Yahaya Hassan

Impact of pharmacist recommendations on the cost of drug therapy in ICU patients at a Malaysian hospital

Objectives: To analyse clinical pharmacists interventions in the ICU of the Penang General Hospital (Penang, Malaysia) and to assess the pharmaco-economic impact of these interventions.Methods: A clinical pharmacist reviewed drug prescriptions during one month. Drug-related problems were documented on a preprepared form including a suggestion for a change in prescribing. Such recommendations were submitted to the nursing/medical staff. Acceptance of the recommendation was entirely at the discretion of the medical staff. All recommendations were analysed with respect to potential pharmaco-economic impact: cost savings, cost avoidance or cost addition.Results: The ICU pharmacist made 57 recommendations, of which the medical staff rejected only 5%. The majority of detected drug-related problems referred to unnecessary drug therapy (37%). Recommendations resulted in net cost savings of RM 15,227 (USD 4,007). This corresponded with RM 634 per patient intervened by the pharmacist. Conclusion: Pharmacists interventions in the ICU of a Malaysian hospital resulted in significant cost savings in terms of drug expenses and can therefore be suggested as a routine practice in our hospital.

Heparin-induced thrombocytopenia and recent advances in its therapy

Objectives:  To highlight therapeutic controversies, and present a critical review of the most recent evidence on the management of heparin‐induced thrombocytopenia (HIT).

Discontinuation of penicillamine in the absence of alternative orphan drugs (trientine-zinc): a case of decompensated liver cirrhosis in Wilson's disease

Objectives:  To report a case of early‐decompensated liver cirrhosis secondary to discontinuation of penicillamine therapy in a patient with Wilsons disease.

Adverse drug events in hospitalized patients with chronic kidney disease

BACKGROUND AND OBJECTIVE Adverse drug events (ADEs) are a common cause of hospitalization and in-hospital complications. The aim of this study was to determine the rates, types, severity and preventability of pre-admission and in-hospital ADEs in patients with chronic kidney disease (CKD). METHODS This study was conducted at the nephrology unit at Penang General Hospital. A random sample of 300 adult patients with CKD was included. Medical records and charts were reviewed by a clinical pharmacist every work day to find any evidence of errors or complications related to drug use. If a suspected ADE was found, further investigations were carried out to assess the causality, severity and preventability of the event. RESULTS A total of 159 ADEs were reported in 122 (40.7%) of the patients. We found 86 suspected pre-admission ADEs in 68 (22.7%) of the patients. These were either the cause of admission for some patients or discovered by the initial physical examination and laboratory investigations. During hospitalization, 64 (21.3%) patients had 73 suspected ADEs. Out of the total 159 suspected ADEs, it was highly probable that 31 events were due to medication, while 61 were of lower probability, and 67 were merely possible. A total of 48 (30.2%) events was considered preventable. 46 events (28.9%) were serious, 93 (58.5%) were less serious and 20 (12.6%) were insignificant. The medication classes most frequently involved in ADEs were diuretics, antibacterials, drugs used for diabetes mellitus, antithrombotic agents, mineral supplements and antihypertensive drugs. CONCLUSION ADEs are very common in hospitalized CKD patients, and some of these events are preventable. The service of a clinical pharmacist may help to reduce ADEs.

Challenge to Clinical Pharmacy Practice in Malaysia

OBJECTIVE: To report on the current status and future trends of clinical pharmacy practice in Malaysia. DATA SOURCES: Published conference reports and journal articles. DATA EXTRACTION: Data on areas related to clinical pharmacy practice in Malaysian hospitals were gleaned from various publications. DATA SYNTHESIS: Malaysia is capable of implementing clinical pharmacy services in hospitals and perhaps also in the community setting. The important factors in clinically oriented pharmacy practice include improvement of the drug-control process, development of physical and human resources, clinical pharmacy skills, and the training of practicing pharmacists. A number of Malaysian pharmacists have already developed a unit-dose drug distribution system, patient counseling, therapeutic drug monitoring, drug information, and total parenteral nutrition services. CONCLUSIONS: The pharmacy profession in Malaysia has many challenges ahead and it is hoped that every practicing pharmacist will be highly committed to future professional needs so that clinical pharmacy practice in Malaysia becomes a reality.

Physician adherence to hypertension treatment guidelines and drug acquisition costs of antihypertensive drugs at the cardiac clinic: a pilot study.

Prescribing pattern surveys are one of the pharmacoepidemiological techniques that provide an unbiased picture of prescribing habits. Prescription surveys permit the identification of suboptimal prescribing patterns for further evaluation. The aims of this study were to determine the prescribing trend, adherence of the prescribers to the guideline, and the impact of drug expenditure on drug utilization at the cardiac clinic of Penang Hospital, Malaysia. This was a cross-sectional study. Demographic data of the patients, diagnoses and the drugs prescribed were recorded. The average drug acquisition costs (ADAC) were calculated for each antihypertensive drug class on a daily and annual basis. Adherence to the guideline was calculated as a percentage of the total number of patients. A total of 313 individuals fulfilled the inclusion criteria. The average age of the study population was 59.30 ± 10.35 years. The mean number of drugs per prescription in the study was 2.09 ± 0.78. There were no significant differences in the demographic data. Antihypertensive drugs were used in monotherapy and polytherapy in 20.8% and 79.2% of the patients, respectively. Adherence to the guideline regarding prescription occurred in 85.30% of the patients. The lowest priced drug class was diuretics and the highest was angiotensin-receptor blockers. In conclusion, the total adherence to the guideline was good; the adherence percentage only slightly decreased with a co-existing comorbidity (such as diabetes mellitus). The use of thiazide diuretics was encouraged because they are well tolerated and inexpensive, and perindopril was still prescribed for diabetic patients since it is relatively cheap (generic drug) and its daily dosage is beneficial.

Statin use prior to ischemic stroke onset is associated with decreased in-hospital mortality

Statins can reduce the risk of stroke in at‐risk populations and improve survival after acute ischemic stroke (AIS) among patients with previous statin use. This study aimed to investigate the impact of statin use before AIS onset on in‐hospital mortality and identify the factors related to in‐hospital mortality among patients with and without previous statin use. A retrospective cohort study of all patients with AIS attending hospital from June 1, 2008 to December 31, 2008. Data were collected from medical records including demographic information, diagnostic information, risk factors, previous statin use, and vital discharge status. Chi‐square, Fisher’s exact tests, student’s t‐test, and Mann–Whitney U test, whatever appropriate, were used to test the significance between the variables, and multiple logistic regression was used to identify factors associated with in‐hospital mortality. Altogether, 386 patients with AIS were studied, of which 113 (29.3%) had a documented previous statin use. A total of 62 (16.1%) patients with AIS died in hospital. In‐hospital mortality was significantly lower among previous statin users (P = 0.013). The presence of atrial fibrillation (AF) increased in‐hospital mortality among patients with or without previous statin use. The independent predictors for in‐hospital mortality among AIS patients without previous statin use were the presence of diabetes mellitus (P = 0.047), AF (P = 0.045), and renal impairment (P < 0.001). The prophylactic administration of statins significantly reduces post‐AIS in‐hospital mortality. Furthermore, the identification of predictors of in‐hospital mortality might reduce death rates and enhance the application of specific therapeutic and management strategies to patients at a high risk of dying.

The complexity of achieving anticoagulation control in the face of warfarin – phenytoin interaction: an Asian case report

Phenytoin has been reported to have major interactions with warfarin. Phenytoin induces warfarin’s metabolism. However, there are many case reports which provide conflicting conclusions. Here, we report a case of a 65-year-old man with mechanical heart valve on chronic warfarin therapy who experienced persistent fluctuations of INR and bleeding secondary to probable warfarin–phenytoin interactions. The patient’s anticoagulation clinic visits prior to hospitalization were thoroughly evaluated and we continued to follow-up the case for 3 months post-hospitalization. The reported interaction could be reasonably explained from the chronology of events and the pattern of INR fluctuations whenever phenytoin was either added or discontinued from his drug regimen.

Does the duration of smoking cessation have an impact on hospital admission and health-related quality of life amongst COPD patients?

Background Lack of awareness among ex-smokers on the benefits of sustaining smoking cessation may be the main cause of their smoking relapse. This study explored health-related quality of life (HRQoL) and hospital admission amongst chronic obstructive pulmonary disease (COPD) patients according to the duration of smoking cessation. Materials and methods This study recruited COPD patients from a chest clinic who agreed to participate in a medication therapy-adherence program from January to June 2013. They were interviewed during their visits to obtain information regarding their smoking history and HRQoL. They were divided into three groups according to smoking status (sustained quitters, quit ≥5 years; quitters, quit <5 years; and smokers, smoking at least one cigarette/day). The effects of the duration of cessation on HRQoL and hospital admission were analyzed using a multinomial logistic model. Results A total of 117 participants with moderate COPD met the inclusion criteria, who were comprised of 41 sustained quitters, 40 quitters, and 36 smokers. Several features were similar across the groups. Most of them were married elderly men (aged >64 years) with low-to-middle level of education, who smoked more than 33 cigarettes per day and had high levels of adherence to the medication regimen. The results showed that sustained quitters were less likely to have respiratory symptoms (cough, phlegm and dyspnea) than smokers (odds ratio 0.02, confidence interval 0–0.12; P<0.001). The hospital admission rate per year was increased in quitters compared to smokers (odds ratio 4.5, confidence interval 1.91–10.59; P<0.005). Conclusion A longer duration of quitting smoking will increase the benefits to COPD patients, even if they experience increased episodic respiratory symptoms in the early period of the cessation. Thus, the findings of this study show the benefits of early smoking cessation.

Impact of Angiotensin-Converting Enzyme Inhibitors Administration Prior to Acute Ischemic Stroke Onset on In-Hospital Mortality

Introduction: Angiotensin-converting enzyme inhibitors (ACEIs) have shown promising results in decreasing the incidence and the severity of ischemic stroke in populations at risk and in improving ischemic stroke outcomes. Objectives: The objectives of this study were to investigate the impact of ACEI use before ischemic stroke onset on in-hospital mortality and to identify the independent predictors of in-hospital mortality among patients with ischemic stroke. Methods and Materials: A retrospective cohort study of all patients with acute ischemic stroke attending the hospital from June 1, 2008 to November 30, 2008 was performed. Data were collected from medical records and included demographic information, diagnostic information, risk factors, previous ACEI use, and vital discharge status. Statistical Package for Social Sciences (SPSS) version 15 was used for data analysis. Results: A total of 327 patients with acute ischemic stroke were studied, of which 119 (36.4%) had documented previous ACEI use. During the study period, 52 (15.9%) of the patients with acute ischemic stroke died in hospital. In-hospital mortality was significantly lower among patients who were on ACEI before the attack (P = 0.002). The independent predictors for in-hospital mortality among patients with ischemic stroke were age ≥65 years (P < .001), the presence of diabetes mellitus (P = .012), renal impairment (P = .002), and heart failure (P = .001). Moreover, prior use of ACEI was an independent predictor for survival after ischemic stroke attack (P < .001). Conclusion: This study provides evidence that the prophylactic administration of ACEI before ischemic stroke may be a potential life-saving strategy. Furthermore, knowledge of in-hospital mortality predictors is necessary to improve survival rate after acute stroke.