Andrés Gaviria-Mendoza

Diagnosis of neurological disorders and the Zika virus epidemic in Colombia 2014 -2016.

• Diagnoses of neurological disorders were obtained from a database of 6.5 million inhabitants.

Endpoints in strategies to reduce polypharmacy

Polypharmacy is closely associated with potentially inappropriate prescriptions that can have negative effects on patients. It is present in approximately 58% of those over 65 years of age and can occur in 70% of nursing home residents [1]. Along with the pharmacokinetic changes induced by ageing, polypharmacy plays an important role in the occurrence of adverse drug events [2] and is associated with multiple clinical problems, such as poor adherence to treatment, drug interactions, development of geriatric syndromes and increased care costs [3]. Recently, Johansson et al. published a meta-analysis on the impact of strategies to reduce polypharmacy in clinically important outcomes (hospitalization and death), and found that there is no evidence of their effectiveness [4]. The included strategies were divided into interventions focusing on pharmacists, other multidisciplinary teams, or medical personnel. It is interesting to note that, of the 25 trials included in the review, the highest proportion of studies (three-quarters of the studies) showing some positive impact on all-cause mortality were those with physician-led interventions [4]. Some of these achieved a significant decrease in the utilization of medical services, the number of drugs per patient and the number of drugs initiated during the intervention [4]. Our research group has conducted various medical education interventions aimed at rationalizing the use of drugs. We gained a good response from the medical community and achieved variable adherence to the recommendations. The success of these activities resulted in a reduction in the number of drugs prescribed and the number of patients with inappropriate prescriptions, avoided the possible occurrence of adverse drug reactions and even generated significant savings in drug costs [5, 6]. We consider the strengthening of the various medical education activities aimed at improving and ensuring appropriate drug use to be of great importance, in order to provide adequate, rational and cost-effective therapies. The meta-analysis of Johansson et al. [4] is a motivation not only to generate new studies seeking to change prescribing patterns and reduce the total number of drugs taken, but also to determine the final impact of these adjustments.

Hormonal contraceptive prescriptions in Colombia and Zika virus.

An epidemic of Zika virus infection was reported in South and Central America and the Caribbean in 2015, with the highest proportion of cases reported in Brazil and Colombia. The association of an increased incidence of microcephaly in newborn babies born to mothers infected with Zika virus is worrying. For this reason, in mid-January, 2016, many ministries of health in the region, including Colombia, recommended families postpone the start of new pregnancies for between 6 months and 2 years, while the epidemic phase of the disease elapses. Based on this recommendation, the rates of hormonal contraceptives prescription in a Colombian population of about 6·5 million people was investigated, resulting in a descriptive study that included all prescriptions of any contraceptive from January, 2015, to February, 2016, in women of childbearing age affi liated with the Colombian health-care system. Data were obtained from the databases of the largest drug dispenser in Colombia, Audifarma SA. An average of 48 574 women (mean age 30·4 years) were prescribed contraceptives each month during the observation period. The number of women who were prescribed hormonal contraceptives after the Colombian Ministry of Health issued the recommendation was similar to the number in the 6 months before the recommendation was made (fi gure). Neither the recommendations made by the Colombian Ministry of Health in January, 2016, nor the fi rst reports of domestic cases in Colombia in October, 2015, have generated increased contraceptive use, as no evidence exists of adherence to the proposal to reduce the risk of malformations in the country with the second highest number of reported cases of Zika virus infection in the Americas. Several factors might explain the absence of a response, as suggested by Monica Roa in her letter to The Lancet (Feb 27, p 843), which suggests that 56% of pregnancies in Latin America are unplanned as a result of poor quality sex education, low access to contraception, the presence of cultural barriers, and other factors that lead to a large number of women who do not have control over their sexual and reproductive lives. The Zika virus outbreak has highlighted the poor quality of sexual health programmes in Colombia and Latin America, where thousands of women ( especially those who are poor and have reduced access to health services) are at greater risk of infection and complications during pregnancy than women in other areas of the world. Therefore, improvement of equitable access of all women of childbearing age to high quality sexual education, contraception, and safe maternity is crucial.

Deprescribing: a new goal focused on the patient

ABSTRACT It is estimated that one-fifth of adult patients are treated with polypharmacy (five or more drugs) and the prevalence of this phenomenon in the elderly is even higher, ranging from 30% to 70%, even reaching 90% in residents of residential aged care facilities. Polypharmacy in the elderly increases the risk of adverse reactions, inappropriate prescriptions, drug interactions, number of hospitalizations, costs, and even death. In a recent systematic review, the authors proposed defining deprescribing as ‘the process of withdrawal of inappropriate medication supervised by a health care professional with the goal of managing polypharmacy and improving outcomes’.

Prescription profile of pyridostigmine use in a population of patients with myasthenia gravis

We determined the pyridostigmine prescription pattern in a population of patients with myasthenia gravis (MG). A descriptive cross‐sectional study was conducted by using a prescription database of 3.5 million individuals from which patients who had been diagnosed with MG and for whom pyridostigmine had been prescribed were selected. A total of 306 outpatients with MG were found, and 258 were receiving pyridostigmine (mean age 53.0 ± 18.0 years). The calculated prevalence of MG was 86.7 cases per million persons. Monotherapy was used by 53.1% of the patients, prednisolone was used by 21.7%, and 30.2% used other immunomodulators. Medications for other comorbidities were taken by 74.8% of the patients, and 43.4% had prescriptions that could potentially trigger worsening symptoms. Pyridostigmine is being prescribed at doses close to the defined daily doses predominantly as monotherapy. A high proportion of patients were also prescribed a medication that could aggravate their condition, including some that can trigger a myasthenic crisis. Muscle Nerve 56: 1041–1046, 2017

Results of the effectiveness of two piperacillin–tazobactam molecules in the real world

OBJECTIVE The objective was to determine the effectiveness of two piperacillin-tazobactam molecules in terms of all-cause mortality, mortality by infection, and hospital stay. METHODS A cohort study was performed involving patients treated with piperacillin-tazobactam at a clinic in Colombia. The patients were divided into those who received the innovator piperacillin-tazobactam (from July to December 2014) and those who received the generic piperacillin-tazobactam (from January to June 2015). Socio-demographic, clinical (all-cause mortality, death by infection, days of hospitalization), microbiological, pharmacological, and comorbidity variables were evaluated. Multivariate analyses were performed. RESULTS A total of 279 patients were included: 140 treated with the innovator piperacillin-tazobactam and 139 with the generic piperacillin-tazobactam. The median age was 63 years, and 56% of the patients were male. There was no statistically significant difference in death from all causes (22.9% vs. 14.4%, p=0.069), death by infection (7.9 vs. 10.8%, p=0.399), or hospital stay (18.1±16.2 vs. 15.7±11.6 days, p=0.178) between the innovator and generic piperacillin-tazobactam, respectively. CONCLUSIONS The generic piperacillin-tazobactam was equivalent to the innovator piperacillin-tazobactam with regards to all-cause mortality, mortality by infection, hospital stay, and safety, and at a lower cost, which may be useful for decision-makers in hospitals.

Factors related to excessive polypharmacy (≥15 medications) in an outpatient population from Colombia

To determine the frequency of excessive polypharmacy (≥15 medications) in an outpatient population from Colombia and the variables associated with this condition.

Patrones de prescripción de fármacos anti-parkinsonianos en un grupo de pacientes de Colombia, 2015

INTRODUCTION Parkinsons disease, whose prevalence in Colombia is 4.7 per 1,000 inhabitants, is a public health problem and a therapeutic challenge for health professionals. OBJECTIVE To determine the prescribing patterns of antiparkinson drugs and the variables associated with its use in a population from Colombia. MATERIALS AND METHODS We conducted a descriptive cross-sectional study. We selected patients who had been given antiparkinson drugs uninterruptedly between January 1st and March 31st, 2015 from a systematized database of approximately 3.5 million people affiliated to the Colombian health system. We included sociodemographic, pharmacologic and comedication variables. For the multivariate analysis, we used the IBM SPSS™-22 software. RESULTS A total of 2,898 patients was included; the mean age was 65.1years, and 50.7% were men; 69.4% (n=2010) of people received monotherapy and 30.6% combination therapy with two to five antiparkinson drugs. The most frequently prescribed drugs were: levodopa 45.5% (n=1,318 patients), biperiden 23.1% (670), amantadine 18.3% (531) and pramipexole 16.3% (471). The most commonly used association was levodopa/carbidopa + entacapone (n=311; 10.7%). Multivariate analysis showed that being male (OR=1.56; 95%CI: 1.321-1.837), over 60 years (OR=1.41; 95%CI 1.112-1.782) and receiving treatment in the city of Barranquilla (OR=2.23; 95%CI 1.675-2.975) were statistically associated with a greater risk of using combination therapy; 68.2% (n=1,977) patients were given concomitant treatment with other drugs. CONCLUSIONS Prescribing habits of drugs with high therapeutic value predominated, mainly in antiparkinson drugs monotherapy. Most were employed in the usual recommended doses. It is necessary to explore the clinical effectiveness of the medications studied and differentiate between disease and parkinsonian syndromes subtypes.

Letter by Machado-Alba et al Regarding Article, “Rivaroxaban Versus Dabigatran or Warfarin in Real-World Studies of Stroke Prevention in Atrial Fibrillation: Systematic Review and Meta-Analysis”

We have reviewed with great interest the article by Bai et al1 where the safety and effectiveness of rivaroxaban, dabigatran, and warfarin were compared for the prevention of thromboembolic events using real-world evidence. It was found that the effectiveness of rivaroxaban is superior to that of warfarin in new users with atrial fibrillation, although it was similar when the patient changed from warfarin to rivaroxaban. Previously, it has been described that the effectiveness of the nonvitamin K oral anticoagulants versus warfarin can vary according to the geographic region where it is evaluated.2 In Colombia, we lack studies comparing the effectiveness of the nonvitamin K oral anticoagulants versus warfarin in the prevention of thromboembolic …

Prescription patterns and costs of antidiabetic medications in a large group of patients

AIMS To determine the prescription patterns of antidiabetic medications and the variables associated with their use in a Colombian population. METHODS A cross-sectional study using a systematized database of approximately 3.5 million affiliates of the Colombian Health System. Patients of both genders and all ages treated uninterruptedly with antidiabetic medications for three months (June-August 2015) were included. A database was designed that included sociodemographic, pharmacological, comedication, and cost variables. RESULTS A total of 47,532 patients were identified; the mean age was 65.5 years, and 56.3% were women. Among the patients, 56.2% (n=26,691) received medication as monotherapy. The most prescribed medications were metformin, 81.3% (n=38,664), insulins, 33.3% (n=15,848), and sulfonylureas, 21.8% (n=10,370). Among the patients, 92.8% received comedications, including antihypertensives (79.7%), hypolipemiants (65.5%), antiplatelet drugs (56.3%), analgesics (33.9%), antiulcerants (33.1%), and thyroid hormone (17.3%). The cost per 1000 inhabitants/day was