Polypharmacy and potentially inappropriate prescribing of benzodiazepines in older nursing home residents.

INTRODUCTION: Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia. METHODS: Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented. RESULTS: The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2-3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8). CONCLUSIONS: Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.

Clinical pharmacy services in mental health in Europe: a commentary paper of the European Society of Clinical Pharmacy Special Interest Group on Mental Health.

A large proportion of the world's disease burden is attributable to mental illnesses. Although effective interventions are available, many patients still have limited access to evidence-based treatments. Aside from access, treatment gaps, including inappropriate medication selection and monitoring, are also routinely recognised. Mental health clinical pharmacists can help address these gaps and enable patients to receive optimised pharmaceutical care, particularly appropriate medication selection and monitoring. The European Society of Clinical Pharmacy (ESCP) Special Interest Group on Mental Health was established to improve standardised service provision in mental health settings across Europe. The Special Interest Group identified significant barriers (predominantly associated with reimbursement and position within the multidisciplinary team) to effective pharmaceutical care amongst those with mental illnesses. This commentary presents recommendations to address these gaps through improved mental health clinical pharmacy service provision.

Recommendations for wider adoption of clinical pharmacy in Central and Eastern Europe in order to optimise pharmacotherapy and improve patient outcomes.

Clinical pharmacy as an area of practice, education and research started developing around the 1960s when pharmacists across the globe gradually identified the need to focus more on ensuring the appropriate use of medicines to improve patient outcomes rather than being engaged in manufacturing and supply. Since that time numerous studies have shown the positive impact of clinical pharmacy services (CPS). The need for wider adoption of CPS worldwide becomes urgent, as the global population ages, and the prevalence of polypharmacy as well as shortage of healthcare professionals is rising. At the same time, there is great pressure to provide both high-quality and cost-effective health services. All these challenges urgently require the adoption of a new paradigm of healthcare system architecture. One of the most appropriate answers to these challenges is to increase the utilization of the potential of highly educated and skilled professionals widely available in these countries, i.e., pharmacists, who are well positioned to prevent and manage drug-related problems together with ensuring safe and effective use of medications with further care relating to medication adherence. Unfortunately, CPS are still underdeveloped and underutilized in some parts of Europe, namely, in most of the Central and Eastern European (CEE) countries. This paper reviews current situation of CPS development in CEE countries and the prospects for the future of CPS in that region.

Clinical pharmacist interventions in the transition of care in a mental health hospital: case reports focused on the medication reconciliation process.

The transition of care represents a key point in the hospital admission and discharge process. A comprehensive transition could lead to fewer medication-related problems. The hospital clinical pharmacist could help in the transition of care process with a comprehensive medication reconciliation process, which has been poorly described in mental health hospitals. This study presents two clinical cases in which hospital clinical pharmacists identified omitted medications and other medication-related issues, including medication errors, during the transition of care in a mental health hospital. These positive experiences may encourage other countries to establish similar collaborations with hospital clinical pharmacists in mental health hospitals.

Bupropion XL unapproved use in the prisons: Two cases focused on the bupropion pharmacology.

BACKGRUND: Bupropion (BUP) is a norepinephrine-dopamine reuptake inhibitor frequently used in prisons. Although its positive effects on depression treatment are often presented, there are many questions about its approved use in prisons and similar facilities. In this context, this article aims to present two case reports of BUP XL unapproved use and a review of the mechanism of action, formulations, and the clinical profile of BUP. METHODS: Two case reports. The patients' data for the case reports were obtained from their medical records. A PubMed search was conducted using the terms BUP, inmates, and efficacy to identify randomized and non-randomized controlled trials and case reports to evaluate the possible effects of BUP in prison settings. Only approved medications were included. RESULTS: The positive effects of BUP XL on major depressive disorder treatment are well-reported, but few reports are on the pharmacokinetics of BUP XL in prisons. The exact mechanism of its effect on the central nervous system is predominantly connected with its unique pharmacokinetics. CONCLUSIONS: This paper shows that BUP XL will continue to play an essential role in treating a major depressive disorder in adults in prisons and other related disorders, although a different treatment strategy should be preferred in patients with high addictive potential. Because of a similar mechanism of action, the most appropriate alternatives for BUP XL could be mirtazapine, agomelatine, aripiprazole, and quetiapine, although clinical trials are needed to confirm these alternatives.

Antipsychotic treatment in elderly patients on polypharmacy with schizophrenia.

PURPOSE OF REVIEW: Elderly patients with schizophrenia (SCH) are treated with antipsychotics and are often on different comedications, including polypharmacy (five or more medications). Evidence-based guidelines and randomized controlled trials do not include patients on polypharmacy, something that represents a 'gap' between evidence-based recommendations and clinical prescribing patterns. In this context, narrative reviews are needed to help clinicians in daily practice. RECENT FINDINGS: Antipsychotic treatment efficacies in meta-analyses are similar in the elderly with SCH compared with the general population (medium effect size). Long-term cohort studies show that antipsychotic treatment reduces overall mortality, hospitalizations, and cardiovascular death. These studies are limited because polypharmacy was not studied. The prevalence of antipsychotic use as potentially inappropriate medications was very high in nursing homes (25%). The prevalence of antipsychotic polypharmacy was 40%. Different strategies to manage these problems are available, including collaboration with clinical pharmacists, leading to reduced polypharmacy and better adherence to treatment guidelines. SUMMARY: Elderly patients with SCH on polypharmacy are less frequently studied, although they represent many patients with SCH. Different potentially inappropriate medication lists and collaboration with clinical pharmacists represent effective strategies for medication optimization. More studies are needed on this topic (e.g., prospective nonrandomized studies).

Clinical pharmacist interventions in ambulatory psychogeriatric patients with excessive polypharmacy.

Psychogeriatric primary care patients are frequently treated with excessive polypharmacy (≥ 10 medications), leading to complications and increased costs. Such cases are rarely included in treatment guidelines and randomized controlled trials. This paper evaluates the impact of clinical pharmacist medication reviews on the quality of pharmacotherapy in primary care psychogeriatric patients with excessive polypharmacy. The retrospective observational multicentric pre-post study included patients (aged 65 or above) treated with at least one psychotropic and ten or more medications. Clinical pharmacists' recommendations were retrieved from medication review forms for the period 2012⁠-⁠2014. The study outcome measures were the number of medications, potentially inappropriate medications in the elderly (PIMs), potential drug-drug interactions which should be avoided (pXDDIs), and adherence to treatment guidelines. The study included 246 patients receiving 3294 medications, of which 14.6% were psychotropics. The clinical pharmacists proposed 374 interventions in psychopharmacotherapy. The general practitioners accepted 45.2% of them (169). Accepting clinical pharmacist recommendations reduced the total number of medications by 7.5% from 13.4 to 12.4 per patient (p < 0.05), the total number of prescribed PIMs by 21.8% from 312 to 244 (p < 0.05), the number of pXDDIs by 54.9% from 71 to 31 (p < 0.05) and also improved treatment guidelines adherence for antidepressants and antipsychotics (p < 0.05). Clinical pharmacist interventions significantly improved the quality of psychopharmacotherapy by reducing the total number of medications, PIMs, and pXDDIs. Accepting clinical pharmacist interventions led to better treatment guidelines adherence.

Positive evidence for clinical pharmacist interventions during interdisciplinary rounding at a psychiatric hospital.

Clinical pharmacists have not yet become an integral part of interdisciplinary ward rounds in most psychiatric hospitals across the European Union. This retrospective observational pre-post study examined the impact of clinical pharmacist recommendations in an interdisciplinary medical team during psychiatric hospital rounding. The study included all patients in a Slovenian psychiatric hospital who were hospitalized 2019-2020. The clinical pharmacist made 315 recommendations for a total of 224 participants (average age M = 59.4, median = 56). Psychiatrists accepted 295 (93.7%) of the recommendations. After the recommendations, the number of expressed and potential drug-related problems decreased in 166 (93.8%) and 129 (93.8%) interventions, respectively. Three months after discharge, 222 accepted recommendations were continued (70.5%). The most common recommendations were related to antipsychotics (19.4%, N = 61) followed by antidepressants (16.8%, N = 53). Including a clinical pharmacist in the interdisciplinary ward rounds at a psychiatric hospital reduced the number of expressed and potential drug-related problems with a very high recommendation acceptance rate. These results are the first in Central Europe to explore the benefits of including a clinical pharmacist in ward rounding.

Clinical pharmacist consultant in primary care settings in Slovenia focused on elderly patients on polypharmacy: successful national program from development to reimbursement.

Clinical pharmacists in most primary care settings across Europe do not offer a reimbursed medication review service. This paper describes the development, implementation, and evaluation of a program in Slovenia that allows all general practitioners to refer patients to clinical pharmacists in primary care settings for a medication review. Between 2012 and 2015, the Health Insurance Institute of Slovenia proposed, funded and evaluated a pilot trial and recommended that the service be extended to all public health insurance beneficiaries in Slovenia. Following successful negotiations, the program (Pharmacist Consultant) has been available in all Slovenian primary care settings since 2018. It was evaluated internally with various questionnaires and externally with three studies that reported fewer medication-related problems, fewer drug-drug interactions, cost effectiveness, better treatment guidelines adherence and better humanistic clinical outcomes. The results demonstrate that including clinical pharmacists in primary care settings is particularly beneficial for patients with multiple diseases and medications, who are often elderly people. Future research should examine the service with improved methodologies (e.g., prospective studies with a larger sample size, measures of clinical outcomes and long-term follow-up). In the context of Slovenia, studies should also examine the effects of further integration of clinical pharmacists in patient care (e.g., through patient monitoring, dependent or independent prescribing and medication reviews in hospitals).

Clinical pharmacist interventions in elderly patients with mental disorders in primary care focused on psychotropics: a retrospective pre-post observational study.

BACKGROUND: Mental disorders pose a significant clinical burden and affect approximately one-third of older adults. Although studies have shown positive impacts of clinical pharmacist (CP) interventions within the general population, the long-term effects of such cooperation on geropsychiatric patients in primary care settings are not yet known. This study evaluated whether CP interventions have a long-term impact on the quality of medication prescribing in geropsychiatric patients. METHODS: We conducted a retrospective non-interventional observational pre-post study for the 2015-2017 period, involving patients aged 65 or above for whom a medication review was provided by a CP. The study included participants with mental disorders treated with polypharmacy, including at least one psychotropic. Potentially inappropriate medications (PIMs) in elderly patients were determined with the Priscus list, and potential type X drug-drug interactions (pXDDIs) with Lexicomp®. Up-to-date treatment guidelines were used to evaluate patient pharmacotherapy, and patient medication was evaluated before the initial medication review and again 6 months later. RESULTS: The study included 48 patients (79.4 years, SD = 8.13) receiving a total of 558 medications (155 for the treatment of mental disorders). The number of medications decreased by 9.5% after the medication review. The CP proposed 198 interventions related to psychotropics, of which 108 (55%) were accepted by the general practitioners. All accepted (99.1%) interventions except one were still maintained 6 months after the interventions had been proposed. They led to a significant decrease in the total number of medications, PIMs, and pXDDIs (p < 0.05), and improved treatment guidelines adherence. CONCLUSIONS: CP interventions decreased the number of medications, PIMs, and pXDDIs, and almost all interventions were maintained 6 months later. These results provide evidence for the positive effects of CP interventions in a primary care setting. Additional research with a larger sample size and a randomized study design is needed.

Clinical pharmacist interventions in cardiovascular disease pharmacotherapy in elderly patients on excessive polypharmacy : A retrospective pre-post observational multicentric study.

BACKGROUND: Cardiovascular diseases (CVD) are often treated with excessive polypharmacy (10 or more medications) in primary care, and these patients are mostly excluded from trials. Collaborative care, including clinical pharmacists (CP), is one of the possible approaches to address these problems; however, it has not been studied yet in this part of Europe. Hence, the main aim of the study was to determine how CP interventions in a medical review form (MR) can have an impact on the pharmacotherapy in patients on excessive polypharmacy with CVD (number of medications, potential drug-drug interactions of type X-pXDDI, potentially inappropriate medications in the elderly-PIM and treatment guidelines adherence). METHODS: This retrospective, observational pre-post multicentric study included elderly patients with CVDs aged 65 years or above, treated with 10 or more medications concomitantly (excessive polypharmacy) in Slovenian primary care (2012-2014). The MR provided by CPs included drug-related problems and potential pXDDIs, as well as PIMs. The pXDDIs were determined with Lexicomp Online. The German Priscus lists was used to determine PIMs. A binary logistic regression model was chosen to examine the influence of independent variables on the dependent variable (treatment guidelines adherence). RESULTS: In this study 243 patients were included and 980 interventions were proposed in the MR form of which 479 (48.9%) were accepted by the general practitioners (GP). The CPs proposed 320 interventions in CVDs treatment, of which 140 were accepted by the GPs (43.8%). The acceptance of the CPs' recommendations reduced the number of medications by 7.3% (from 13.1 to 12.1 per patient; p < 0.05), the number of pXDDIs by 47.8% (from 40 to 12 patients; p < 0.05), the total of prescribed PIMs by 26.6% (p = 0.752) and adherence to arterial hypertension treatment guidelines was improved (p < 0.05). CONCLUSION: CPs' interventions significantly improved the quality of pharmacotherapy prescribing by reducing the total number of medications and pXDDIs and led to better hypertension treatment guidelines adherence.

A Collaborative Care Model between General Practitioners and Clinical Pharmacists in a Community Health Centre Setting in Depression Treatment.

BACKGROUND: A collaborative care model between clinical pharmacists (CP) and general practitioners (GPs) for treating patients with treatment-resistant depression (TRD) and major depressive disorder (MDD) has not been described yet in the medical literature in Central Europe. Therefore, the main aim of this paper was compared standard of care and collaborative care model including clinical pharmacist in a systematic review form. SUBJECTS AND METHOD: A systematic search in Pubmed/Medline using the terms pharmacist, depression, and primary care in Medline through to September 2016 was conducted to identify randomized controlled clinical trials (RCTs). The patient's data for the case report was obtained from the medical records. RESULTS: 23 RCTs were found. In total 3 RCTs were included in this systematic review. Efficacy in reducing depressive symptoms in collaborative care model compared to the standard of care (without clinical pharmacist) were shown in all RCTs. A collaborative care model also showed positive treatment outcomes in case report. CONCLUSION: This systematic review shows positive treatment outcomes in patients included in collaborative care model compared to current standard of care. This positive case report shows evidence for the effectiveness of a collaborative care model with a CP in a primary care setting. CPs can assist GPs in choosing the appropriate pharmacotherapy.

Impact of clinical pharmacist's interventions on pharmacotherapy management in elderly patients on polypharmacy with mental health problems including quality of life: A prospective non-randomized study.

Mental health problems (MHPs) are very common in the elderly and can have an important influence on their quality of life (QoL). There is almost no data on the impact of clinical pharmacists' (CPs) interventions on the QoL including elderly patients and MHPs. The main aim of this study was to determinate the impact of (CP's) interventions on the QoL and quality of pharmacotherapy. A prospective non-randomized pre-post study was designed which included residents of a nursing home aged 65 age or more with at least one MHP. Each patient also filled out the EQ-5D questionnaire. The medical review MR included drug-related problems (DRPs) and potentially drug-drug interactions (pDDIs), as well as potentially inappropriate medications (PIMs). After 2 months, the participants were interviewed again. The mean number of medications before the intervention was 12,2 ± 3,1 per patient and decreased to 10,3 ± 3,0 medications per patient (p < 0,05) (n = 24). The total number of PIMs and pDDIs was also reduced and QoL was also significantly higher (p < 0,05). A collaborative care approach with a CP led to a decrease of DRPs, pDDIs, PIMs, the total number of medications and to an improvement in the patients' QoL.

Potential drug interactions with antibacterials in long-term care facilities analyzed by two interaction checkers.

Background Residents in long-term care facilities take many medications concomitantly, including antibacterials, which increases the risk of drug-drug interactions. Objectives The aims of the study were to investigate the prevalence of severe potential interactions between antibacterials and other medications in Slovenian long-term care facilities and to compare the performance of two different drug-drug interaction checkers in these settings. Setting Residents in long-term care facilities in Slovenia. Method A point-prevalence study was conducted from April 2016 to June 2016. Residents' characteristics, antibacterial treatment, and concomitant medications were obtained from their medical charts. Potential drug-drug interactions were determined using Lexicomp Online™ 3.0.2 and the online Drugs.com Drug Interactions Checker. The study only included potential drug-drug interactions categorized as type MA (major interactions) by the Drugs.com checker and as type X (should be avoided) by Lexicomp Online™. The study calculated the differences in the number of type X and MA potential drug-drug interactions between different antibacterial classes and between the two drug-drug interactions checkers. Main outcome measure Number of medications per patient, number of potential drug-drug interactions with antibacterial, and differences between two drug-drug interactions checkers. Results Eighty (68.4%) of Slovenian general long-term care facilities with 13,032 residents responded to the invitation. 317 (2.4%) of the residents received antibacterial treatment and 212 residents were included in the analysis. On average, they received 10.9 medications (SD = 3.9). Antibacterials were involved in 24.1% type MA potential drug-drug interactions and 26.4% type X potential drug-drug interactions. A significant difference in the total number of potential drug-drug interaction between the two checkers was found for all antibacterials, co-trimoxazole and fluoroquinolones (p < 0.005). Type X and MA potential drug-drug interactions were more common with fluoroquinolones than with beta-lactams or co-trimoxazole (p < 0.005). Conclusion Potential interactions between antibacterials, especially fluoroquinolones and other drugs, were common in long-term care facility residents treated with antibacterials. Differences in the number of potential drug-drug interactions between the two checkers indicate that if available the use of several sources of information is recommended in clinical practice. The results call for a collaborative approach to address the risks of drug-drug interactions.

Evaluation of a collaborative care approach between general practitioners and clinical pharmacists in primary care community settings in elderly patients on polypharmacy in Slovenia: a cohort retrospective study reveals positive evidence for implementation.

BACKGROUND: The population of developed countries is aging, leading to an increase in the use of medication in daily practice, which can lead to serious treatment costs and irrational polypharmacy. A collaborative care approach, such as providing medication review service provided by a clinical pharmacist (CP), is a possible way to reduce drug-related problems and irrational polypharmacy. The aim of this study was to determinate whether a CP's medication review service can improve the quality of drug prescribing in elderly patients treated with polypharmacy in primary care. METHODS: In a retrospective observational medical chart review study, patients aged 65 years or more in the period 2012-2014 who received 10 or more medications concomitantly and who were screened by a CP were included. Data on pharmacotherapy and CPs' interventions were obtained from the patients' medical records (non-electronic chart review). Potential drug-drug interactions (pDDIs) were determined with Lexicomp Online™ 3.0.2. Only potential X-type DDIs (pXDDIs) were included. Potentially inappropriate medications in the elderly (PIMs) were identified using the PRICUS list. RESULTS: Ninety-one patients were included. The CPs suggested 625 interventions, of which 304 (48.6%) were accepted by the general practitioners (GPs). After adopting the CPs' interventions, the number of total medications decreased by 11.2% (p <  0.05) and the number of pXDDIs decreased by 42% (p <  0.05). The number of clinically important pXDDIs decreased by 50% (3 cases). The number of prescribed PIMs decreased by 20% (p = 0.069). The acceptance of CP's recommendations reduced the number of pXDDIs (p < 0.05) and improved the adherence to heart failure treatment guidelines. CONCLUSIONS: A collaborative care approach offering a CP medication review service significantly improved the quality of pharmacotherapy by reducing the total number of medications and pXDDIs. The results support the implementation of this service in the Slovenian healthcare system.

Efficacy, Acceptability, and Tolerability of Lisdexamfetamine, Mixed Amphetamine Salts, Methylphenidate, and Modafinil in the Treatment of Attention-Deficit Hyperactivity Disorder in Adults: A Systematic Review and Meta-analysis.

OBJECTIVE: Psychostimulants are the first-line treatment in adults with attention-deficit hyperactivity disorder (ADHD). This meta-analysis aimed to evaluate the efficacy, acceptability, and tolerability of lisdexamfetamine (LDX), mixed amphetamine salts (MASs), modafinil (MDF), and methylphenidate (MPH) in comparison with placebo. DATA SOURCES: We systematically searched PubMed/MEDLINE and Clinicaltrials.gov in May 2016, along with CENTRAL and EU Clinical Trials Register in February 2016, for the randomized, double-blind, placebo-controlled, parallel-group clinical trials conducted on adults diagnosed with ADHD. STUDY SELECTION AND DATA EXTRACTION: Substantial comorbidity, substance abuse or dependence, and nonpharmacological interventions represented grounds for exclusion. Published reports were the sole source for data extraction. Improvement in ADHD symptoms was the primary outcome. Random-effects model meta-analysis was applied to calculate the standardized mean difference (SMD) with 95% CIs. DATA SYNTHESIS: The search retrieved 701 records, of which 20 studies were eligible for analysis. High effect size (expressed as SMD) in reducing ADHD symptoms was observed for LDX (-0.89; 95% CI = -1.09, -0.70), whereas MASs (-0.64; 95% CI = -0.83, -0.45) and MPH (-0.50; 95% CI = -0.58, -0.41) reduced symptoms moderately compared with placebo. No efficacy was shown for MDF (0.08; 95% CI; -0.18, 0.34). Relevance to Patient Care and Clinical Practice: In this meta-analysis, the efficacy, tolerability, and acceptability of psychostimulants were compared with that for placebo. Five of the included trials have not been evaluated in any of the previously published meta-analyses. CONCLUSIONS: The results suggest that LDX has the largest effect size and has a promising potential for treating adults with ADHD.