[Thesaurus of pharmacist interventions associated with inappropriate proton pump inhibitors prescriptions]. / Thésaurus d'interventions pharmaceutiques associées aux prescriptions injustifiées d'inhibiteurs de la pompe à protons.

OBJECTIVES: Proton pump inhibitors (PPI) are the most effective drugs in the treatment of acid-related gastrointestinal disorders. Yet, many studies reported potential adverse drug reactions associated with long-term use. In order to reduce the rates of inappropriate PPI prescriptions and to improve patient safety, a tool aimed at guiding pharmacists to analyze PPI prescriptions was designed. It results in a thesaurus of clinical situations designed to argue about the inappropriateness of some PPI prescriptions and to highlight the risk associated with them. METHODS: Clinical situations in which PPIs are inappropriate were identified by four pharmacists in one gastroenterological, one surgery/liver transplantation, one internal medicine and one oncology units. A scientific literature search was performed for each clinical situation in order to corroborate the pharmacist interventions. RESULTS: The thesaurus comprises two parts, the first one is dedicated to 12 clinical situations in which a PPI is not required (acute pancreatitis, cholecystectomy etc.), while the second one focus on 22 situations in which PPIs are associated with specific adverse drug reactions (Clostridium difficile infection, vitamin deficiency etc.). Eighty-one articles were used to support the pharmacist interventions. CONCLUSION: This thesaurus is an analysis tool aimed at guiding pharmacists identify and argue about the inappropriateness of some PPI prescriptions in order to convince doctors to discontinue or not to initiate PPI prescriptions.

Characteristics of Pharmacists' Interventions Related to Proton-Pump Inhibitors in French Hospitals: An Observational Study.

Methods: The study was based on a retrospective analysis of pharmacist interventions for DRPs detected during the medication order review and documented into the French Act-IP© database over a 12-year period. DRPs and PIs were analyzed, and independent factors of physician acceptance were assessed via multiple logistic regression. Results: Out of the 620,620 PIs registered, 29,694 targeted a PPI (4.8%). PPI's DRPs were mostly related to the prescription of a "drug not available at the hospital" (26.1%) and a "drug use without indication" (18.3%); PIs were mostly "drug switch" (35.9%) and "drug discontinuation" (26.1%). In all, 18,919 PIs were accepted by physicians (63.7%). Acceptance was significantly associated with patient age: less accepted for the 18-75 years group (OR = 0.59, 95 CI [0.46-0.76]), and the >75 years group (OR = 0.57, 95 CI [0.44-0.73]) vs. <18 years group; for the type of DRP, "drug use without indication" was the less accepted (OR = 0.73, 95 CI [0.63-0.85]); for the type of PI, "dose adjustment" was the less accepted (OR = 0.32, 95 CI [0.23-0.45]). Conclusion: Pharmacists contribute to preventing DRPs associated with PPI prescriptions during the medication order review process. Moreover, they often detect PPIs used without indication and they propose drug discontinuation, which contributes to the PPI deprescribing process. PIs should be further developed in the future to reduce PPI overprescription.

[Prospective risk analysis in a retrocession unit: Focus on drug dispensation process]. / Analyse des risques a priori en unité de rétrocession hospitalière : focus sur le processus de dispensation.

OBJECTIVES: Failure mode effect analysis (FMEA) improves safety in the drug life cycle. As the drug dispensation by hospital's pharmacy can be at risk, the FMEA tool has been used to evaluate and enhance the process. METHODS: After detailing the process, a first FMEA has been run in 2015. Corrective actions were implemented every time criticality indexes (CI) were above 15. One year later, we have evaluated potential impacts of these actions by running a new FMEA. RESULTS: In 2015, 11 failure modes were prioritized (CI>15) and the total CI for the overall process was 397. Corrective actions were implemented and one year later this amount has decreased by 14% (340) with 6 failure modes still prioritized. Thus, thanks to the FMEA, risks could be identified in year "y", they were taken into account and corrected and then effectively reassessed in year "y+1". CONCLUSION: This study showed us the interest of performing FMEA analysis in the drug dispensation process by hospital. The renewal of this risk analysis after a year helped us to monitor corrective actions, to evaluate their effectiveness and to improve safety. Finally, FMEA seems to be an effective way to steer the drug dispensation process.

[Pharmaceutical interviews for rheumatoid arthritis patients: Perceptions and expectations of community pharmacists]. / Entretiens pharmaceutiques destinés aux patients atteints de polyarthrite rhumatoïde : perceptions et attentes des pharmaciens d'officine.

INTRODUCTION: Rheumatoid arthritis has a low level of medication adherence. Abroad, the community pharmacist has a positive impact on the patients' adherence in several chronic diseases. In France, community pharmacists' missions are developing with the implementation of pharmaceutical interviews. OBJECTIVE: To evaluate community pharmacists' perceptions on the interest and feasibility of pharmaceutical interviews targeting patients with rheumatoid arthritis. METHOD: Semi-structured interviews were conducted between August and October 2017, with pharmacists in the Auvergne-Rhône-Alpes region. The inductive analysis of the interview verbatim was realized by two independent persons. RESULTS: Fifteen community pharmacists highlighted barriers in recruiting patients for the interviews currently possible at the pharmacy, the complexity of the organization and the financing, a weakness of the hospital-to-community liaison. Nevertheless pharmacists were motivated to expand the service to other pathologies. Regarding rheumatoid arthritis, pharmacists would see them in the form of structured interviews preferentially at the pharmacy, in connection or even "prescribed" by physicians for optimal and multi-professional information sharing. Prior training and funding for these interviews should be considered to motivate pharmacists to this activity. CONCLUSION: This study allowed to discuss with community pharmacists their expectations and needs to widen the service of pharmaceutical interviews in the rheumatoid arthritis. These results will have to be taken into account to build a support interviews model for rheumatoid arthritis patients who can be integrated in their daily pharmaceutical activity.

[Identification of knowledge deficits of pharmacy students at the beginning of the fifth year of pharmacy practice experience: Proposals to change the content of academic programs]. / Identification des lacunes de connaissances des étudiants en filière officine débutant le stage de 5(e) année : propositions pour modifier le contenu de l'enseignement.

INTRODUCTION: In France, community pharmacy students performed a hospital pharmacy practice experience during the 5th year of the university curriculum. The purpose of a part of the content of the academic teaching program delivered before this practice experience is to prepare the students for their future hospital activities. It should enable them for the practical use of knowledge in order to improve pharmacotherapy, laboratory diagnosis and monitoring of patients' care. The aim of this study was to show if there are gaps in this program. METHODS: Fourteen students performing their clerkship in a teaching hospital were invited to highlight these gaps when they were gradually immersed in the pharmaceutical care. They did so under the careful observation of hospital pharmacist preceptors. These practitioners referred to professional guidelines, documentary tools used in daily clinical practice and publications supporting their pharmaceutical care practices. RESULTS: Shortcomings and gaps identified were: how to communicate with other healthcare professionals and the content of verbal exchanges, how to conduct a patient-centered consultation, documentation tools required for relevant pharmacist' interventions, codification of pharmacist's interventions, risks related to drug packaging and benefit risk assessment of health information technologies. DISCUSSION: These gaps represent a handicap by delaying the process that led to move from student to healthcare professional. Hospital pharmacist preceptors have to fill in these gaps before engaging students in pharmaceutical care. CONCLUSION: These results invite to revise partly the content of the academic teaching program delivered before the 5th year hospital pharmacy practice experience.

[Management of outpatient medications in care units: An audit of clinical practices]. / Traitement personnel du patient hospitalisé : audit de pratiques.

OBJECTIVES: To assess the outpatient medication management in care units two years after the release of an institutional procedure. To assess the patients' satisfaction with their treatment and with the information transmitted by healthcare professionals. METHODS: An audit of clinical practices was conducted in 23 units of our universitary hospital - general, surgery, emergency departments. Questionnaires were developed and validated by an institutional working group and were composed of three themes: management of the outpatient medication at the admission, awareness of tools and information transmission. Two physicians (a senior and a resident), a registered nurse, a head nurse and a patient were interviewed. RESULTS: Eighty-one medical and paramedical team members and 21 patients were interviewed for the study. According to statements collected, the procedure was unknown by 100% of the interviewed surgeons and 69% of the interviewed physicians. The practices being used by the medical units were more in line with recommendations than the surgery units. Among the patients interviewed, 19 (86%) were satisfied with the information they received during their hospitalization and 4 (19%) managed their own medication treatment with the help of a nurse in only 36% of the cases according to their statements. CONCLUSIONS: The management of outpatient medications during hospitalization is representative of the difficulties to master the continuity of pharmaceutical care at the various transition points. Coordination and cooperation between the different healthcare professionals and patients are the major key success to ensure an optimized healthcare procedure.

Improved outcome of children transplanted for high-risk leukemia by using a new strategy of cyclosporine-based GVHD prophylaxis.

There is currently a major concern regarding the optimal immunosuppression therapy to be administered after hematopoietic stem cell transplantation (HSCT) to reduce both the toxicity of GvHD and the rate of relapse. We report the outcome of high-risk leukemia children transplanted with a new way of managing cyclosporine (CsA)-based GvHD prophylaxis. A total of 110 HSCT in 109 ALL or AML children who received CsA without mycophenolate or methotrexate in matched related as well as in matched or mismatched unrelated stem cell transplantation were included. CsA dosage regimens were individualized to obtain specific trough blood concentrations values. The incidences of grade I-II and III-IV acute GvHD were 69.1% and 1.8%, respectively, and 8.4% for chronic GvHD. GvHD was neither more frequent nor severe in unrelated than in related HSCT. GvHD occurred in 87% of patients with a mean CsA trough concentration ⩽120 ng/mL versus 43% with concentration >120 ng/mL (P<0.0001). Five-year disease-free survival (DFS) and overall survival were 78% and 83.6%, respectively. DFS was 76.9% for ALL and 80.4% for AML patients. There was no difference in DFS between matched siblings and matched unrelated or mismatched unrelated HSCT. DFS in patients with minimal residual disease (MRD) ⩾10(-3) and in those with MRD <10(-3) before SCT was comparable. Our results indicate that a GvHD prophylaxis regimen based on CsA without mycophenolate or methotrexate is safe and effective whatever the donor compatibility is. These results suggest that GvL effect may be enhanced by this strategy of GvHD prophylaxis.

[Pharmacist's interventions on proton pump inhibitor prescriptions in a University Hospital]. / Interventions des pharmaciens sur les prescriptions d'inhibiteurs de la pompe à protons dans un centre hospitalier universitaire.

PURPOSE: In France, efforts to optimize prescribing of proton-pump inhibitors (PPIs) are rare. Various studies have shown that the prescription of these drugs is excessive. This has consequences regarding costs and iatrogenesis. The objective of this study was to describe the type of drug related problems (DRP) and pharmaceutical interventions reported by pharmacists practicing in a university hospital. METHODS: Drug related problems and pharmaceutical interventions (PI) made, were recorded on a database. They were classified according to the grid code of the French Society of Clinical Pharmacy. RESULTS AND DISCUSSION: Over a 3 years period, 132.890 prescriptions were analysed. 15.347 generated PI. Among them 701 (4.6%) concerned PPIs. Most frequently reported problems were: lack of indication or patients without a documented indication (24.4%), drug-drug interactions (22.4%) and inappropriate route or mode of administration (19.8%). Discontinuation has been proposed in 40.5% of cases, followed by substitution (22.0%) and dosage titration (17.3%). Physicians modified the prescription according to 51.3% of PI. The main PI, discontinuation therapy, is associated with over-prescription of this drug class. Nevertheless, the rate of DRP recorded (0.5%) is low compared to the high exposure of patients on PPIs and misuse (or overuse?) reported in the literature. CONCLUSION: PI made during the analysis of prescription contributes to rationalizing the use of PPIs. The action of the pharmacist must be strengthened through training of health professionals, and communication strategies to improve practices.

[Pharmacist's interventions on outpatient prescriptions in a university hospital drugs sales service]. / Interventions des pharmaciens sur les prescriptions ambulatoires dans le cadre de l'activité de rétrocession d'un centre hospitalier universitaire.

UNLABELLED: For public health reasons, some drugs are only available in hospital drugs sales service. This activity takes place in a specific risk context of organization, patients and/or drugs. A systematic prescription analysis by pharmacist contributes to securise treatment dispensed. The aim of this paper is to present the main drugs problems in the analysis of outpatient prescriptions and pharmaceutical interventions in three units of hospital drugs sales service belong to university hospital. METHODS: Throughout the year 2013, drug problems detected were recorded prospectively and systematically. RESULTS: Of the 22,279 prescriptions analyzed, 247 pharmaceutical interventions (1.1%) were detected including 27.6% of problems concerning the dosages, 15.4% the unconformity, 6.9% contraindications. Regarding ATC drugs classes, we found 43.7% for anti-infectives and 17.4% for antineoplatics. The overall acceptance rate is 81.8%. CONCLUSION: These results show the importance of the analysis of outpatient prescriptions before dispensing and the need to have all prescriptions, clinical and biological elements and to develop interprofessionality. The implementation of a platform for dematerialized data exchanges between professionals, including data from the pharmaceutical patient record should contribute to improving drug management of the patient.

Oral anticoagulant treatment - evaluating the knowledge of patients admitted in physical medicine and rehabilitation units.

INTRODUCTION: While numerous therapeutic education programs exist in physical medicine and rehabilitation (PM&R), they rarely concern pharmacological treatments. Nevertheless, drugs prescribed during a hospital stay can have a significant risk of adverse events. Vitamin K antagonists (VKA) are among them. OBJECTIVE OF THE STUDY: To assess patients' knowledge on their oral anticoagulant treatment before their hospital discharge. METHODS: Fifty patients were enrolled in this prospective, monocenter study. Their level of knowledge was assessed by a semi-structured interview between the pharmacist and the patients and/or their caregivers. RESULTS: Seventy percent of patients were able to give the name of the drug they were taking, 82% could explain its effect and finally, 24% of patient knew their INR target values. Twenty-two percent of patients were able to describe the symptoms in case of overdose and what to do in that case. Forty percent of patients were aware of food interactions and 60% of self-medication risks. The patient's knowledge and behavior acquired during their hospital stay are not enough to guarantee a safe treatment management upon discharge. Based on this study, therapeutic patient education sessions were implemented. CONCLUSION: These results suggest that specific drug therapy management sessions should be developed as part of PM&R's therapeutic education programs for patients.

[Most frequent drug-related events detected by pharmacists during prescription analysis in a university hospital]. / Problèmes médicamenteux les plus fréquemment détectés par l'analyse pharmacothérapeutique des prescriptions dans un centre hospitalier universitaire.

PURPOSE: In France, the analysis of the prescriptions by a pharmacist in hospital is mandatory since 1991. However, for various reasons, this activity remained poorly developed and little research has been performed. Consequently, this activity suffers of a lack of visibility to hospital decision-makers and others health care professionals. The aim of this paper is to describe drugs related problems identified by pharmacist prescriptions analysis on a large number of orders in a large teaching hospital. This was done in order to highlight recurrent and preventable problems. METHODS: During 1 year period, drug related problems detected by pharmacists when performing prescription analysis were registered prospectively. RESULTS: Among 70,849 orders, 7073 drug related problems were registered. Most frequently detected drug related problems were: over dosages, especially with three drugs (zopiclone, zolpidem and acetaminophen) representing more than 10% of the pharmacist's interventions; optimization of drug administration especially with tablets that should not be crushed and intravenous to oral step-down therapy (7.5%); lack of conformity with consensus recommendations and contra-indications (12.8%); drug-drug interactions (11.6%) with a high proportion of absorption inhibition of one drug by another along the digestive tract; problems related to computerized physicians order entry (5.1%) appeared as an emerging phenomenon. CONCLUSION: These results should be used to reexamine hospital drug prescription policy. They prompt health care professionals to be aware about new medications errors potentially related to computerized prescription order entry. Finally, they invite to modify initial and continuous education programs of health care professionals.

Near infrared spectroscopy and process analytical technology to master the process of busulfan paediatric capsules in a university hospital.

The prescription of unlicensed oral medicines in paediatrics leads the hospital pharmacists to compound hard capsules, such as busulfan, an alkylating agent prescribed in preparative regimens for bone marrow transplantation. In this study, we have investigated how the general principle of process analytical technology (PAT) can be implemented at the small size of our hospital pharmacy manufacturing unit. Near infrared spectroscopy (NIRS) was calibrated for raw material identification, blend uniformity analysis and final content uniformity of busulfan hard capsules of 11 different strengths. Measurements were performed on capsules from 2 to 40 mg (n=440). After optimisation, accuracy and linearity of the NIRS quantitative method was demonstrated after comparison with a previously validated quantitative high performance thin layer chromatography (HPTLC) method. Such a comparison led to attractive NIRS precision: +/-0.7 to +/-1.0 mg for capsules from 2 to 40 mg, respectively. As NIRS is a rapid and non-destructive technique, the individual control of a whole batch of busulfan paediatric capsules intended to be administrated is possible. Actually, mastering the process of busulfan paediatric capsules with the NIRS integrated into the notion of PAT is a powerful analytical tool to assess the process quality and to perform content uniformity of at least 5mg busulfan-containing capsules.