Drug Interaction Between Favipiravir and Warfarin: A Case Series.

Introduction: Initiating favipiravir in COVID-19 patients with long-term warfarin use can lead to increased INR. However, data on the onset and duration of the increasing INR are limited. Method: We reviewed patient charts to include COVID-19 adult patients who received favipiravir for at least 5 days and used warfarin at the same dose for at least 12 weeks. Data on demographics, comorbidities, other medical characteristics, international normalized ratio (INR), and signs of bleeding were collected. Result: Eight patients, with a mean age of 70.88 ± 8.49 years old, received the standard dose of favipiravir. The mean maximum INR (4.30 ± 1.26) was statistically different from the baseline INR (P = .00029) and the change was observed within 4.38 ± 1.99 days after initiating favipiravir. Warfarin was then discontinued without favipiravir discontinuation in most patients, allowing the INR to gradually decrease within 2 to 3 days. Conclusion: Concurrent use of favipiravir and warfarin led to INR prolongation within approximately 4 days. The effect of such interaction can be acute as the prolongation occurred within 1 day in 1 of the patients.

The Impact of Omitting 5-FU Bolus From mFOLFOX6 Chemotherapy Regimen on Hematological Adverse Events Among Patients With Metastatic Colorectal Cancer.

Background: Metastatic colorectal cancer (mCRC) is often treated with a mFOLFOX6 regimen. The 5-fluorouracil (5-FU) bolus is often omitted from the regimen to reduce the risk of hematological adverse events (AEs) in patients with poor performance status. We aimed to investigate the incidence of hematological AEs in Asian patients with mCRC who were treated with the mFOLFOX6 with and without 5-FU bolus dosing. Methods: This retrospective chart review was conducted at King Chulalongkorn Memorial Hospital, Thailand from June 2021 to June 2022. The primary endpoints were hematological AEs. Secondary endpoints were any AEs. The comparison of continuous data was conducted with an independent t-test. The Chi-squared test was used to compare categorical data. Results: From 110 patients, we found that hematological and non-hematological AEs of any grade in the two groups were not significantly different. However, patients in the bolus arm had a significantly lower absolute neutrophil count (ANC) than those in the non-bolus arm (mean difference = 43.13 (95% confidence interval (CI): 20.74, 65.51), P-value = 0.0002). A subgroup analysis in patients who received first-line treatment with mFOLFOX6 showed that the bolus arm had a significantly lower ANC (mean difference = 46.01 (95% CI: 19.99, 72.03), P-value = 0.0007). Conclusions: mCRC patients who were treated with bolus 5-FU had lower ANC. The 5-FU bolus omission from the mFOLFOX6 regimen may be required in patients with a high risk of neutropenia.

After morning, phew! A knowledge, attitudes, and practices survey related to emergency oral contraception in Thai pharmacists.

INTRODUCTION: Pharmacists' knowledge and attitude toward Emergency Oral Contraception (EOC) can affect users' access to EOCs, especially where EOCs are provided by pharmacists without the need for prescriptions. We conducted a Knowledge, Attitudes, and Practice (KAP) survey on Thai pharmacists to better understand KAP related to EOCs and the correlation among KAP components. METHODS: An in-depth interview, GoogleTrend search, and Pantip.com search were conducted. The findings, together with data from a previously published systematic review and meta-analysis, were used to develop KAP survey questions which were distributed online. Spearman's rank correlation coefficient and linear mixed model were used to investigate the correlation and association among KAP components. RESULTS: The in-depth interview with pharmacists showed that sex and unwanted pregnancy are very sensitive topics in Thailand. Sex and EOC education should be provided by parents and healthcare professionals at a young age. This agreed with opinions from Thai internet users that sex literacy was generally low and sex education was not provided adequately. From the total of 421 survey responses, Thai pharmacists had average knowledge, poor attitude, and average practice related to EOCs (median score = 51.02%, 21.81%, and 60.0%, respectively). The correlations between KAP in pharmacists were weak (ρ = 0.107-0.525, p < 0.02). Pharmacists who rated themselves as having higher scores in knowledge and attitude also rated themselves higher in the practice score. However, the total scores describing the knowledge of or attitude toward EOCs were not associated with EOC practice scores. CONCLUSIONS: In Thai pharmacists, self-rating KAP scores overestimated total KAP scores. The correlation among KAP components was weak. EOC knowledge and attitudes should be promoted, although this may not improve EOC practice in Thai pharmacists.

A systematic review and meta-analysis of the prevalence and association between levonorgestrel and ectopic pregnancy.

BACKGROUND: The use of levonorgestrel emergency oral contraceptives (EOCs) is one of the factors that may be associated with ectopic pregnancy. We aimed to investigate the incidence of ectopic pregnancy in EOC users and the association between EOCs and ectopic pregnancy. RESEARCH DESIGN AND METHODS: We searched for articles that provided the incidence of and the association between levonorgestrel EOCs and ectopic pregnancy in women of reproductive ages in CINAHL Complete, Medline, OpenDissertations, Scopus, Science Direct, and Thai Journal Online. The risk of bias was assessed by Risk Of Bias In Non-randomized Studies or Risk of Bias 2. A meta-analysis was conducted using the random-effects model. RESULTS: We retrieved 1839 nonredundant articles from the systematic search. The meta-analysis showed that the prevalence of ectopic pregnancy was not statistically different from zero (pooled prevalence estimate = 0.029%; 95%CI: -0.006, 0.065; N = 9; I2 = 0) and rare. In addition, levonorgestrel EOCs increased the risk of ectopic pregnancy (OR = 6.17; 95%CI: 3.78, 10.08; N = 5; I2 = 43%). CONCLUSIONS: Women with extrauterine or ectopic pregnancy had higher odds of using levonorgestrel emergency oral contraceptives than those with intrauterine pregnancy. However, the prevalence of ectopic pregnancy is rare.

Safety of Vitamin K in mechanical heart valve patients with supratherapeutic INR: A systematic review and meta-analysis.

BACKGROUND: Patients who had mechanical heart valves and an international normalized ratio (INR) of >5.0 should be managed by temporary cessation of vitamin K antagonist. This study aimed to investigate the safety of low-dose vitamin K1 in patients with mechanical heart valves who have supratherapeutic INR. METHODS: CINAHL, Cochran Library, Clinical trial.gov, OpenGrey, PubMed, ScienceDirect, and Scopus were systematically searched from the inception up to October 2021 without language restriction. Studies comparing the safety of low-dose vitamin K1 treatment in patients with placebo or other anticoagulant reversal agents were included. We used a random-effect model for the meta-analysis. Publication bias was determined by a funnel plot with subsequent Begg's test and Egger's test. RESULTS: From 7529 retrieved studies, 3 randomized control trials were included in the meta-analysis. Pooled data demonstrated that low-dose vitamin K was not associated with thromboembolism rate (risk ratio [RR] = 0.94; 95% CI: 0.19-4.55) major bleeding rate (RR = 0.58; 95% CI: 0.07-4.82), and minor bleeding rate (RR = 0.60; 95% CI: 0.07-5.09). Subgroup and sensitivity analysis demonstrated the nonsignificant effect of low-dose vitamin K on the risk of thromboembolism. Publication bias was not apparent, according to Begg's test and Egger's test (P = .090 and 0.134, respectively). CONCLUSION: The current evidence does not support the role of low-dose vitamin K as a trigger of thromboembolism in supratherapeutic INR patients with mechanical heart valves. Nevertheless, more well-designed studies with larger sample sizes are required to justify this research question.