Counselling customers at risk of the triple whammy effect at community pharmacies - A feasibility study.

The combination of diuretics, angiotensin-converting enzyme inhibitors (ACE-i)/angiotensin II receptor blockers (ARBs) and non-steroidal anti-inflammatory drugs (NSAID) involves a risk of acute renal failure known as the triple whammy effect (TWE). NSAID can be provided by prescription or over the counter (OTC) and community pharmacies counsel on this medication every day to contribute to medication safety. The objective of this study is to test the feasibility of an intervention where community pharmacies identify and counsel customers at risk of the TWE. Participating pharmacies were recruited across Denmark and the Faroe Islands. In April to May 2021, all staff at 13 community pharmacies chose 10 workdays to collect data in an electronic tool on their risk assessment, the customers' medication, and counselling about the TWE for customers asking for NSAID. Pharmacy staff were instructed in correct data collection and received learning material and a patient information leaflet on the TWE. These data were analysed descriptively. Staff evaluated the learning material and patient information leaflet in a questionnaire. The quantitative answers from the questionnaire were analysed descriptively and the qualitative answers were analysed using content analysis. According to the pharmacies' risk assessment, 12.1% (n = 215) of customers asking for NSAID were at risk of the TWE. The data on customers' medication showed that only 8.0% (n = 142) were actually at risk of TWE. Of those, 43.0% (n = 61) asked for NSAID on prescription and 57.0% (n = 81) for OTC. In the evaluation of materials pharmacy staff reported overall satisfaction with the learning material, which they reported increased their knowledge of TWE and helped them in their counselling. They also reported satisfaction with the patient information leaflet. Despite pharmacy staff reporting satisfaction with the learning material, it still did not educate staff well enough in assessing the risk of TWE for customers asking for NSAID. More research is needed on TWE interventions in community pharmacies because this study shows that there is a potential for community pharmacies to identify and counsel persons at risk of the TWE.

Recommendations on deprescribing of bisphosphonates in osteoporosis guidelines: a systematic review.

PURPOSE: Advancing age, declining health status, and a shift in benefit/risk balance warrant judicious use of preventive medications in older persons, including consideration of deprescribing. Lack of guidance on deprescribing is a major barrier for prescribers to consider deprescribing in daily practice. The aim of this review was to evaluate to what extent osteoporosis guidelines include bisphosphonate deprescribing recommendations. METHODOLOGY: We conducted a systematic review, searching PubMed, Embase, and grey literature. We included guidelines on treatment of osteoporosis with bisphosphonates. Two independent reviewers screened titles, abstracts, and full texts. Recommendations for deprescribing were extracted, and quality of guidelines were assessed. RESULTS: Among 9345 references, 42 guidelines were included. A total of 32 (76%) guidelines included deprescribing recommendations: 29 (69%) guidelines included non-specific deprescribing recommendations framed as a drug holiday, of which 2 (5%) also included specific deprescribing recommendations based on individual health context (e.g. life expectancy, frailty, function, preferences/goals). Twenty-four (57%) guidelines included practical deprescribing recommendations, and 27 (64%) guidelines included recommendations for when deprescribing should not be considered. CONCLUSION: Bisphosphonate deprescribing recommendations in osteoporosis guidelines were primarily framed as drug holidays, with limited guidance on how to make individualized deprescribing decisions based on individual health context. This suggests a need for additional focus on deprescribing in osteoporosis guidelines.

Use of analgesics in Denmark: A national survey.

People suffering from pain constitute a sizeable and heterogeneous patient group. Conventional oral analgesics are considered a cheap and safe first-line treatment. These drugs are used on both a regular and 'as needed' basis and are often obtained over-the-counter (OTC). We explored patient-reported patterns of use and adverse effects of analgesics in a community pharmacy questionnaire. Eight pharmacies invited persons aged ≥18 years requesting analgesics via prescription or OTC to complete an electronic questionnaire. A total of 2410 participants completed the questionnaire (68% female; 50% ≥ 60 years). Most participants filled a prescription for paracetamol (61%; n = 842) and non-steroidal analgesics (n = 363; 26%). Among OTC users, most obtained paracetamol (61%). Among prescription users, 73% (n = 1114) had their analgesic prescribed for daily use; however, of these only 61% (n = 630) reported using it daily, while 35% (n = 363) reported 'as needed' use. Of all prescriptions, 80% (n = 898) were labelled with the standardized indication 'against pain'. Self-reported indications showed that back pain and muscle/joint pain were the most common indications. Among non-new users of OTC analgesics (n = 841), 17% (n = 141) used their medication daily. Finally, 90% (n = 1658) of all participants reported not experiencing adverse effects. Our findings suggest a need for continuous assessment of analgesic patterns of use after treatment initiation to inform counselling in community pharmacies and elsewhere.

[Deprescribing in Danish clinical treatment guidelines].

Lack of clinical guidance constitutes a significant barrier to deprescribing. Within Danish clinical guidelines on treatment of dementia, type 2 diabetes, hypertension, and osteoporosis, only limited attention was given to deprescribing. For dementia, type 2 diabetes, and osteoporosis, guidance was primarily focused on when to consider and implement deprescribing, with limited practical guidance on how to deprescribe. No guidance for deprescribing antihypertensives was identified. This highlights a need to consider deprescribing more broadly when developing and updating clinical guidelines, as argued in this review.

The Danish Network for Community Pharmacy Practice Research and Development.

The community pharmacy has a number of attributes that makes it an excellent setting for research and development projects, as it is a highly accessible part of the healthcare system and is staffed by highly trained health care professionals. The big turnover in patients in the community pharmacy makes it possible to reach a great number of patients and collect a lot of data in a relatively short time. However, conducting nation-wide research and development projects can be a rather time-consuming process for the individual community pharmacy, and can thus require collaboration with other community pharmacies and researchers. This will help ensure strong results and better implementation. Thus, the Danish Network for Community Pharmacy Practice for Research and Development (NUAP) was established in Denmark by a number of highly committed community pharmacies and researchers. NUAP consists of 102 member pharmacy owners in addition to a number of researchers. The aim of the network is to strengthen pharmacy practice and pharmacy practice research in Denmark by providing a forum where community pharmacy practitioners and researchers meet and work together. The network is led by a steering committee elected by the members in the network.

Multidisciplinary telephone conferences about medication therapy after discharge of older inpatients: a feasibility study.

Background Studies have shown poor post-discharge implementation by the general practitioner of changes made to patients' medication during admission. Objective To assess the feasibility of conducting telephone conferences delivering information about changes in older patients' medications from hospital to general practitioners. Setting Two departments of geriatric medicine in a Danish routine healthcare setting. Method Older polypharmacy patients (≥ 65 years and ≥ 5 prescriptions) consecutively admitted were eligible for inclusion. Telephone conferences based on a review of these patient's medication therapy during hospital stay were arranged between a pharmacist and a geriatrician from the hospital, and a general practitioner. Interviews were conducted with pharmacists, geriatricians, and general practitioners about their perspectives on the feasibility of telephone conferences. Interviews were analyzed using systematic text condensation. Main outcome measure The proportion of telephone conferences conducted and perspectives on the feasibility of the study. Results A total of 113 patients were included and 82 patients (75%) were eligible for telephone conferences. A total of 40 (49%) telephone conferences were conducted. The main reasons for conferences not being conducted were general practitioners not wanting to participate or not returning the calls from the pharmacists. Three themes emerged from the qualitative analysis: considerations on planning and running the project, Barriers, facilitators, and implications of the telephone conference, and Actual and desirable cross-sectorial communication. Conclusion Telephone conferences were only possible for half of the patients. The participating general practitioners, pharmacists and geriatricians expressed varied benefit and agreed that telephone conferences were mainly relevant for complex patients.

Attitudes Towards Deprescribing Among Older Adults with Limited Life Expectancy and Their Relatives: A Systematic Review.

BACKGROUND: Deprescribing is of particular importance in older adults with limited life expectancy since this population group is highly susceptible to the potential harms of inappropriate medications. OBJECTIVE: This systematic review aimed to explore attitudes towards deprescribing among older adults with limited life expectancy and their relatives. METHODS: A systematic literature review was conducted in the MEDLINE and EMBASE databases from inception to October 2019. Inclusion criteria were studies specifically describing attitudes towards deprescribing among older adults (≥ 65 years) with limited life expectancy and/or their relatives regardless of study type. Results were analyzed, inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. RESULTS: A total of 842 studies were identified and screened; 84 were full-text assessed for eligibility and 7 were ultimately included. Two studies investigated the attitudes of older adults with limited life expectancy and their relatives towards deprescribing of statins and donepezil, respectively, while the five remaining studies related to attitudes towards deprescribing in general. Four main themes were identified: (1) the well-being of older adults with limited life expectancy; (2) involvement of older adults and their relatives in deprescribing; (3) the role of health care professionals in deprescribing; and (4) medication-related factors affecting deprescribing. Within each of these themes, several subthemes were identified. CONCLUSIONS: Attitudes towards deprescribing among older adults with limited life expectancy and their relatives vary and highlight several barriers and enablers to the deprescribing process. Several of these factors must be addressed to successfully implement deprescribing initiatives in this patient group.

Pharmaceutical care services available in Danish community pharmacies.

In recent years, increased longevity of the Danish population has resulted in a growing segment with age-related and chronic health conditions. This, together with a general increase in the demand on the services of doctors, has augmented the role of pharmacies in the provision of healthcare services. In Denmark, a variety of pharmacy services has been developed, evaluated and implemented since the introduction of pharmaceutical care. The services are aimed at the person responsible for administering the medicine e.g. the patient themselves or care workers, thereby supporting medication safety. The services available have been developed, evaluated and implemented in collaboration between community pharmacies, the Danish Association of Pharmacies, the Danish College of Pharmacy Practice and international collaborators. In this commentary we present an overview of the available pharmacy service, the contents of each service, remuneration and the scientific evidence behind each service. The commentary covers: Inhaler Technique Assessment Service; New Medicines Service; Medication Review; and Medication Safety in Residential Facilities.

Customers' information seeking behavior prior to community pharmacy visits: A community pharmacy survey.

BACKGROUND: Customers are commonly seeking information, e.g. via the internet, to achieve information on health, diseases, and treatment options. However, little is known about customers' information seeking behavior prior to community pharmacy visits. OBJECTIVE: To quantify and describe customers' information seeking behavior prior to community pharmacy visits, and to describe how pharmacy staff utilize information obtained by customers. METHODS: Six Danish community pharmacies collected data on customers' information seeking behavior through an online survey for five days in a three week-period in November 2018. Customers were asked about their information seeking behavior regarding their errand at the pharmacy that specific day, what kind of information they had sought, which sources they had used, and their motivation for seeking that information. Hereafter, the pharmacy staff recorded whether they confirmed or disconfirmed the information, and whether they used the information in their counselling. The results were reported using descriptive statistics. RESULTS: A total of 3424 customers were invited to participate in the study. Among 2623 customers agreeing to participate, 14.4% (n = 377) had obtained information prior to the pharmacy visit. Information seeking was more frequent among younger customers (<40 years: 22%; 40-60 years: 17%; ≥60 years: 10%). Further, women sought information more often (17%) than men (11%). Customers sought information to gain knowledge about self-management (42%), the purchased product (35%), and how others might help (29%). Information was mainly obtained from official sources of health and drug information (44%), Google (41%), and non-pharmacy health care professionals (28%). The information presented by the customer was generally confirmed or integrated into the pharmacy counselling (70%) and only rarely disconfirmed by pharmacy staff (5%). CONCLUSION: A total of 14.4% of customers had sought information prior to visiting the community pharmacy. The majority of customers had used reliable sources, and the information was used during pharmacy counselling.

Topical Antimycotics for Oral Candidiasis in Warfarin Users.

Treatment for oral candidiasis in warfarin users may be complicated by drug-drug interactions (DDIs) between warfarin and topically applied antimycotics. However, current knowledge of these putative DDIs is merely based on case series. We therefore performed a cohort cross-over study with the objective to evaluate the potential DDIs between warfarin and miconazole oral gel or nystatin oral solution. The cohort consisted of individuals using warfarin in the period of 1998-2012 (n ≈ 7400). We collected data on cohort members' measurements of the international normalized ratio (INR) from a clinical database, and obtained information on their use of topically applied miconazole and nystatin from a regional prescription register. Potential DDIs were assessed by comparing INR values before and after initiation of an antimycotic drug. Among 17 warfarin users exposed to miconazole oral gel, the mean INR increased from 2.5 (95% CI: 2.1-2.8) to 3.8 (95% CI: 2.8-4.8) after exposure, corresponding to a mean INR increase of 1.4 (95% CI: 0.3-2.4). Among 30 warfarin users exposed to nystatin oral solution, the mean INR was 2.7 (95% CI: 2.3-3.1) before and 2.5 (95% CI: 2.2-2.9) after exposure. In conclusion, we found evidence supporting a clinically relevant drug-drug interaction between warfarin and miconazole oral gel. In contrast, we did not find any indication of an interaction between warfarin and nystatin oral solution. Nystatin rather than miconazole should be preferred when treating warfarin users for oral candidiasis.