Rational selection of inhalation devices in the treatment of chronic obstructive pulmonary disease by means of the System of Objectified Judgement Analysis (SOJA).

OBJECTIVES: The large number of available medicines and devices makes it almost impossible to have sufficient knowledge of each individual medicine and device, especially for general practitioners. This may lead to suboptimal treatment, more exacerbations, hospitalisations and higher treatment costs. Reducing the number of medicines and devices, based on rational criteria, allows physicians and pharmacists to build experience with a more limited set of medicines and to standardise the inhalation instructions. METHODS: In this study inhalers are compared by means of the System of Objectified Judgement Analysis (SOJA) method. The following selection criteria were applied: uniformity in device, number of steps per inhalation, risk of errors, hygienic aspects, feedback mechanism, and risk of inhalation with an empty inhaler. RESULTS: Substantial differences were seen in the overall scores, with the Ellipta device showing the highest score, followed by Diskus/Accuhaler, Genuair and Nexthaler. Several devices require more or less identical techniques, such Ellipta and Diskus/Accuhaler as well as Genuair and Novolizer. When patients use these devices in combination this increases their uniformity, because additional medicines become available for the devices: starting therapy with Diskus or Novolizer and follow-up with Ellipta or Genuair. The resistance of Respimat and Breezhaler is lower than that of other devices, which makes these devices suitable for patients who cannot generate sufficient inhalation flow. CONCLUSIONS: A substantial reduction of inhalers, combined with optimal and standardised instructions, should improve the care of patients with chronic obstructive pulmonary disease.

The association between antidepressant use and hypoglycaemia in diabetic patients: a nested case-control study.

PURPOSE: Hypoglycaemia is a limiting factor for glycaemic management of diabetes with intensive insulin and/or oral antidiabetic drug (OAD) regimen. Case reports suggest that antidepressants may interfere with blood glucose metabolism in patients with diabetes mellitus potentially increasing the risk of clinically relevant hypoglycaemia. Comorbid depression treated with antidepressants could therefore further complicate glycaemic control. We have carried out a nested case-control study among diabetic patients to assess the risk of hypoglycaemia requiring hospitalisation associated with the use of antidepressants. METHODS: Diabetic patients treated with insulin and/or OADs were selected from the Dutch Pharmo system. Exposure to antidepressants was the primary determinant investigated. Use of antidepressants was further subclassified based on the receptor binding profile to investigate whether specific pharmacological properties could explain a potential influence on glucose homeostasis. Conditional logistic regression was used to estimate odds ratios and to adjust for confounding factors. RESULTS: From the base cohort (40 600 patients), 549 (1.35%) cases were identified and 1897 controls were selected. Current use of any antidepressant was not associated with a significantly higher risk of hypoglycaemia requiring hospitalisation (OR: 1.36 (95%CI: 0.84-2.20)). A trend for a higher risk on hypoglycaemia was identified for antidepressants with high affinity for the serotonin reuptake transporter. The risk on severe hypoglycaemia was increased after 3 years of use (OR: 2.75 (95%CI: 1.31-5.77)). CONCLUSIONS: It is important for diabetic patients using antidepressants for more than 3 years to pay attention for symptoms of hypoglycaemia and strict blood glucose self-monitoring.

Practical differences between luteinizing hormone-releasing hormone agonists in prostate cancer: perspectives across the spectrum of care.

BACKGROUND: Androgen deprivation therapy (ADT) with luteinizing hormone-releasing hormone (LHRH) agonists is well established for the treatment of men with metastatic prostate cancer. As clear differences in efficacy, safety, or tolerability between the available LHRH agonists are lacking, the healthcare management team needs to look to practical differences between the formulations when selecting therapy for their patients. Moreover, as the economic burden of prostate cancer rises alongside earlier diagnosis and improved survival, the possibility for cost savings by using products with specific features is growing in importance. METHODS: A review was conducted to summarize the information on the different LHRH agonist formulations currently available and offer insight into their relative benefits and disadvantages from the perspectives of physicians, a pharmacist, and a nurse. RESULTS: The leuprorelin acetate and goserelin acetate solid implants have the advantage of being ready to use with no requirement for refrigeration, whereas powder and microsphere formulations have to be reconstituted and have specific storage or handling constraints. The single-step administration of solid implants, therefore, has potential to reduce labor time and associated costs. Dosing frequency is another key consideration, as administering the injection provides an opportunity for face-to-face interaction between the patient and healthcare professionals to ensure therapy is optimized and give reassurance to patients. Prostate cancer patients are reported to prefer 3- or 6-monthly dosing, which aligns with the monitoring frequency recommended in European Association of Urology guidelines and has been shown to result in reduced annual costs compared with 1-month formulations. CONCLUSIONS: A number of practical differences exist between the different LHRH agonist preparations available, which may impact on clinical practice. It is important for healthcare providers to be aware and carefully consider these differences when selecting treatments for their prostate cancer patients.

Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis.

Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient.

InforMatrix: ADP antagonists in acute coronary syndromes.

INTRODUCTION: InforMatrix is an interactive matrix model, in which pharmacotherapeutic strategies are supported in a rational manner, by means of a transparent selection methodology. AREAS COVERED: In this paper, InforMatrix is applied to ADP antagonists, including clopidogrel, prasugrel and ticagrelor. These drugs are important additions to the treatment of acute coronary syndromes. The drugs are compared using the following selection criteria: efficacy, safety, tolerability, ease of use, applicability and cost. All direct comparative studies, as well as placebo-controlled or double-blind comparisons with other drugs, were used in the assessment. EXPERT OPINION: By means of the interactive program, users may assign their own individual weight to each criterion and to the properties of the individual drugs, which stimulates concrete discussions on the relative importance of the various aspects of the drugs. When applied to ADP antagonists, the discussion focuses on the documentation of relative efficacy, safety and acquisition cost. The extensive clinical experience with clopidogrel must be balanced against the potential advantages of the other two compounds concerning efficacy. In those countries where generic clopidogrel is available, there are also major differences in acquisition cost between generic clopidogrel and patented prasugrel and ticagrelor. The interactive program provides the opportunity to quantify existing differences in opinion on the (importance of) various properties of the drugs, which greatly facilitates concrete discussions and rational formulary decision making.

ACE inhibitors for the treatment of hypertension drug selection by means of the SOJA method.

ACE inhibitors have proven to be effective blood pressure lowering agents with an excellent tolerability profile. The family of these drugs is still expanding, necessitating the definition of selection criteria in order to choose the "right drug". In this article the ACE inhibitors available in the United Kingdom (UK) are scored by means of the SOJA method. The System of Objectified Judgement Analysis (SOJA) method is a model for rational drug selection. The relevant selection criteria for a certain group of drugs are defined and judged by a panel of experts and each selection criterion is given a relative weight. The more important that a selection criterion is considered, the higher the relative weight that is given to that criterion. The ideal properties for each selection criterion are determined and each drug is scored as a percentage of the score of the ideal drug for all selection criteria. The following selection criteria were used (relative weight): number of formulations (20), number of indications (20), variation in bioavailability (40), interactions (40), trough/peak ratio diastolic blood pressure lowering effect (20), efficacy (250), side-effects (150), dosage frequency (100), documentation (100) and effect on clinical endpoints (260). Ramipril showed the highest score, followed by perindopril, lisinopril and enalapril. The well documented effects on clinically relevant end points, such as cardiovascular morbidity and mortality contributed to the high score for ramipril.

InforMatrix for attention deficit hyperactivity disorder.

The purpose of this review is to facilitate discussion on drug selection for the treatment of ADHD by using only clinically relevant selection criteria and providing an up-to-date overview. The InforMatrix method was used to select drugs to treat attention deficit hyperactivity disorder (ADHD). The following selection criteria were applied: clinical efficacy, safety, tolerability, ease of use, applicability, and cost. The drugs approved for ADHD in the Netherlands were included in the analysis, namely: atomoxetine, immediate-release methylphenidate, and various formulations of slow-release methylphenidate (Concerta, Equasym and Medikinet). Most studies are of limited quality, duration, and size. In one study, Concerta was more effective than atomoxetine. Although no relevant differences were seen in other comparative studies, the clinical experience with atomoxetine is still limited and unexpected toxicity cannot be excluded; few studies have been published with Equasym and Medikinet. No major differences were seen in general tolerability between the drugs. The ease of use of immediate-release methylphenidate is less than for the other drugs. The acquisition cost of immediate-release methylphenidate is considerably lower than that of the slow-release formulations. Atomoxetine is the most expensive drug. The InforMatrix program is available in an interactive format. It enables the user to judge both the importance of the selection criteria and the properties of each therapeutic option per criterion on the basis of his or her own personal expertise and/or the present document.

Triptans in the treatment of migraine: drug selection by means of the SOJA method.

In this paper, drug selection of triptans for the treatment of migraine is performed by means of the SOJA method, which prospectively defines and scores selection criteria. All drugs available in the Netherlands were included in the analysis. The following selection criteria were used (relative weight between brackets): approved indications (40), number of formulations (50), variability of bioavailability (40), drug interactions (85), clinical efficacy (415), side effects (190), acquisition cost (75) and documentation (105). Almotriptan, rizatriptan and sumatriptan show the highest scores, and are the most suitable triptans for formulary inclusion.

InforMatrix nucleoside/nucleotide reverse transcriptase inhibitor 'backbones'.

InforMatrix is an interactive decision matrix technique. This paper describes the use of InforMatrix to determine an order of merit within the various nucleoside and nucleotide reverse transcriptase inhibitors. In the order of merit, six criteria (effectiveness, safety, tolerance, convenience, usability and costs) are weighted against each other. Data necessary for this weighting process are derived from literature as well as personal practical experience. This article gives an overview of the most relevant information from clinical trials, cohort studies and databases concerning backbones consisting of two nucleoside/nucleotide reverse transcriptase inhibitors in the treatment of HIV infections, as well as a description of the interactive decision matrix technique. By using this interactive matrix technique, a rational consideration of the treatment options for backbones consisting of two nucleoside/nucleotide reverse transcriptase inhibitors becomes possible.

Application of SOJA and InforMatrix in practice: interactive web and workshop tools.

System of Objectified Judgement Analysis (SOJA) and InforMatrix are decision-matrix techniques designed to support a rational selection of drugs. Both SOJA and InforMatrix can be considered as strategic tools in the practical implementation of rational pharmacotherapy. In order to apply the matrix techniques to drug selection, strategic navigation through essential information (with the aim of reaching consensus in pharmacotherapy) is required. The consensus has to be reached in an interactive, communicative, collegial manner, within a professional environment. This environment is realised in the form of interactive applications in workshops and on the internet. Such interactive applications are illustrated and discussed in this article.

A prelude to the matrix models supplement.

This paper introduces the concept of matrix models: a new project to ensure that there is clinically effective, safe and economic prescribing of medicines in an integrated manner, in both primary and secondary care, in Northern Ireland.

InforMatrix as an alternative tool in rational and transparent drug-decision making.

InforMatrix is a decision matrix technique by means of which a group of experts on a subject (health condition) determine, on the basis of agreed criteria, an order of merit for the various available treatment options for that condition. The goal of the InforMatrix program is to make a rational selection of first-choice medications or drugs following the evaluation of the clinical value of available therapeutic agents. This paper describes the InforMatrix methodology, and also provides an explanation of the various selection criteria that are used by the InforMatrix technique of drug selection.

System of Objectified Judgement Analysis (SOJA) as a tool in rational and transparent drug-decision making.

Drug selection should be a rational process that embraces the principles of evidence-based medicine. However, many factors may affect the choice of agent. It is against this background that the System of Objectified Judgement Analysis (SOJA) process for rational drug-selection was developed. This article describes how the information on which the SOJA process is based, was researched and processed.

Safe Therapeutic Economic Pharmaceutical Selection (STEPS): development, introduction and use in Northern Ireland.

A number of medicine selection methods have been used worldwide for formulary purposes. In Northern Ireland, integrated medicines management is being developed, and related projects have been carried out. This paper deals with the description of the STEPS (Safe Therapeutic Economic Pharmaceutical Selection) programme. The paper outlines the development of STEPS and its application as an element of a cost-effective medicines-management process in Northern Ireland.

Matrix models and STEPS: concluding remarks.

This paper provides an overview of the use of matrix models within the context of Pharmacotherapy. It also discusses the application of these matrix models to the Safe Therapeutic Economic Pharmaceutical Selection (STEPS) approach used in Northern Ireland.