Yaman Walid Kassab

Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care

Objective: To evaluate the impact of pharmacist-led warfarin management and standardized treatment protocol. Methods: A retrospective cohort study was carried out in a cardiology referral hospital located in central Kuala Lumpur, Malaysia, from 2009 to 2014. The inclusion criteria were: adult patients who were diagnosed and treated for atrial fibrillation (AF) with warfarin, attended the warfarin medication therapy adherence clinic (WMTAC) for at least 12 weeks, and with at least four international normalized ratio (INR) readings. The electronic medical records were reviewed for demographics, type of AF, warfarin dose, INRs, adverse events, co-morbidities, and drug–drug interactions. The outcome measures included the mean time to therapeutic INR, the mean percentage of time in therapeutic range (TTR), bleeding events, and common drug interactions. Results: Out of 473 patients, 151 patients fulfilled the inclusion criteria. The findings revealed that there were significant associations between the usual medical care (UMC) group and pharmacist-led WMTAC in terms of TTR (p = 0.01) and INR (p = 0.02) levels. A positive impact of pharmacists’ involvement in the WMTAC clinic was where the “pharmacist’s recommendation accepted” (p = 0.01) and “expanded therapeutic INR range” (p = 0.04) were statistically significantly higher in the WMTAC group. Conclusion: There was a significant positive association between the pharmacist-led WMTAC and anticoagulation effect (therapeutic TTR, INR). The identified findings revealed that expanded role of pharmacist in pharmacist-managed warfarin therapy is beneficial to optimize the warfarin therapy. This study also highlighted the critical roles that pharmacists can actively play to ensure optimal anticoagulation pharmaceutical care. Key messages: What is already known on this subject? • Pharmacist-managed warfarin therapy is beneficial for optimizing warfarin therapy. In such therapy, recommendations such as dose adjustment and safer alternative drugs (given drug–drug interactions and/or food–drug interactions) are made. • The active involvement of pharmacists in warfarin adherence clinics could significantly improve adherence. • However, the warfarin treatment outcomes from UMC, pharmacist-and-physician-led care and pharmacist-led care have not been studied. • The impact of the implementation of the standardized protocol for the warfarin adherence clinic has not been assessed. What this study adds? • INR levels among UMC group and WMTAC group were significantly different. • Though the TTR level for the WMTAC group was not significantly different than the UMC group, it was higher and close to the targeted 60% level. • The identified findings show that pharmacists’ focus on intervention for missed doses, adherence and dose adjustment provide positive impact on patients’ warfarin therapy.

Pharmacovigilance and adverse drug reaction reporting: a perspective of community pharmacists and pharmacy technicians in Sana’a, Yemen

Objective The aim of this study was to compare the knowledge, attitude and barriers of pharmacy technicians and pharmacists toward pharmacovigilance, adverse drug reactions (ADRs) and ADR reporting in community pharmacies in Yemen. Methods This cross-sectional survey was conducted among community pharmacists and pharmacy technicians in the capital of Yemen, Sana’a. A total of 289 community pharmacies were randomly selected. The validated and pilot-tested questionnaire consisted of six sections: demographic data, knowledge about pharmacovigilance, experience with ADR reporting, attitudes toward ADR reporting, and the facilitators to improve ADR reporting. Results A total of 428 pharmacy technicians and pharmacists were contacted and 179 went on to complete a questionnaire (response rate: 41.8%). Of the 179 respondents, 21 (11.7%) were pharmacists and 158 (88.3%) were pharmacy technicians, of which, 176 (98.3%) were male and 3 (1.7%) were female. The mean age of the respondents was 25.87±2.63 years. There was a significant difference between the pharmacists and pharmacy technicians in terms of knowledge scores (P<0.05). The mean knowledge scores for pharmacists was 3.33±2.852 compared to 0.15±0.666 for pharmacy technicians. With regard to attitudes toward ADR reporting, all pharmacists (100%) showed a positive attitude, while only 43% of pharmacy technicians showed a positive attitude. Conclusion Pharmacists have a significantly better knowledge than pharmacy technicians with regard to pharmacovigilance. More than half of pharmacy technicians showed a negative attitude toward ADR reporting. Therefore, educational interventions and training is very important for community pharmacists and pharmacy technicians in Yemen to increase their awareness and participation in ADR reporting.

How to help patients to control their blood pressure? Blood pressure control and its predictor

Introduction: Good blood pressure (BP) control is one of the aims of hypertension disease management. Consistently achieving the targeted BP could reduce patient′s risk of developing the complication of hypertension. Materials and Methods: This study is a prospective cohort study aimed to investigate the blood pressure reading among in patients in a public tertiary hospital in northern Malaysia and to determine predictor of good BP control among patients. Patients were followed from their admission day until discharge. Data were collected by the researcher from the medical records. Information collected were BP reading on admission, day 1 and discharge. Other information includes demographic data, social factors, medication name and number, co-morbidities, target organ damage, cardiovascular risk factors. Descriptive analysis was done to determine the characteristic of patients and logistic regression was done to identify factors associated with BP control. Results: A total of 400 patients were followed up from admission till discharge. BP was controlled in 24% on admission and in 54% of patients on discharge. Multivariate analysis on admission revealed that the predictors of BP control were the use of diuretics and statin. Factors identified to be associated with poor BP control were diabetes mellitus, cerebrovascular disease and retinopathy. Multivariate analysis on discharge showed that the predictors of good BP control were diuretics and beta-blockers and the predictors of poor BP control were diabetes, chronic kidney disease, diabetic nephropathy, cerebrovascular disease and number of comorbidity. Conclusion: These results demonstrated that hypertension was poorly controlled among in-patients and that BP control was better on discharge than on admission. Patients with diabetes mellitus, renal disease and cerebrovascular disease were more likely to have poor hypertension control.

Factor Structure of Urdu Version of the Flourishing Scale

Background: A great deal of research has been carried out on the assessment of the eudaimonic perspective of psychological well-being and the hedonic perspective of subjective well-being. The Flourishing Scale (FS) has been extensively used in research and practice, as it assesses the fundamental aspects of social psychological functioning. Nevertheless, the psychometric properties of Urdu versions of eudaimonic measures, such as the FS, have not yet been ascertained. The translation and validation of the FS in the Urdu language was not available, and hence this study was planned with the aim to validate the Urdu version of the FS. Methods: We assessed the psychometric properties of the FS in a sample of adults aged 18 years and above in Pakistan (N = 130) using exploratory factor analysis based on principal component analysis with varimax rotation and confirmatory factor analysis. Results: The exploratory factor analysis confirmed the unidimensional nature of the 8-item FS. We assessed that the Urdu version of the FS showed a high internal consistency reliability (α = 0.914) with a significant intraclass correlation coefficient (ICC), p < 0.001). In our study, the Kaiser–Mayer–Olkin value was 0.915 with a chi-square test value (χ2) of 637.687, and Bartletts test of sphericity was significant (df = 28, p < 0.001). The intraclass correlation coefficients (ICCs) at test–retest for all domains were statistically significant (p < 0.001) and showed excellent agreement for all the items. The revised confirmatory factor analysis revealed a good-fit model, but with item 8—“People respect me”—removed due to its lower factor loading. Conclusions: The findings suggest that the FS is a psychometrically sound instrument for assessing social psychological functioning among adults in Pakistan. Therefore, the validated Urdu version of the FS may be used in future studies of well-being in clinical psychology and positive psychology.

Self-Care and Self-Management Among Adolescent T2DM Patients: A Review

Uncontrolled hyperglycaemia can lead to macro- and microvascular complications. Adolescents with T2DM develop similar complications as in adults, including cardiovascular disease, stroke, myocardial infarction, renal insufficiency, and chronic renal failure. Although regular medical follow-up is essential to avoid long-term complications, patients with diabetes mellitus need to perform holistic self-care activities such as opting for a healthy diet, physical activity, self-monitoring, and proper medication. To the best of our knowledge, only a limited number of studies have focused on self-care activities and self-management, including self-care practices, supportive networks, and self-care education programs in adolescent with T2DM. Some of the studies focused on the appreciation of self-care in adolescents with T2DM. This review aimed to analyse self-care and self-management among adolescents with T2DM, and discuss the impact of self-care and self-management on glycaemic control. The difficulties faced by adolescents in self-managing their disease are also highlighted. Such information is essential for healthcare providers in promoting self-care practices among adolescents with T2DM. A thorough search of the literature was performed using three databases: Medline, Google Scholar, and Scopus. The articles focused on self-care and self-management of adolescents patients with T2DM aged between 12 and 19 years old were included. Findings from this review reveal that healthy food adaptation, adequate physical activity, proper medication practices, and regular glucose monitoring are the most common self-care practices. Parental involvement and clinician encouragement also contribute toward the practice of self-care and self-management among the adolescents with T2DM. In conclusion, independent self-management regimens and supportive networks for appropriate administration are vital factors to enhance clinical outcomes of adolescents with T2DM.

A review on safety and efficacy of products containing Longifolia

Eurycoma longifolia (commonly called tongkat ali) is a flowering plant in the family Simaroubaceae, native to Indonesia, Malaysia, and, to a lesser extent, Thailand, Vietnam and also Laos. The roots extract of E. longifolia, is a well-known traditional herbal medicine in Asia used for many purposes such as sexual dysfunction, aging, malaria, cancer, diabetes, anxiety, aches, constipation, exercise recovery, fever, increased energy, increased strength, leukemia, osteoporosis, stress, syphilis and glandular swelling. The roots are also used as an aphrodisiac, antibiotic, appetite stimulant and health supplement. It is very important to conserve this valuable medicinal plant for the health benefit of future generations. The purpose of this review article is to evaluate and summarize the existing literatures regarding the efficacy and safety of products which contain E. longifolia as its main ingredient. In summary, based on the literature evaluated in this review article, products which contain tongkat ali showed a clinical benefit on improving erectile dysfunction as well as a good safety profile. We recommend consumers to check the level of the bioactive compound “eurycomanone” as their guide before choosing any E. longifolia product.

Predictors of the Common Adverse Drug Reactions of Statins

Statins are common lipid lowering agents to reduce elevation of cholesterol or as prophylaxis against other cardiac diseases. It estimated that 62.5% to 91.7% of dyslipidemic patients in United State of America are using statins1 These agents widely used among cardiovascular patients in Malaysia2. In other countries, for example in UK, it has found that most patients who use statins are older than 35 years old and more of them are males (56%)3. In Canada, about 90% of cardiac patients are using statin, while in US, at least one third of all cardiac patients are using statins4. About 60% of American patients who older than 60 years old are using statin5. Thus, high number of users contributed to increase the risk of adverse drug reactions (ADRs). The Food and Drug Administration (FDA) has determined that common statin-associated ADRs are fatigue, muscle pain, joints pain, back pain, visual disturbance and insomnia6,7. Previous studies have examined the incidence of these ADRs, and their results showed that more than half of the reported cases of muscle pain were related to statin use8,9. Clearfield et al found that fatigue, muscle pain, and bone pain were common and frequent ADRs in UK, and related to atorvastatin and rosuvastatin use10. Other studies exploring ADRs in patients using atorvastatin and lovastatin in the US found that muscle pain and fatigue were the most common statin-related ADRs11. The UK Committee on Safety of Medicines, as well as other studies, have reported that these symptoms should consider as early signs for more serious ADRs8,12-15. However, from our knowledge, no data available on the common ADRs statin-related and their predictors for Asian patients. Only a few studies (not related with Asian patients) have found out the predictors of the statin-related ADRs8,9,10,16,17. As health care professional, they should find methods to ensure patients not only receive effective medication but also feel comfortable with the therapy. Thus, the objectives of this study was to determine the common statin-related ADRs and their predictors in one of the referral hospital in Malaysia (one of country in South East Asia).