Svetla Gadzhanova

Initiation and duration of proton pump inhibitors in the Australian veteran population.

Aim: To determine the duration of initial treatment with high strength proton pump inhibitors prescribed for gastro‐oesophageal reflux disease in the veteran population in Australia and variance by the medical professional who initiated treatment.

Anticholinesterase duration in the Australian veteran population

Objective: The aim of the present study was to determine the duration of initial anticholinesterase treatment in veteran patients in Australia. Three anti-dementia medications were investigated (donepezil, rivastigmine and galantamine) and two different setting were compared (community and residential aged care facilities). Method: A retrospective cohort study was performed using the Department of Veterans’ Affairs pharmacy claims data. Patients were included in the cohort if they had been dispensed at least one anticholinesterase prescription (index) between 2003 and 2006, were aged 65 years or over at the time of that index dispensing, and had not been dispensed any anticholinesterase medicine in the previous 12 months. Patients were followed until discontinuation (ceased or switched), death or 1 year of follow up. Time to treatment discontinuation was analysed utilizing the Kaplan-Meier method. Cox proportional hazards models were used to compare the risk of treatment discontinuation among the three treatment groups adjusting for the effect of patients’ characteristics. Results: Of the new users of anticholinesterases (n = 10088), 47% of those on donepezil, 46% of those on galantamine, and 47% of rivastigmine patients discontinued their initial therapy within 6 months. A total of 32% of patients who ceased therapy reinitiated it during the study period; 28% returned to the same index medication and 4% restarted therapy with a different anticholinesterase. The median treatment duration was: 199 days (95% CI, 182–208) for donepezil patients (n = 6705), 233 days (95% CI, 212–259) for galantamine patients (n = 2898), and 219 days (95% CI, 176–260) for rivastigmine patients (n = 394). Patients in community settings were more likely to discontinue their initial anticholinesterases earlier compared to those living at residential aged care facilities (relative risk, RR=1.21; 95% CI, 1.12, 1.31). Conclusions: Almost half of the Australian veteran patients who initiated anticholinesterases treatment discontinued (ceased or switched) therapy within 6 months. However, one-third of those who ceased therapy reinitiated it during the study period.

Developing High-specificity Anti-hypertensive Alerts by Therapeutic State Analysis of Electronic Prescribing Records

OBJECTIVE This paper presents a model for analysis of chronic disease prescribing action over time in terms of transitions in status of therapy as indicated in electronic prescribing records. The quality of alerts derived from these therapeutic state transitions is assessed in the context of antihypertensive prescribing. DESIGN A set of alert criteria is developed based on analysis of state-transition in past antihypertensive prescribing of a rural Australian General Practice. Thirty active patients coded as hypertensive with alerts on six months of previously un-reviewed prescribing, and 30 hypertensive patients without alerts, are randomly sampled and independently reviewed by the practices two main general practice physicians (GPs), each GP reviewing 20 alert and 20 non-alert cases (providing 10 alert and 10 non-alert cases for agreement assessment). MEASUREMENTS GPs provide blind assessment of quality of hypertension management and retrospective assessment of alert relevance. RESULTS Alerts were found on 66 of 611 cases with coded hypertension with 37 alerts on the 30 sampled alert cases. GPs assessed alerting sensitivity as 74% (CI 52% - 89%) and specificity as 61% (CI 45% - 74%) for the sample, which is estimated as 26% sensitivity and 93% specificity for the antihypertensive population. Agreement between the GPs on assessment of alert relevance was fair (kappa = 0.37). CONCLUSIONS Data-driven development of alerts from electronic prescribing records using analysis of therapeutic state transition shows promise for derivation of high-specificity alerts to improve the quality of chronic disease management activities.

Improving cardiovascular disease management in Australia: NPS MedicineWise.

Objectives: To determine the impact of four NPS MedicineWise programs targeting quality use of medicines in cardiovascular management in primary care.

Use of SGLT2 inhibitors for diabetes and risk of infection: Analysis using general practice records from the NPS MedicineWise MedicineInsight program

AIMS To explore the feasibility of MedicineInsight data to support risk management plan evaluation, focusing on sodium glucose co-transporter 2 (SGLT2) inhibitors for type 2 diabetes. METHODS A retrospective study using de-identified electronic general practitioner records. Patients who initiated SGLT2 inhibitor between 1 Jan 2012 to 1 Sep 2015 were compared to patients who initiated dipeptidyl peptidase 4 (DPP-4) inhibitors. The two cohorts were followed-up for six months. Risk of urinary-tract (UT) and genital infections was evaluated. The indication for use of SGLT2 inhibitors, recommended prior diabetes therapies and recommended monitoring were investigates. RESULTS There were 1977 people in the SGLT2 cohort (with 93% initiated on dapagliflozin) and 1964 people in the DPP-4 cohort. Of the SGLT2 initiators, 54% had a documented indication for use as type 2 diabetes; 86% had used metformin and/or a sulfonylurea in the prior 12months. Renal function monitoring was documented for only 25% in the 6months initiation. The frequency of UTI in the 6months post SGLT2 initiation was not significantly increased compared to the DPP-4 cohort (3.6%vs 4.9%; aHR=0.90, 95% CI 0.66-1.24). Genital infection were more frequent in the SGLT2 than in the DPP-4 cohort (2.9% vs 0.9%, aHR=3.50, 95% CI 1.95-5.89). CONCLUSIONS Similar to existing evidence, we found a higher risk of genital infection associated with SGLT2 inhibitors (primarily dapagliflozin) but no increased risk of UTIs compared to DPP-4 use.

The use of antipsychotics among people treated with medications for dementia in residential aged care facilities.

BACKGROUND Antipsychotic agents have limited efficacy for Behavioral and Psychological Symptoms of Dementia (BPSD) and there are concerns about their safety. Despite this, they are frequently used for the management of BPSD. This study aimed to assess the use of antipsychotics among people on anti-dementia medicines in Australian residential aged care facilities. METHODS Data were obtained from an individual patient unit dose packaging database covering 40 residential aged care facilities in New South Wales, Australia. Residents supplied an anti-dementia medicine between July 2008 and June 2013 were included. Prevalence of concurrent antipsychotic use was established. Incident antipsychotic users between January 2009 and December 2011 were identified. We examined initial antipsychotic dose, maximum titrated doses, type and duration of antipsychotic use, and compared use with Australian guidelines. RESULTS There were 291 residents treated with anti-dementia medicines, 129 (44%) of whom received antipsychotics concomitantly with an anti-dementia medicine. Among the 59 incident antipsychotic users, risperidone (73%) was the most commonly used antipsychotic agent. Amongst the risperidone initiators, 43% of patients had initial doses greater than 0.5 mg/day and 6% of patients exceeded 2.0 mg/day for their maximum dose. 53% of concomitant users received daily treatment for greater than six months. CONCLUSIONS Our study using records of individual patient unit dose supply, which represents the intended medication consumption schedule, shows high rates of concurrent use of antipsychotics and anti-dementia medicines and long durations of use. The use of antipsychotics in patients with dementia needs to be carefully monitored to improve patient outcomes.

Use of Statins in an Australian Elderly Population

Background: Statins are the first drug choice for lowering high cholesterol and are one of the most widely used classes of medicines in Australia. Although well tolerated, some adverse effects are dose and potency dependent to which older people are particularly susceptible. Objective: The aim of this study was to examine the use of statins in elderly Australians, and how usage had changed over time with respect to dose and potency of statin prescribed. Methods: A retrospective study was conducted using data from the

Safety of opioid patch initiation in Australian residential aged care.

Objective: To explore opioid use by aged care facility residents before and after initiation of transdermal opioid patches.

Co-prescribing of Warfarin with Statins and Proton Pump Inhibitors in Elderly Australians

Background: Comorbidity is common in individuals with atrial fibrillation (AF). The predominant treatment for AF is warfarin and medicine interactions with warfarin represent a challenge for optimising treatment of AF in older people with comorbidities. Statins and Proton Pump Inhibitors are commonly prescribed therapies and in both classes, there are medicines with greater or lesser potential to interact with warfarin. Objective: The aim of this study was to examine use of antithrombotic treatment in elderly Australians, and the extent of concurrent use of interacting statins and proton pump inhibitors (PPIs) with warfarin. Methods: A retrospective cohort study was conducted using data from the Australian Government Department of Veterans’ Affairs. The cohort included all patients who had at least one hospitalisation with a primary diagnosis for AF between 2007 and 2011. Individuals contributed person-months from the date of first AF hospitalisation to death or end of study (December 2011). Monthly utilisation of antithrombotics was assessed. A sub-cohort of warfarin users was defined as those with AF who received warfarin as monotherapy and the proportions of those co-dispensed statins or PPIs were established. Results: Around 70% of patients with AF were receiving antithrombotic treatment, with 35% dispensed warfarin, 17% aspirin, and 7% clopidogrel as monotherapy. In December 2011, 54% of patients with AF on warfarin monotherapy were co-dispensed a statin, with the statins with potential for interaction dispensed at highest rates; atorvastatin followed by simvastatin and rosuvastatin. At study end, 43% of the warfarin cohort were also dispensed PPIs, with one-third using esomeprazole, followed by pantoprazole, both of which have the potential to interact with warfarin. Conclusion: 30% of patients with AF were not receiving antithrombotic treatment. In those receiving an antithrombotic agent, warfarin was the most commonly dispensed (35%). The most common statin and PPI coprescribed with warfarin were agents with the potential to interact with warfarin, despite alternative agents being available. Raising awareness of the safer alternative for people with comorbidities may improve warfarin management.

Improvement in metformin and insulin utilisation in the Australian veteran population associated with quality use of medicines intervention programs

To examine the impact of 2001 and 2005 quality use of medicines (QUMs) diabetes programs implemented by National Prescribing Service (NPS) on the prevalence of utilisation of metformin and insulin among the Australian diabetes veteran population.