Power outages and refrigerated medicines: The need for better guidelines, awareness and planning.

WHAT IS KNOWN AND OBJECTIVE: Vaccines and other pharmaceuticals are essential medical supplies that require continuous storage at specific temperatures to maintain viability. Power outages can lead to a break in the cold chain, resulting in the degradation of essential medicines. COMMENT: After a power outage, the stability of vaccines and other medicines can be difficult to ascertain. Many public health guidelines therefore recommend discarding potentially compromised pharmaceuticals unless the cold chain can be guaranteed-a costly endeavour. There are government guidelines aimed at minimizing exposure to high temperatures in the event of a power outage; however, the usefulness of these guidelines is uncertain. WHAT IS NEW AND CONCLUSION: The actual cost of vaccine and pharmaceutical loss due to a break in the cold chain is poorly studied and requires further research. Additional recommendations regarding the stability of specific medicines would also be a valuable resource.

Quality use of medicines in aged care facilities: A need for new models of care.

WHAT IS KNOWN AND OBJECTIVE: Despite all the advancement in aged care, medication adverse events are still reported to occur frequently in aged care residents and to be a major contributor to hospitalization and reduced quality of life in older adults. Thus, there is an urgent need for interventions and developing new models of care to address medication safety. COMMENT: Interdisciplinary collaboration, as well as accessibility to health professionals, is amongst the factors affecting medication safety in aged care. Increasing access to pharmacists and forming an interdisciplinary team with doctors and nursing staff may improve medication safety in aged care facilities. WHAT IS NEW AND CONCLUSION: To address the medication safety, we suggest a novel model of care in residential aged care facilities, in which an on-site pharmacist integrates with nursing staff to form an interdisciplinary team to prevent medication-related harm and improves the quality use of medicines.

We have had a gutful: The need for deprescribing proton pump inhibitors.

WHAT IS KNOWN AND OBJECTIVE: Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue. METHODS: Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review. RESULTS AND DISCUSSION: Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications. WHAT IS NEW AND CONCLUSION: Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Does the "script" need a rewrite? Is medication advice in television medical dramas appropriate?

WHAT IS KNOWN AND OBJECTIVE: Television medical dramas depict the healthcare industry and draw considerable interest from the public, while pharmacists play an integral part in providing medication-related advice to the public and other health practitioners in real life. The main objective of this retrospective, observational study was to assess the appropriateness of medication advice given in televised medical dramas and how frequently pharmacists were involved in providing the medication advice. METHODS: Show selection was based on fictional series with a medical drama theme and having the highest viewership. Approximately 100 randomly selected hours of five medical television dramas (House, Grey's Anatomy, Nurse Jackie, Doc Martin and Royal Pains) were assessed for the appropriateness of advice given based on the medication indicated, number of safety checks performed, and the level of adherence to standard clinical guidelines. The appropriateness of medication advice was assessed as appropriate, mostly appropriate, partially appropriate and inappropriate using a piloted, 0-6 point scale. Other parameters recorded included patient demographics, health professionals involved, and the categories of medicines. RESULTS AND DISCUSSIONS: Medications were mentioned on 424 occasions (on average four times per hour), including 239 occasions where medication advice was given. A pharmacist was involved in giving medication advice only 16 times (7%). Using the assessment tool, overall, medication advice was deemed to be appropriate 24% of the time, mostly appropriate 34%, partially appropriate 13% and inappropriate 7%. Although the medication advice given was often for the correct indication and the advice somewhat followed clinical guidelines, it frequently omitted adequate safety checks. Doc Martin had the highest mean appropriateness score, whereas House and Grey's Anatomy had the lowest. WHAT IS NEW AND CONCLUSIONS: Medication was often used for the correct indication in television medical dramas; however, key safety checks were frequently omitted and other medication-related advice, including dose, was less reliable and accurate. Pharmacists were rarely involved in providing medication advice. Viewers should not base medication-related decisions solely on what they see in television medical dramas, and any medication-related advice should be interpreted with extreme caution.

Nutrition Screening Practices amongst Australian Residential Aged Care Facilities.

OBJECTIVES: To determine the proportion of Residential Aged Care Facilities (RACFs) in Australia who use a nutrition screening tool on residents to identify those at risk of malnutrition, and to review practice following identification of residents as being at high risk of malnutrition. DESIGN: Multi-center, cross sectional observational study. SETTING: Residential Aged Care Facilities. PARTICIPANTS: The Director of Nursing at each site was contacted by telephone and asked questions relating to current nutrition screening practices at their residential aged care facility. MEASUREMENTS: Data was collected from a stratified sample of 229 residential aged care facilities in each state and territory in Australia. RESULTS: 82% of RACFs (n = 188) use a nutrition screening tool on residents to identify those at risk of malnutrition, however only 52% of RACFs (n = 119) used a screening tool which is validated in the residential aged care setting. There was a significant association between facilities using a nutrition screening tool and the staff members being trained to conduct nutrition screening (p < 0.001). Facilities that employed a dietitian were more likely to use a validated nutrition screening tool (p < 0.005). The most frequently used nutrition screening tool was the 'Mini Nutritional Assessment - Short Form (MNA-SF)', which was used by 32% (n = 60) of the RACFs, followed by the 'Malnutrition Universal Screening Tool (MUST)' (15%, n = 29). CONCLUSION: We found that the majority of RACFs in Australia use a nutrition screening tool, however many of these RACFs use a tool which has not been validated in the RACF setting. This study highlights the need for greater dietetic advocacy in using validated nutrition screening tools to ensure malnutrition is identified.

Travelling with medications and medical equipment across international borders.

The international traveller needs to plan ahead to ensure medicines are available and used as directed for optimal therapeutic outcome. The planning needs to take account of legal and customs requirements for travelling with medicines for personal use. The standard advice by travel health providers is that travellers should check with the country of destination for requirements when travelling into the country with medicines for personal use. This is akin to introducing a barrier to care for this category of travellers. Innovative method of care for this group of traveller is needed.

Pharmacist review prevents evolving metformin-associated lactic acidosis.

WHAT IS KNOWN: There is controversy surrounding the risk of metformin and the development of lactic acidosis. There have been no reports of a pharmacist preventing a patient developing metformin-associated lactic acidosis. OBJECTIVES: Our objective was to report on a pharmacist potentially preventing an evolving case of metformin-associated lactic acidosis (MALA). CASE DESCRIPTION: A patient who had been having episodes of nausea and vomiting for a year was referred for a home medicines review (HMR) by his general practitioner. The pharmacist who conducted the HMR suspected that the patient's symptoms could have been due to metformin. It was recommended to measure the serum lactate level and suspend metformin. Our patient was found to have a high lactate level and was referred to the emergency department by his general practitioner. Recovery was prompt with symptomatic support and cessation of metformin. WHAT IS NEW: This appears to be the first case reported in the literature of a pharmacist recognizing an evolving case of MALA. CONCLUSION: Although the incidence of MALA is rare, health professionals should be aware of the initial symptoms of lactic acidosis, especially in elderly patients with risk factors, to prevent a fatal lactic acidosis event.

Doctors' beliefs and knowledge on corticosteroid-induced osteoporosis: identifying barriers to improve prevention.

WHAT IS KNOWN AND OBJECTIVE: Despite the availability of effective treatments for the management of corticosteroid-induced osteoporosis (CIOP), the condition is undertreated. Our objective was to assess prescribers' knowledge and likely prescribing patterns concerning the diagnosis and treatment of CIOP. Another goal was to identify key barriers to the use of preventive therapy in patients using long-term corticosteroids. METHODS: We used a postal survey of general practitioners (GPs) and specialists in the Netherlands. The survey comprised of questions on: demographic data, perceived barriers to the use of preventive therapy for CIOP, and knowledge of diagnosis and treatment of CIOP. Case scenarios were questioned to assess practice patterns. RESULTS: Responding prescribers correctly answered an average of 55% of knowledge questions and 69% of case scenarios. Multiple questions and cases showed that knowledge on the use of bone mineral density (BMD) determination was poor. BMD was determined in patients who, according to the national osteoporosis guideline, should be treated with bisphosphonates independent of BMD. Moreover, only 18% of doctors correctly answered that the BMD cutoff in CIOP patients is a T-score of ≤-1 or ≤-1·5. Key barriers identified were: (i) GPs, significantly more than specialists, consider prescription of preventive therapy the responsibility of another doctor; (ii) discontinuation of anti-resorptive medication due to adverse effects and (iii) the reluctance to prescribe preventive therapy in patients already prescribed multiple medications. WHAT IS NEW AND CONCLUSION: Doctors did not identify many barriers to the prescribing of anti-resorptive therapies. Lack of knowledge, especially concerning use of BMD-results, likely led to the under-treatment of the presented patients.

PPI use in patients commenced on clopidogrel: a retrospective cross-sectional evaluation.

BACKGROUND/AIMS: Antiplatelet therapy with aspirin and clopidogrel is an important component of the management of acute coronary syndrome, but it also increases the risk of bleeding. There are no formal guidelines about the use of a proton pump inhibitor (PPI) for gastroprotection in patients on clopidogrel. This study assessed how many patients in the Royal Darwin Hospital (RDH) and the Royal Hobart Hospital (RHH) prescribed clopidogrel and at risk of bleeding were co-prescribed PPIs. METHODS: We conducted a retrospective cohort study using a pharmacy database to select all patients commenced on clopidogrel in a 1-year period. We identified all patients newly prescribed clopidogrel and determined the proportion that had a risk factor for bleeding and also received a PPI. We also assessed the effect of the use of PPIs on the number of reported bleeds. RESULTS: The final study cohort consisted of 385 patients who had been newly prescribed clopidogrel. Of all patients discharged on clopidogrel, 95.6% (368/385) had >or=1 risk factor for bleeding. One hundred and twenty-eight of these patients [128/368, (34.8%)] were discharged on a PPI. Patients on dual antiplatelet therapy with an additional risk factor for bleeding and not discharged on a PPI were more likely to develop a major bleed than patients on dual antiplatelet therapy without a risk factor for bleeding not discharged on a PPI (11.1% vs. 1.8%; P < 0.01). Patients on dual antiplatelet therapy with an additional risk factor for bleeding not discharged on a PPI had a higher probability (borderline significance) of major bleeding, compared with patients on dual antiplatelet therapy with an additional risk factor for bleeding discharged on a PPI [PPI: 1/60, (1.7%) vs. no PPI: 6/54, (11.1%); P = 0.05]. CONCLUSIONS: Our results indicate that PPIs may only lower the probability of major bleeding in patients treated with dual antiplatelet therapy, who possess additional risk factor(s) for bleeding.

Systematic review of trends in prophylaxis of corticosteroid-induced osteoporosis: the need for standard audit guidelines.

UNLABELLED: Corticosteroid-induced osteoporosis (CIOP) is currently undertreated. Systematic review of the literature revealed that the percentage of patients treated adequately is dependent on study quality. Therefore, it remains unknown whether adherence to the guidelines is really so poor. Five major quality criteria provide the standard for future studies on this scope. INTRODUCTION: It has recently been stated that the degree of prophylaxis of corticosteroid-induced osteoporosis (CIOP) is low and effort should be put into determining reasons for non-prescribing of preventive agents. The aim of this study was to identify: how many studies adequately audit the prevalent guideline; the longitudinal trends in prevention of CIOP; which patient groups appear to be most undertreated; and which intervention strategies are effective. METHODS: We performed a comprehensive search of MEDLINE and systematically recorded the outcomes and quality of published studies, using five major criteria. RESULTS: Twenty-four studies were included in the analysis. The quality of the included studies was poor (31%) or moderate (37%). There was a longitudinal increase in quality of the studies and percentage of prevention. Multivariable linear regression showed that the quality of the study was the only independent predictor of the prevention rate reported in the study. CONCLUSIONS: The results show undertreatment of CIOP might be due to insufficient quality of the studies rather than poor practice or failure to recognise the right patients. Future interventions should comply with five major quality criteria, and a multifaceted approach is required in order to make an impact on the underprescribing of CIOP prophylaxis.

Corticosteroid-induced osteoporosis prevention: longitudinal practice patterns in The Netherlands 2001-2005.

UNLABELLED: We investigated prevention trends and predictors for osteoporosis prevention in long term corticosteroid users. The use of bisphosphonates increased from 2001 to 2005. Longer duration of corticosteroid use and DMARD use were predictors for receiving prevention. Females appear reasonably well treated; however, men require more attention. INTRODUCTION: Previous studies have shown that long-term corticosteroid users are undertreated for osteoporosis prevention. Our aim was to identify prevention trends in long-term corticosteroid users from 2001-2005 in The Netherlands and to identify predictors for bisphosphonate prophylaxis. METHODS: Pharmacy dispensing data were used from 9 community pharmacies. All oral corticosteroid doses were converted to "prednisolone equivalents". We then identified long-term (> or =90 days) corticosteroid episodes, which required bisphosphonate prophylaxis as per 2002 Dutch guidelines; Multivariate logistic regression was used to identify predictors for receiving prevention. RESULTS: We identified 615 different corticosteroid patients requiring prophylaxis. From 2001-2005 the use of bisphosphonates increased from 38% to 54% (p = 0.001). In 2005 females were prescribed more bisphosphonates than males (61% vs. 39%; p = 0.002), or any treatment (72% vs. 45%; p < 0.001). Multivariate analysis showed that longer duration of corticosteroid use and disease-modifying anti-rheumatic drug (DMARD) use were independent predictors of bisphosphonate use. Use of respiratory medication was a negative predictor of bisphosphonate use. CONCLUSION: There has been a significant increase in osteoporosis prophylaxis in a population at high risk for osteoporosis/fractures. In particular, females appear reasonably well treated; however, men are still not receiving prevention to the same degree as women.

Impact of pharmacist-conducted home visits on the outcomes of lipid-lowering drug therapy.

OBJECTIVE: To evaluate a pharmacist-conducted educational and monitoring programme, designed to promote dietary and lifestyle modification and compliance with lipid-lowering drug therapy, for patients with dyslipidaemia. METHODS: This was a prospective, randomized, controlled study. The participants were 94 adults, with 81 completing the study (intervention group: 39; control group: 42), with a cardiovascular-related diagnosis and discharged from hospital, between April and October 2001, on lipid-lowering drug therapy. Patients in the intervention group were visited at home monthly by a pharmacist, who educated the patients on the goals of lipid-lowering treatment and the importance of lifestyle issues in dyslipidaemia and compliance with therapy, assessed patients for drug-related problems, and measured total blood cholesterol levels using point-of-care testing. Patients in the control group received standard medical care. The main outcome measure was total blood cholesterol levels after 6 months, and an evaluation of patient and general practitioner satisfaction with the programme. RESULTS: There was no significant difference in baseline total blood cholesterol levels between the two groups. The reduction over the course of the study in cholesterol levels within the intervention group was statistically significant (4.9 +/- 0.7 to 4.4 +/- 0.6, P<0.005), whereas there was no change within the control group (P=0.26). At follow-up, 44% of the intervention group patients and 24% of the control group patients had cholesterol levels below 4.0 mmol/L (P=0.06). The reduction in total cholesterol in the intervention group should translate to an expected 21% reduction in cardiovascular mortality risk and a 16% reduction in total mortality risk--more than twice the risk reduction achieved in the control group. In addition, the programme was very well received by the patients and their general practitioners, by satisfaction questionnaire. CONCLUSION: A pharmacist-conducted educational and monitoring intervention improved the outcomes of lipid-lowering drug therapy.

Overuse of proton pump inhibitors.

BACKGROUND: There have been concerns raised about the potential adverse effects of proton pump inhibitors, especially with long-term use. In particular, their potent action can suppress the features and delay the diagnosis of gastric cancer, while prolonged exposure may hasten the development of gastric carcinoids. AIM: To examine the use of proton pump inhibitors in patients at the major teaching hospital in Tasmania, Australia, principally to determine the appropriateness of the therapy according to published guidelines. METHODS: A retrospective review of the medical records of all patients prescribed any of the proton pump inhibitors at the hospital over a 7-month period, was performed. An extensive range of demographic and clinical variables was recorded for each patient. The patients were also asked a series of questions during their hospitalization to extract some of the relevant information - in particular, if and when they had undergone endoscopy. RESULTS: The 200 patients (52% males) had a mean age of 69 +/- 16.4 years. The most common indications for using proton pump inhibitors were acute gastrointestinal bleeding (20.9%), severe refractory ulcerating oesophagitis (17.3%), mild/moderate oesophageal reflux (17.3%) and refractory peptic ulcer (11.7%). A large number of patients were using a proton pump inhibitor for 'other' indications (39.6%). The prescribing of proton pump inhibitors satisfied the approved indications, as outlined in the Australian Schedule of Pharmaceutical Benefits, in only 37.1% of cases. Endoscopy had been performed in 54.1% of patients prior to commencing therapy with a proton pump inhibitor and within the next 7 days in another 12.8% of patients. Only 59% of patients had previously been treated with an H2-receptor antagonist before commencing therapy with a proton pump inhibitor. Even worse, only 58.5% of patients had used an H2-receptor antagonist before a proton pump inhibitor for mild/moderate oesophagitis. The median duration of proton pump inhibitor therapy for patients admitted to the hospital and already receiving one of the drugs was 450 days. Over half of the patients were being concurrently treated with other drugs which are known to cause or exacerbate gastro-oesophageal disease, and 18% were smokers. CONCLUSION: Whereas the proton pump inhibitors are undoubtedly effective agents, studies of their prescribing in practice consistently suggest over-use prior to endoscopy, use in patients who do not fit the approved criteria, and prescribing for indications in which 'less powerful' agents should have been sufficiently effective for the patient's symptoms. This poses economic and safety concerns, particularly in light of the suggestion that these drugs could delay the diagnosis of gastric cancer.