Leonardo Régis Leira Pereira

A evolução da Atenção Farmacêutica e a perspectiva para o Brasil

The Pharmaceutical Care, recent practice of the pharmaceutical activity, prioritizes the orientation and the pharmacotherapeutic follow up, besides direct relation among the pharmacist and the medicines user. In most developed countries the Pharmaceutical Care is already a reality and has demonstrated efficacy in the reduction of aggravation in the chronical diseases and in the cost of the health system. In Brazil, this activity is still incipient due to the difficulty of access to the medicines by the users of the Health System, absence of pharmacists in the Basic Units of Health and absence of scientific documentation that may demonstrate to the managers of the public and private system of Health that the implementation of Pharmaceutical Care represent investment and not cost. However, for being a new activity of the pharmacist, it is demanding that the pharmaceutical education institutions promote the necessary adaptations, providing the formal knowledge for the practice of this activity. This paper discuss the Pharmaceutical Care in countries that present more evolution in your desenvelopment according with MedLine/Pubmed (www.ncbi.nlm.nih.gov/PubMed). This article compared the difficulties of the Brazil and others countries for the implantation of Pharmaceutical Care and the prospect for the future.

Perfil da assistência farmacêutica na atenção primária do Sistema Único de Saúde

This paper presents a review and analysis of Pharmacist Care as an integrated part of the Primary Health Care System, in which quality use of medicines is directly related to quality health service and to elements for its evaluation. In our country the Basic Health Units represent the main entrance to the public health care system. The pharmaceutical services however are still linked to the care model centered in medical consultation and emergency care, with the pharmacy just satisfying their needs. Provide orientation to the users of a Basic Unit pharmacy is almost impossible because nearly all sore spots of the health system end up at the pharmacy as the final step in the care process. The solution of the problem will not be easy if the present structure of the service is maintained. Great part of the pressure resulting from the demand does not depend on the health service itself but on inclusive social policies with direct impact on the health conditions of the population. Rational use of medicines from the prescriber to the user is fundamental in this specific environment.

The Pharmaceutical care of patients with type 2 diabetes mellitus

Objective To evaluate the efficiency of pharmaceutical care on the control of clinical parameters, such as fasting glycaemia and glycosylated haemoglobin in patients with Type 2 Diabetes mellitus. Setting This study was conducted at the Training and Community Health Centre of the College of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil. Methods A prospective and experimental study was conducted with 71 participants divided in two groups: (i) pharmaceutical care group (n=40), and (ii) the control group (n=31). The distribution of patients within these groups was made casually, and the patients were monitored for 12 months. Main outcome measure: Values for fasting glycaemia and glycosylated haemoglobin were collected. Results Mean values of fasting glycaemia in the pharmaceutical care group were significantly reduced whilst a small reduction was detected in the control group at the same time. A significant reduction in the levels of glycosylated haemoglobin was detected in patients in the pharmaceutical care group, and an average increase was observed in the control group. Furthermore, the follow-up of the intervention group by a pharmacist contributed to the resolution of 62.7% of 142 drug therapy problems identified. Conclusion In Brazil, the information provided by a pharmacist to patients with Type 2 Diabetes mellitus increases compliance to treatment, solving or reducing the Drug Therapy Problem and, consequently, improving glycaemic control.

Economic evaluation of outpatients with type 2 diabetes mellitus assisted by a pharmaceutical care service

OBJECTIVE To analyze the costs related to visits and drug prescription in outpatients with type 2 diabetes mellitus assisted by a pharmaceutical care service. SUBJECTS AND METHODS A prospective and experimental study was carried out. Seventy one patients were divided into two groups: control and pharmaceutical care. Patients in the pharmaceutical care group were followed up monthly by a single clinical pharmacist. RESULTS The pharmaceutical care group had a statistically significant reduction in costs of metformin and emergency department visits, and increased costs with their family physicians. On the other hand, the control group had a statistically significant increase of 21.3% in the general costs of treatment and visits. CONCLUSION The pharmaceutical care group maintained the same costs related to drugs and visits, while the control group showed a significant increase in general costs.

Assistência ao diabetes no Sistema Único de Saúde: análise do modelo atual

The Brazilian Health Care System stimulated for restrictive economic contexts had passed for reorganization in the decade of 1990, directed mainly to the primary attention. Although the reforms, the incidence of diabetes mellitus still reaches epidemic levels. The diabetes prevention has become actual preoccupation due the high morbimortality that accompanies this disease, becoming necessary the development of efficient and viable programs for Brazilian Public Health system such as emphasis in the primary prevention, control of the diseases incidence and complications. To obtain this goal, the current model of attention given to the patient must be modified, prioritizing the primary attention and a replacement of the hegemonic medical model for another one, formed by an interdisciplinary team, where the pharmacist as a member could offer his/her services should occur, thus minimizing social, humanistic and economic impacts that the diabetes causes for the society. The aim of this present revision is to approach the diabetes mellitus, the difficulties for its control associated with the adopted ineffective system, mainly in the Brazilian Public Health System.

Prescription patterns for diabetes mellitus and therapeutic implications: a population-based analysis

OBJECTIVE To analyze drug prescriptions for insulin and oral antidiabetic drugs in type 1 and type 2 diabetes mellitus patients seen in the Brazilian Public Healthcare System (Unified Health System - SUS) in Ribeirao Preto, SP, Brazil. SUBJECTS AND METHODS All the patients with diabetes seen in the SUS in the western district of Ribeirao Preto, SP, Brazil between March/2006 and February/2007 were included in the study. RESULTS A total of 3,982 patients were identified. Mean age of the patients was 60.6 years, and 61.0% were females. Sixty percent of the patients were treated with monotherapy. Doses of oral antidiabetic drugs were lower in monotherapy than in polytherapy. Ten patients received doses of glibenclamide or metformin above the recommended maximum doses, and in elderly patients there was no reduction in drug doses. CONCLUSION Monotherapy with oral antidiabetic drugs was the predominant procedure, and the doses were not individualized according to age.

Use of simulated patients to evaluate combined oral contraceptive dispensing practices of community pharmacists.

Background Combined oral contraceptive (COC) use is the most commonly used reversible method of birth control. The incorrect use of COCs is frequent and one of the most common causes of unintended pregnancies. Community pharmacists (CPs) are in a strategic position to improve COC use because they are the last health professional to interact with patients before drug use. Objective To evaluate the COC dispensing practices of CPs in a developing country. Method A cross-sectional study was conducted in community pharmacies of Assis and Ourinhos microregions, Brazil, between June 1, 2012, and October 30, 2012. Four simulated patients (SPs) (with counseled audio recording) visited community pharmacies with a prescription for Ciclo 21® (a COC containing ethinyl estradiol 30 mcg + levonorgestrel 15 mcg). The audio recording of every SP visit was listened to independently by 3 researchers to evaluate the COC dispensing practice. The percentage of CPs who performed a screening for safe use of COCs (i.e., taking of patients’ medical and family history, and measuring of blood pressure) and provided counseling, as well as the quality of the screening and counseling, were evaluated. Results Of the 185 CPs contacted, 41 (22.2%) agreed to participate in the study and finished the study protocol. Only 3 CPs asked the SP a question (1 question asked by each professional), and all of the questions were closed-ended, viz., “do you smoke?” (n = 2) and “what is your age?” (n = 1). None of the CPs measured the patient’s blood pressure. Six CPs provided counseling when dispensing COCs (drug dosing, 5 CPs; possible adverse effects, 2 CPs), and one CP provided counseling regarding both aspects. Conclusion The CPs evaluated did not dispense COC appropriately and could influence in the occurrence of negatives therapeutic outcomes such as adverse effects and treatment failure.

Elderly and drugs: risks and necessity of rational use

In recent decades, the world has undergone a demographic transformation with a rapid growth of the elderly population, resulting in an increased demand for funds to maintain their health and drug consumption. Pharmacokinetic and pharmacodynamic changes occurring in the elderly can interfere directly in the adverse effects of drugs and increase the risk of intoxication. In addition, there are external factors interfering with the pharmacotherapy of the elderly, such as inappropriate use and the lack of access to information. Many therapeutic classes of drugs should be used with caution or avoided in the elderly population, such as anti-inflammatory and some anti-hypertensive drugs, diuretics and digitalis. If not managed carefully, these medicines can affect the safety and quality of life in the elderly. Thus, the aim of this review was to identify drugs that should be used with caution in elderly patients in order to avoid intoxication and/or adverse drug events.

Efficacy and Tolerability of Antiepileptic Drugs in Patients with Focal Epilepsy: Systematic Review and Network Meta-analyses

Several newer antiepileptic drugs (AEDs) have been introduced into clinical practice, offering choices for individualizing the treatment of epilepsy since AEDs have different efficacy and tolerability profiles. In particular, questions exist regarding which AEDs are the best options for the monotherapy of focal epilepsy. Is carbamazepine (CBZ), which is considered the standard treatment for focal epilepsy, still the best option for monotherapy of focal epilepsy, despite the emergence of new AEDs? In this systematic review, we compared the relative tolerability of all available AEDs for monotherapy of all types of epilepsy as well as their efficacy in the monotherapy of focal epilepsy. In addition, we compared CBZ with other AEDs for the monotherapy of focal epilepsy. We performed a search of the MEDLINE/PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for randomized controlled clinical trials. To compare the relative efficacy and tolerability of the AEDs, we performed network meta‐analyses using a Bayesian random‐effects model. Sensitivity analyses were conducted to determine the robustness of the results. A total of 65 studies were included in this review, composing 16,025 patients. Clobazam, levetiracetam, lamotrigine, oxcarbazepine, sulthiame, topiramate, and valproate had the best efficacy profiles and demonstrated no evidence of superiority or inferiority compared with CBZ. However, CBZ showed the greatest risk of patient discontinuation due to intolerable adverse reactions, whereas lamotrigine had the best safety profile and an 81% probability of being the best for the tolerability outcome of patient withdrawals from the study due to intolerable adverse reactions, followed by sulthiame (60%) and clobazam (51%). The newer AEDs—levetiracetam, lamotrigine, oxcarbazepine, sulthiame, and topiramate—should be considered for monotherapy of focal epilepsy because they were demonstrated to be as effective as the older ones (CBZ, clobazam, and valproate) for the treatment of focal epilepsy and were more tolerable. Lamotrigine was the AED with the best tolerability profile, suggesting that it may be the best option for the treatment of focal epilepsy in children and adults.

Influence of enzyme inducing antiepileptic drugs on the pharmacokinetics of levetiracetam in patients with epilepsy

To assess whether levetiracetam elimination is influenced by enzyme inducing antiepileptic drugs (EIAEDs), serum levetiracetam levels were determined at frequent intervals after a single oral 1000mg dose in 15 subjects co-medicated with EIAEDs and 15 matched controls. The EIAED group showed a higher levetiracetam oral clearance (p=0.01) and a shorter half-life (p=0.02) than controls. Although the magnitude of interaction is relatively modest, it could have clinical significance for some patients.