Manuel Enrique Machado-Duque

International trends in clozapine use: a study in 17 countries

There is some evidence that clozapine is significantly underutilised. Also, clozapine use is thought to vary by country, but so far no international study has assessed trends in clozapine prescribing. Therefore, this study aimed to assess clozapine use trends on an international scale, using standardised criteria for data analysis.

International trends in antipsychotic use : A study in 16 countries, 2005-2014

The objective of this study was to assess international trends in antipsychotic use, using a standardised methodology. A repeated cross-sectional design was applied to data extracts from the years 2005 to 2014 from 16 countries worldwide. During the study period, the overall prevalence of antipsychotic use increased in 10 of the 16 studied countries. In 2014, the overall prevalence of antipsychotic use was highest in Taiwan (78.2/1000 persons), and lowest in Colombia (3.2/1000). In children and adolescents (0-19 years), antipsychotic use ranged from 0.5/1000 (Lithuania) to 30.8/1000 (Taiwan). In adults (20-64 years), the range was 2.8/1000 (Colombia) to 78.9/1000 (publicly insured US population), and in older adults (65+ years), antipsychotic use ranged from 19.0/1000 (Colombia) to 149.0/1000 (Taiwan). Atypical antipsychotic use increased in all populations (range of atypical/typical ratio: 0.7 (Taiwan) to 6.1 (New Zealand, Australia)). Quetiapine, risperidone, and olanzapine were most frequently prescribed. Prevalence and patterns of antipsychotic use varied markedly between countries. In the majority of populations, antipsychotic utilisation and especially the use of atypical antipsychotics increased over time. The high rates of antipsychotic prescriptions in older adults and in youths in some countries merit further investigation and systematic pharmacoepidemiologic monitoring.

Time to and factors associated with insulin initiation in patients with type 2 diabetes mellitus.

AIMS Determine the time between the start of oral antidiabetic therapy (OAD) and the initiation of insulin therapy and to establish factors associated with insulin prescription among patients with type 2 diabetes mellitus (T2DM) in Colombia. METHODS Cohort, retrospective, population-based study. We identify patients with T2DM who started OAD therapy between 1 January 2007 and 31 December 2008, and a 5-year follow-up was performed. Kaplan-Meier survival analysis for time to start insulin therapy was generated and factors associated with insulin initiation were determined using logistic regression. RESULTS A total of 1042 patients (52.4% women), mean age 63.4 years at the start of pharmacological treatment. After 5 years, 272 patients (26.1%) initiated insulin therapy. Using combination therapy of metformin and glibenclamide was associated with greater risk of insulin initiation (OR: 1.64, 95% CI: 1.12-2.40, p=0.010), while being a male over 45 years of age (OR: 0.59, 95% CI: 0.37-0.96, p=0.034) and initiating OAD therapy with metformin (OR: 0.30, 95% CI: 0.20-0.46, p<0.001) reduced the risk of insulin use. CONCLUSIONS After 5 years of OAD treatment, 26.1% of people with T2DM started insulin therapy. Age, sex and type of initial OAD affected the probability of switching to insulin in these patients in Colombia.

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.

Calidad de la prescripción de verapamilo de liberación convencional en pacientes con hipertensión arterial

OBJECTIVE To identify patients who were being treated for hypertension with conventional release verapamil (CRV), and to notify the professional responsible for their health care on cardiovascular risk to which they are exposed and achieve a reduction in the number of patients who are treated with this drug. METHODS A quasi-experimental prospective before and after study without a control group was conducted on 7289 patients diagnosed with hypertension who were on treatment with CRV, between October 1, 2012 and December 31, 2012 in 8 Colombian cities, collected from a database for dispensing medicines. Socio-demographic and pharmacological variables were evaluated. A total of 108 educational interventions were performed on those responsible for their health care, and evaluated within three months with the proportion of suspension of the prescriptions of CRV being evaluated. Multivariate analysis was performed using SPSS 22.0. RESULTS The mean age of patients was 67.9±11.8 years (range: 26-96 years), of which 70.6% were men. Withdrawal of treatment with CRV was achieved in a total of 1922 patients (26.3% of users), distributed as follows: 1160 (60.4%) were the presentation of 120mg, while 762 (39.6%) the 80mg. The variable being treated in the city of Medellin (OR: 17.6; 95% CI: 11.949 to 25.924; P<.01) was statistically significantly associated with the replacement of CRV for another antihypertensive. CONCLUSIONS A relatively moderate adherence to recommendations about the proper use of CRV in hypertensive patients, was found. Intervention programs that reduce inappropriate prescribing of potential risks to patients of insurance companies and cities where the change was not achieved, must be enforced.

Intervención en la prescripción de la combinación de inhibidor de la enzima convertidora de angiotensina (IECA) y bloqueador del receptor de angiotensina ii (BRA-II)

En el manejo farmacológico de la hipertensión arterial y la falla cardiaca se han utilizado los inhibidores de la enzima convertidora de angiotensina (IECA) y los bloqueadores del receptor de angiotensina ii (BRA-II) en monoterapia o sumados con otros grupos farmacológicos con muy buenos resultados a corto y a largo plazo1. Sin embargo, al utilizar estos 2 bloqueantes del sistema reninaangiotensina-aldosterona (SRAA) simultáneamente no se obtienen beneficios clínicos importantes; de hecho, no disminuye la mortalidad cardiovascular ni general comparada con la monoterapia de cualquiera de los 2, pero sí se incrementan potencialmente las reacciones adversas, en especial el daño sobre el riñón. Por lo tanto, el doble bloqueo del SRAA debe evitarse en estos pacientes y solo debe emplearse de forma selectiva con algunos beneficios solo en nefropatía diabética2-4. Por esta razón se plantea describir los resultados obtenidos a partir de la intervención periódica y sistemática de prescriptores de IECA + BRA-II en 2 empresas aseguradores denominadas Entidad Promotora de Salud (EPS) del régimen pago de salud en Colombia, en la ciudad de Bogotá, durante los años 2010 a 2014, con el fin de reducir esta práctica inadecuada. Se llevó a cabo un estudio cuasiexperimental, prospectivo, antes y después, sin grupo control, donde se realizó una intervención en pacientes que se encontraban en manejo farmacológico con la combinación de IECA + BRA-II, en

Somnolencia diurna excesiva, mala calidad del sueño y bajo rendimiento académico en estudiantes de Medicina

INTRODUCTION Quality of sleep and excessive daytime sleepiness (EDS) affect cognitive ability and performance of medical students. This study attempts to determine the prevalence of EDS, sleep quality, and assess their association with poor academic performance in this population. MATERIAL AND METHODS A descriptive, observational study was conducted on a random sample of 217 medical students from the Universidad Tecnológica de Pereira, who completed the Pittsburgh Sleep Quality Index (PSQI) questionnaire and the Epworth sleepiness scale. Sociodemographic, clinic and academic variables were also measured. Multivariate analyses for poor academic performance were performed. RESULTS The included students had a mean age of 21.7±3.3 years, of whom 59.4% were men. Almost half (49.8%) had EDS criteria, and 79.3% were poor sleepers (PSQI ≥ 5), while 43.3% had poor academic performance during the last semester. The bivariate analysis showed that having used tobacco or alcohol until intoxicated, fairly bad subjective sleep quality, sleep efficiency < 65%, and being a poor sleeper were associated with increased risk of low performance. Sleep efficiency < 65% was statistically associated with poor academic performance (P=.024; OR = 4.23; 95% CI, 1.12-15.42) in the multivariate analysis. CONCLUSIONS A poor sleep quality determined by low efficiency was related to poor academic achievement at the end of semester in medical students.

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.

Effectiveness of treatment with biologic- and disease-modifying antirheumatic drugs in rheumatoid arthritis patients in Colombia

Rheumatoid arthritis (RA) is an autoimmune disease cause of disability and high costs. To determine the effectiveness of therapy with biologic‐ and disease‐modifying antirheumatic drugs (DMARDs) in patients with RA and factors associated with the control of the disease.