Real-world evidence of the effects of sodium-glucose co-transporter 2 inhibitors on the dosing of diuretics in patients with heart failure: a retrospective cohort study.

Background: Heart failure (HF) was estimated to impact approximately 64 million individuals worldwide in 2017 and is predicted to rise in the coming years. Therefore, the aim of our study was to evaluate the effects of sodium-glucose transport protein 2 (SGLT2) inhibitors on the dosing of diuretics among individuals diagnosed with HF. Methods: A retrospective cohort study was conducted at Security Forces Hospital in Riyadh, Saudi Arabia, between January 2018 and August 2022. The study included adult patients who were diagnosed with heart failure and received dapagliflozin and/or diuretic. A descriptive analysis was conducted to identify significant differences between both groups by using the chi-square test for categorical variables and the Student's t-test for continuous variables. A logistic regression model was also run to identify the odds of each event. Statistical significance was indicated by p values less than .05. Results: Overall reduction in diuretics was reported in 68 patients in the SGLT2 inhibitors plus diuretic therapy group, while in the diuretic therapy group 25 patients reported overall reduction in diuretics (OR = 4.81, 95% [2.74-8.45]). The reduction of the loop dose level was reported by 58 patients in the SGLT2 inhibitors plus diuretic group and by 25 patients in the diuretic group (OR = 3.48, 95% [1.98-6.11]). The discontinuation of thiazide was reported by 16 patients in the SGLT2 inhibitors plus diuretic therapy group, but by only two patients in the diuretic group (OR = 9.04, 95% [2.03-40.19]). After 6 months, ejection fraction was increased by 2.74 in the SGLT2 inhibitors plus diuretic group (p = .0019) and decreased by 2.56 in the diuretic group (p = .0485), both of which were statistically significant. The mean dose changes were decreased by 14.52 in the SGLT2 inhibitors plus diuretic group (p < .0001), which was statistically significant. Conclusion: Treatment with SGLT2 inhibitors plus diuretic significantly reduced the patients' diuretic requirements. Therefore, our finding supports the theoretical concept of minimizing the level of diuretic upon the initiation of SGLT2 inhibitors.

Factors Associated with Statin Discontinuation Following Metabolic and Bariatric Surgery: A Retrospective Analysis of 2012-2021 Electronic Medical Records Network Data.

BACKGROUND: Bariatric surgery has been shown to improve hyperlipidemia, decreasing the need for statin medications. Although maintaining statin therapy post-surgery for those with a history of atherosclerotic cardiovascular disease (ASCVD) is advised, it is uncertain if discontinuation risks differ between those with and without ASCVD history. AIM: The study aims to analyze the rate and reasons for statin cessation post-bariatric surgery in the US using real-world data. METHODS: Using the TriNetX electronic medical records network from 2012 to 2021, the study involved patients aged 18 or older on statins at the time of bariatric surgery. They were categorized into primary and secondary prevention groups based on prior ASCVD. Statin discontinuation was defined as a 90-day gap post the last statin dosage. The Cox model assessed factors influencing statin cessation. RESULTS: Seven hundred and thirty-three statin users undergoing bariatric surgery were identified, with 564 (77%) in primary prevention. Six months post-surgery, 48% of primary prevention patients and 34.5% of secondary ones stopped statins. Primary prevention patients had a 30% higher likelihood of cessation compared to secondary prevention (hazard ratio, 1.30; 95% CI, 1.06-1.60) as shown by multivariable analysis. CONCLUSIONS: Post-bariatric surgery, primary prevention patients are more likely to discontinue statins than secondary prevention patients.

The Association between Self-Care Activities and Depression in Adult Patients with Type 2 Diabetes in Saudi Arabia: A Cross-Sectional Web-Based Survey Study.

This study examined the level of adherence to self-care behaviors among individuals with type 2 diabetes in Saudi Arabia and its connection with depression and demographic factors. A cross-sectional survey was conducted among diabetes patients using the Patient Health Questionnaire (PHQ-9) to measure depression and the Summary of Diabetes Self-Care Activities (SDSCA) to evaluate diabetes self-care activities. Among the 252 participants who completed the survey, 43.2% were older than 55 and 59% were men. The ordinal regression model showed an association between the PHQ-9 and SDSCA scores with an OR of 0.83 (95% CI: 0.71 to 0.96, p = 0.013). The PHQ-9 score was significantly associated with blood sugar monitoring (OR: 0.90 [95% CI: 0.82 to 0.99, p = 0.003]), exercise (OR: 0.88 [95% CI: 0.79 to 0.98, p = 0.002]), and diet (OR: 0.94 [95% CI: 0.85 to 1.03, p = 0.045]). Of all the diabetes-related factors, only a history of hospitalization and receiving diabetes education were found to be associated with improved self-care behaviors. In conclusion, a negative association was found between PHQ-9 scores and the SDSCA mean score and most daily diabetic self-care behavior components.

A survey of drive-thru pharmacy services: Evaluating the acceptance and perspectives of community pharmacists in Saudi Arabia.

Background: The practice of dispensing drugs in primary healthcare centers has shifted to community pharmacies in Saudi Arabia. These changes increase demand and mandate improving their services; one such is establishing pharmacy drive-thru services. To explore the effects of drive-thru services on the pharmacy profession, this study aimed to measure community pharmacists' acceptance, perception, and satisfaction regarding drive-thru services. Methods: This cross-sectional study design was conducted in Saudi Arabia between January 2023 and May 2023-comparing the perception, acceptance, and satisfaction of pharmacists who work in a community pharmacy that provides a drive-thru service versus no drive-thru service. Community pharmacists were invited to complete an online questionnaire consisting of four sections developed from previous studies with some modifications. Descriptive statistical analysis and an independent t-test were utilized to test the difference between the two groups (providing drive-thru service vs. non) in their responses. Results: This study included 380 community pharmacists, of whom 33 % provided drive-thru services and 67 % did not. Pharmacists' perceptions of drive-thru services differed significantly. Those with drive-thru services perceived lower convenience for delivering drug information and patient counseling, and they were concerned about the potential impact on their health effects (M = 3.15, SD = 1.34) compared to those without (M = 3.58, SD = 1.10), t (3 7 8) = -3.32, p < 0.01). However, they recognized the convenience of serving sick patients, the elderly, disabled individuals, and mothers with children in cars (M = 3.71, SD = 1.17), which was higher than those without (M = 4.04, SD = 1.21), t (3 7 8) = -2.70, p < 0.01). Regarding the current pharmacy layout suitability, pharmacists with drive-thru services found it more suitable (M = 3.13, SD = 1.14) than those without (M = 2.49, SD = 1.14), t (3 7 8) = 5.1, p < 0.01). However, the two groups had no significant difference in overall satisfaction. Conclusion: Pharmacists working in pharmacies offering drive-thru services recognized certain benefits but also expressed concerns about health effects and decreased convenience for counseling. These findings provide valuable insights for policymakers and pharmacy management, highlighting the nuanced views of pharmacists in adopting drive-thru services.

Prevalence of polypharmacy in heart failure patients: A retrospective cross-sectional study in a tertiary hospital in Saudi Arabia.

Background: Cardiovascular disease is the leading cause of death and disability worldwide. It is a general term used to describe a group of disorders that affect the heart or blood vessels. This study aimed to evaluate the prevalence and predictors of polypharmacy in patients with heart failure. Methods: We conducted a cross-sectional study in a tertiary hospital in Saudi Arabia. Data was extracted from an electronic database between January 2019, and December 2022. The study included all adult patients with heart failure who visited outpatient clinics; individuals with cancer were excluded. The outcome variable in our study was "polypharmacy" which was defined as the use of eight or more medications. Descriptive analysis was performed using frequencies and percentages for categorical variables. In addition, Multivariate logistic regression was used to assess the covariates associated with polypharmacy. Results: A total of 331 patients with heart failure were included in this study. The prevalence of polypharmacy among our HF population was 39.88 %. Most participants were male (60.73 %), and 60 years or older (68 %). The most frequently used medications were beta-blockers (67.98 %) and diuretics (58.31 %), whereas the least frequently used medications were hydralazine and histamine H2 blockers (5.74, and 3.02 %, respectively). Polypharmacy was likely to be a non-significantly higher in individuals aged between 60 and 69 years (adjusted odds ratio (AOR) = 1.52; 95 % confidence interval (CI) 0.78-2.98) and suffering from hypertension (AOR = 1.48; 95 % CI 0.83-2.64). However, patients with heart failure and diabetes mellitus had a significant six-fold higher of polypharmacy than those without diabetes mellitus (AOR = 6.55; 95 % CI 3.71-11.56). Conclusion: Patients with heart failure often use multiple medications. Patients with heart failure together with diabetes have a higher risk of polypharmacy. Therefore, healthcare professionals should manage polypharmacy to improve the outcomes in patients with heart failure.

Effectiveness and safety of edoxaban versus warfarin in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis of observational studies.

Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia type. Patients with AF are often administered anticoagulants to reduce the risk of ischemic stroke due to an irregular heartbeat. We evaluated the efficacy and safety of edoxaban versus warfarin in patients with nonvalvular AF by conducting an updated meta-analysis of real-world studies. Methods: In this comprehensive meta-analysis, we searched two databases, PubMed and EMBASE, and included retrospective cohort observational studies that compared edoxaban with warfarin in patients with nonvalvular AF from 1 January 2009, to 30 September 2023. The effectiveness and safety outcomes were ischemic stroke and major bleeding, respectively. In the final analysis, six retrospective observational studies involving 87,236 patients treated with warfarin and 40,933 patients treated with edoxaban were included. To analyze the data, we used a random-effects model to calculate the hazard ratio (HR). Results: Patients treated with edoxaban had a significantly lower risk of ischemic stroke [hazard ratio (HR) = 0.66; 95% confidence interval (CI) = 0.61-0.70; p < 0.0001] and major bleeding (HR = 0.58; 95% CI = 0.49-0.69; p < 0.0001) than those treated with warfarin. The sensitivity analysis results for ischemic stroke and major bleeding were as follows: HR = 0.66; 95% CI = 0.61-0.70; p < 0.0001 and HR = 0.58; 95% CI = 0.49-0.69; p < 0.0001, respectively. Conclusion: Our findings revealed that edoxaban performed better than warfarin against major bleeding and ischemic stroke.

Knowledge, Attitude, and Perception of Health Care Providers Providing Medication Therapy Management (MTM) Services to Older Adults in Saudi Arabia.

INTRODUCTION: Medication Therapy Management (MTM) is identified as a group of services provided to the patient in order to optimize the medication use in order to mitigate adverse drug reactions (ADRs), drug-drug interaction (DDI), and polypharmacy. Elderly populations above 60 years old are at high risk for Medication-related Problems (MRPs) due to several factors. Therefore, MTM programs showed good contributions globally regarding enhancing medication use in the elderly population. Thus, evident information regarding its implementation in Saudi Arabia is lacking in the literature. OBJECTIVE: Our objective is to assess community pharmacists' knowledge, attitude, and barriers to providing MTM services to the older adult population in Saudi Arabia. METHODOLOGY: A cross-sectional study has been conducted among community pharmacists across the Kingdom. It was survey-based research that was designed and conducted through (QuestionPro). The survey was distributed for the community pharmacists from Feb-May 2023 via (QuestionPro). Descriptive analysis was performed using SAS OnDemand to analyze the categorical variables and test it with the outcome of interest. RESULTS: Out of the 528 participants who have viewed our questionnaire, 319 participants have completed the survey in 5 min average time. Most of our participants were male, holding a bachelor's degree, and had an average working load of more than 40 h a week, respectively (84.95%, 92.48%, and 76.18%). In addition, the participants were from different regions of the Kingdom, which enhanced the generalizability of our findings. Moreover, 65.52% have reported a higher level of knowledge, while 34.48% have reported a moderate to low level of knowledge regarding MTM service. Most of those with a higher level of knowledge maintain a positive attitude regarding MTM service, its implementation, and dealing with older adult patients in the community pharmacy. In addition, lacking the time, training, and presence of a private consultation room were the top barriers to provide MTM services in the community pharmacy in Saudi Arabia. CONCLUSION: Educational sessions regarding MTM services among the older adult population are highly recommended for community pharmacists before its implementation.

Extended infusion versus intermittent infusion of Piperacillin/ tazobactam: altering current methods to optimize future outcome

Due to worldwide bacterial resistance, researchers and clinicians were required to optimize existing antimicrobials by influencing the pharmacokinetics and pharmacodynamics (PK/PD) features. Piperacillin/tazobactam (PIP/TZB) is one of the most frequently empirical antibiotics prescribed globally. The aim of the review was to evaluate the use of an extended infusion (EI) versus an intermittent infusion (II) of PIP/TZB in hospital settings in terms of patient safety and efficacy. Several PK/PD studies assessed the use of an extended infusion of PIP/TZB to reach different minimum inhibitory concentration (MIC) levels for many microorganisms including Pseudomonas aeruginosa. One of the main parameters to define the size of the effect of PIP/TZB to various microorganisms is the percentage of time the free drug concentration above MIC (%fT > MIC). Many studies have compared extended infusion (EI) versus intermittent infusion (II) in terms of mortality rate, clinical cure or efficacy, length of stay whether in an intensive care unit (ICU) or hospital, duration of therapy, and cost. The clinical data reviewed in this article include PK/PD studies, prospective trials, systematic reviews, and meta-analysis. The review emphasized the role of an extended infusion in a population with altered pharmacokinetics including patients on continuous renal replacement therapy (CRRT), critically ill patients with augmented renal clearance, and patients with cystic fibrosis. Our review reports a positive trend when using an extended infusion of PIP/TZB which encourages the adoption and implementation of the extended infusion to achieve positive patient outcomes. Nevertheless, more studies are required to attain generalizable and reliable data to determine whether an extended infusion improves patient outcomes. (AU)

Uptake, Safety and Attitudes Towards COVID-19 Vaccination: A Cross-Sectional Study on First and Second Doses Among the General Public.

Objective: To investigate public uptake, attitudes and the safety of the first and second doses of COVID-19 vaccination. Methods: This was a cross-sectional web-based survey study. A self-administered questionnaire was prepared from a literature search and information about COVID-19 available at various resources. The developed questionnaire was validated for readability by experts and refined in light of the feedback received from the experts and the final version was prepared. The reliability of the questionnaire was 0.7 which shows an acceptable level of scale internal consistency. The data analysis was performed using IBM SPSS software (version 25). Results: A total of 513 participants completed the survey, including 311 (60.6%) women and 202 (39.4%) men. The mean age was (31.5±12.8) years. It was found that 493 (96.1%) took the first and second doses of COVID-19 and 376 (73.3%) suffered from side effects, of these 14% (56/376) reported the side effects to the health authorities. The most common side effects were fatigue (51.5%), fever (42.3%), headache (39.5%), and injection site pain (37.6%). Half of the participants (50.5%) had a positive attitude towards COVID-19 preventive measures. Females had higher odds of experiencing side effects than males OR (95% CI); 2.002 (1.312-3.056). Individuals living in urban areas had lower odds of experiencing side effects than those living in rural areas OR (95% CI); 0.364 (0.142-0.933). Conclusion: Vaccine uptake was massive and side effects due to the COVID-19 vaccine were common but minor. The majority of the participants had positive attitudes towards recommended COVID-19 preventive measures. Being female and living in rural areas were associated with experiencing side effects.

Trends in utilization, reimbursement, and price for DOACs and warfarin in the US Medicaid population from 2000 to 2020.

The use of direct oral anticoagulants (DOACs) is widely increasing in the United States (US). Warfarin has been the conventional anticoagulant used in the past few decades, but it has been gradually replaced by DOACs. The objective of the study was to analyze trends in utilization, reimbursement, and price for those anticoagulants in the US Medicaid population. Retrospective data analysis was conducted using the National Summary Files for the Medicaid State Drug Utilization Data. Study drugs included dabigatran, rivaroxaban, apixaban, edoxaban and warfarin. The study assessed secular trends of utilization, reimbursement, and per-prescription price. The data was collected from the first quarter of 2000 through to the second quarter of 2020 restricted for outpatient prescriptions only. During the 21-year study period, a substantial rise in total expenditures on warfarin and DOACs was observed from $144 million in 2000 to $694 million in 2020. Moreover, the utilization of DOACs has increased significantly since the first approval of Xarelto in 2010 from 1079 in 2011 to 1.5 million in 2019. The per-prescription price of DOACs increased from an average of $200 in 2011 to $407 in 2020. Conversely, the total number of prescriptions of Warfarin and branded Coumadin decreased from 2.4 million to 1.4 million and from 3.9 million to less than a million, respectively. The present study demonstrated a change in the trends of US expenditure and utilization for warfarin and DOACs with DOACs representing the majority of market share of both spending per prescription and reimbursement.

Factors Associated with Length of Hospital Stay among COVID-19 Patients in Saudi Arabia: A Retrospective Study during the First Pandemic Wave.

The COVID-19 pandemic severely affected healthcare systems and tested their preparedness. To date, the length of hospital stay (LoHS) and its factors among COVID-19 patients has not been thoroughly studied. Moreover, it is essential to identify the features of these patients. Adult COVID-19 patients in Saudi Arabia with complete electronic medical records and who were hospitalised for >1 day between 1 May 2020 and 30 July 2020 at one of two hospitals were considered for this retrospective cohort study. Descriptive statistics and multivariate generalized linear models were performed using the data. Of the patients, 34% were ≥50 years old and 80.14% were female. More than 70% had mild-to-moderate symptoms; 45% had either diabetes or hypertension. The median LoHS was 7.00 days (IQR: 3−11). Patients who were females, had either critical or severe disease, were on mechanical ventilation, had diabetes, and administered ceftriaxone had significantly longer LoHS (p < 0.05). Patients administered zinc sulphate had significantly shorter LoHS (p = 0.0008). During the first pandemic wave, COVID-19 patients were hospitalised for 7 days. Healthcare professionals should pay more attention to women, patients with diabetes, and those with severe or critical symptoms. Unnecessary use of ceftriaxone should be minimised, and zinc sulphate can be administered.

Utilization, Spending, and Price of Opioid Medications in the US Medicaid Programs Between 1991 and 2019.

Background: The opioid epidemic and drug abuse are critical public health challenges in the United States. The number of deaths from exceeding the recommended opioid dose is increasing. Objective: To describe the recent trends in utilization, spending, and cost of opioid medications in the US Medicaid population between 1991 and 2019. Methods: This retrospective, descriptive study was designed to evaluate the utilization of, spending on, and cost of opioids from 1991 to 2019 in the Medicaid population. We extracted data from the Centers for Medicare & Medicaid Services national Medicaid pharmacy files. The opioids received included fentanyl, meperidine, morphine, hydromorphone, oxymorphone, hydrocodone, hydrocodone plus acetaminophen, oxycodone, oxycodone plus acetaminophen, tapentadol, and tramadol. The number of prescriptions and reimbursement spending were calculated for each medication per quarter year. The average per-prescription reimbursement as a proxy of drug price was calculated as the reimbursement amount divided by the number of prescriptions per quarter year. The market shares by spending and utilization were also calculated for each opioid medication. Results: The number of all opioid prescriptions in Medicaid increased from approximately 2.1 million in 1991 to approximately 41.6 million in 2015, and then reduced to approximately 19.1 million in 2019. During this 29-year study period, the opioid medications that were used as monotherapy were hydrocodone (246.8 million prescriptions), oxycodone (111.9 million prescriptions), and tramadol (75.2 million prescriptions). The total spending in the Medicaid population on opioids was $19.4 billion, including approximately $7.3 billion spending on oxycodone, approximately $3.7 billion on fentanyl, and approximately $3.3 billion on hydrocodone. The majority of opioid prices increased over time, and the highest average costs per opioid prescription in 2019 were $1188 for oxymorphone, $641 for tapentadol, and $198 for fentanyl. Conclusions: The utilization of and spending on opioid medications in Medicaid increased over time, peaked in 2015, and then declined with the initiation of nationwide programs to combat the opioid epidemic. Effective cost-containment strategies and programs to combat the abuse of opioids are warranted in Medicaid programs.

Healthcare services expenditures among prostate cancer patients with and without mood disorders in the United States: A propensity score-matched cross-sectional study.

OBJECTIVES: To compare the averages of healthcare services utilization and of expenditures for men with prostate cancer with and without diagnoses of mood disorders applying propensity score matching (PSM), and to identify the potential predictors associated with increased healthcare expenditures. DESIGN: Cross-sectional study. SAMPLE AND METHODS: A total of 308,602 weighted patients with prostate cancer were identified after applying PSM. The datasets for men with prostate cancer were extracted from the Medical Expenditure Panel Survey (MEPS) from 2010 to 2015. For cohort formation, 1:1 PSM was applied. Healthcare utilization and expenditures analyzed included emergency room visits, length of stay for hospital inpatients, outpatient visits, office-based visits, and prescriptions. Generalized linear model with gamma distribution and log link was used to determine which covariates are associated with the increase in healthcare expenditures for each healthcare service. FINDINGS: The mean expenditures for emergency room visits between men with prostate cancer and mood disorders was $3,092.34, and it was $1,330.64 for patients without mood disorders (p = 0.038). The weighted total expenditures for emergency room visits in prostate cancer patients with mood disorders is 57% higher (p = 0.0109). Moreover, the weighted total expenditures for outpatient visits in prostate cancer patients with mood disorders is 93% higher (p = 0.0001). The potential predictor in total healthcare expenditures is perceived health status (fair/poor) (p = 0.0066). CONCLUSIONS AND IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS OR POLICY: Individuals with a diagnosis of mood disorders were found to have higher average healthcare expenditures in emergency room visits than those without mood disorders. Therefore, the implications of this study are to inform the patient care team that the assessment and management of mood disorders is a priority. Moreover, screening of mood- disorder symptoms should occur early to optimize care. Finally, policymakers should provide accessible care to minimize emergency room visits.