Estudio de utilización de nirmatrelvir/ritonavir en tres centros de atención primaria durante 2022 / Drug use evaluation of nirmatrelvir/ritonavir in three primary care centres during 2022

Introducción: Nirmatrelvir/ritonavir (Paxlovid®) es el único tratamiento oral autorizado en Europa para tratar la enfermedad por COVID-19 en adultos que no requieren aporte de oxígeno suplementario y que tienen un riesgo alto de progresar a COVID-19 grave. Está disponible en España previa validación debido al perfil de interacciones y advertencias de uso. El objetivo es determinar efectividad, seguridad y manejo de interacciones. Método: Estudio retrospectivo de todos los pacientes con tratamiento validado de nirmatrelvir/ritonavir en tres centros de salud urbanos durante 2022. La efectividad fue la proporción de participantes sin hospitalización relacionada con COVID-19 o muerte por cualquier causa hasta el día 28. Resultados: Se analizaron 24 pacientes. Se consideró efectivo en 23 (95,8 %). Más del 80 % de pacientes presentaban interacción potencial con la medicación concomitante, recomendándose la suspensión temporal de medicamentos destacando simvastatina y metamizol. Conclusiones: Nirmatrelvir/ritonavir se ha considerado efectivo pero con difícil manejo en pacientes pluripatológicos polimedicados. (AU)

Introduction: Nirmatrelvir/ritonavir (Paxlovid®) is the only oral treatment authorized in Europe to treat COVID-19 disease in adults who do not require supplemental oxygen and who are at high risk for progression to severe COVID-19. It is available in Spain after validation due to the profile of interactions and warnings for use. The objective is to determine effectiveness, safety and management of interactions. Method: Retrospective study of all patients on validated nirmatrelvir/ritonavir treatment at three urban health cen-tres during 2022. Effectiveness was the proportion of participants without COVID-19-related hospitalization or death from any cause through day 28. Results: 24 patients were analyzed. It was considered effective in 23 (95.8 %). More than 80 % of patients presented potential interaction with the concomitant medication, recommending the temporary suspension of medications, highlighting simvastatin and metamizole. Conclusions: Nirmatrelvir/ritonavir has been considered effective but difficult to manage in polymedicated poly-pathological patients. (AU)

Impacto de la pandemia COVID-19 en la prescripción de fármacos en Atención Primaria / Impact of the COVID-19 pandemic on the prescription of drugs in Primary Care

Objetivo: la pandemia por SARS-CoV-2 ha estresado el sistema sanitario y ha producido cambios en la organización de los centros de salud para atender a los pacientes con COVID-19. Como consecuencia, en la Atención Primaria se ha observado una disminución significativa en el seguimiento, control de los pacientes y en el diagnóstico de enfermedades crónicas. Este estudio tiene por objetivo analizar retrospectivamente el impacto de la pandemia de COVID-19 en los tratamientos farmacológicos en tres centros de salud de Atención Primaria urbanos.Métodos: se analizaron las prescripciones farmacológicas realizadas por médicos de familia entre 2017 y 2020. Se registró el número total de tratamientos y los inicios de tratamiento para diferentes grupos farmacológicos. Calculamos las tasas de incidencia anuales de los pacientes tratados y se comparó la ratio de incidencia de 2020 con la media de las ratios del período 2017-2019.Resultados: los grupos farmacológicos con mayor reducción en el porcentaje de pacientes tratados en 2020 en comparación con la media de 2017-2019 fueron los antibióticos (-8,5%), los antinflamatorios no esteroideos (-5,9%) y los antiulcerosos (-2,8%). Se observó una reducción significativa en las tasas de incidencia de 2020 en comparación con la media de 2017-2019 para todos los grupos farmacológicos analizados, excepto para los anticoagulantes orales y los antipsicóticos.Conclusiones: se ha observado una reducción en el consumo global de los fármacos. Se ha producido una disminución significativa en los inicios de tratamiento para la mayoría de grupos farmacológicos analizados.(AU)

Aim: the SARS-CoV-2 pandemic has stressed the health system and led to changes in the organization of health centres to treat COVID-19 patients. As a consequence, in primary care a significant decline has been observed in the follow-up, monitoring of patients and diagnosis of chronic diseases. This study aimed to retrospectively analyse the impact of the COVID-19 pandemic on drug treatments in three urban primary healthcare centres.Methods: we analysed the pharmacological prescriptions issued by general practitioners between 2017 and 2020. We counted total number of treatments and new treatments for different pharmacological groups. We calculated the annual incidence rate of treated patients and compared incidence rate ratios in 2020 with the mean rate in 2017-2019.Results: the pharmacological groups with the greatest reduction in the percentage of patients treated in 2020 compared to the mean of 2017-2019 were antibiotics (-8.5%), non-steroidal anti-inflammatory drugs (-5.9%) and anti-ulcer drugs (-2.8%). There was a significant decrease in incidence rates in 2020 compared to the mean of the 2017-2019 period for all pharmacological groups analysed, except for oral anticoagulants and antipsychotics.Conclusion: a decreased overall consumption of drugs was observed. There has been a significant decline in new patients commencing treatments in most pharmacological groups analysed.(AU)

Appropriateness of drug prescriptions in patients with chronic kidney disease in primary care: a double-center retrospective study.

BACKGROUND: Chronic kidney disease (CKD) is a highly prevalent disease worldwide. A basic pillar for the management of a patient with CKD is the safe use of drugs. Inadequate dosing of medication or contraindicated drugs in renal impairment can lead to negative outcomes. The primary objective was to analyse the drug prescriptions of patients with CKD from two primary care centres to see if they were optimally adapted to the patient's estimated glomerular filtration rate (eGFR). METHODS: A retrospective observational study was conducted in two urban primary care centres. The study period was between September-October 2019. Patients over 18 years of age, with established CKD and with an eGFR less than 60 mL/min/1.73m2 for at least three months were included. Their demographic data (age and sex) and clinical variables such as associated comorbidities, eGFR value were retrospectively registered. Finally, their medication plans were reviewed in order to detect: inappropriate prescribing (IP), defined as an incorrect dose/frequency or contraindicated drug according to the renal function of the patient; nephrotoxic drugs and drugs with a high sodium content. RESULTS: A total of 273 patients were included. The most common patient profile was an elderly woman, polymedicated, with other concomitant diseases and with mild CKD. Two hundred and one IPs were detected, 13.9% of which were contraindicated drugs. Of all patients, 49.1% had been prescribed at least one IP on their medication plan, 93.8% had some potentially nephrotoxic drug and 8.4% had drugs with a high sodium content prescribed. CONCLUSIONS: Patients with CKD are at increased risk of medication-related problems. It is necessary to implement measures to improve the safety in the prescription of drugs in patients with CKD.

Pharmacy and therapeutics committees strategy to address olmesartan safety issues at a primary care level.

Background Olmesartan, an antihypertensive drug, has been associated with a severe and potentially life-threatening sprue-like enteropathy, consisting of a serious, chronic diarrhoea and malabsorption syndrome. Treatment with this drug should be discontinued if patients develop such symptoms. Objective To retrospectively determine the reduction in olmesartan prescription following a strategy promoted by pharmacy and therapeutics committees within daily clinical practice to manage updated safety information on olmesartan. Setting Three primary healthcare centres. Method In May 2016, local pharmacy and therapeutics committees integrated by general practitioners, nursing staff and clinical pharmacists sent information about olmesartan safety issues to general practitioners, together with an individual list of their patients who were then being treated with olmesartan. Moreover, information about dose equivalents between angiotensin II receptor blockers and angiotensin II receptor blockers versus angiotensin-converting-enzyme inhibitors was also attached. The strategy aimed to promote individual benefit/risk assessment by general practitioners of the continuation of olmesartan treatment as a means to achieving a decrease in the risk of sprue-like enteropathy. The investigation team retrospectively reviewed the clinical records. Main outcome measure Reduction of olmesartan prescription. Results Olmesartan was discontinued in 44.4% of patients (197/444) in the year after the safety alert e-mail. In their medical records general practitioners registered that, after informing about olmesartan safety warnings, in four cases (0.9%), patients reported gastrointestinal symptoms. Conclusion A multidisciplinary strategy implemented to promote individual benefit/risk assessment regarding continuation of olmesartan treatment showed an important reduction in olmesartan prescriptions 1 year later.

An Interactive Mobile Phone-Website Platform to Facilitate Real-Time Management of Medication in Chronically ill Patients.

Poor adherence to medication is a prevalent issue that affects 50-60% of chronically ill patients. We present Medplan, a platform for patients/caregivers and healthcare professionals (HCPs) that aims to enhance adherence, increase patient medication knowledge, and facilitate communication between patients and HCPs. The Medplan platform was designed and developed by a multidisciplinary team composed of primary care and hospital physicians, pharmacists, patients, and developers. We questioned 62 patients in order to know their opinion about the different functions the app would incorporate and other possible features that should be taken into consideration. Medplan comprises a website for HCPs and an application (app) that is installed on the patient's phone. The app is available in Spanish, Catalan, and English. The patient's medication plan was introduced by the HCP and interfaced with the app. Each medicine is represented by an icon showing the indication of the treatment, the trade name, active ingredients, dose, and route of administration. Information about special requirements (e.g., need to take medication on an empty stomach), side effects, or lifestyle recommendations can also be provided. Additional functions include a medication reminder alarm system, by which patients can confirm whether or not they have taken the drug. Patients can self-track their adherence, and all data collected are sent automatically to the website for analysis by the HCP. Weekly motivation messages are sent to encourage adherence. A tool enabling interactive communication between patients and HCPs (primary care or hospital care) is also included. The app contains a feature enabling the HCP to verify the suitability of over-the-counter drugs. Medplan has the potential to significantly improve management of medication in chronically ill patients. A pilot study is being conducted to test whether Medplan is useful and effective.

mHealth intervention to improve medication management in chronically ill patients: analysis of the recruitment process.

OBJECTIVES: Mobile phones have been rapidly adopted by the general population and are now a promising technology with considerable potential in health care. However, refusal rates of 24%-75% have been reported in telemedicine studies. We aimed to report the challenges faced when recruiting patients to use Android and iOS smartphone applications aimed at improving medication management and communication between patients and healthcare professionals. METHODS: The patients invited to participate had heart failure and/or hypertension and/or dyslipidemia. After reaching the number of participants required for inclusion, the recruitment process was analyzed, and the study team determined the reasons for refusal. RESULTS: Of the 448 potential participants who were invited to participate, 210 responded. Of these, 37.1% did not use a smartphone, 2.9% owned a mobile phone that was neither iOS nor Android, and 28.6% were smartphone users who refused to participate. In this case, the most common motive was that patients considered their routine healthcare sufficient and had no trouble remembering to take their medicines (81.7%). The final study sample comprised 48 patients. The mean age of the patients enrolled was significantly lower than that of participants who were not included (59.9 ± 10.6 vs. 66.8 ± 11.4 years, respectively; p=0.00). CONCLUSION: We found age to be an important barrier to smartphone use in healthcare. Among smartphone users, good adherence and sufficient routine healthcare were the most common reasons for refusal to participate. Thus, this type of intervention could enhance participation for poor adherers or caregivers. Implementing educational initiatives could play a key role in improving patient perceptions of technology.

Feasibility and Preliminary Outcomes of a Web and Smartphone-Based Medication Self-Management Platform for Chronically Ill Patients.

OBJECTIVE: The aim of this study was to assess the feasibility and preliminary outcomes of a medication self-management platform for chronically ill patients, Medplan. METHODS: We performed a 6-month single-arm prospective pre-post intervention study of patients receiving treatment for hypertension and/or dyslipidemia and/or heart failure and/or human immunodeficiency virus infection. During the pre-intervention phase, participants were followed according to their usual care; during the intervention phase, they used Medplan. We evaluated adherence, health outcomes, healthcare resources and measured the satisfaction of patients and health care professionals. RESULTS: The study population comprised 42 patients. No differences were found in adherence to medication measured by proportion of days covered with medication (PDC). However, when adherence was measured using the SMAQ, the percentage of adherent patients improved during the intervention phase (p < 0.05), and the number of days with missed doses decreased (p < 0.05). Adherence measured using the Medplan app showed poor concordance with PDC. No differences were found in health outcomes or in the use of health care resources during the study period. The mean satisfaction score for Medplan was 7.2 ± 2.7 out of 10 among patients and 7.3 ± 1.7 among health care professionals. In fact, 71.4 % of participants said they would recommend the app to a friend, and 88.1 % wanted to continue using it. CONCLUSION: The Medplan platform proved to be feasible and was well accepted by its users. However, its impact on adherence differed depending on the assessment method. The lack of effect on PDC is mainly because patients were already good adherers at baseline. The study enabled us to validate the platform in real patients using many different mobile devices and to identify potential barriers to scaling up the platform.

[Clinical value of estimated half-life in paracetamol poisoning as a complement to Rumack's nomogram]. / Interés clínico de la semivida de eliminación del paracetamol como complemento al nomograma de Rumack en la valoración de la intoxicación por paracetamol.

BACKGROUND AND OBJECTIVE: Rumack's nomogram is usually used to indicate the treatment with N-acetilcysteine in the paracetamol poisoning, but it has several limitations. Paracetamol half-life elimination (t1/2) is approximately of 2 h with therapeutic doses and it increases to more than 4 h in patients with hepatotoxicity. The aim of this study was to determine the usefulness of estimated paracetamol t1/2 as greater than or inferior to 4 h by using a simple ratio in relation to the development of hepatotoxicity. PATIENTS AND METHOD: 21 patients with paracetamol overdose were admitted to Son Dureta Hospital (Palma de Mallorca) and Clínic Hospital (Barcelona) over 13 months. The estimated t1/2 is calculated using the quotient between 2 plasma paracetamol concentrations separated by 2 or more hours. RESULTS: We found a significant difference (p < 0.005) between the group with hepatotoxicity (n = 3; t1/2 = 8,5 h; range: 3,6 - 8,7 h); and without hepatotoxicity (n = 18; t1/2 = 2,4 h; (range: 1,6 - 4,3 h). We observed an agreement between positive ratio and a t1/2 > 4 h, and negative ratio with t1/2 < 4 h, bearing in mind that the quotient is obtained through mathematical equations. CONCLUSIONS: Rumack's nomogram should be complemented with t1/2 estimation in all cases of paracetamol poisoning, especially with those patients for whom we are not able to determine the time of ingestion at presentation or if there has been a multiple-timepoint ingestion.

Interés clínico de la semivida de eliminación del paracetamol como complemento al nomograma de Rumack en la valoración de la intoxicación por paracetamol / Clinical value of estimated half-life inparacetamol poisoning as a complement to Rumack’s nomogram

FUNDAMENTO Y OBJETIVO: El nomograma de Rumack seutiliza para indicar el tratamiento con el antídoto Nacetilcisteínaen la intoxicación por paracetamol, perotiene varias limitaciones de uso. La semivida de eliminación(t1/2) del paracetamol, que con dosis terapéuticases de unas 2 h, se incrementa hasta más de4 h en caso de hepatotoxicidad. El objetivo de estetrabajo ha sido validar la predicción de hepatotoxicidada partir de la estimación de la t1/2 como superior oinferior a 4 h obtenida mediante un simple cociente.PACIENTES Y MÉTODO: Se ha estudiado a 21 pacientescon sobredosificación de paracetamol que acudierona los Hospitales de Son Dureta de Palma de Mallorcay Clínic de Barcelona durante un período de 13meses. La estimación de la t1/2 se realizó medianteun cociente entre 2 determinaciones consecutivasde paracetamol en plasma, separadas por un intervalode tiempo de 2 h o más.RESULTADOS: Se observó una diferencia significativa(p < 0,005) en la t1/2 entre el grupo con hepatotoxicidad(n = 3; t1/2 mediana de 8,5 h; extremos: 3,6-8,7 h) y el grupo sin hepatotoxicidad (n = 18; t1/2mediana de 2,4 h; extremos: 1,6-4,3 h). Se hallóuna coincidencia entre cociente positivo y t1/2 superiora 4 h, y entre cociente negativo y t1/2 inferior a4 h, teniendo en cuenta que el cociente se obtuvoa través de ecuaciones matemáticas.CONCLUSIONES: Se propone que se complemente elnomograma de Rumack con la estimación de la t1/2en todos los casos de intoxicación por paracetamol enque se planteen dudas respecto a la indicación detratamiento con antídoto, y en aquellos en los que sedesconozca el tiempo transcurrido desde la ingestao cuando ésta haya sido fraccionada

Rumack’s nomogram isusually used to indicate the treatment with N-acetilcysteinein the paracetamol poisoning, but it hasseveral limitations. Paracetamol half-life elimination(t1/2) is approximately of 2 h with therapeutic dosesand it increases to more than 4 h in patients with hepatotoxicity.The aim of this study was to determinethe usefulness of estimated paracetamol t1/2 as greaterthan or inferior to 4 h by using a simple ratio inrelation to the development of hepatotoxicity.PATIENTS AND METHOD: 21 patients with paracetamoloverdose were admitted to Son Dureta Hospital (Palmade Mallorca) and Clínic Hospital (Barcelona)over 13 months. The estimated t1/2 is calculatedusing the quotient between 2 plasma paracetamolconcentrations separated by 2 or more hours.RESULTS: We found a significant difference (p < 0.005)between the group with hepatotoxicity (n = 3; t1/2 =8,5 h; range: 3,6 – 8,7 h); and without hepatotoxicity(n = 18; t1/2 = 2,4 h; (range: 1,6 – 4,3 h). Weobserved an agreement between positive ratio and at1/2 > 4 h, and negative ratio with t1/2 < 4 h, bearingin mind that the quotient is obtained through mathematicalequations.CONCLUSIONS: Rumack’s nomogram should be complementedwith t1/2 estimation in all cases of paracetamolpoisoning, especially with those patientsfor whom we are not able to determine the time ofingestion at presentation or if there has been amultiple-timepoint ingestion (AU)