Asim Ahmed Elnour

Nonadherence to antihypertensive drugs: A systematic review and meta-analysis.

Background: Hypertension drives the global burden of cardiovascular disease and its prevalence is estimated to increase by 30% by the year 2025. Nonadherence to chronic medication regimens is common; approximately 43% to 65.5% of patients who fail to adhere to prescribed regimens are hypertensive patients. Nonadherence to medications is a potential contributing factor to the occurrence of concomitant diseases. Objective: This systematic review applied a meta-analytic procedure to investigate the medication nonadherence in adult hypertensive patients. Methods: Original research studies, conducted on adult hypertensive patients, using the 8-item Morisky medication adherence scale (MMAS-8) to assess the medication adherence between January 2009 and March 2016 were included. Comprehensive search strategies of 3 databases and MeSH keywords were used to locate eligible literature. Study characteristics, participant demographics, and medication adherence outcomes were recorded. Effect sizes for outcomes were calculated as standardized mean differences using random-effect model to estimate overall mean effects. Results: A total of 28 studies from 15 countries were identified, in total comprising of 13,688 hypertensive patients, were reviewed. Of 25 studies included in the meta-analysis involving 12,603 subjects, a significant number (45.2%) of the hypertensive patients and one-third (31.2%) of the hypertensive patients with comorbidities were nonadherent to medications. However, a higher proportion (83.7%) of medication nonadherence was noticed in uncontrolled blood pressure (BP) patients. Although a higher percentage (54%) of nonadherence to antihypertensive medications was noticed in females (Pu200a<u200a0.001), the risk of nonadherence was 1.3 times higher in males, with a relative risk of 0.883. Overall, nearly two-thirds (62.5%) of the medication nonadherence was noticed in Africans and Asians (43.5%). Conclusion: Nonadherence to antihypertensive medications was noticed in 45% of the subjects studied and a higher proportion of uncontrolled BP (83.7%) was nonadherent to medication. Intervention models aiming to improve adherence should be emphasized.

Community pharmacy and the extended community pharmacist practice roles: The UAE experiences

Background: The pharmaceutical care and ‘extended’ roles are still not practiced optimally by community pharmacists. Several studies have discussed the practice of community pharmacy in the UAE and have shown that most community pharmacists only counsel patients. However, UAE, has taken initiatives to allow and prepare community pharmacists to practice ‘extended’ roles. Aim of the review: The aim was to review the current roles of community pharmacists in Abu Dhabi Emirate, United Arab Emirates (UAE). Objective: The objective was to encourage community pharmacists toward extending their practice roles. Methods: In 2010, Health Authority Abu Dhabi (HAAD) surveyed community pharmacists, using an online questionnaire, on their preferences toward extending their counseling roles and their opinion of the greatest challenge facing the extension of their counseling roles. Results: Following this survey, several programs have been developed to prepare community pharmacists to undertake these extended counseling roles. In addition to that, HAAD redefined the scope of pharmacist roles to include some extended/enhanced roles. Abu Dhabi Health Services (SEHA) mission is to ensure reliable excellence in healthcare. It has put clear plans to achieve this; these include increasing focus on public health matters, developing and monitoring evidence-based clinical policies, training health professionals to comply with international standards to deliver world-class quality care, among others. Prior to making further plans to extend community pharmacists’ roles, and to ensure the success of these plans, it is imperative to establish the views of community pharmacists in Abu Dhabi on practicing extended roles and to gain understanding and information on what pharmacists see as preferred change strategies or facilitators to change. Conclusions: In an attempt to adapt to the changes occurring and to the growing needs of patients and to maximize the utilization of community pharmacists’ unique structured strategies are needed to be introduced to the community pharmacy profession.

A Clinical Audit on Diabetes Care in Patients with Type 2 Diabetes in Al- Ain, United Arab Emirates

Objectives: To implement a prospective interventional clinical audit to evaluate the current clinical practice and the effect of standard interventions on the management of type 2 diabetes (T2DM). Methods: 254 patients with T2DM where recruited in a specialized diabetes care center in Al-Ain, UAE. The diabetes care components were audited before (baseline) and after (3 and 6 months) implementation of Institute of Clinical System Improvement (ICSI) guidelines. Data was compared against international guidelines to achieve target goals of normoglycemia, blood pressure (BP), and low density lipoprotein-cholesterol (LDL-C). We measured changes in mean scores of patient satisfaction level regarding diabetes care at similar intervals, by validated Patient Satisfaction Questionnaire (PSQ-18). Results: We observed a significant reduction in fasting blood glucose (FBG; mean± SD; 9.3 ± 0.03 vs 7.4 ± 0.3mmol/l; P=0.03), and HbA1c (8.7 ± 0.02 vs 8.1 ± 0.02 %; P=0.04) levels after 6 months compared with baseline. Patients who achieved target FBG and HbA1c levels improved significantly (45.7 vs 81.1%; P=0.03), and (40.1 vs 73.6%; P=0.04), respectively. The LDL-C levels improved, though this was not statistically significant. Patients achieving target of BP control improved significantly (SBP 142±7.6 and DBP 95±6.2 vs SBP 136±8.2 and DBP 87±5.8 mmHg;P=0.05). Conclusions: The results of this interventional audit were generally positive and emphasized the feasibility of improving the current clinical practice. Our individualized approach has helped us to achieve a better target in glycemic and BP control as well as patient satisfaction. Further research is needed to understand the long-term impact of our structured approach to improve the quality of T2DM care in the UAE.

Health Professionals' Knowledge, Attitudes and Practices about Pharmacovigilance in India: A Systematic Review and Meta-Analysis

Background Spontaneous or voluntary reporting of suspected adverse drug reactions (ADRs) is one of the vital roles of all health professionals. In India, under-reporting of ADRs by health professionals is recognized as one of the leading causes of poor ADR signal detection. Therefore, reviewing the literature can provide a better understanding of the status of knowledge, attitude and practice (KAP) of Pharmacovigilance (PV) activities by health professionals. Methods A systematic review was performed through Pubmed, Scopus, Embase and Google Scholar scientific databases. Studies pertaining to KAP of PV and ADR reporting by Indian health professionals between January 2011 and July 2015 were included in a meta-analysis. Results A total of 28 studies were included in the systematic review and 18 of them were selected for meta-analysis. Overall, 55.6% (95% CI 44.4–66.9; p<0.001) of the population studied were not aware of the existence of the Pharmacovigilance Programme in India (PvPI), and 31.9% (95% CI 16.3–47.4; p<0.001) thought that all drugs available in the market are safe. Furthermore, 28.7% (95% CI 16.4–40.9; p<0.001) of them were not interested in reporting ADRs and 74.5%, (95% CI 67.9–81.9; p<0.001) never reported any ADR to PV centers. Conclusion There was an enormous gap of KAP towards PV and ADR reporting, particularly PV practice in India. There is therefore an urgent need for educational awareness, simplification of the ADR reporting process, and implementation of imperative measures to practice PV among healthcare professionals. In order to understand the PV status, PvPI should procedurally assess the KAP of health professionals PV activities in India.

Alternatives to currently used antimalarial drugs: in search of a magic bullet

Malaria is a major cause of morbidity and mortality in many African countries and parts of Asia and South America. Novel approaches to combating the disease have emerged in recent years and several drug candidates are now being tested clinically. However, it is long before these novel drugs can hit the market, especially due to a scarcity of safety and efficacy data.To reduce the malaria burden, the Medicines for Malaria Venture (MMV) was established in 1999 to develop novel medicines through industry and academic partners’ collaboration. However, no reviews were focused following various preclinical and clinical studies published since the MMV initiation (2000) to till date.We identify promising approaches in the global portfolio of antimalarial medicines, and highlight challenges and patient specific concerns of these novel molecules. We discuss different clinical studies focusing on the evaluation of novel drugs against malaria in different human trials over the past five years.The drugs KAE609 and DDD107498 are still being evaluated in Phase I trials and preclinical developmental studies. Both the safety and efficacy of novel compounds such as KAF156 and DSM265 need to be assessed further, especially for use in pregnant women. Synthetic non-artemisinin ozonides such as OZ277 raised concerns in terms of its insufficient efficacy against high parasitic loads. Aminoquinoline-based scaffolds such as ferroquine are promising but should be combined with good partner drugs for enhanced efficacy. AQ-13 induced electrocardiac events, which led to prolonged QTc intervals. Tafenoquine, the only new anti-relapse scaffold for patients with a glucose-6-phosphate dehydrogenase deficiency, has raised significant concerns due to its hemolytic activity. Other compounds, including methylene blue (potential transmission blocker) and fosmidomycin (DXP reductoisomerase inhibitor), are available but cannot be used in children.At this stage, we are unable to identify a single magic bullet against malaria. Future studies should focus on effective single-dose molecules that can act against all stages of malaria in order to prevent transmission. Newer medicines have also raised concerns in terms of efficacy and safety. Overall, more evidence is needed to effectively reduce the current malaria burden. Treatment strategies that target the blood stage with transmission-blocking properties are needed to prevent future drug resistance.

Novel oral anticoagulants and the 73rd anniversary of historical warfarin

International guidelines have recommended the use of NOACs in line with their established safety, efficacy and compliance [29], [30], [31]. The safety of NOAC is supported by real world post-marketing surveillance registry studies, such as the Danish registry where bleeding and MI were not attributed to dabigatran [32]. In addition, reports from the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA™-AF) which emphasizes the under clinical utility of NOACs, have recently emerged. Dabigatran was coined as the most prescribed NOAC in the Phase II registry [33], [34]. The GLORIA™-AF was the largest, global observational study to date on the use of anticoagulants in patients with AF. The early reported findings were based on treatment trends in 3415 AF patients who entered the GLORIA™-AF registry from November 2011 to February 2014. n nThe GLORIA™-AF results demonstrated that 21.9% of patients with occasional AF and a CHADS2-VASC score of 2 or higher were either undertreated with aspirin or given no anticoagulant treatment at all, compared to 12.4% and 11.2% of those diagnosed with persistent or permanent AF, respectively [33]. Current AF guidelines call for patients to receive oral anticoagulant therapy based on their risk of stroke, rather than their type of AF [34], [35]. Furthermore, given the availability of NOACs, guidelines state that the use of antiplatelet therapies (such as aspirin) for stroke prevention in AF should be limited to the few patients who refuse any form of oral anticoagulant, as the evidence for effective stroke prevention from Apixaban versus acetylsalicylic acid (ASA) is weak, with a potential for harm [35]. n nNOAC is the standard therapy in significantly reducing the risk of stroke and systemic embolism in AF patients. Physicians have diverse factors to consider when selecting a NOAC option for antithrombotic treatment in AF patients. Revealing factors such as risk stratification for bleeding, therapeutic monitoring, and renal status may serve in bridging the treatment gap. n nNOAC limitations nThere was no treatment evidence for NOACs in patients with valvular AF (valves/devices). There are other NOAC limitations, such as not having a reversal agent in the event of bleeding. Currently, however, antidote trials for each specific NOAC reversal are underway (Phase II and III trials); and these include idarucizumab for dabigatran (RE-VERSE AD trial), andexanet for apixaban-alfa (ANNEXA™, Andexanet Alfa a Novel Antidote to the Anticoagulant Effects of factor XA Inhibitors trial) [36]. There is no FDA-approved NOAC antidote for clinical use in case of medical emergencies. Despite the fact that no routine laboratory monitoring is required for general outpatient follow-up, some laboratory assays such as ECT and aPTT are available for emergency situations in which patients are suffering from life-threatening bleeding. Activated charcoal can be used to decrease the absorption of dabigatran [37], and prothrombin complex concentrates (PCC) have been shown to completely reverse the anticoagulant effect of rivaroxaban in healthy subjects [38]. n nHowever, a recent randomized, double-blind, placebo controlled trial of 145 healthy volunteers demonstrated that idarucizumab, a humanized antibody that binds dabigatran with high affinity, could result in immediate and sustained reversal of the anticoagulant effect [39], [40]. The study reported that idarucizumab is well tolerated without adverse events and completely reverses prolonged clotting time within five minutes of administration. This was the sole specific antidote for one of the NOACs; however, further research is required to demonstrate its clinical utility. n n nIn order to be implicated in clinical practice, the following points need to be considered: n n n1. n nClinical use according to patient need: life-threatening hemorrhage, trauma, procedure with anticipated risk for major bleeding. n n n2. n nCareful risk assessment will be needed as the risk for bleeding outweighs the benefit of thrombo-prophylaxis. n n n3. n nAttention to fundamentals of hemostasis and supportive measures. n n n4. n nWill the availability of NOAC antidotes drive the uptake of NOACs? n n n n n nThe future of NOACs nSome gaps need to be addressed in order for clinicians to select a NOAC and/or convert and switch from warfarin to a NOAC. These gaps have to be highlighted by expert opinions from the gained meta-analysis, registries and from global experiences who can summarize them for clinicians without bias or conflict of interest. This may help solve the various controversies and disparities in the clinical utility of NOACs. n nThe research conducted by clinicians working in day-to-day clinical practice will be of extreme value as their views and that of their patients (treatment satisfaction) will provide deeper insights into the authentic clinical utility of NOACs. Researchers are encouraged to focus on patient satisfaction and quality of life aspects of these NOACs. n nThe emerging betrixaban novel once-daily factor Xa inhibitor has been shown in a small phase II study to competitively bind to factor Xa and to inhibit its activity. The EXPLORE-Xa study was designed to evaluate the safety and tolerability of betrixaban compared to warfarin in patients with AF who are receiving or are eligible for VKA. This phase II study of betrixaban, at doses of 40–80xa0mg per day, indicated that it was well tolerated in AF patients at risk for stroke, with a risk of bleeding that was similar to, or lower than, that of well-managed warfarin. The most important fact about this drug is its hepatic elimination, which may provide preferences over other NOACs in patients with renal impairment of <30xa0mL/min [41].

Evaluation of rational use of medicines (RUM) in four government hospitals in UAE.

Rational: Studies conducted showed that there were gaps regarding the rational use of medicines (RUM). Aims and objectives: Evaluate RUM in main government hospitals in four emirates in UAE, using WHO prescribing indicators. Method: Multicenter prospective cross-sectional comparative study was conducted in 4 hospitals in 4 different Emirates in UAE. Using consecutive random sampling method, a total of 1100 prescriptions (2741 prescribed drugs) were collected and analyzed from surveyed hospitals from April to October 2012. Index of Rational Drug Prescribing (IRDP) was used as an indicator of RUM. Results: The main finding of this study was that, the mean values of prescribing indicators of RUM in the surveyed hospitals were estimated to be within the WHO optimal values for generics (100.0 vs. 100.0), antibiotics (9.8 ± 4.8 vs. ⩽30), injections (3.14 ± 1.7 vs. ⩽10) and formulary (EML) prescribing (100.0 vs. 100.0). However, the only discrepancy was reported regarding the number of drugs per prescription which was found to be more than the WHO optimal value (2.49 ± 0.9 vs. ⩽2); respectively. The mean IRDP was 4.55 which was less than the WHO optimal value of 5. Conclusions: Strategies and interventions are desirable to promote RUM and minimize the consequences of poly-pharmacy.

Pharmacovigilance on sexual enhancing herbal supplements

The use of herbal medicines continues to expand rapidly across world and many people show positive interest to use herbal products for their health. The safety of herbal supplements has become a globally major concern in national and international health authorities due to increasing adverse events and adulterations. It is difficult to analyze herbal products that cause adverse events due to lack of sufficient information and expertise. Inadequate regulatory measures, weak quality control system and uncontrolled distribution channels are some of reasons that enhance the informal pharmaceutical market. In recent years, the unfulfilled desire for sex has been a subject that has aroused increasing public interest with respect to improve sexual functions. The use of herbal medicines substantially increased due to escalated prevalence and impact of sexual problems worldwide and estimates predicting the incidence to raise over 320 million by year 2025. The various reasons to use herbal supplements in men may be due to experiencing changes in erectile dysfunction (ED) due to certain medical conditions such as diabetes and hypertension and bodily changes as a normal part of life and aging. There is a lack of adequate evidence, no impetus to evaluate and absence of any regulatory obligations to undertake rigorous testing for safety and efficacy of herbal supplements before they sold over-the-counter (OTC). Pharmacovigilance on herbal supplements is still not well established. Sexual enhancing herbals are on demand in men health but informal adulteration is growing issue of concern. Recently, increase in use of herbal supplements for erectile dysfunction has laid a path for many illegal compositions. This paper explores facts and evidences that were observed in different countries attempting to demonstrate the importance of strengthening regulatory system to strengthen the application of pharmacovigilance principles on sexual enhancing supplements. We hereby explore the problem of sexual herbal supplements from pharmacovigilance perspectives. We provide insights into the various concerns and call for collaboration to resolve the problem. We highly recommend to include herbal medicines in national pharmacovigilance systems and to establish comprehensive national pharmacovigilance program to raise the awareness about herbal medicines particularly those used in enhancing sexual desire.

The Value of U/S to Determine Priority for Upper Gastrointestinal Endoscopy in Emergency Room.

AbstractIn countries endemic for liver and GIT diseases, frequent emergency department (ED) patients contribute to a disproportionate number of visits consuming substantial amount of medical resources. One of the most frequent ED visits is patients who present with hypovolemic shock, abdominal pain, or confusion with or without signs of upper gastrointestinal bleeding (UGIB). The use of conventional two-dimensional ultrasound (2D-U/S) may provide immediate and useful information on the presence of esophageal varices, gastrointestinal tumors, and other GIT abnormalities.The current study investigated the feasibility of using (2D-U/S) to predict the source of UGIB in ED and to determine patients’ priority for UGE.Between February 2003 and March 2013, we retrospectively reviewed the profiles of 38,551 Egyptian patients, aged 2 to 75 years old, who presented with a history of GI/liver diseases and no alcohol consumption. We assessed the value of 2D-U/S technology in predicting the source of UGIB.Of 38,551 patients presenting to ED, 900 patients (2.3%), 534 male (59.3%) and 366 female (40.7%) developed UGIB. Analyzing results obtained from U/S examinations by data mining for emergent UGE were patients with liver cirrhosis (LC), splenomegaly, and ascites (42.6% incidence of UGIB), followed by LC and splenomegaly (14.6%), LC only (9.4%), and was only 0.5% who had no morbidity finding by 2D-U/S.Ultrasonographic instrumentation increases the feasibility of predictive emergency medicine. The area has recently not only gained a fresh impulse, but also a new set of complex problems that needs to be addressed in the emergency medicine setting according to each priority.

Clinical pharmacists’ review of surgical antimicrobial prophylaxis in a tertiary hospital in Abu Dhabi

AbstractBackground There is a lack of evidence to support standard of care and concordance with surgical antimicrobial prophylaxis (SAP) guidelines in our setting. There is an opportunity for clinical pharmacists to facilitate this process across all surgical disciplines. Objective To assess adherence of surgeons to SAP guidelines. Method This was a retrospective study of 250 patients who underwent surgery during 2012 in Mafraq Hospital, Abu Dhabi. We evaluated prescribing of SAP, antimicrobial selection, first-dose timing, dose interval, treatment duration and adherence of surgeons to local hospital guidelines.n Results We reviewed 250 patients (193 were male and 57 were female, mean age 36xa0±xa01.2xa0years); 54xa0% had elective operations and 46xa0% underwent emergency surgery. Adherence to hospital guidelines was 32.1xa0%. Antimicrobial selection, timing of the first dose, dosage interval and treatment duration were concordant with the hospital guidelines in 26, 31 and 40.3xa0% of cases, respectively. Main barriers to adherence to hospital guidelines were lack of awareness and education. Conclusions The present study indicated poor adherence to the SAP guidelines. The timing of administration of SAP was not appropriate in two-thirds of the patients and more than half received more than three doses of SAP inappropriately. Continuing medical education should target antimicrobial prophylaxis (selection, timing and duration), clinical pharmacy antibiotic services and cyclic auditing.