring replacement therapy receiving vancomycin and dialysed with the FX8 low-flux filter, and calculated the proportion of pre-dialysis concentrations that were within, above or below a specified range. One and two-compartment models in the pharmacokinetic software were assessed by computing mean prediction error (MPE) and root mean square error (RMSE) of observed versus predicted concentrations. Vancomycin extracorporeal clearance was prospectively determined using the extraction method. RESULTS In 24 patients (34 courses; 139 paired observed and predicted concentrations), 62/139 (45%) pre-dialysis concentrations were 15-25 mg/L, 29/139 (21%) were above, and 48/139 (35%) were below. MPE for the one-compartment model was -0.2 mg/L, RMSE 5.3 mg/L. MPE for the two-compartment model was 2.0 mg/L, RMSE 5.6 mg/L. Excluding the first paired concentrations, the subsequent MPE (n = 105) using one-compartment model was -0.5 mg/L, RMSE 5.6 mg/L. The MPE for the two-compartment model was 2.1 mg/L, RMSE 5.8 mg/L. The median extracorporeal clearance was 70.7 mL/min (range: 10.3-130.3; n = 22). CONCLUSIONS Vancomycin dosing was suboptimal and the pharmacokinetic software was not sufficiently predictive. These may improve with a loading dose. The substantial removal of vancomycin by low-flux filters is not accounted for by the models tested.
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Affiliation(s)
- Maurizio Stefani
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Department of Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
| | - Kirsty Musgrave
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Jacob Sevastos
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Mark Penny
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Edith Collins Centre, Drug Health Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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12
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Selvadurai D, Coleshill MJ, Day RO, Briggs NE, Schulz M, Reath J, Aung E. Patient factors and health outcomes associated with illness perceptions in people with gout. Rheumatology (Oxford) 2023:kead501. [PMID: 37769230 DOI: 10.1093/rheumatology/kead501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/10/2023] [Accepted: 09/01/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE Illness perceptions are views and beliefs formed in response to a health threat which may influence self-management behaviours and chronic disease outcomes. Despite effective medication, sub-optimal outcomes in gout are common. This study aimed to quantitatively investigate illness perceptions in gout to examine how illness perceptions relate to health outcomes. METHODS Data were obtained from a randomised-controlled trial where people with gout (n = 493) completed surveys measuring illness perceptions (Brief Illness Perception Questionnaire (B-IPQ)), gout flares, medication adherence, health-related quality of life, healthcare utilisation and productivity, alongside serum urate blood tests at baseline, 6- and 12-month follow-ups. Multivariable linear regression identified patient factors independently associated with each B-IPQ item score. Logistic and linear regression, adjusted for age and sex, determined whether baseline B-IPQ items could predict current and future health outcomes. RESULTS Younger individuals and those with severe gout were more likely to experience pessimistic illness perceptions at baseline. Optimistic illness perceptions were associated with lower odds of having at least one flare in the preceding 6 months. Every 1-point increase in B-IPQ treatment control, indicating the optimistic view that gout is treatable, decreased the odds of a recent flare prior to baseline by 33% (OR : 0.67; 95%CI : 0.53,0.85; p< 0.001) and prior to 12-month follow-up by 15% (OR : 0.85; 95%CI : 0.76,0.96; p= 0.01). Pessimistic illness perceptions also predicted poorer medication adherence, health-related quality of life and productivity but not serum urate levels. CONCLUSION Modifying pessimistic illness perceptions, including, but not limited to, patient education, may promote prudent self-management behaviours and better outcomes in gout. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry; https://www.anzctr.org.au/; ACTRN12616000455460.
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Affiliation(s)
- Daniel Selvadurai
- St Vincent's Healthcare Clinical Campus, UNSW Medicine & Health, UNSW Sydney, Sydney, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Matthew J Coleshill
- Black Dog Institute, Sydney, Australia
- UNSW Medicine & Health, UNSW Sydney, Sydney, Australia
| | - Richard O Day
- St Vincent's Healthcare Clinical Campus, UNSW Medicine & Health, UNSW Sydney, Sydney, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Nancy E Briggs
- Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, Australia
| | - Marcel Schulz
- St Vincent's Healthcare Clinical Campus, UNSW Medicine & Health, UNSW Sydney, Sydney, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Jennifer Reath
- Department of General Practice, Western Sydney University, Sydney, Australia
| | - Eindra Aung
- St Vincent's Healthcare Clinical Campus, UNSW Medicine & Health, UNSW Sydney, Sydney, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
- Kolling Institute of Medical Research, Pain Management Research Institute, University of Sydney, Sydney, Australia
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Lin J, Pearson SA, Greenfield JR, Park KH, Havard A, Brieger D, Day RO, Falster MO, de Oliveira Costa J. Trends in use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) in Australia in the era of increased evidence of their cardiovascular benefits (2014-2022). Eur J Clin Pharmacol 2023; 79:1239-1248. [PMID: 37449993 PMCID: PMC10427543 DOI: 10.1007/s00228-023-03539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To investigate trends in SGLT2i and GLP-1RA use in Australia in the era of increased evidence of their cardiovascular benefits. METHODS We used national dispensing claims for a 10% random sample of Australians to estimate the number of prevalent and new users (no dispensing in the prior year) of SGLT2i or GLP-1RA per month from January 2014 to July 2022. We assessed prescriber specialty and prior use of other antidiabetic and cardiovascular medicines as a proxy for evidence of type 2 diabetes (T2D) and cardiovascular conditions, respectively. RESULTS We found a large increase in the number of prevalent users (216-fold for SGLT2i; 11-fold for GLP-1RA); in July 2022 approximately 250,000 Australians were dispensed SGLT2i and 120,000 GLP-1RA. Most new users of SGLT2i or GLP-1RA had evidence of both T2D and cardiovascular conditions, although from 2022 onwards, approximately one in five new users of SGLT2i did not have T2D. The proportion of new users initiating SGLT2i by cardiologists increased after 2021, reaching 10.0% of initiations in July 2022. Among new users with evidence of cardiovascular conditions, empagliflozin was the most commonly prescribed SGLT2i, while dulaglutide or semaglutide was the most common GLP-1RA. CONCLUSION SGLT2i and GLP-1RA use is increasing in Australia, particularly in populations with higher cardiovascular risk. The increased use of SGLT2i among people without evidence of T2D suggests that best-evidence medicines are adopted in Australia across specialties, aligning with new evidence and expanding indications.
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Affiliation(s)
- Jialing Lin
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Darlinghurst, Australia
- St Vincent's Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Clinical Diabetes, Appetite and Metabolism, Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Kyeong Hye Park
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Endocrinology and Metabolism, National Health Insurance Ilsan Hospital, Goyang-shi, Gyeonggi-do, South Korea
| | - Alys Havard
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Richard O Day
- St Vincent's Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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Jones CMP, Lin CWC, Day RO, Koes BW, Latimer J, Maher CG, McLachlan A, Billot L. Correction: OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain-a statistical analysis plan. Trials 2023; 24:479. [PMID: 37501161 PMCID: PMC10375598 DOI: 10.1186/s13063-023-07525-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Level 10N, KGV Building, Missenden Road, Camperdown, Sydney, NSW, Australia.
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Level 10N, KGV Building, Missenden Road, Camperdown, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney and St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Jane Latimer
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Level 10N, KGV Building, Missenden Road, Camperdown, Sydney, NSW, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Level 10N, KGV Building, Missenden Road, Camperdown, Sydney, NSW, Australia
| | - Andrew McLachlan
- Faculty of Pharmacy and The Centre for Education and Research On Ageing (CERA), The University of Sydney and Concord Hospital, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
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15
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Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CWC. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet 2023; 402:304-312. [PMID: 37392748 DOI: 10.1016/s0140-6736(23)00404-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain. METHODS OPAL was a triple-blinded, placebo-controlled randomised trial that recruited adults (aged ≥18 years) presenting to one of 157 primary care or emergency department sites in Sydney, NSW, Australia, with 12 weeks or less of low back or neck pain (or both) of at least moderate pain severity. Participants were randomly assigned (1:1) using statistician-generated randomly permuted blocks to guideline-recommended care plus an opioid (oxycodone-naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks. The primary outcome was pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale), analysed in all eligible participants who provided at least one post-randomisation pain score, by use of a repeated measures linear mixed model. Safety was analysed in all randomly assigned eligible participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000775516). FINDINGS Between Feb 29, 2016, and March 10, 2022, 347 participants were recruited (174 to the opioid group and 173 to the placebo group). 170 (49%) of 346 participants were female and 176 (51%) were male. 33 (19%) of 174 participants in the opioid group and 25 (15%) of 172 in the placebo group had discontinued from the trial by week 6, due to loss to follow-up and participant withdrawals. 151 participants in the opioid group and 159 in the placebo group were included in the primary analysis. Mean pain score at 6 weeks was 2·78 (SE 0·20) in the opioid group versus 2·25 (0·19) in the placebo group (adjusted mean difference 0·53, 95% CI -0·00 to 1·07, p=0·051). 61 (35%) of 174 participants in the opioid group reported at least one adverse event versus 51 (30%) of 172 in the placebo group (p=0·30), but more people in the opioid group reported opioid-related adverse events (eg, 13 [7·5%] of 174 participants in the opioid group reported constipation vs six [3·5%] of 173 in the placebo group). INTERPRETATION Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions. FUNDING National Health and Medical Research Council, University of Sydney Faculty of Medicine and Health, and SafeWork SA.
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Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney and St Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus MC, Rotterdam, Netherlands; Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Jane Latimer
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sana Shan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia.
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16
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Spragg JCJ, Michael TJF, Aslani P, Coleshill MJ, Chan JS, Day RO, Stocker SL. Optimizing adherence to allopurinol for gout: patients' perspectives. Br J Clin Pharmacol 2023; 89:1978-1991. [PMID: 36607199 DOI: 10.1111/bcp.15657] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/15/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023] Open
Abstract
AIMS Poor adherence to allopurinol among people with gout contributes to suboptimal gout management. This study sought to understand the facilitators and barriers to allopurinol adherence across the three stages of medication adherence, and patient perspectives on strategies to improve adherence, including self-monitoring urate concentration. METHODS Semi-structured interviews were conducted with 26 people with gout, previously or currently taking allopurinol. De-identified verbatim transcripts were thematically analysed using an inductive and deductive approach. RESULTS Facilitators of adherence during allopurinol initiation were motivation to prevent gout flares and trust in the advice of their healthcare professionals (HCPs). Reluctance to commence long-term medication was a barrier to allopurinol initiation. Believing in the effectiveness and necessity of allopurinol and reminder systems were facilitators of implementation. Barriers to implementation included forgetfulness, gout flares and limited feedback on allopurinol's effectiveness. Patients discontinued therapy when allopurinol was perceived as ineffective or unnecessary. Discontinuation coincided with patients experiencing gout flares while adhering to allopurinol and receiving suboptimal advice about gout management. Patients identified receiving accurate advice from HCPs and regular urate monitoring for feedback on allopurinol's effectiveness as potential strategies to improve adherence. Perceived benefits of self-monitoring urate as a strategy to promote adherence included the ability to self-manage gout and make informed decisions about allopurinol therapy with their HCP. CONCLUSION Patient perceptions of the effectiveness and necessity of allopurinol influenced intentional adherence during medication initiation, implementation and discontinuation. Strategies that inform patients of their urate control and provide accurate medical advice have the potential to improve adherence to allopurinol.
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Affiliation(s)
- Jane C J Spragg
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Toni J F Michael
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Parisa Aslani
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Matthew J Coleshill
- Black Dog Institute, Faculty of Medicine, The University of New South Wales, Randwick, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jian S Chan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- St Vincent's Clinical Campus, School of Clinical Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Sophie L Stocker
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- St Vincent's Clinical Campus, School of Clinical Medicine, The University of New South Wales, Kensington, New South Wales, Australia
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17
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Stojanova J, Day RO, Suthers G. Avoiding severe drug hypersensitivity reactions: a case for HLA genotyping for at-risk patients. Med J Aust 2023; 218:441-444. [PMID: 37270788 DOI: 10.5694/mja2.51937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/27/2023] [Accepted: 03/20/2023] [Indexed: 06/06/2023]
Affiliation(s)
| | - Richard O Day
- St Vincent's Hospital Sydney, Sydney, NSW
- St Vincent's Clinical School, UNSW, Sydney, NSW
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18
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Chowdhury G, Carland JE, Kumar S, Olsen N, Graham G, Kumarasinghe G, Hayward CS, Greenfield JR, Macdonald P, Day RO, Stocker SL. The safe use of metformin in heart failure patients both with and without T2DM: a cross-sectional and longitudinal study. Br J Clin Pharmacol 2023. [PMID: 37016750 DOI: 10.1111/bcp.15737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 04/06/2023] Open
Abstract
AIMS This study investigated the safe use of metformin in patients with (1) type 2 diabetes mellitus (T2DM) and heart failure on metformin, and (2) heart failure without T2DM and metformin naïve. METHODS Two prospective studies on heart failure patients were undertaken. The first was a cross-sectional study with two patient cohorts, one with T2DM on metformin (n=44) and one without T2DM metformin naive (n=47). The second was a 12-week interventional study of patients without T2DM (n=27) where metformin (500 mg immediate release, twice daily) was prescribed. Plasma metformin and lactate concentrations were monitored. Individual pharmacokinetics were compared between cohorts. Univariable and multivariable analysis analysed the effects of variables on plasma lactate concentrations. RESULTS Plasma metformin and lactate concentrations mostly (99.9%) remained below safety thresholds (5 mg/L and 5 mmol/L, respectively). Metformin concentration had no significant relationship with lactic acidosis safety markers. In the interventional study, New York Heart Association (NYHA) II (p<0.03) and III (p<0.001) grading was associated with higher plasma lactate concentrations, whereas male sex was associated with 47% higher plasma lactate concentrations (p<0.05). The pharmacokinetics of heart failure patients with and without T2DM were similar. CONCLUSIONS We observed no unsafe plasma lactate concentrations in patients with heart failure treated with metformin. Metformin exposure did not influence plasma lactate concentrations; however, NYHA class and sex did. The pharmacokinetics of metformin in heart failure patients are similar irrespective of T2DM. These findings may support the safe use of metformin in heart failure patients with and without T2DM.
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Affiliation(s)
- G Chowdhury
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Medical Science, The University of New South Wales, Sydney, Australia
| | - J E Carland
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - S Kumar
- Clinical Pharmacology, Modelling and Simulation, Parexel International, Sydney, Australia
| | - N Olsen
- School of Mathematics and Statistics, The University of New South Wales, Sydney, Australia
| | - G Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - G Kumarasinghe
- Heart & Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
| | - C S Hayward
- Heart & Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - J R Greenfield
- Department of Endocrinology, St Vincent's Hospital Sydney, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - P Macdonald
- Heart & Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - R O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - S L Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
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Kirubakaran R, Uster DW, Hennig S, Carland JE, Day RO, Wicha SG, Stocker SL. Adaptation of a population pharmacokinetic model to inform tacrolimus therapy in heart transplant recipients. Br J Clin Pharmacol 2023; 89:1162-1175. [PMID: 36239542 PMCID: PMC10952588 DOI: 10.1111/bcp.15566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 09/24/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022] Open
Abstract
AIM Existing tacrolimus population pharmacokinetic models are unsuitable for guiding tacrolimus dosing in heart transplant recipients. This study aimed to develop and evaluate a population pharmacokinetic model for tacrolimus in heart transplant recipients that considers the tacrolimus-azole antifungal interaction. METHODS Data from heart transplant recipients (n = 87) administered the oral immediate-release formulation of tacrolimus (Prograf®) were collected. Routine drug monitoring data, principally trough concentrations, were used for model building (n = 1099). A published tacrolimus model was used to inform the estimation of Ka , V2 /F, Q/F and V3 /F. The effect of concomitant azole antifungal use on tacrolimus CL/F was quantified. Fat-free mass was implemented as a covariate on CL/F, V2 /F, V3 /F and Q/F on an allometry scale. Subsequently, stepwise covariate modelling was performed. Significant covariates influencing tacrolimus CL/F were included in the final model. Robustness of the final model was confirmed using prediction-corrected visual predictive check (pcVPC). The final model was externally evaluated for prediction of tacrolimus concentrations of the fourth dosing occasion (n = 87) from one to three prior dosing occasions. RESULTS Concomitant azole antifungal therapy reduced tacrolimus CL/F by 80%. Haematocrit (∆OFV = -44, P < .001) was included in the final model. The pcVPC of the final model displayed good model adequacy. One recent drug concentration is sufficient for the model to guide tacrolimus dosing. CONCLUSION A population pharmacokinetic model that adequately describes tacrolimus pharmacokinetics in heart transplant recipients, considering the tacrolimus-azole antifungal interaction was developed. Prospective evaluation is required to assess its clinical utility to improve patient outcomes.
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Affiliation(s)
- Ranita Kirubakaran
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- Department of PharmacyHospital Seberang JayaPenangMalaysia
| | - David W. Uster
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Stefanie Hennig
- Certara Inc.PrincetonNew JerseyUSA
- School of Clinical Sciences, Faculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Jane E. Carland
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Richard O. Day
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Sophie L. Stocker
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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20
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Ferreira GE, Abdel-Shaheed C, Underwood M, Finnerup NB, Day RO, McLachlan A, Eldabe S, Zadro JR, Maher CG. Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews. BMJ 2023; 380:e072415. [PMID: 36725015 PMCID: PMC9887507 DOI: 10.1136/bmj-2022-072415] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition. DESIGN Overview of systematic reviews. DATA SOURCES PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Systematic reviews comparing any antidepressant with placebo for any pain condition in adults. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework. RESULTS 26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference -5.3, 95% confidence interval -7.3 to -3.3), postoperative pain (-7.3, -12.9 to -1.7), neuropathic pain (-6.8, -8.7 to -4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons). CONCLUSIONS Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews-seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022311073.
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Affiliation(s)
- Giovanni E Ferreira
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Christina Abdel-Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard O Day
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | - Joshua R Zadro
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Christopher G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
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21
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Sullivan JK, Fahey PP, Agho KE, Hurley SP, Feng Z, Day RO, Lim D. Valproic acid as a radio-sensitizer in glioma: A systematic review and meta-analysis. Neurooncol Pract 2023; 10:13-23. [PMID: 36659976 PMCID: PMC9837785 DOI: 10.1093/nop/npac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Histone deacetylase inhibitors (HDACi) including valproic acid (VPA) have the potential to improve radiotherapy (RT) efficacy and reduce treatment adverse events (AE) via epigenetic modification and radio-sensitization of neoplastic cells. This systematic review and meta-analysis aimed to assess the efficacy and AE associated with HDACi used as radio-sensitizers in adult solid organ malignancy patients. Methods A systematic review utilized electronic searches of MEDLINE(Ovid), Embase(Ovid), The Cochrane Library, and the International Clinical Trials Registry Platform to identify studies examining the efficacy and AEs associated with HDACi treatment in solid organ malignancy patients undergoing RT. Meta-analysis was performed with overall survival (OS) reported as hazard ratios (HR) as the primary outcome measure. OS reported as median survival difference, and AEs were secondary outcome measures. Results Ten studies reporting on the efficacy and/or AEs of HDACi in RT-treated solid organ malignancy patients met inclusion criteria. All included studies focused on HDACi valproic acid (VPA) in high-grade glioma patients, of which 9 studies (n = 6138) evaluated OS and 5 studies (n = 1055) examined AEs. The addition of VPA to RT treatment protocols resulted in improved OS (HR = 0.80, 95% CI 0.67-0.96). No studies focusing on non-glioma solid organ malignancy patients, or non-VPA HDACi met the inclusion criteria for this review. Conclusions This review suggests that glioma patients undergoing RT may experience prolonged survival due to HDACi VPA administration. Further randomized controlled trials are required to validate these findings. Additionally, more research into the use of HDACi radio-adjuvant treatment in non-glioma solid organ malignancies is warranted.
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Affiliation(s)
| | - Paul P Fahey
- School of Health Sciences, Western Sydney University, New South Wales, Australia
| | - Kinglsey E Agho
- School of Health Sciences, Western Sydney University, New South Wales, Australia
| | - Simon P Hurley
- School of Medicine, Flinders University, South Australia, Australia
| | - Zhihui Feng
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Richard O Day
- St Vincent’s Clinical Campus, University of New South Wales, New South Wales, Australia
| | - David Lim
- School of Medicine, Flinders University, South Australia, Australia
- School of Health Sciences, Western Sydney University, New South Wales, Australia
- Centre for Remote Health: A JBI Affiliated Centre, Alice Springs, Australia
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22
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Carland JE, Stacy AE, Schaffer AL, Day RO, Brett J, Reuter SE, Stocker SL. Blood, dose recommendation reports and phone calls: Experiences of a therapeutic drug monitoring advisory service for vancomycin. Br J Clin Pharmacol 2023; 89:1896-1902. [PMID: 36662777 DOI: 10.1111/bcp.15668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/18/2022] [Accepted: 01/14/2023] [Indexed: 01/21/2023] Open
Abstract
Dose-prediction software is recommended to enable area under the curve over 24 h (AUC24 )-guided dosing of the antibiotic vancomycin. However, uncertainty remains about how best to implement software in the clinic. We describe the activity, over 18 months, of a consultative therapeutic drug monitoring Advisory Service (the Service) for vancomycin that used dose-prediction software alongside clinical expertise, identifying factors that influence attainment of therapeutic targets. Of the 408 vancomycin dose reports provided for 182 courses of therapy, most (57%) recommended a dose change. The majority (82.8%, 193/233) of recommended dose adjustments were accepted by treating teams. A dose report was not published for 125 courses of therapy, with reasons including patient in intensive care unit or service error. An estimated 26.6 h of staff time was allocated to Service activities each month. Publication of a dose report facilitated attainment of therapeutic targets (P = .002). Software integration could improve Service outcomes, avoiding errors and reducing staff workload.
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Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW, Sydney, Australia
| | - Alexandra E Stacy
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,The School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Andrea L Schaffer
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW, Sydney, Australia
| | - Jonathan Brett
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW, Sydney, Australia.,Centre for Big Data Research in Health, Faculty of Medicine, UNSW, Sydney, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW, Sydney, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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23
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Chaudhri K, Kearney M, Di Tanna GL, Gnanenthiran SR, Day RO, Rodgers A, Atkins ER. Does splitting a tablet obtain an accurate dose? A systematic review and meta‐ analysis. Pharmacy Practice and Res 2023. [DOI: 10.1002/jppr.1843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Kanika Chaudhri
- The George Institute for Global Health UNSW Sydney Australia
- Faculty of Medicine UNSW Sydney Australia
| | | | - Gian Luca Di Tanna
- The George Institute for Global Health UNSW Sydney Australia
- Faculty of Medicine UNSW Sydney Australia
| | - Sonali R. Gnanenthiran
- The George Institute for Global Health UNSW Sydney Australia
- Faculty of Medicine UNSW Sydney Australia
| | - Richard O. Day
- Faculty of Medicine UNSW Sydney Australia
- Department of Clinical Pharmacology and Toxicology St Vincent's Hospital Darlinghurst Australia
- St Vincent's Clinical School Faculty of Medicine UNSW Sydney Australia
| | - Anthony Rodgers
- The George Institute for Global Health UNSW Sydney Australia
- Faculty of Medicine UNSW Sydney Australia
| | - Emily R. Atkins
- The George Institute for Global Health UNSW Sydney Australia
- Faculty of Medicine UNSW Sydney Australia
- Westmead Clinical School University of Sydney Sydney Australia
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24
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Kamel B, Abuhelwa AY, Foster D, Duong JK, Graham GG, Williams KM, Pile KD, Day RO. Population pharmacokinetic modelling of febuxostat in healthy subjects and people with gout. Br J Clin Pharmacol 2022; 88:5359-5368. [PMID: 35849446 PMCID: PMC9796681 DOI: 10.1111/bcp.15462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 01/07/2023] Open
Abstract
AIMS To investigate and characterise the pharmacokinetics of febuxostat and the effect of the covariates of renal function and body size descriptors on the pharmacokinetics of the drug. METHODS Blood samples (n = 239) were collected using sparse and rich sampling strategies from healthy (n = 9) and gouty (n = 29) subjects. Febuxostat plasma concentrations were measured by a validated high-performance liquid chromatography method. Population pharmacokinetic analysis was performed using NONMEM. A common variability on bioavailability (FVAR) approach was used to test the effect of fed status on absorption parameters. Covariates were modelled using a power model. RESULTS The time course of the plasma concentrations of febuxostat is best described by a two-compartment model. In the final model, the population mean for apparent clearance (CL/F), apparent central volume of distribution (Vc/F), apparent peripheral volume of distribution (Vp/F), absorption rate constant (ka) and apparent intercompartmental clearance (Q/F) were 6.91 l h-1 , 32.8 l, 19.4 l, 3.6 h-1 and 1.25 l h-1 , respectively. The population parmater variability (coefficient of variation) for CL/F, Vc/F and Vp/F were 13.6, 22 and 19.5%, respectively. Food reduced the relative biovailability and ka by 67% and 87%, respectively. Renal function, as assessed by creatinine clearance, was a significant covariate for CL/F while body mass index was a significant covariate for Vc/F. CONCLUSIONS Renal function and body mass index were significant covariates. Further work is warranted to investigate the clinical relevance of these results, notably as renal impairment and obesity are common occurrences in people with gout.
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Affiliation(s)
- Bishoy Kamel
- The George Institute for Global HealthSydneyNew South WalesAustralia,St Vincent's Clinical SchoolUniversity of New South Wales SydneyNew South WalesAustralia,Department of Clinical Pharmacology and ToxicologySt Vincent's Hospital and University of New South Wales SydneyNew South WalesAustralia,School of Medical SciencesUniversity of New South Wales SydneyNew South WalesAustralia
| | - Ahmad Y. Abuhelwa
- College of PharmacyUniversity of SharjahSharjahUnited Arab Emirates,College of Medicine and Public HealthFlinders UniversitySouth AustraliaAustralia,Australian Centre for Precision Health, Clinical and Health SciencesUniversity of South AustraliaSouth AustraliaAustralia
| | - David Foster
- Australian Centre for Precision Health, Clinical and Health SciencesUniversity of South AustraliaSouth AustraliaAustralia
| | - Janna K. Duong
- Faculty of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Garry G. Graham
- Department of Clinical Pharmacology and ToxicologySt Vincent's Hospital and University of New South Wales SydneyNew South WalesAustralia,School of Medical SciencesUniversity of New South Wales SydneyNew South WalesAustralia
| | - Kenneth M. Williams
- Department of Clinical Pharmacology and ToxicologySt Vincent's Hospital and University of New South Wales SydneyNew South WalesAustralia,School of Medical SciencesUniversity of New South Wales SydneyNew South WalesAustralia
| | - Kevin D. Pile
- Department of MedicineWestern Sydney UniversityNew South WalesAustralia,Department of Rheumatology, Campbelltown HospitalSydneyNew South WalesAustralia
| | - Richard O. Day
- St Vincent's Clinical SchoolUniversity of New South Wales SydneyNew South WalesAustralia,Department of Clinical Pharmacology and ToxicologySt Vincent's Hospital and University of New South Wales SydneyNew South WalesAustralia
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25
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Nguyen AD, Lind KE, Day RO, Ross D, Raban MZ, Georgiou A, Westbrook JI. Measuring quality of gout management in residential aged care facilities. Rheumatol Adv Pract 2022; 6:rkac091. [DOI: 10.1093/rap/rkac091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/14/2022] [Indexed: 11/30/2022] Open
Abstract
Abstract
Objectives
Gout, a common form of arthritis, can be successfully controlled with pharmacotherapy and thus an ideal model for examining chronic disease management. Our aim was to examine treatment of gout evaluated in accordance with general management guidelines for gout as applied to Australian residential aged care facilities (RACFs).
Methods
Electronic health record data linked with aged care clinical notes and electronic medication administration information (11,548 residents in 68 RACFs, over 65 years) was interrogated to identify people with gout, other chronic conditions and gout medication use. Outcomes examined: 1) proportion receiving urate-lowering therapy (ULT) (preventative medication) and/or colchicine/non-steroidal anti-inflammatory drugs (NSAID) (treat gout flares); 2) number of ULT and colchicine/NSAID treatment episodes (periods of continuous days of medication use); 3) duration of these medication uses.
Results
Cohort included 1179 residents with gout, of which 62% used a ULT, with median of one episode of use for a very short duration (median=4 days, median of use in total (i.e. repeated use) =52 days). Among residents with gout, 9% also used colchicine or an NSAID. Female residents were less likely to receive ULT and for shorter periods.
Conclusion
Nearly a third of residents with gout did not receive ULTs. In those receiving ULT, recurrent short courses were common. Overall, management of gout in aged care residents appears to be suboptimal, largely due to intermittent and short exposure to ULT, and with female residents at greater risk of poor gout management.
Lay summary
What does this mean for patients ?
Residents living in aged care facilities are at risk of receiving suboptimal pharmacological management of their gout. Instead of receiving the recommended long-term urate-lowering therapies, aged care residents have intermittent short exposures to these medications, which may not elicit the appropriate protection against painful gout flares. Female aged care residents are at greater risk of receiving poor gout management. Further research exploring the reasons why gout management is not concordant to guidelines within the residential aged care setting is required. This will ensure residents receive appropriate gout management to minimise the debilitating painful effects of gout. This study also demonstrates the ability to use routinely collected patient data to improve delivery of care in the aged care setting.
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Affiliation(s)
- Amy D Nguyen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , NSW, Australia
- UNSW Sydney St Vincent’s Clinical School, UNSW Medicine, , NSW, Australia
| | - Kimberly E Lind
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , NSW, Australia
| | - Richard O Day
- UNSW Sydney St Vincent’s Clinical School, UNSW Medicine, , NSW, Australia
- St Vincent’s Hospital Department of Clinical Pharmacology & Toxicology, , NSW, Australia
| | - Daniel Ross
- Macquarie University Faculty of Medicine, Health and Human Sciences, , NSW, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , NSW, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , NSW, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , NSW, Australia
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26
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Coleshill MJ, Day RO, Tam K, Kouhkamari M, Caillet V, Aung E, Kannangara DRW, Cronin P, Rodgers A, Stocker SL. Persistence with urate-lowering therapy in Australia: A longitudinal analysis of allopurinol prescriptions. Br J Clin Pharmacol 2022; 88:4894-4901. [PMID: 35675118 PMCID: PMC9795926 DOI: 10.1111/bcp.15435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/12/2022] [Accepted: 05/27/2022] [Indexed: 12/30/2022] Open
Abstract
AIM Gout is the most common form of inflammatory arthritis in men. Despite the availability of effective urate-lowering therapies (ULT), the management of gout is suboptimal due to poor persistence with ULT. This study examined national prescribing patterns of ULT to determine persistence with allopurinol in Australia. METHODS A 10% sample of the Australian Pharmaceutical Benefits Scheme dispensing claims database was used to identify individuals initiated on allopurinol between April 2014 and December 2019. The number of allopurinol scripts dispensed was used to estimate persistence with allopurinol. Persistence was defined as the number of months from initiation until discontinuation (last prescription with no further scripts acquired for a period thereafter). Kaplan-Meier curves were used to examine persistence, while Cox regression analysis was used to examine the influence of gender, concomitant colchicine and age. RESULTS The largest drop in persistence occurred immediately after initiation, with 34% of patients discontinuing allopurinol 300-mg therapy in the first month. Median persistence with allopurinol 300 mg was 5 months (95% confidence interval 4.76-5.24), with around 63% of individuals not persisting with this therapy for more than 12 months. Concomitant prescription of colchicine on the day of allopurinol initiation only occurred in 7% of allopurinol initiations. No increase in persistence was observed for those co-prescribed colchicine. CONCLUSION Persistence with allopurinol was poor. More effective methods targeting prescribers, patients and systems are required to promote persistence with allopurinol. Improving persistence to allopurinol is an important public health goal given the proven potential of this medication to eliminate gout.
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Affiliation(s)
- Matthew J. Coleshill
- Department of Clinical Pharmacology & ToxicologySt Vincent's HospitalSydneyAustralia,St Vincent's Clinical SchoolUniversity of New South WalesSydneyAustralia
| | - Richard O. Day
- Department of Clinical Pharmacology & ToxicologySt Vincent's HospitalSydneyAustralia,St Vincent's Clinical SchoolUniversity of New South WalesSydneyAustralia
| | - Karson Tam
- Department of Clinical Pharmacology & ToxicologySt Vincent's HospitalSydneyAustralia
| | | | | | - Eindra Aung
- Department of Clinical Pharmacology & ToxicologySt Vincent's HospitalSydneyAustralia,St Vincent's Clinical SchoolUniversity of New South WalesSydneyAustralia
| | - Diluk R. W. Kannangara
- Department of Clinical Pharmacology & ToxicologySt Vincent's HospitalSydneyAustralia,Notre Dame Medical SchoolSydneyAustralia
| | | | - Anthony Rodgers
- George Institute for Global StudiesUniversity of New South WalesSydneyAustralia
| | - Sophie L. Stocker
- Department of Clinical Pharmacology & ToxicologySt Vincent's HospitalSydneyAustralia,St Vincent's Clinical SchoolUniversity of New South WalesSydneyAustralia,Sydney Pharmacy School, Faculty of Medicine & HealthThe University of SydneySydneyAustralia
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27
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Tiwary M, Milder TY, Stocker SL, Day RO, Greenfield JR. Sodium-glucose co-transporter 2 inhibitor therapy: use in chronic kidney disease and adjunctive sodium restriction. Intern Med J 2022; 52:1666-1676. [PMID: 35257458 PMCID: PMC9796501 DOI: 10.1111/imj.15727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/02/2022] [Accepted: 02/21/2022] [Indexed: 01/01/2023]
Abstract
The global burden of chronic kidney disease (CKD) has increased significantly over the past few decades. This reflects the rising prevalence of type 2 diabetes mellitus (T2DM) and hypertension, two leading causes of CKD. Hypertension, which can also be a complication of CKD, accelerates renal disease progression and augments cardiovascular risk, especially in individuals with diabetic kidney disease. Hence, blood pressure (BP) reduction is a vital component of CKD management. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a relatively novel class of medications developed to treat T2DM by inducing glycosuria and hence, lowering glycaemia. Additionally, SGLT2 inhibitors are antihypertensive, renoprotective and cardioprotective, even in individuals without T2DM, making them effective therapeutic agents for CKD. Another therapy that has proven to be antihypertensive, renoprotective and cardioprotective is dietary sodium restriction. This review evaluates the potential combined benefits of SGLT2 inhibition and dietary sodium restriction on the BP and renal parameters of individuals with CKD.
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Affiliation(s)
- Mansi Tiwary
- St Vincent's Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia,Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia,School of PharmacyUniversity of SydneySydneyNew South WalesAustralia
| | - Tamara Y. Milder
- St Vincent's Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia,Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia,Department of Diabetes and EndocrinologySt Vincent's HospitalSydneyNew South WalesAustralia,Healthy AgeingGarvan Institute of Medical ResearchSydneyNew South WalesAustralia
| | - Sophie L. Stocker
- St Vincent's Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia,Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia,School of PharmacyUniversity of SydneySydneyNew South WalesAustralia
| | - Richard O. Day
- St Vincent's Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia,Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia
| | - Jerry R. Greenfield
- St Vincent's Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia,Department of Diabetes and EndocrinologySt Vincent's HospitalSydneyNew South WalesAustralia,Healthy AgeingGarvan Institute of Medical ResearchSydneyNew South WalesAustralia
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Wong DD, van Zuylen WJ, Novos T, Stocker S, Reuter SE, Au J, Foster CSP, Day RO, Horvath AR, Endre Z, Rawlinson WD. Detection of Ganciclovir-Resistant Cytomegalovirus in a Prospective Cohort of Kidney Transplant Recipients Receiving Subtherapeutic Valganciclovir Prophylaxis. Microbiol Spectr 2022; 10:e0268421. [PMID: 35658598 PMCID: PMC9241781 DOI: 10.1128/spectrum.02684-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/20/2022] [Indexed: 11/20/2022] Open
Abstract
Cytomegalovirus infection during antiviral prophylaxis occurs in transplant recipients despite individualized regimens based on renal function. Fifty kidney transplant recipients were assessed between 2016 and 2019 for valganciclovir dosing, ganciclovir exposure, cytomegalovirus infection, and genotypic resistance markers during the first year posttransplant. Ganciclovir plasma concentrations were measured using mass spectrometry. Population pharmacokinetics was used to determine individual ganciclovir exposure and to evaluate the ability of manufacturer dosing guidelines to meet therapeutic target daily area under the curve (AUC24) of 40 to 50 μg·h/mL. Full-length UL54 and UL97 were assessed using high-throughput sequencing in cytomegalovirus DNA-positive patient specimens. Valganciclovir doses administered to recipients with creatinine clearance of <40 mL/min were higher than specified by guidelines, and they were lower for recipients with creatinine clearance of ≥40 mL/min. The mean ganciclovir AUC24 was 33 ± 13 μg·h/mL, and 82% of subjects did not attain the therapeutic target. Pharmacokinetic simulations showed that the guidelines similarly could not attain the therapeutic target in 79% of individuals. Cytomegalovirus breakthrough occurred in 6% (3/50) of recipients, while 12% (6/50) developed late-onset infection. The mean AUC24s of recipients with (n = 3) and without (n = 47) infection were not significantly different (P = 0.528). However, one recipient with an AUC24 of 20 μg·h/mL acquired two UL97 ganciclovir resistance mutations. Current prophylaxis guidelines resulted in subtherapeutic ganciclovir exposure in several study recipients, including the emergence of resistance genotypes. IMPORTANCE This study examined the pharmacokinetics and viral genomic data from a prospective cohort of kidney transplant recipients undergoing valganciclovir prophylaxis for cytomegalovirus (CMV) prevention. We showed for the first time using high-throughput sequencing the detection of ganciclovir resistance mutations in breakthrough CMV infection during subtherapeutic plasma ganciclovir as indicated by the pharmacokinetic parameter daily area under the curve (AUC24). In addition, we found that current valganciclovir dosing guidelines for CMV prophylaxis are predicted to attain therapeutic targets in only 21% of recipients, which is consistent with previous pharmacokinetic studies. The novel findings of resistance mutations during subtherapeutic ganciclovir exposure presented here can inform future studies investigating the dynamics of drug selection pressure and the emergence of resistance mutations in vivo.
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Affiliation(s)
- Diana D. Wong
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Wendy J. van Zuylen
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Talia Novos
- Department of Chemical Pathology, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sophie Stocker
- Sydney Pharmacy School, Faculty of Medicine & Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Stephanie E. Reuter
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Jane Au
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Charles S. P. Foster
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Richard O. Day
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Andrea R. Horvath
- Department of Chemical Pathology, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Zoltan Endre
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - William D. Rawlinson
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
- School of Biotechnology and Biomolecular Sciences, University of New South Wales Sydney, Sydney, New South Wales, Australia
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Wise S, Coleshill MJ, Taylor N, Le M, Debono D, Day RO, Melocco T, Baysari MT, Laba T, Carland JE. Australian hospital outpatient pharmacies: service adaptations during the 2020 national coronavirus disease 2019 lockdown. Pharmacy Practice and Res 2022; 52:326-328. [PMID: 35942385 PMCID: PMC9348013 DOI: 10.1002/jppr.1810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Sarah Wise
- Centre for Health Economics Research and Evaluation University of Technology Sydney Sydney Australia
- St Vincent’s Clinical Campus University of NSW Kensington Australia
| | - Matthew J. Coleshill
- St Vincent’s Clinical Campus University of NSW Kensington Australia
- Department of Clinical Pharmacology and Toxicology St Vincent’s Hospital Darlinghurst Australia
- Black Dog Institute Randwick Australia
| | - Natalie Taylor
- School of Population Health University of NSW Kensington Australia
| | - Michelle Le
- Department of Pharmacy St Vincent’s Hospital Sydney Australia
| | - Deborah Debono
- Faculty of Health University of Technology Sydney Sydney Australia
| | - Richard O. Day
- St Vincent’s Clinical Campus University of NSW Kensington Australia
- Department of Clinical Pharmacology and Toxicology St Vincent’s Hospital Darlinghurst Australia
| | - Terry Melocco
- Department of Pharmacy St Vincent’s Hospital Sydney Australia
| | - Melissa T. Baysari
- Biomedical Informatics and Digital Health School of Medical Sciences Faculty of Medicine and Health The University of Sydney Sydney Australia
| | - Tracey‐Lea Laba
- Centre for Health Economics Research and Evaluation University of Technology Sydney Sydney Australia
- Pharmacy Program, Clinical and Health Services Unit University of South Australia Adelaide Australia
| | - Jane E. Carland
- St Vincent’s Clinical Campus University of NSW Kensington Australia
- Department of Clinical Pharmacology and Toxicology St Vincent’s Hospital Darlinghurst Australia
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Abdel Shaheed C, Awal W, Zhang G, Gilbert SE, Gallacher D, McLachlan A, Day RO, Ferreira GE, Jones CMP, Ahedi H, Tamrakar M, Blyth FM, Stanaway F, Maher CG. Efficacy, safety, and dose‐dependence of the analgesic effects of opioid therapy for people with osteoarthritis: systematic review and meta‐analysis. Med J Aust 2022; 216:305-311. [DOI: 10.5694/mja2.51392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/01/2021] [Accepted: 08/17/2021] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Stephen E Gilbert
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | | | - Andrew McLachlan
- The University of Sydney Sydney NSW
- Centre for Education and Research on Ageing University of Sydney Sydney NSW
| | - Richard O Day
- St Vincent's Hospital Sydney NSW
- St Vincent's Clinical School UNSW Sydney NSW
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Caitlin MP Jones
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Harbeer Ahedi
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Mamata Tamrakar
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Fiona M Blyth
- Centre for Education and Research on Ageing University of Sydney Sydney NSW
| | | | - Christopher G Maher
- The University of Sydney Sydney NSW
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
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Radovanovic M, Jones G, Day RO, Galettis P, LG Norris R. Mitigating analyte to stable isotope labelled internal standard cross-signal contribution in quantitative liquid chromatography-tandem mass spectrometry. J Mass Spectrom Adv Clin Lab 2022; 24:57-64. [PMID: 35520954 PMCID: PMC9065310 DOI: 10.1016/j.jmsacl.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/31/2022] [Accepted: 04/24/2022] [Indexed: 11/30/2022] Open
Abstract
Mitigating cross-signal contribution in LC-MS/MS. Using stable isotope labelled internal standard isotopes of lesser abundance to counteract cross-signal contribution. Novel approach to correct for non-linearity from cross-signal contribution.
Background Utilising stable isotope labelled internal standards (SIL-IS) in quantitative LC-MS/MS drug analysis is the most widely used approach to normalise for variability during sample quantification processes. However, compounds containing atoms such as Sulphur, Chlorine or Bromine, could potentially cause cross-signal contribution to the SIL-IS from the naturally occurring isotopes, resulting in non-linear calibration curves. A simple, novel method of mitigating the effect is presented here. It entails monitoring of a less abundant SIL-IS isotope, as the precursor ion, of a mass that has no/minimal isotopic contribution from the analyte isotopes. Methods Experiments were conducted on two LC-MS/MS analysers: Waters Xevo TQ-S and Shimadzu 8050. Flucloxacillin (FLX) was used as an example. Two transitions were selected for FLX (m/z 454 → 160 → 295) and one for each of the SIL-IS isotopes (m/z 458 → 160 for the isotope 457 g/mol and m/z 460 → 160 for the isotope 459 g/mol). Assay biases were assessed at three SIL-IS concentrations: 0.7, 7 and 14 mg/L for each isotope. Results When using the SIL-IS isotope m/z 458 → 160 at a concentration of 0.7 mg/L, biases were up to 36.9 % on both instruments. Increasing the SIL-IS concentration to 14 mg/L, reduced the bias to 5.8 %. Using the less abundant isotope, m/z 460 → 160, resulted in biases of 13.9 % at an SIL-IS concentration of 0.7 mg/L. Conclusions Applying this method will mitigate cross-signal contribution from the analyte isotopes to the corresponding SIL-IS, minimise the use of SIL-IS, and, thereby, reduce overall cost.
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Jones CMP, Lin CWC, Day RO, Koes BW, Latimer J, Maher CG, McLachlan A, Billot L. OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain—a statistical analysis plan. Trials 2022; 23:212. [PMID: 35287698 PMCID: PMC8919636 DOI: 10.1186/s13063-022-06028-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/15/2022] [Indexed: 12/01/2022] Open
Abstract
Background Low back and neck pain are a leading cause of disease burden globally. Opioids are recommended in guidelines for acute low back and neck pain; however, there is a lack of compelling efficacy data to support this. Methods The OPAL trial is a prospectively registered, triple-blinded, randomised, placebo-controlled trial. Patients with acute (≤12 weeks duration) back and/or neck pain receive guideline care plus either an opioid (oxycodone + naloxone, up to 20 mg per day) or a placebo for up to 6 weeks or earlier, if pain is resolved. The primary outcome is pain measured using the Pain Severity Score of the Brief Pain Inventory with the primary time point being 6 weeks. Secondary outcomes include physical function, time to recovery, quality of life, adverse events and risk of opioid misuse. Outcomes are collected at weeks 2, 4, 6, 12, 26 and 52. Analysis will be done on an intention-to-treat principle. p values of < 0.05 will be considered significant and 95% confidence intervals will be reported. Repeated-measures linear mixed models will be used to assess the effect of the treatment group on the primary outcome and continuous secondary outcomes. Adverse events will be compared between groups using Fisher’s exact test. Cost-effectiveness analyses will be conducted if a treatment effect on pain is seen at week 6. Subgroup analyses will be performed to assess whether pain duration and pain location are treatment effect modifiers. Discussion The OPAL trial will provide important evidence about whether a short course of opioids is effective in the treatment of acute non-specific low back and/or neck pain. This pre-specified statistical analysis plan details the methodology for the analysis of the OPAL trial results. Trial registration ACTRN12615000775516. The trial has completed recruitment. Follow-up on the last patient will be completed in March 2022.
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Abdel Shaheed C, Beardsley J, Day RO, McLachlan AJ. Immunomodulatory effects of pharmaceutical opioids and antipyretic analgesics: Mechanisms and relevance to infection. Br J Clin Pharmacol 2022; 88:3114-3131. [PMID: 35229890 DOI: 10.1111/bcp.15281] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 12/12/2022] Open
Abstract
Understanding how pharmaceutical opioids and antipyretic analgesics interact with the immune system potentially has major clinical implications for management of patients with infectious diseases and surgical and critical care patients. An electronic search was carried out on MEDLINE, EMBASE, PsycINFO, CENTRAL and the Cochrane library to identify reports describing the immunomodulatory effects of opioid analgesics and antipyretic analgesics, and their effects in infectious diseases. In adaptive immunity, nonsteroidal anti-inflammatory drugs have divergent effects: augmenting cell-mediated immunity but inhibiting humoral immunity. Nonsteroidal anti-inflammatory drugs have demonstrated a beneficial role in Mycobacterium tuberculosis infection and histoplasmosis in animals, and may be plausible adjuvants to antimicrobial agents in these diseases. There is a need to evaluate these findings rigorously in human clinical trials. There is preliminary evidence demonstrating antiviral effects of indomethacin in SARS CoV-2 in vitro; however, uncertainty regarding its clinical benefit in humans needs to be resolved in large clinical trials. Certain opioid analgesics are associated with immunosuppressive effects, with a developing understanding that fentanyl, morphine, methadone and buprenorphine suppress innate immunity, whilst having diverse effects on adaptive immunity. Morphine suppresses key cells of the innate immunity and is associated with greater risk of infection in the postsurgical setting. Efforts are needed to achieve adequate analgesia whilst avoiding suppression of the innate immunity in the immediate postoperative period caused by certain opioids, particularly in cancer surgery.
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Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Justin Beardsley
- Westmead Institute for Medical Research, Sydney, Australia.,Sydney Institute for Infectious Diseases, University of Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, Australia
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34
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Kirubakaran R, Stocker SL, Carlos L, Day RO, Carland JE. Tacrolimus Therapy in Adult Heart Transplant Recipients: Evaluation of a Bayesian Forecasting Software. Ther Drug Monit 2021; 43:736-746. [PMID: 34126624 DOI: 10.1097/ftd.0000000000000909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring is recommended to guide tacrolimus dosing because of its narrow therapeutic window and considerable pharmacokinetic variability. This study assessed tacrolimus dosing and monitoring practices in heart transplant recipients and evaluated the predictive performance of a Bayesian forecasting software using a renal transplant-derived tacrolimus model to predict tacrolimus concentrations. METHODS A retrospective audit of heart transplant recipients (n = 87) treated with tacrolimus was performed. Relevant data were collected from the time of transplant to discharge. The concordance of tacrolimus dosing and monitoring according to hospital guidelines was assessed. The observed and software-predicted tacrolimus concentrations (n = 931) were compared for the first 3 weeks of oral immediate-release tacrolimus (Prograf) therapy, and the predictive performance (bias and imprecision) of the software was evaluated. RESULTS The majority (96%) of initial oral tacrolimus doses were guideline concordant. Most initial intravenous doses (93%) were lower than the guideline recommendations. Overall, 36% of initial tacrolimus doses were administered to transplant recipients with an estimated glomerular filtration rate of <60 mL/min/1.73 m despite recommendations to delay the commencement of therapy. Of the tacrolimus concentrations collected during oral therapy (n = 1498), 25% were trough concentrations obtained at steady-state. The software displayed acceptable predictions of tacrolimus concentration from day 12 (bias: -6%; 95%confidence interval, -11.8 to 2.5; imprecision: 16%; 95% confidence interval, 8.7-24.3) of therapy. CONCLUSIONS Tacrolimus dosing and monitoring were discordant with the guidelines. The Bayesian forecasting software was suitable for guiding tacrolimus dosing after 11 days of therapy in heart transplant recipients. Understanding the factors contributing to the variability in tacrolimus pharmacokinetics immediately after transplant may help improve software predictions.
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Affiliation(s)
- Ranita Kirubakaran
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- Department of Pharmacy, Ministry of Health, Putrajaya, Malaysia
| | - Sophie L Stocker
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney
- Garvan Institute of Medical Research
| | | | - Richard O Day
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Jane E Carland
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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35
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Counsell AB, Nguyen AD, Baysari MT, Kannangara DRW, Gamboa S, Day RO. Expanding the role of Australian community dietitians in gout management. Int J Rheum Dis 2021; 24:1402-1408. [PMID: 34658154 DOI: 10.1111/1756-185x.14224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
AIM Gout is a common form of inflammatory arthritis with suboptimal management. Management guidelines for gout highlight the importance of both pharmacological and non-pharmacological treatments. Dietitians can potentially assist in improving gout's associated dietary and lifestyle factors, and thereby play a role in improving its management. The aim of this study was to investigate perspectives of Australian community dietitians on whether their role in gout management could be expanded to improve management and treatment of gout. METHOD A snowballing recruitment strategy was used. Dietitians known to the research team were invited to participate and then they suggested further dietitians. Semi-structured interviews (one-on-one) were conducted with 16 dietitians. The focus was on their experiences of contributing to the management of gout, including any barriers and facilitators experienced. Interviews were transcribed verbatim and independently analyzed by 2 reviewers to identify themes. RESULTS The main reported role of dietitians in gout management was providing patient education. An identified facilitator was dietitians' understanding of gout and its dietary management. Barriers included the emphasis placed on medications for treatment by clinicians and patients, consultation costs, limitations in the evidence for the efficacy of dietary changes and lack of specific training in gout for dietitians. Dietitians predominantly managed the other metabolic conditions commonly associated with gout. CONCLUSION Currently, the role dietitians play in gout management is limited. However, dietitians have the potential to take on larger roles in gout education and can also indirectly contribute by way of management of commonly associated comorbidities in gout patients.
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Affiliation(s)
- Allyce B Counsell
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Amy D Nguyen
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia.,Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Melissa T Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Diluk R W Kannangara
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sarah Gamboa
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Richard O Day
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Milder TY, Stocker SL, Baysari M, Day RO, Greenfield JR. Prescribing of SGLT2 inhibitors in primary care: A qualitative study of General Practitioners and Endocrinologists. Diabetes Res Clin Pract 2021; 180:109036. [PMID: 34481911 DOI: 10.1016/j.diabres.2021.109036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/21/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023]
Abstract
AIMS To explore: 1) General Practitioners' (GPs') perspectives regarding initiating SGLT2 inhibitors and the resources that inform their pharmacotherapy choices; and 2) The support provided to GPs by Endocrinologists in relation to the prescription of type 2 diabetes medications. METHODS Semi-structured interviews with 15 GPs and 12 Endocrinologists working in diverse areas in New South Wales, Australia. Interviews were recorded, transcribed, and emergent themes were identified using a general inductive approach. RESULTS Under-appreciation of the cardio-renal benefits of SGLT2 inhibitors, a preference for an Endocrinologist to initiate therapy, and patients' experiences with adverse effects were identified as reasons for low rates of initiating SGLT2 inhibitors by some GPs. GPs reported that they would like to receive education about this topic from Endocrinologists, ideally via case-based discussions. A perceived challenge faced by Endocrinologists in providing GP education included potential constraints on talk content imposed by industry at sponsored events. Endocrinologists indicated that interactive sessions were most useful to GPs. CONCLUSIONS Despite the evidence for the cardio-renal benefits of SGLT2 inhibitors, there are barriers to GPs prescribing these agents. Case-based discussions between GPs and Endocrinologists about type 2 diabetes treatment including the role of SGLT2 inhibitors could overcome some of these barriers.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Diabetes and Metabolism, Garvan Institute of Medical Research, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia.
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, 2006, Australia
| | - Melissa Baysari
- Discipline of Biomedical Informatics and Digital Health, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, 2006, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Diabetes and Metabolism, Garvan Institute of Medical Research, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia
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37
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Kirubakaran R, Hennig S, Maslen B, Day RO, Carland JE, Stocker SL. Evaluation of published population pharmacokinetic models to inform tacrolimus dosing in adult heart transplant recipients. Br J Clin Pharmacol 2021; 88:1751-1772. [PMID: 34558092 DOI: 10.1111/bcp.15091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/26/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIM Identification of the most appropriate population pharmacokinetic model-based Bayesian estimation is required prior to its implementation in routine clinical practice to inform tacrolimus dosing decisions. This study aimed to determine the predictive performances of relevant population pharmacokinetic models of tacrolimus developed from various solid organ transplant recipient populations in adult heart transplant recipients, stratified based on concomitant azole antifungal use. Concomitant azole antifungal therapy alters tacrolimus pharmacokinetics substantially, necessitating dose adjustments. METHODS Population pharmacokinetic models of tacrolimus were selected (n = 17) for evaluation from a recent systematic review. The models were transcribed and implemented in NONMEM version 7.4.3. Data from 85 heart transplant recipients (2387 tacrolimus concentrations) administered the oral immediate-release formulation of tacrolimus (Prograf) were obtained up to 391 days post-transplant. The performance of each model was evaluated using: (i) prediction-based assessment (bias and imprecision) of the individual predicted tacrolimus concentration of the fourth dosing occasion (MAXEVAL = 0, FOCE-I) from 1-3 prior dosing occasions; and (ii) simulation-based assessment (prediction-corrected visual predictive check). Both assessments were stratified based on concomitant azole antifungal use. RESULTS Regardless of the number of prior dosing occasions (1-3) and concomitant azole antifungal use, all models demonstrated unacceptable individual predicted tacrolimus concentration of the fourth dosing occasion (n = 152). The prediction-corrected visual predictive check graphics indicated that these models inadequately predicted observed tacrolimus concentrations. CONCLUSION All models evaluated were unable to adequately describe tacrolimus pharmacokinetics in adult heart transplant recipients included in this study. Further work is required to describe tacrolimus pharmacokinetics for our heart transplant recipient cohort.
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Affiliation(s)
- Ranita Kirubakaran
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Ministry of Health, Putrajaya, Malaysia
| | - Stefanie Hennig
- Certara Inc., Princeton, NJ, USA.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Maslen
- Mark Wainwright Analytical Centre, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Jane E Carland
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sophie L Stocker
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Ludlow K, Westbrook J, Jorgensen M, Lind KE, Baysari MT, Gray LC, Day RO, Ratcliffe J, Lord SR, Georgiou A, Braithwaite J, Raban MZ, Close J, Beattie E, Zheng WY, Debono D, Nguyen A, Siette J, Seaman K, Miao M, Root J, Roffe D, O'Toole L, Carrasco M, Thompson A, Shaikh J, Wong J, Stanton C, Haddock R. Co-designing a dashboard of predictive analytics and decision support to drive care quality and client outcomes in aged care: a mixed-method study protocol. BMJ Open 2021; 11:e048657. [PMID: 34433599 PMCID: PMC8388274 DOI: 10.1136/bmjopen-2021-048657] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION There is a clear need for improved care quality and quality monitoring in aged care. Aged care providers collect an abundance of data, yet rarely are these data integrated and transformed in real-time into actionable information to support evidence-based care, nor are they shared with older people and informal caregivers. This protocol describes the co-design and testing of a dashboard in residential aged care facilities (nursing or care homes) and community-based aged care settings (formal care provided at home or in the community). The dashboard will comprise integrated data to provide an 'at-a-glance' overview of aged care clients, indicators to identify clients at risk of fall-related hospitalisations and poor quality of life, and evidence-based decision support to minimise these risks. Longer term plans for dashboard implementation and evaluation are also outlined. METHODS This mixed-method study will involve (1) co-designing dashboard features with aged care staff, clients, informal caregivers and general practitioners (GPs), (2) integrating aged care data silos and developing risk models, and (3) testing dashboard prototypes with users. The dashboard features will be informed by direct observations of routine work, interviews, focus groups and co-design groups with users, and a community forum. Multivariable discrete time survival models will be used to develop risk indicators, using predictors from linked historical aged care and hospital data. Dashboard prototype testing will comprise interviews, focus groups and walk-through scenarios using a think-aloud approach with staff members, clients and informal caregivers, and a GP workshop. ETHICS AND DISSEMINATION This study has received ethical approval from the New South Wales (NSW) Population & Health Services Research Ethics Committee and Macquarie University's Human Research Ethics Committee. The research findings will be presented to the aged care provider who will share results with staff members, clients, residents and informal caregivers. Findings will be disseminated as peer-reviewed journal articles, policy briefs and conference presentations.
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Affiliation(s)
- Kristiana Ludlow
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Mikaela Jorgensen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kimberly E Lind
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Arizona, USA
| | - Melissa T Baysari
- Discipline of Biomedical Informatics and Digital Health, Charles Perkins Centre, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Leonard C Gray
- Centre for Research in Geriatric Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Richard O Day
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Julie Ratcliffe
- College of Nursing and Health Sciences, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Stephen R Lord
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- The International Society for Quality in Health Care (ISQua), Dublin, Ireland
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jacqueline Close
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Wu Yi Zheng
- Black Dog Institute, Sydney, New South Wales, Australia
| | - Deborah Debono
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Amy Nguyen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Joyce Siette
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Karla Seaman
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Melissa Miao
- Graduate School of Health, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jo Root
- Consumers Health Forum of Australia, Deakin, Victoria, Australia
| | - David Roffe
- IT Consultant, Sydney, New South Wales, Australia
| | - Libby O'Toole
- Aged Care Quality and Safety Commission, Sydney, New South Wales, Australia
| | | | - Alex Thompson
- Anglicare Sydney, Sydney, New South Wales, Australia
| | - Javed Shaikh
- Anglicare Sydney, Sydney, New South Wales, Australia
| | - Jeffrey Wong
- Anglicare Sydney, Sydney, New South Wales, Australia
| | - Cynthia Stanton
- Sydney North Health Network, Sydney, New South Wales, Australia
| | - Rebecca Haddock
- Deeble Institute for Health Policy Research, Australian Healthcare and Hospitals Association, Canberra, Australian Capital Territory, Australia
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Sandaradura I, Alffenaar JW, Cotta MO, Daveson K, Day RO, Van Hal S, Lau C, Marriott DJE, Penm J, Roberts JA, Tabah A, Williams P, Imani S. Emerging therapeutic drug monitoring of anti-infective agents in Australian hospitals: Availability, performance and barriers to implementation. Br J Clin Pharmacol 2021; 88:669-679. [PMID: 34289135 DOI: 10.1111/bcp.14995] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS The purpose of the study was to assess the status of emerging therapeutic drug monitoring (TDM) of anti-infective agents in Australian hospitals. METHODS A nationwide cross-sectional survey of all Australian hospitals operating in the public and private health sector was conducted between August and September 2019. The survey consisted of questions regarding institutional TDM practice for anti-infective agents and clinical vignettes specific to β-lactam antibiotics. RESULTS Responses were received from 82 unique institutions, representing all Australian states and territories. All 29 (100%) of principal referral (major) hospitals in Australia participated. Five surveys were partially complete. Only 25% (20/80) of hospitals had TDM testing available on-site for any of the eight emerging TDM candidates considered: β-lactam antibiotics, anti-tuberculous agents, flucytosine, fluoroquinolones, ganciclovir, human immunodeficiency virus (HIV) drugs, linezolid and teicoplanin. A considerable time lag was noted between TDM sampling and reporting of results. With respect to β-lactam antibiotic TDM, variable indications, pharmacodynamic targets and sampling times were identified. The three greatest barriers to local TDM performance were found to be (1) lack of timely assays/results, (2) lack of institutional-wide expertise and/or training and (3) lack of guidelines to inform ordering of TDM and interpretation of results. The majority of respondents favoured establishing national TDM guidelines and increasing access to dose prediction software, at rates of 89% and 96%, respectively. CONCLUSION Translating emerging TDM evidence into daily clinical practice is slow. Concerted efforts are required to address the barriers identified and facilitate the implementation of standardised practice.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia.,Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Jan-Willem Alffenaar
- Department of Pharmacy, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia
| | - Menino O Cotta
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases, Canberra Hospital, Canberra, ACT, Australia.,Queensland Statewide Antimicrobial Stewardship Program, Metro North Hospital and Health Services, Brisbane, QLD, Australia
| | - Richard O Day
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sebastiaan Van Hal
- Department of Infectious Diseases and Microbiology, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Cindy Lau
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, St Vincent's Hospital, Sydney, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Microbiology, SydPath, St Vincent's Hospital, Sydney, NSW, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Paul Williams
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Sahand Imani
- Northern Sydney Local Health District, Hornsby Ku-ring-gai Hospital, Sydney, NSW, Australia
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Chaudhri K, Stocker SL, Williams KM, McLeay RC, Marriott DJE, Di Tanna GL, Day RO, Carland JE. Voriconazole: an audit of hospital-based dosing and monitoring and evaluation of the predictive performance of a dose-prediction software package. J Antimicrob Chemother 2021; 75:1981-1984. [PMID: 32277819 DOI: 10.1093/jac/dkaa098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/20/2020] [Accepted: 02/22/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is recommended to guide voriconazole therapy. OBJECTIVES To determine compliance of hospital-based voriconazole dosing and TDM with the Australian national guidelines and evaluate the predictive performance of a one-compartment population pharmacokinetic voriconazole model available in a commercial dose-prediction software package. METHODS A retrospective audit of voriconazole therapy at an Australian public hospital (1 January to 31 December 2016) was undertaken. Data collected included patient demographics, dosing history and plasma concentrations. Concordance of dosing and TDM with Australian guidelines was assessed. Observed concentrations were compared with those predicted by dose-prediction software. Measures of bias (mean prediction error) and precision (mean squared prediction error) were calculated. RESULTS Adherence to dosing guidelines for 110 courses of therapy (41% for prophylaxis and 59% for invasive fungal infections) was poor, unless oral formulation guidelines recommended a 200 mg dose, the most commonly prescribed dose (56% of prescriptions). Plasma voriconazole concentrations were obtained for 82% (90/110) of courses [median of 3 (range: 1-27) obtained per course]. A minority (27%) of plasma concentrations were trough concentrations [median concentration: 1.5 mg/L (range: <0.1 to >5.0 mg/L)]. Of trough concentrations, 57% (58/101) were therapeutic, 37% (37/101) were subtherapeutic and 6% (6/101) were supratherapeutic. The dose-prediction software performed well, with acceptable bias and precision of 0.09 mg/L (95% CI -0.08 to 0.27) and 1.32 (mg/L)2 (95% CI 0.96-1.67), respectively. CONCLUSIONS Voriconazole dosing was suboptimal based on published guidelines and TDM results. Dose-prediction software could enhance TDM-guided therapy.
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Affiliation(s)
- Kanika Chaudhri
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Kenneth M Williams
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | | | - Deborah J E Marriott
- St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health, Newtown, NSW, Australia.,Faculty of Medicine, University of NSW, Kensington, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
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Roydhouse SA, Carland JE, Debono DS, Baysari MT, Reuter SE, Staciwa AJ, Sandhu APK, Day RO, Stocker SL. Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions. Br J Clin Pharmacol 2021; 87:4273-4282. [PMID: 33792079 DOI: 10.1111/bcp.14844] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS Accurate documentation of medication administration time is imperative for many therapeutic decisions, including dosing of intravenous antimicrobials. The objectives were to determine (1) the discrepancy between actual and documented administration times for antimicrobial infusions and (2) whether day of the week, time of day, nurse-to-patient ratio and drug impacted accuracy of documented administration times. METHODS Patient and dosing data were collected (June-August 2019) for 55 in-patients receiving antimicrobial infusions. "Documented" and "actual" administration times (n = 660) extracted from electronic medication management systems and smart infusion pumps, respectively, were compared. Influence of the day (weekday/weekend), time of day (day/evening/night), nurse-to-patient ratio (high 1:1/low 1:5) and drug were examined. Monte Carlo simulation was used to predict the impact on dose adjustments for vancomycin using the observed administration time discrepancies compared to the actual administration time. RESULTS The median discrepancy between actual and documented administration times was 16 min (range, 2-293 min), with discrepancies greater than 60 minutes in 7.7% of administrations. Overall, discrepancies (median [range]) were similar on weekends (17 [2-293] min) and weekdays (16 [2-188] min), and for high (16 [2-157] min) and low nurse-to-patient ratio wards (16 [2-293] min). Discrepancies were smallest for night administrations (P < .05), and antimicrobials with shorter half-lives (P < .0001). The observed discrepancies in vancomycin administration time resulted in a different dose recommendation in 58% of cases (30% higher, 28% lower). CONCLUSIONS Overall, there were discrepancies between actual and documented antimicrobial infusion administration times. For vancomycin, these discrepancies in administration time were predicted to result in inappropriate dose recommendations.
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Affiliation(s)
- Stephanie A Roydhouse
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Deborah S Debono
- Centre for Health Services Management, School of Public Health, The University of Technology Sydney, Sydney, Australia
| | - Melissa T Baysari
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Stephanie E Reuter
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Alice J Staciwa
- Pharmacy Department, St Vincent's Hospital Sydney, Sydney, Australia
| | - Anmol P K Sandhu
- Pharmacy Department, St Vincent's Hospital Sydney, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Sydney Pharmacy School, The University of Sydney, Sydney, Australia
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Abdel Shaheed C, Ferreira GE, Dmitritchenko A, McLachlan AJ, Day RO, Saragiotto B, Lin C, Langendyk V, Stanaway F, Latimer J, Kamper S, McLachlan H, Ahedi H, Maher CG. The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews. Med J Aust 2021; 214:324-331. [PMID: 33786837 DOI: 10.5694/mja2.50992] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of paracetamol as an analgesic medication in a range of painful conditions. STUDY DESIGN Systematic review of systematic reviews of the analgesic effects of paracetamol in randomised, placebo-controlled trials. Conduct of systematic reviews was assessed with AMSTAR-2; confidence in effect estimates (quality of evidence) was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. DATA SOURCES MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews; systematic reviews published 1 January 2010 - 30 April 2020. DATA SYNTHESIS We extracted pain and adverse events outcomes from 36 systematic reviews that assessed the efficacy of paracetamol in 44 painful conditions. Continuous pain outcomes were expressed as mean differences (MDs; standardised 0-10-point scale); dichotomous outcomes were expressed as risk ratios (RRs). There is high quality evidence that paracetamol provides modest pain relief for people with knee or hip osteoarthritis (MD, -0.3 points; 95% CI, -0.6 to -0.1 points) and after craniotomy (MD, -0.8 points; 95% CI, -1.4 to -0.2 points); there is moderate quality evidence for its efficacy in tension-type headache (pain-free at 2 hours: RR, 1.3; 95% CI, 1.1-1.4) and perineal pain soon after childbirth (patients experiencing 50% pain relief: RR, 2.4; 95% CI, 1.5-3.8). There is high quality evidence that paracetamol is not effective for relieving acute low back pain (MD, 0.2 points; 95% CI, -0.1 to 0.4 points). Evidence regarding efficacy in other conditions was of low or very low quality. Frequency of adverse events was generally similar for people receiving placebo or paracetamol, except that transient elevation of blood liver enzyme levels was more frequent during repeated administration of paracetamol to patients with spinal pain (RR, 3.8; 95% CI, 1.9-7.4). CONCLUSIONS For most conditions, evidence regarding the effectiveness of paracetamol is insufficient for drawing firm conclusions. Evidence for its efficacy in four conditions was moderate to strong, and there is strong evidence that paracetamol is not effective for reducing acute low back pain. Investigations that evaluate more typical dosing regimens are required. PROSPERO REGISTRATION CRD42015029282 (prospective).
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Affiliation(s)
| | | | | | - Andrew J McLachlan
- Centre for Education and Research on Ageing, University of Sydney, Sydney, NSW
| | - Richard O Day
- St Vincent's Hospital, Sydney, NSW.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW
| | | | - Christine Lin
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | | | | | - Jane Latimer
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Steven Kamper
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Hanan McLachlan
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Harbeer Ahedi
- Institute for Musculoskeletal Health, University of Sydney, Sydney
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Carland JE, Stocker SL, Baysari MT, Li C, Själin J, Moran MA, Tang S, Sandaradura I, Elhage T, Gilbey T, Williams KM, Marriott DJE, Day RO. Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices. Br J Clin Pharmacol 2021; 87:4221-4229. [PMID: 33769612 DOI: 10.1111/bcp.14834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS Despite the availability of international consensus guidelines, vancomycin dosing and therapeutic drug monitoring (TDM) remain suboptimal. This study aimed to assess concordance of vancomycin dosing and TDM with institutional guidelines and to identify factors taken into consideration by clinicians when prescribing vancomycin. METHODS A retrospective audit of 163 patients receiving vancomycin therapy (≥48 hours) was undertaken. Data collected included patient characteristics, dosing history and plasma vancomycin and creatinine concentrations. Concordance of dosing and TDM with institutional guidelines was evaluated. Semi-structured interviews, including simulated prescribing scenarios, were undertaken with prescribers (n = 17) and transcripts analysed. RESULTS Plasma vancomycin concentrations (n = 1043) were collected during 179 courses of therapy. Only 24% of courses commenced with a loading dose with 72% lower than recommended. The initial maintenance dose was concordant in 42% of courses with 34% lower than recommended. Only 14% of TDM samples were trough vancomycin concentrations. Dose was not adjusted for 60% (21/35) of subtherapeutic and 43% (18/42) of supratherapeutic trough vancomycin concentrations, respectively. Interview participants reported that patient characteristics (including renal function), vancomycin concentrations, guidelines and expert advice influenced vancomycin prescribing decisions. Despite referring to guidelines when completing simulated prescribing scenarios, only 37% of prescribing decisions aligned with guideline recommendations. CONCLUSION Poor compliance with institutional vancomycin guidelines was observed, despite prescriber awareness of available guidelines. Multifaceted strategies to support prescriber decision-making are required to improve vancomycin dosing and monitoring.
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Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,Department of Pharmacology, School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Melissa T Baysari
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Crystal Li
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Jacqueline Själin
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Maria A Moran
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Sarah Tang
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Pharmacy Department, Singapore General Hospital, Singapore, Singapore
| | - Indy Sandaradura
- Centre for Infectious Diseases and Clinical Microbiology, Westmead Hospital, Westmead, NSW, Australia.,Sydney School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Tania Elhage
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Timothy Gilbey
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Kenneth M Williams
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
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Braithwaite HE, Darley DR, Brett J, Day RO, Carland JE. Identifying the association between tacrolimus exposure and toxicity in heart and lung transplant recipients: A systematic review. Transplant Rev (Orlando) 2021; 35:100610. [PMID: 33756310 DOI: 10.1016/j.trre.2021.100610] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 12/23/2022]
Abstract
AIMS Tacrolimus is the cornerstone of immunosuppression management in heart and lung transplant recipients, improving overall survival. However, tacrolimus-associated toxicities, including nephrotoxicity, neurotoxicity, new-onset diabetes mellitus after transplant (NODAT), and gastrointestinal toxicity, are known contributors to increased post-transplant morbidity outcomes and reduced graft and recipient survival rates. The aim of this systematic review was to identify correlations between pharmacokinetic measures of tacrolimus exposure in heart and lung recipients and tacrolimus toxicities. METHODS MEDLINE, Embase, the Cochrane Library, CENTRAL and WHO Clinical Trial Registries were searched for published studies evaluating tacrolimus toxicities and their correlation to pharmacokinetic monitoring parameters in thoracic transplant recipients. Studies were reviewed by two authors, with data extracted for evaluation. Risk of bias was assessed using the PEDro scale for randomised control trials and the Newcastle Ottawa Scale for non-randomised cohort studies. RESULTS Eighteen studies were eligible; a randomised control trial, 11 observational cohort studies, and 6 case series or studies. Of these, 9 studies were in heart transplant recipients alone and 5 in lung transplant recipients alone, 2 studies were in heart and lung transplant recipients and 2 were heart, lung, liver or renal transplant recipients. Studies used variable criteria to define toxicities. Tacrolimus trough concentration (C0) was the marker of tacrolimus exposure most commonly used. Ten studies reported on nephrotoxicity. Elevated tacrolimus C0 was associated with acute kidney injury occurrence and severity in three observational studies. Increasing C0 was a predictor of renal impairment in 6 studies. One study found that for each 5 ng/mL per year of tacrolimus exposure, defined by consecutive AUC, eGFR declined by 1.3 mL/min/1.73m2 (p < 0.001). Comparatively, 2 studies failed to find a significant association between nephrotoxicity and tacrolimus exposure. Seven studies reported on neurotoxicity, including neuro-encephalopathies, polyneuropathies and symptomatic change in neurological status. Neurotoxicity occurred both with tacrolimus C0 within therapeutic range and with supratherapeutic C0. No significant association was found between NODAT and tacrolimus C0 in two studies. One study reported on gastrointestinal toxicity, with supratherapeutic C0 and elevated peak concentration in one lung transplant recipient three days prior to symptom development. CONCLUSION No clearly defined relationship between tacrolimus exposure and toxicities is described in the literature. Studies with clear toxicity criteria and pharmacokinetic markers of tacrolimus exposure are required to provide valuable information that may optimise tacrolimus therapy, helping to reduce toxicities in heart and lung transplant recipients.
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Affiliation(s)
- H E Braithwaite
- St Vincent's Clinical School, UNSW Medicine, University of New South Wales, Sydney, Australia.
| | - D R Darley
- St Vincent's Clinical School, UNSW Medicine, University of New South Wales, Sydney, Australia; Lung Transplant Unit, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - J Brett
- St Vincent's Clinical School, UNSW Medicine, University of New South Wales, Sydney, Australia; Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - R O Day
- St Vincent's Clinical School, UNSW Medicine, University of New South Wales, Sydney, Australia; Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - J E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia; Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
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Abstract
PURPOSE OF REVIEW There is controversy regarding the impact of hyperuricemia on the progression of chronic kidney disease (CKD), and gout remains sub optimally managed in this population. We discuss the prescribing of drugs for the treatment of gout in patients with CKD. RECENT FINDINGS There is a lack of consensus from expert guidelines, and prescribers have concerns regarding the risk of adverse reactions from medicines used to treat gout. These situations appear to contribute to suboptimal management of gout in this cohort. Recent data have challenged the role of urate lowering therapy (ULT) in the management of asymptomatic hyperuricemia in CKD. SUMMARY ULT should be commenced in all patients with severe, recurrent disease, tophaceous gout and evidence of joint damage. Most international guidelines recommend a treat-to-target approach for the management of gout. In CKD, ULT should be started at low dose with up titration adjusted to serum urate levels, rather than being based on the creatinine clearance. If patients fail first-line therapy, alternative agents are utilized, the specific agent depending on ease of access, burden of disease and other comorbidities. This approach should be incorporated into routine practice to ensure optimal treatment of gout in CKD. More research is required to investigate whether treatment of asymptomatic hyperuricemia has clinical benefits.
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Affiliation(s)
- Kulanka H Premachandra
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital
- St Vincent's Clinical School, University of New South Wales
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital
- St Vincent's Clinical School, University of New South Wales
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital
- St Vincent's Clinical School, University of New South Wales
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Sandaradura I, Marriott DJE, Day RO, Norris RLG, Pang E, Stocker SL, Reuter SE. Current fluconazole treatment regimens result in under-dosing of critically ill adults during early therapy. Eur J Clin Microbiol Infect Dis 2021; 40:1521-1528. [PMID: 33638727 DOI: 10.1007/s10096-021-04201-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/16/2021] [Indexed: 01/30/2023]
Abstract
PURPOSE To evaluate current fluconazole treatment regimens in critically ill adults over the typical treatment course. METHODS Data from critically ill adults treated with fluconazole (n=30) were used to develop a population pharmacokinetic model. Probability of target attainment (PTA) (fAUC24/MIC >100) was determined from simulations for four previously proposed treatment regimens: (i) 400 mg once daily, (ii) an 800 mg loading dose followed by 400 mg once daily, (iii) 400 mg twice daily, and (iv) a 12 mg/kg loading dose followed by 6 mg/kg once daily. The effect of body weight (40, 70, 120 kg) and renal function (continuous renal replacement therapy (CRRT); 20, 60, 120, 180 mL/min creatinine clearance) on PTA was assessed. RESULTS Early (0-48 h) fluconazole target attainment for infections with a minimum inhibitory concentration (MIC) of 2 mg/L was highly variable. PTA was highest with an 800 mg loading dose for underweight (40 kg) patients and with a 12 mg/kg loading dose for the remainder. End-of-treatment PTA was highest with the 400 mg twice daily maintenance dosing for patients who were under- or normal weight and 6 mg/kg maintenance dosing for overweight (120 kg) patients. None of the fluconazole regimens reliably attained early targets for MICs of ≥4 mg/L. CONCLUSION Current fluconazole dosing regimens do not achieve adequate early target attainment in critically ill adults, particularly in those who are overweight, have higher creatinine clearance, or are undergoing CRRT. Current fluconazole dosing strategies are generally inadequate to treat organisms with an MIC of ≥4 mg/L.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia.
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia.
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.
- Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Deborah J E Marriott
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Ross L G Norris
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- Discipline of Clinical Pharmacology, School of Medicine & Public Health, University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW, Australia
| | - Edna Pang
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sophie L Stocker
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, NSW, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
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Sandaradura I, Wojciechowski J, Marriott DJE, Day RO, Stocker S, Reuter SE. Model-Optimized Fluconazole Dose Selection for Critically Ill Patients Improves Early Pharmacodynamic Target Attainment without the Need for Therapeutic Drug Monitoring. Antimicrob Agents Chemother 2021; 65:e02019-20. [PMID: 33361309 PMCID: PMC8092533 DOI: 10.1128/aac.02019-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/20/2020] [Indexed: 12/19/2022] Open
Abstract
Fluconazole has been associated with higher mortality compared with the echinocandins in patients treated for invasive candida infections. Underexposure from current fluconazole dosing regimens may contribute to these worse outcomes, so alternative dosing strategies require study. The objective of this study was to evaluate fluconazole drug exposure in critically ill patients comparing a novel model-optimized dose selection method with established approaches over a standard 14-day (336-h) treatment course. Target attainment was evaluated in a representative population of 1,000 critically ill adult patients for (i) guideline dosing (800-mg loading and 400-mg maintenance dosing adjusted to renal function), (ii) guideline dosing followed by therapeutic drug monitoring (TDM)-guided dose adjustment, and (iii) model-optimized dose selection based on patient factors (without TDM). Assuming a MIC of 2 mg/liter, free fluconazole 24-h area under the curve (fAUC24) targets of ≥200 mg · h/liter and <800 mg · h/liter were used for assessment of target attainment. Guideline dosing resulted in underexposure in 21% of patients at 48 h and in 23% of patients at 336 h. The TDM-guided strategy did not influence 0- to 48-h target attainment due to inherent procedural delays but resulted in 37% of patients being underexposed at 336 h. Model-optimized dosing resulted in ≥98% of patients meeting efficacy targets throughout the treatment course, while resulting in less overexposure compared with guideline dosing (7% versus 14%) at 336 h. Model-optimized dose selection enables fluconazole dose individualization in critical illness from the outset of therapy and should enable reevaluation of the comparative effectiveness of this drug in patients with severe fungal infections.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- School of Medicine, University of Sydney, NSW, Australia
| | | | - Deborah J E Marriott
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sophie Stocker
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
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48
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Affiliation(s)
- Gustavo C Machado
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Christina Abdel-Shaheed
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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49
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Sarkies MN, Francis-Auton E, Long JC, Partington A, Pomare C, Nguyen HM, Wu W, Westbrook J, Day RO, Levesque JF, Mitchell R, Rapport F, Cutler H, Tran Y, Clay-Williams R, Watson DE, Arnolda G, Hibbert PD, Lystad R, Mumford V, Leipnik G, Sutherland K, Hardwick R, Braithwaite J. Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments. BMJ Open 2020; 10:e044049. [PMID: 33371049 PMCID: PMC7757496 DOI: 10.1136/bmjopen-2020-044049] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/27/2020] [Accepted: 11/19/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts. METHODS AND ANALYSIS This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed. ETHICS AND DISSEMINATION Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.
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Affiliation(s)
- Mitchell N Sarkies
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Emilie Francis-Auton
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Andrew Partington
- Centre for the Health Economy, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Chiara Pomare
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Hoa Mi Nguyen
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Wendy Wu
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Johanna Westbrook
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Richard O Day
- Clinical Pharmacology, St Vincents Hospital Sydney, Darlinghurst, New South Wales, Australia
- Pharmacology, University of New South Wales, Kensington, New South Wales, Australia
| | - Jean-Frederic Levesque
- Bureau of Health Information, St Leonards, New South Wales, Australia
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, New South Wales, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Henry Cutler
- Centre for the Health Economy, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Yvonne Tran
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Diane E Watson
- Bureau of Health Information, St Leonards, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
- University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Reidar Lystad
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - George Leipnik
- New South Wales Ministry of Health, St Leonards, New South Wales, Australia
| | - Kim Sutherland
- New South Wales Agency for Clinical Innovation, St Leonards, New South Wales, Australia
| | | | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
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50
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Stocker SL, Carland JE, Reuter SE, Stacy AE, Schaffer AL, Stefani M, Lau C, Kirubakaran R, Yang JJ, Shen CFJ, Roberts DM, Marriott DJE, Day RO, Brett J. Evaluation of a Pilot Vancomycin Precision Dosing Advisory Service on Target Exposure Attainment Using an Interrupted Time Series Analysis. Clin Pharmacol Ther 2020; 109:212-221. [PMID: 33190285 DOI: 10.1002/cpt.2113] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/10/2020] [Indexed: 12/30/2022]
Abstract
This study evaluated the ability of a pilot therapeutic drug monitoring (TDM) Advisory Service to facilitate vancomycin therapeutic target attainment within a real-world clinical setting. The Service provided area under the concentration-time curve (AUC)-guided vancomycin dose recommendations, using Bayesian forecasting software and clinical expertise, to prescribers at an Australian hospital. A retrospective audit of intravenous vancomycin therapy (> 48 hours) in adults (≥ 18 years old) was undertaken over a 54-month period to evaluate attainment of established vancomycin pharmacokinetic/pharmacodynamic targets (AUC over 24 hours / minimum inhibitory concentration: 400-600) before (36-month period) and after (18-month period) Service implementation. Interrupted time series analysis was employed to evaluate monthly measures of the median proportion of therapy spent within the target range. Indices of time to target attainment were also assessed before and after Service implementation. The final cohort comprised 1,142 courses of vancomycin (816 patients); 835 courses (596 patients) and 307 courses (220 patients) administered before and after Service implementation, respectively. Prior to piloting the Service, the median proportion of time in the target range was 40.1% (95% CI, 34.3-46.0%); this increased by 10.4% (95% CI, 1.2-19.6%, P = 0.03) after the Service, and was sustained throughout the post-Service evaluation period. Post-Service target attainment at 48-72 hours after initiation of therapy was increased (7.8%, 95% CI, 1.3-14.3%, P = 0.02). The findings of this study provide evidence that a consultative TDM Service can facilitate attainment of vancomycin therapeutic targets; however, optimization of the Service may further improve the use of vancomycin.
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Affiliation(s)
- Sophie L Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Sydney Pharmacy School, Faculty of Medicine & Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Alexandra E Stacy
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Andrea L Schaffer
- Centre for Big Data Research in Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Maurizio Stefani
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Cindy Lau
- Sydney Pharmacy School, Faculty of Medicine & Health, The University of Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Ranita Kirubakaran
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Jennifer J Yang
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Catriona F J Shen
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Clinical Microbiology & Infectious Diseases, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathan Brett
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
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