Hein A.W. van Onzenoort

Use of dipeptidyl peptidase-4 inhibitors for type 2 diabetes mellitus and risk of fracture

INTRODUCTION Although patients with type 2 diabetes mellitus have an increased bone mineral density as compared to healthy patients, their risk of fracture is elevated. Incretins, new anti-diabetic drugs, may have a protective effect on bone mineral density. However, data on the effect of incretins on fracture risk are limited. Therefore the aim of this study was to investigate the association between the use of DPP4-I and the risk of fracture. METHODS A retrospective population based cohort study, using data from the Clinical Practice Research Datalink (CPRD) database (2007-2012), was conducted. Patients (N=216,816) with at least one prescription for a non-insulin anti-diabetic drug (NIAD), aged 18+ during data collection, were matched to one control patient. Cox proportional hazards models were used to estimate the hazard ratio of any fracture in DPP4 inhibitor (DPP4-I) users versus controls and versus other NIAD patients. Time-dependent adjustments were made for age, sex, life style, comorbidity and drug use. RESULTS The actual duration of DPP4-I use was 1.3years. There was no different risk of fracture comparing current DPP4-I users to controls (adjusted hazard ratio (adj. HR) 0.89, 95% confidence interval (CI) 0.71-1.13). There was also no increased risk comparing current DPP4-I users to other NIAD users, adj. HR 1.03 (95% CI 0.92-1.15). CONCLUSIONS DPP4-I use was not associated with fracture risk compared to controls and to other NIAD users. However, the duration of DPP4-I use in our database might have been too short to show an association with fracture risk.

Assessing Medication Adherence Simultaneously by Electronic Monitoring and Pill Count in Patients With Mild-to-Moderate Hypertension

BACKGROUND Poor adherence to antihypertensive medication is one of the major problems in the treatment of hypertension. Electronic monitoring is currently considered to be the gold standard for assessing adherence, but it may trigger patients to open the pill bottle without taking medication or to take out more than prescribed. In adjunct to electronic monitoring, pill count could be a valuable tool for exploring adherence patterns, and their effects on blood pressure reduction. METHODS Among a total of 228 patients with mild-to-moderate hypertension, adherence to treatment was measured by means of both the Medication Event Monitoring System (MEMS) and pill count. Patients were followed-up for seven visits over a period of 1 year. At each visit to the physicians office, patients adherence was assessed by both methods. RESULTS Adherence is defined as the percentage of days with correct dosing; median adherence according to MEMS was lower than median adherence according to pill count (91.6 vs. 96.1; P < 0.001). Both methods agreed in defining patients as adherent in 107 (47%) and nonadherent in 33 (14%) patients. Thirty-one (14%) patients were adherent only by MEMS and 59 (25%) patients only by pill count. At the end of the study, patients in the four categories reached comparable blood pressure values and reductions. CONCLUSIONS Pill count could be a useful adjunct to electronic monitoring in assessing adherence patterns. Although deviant intake behavior occurred frequently, the effect on achieved blood pressure and blood pressure reduction was not remarkable.

Factors influencing bar-code verification by nurses during medication administration in a Dutch hospital

PURPOSE Factors influencing the bar-code verification by nurses during medication administration in a Dutch hospital were studied. SUMMARY The use of bar-code verification during medication administration in five medical departments was recorded daily for three weeks. These data were collected via electronic medication administration records. The frequency of bar-code verification was calculated as a percentage of all administrations, corrected for the availability of bar-coded packages. Nurses were asked why bar-code verification was not always used. A total of 23,492 medication administrations were recorded, 15,162 (64.5%) of which required bar-code verification. Bar-code verification was significantly influenced by the medical department, deviation between prescribed and administered times, administration route of the drug, number of nurses available in each department, and age of the nurse. The five most cited reasons for not verifying bar codes were difficulties in scanning bar codes on the medication labels, lack of awareness of bar codes on medication labels, delays in responses from the computerized system, shortage of time, and administration of medication before prescription. CONCLUSION Nurses verified the bar codes of only about half of medications administered to patients. Various factors influenced the frequency of bar-code verification by nurses except the number of medications administered. More education regarding medication safety is warranted to increase compliance to a bar-code-enabled point-of-care system.

Participation in a Clinical Trial Enhances Adherence and Persistence to Treatment A Retrospective Cohort Study

Poor adherence to treatment is one of the major determinants of an uncontrolled blood pressure. Participation in a clinical trial may increase patients adherence to treatment. This prompted us to investigate adherence and persistence profiles in patients with hypertension who had participated in a clinical trial, by collecting pharmacy refill data before, during, and after participation in the trial. Pharmacy refill data of 182 patients with hypertension who participated in the Home Versus Office Blood Pressure Measurements: Reduction of Unnecessary Treatment Study between 2001 and 2005 were obtained from 1999 until 2010. Refill adherence to treatment was compared for the periods before, during, and after this trial. Persistence to medication was investigated for the period after termination of the trial. Refill data were available for 22 600 prescriptions. Participation into the trial significantly increased refill adherence, from 90.6% to 95.6% (P<0.001). After the trial period, refill adherence decreased again to 91.8% (P<0.001), which did not differ from the adherence before the start of the trial (P=0.45). Except for adherence to trial medication, adherence to nontrial-related drugs also increased as a consequence of trial participation, from 77.6% to 89.6% (P<0.001). After termination of the trial, median persistence was 1424 days. Participants classified as adherent (adherence: >90%) were less likely to discontinue treatment compared with nonadherent participants (odds ratio: 0.66 [95% CI: 0.45 to 0.98]). Participation in a clinical trial significantly increases adherence to both trial-related and nontrial-related treatment, suggesting that participants in a trial are more involved with their conditions and treatments.

Effect of self-measurement of blood pressure on adherence to treatment in patients with mild-to-moderate hypertension.

Background Poor adherence to treatment is one of the major problems in the treatment of hypertension. Self blood pressure measurement may help patients to improve their adherence to treatment. Method In this prospective, randomized, controlled study coordinated by a university hospital, a total of 228 mild-to-moderate hypertensive patients were randomized to either a group that performed self-measurements at home in addition to office blood pressure measurements [the self-pressure group (n = 114)] or a group that only underwent office blood pressure measurement [the office pressure group (n = 114)]. Patients were followed for 1 year in which treatment was adjusted, if necessary, at each visit to the physicians office according to the achieved blood pressure. Adherence to treatment was assessed by means of medication event monitoring system TrackCaps. Results Median adherence was slightly greater in patients from the self-pressure group than in those from the office pressure group (92.3 vs. 90.9%; P = 0.043). Although identical among both groups, in the week directly after each visit to the physicians office, adherence [71.4% (interquartile range 71–79%)] was significantly lower (P < 0.001) than that at the last 7 days prior to each visit [100% (interquartile range 90–100%)]. On the remaining days between the visits, patients from the self-pressure group displayed a modestly better adherence than patients from the office pressure group (97.6 vs. 97.0%; P = 0.024). Conclusion Although self-blood pressure measurement as an adjunct to office blood pressure measurement led to somewhat better adherence to treatment in this study, the difference was only small and not clinically significant. The time relative to a visit to the doctor seems to be a more important predictor of adherence.

Use of dipeptidyl peptidase 4 inhibitors and fracture risk compared to use of other anti-hyperglycemic drugs

Dipeptidyl peptidase‐4 inhibitors (DPP4‐Is) are a new class of anti‐hyperglycemic drugs which might have a potential beneficial effect on bone metabolism. Data on the effect of DPP4‐I use and fracture risk is limited and conflicting. The aim of the present study was to investigate the association between use of DPP4‐Is and fracture risk.

Determining the feasibility of objective adherence measurement with blister packaging smart technology

PURPOSE The results of a feasibility study of blister-pack smart technology for monitoring medication adherence are reported. METHODS Research in the area of objective therapy compliance measurement has led to the development of microprocessor-driven systems that record the time a unit dose is removed from blister packaging. One device under development is the Smart Blister-a label imprinted with event-detection circuitry that can be affixed to standard commercial blister cards. In the first trial of the device in actual clinical practice, 115 community-dwelling Dutch patients receiving valsartan maintenance therapy (160 mg once daily) were given 14-day blister packages equipped with the Smart Blister. On the return of empty blister cards to the 20 participating community pharmacies, the stored information was scanned and downloaded for data analysis and patient counseling purposes. RESULTS A total of 245 Smart Blister-equipped packages were used by valsartan recipients during the eight-month study. The device was largely effective in recording patient and blister-card identification data and other desired information. However, in 17% of cases, the Smart Blister system registered multiple tablet-removal events at the same time, presumably indicating unintentional breakage of nearby conductive circuits and the need for design refinements. The Smart Blister-equipped medication cards were generally well received by patients and pharmacies. CONCLUSION An evaluation of the functionality and robustness of the Smart Blister in a real-world clinical practice situation yielded some promising results, but the findings also indicated a need for design refinements and additional performance testing of the device.

Long-term use of dipeptidyl peptidase-4 inhibitors and risk of fracture : A retrospective population-based cohort study

To investigate the association between long‐term dipeptidyl peptidase‐4 (DPP‐4) inhibitor use and risk of fracture among people with type 2 diabetes mellitus (T2DM).

A simple intervention to reduce the anesthetic pharmacy budget; the effect of price list stickers placed on vaporizers

STUDY OBJECTIVE The study objective is to investigate the effects of a simple price list sticker placed on vaporizers on anesthetic use and costs. The price list only showed the cost per hour of the annually most expensive drugs, which had a low-cost alternative. DESIGN The design is a prospective database study with historical controls. SETTING The setting is at operating rooms. PATIENTS All patients are undergoing a surgical procedure under anesthesia in both study periods, except cardiothoracic and day care patients. INTERVENTIONS The intervention is application of a price list sticker on the vaporizers. MEASUREMENTS Monthly cost and amount of anesthetic agents used during the 9 months before and after the intervention. MAIN RESULTS After application of the price stickers, the use of both the annually most expensive agents and the anesthetic budget decreased substantially. Most notable was a decrease of 28% in the use of sevoflurane. CONCLUSIONS Price sticker on vaporizers may be an effective, simple, and cheap method to reduce anesthetic costs.