Pharmacogenetic information in Swiss drug labels - a systematic analysis.

Implementation of pharmacogenetics (PGx) and individualization of drug therapy is supposed to obviate adverse drug reactions or therapy failure. Health care professionals (HCPs) use drug labels (DLs) as reliable information about drugs. We analyzed the Swiss DLs to give an overview on the currently available PGx instructions. We screened 4306 DLs applying natural language processing focusing on drug metabolism (pharmacokinetics) and we assigned PGx levels following the classification system of PharmGKB. From 5979 hits, 2564 were classified as PGx-relevant affecting 167 substances. 55% (n = 93) were classified as "actionable PGx". Frequently, PGx information appeared in the pharmacokinetics section and in DLs of the anatomic group "nervous system". Unstandardized wording, appearance of PGx information in different sections and unclear instructions challenge HCPs to identify and interpret PGx information and translate it into practice. HCPs need harmonization and standardization of PGx information in DLs to personalize drug therapies and tailor pharmaceutical care.

Methotrexate intoxication: the Pharmaceutical Care process reveals a critical error.

WHAT IS KNOWN AND OBJECTIVES: Intoxication with oral low-dose methotrexate (MTX) is a well-known and frequent problem, which is often discovered accidently. The major reason is error in the frequency of dosing, mostly of daily instead of weekly intake. We report a case where the critical error was discovered by the community pharmacist during the routine implementation of the Pharmaceutical Care process SOAP while dispensing a new prescription for the patient. DETAILS OF THE CASE: A 78-year-old widow went to her regular community pharmacy to pick up a prescription for oral mucositis. The evaluation of the case by the pharmacist using the SOAP (an acronym for Subjective, Objective, Assessment and Plan) note method revealed the underlying oral low-dose MTX intoxication which led to hospitalization a few days later. The incorrect interpretation of the required dose had arisen from the written instructions for use and led to the erroneous intake of MTX daily (instead of weekly). We interviewed the patient at her home 2months after discharge. She explained that her continued intake of MTX in spite of manifest adverse effects was because of a profound conviction that she was doing right. Her confidence in physicians remained unchanged after the incident, but she would now refuse to take MTX. WHAT IS NEW AND CONCLUSION: The reasons for the intoxication were not discovered accidently but by the routine use of the Pharmaceutical Care process SOAP by the community pharmacist. We describe three main errors that might have been avoided and provide solutions for physicians, pharmacists, manufacturers and patients, to reduce such risks. Our case highlights the dangers of teleconsultation, the crucial role of Pharmaceutical Care provided by community pharmacists and the continued need to supply advice to patients being prescribed low-dose MTX. The fact that a patient has had a previous and successful experience with a similar treatment should not deter health professionals from verifying a patient's understanding via questions and feedback.

Prescribed medications and pharmacy interventions for acute respiratory tract infections in Swiss primary care.

BACKGROUND AND OBJECTIVES: Symptomatic medications are often not considered in clinical studies assessing interventions to reduce prescribing of antibiotics for acute respiratory tract infections (ARTI). Our study objectives were to examine prescribing patterns of antibiotics and symptomatic medications for ARTI in Swiss primary care and to monitor pharmacists' interventions during the prescription-dispensing process. METHODS: Medical records of 695 patients participating in a clinical trial which was designed to reduce use of antibiotics for ARTI in primary care, were linked to their prescriptions. Matching of prescribed and dispensed medications enabled the assessment of interventions by community pharmacists. RESULTS: On average, 2.4 different drugs were prescribed per patient (in total 142 antibiotics, 1599 symptomatic medications, and 56 non-ARTI-medication). Most patients (80%) were treated only with symptomatic medications. Most frequently prescribed symptomatic ARTI-medications were nasal decongestants (39%), cough suppressants (36%), and mucolytics (31%). Patients with prescribed antibiotics received significantly fewer symptomatic medications (odds ratio, 0.24; 95% confidence interval 0.16-0.37). Over 20% of prescriptions prompted at least one intervention by a pharmacist in the dispensing process. A discrepancy between prescribed and dispensed medications was seen in 19% of patients. CONCLUSIONS: Prescription rates of antibiotics for ARTI in this trial were low and patients were treated mainly with non-antibiotic symptomatic medications. Efforts to reduce antibiotic prescribing may induce higher rates of use of medications for intensive symptomatic treatment. Considerable differences between prescribed and dispensed medications were noted.

Management of drug-interaction alerts in community pharmacies.

BACKGROUND AND OBJECTIVE: Drug-interaction alert systems are commonly used in community pharmacies to identify potential drug-drug interactions. However, depending on the software default setting, pharmacists may override alerts because they are too numerous. We explored the handling of drug-interaction alerts by community pharmacies in Switzerland. METHODS: Data were collected by 15 trained pharmacy students in 15 Swiss community pharmacies. The medication history and the drug-interaction alerts of 600 patients who had >or=2 drugs on prescription were assessed, and the pharmacists in charge were interviewed about their management of drug-interaction alerts. RESULTS: In the 15 pharmacies studied, the computer systems were programmed to flag only 'severe' drug interactions in four, 'severe or moderate' in six or 'severe, moderate or minor' in five pharmacies. The median frequency of drug-interaction alerts increased with decreasing default severity level from 0.5 to 40, respectively, to 76 per 40 patient visits and pharmacy. Because of these default settings, 277 (35 x 2%) of 787 potential drug-interaction alerts on new or repeated prescriptions were overridden by the computer systems. Only 256 (32 x 5%) of 787 potential drug interactions emerged from new prescriptions. The alert systems produced 656 alerts of which 146 were irrelevant because of multiple alerting of the same interaction or of drug combinations currently no longer taken. Of the 510 remaining relevant drug-interaction alerts, 289 (56 x 7%) were overridden by community pharmacists without any action taken. If the pharmacist took care of a patient's prescription him- or herself (as opposed to just controlling a prescription after a technician took care of the patient), fewer drug-interaction alerts were overridden by the pharmacist [Odds ratio (OR) 0 x 6, 95% confidence interval (CI) 0 x 42-0 x 98; P=0 x 042). Technical overrides (by default settings) and pharmacists' overrides together accounted for 71 x 9% (566 of 787 potential drug interactions). Of the remaining 211 interactions alerts, 87 (41 x 2%) were checked more closely by consulting the literature, contacting the prescribing physician or discussion with the patient. This led to 55 (63 x 2%) interventions (close monitoring, adjustment of dose or ingestion time, therapy stop or switching to alternative therapy). Determinants associated with action taken after an interaction alert were potential high severity (severe or moderate) (OR 3 x 34, 95% CI 1 x 77-6 x 31; P<0 x 001) and alert flagged for the first time (OR 3 x 76, 95% CI 1 x 98-7 x 14; P<0 x 001). All severe potential drug interactions (n=10) generated an alert and all caused an intervention. CONCLUSIONS: Pharmacists override a substantial proportion of drug-interaction alerts of minor or moderate potential severity by ignoring them or by programming the system to only flag drug interactions of potentially high severity. More sophisticated systems with improved sensitivity and specificity are required. Until these become available, it is important to ensure that at least potentially severe drug interactions are not missed; a goal that seems to be largely achieved.

Prevalence and patient awareness of selected potential drug interactions with self-medication.

BACKGROUND AND OBJECTIVE: In community pharmacies potential drug interactions between prescription only medicines (POM) and over-the-counter (OTC) drugs purchased for self-medication arise mainly in two situations: (i) if an OTC drug is purchased by a passer-by customer whose prescribed drug therapy is not known; or (ii) if a POM or an OTC drug is requested by a regular customer whose prescribed drug therapy is usually recorded. With this study we aimed to assess the prevalence of potential drug interactions with selected POM and OTC drugs in passer-by and regular customers as well as their awareness of these potential drug interactions. METHODS: Data were collected in 14 community pharmacies in the region of Basel, Switzerland by observation of customer contacts and interviews with passer-by customers purchasing selected OTC drugs, and telephone-interviews with regular customers treated with selected POMs identified in community pharmacies' databases. The selected POMs and OTC drugs are drugs which could lead to clinically relevant drug interactions of varying severity but manageable through different interventions such as adjustment of dose and its timing and/or monitoring of the therapy, and avoidance of the combination by choosing an alternative treatment. RESULTS: Of 1183 passer-by customers observed, 164 (14 x 4%) purchased at least one of the selected OTC drugs. One hundred and two (62 x 2%) of those subjects were interviewed. Forty-three (42 x 2%) mentioned taking prescribed drugs, and three of them were exposed to potential drug interactions of moderate severity. Out of 592 regular customers selected from the community pharmacy database, 434 (73 x 3%) could be interviewed. Sixty-nine (15 x 9%) of them were exposed to a potential drug interaction between purchased OTC drug for self-medication and their POM. Furthermore, 116 (26 x 7%) regular customers were exposed to potential drug interactions within their prescribed drugs and in 28 (6 x 5%) multiple (>or=2) potential drug interactions were found. Two hundred and three (46 x 8%) regular customers were aware of potential drug interactions between their POM and OTC drugs. Ninety-six (47 x 3%) of them were informed by their prescribing physician and 52 (25 x 6%) by their community pharmacist. Awareness of potential drug interaction was higher in younger customers [odds ratio (OR) 0 x 95; 95% confidence intervals (CI) 0 x 93, 0 x 97, P<0 x 0001] and higher for drug interactions classified as 'severe' [OR 1 x 79; 95% CI 1 x 16, 2 x 77, P=0 x 009]. CONCLUSION: Efforts to increase awareness of potential drug interactions is needed. Although community pharmacies are adequately equipped with computerized drug interaction surveillance systems this is often not applied to self-medication. Vigilance for potential interactions of all drugs, including those sold over the counter, should be increased.

[Application aids in pharmacotherapy]. / Applikationshilfen aus der Apotheke.

The actual administration of pharmacotherapy is in most cases entirely up to the patient. Correct application can often be only achieved with application aids. They are already part of many preparations: printed blister packages, measures for dosing liquids, applicators for topical use, dosage sprays, and supports for eye drop containers. Special needs can be covered by additional application aids like dosage syringes for child medication, spacers for asthma sprays, devices for splitting or crunching tablets. Filling the medicines in containers better manageable by the patient, in week dispensers or week blisters, may also be crucial to guarantee correct dosing and regimen. Application aids often play a significant part in the success of a therapy. Needed are evidence based criteria for the selection of devices and instructions. Such criteria need to be developed because they are still largely lacking.

Screening for sleep disorders in community pharmacies--evaluation of a campaign in Switzerland.

BACKGROUND: In 2003 the Swiss federation of pharmacists organized a campaign "sleep disturbances--daytime sleepiness". The goal was to assist pharmacy clients in detecting likely causes of any sleep disturbance or daytime sleepiness through a free of charge screening, and to deliver targeted counselling. For pharmacy practice there are no screening or triage guidelines to assess the severity of sleep and wakefulness disturbances and potential causes for those disturbances. In this paper the outcome of the campaign in terms of feasibility, participation, observed response patterns, sale of over-the-counter (OTC) sleeping pills, and counselling activities is evaluated. METHODS: The Stanford sleep disorders questionnaire and the Epworth sleepiness scale served to identify patterns of symptoms suggestive of four major categories of sleep disorders. The questionnaires were posted on a web-site and the clients' data were entered online in the pharmacies. A report was automatically generated and immediately available online to the pharmacists. The pharmacists documented separately their counselling activities in a pharmacist's activity report. RESULTS: Six hundred and twenty-two (23%) of 2743 pharmacy clients had response patterns suggestive of obstructive sleep apnoea, 418 (15%) of restless-legs-syndrome, 39 (1%) of a sleep disorder potentially associated with a psychiatric condition and 79 (3%) of narcolepsy. An Epworth sleepiness score >10 points was found in 567 (21%). After screening, 2345 (86%) pharmacy clients received targeted counselling. Only 216 (8%) purchased an OTC sleeping pill and 704 (26%) were recommended to consult a physician, but of these, 446 (63%) were already under medical supervision. CONCLUSIONS: The online screening tool for sleep disorders and daytime sleepiness was successfully introduced in Swiss pharmacies. Pharmacies were able to assess the pattern of individual sleep disorders and to identify a possible cause in nearly one-third of the cases.

[Return of unused drugs to pharmacies]. / Rücklauf ungenutzter Medikamente in Apotheken.

For the first time unused drugs have been analyzed in Switzerland. The two non profit organizations MEDI HELP DIRECT in Zurich and Pharmaciens sans Frontières in Neuchâtel collected the unused drugs with the aim to examine the quality and the quantity of the medication returned to the pharmacies. In both cantons about 5000 units have been registered and examined with the respect to shelf-life, contents, requirement of prescription and reimbursement by health companies. Two thirds of the drugs have 50-100% contents left over. Prescribed medicines returned faster to the pharmacies and are less often expired.