Adrianne Faber

Effects of Medication Review on Drug-Related Problems in Patients Using Automated Drug-Dispensing Systems

Background: There are concerns that automated drug dispensing may increase inappropriate drug use. Automated dispensing could lead to perpetual repeating of drug therapies without the necessary re-evaluation.Objectives: The aim of this study was to examine the effect of a pharmacist-led medication review on drug-related problems (DRPs) in older patients receiving their drugs via automated dispensing.Methods: This was a pragmatic randomized controlled study conducted in primary care. Patients were recruited from six Dutch community pharmacies. They were eligible if they lived at home, were aged ≥65 years, and used five or more different drugs, of which at least one had to be dispensed via an automated system. Patients were randomly allocated to receive a medication review at the start of the study (intervention group) or after 6 months (waiting-list group). Each patient was independently reviewed by two pharmacist reviewers. The results of these medication reviews were sent to the community pharmacist to be discussed with the patient’s general practitioner (GP). The primary outcome measure was the number of DRPs leading to a recommendation for drug change. Secondary outcomes were the total number of drug changes and the number of drug changes related to a recommendation. In order to analyse drug changes, medication records were collected 6 months after the medication review or index date in the waiting-list group. Potential DRPs were classified using the DOCUMENT classification.Results: There were no baseline differences between the 63 patients in the intervention group and the 55 patients in the waiting-list group with respect to age, sex, number of drugs per patient and type of drug prescribed. The mean number of DRPs per patient at baseline in the intervention group and waiting list combined was 8.5, with no difference between the groups. At baseline, the mean number of DRPs leading to a recommendation for drug change was 4.5 per patient and did not differ between the two groups. After 6 months, the number of DRPs leading to a recommendation for drug change decreased by 29% in the intervention group versus 5% in the waiting-list group (p < 0.01). Recommendations for cessation of a drug were more frequently accepted than recommendations to add a new drug (82% vs 44%, p = 0.01).Conclusions: This study shows that patients using automated drug dispensing have a high number of DRPs. Medication review decreases the number of DRPs among these patients. We recommend that all patients with automatic drug dispensing should have a thorough medication review by pharmacists and prescribers.

The contribution of patient interviews to the identification of drug-related problems in home medication review.

What is known and Objective:  To determine to what extent patient interviews contribute to the identification of drug‐related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance.

Current issues around the pharmacotherapy of ADHD in children and adults

Background New drugs and new formulations enter the growing market for ADHD medication. The growing awareness of possible persistence of ADHD impairment beyond childhood and adolescence resulting in increased pharmacotherapy of ADHD in adults, is also a good reason for making an inventory of the what is generally known about pharmacotherapy in ADHD. Aim To discuss current issues in the possible pharmacotherapy treatment of ADHD in children, adolescents and adults with respect to the position of pharmacotherapy in ADHD treatment guidelines, the pharmacoepidemiological trends, and current concerns about the drugs used. Methods A search of the literature with an emphasis on the position of pharmacotherapy in ADHD treatment guidelines, the pharmacoepidemiological trends, and current concerns about the drugs used in pharmacotherapy. Results According to the guidelines, the treatment of ADHD in children consists of psychosocial interventions in combination with pharmacotherapy when needed. Stimulants are the first-choice drugs in the pharmacological treatment of ADHD in children despite a number of well known and frequently reported side effects like sleep disorders and loss of appetite. With regard to the treatment of adults, stimulant treatment was recommended as the first-choice pharmacotherapy in the single guideline available. Both in children and adults, there appears to be an additional though limited role for the nonadrenergic drug atomoxetine. The increase of ADHD medication use, in children, adolescents and in adults, can not only be interpreted as a sign of overdiagnosis of ADHD. Despite the frequent use of stimulants, there is still a lack of clarity on the effects of long-term use on growth and nutritional status of children. Cardiovascular effects of both stimulants and atomoxetine are rare but can be severe. The literature suggests that atomoxetine may be associated with suicidal ideation in children. Conclusion Although pharmacotherapy is increasing common in the treatment of ADHD in both children and adults, there are still a lot of questions about side effects and how best to counter them. This suggests an important role for close monitoring of children and adults treated with stimulants or atomoxetine.

Medication adherence and knowledge of older patients with and without multidose drug dispensing

OBJECTIVE we compared the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD users) with patients receiving manually dispensed drugs (non-MDD users). METHODS MDD users (≥ 65 years, ≥ 5 oral chronic drugs) were randomly selected from eight Dutch community pharmacies. Non-MDD users (≥ 5 oral chronic drugs) were matched on age and gender. Medication adherence was assessed by using the Medication Adherence Reporting Scale (MARS) and medication knowledge by asking the indication of drugs. Cognitive function was measured with Mini-Mental State Examination (MMSE) for a sub selection of patients. RESULTS the percentage of patients being adherent to all drugs was higher for MDD users (n = 119, 81%) compared with non-MDD users (n = 96, 58%, P < 0.001).The percentage of patients with adequate knowledge was lower for MDD users (40%) compared with non-MDD users (79%, P < 0.001). The differences in adherence were independent of knowledge and MMSE scores. CONCLUSION this study shows that older patients receiving their drugs via MDD reported a higher medication adherence compared with patients receiving manually dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving MDD.

Long-Acting Methylphenidate-OROS in Youths with Attention-Deficit Hyperactivity Disorder Suboptimally Controlled with Immediate-Release Methylphenidate. A study of cost effectiveness in The Netherlands.

AbstractBackground: Attention-deficit hyperactivity disorder (ADHD) is the most common mental health disorder in youths. Stimulants are the drugs of first choice in the treatment of ADHD. It has been suggested that full costs associated with the treatment of ADHD may be reduced by once-daily administration regimens of stimulants. Objectives: To estimate the cost effectiveness of treatment with long-acting methylphenidate osmotic release oral system (OROS) [Concerta®] for youths with ADHD for whom treatment with immediate-release (IR) methylphenidate is suboptimal. Study design: We developed a Markov model to obtain an incremental cost-effectiveness ratio (ICER). The analysis covered 10 years, with a Markov cycle of 1 day. Costs (in 2005 euros [€]) included medication, consultations and treatment interventions, and additional costs for attending special education. Quality-adjusted life-years (QALYs) were used as the effectiveness measure. Outcome probabilities were taken from the medical literature and an expert panel of five child psychiatrists and paediatricians. Univariate sensitivity analyses were performed to assess the robustness of the base-case estimate. Multivariate sensitivity analysis was used to estimate a worst- and best-case ICER. Results: The ICER of methylphenidate-OROS treatment in youths with ADHD for whom treatment with IR methylphenidate is suboptimal was €2004 per QALY. Total costs after 10 years were €15 739 for the IR methylphenidate pathway and €16 015 for the methylphenidate-OROS pathway. In the univariate sensitivity analysis, the ICER was sensitive to changes in resource use and the robability of stopping stimulant treatment in favour of IR methylphenidate. An ICER of 0 was reached with a 6.2% price reduction of methylphenidate-OROS. Conclusion: Methylphenidate-OROS is a cost-effective treatment for youths with ADHD for whom treatment with IR methylphenidate is suboptimal. Higher medication costs of methylphenidate-OROS were compensated for by savings on resource use, yielding similar 10-year costs compared with treatment with IR methylphenidate. Our analysis is sensitive to both clinical parameters and (differences in) resource utilization and costs between the groups modelled, warranting further research within clinical trials and observational databases, and into the full scope of costs.

Completeness of medication reviews provided by community pharmacists

Little is known about the ability of community pharmacists who are inexperienced in medication review to identify drug‐related problems (DRPs). The objective of our study was to investigate the completeness of DRPs in terms of number, type and clinical relevance identified by community pharmacists when performing home medication reviews (HMRs).

Optimaliseren geneesmiddelengebruik door ouderen

SamenvattingKwint H-F, Faber A, Gussekloo J, Bouvy ML. Optimaliseren geneesmiddelengebruik door ouderen. Huisarts Wet 2015;58(3):134-8. In het kader van het proefschrift Improving appropriate medication use for older people in primary care hebben we onderzoek verricht naar het optimaliseren van de kwaliteit van het geneesmiddelengebruik door ouderen met polyfarmacie in de eerste lijn, waarbij de focus lag op medicatiebeoordeling en medicatie op rol. In dit artikel beschrijven we enkele onderzoeken uit dit proefschrift. We bespreken het effect van medicatiebeoordeling op farmacotherapiegerelateerde problemen, ziektegerelateerde uitkomsten en de kwaliteit van leven. Daarnaast richten we ons meer specifiek op de verschillende stappen van het proces van medicatiebeoordeling, zoals de bijdrage van de farmacotherapeutische anamnese en het mogelijke aandeel van expliciete STOPP-START-criteria bij de identificatie van farmacotherapiegerelateerde problemen. Voor gebruikers van medicatie op rol hebben we de mate van ongewenste farmacotherapie onderzocht en hebben we hun therapietrouw en medicatiekennis vergeleken met die van gebruikers van reguliere verpakkingen.De onderzoeken in dit proefschrift tonen de bijdragen van verschillende stappen van het proces van medicatiebeoordeling bij ouderen en de uitkomsten van dit proces. Onderzoeken onder oudere gebruikers van medicatie op rol geven inzicht in de kwaliteit van het geneesmiddelgebruik van deze specifieke groep. Vervolgonderzoek is gewenst. Zo willen we bijvoorbeeld weten welke specifieke groep ouderen het meest baat heeft bij een medicatiebeoordeling of gebruik van medicatie op rol.AbstractKwint H-F, Faber A, Gussekloo J, Bouvy ML. Optimizing medication use for elderly patients. Huisarts Wet 2015;58(3):134-8. The thesis Improving appropriate medication use for older people in primary care investigated how the medication use of elderly patients on polypharmacy in primary care can be optimized, with emphasis on the effects of medication review and multidose dispensing systems. In this article, we present a series of studies from this thesis. We describe the effect of medication review on drug-related problems, disease-specific outcomes, and health-related quality of life. Thereafter we focus on the different steps of the medication review process, such as the medication history and the possible role of explicit STOPP-START criteria in the identification of drug-related problems. We investigated the extent of inappropriate prescribing to older patients receiving their drugs via multidose drug dispensers and compared the self-reported medication adherence and knowledge of these patients with those of patients receiving manually dispensed drugs.In conclusion, the studies presented in the thesis show the importance of the different steps of the medication review process when prescribing for elderly patients and the outcomes achieved. Studies of older users of multidose drug dispensing systems provide insight into the quality of medication use in these individuals. Further research is needed, for example, to determine which older patients will benefit the most from medication review or use of multidose drug dispensing systems.

InforMatrix for attention deficit hyperactivity disorder

The purpose of this review is to facilitate discussion on drug selection for the treatment of ADHD by using only clinically relevant selection criteria and providing an up-to-date overview. The InforMatrix method was used to select drugs to treat attention deficit hyperactivity disorder (ADHD). The following selection criteria were applied: clinical efficacy, safety, tolerability, ease of use, applicability, and cost. The drugs approved for ADHD in the Netherlands were included in the analysis, namely: atomoxetine, immediate-release methylphenidate, and various formulations of slow-release methylphenidate (Concerta, Equasym and Medikinet). Most studies are of limited quality, duration, and size. In one study, Concerta was more effective than atomoxetine. Although no relevant differences were seen in other comparative studies, the clinical experience with atomoxetine is still limited and unexpected toxicity cannot be excluded; few studies have been published with Equasym and Medikinet. No major differences were seen in general tolerability between the drugs. The ease of use of immediate-release methylphenidate is less than for the other drugs. The acquisition cost of immediate-release methylphenidate is considerably lower than that of the slow-release formulations. Atomoxetine is the most expensive drug. The InforMatrix program is available in an interactive format. It enables the user to judge both the importance of the selection criteria and the properties of each therapeutic option per criterion on the basis of his or her own personal expertise and/or the present document.