Utilization of targeted disease-modifying anti-rheumatic drugs (DMARDs) for managing rheumatoid arthritis in the last decade: A two-country comparison.

OBJECTIVE: To compare trends in the use of targeted disease-modifying anti-rheumatic drugs (DMARDs) for rheumatoid arthritis (RA), between Korea and Australia. MATERIALS AND METHODS: Using sampled claims databases in Korea and Australia (2010 - 2018), we analyzed the trends in the use of individual targeted DMARDs (biologic and targeted synthetic) for RA in both countries. RESULTS: The use of targeted DMARDs for the management of RA showed an increase of over 200 and 300% in Australia and Korea, respectively. The tumor necrosis factor inhibitors (TNFis) etanercept and adalimumab were the most commonly prescribed drugs in 2010 in both countries, with non-TNFi use increasing over the study period. The introduction of tofacitinib in 2015 led to 10 and 15% market share uptake in Korea and Australia, respectively. CONCLUSION: Trends in the use of targeted DMARDs for RA were similar in Korea and Australia, and the use of non-TNFis, including tofacitinib, increased in both countries.

A Systematic Review and Meta-Analysis Considering the Risk for Congenital Heart Defects of Antidepressant Classes and Individual Antidepressants.

INTRODUCTION: Antidepressant use during the first trimester is reported in 4-8% of pregnancies. The use of some selective serotonin reuptake inhibitors during the first trimester has been identified as increasing the odds for congenital heart defects; however, little is known about the safety of non-selective serotonin reuptake inhibitor antidepressants. OBJECTIVE: The objective of this study was to assess the odds of congenital heart defects associated with the use of antidepressants during the first trimester of pregnancy, and to update the literature as newer studies have been published since the latest systematic literature review and meta-analysis. METHODS: PubMed and Embase were searched till 3 June, 2020. Study quality was assessed, and study details were extracted. Meta-analyses were performed using RevMan 5.4, which assessed: (1) any antidepressant usage; (2) classes of antidepressants; and (3) individual antidepressants. RESULTS: Twenty studies were identified, encompassing 5,337,223 pregnancies. The odds ratio for maternal use of any antidepressant during the first trimester of pregnancy and the presence of congenital heart defects from the random effects meta-analysis was 1.28 (95% confidence interval [CI] 1.17-1.41). Significant odds ratios of 1.69 (95% CI 1.37-2.10) and 1.25 (95% CI 1.15-1.37) were reported for serotonin norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors, respectively. A non-statistically significant odds ratio of 1.02 (95% CI 0.82-1.25) was reported for the tricyclic antidepressants. Analyses of individual SSRIs produced significant odds ratios of 1.57 (95% CI 1.25-1.97), 1.36 (95% CI 1.08-1.72), and 1.29 (95% CI 1.14-1.45) for paroxetine, fluoxetine, and sertraline, respectively. The norepinephrine-dopamine-reuptake inhibitor bupropion also produced a significant odds ratio of 1.23 (95% CI 1.01-1.49). CONCLUSIONS: The selective serotonin reuptake inhibitor and serotonin norepinephrine reuptake inhibitor classes of antidepressants pose a greater risk for causing congenital heart defects than the tricyclic antidepressants. However, this risk for individual antidepressants within each class varies, and information regarding some antidepressants is still lacking.

Reducing adverse medication events in mental health: Australian National Survey.

AIM: To determine the extent to which evidence-based medication safety practices have been implemented in public and private mental health inpatient units across Australia. METHODS: The Reducing Adverse Medication Events in Mental Health survey was piloted in Victoria, Australia, in 2015, and rolled out nationally in 2016. In total, 235 mental health inpatient units from all States and Territories in Australia were invited to participate. The survey included questions about the demographics of the mental health unit, evidence-based strategies to improve prescription writing, the administration and dispensing of medicines and pharmacy-led interventions, and also questions relating to consumer engagement in medication management and shared decision-making. RESULTS: The response rate was 45% (N = 106 units). Overall, the survey found that 57% of the mental health units had fully or partially implemented evidence-based medication safety practices. High levels of implementation (80%) were reported for the use of standardized medication charts such as the National Inpatient Medication Chart as a way to improve medication prescription writing. Most (71%) of the units were using standardized forms for recording medication histories, and 56% were using designated forms for Medication Management Plans. However, less than one-fifth of the units had implemented electronic medication management systems, and the majority of units still relied on paper-based documentation systems.Interventions to improve medicine administration and dispensing were not highly utilized. Individual patient-based medication distribution systems were fully implemented in only 9% of the units, with a high reliance (81%) on ward stock or imprest systems. Tall Man lettering for labelling was implemented in only one-third of the units.Pharmacy services were well represented in mental health units, with 80% having access to onsite pharmacist services providing assessments of current medications and clinical review services, adverse drug reaction reporting and management services, patient and carer education and counselling, and medicines information services. However, pharmacists were involved in only half of medical reconciliations. Their involvement in post-discharge follow-up was limited to 4% of units. CONCLUSIONS: Gaps in medication safety practices included limited use of individual patient supply systems for medication distribution, a high reliance on ward stock systems and high reliance on paper-based systems for medication prescribing and administration. With regards to service provision, clinical pharmacist involvement in medical reconciliation services, therapeutic drug monitoring and interdisciplinary ward rounds should be increased. Discharge and post-discharge services were major gaps in service provision.

Risk of falls and injuries requiring hospitalisation after first-eye cataract surgery in elderly Australians.

PURPOSE: To investigate the impact of the type of the intraocular lenses (IOLs) in first-eye cataract surgery in elderly people on the risk of hospitalisation due to falls and injuries. METHODS: A retrospective cohort study was conducted using the Australian Government Department Veterans' Affairs claims data. All people aged 65 years and above who had first cataract surgery between January 2007 and July 2017 were identified. Two cohorts were established depending on the type of IOL-monofocal and multifocal. The risk of injuries and falls requiring hospitalisation in the first 3 months post the surgery was assessed using Cox proportional hazard models with age at entry as primary time scale and adjusting for gender, comorbidities and prior history of falls. RESULTS: There were 45 728 people across the two cohorts with the majority receiving monofocal lenses (97%), followed by multifocal lenses (3%) at the time of first cataract surgery. The risk of injury and falls was lower (but not significant) in the multifocal cohort compared to monofocal cohort (adjusted hazard ratio (aHR) 0.56, 95% CI 0.26-1.17). The risk was also lower (but not significant) when stratifying by age group at the time of the surgery. CONCLUSIONS: Regardless of age, multifocal lenses did not appear to be associated with the higher risk of serious injuries and falls after first-eye cataract surgery compared to monofocal lenses.

Reduction in Use of Risperidone for Dementia in Australia Following Changed Guidelines.

Background: Risperidone is the only antipsychotic approved in Australia for the management of the behavioural and psychological symptoms of dementia (BPSD). In June 2015, the Australian Government Therapeutic Goods Administration (TGA) amended the indication to restrict use in BPSD to patients with Alzheimer's dementia for a maximum twelve-week duration. We aimed to determine whether the rate and duration of risperidone use for BPSD decreased following the regulatory changes. Methods: we conducted a study using the Australian Government Department of Veterans' Affairs administrative claims data and Pharmaceutical Benefits Scheme (PBS) 10% sample data. We included people aged 65 years or older and compared the rate and duration of risperidone use before and after the TGA labelling changes. Results: There was a sustained decrease in the trend of risperidone use for BPSD following the TGA labelling changes, with a monthly decrease of 1.7% in the aged care population, 0.5% in the community living population and 1.5% in the general older Australian population. Overall, in the 24 months post the TGA changes the reduction in the rate of use of risperidone ranged from 20% to 28% lower than compared to what the rate would have been without the TGA changes. The median duration of use of risperidone in aged-care residents decreased from 338 days in the year prior to the TGA labelling changes, to 240 days per person in the year after the changes. Conclusion: The TGA labelling changes were associated with a significant reduction in the rate of use of risperidone for BPSD in veterans living in both the aged care and community settings, and in the general older Australian population. The labelling changes were also associated with a reduced duration of risperidone use in aged care residents, although for most people the duration of use still exceeded the recommended 12-week maximum duration.

Antidepressant switching patterns in the elderly.

ABSTRACTBackground:Switching between antidepressants is complex due to potential adverse outcomes such as serotonin syndrome and antidepressant discontinuation syndrome, yet switching is often required due to non-response to initial treatment. This study aimed to examine the patterns and extent of antidepressant switching in a cohort of older adults in long-term residential care. METHODS: A cohort study of medication supply data from 6011 aged care residents in 60 long-term care facilities was conducted. Incident antidepressant users were followed for 12 months and their patterns of antidepressant use determined. The type of switching from and to different antidepressant classes was determined according to National and International recommendations for antidepressant switching. RESULTS: In total, 11% (n = 44) of the residents were initiated on an antidepressant medication (n = 402) switched to a different antidepressant agent within 12 months. Residents commenced on a SNRI or TCA were most likely to switch antidepressants (17% in each group). Almost half of the switches (n = 21, 48% of all switches) were not implemented according to guideline recommendations. Direct switch and taper followed by wash out and switch, accounted for all of the inappropriate switching (29% and 71%, respectfully), with half occurring to mirtazapine (N = 7) or from mirtazapine (N = 3). CONCLUSIONS: Over one in 10 long-term aged care residents who commence an antidepressant will switch to a different antidepressant within 12 months. Current antidepressant switching practices in long-term residential aged care may be increasing the risk of harm associated with antidepressant switching, with around half of all switches not following current guideline recommendations.

Use of SGLT2 inhibitors for diabetes and risk of infection: Analysis using general practice records from the NPS MedicineWise MedicineInsight program.

AIMS: To explore the feasibility of MedicineInsight data to support risk management plan evaluation, focusing on sodium glucose co-transporter 2 (SGLT2) inhibitors for type 2 diabetes. METHODS: A retrospective study using de-identified electronic general practitioner records. Patients who initiated SGLT2 inhibitor between 1 Jan 2012 to 1 Sep 2015 were compared to patients who initiated dipeptidyl peptidase 4 (DPP-4) inhibitors. The two cohorts were followed-up for six months. Risk of urinary-tract (UT) and genital infections was evaluated. The indication for use of SGLT2 inhibitors, recommended prior diabetes therapies and recommended monitoring were investigates. RESULTS: There were 1977 people in the SGLT2 cohort (with 93% initiated on dapagliflozin) and 1964 people in the DPP-4 cohort. Of the SGLT2 initiators, 54% had a documented indication for use as type 2 diabetes; 86% had used metformin and/or a sulfonylurea in the prior 12months. Renal function monitoring was documented for only 25% in the 6months initiation. The frequency of UTI in the 6months post SGLT2 initiation was not significantly increased compared to the DPP-4 cohort (3.6%vs 4.9%; aHR=0.90, 95% CI 0.66-1.24). Genital infection were more frequent in the SGLT2 than in the DPP-4 cohort (2.9% vs 0.9%, aHR=3.50, 95% CI 1.95-5.89). CONCLUSIONS: Similar to existing evidence, we found a higher risk of genital infection associated with SGLT2 inhibitors (primarily dapagliflozin) but no increased risk of UTIs compared to DPP-4 use.

Use of proton pump inhibitors among older Australians: national quality improvement programmes have led to sustained practice change.

OBJECTIVE: To evaluate the impact of national multifaceted initiatives to improve use of proton pump inhibitors (PPIs) on the use of PPIs among older Australians. DESIGN: Interrupted time series analysis using administrative health claims data from the Australian Government Department of Veterans' Affairs (DVA). SETTING: Australia. PARTICIPANTS: All veterans and dependents who received PPIs between January 2003 and December 2013. INTERVENTION(S): National, multifaceted interventions to improve PPI use were conducted by the Australian Government Department of Veterans' Affairs Veterans' MATES programme and Australia's NPS MedicineWise in April 2004, June 2006, May 2009 and August 2012. MAIN OUTCOME MEASURE(S): Trends in monthly rate of use of any PPI among the veteran population, and the monthly rate of use of low strength PPIs among all veterans dispensed a PPI. RESULTS: Interventions in 2004, 2006, 2009 and 2012 slowed the rate of increase in PPI use significantly, with the 2012 intervention resulting in a sustained 0.04% decrease in PPI use each month. The combined effect of all four interventions was a 20.9% (95% CI 7.8-33.9%) relative decrease in PPI use 12 months after the final intervention. The four interventions also resulted in a 42.2% (95% CI 19.9-64.5%) relative increase in low strength PPI use 12 months after the final intervention. CONCLUSIONS: National multifaceted programmes targeting clinicians and consumers were effective in reducing overall PPI use and increasing use of low strength PPIs. Interventions to improve PPI use should incorporate regular repetition of key messages to sustain practice change.

Prescribed antibiotic use in Australian children aged 0-12 years.

BACKGROUND: Children are commonly prescribed antibiotics; however, little is known about the extent of their use. OBJECTIVE: The objective of this study was to examine the current use of medicines in Australian children by using a large national dataset, with a special focus on antibiotics. METHODS: The method for this study included a longitudinal study using the 10% random sample from the Australian Pharmaceutical Benefits Scheme (PBS) data. Children aged 0-12 years who were dispensed medicine(s) in 2013 were included, and prescribing patterns were reported. RESULTS: Population rates for children with at least one systemic antibiotic in 2013 were found to be 49% for those aged 0-4 years, 44% for those aged 5-9 years, and 33% for those aged 10-12 years. More than half (53%) of the children received single antibiotic dispensing, and the majority (71%) had no comorbid condition. Most of the time, antibiotics were dispensed without any other medicines. DISCUSSION: The high level of antibiotic use in children imposes the need to educate children and parents of the appropriate place of antibiotics in healthcare.

Long-term persistence to mono and combination therapies with angiotensin converting enzymes and angiotensin II receptor blockers in Australia.

PURPOSE: The purpose of this study was to compare the impact of initial antihypertensive therapy including angiotensin converting enzyme inhibitors (ACE) or angiotensin II receptor blockers (ARB) on long-term persistence to therapy. METHODS: A retrospective cohort study using prescription claims data from the Australian Pharmaceutical Benefit Scheme (PBS). Kaplan-Meier analysis of prescription refills and cox proportional hazard models were used to compare the time on therapy (persistence) in people newly initiated to monotherapy or combination therapy including ACE or ARB, between April 2007 and March 2008. Differences in persistence to initial drug class or any antihypertensive therapy were reported at 4-year follow-up. RESULTS: About 119,500 persons initiated ACE or ARB: 47 % initiated ACE monotherapy; 32 % ARB monotherapy; 13 % ACE combinations; and 8 % ARB combinations. Persistence (% on treatment at 4 years) to index therapy was lower in people starting ACE and ARB combinations compared to ACE or ARB monotherapies: ACE combination (12 %) versus ACE monotherapy (25 %) and ARB combinations (22 %) versus ARB monotherapy (35 %). Persistence was higher in those initiating fixed dose combinations (FDC) versus separate pill combinations of ACEs (19 vs. 10 %) and ARBs (25 vs. 14 %). Persistence at 4 years to any antihypertensive therapy was similar between initiators to ACE or ARB monotherapy (60 and 61 %, p = 0.08), ACE or ARB combinations (56 %, p = 0.99), and was slightly higher for separate pill combinations (57-59 %) versus FDC (55 %). CONCLUSION: Choice of initial antihypertensive may have little impact on long-term persistence to therapy.

The use of antipsychotics among people treated with medications for dementia in residential aged care facilities.

BACKGROUND: Antipsychotic agents have limited efficacy for Behavioral and Psychological Symptoms of Dementia (BPSD) and there are concerns about their safety. Despite this, they are frequently used for the management of BPSD. This study aimed to assess the use of antipsychotics among people on anti-dementia medicines in Australian residential aged care facilities. METHODS: Data were obtained from an individual patient unit dose packaging database covering 40 residential aged care facilities in New South Wales, Australia. Residents supplied an anti-dementia medicine between July 2008 and June 2013 were included. Prevalence of concurrent antipsychotic use was established. Incident antipsychotic users between January 2009 and December 2011 were identified. We examined initial antipsychotic dose, maximum titrated doses, type and duration of antipsychotic use, and compared use with Australian guidelines. RESULTS: There were 291 residents treated with anti-dementia medicines, 129 (44%) of whom received antipsychotics concomitantly with an anti-dementia medicine. Among the 59 incident antipsychotic users, risperidone (73%) was the most commonly used antipsychotic agent. Amongst the risperidone initiators, 43% of patients had initial doses greater than 0.5 mg/day and 6% of patients exceeded 2.0 mg/day for their maximum dose. 53% of concomitant users received daily treatment for greater than six months. CONCLUSIONS: Our study using records of individual patient unit dose supply, which represents the intended medication consumption schedule, shows high rates of concurrent use of antipsychotics and anti-dementia medicines and long durations of use. The use of antipsychotics in patients with dementia needs to be carefully monitored to improve patient outcomes.

Use of prescription medicines in Australian women of child-bearing age.

BACKGROUND: This study aimed to examine current utilisation of prescribed medicines amongst Australian women of child-bearing age, with a particular focus on the extent of use of medicines in Category D and X risk groups, which are moderate and high risk teratogens, respectively. The use of those medicines may pose risk of birth defects in pregnant women. METHODS: A retrospective cross-sectional study was undertaken involving all women of child-bearing age (15 to 44 years) who were dispensed medicines in 2013 using the 10% random sample of dispensing data from the Australian Government Department of Human Services. Dispensing patterns were reported by medicine, therapeutic class, pregnancy risk category and women's age. RESULTS: Over one-third of women aged 15 to 44 years received at least one prescribed medicine in 2013. Psychoanaleptics, antibiotics and analgesics were the top three classes. Around 9% of all dispensings were for medicines from risk category D, with statins, agents acting on renin-angiotensin system, and some anti-epileptic agents being the most commonly used. Both statins and agents acting on renin-angiotensin system showed increasing use with age, estimated to be 35,600 women nationally for each group. Collectively between 2% and 4% of women used anti-epileptics from risk category D in each year of age, with overall use estimated to be 51,000 women nationally. Below 1% of all dispensings were for category X medicines, mainly isotretinoin. CONCLUSIONS: It is important for medical practitioners to offer counselling around pregnancy planning and the risk of birth defects when prescribing moderate or high risk teratogens to women in child-bearing age. For the antihypertensives and some anti-epileptics, alternative medicines with lower risk categorization are available.

Survival after initiation of androgen deprivation therapy for prostate cancer of Australian men.

OBJECTIVE: To examine duration of use and survival rates of Australian males who initiated androgen deprivation therapy for prostate cancer, including survival rates stratified by the type of the initial androgen deprivation therapy and age at initiation. METHOD: Cohort study using Australian Government Department of Veterans' Affairs (DVA) data. Males aged 50 and over initiating androgen deprivation therapy (2008-2010) were included in the cohort. Time to death or end of study (31 Dec 2012), duration of therapy and 1 to 5-year relative survival rates stratified by type of initial therapy and age were presented. RESULTS: Of the androgen deprivation therapy initiators (n=3,611, mean age 84), 92% survived 1 year with the relative survival rate decreasing to 79% at 3 years and to 57% at 5 years. Survival outcomes stratified by the type of initial therapy showed slightly higher rates amongst those initiated on gonadotropin releasing hormone analogues or on combined androgen blockage compared to those initiated on anti-androgens. Age specific rates were similar amongst the younger groups (under 80 years old) at each single point of time and were slightly higher than in those aged 80 years and over for some points of time. Fifty percent of patients received androgen deprivation therapy for extended periods (30 months). CONCLUSIONS: The 1-year relative survival of veterans was high and similar to that of the general Australian population with prostate cancer. Factors such as tumour stage and grade (not available in the data) could explain differences in survival based on the type of the initial therapy.

Safety of opioid patch initiation in Australian residential aged care.

OBJECTIVE: To explore opioid use by aged care facility residents before and after initiation of transdermal opioid patches. DESIGN: A cross-sectional cohort study, analysing pharmacy data on individual patient supply between 1 July 2008 and 30 September 2013. SETTING: Sixty residential aged care facilities in New South Wales. PARTICIPANTS: Residents receiving an initial opioid patch during the study period. MAIN OUTCOME MEASURE: The proportion of residents who were opioid-naive in the 4 weeks prior to patch initiation was determined. In addition, the patch strength at initiation and the daily dose of transdermal patches and of additional opioids 1 month after initiation were determined. RESULTS: An opioid patch was initiated in 596 of 5297 residents (11.3%: 2.6% fentanyl, 8.7% buprenorphine) in the 60 residential aged care facilities. The mean age at initiation was 87 years, and 74% of the recipients were women. The proportion of recipients who were opioid-naive before patch initiation was 34% for fentanyl and 49% for buprenorphine. Most were initiated at the lowest available patch strength, and the dose was up-titrated after initiation. Around 15% of fentanyl users and 10% of buprenorphine users needed additional regular opioids after patch initiation. CONCLUSIONS: The results suggest some inappropriate initiation of opioid patches in Australian residential aged care facilities. Contrary to best practice, a third of residents initiated on fentanyl patches were opioid-naive in the 4 weeks before initiation.

Use of Medicines with Anticholinergic and Sedative Effect Before and After Initiation of Anti-Dementia Medications.

BACKGROUND: People with dementia may be particularly sensitive to cognitive impairment induced by anticholinergic and sedative medicines. OBJECTIVE: This study aimed to examine if utilisation of medicines with anticholinergic and sedative effects changed before and after initiation of anti-dementia therapy. METHODS: A retrospective cohort study was conducted using Australian pharmacy claim data (Pharmaceutical Benefit Scheme). People with first (index) dispensing for a cholinesterase inhibitor or memantine between 1 January 2009 and 31 December 2010 who were aged 65 years or over at the time of initiation were included. The proportion who received sedatives or anticholinergics in the 6 months prior to and post initiation of anti-dementia therapy was determined. RESULTS: The cohort included 24,110 patients, with over half aged 75-84 years. Overall, 30 % received any class of anticholinergic or sedative medicine for at least 1 month in the 6 months prior to initiation of anti-dementia agents, and 36 % post initiation. Some patients (6 %) ceased anticholinergics or sedatives post initiation even though they had them in the months prior. However, 12 % commenced therapy with anticholinergics or sedatives post anti-dementia therapy initiation even though they were naïve to them in the 6 months prior to therapy. CONCLUSION: Medicines with anticholinergic or sedative effects were commonly dispensed in one-third of people with dementia. Prescribers need to consider a review of patients on anticholinergic therapy with cholinesterase inhibitors as the effectiveness of the cholinesterase therapy may be compromised.

What analgesics do older people use prior to initiating oxycodone for non-cancer pain? A retrospective database study.

BACKGROUND: Increased oxycodone use has been associated with adverse drug events, non-medical use and overdose deaths. OBJECTIVES: To explore patterns of non-opioid, weak opioid and strong opioid use prior to initiation of oxycodone for non-cancer pain in a predominantly older Australian population. METHODS: A retrospective study was conducted using the Australian Government Department of Veterans' Affairs administrative claims database. Analgesic use 12 months prior to incident dispensing of oxycodone was determined for people in the community and in residential aged-care facilities (RACFs). Log-binomial regression was used to compute adjusted rate ratios (RRs) and 95 % confidence intervals (95 % CIs) for the use of other analgesics prior to initiating oxycodone. RESULTS: Of 10,791 people who initiated oxycodone in 2010, 26 % in community settings and 13 % in RACFs were not dispensed other analgesics in the 12 months prior to initiating oxycodone. Thirty-four percent and 20 % of those in community settings and RACFs, respectively, were not dispensed other analgesics in the previous 4 months. Co-morbidity had little impact on prior analgesic use. Each additional co-morbid condition was associated with a 1.4 % increased likelihood (RR 1.014, 95 % CI 1.012-1.016; p < 0.0001) and a 1.2 % increased likelihood (RR 1.012, 95 % CI 1.009-1.015; p < 0.0001) of being dispensed another analgesic prior to initiating oxycodone in community and RACF settings, respectively. CONCLUSIONS: Oxycodone is frequently initiated for non-cancer pain without first trialing other analgesics. This highlights the need for prescribing practices to be reviewed in light of increasing concerns about adverse drugs events and death due to oxycodone, particularly in older people.

Improving cardiovascular disease management in Australia: NPS MedicineWise.

OBJECTIVES: To determine the impact of four NPS MedicineWise programs targeting quality use of medicines in cardiovascular management in primary care. DESIGN: Interrupted time-series analysis using the Department of Veterans' Affairs (DVA) claims dataset from 1 January 2002 to 31 August 2010. We examined the use of antithrombotics in people with atrial fibrillation and in those who had had a stroke, and the use of echocardiography and spironolactone in the population with heart failure. PARTICIPANTS: All veterans and their dependants in Australia who had received cardiovascular medicines or health services related to the targeted intervention. INTERVENTION: NPS MedicineWise national programs to improve cardiovascular management in primary care, which included prescriber feedback, academic detailing, case studies and audits as well as printed educational materials. MAIN OUTCOME MEASURES: Changes in medication and health service use before and after the interventions. RESULTS: All national programs were positively associated with significant improvements in related prescribing or test request practice. The interventions to improve the use of antithrombotics resulted in a 1.27% (95% CI, 1.26%-1.28%) and 0.63% (95% CI, 0.62%-0.64%) relative increase in the use of aspirin or warfarin in the population with atrial fibrillation 6 and 12 months after the program, respectively, and in a 1.51% (95% CI, 1.49%-1.53%) relative increase in the use of aspirin as monotherapy for secondary stroke prevention 12 months after the intervention. The heart failure programs resulted in a 3.69% (95% CI, 3.67%-3.71%) relative increase in the use of low-dose spironolactone and a 4.31% (95% CI, 4.27%-4.35%) relative increase in the use of echocardiogram tests 12 months after the intervention. CONCLUSIONS: NPS MedicineWise programs were effective in achieving positive changes in medicine and health service use for patients with cardiovascular diseases.

Antihypertensive use before and after initiation of fixed-dose combination products in Australia: a retrospective study.

UNLABELLED: BACKGROUND National guidelines in Australia advise that patients should be stabilised on both individual antihypertensive medicines before initiating a fixed-dose combination (FDC) product. OBJECTIVE: The aim of this study was to examine the antihypertensive medicines use before and after initiation of four antihypertensive FDC products recently listed under the Australian Pharmaceutical Benefits Scheme--olmesartan or valsartan with hydrochlorothiazide, valsartan with amlodipine and ramipril with felodipine. SETTING Australian veteran population METHODS: This was a retrospective cohort study using Australian Government Department of Veterans' Affairs pharmacy claims data. Subjects initiating a FDC between 2008 and 2010 were included. Their antihypertensive medicine use was investigated in the 12-months prior to and post FDC product initiation. MAIN OUTCOME MEASURE: Proportions of FDC initiators dispensed one or both of the individual medicines, or who had antihypertensive medicines other than the individual ones were assessed for the 12 months prior to initiation. For the post history, proportions of patients who continued the FDC as a sole therapy, had other antihypertensives co-administered with FDC, or ceased the FDC were established. RESULTS: 2,513 participants initiated one of the four FDC products in the study period. Immediately prior to FDC initiation, below 1 % had both individual medicines, 29 % had one of the individual medicines, 58 % had antihypertensive medicines other than the individual ones, and 12 % had no antihypertensive therapy. At 12 months post initiation, 25 % of the FDC initiators continued it as a sole treatment, 35 % required an additional antihypertensive medicine in addition to FDC product, and 40 % ceased the FDC. CONCLUSION: A minority of patients initiated combination products after being stabilised on both individual medicines. Significant number had no prior history of antihypertensive use. One-third of FDC initiators still required additional antihypertensive medication concurrently with the FDC product at 12 months post initiation.

COX-2 inhibitor and non-selective NSAID use in those at increased risk of NSAID-related adverse events: a retrospective database study.

BACKGROUND: Adverse events related to analgesic use represent a challenge for optimizing treatment of pain in older people. OBJECTIVE: The aim of this study was to determine whether non-selective non-steroidal anti-inflammatory drug (NS-NSAID) and cyclo-oxygenase (COX)-2 inhibitor use is appropriately targeted in those with a prior history of gastrointestinal (GI) events, myocardial infarction (MI) or stroke. METHODS: A retrospective study of pharmacy claims data from the Australian Government Department of Veterans' Affairs was conducted, involving 288,912 veterans aged 55 years and over. Analgesic utilization from 2007 to 2009 was assessed. Three risk cohorts (veterans with prior hospitalization for GI bleed, MI or stroke) and a low-risk cohort were identified. Poisson regression was applied to test for a linear trend over the study period. RESULTS: The prevalence of analgesics dispensed in the overall study population was approximately 34 % between 2007 and 2009. COX-2 inhibitors were more widely dispensed than NS-NSAIDs in all those at risk of NSAID-related adverse events. At the end of 2009, the ratio was 5.1 % to 2.5 % in the GI cohort, 3.6 % to 3.2 % in the MI cohort and 3.6 % to 2.6 % in the stroke cohort. CONCLUSIONS: Although COX-2 inhibitors appeared to be preferred over NS-NSAIDs in those with a prior history of GI events, 2.5 % of patients were still using an NS-NSAID at the end of the study period. Consistent with treatment guidelines, in most of these cases, these drugs were co-dispensed with proton pump inhibitors. COX-2 inhibitors were used at slightly higher rates than NS-NSAIDs in those with a prior history of MI or stroke, which is not consistent with guidelines recommending NS-NSAID use.