Strategies for Avoiding Typical Drug-Drug Interactions and Drug-Related Problems in Patients with Vascular Diseases.

Background and objectives: Drug-drug interactions and drug-related problems in patients with vascular diseases are common. To date, very few studies have focused on these important problems. The aim of the present study is to investigate the most common drug-drug interactions and DRPs in patients with vascular diseases. Materials and Methods: The medications of 1322 patients were reviewed manually in the time period from 11/2017 to 11/2018; the medications of 96 patients were entered into a clinical decision support system. Potential drug problems were identified, and a read-through consensus was reached between a clinical pharmacist and a vascular surgeon during the clinical curve visits; possible modifications were implemented. The focus was on additional dose adjustment and drug antagonization on drug interactions. Interactions were classified as contraindicated/high-risk combination (drugs must not be combined), clinically serious (interaction can be potentially life-threatening or have serious, possibly irreversible consequences), or potentially clinically relevant and moderate (interaction can lead to therapeutically relevant consequences). Results: A total of 111 interactions were observed. Of these, 6 contraindicated/high-risk combinations, 81 clinically serious interactions, and 24 potentially clinically relevant and moderate interactions were identified. Furthermore, 114 interventions were recorded and categorized. Discontinued use of the drug (36.0%) and drug dose adjustment (35.1%) were the most common interventions. Mostly, antibiotic therapy was continued unnecessarily (10/96; 10.4%), and the adjustment of the dosage to kidney function was overlooked in 40/96; 41.7% of the cases. In the most common cases, a dose reduction was not considered necessary. Here, unadjusted doses of antibiotics were found in 9/96, 9.3% of the cases. Notes for medical professionals summarized information that did not require direct intervention but rather increased attention on the part of the ward doctor. It was usually necessary to monitor laboratory parameters (49/96, 51.0%) or the patients for side effects (17/96, 17.7%), which were expected with the combinations used. Conclusions: This study could help identify problematic drug groups and develop prevention strategies for drug-related problems in patients with vascular diseases. A multidisciplinary collaboration between the different professional groups (clinical pharmacists and surgeons) might optimize the medication process. Collaborative care could have a positive impact on therapeutic outcomes and make drug therapy safer for patients with vascular diseases.

Improving the Management and Follow-up of Atopic Dermatitis: A Delphi Process Report of Consensus Between Hospital Dermatologists and Pharmacists. / Líneas de mejora asistencial entre dermatólogos y farmacéuticos hospitalarios para el manejo y seguimiento de la dermatitis atópica: consenso Delphi.

Managing atopic dermatitis, one of the most common dermatologic conditions, is often challenging. To establish consensus on recommendations for responding to various situations that arise when treating atopic dermatitis, a group of hospital pharmacists and dermatologists used the Delphi process. A scientific committee developed a Delphi survey with 2 blocks of questions to explore the group's views on 1) evaluating response to treatment in the patient with atopic dermatitis and 2) cooperation between the dermatology department and the hospital pharmacy service. The experts achieved an overall rate of consensus of 86% during the process. Conclusions were that dermatologists and hospital pharmacists must maintain good communication and coordinate their interventions to optimize the management of atopic dermatitis and patients' responses to treatment.

Preference and usage pattern of mobile medical apps for drug information purposes among hospital pharmacists in Sarawak, Malaysia.

INTRODUCTION: Pharmacists are frequent users of mobile medical apps (MMA) for drug information (DI) and clinical decision-making purposes. However, the wide range of available MMA may be of variable credibility and results in heterogeneous recommendations. The need for subscription may also influence choice of apps. OBJECTIVE: The objective of this study was to determine the usage pattern of MMA among hospital pharmacists, including their perceptions and factors affecting their choice of apps. METHODS: This cross-sectional study required respondents to fill in an online questionnaire. The questionnaire included sections on respondents' demographic data, MMA usage pattern, perceived usefulness and opinion on subscription fees. Items were adapted from available literature and validated locally. It was made accessible for 6 weeks starting November 2019 for all pharmacists working in the 23 public hospitals in Sarawak to response (universal sampling). Collected data were analysed using descriptive and inferential statistics. RESULTS: A response rate of 37.2% was achieved (n = 162). Respondents were heavily reliant on MMA, with 78.4% accessing them multiple times daily. The majority also agreed that MMA contain correct and up-to-date information. A median of 5 apps were downloaded, suggesting an ultimate app catering for all DI needs was lacking. The Malaysian Drug Formulary was the most downloaded app (88.3%), whereas Lexicomp® was the most "well-rounded" in terms of functionality. Clinical pharmacists were significantly more likely to purchase MMA, in particular UpToDate® (p < 0.01) due to their need to access clinical updates. Respondents highly recommended institutional access for either UpToDate® or Lexicomp® be made available. Pre-registration pharmacists should be guided on judicious MMA usage, as they downloaded significantly more apps and were more likely to indicate not knowing which DI recommendation to follow (both p < 0.01). CONCLUSION: MMA has become an indispensable tool for hospital pharmacists, however there was a tendency to download multiple apps for DI needs. Institutional access can be considered for credible apps identified to ensure accuracy and uniformity of DI recommendations, with purchase decision made after surveying the needs and preferences of end users.

Implementation of pharmacist targeted discharge prescription review in an emergency department.

BACKGROUND/PURPOSE: Little data has been published regarding emergency medicine pharmacist (EMP) review of discharge prescriptions. An internal retrospective review of a limited sample size of emergency department (ED) discharge prescriptions demonstrated a 13.6% potential intervention rate by EMPs. With this information, it was postulated that EMPs could provide a valuable service via a process of targeted review of ED discharge prescriptions that would yield intervention rates higher than the internal audit. The aim of this project was therefore to develop a real-time notification system within the electronic health record (EHR) for targeted discharge prescription review, to establish an associated EMP workflow, and to evaluate the intervention rate achieved through targeted discharge prescription review. METHODS: This was a single-center, retrospective review of the implementation of a new pharmacist-driven clinical service over a 12 week period from February 19th, 2018 to May 14th, 2018. Criteria for prescription review were determined after an internal audit by the EMPs and included an assessment of established high-alert medications. Discharge prescriptions that met the inclusion criteria were filtered into a real-time work queue in the EHR for EMP review. When necessary, EMPs discussed recommendations with prescribers, or adjusted prescriptions according to institutional pharmacist privileges. Interventions were reviewed and categorized to assess rate of intervention and the types of medication-related problems (MRPs) identified. RESULTS: EMPs reviewed 378 discharge prescriptions and a total of 158 prescriptions were identified as having at least one MRP. Of these, 70 prescriptions were intervened upon thereby resulting in an 18.5% intervention rate. The most common interventions included a change in the dose/frequency, duration/refills of the medication, and patient education. The highest number of interventions were made for anticoagulant and antiinfective agents. CONCLUSION: Utilization of a real-time notification system for prospective ED discharge prescription review is feasible. Using targeted criteria for review, pharmacists intervened on 18.5% of prescriptions reviewed. Prospective discharge prescription review by EMPs using a real-time notification system within the electronic health record identified opportunities for the pharmacist to ensure safe and optimal prescribing.

Impact of Clinical Pharmacists on Initiation of Postintubation Analgesia in the Emergency Department.

BACKGROUND: Pain and anxiety are common in mechanically ventilated patients, and frequently undertreated in the emergency department (ED) setting. OBJECTIVE: We sought to compare the rate of initiation of postintubation analgesia in the ED before and after intervention by pharmacists specialized in emergency medicine. METHODS: This was a retrospective cohort study of patients who underwent rapid sequence intubation (RSI) in the ED. The primary endpoint was overall frequency of analgesia initiation, with subset analysis of RSI during the ED pharmacist (EDP) duty hours. Secondary endpoints included frequency of sedative or anxiolytic use without analgesia, time to initiation of postintubation analgesia, and adverse drug events (ADEs) resulting in analgesia discontinuation. RESULTS: Forty-one patients were included in each group. The overall rate of postintubation analgesia increased after pharmacist intervention, from 20% to 49% (p = 0.005). Analgesia initiation during EDP hours was 50% and 85% in the pre- and postintervention groups, respectively. In the preintervention group, more patients received sedation without analgesia (73% vs. 51%; p = 0.04), and a small percentage (7%) received neither sedation nor analgesia. Time to initiation of postintubation analgesia decreased from 98 min to 45 min. ADEs were rare: there were no discontinuations of analgesic therapy in the preintervention group and one temporary discontinuation because of hypotension in the postintervention group. CONCLUSION: Analgesic use after RSI in the ED significantly increased after the implementation of ED pharmacy services. The large proportion of patients receiving analgesia during the EDP duty hours suggest the increase may be related to direct pharmacist involvement in postintubation management.

Pharmacotherapy of carbamazepine-treated patient after bariatric surgery: a complex interplay between altered absorption and drug-drug interactions.

Changes in absorption and bioavailability of drugs have been described after bariatric surgery, especially shortly after the procedure. When a significant drug-drug interaction also occurs, it is difficult to predict the final combined effect of the surgery and the interaction. In this article, we present a case report of a patient with chronic psychiatric poly-medication including carbamazepine, a strong cytochrome P450 3A4 (CYP3A4) inducer. Significant changes in serum drug concentrations were observed during the 6 months after the surgery, including increased levels of quetiapine and trazodone, that cannot be attributed to the post-surgical alteration of absorption from the gastrointestinal tract. The influence of fluctuating carbamazepine levels on concomitant medication seemed to outweigh the effect of reduced absorption after surgery. This report highlights the need for careful pre-surgical evaluation of the patient's pharmacotherapy and pre- and post-operative therapeutic drug monitoring to prevent destabilisation of chronic conditions.

Appropriateness of antithrombotics in geriatric inpatients with atrial fibrillation: a retrospective, cross-sectional study.

BACKGROUND: Atrial fibrillation occurs in nearly half of geriatric inpatients and is a major cause of morbidity and mortality. Suboptimal anticoagulation use is an important concern in this population. This study aimed to evaluate the appropriateness of antithrombotic therapies in this patient cohort. METHODS: A retrospective analysis was conducted on the geriatric wards of a teaching hospital in Belgium, on a background of clinical pharmacy services. The first 90 atrial fibrillation patients from 2020 to 2022 were included if they received an oral anticoagulant. We assessed utilisation and appropriateness of antithrombotics at discharge, examined reasons for guideline deviations, and explored factors associated with underdosing. Temporal associations for appropriateness and type of anticoagulant (vitamin K antagonist (VKA) vs direct oral anticoagulant (DOAC)) were assessed. RESULTS: The mean age of patients was 86.5 (±5.3) years and the median CHA2DS2-VASc score was 5 (interquartile range (IQR) 4-6). At discharge, 256 (94.8%) patients used a DOAC; nine (3.3%) used a VKA; one (0.4%) a DOAC-antiplatelet combination, and in four patients (1.5%) all antithrombotics were discontinued. The majority (64.4%) of patients received reduced DOAC doses with apixaban prescribed in 40.7%. In 39 (14.4%) patients, antithrombotic use was considered inappropriate, mostly without a rationale (23/39). Year 2022 (odds ratio (OR) 0.104; 95% confidence interval (CI), 0.012-0.878) was the sole determinant for underdosing. No significant differences were found with respect to appropriateness (p=0.533) or anticoagulant class (p=0.479) over time. CONCLUSION: Most geriatric inpatients received a justified reduced DOAC dose. A significant proportion was managed inappropriately with underdosing (= unjustified reduced dose) being most common. Frequently no rationale was provided for deviating from trial-tested doses.

Enhancing pharmaceutical decision support system: evaluating antithrombotic-focused algorithms for addressing drug-related problems.

OBJECTIVES: To evaluate the efficacy of integrating antithrombotic-focused pharmaceutical algorithms (PAs) into a pharmaceutical decision support system (PDSS) for detecting drug-related problems (DRPs) and facilitating pharmaceutical interventions. METHODS: A set of 26 PAs (12.4%) out of a total of 210 were created to model patient situations involving antithrombotics, and their contributions were compared with the entire PDSS system.The observational prospective study was conducted between November 2019 and June 2023 in two health facilities with 1700 beds. Pharmacists, who followed a DRP resolution strategy to support human supervision, analysed alerts generated by these encoded PAs. They registered their interventions and the acceptance by physicians. RESULTS: From 3290 alerts analysed targeting antithrombotics, the pharmacists issued 1170 interventions of which 676 (57.8%) were accepted by physicians. With the 184 other PAs, from 9484 alerts the pharmacists issued 3341 interventions of which 1785 were accepted (53.4%).Results indicate that the detection of DRPs related to antithrombotics usage represents a high proportion of those detected by the PDSS, highlighting the importance of incorporating tailored PA elements at the modelling stage. CONCLUSIONS: The system evolves alongside the physiological changes associated to the patient situations, adapts the alerts and complements the current care. Therefore, we recommend that all PDSS should integrate specific algorithms targeting DRPs associated with antithrombotics to enhance pharmaceutical interventions and improve patient safety.

Clinical pharmacy as a guarantee of safety in times of crisis: evolution and relevance of the continued presence of clinical pharmacists in frontline medical units during the first wave of COVID-19.

BackgroundThe COVID-19 pandemic has had a major impact on the organisation of health services worldwide. In the first wave, many therapeutic options were explored, exposing patients to significant iatrogenic risk. In a context in which patient management was not well defined by clear recommendations and in which healthcare professionals were under great stress, was it still relevant to maintain pharmaceutical care or did it bring an additional factor of disorganisation? OBJECTIVE: The aim of our study was to compare the relevance of pharmaceutical care practices before and during the COVID-19 crisis. METHODS: A retrospective, comparative, observational analysis was conducted in two medical units in a French university hospital that were receiving patients with COVID-19 and benefiting from pharmaceutical care prior to the crisis. This study compared clinical pharmacy performance between two 1.5-month periods before and during the COVID-19 crisis. Performance was assessed according to the CLEO scale, rating the clinical, economic and organisational impacts of the accepted pharmaceutical interventions (PIs) performed in these units. RESULTS: Of the 675 accepted PIs carried out in the two medical units over the entire study period, PIs performed during the COVID-19 period had a greater significant clinical impact (72% vs 56%, p˂0.0001), a more positive economic impact (38% vs 23%, p˂0.0001) and a more favourable organisational impact (52% vs 20%, p˂0.0001) than those performed prior to the COVID-19 period. CONCLUSIONS: The health crisis generated important changes in care practices. Our study demonstrates the sustained relevance of pharmaceutical care during a health crisis. This local experience confirms the major interest in improving the integration of pharmaceutical expertise within French healthcare teams.

Development of hospital clinical pharmacy services in Denmark from 2008 to 2023.

OBJECTIVES: The role of the hospital pharmacist is evolving, and in many countries pharmacists play an increasingly patient-centred role in healthcare. This study aimed to investigate the development of Danish hospital clinical pharmacy services from 2008 to 2023 and compare their current state to the European Association of Hospital Pharmacists (EAHP) statements of clinical pharmacy services. METHODS: Four Danish reports describing the current state of clinical pharmacy in Danish hospitals released in 2008, 2013, 2019 and 2023 were analysed and compared. The reports' data were obtained through questionnaires sent to all hospital pharmacies in Denmark. Data on staff resources and the clinical pharmacy services provided by all hospital pharmacies were extracted, analysed using descriptive statistics and compared with the EAHP statements of hospital clinical pharmacy services. RESULTS: The number of clinical pharmacists increased by 85% from 2008 to 2023, and the number of pharmaconomists (Danish title of a healthcare professional with responsibilities comparable to a pharmacy technician) increased by 59% from 2013 to 2023. In 2023, there were 2.77 pharmaconomists for every pharmacist employed. The pharmaconomist ratio/100 beds increased from 1.93 in 2013 to 3.92 in 2023. The pharmacist ratio/100 beds increased from 0.54 in 2008 to 1.41 in 2023. In 2023, the main patient-level services provided by pharmacists were medication reviews, medication histories and reconciliation, and dispensing and administration. The main pharmaconomist services were dispensing and administration, medication histories and reconciliation, and prescription reviews. The time spent on clinical pharmacy services shifted towards patient-level services over the years. Furthermore, clinical pharmacy services shifted towards greater fulfilment of the EAHP statements. CONCLUSIONS: By providing an overview and comparing Danish clinical pharmacy services to the EAHP statements, we have identified areas for further development, such as the hospital pharmacist being an integral part of all patient care teams, to guide future research and practice.

Deep learning classification of drug-related problems from pharmaceutical interventions issued by hospital clinical pharmacists during medication prescription review: a large-scale descriptive retrospective study in a French university hospital.

OBJECTIVES: Pharmaceutical interventions are proposals made by hospital clinical pharmacists to address sub-optimal uses of medications during prescription review. Pharmaceutical interventions include the identification of drug-related problems, their prevention and resolution. The objective of this study was to exploit a newly developed deep neural network classifier to identify drug-related problems from pharmaceutical interventions and perform a large retrospective descriptive analysis of them in a French university hospital over a 3-year period. METHODS: Data were collected from prescription support software from 2018 to 2020. A classifier running in Python 3.8 and using Keras library was then used to automatically categorise drug-related problems from pharmaceutical interventions according to the coding of the French Society of Clinical Pharmacy. RESULTS: 2 930 656 prescription lines were analysed for a total of 119 689 patients. Among these prescription lines, 153 335 (5.2%) resulted in pharmaceutical interventions (n=48 202 patients; 40.2%). Pharmaceutical interventions were predominantly observed in patients aged 65 years or older (n=26 141 patients out of 53 186; 49.1%) and in patients taking five or more medications (44 702 patients out of 93 419; 47.8%). The most frequently identified types of drug-related problems associated with pharmaceutical interventions were 'Non-conformity to guidelines or contra-indication' (n=88 523; 57.7%), 'Overdosage' (16 975; 11.1%) and 'Improper administration' (13 898; 9.1%). The most frequently encountered drugs were: paracetamol (n=10 585; 6.9%), esomeprazole (6031; 3.9%), hydrochlorothiazide (2951; 1.9%), enoxaparin (2191; 1.4%), tramadol (1879; 1.2%), calcium (2073; 1.3%), perindopril (1950; 1.2%), amlodipine (1716; 1.1%), simvastatin (1560; 1.0%) and insulin (1019; 0.7%). CONCLUSIONS: The deep neural network classifier used met the challenge of automatically classifying drug-related problems from pharmaceutical interventions from a large database without mobilising significant human resources. The use of such a classifier can lead to alerting caregivers about certain risky practices in prescription and administration, and triggering actions to improve patients' therapeutic outcomes.

Complementary and alternative medicine in HIV care: frequency of consumption, risks and interactions with antiretroviral therapy.

OBJECTIVES: People living with HIV (PLWH) are common users of complementary and alternative medicine (CAM). The main objective of this study was to study the frequency and patterns of CAM natural products use in a large cohort of PLWH and to identify potential drug-drug interactions (DDIs) and the impact on their antiretroviral treatment (ART) adherence and efficacy. METHODS: This was a cross-sectional multicenter survey including 420 PLWH from different Spanish hospitals. Participants completed a face-to-face questionnaire on CAM consumption and different sociodemographic and clinical data were collected. DDIs between CAM and ART were identified and classified according to the Liverpool University Database and patient factors related to CAM consumption were assessed. RESULTS: 420 participants were included (82.6% male, mean age 47 years); 209 patients (49.8%) were taking at least one CAM. The most consumed CAM were green, black and red tea (n=146, 25.4%), ginger (n=26, 4.5%), fish oil (n=25, 4.4%) and cannabis (n=24, 4.2%). An ART based on integrase inhibitors was the only factor independently associated with CAM consumption (OR 1.54, 95% CI 1.04 to 2.26). 50 potential CAM-ART interactions in 43 (20.6%) patients taking CAM were identified, being clinically significant in 80% of the cases. CAM products most frequently involved with a potential significant DDI were supplements containing divalent cations (n=11) and garlic (n=7). No differences in ART efficacy and adherence were observed between patients with and without CAM consumption. CONCLUSIONS: Almost 50% of patients were taking at least one CAM product and its use was associated with an integrase inhibitor based ART. One out of every six patients was at risk of presenting with an interaction between a CAM and their ART, confirming the need to review continuously the use of CAM as part of the medication review process.

Medication safety strategies in European adult, paediatric, and neonatal intensive care units: a cross-sectional survey.

OBJECTIVES: Patients in intensive care units (ICUs) are potentially more vulnerable to medication errors than patients admitted to general wards. However, little is known about medication safety strategies used in European ICUs. Our objectives were to explore the strategies being used and being planned within European ICUs, to identify areas of variation, and to inform recommendations to improve medication safety in this patient group. METHODS: We distributed an online survey, in seven European languages, via professional networks and social media. The survey explored a range of medication safety strategies and whether they were in use (and if so, whether fully or partially implemented) or being planned. Demographic information about respondents and their ICUs was also captured. A descriptive analysis was conducted, which included exploring geographical variation. RESULTS: We obtained 587 valid responses from 32 different countries, with 317 (54%) completed by pharmacy staff. Medication safety practices most commonly implemented were patients' allergies being visible for all staff involved in their care (fully implemented in 382 (65%) of respondents' ICUs), standardised emergency medication stored in a fixed place (337, 57%), and use of standardised medication concentrations for commonly used intravenous infusions (330, 56%). Electronic prescribing systems were fully implemented in 310 (53%). A pharmacist was reported to be fully implemented in 181 (31%) of ICUs, of which there was 126 (70%) where there was a pharmacist review of all ordered medication five days per week. Critical care pharmacists were most common in Northern European ICUs (fully implemented to ICUs in 102, 50%) and electronic prescribing in Western Europe (108, 65%). CONCLUSIONS: There is considerable variation in medication safety strategies used within European ICUs, both between and within geographical areas. Our findings may be helpful to ICU staff in identifying strategies that should be considered for implementation.

Exploring susceptibility factors to medication dispensing errors through a retrospective study of patient-reported dispensing errors over 11 years: are dispensing errors indeed due to personal reasons for pharmacists?

BACKGROUND: Medication dispensing errors cause wastage of medicines and increase healthcare costs, with serious consequences for patients. However, few studies have systematically and completely reviewed dispensing errors, with inadequate attention to the objective regularity and risk factors for dispensing errors. OBJECTIVES: To explore the potential causes and risk factors influencing the prevalence of medication dispensing errors. METHODS: We collected patient-reported medication dispensing errors from a large tertiary care hospital in South China over 11 years. We assessed the characteristics of dispensing errors, labelled the causes, compared them with more than 25 million prescriptions from 2012 to 2022, identified the susceptibility factors for the occurrence of dispensing errors, and analysed the characteristics and patterns of the errors. RESULTS: A total of 376 patient-reported dispensing errors were recorded. It took an average of 5.2 days for a patient to find an error. Only 37.5% of errors were reviewed by the patient within 24 hours. These errors directly contributed to a medication loss of US$188 406. Of the 160 recorded pharmacists, 112 (70%) committed dispensing errors. Dispensing errors were affected by the pharmacists' use of the machine, workload and the length of monthly vacation. Of the dispensing errors, 47.9% (n=180) were caused by medication packaging or names that were similar. Antibiotics (n=32, 8.5%) were the most common types of drugs dispensed incorrectly, and traditional Chinese medicines (n=31, 8.2%) and immunosuppressants (n=21, 5.6%) were the most likely to be dispensed in inaccurate quantities. CONCLUSIONS: Organising adequate staff and using machines to prepare medicines may be necessary to reduce dispensing errors. When pharmacists have been away from work for more than 72 hours they should find their rhythm in other positions before dispensing medicines. It is more important to prioritise the differentiation of medicines with similar packaging over those with similar names when arranging drug shelving.

European Association of Hospital Pharmacists (EAHP) guidance on the pharmacy handling of in vivo gene therapy medicinal products.

Gene therapy is becoming increasingly prevalent, with new gene therapy medicinal products (GTMPs) being approved for use every year. Hospital pharmacists are expected to prepare and dispense these products, but there is substantial heterogeneity in the availability of up-to-date, practical guidance at a national level in Europe. Many institutions have no or very limited experience in handling GTMPs. As such, there is a need for updated, practical guidance to aid hospital pharmacy teams in developing institutional standard operating procedures (SOPs) for the safe handling of GTMPs across the entire workflow. Here, we present the European Association of Hospital Pharmacists' updated guidance on the handling of GTMPs, developed by a team of recognised experts from around Europe. Each aspect of the GTMP handling process is addressed, including receipt and storage, dispensing and reconstitution, transportation, administration, waste disposal, decontamination of spills and accidental exposure. A series of figures are provided to aid the development of practical workflows. This guidance document is intended as a framework to help develop institutional SOPs and should always be used in conjunction with local regulations.

Impact of the use of a drug-drug interaction checker on pharmacist interventions involving well-known strong interactors.

OBJECTIVES: Several drug-drug interaction (DDI) checkers such as DDI-Predictor have been developed to detect and grade DDIs. DDI-Predictor gives an estimate of the magnitude of an interaction based on the ratio of areas under the curve. The objective of the present study was to analyse the frequencies of DDIs involving well-known strong interactors such as rifampicin and selective serotonin reuptake inhibitors (SSRIs), as reported by a clinical pharmacy team using DDI-Predictor, and the pharmacist intervention acceptance rate. METHODS: The pharmacist intervention rate and the physician acceptance rate were calculated for DDIs involving rifampicin or the SSRIs fluoxetine, paroxetine, duloxetine and sertraline. The rates were compared with a bilateral χ2 test or Fisher's exact test. RESULTS: Of the 284 DDIs recorded, 38 (13.4%) involved rifampicin and 78 (27.5%) involved SSRIs. The pharmacist intervention rate differed significantly (68.4% for rifampicin vs 48.8% for SSRIs; p=0.045) but the physician acceptance rate did not (84.6% for rifampicin vs 81.6% for SSRIs; p=1). Pharmaceutical interventions for SSRIs were more frequent when the ratio of the area under the drug concentration versus time curve in DDI-Predictor was >2. Pharmacists were more likely to issue a pharmacist intervention for DDIs involving rifampicin because of a high perceived risk of treatment failure and were less likely to issue a pharmacist intervention for DDIs involving an SSRI, except when the suspected interaction was strong. CONCLUSIONS: DDI checkers can help pharmacists to manage DDIs involving strong interactors. DDIs involving strong inhibitors versus a strong inducer differ with regard to their intervention and acceptance rates, notably due to the estimation of the magnitude of the DDI.

Pharmaceutical care in the screening process of phase I oncohaematological clinical trials.

OBJECTIVE: To determine the pharmaceutical interventions in patients eligible for phase I cancer clinical trials, focusing specifically on exclusion criteria related to medication or relevant interactions. METHOD: Descriptive, observational study conducted at a comprehensive cancer centre. Patients undergoing screening for phase I clinical trials (March 2019-December 2022) were included. The pharmacist reviewed concomitant medication and provided a recommendation. RESULTS: The concomitant medication of 512 patients eligible to participate in 84 phase I clinical trials was analysed. In 230 (44.9%) patients, the clinical trial treatment included oral medication. The median number of concomitant medications was 5 (IQR 3-8) per patient.A total of 280 pharmaceutical interventions were performed in 140 (27.3%) patients: 240 (85.7%) were due to interactions in 124 (24.2%) patients, and 40 (14.3%) were due to exclusion criteria in 34 (6.6%) patients. Interactions and exclusion criteria were detected in 18 (3.5%) patients. The main groups of drugs involved were 68 (24.3%) antacids and antiulcer drugs, 28 (10.0%) antidepressants and 26 (9.3%) opioids. Acceptance analysis of the recommendation was applicable in 215 cases; in 208 (96.7%), the pharmaceutical intervention was accepted.Differences were identified for exclusion criteria (7 vs 27) and interactions (37 vs 87) between parenteral and oral clinical trial medication (p<0.001). CONCLUSION: The pharmacist's review of concomitant medication during the screening period in phase I clinical trials enables the detection of prohibited medication or relevant interactions, potentially avoiding screening failures and increasing the efficacy and safety of treatments.

Therapeutic drug monitoring of vancomycin in the case of augmented renal clearance: a case report of a paediatric patient.

Augmented renal clearance (ARC) is a condition in which renal circulation increases, causing drug levels in the blood to remain at subtherapeutic levels in severe trauma patients. Vancomycin, a hydrophilic anti-Gram-positive drug, has been shown in the literature to have its levels fall below the therapeutic range in the case of ARC. However, vancomycin dosing recommendations in the case of ARC are still lacking. Here, we identify an ARC case measured with urinary creatinine clearance in a severe trauma paediatric patient, causing vancomycin blood trough levels to drop. We could not be able to increase the vancomycin trough levels with intermittent dosing; hence, we administered vancomycin with continuous infusion, and this resulted in vancomycin blood trough levels remaining in the therapeutic range. No adverse effect was seen. Continuous infusion of vancomycin can be safely administered to paediatric patients in these cases.

Analysis of the use of antibiotics by AWaRe categories during the COVID-19 pandemic in hospitals across Scotland: a national population-based study.

OBJECTIVE: The Access, Watch and Reserve (AWaRe) list of antibiotics was developed by the WHO to support antibiotic stewardship programmes (ASP). The Access group incorporates first-line options, while Watch antibiotics have higher resistance potential or toxicity, and Reserve drugs should be used only for complex infections. ASP implementation has been challenged during the COVID-19 pandemic. There is a knowledge gap regarding in-hospital prescribing patterns of antibiotics nationally during the COVID-19 pandemic, and on the characteristics of hospitalised patients prescribed antibiotics during this time. We aimed to evaluate quality of antibiotic use according to AWaRe classification in Scottish hospitals, including assessing the impact of COVID-19 on trends. METHODS: Cross-sectional study of antibiotics prescribed to hospitalised patients from 1 January 2019 to 30 June 2022 in a selection of Scottish hospitals, covering approximately 60% (3.6 million people) of the Scottish population. Data were obtained from the Hospital Electronic Prescribing and Medicines Administration system. Prescribing trends were explored over time, by age and by sex. RESULTS: Overall, a total 1 353 003 prescriptions were identified. An increase in Access antibiotics was found from 55.3% (31 901/57 708) to 62.3% (106 449/170 995) over the study period, alongside a decrease in Watch antibiotics from 42.9% (24 772/57 708) to 35.4% (60 632/170 995). Reserve antibiotic use was limited throughout, with minor changes over time. Changes in prescribing were most pronounced in the older age group (>65 years): proportions of Access antibiotics increased from 56.4% (19 353/34 337) to 65.8% (64 387/97 815, p<0.05), while Watch antibiotics decreased from 41.9% (14 376/34 337) to 32.3% (31 568/97 815, p<0.05) between Q1 2019 and Q2 2022. Differences between males and females were insignificant. CONCLUSIONS: Findings showed encouraging trends in Access and Watch use among hospitalised patients, in line with Scottish national standards. There was no noteworthy effect of COVID-19 on prescribing trends despite reports indicating stewardship programmes being negatively impacted by the pandemic.

Losartan potassium liquid formulation for paediatric hospital use: development and stability evaluation.

OBJECTIVES: This study aimed to develop a liquid oral formulation containing losartan potassium, an angiotensin II receptor antagonist drug used for its antihypertensive activity, and to perform a preliminary stability assessment under different temperatures and packages to ensure paediatric therapeutic adherence and facilitate the hospital routine. METHODS: A syrup containing losartan potassium (1.0 and 2.5 mg/mL) (excipients: potassium sorbate, sucrose (85%), water, citric acid and raspberry flavouring) was prepared. The packaging was carried out in amber polyethylene terephthalate (PET) and amber glass bottles (in triplicate) under the following conditions: (a) room temperature (15-30°C); (b) refrigeration (2-8°C); and (c) oven temperature (40°C) for 28 days. An analytical method by high performance liquid chromatography using a reverse-phase column was also developed and validated for quantitative determination of the drug in the formulations. RESULTS: The analytical method showed satisfactory linearity, detection and quantification limits, precision, accuracy and robustness. Samples at room temperature maintained content values between 90% and 110% for 7 days, while those stored under refrigeration maintained a homogeneous appearance and content between 90% and 110% for a period of 21 days. Values of pH stayed in a narrow range. Viscosity results were between 40.1 and 49.2 centipoise (cp) for glass bottles and 42.4 and 54.7 cp for PET bottles. CONCLUSIONS: A simple and economical losartan potassium liquid formulation was produced and was shown to be stable under refrigeration for 21 days in both PET and glass packages.