Development of a pharmaceutical care program in progressive stages in geriatric institutions.

BACKGROUND: To introduce and manage a Pharmaceutical care programs in geriatric care institutions presents difficulties such as reduced pharmacy service staff, complexity of the patients or lack of integration of the pharmacist in the health care team. This work describes the evolution of the implementations of a program of pharmaceutical care centered in drug related problems (DRP) in a group of geriatric institutions of different levels of complexity. METHODS: Setting: Long-term and subacute care hospitals (HSS) and Health care teams attending nursing homes (EARs). PARTICIPANTS: Patients attended in HSS and EARs during different periods between 2010 and 2016. INTERVENTIONS: The program was developed in different stages, in which pharmacists made interventions of increasing complexity. RESULTS: Between 2010 and 2013, the approach was only to improve the prescription of non-appropriate drugs for the elderly, which was reduced from 19 to 14.5%. Subsequent steps included detection of drug-related problems (DRP), systematization of treatment revisions, recording of pharmacist interventions, improvements in the classification of interventions and the creation of a web-based database for recording in a more efficient way. During these years, there was an increase in the number of patients included in pharmaceutical care activities and thus the number of pharmacist interventions (3872 in 2014 vs 5903 in 2016). In 2016, mean age in 2016: 83.2 years old. Mean number of medicines/patient: 8.4 ± 3.3, and mean interventions/patient: 1.62. Degree of acceptance of the interventions by physicians improved (68.6% in 2016 vs 45.5% in 2012), even though there is still much work to do. The Medication Appropriateness Index (MAI) showed that when the interventions were accepted, there was an important improvement. HSS mean MAI values pre-intervention: 2.52, post-intervention 0.80. In EARs: 5 pre and 1.39 post. In both cases p < 0.0001. CONCLUSIONS: Approaching the deployment of activities in a progressive way has made us more efficient and able to confront and solve the problems that have arisen. Even though there has been a very restricted increase in the staff and budget, we are able to implement a DRP detection programme with guaranties of quality.

Efficacy of Hepatitis B Virus Vaccines HBVaxpro40© and Fendrix© in Patients with Chronic Liver Disease in Clinical Practice.

Chronic liver disease results in a low response rate to the hepatitis B virus vaccine. Information on the efficacy of the double adjuvanted vaccine FENDRIX® (3-O-desacyl-4'-monophosphoryl lipid A and aluminum phosphate) and single adjuvant HBVAXPRO®40 (aluminum hydroxyphosphate sulfate) in chronic liver disease is scarce. The primary aim of this prospective study in clinical practice was to evaluate the effectiveness of HBVAXPRO®40 and FENDRIX® in this setting. Patients received HBVAXPRO® (0, 1 and 6 months) or FENDRIX® (0, 1, 2 and 6 months) depending on availability. Clinical data and anti-HBs levels were collected at 2, 6 and 12 months. A total of 125 patients were included (mean age 61.8 years; 57.6% males; 43.2% liver cirrhosis; 75.9% Child A and 24.1% Child B): 76 were vaccinated with HBVAXPRO® and 49 with FENDRIX®. There were no significant differences between the two vaccines. The overall response rates at 2, 6 and 12 months were 76.8, 72.8 and 59.2%, respectively. In the univariate analysis, active alcohol intake, alcohol etiology, liver cirrhosis and ultrasound signs of portal hypertension were associated with a lower response to vaccination, whereas in the multivariate analysis, liver cirrhosis was the only factor that significantly increased the likelihood of nonresponse (OR 10.5). HBVAXPRO® and FENDRIX® are good options for HBV vaccination in patients with chronic liver disease.

The use of tocilizumab in the treatment of refractory eosinophilic fasciitis: a case-based review.

Eosinophilic fasciitis (EF) is a rare disorder involving chronic inflammation of the fascia and connective tissue of unknown aetiology and poorly understood pathogenesis. We present the case of a 60-year-old man diagnosed with eosinophilic fasciitis with extensive cutaneous involvement and severe functional repercussion, which appeared weeks after suffering from pneumonia due to Legionella pneumophila. The patient did not experience any clinical response with high-dose corticosteroids, subcutaneous methotrexate, and intravenous immunoglobulins. Consequently, tocilizumab was initiated at 8 mg/Kg monthly achieving clinical response measured by a control MRI at the fifth dose. Response in terms of cutaneous thickness has been slower however favourable, therefore, more months of follow-up are necessary to assess the complete remission at skin level. EF treatment still constitutes a challenge, and experience with tocilizumab in the management of the disease is very limited. Through a systematic search of medical literature, we retrieved two cases describing EF treated with tocilizumab and several cases using another monoclonal antibody or Janus kinase inhibitor. We report the third case to our knowledge of the efficacy of tocilizumab in a refractory EF to corticosteroids and other immunosuppressive drugs.

Pharmacist Intervention Program at Different Rent Levels of Geriatric Healthcare.

As a pharmacy service giving pharmaceutical care at different levels of health care for elderly people, we needed a standardization procedure for recording and evaluating pharmacists' interventions. Our objective was to homogenize pharmacist interventions; to know physicians' acceptance of our recommendations, as well as the most prevalent drug related problems (DRP); and the impact of the pharmacists' interventions. To achieve this goal we conducted a one year prospective study at two levels of health care: 176 nursing homes (EAR) (8828 patients) and 2 long-term and subacute care hospitals (HSS) (268 beds). Pharmacists' interventions were recorded using the American Society of Health-System Pharmacists classification as the basis. Frequency of the different DRP and the level of response and acceptance on the part of physicians was determined. The Medication Appropriateness Index (MAI) was used to evaluate the impact of the interventions on the prescription quality. Patients' mean age was 84.2 (EAR) and 80.7 (HSS), and in both cases, polypharmacy ≥ 9 drugs was around 63-69%. There were 4073 interventions done in EAR and 2560 in HSS. Level of response: 44% (EAR), 79% (HSS); degree of acceptance of the recommendations: 84% (EAR), 72% (HSS). Most frequent DRP: inappropriate dose, length of therapy, omissions, and financial impact. Drugs for the nervous system are those with the most DRP. MAI values/medication improved from 4.4 to 2.7 (EAR) and 3.8 to 1.7 (HSS). A normalized way of managing pharmacists' interventions for different health care levels has been established. We are on the way to increasing collaborative work with physicians and we know which DRPs are most prevalent.