The Role of Direct Oral Anticoagulant in Patients with Acute Coronary Syndrome on Single or Dual Antiplatelet Regime: Review of Opportunities and Challenges.

BACKGROUND: Despite the developments of single or dual antiplatelet therapy consisting of aspirin and/or clopidogrel, prasugrel or ticagrelor, post-acute coronary syndrome a room for potential improvement towards optimal prevention persist. The addition of a direct oral anticoagulant to the antiplatelet treatment of patients with the acute coronary syndrome is clinically practiced in cases where anticoagulation is indicated by high thromboembolic risk. OBJECTIVE: The main objective of this review was to explore the role of supplementation with a direct oral anticoagulant to antiplatelet (aspirin or P2Y12 inhibitor) in patients with the acute coronary syndrome. METHODS: We have searched the Medline for studies involving direct oral anticoagulant use in acute coronary syndrome. We have reviewed specific relevant 9 meta-analyses between the years 2012 to 2019. RESULTS: Our review of nine meta-analyses has revealed that the addition of direct oral anticoagulant to antiplatelet therapy compared with antiplatelet alone was beneficial about the composite endpoints of major ischemic events in patients with the acute coronary syndrome. Furthermore, the combined regimen of single antiplatelet plus direct oral anticoagulant is as effective as the triple regimen of dual antiplatelet plus direct oral anticoagulant and results in less bleeding. CONCLUSION: Cardiologists should balance the efficacy with a higher risk of bleeding with more intensified DOAC therapy. Better risk characterization and timely adaptation of the regime to the patient's need should be tested. Recurrent ischemic events and bleeding event risk scoring should guide individualized treatment.

Value of venous thromboembolism prophylaxis by enoxaparin with anti-factor Xa trough concentration monitoring in surgical care

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Decentralize-Change-Recentralize Model of Drug Information Networks in Health Centers: Decentralized Drug Information Services.

Large health centers usually decentralize their services to small self-sufficient sub-centers of care delivery. These small centers are part of an extensive network of practitioners who are connected. The drug information services of independent clinical pharmacists in a health center could be fragmented. Drug information centers thus need to have a new definition of the mode of operation. While maintaining autonomy in information exchange, professionals are integrated to form a large community of practitioners. Technological advancements in communication and access to resources enable efficient collaborations to happen. Immersed in patient-centered collaborative practice environments, networks of professionals integrate drug information services. Drug information networks thus hold a similar philosophy of health centers to decentralize-change-centralize its services. Further research is required to measure the impact of this model of drug information services.

Coxibs Refocus Attention on the Cardiovascular Risks of Non-Aspirin NSAIDs.

Non-steroidal anti-inflammatory drugs (NSAIDs) were differentiated from steroidal anti-inflammatory medicines to help clinicians who needed to use anti-inflammatory agents that were safer than steroids. With market entry of rofecoxib in 1999, NSAIDs were then further classified into traditional NSAIDs and cyclooxygenase (COX)-2 inhibitors (coxibs), the latter posing potentially fewer gastrointestinal risks. In 2005, rofecoxib was withdrawn from the market because of concerns about the risk of heart attack and stroke with long-term use, and clinical practice began focusing more on the cardiovascular versus gastrointestinal safety of coxibs. Since then, many coxibs have remained unapproved by the US FDA or have been removed from the market. This article explains how coxibs refocused attention on the cardiovascular safety of NSAIDs and the general implications of that. COX-2 activity/specificity is one factor associated with increased cardiovascular risks; however, these risks cannot be attributed to coxibs alone. The traditional NSAIDs (i.e., meloxicam, etodolac, and nabumetone) have significant COX-2 specificity, but naproxen and ibuprofen have less specificity. All NSAIDs, whether traditional or a coxib, pose some cardiovascular risks. It is possible that clinicians continue to focus more on decreasing the immediate gastric risks than preventing the later cardiovascular risks. The cardiovascular risks posed by NSAIDs should not be disregarded for the sake of achieving gastrointestinal benefits. Current recommendations suggest NSAIDs should be considered a single class of non-aspirin NSAIDs. Preferred NSAIDs are ibuprofen and naproxen. Coxibs are preferred in patients with low cardiovascular risk and high gastrointestinal risk who are intolerant to anti-dyspepsia therapy.

Cost-analysis of the WHO Essential Medicines List in A Resource-Limited Setting: Experience from A District Hospital in India.

The World Health Organization (WHO) has been publishing the essential medicines list (EML) since 1977. The EML includes the most efficacious, safe and cost-effective drugs for the most relevant public health conditions worldwide. The WHO performs a cost-effectiveness analysis within each therapeutic group, but very little is known about which therapeutic groups are costliest for hospitals that adopt the WHO EML concept. In this study, we have described the annual consumption of medicines in a district hospital in India, that limited the list of available drugs according to the WHO EML concept. Only 21 drugs constituted 50% of the hospital spending. Anti-infective medicines accounted for 41% of drug spending, especially antiretrovirals which were used to treat HIV infection. Among other therapeutic groups, insulin had the highest impact on the hospital budget. We identified medicines used in perinatal care, which included anti-D immunoglobulin and lung surfactants, that were used rarely, but bore a relatively high cost burden. The results of this study indicate that, in district that adopt the WHO EML, antiretrovirals and antibiotics were the top therapeutic groups for the drug hospital budgets.

High prescription of antimicrobials in a rural district hospital in India.

BACKGROUND: The World Health Organization (WHO) recommends surveillance of antibiotic use as part of the strategy to fight against antimicrobial resistance. However, there is little information about the antibiotic consumption in developing countries, especially in rural areas. OBJECTIVE: The objective of this study was to describe the antimicrobial consumption in a rural hospital in India. METHODS: The study was performed in a district hospital situated in Anantapur, Andhra Pradesh. In accordance with WHO recommendations, we used the defined daily dose (DDD) methodology to measure the antibiotic use during one year (from 1st August 2011 to 1st August 2012). The antibiotic use was measured using DDDs/100 admissions and DDDs/100 patient-days for inpatients, and DDDs/100 visits for outpatients. RESULTS: During the study period, there were 15,735 admissions and 250,611 outpatient visits. Antibiotics were prescribed for 86% of inpatients and 12.5% of outpatients. Outpatient prescriptions accounted for 2/3 of the overall antibiotic consumption. For inpatients, the total antibiotic use was 222 DDDs/ 100 patient-days, 693 DDDs/ 100 admissions and the mean number of antibiotics prescribed was 1.8. For outpatients, the total antibiotic use was 86 DDDs/ 100 outpatient visits and the mean number of antibiotics prescribed was 1.2. The most common antibiotics prescribed were aminopenicillins and 3rd generation cephalosporins for inpatients, and tetracyclines and quinolones for outpatients. In a sample of patients with diarrhoea or upper respiratory tract infections (URTI), the proportion of patients who received antibiotics was 84% (95% confidence interval [CI], 67-93) and 52% (95% CI, 43-62), respectively. CONCLUSION: In this rural setting, the use of antimicrobials was extremely high, even in conditions with a predominantly viral aetiology such as diarrhoea or URTI.

High prescription of antimicrobials in a rural district hospital in India / Elevada prescripción de antimicrobianos en un hospital rural comarcal en India

Background: The World Health Organization (WHO) recommends surveillance of antibiotic use as part of the strategy to fight against antimicrobial resistance. However, there is little information about the antibiotic consumption in developing countries, especially in rural areas. Objective: The objective of this study was to describe the antimicrobial consumption in a rural hospital in India Methods: The study was performed in a district hospital situated in Anantapur, Andhra Pradesh. In accordance with WHO recommendations, we used the defined daily dose (DDD) methodology to measure the antibiotic use during one year (from 1st August 2011 to 1st August 2012). The antibiotic use was measured using DDDs/100 admissions and DDDs/100 patient-days for inpatients, and DDDs/100 visits for outpatients. Results: During the study period, there were 15,735 admissions and 250,611 outpatient visits. Antibiotics were prescribed for 86% of inpatients and 12.5% of outpatients. Outpatient prescriptions accounted for 2/3 of the overall antibiotic consumption. For inpatients, the total antibiotic use was 222 DDDs/ 100 patient-days, 693 DDDs/ 100 admissions and the mean number of antibiotics prescribed was 1.8. For outpatients, the total antibiotic use was 86 DDDs/ 100 outpatient visits and the mean number of antibiotics prescribed was 1.2. The most commonantibiotics prescribed were aminopenicillins and 3rd generation cephalosporins for inpatients, and tetracyclines and quinolones for outpatients. In a sample of patients with diarrhoea or upper respiratory tract infections (URTI), the proportion of patients who received antibiotics was 84% (95% confidence interval [CI], 67-93) and 52% (95% CI, 43-62), respectively. Conclusion: In this rural setting, the use of antimicrobials was extremely high, even in conditions with a predominantly viral aetiology such as diarrhoea or URTI (AU)

Antecedentes: La Organización Mundial de la Salud (OMS) recomienda la vigilancia del uso de antibióticos como parte de la estrategia de lucha contra la resistencia a antibióticos. Sin embargo, existe poca información del consumo de antibióticos en países en vías de desarrollo, especialmente en áreas rurales. Objetivos: El objetivo de este estudio fue describir el consumo de antimicrobianos en un hospital rural de India. Métodos: El estudio se realizó en un hospital comarcal situado en Anantapur, Andhra Pradesh. De acuerdo con las recomendaciones de la OMS, usamos la metodología de la dosis diaria definida (DDD) para medir el uso de antibióticos durante un año (del 1 de agosto de 2011 a 1 de agosto de 2012). El uso de antibióticos se midió usando las DDD/100 ingresos y las DDD/100 pacientes-día para internados y DDD/100 visitas para los externos. Resultados: Durante el periodo de estudio, hubo 15.735 ingresos y 250.611 consultas externas. Se prescribieron antibióticos en el 86% de los internados y en el 12,5% de los externos. Las prescripciones de los externos sumaron 2/3 del consumo total de antibióticos. Para internados, el uso total de antibióticos fue de 222 DDD/100 pacientes-día, de 693 DDD/100 ingresos y el número medio de antibióticos prescritos fue de 1,8. Para los pacientes externos, el uso de antibióticos fue de 86 DDD/100 visitas y la media de antibióticos prescritos fue de 1,2. Los antibióticos más frecuentemente prescritos fueron las aminopenicilinas y las cefalosporinas de 3a generación para los internados, y las tetraciclinas y quinolonas para los externos. En una muestra de pacientes con diarrea o infecciones del tracto respiratorio superior (URTI), la proporción de pacientes que recibió antibióticos fue del 84% (intervalo de confianza [IC] 95% 67-93) y del 52% (IC95% 43-62), respectivamente. Conclusión: En un entorno rural, el consumo de antibióticos fue extremamente elevado, incluso en situaciones de una etiología predominantemente vírica como diarrea o URTI (AU)

Assessment of Adverse Events and Quality of Life of Cancer Patients in a Secondary Level Care, Rural Hospital in South India.

OBJECTIVE: To grade adverse events (AEs) occurring after chemotherapy in the cancer patients and to explore the quality-of-life (QOL) findings among posttherapy cancer patients in a rural, secondary level care Indian hospital. METHODS: A cross-sectional study was carried out during a 6-month period in a rural secondary level care hospital situated at Anantapur district in South India. Patient and cancer demographics were collected from the cases treated in the study site. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 v 3.0 Telugu (regional language of the study site) module and Common Terminology Criteria for Adverse Events v 4.0 of Cancer Therapy Evaluation Program, USA, were used to assess the QOL and severity grades of AEs, respectively. RESULTS: Most AEs were mild or moderate, with only a few being severe. Insomnia (27.98%), nausea (13.50%), vomiting (12.81%), fatigue (10.90%), and pain (11.68%) were common, with insomnia being the most frequent. The different scores of the QOL scale (functional, symptomatic, financial, and global health status scores) were assessed independently. Among the functional scale parameters, the cognitive and physical functioning scores were good (85.14 and 82.79, respectively) and the social, emotional, and role functioning scores were moderate (77.94, 72.30, and 71.65, respectively). The overall effect of symptoms on QOL showed that the pain score was higher and interfered to a higher extent in patients (36.02) and the dyspnea score was the least and occurred to a lesser extent (7.20). But certain variables such as anorexia, for example, showed a greater interquartile range and SD, which implied that it gave a lesser chance for the prediction of results for that particular condition. Financial burden existed to a moderate level on an average in all the patients. CONCLUSIONS: The occurrence and severity of AEs was low, indicating that the patients tolerated and responded well to therapy. The survivorship is yet to be estimated and the life expectancy to be studied by further investigation of the subjects.

An interventional study on intensive care unit drug therapy assessment in a rural district hospital in India.

BACKGROUND: Intensive care unit is a potential area for drug-related problems. As many of the patients treated are complex patients, clinical pharmacy intervention could find drug therapy problems. MATERIALS AND METHODS: Drug information liaisons daily attended ward rounds with intensivists and screened the patient for drug therapy assessment using the American Society for Health-System Pharmacists clinical skills competition DTA format. This was a prospective study done for 6 months from August 2012 to January 2013. Simple statistics were used to tabulate the drug-related problems assessed. RESULTS: A total of 72 patients were screened for drug therapy problems, for which 947 drug doses were prescribed in the study period. The total number of prescriptions was 148. The average number of drugs per prescription was 6.39 and the average number of drugs per patient was 13.15. A total of 243 problems were identified; on an average, 1.67 problems were present per prescription. The total number of drug interactions identified was N = 192 (78.2%); majority of them (61.4%) were of type C (not serious). So, 55.73% of them were monitored and not stopped or substituted. The second type of problem was a correlation between drug therapy and medical problem (7.4%). Appropriate drug selection and drug regimen was the third problem, and the adverse drug reactions and therapeutic duplications accounted for approximately 2% of the drug-related problems identified. CONCLUSION: Drug interactions constituted the major problem of ICUs, but not many were serious or significant. Consensus in assessment of drug-related problems and convincing intensivists with good quality evidences are required for better acceptance of interventions.

Evaluation and appraisal of drug information services in a rural secondary level care hospital, Anantapur, AP.

BACKGROUND: Drug Information Center (DIC) is an information center which provides drug information (DI) to healthcare professionals. The aim was to evaluate the performance of DIC for improving the quality and quantity of information services provided to the healthcare professionals. The service was provided free of cost to the customers. MATERIALS AND METHODS: This descriptive study was conducted for the period of 6 months from February to August 2011 excluding May due to vacation. Customers were asked: how did they find the service provided to them? Was it good, satisfactory, or need improvement? There were written feedback forms to be filled by the customers, including customer satisfaction questions. The official publication of the DIC, RIPER PDIC Bulletin was screened for its types of articles/number of drug news published. The bulletin is circulated for free to the healthcare professionals electronically. RESULTS AND DISCUSSION: A total of 232 queries were obtained during the study period of 6 months. Average number of queried received to the DIC was 39 per month. Most preferred mode of queries was personal access (89%). Majority of queries were received from nurses, i.e., 162 (70%) queries and 81% of all queries were drug oriented for improving knowledge. There were only 19% of the queries for individual patients; doctors asked most of those queries. Only 3% queries answered were rated as need improvement by the healthcare professionals. Rest were considered as either Good (56%) or satisfactory (49%). Range of drug news published in each bulletin was 3-4 and most of the other articles include expert opinion to improve practice or training. CONCLUSION: The DI services were satisfactorily used for academic interests. Nurses used the service for the highest compared to other health care professionals. Future studies should plan to establish the usefulness of DI to improve healthcare practice.

Comparison of essential drug list in a rural secondary care hospital in south India with Indian & World Health Organization list 2011.

OBJECTIVE: Fixed drug combinations are a major marketing strategy in India but it can compromise the rational use of medicines. In this study we compared the fixed drug combinations and dosage forms in the hospital pharmacy before and after introducing the essential drug list. We also compared the Hospital Essential Drug List (HEDL) 2011 with the World Health Organization (WHO) Essential Drug List (EDL) 2011 and the National Essential Drug List of India (NEDL) 2011. METHODS: The study was done in a secondary level care charity hospital at Anantapur, AP with a bed size of 315 and an average OP per day of 1200-1700 visits. We compared the three essential drug lists (HEDL, WHOEDL and NEDL) and the hospital drug list before introducing EDL. Drugs which were present in NEDL and not present in the HEDL were also screened. Microsoft excel was used to tabulate the results and for graphs. RESULTS: The number of medicines used in the hospital before and after the introduction of the HEDL was 1627 and 424 respectively. On comparison, WHOEDL 2011 have 350 and NEDL of India have 348 medicines. While preparing the HEDL, 46 double drug combinations decreased to 15 and 9 triple drug combinations decreased to 1. In the case of injections, 20 double drug combinations decreased to 6 and 1 triple drug combination increased to 2. The number of tablets, capsules, injections, syrups, powders and inhalers was reduced to almost half. The great reductions were in 51 ointments to 9, 69 drops to 5, 11 paste to 0, 21 solutions to 3 and 14 creams to 1. The dosage forms removed included elixirs, insulin pens, gums, paste, paints, gargles and mouthwashes. CONCLUSIONS: There was drastic reduction in the number of medicines and dosage forms when the HEDL was implemented. Many of the fixed drug combinations were also removed for improving the rational use of medicines. The WHO essential drug list 2011, national essential drug list of India 2011 and the hospital essential drug list 2011 were comparable with few exceptions.