Maria Sjölander

Persistent Use of Secondary Preventive Drugs Declines Rapidly During the First 2 Years After Stroke

Background and Purpose— To prevent new cardiovascular events after stroke, prescribed preventive drugs should be used continuously. This study measures persistent use of preventive drugs after stroke and identifies factors associated with persistence. Methods— A 1-year cohort (21 077 survivors) from Riks-Stroke, the Swedish Stroke Register, was linked to the Swedish Prescribed Drug Register. Results— The proportion of patients who were persistent users of drugs prescribed at discharge from hospital declined progressively over the first 2 years to reach 74.2% for antihypertensive drugs, 56.1% for statins, 63.7% for antiplatelet drugs, and 45.0% for warfarin. For most drugs, advanced age, comorbidity, good self-perceived health, absence of low mood, acute treatment in a stroke unit, and institutional living at follow-up were independently associated with persistent medication use. Conclusion— Persistent secondary prevention treatment declines rapidly during the first 2 years after stroke, particularly for statins and warfarin. Effective interventions to improve persistent secondary prevention after stroke need to be developed.

The association between patients’ beliefs about medicines and adherence to drug treatment after stroke: a cross-sectional questionnaire survey

Objectives Adherence to preventive drug treatment is a clinical problem and we hypothesised that patients’ beliefs about medicines and stroke are associated with adherence. The objective was to examine associations between beliefs of patients with stroke about stroke and drug treatment and their adherence to drug treatment. Design Cross-sectional questionnaire survey. Setting Patients with stroke from 25 Swedish hospitals were included. Measurements Questionnaires were sent to 989 patients to assess their perceptions about stroke (Brief Illness Perception Questionnaire, Brief IPQ), beliefs about medicines (Beliefs about Medicines Questionnaires, BMQ) and adherence to treatment (Medication Adherence Report Scale, MARS) 3 months after stroke onset. Only patients living at home were included in the analysis. The primary outcome was self-reported adherence as measured on MARS. MARS scores were dichotomised into adherent/non-adherent. Background and clinical data from the Swedish Stroke register were included. Results 811 patients were still living at home and 595 answered the questionnaire. Complete MARS data were available for 578 patients and 72 (12.5%) of these were classified as non-adherent. Non-adherent patients scored lower on positive beliefs as measured on BMQ-necessity (OR = 0.90, 95% CI 0.83 to 0.98) and BMQ-benefit (OR=0.77, 95% CI 0.68 to 0.87), and higher on negative beliefs as measured on BMQ-concern (OR=1.12, 95% CI 1.05 to 1.21), BMQ-overuse (OR=1.29, 95% CI 1.14 to 1.45), and BMQ-harm (OR=1.12, 95% CI 1.01 to 1.24). The Brief IPQ showed that non-adherent patients believed their current treatment to be less useful (p=0.001). Conclusions This study showed associations between beliefs of Swedish patients with stroke about medicines and adherence. Positive beliefs were less common and negative more common among non-adherent. To improve adherence, patients’ beliefs about medicines should be considered.

Socioeconomic Inequalities in the Prescription of Oral Anticoagulants in Stroke Patients With Atrial Fibrillation

Background and Purpose— Oral anticoagulants (OACs) are effective against ischemic stroke in patients with atrial fibrillation. Our aim was to investigate differences in the prescribing of OACs after ischemic stroke in patients with atrial fibrillation based on age, sex, country of birth, and socioeconomic status. Methods— Patients with first-ever ischemic stroke and atrial fibrillation without OAC treatment were included from the Swedish stroke register from 2009 to 2012. The outcome was OAC prescribed at discharge. Income, education, country of birth, and risk factors were obtained from official registers. Risk factors and health status were controlled for in multivariable logistic regression. Results— Of 12 088 stroke patients, 36.3% were prescribed an OAC. Prescribing was less common with older age and, in patients born in other Nordic countries (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.68–0.98) or countries outside of Europe (OR, 0.65; 95% CI, 0.42–0.99) compared with those born in Sweden. University education (OR, 1.20; 95% CI, 1.05–1.36) and highest income (OR, 1.19; 95% CI, 1.06–1.33) were associated with higher levels of OAC prescribing compared with those with primary school education or lowest income level. Conclusion— Differences by age, income, education, and country of birth were found in the prescribing of OACs after stroke. Differences were not explained by common risk factors. This indicates socioeconomic inequalities in the prescribing of preventive treatment after stroke.

Few sex differences in the use of drugs for secondary prevention after stroke : a nationwide observational study

This observational study describes the sex differences in the use of secondary preventive drugs after ischemic stroke in terms of prescribing and persistence. Also, sex differences in patient‐ and treatment‐related factors associated with drug use were investigated.

Inequalities in medication adherence to statin treatment after stroke: A nationwide observational study:

Introduction The objective was to investigate differences in adherence to statins after stroke based on age, sex, socioeconomic status and country of birth. Patients and methods Patients with ischemic stroke in 2009–2010 were included from the Swedish stroke register. Adherence to statin treatment was measured over two years as proportion of days covered with 80% as cut-off for adherence. Income, education, and country of birth were obtained from official registers. Factors associated with adherence were controlled for in multivariable logistic regression. Results Of 15,192 included patients, 73.9% had an adherence rate ≥80%. The oldest (85+ years) and youngest (18–54 years) had the lowest adherence, and a smaller proportion of women were adherent (odds ratio (OR) 0.84; 95% confidence interval (CI) 0.77–0.92). Adherence was less common in patients born in Nordic countries (OR 0.82; 95% CI (0.68–0.97), Europe (OR 0.78; 95% CI 0.65–0.93), and in non-European countries (OR 0.65; 95% CI 0.50–0.84) compared to Sweden-born. Patients with university education were to a lower extent adherent compared to patients with primary school education (OR 0.81; 95% CI 0.72–0.91). There was no association between adherence and income. Discussion The study was based on individual level real-life data with national coverage. Adherence was estimated from data on filled prescriptions, but filled prescription does not mean that drugs are used as intended. Conclusion Adherence to statin treatment over two years was suboptimal, and adherence was less common among women, patients born outside of Sweden and patients with university education.

Doctors’ and nurses’ perceptions of a ward-based pharmacist in rural northern Sweden

Background This project is part of the prospective quasi experimental proof-of-concept investigation of clinical pharmacist intervention study to reduce drug-related problems among people admitted to a ward in a rural hospital in northern Sweden. Objective To explore doctors’ and nurses’ perceptions and expectations of having a ward-based pharmacist providing clinical pharmacy services. Setting Medical ward in a rural hospital in northern Sweden. Method Eighteen face-to-face semi-structured interviews were conducted with a purposive sample of doctors and nurses working on the ward where the clinical pharmacy service was due to be implemented. Semi-structured interviews were digitally recorded, transcribed and analysed using thematic analysis. Main outcome measure Perceptions and expectations of nurses and doctors. Results Doctors and nurses had limited experience of working with pharmacists. Most had a vague idea of what pharmacists can contribute within a ward setting. Participants, mainly nurses, suggested inventory and drug distribution roles, but few were aware of the pharmacists’ skills and clinical competence. Different views were expressed on whether the new clinical pharmacy service would have an impact on workload. However, most participants took a positive view of having a ward-based pharmacist. Conclusion This study provided an opportunity to explore doctors’ and nurses’ expectations of the role of clinical pharmacists before a clinical pharmacy service was implemented. To successfully implement a clinical pharmacy service, roles, clinical competence and responsibilities should be clearly described. Furthermore, it is important to focus on collaborative working relationships between doctors, nurses and pharmacists.

Effects of Pharmacists’ Interventions on Inappropriate Drug Use and Drug-Related Readmissions in People with Dementia—A Secondary Analysis of a Randomized Controlled Trial

Age-associated physiological changes and extensive drug treatment including use of potentially inappropriate medications (PIMs) pose a significant risk of drug–drug interactions and adverse drug events among elderly people with dementia. This study aimed at analysing the effects of clinical pharmacists’ interventions on use of PIMs, risk of emergency department visits, and time to institutionalization. Furthermore, a descriptive analysis was conducted of circumstances associated with drug-related readmissions. This is a secondary analysis of data from a randomized controlled intervention study conducted in two hospitals in Northern Sweden. The study included patients (n = 460) 65 years or older with dementia or cognitive impairment. The intervention consisted of comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team. There was a larger decrease in PIMs in the intervention group compared with the control group (p = 0.011). No significant difference was found in time to first all-cause emergency department visits (HR = 0.994, 95% CI = 0.755–1.307 p = 0.963, simple Cox regression) or time to institutionalization (HR = 0.761, 95% CI = 0.409–1.416 p = 0.389, simple Cox regression) within 180 days. Common reasons for drug-related readmissions were negative effects of sedatives, opioids, antidepressants, and anticholinergic agents, resulting in confusion, falling, and sedation. Drug-related readmissions were associated with living at home, heart failure, and diabetes. Pharmacist-provided interventions were able to reduce PIMs among elderly people with dementia and cognitive impairment.

4CPS-237 Clinically-relevant drug-drug interactions among elderly people with dementia living in northern sweden

Background The prevalence of drug-related problems increases with age. One important cause is drug-drug interactions, which contribute to hospital admissions among the elderly. Elderly people with dementia are particularly vulnerable. Purpose The aim of the present study was to assess the occurrence and characteristics of drug-drug interactions and to investigate potential risk factors among elderly people with dementia. Material and methods Medical records of 458 people aged ≥65 years, with dementia or cognitive impairment that were admitted to two hospitals in northern Sweden between 9 January 2012 and 2 December 2014, were reviewed retrospectively. Information on medication use at the time of admission was collected. Clinically-relevant drug-drug interactions requiring either dose adjustments or avoidance of concomitant use were identified using the Janusmed interactions database. Interactions were further classified regarding pharmacological mechanism, i.e. pharmacokinetic or pharmacodynamic interactions and their subdivisions, according to Stockley’s classification system. Descriptive statistics and simple and multiple logistic regressions were used to analyse data. Results Four hundred and one drug-drug interactions were identified and 43.2% of the persons had at least one interaction. This is in line with, or somewhat higher than, results shown in other studies. In 95.8% of cases interactions required dose adjustment and in 4.2% of cases it was considered that the drug combination should be avoided. Pharmacokinetic interactions were most frequently observed of which warfarin – acetaminophen (n=26) was most common. Among pharmacodynamic interactions, furosemide – citalopram (n=35) and acetylsalicylic acid – citalopram (n=32) were the most frequently observed. An association was found in the multivariable model between the number of medications prescribed in the individual patient and the risk of one or more drug-drug interaction (OR 1.312, 95% CI: 1.227 to 1.403). No associations were found between sex, age, MMSE score, type of accommodation or geographic location, and the risk of at least one drug-drug interaction. Conclusion Clinically-relevant drug-drug interactions are prevalent among elderly people with dementia living in northern Sweden. To avoid drug-related problems, the risk of drug-drug interactions should be noted, especially in the present population. This is particularly important with increasing numbers of medications prescribed. No conflict of interest

Few sex differences in use of drugs for secondary prevention after stroke : a nationwide observational study

Background: Two case reports of polymyalgia rheumatica (PMR) and one case-report of PMR and temporalis arteritis (AT) suggest that the use of statins may have triggered the development of these inflammatory rheumatic diseases. PMR is closely linked to the disease arteritis temporalis which makes it difficult for physicians to distinguish these two diseases. Data on the association between the use of statins and PMR and/or AT are scarce. Objectives: To assess the association between statin use and the occurrence of PMR/AT. Methods: A case/non-case study based on individual case safety reports (ICSR) listed in the World Health Organisation (WHO) global ICSR database (Vigibase) was conducted. According to WHO adverse reaction terminology, cases were defined as reports of PMR. Each case was matched with five non-cases by age, gender and time of reporting. Non-cases were all other ADR-reports. Use of statins was classified according to the Anatomical Therapeutic Chemical (ATC) classification code system (C10AA, C10BA, C10BX). Potential confounders in the analysis, i.e., use of corticosteroids, immunosuppressive drugs, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, anti-epileptics, proton pump inhibitors and cardiovascular drugs were determined. Multivariate logistic regression was used to calculate the reporting odds ratios (RORs) with 95% confidence intervals (CI). In addition, three case-reports from the VigiBase were studied in detail. Results: We identified 327 reports of PMR/AT as cases and 1635 reports of other ADRs as non-cases. Among cases statins were more frequently reported as suspected agent (29.4%) compared to non-cases (2.9%). After adjustment for several covariates, statins were statistically significantly associated with reports of PMR/AT (ROR 14.21; 95% CI 9.89-20.85). Conclusions: The result of this study underlines findings of the case reports that the use of statins may be associated with the occurrence of PMR/AT.Background: In The Netherlands, the largest outbreak of Q fever worldwide is ongoing. A particular risk group concerns pregnant women in which the infection is mostly asymptomatic. Q fever during pregnancy may cause both obstetric complications as well as chronic infection in the mother. Long term antibiotic treatment of infected women may reduce the risk of complications. Objectives: A clustered randomized controlled trial to assess the effects of screening for Q fever during pregnancy is ongoing (trial register number NL30340.042.09). The primary endpoint is a maternal or obstetric complication in Q fever positive women. Methods: Midwife centers in high-risk Q fever areas were randomized to recruit pregnant women for the screening or control strategy. In both groups a blood sample was taken between 20 and 32 weeks of gestation. In the screening group this sample was immediately analyzed with indirect immunofluorescence assay for the detection of IgG and IgM antibodies. Every positive sample was fully titrated. In case of acute or chronic infection antibiotic treatment advice was given. In the control group serum was frozen for analysis after delivery. Results: In all, 55 of 99 eligible midwife centers were randomized. They recruited 1222 pregnant women from which a blood sample was taken; 534 for the screening group and 688 for the controle group. Fourteen percent in both groups had serologic evidence for an acute or previous Q fever infection. Only 7 participants in the intervention group had evidence for an acute infection and were treated with antibiotics (erythromycin or cotrimoxazole). Three of them experienced side-effects, mainly gastro-intestinal, of which one consulted the gynecologist due to the side-effects. Since a part of the participants still have to deliver, data collection on clinical outcome is still ongoing. Conclusions: Fourteen percent of the pregnant women in high-risk Q fever areas have evidence of Q fever infection. Only a very small part has an acute infection, in which treatment is though to be needed. Clinical outcome data and cost-effectiveness analyses are expected in spring and will be presented.