F Falcão

Hospital pharmacist interventions in a central hospital

Objective The aim of this study is to describe and categorise pharmacist interventions (PIs) in a central hospital and report acceptance rates by physicians. Methods A retrospective study was carried out in a 350-bed central hospital between January and June 2013. Eleven pharmacists screened the pharmacotherapy charts for drug-related problems leading to PIs. The recommendations resulting from this analysis were entered in the electronic prescribing system. All the PIs registered on the electronic medical record system during the study period were eligible for inclusion. Interventions were quantified and characterised. Computer records were consulted to assess acceptance rate by physicians. Results A total of 1249 PIs were made by 11 pharmacists, and covered 147 drugs, with the most common being antibacterial (25%) and for the central nervous system (24%) and cardiovascular system (18%). Of the 1249 PIs, 18% concerned acetaminophen, 13% enoxaparin and 10% amoxicillin/clavulanic acid. The PIs were classified into three main categories: drug, dosage and administration related. When we analysed the most relevant PI type (n>20), the highest acceptance rate was for dosage adjustment according to therapeutic indication (58.1%) and renal function (57.4%). The global rate of acceptance was 53%. Conclusions Pharmacists’ recommendations entered in the electronic prescribing system with a short explanation, as well as the pharmacotherapy recommendation, are immediately available to the doctor; however, the relatively low acceptance rate suggests that a further study also evaluating verbal interventions is needed, since the most urgent recommendations are made verbally, and this would likely increase the acceptance rate.

4CPS-114 Medication review in patients with prescription of drugs subject to additional monitoring

Background Polymedication increases the risk of developing drug interactions, and this risk is higher as the number of drugs used increases. At the hospital, medication review is performed for patients receiving treatment with drugs subject to additional monitoring. Purpose Characterise the profile of drug interactions in oncological/haematological patients proposed for treatment with drugs subject to justification. Material and methods Descriptive, observational, retrospective study conducted between January and December 2016 in a central general hospital. Oncological/haematological patients with drug prescription subject to justification were included. Information was collected through consultation of the clinical process and other hospital records. Drug interactions were manually screened and classified using Lexi-interact database risk rating. Data were recorded and processed in Microsoft Excel 2010. Results A total of 174 patients that had drugs subject to justification were included. We identified 57 drug interactions between the drug for other comorbidities and the proposed therapy, corresponding to 32.7% of the patients. The majority of patients in this group were on five or more drugs. Drug-drug interactions identified had the following risk classification: 48 with risk C, five with risk D and four with risk X. The groups with the highest number of interactions were the cardiovascular system, CNS and drugs used to treat endocrine diseases. Everolimus (three drug interactions/two requests) followed by bortezomib (28 drug interactions/23 requests) had the highest number of drug interactions/number of requests. A management plan for patients’ therapy that included monitoring (risk C interactions), suggestions to change therapy (risk D interactions) and therapy modification (risk X interactions) was established with the oncologist. Conclusion The present study allowed the identification of the need for pharmaceutical intervention in the pharmacotherapy review. Knowledge of potential drug interactions can lead to the development of institutional strategies to minimise it and to prevent significant changes in therapy goal. Thus, it is important to identify thecriteria for selecting patients who can benefit most from this type of evaluation. References and/or Acknowledgements 1. Riechelmann RP, Girardi D. Drug interactions in cancer patients: a hidden risk? J Res Pharm Pract2016Apr–Jun;5(2):77–78. 2. Blenkinsopp A, Bond C, Raynor DK. Medication reviews. Br J Clin Pharmacol2012Oct;74(4):573–580. No conflict of interest

4CPS-027 Hospital pharmacist interventions in an accredited cardiology department

Background Pharmaceutical care is the pharmacist’s contribution to the care of individuals in order to optimise medicines use and improve health outcomes. Pharmacist interventions involve the identification of actual or potential drug-related problems and the provision of recommendations to resolve or prevent them. Purpose The aim of this study was to characterise interventions performed during the review of prescription orders from the pharmacist responsible for supporting the Cardiology Department and evaluate prescribers’ acceptance rates. Material and methods A descriptive, observational and retrospective study was performed between January 2015 and August 2017. The pharmacist screened the pharmacotherapy charts for drug-related problems leading to pharmacist interventions. All the pharmacist interventions registered on the electronic medical record system during the study period were eligible for inclusion. Interventions were quantified and characterised. Computer records were consulted to assess acceptance rates by prescribers. A descriptive analysis methodology was performed. Results A total of 15 707 prescriptions were reviewed and 1152 pharmacist interventions were made. The pharmacist interventions were categorised into three main sets: drug-, dosage- and administration-related. The majority of interventions made were classified as alternative/new therapy recommended (19.0%), more appropriate dose/dosage regimen (12.9%) and optimisation of drug administration (11.9%). Of the total of the pharmacist interventions made, 544 were accepted, 330 were not accepted and 278 were unresolved. Analysing the most relevant types of pharmacist interventions, the highest acceptance rates were for interventions advising the wrong length of therapy/discontinue therapy (87.0%), wrong dose prescribed (79.0%), alternative route of administration (79.0%) and duplicate therapy (75.3%). The global rate of acceptance was 62.2%. Conclusion The results from this study revealed that prescribers’ acceptance rates for pharmacist interventions were higher for medication-prescribing errors compared with recommendations for pharmacological therapy optimisation or safety concerns. The acceptance rate could be more accurate if in a further study verbal interventions would be included, since the most urgent recommendations are made verbally, which would likely increase the acceptance rate. The integration of clinical pharmacists on the multidisciplinary team seems to be essential in promoting a more safety and efficacy culture in hospital settings. No conflict of interest

PS-047 Implementing a pharmacovigilance programme in oncology

This abstract was published in error and withdrawn at the author’s request.

PS-099 Drug-drug interactions in fluoropyrimidines-based regimens used in colorectal cancer treatment

Background Drug interactions in oncology are of particular importance due to the narrow therapeutic range and inherent toxicity. The incidence of interactions increases when patients are polymedicated, which is very common in cancer patients as they often have other co-morbidities. Purpose To identify potential drug–drug interactions in patients with colorectal cancer treated with fluoropyrimidines-based regimens and concomitant treatment. Material and methods Retrospective study to evaluate drug interactions in patients with colorectal cancer who started chemotherapy between January and March 2014, in a central hospital, and who were also prescribed other drugs. Interactions were screened using the Lexi-Interact database between chemotherapy regimens including FOLFOX4, mFOLFOX6, FOLFIRI, capecitabine and fluorouracil continuous infusion, supportive treatment for prevention of emesis (dexamethasone, ondansetron) and other prescribed treatment. Results Of the patients who started fluoropyrimidines-based chemotherapy, 29 were also prescribed other drugs, the majority cardiovascular and Central Nervous System drugs. Of the 108 drugs prescribed, 20 interacted with the chemotherapeutic regimen, and accounted for 34 interactions, with an average of 1.2 interactions per prescription. According to the Lexi-Interact database 10 had risk rating C and required monitoring of side effects; 23 had risk rating D and were recommended for treatment modification or aggressive monitoring; 1 had risk rating X which required avoidance of the combination. The drugs included in the chemotherapy regimens with the highest number of interactions were dexamethasone (n = 20) and fluorouracil (n = 8). Conclusion The screening of drugs for the treatment of co-morbidities was based on electronic medical records hence OTC drugs and dietary supplements were not included in this study. The identification of these drug interactions enables their inclusion in the prescription program, allowing alerts to be issued at the time of prescription. Reference Crul M, Yap KD, Terpstra WE. Frequent interactions between chemotherapy and community-dispensed drugs in a continuous screening programme. Eur J Hosp Pharm 2012;19:171 No conflict of interest.

CP-019 Hospital pharmacists’ interventions in a central hospital

Background Several studies have demonstrated the positive impact of clinical pharmacy services in the hospital setting. Interventions by clinical pharmacists have been shown to reduce the frequency of drug-related problems. Pharmacist interventions (PIs) are defined as a professional activity performed by pharmacists, directed towards improving the quality use of medicines and resulting in a recommendation for a change in the patient’s drug treatment. Purpose To characterise all PIs recorded in the electronic medical record and quantify their acceptance by the medical team. Materials and methods An observational, retrospective study was carried out in a 350-bed central hospital, between January and June 2013. All the PIs recorded in the electronic medical record during the study period were eligible for inclusion; verbal PIs and related to clinical pharmacokinetics were excluded. Results 1449 PIs were performed during the study period. The majority of these PIs involved the following therapeutic classes: antibacterial (25%), CNS (24%), cardiovascular (18%) and blood (9%). 147 drugs were targeted in an intervention; acetaminophen (18%) was the subject of the largest number of pharmacist interventions, followed by enoxaparin (13%) and amoxicillin/clavulanic acid (10%). When we looked at the type of intervention we found that most corresponded to dose adjustment for renal failure (29%), change of administration route (24%) or other dose adjustment (9%). Discharge, transfer between clinical services and drug discontinuation led to it only being possible to assess 69% of interventions performed. The acceptance rate was 48%. Conclusions Our results, in particular those referring to dose-dependent problems, confirm the need for pharmacotherapy follow-up. From this study it can be concluded that a high percentage of PIs are focused on a limited number of drugs, suggesting the need to make specific recommendations in order to improve drug use. The ultimate goal of PI is to improve health outcomes for each patient by promoting the rational use of medicines. No conflict of interest.

GRP-077 Generic Mycophenolate Mofetil in Heart Transplant Recipients: Implementation of Active Pharmacovigilance

Background Immunossupressant drugs have an important role in the prophylaxis of transplant rejection, so they are considered ‘critical dose drugs’. Use of a generic immunosuppressant represents a significant cost savings to the medical system. Since safety data for new medicines are always limited, post-marketing surveillance is essential to determine medicines’ safety in real life use. With the introduction of generic mycophenolate mofetil (MMF) in CHLO, EPE–HSC, the pharmaceutical services (PHS) have implemented an MMF active pharmacovigilance programme (APP) for HT recipients. Purpose To describe and quantify suspected adverse drug reactions (ADRs) identified with an APP implemented by the PHS. Materials and Methods Between 11/2011 and 09/2012, all adult HT recipients who switched from innovator to the generic MMF were included in the MMF APP. This substitution was made under medical supervision and the pharmacist provided the patients with all necessary explanations. Subsequent pharmaceutical assessment was done with a questionnaire (in person or telephone), which identified demographic data, concomitant treatment and suspected ADRs. Results 55 patients were included in the MMF APP, 78% male, average age 55 ± 13 [22–76] years. 14 patients (25%) reported ADRs at MMF switch. These patients had not experienced ADRs with the innovator drug. The most common ADRs identified were diarrhoea (25%), stomach ache (12.5%) and asthenia (12.5%). All ADRs notifications were reported to the Portuguese National Pharmacovigilance Unit. Conclusions Most suspected ADRs identified corresponded to MMF’s profile ADRs described in the summary of product characteristics. The switch to generic from innovator drug should have a surveillance strategy that includes medical monitoring, patient education and the contribution of all health professionals involved in the patient immunosuppressant regimen in order to create a system that allows adverse reactions to be detected, with the ultimate goal of maximising benefit and minimising risk by promoting safer use of medicines. No conflict of interest.