Pauline Siew Mei Lai

Effects of pharmaceutical care on adherence and persistence to bisphosphonates in postmenopausal osteoporotic women

What is known and Objective:  Studies have shown that comprehensive interventions by pharmacists can improve adherence and persistence to osteoporosis therapy, but the association between adherence and bone turnover markers (BTMs) has never been studied. Therefore, the aim of this study was to evaluate the effects of pharmaceutical care on medication adherence (and its effects on BTMs), as well as persistence of postmenopausal osteoporotic women to prescribed bisphosphonates.

Barriers and facilitators to starting insulin in patients with type 2 diabetes: a systematic review

To identify the barriers and facilitators to start insulin in patients with type 2 diabetes.

Effects of a pharmaceutical care model on medication adherence and glycemic control of people with type 2 diabetes.

Background Diabetes mellitus is a lifelong chronic condition that requires self-management. Lifestyle modification and adherence to antidiabetes medications are the major determinants of therapeutic success in the management of diabetes. Purpose To assess the effects of a pharmaceutical care (PC) model on medication adherence and glycemic levels of people with type 2 diabetes mellitus. Patients and methods A total of 241 people with type 2 diabetes were recruited from a major teaching hospital in Malaysia and allocated at random to the control (n=121) or intervention (n=120) groups. Participants in the intervention group received PC from an experienced pharmacist, whereas those in the control group were provided the standard pharmacy service. Medication adherence was assessed using the Malaysian Medication Adherence Scale, and glycemic levels (glycated hemoglobin values and fasting blood glucose [FBG]) of participants were obtained at baseline and after 4, 8, and 12 months. Results At baseline, there were no significant differences in demographic data, medication adherence, and glycemic levels between participants in the control and intervention groups. However, statistically significant differences in FBG and glycated hemoglobin values were observed between the control and intervention groups at months 4, 8, and 12 after the provision of PC (median FBG, 9.0 versus 7.2 mmol/L [P<0.001]; median glycated hemoglobin level, 9.1% versus 8.0% [P<0.001] at 12 months). Medication adherence was also significantly associated with the provision of PC, with a higher proportion in the intervention group than in the control group achieving it (75.0% versus 58.7%; P=0.007). Conclusion The provision of PC has positive effects on medication adherence as well as the glycemic control of people with type 2 diabetes. Therefore, the PC model used in this study should be duplicated in other health care settings for the benefit of more patients with type 2 diabetes.

Long-term nasogastric tube feeding in elderly stroke patients--an assessment of nutritional adequacy and attitudes to gastrostomy feeding in Asians.

BackgroundGastrostomy feeding is superior to long-term nasogastric (NG) feeding in patients with dysphagic stroke, but this practice remains uncommon in Asia. We sought to examine the nutritional adequacy of patients on long term NG feeding and identify barriers to gastrostomy feeding in these patients.MethodologyA prospective comparison of Subjective Global Assessment (SGA), and anthropometry (mid-arm muscle circumference, MAMC; triceps skinfold thickness, TST) between elderly stroke patients on long-term NG feeding and matched controls was performed. Selected clinicians and carers of patients were interviewed to assess their knowledge and attitudes to gastrostomy feeding.Results140 patients (70 NG, 70 oral) were recruited between September 2010 and February 2011. Nutritional status was poorer in the NG compared to the oral group (SGA grade C 38.6% NG vs 0% oral, p<0.001; TST males 10.7 + 3.7 mm NG vs 15.4 + 4.6 mm oral, p<0.001; MAMCmales 187.9 + 40.4 mm NG vs 228.7 + 31.8 mm oral, p<0.001). 45 (64.3%) patients on long-term NG feeding reported complications, mainly consisting of dislodgement (50.5%), aspiration of feed content (8.6%) and trauma from insertion (4.3%). Among 20 clinicians from relevant speciliaties who were interviewed, only 11 (55%) clinicians would routinely recommend a PEG. All neurologists (100%) would recommend a PEG, whilst the response was mixed among non-neurologists. Among carers, lack of information (47.1%) was the commonest reason stated for not choosing a PEG.ConclusionElderly patients with stroke on long term NG feeding have a poor nutritional status. Lack of recommendation by clinicians appears to be a major barrier to PEG feeding in these patients.

A systematic review of interventions by healthcare professionals on community-dwelling postmenopausal women with osteoporosis

SummaryA systematic review was conducted to evaluate evidence concerning the effect of non-drug interventions by healthcare professionals on community-dwelling postmenopausal osteoporotic women. Evidence available indicates that such interventions are effective in improving the quality of life, medication compliance, and calcium intake, but effect on other outcomes is less conclusive.IntroductionThe purpose of this study is to conduct a systematic review to evaluate evidence concerning the effect of non-drug interventions by healthcare professionals on community-dwelling postmenopausal osteoporotic women.MethodsRandomized controlled trials (RCTs) published in English between year 1990 and 2009 were identified. Types of patient outcome used as assessment included quality of life (QOL), bone mineral density (BMD), medication compliance and persistence, knowledge level, and lifestyle modification.ResultsTwenty four RCTs met the inclusion criteria. Seven studies assessed interventions by physiotherapists, six by physicians, seven by nurses, three by multi-disciplinary teams and one by dietitians. Variability in the types and intensity of interventions made comparison between each study difficult. Collectively, these studies provided some evidence to show that interventions by healthcare professionals improved the QOL medication compliance and calcium intake of patients but its effects on BMD, medication persistence, knowledge, and other lifestyle modifications were less conclusive.ConclusionsFrom this review, it was found that some outcome measures of such non-drug interventions still required further studies. Future studies should use validated instruments to assess the outcomes, with focus on common definitions of interventions and outcome measures, more intensive one-to-one interventions, appropriate control groups, adequate randomization procedures, and also provide information on effect size.

Healthcare Professionals’ and Policy Makers’ Views on Implementing a Clinical Practice Guideline of Hypertension Management: A Qualitative Study

Introduction Most studies have reported barriers to guideline usage mainly from doctors’ perspective; few have reported the perspective of other stakeholders. This study aimed to determine the views and barriers to adherence of a national clinical practice guideline (CPG) on management of hypertension from the perspectives of policymakers, doctors and allied healthcare professionals. Methods This study used a qualitative approach with purposive sampling. Seven in depth interviews and six focus group discussions were conducted with 35 healthcare professionals (policy makers, doctors, pharmacists and nurses) at a teaching hospital in Kuala Lumpur, Malaysia, between February and June 2013. All interviews were audio-recorded, transcribed verbatim and checked. Thematic approach was used to analyse the data. Results Two main themes and three sub-themes emerged from this study. The main themes were (1) variation in the use of CPG and (2) barriers to adherence to CPG. The three sub-themes for barriers were issues inherent to the CPG, systems and policy that is not supportive of CPG use, and attitudes and behaviour of stakeholders. The main users of the CPG were the primary care doctors. Pharmacists only partially use the guidelines, while nurses and policy makers were not using the CPG at all. Participants had suggested few strategies to improve usage and adherence to CPG. First, update the CPG regularly and keep its content simple with specific sections for allied health workers. Second, use technology to facilitate CPG accessibility and provide protected time for implementation of CPG recommendations. Third, incorporate local CPG in professional training, link CPG adherence to key performance indicators and provide incentives for its use. Conclusions Barriers to the use of CPG hypertension management span across all stakeholders. The development and implementation of CPG focused mainly on doctors with lack of involvement of other healthcare stakeholders. Guidelines should be made simple, current, reliable, accessible, inclusive of all stakeholders and with good policy support.

The Malaysian Medication Adherence Scale (MALMAS): Concurrent Validity Using a Clinical Measure among People with Type 2 Diabetes in Malaysia.

Medication non-adherence is a prevalent problem worldwide but up to today, no gold standard is available to assess such behavior. This study was to evaluate the psychometric properties, particularly the concurrent validity of the English version of the Malaysian Medication Adherence Scale (MALMAS) among people with type 2 diabetes in Malaysia. Individuals with type 2 diabetes, aged 21 years and above, using at least one anti-diabetes agent and could communicate in English were recruited. The MALMAS was compared with the 8-item Morisky Medication Adherence Scale (MMAS-8) to assess its convergent validity while concurrent validity was evaluated based on the levels of glycated hemoglobin (HbA1C). Participants answered the MALMAS twice: at baseline and 4 weeks later. The study involved 136 participants. The MALMAS achieved acceptable internal consistency (Cronbach’s alpha=0.565) and stable reliability as the test-retest scores showed fair correlation (Spearman’s rho=0.412). The MALMAS has good correlation with the MMAS-8 (Spearman’s rho=0.715). Participants who were adherent to their anti-diabetes medications had significantly lower median HbA1C values than those who were non-adherence (7.90 versus 8.55%, p=0.032). The odds of participants who were adherent to their medications achieving good glycemic control was 3.36 times (95% confidence interval: 1.09-10.37) of those who were non-adherence. This confirms the concurrent validity of the MALMAS. The sensitivity of the MALMAS was 88.9% while its specificity was 29.6%. The findings of this study further substantiates the reliability and validity of the MALMAS, in particular its concurrent validity and sensitivity for assessing medication adherence of people with type 2 diabetes in Malaysia.

Pharmaceutical care issues encountered by post-menopausal osteoporotic women prescribed bisphosphonates

What is known and Objective:  Pharmacists have been involved in providing comprehensive interventions to osteoporosis patients, but pharmaceutical care issues (PCIs) encountered during such interventions have not been well documented. Therefore, the aim of this study was to document PCIs encountered by post‐menopausal osteoporotic women prescribed bisphosphonates.

Validation of the English version of the quality of life questionnaire of the European Foundation for Osteoporosis (QUALEFFO) in Malaysia

Background:  Osteoporotic fractures will soon become a common problem in Asian countries including Malaysia, as the growth in the elderly population will be more marked in this region. This leads to loss of independence and reduced quality of life (QOL). QOL is used as an outcome measure in clinical trials to focus the management of diseases on the patient rather than the disease. To date, no such instrument for measuring QOL of osteoporosis patients has been validated in Malaysia.

The effect of mandatory generic substitution on the safety of alendronate and patients’ adherence

Abstract Objective: Generic medicines are often used in public hospitals. However, data on the quality of generic alendronate, its efficacy, side-effects and medication adherence in clinical practice is scarce. Therefore, this study aimed to compare the side-effects and medication adherence of generic (apo-alendronate) and proprietary alendronate (Fosamax). *Apotex Inc, Toronto, Ontario, Canada. †Merck Sharp & Dohme Corp., Pavia, Italy. Research design and methods: This prospective study involved two groups of patients: (1) postmenopausal osteoporotic women prescribed once-weekly Fosamax (proprietary group) but were switched to apo-alendronate after 2 years (‘switched over’ group); and (2) patients initiated with once-weekly apo-alendronate (generic group). Participants were recruited from the Osteoporosis Clinic of a tertiary hospital. Data were collected through interviews. Main outcome measures: Side-effects and medication adherence. Results: A total of 131 participants were recruited: proprietary group = 64 and generic group = 67. An intergroup and a within-group comparison were made. Side-effects were reported by 6 (9.4%), 30 (44.8%) and 12 (18.8%) participants in the proprietary, generic and ‘switched over’ groups, respectively. Participants who were on generic alendronate were at a significantly higher risk of experiencing side-effects compared to those who were taking proprietary alendronate [odds ratio (OR):7.84 (95% CI: 2.98–20.65), p < 0.001]. However, no significant statistical difference was found between the ‘switched over’ and the proprietary group [OR: 2.23 (95% CI: 0.78–6.37), p = 0.127]. Four out of 12 (33.3%) patients who experienced side-effects immediately after switching to generic alendronate discontinued generic alendronate due to intolerable gastrointestinal side-effects. There was no difference in medication adherence to generic or proprietary alendronate. Conclusions: Medication adherence to both generic and proprietary alendronate appeared similar although patients who were taking generic alendronate* were significantly more likely to experience side-effects than those on proprietary alendronate. Therefore, the switch from proprietary alendronate to the generic forms should not only consider the cost of the products but must also ensure that the generic and proprietary alendronate are equivalent in all aspects of efficacy and safety.