Dosage adjustment recommendations of drugs in non-nephrology units with kidney disease / Recomendaciones de ajuste posológico de fármacos para enfermedad renal en unidades no nefrológicas

Purpose: Kidney disease (KD) is defined as an abnormality of the kidney in the structure or function with implications for the health, which can occur abruptly, and either resolve or become chronic. This status use to require medication dosage adjustment. Inappropriate prescribing is a common drug-related problem. The aim of this study is to evaluate the acceptance rate through pharmaceutical interventions with implementation of a daily cross-validation procedure in electronic prescription in patients with KD, susceptible to suffer a drug-related problem (DRP). Methods: A nine month-prospective study, in renal insufficiency inpatients (serum creatinine >1.7 mg/dl) treated with drugs that require dosage adjustment.Results: 539 patients with renal failure were identified, 135 of them needed any adjust in their prescription. We performed 179 dosage recommendations, 104 of which were accepted. Most of the recommendations were done in patients with G4 renal damage. Dose modification was the adjustment most widely required. 25 active ingredients were analyzed and the drugs with higher number of interventions were spironolactone, ranitidine, meropenem and allopurinol. General Internal Medicine was the unit with most interventions and acceptance rate. Conclusions: Pharmaceutical intervention stands out as a strategy to improve the population’s pharmacotherapeutic quality taking into account the integration of assisted electronic prescription systems to facilitate a fast and immediate intervention in decision-making in these situations. (AU)

Objetivos: Evaluar la tasa de aceptación de las intervenciones farmacéuticas con la implementación de un procedimiento diario de validación cruzada en prescripción electrónica de pacientes con IR susceptibles de sufrir un problema relacionado con la medicación (PRM). Material y método: Se trata de un estudio prospectivo de nueve meses de duración realizado en un hospital general universitario de 400 camas en pacientes con insuficiencia renal (creatinina sérica >1,7mg/dl) tratados con medicamentos que pueden requerir un ajuste posológico. La variable principal fue la tasa de aceptaación de las intervenciones farmacéuticas.Resultados: Se identificaron 539 pacientes con insuficiencia renal durante el período de estudio, 135 de ellos necesitaron algún ajuste en su prescripción. Se realizaron 179 recomendaciones farmacéuticas, 104 de las cuales fueron aceptadas. La mayoría de las recomendaciones se realizaron en pacientes con insuficiencia renal G4. Se analizaron 25 principios activos y los fármacos con mayor número de intervenciones fueron: espironolactona, ranitidina, meropenem y alopurinol. El servicio con más intervenciones y tasa de aceptación fue Medicina Interna. (AU)

[Thermolabile drugs stability faced with an accidental interruption in the cold chain]. / Estabilidad de los medicamentos termolábiles ante una interrupción accidental de la cadena de frío.

OBJECTIVE: To develop an updated guide about the stability of thermolabile drugs included in the Pharmacotherapeutic Guide that,according to product information sheet, should be stored under refrigeration or freezing, when are accidentally exposed to temperatures outside the range recommended by the manufacturer. METHODS: It was reviewed the information about storage temperatures recommended in the product information sheet and the available stability data at different temperatures of thermolabile drugs included in the Pharmacotherapeutic Guide of a 400-bed hospital that, according to the manufacturer, should be stored under refrigeration or freezing. Drugs of clinical trials were excluded. Stability data were obtained from the product information sheet, the last two guides published in Spain about thermolabile drugs and through consultations to laboratories(via phone or e-mail). RESULTS: It was created a table with the storage temperatures recommended in the product information sheet and currently available stability data at different temperatures of 209 presentations of several drugs. Stability data were requested to laboratories in 172 cases. CONCLUSIONS: The stability guide is a tool that facilitates decisions of pharmacists when they are faced with an accidental interruption of the cold chain, when it is necessary to know whether the drug can be used and it is not possible to contact the laboratory.

Objetivo: Elaborar una guía actualizada sobre la estabilidad delos medicamentos termolábiles incluidos en la Guía Farmacoterapéuticaque, según ficha técnica, deben conservarse bajorefrigeración o congelación, expuestos accidentalmente a temperaturasde conservación fuera del rango recomendado por elfabricante.Métodos: Se revisó la información sobre las temperaturas deconservación recomendadas en ficha técnica y los datos deestabilidad disponibles a distintas temperaturas de los medicamentostermolábiles incluidos en la Guía Farmacoterapéuticade un hospital de 400 camas que, según el fabricante, debenconservarse bajo refrigeración o congelación. Se excluyeron losmedicamentos incluidos en ensayos clínicos. Los datos de estabilidadse obtuvieron a partir de la ficha técnica, la informacióncontenida en las dos últimas guías de conservación de medicamentostermolábiles publicadas en España y a través de las consultasrealizadas a los laboratorios (vía telefónica o por e-mail).Resultados: Se confeccionó una tabla con las temperaturas deconservación recomendadas en ficha técnica y los datos deestabilidad disponibles actualmente a distintas temperaturas de209 presentaciones de distintas especialidades farmacéuticas.Se solicitaron datos de estabilidad actualizados de 172 de ellasa los laboratorios.Conclusiones: La guía elaborada constituye una herramientaque facilita la toma de decisiones del farmacéutico ante unarotura accidental de la cadena de frío, cuando sea necesarioconocer si el fármaco puede ser utilizado y no sea posible contactarcon el laboratorio fabricante.

[Thermolabile drugs: pharmacist intervention as a guarantee of cold chain maintenance]. / Medicamentos termolábiles: intervención farmacéutica como garantía del mantenimiento de la cadena del frío.

OBJECTIVE: To determine whether pharmacist is able to guarantee cold chain maintenance of thermolabile drugs during transport using the available information in the reception process and to compare these results with those obtained in a subsequent intervention phase, in which the manufacturing laboratories were contacted. METHODS: Intervention study, prospective and comparative"before-after". It was analyzed the storage conditions during transport of all thermolabile drugs received in a 400-bed hospital for 3 months, excluding those from clinical trials. RESULTS: The intervention allowed to ensure cold chain maintenance in 76,5% (n = 488) of received drugs, representing an increase of 41,8% (IC 95% 36,7-46,6%; p < 0,001) compared with the percentage obtained before the intervention. CONCLUSIONS: The pharmacist isn't able to ensure the cold chain maintenance of received thermolabile drugs without temperature monitoring device (64,6%). Reports requested from laboratories allowed to increase significantly that percentage.

Objetivo: Determinar si el farmacéutico puede garantizar elmantenimiento de la cadena de frío (CF) durante la distribuciónde los medicamentos termolábiles (MT) utilizando la informacióndisponible durante la recepción y comparar estos resultadoscon los obtenidos en una fase posterior de intervención, enla que se contactó con los laboratorios.Métodos: Estudio de intervención, prospectivo, comparativo"antes-después". Se analizaron las condiciones de conservacióndurante el transporte de todos los MT recepcionados enun hospital de 400 camas durante 3 meses, excluyéndose losensayos clínicos.Resultados: Tras la intervención pudo garantizarse el mantenimientode la CF en el 76,5% (n = 488) de los pedidos recepcionados,lo que supuso un incremento del 41,8% (IC95% 36,7-46,6%; p < 0,001) respecto al porcentaje pre-intervención.Conclusiones: El farmacéutico no dispone de medios a sualcance para poder garantizar el mantenimiento de la CF de MTrecepcionados sin indicador (64,6%). Los informes solicitadosa los laboratorios permitieron incrementar significativamenteeste porcentaje.

[Assessment of the utilization of angiotensin receptor blockers in hypertension]. / Evaluación de la utilización de los antagonistas de los receptores de la angiotensina II en hipertensión arterial.

OBJECTIVE: To assess the degree in which the utilization of angiotensin receptor blockers (ARBs) in our Healthcare Area fits the criteria proposed by the Autonomous Community of Madrid (CAM) before setting «Plan de Actuación de ARA-II¼ («Action Plan ARA-II¼). To study the indications for which are prescribed and to identify those factors that can show influence in prescription. METHODS: Drug utilization study of the type indication-prescription, descriptive and transversal, for which ARBs-treated and hypertensive patients admitted to a University General Hospital for a study period of 3 months were selected. Based on the clinical situations summarized in the CAM Document «Criterios para establecer el lugar en la terapéutica de los antagonistas de los receptores de la angiotensina II¼ («Criteria for the place of angiotensin receptor blockers in the therapeutic¼), a percentage of patients with «appropriate prescription¼ and «inadequate prescription« of ARBs was calculated and analyzed in order to determine if the age and the sex were related to the type of prescription or the main indications for which they had been prescribed. RESULTS: Out of the 153 patients included in the study, 67.3% had a «inadequate prescription«, 47.6% of them due to an ARBs prescription as the first drug inhibitor of the reninangiotensin- aldosterone system and 34.0% owing to a poor control of blood pressure with angiotensin-converting enzyme inhibitors (ACEi). There were no statistically significant differences found either by age or sex in the type of prescription or in the main indications for which they were prescribed. CONCLUSIONS: The adequacy of the criteria for the utilisation of ARBs Document occurred in 32.7% of cases. In addition, factors such as age and sex did not seem to affect the type of prescription. Misconceptions of superiority of ARBs versus ACEi were evidenced as well.

Objetivo: Evaluar en nuestra área de Salud el grado en que la utilización de antagonistas de los receptores de la angiotensina II (ARA-II) se ajusta a los criterios propuestos por la Comunidad Autónoma de Madrid (CAM) antes de la instauración del «Plan de Actuación de ARA-II¼. Estudiar las indicaciones para las que se prescriben e identificar aquellos factores que han podido influir en su prescripción. Métodos: Estudio de utilización de medicamentos del tipo indicación- prescripción, descriptivo y transversal, en el que se seleccionaron pacientes con hipertensión arterial y en tratamiento con ARA-II ingresados en un Hospital General Universitario durante un periodo de estudio de 3 meses. De acuerdo con las situaciones clínicas recogidas en el Documento de la CAM «Criterios para establecer el lugar en la terapéutica de los antagonistas de los receptores de la angiotensina II¼, se calculó el porcentaje de pacientes con «prescripción adecuada¼ y «prescripción no adecuada¼ de ARA-II y se analizó si la edad y el sexo tenían influencia en el tipo de prescripción o en las principales indicaciones para las que se prescribieron. Resultados: De los 153 pacientes que se incluyeron en el estudio, el 67,3% tuvieron una «prescripción no adecuada¼, el 47,6% de ellos por prescripción de ARA-II como primer fármaco antagonista del sistema renina angiotensina aldosterona y el 34,0% por mal control de la tensión arterial con inhibidores de la enzima convertidora de angiotensina (IECA). No se encontraron diferencias estadísticamente significativas por edad o sexo en cuanto al tipo de prescripción o en las principales indicaciones para las que se prescribieron. Conclusiones: La adecuación a los criterios de uso del Documento de ARA-II se produjo en el 32,7% de los casos. Además, no se observó que factores como la edad y el sexo influyeran en el tipo de prescripción. Asimismo, se evidenciaron percep-

[A pharmacoeconomic study of in-hospital treatment against community-acquired pneumonia]. / Estudio farmacoeconómico del tratamiento hospitalario de numonía adquirida en la comunidad.

INTRODUCTION: A computer-driven unit-dose drug-dispensing system allows for improved knowledge on pharmaceutical costs per DRG and clinical department, between-hospital pharmacoeconomic studies to be carried out, as well as deviation analysis. METHODS: A retrospective, cost-minimization study was undertaken to both analyze and compare prescriptions for a number of antibiotics and bronchodilators, and their costs in both 89 and 90 DRGs, as well as their cost per hospital stay in patients admitted to the Internal Medicine Departments of two hospitals in Areas 6 (HUPH) and 9 (SVO) in CAM (Autonomous Community of Madrid). A statistical analysis was performed using the Kolmogorov-Smirnov test, Student 's "t" test, Mann-Whitney test, and least squares method. RESULTS AND CONCLUSIONS: Patient samples are similar, with no significant differences existing in clinical status at admission or in cure percentage. Also, no significant differences exist in antibiotic use, except for clarithromycin and ceftriaxone, which were more commonly used at SVO (P = 0.001 and P = 0.003, respectively), and levofloxacin, which was more commonly prescribed at HUPH (P < 0.001). For identical results measured by using the cure index and mean stay, the cost of antibiotic therapy was significantly higher at HUPH (113.57 euro) versus SVO (78.32 euro), which related to a wider use of levofloxacin; while no statistical relation to clinical status was found that warranted its choice. No differences were seen in bronchoinhaler use which, together with antibiotics, represent 82.6% of cost at HUPH and 72% at SVO.

[Antioxidants: the therapy of the future?]. / Antioxidantes: una terapéutica de futuro?

In the present review piece, we analyze the formation of free radicals as a consequence of the cellular metabolism in aerobe organism, and the beneficious and harmful actions thereof on cellular structures. The balance existing between free radicals and the so-called antioxidant defenses, is a key factor for preventing the development of noxious processes at the cellular and tissue level. In accordance with the present scientific knowledge, the excessive production of free radicals in the organism, and the imbalance between the concentrations of these and the antioxidant defenses, may be related to processes such as aging and several diseases, among which we find cancer, ischemic processes, senile dementia, diabetes, pulmonary and pancreatic diseases, lupus erythematosus, cirrhosis, intestinal inflammatory disease, multiple sclerosis, arthritis, arteriosclerosis, cardiovascular disease, diseases of the central nervous system and the brain. According to the results of numerous research works conducted with the administration of several molecules with an antioxidant activity, one is beginning to see what their role will be in the pharmacological therapeutics for the treatment of a large number of patients such as those with burns, traumas, septics, shock, surgery, transplantation, radiation or chemotherapy, respiratory distress syndrome, AIDS, etc. We may possibly be facing a therapeutic tool which is of great interest in the clinical area, which shall be developed in the near future, as clinical trials which permit confirmation of their efficacy are conducted.

[Description of a computer program and results of its application to the follow up of enteral nutrition]. / Descripción de un programa informático y resultados de la aplicación del mismo al seguimiento de la nutrición enteral.

Computerization has been introduced little by little in the different activities which take place in a department of pharmacy, due to the fact that it means an increased agility of the tasks to be performed as well as an improvement of the care and managerial quality. In our hospital, the department of pharmacy makes up enteral nutrition units, and it participates in the follow up and control of the patients with this type of nutrition through a computer program designed for this purpose. The objective of the present study is to describe this computerized program as well as the results obtained by its application. The enteral nutrition computer program is made up of two data bases which are indexed between each other: that of daily follow up of the enteral nutrition prescriptions, and that of the follow up of the patients who have been given this nutritional support. In this way it allows us to obtain identification labels and consumption listings. During a two year period a total of 632 enteral nutrition treatments were given. The department with the greatest number of prescriptions was internal medicine (187, 29.5%). The polymeric diets were the most frequently used (435, 68.7%). The have mainly been used as a supplement to a hospital kitchen diet (149, 41.8%). The oral administration was the most frequent route of administration (331, 52.4%). The main reason for not implementing the nutrition was refusal by the patient (114, 38%). The computer program allows greater agility of the circuit which in our hospital generates the preparation of the enteral nutrition formulations, which are made up in the Department of Pharmacy, and given the large number of variables which this implies, this means a quality guarantee in the preparation and follow up of the patients with enteral nutrition.

[Lipid vehicles for the parenteral administration of drugs (2): liposomes]. / Vehículos lipídicos para la administración parenteral de medicamentos (2a. parte): liposomas.

The studies conducted in the past decades of the different medication carriers, have made different active substances available to the therapeutic arsenal, by using liposomes as a vehicle. Since Bangham discovered their preparation in the sixties, important technological advances have taken place on this formulation, with there being great expectations for its potential application as a vehicle for medication or other active molecules. The presently available knowledge in preclinical and clinical studies with different liposomal formulations of narrow range active substances with a high toxicity, have allowed them to be objectively seem as a good administration system for these drugs, since their more selective action improves their tolerance. Nevertheless, there are problems with regard to the implementation of their use, which in general we could summarize as its chemical instability, difficulty in manufacturing, and high cost of technology. In the present study, the physical and chemical characteristics, the properties and the formulations of the liposomes are reviewed, as well as the results of studies published with reference to the efficacy and the therapeutic applications, mainly in the area of chemotherapy and anti-infectious therapy.

[Lipid vehicles for the parenteral administration of drugs (1): emulsions]. / Vehículos lipídicos para la administración parenteral de medicamentos (1. parte): emulsiones.

To increase the efficiency of medication used in therapy and diagnostics, there have been, during the last decades, important advances in the inclusion techniques hereof, in vehicles which give greater selectivity and tolerance. Among the colloidal vehicle systems of medications with different medications, the object of the present review study. Therefore, we analyze the rationale of their use as a vehicle of medication, their physical and chemical characteristics, the ways of elimination after their administration, as well as the formulations in oil-water emulsions for the parenteral administration of diferent active substances such as diazepam, propofol, methohexital, ethomidate, amphotericin B, cytostatics, and cyclosporine, among others. The results of published studies on the efficiency and therapeutic applications of these are presented.