Interprofessional peer-assisted learning for pharmacy and physical therapy students using inhalers and inhalation devices.

BACKGROUND: Peer-assisted learning (PAL) is exchanging knowledge between learners often from similar professional levels. Limited evidence exists on the effectiveness of PAL between different healthcare professions. The purpose of this study is to evaluate the knowledge, confidence, and perception of students engaged in an interprofessional PAL activity with pharmacy students instructing physical therapy students on the proper technique, cleaning/storage and therapeutic knowledge on inhaler devices for treatment of pulmonary conditions. METHODS: Pharmacy and physical therapy students completed a survey before and immediately after the PAL activity. As instructors, pharmacy students rated their experience with inhalers, their confidence if they were to assist clients on the use of inhaler devices and confidence in teaching peers. Physical therapy students completed surveys on inhaler knowledge with 10 scenario-based multiple-choice questions, and their confidence if they were to assist clients with inhaler devices. The knowledge questions were grouped into three categories: storage and cleaning of inhalers (3 questions), technique of using inhalers (4 questions), and therapeutic knowledge of drugs given by inhalation (3 questions). RESULTS: 102 physical therapy and 84 pharmacy students completed the activity and surveys. For the physical therapy students, the mean improvement of the total score for knowledge-based questions was 3.6 ± 1.8 (p < 0.001). The question with the fewest number of correct answers (13%) before the PAL activity had the highest number of correct answers post-activity (95%). Prior to the activity, no physical therapy students felt certain/very certain about their knowledge on inhalers, yet after PAL activity this proportion increased to 35%. The percent of pharmacy students reporting their confidence as "certain" and "very certain" in teaching peers increased from 46% before the activity to 90% afterwards. Pharmacy students rated the monitoring and follow-up of inhaler devices as the lowest expectation for physical therapists to play a role. Steps taken to prepare for this PAL activity were also discussed. CONCLUSIONS: Interprofessional PAL can increase knowledge and confidence of healthcare students reciprocally learning and teaching in joint activities. Allowing such interactions facilitate students to build interprofessional relationships during their training, which can increase communication and collaboration to foster an appreciation for each other's roles in clinical practice.

The effect of renin-angiotensin-aldosterone system inhibitors on continuous and binary kidney outcomes in subgroups of patients with diabetes: a meta-analysis of randomized clinical trials.

INTRODUCTION: Diabetic nephropathy is the leading cause of kidney failure. Clinical practice guidelines recommend prescribing renin-angiotensin aldosterone system inhibitors (RAASi) to prevent diabetic nephropathy at any stage. We conducted this systematic review and meta-analysis to compare the effects of RAASi with placebo and other antihypertensive agents in adults with diabetes on continuous and binary kidney outcomes to provide a comprehensive review of the class effect of RAASi on several subgroups. METHODS: A systematic electronic search to identify randomized clinical trials of a duration of ≥ 12 months that recruited ≥ 50 adult participants with type 1 or 2 diabetes with any stage of chronic kidney disease and proteinuria was conducted in MEDLINE, CINAHL, EMBASE, and Cochrane library with no language restriction. Studies were screened against the inclusion and exclusion criteria by two reviewers independently. RESULTS: In this meta-analysis, evidence was drawn from 26,551 patients with diabetes from 46 studies. Our analysis shows that RAASi were better than placebo in reducing SrCr (the raw mean difference [RMD] = -13.4 µmol/L; 95%CI: -16.78; -10.01) and albuminuria levels (standardized mean difference [SMD] = -1; 95%CI: -1.57, -0.44, I2 = 96%). When compared to other active treatments, RAASi did not reduce SrCr (RMD = 0.03 µmol/L; 95%CI: -6.4, 6.10, I2 = 76%), caused a non-significant reduction of GFR levels (RMD = -1.21 mL/min; 95%CI: -4.52, 2.09, I2 = 86%), and resulted in modest reduction of albuminuria levels (SMD = -0.55; 95%CI: -0.95, -0.16, I2 = 90%). RAASi were superior to placebo in reducing the risks of kidney failure (OR = 0.74; 95%CI: 0.56, 0.97) and doubling of serum creatinine levels (SrCr; OR = 0.71; 95%CI: 0.55, 0.91), but not in promoting the regression of albuminuria (OR = 3.00; 95%CI: 0.96, 9.37). RAASi, however, were not superior to other antihypertensives in reducing the risks of these outcomes. Patients with type 2 diabetes, macroalbuminuria and longer duration of diabetes had less risk of developing kidney failure in placebo-controlled trials, while longer duration of diabetes, normal kidney function, and hypertension increased the probability of achieving regression of albuminuria in active-controlled trials. CONCLUSION: While our findings revealed the non-superiority of RAASi over other antihypertensives and portrayed a class effect on several subgroups of study participants, it raised a challenging question on whether RAASi deserve their place as first-line therapy in managing diabetic nephropathy.

Barriers and facilitators of implementing an antimicrobial stewardship intervention for urinary tract infection in a long-term care facility.

BACKGROUND: Fifty percent of antibiotic courses in long-term care facilities (LTCFs) are unnecessary, leading to increased risk of harm. Most studies to improve antibiotic prescribing in LTCFs showed modest and unsustained results. We aimed to identify facilitators, barriers and strategies in implementing a urinary tract infection (UTI)-focused antimicrobial stewardship (AS) intervention at a LTCF, with the secondary objective of exploring the pharmacist's potential roles. METHODS: The study used a qualitative descriptive design. Participants attended either a focus group or one-on-one interview. Data were analyzed inductively using a codebook modified in an iterative analytic process. Barrier and facilitator themes were mapped using the capability, opportunity, motivation and behaviour (COM-B) model. Similarly, themes were identified from the transcripts regarding the pharmacist's roles. RESULTS: Sixteen participants were interviewed. Most barriers and facilitators mapped to the opportunities domain of the COM-B model. The main barrier themes were lack of access, lack of knowledge, ineffective communication, lack of resources and external factors, while the main facilitator themes were education, effective collaboration, good communication, sufficient resources and access. For the pharmacist's role, the barrier themes were ineffective collaboration and communication. CONCLUSION: This study supports the importance of tailoring interventions to target factors underlying barriers to behaviour change. At this LTCF, an effective antimicrobial stewardship intervention should incorporate strategies to improve access, knowledge, communication and collaboration in its design, having sufficient resources and addressing external factors to optimize its success and long-term sustainability. Can Pharm J (Ott) 2021;154:xx-xx.

Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: a pragmatic randomized controlled trial.

BACKGROUND: Type II diabetes mellitus (T2DM) affects upwards of 25% of Canadian older adults and is associated with high comorbidity and burden. Studies show that lifestyle factors and self-management are associated with improved health outcomes, but many studies lack rigour or exclude older adults, particularly those with multimorbidity. More evidence is needed on the effectiveness of community-based self-management programs in older adults with T2DM and multimorbidity. The study purpose is to evaluate the effect of a community-based intervention versus usual care on physical functioning, mental health, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with T2DM and 2 or more comorbidities. METHODS: Community-living older adults with T2DM and two or more chronic conditions were recruited from three Primary Care Networks (PCNs) in Alberta, Canada. Participants were randomly allocated to the intervention or control group in this pragmatic randomized controlled trial comparing the intervention to usual care. The intervention involved up to three in-home visits, a monthly group wellness program, monthly case conferencing, and care coordination. The primary outcome was physical functioning. Secondary outcomes included mental functioning, anxiety, depressive symptoms, self-efficacy, self-management, and the cost of healthcare service use. Intention-to-treat analysis was performed using ANCOVA modeling. RESULTS: Of 132 enrolled participants (70-Intervention, 62-Control), 42% were 75 years or older, 55% were female, and over 75% had at least six chronic conditions (in addition to T2DM). No significant group differences were seen for the baseline to six-month change in physical functioning (mean difference: -0.74; 95% CI: - 3.22, 1.74; p-value: 0.56), mental functioning (mean difference: 1.24; 95% CI: - 1.12, 3.60; p-value: 0.30), or other secondary outcomes.. CONCLUSION: No significant group differences were seen for the primary outcome, physical functioning (PCS). Program implementation, baseline differences between study arms and chronic disease management services that are part of usual care may have contributed to the modest study results. Fruitful areas for future research include capturing clinical outcome measures and exploring the impact of varying the type and intensity of key intervention components such as exercise and diet. TRIAL REGISTRATION: NCT02158741 Date of registration: June 9, 2014.

The role and impact of the pharmacist in long-term care settings: A systematic review.

OBJECTIVE: Older adults in long-term care (LTC) are often frail and comorbid and have multiple medications. Although medication review by pharmacists has been integrated into LTC practice in many countries through policy and reimbursement models, the impact is variable in the literature. The purpose of our study was to review the literature regarding the impact of the pharmacist in LTC. DATA SOURCES: Four databases were searched from inception to September 2017, including Ovid MEDLINE, Ovid Embase, Ovid Evidence-Based Medicine Reviews (Cochrane Library), and Ovid International Pharmaceutical Abstracts. STUDY SELECTION: Studies in any language were included if they met the following criteria: (1) pharmacist involved in care, (2) quasi-experimental or experimental design, and (3) conducted in LTC. DATA EXTRACTION: Two reviewers independently reviewed the titles, abstracts, and full-text articles to determine if they met inclusion criteria, with a third researcher resolving discrepancies. Data of included studies were independently abstracted by 2 reviewers and confirmed by a third researcher. RESULTS: Twenty-six studies (total N = 20,228, median study duration = 12 months) met the inclusion criteria. Medication review was the most common intervention, evaluated in 24 studies (92%). Eleven studies (42%) reported on the total number of medications per patient, with 7 studies finding a statistically significant reduction in medication usage. Six studies focused on psychotropic medications, with 4 of those leading to a reduction in medication. Explicit medication appropriateness criteria showed improvement in 5 studies. Medication and health care costs were evaluated in 14 studies (54%), with 4 reporting a statistically significant reduction. Studies reporting hospitalizations (10, 38%) were moderately heterogeneous (I2 = 59%) and failed to demonstrate an impact. Studies reporting mortality (8, 31%) were less heterogeneous (I2 = 0%), but they also failed to show a change. CONCLUSION: There is evidence to support pharmacist intervention, primarily through medication review, to improve measures in medication appropriateness.

An analysis of online content related to testosterone supplementation.

OBJECTIVE: To describe the quality of online information on testosterone replacement therapy (TRT) in men. METHODS: A quantitative content analysis was conducted on websites providing patient-directed information on TRT for the purpose of treating late onset hypogonadism (LOH). Websites were identified through Google in March 2017. The DISCERN instrument was used to determine the quality of health information. RESULTS: A total of 20 websites met inclusion criteria. Websites were primarily from the United States (45%), United Kingdom (25%), and Australia (15%). Sources of information were cited by 40% of websites. Several websites (40%) claimed that TRT had benefits, with 25% claiming that TRT was effective for treating LOH. TRT was described as a safe therapy by one website (5%), with gynecomastia (35%) and increased hematocrit (35%) representing the most commonly described side effects. Prostate specific antigen (35%) and serum testosterone monitoring (30%) were the most commonly described monitoring parameters. The mean DISCERN score was 46.4, indicating fair quality information. The Flesh-Kincaid Grade Level was 12.2. CONCLUSION: Online TRT information is incomplete, often failing to describe important safety information and the need for regular monitoring.

Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline.

OBJECTIVE: To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop benzodiazepine receptor agonists (BZRAs); to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes. METHODS: The overall team comprised 8 clinicians (1 family physician, 2 psychiatrists, 1 clinical psychologist, 1 clinical pharmacologist, 2 clinical pharmacists, and 1 geriatrician) and a methodologist; members disclosed conflicts of interest. For guideline development, a systematic process was used, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence was generated by conducting a systematic review of BZRA deprescribing trials for insomnia, as well as performing a review of reviews of the harms of continued BZRA use and narrative syntheses of patient preferences and resource implications. This evidence and GRADE quality of evidence ratings were used to generate recommendations. The team refined guideline content and recommendations through consensus and synthesized clinical considerations to address front-line clinician questions. The draft guideline was reviewed by clinicians and stakeholders. RECOMMENDATIONS: We recommend that deprescribing (tapering slowly) of BZRAs be offered to elderly adults (≥ 65 years) who take BZRAs, regardless of duration of use, and suggest that deprescribing (tapering slowly) be offered to adults aged 18 to 64 who have used BZRAs for more than 4 weeks. These recommendations apply to patients who use BZRAs to treat insomnia on its own (primary insomnia) or comorbid insomnia where potential underlying comorbidities are effectively managed. This guideline does not apply to those with other sleep disorders or untreated anxiety, depression, or other physical or mental health conditions that might be causing or aggravating insomnia. CONCLUSION: Benzodiazepine receptor agonists are associated with harms, and therapeutic effects might be short term. Tapering BZRAs improves cessation rates compared with usual care without serious harms. Patients might be more amenable to deprescribing conversations if they understand the rationale (potential for harm), are involved in developing the tapering plan, and are offered behavioural advice. This guideline provides recommendations for making decisions about when and how to reduce and stop BZRAs. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.

Beyond equality: Providing equitable care for persons with disabilities.

BACKGROUND: Almost 14% of Canadians have a disability, and older adults are most commonly affected. People living with disabilities have challenges accessing health care services, including medications and other services provided in pharmacies. METHODS: A literature review was conducted regarding disability and pharmacy services. Resources regarding accessibility were also incorporated. RESULTS: A number of organizations provide guidance on caring for those with disabilities. A primary concern for these vulnerable individuals relates to being invisible or overlooked by the health care system. There are also the stresses of physical, communication and attitudinal barriers. Pharmacists may be unaware of these barriers and may actually be contributing to them. To understand their patients' accessibility needs, pharmacists can consider physical and nonphysical barriers and engage in education, advocacy and communications training to improve their patient-centred care for individuals with disabilities. DISCUSSION AND CONCLUSION: Pharmacists can improve the care of individuals with disabilities by learning more about accessibility. Within the community pharmacy environment, there are physical and nonphysical interventions that pharmacists can implement to ensure that patient-centred care is prioritized.

Administration Technique and Acceptance of Inhaler Devices in Patients With Asthma or COPD.

BACKGROUND: Correct technique and patient acceptance of inhalation devices for lung disease influence successful long-term management. Patient ability to use the proper technique may differ depending on the device as well as patient factors. OBJECTIVES: The objectives of our study are to measure self-reported level of acceptability of inhaler devices in community settings and compare correct use of inhaler devices using a novel scale for measuring appropriate inhaler technique. METHODS: This prospective observational study enrolled patients from 3 different practice sites with asthma and/or chronic obstructive pulmonary disease (COPD) who were using an inhaler device. In addition to describing the samples' overall acceptability and correct use scores for the different inhalers, acceptability and correct use scores were compared based on patient characteristics. RESULTS: A total of 161 patients completed the study. The results show that acceptability was lowest for the pressurized metered dose inhaler (pMDI) with a spacer (S); effective use was best demonstrated with pMDI and poorest with pMDI-S. Older patients were found to be more accepting of the HandiHaler device than younger patients. Patients reporting taking more inhaled drugs were found to be more accepting of the pMDI-S than those taking fewer drugs. Finally, patients reporting taking more inhaled drugs demonstrated less-effective use of the HandiHaler device than patients taking fewer drugs. CONCLUSION: Pulmonary disease duration does not ensure improved use for all inhalers; patients taking more drugs demonstrate less-effective use for some devices. Assessment of patient acceptance and factors that predict the ability to use a device should be considered to individualize therapy.

A review of acute care interventions to improve inpatient pneumococcal vaccination.

OBJECTIVE: To provide a narrative review of the impact of provider-based, organizational strategies in acute care settings to improve pneumococcal vaccination rates among patients over 65, and 2-64 years with high risk medical conditions. METHODS: A search was conducted using MEDLINE, Scopus, CINAHL and Web of Science databases for hospital-based, inpatient studies which evaluated strategies to improve pneumococcal vaccination rates. Studies published in English from 1983 to 2013 were included. Data abstracted was analyzed descriptively. RESULTS: A total of 35 studies were included; 15 evaluated physician reminders (e.g. chart or paper reminders, pre-printed orders (PPOs), computerized reminders, checklists) and 21 standing orders programs (SOPs). The most common study design was pre/post, and only 7 studies had a control group. Overall, 32 studies showed improvements in the rate of pneumococcal vaccination following intervention (19 statistically significant), with reminders showing 29-74% immunization rate, PPCO 5-42%, and SOPs 3.4-78%. CONCLUSION: Hospital-based interventions improve pneumococcal vaccination in older adults and younger individuals at risk. Although this review found that more success was observed with SOPs the impact on immunization rates in eligible patients varied significantly. Thus, high quality, randomized-controlled studies are required to determine the effect of each type of institutional immunization strategy.

Case mapping of geriatrics: Looking beyond age in skills laboratories.

BACKGROUND AND PURPOSE: Development of competencies related to care of older adults is necessary in pharmacy education. Skills laboratories as an essential part of the curriculum represent an important setting to teach geriatrics. The purpose of this research was to describe geriatrics cases in skills/simulation activities of an undergraduate pharmacy program. EDUCATIONAL ACTIVITY AND SETTING: A retrospective review of one academic year of skills laboratories from the pharmacy program at the Faculty of Pharmacy of University of Montreal was performed. Sessions including cases aged ≥65 years were selected. Content was extracted for characteristics relating to the patient, health, medications, and care context. A framework including geriatric considerations such as geriatric syndromes, frailty status, and potentially inappropriate medications was developed for data collection. FINDINGS: In total, 210 patient cases were extracted. Older adults (≥ 65 years) were represented in 51 cases (24%), with 8 cases (4%) aged ≥80 years. Geriatric syndromes were documented in 8%, functional status in 10%, and mobility in 12% of the cases. The median number of comorbidities and medications were 4 and 7, respectively. Regarding polypharmacy, only 10 cases had >10 medications, and none had >15 medications. Potentially inappropriate medications were found in 47% (n = 24) of the cases but were addressed in only 14% (n = 7) cases. SUMMARY: This mapping of skills laboratories highlights gaps in geriatrics content. Inclusion of the oldest patients and geriatrics issues were incorporated in a minority of cases and lacked many characteristics essential for geriatrics care.

Factors influencing the effects of policies and interventions to promote the appropriate use of medicines in high-income countries: A rapid realist review.

BACKGROUND: The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use). METHODS: We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted. RESULTS: From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy. CONCLUSION: Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs.

Development and evaluation of shared decision-making tools in rheumatology: A scoping review.

INTRODUCTION: Shared decision-making (SDM) tools are facilitators of decision-making through a collaborative process between patients/caregivers and clinicians. These tools help clinicians understand patient's perspectives and help patients in making informed decisions based on their preferences. Despite their usefulness for both patients and clinicians, SDM tools are not widely implemented in everyday practice. One barrier is the lack of clarity on the development and evaluation processes of these tools. Such processes have not been previously described in the field of rheumatology. OBJECTIVE: To describe the development and evaluation processes of shared decision-making (SDM) tools used in rheumatology. METHODS: Bibliographic databases (e.g., EMBASE and CINAHL) were searched for relevant articles. Guidelines for the PRISMA extension for scoping reviews were followed. Studies included were: addressing SDM among adults in rheumatology, focusing on development and/or evaluation of SDM tool, full texts, empirical research, and in the English language. RESULTS: Of the 2030 records screened, forty-six reports addressing 36 SDM tools were included. Development basis and evaluation measures varied across the studies. The most commonly reported development basis was the International Patient Decision Aids Standards (IPDAS) criteria (19/36, 53 %). Other developmental foundations reported were: The Ottawa Decision Support Framework (ODSF) (6/36, 16 %), Informed Medical Decision Foundation elements (3/36, 8 %), edutainment principles (2/36, 5.5 %), and others (e.g. DISCERN and MARKOV Model) (9/31,29 %). The most commonly used evaluation measures were the Decisional Conflict Scale (18/46, 39 %), acceptability and knowledge (7/46, 15 %), and the preparation for decision-making scale (5/46,11 %). CONCLUSION: For better quality and wider implementation of such tools, there is a need for detailed, transparent, systematic, and consistent reporting of development methods and evaluation measures. Using established checklists for reporting development and evaluation is encouraged.

The Aging Care 5Ms Competencies: A Modified Delphi Study to Revise Medical Student Competencies for the Care of Older Adults.

PURPOSE: To revise the 2009 Canadian Geriatrics Society (CGS) Core Competencies in the Care of Older Persons for Canadian Medical Students by applying current frameworks and using a modified Delphi process. METHOD: The working group chose the Geriatric 5Ms model and CanMEDS framework to develop and structure the competencies. National (i.e., Canadian) Delphi participants were recruited, and 3 Delphi survey rounds were conducted from 2019 to 2021. Each survey round collected quantitative data using a 7-point Likert scale (LS) and qualitative data using free-text comments. The purpose of the first round was to establish the importance of the components of the proposed competencies (categorized into 13 subsections) and identify additional themes. The second round assessed agreement with 31 proposed competencies organized into 7 themes: aging, caring for older adults, mind, mobility, medications, multicomplexity, and matters the most. The third survey-rated agreement levels after further revisions to the competencies were applied. The final 33 competencies were shared with survey participants for feedback and other stakeholders for external validation. RESULTS: Mean LSs for the importance of the 13 competency component subsections on the first survey varied from 5.11 to 6.54, with an agreement level of 73%-93%. New themes emerged from the qualitative comments. Mean LSs for the 31 competencies on the second survey ranged from 5.57 to 6.81, with an agreement level of 80%-97%. Mean LSs for the revised competencies on the third survey ranged from 5.83 to 6.65, with an agreement level of 83%-95%. CONCLUSIONS: The authors developed the 33 Aging Care 5Ms Competencies for Canadian medical students using a consensus process. The competencies fulfill an important need in medical education, and ultimately, society. The authors strongly believe that the competencies can be woven into existing undergraduate medical curricula through purposeful integration and collaboration, including with other specialties.

Evidence for the use of cannabis-based medicines in osteoarthritis: a scoping review.

The purpose of this study was to conduct a scoping review to describe the evidence on the efficacy and safety of using cannabis-based medicines for osteoarthritis. The review was conducted following the framework proposed by Arksey and O'Malley and reported following PRISMA extension for scoping reviews guidelines. We conducted a comprehensive search across various databases including MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, and Proquest, spanning from inception of each database to March 2023. We retrieved 2533 citations, and after deduplication, title and abstract screening, and full-text screening, 10 articles were included for analysis. These studies were composed of randomized-controlled trials (n = 4/10), cross-sectional surveys (n = 3/10), case studies (n = 2/10), and a cohort study (n = 1/10). Evidence for using cannabis-based medicines was mixed, with just 60% (n = 6/10) of included studies reporting statistically significant improvements in pain. Studies with larger samples sizes and longer durations of exposure did not find significant benefits for pain. The few adverse effects reported were generally mild and affected a minority of participants. Several studies also discovered that cannabis-based medicines were associated with a reduction in opioid use. Currently available data on the use of cannabis-based medicines in osteoarthritis is insufficient to make recommendations. Future research should address concerns regarding small sample sizes and short treatment durations to provide a more robust evidence base. Key Points • Current evidence remains mixed; studies that found a positive benefit with using cannabis-based medicines had limitations with small sample sizes and short durations of exposure • The use of cannabis-based medicines in osteoarthritis appears to be generally well tolerated, adverse effects are mild and experienced by a minority of participants • Cannabis-based medicines may decrease the use of opioids in patients with osteoarthritis • Future research should address the gaps in long-term efficacy and safety data.

Déprescription des agonistes des récepteurs des benzodiazépines: Lignes directrices de pratique clinique fondées sur les données probantes.

OBJECTIF: Formuler des lignes directrices fondées sur les données probantes visant à aider les cliniciens à décider du moment et de la façon sécuritaire de réduire la dose des agonistes des récepteurs des benzodiazépines (BZRA) pour mettre fin au traitement; se concentrer sur le niveau le plus élevé des données disponibles et obtenir les commentaires des professionnels de première ligne durant le processus de rédaction, de révision et d'adoption des lignes directrices. MÉTHODES: L'équipe comptait 8 cliniciens (1 médecin de famille, 2 psychiatres, 1 psychologue clinique, 1 pharmacologue clinique, 2 pharmaciennes cliniques et 1 gériatre) et une spécialiste de la méthodologie; les membres ont divulgué tout conflit d'intérêts. Nous avons eu recours à un processus systématique, y compris l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour formuler les lignes directrices. Les données ont été générées par une revue systématique d'études portant sur la déprescription des BZRA contre l'insomnie, de même que par une revue des revues sur les torts liés à la poursuite du traitement par BZRA et des synthèses narratives sur les préférences des patients et les répercussions sur les ressources. Ces données et le score GRADE de qualité des données ont servi à formuler les recommandations. L'équipe a peaufiné le texte sur le contenu et les recommandations des lignes directrices par consensus et a synthétisé les considérations cliniques afin de répondre aux questions des cliniciens de première ligne. Une version préliminaire des lignes directrices a été révisée par les cliniciens et les intervenants. RECOMMANDATIONS: Nous recommandons d'offrir la déprescription (réduction lente de la dose) des BZRA à tous les patients âgés (≥ 65 ans) sous un BZRA, sans égard à la durée de l'usage, et suggérons d'offrir la déprescription (réduction lente de la dose) à tous les adultes de 18 à 64 qui prennent un BZRA depuis plus de 4 semaines. Ces recommandations visent les patients qui prennent un BZRA contre l'insomnie seule (insomnie primaire) ou l'insomnie comorbide lorsque les comorbidités sous-jacentes sont efficacement prises en charge. Ces lignes directrices ne visent pas les personnes atteintes d'autres troubles non traités du sommeil ou d'anxiété, de dépression, ou d'autres troubles physiques ou de santé mentale pouvant causer ou aggraver l'insomnie. CONCLUSION: Les agonistes des récepteurs des benzodiazépines sont liés à des torts, et leur effet thérapeutique serait bref. La réduction graduelle de la dose de BZRA améliore le taux d'abandon comparativement aux soins habituels, et ce, sans causer de torts graves. Les patients seraient plus ouverts à une conversation sur la déprescription s'ils comprennent le pourquoi (potentiel de torts), participent à l'élaboration du plan de réduction de la dose et reçoivent des conseils en matière de comportement. Les présentes lignes directrices émettent des recommandations pour décider du moment et de la façon de réduire la dose de BZRA pour mettre fin au traitement. Elles visent à contribuer au processus de décision conjointement avec le patient et non à le dicter.