Potentially Inappropriate Medications in Older Adults-Prevalence, Trends and Associated Factors: A Cross-Sectional Study in Saudi Arabia.

(1) Background: Potentially inappropriate medications (PIMs) in older adults are associated with drug-related problems, adverse health consequences, repeated hospital admissions and a higher risk of mortality. In Saudi Arabia and some Arab countries, studies of PIMs among large cohorts of older adults are limited. This study aimed to determine the prevalence of PIMs, trends and associated factors among outpatient older adults in Saudi Arabia. (2) Methods: A cross-sectional study was carried out. Over three years (2017-2019), data on 23,417 people (≥65 years) were retrieved from outpatient clinics in a tertiary hospital in Riyadh, Saudi Arabia. PIMs were assessed using the 2019 Beers Criteria. Covariates included sex, age, nationality, number of dispensed medications, and number of diagnoses. A generalized estimating equation model was used to assess trends and factors associated with PIMs. (3) Results: The prevalence of PIMs was high and varied between 57.2% and 63.6% over the study years. Compared with 2017, the prevalence of PIMs increased significantly, with adjusted odds ratios (OR) (95% confidence interval (95% CI)) of 1.23 (1.18-1.29) and 1.15 (1.10-1.21) for 2018 and 2019, respectively. Factors associated with being prescribed PIMs included ≥5 dispensed medications (OR_adjusted = 23.91, 95% CI = 21.47-26.64) and ≥5 diagnoses (OR_adjusted = 3.20, 95% CI = 2.88-3.56). Compared with females, males had a lower risk of being prescribed PIMs (OR_adjusted = 0.90, 95% CI = 0.85-0.94); (4) Conclusions: PIMs were common with an increasing trend among older adults in Saudi Arabia. A higher number of dispensed medications, increased number of diagnoses and female sex were associated with being prescribed PIMs. Recommendations on how to optimize prescriptions and implement de-prescribing strategies are urgently needed.

Feasibility, and barriers to use escitalopram in functional gastrointestinal disorders.

Background and study aims: The feasibility and barriars of escitalopram use in patients with functional gastrointestinal disorders (FGIDs) are still debated. We aimed to evaluate the feasibility, safety and efficacy and barriars of escitalopram use in managing FGIDs in the Saudi population. Patients and Methods: We included 51 patients who received escitalopram for irritable bowel syndrome (n = 26), functional heartburn (n = 10), globus sensation (n = 10) or combined disorders (n = 5). We used an irritable bowel syndrome-severity scoring system IBS-SSS), GerdQ questionnaire and Glasgow Edinburg Throat Scale (GETS) to assess disease severity change before and after treatment. Results: The median age was 33 years (25th- 75th percentiles: 29-47), and 26 (50.98%) were males. Forty-one patients experienced side effects (80.39%), but most side effects were mild. The most common side effects were drowsiness/fatigue/dizziness (54.9%), xerostomia (23.53%), nausea/vomiting (21.57%) and weight gain (17.65%). IBS-SSS was 375 (255-430) and 90 (58-205) before and after treatment, respectively (p < 0.001). GerdQ score was 12 (10-13) before treatment and 7 (6-10) after treatment (p = 0.001). GETS score before treatment was 32.5 (21-46) and after treatment became 22 (13-31) (p = 0.002). Thirty-five patients refused to take the medications, and seven patients discontinued the medication. Possible causes of the poor compliance were fear of the medications and not being convinced of taking psychiatric medications for functional disorders (n = 15). Conclusion: Escitalopram could be a safe and effective treatment for functional gastrointestinal disorders. Targeting and managing factors leading to poor compliance could further improve the treatment outcome.

Burnout and Depressive Symptoms in Healthcare Professionals: A Cross-Sectional Study in Saudi Arabia.

OBJECTIVES: The study objectives were to examine the prevalence of burnout among healthcare professionals, analyze the association of depression and burnout among healthcare professionals, and explore the factors related to burnout. METHODS: A prospective cross-sectional study using a validated questionnaire was conducted among healthcare professionals in a tertiary teaching hospital in Saudi Arabia's central region. The Maslach Burnout Inventory (MBI) questionnaire was used to measure burnout through emotional exhaustion, depersonalization, and personal accomplishment. Descriptive and inferential statistics were carried out using SAS version 9.4. RESULTS: The study sample was composed of 139 healthcare professionals. Around 48% of the study sample were nurses, 26% were physicians, 19% were pharmacists, and 6% were other healthcare professionals. About 61% screened positive for depression. Overall, one third of the participants had a high risk of burnout. Around 61.8% of the participants were in the high-risk group of the EE, 58.3% of the DP, and 41.0% of the PA subscales. Scores for the overall MBI were significantly different between various age groups, gender, those with social and financial responsibility, income, job titles, or years of experience. A higher risk of burnout in all subscales was observed among those with depression. CONCLUSIONS: A high risk of burnout was observed among healthcare professionals. The level of burnout was connected to workplace factors and the presence of depression. The burnout suffering among these healthcare professionals underlines the need to study further how to reduce the factors that contribute to burnout and the impact of interventions to reduce healthcare professionals' burnout levels. The burnout scientific literature would benefit from further high-quality research with larger samples using longitudinal study designs to identify the causal risk factors.

Drug-Induced Rhinitis: Narrative Review.

OBJECTIVES: Rhinitis, one of the most common inflammatory conditions of the nasal mucosa, is known to affect a large proportion of people worldwide. It is generally classified into allergic and non-allergic types and both are associated with several unpleasant symptoms. Several medications prescribed for different medical conditions can cause unpleasant rhinitis as an adverse effect, which is known as drug-induced non-allergic rhinitis. The aims of this article were to review the literature to identify drugs that could induce rhinitis, prevalence of drug-induced rhinitis, and the associated pathogenic mechanisms if known. METHODS: Literature search screening for eligible papers published up to December 31st, 2021, in Medline (via PubMed) and Embase was conducted. The search included the following combination of keywords and terms: rhinitis, sneezing, congestion, allergic, non-allergic, rhinorrhea, vasomotor, medication, drug-induced. RESULTS: The review findings suggest that 12 subtypes of drugs potentially could induce rhinitis. Based on their mechanisms of action, the pathogenic causes for the induction of rhinitis have been recognized for some drugs, while others remain unknown. CONCLUSION: Awareness of the list of drugs that reportedly induce non-allergic nasal symptoms, along with taking the patient's medication history, is important in the diagnosis of rhinitis.

Gene Therapy Knowledge and Attitude Among Healthcare Professionals: A Cross-Sectional Study.

This study aimed to assess healthcare professionals' knowledge, attitudes, and concerns toward gene therapy in Saudi Arabia. We conducted an online cross-sectional survey via convenience sampling during the period from December 2018 to March 2019. A total of 419 (358 pharmacists and 61 physicians) responded to our questionnaire. Three hundred and nine (73.7%) were male, and the mean (±SD) age of 32.0 ± 7.7 years. The mean knowledge scores of all participants, pharmacists, and physicians were 3.8 ± 1.9, 3.8 ± 1.9, and 3.7 ± 1.9, respectively (P = 0.73). Higher knowledge score was associated with younger age (Coefficient: -0.03; P = 0.02), male (Coefficient: 0.57; P = 0.01), master's degree (Coefficient: 0.93; P = 0.003) and Ph.D. holders (Coefficient: 1.10; P = 0.01), and participants graduated from Canada (Coefficient: 2.10; P = 0.01).Moreover, about half of the respondents (55%) were concerned about gene therapy, and genetics training at college was considered the best gene therapy education method by 69.4%. Attitude score was not significantly associated with the profession (P = 0.88) but positively correlated with the knowledge score (rho= 0.4; P < 0.001). In conclusion, pharmacists and physicians showed limited knowledge with a positive attitude toward gene therapy. Therefore, educational programs on gene therapy need to be considered, focusing primarily on the safety, and social acceptance of such new therapeutic management.

Genetic Insights into the Middle East Respiratory Syndrome Coronavirus Infection among Saudi People.

BACKGROUND: The Middle East respiratory syndrome coronavirus (MERS-CoV) was isolated for the first time in Saudi Arabia from a patient suffering from atypical pneumonia. The Saudi Genome database was built by King Abdulaziz Medical City via the next-generation sequencing of 7000 candidates. METHOD: A large list of point mutations were reported in the region of the dipeptidyl peptidase 4 (DPP4) gene. The DPP4 amino acid residues correlated to MERS-CoV entry and the site of activity of DPP4 inhibitors was investigated. We retrieved the SNPs (Single-Nucleotide Polymorphism) with a variation frequency of >0.05. RESULTS: SNP 2:162,890,175 and SNP 2:162,891,848 in the intronic region were located within 50 bp of amino acid residues responsible for MERS-CoV entry, amino acids 259-296 and 205-258, respectively. The variation frequency of SNP 2:162,890,175 was 2321 out of 2379 screened individuals. Moreover, mutation of SNP 2:162,891,848, which is located near amino acid residues E205 and E206 (crucial for the activity of DPP4 inhibitors), occurred in 76 out of 2379 screened individuals. CONCLUSIONS: Our study shows high variation frequency in the DPP4 region reported in the Saudi Genome database. The identified SNPs are of high significance for MERS-CoV infection in better understanding disease pathogenesis.

Knowledge, Attitude, and Practice Towards COVID-19 Among Pharmacists: A Cross-Sectional Study.

PURPOSE: The COVID-19 outbreak has caused governments to put pandemic-related guidelines requiring compliance and understanding by healthcare professionals to mitigate its spread uncontrollably. We studied pharmacists' knowledge, attitude, and practice towards the COVD-19 outbreak compared with other healthcare workers during the pandemic in Saudi Arabia. METHODS: We surveyed pharmacists' socio-demographics (n=50) compared with other healthcare professionals (n=378) during lockdown starting in June 2020. We measured respondents' level of knowledge (n=10 questions, maximum score of 10), attitude (n=17 questions, maximum score of 80), and their practices (n=16 questions, maximum score of 80) towards COVID-19 infection. RESULTS: Median knowledge score was 8 (25th-75th percentiles: 7-9), attitude score 76 (70-80) and practice score 74 (68-78). Good knowledge predictors were >20 years working experience [OR: 2.05 (95% CI: 1.03-4.06); P=0.04] and >50% working in clinical practice [OR: 1.72 (95% CI: 1.12-2.66); P=0.01], in inverse relationship with paramedical professions [OR: 0.45 (95% CI: 0.45 (0.28-0.72)); P=0.001] and working in a university hospital [OR: 0.51 (95% CI: 0.33. 0.81); P=0.004]. Availability of pharmaceutical information and treatment options was associated with good attitude [OR: 2.19 (95% CI: 1.04-4.59); P=0.039] and acquaintance as primary information sources negatively associated with good attitude [OR: 0.34 (95% CI: 0.15-0.8); P=0.013]. Good practice predictors were female gender [OR: 3.84 (95% CI: 2.37-6.24); P<0.001], military hospital employment [OR: 2.32 (95% CI: 1.25-4.31); P=0.008], USA [OR: 3.41 (95% CI: 1.03-11.22); P=0.044] or UK [OR: 8.86 (95% CI: 1.91-41.07); P=0.005] qualifications, and information on supportive measures [OR: 2.2 (95% CI: 1.36-3.56); P=0.001]. CONCLUSION: Health workers displayed good knowledge about COVID-19, while profession and working experience predicted adequate knowledge, positive attitude, or practice towards disease management.

Relationship between different anti-rheumatic drug therapies and complementary and alternative medicine in patients with rheumatoid arthritis: an interview based cross-sectional study.

OBJECTIVES: The use of complementary and alternative medicine (CAM) by patients with rheumatoid arthritis (RA) is highly prevalent. The relationship of these remedies with disease therapy are not fully studied. We aimed to explore the relationship between different anti-rheumatic drug therapy and CAM use in RA patients. METHODS: The study used an interview-based cross-sectional survey in two major referral centres in Riyadh, Saudi Arabia. Patients were adults with confirmed RA that attended rheumatology clinics. Information on the utilization of CAM, RA duration, drug therapy, and laboratory parameters were obtained. Descriptive statistics as well as adjusted odds ratio using bivariate logistic regression were used to explore the different factors related to CAM use, including drug therapy. RESULTS: A total of 438 adult patients with RA were included. The mean (±SD) age of the patients was 49 (±15.0) years. The majority were women 393 (89.7%). Two hundred and ninety-two patients (66.7%) had used CAM. The CAM users who had a longer disease duration (AOR 1.041 [95% CI: 1.011, 1.073]; p = 0.008) were more likely to be female (AOR 2.068 [95% CI: 1.098, 3.896]; p = 0.024), and use methotrexate (AOR 1.918 [95% CI: 1.249, 2.946]; p = 0.003) as opposed to celecoxib (AOR 0.509 [95% CI: 0.307, 0.844]; p = 0.009) and biologic monotherapy (AOR 0.443 [95% CI: 0.224, 0.876]; p = 0.019). Other factors related to CAM were meloxicam use (AOR 2.342 [95% CI: 1.341, 4.089]; p = 0.003) and traditional therapy (AOR 2.989 [95% CI: 1.647, 5.425]; p = 0.000). The remaining factors were not significant. CONCLUSION: CAM use is prevalent in patients with RA. Understanding patients and disease related factors associated with higher use of CAM is warranted to improve RA management and provide more rational use of these remedies.

Prescribing errors among adult patients in a large tertiary care system in Saudi Arabia.

BACKGROUND: Multiple studies have investigated medication errors in hospitals in Saudi Arabia; however, prevalence data on prescribing errors and associated factors remains uncertain. OBJECTIVE: Assess the prevalence, type, severity, and factors associated with prescribing errors. DESIGN: Retrospective database review. SETTING: Large tertiary care setting in Riyadh. PATIENTS AND METHODS: We described and analyzed data related to prescribing errors in adults (>14 years of age) from the Medication Error Electronic Report Forms database for the two-year period from January 2017 to December 2018. MAIN OUTCOME MEASURE: The prevalence of prescribing errors and associated factors among adult patients. SAMPLE SIZE: 315 166 prescriptions screened. RESULTS: Of the total number of inpatient and outpatient prescriptions screened, 4934 prescribing errors were identified for a prevalence of 1.56%. The most prevalent types of prescribing errors were improper dose (n=1516; 30.7%) and frequency (n=987; 20.0%). Two-thirds of prescribing errors did not cause any harm to patients. Most prescribing errors were made by medical residents (n=2577; 52%) followed by specialists (n=1629; 33%). Prescribing errors were associated with a lack of documenting clinical information (adjusted odds ratio: 14.1; 95% CI 7.7-16.8, P<.001) and prescribing anti-infective medications (adjusted odds ratio 2.9; 95% CI 1.3-5.7, P<.01). CONCLUSION: Inadequate documentation in electronic health records and prescribing of anti-infective medications were the most common factors for predicting prescribing errors. Future studies should focus on testing innovative measures to control these factors and their impact on minimizing prescribing errors. LIMITATIONS: Polypharmacy was not considered; the data are from a single healthcare system. CONFLICT OF INTEREST: None.

Description of pharmacists' reported interventions to prevent prescribing errors among in hospital inpatients: a cross sectional retrospective study.

BACKGROUND: Prescribing errors (PEs) are a common cause of morbidity and mortality, both in community practice and in hospitals. Pharmacists have an essential role in minimizing and preventing PEs, thus, there is a need to document the nature of pharmacists' interventions to prevent PEs. The purpose of this study was to describe reported interventions conducted by pharmacists to prevent or minimize PEs in a tertiary care hospital. METHODS: A retrospective analysis of the electronic medical records data was conducted to identify pharmacists' interventions related to reported PEs. The PE-related data was extracted for a period of six-month (April to September 2017) and comprised of patient demographics, medication-related information, and the different interventions conducted by the pharmacists. The study was carried in a tertiary care hospital in Riyadh region. The study was ethically reviewed and approved by the hospital IRB committee. Descriptive analyses were appropriately conducted using the IBM SPSS Statistics. RESULTS: A total of 2,564 pharmacists' interventions related to PEs were recorded. These interventions were reported in 1,565 patients. Wrong dose (54.3 %) and unauthorized prescription (21.9 %) were the most commonly encountered PEs. Anti-infectives for systemic use (49.2 %) and alimentary tract and metabolism medications (18.2 %) were the most common classes involved with PEs. The most commonly reported pharmacists' interventions were dose adjustments (44.0 %), restricted medication approvals (21.9 %), and therapeutic duplications (11 %). CONCLUSIONS: In this study, PEs occurred commonly and pharmacists' interventions were critical in preventing possible medication related harm to patients. Care coordination and prioritizing patient safety through quality improvement initiatives at all levels of the health care system can play a key role in this quality improvement drive. Future studies should evaluate the impact of pharmacists' interventions on patient outcomes.

Cardiovascular disease risk prevention services by pharmacists in Saudi Arabia: what do policymakers and opinion leaders think?

BACKGROUND: Cardiovascular disease (CVD) is an emerging contributor to national morbidity and mortality in Saudi Arabia. CVD risk prevention services are limited, particularly with an over-utilised public health sector and an under-utilised and under-resourced primary care sector. Globally, there is evidence that community pharmacists can play a key role in CVD prevention within primary care. However, the perspectives of policymakers and opinion leaders are critical to successful translation of evidence into practice. Thus, the aim was to engage policymakers and professional leaders in discussions about implementing high-quality CVD risk prevention services in community pharmacy. METHODS: Qualitative semi-structured interviews were conducted, audio-recorded and transcribed verbatim. All transcripts were thematically analysed. RESULTS: A total of 23 participants (87% male) from government and non-government sectors were interviewed. Of these, almost 65% had pharmacy qualifications. Limited provision of CVD risks preventative services in primary care was acknowledged by most participants and building community pharmacists' capacity to assist in preventive health services was viewed favourably as one way of improving the status quo. The data yielded four key themes: (1) future pharmacy CVD health service models; (2) demonstrable outcomes; (3) professional engagement and advocacy; and (4) implementability. CVD health services roles (health screening, primary and secondary prevention services), pragmatic factors and tiered models of care (minimal, medium, and comprehensive pharmacist involvement) were discussed. The need for humanistic, clinical, and cost effectiveness outcomes to be demonstrated and active involvement of professional bodies were deemed important for such services to be sustainable. Professional pharmacy governance to develop pharmacy careers and workforce, pharmacy curricular reform and ongoing education were posed as key success factors for novel pharmacy roles. Practice policies, standards, and guidelines were seen as required to adhere to stringent quality control for future pharmacy services provision. Participant's implementation vision for such services included scalability, affordability, access, adoption and health system reform. Most discussions focused on the need for structural improvement with limited input regarding processes or outcomes required to establish such models. CONCLUSIONS: Most participants favoured pharmacy-based CVD risk prevention services, despite the variability in proposed service models. However, prior to developing such services, support structures at the health system and health professional level are needed as well as building public support and acceptability for pharmacy services.

Evaluating the frequency, consumers' motivation and perception of online medicinal, herbal, and health products purchase safety in Saudi Arabia.

OBJECTIVES: Purchasing medicinal products from the internet has become more popular in the last three decades. Understanding consumers' use and perception of the safety of medicinal products obtained online is essential. Therefore, this study aims to evaluate the extent of medicines purchased from the internet in Saudi Arabia, types of products, sources of information, the satisfaction, the motivational factors, and estimate consumers' vigilance and tendency to report ADRs if occurred. DESIGN: A prospective cross-sectional study using a custom-designed questionnaire was conducted among community adults in Saudi Arabia, age ≥ 18. SETTING: Evaluation of community subjects' perception towards buying medicinal products was done through the internet in Saudi Arabia from 1st July 2020 until the end of August 2020. MAIN OUTCOME MEASURES: The main outcome of the study was purchasing medicinal products from the internet (Yes, No). RESULTS: Overall, 36% of the study participants (n = 643) have ever bought medicinal products from the internet (Table 2). Of those, the most obtained was herbal medicine, supplements, or cosmetics (61.3%). Motivational factors towards purchasing medicinal products from the internet were mostly positive, with the most commonly reported agreed motivational factors were lower cost (55.7%), easy online access (54.1%), a wide variety of products (52.6%), and more privacy (43.6%). Around 60.4% of participants believed that buying medicinal products from the internet can be safe. The most perceived risk was the difficulty of distinguishing between registered online pharmacies and other unlicensed commercial websites, with only 32.7% of the participants distinguishing between registered and unlicensed commercial websites. CONCLUSIONS: This study sheds light on the consumers' use and perception of the safety and risks of medicinal products purchased from the internet. The study findings noticeably describe the great need to increase safety awareness about obtaining medicinal products from the internet among the Saudi community.

Prescribing errors and associated factors in discharge prescriptions in the emergency department: A prospective cross-sectional study.

OBJECTIVES: Evidence regarding the prevalence of medication prescribing errors (PEs) and potential factors that increase PEs among patients treated in the emergency department (ED) are limited. This study aimed to explore the prevalence and nature of PEs in discharge prescriptions in the ED and identify potential risk factors associated with PEs. METHODS: This was a prospective observational cross-sectional study in an ambulatory ED in a tertiary teaching hospital. Data were collected for six months using a customized reporting tool. All patients discharged from ED with a discharged prescription within the study period were enrolled in this study. RESULTS: About 13.5% (n = 68) of the 504 prescriptions reviewed (for 504 patients) had at least one error. Main PEs encountered were wrong dose (23.2%), wrong frequency (20.7%), and wrong strength errors (14.6%). About 36.8% of identified PEs were related to pediatric prescriptions, followed by the acute care emergency unit (26.5%) and the triage emergency unit (20.6%). The main leading human-related causes associated with PEs were lack of knowledge (40.9%) followed by an improper selection from a computer operator list (31.8%). The leading contributing systems related factors were pre-printed medication orders (50%), lack of training (31.5%), noise level (13.0%), and frequent interruption of prescriber and distraction (11.1%). Prescribers' involved with the identified errors were resident physicians (39.4%), specialists (30.3%), and (24.4%) were made by general practitioners. Physicians rejected around 12% of the pharmacist-raised recommendations related to the identified PEs as per their clinical judgment. CONCLUSION: PEs in ED setting are common, and multiple human and systems-related factors may contribute to the development of PEs. Further training to residents and proper communication between the healthcare professionals may reduce the risk of PEs in ED.

Physicians' views on cardiovascular disease risk prevention services by pharmacists and potential for collaboration.

Background: Cardiovascular diseases (CVD) are the leading cause of mortality worldwide. Early identification and management of modifiable CVD risk factors are highly effective in preventing disease onset and/or improving outcomes in CVD. As highly accessible primary health professionals, pharmacists can assume a role in screening and risk factor management in collaboration with physicians; however, such prevention services are not established practice in Saudi pharmacies. Therefore, the aim was to explore physicians' perceptions about the utility of a role in CVD risk screening and management for Saudi pharmacists. Methods: Qualitative semi-structured interviews were conducted, audio-recorded and transcribed verbatim in Arabic or English. All transcripts were thematically analyzed in an inductive approach after translation into English if required. Results: A total of 26 physicians recruited from public hospitals and primary healthcare centers were interviewed. Most were unaware of pharmacists' potential to undertake a role in CVD risk prevention. Although there was broad support for the concept, they recommended physician-pharmacist collaborative models, extensive provider pharmacist training, and strict oversight by the Saudi Ministry of Health (MoH)/other official authorities to ensure service quality and sustainability, should implementation occur. Healthcare system reform was considered key to expanding private sector (i.e., community pharmacy) involvement in healthcare, as was incentivizing providers and 'marketing' for patient acceptance. Conclusion: Physicians were positive about setting up a collaborative community pharmacist-physician CVD risk screening and management service model with the help of an authorized body within the Saudi Arabian healthcare system.

Prevalence and Factors Associated With Polypharmacy Use Among Adult Patients in Saudi Arabia.

BACKGROUND: Polypharmacy is very common in clinical practice, especially among adult patients. The use of multiple medications may increase the risk of adverse drug events, medication cost, and medication errors. In addition, polypharmacy exacerbates treatment complexity, which consequently leads to poor patients' adherence to their medications. Despite being a well-recognized problem, few studies have investigated the prevalence and predictors of polypharmacy in Saudi Arabia. OBJECTIVES: The aims of the study were to investigate the prevalence of polypharmacy among adult patients in a tertiary teaching hospital and to determine patients' characteristics that are associated with polypharmacy. METHODS: This was a retrospective cross-sectional study using data extracted from the electronic health records database for a period of 6 months between January and June 2016 in outpatient setting. Descriptive statistics were used to analyze the study sample. A multivariate logistic regression model was used to examine the association between different variables and polypharmacy. Statistical analysis software (SAS 9.2) was used to analyze the study data. RESULTS: A total of 17,237 observations (67.2% females) were included in the final analysis. Of these, nearly 54% (n = 9222) of reported observations were found using up to four prescription drugs and the other 46% (n = 8015) were using five or more prescription drugs. Interestingly, the prevalence of polypharmacy use was doubled among adults with hypertension as compared with those without hypertension (odds ratio [OR] = 2.68, 95% confidence interval [CI] = 2.51-2.87). In addition, polypharmacy use was two times more prevalent among adults with diabetes as compared with those without diabetes (OR = 2.31, 95% CI = 1.99-2.28) and five times more prevalent in patient with dementia (OR = 5.57, 95% CI = 1.26-24.7). Moreover, polypharmacy in adult patients was significantly influenced by sex (OR = 1.69, 95% CI = 1.59-1.80) and nationality (OR = 2.15, 95% CI = 2.00-2.31). CONCLUSIONS: Polypharmacy is common among adult patients especially those who are older than 60 years. Polypharmacy may affect the overall process of drug therapy. It can be a risk factor to develop undesirable adverse drug events, especially in those with chronic health conditions. A special care should be taken to manage polypharmacy among adults in Saudi Arabia.

Pharmacovigilance in healthcare education: students' knowledge, attitude and perception: a cross-sectional study in Saudi Arabia.

BACKGROUND: Medication safety and pharmacovigilance (PV) remains as an important discipline worldwide. However, there is a significant lack of knowledge of PV and adverse drug reaction (ADR) reporting among students in the healthcare field. Thus, this study is aimed to measure knowledge, attitude, and perceptions and compares it between healthcare students (i.e., medicine, dentistry, and nursing). METHODS: A cross-sectional study involving 710 undergraduate healthcare students from different universities in Saudi Arabia was conducted. A validated structured pilot-tested questionnaire was administered to the participants to assess their knowledge, attitude, and perceptions towards PV and ADRs reporting. Descriptive statistics were used to describe the study findings. Data were analyzed using SPSS version 21. RESULTS: Overall, the study found that 60.8 and 40.0% of healthcare students correctly defined PV and ADRs respectively. Most students showed positive attitudes and perceptions towards PV and ADRs reporting. PV knowledge, attitude, and perceptions towards PV were significantly higher among pharmacy students as compared to other healthcare students. Only 39% of healthcare students revealed that they have received any form of PV education and 49% of them indicated that PV is well covered in their school curriculum. Pharmacy students are more trained in their schools to report and have performed ADRs reporting in their school as compared to other healthcare students. CONCLUSIONS: Pharmacy students have better knowledge, attitude, and perception towards PV and ADR reporting in comparison to other healthcare students. The study clearly describes the need for integrating pharmacovigilance education in Saudi healthcare schools' curriculums to prepare them for real-world practices and workplaces.

Humanistic and economic burden of depression and anxiety among adults with migraine: A systematic review.

BACKGROUND: Depression and anxiety are well-recognized comorbid health conditions among adults with migraine due to their humanistic and economic burden. This review was conducted to systematically assess the humanistic and economic burden of comorbid depression and/or anxiety disorder among adults with migraine. METHODS: A systematic literature search was conducted using MEDLINE and CINAHL via EBSCO, EMBASE, and Cochrane Database of Systematic Reviews via OVID. Studies evaluating the humanistic burden and the economic burden of comorbid depression and anxiety among adults with migraine that were published in peer-reviewed English language journals from inception until January 2020 were included. RESULTS: Out of the 640 identified articles, 23 studies were found eligible and included in this review. Regarding the humanistic burden, health-related quality of life (HRQoL) was examined by 11 studies, 7 studies examined disability, while 2 studies evaluated both HRQoL and disability measures. These studies reported an association between depression and/or anxiety and lower HRQoL and higher disability among adults with migraine. Regarding the economic burden, only three studies were identified and all concluded that depression and/or anxiety are significantly associated with higher healthcare expenditures and utilization among adults with migraine. CONCLUSIONS: Results of this review highlight the substantial burden of depression and/or anxiety for adults with migraine. Healthcare providers need to identify and treat anxiety and depression for patients living with migraine.

Health consumer engagement in developing novel preventive health community pharmacy roles in cardiovascular disease in Saudi Arabia: A qualitative analysis.

INTRODUCTION: Cardiovascular diseases (CVD) are one of key leading causes of mortality worldwide. Both modifiable and non-modifiable risk factors contribute to the development of CVD. Modifiable risk factors such as smoking, unhealthy diets and lack of exercise are increasing in prevalence in Saudi Arabia but may be mitigated using pharmacological and non-pharmacological approaches. Thus, identifying, assessing and managing these modifiable risks at an early stage is essential. Pharmacists are highly accessible primary health professionals and can play a crucial role in screening and managing these risk factors in collaboration with primary care physicians. There is currently no research in Saudi Arabia exploring the views of health consumers with CVD risk factors regarding their preferences for or willingness to engage with community pharmacy CVD preventive health services. OBJECTIVES: To explore the perceptions of health consumers about current and feasible future services by pharmacists with a specific focus on CVD risk screening and management in Saudi Arabia. METHODS: Semi-structured interviews were conducted with consumers with at least one modifiable CVD risk factor. The interviews were audio-recorded, transcribed verbatim, translated into English and then thematically analysed. RESULTS: A total of 25 individuals, most of whom were Saudi (88%) and women (65%), participated in face to face interviews. Five main themes emerged from the analysis of consumers' responses. 1. Perception of pharmacists' role, the pharmacists' main role was perceived as medication supply. 2. Trust and satisfaction with current service, most participants appeared to have low trust in pharmacists. 3. Preferences for future pharmacy services, most participants were willing to engage in future pharmacy delivered CVD preventive health services, provided there was stringent regulation and oversight of the quality of such services. 4. Viability of new pharmacy services was raised with promotion of such services to the public, collaboration with other health professionals, financial incentivization and motivational rewards thought of as essential ingredient to ensure service feasibility. 5. Health beliefs and help seeking behaviours of consumers were diverse and low health literacy was evident; it was thought that pharmacists can help in these matters by educating and advocating for such consumers. Overall, the data suggested that clinical, communication and professional skills need to be enhanced among Saudi pharmacists to enable them to provide optimal patient cantered services. CONCLUSION: Health consumers participants were willing to participate and utilise CVD risk screening and management pharmacy-based services, when offered, provided their concerns are addressed. Therefore, in light of the burden of CVD disease in the country, development, implementation and evaluation of pharmacist provided CVD risk screening and management should be undertaken.

Cytotoxic Evaluation and Anti-Angiogenic Effects of Two Furano-Sesquiterpenoids from Commiphora myrrh Resin.

Commiphora myrrh resin (Myrrh) has been used in traditional Arabic medicine to treat various inflammatory diseases. Two furano-sesquiterpenoids, 2-methoxyfuranodiene (CM1) and 2-acetoxyfuranodiene (CM2), were isolated from the chloroform fraction of the ethanolic extract of Arabic Commiphora myrrh resin. The cytotoxicity of the compounds was evaluated using human liver carcinoma, breast cancer cells (HepG2 and MCF-7, respectively) and normal human umbilical vein endothelial cells (HUVECs) cell lines. The development toxicity and anti-angiogenic activity of both compounds were also evaluated using zebrafish embryos. Cell survival assays demonstrated that both compounds were highly cytotoxic in HepG2 and MCF7 cells, with IC50 values of 3.6 and 4.4 µM, respectively. Both compounds induced apoptosis and caused cell cycle arrest in treated HepG2 cells, which was observed using flow cytometric analysis. The development toxicity in zebrafish embryos showed the chronic toxicity of both compounds. The toxicity was only seen when the embryos remained exposed to the compounds for more than three days. The compound CM2 showed a significant level of anti-angiogenic activity in transgenic zebrafish embryos at sublethal doses. Thus, we demonstrated the cytotoxic properties of both compounds, suggesting that the molecular mechanism of these compounds should be further assessed.

Cardiovascular disease risk screening by pharmacists: a behavior change wheel guided qualitative analysis.

BACKGROUND: In common with many developed countries, Saudi Arabia is currently experiencing an increasing cardiovascular disease (CVD) burden. However, systematic screening programs for early identification and minimization of CVD risk within community or general clinical settings are limited. Globally, research suggests that pharmacists can play an effective role in identifying, assessing, managing and referring people at risk of CVD in the community as well as in the hospital setting. This role is not yet developed in Saudi Arabia. OBJECTIVES: This study aimed to explore the perspectives of hospital and community pharmacists in Saudi Arabia about potential roles in CVD risk screening. The purpose of the study was to propose potential interventions to facilitate the development of pharmacist delivered models for CVD risk prevention and management services in Saudi Arabia. METHODS: A qualitative study was conducted using semi-structured in-depth interviews and focus group discussions with a purposive convenience sample of hospital and community pharmacists in Saudi Arabia. Data collection continued until saturation was achieved. All interviews were audio recorded, transcribed verbatim and thematically analyzed. RESULTS: A total of 50 pharmacists (26 hospital and 24 community pharmacists) participated in this study. Twenty hospital and eight community pharmacists were interviewed individually, while the remaining participants contributed to three focus groups discussions. Currently, it appears that CVD risk prevention services are rarely provided, and when offered involved provision of discrete elements only such as blood pressure measurement, rather than a consolidated evidence based approach to risk assessment. Participating pharmacists did not appear to have a clear understanding of how to assess CVD risk. Four key themes were identified: pharmacists' perception about their current roles in CVD, proposed future clinical and service roles, impeding factors and enabling factors. Subthemes were mainly related to determinants likely to influence future CVD services. These subthemes included public perception of pharmacists' roles, pharmacist-physician collaboration, legislative restrictions, systemic issues, sociocultural barriers, organizational pharmacy issues, lack of professional motivation, government and organizational support and professional pharmacy support frameworks. These influencing factors need to be addressed at micro, meso and macro systems level in order to facilitate development of new pharmacist delivered cognitive services in Saudi Arabia. CONCLUSIONS: Pharmacists in Saudi Arabia are willing to expand their role and offer pharmacy-based services, but influencing determinants have to be addressed at the individual, professional and health system levels. Further work is needed to clarify and develop practical and appropriate protocols for pharmacist CVD prevention and management services within the Saudi public and health care system. Such work should be guided by implementation science frameworks rather than embarking on conventional research trial pipelines where public benefit of generated evidence is delayed or limited.