Prescribed heart failure pharmacotherapy: How closely do GPs adhere to treatment guidelines?

BACKGROUND: Heart failure patients need GPs to adhere to treatment guidelines to improve health outcomes. OBJECTIVE: To examine the extent to which pharmacotherapy of heart failure patients referred for a Home Medicines Review (HMR) adheres to heart failure management guidelines. METHODS: This retrospective study examined HMR reports of patients with heart failure, who were referred for a HMR due to polypharmacy. Analysis established current pharmacotherapy patients were taking and whether it aligned with heart failure guidelines. Further analysis established the types of recommendations made to the referring GPs, in order to optimise heart failure pharmacotherapy. RESULTS: There were 258 patients referred for HMRs between 2015 and 2018; 30 patients had a diagnosis of heart failure and therefore included in the analysis. Out of these, 13 patients were not on an ACEI and 23 were not on an AR2B; seven patients were neither on ACEI nor AR2B. The pharmacist recommended commencing ACEI in 4 patients and an AR2B in 2 patients. Nine patients were not on any B-blocker, and 4 patients were recommended to commence a B-blocker. Most patients were on suboptimal doses of their heart failure medicines, for which dose up-titrations were recommended. There was a recommendation to assess 6 patients for symptoms indicative of heart failure exacerbation, e.g. SOB. CONCLUSION: Heart failure pharmacotherapy in patients referred for HMRs was not optimised. Pharmacists play a crucial role in optimising the treatment of heart failure, and in prompting GPs to align pharmacotherapy with treatment guidelines.

Combined Omics Reveals That Disruption of the Selenocysteine Lyase Gene Affects Amino Acid Pathways in Mice.

Selenium is a nonmetal trace element that is critical for several redox reactions and utilized to produce the amino acid selenocysteine (Sec), which can be incorporated into selenoproteins. Selenocysteine lyase (SCL) is an enzyme which decomposes Sec into selenide and alanine, releasing the selenide to be further utilized to synthesize new selenoproteins. Disruption of the selenocysteine lyase gene (Scly) in mice (Scly-/- or Scly KO) led to obesity with dyslipidemia, hyperinsulinemia, glucose intolerance and lipid accumulation in the hepatocytes. As the liver is a central regulator of glucose and lipid homeostasis, as well as selenium metabolism, we aimed to pinpoint hepatic molecular pathways affected by the Scly gene disruption. Using RNA sequencing and metabolomics, we identified differentially expressed genes and metabolites in the livers of Scly KO mice. Integrated omics revealed that biological pathways related to amino acid metabolism, particularly alanine and glycine metabolism, were affected in the liver by disruption of Scly in mice with selenium adequacy. We further confirmed that hepatic glycine levels are elevated in male, but not in female, Scly KO mice. In conclusion, our results reveal that Scly participates in the modulation of hepatic amino acid metabolic pathways.

Anaemia in heart failure patients: the prevalence of haematinic deficiencies and the role of ACE inhibitors and aspirin doses as risk factors.

BACKGROUND: Patients with heart failure often have comorbidities that alter the progression of heart failure and impact on prognosis. One such comorbidity is anaemia, and clinicians have started to appreciate the full gravity of its impact on heart failure patients. Yet, the extent of the problem is not fully understood, particularly the role of heart failure therapy itself as a risk factor for developing anaemia. OBJECTIVE: This study aimed to investigate the prevalence of anaemia in a cohort of heart failure patients. The impact of using different ACEIs and different doses of aspirin was also explored, together with the prevalence of haematinic deficiencies. METHODS: Medication lists and pathology results were examined to establish the prevalence of ACEIs use, and the use of aspirin at its most common doses of 100mg and 150mg, together with haematinic deficiencies. Multinomial logistic regression and the Student's t-test were utilised for the analysis of data. Statistical significance was pre-set at p<0.05. RESULTS: Ninety-six patients were eligible for analysis, with 26% having anaemia. The use of ACEIs had a RR of 17.4 for the presence of anaemia. Perindopril was associated with a RR of 20.8, while the use of ramipril was not significantly associated with such a high RR. Haematinic anaemia occurred only at a rate of 3.3%, but borderline deficiencies were found in more than a third of all patients. An aspirin dose of 150mg was associated with a higher risk for anaemia, compared to a dose of 100mg. CONCLUSIONS: ACEIs are associated with the presence of anaemia, with perindopril posing more risk than ramipril when used in heart failure patients. The dose of aspirin may also be a factor in the development of anaemia, with lower doses being safer. Despite the lack of high prevalence of haematinic anaemia among this cohort of patients, borderline haematinic deficiencies were common.

Anaemia in heart failure patients: the prevalence of haematinic deficiencies and the role of ACE inhibitors and aspirin doses as risk factors

Background: Patients with heart failure often have comorbidities that alter the progression of heart failure and impact on prognosis. One such comorbidity is anaemia, and clinicians have started to appreciate the full gravity of its impact on heart failure patients. Yet, the extent of the problem is not fully understood, particularly the role of heart failure therapy itself as a risk factor for developing anaemia. Objective: This study aimed to investigate the prevalence of anaemia in a cohort of heart failure patients. The impact of using different ACEIs and different doses of aspirin was also explored, together with the prevalence of haematinic deficiencies. Methods: Medication lists and pathology results were examined to establish the prevalence of ACEIs use, and the use of aspirin at its most common doses of 100mg and 150mg, together with haematinic deficiencies. Multinomial logistic regression and the Student's t-test were utilised for the analysis of data. Statistical significance was pre-set at p<0.05. Results: Ninety-six patients were eligible for analysis, with 26% having anaemia. The use of ACEIs had a RR of 17.4 for the presence of anaemia. Perindopril was associated with a RR of 20.8, while the use of ramipril was not significantly associated with such a high RR. Haematinic anaemia occurred only at a rate of 3.3%, but borderline deficiencies were found in more than a third of all patients. An aspirin dose of 150mg was associated with a higher risk for anaemia, compared to a dose of 100mg. Conclusions: ACEIs are associated with the presence of anaemia, with perindopril posing more risk than ramipril when used in heart failure patients. The dose of aspirin may also be a factor in the development of anaemia, with lower doses being safer. Despite the lack of high prevalence of haematinic anaemia among this cohort of patients, borderline haematinic deficiencies were common

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Bicalutamide causes heart failure in an elderly patient with prostate cancer.

OBJECTIVE: To examine the molecular mechanisms by which bicalutamide may cause heart failure in an elderly patient. METHODS: Retrospective analysis of bicalutamide as a cause of heart failure in Mr FD, an 82 years old with prostate cancer. RESULTS: Following months of therapy, Mr FD was diagnosed with heart failure. Bicalutamide has been ceased, but 21 months later, Mr FD was still on heart failure medications, and passed away months later probably due to complications of prostate cancer. The Naranjo ADR probability scale gave this case a score of seven. CONCLUSION: The Naranjo scale strongly suggests that bicalutamide was the cause of heart failure. Apoptosis seems to be one of the mechanisms mediating heart failure, with the involvement of many molecular actors, such as ET-1, Bcl-2 and cyclin-A. The author believes this to be the first analysis describing bicalutamide as a probable cause of heart failure.

The use of nonprescription medicines among elderly patients with chronic illness and their need for pharmacist interventions.

OBJECTIVE: The use of over-the-counter (OTC) products and complementary medicines (CM) often results in adverse events. Little is known about the type of pharmacist interventions needed by elderly patients to optimize their use of such products. This study examines the prevalence of OTC/CM products used among chronically ill elderly patients and the types of pharmacist interventions the patients need. Gender differences were also investigated. DESIGN: Retrospective cohort study. SETTING: Homes of 51 patients recruited from a major metropolitan hospital in Melbourne, Australia. PATIENTS: Fifty-one elderly patients with chronic illness referred to the Outreach Medication Review program. INTERVENTION: Pharmacists' interventions to optimize the use of OTC/CM products. MAIN OUTCOME MEASURES: Number of OTC/CM products used and the number and type of pharmacists' interventions. RESULTS: 80.4% of patients were using OTC products, while 21.6% used CM products. Many OTC products were not used at the right dose, requiring pharmacists to adjust the dose in 18.7% of cases. Other patients (18.8%) were unaware of dosing regimens, while about one-third of patients needed to be educated on managing the ailment that required their use of the OTC/CM product in the first place. Men showed a nonsignificant increase in their need for pharmacist interventions. CONCLUSION: Elderly patients in this study used OTC/CM products, often without a proper understanding of the management principles of their condition or the dosing regimens of the products they use. Men may need more pharmacist interventions in relation to their use of OTC/CM products. Pharmacists should offer comprehensive advice on managing presenting ailments and requests for OTC/CM products.

Medications collected for disposal by outreach pharmacists in Australia.

OBJECTIVE: To examine the types, quantities, and monetary value of drugs which are disposed of by patients of outreach pharmacists, and to describe the role of outreach pharmacists in promoting the safe disposal of drug waste and reducing medication cost. SETTING: An Outreach Medication Review service at a major public hospital in Melbourne, Australia. METHODS: Part of the service offered by outreach pharmacists in OMR at St Vincent's Hospital Melbourne is to collect the medications that have expired, or are no longer needed by patients. This audit looked at all the items collected over a period of 2 months, July and August of 2008. We recorded the types of medication groups and the number of items in each of these groups. An estimate of the value of this medicinal waste was also made. MAIN OUTCOME MEASURE: Measurable parameters were the number of medications collected in the various therapeutic groups, and an estimate of their monetary value. This served to provide an estimate of the total value of wasted medications. RESULTS: Medications collected fell into 11 therapeutic groups, with a total of 293 items collected. The largest number of medications belonged to the cardiovascular group. The number of patients seen was 40 patients, with each patient having an average of 7.3 items that are either expired or unnecessary. The estimated value of medicinal waste per patient is about AU$1308 annually. CONCLUSION: Outreach pharmacists are in a good position to collect unnecessary medications, and to educate patients on the prudent use of government subsidy of medications. The economic ramification of medication disposal is significant, in terms of the cost of medications that end up not being used. Cardiovascular medications are the main group that end up being wasted, and is among the most expensive to subsidize. Further studies are needed to examine ways of minimising medication waste and reducing the cost of such wastage.