Milica Ćulafić

Potentially Inappropriate Prescribing in Older Primary Care Patients

Objectives The aim of the study was to determine the rate of Potentially Inappropriate Medicines (PIM) and Potential Prescription Omissions (PPO) according to Screening Tool of Older Persons potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment (STOPP/START) criteria. Study Design A cross-sectional survey in community pharmacy. Method A prospective cross-sectional study was performed, during March-May 2012, in five community pharmacies. Patients aged ≥65 years, who collected one or more prescribed medications, were asked to participate in the study, and an interview was scheduled. Patients were asked to provide their complete medical and biochemical record from their general practitioner. Results 509 patients, mean age 74.8±6.5 years, 57.4% female, participated in the study. 164 PIM were identified in 139 patients (27.3%). The most common were: long-term use of long-acting benzodiazepines (20.7%), use of non-steroidal antiinflammatory drugs (NSAID) in patients with moderate-severe hypertension (20.1%), use of theophylline as monotherapy for chronic obstructive pulmonary disease (COPD, 15.9%) and use of aspirin without appropriate indication (15.2%). Patients with more than four prescpritions had a higher risk for PIM (OR 2.85, 95% CI 1.97–4.14, p<0.001). There were 439 PPO, identified in 257, (50.5%) patients. Predictors for PPO were older age, presence of diabetes, myocardial infarction, osteoporosis, stroke, COPD and/or angina pectoris. Conclusion STOPP/START criteria may be useful in identifying inappropriate prescribing and improving the current prescribing practices. Pharmacists should focus more on patients with more than four medications and/or patients with gout or pain accompanied with arterial hypertension because those patient may be at higher risk of PIM. Additionlly, patients older than 74 years with diabetes, osteoporosis, myocardial infarction, stroke, angina pectoris and/or COPD may have an increased risk of PPO.

Role of cystatin C and renal resistive index in assessment of renal function in patients with liver cirrhosis.

AIM To evaluate the clinical significance of cystatin C and renal resistive index for the determination of renal function in patients with liver cirrhosis. METHODS We conducted a study of 63 patients with liver cirrhosis. A control group comprised of 30 age and gender-matched healthy persons. Serum cystatin C was determined in all study subjects and renal Doppler ultrasonography was made. Estimated glomerular filtration rate from serum creatinine (GFRCr) and cystatin C (GFRCys) was calculated. RESULTS We confirmed significant differences in values of cystatin C between patients with different stages of liver cirrhosis according to Child-Pugh (P = 0.01), and a significant correlation with model of end stage liver disease (MELD) score (r s = 0.527, P < 0.001). More patients with decreased glomerular filtration rate were identified based on GFRCys than on GFRCr (P < 0.001). Significantly higher renal resistive index was noted in Child-Pugh C than in A (P < 0.001) and B stage (P = 0.001). Also, a significant correlation between renal resistive index and MELD score was observed (r s = 0.607, P < 0.001). Renal resistive index correlated significantly with cystatin C (r s = 0.283, P = 0.028) and showed a negative correlation with GFRCys (r s = -0.31, P = 0.016). CONCLUSION Cystatin C may be a more reliable marker for assessment of liver insufficiency. Additionally, cystatin C and renal resistive index represent sensitive indicators of renal dysfunction in patients with liver cirrhosis.

Dabigatran - Metabolism, Pharmacologic Properties and Drug Interactions

BACKGROUND The superiority of dabigatran has been well proven in the standard dosing regimen in prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) and extended venous thromboembolism (VTE) treatment. Dabigatran, an anticoagulant with a good safety profile, reduces intracranial bleeding in patients with atrial fibrillation and decreases major and clinically relevant non-major bleeding in acute VTE treatment. However, several important clinical issues are not fully covered by currently available directions with regard to dabigatran administration. The prominent one is reflected in the fact that dynamic impairment in renal function due to dehydratation may lead to haemorragic complications on the one hand, while on the other hand glomerular hyperfiltration may be a possible cause of dabigatran subdosing, hence reducing the drugs efficacy. Furthermore, limitations of the Cockcroft-Gault formula, considered a standard equation for assessing the renal function, may imply that other calculations are likely to obtain more accurate estimates of the kidney function in specific patient populations. Method and Conclusions: Although not routinely recommended, a possibility of monitoring dabigatran in special clinical settings adds to optimization of its dosage regimens, timely perioperative care and administration of urgently demanded thrombolytic therapy, therefore significantly improving this drugs safety profile. Despite the fact that dabigatran has fewer reported interactions with drugs, food constituents, and dietary supplements, certain interactions still remain, requiring considerable caution, notably in elderly, high bleeding risk patients, patients with decreased renal function and those on complex drug regimens. Additionally, upon approval of idarucizumab, an antidote to dabigatran solution, hitherto being a major safety concern, has been finally reached, which plays a vital role in life-threatening bleeding and emergency interventions and surgery.

Expectations, concerns, and needs of patients who start drugs for chronic conditions. A prospective observational study among community pharmacies in Serbia

Abstract Background: During the initiation of treatment of a chronic disease, patients may have varying interests, expectations, concerns, and reasons to stop treatment, influencing compliance with prescribed treatment. Thus, healthcare professionals are expected to integrate these needs into medicines management. Objectives: To determine what information is important to patients; assess predictors of patients’ interests, expectations, concerns, reasons to stop therapy; evaluate drug-related problems following initiation of therapy and summarize how pharmacists resolve them during patient–pharmacist counselling. Methods: In 2014, a four-month study was performed in Serbian community pharmacies, as part of the Pharmaceutical Care Quality Indicators Project led by the European Directorate for the Quality of Medicines & Healthcare. Seventy community pharmacists were asked to participate in the study. Pharmacists recruited adult patients who consented to participate in the study and who initiated treatment, lasting at least six months. Patients completed an open-ended questions form. After two-to-four weeks, a patient–pharmacist consultation was performed. Results: Forty-four community pharmacists (response rate 62.9%) sent back the completed forms from 391 patients (response rate 67.1%). The total number of dispensed drugs was 403. In terms of drug safety, 29.4% of patients sought information, 32.5% expressed concerns, and 28.1% of patients cited it as a reason to discontinue treatment. During the first weeks of therapy, 18% of patients experienced practical problems, while 27.3% reported adverse drug reactions. Conclusion: Safety issues are a major focus of patients’ prescribed new medicines for long-term treatment.

The Clinical Importance of Cystatin C and Hepatic Artery Resistive Index in Liver Cirrhosis

Background: Data suggest cystatin C (CysC) levels and hepatic artery resistive index (HARI) correspond to the progression of chronic liver disease. We aimed to evaluate the clinical significance of these parameters in assessment of fibrosis in patients with liver cirrhosis. Methods: The cross-sectional study included 63 patients with liver cirrhosis. A control group consisted of 30 age- and gender-matched healthy persons. Results: We confirmed significantly higher values of CysC in patients with cirrhosis compared to control group (p = 0.036). Average value of HARI in the examined group was increased (0.72 ± 0.06) and there was the statistically significant difference compared to controls (0.66 ± 0.03) (p < 0.001). We found statistically significant correlation between HARI and CysC in the study group. Analyzing the possibility of distinguishing healthy subjects from patients with fibrosis, we have found that the area under the curve is far greater in the HARI index than CysC. Comparison of CysC among Child–Pugh stages and correlation with a model for end-stage liver disease (MELD) score showed statistically significant results. Conclusion: We confirmed HARI is a more accurate parameter than CysC in discriminating healthy subjects from patients with fibrosis, while CysC could be a better indicator of the stage of liver cirrhosis.

CP-193 Drug-drug interactions among patients with chronic liver disease: A snapshot by clinical pharmacist

Background People with chronic liver diseases constitute a group of patients who often have polypharmacy, comorbidities, and pharmacokinetic and pharmacodynamic changes, that cause an increase in the risk of drug-drug interactions. Purpose To identify and describe drug-drug interactions based on their clinical significance and predictors of their occurrence among patients with chronic liver diseases. To compare the results from two available electronic sources for interaction evaluation. Material and methods A study was conducted on a hepatology ward from May to July 2015, at the gastroenterology and hepatology clinic. Data were gathered through a prospective chart review performed by a clinical pharmacist during a 4 h visit once per week. An estimate of whether gender, age, liver disease, comorbidities, use of certain drugs and total number of drugs per patient influenced the occurrence of drug-drug interactions was made, using correlation and binary regression analysis. Two separate drug interaction programs (Lexi-Interact and Epocrates) were applied to provide the analysis. Results From medicines use review of 100 patients with chronic liver diseases, we identified 486 drug-drug interactions (DDIs) using the Lexi-Interact and 293 using the Epocrates database. The most common type of interaction was class C and monitor/mоdify, deemed as clinically significant (367 DDIs; at least one was found in 83.5% of patients). Acetylsalicylic acid had the highest risk of causing potentially serious (class D, major severity; Lexi-Interact) interactions (25.3%). Most common interacting drug pairs were hydrochlorothiazide/bisoprolol, hydrochlorothiazide/ibuprofen and furosemide/spironolactone. Predictors of DDIs were total number of drugs per patient, number of comorbidities and gender. Statistically significant correlation with occurrence of DDIs was observed for the following covariates: total number of drugs per patient (p = 0.049), number of comorbidities (p = 0.023) and patient age (p = 0.039). Conclusion Most DDIs in the study identified the need for monitoring/modifying therapy. Patients on hydrochlorothiazide, furosemide and bisoprolol were more likely to have DDIs. Lexi-Interact was shown to be the more sensitive source. We advocate that on-ward participation of a clinical pharmacist in a hepatology team may prevent/minimise the frequency and severity of DDIs, provide prompt solutions and enhance patient care. References and/or Acknowledgements lexi.com/PDA-Software-for-Pharmacists/Lexi-Drugs-Interact https://online.epocrates.com No conflict of interest.

CPC-066 Identification of Patient Groups with Insufficient Knowledge About Their Medicines at Hospital Discharge

Background Hospital patients in Serbia receive information about their medicines from physicians and nurses. Pharmacists are not involved in medicines counselling. In countries with developed health care, pharmacists provide counselling to patients at discharge. Purpose To establish which groups of hospital patients got the least information about their medicines, since these patients could profit from additional counselling at discharge, provided by pharmacists. Materials and Methods The study was carried out in five hospitals in Serbia, over a period of 8 weeks. Pharmacists collected clinical data from the patient’s medical notes. Patients’ knowledge of medicines was assessed through an interview using a structured questionnaire, on the morning of discharge. We evaluated 3 groups of patients according to age, length of hospital stay and number of newly-introduced medicines. They were asked seven questions: if they were informed about all medicines, reasons for treatment, the effects of the drug, duration of treatment, posology and method of administration, undesirable effects and interactions. ‘Yes’ was awarded two points, ‘partially’ one and ‘no’ no points. A total ≤10 of all answers per patient was defined as insufficient knowledge. Results 148 patients (mean age 60 years) were interviewed. 74% of patients younger than 65 years and 89% of elder patients showed insufficient knowledge. Length of hospital stay had impact on patient knowledge. 70% who stayed more than 20 days had insufficient knowledge vs. 85% who were hospitalised less than 10 days. Insufficient knowledge increased with number of newly-introduced medicines (80% who had 1 vs. 96% who had ≥5 new drugs on discharge). Conclusions The findings of this study indicate that older patients, those who stay less time in hospital and those who receive more new drugs on discharge need to get more counselling about their treatment. Serbian pharmacists can take a proactive role for these patients. No conflict of interest.