Development and validation of the Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE)

Background

Residents of aged care facilities use increasingly complex medication regimens. Reducing unnecessary medication regimen complexity (eg, by consolidating the number of administration times or using alternative formulations) may benefit residents and staff.

Objective

To develop and validate an implicit tool to facilitate medication regimen simplification in aged care facilities.

Method

A purposively selected multidisciplinary expert panel used modified nominal group technique to identify and prioritize factors important in determining whether a medication regimen can be simplified. The five prioritized factors were formulated as questions, pilot-tested using non-identifiable medication charts and refined by panel members. The final tool was validated by two clinical pharmacists who independently applied the tool to a random sample of 50 residents of aged care facilities to identify opportunities for medication regimen simplification. Inter-rater agreement was calculated using Cohen’s kappa.

Results

The Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) was developed as an implicit tool comprising of five questions about 1) the resident; 2) regulatory and safety requirements; 3) drug interactions; 4) formulation; and 5) facility and follow-up considerations. Using MRS GRACE, two pharmacists independently simplified medication regimens for 29/50 and 30/50 residents (Cohen’s kappa=0.38, 95% CI 0.12–0.64), respectively. Simplification was possible for all residents with five or more administration times. Changing an administration time comprised 75% of the two pharmacists’ recommendations.

Conclusions

Using MRS GRACE, two clinical pharmacists independently simplified over half of residents’ medication regimens with fair agreement. MRS GRACE is a promising new tool to guide medication regimen simplification in aged care.

Medication regimen complexity and prevalence of potentially inappropriate medicines in older patients after hospitalisation

Background There is a relative paucity of information to characterise potential changes in medication regimen complexity and prevalence of prescribing of potentially inappropriate medications after hospitalisation, both in Australia and elsewhere. Objective To evaluate medication regimen complexity and the prevalence of potentially inappropriate medications before and after admission to hospital. Setting General medical units of a tertiary care hospital in Australia. Methods Retrospective cohort study of patients aged 65 years and above. Medication complexity was measured by using the Medication Regimen Complexity Index (MRCI). Main outcome measure The primary outcome was the change in the Medication Regimen Complexity Index for all prescribed medications after hospitalization. Results A convenience sample of 100 patients was included in the study. There was a significant change in the mean medication complexity score (as measured using the MRCI), increasing from 29 at the time of admission to 32 at the time of discharge (p < 0.05). Factors such as baseline medication regimen complexity (pre-admission MRCI) and length of stay in the hospitals appear to influence the change in medication complexity. However, the proportion of patients prescribed at least one potentially inappropriate medicine (PIM) decreased significantly, from 52% pre-hospitalization to 42% at discharge (p = 0.04). Conclusions Relative to the time of admission, overall medication complexity increased and the proportion of patients who were prescribed PIMs decreased after hospitalisation.

Probable Drug-Related Meningioma Detected During the Course of Medication Review Services

There is evidence to support a link between treatment with high-dose cyproterone acetate and the development of meningioma. This report describes a case where an elderly man with intellectual disability who was treated with cyproterone for problematic sexual behavior developed a meningioma. The case was the subject of a residential medication management review provided under the auspices of a program funded by the Commonwealth Government of Australia. A discussion of clinical and ethical implications of the case is provided.

Development and Evaluation of an Electronic Drug and Therapeutics Bulletin

OBJECTIVE:

To describe the development, implementation, and initial evaluation of a paperless drug and therapeutics bulletin that is distributed by electronic mail from the pharmacy department of an Australian teaching hospital.

OUTCOMES:

A standardized format for the bulletin was designed and approved in February 2001. The aim of the bulletin is to facilitate the timely dissemination of concise, factual information about issues of current interest in therapeutics, drug safety, and the cost-effective use of medicines. A simple and attractive graphic design was chosen, and the hospital's clinical pharmacists and drug information staff developed an initial bank of content during the period immediately preceding the launch. The bulletin is presented as a 1-page, read-only file in Word for Windows format and was initially distributed by electronic mail to all users of the hospital's computerized communication network. As the popularity of the bulletin increased, healthcare practitioners from outside of the hospital began to request permission for inclusion on the circulation list, and the content was frequently forwarded by E-mail to workers in other hospitals and community-based settings. The bulletin is now distributed to pharmacists around Australia via 2 separate moderated discussion lists, one of which provides an archive site for previous editions. Healthcare workers in Singapore, the US, Canada, and New Zealand also receive the bulletin, which is now also abstracted by a major Australian pharmacy journal. A readership survey (also electronically distributed) was used to seek feedback after the publication of the first 12 editions. Readers indicated a high level of satisfaction with the content, format, and frequency of distribution of the materials.

CONCLUSIONS:

Although the concept and execution of this project was relatively simple, an extensive literature review did not reveal any previously published reports describing this type of approach to the distribution of a pharmacy bulletin. The development and implementation of the electronic drug and therapeutics bulletin has provided an opportunity to use modern communication technology to promote safe and effective medication use and appears to have been well received.

Potential Cross-Reactivity Between Penicillin Derivatives and Cephalosporins

Allergic reactions to both penicillins and cephalosporins are relatively common. Patients who have had a previous allergic reaction to a penicillin derivative may also be prone to a further reaction if treated with cephalosporins. This case illustrates several important points about potential cross-reactivity between penicillin derivatives and cephalosporins, as well as the benefits of an extended-hours pharmacy service in a longterm care facility.

Effect of an ACE inhibitor on allergic reaction to a bee sting

An 83-year-old man being treated with combination product containing perindopril and indapamide had a systemic reaction after being stung by a bee. An angiotensin-converting enzyme inhibitor may significantly increase the severity of allergic reactions after being stung by bees, ants, or wasps. Clinicians should be aware of the potential for this phenomenon if assisting people who have been stung.

Pharmacotherapy for post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a serious mental illness of considerable importance from a public health perspective. Management of PTSD may involve the use of various treatment modalities, involving both nondrug treatments and pharmacotherapy. Nondrug treatment is regarded as the first-line option for PTSD and should be routinely incorporated into management plans for patients with PTSD. However, some patients do not achieve a sufficient response to nondrug therapy or are left with disabling residual symptoms in one or more areas. Antidepressants are currently the preferred medication for PTSD, with the most substantial evidence available to support the use of the selective serotonin reuptake inhibitors. Many patients with PTSD have symptoms that are resistant to initial drug treatment, meaning that it is often necessary to explore additional pharmacotherapy options to achieve optimal symptom control: antipsychotics, anti-adrenergic drugs, anxiolytics and anticonvulsants have all been advocated as treatments for PTSD. In addition to the management of core PTSD symptoms, it is also necessary for clinicians to address important associated comorbidities, most notably, substance-use disorders and mood disturbances. Interpretation of research studies of the efficacy and safety of PTSD pharmacotherapy is often difficult owing to methodological limitations and factors such as inclusion bias. Further research in fundamental neurosciences and pharmacogenomics may help to elucidate optimal pharmacotherapy options for PTSD in the future.

Prevalence of concomitant use of alcohol and sedative-hypnotic drugs in middle and older aged persons: a systematic review

OBJECTIVE

To systematically review the prevalence of concomitant alcohol and sedative-hypnotic use among middle-aged and older persons.

DATA SOURCES

A bibliographic search of English-language literature was performed using MEDLINE, EMBASE, and PsycINFO (January 1990-August 2012). The reference lists of all included articles were screened for additional relevant articles not identified by any of the bibliographic searches.

STUDY SELECTION AND DATA EXTRACTION

Population-based studies in which the mean age of participants was 40 years or older were included. For a study to be included in the review, alcohol use had to be reported in terms of the quantity or frequency consumed. Data from included articles were extracted using a standardized data extraction tool.

DATA SYNTHESIS

Five population-based studies conducted in North America, 10 in Europe, and 1 in Australia were included in the review. Up to 88% of men and 79% of women who used sedative-hypnotics also consumed alcohol. Up to 28% of those who consumed alcohol were concomitant users of sedative-hypnotics. Alcohol was consumed at higher levels among middle-aged than older persons. Risky drinking (eg, binge drinking, heavy drinking) was more prevalent among middle-aged than older persons. In contrast, sedative-hypnotic use was more prevalent among older persons.

CONCLUSIONS

Our review identified a higher prevalence of alcohol consumption among middle-aged than older persons. However, middle-aged persons may experience harm from alcohol/sedative-hypnotic drug interactions due to risky drinking behavior. Despite lower levels of alcohol consumption, older persons may be more susceptible to addictive central nervous system effects than younger persons because of physiologic changes in psychotropic drug and alcohol metabolism. Clinicians should consider patients' alcohol consumption patterns before prescribing sedative-hypnotic drugs.

Prescribing for older people with chronic renal impairment

BACKGROUND

Renal function is an important prescribing consideration. On average, glomerular filtration rate declines by about 10 mL/min every 10 years after the age of 40. Renal impairment may cause medicines to accumulate or cause toxicity, especially if the medicine has a narrow therapeutic index.

OBJECTIVE

To present an overview of prescribing considerations in the primary care setting for patients with chronic renal impairment.

DISCUSSION

Serum creatinine considered in isolation is not a reliable indicator of renal function. The estimated glomerular filtration rate provided in pathology reporting can alert prescribers to possible renal impairment and the need to consider dose adjustments. The Cockcroft-Gault equation should be used to adjust medicine doses. Renal function monitoring is recommended for patients using medicines that can impair renal function or cause nephrotoxicity (eg. NSAIDs, ACEIs, ARBs).

Survey of Australian inpatients on vaccination status and perceptions of influenza vaccination

OBJECTIVE

To assess vaccination status, potential influences upon vaccination status, and attitudes and beliefs about vaccination among hospital inpatients.

DESIGN

This prospective, cross-sectional audit assessed vaccination status for important communicable diseases, patient perceptions about the influenza vaccination, and possible influences on vaccination status. Information was collected during face-to-face interviews using a structured questionnaire.

SETTING

This study was undertaken in a general teaching hospital in suburban Adelaide, South Australia.

PARTICIPANTS

The study participants comprised a convenience sample of 50 inpatients at the hospital from April 25, 2011, to May 18, 2011.

INTERVENTION

Interview and structured questionnaire at bedside.

MAIN OUTCOME MEASURES

Vaccination status for seasonal influenza, pneumococcal vaccine, diphtheriatetanus-pertussis/diphtheria-tetanus vaccination, herpes zoster virus, and hepatitis B were assessed for inpatients. Qualitative information regarding patient perceptions about the influenza vaccination was also surveyed. Possible influences on vaccination status including comorbidities or high-risk conditions, area of residence, age, and gender were also assessed.

RESULTS

The self-reported vaccination rates were: seasonal influenza vaccine 2010 (64%), seasonal influenza vaccine 2011 (52%), pneumococcal vaccine (46%), diphtheria-tetanuspertussis/ diphtheria-tetanus vaccination (70%), herpes zoster vaccination (34%), and hepatitis B vaccination (40%). Vaccination was significantly more common among those older than 64 years of age (P = 0.01), with 46% of patients older than 64 years vaccinated against influenza. There was no significant association between vaccination status and other characteristics such as gender, number of risk factors, recent hospital admission, and living in a residential facility. Regarding perceptions toward the influenza vaccine, the only factor associated with significantly increased likelihood of vaccination was self-reported risk perception (P = 0.03). The majority of patients described positive views about influenza vaccine efficacy and expressed willingness to receive the vaccine if recommended by their doctor.

CONCLUSIONS

In this audit, vaccination status appeared to be age-dependent, with higher vaccination coverage among older patients. Those who perceived that the influenza vaccine is associated with many side effects were less likely to be vaccinated. Pharmacists may have a role in encouraging older adults to be vaccinated.

Psychotropic drug-related problems in the elderly

Almost any drug therapy has the potential to cause iatrogenic complications for older people, but the risk is particularly significant for those being treated for major psychiatric illnesses. In the past, focus was centered mostly upon relatively obvious forms of drug-related harm, such as adverse drug reactions and drug interactions, but it is clear that this approach substantially under-represents the extent of the problem. Other, more inclusive categorization systems can be used to capture a broader representation of the profile and severity of medication-related problems, and these can provide insight into more subtle concerns. Analysis of psychotropic drug-related problems in the elderly provides a basis for individual interventions to lessen the impact of iatrogenic harm, as well as systematic approaches that can be used in the clinical setting to diminish the likelihood of preventable problems in a vulnerable patient population.

Osteoporosis - pharmacological prevention and management in older people

BACKGROUND

Osteoporosis remains undertreated in Australian primary care, with as few as 30% of postmenopausal women with a fracture and 10% of men with osteoporosis receiving pharmacological treatment.

OBJECTIVE

This article presents an overview of the pharmacological management of osteoporosis in older people in the general practice setting.

DISCUSSION

Lifestyle factors and ensuring adequate calcium and vitamin D intake are important in preventing and treating osteoporosis. Pharmacological treatments are recommended for patients with a minimal trauma fracture, for those aged 70 years or over with a T-score of -3.0 or lower, or for those who are currently taking prolonged high dose corticosteroids and who have a T-score of -1.5 or lower. Bisphosphonates are recommended as first line therapy for established postmenopausal osteoporosis. Medicine selection is guided by patient gender, menopausal status, medical and fracture history, patient preference and eligibility for government subsidy.

A national, one-day, consumer-oriented telephone drug information project in Australia

The design and execution of a nationwide, one-day telephone drug information service for the general public are described and data collected during the project analysed.

The Australian public was provided with access to a toll-free telephone service on September 4, 1992, for seeking direct information about medication from a team of pharmacists and medical practitioners based at a temporary telecommunications centre in Melbourne. Details of the project had been agreed by a multidisciplinary steering group. Over 2,000 calls were connected to the centre, averaging 167 calls per hour (range nine to 215). Calls were processed through central triage lines prior to referral to appropriate personnel. Information was gathered from 1,650 calls using a standard data collection form, and the details of a sample of 895 of these were analysed using Epi-info 5.01a (public domain) software for epidemiology and disease surveillance.

The success of this project, as well as that of other similar telephone information services in other countries, indicates a high level of interest among the public. In the future, information gained in this type of data collection process may be of benefit to clinicians in assisting them to provide information to patients about their drug therapy.

Suicidal Behavior and Psychotropic Medications for Adolescents: An Uneasy Association, as Yet Not Clarified

Despite considerable recent attention and wide-scale interventions by regulatory authorities that have changed drug usage patterns, the possible relationship between psychotropic pharmacotherapy and suicidal behavior among children and adolescents remains unclear. Confounding by diagnosis adds to confusion in the interpretation of the relationship between antidepressant use and suicidal behavior among young people. Recent research suggests that antidepressants may be protective against early readmission after hospitalization for suicide attempts or ideation, but that psychotropic polypharmacy (although common) may be associated with increased risk of rehospitalization. There remains an urgent need for high-quality, ongoing research into these clinical dilemmas.

A qualitative investigation of long-term zopiclone use and sleep quality among Vietnam war veterans with PTSD

BACKGROUND

Self-reported sleep difficulties are common among patients with posttraumatic stress disorder (PTSD), but the routine use of hypnosedatives over extended periods is not generally recommended.

OBJECTIVE

To examine the effects of the extended use of zopiclone among a cohort of patients with combat-related PTSD.

METHODS

We conducted a 6-month follow-up cohort study of zopiclone usage characteristics for 26 combat veterans with PTSD. Psychometric and sleep assessments were also conducted at baseline and 6 months.

RESULTS

The mean baseline score obtained on the tranquilizer dependence questionnaire was 20.4 +/- 13.4, below the cutoff score proposed as indicative of a high likelihood of dependence (23 points). Eight (30.7%) subjects exceeded the proposed cutoff score for dependence at baseline. Most (n = 24) subjects reported poor sleep quality at baseline. Actigraphy revealed that the mean sleep efficiency score was 71.2 +/- 13.7% at baseline. A cohort of 13 men was available for inclusion in the follow-up phase of the study. The tranquilizer dependence questionnaire score at follow-up was broadly similar to the baseline score after a further 6 months of zopiclone use (18.9 at baseline compared with 19.9 +/- 2.6 at follow-up). Individual analysis revealed that the tranquilizer dependence scale score increased for 5 subjects and decreased for 8 subjects at follow-up. Four (30.7%) subjects in the follow-up cohort exceeded the proposed cutoff score for dependence at baseline and 6 (46.1%) subjects exceeded it at follow-up. Actigraphy data were consistent across measurements for individual subjects at baseline and follow-up, with similar mean sleep efficiency scores at baseline and after 6 months of treatment with zopiclone (69.6 +/- 12.7% at baseline; 71.33 +/- 19.0% at follow-up). The proportion of relatively poor sleepers (5/13 at baseline and 4/13 at follow-up) remained essentially unchanged.

CONCLUSIONS

Overall, the results of this study suggest that, although the subjects in the follow-up phase of the research continued to use zopiclone on a regular basis for an extended period, the efficacy of this intervention for addressing PTSD-related sleep disturbance was low. Extended treatment with zopiclone may not necessarily be associated with increased risk for dependence. Further robust research to examine the consequences of long-term zopiclone therapy for PTSD-related sleep disturbance is warranted.

An open-label study of mirtazapine as treatment for combat-related PTSD

BACKGROUND

Posttraumatic stress disorder (PTSD) is common among war veterans. Antidepressants are effective in reducing symptoms and associated disability for some patients.

OBJECTIVE

To assess the effectiveness of mirtazapine for combat-related PTSD among veterans treated in an Australian hospital.

METHODS

This open-label prospective study assessed the effectiveness of mirtazapine as empirical treatment for combat-related PTSD. The initial dose was 15 mg at night, titrated against response to 15-45 mg. PTSD symptoms were assessed using the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Clinician-Administered PTSD Scale (CAPS). Subjects also completed the Hospital Anxiety and Depression Scale (HADS). Body weight and biochemical assessments, including fasting blood glucose (FBG), total serum cholesterol, and serum triglycerides, were also measured. Baseline measurements were repeated after 12 weeks.

RESULTS

During the 18-month recruitment phase, 17 subjects were enrolled and 13 completed the protocol. The CAPS measurement decreased from a mean pretreatment score of 87.5 to 64.4 (p = 0.01). In 4 cases, the CAPS score decreased to below the diagnostic cut-point, consistent with a remission of PTSD. The Mississippi scale measurement decreased from a mean pretreatment score of 126.6 to 115.5 (p < 0.01). The mean HADS anxiety score decreased from 15.6 +/- 4.2 to 13.5 +/- 5.6 (p = 0.016), although the proportion of subjects with scores above the diagnostic cut-point remained high. The mean HADS depression score at baseline was not significantly different from the postintervention score. One subject had a postintervention FBG of 155 mg/dL (consistent with diabetes mellitus), which was increased from the baseline level of 83 mg/dL. All subjects experienced an increase in body weight. One subject had an increase in body weight of 8.75 kg (8.4%) from baseline.

CONCLUSIONS

Although small and with methodological limitations, this study suggests that mirtazapine is an effective treatment for combat-related PTSD. Additional research incorporating an appropriately powered, double-blind, placebo-controlled study design is required.

Topiramate in combat-related posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a disabling psychiatric disorder that is common among combat veterans and may lead to very poor sleep and disturbing nightmares.

OBJECTIVE

To examine the safety and effectiveness of topiramate as add-on therapy for the management of combat-related PTSD and to examine the effects of topiramate on sleep and alcohol consumption.

METHODS

We conducted an 8-week open-label pilot study of topiramate for male combat veterans (N = 43) with PTSD, with analysis of veterans who completed the protocol. Psychometric, sleep, and alcohol consumption assessments were conducted at baseline and at week 8.

RESULTS

Twenty-nine subjects completed the 8-week study. Significant reductions in Clinician Administered PTSD Scale scores were observed at the 8-week endpoint (from 86.3 +/- 21.1 to 67.1 +/- 25.1; p < 0.01). Decreases were seen in both Stanford Sleepiness Scale scores (from 10.5 +/- 0.72 to 9.0 +/- 0.58; p = 0.08) and Mississippi PTSD scores (from 120.4 +/- 6.5 to 111.5 +/- 20.9; p = 0.08), but the extent of the changes did not attain statistical significance for either scale. There was a significant reduction in the proportion of patients with nightmares (from 100% to 62%; p < 0.001) and patients who experienced anxiety that interfered with falling asleep (from 90% to 62%; p < 0.05). The proportion of patients with high-risk drinking patterns also decreased (from 31% to 14%). Two serious adverse events were reported during the study: an increase in low back pain and an episode of acute confusion.

CONCLUSIONS

When used in addition to other empiric therapy, topiramate may be effective at reducing general symptoms of combat-related PTSD and reducing high-risk alcohol intake and nightmares. Further randomized controlled trials of topiramate for the treatment of combat-related PTSD are warranted.

Complementary medicine use by psychiatry patients of an Australian hospital

BACKGROUND

Complementary medicine (CM) usage continues to grow in popularity and is now widespread in many cultures throughout the world. Even so, detailed research addressing the use of many of these products in specific populations has yet to be undertaken.

OBJECTIVE

To investigate CM usage among patients treated in an Australian psychiatry unit and to assess fundamental attitudes and beliefs regarding CM in this cohort.

METHODS

Fifty-two patients were recruited from the department of psychiatry of an Australian teaching hospital. Forty-eight subjects were men, 4 were women, and the mean +/- SD age of subjects was 56.7 +/- 9.1 years. Structured interviews were conducted to obtain details of the extent of CM use, usage patterns, reasons for use, and general perceptions about CM. The questionnaire also elicited information about the subjects' past medical and psychiatric history, prescribed medication, and substance use. Satisfaction with conventional drugs and CMs was measured using visual analog scales. Responses to a series of structured statements were used to assess attitudes and beliefs about complementary therapies.

RESULTS

Eighty-five CM treatments had been used by 27 (51.9%) subjects during the preceding 6 months, and 18 subjects were current CM users (44 items). The most common products taken were vitamins and minerals (n = 18) and herbal medicines (n = 14). Use of CM products was not related to demographic or medical factors, but was significantly less frequent among patients seeing their local physician >1 time per month. Only 17 of the respondents using CMs (63.0%) informed their physician about these therapies. Daily users of CMs ranked their satisfaction level with these products significantly higher (mean satisfaction score 79.0 +/- 21.9) than with conventional therapies (62.9 +/- 26.8). The attitude toward CMs was positive overall, and was slightly more favorable among users than nonusers.

CONCLUSIONS

This survey provides insight into the nature of CM usage in an Australian population of psychiatry patients. As this and other studies have revealed extensive use of CM products in various populations, healthcare providers should take this into account and include this issue in discussions with patients.

Venous Thromboembolism Prophylaxis in a South Australian Teaching Hospital

BACKGROUND

Venous thromboembolism (VTE) is relatively common among hospitalized patients, is often clinically silent, and is associated with substantial morbidity and mortality. Risk stratification and routine use of thromboprophylaxis for patients at moderate to high risk for VTE are key strategies that can be used to prevent VTE.

OBJECTIVE

To assess the appropriateness of the selection and implementation of thromboprophylactic measures for prevention of VTE within a South Australian teaching hospital.

METHODS

Guidelines for risk stratification and prophylaxis were compiled from a range of studies, consensus statements, and tertiary references. Using prospective, observational methodology, data collection was performed through case note audit for 130 inpatient admissions over a 4-week period.

RESULTS

The decisions regarding the usage of thromboprophylaxis were considered inappropriate in 32% of cases in the study cohort. Suboptimal practices were also observed with respect to factors including the choice between mechanical and pharmacologic methods and the timing of initiation and cessation of thromboprophylaxis.

CONCLUSIONS

These findings provide evidence suggesting that the selection and implementation of thromboprophylaxis require improvement and that appropriate means to facilitate this improvement need to be developed and evaluated through future research.

Validation of a high-performance liquid chromatographic method for the enantiospecific quantitation of zopiclone in plasma

Zopiclone is a hypnosedative with clinical effects similar to benzodiazepines but thought to have less potential for rebound insomnia and withdrawal effects. Zopiclone is administered as a racemic mixture, and an enantiospecific method of analysis of zopiclone in plasma is desirable in the study of pharmacokinetic drug interactions. We report a modification of an HPLC method reported by Foster et al. using a closely related structural analogue of zopiclone as internal standard. Zopiclone was detected at 306 nm and linear calibration curves were constructed in the range of 1.0-250 ng/mL for each enantiomer. The % CV at 2.5 ng/mL was 12.0% for (-)-zopiclone and 14.3% for (+)-zopiclone, and the limit of quantification of each enantiomer was 2.5 ng/mL. At higher concentrations, the coefficient of variation was less than 10%. The nominal concentration of quality control samples was predicted with an accuracy within a range of +/-11.6%. The method was used in the analysis of plasma obtained from psychiatric patients. One sample obtained following a non-fatal overdose with zopiclone contained the metabolites (-)-N-oxide zopiclone and both enantiomers of desmethyl zopiclone. The metabolite enantiomers were resolved on the column with retention times similar to zopiclone. The N-oxide metabolite co-eluted with internal standard.

A brief analysis of clinical pharmacy interventions undertaken in an Australian teaching hospital

Selected clinical pharmacy interventions undertaken during a 30-day data capture period were analysed, seeking to gain a greater understanding of the nature of the drug-related problems involved. Pharmacists were asked to record only interventions that were of potentially major significance. A total of 67 interventions were submitted for analysis. In 28 cases (41.7% of the initial total) the intervention reports were excluded from further analysis after initial review. For the remaining 39 interventions, 20 patients (51%) were under the care of a medical unit, and cardiovascular/antithrombotic agents accounted for 17 reports (43.5%). The majority of interventions were implemented at the time of inpatient medication order review by the clinical pharmacist (n=25, 64%). The most common category of drug-related problem addressed in the interventions related to the prescription of inappropriately high doses of the correct drug for the patient (n=17, 43.6%). Deficiencies in technical knowledge accounted for less than 25% of all cases.

Possible interaction of zopiclone and nefazodone

OBJECTIVE

To describe a case in which concurrent treatment with nefazodone was associated with an elevation in the plasma concentration of zopiclone, possibly resulting in enhanced hypnosedative efficacy.

CASE REPORT

An 86-year-old white woman was treated with nefazodone for depression. Zopiclone was also introduced for the management of insomnia, but she subsequently experienced morning drowsiness. The concentration of zopiclone in plasma was subsequently measured eight hours after administration on two occasions, during nefazodone therapy and after its withdrawal. After discontnuation of nefazodone, the plasma concentration of the S-enantiomer of zopiclone decreased from 107 to 16.9 ng/mL, while the R-enantiomer plasma concentration decreased from 20.6 to 1.45 ng/mL.

DISCUSSION

Nefazodone is a relatively potent inhibitor of CYP3A4, a hepatic isoenzyme thought to play a major role in the metabolic elimination of zopiclone. The substantial decrease in the plasma zopiclone concentrations observed after withdrawal of nefazodone likely reflects a drug interaction. Despite the normally short elimination half-life of zopiclone, the residual sedation initially observed in this case suggests that the interaction may have clinical significance.

CONCLUSIONS

The features observed in this case suggest the possibility of a drug-drug interaction between nefazodone and zopiclone. Further prospective investigation is required to elucidate the nature and magnitude of this effect.

Characteristics of tranquilizer use among Australian Vietnam War veterans

OBJECTIVE

To examine characteristics of tranquilizer use in a cohort of Australian Vietnam War veterans.

DESIGN

Prospective analysis of medication use and assessment of social and clinical variables, including tranquilizer dependence.

PATIENTS

Fifty-one Australian Vietnam War veterans were recruited from the department of psychiatry of an Australian teaching hospital. All subjects were men, with a mean +/- SD age of 52.2 +/- 3.3 years.

MAIN OUTCOME MEASURES

A structured interview was used to obtain details of medical and psychiatric history, medication use, substance use, forensic history, and health service utilization data. Anxiety was assessed using the Hamilton Anxiety Rating Scale (Ham-A). A validated tranquilizer dependence rating scale was administered for each patient.

RESULTS

Commonly used tranquilizers included diazepam (n = 19 patients) and zopiclone (26). Most patients (44) reported the use of one or more drugs for the purpose of nighttime sedation, while exclusive daytime use of tranquilizers for anxiolytic effect was uncommon. The median time spent in the hospital during the preceding year was 21.0 +/- 56.8 days. Symptoms of anxiety were prevalent, with a mean Ham-A score of 35.5 +/- 7.8. Screening criteria suggestive of tranquilizer dependence were met in 34 subjects. Health service utilization was correlated with tranquilizer intake and overall medication use. Tranquilizer dependence was independently associated with cigarette smoking (p = 0.039; odds ratio = 5.13, 95% CI 1.08 to 24.33).

CONCLUSIONS

This study provides insight into the nature of tranquilizer use in an Australian population of Vietnam War veterans. The extensive use of these drugs suggests that further research and possibly intervention in this area is needed.