Pharmacist-led antimicrobial stewardship programme in a small hospital without infectious diseases physicians.

Pharmacists may be tasked to lead antibiotic stewardship programmes (ASP) implementation in small hospitals in absence of infectious diseases (ID) physicians. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a hospital without ID physician support, with special focus on indicators of the hospital use of antimicrobial agents based on consumption and asess the potential clinical and economic impact of pharmacist interventions (PIs) through the CLEO tool. A prospective quasi-experimental study to implement an ASP in a 194-bed hospital. We evaluated changes in antimicrobial use measured as mean defined daily doses per 1000 patient-days (AUD) for intervention versus preintervention period. A total of 847 antimicrobial PIs were proposed, being 88.3% accepted. Discontinuation due to excessive duration was the most frequently performed PI (23.4%). Most of PIs was classified as major or moderate clinical impact, 41.7% and 37.8% respectively. The global consumption of antimicrobial was reduced from 907.1 to 693.8 AUD, with a signifcant drop in carbapenems and quinolones. Direct expenditure of antibiotics decreased significantly. Pharmacist-led ASP has being effective in reducing consumption of antibiotics. In the absence of ID physician´s support and oversight, pharmacists could lead the improvement of the use of antimicrobials.

Pharmacist-driven antimicrobial stewardship program in a long-term care facility by assessment of appropriateness.

Antimicrobials are the most frequently prescribed drugs in long-term care facilities (LTCF). Antibiotic stewardship programs (ASP) are coordinated interventions promoting the responsible use of antibiotics to improve patient outcomes and reduce antibiotic resistant bacterias. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a LTCF, to characterise antibiotic therapy and assess the appropriateness of antibiotic prescriptions. A prospective quasi-experimental study to implement an ASP in a LTCF. Antibiotic prescriptions for suspected infections initiated in any setting for LTCF residents were included. We assessed appropriateness and prospective audits and feedback of each inappropriate antimicrobial prescription were carried out. Associations of variables with appropriate antibiotic prescribing were estimated using logistic regression. A total of 416 antibiotic prescriptions were included. The mean consumption of antibiotics was reduced from 63.2 defined daily doses per 1000 residents-days (DRD) in the preintervention period to 22.8 in the intervention period (- 63.8%), with a signifcant drop in fluoroquinolones (81.4%). Overall, 46.6% of antibiotic prescriptions were judged inappropriate, mainly because of a use not recommended in treatment guidelines (63.2%). Multivariable analysis showed that empirical therapy, some classes of antibiotics (cephalosporins, fluoroquinolones, fosfomycin calcium, macrolides) and prescription initiation in the emergency department were independent predictors of antimicrobial inappropriateness. Pharmacist-led ASP in a LTCF has being effective in reducing consumption of antibiotics by improving appropriateness of treatment decisions. However, ASP should include interventions in the emergency department because of the high inappropriate use in this setting.

Influence of the FCGR2A rs1801274 and FCGR3A rs396991 Polymorphisms on Response to Abatacept in Patients with Rheumatoid Arthritis.

Abatacept (ABA) is an immunosuppressant indicated for treatment of rheumatoid arthritis (RA). Effectiveness might be influenced by clinical RA variants and single-nucleotide polymorphisms (SNPs) in genes encoding protein FCGR2A (His131Arg) and FCGR3A (Phe158Val) involved in pharmacokinetics of ABA. An observational cohort study was conducted in 120 RA Caucasian patients treated with ABA for 6 and 12 months. Patients with the FCGR2A rs1801274-AA genotype (FCGR2A-p.131His) showed a better EULAR response (OR = 2.43; 95% CI = 1.01-5.92) at 12 months and low disease activity (LDA) at 6 months (OR = 3.16; 95% CI = 1.19-8.66) and 12 months (OR = 6.62; 95% CI = 1.25-46.89) of treatment with ABA. A tendency was observed towards an association between the FCGR3A rs396991-A allele (FCGR3A-p.158Phe) and better therapeutic response to ABA after 12 months of treatment (p = 0.078). Moreover, we found a significant association between the low-affinity FCGR2A/FCGR3A haplotypes variable and LDA after 12 months of ABA treatment (OR = 1.59; 95% CI = 1.01-2.58). The clinical variables associated with better response to ABA were lower age at starting ABA (OR = 1.06; 95% CI = 1.02-1.11) and greater duration of ABA treatment (OR = 1.02; 95% CI = 1.01-1.04), lower duration of previous biological therapies (OR = 0.99; 95% CI = 0.98-0.99), non-administration of concomitant disease-modifying antirheumatic drugs (DMARDs) (OR = 24.53; 95% CI = 3.46-523.80), non-use of concomitant glucocorticoids (OR = 0.12; 95% CI = 0.02-0.47), monotherapy (OR = 19.22; 95% CI = 2.05-343.00), lower initial patient's visual analogue scale (PVAS) value (OR = 0.95; 95% CI = 0.92-0.97), and lower baseline ESR (OR = 0.92; 95% CI = 0.87-0.97). This study showed that high-affinity FCGR2A-p.131His variant, low-affinity FCGR3A-p.158Phe variant, and combined use of FCGR2A/FCGR3A genetic variations could affect ABA effectiveness. Further studies will be required to confirm these results.

Impact of a risk-sharing agreement in rheumatoid arthritis in Spain.

CONTEXT AND OBJECTIVE: Risk-sharing agreements(RSA) allow decision-makers to manage the uncertainty associated with effectiveness and costs of treatments. Our objective was to estimate the economic impact of RSA implementation on treatment of patients diagnosed with rheumatoid arthritis(RA) with certolizumab pegol(CZP) and assess the potential impact of alternative RSA. METHODS: Under original RSA, treatment with CZP was reimbursed when the response was optimal (DAS28 score <3.2) or satisfactory (DAS28 score ≥3.2 and reduction from baseline ≥1.2) at 12 weeks. Alternative RSA would additionally include a 50 % reimbursement for moderate responders(DAS28 score >3.2 and ≤5.1, and reduction from baseline between 0.6 and 1.2). We estimated average savings per patient for hospital's pharmacy service(HPS) at 12 weeks, taking into account the pharmacological cost of CZP. Uncertainty associated with effectiveness of CZP was assessed through 1000 Monte Carlo simulations. RESULTS: After 12 weeks of treatment, 57.8 % (n = 52) and 22.2 %(n = 20) of patients had optimal and satisfactory responses, respectively, and average disease activity improved by 1.77 points. Average savings for HPS amounted to 876.9€ and 706.4€ per patient under original and alternative RSA, respectively. Savings in simulated cohort reached 846.2€ and 681.8€ per patient, respectively, leading to estimated net savings for HPS of 846,209€ and 681,790€, respectively. CONCLUSIONS: RSA implementation on patients with RA treated with CZP has generated savings and improved efficiency within HPS.

Impact of Single-Nucleotide Polymorphisms of CTLA-4, CD80 and CD86 on the Effectiveness of Abatacept in Patients with Rheumatoid Arthritis.

Abatacept (ABA) is used as a first-line treatment in patients diagnosed with moderate and severe rheumatoid arthritis (RA). The interindividual response to ABA therapy is very variable in these patients. The objective of our study was therefore to investigate the role of polymorphisms of the CTLA-4, CD80 and CD86 genes, as well as that of clinical factors of the disease, in the response to ABA in patients with RA. A retrospective cohort study was carried out in 109 patients receiving treatment with ABA and diagnosed with RA. The genetic variables were analyzed using real-time PCR with TaqMan® probes. The patients were classified according to the European League Against Rheumatism (EULAR) criteria at 6 and 12 months from start of treatment. The independent variables associated with higher EULAR response were lower duration of previous biologic disease-modifying anti-rheumatic drugs and lower baseline values of the disease activity score 28 after 6 months of ABA treatment; and lower baseline patient's visual analogue scale (PVAS) after 12 months. In addition, a significant association was found between duration of ABA treatment, non-administration of concomitant glucocorticoids and lower baseline values of the number of inflamed joints and erythrocyte sedimentation rate clinical variables, with remission of the disease after 6 months' treatment with ABA. Finally, remission of the disease after 12 months' treatment with ABA was associated with earlier age at start of ABA therapy and lower number of previous biologic therapies (BTs). The CTLA-4rs5742909-T allele and the CTLA-4rs231775-G allele were found to be associated with satisfactory EULAR response and low disease activity (LDA) after 12 months' treatment with ABA (CTLA-4rs5742909 T vs. CC; OR = 5.88; CI95% = 1.48-23.29 and OR = 4.75; CI95% = 1.35-17.94, respectively, and CTLA-4rs231775 G vs. AA, OR = 3.48; CI95% = 1.20-10.09 and OR = 4.68; CI95% = 1.49-17.94, respectively). In conclusion, patients with RA treated with ABA showed better EULAR response and LDA rate when they had the CTLA-4 rs5742909-T or CTLA-4 rs231775-G polymorphisms; furthermore, this remission rate increased in patients that began ABA treatment earlier, those with a lower number of previous BTs and those with a lower PVAS value.

Identification and prioritisation of risks in a hospital pharmacy using healthcare failure mode and effect analysis.

OBJECTIVES: The goals of this project included identifying the processes and subprocesses performed in hospital pharmacies, identifying potential adverse events, detecting failure modes and the causes of errors, prioritising the risks identified and designing a map of risks for hospital pharmacies. METHODS: A task force composed of hospital pharmacy staff was committed to update the diagram of processes and design a map of processes performed in hospital pharmacies. Risks were identified by failure mode and effect analysis annd prioritised according to their risk priority index (RPI) and criticality. A risk map of adverse events was designed based on the diagram of processes and/or primary activities where the prioritised failure modes were most frequent. RESULTS: In total, 99 failure modes associated with 80 adverse events and 129 causes were identified in eight hospital pharmacy areas/subprocesses. The three areas with the highest percentages of failure modes were inpatient pharmaceutical care, pharmacy laboratory and pharmaceutical technology, and medication management. The 25 failure modes (first quartile) with the highest RPI scores (RPI≥20) and the 25 failure modes with the highest frequency and criticality scores were classified as priority. CONCLUSIONS: According to their RPI, priority failure modes mostly occurred in the area of inpatient pharmaceutical care (92%). However, according to their criticality, priority failure modes were found to homogeneously occur across all pharmaceutical care areas. As general recommendations pharmacists should assume responsibility and leadership in the implementation of safe medication use practices in healthcare centres.

FCGR2A/FCGR3A Gene Polymorphisms and Clinical Variables as Predictors of Response to Tocilizumab and Rituximab in Patients With Rheumatoid Arthritis.

We evaluated the influence of clinical, biochemical, and genetic factors on response in 142 patients diagnosed with rheumatoid arthritis, of whom 87 patients were treated with tocilizumab (61.26%) and 55 patients were treated with rituximab (38.7%;) according to the variables European League Against Rheumatism (EULAR) response, remission, low disease activity, and improvement in Disease Activity Score, 28 joints (DAS28) at 6, 12, and 18 months. A retrospective prospective cohort study was conducted. Patients carrying the FCGR3A rs396991-TT genotype treated with tocilizumab showed higher EULAR response (OR, 5.075; 95%CI, 1.20-21.33; P = .027) at 12 months, those who were naive for biological disease-modifying antirheumatic drugs (bDMARDs) at the beginning of treatment showed satisfactory EULAR response, higher remission, and greater improvement in DAS28 at 6 months. Younger age at start of tocilizumab treatment was associated with satisfactory EULAR response at 18 months and greater remission at 6 and 18 months. Subcutaneous tocilizumab administration was associated with higher remission at 6 months and improved low disease activity rate at 12 months. In patients treated with rituximab, carriers of the FCGR2A rs1801274-TT genotype had higher EULAR response at 6 months (OR, 4.861; 95%CI, 1.11-21.12; P = .035), 12 months (OR, 4.667; p = 0.066, 95%CI, 0.90-24.12; P = .066), and 18 months (OR, 2.487; 95%CI, 0.35-17.31; P = .357), higher remission (OR: 10.625; p = 0.044, CI95% : 1.07, 105.47) at 6 months, and greater improvement in DAS28 at 12 months (B = 0.782; 95%CI, -0.15 to 1.71; P = .098) and 18 months (B = 1.414; 95%CI, 0.19-2.63; P = .025). The FCGR3A rs396991-G allele was associated with improved low disease activity rate (OR, 4.904; 95%CI, 0.84-28.48; P = .077) and greater improvement in DAS28 (B = -1.083; 95%CI, -1.98 to -0.18; P = .021) at 18 months. Patients with a lower number of previous biological therapies had higher remission at 12 months. We suggest that the FCGR3A rs396991-TT genotype, higher baseline value of DAS28, subcutaneous tocilizumab administration, younger age at the beginning of treatment, and being bDMARD naive are associated with better response to tocilizumab. In patients treated with rituximab, we found better response in those patients with the FCGR2A rs1801274-TT genotype, the FCGR3A rs396991-G allele, and lower number of previous biological therapies.

[Biosimilars, the journey has begun]. / Biosimilares, el camino ha comenzado.

According to the European Medicine Agency, a "biosimilar" is a biological medicinal product that contains a version of the active substance of an original biological medicinal product (reference or innovative medicinal product) that has been authorized in the European Economic Area. The similarity to the reference medicinal product in terms of quality, biological activity, safety and efficacy needs to be set on a comprehensive comparability basis. The generic standard approach (demonstration of bioequivalence with a reference medicinal product by appropriate bioavailability studies), which is applicable to a wide range of chemically derived medicinal products, is not sufficient to prove the similarity of biotechnology derived products due to their structural complexity. Furthermore, these biopharmaceuticals products, in comparison with the conventional ones, show a greater ability to activate the immune response. The evaluation of biosimilar medicines for authorisation purposes by the European Medicine Agency does not include recommendations on whether a biosimilar should be used interchangeably with its reference medicine. Substitution policies are, therefore, within the remit of the EU member states. In order to support pharmacovigilance monitoring, all appropriate measures should be taken to clearly identify any biological medicinal product with due regard to its brand name and batch number. The situation of the European Community and the regulatory framework have been developed since the first applications (growth hormone), almost a decade ago, until the recent advent (monoclonal antibodies). The introduction to the market of biosimilars have positive effects on competition by improving access to biological therapies.

Según la Agencia Europea del Medicamento, un medicamento biosimilar es aquel obtenido por biotecnología que contiene una versión de la sustancia activa del medicamento biológico original (de referencia o innovador), previamente autorizado en el Espacio Económico Europeo. La similitud entre medicamento de referencia y biosimilar en términos de calidad, actividad biológica, seguridad y eficacia debe ser establecida según criterios de comparabilidad integral. El enfoque estándar para un medicamento genérico (demostración de bioequivalencia por estudios de biodisponibilidad) es aplicable a medicamentos derivados de síntesis química y no es suficiente para productos obtenidos por biotecnología, debido a su mayor complejidad estructural. Además estos productos biofarmacéuticos, en contraste con los convencionales, demuestran una mayor capacidad para activar la respuesta inmunitaria. La intercambiabilidad y sustitución en el acto de la prescripción y dispensación, respectivamente, es un aspecto que se plantea de forma continuada y deberá ser tratado por cada Estado Miembro de la Unión Europea, según comunica la Agencia Europea del Medicamento. Con el fin de apoyar la farmacovigilancia y trazabilidad se deberán tomar medidas oportunas para la identificación, atendiendo al nombre del producto, número de lote y fecha de caducidad. La situación en el entorno de la Comunidad Europea así como el marco regulatorio en términos de autorización y comercialización han evolucionado desde las primeras solicitudes (hormona del crecimiento), hace casi una década, hasta la reciente aparición de medicamentos biosimilares molecularmente complejos (anticuerpos monoclonales). Actualmente, la introducción en el mercado de estos medicamentos favorece la competencia mejorando el acceso a nuevas terapias biológicas.

Bosentan and oral anticoagulants in HIV patients: what we can learn of cases reported so far.

Pulmonary arterial hypertension is an infrequent but nevertheless serious life-threatening severe complication of HIV infection. It can be treated with bosentan and oral anticoagulants. Bosentan could induce the acenocoumarol metabolism and it increases the INR values. Until now, no study of interaction between bosentan and oral anticoagulants in HIV patients has reported. So we present a case of this interaction between these drugs and we reviewed MEDLINE to identify all the papers published so far. In our case, several weeks after increasing dose of bosentan acenocoumarol dose had to be progressively increased to 70 mg/week (+33%) without obtaining an adequate INR level (2.0-3.0). Forty-nine days later, we achieved a therapeutic INR with 90 mg/week of warfarin. The use of bosentan and oral anticoagulants together in these patients require a closer monitoring during first weeks of treatment, after increasing the bosentan dose and even during longer periods of time.