Drug utilization evaluation of i.v. paracetamol at a large teaching hospital.

BACKGROUND: I.v. paracetamol has recently become available in Australia for the treatment of pain when the oral or rectal administration route is not accessible. Our primary aim was to assess compliance with prescribing guidelines and our secondary aim to evaluate the safety of i.v. paracetamol use (4 g/day) and the effect of patient comorbidities on drug safety. METHODS: Eighty-five consecutive patients were identified through the pharmacy dispensing system at a 900-bed, metropolitan, primary care and tertiary referral hospital over a period of 7 months from December 2005 to June 2006. Cross-sectional evaluation by patient interview, review of medical records and pathology parameters were carried out. The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee. RESULTS: I.v. paracetamol was given for pain following abdominal surgery (90%) and musculoskeletal pain (10%). The comorbid conditions included severe renal impairment (9.4%), alcohol dependence (3.5%), pre-existing liver failure (2.4%) and malnutrition (18.8%). Prescribing guidelines were not adhered to in 25% of patients. The main cause for discordance observed in 90% of this group was the administration of i.v. paracetamol despite the presence of an alternative route of administration. Eight patients received i.v. paracetamol despite not having had a surgical procedure. Twelve patients received i.v. paracetamol for longer than 48 h; no injection site reactions or toxicity were noted. CONCLUSION: A lack of concordance between i.v. paracetamol use and prescribing guidelines was identified. There were no new safety concerns.

Concordance between clopidogrel use and prescribing guidelines.

BACKGROUND: Clopidogrel is an antiplatelet drug increasingly used in the secondary prevention of atherosclerotic vascular events. Compared with aspirin, clopidogrel has marginal additional efficacy and similar safety, but carries a substantial price premium. It remains unclear whether its use is cost-effective. AIMS: (i) To determine concordance between clopidogrel use and the Pharmaceutical Benefits Scheme and local hospital prescribing guidelines and (ii) to determine the intended duration of clopidogrel therapy and ascertain whether this is supported by other published reports. METHODS: Cross-sectional evaluation by patient interview and chart review of appropriateness of clopidogrel prescribing was carried out for 100 consecutive patients attending a 700 bed metropolitan, primary care and tertiary referral hospital. RESULTS: Clopidogrel was predominantly used for secondary prevention of ischaemic heart disease (60%) and following percutaneous coronary intervention (34%). A significant proportion of patients (29%) received clopidogrel outside the prescribing guidelines. Many patients were intended to receive indefinite therapy for secondary prevention of ischaemic vascular events. Concomitant aspirin therapy was not prescribed in 23% of patients, for 78% of whom it was inappropriate. CONCLUSIONS: There is a lack of concordance between clopidogrel use and prescribing guidelines. In the majority of patients (71%), clopidogrel is used for valid indications but there is considerable leakage of use beyond prescribing guidelines. Concomitant aspirin therapy is often not prescribed in the absence of clinically relevant contraindications. Moreover, treatment is continued in many patients beyond what is supported by current published data.

Emotional distress induced rhabdomyolysis in an individual with carnitine palmitoly-transferase deficiency.

A 48-year-old male patient with underlying CPT II enzyme deficiency is described. Emotional stress appeared to precipitate recurrent myalgias, rhabdomyolysis and reversible renal impairment over a 40-year period. Our search of the English literature indicates this to be the first time that the emotional stress has been documented to precipitate the CPT II syndrome. Although the pathogenesis of this syndrome has yet to be established, existing knowledge is briefly reviewed and the likely metabolic and neuroendocrine mechanisms which link emotional stress to muscle metabolism are examined. These mechanisms influence the extent of lipolysis or glycolysis that occurs during the process of muscle ATP generation. It is suggested that neuroendocrine and other stress related changes which favour lipolysis over glycolysis adversely affect muscle energy metabolism in patients whose mitochondria are deficient in CPT II enzyme. Possible treatment strategies are those that favour glycolysis over fatty acid metabolism and include a variety of ways of modulating sympathetic and parasympathetic tone. The use of carbohydrate supplementation beta-blockers and anxiolytic agents is discussed.

Osteoarticular brucellosis with long latent period.

We describe the case of a young male who manifested Brucella suis osteomyelitis after a 5-year period of relapsing monoarthritis. We discuss some of the difficulties regarding the diagnosis of osteoarticular brucellosis and review presentation patterns of the disease.

Concordance between use of proton pump inhibitors and prescribing guidelines.

OBJECTIVE: To determine (i) the relationship between prescriptions for proton pump inhibitors (PPIs) and upper gastrointestinal conditions, and (ii) compliance with Pharmaceutical Benefits Scheme (PBS) prescribing guidelines for PPIs. DESIGN: Drug utilisation evaluation. SETTING: 800-bed metropolitan teaching hospital. PARTICIPANTS: 253 patients dispensed PPIs from the hospital pharmacy over five consecutive weeks (11 January to 15 February 1999). MAIN OUTCOME MEASURES: Recorded gastrointestinal conditions; previous trial of H2-antagonist therapy; compliance with PBS criteria for prescribing PPIs. RESULTS: Seventy patients (27.7%) had no appropriate upper gastrointestinal tract investigations, and 62 patients (24%) did not receive an adequate trial of H2-antagonist therapy before the commencement of a PPI. The major indications for use of PPIs in investigated patients were gastro-oesophageal reflux in 99 (54%) and peptic ulcer disease in 30 (16.4%). In only 57 patients (22.5%) did PPI prescriptions comply with PBS prescribing guidelines. Clinical indications that failed to meet prescribing criteria included milder forms of gastro-oesophageal reflux, gastritis/duodenitis, and non-specific dyspepsia with normal endoscopy results. CONCLUSION: Drug utilisation data indicate widespread use of PPIs outside current prescribing guidelines. Many patients have not had relevant investigations and/or an adequate trial of H2-antagonist therapy. These findings explain the considerable hospital expenditure on PPIs.