A Multifaceted Intervention to Reduce Pediatric Acid-Suppressant Prescriptions for Gastroesophageal Reflux: What Have We Learned?

OBJECTIVE: Acid-suppressant prescriptions for children have increased over past decades, despite guideline recommendations to prescribe prudently. Acid suppressants are often ineffective and may lead to side effects. We aimed to reduce inappropriate acid-suppressant prescriptions for gastroesophageal reflux in a tertiary care setting through active implementation of national guideline recommendations and to evaluate intervention effect. METHODS: Implementation consisted of 2 steps. First, all pediatric clinicians in an academic hospital received information on appropriate acid-suppressant prescribing, a link to an online national guideline application and summary card with important evidence-based recommendations-Wise Choices. Hereafter, clinicians prescribing acid suppressants were contacted to provide feedback on indications and to assess their knowledge of the guideline and Wise Choices. The pharmacy database supplied prescription data before, during, and after this intervention. RESULTS: During the study period prescriptions ranged from 115 to 201/month. Ten months postintervention, a nonsignificant decrease of 4 prescriptions/month was measured (95% confidence interval -49-41). Of the 78 prescribers 76 were successfully contacted: 63% were familiar with the guideline and 45% with Wise Choices. Thirty percent of prescriptions were for gastroesophageal reflux symptoms. CONCLUSION: This multifaceted implementation strategy did not lead to a significant difference in acid-suppressant prescriptions by tertiary care clinicians of whom the majority was familiar with the gastroesophageal reflux disease guideline. Future studies should clarify, which implementation strategies are most effective in reducing inappropriate prescribing of acid suppressants for children. Uniform registration of prescriptions and indications in a national database will enable monitoring of the intervention effect.

Product standardisation as a tool to control prescribing costs - a case study of alginate liquid preparations.

INTRODUCTION: Product standardisation involves promoting the prescribing of pre-selected products within a particular category across a healthcare region and is designed to improve patient safety by promoting continuity of medicine use across the primary/secondary care interface, in addition to cost containment without compromising clinical care (i.e. maintaining safety and efficacy). OBJECTIVES: To examine the impact of product standardisation on the prescribing of compound alginate preparations within primary care in Northern Ireland. METHODS: Data were obtained on alginate prescribing from the Northern Ireland Central Services Agency (Prescription Pricing Branch), covering a period of 43 months. Two standardisation promotion interventions were carried out at months 18 and 33. In addition to conventional statistical analyses, a simple interrupted time series analysis approach, using graphical interpretation, was used to facilitate interpretation of the data. RESULTS: There was a significant increase in the prescribed share of the preferred alginate product in each of the four health boards in Northern Ireland and a decrease in the cost per Defined Daily Dose for alginate liquid preparations overall. Compliance with the standardisation policy was, however, incomplete and was influenced to a marked degree by the activities of the pharmaceutical industry. The overall economic impact of the prescribing changes during the study was small (3.1%). CONCLUSION: The findings suggested that product standardisation significantly influenced the prescribing pattern for compound alginate liquid preparations within primary care across Northern Ireland.

Invitro evaluation of the neutralising capacity of twenty brands of antacids in Lagos, Nigeria.

BACKGROUND: The use of substandard drugs is a great threat to the lives of people in the community. Identification of substandard drugs is important to exclude their use in clinical practice. These drugs may lead to reduced efficacy of pharmacotherapy. Antacid preparations are weakly basic and consist of metal salts, most commonly aluminium hydroxide or magnesium hydroxide. These salts dissociate to neutralise gastric acid and form neutral salts. The ultimate goal of antacid therapy is to reduce the concentration and the total load of acid in gastric juice with a pH of 1.3 to a pH between 3.5 and 5.0. OBJECTIVE: The aim of this work is to carry out an in-vitro test on the acid neutralising capacity (ANC) of commonly available antacid brands in Lagos market. METHOD: The British pharmacopoeia (BP) method of analysis of antacids was adopted. Twenty different brands of antacid suspensions and tablets were analysed. RESULT: Brand SH suspension gave the highest neutralising capacity, 101.65 ml +/- 0.15, while brand SN gave the lowest, 99.75 ml +/- 0.75. All the fourteen antacid suspensions analysed complied with the official specification and therefore passed the analysis. Brand TB tablet gave the highest acid neutralising capacity (ANC), 54.10 ml +/- 0.2 while brand TD 49.50 ml +/- 0.1 gave the lowest. All the six antacid tablet brands analysed passed the assay. The ANC of an antacid is a parameter used to measure the effectiveness of an antacid in relieving ulcer pain. CONCLUSION: The acid-neutralising capacity of the antacid brands analysed were within the BP specification. The acid neutralising capacity of antacids should be determined before administration.

An improved in vitro method for the evaluation of antacids with in vivo relevance.

An improved in vitro method for the evaluation of antacids for use with standard equipment is described. The method is a modification of an older method (RIGO method) and has in vivo relevance. The improved method uses USP dissolution test apparatus 2 with a stirring rate of 125 rpm in combination with a computerized automatic burette. The test solution is 250 ml 0.02 M HCl. A total of 20 min after addition of an antacid to the test solution titration starts at a constant speed of 2.0 ml/min 0.1 M HCl. The proposed acceptance criteria for a waiver for clinical studies are: pH after 4 min not less than 2.5 to ensure a rapid onset of effect, pH after 20 min not exceeding 7.0 to ensure that the pH in the stomach remains within physiological values, buffering capacity between pH 2.5 and 4.5 not less than 8 meq/dose and neutralizing capacity not less than 10 meq/dose to ensure sufficient efficacy within the physiological range. The improved method has been validated with respect to robustness to variations in sample preparation, repeatability and intermediate precision and has been cross-validated versus the RIGO method. The improved method has been found to be rather insensitive to variations in sample pretreatment and at least equivalent to the RIGO method.

Use of a urea breath test to evaluate short-term treatments for cats naturally infected with Helicobacter heilmannii.

OBJECTIVE: To evaluate efficacy of 3 short-term treatments in cats naturally infected with Helicobacter heilmannii. ANIMALS: 29 cats infected with H heilmannii that had positive results for a urea breath test, rapid urease test, and Helicobacter species-specific polymerase chain reaction test. PROCEDURES: Cats anesthetized for routine surgical procedures were randomly allocated to 4 groups: group 1, control cats; group 2, cats treated with azithromycin, tinidazole, ranitidine, and bismuth once daily for 4 days; group 3, cats treated with clarithromycin, metronidazole, ranitidine, and bismuth twice daily for 4 days; and group 4, cats treated with clarithromycin, metronidazole, ranitidine, and bismuth twice daily for 7 days. Efficacy was determined on the basis of results of a urea breath test performed 10 and 42 days after end of treatment. RESULTS: Ten days after treatment, 0 of 4, 4 of 6, 11 of 11, and 8 of 8 cats in groups 1 to 4, respectively, had a negative result for a urea breath test. Forty-two days after treatment, 0 of 4, 3 of 6, 7 of 11, and 4 of 8 cats in groups 1 to 4, respectively, still had a negative result. CONCLUSIONS AND CLINICAL RELEVANCE: Treatments used in this study regularly suppressed breath 13CO2 production. However, although 23 of 25 (92%) cats had negative results for a urea breath test 10 days after treatment, only 14 of 25 (56%) cats still had negative results 42 days after treatment. It is difficult to achieve a definitive long-term cure in cats naturally infected with H heilmannii.

A comparative study of the neutralising capacity of eight brands of antacids.

Eight brands of antacid tablets commonly available in the private market in Kenya were subjected to in-vitro tests for neutralizing capacity. The neutralizing capacity per gram and per tablet of the products was compared. The neutralizing capacity in millilitres of 0.1 M HC1 per gram ranged from 103.10 for Gelusil to 225.13 for Maalox, with others ranging between +/- 18.1% and -12% about the average. The neutralizing capacity per tablet ranged from 64.90 ml for Magnesium trisilicate Co tablets B.P. to 263.15 ml for Maalox, with the others ranging between +/- 24.9% and -33.1% about the average. This shows high variation in the neutralizing capacities of the different brands available especially in relations to the neutralizing capacities per tablet due to the high variation in the tablet weight.

Evaluation of antacid suspensions containing aluminum hydroxide and magnesium hydroxide.

Liquid antacid suspensions containing aluminum hydroxide and magnesium hydroxide were evaluated for composition, antacid properties, and product quality. The equivalent aluminum oxide and magnesium hydroxide content was determined by chelatometric titration, and sodium content was determined by flame photometry. Antacid properties measured were acid-consuming capacity, antacid effectiveness (preliminary antacid test, acid-neutralizing capacity test), and pH-stat titration. Content uniformity, consistency of the antacid properties, and microbiological content were examined for each product. Data are presented for 36 products for which samples from four or more lots were obtained. The ratio of percentage of equivalent aluminum oxide to percentage of magnesium hydroxide ranged from 1:0.6 to 1:3.5; this range allows for selection of the desired balance between the laxative effect of magnesium hydroxide and the constipating effect of aluminum hydroxide. Based on a daily dose of 280 meq of antacid, the sodium content of the products tested ranged from less than 2% to approximately 45% of the 500 mg per day of sodium allowed in a sodium-restricted diet. The concept of bioavailability was related to the amount of the antacid reacting at pH 3, 37 degrees C during the estimated gastric residence time of 15 minutes. Antacid suspensions are available which will react almost completely (neutralizing greater than 90% of the theoretical quantity of acid) during the estimated gastric residence time. Approximately 4% of the samples contained unacceptable numbers of bacteria. An antacid suspension cannot be adequately evaluated by a single test; choice of a product should be based on an evaluation that integrates several characteristics including sodium content, time and volume required to neutralize a given amount of acid, and uniformity of content.

Neutralizing capacity and cost effectiveness of antacids.

The prescribing physician is faced with a wide choice of antacid preparations. To provide a guide, we tested the commonly available antacids, both liquid and tablet, for their acid-neutralizing capacity. We calculated the cost effectiveness of antacids and tabulated the cost of 1 month of therapy. The acid-neutralizing capacity and cost effectiveness of liquid antacids are generally better than tablet antacids. The most effective liquid antacids, which are composed of either aluminum and magnesium hydroxide mixtures or calcium carbonate, vary in buffering capacity from 3 to 4.2 meq/mL of antacid and range in monthly cost of therapy from $35 to $74. In contrast, the five least effective liquid antacids vary in acid-neutralizing capacity from 0.3 to 2.3 meq/mL of antacid and in monthly cost of therapy from $78 to $498. Because the monthly cost of therapy is influenced primarily by the acid-neutralizing capacity of the antacid, a high-potency antacid should be prescribed. The taste and sodium content of the antacids should also be taken into account by the prescribing physician.

[Intragastric titration, a method for clinically testing the effect of antacids]. / Intragastrale Titration. Eine Methode zur klinischen Testung von Antacida

Intragastric titration can be used not only for the quantiative assessment of gastric secretion in healthy subjects and patients with peptic ulcer, but also for differentiating disorders in the regulation of HCI secretion. It is useful foe evaluating the effect of antacids after stimulation of acid secretion with a test meal. The duration of action of an antacid taken about one hour after a meal was much greater than when taken on an empty stomach. Results in 12 healthy subjects indicate that frequent small meals (6 to 8 daily) and antacids between meals greatly reduce gastric acidity. Whether these findings hold true for patients with peptic ulcer remains to be determined.