Prescrição de medicamentos potencialmente inapropriados para idosos segundo os Critérios de Beers: revisão sistemática / Prescribing potentially inappropriate medications for the elderly according to Beers Criteria: systematic review

Resumo Objetivou-se realizar uma revisão sistemática para identificar e avaliar a prevalência da prescrição de medicamentos potencialmente inapropriados (MPI), segundo os Critérios de Beers, em idosos hospitalizados com ≥65 anos. Foram consultadas cinco bases de dados: BVS, Cochrane Library, CINAHL, MEDLINE e Web of Science. Foram identificados 19 artigos, selecionados a partir de critérios de elegibilidade. A média de idade foi 78,2 anos e o critério mais utilizado para a identificação dos MPI para idosos foi o de Beers 2015 (57,9%). Um total de 221.879 idosos recebeu prescrição inapropriada, a prevalência média foi de 65.0%, com destaque para o sistema gastrointestinal (15,3%) e os inibidores da bomba de prótons (27,7%) como a principal classe de medicamento prescrita. Conclui-se que os Critérios de Beers possibilitaram a identificação da alta prevalência na prescrição dos MPI. Os resultados desta revisão poderão auxiliar na tomada de decisão dos profissionais de saúde, no intuito de se evitar a administração dos MPI e propor melhores práticas que garantam a segurança do idoso hospitalizado.

Abstract The study aimed to perform a systematic review to identify and evaluate the prevalence of potentially inappropriate medicines (PIM) prescriptions for the elderly, according to Beers Criteria, in hospitalized elderly individuals aged 65 years or older. Five databases consulted: VHL; Cochrane Library; CINAHL; MEDLINE and Web of Science. Nineteen articles identified, selected based on eligibility criteria. The mean age was 78.2 years and the most used criterion for the identification of PIM for the elderly was Beers 2015 (57.9%). A total of 221,879 elderly received a prescription for PIM, the mean prevalence was 65.0%, for the gastrointestinal system (15.3%) and proton-pump inhibitors (27.7%) highlighted as the main class of medicine prescribed. It concluded that the Beers Criteria have made it possible to identify the high prevalence in the prescription of PIM. The results of this review may help in the decision making of health professionals, to avoid the administration of PIM and to propose best practices to ensure the safety of the elderly hospitalized.

Criterios de medicación potencialmente inapropiada para el anciano: una propuesta cubana / Medication approaches potentially inappropriate for the elderly: a Cuban proposal

Introducción: El impacto de la prescripción inapropiada de fármacos en el anciano ha llevado al desarrollo de métodos para su reducción en varias partes del mundo. Objetivo: Diseñar y validar los criterios de medicación potencialmente inapropiada en el anciano, adaptados al entorno sociosanitario de Cuba. Métodos: Se realizó una investigación cualitativa, en la cual los criterios fueron validados por medio de la metodología Delphi, por un comité de expertos (especialistas en medicina geriátrica y clínica de diferentes zonas geográficas del país), y se les calculó la consistencia interna mediante el coeficiente alfa de Cronbach. Resultados: Los criterios quedaron estructurados en tres listas: 1) medicación potencialmente inapropiada, medicamento indicado no prescripto, cuando no existe contraindicación para su uso; 2) medicación potencialmente inapropiada independiente del diagnóstico o la condición clínica; 3) medicación potencialmente inapropiada dependiente del diagnóstico o la condición clínica. Conclusiones: Se demostró la validez del contenido y la adecuada consistencia interna de los criterios diseñados para la identificación de medicación potencialmente inapropiada en el anciano.

Introduction: The impact of inappropriate prescription of medication in the elderly has led to the development of methods for its reduction in several parts of the world. Objective: To design and validate the medication approaches potentially inappropriate in the elderly, adapted to the socio-sanitary environment of Cuba. Methods: A qualitative investigation was carried out, in which the approaches were validated by means of the Delphi methodology, by an experts committee (specialists in geriatrics medicine and clinic from different geographical areas of the country), and the internal consistency was calculated by means of the alpha coefficient of Cronbach. Results: The approaches were structured in three lists: 1) potentially inappropriate medication, advised medication non prescribed, when contraindication doesn't exist for its use; 2) medication potentially inappropriate, independent from the diagnosis or clinical condition; 3) potentially inappropriate medication, depending on the diagnosis or clinical condition. Conclusions: The validity of the content and the appropriate internal consistency of the designed approaches for the medication identification potentially inappropriate in the elderly were demonstrated.

Criterios STOPP-START y la prescripción inapropiada del anciano / STOPP/START criteria and inappropriate prescription in the elderly

Introducción: El envejecimiento no solo promueve daños moleculares y celulares con deterioro progresivo de las funciones del cuerpo, sino que este proceso trasciende a los tratamientos y predispone a las prescripciones potencialmente inapropiadas y a la polifarmacia. Esta situación complejiza la atención del anciano con mayor utilización de servicios sanitarios y gastos en medicamentos. Objetivo: Identificar posibles prescripciones potencialmente inapropiadas y estimar la influencia de factores biomédicos en la polifarmacia de los ancianos hospitalizados. Material y Métodos: Investigación cuasi-experimental estudio antes-después, que acopió información de variables biomédicas de las historias clínicas de 200 pacientes hospitalizados en el Centro de Investigaciones sobre Longevidad, Envejecimiento y Salud, se utilizaron los criterios STOPP-START para identificar prescripciones potencialmente inapropiadas; se realizaron pruebas para estadística descriptiva e inferencial (α=0,05). Resultados: Se identificaron al ingreso 349 prescripciones inapropiadas STOPP y 357 prescripciones inapropiadas START, la sección correspondiente al sistema nervioso central aportó el 24,8 por ciento de las prescripciones inapropiadas STOPP y el sistema cardiovascular reveló el 59,9 por ciento de las prescripciones inapropiadas START. La polifarmacia estuvo presente en el 43,0 por ciento de los ancianos y la comorbilidad fue la variable que mostró mayor fuerza de asociación con la polifarmacia (OR =8,65; IC-95 por ciento: 4,51-16,59), seguido por la presencia de dos o más prescripciones inapropiadas según los criterios STOPP. Conclusiones: Los criterios STOPP-START identifican prescripciones inapropiadas en el contexto sanitario cubano, todo lo cual impacta de forma negativa en la polifarmacia de los ancianos. El sistema nervioso central y el sistema cardiovascular mostraron el mayor número de prescripciones potencialmente inapropiadas(AU)

Introduction: Aging not only promotes molecular and cellular damage with progressive deterioration of body functions, but this process transcends treatments and predisposes to potentially inappropriate prescriptions and polypharmacy. This situation complicates the care of the elderly with greater use of health services and drug expenses. Objective: To identify possible potentially inappropriate prescriptions and estimate the influence of biomedical factors on polypharmacy in hospitalized elderly people. Material and Methods: Quasi-experimental before-after study which collected information on biomedical variables from the medical records of 200 hospitalized patients at the Longevity, Aging and Health Research Center. The STOPP/START criteria were used to identify potentially inappropriate prescriptions. Descriptive and inferential statistical tests were performed (α = 0.05). Results: A total of 349 inappropriate STOPP prescriptions and 357 inappropriate START prescriptions were identified upon admission. The section corresponding to the central nervous system contributed 24.8 percent of the inappropriate STOPP prescriptions and the cardiovascular system revealed 59.9 percent of the inappropriate START prescriptions. Polypharmacy was present in 43.0 percent of the elderly and comorbidity was the variable that showed the greatest strength of association with polypharmacy (OR = 8.65; 95 percent CI: 4.51-16.59), followed by the presence of two or more inappropriate prescriptions according to the STOPP criteria. Conclusions: The STOPP/START criteria identify inappropriate prescriptions in the Cuban healthcare context which has a negative impact on polypharmacy in the elderly. The central nervous system and the cardiovascular system showed the highest number of potentially inappropriate prescriptions(AU)

Los médicos y la industria farmacéutica: impacto sobre actitudes y hábitos de prescripción / Physicians and the pharmaceutical industry: impact on prescription attitudes and habits

Resumen Introducción: La relación médico-industria farmacéutica (IF) se ha identificado como un problema ético por favorecer conflictos de interés derivados de los beneficios que reciben los médicos y que pueden afectar su juicio clínico. Objetivo: Identificar la frecuencia de participación de médicos en actividades financiadas por la IF, las actitudes de estos profesionales hacia los representantes de la IF, su conducta prescriptiva y la asociación de sus características y del trabajo con la participación en actividades financiadas por la IF. Método: Encuesta transversal a médicos internistas y cardiólogos. El cuestionario incluyó características de los médicos y centro de trabajo, participación en actividades financiadas por la IF, actitudes hacia los representantes y conducta de prescripción. Resultados: Se analizaron 455 cuestionarios, 78.5 % de los encuestados tuvo conocimiento de la relación médico-IF, la mayoría respondió reunirse con representantes de la IF, 30 % indicó haber recibido subsidios financieros y 10 % consideró que los obsequios afectan su prescripción. Tener conocimiento previo de la relación médico-IF se asoció con menor participación en actividades educativas financiadas por por la IF. Conclusión: Las prácticas y preferencias hacia la IF muestran la necesidad de diseñar estrategias para evitar la prescripción inapropiada.

Abstract Introduction: The physician-pharmaceutical industry relationship has been identified as an ethical problem, due to conflicts of interest motivated by the benefits that doctors receive and that can affect their clinical judgment. Objective: To identify the frequency of physicians participation in activities financed by the pharmaceutical industry (PI), their attitudes towards PI representatives (PIRs), their prescriptive behavior and the association between their characteristics and their workplace with their participation in activities financed by the PI. Method: Cross-sectional survey to internists and cardiologists. The questionnaire included characteristics of the doctors and their workplace, participation in activities financed by the PI, attitudes towards PIRs, and prescription behavior. Results: 455 questionnaires were analyzed; 78.5 % of surveyed subjects were aware of the physician-PI relationship, the majority acknowledged meeting with PIRs, 30 % indicated having received financial subsidies and 10 % considered that gifts affect their prescription. Having prior knowledge of the physician-PI relationship was associated with less participation in PI-financed educational activities. Conclusion: Practices and preferences towards the PI show the need to design strategies to avoid inappropriate prescription.

Deprescripción en el anciano polimedicado. Una mirada reflexiva en el contexto cubano / Deprescription in the polymedicated elderly. A reflexive look at the Cuban context

Introducción: El intervencionismo terapéutico excesivo propicia polifarmacia y errores de prescripción en ancianos. En Cuba, el anciano polimedicado es un problema recurrente; sin embargo, la información sobre deprescripción posee difusión limitada en el ámbito científico. Objetivo: Describir el conocimiento actual sobre deprescripción y la necesidad de una estrategia dirigida al anciano polimedicado en Cuba. Material y Métodos: Se realizó una revisión extendida desde 2003 hasta 2020, basado en la experticia de los autores. Los criterios de búsqueda, selección y el acceso a bases de datos y fuentes indexadas Cochrane Library, SciELO, Lilacs, PubMed, Hinari, MEDLINE, ScienceDirect, Elsevier permitió citar 54 investigaciones (70 por ciento actualización) y redactar con metodología cualitativa, enfoque histórico-lógico, análisis-síntesis el documento final. Desarrollo: La deprescripción aparece desde 2003 para resolver la polifarmacia, es una herramienta de la prevención cuaternaria, implica desmontaje de medicación con varios matices. Su auge revolucionó diversas corrientes de trabajo en el mundo. Suficientes evidencias científicas de su necesidad y oportunidad para el mejor manejo farmacoterapéutico del anciano justifican un diseño e implementación atendiendo a las determinantes sociales de cada país. Se proponen elementos a la definición, se asevera la importancia de la farmacología geriátrica ante diseños de intervención. Conclusiones: La deprescripción es un proceso inherente de decisiones farmacoterapéuticas en ancianos atendidos en sistemas sanitarios de avanzada. Demuestra reducir mortalidad, medicamentos prescritos y prescripciones inapropiadas. El Programa Nacional de Medicamentos no dispone de directrices para su implementación, por lo que desarrollar una estrategia será un reto para la Salud Pública Cubana(AU)

Introduction: The excessive therapeutic interventionism promotes polypharmacy and prescription errors in the elderly. In Cuba, the polymedicated elderly is a recurrent problem; however, the information about prescription has a limited diffusion in the scientific field. Objective: To describe the current knowledge about deprescription and the need for a strategy aimed at addressing the problem of the polymedicated elderly in Cuba. Material and Methods: An extended review based on the authors' expertise was carried out from 2003 to 2020. The search and selection criteria and the access to databases and sources indexed in Cochrane Library, SciELO, Lilacs, PubMed, Hinari, MEDLINE, ScienceDirect, and Elsevier allowed us to cite 54 research works (70 percent updated). The final document was written on the basis of qualitative research methodology and historical-logical and analysis-synthesis approaches. Development: The term "deprescription" appeared in 2003 to solve the problem of polypharmacy. It is a quaternary prevention tool that involves dismantling medication treatment with various nuances. Its rise revolutionized different work currents worldwide. Adequate scientific evidences of its need and opportunity for the best pharmacotherapeutic management in the elderly justify a design and implementation that takes into account the social determinants of each country. Some elements are suggested for the definition; the importance of geriatric pharmacology is affirmed in the face of intervention designs. Conclusions: Deprescription is an inherent process of pharmacotherapeutic decisions in elderly patients attended in advanced healthcare systems. It shows a reduction of mortality, prescription of drugs and inappropriate prescriptions. The National Drug Program does not have guidelines for its implementation; therefore, to develop a strategy will be a challenge for the Cuban Public Health(AU)

Prescripción inapropiada de antifúngicos y la necesidad de programas para su uso racional / Inappropriate antifungal prescription and the need for antifungal stewardship programs

Resumen La enfermedad fúngica invasora (EFI) es una entidad que afecta pacientes inmunocomprometidos y críticamente enfermos. En los últimos años, el número de pacientes con riesgo de presentarla viene en aumento, con el consecuente incremento de la formulación de antifúngicos de manera profiláctica, anticipada o empírica. Algunos estudios que evaluaron el uso adecuado de antifúngicos han mostrado que hasta 72% de las formulaciones pueden ser inapropiadas, exponiendo a los pacientes al riesgo de efectos adversos e interacciones medicamentosas, con mayores costos de la atención. Se han recomendado diferentes intervenciones para el control y el uso racional de antimicrobianos, conocidas como "antimicrobial stewardship", las que se pueden aplicar al uso de antifúngicos denominándose "antifungal stewardship"". Se presenta una revisión de la literatura médica sobre el uso apropiado de antifúngicos y el impacto de la implementación de programas de optimización del uso de estos medicamentos en algunos centros.

Invasive fungal disease (IFD) is a condition affecting immunosuppressed and critically ill patients. Recently there has been an increase in the amount of patients at risk for IFD, which implies an increase in the prescription of antifungal agents as prophylactic, pre-emptive or empiric therapy. Some studies evaluating appropriateness of antifungal prescription have shown that inappropriate formulations reach 72%, exposing patients to side effects, pharmacological interactions and rising costs. Some groups have recommended many interventions to control and make a rational use of antimicrobials, into strategies known as "antimicrobial stewardship", these interventions are useful also for antifungal agents and it has been named "antifungal stewardship". Here we present a narrative review of the scientific literature showing published articles about appropriate use of antifungal agents and the experience of some centers after implementing antifungal stewardship programs.

Interventions to reduce the prescription of inappropriate medicines in older patients / Intervenções para reduzir a prescrição de medicamentos inapropriados para idosos

ABSTRACT OBJECTIVE: Identify and critically evaluate systematic reviews addressing the effectiveness of interventions to reduce the number of prescriptions of potentially inappropriate medication to older patients. METHODS: This is an overview of systematic reviews. The studies were searched and selected from Medline, Cochrane Library, Embase, CINAHL, Virtual Health Library, and Web of Science databases, combining the terms aged, prescriptions, inappropriate prescribing and potentially inappropriate medication list with their entry terms and other related descriptors, published by June 2017. This study included systematic reviews with or without meta-analysis that addressed the effectiveness of any intervention or combined interventions to reduce the number of prescriptions of potentially inappropriate medications to older patients, without restriction in terms of design, language or date of publication of primary studies. AMSTAR - A MeaSurement Tool to Assess systematic Reviews - was used to evaluate the methodological quality of selected systematic reviews. Study selection and the methodological quality evaluation were performed by two independent evaluators, who resolved any divergence by consensus. The main findings were grouped into thematic categories, defined after a content analysis and discussed qualitatively as narrative synthesis. RESULTS: This study analyzed 24 systematic reviews. In terms of study design and methodological quality evaluation, most were systematic reviews of randomized controlled clinical trials and studies of moderate quality, respectively. The interventions were analyzed in five thematic categories: medication review services, pharmaceutical interventions, computerized systems, educational interventions, and others. The interventions analyzed showed good results and most of them helped reduce the number of prescriptions of potentially inappropriate medication to older patients. CONCLUSIONS: The systematic reviews included in this overview showed potential benefits of different interventions. However, it was not possible to determine the most effective intervention. Combined interventions are likely to provide better results than isolated interventions.

RESUMO OBJETIVO: Identificar e avaliar criticamente revisões sistemáticas sobre a efetividade de intervenções para reduzir a prescrição de medicamentos potencialmente inapropriados para pacientes idosos. MÉTODOS: Overview de revisões sistemáticas. A busca e a seleção dos estudos foram feitas nas bases de dados Medline, Biblioteca Cochrane, Embase, CINAHL, Biblioteca Virtual em Saúde e Web of Science, combinando os termos aged, prescriptions, inappropriate prescribing e potentially inappropriate medication list com seus sinônimos remissivos e outros descritores associados até junho de 2017. Foram incluídas revisões sistemáticas com ou sem metanálise, que tenham abordado a efetividade de qualquer intervenção ou a combinação de intervenções para reduzir a prescrição de medicamentos potencialmente inapropriados para pacientes idosos, sem restrição quanto ao desenho dos estudos primários, idioma ou data de publicação. Para avaliação da qualidade metodológica das revisões sistemáticas selecionadas, foi utilizado o instrumento A MeaSurement Tool to Assess systematic Reviews. A seleção e a avaliação da qualidade metodológica foram realizadas por dois avaliadores independentes. As divergências foram superadas por consenso. Os principais achados foram agrupados em categorias temáticas, definidas com base em análise de conteúdo e discutidas qualitativamente na forma de síntese narrativa. RESULTADOS: Vinte e quatro revisões sistemáticas foram incluídas no estudo. Quanto ao desenho do estudo e à avaliação da qualidade metodológica, prevaleceram revisões sistemáticas de ensaios clínicos controlados randomizados e estudos de qualidade moderada, respectivamente. As intervenções foram analisadas em cinco categorias temáticas: serviços de revisão de medicamentos, intervenções farmacêuticas, sistemas informatizados, intervenções educacionais e outras. As intervenções estudadas apresentaram bons resultados e a maioria contribuiu para reduzir a prescrição de medicamentos inapropriados para pacientes idosos. CONCLUSÕES: As revisões sistemáticas incluídas nesse overview apontaram benefícios potenciais de diferentes intervenções. No entanto, não foi possível determinar qual a mais efetiva. É provável que intervenções multifacetadas alcancem resultados melhores do que intervenções isoladas.

Reducción de prescripción inapropiada y eventos adversos a medicamentos en ancianos hospitalizados / Reduction of inappropriate prescriptions and adverse effects to medications in hospitalized elderly patients

La combinación de prescripción inapropiada de medicamentos (PIM) y prescripción apropiada omitida (PPO) en ancianos requiere intervenciones múltiples para reducir su magnitud y los subsecuentes eventos adversos. Este estudio tiene como objetivo evaluar la PIM, la PPO, y los eventos adversos a medicamentos (EAM) antes y después de la intervención de un farmacéutico clínico sobre la prescripción del médico. En un estudio de tipo pre-post, se analizó la prescripción de un total de 16 542 fármacos realizada a 1262 pacientes aplicando los criterios STOPP-START (screening tool of older people's prescriptions/screening tool to alert to right treatment). La intervención consistió en la difusión de los criterios STOPP-START en todas las áreas del hospital mediante clases y publicaciones y las sugerencias diarias del farmacéutico clínico al médico responsable sobre la prescripción a cada paciente. Antes de la intervención, la PIM fue 48.9% al ingreso y 46.1% al egreso y luego de la intervención 47.4% al ingreso y 16.7% al egreso. La PPO antes de la intervención fue 10% al ingreso y 7.6% al egreso; después de la intervención fue 12.2% al ingreso y 7.8% al egreso. El porcentaje de pacientes con EAM fue 50.9% antes de la intervención y 34.4% después. Las readmisiones a emergencias fueron 12.2% y 4.7% antes y después de la intervención. La PIM, los EAM, el error de conciliación, la interacción medicamentosa clínicamente grave y el delirio fueron reducidos significativamente. Se concluye que, coincidiendo con buena parte de la literatura internacional, la intervención obtuvo resultados positivos.

Together, potentially inappropriate prescribing of medications (PIP) and appropriate prescribing omission (APO) constitute a problem that requires multiple interventions to reduce its size and the occurrence of adverse drug events (ADE). This study aims to assess PIP, APO, ADE before and after the intervention of a clinical pharmacist over medical prescriptions for elderly hospitalized patients. In a before-after study, a total of 16 542 prescriptions for 1262 patients were analyzed applying the criteria defined in both STOPP- START (screening tool of older people's prescriptions and screening tool to alert to right treatment). The intervention consisted in lectures and publications on STOPP-START criteria made available to all the areas of the hospital and suggestions made by the clinical pharmacist to the physician on each individual prescription. Before intervention, PIM was 48.9% on admission and 46.1% at discharge, while after the intervention it was 47.4% on admission and 16.7% at discharge. APO was 10% on admission and 7.6% at discharge, while after intervention it was 12.2% on admission and 7.9% at discharge. ADE were 50.9% before and 34.4% after intervention. The frequency of return to emergency was 12.2% and 4.7% before and after intervention. PIM, EAM, conciliation error, clinically serious drug interaction, and delirium were reduced to statistically significant levels. In line with various international studies, the intervention showed to attain positive results.

Renovação de Prescrição Médica na atenção primária: uma análise crítica / Prescription refill in primary health care: a critical analysis

A renovação de receita é uma prática comum nos serviços de atenção básica no Brasil, ainda que pouco discutida. Embora exista um número expressivo de artigos em língua inglesa sobre o assunto, pouco se encontra a respeito na literatura brasileira. A renovação de medicamentos de uso contínuo traz consigo riscos e potenciais danos à saúde do usuário quando praticada sem protocolos bem definidos e sem a correta avaliação clínica das pessoas acompanhadas. Dessa forma, a renovação de receita pode perpetuar o uso de medicações com indicação duvidosa, efeitos colaterais significativos, interações medicamentosas importantes, medicamentos contraindicados e/ou que não são mais necessários. Além disso, pode transmitir a sensação de que a população está sendo bem assistida apenas pelo fato de as pessoas conseguirem receber medicamentos, ainda que sem uma avaliação periódica. Por outro lado, caso realizada de forma ideal, poderia favorecer aumento da adesão ao tratamento, bem como a avaliação de interações medicamentosas, o cumprimento da terapêutica e a necessidade de exames complementares. O presente artigo realizará uma discussão crítica sobre os riscos e benefícios da renovação de receita da maneira como é feita no Brasil, incluindo seus aspectos legais e pontos passíveis de melhorias segundo a literatura internacional. (AU)

Repeat prescribing is a common practice at primary health care in Brazil which is poorly discussed. Despite the large number of articles in English, the Brazilian literature barely discuss this subject. The renewal of continuous-use medication may lead to risks and potential harms to patient health when used without defined protocols or adequate clinical evaluation. This practice may perpetuate the use of medication with arguable indication, significant side effects, significant drug interactions, contraindicated drugs or that are no longer needed. It also may leads to a misperception of being well attended, although it is a mere transcription of medical receipts. However, if performed in an adequate way, it might be associated with increased adherence to treatment. It also might allow assessment of drug interactions, compliance with therapy and checking out the need for complementary tests. This article will critically discuss the risks and benefits of prescription renewal in the way it is done in Brazil, including its legal aspects and possible points for improvement according to the international literature. (AU)

Medicamentos impróprios para o idoso disponibilizados pelo estado do Rio de Janeiro segundo os critérios de Beers-Fick / Medicamentos inadecuados para el anciano proporcionados por el estado de Río de Janeiro, Brasil según los criterios de Beers-Fick / Inappropriate medications for the elderly provided by the Rio de Janeiro state, Brazil according to the criteria of Beers-Fick

Objective: To check the prevalence of Potentially Inappropriate Medications (MPI) for the elderly among the available ones in primary health care by the State Secretariat of Health of the state of Rio de Janeiro, Brazil. Method: This is a study with secondary data from the State Directory of Medicines (rem) and it is analyzed in the light of the guidelines provided for in respect of according to the Beers-Fick of 2012. Results: It was found that in REM-RJ, out of a total of 124 medicines, 13.70% (n = 17) are considered MPIs to elderly, with consumption in 2 broad categories (that act in the CNS and peripheral = 35.29%; and operating in cardiovascular and renal system = 29.41%). Conclusion: This research highlights the need to develop criteria aligned with the perspective of the brazilian elderly and the adaptation of the Beers-Fick criteria, and the elaboration of specific overviews, you behold reflecting its this population and its peculiarities, considering references scientific significance.

Objetivo: Verificar a prevalência de Medicamentos Potencialmente Inapropriados (MPI) para idosos entre os disponibilizados na atenção primária à saúde pela Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Método: Trata-se de estudo realizado com dados secundários provenientes da Relação Estadual de Medicamentos (REM) e analisados à luz das orientações previstas pela Relação de Beers-Fick de 2012. Resultados: Verificou-se que na REM-RJ, de um total de 124 medicamentos, 13,70% (n = 17) são considerados MPIs para idosos, com consumo em 2 grandes categorias (que atuam no SNC e periférico = 35,29%; e que atuam no sistema cardiovascular e renal = 29,41%). Conclusão: A presente investigação evidencia a necessidade de se desenvolver critérios alinhados à perspectiva do idoso brasileiro, sendo possível a adaptação dos critérios de Beers-Fick, e a elaboração de súmulas específicas que contemplem esta população e suas peculiaridades, considerando referenciais de significância científica.

Objetivo: Demostrar la prevalencia de medicamentos potencialmente inadecuados (MPI) para ancianos entre los disponibles en la atención primaria de salud de la Secretaría de Estado de Salud del estado de Río de Janeiro, Brasil. Método: Este es un estudio desarrollado con datos secundarios de la Relación Estadual de Medicinas (REM) y analizadas a la luz de las listage Beers-Fick de 2012. Resultados: Se encontró en la REM-RJ, de un total de 124 medicamentos, 13,70% (n = 17) se considera mpi para ancianos, con un consumo en 2 categorías (que actúan en el snc y periférico = 35,29%; y de funcionamiento en el sistema cardiovascular y renal = 29.41%). Conclusión: Este estudio resalta la necesidad de desarrollar criterios alineados con la perspectiva del anciano brasileño y la adaptación de los criterios de Beers-Fick, y la elaboración de descripciones específicas, que lleve en cuenta sus particularidades, considerando referenciales de importancia científica.

Impacto del uso racional de antimicrobianos en una clínica de tercer nivel en Colombia / Impact of rational use of antibiotics in a third level clinic in Colombia

Background: The increasing resistance of bacteria to antibiotics threatens the survival of patients and health costs. Aim: To determine the impact of an antimicrobial stewardship program in bacterial resistance and antibiotic consumption. Materials and Methods: Quasi experimental study in a third level clinic in the city of Medellin, that evaluate in two time periods (pre-intervention between October 2012 and September 2013 and post intervention between October 2013 and September 2014) the impact of an antimicrobial stewardship program in terms of antibiotic consumption and bacterial ecology. Results: Adherence to institutional guidelines for management of infections in the post-intervention period was 82%. Antibiotic consumption of meropenem, ceftriaxone, vancomycin and colistin decreased, and imipenem, daptomycin and linezolid was increased. A significant decrease in antibiotic resistance in Pseudomonas aeruginosa was observed, including carbapenems. An increase of extended spectrum beta lactamase production (ESBL) in Enterobacteriaceae (especially E. coli) and piperacillin/tazobactam resistance was observed. Conclusions: The construction and implementation of a strategy in hospitals with guidelines for managing infectious diseases, restrictions in antibiotic use, a permanent monitoring system for the formulation of antibiotics, achieved a positive impact on reducing antibiotic use and bacterial resistance.

Introducción: El aumento progresivo de la resistencia bacteriana a antimicrobianos amenaza la sobrevida de los pacientes y los costos en salud. Objetivo: Determinar el impacto de un programa para el uso racional de antimicrobianos en resistencia bacteriana y consumo de antimicrobianos en una institución de tercer nivel de atención. Materiales y Métodos: Estudio cuasi experimental realizado en una clínica de tercer nivel de la ciudad de Medellín, donde se comparó en dos períodos de tiempo (pre intervención entre octubre de 2012 y septiembre de 2013 y post intervención entre octubre de 2013 y septiembre de 2014) el consumo y la resistencia a antimicrobianos de las bacterias hospitalarias. Resultados: La adherencia a las guías institucionales para el manejo de la patología infecciosa en el período post intervención fue 82%. Se observó una disminución en el consumo de meropenem, ceftriaxona, colistín, vancomicina, y un incremento en el consumo de imipenem, daptomicina y linezolid. Se observó una disminución significativa en la resistencia de Pseudomonas aeruginosa a los antimicrobianos, incluyendo los carbapenémicos. Se presentó un incremento en la proporción de enterobacteriaceas productoras de BLEE (principalmente Escherichia coli) y resistencia a piperacilina/tazobactam. Conclusiones: La construcción e implementación en las instituciones hospitalarias de una estrategia conformada por guías de manejo de la patología infecciosa, restricción en el uso de antimicrobianos y un sistema de vigilancia y un monitoreo permanente a la formulación de éstos, logra un impacto positivo en disminución del consumo de antimicrobianos y resistencia bacteriana.

Implementing a clinical pharmacy service in hematology / Implementação de um serviço farmacêutico clínico em hematologia

ABSTRACT Objective: To implement a clinical pharmacy service focused on the comprehensive review of antineoplastic drugs used in therapy of hematological diseases. Methods: An interventional study was conducted in a Brazilian tertiary teaching hospital in two different periods, with and without a clinical pharmacy service, respectively. This service consisted of an antineoplastic prescription validation (analysis of patients' characteristics, laboratory tests, compliance with the therapeutic protocol and with pharmacotechnical parameters). When problems were detected, the pharmacist intervened with the physician or another health professional responsible for the patient. Inpatients and outpatients with hematological diseases were included. Results: We found an increased detection of drug-related problem by 106.5% after implementing the service. Comparing the two periods, an increase in patients' age (26.7 years versus 17.6 years), a predominance of outpatients (54% versus 38%), and an increase in multiple myeloma (13% versus 4%) and non-Hodgkin lymphoma (16% versus 3%) was noted. The most commonly found problems were related to dose (33% versus 25%) and cycle day (14% versus 30%). With regard to clinical impact, the majority had a significant impact (71% versus 58%), and in one patient from the second period could have been fatal. The main pharmaceutical interventions were dose adjustment (35% versus 25%) and drug withdrawal (33% versus 40%). Conclusion: The pharmacy service contributed to increase the detection and resolution of drug-related problems, and it was an effective method to promote the safe and rational use of antineoplastic drugs.

RESUMO Objetivo: Implementar um serviço farmacêutico clínico centrado na revisão completa dos antineoplásicos utilizados no tratamento de doenças hematológicas. Métodos: Estudo intervencional conduzido em um hospital universitário terciário brasileiro em dois períodos distintos, com base na ausência e na presença do serviço farmacêutico clínico, respectivamente. O referido serviço consistiu na validação farmacêutica de prescrição de medicamentos antineoplásicos (análise de características do paciente, exames laboratoriais, conformidade com o protocolo terapêutico e parâmetros farmacotécnicos). Após a detecção dos problemas, o farmacêutico interveio junto ao médico ou outro profissional de saúde responsável pelo paciente. Foram incluídos pacientes internados e ambulatoriais com doenças hematológicas. Resultados: Observou-se um aumento de 106,5% na detecção de problemas relacionados com medicamentos após a implementação do serviço. Comparando-se os dois períodos, verificou-se aumento na idade dos pacientes (26,7 anos versus 17,6 anos), predomínio de pacientes ambulatoriais (54% versus 38%) e aumento de mieloma múltiplo (13% versus 4%) e linfoma não Hodgkin (16% versus 3%). Os problemas mais comumente encontrados foram relacionados à dose (33% versus 25%) e ao dia do ciclo (14% versus 30%). Quanto ao impacto clínico, a maioria apresentou impacto significante (71% versus 58%) e um poderia ter sido fatal no segundo período. As principais intervenções farmacêuticas realizadas foram ajuste de dose (35% versus 25%) e suspensão de medicamento (33% versus 40%). Conclusão: O serviço farmacêutico contribuiu para o aumento da detecção e resolução de problemas relacionados com medicamentos, tratando-se de um método efetivo para promover o uso seguro e racional de medicamentos antineoplásicos.

Adaptación y validación de instrumentos para medir errores en las recetas médicas y en el proceso de preparación de medicamentos en farmacia de pacientes ambulatorios / Adaptation and validation of checklists to detect medication prescription and dispensing errors

Background: Adverse effects of medications are an important source of morbidity. Prescription and dispensing errors are an important cause of these adverse effects. Aim: To adapt and validate two checklists, one to measure errors in handwritten prescriptions and other to detected errors in the medication dispensing process of hospital pharmacies for outpatient care. Material and Methods: The study was conducted in three stages. First, checklists for medication errors developed elsewhere were adapted. Afterwards, the checklists were reviewed by experts. Finally, the inter and intra-observer reliability of each checklist was assessed, testing them in 32 occasions by two independent observers. Results: The checklists for medication prescription and dispensing were composed by 12 and seven items, respectively. They were corrected according to experts’ opinions. The intraclass correlations of the results of each tester were 0.68 and 0.82 for the prescription and dispensing error checklists, respectively. Conclusions: The developed checklists for the detection of errors in prescription and dispensing of medications are reliable en can be applied in future studies.

Programas de monitoreo de medicamentos de prescripción en los Estados Unidos de América / Prescription drug monitoring programs in the United States of America

Desde finales de la década de los años noventa, el número de muertes por sobredosis que involucran analgésicos opioides se ha cuadriplicado en los Estados Unidos de América (de 4 030 muertes en 1999 a 16 651 en 2010). Los objetivos de este artículo son proporcionar una visión general del problema de sobredosis de medicamentos de prescripción en los Estados Unidos y discutir las acciones que podrían ayudar a reducir el problema, abordando en forma directa las características de los Programas de monitoreo de medicamentos de prescripción (PDMP). Estos programas están compuestos de bases de datos a nivel estatal que vigilan las sustancias controladas. La información recopilada en las bases de datos está a disposición de las personas autorizadas por el Estado (por ejemplo, los médicos, los farmacéuticos y otros proveedores de cuidado médico) y debe ser utilizada solo con propósitos profesionales. Los proveedores pueden utilizar dicha información para evitar la interacción con otros medicamentos, la duplicación terapéutica o la identificación de conductas de búsqueda de drogas. Las agencias del orden público pueden utilizar estos programas para identificar patrones de prescripción inadecuada, dispensación o desviación.

Since the late 1990s, the number of opioid analgesic overdose deaths has quadrupled in the United States of America (from 4 030 deaths in 1999 to 16 651 in 2010). The objectives of this article are to provide an overview of the problem of prescription drug overdose in the United States and to discuss actions that could help reduce the problem, with particular attention to the characteristics of prescription drug monitoring programs (PDMPs). These programs consist of state-level databases that monitor controlled substances. The information compiled in the databases is at the disposal of authorized persons (e.g., physicians, pharmacists, and other health-care providers) and may be used only for professional purposes. Suppliers can use such information to prevent interaction with other drugs or therapeutic duplication, or to identify drug-search behavior. Law enforcement agencies can use these programs to identify improper drug prescription or dispensing patterns, or drug diversion.

Safety assessment of essential medicines for elderly people: a bibliographic survey

Certain medicines are considered potentially inappropriate (PIM) for elderly people as they increase the risk of adverse drug events (ADE) and because safer alternative therapies are available on the market. In this context, in order to identify the instruments that assess the quality of medical prescriptions for elderly and to determine which drugs are considered PIM, a bibliographic survey was conducted in PUBMED, LILACS and PAHO databases, in February and March/2010. The search strategy included the use of health descriptors and a manual search in the references cited by selected papers. During the period of data collection, 15 instruments were identified. In 2012, with the publication of the update of Beers criteria, this instrument was included in the study. We identified 163 PIM of 25 therapeutic classes, of which 125 (76.7%) are marketed in Brazil. Of these, 31 (24.8%) are essential medicines (RENAME 2012), of which 13 have safer therapeutic equivalents and 19 (15.2%) are over-the-counter drugs. Data suggest the need for inclusion of safer alternatives for the elderly in the national list of essential medicines and the pharmaceutical care for early detection of ADE in this age group, in order to contribute to the safe use of medicines.

Determinados medicamentos são considerados potencialmente inapropriados (MPI) para idosos, por aumentarem o risco de ocorrência de eventos adversos a medicamentos (EAM) e por existirem alternativas terapêuticas mais seguras. Neste contexto, com o intuito de identificar os instrumentos que avaliam a qualidade das prescrições médicas para idosos e verificar quais medicamentos são considerados MPI, levantamento bibliográfico foi realizado nas bases de dados PUBMED, LILACS e PAHO em fevereiro e março de 2010. Para a seleção dos manuscritos utilizaram-se descritores em saúde e busca manual nas referências bibliográficas dos artigos identificados. No período da coleta de dados, foram identificados 15 instrumentos. Em 2012, com a publicação da atualização da lista de Beers, este instrumento foi incluído no estudo. Foram identificados 163 MPI de 25 classes terapêuticas, dos quais 125 (76,7%) são comercializados no Brasil. Destes, 31 (24,8%) são medicamentos essenciais (RENAME 2012), sendo que para 13 deles há equivalentes terapêuticos mais seguros e 19 (15,2%) são medicamentos isentos de prescrição. Os dados sugerem a necessidade de inclusão de medicamentos mais seguros para idosos na lista nacional de medicamentos essenciais e do monitoramento farmacoterapêutico para a detecção precoce de EAM nesta faixa etária para contribuir com o uso seguro de medicamentos.

Evaluación del uso inapropiado de medicamentos mediante la aplicación de los Criterios de Beers 2012 en adultos mayores del Hospital de Día Geriátrico del H. N. G. Almenara Irigoyen Enero a Junio 2012 / Evaluation of the inappropriate use of drugs through the application of the criteria of Beers 2012 in older adults of the Geriatric Day Hospital at the N.H.G. Almenara Irigoyen - January to June 2012

OBJETIVOS: Determinar la prevalencia y factores asociados al uso inapropiado de medicamentos mediante la aplicación de los criterios de Beers del 2012 en adultos mayores del hospital de Día Geriátrico del Hospital N. Guillermo Almenara Irigoyen, Lima-Perú. METODOS: Se evaluó el uso inapropiado de medicamentos con la aplicación de Criterios de Beers del 2012 en 150 adultos mayores (edad promedio 78 años) del hospital de Día Geriátrico en el periodo de enero a junto 2012. Se utilizaron pruebas estadísticas simples de frecuencias relativas y absolutas; para determinar la asociación entre variables categóricas se utilizó el test Chi cuadrado y prueba exacta de Fisher y para variables cuantitativas el test de Student con significancia estadística de p<0.05. RESULTADOS: La prevalencia de uso inapropiado de medicamentos fue de 52.7 por ciento. Los medicamentos inapropiados según los criterios de Beers 2012 más frecuentemente utilizados fueron AINES (33 por ciento), sulfonilureas de larga duración (27 por ciento) y benzodiacepinas (20 por ciento). Los medicamentos asociados a interacción droga-enfermedad que se utilizaron con más frecuencia fueron benzodiacepinas y deterioro cognitivo (32 por ciento), calcio antagonistas y estreñimiento (18 por ciento), antagonistas de receptores H2 con deterioro cognitivo y benzodiacepinas con historia de caídas (16 por ciento). La mirtazapina (28.6 por ciento) y la aspirina en mayores de 80 años en prevención primaria (28.6 por ciento) fueron los medicamentos utilizados con precaución más frecuentes. La polifarmacia, síndrome de caídas y trastorno del sueño estuvieron asociados con significancia estadística (p<0.05) a uso inapropiado de medicamentos. Los adultos mayores de sexo femenino, dependencia funcional, más de comorbilidades, depresión y deterioro cognitivo utilizaron frecuentemente medicamentos inapropiados pero sin asociación estadísticamente significativa. CONCLUSIONES: Se determinó la prevalencia elevada de uso...

OBJECTIVE: To determine the prevalence and associated factors of potentially inappropriate medication use defined by the Beers Criteria 2012 among older adults in a Geriatric Day Hospital in Lima-Peru. METHODS: A sample of 150 older adults (mean age 68 years) admitted to the geriatric day hospital between January and June 2012 were included and the inappropriate medication use were evaluated with the Beers Criteria 2012. We use statistics test of relative and absolute frequency and the Chi square test and Fisher exact test to determine the associated factors between qualitative variables and Student Test for quantitative variables, with significance statistic p<0.05. RESULTS: The prevalence of inappropriate medication use was 52.7 per cent. The more common inappropriate medications were NSAIDS (33 per cent), long action sulfonylurea (27 per cent) and benzodiazepines (20 per cent). The more common medication with drug-disease interaction were benzodiazepines with cognitive impairment (32 per cent), constipation and calcium channel blockers (18 per cent), antihistamines of H2 receptors with cognitive impairment and benzodiazepines with previous falls (16 per cent). Mirtazapine (28.6 per cent) and aspirin in over 80 years (28.6 per cent) were the medications more common used with precaution. Polypharmacy, falls, and sleep disturbances were associated with inappropriate medication use and they had significance statistic p<0.05. Female sex, dependence, more than 3 comorbidities, depression, and cognitive impairment were not associated with significance statistic. CONCLUSION: We determine a prevalence of 52.7 per cent of inappropriate medication use in older adults in a geriatric day hospital in Lima Peru. Polypharmacy falls and sleep disturbances were associated with significance statistic.