[Pharmacological intervention in the medication review of institutionalised elderly patients under polypharmacy]. / Intervención farmacéutica en la revisión del tratamiento en pacientes mayores polimedicados institucionalizados.

OBJECTIVE: To describe the Drug-Related Problems (DRP) and their resolution after pharmacological review in institutionalised elderly patients under polypharmacy. DESIGN: Descriptive, retrospective cohort study from January to October of 2022. LOCATION: Twelve nursing homes at the Community of Madrid. PARTICIPANTS: 295 patients aged 65 or older taking at least 5 chronic medications prescribed prior to the treatment review. INTERVENTIONS: Medication reviews carried out by the pharmacist and agreed upon in face-to-face meetings between the primary care doctor, the nursing home doctor and the pharmacist. MAIN MEASUREMENTS: Detected DRP, types and resolution. A age, sex, and number of medications before and after the intervention. Pharmacological subgroups according to anatomical therapeutic chemical classification system (ATC) and active pharmaceutical ingredients involved in the detected DRPs. RESULTS: 1425 DRP were detected, with a mean of 4.85 (SD 3.33) DRPs/patient. The most frequent DRP was reconciliation error (32.52%), followed by pharmaceutical regimen and dosaje. Among the 1425 improvement proposals, 86.73% of them were accepted.Significant statistically differences were observed between the number of medications per patient prior to the pharmacotherapy review (12.29) and after it (10.20), obtaining an average difference of 2.09 (95%CI: 1.98-2.21; P<.001). CONCLUSIONS: It is found that the intervention of multidisciplinary team in which the pharmacist performs a revision of the medication decreased the number of prescribed medications. Therefore, it reduces polymedication and its associated risks.

[Use of leflunomide in a cytomegalovirus infection resistant: a report of a case]. / Uso de leflunomida en infección de citomegalovirus resistente: a propósito de un caso.

BACKGROUND AND OBJECTIVE: cytomegalovirus (CMV) infection is one of the most common complications in transplant patients, which can lead to multiple organ failure. The 80-90% of patients are cured with intravenous treatment standard (ganciclovir), or its oral prodrug (valganciclovir). In case there is no answer, we have alternatively another antiviral, foscarnet. A small number of patients do not respond to this, having a bad prognosis. The aim is to describe the case of a double lung transplant for cystic fibrosis, and recurrent CMV infection in which the use of leflunomide gets lower and even reach undetectable viral load. DESCRIPTION OF CASE: woman, 22 year old, double lung transplant for cystic fibrosis in March 2014. The CMV serology performed was positive in the donor and negative in the recipient. Controls viral load during prophylaxis with valganciclovir were negative in the receiver until the 6th month after transplantation, at which viral load was detected in controls (2 090 IU/ml). The patient was admitted to our hospital to receive intravenous treatment with ganciclovir, after one month with intravenous therapy viral load persisted positive (42 400 IU/ml). One study of resistance showed that was resistant to ganciclovir, so began treatment with intravenous foscarnet. This drug achieved negativizar viral load, so the treatment was discontinued, continuing with fortnightly controls viral load. After two months without treatment, viral load increased to 13 665 IU/ml, why was requested to Pharmacy Service the off-label use of leflunomide, with the intention that use oral therapy, instead of intravenous therapy. The patient was treated with valganciclovir until have the authorization of use of leflunomide, although unanswered, since in March 2015, at the start of leflunomide treatment the patient had a viral load of 17 344 IU/ml. The initial regimen was 100 mg of leflunomide daily for the first five days, followed by 20 mg every 12 hours. After fifteen days of treatment viral load had fallen to 531 IU/ml, becoming undetectable in one month. After four months of treatment the patient remains with undetectable viral load without having any adverse effect associated with it. CONCLUSION: our case is an example where the use of leflunomide in CMV infection resistant to other therapies is an effective and convenient alternative for patients because it keeps undetectable viral load with an oral therapy without having to enter the hospital for intravenous treatment.

Introducción: la infección por citomegalovirus (CMV) es una de las complicaciones más habituales en pacientes trasplantados, que puede desembocar en un fallo multiorgánico. El 80-90% de los pacientes se cura con el tratamiento estándar intravenoso (ganciclovir), o su profármaco oral (valganciclovir). En caso de no responder a ellos existe como alternativa otro antivírico, foscarnet. Un pequeño número de pacientes tampoco responden a este, teniendo un mal pronóstico. Objetivo: describir el caso de una paciente con trasplante bipulmonar por fibrosis quística y recidiva de infección por CMV en la cual el uso de leflunomida consigue disminuir e incluso llegar a niveles indetectables de la carga viral. Descripción del caso: mujer de 22 años, trasplantada bipulmonar por fibrosis quística en marzo del 2014. Las serologías de CMV realizadas fueron positivas en el donante y negativas en el receptor. Los controles de la carga viral durante la profilaxis con valganciclovir fueron negativos en el receptor hasta el sexto mes después del trasplante, momento en el que se detectó carga viral en los controles (2.090 UI/ml). La paciente ingresó en nuestro hospital para recibir tratamiento intravenoso con ganciclovir, persistiendo la carga viral positiva (42.400 UI/ml) al mes del inicio con esta terapia intravenosa. Un estudio de resistencias mostró que era resistente a ganciclovir, y por ello se inició tratamiento con foscarnet intravenoso. Con este fármaco se consiguió negativizar la carga viral, por lo que se suspendió el tratamiento, continuándose con controles quincenales de la carga viral. A los dos meses sin tratamiento se observó un aumento de la carga viral hasta 13.665 UI/ml, motivo por el cual se solicitó al Servicio de Farmacia el uso fuera de ficha técnica de leflunomida, con la intención de que la paciente recibiera terapia oral en lugar de intravenosa. La paciente fue tratada con valganciclovir hasta disponer de la autorización de uso de leflunomida, aunque sin respuesta, ya que en marzo del 2015, al inicio del tratamiento con leflunomida, la paciente presentaba una carga viral de 17.344 UI/ml. La pauta inicial fue de 100 mg de leflunomida al día durante los cinco primeros días, seguida de 20 mg cada 12 horas. A los quince días de tratamiento la carga viral había disminuido hasta 531 UI/ml, volviéndose indetectable antes del mes. Después de cuatro meses de tratamiento, la paciente mantiene la carga viral indetectable sin presentar ningún efecto adverso asociado al mismo. Conclusión: nuestro caso es un ejemplo en el que el uso de leflunomida en infección por CMV resistentes a otras terapias es una alternativa eficaz y conveniente para los pacientes, ya que mantiene indetectable la carga viral con una terapia oral, sin necesidad de ingresar en el hospital para tratamiento intravenoso.