Unlocking Deprescribing Potential in Nursing Homes: Insights from a Focus Group Study with Healthcare Professionals.

BACKGROUND: The nursing home population is characterized by multimorbidity and disabilities, which often result in extensive prescription of medication and subsequent polypharmacy. Deprescribing, a planned and supervised process of dose reduction or total cessation of medication, is a solution to combat this. OBJECTIVE: This study aimed to identify barriers and enablers of deprescribing as experienced by nursing home physicians (NHPs) and collaborating pharmacists in the specific nursing home setting. METHODS: This qualitative study utilized a semi-structured interview format with two focus groups consisting of a mix of NHPs and pharmacists. Directed content analysis was performed based on the Theoretical Domains Framework, a validated framework for understanding determinants of behavior change among health care professionals. RESULTS: Sixteen health care professionals participated in two focus groups, including 13 NHPs and three pharmacists. The participating NHPs and pharmacists believed that deprescribing is a valuable process with enablers, such as multidisciplinary collaboration, good communication with patients and family, and involvement of the nursing staff. NHPs and pharmacists view deprescribing as a core task and feel assured in their ability to carry it out successfully. However, they also noted barriers: deprescribing is time-consuming; communication with residents, their relatives or medical specialists is difficult; and electronic patient systems often do not adequately support it. CONCLUSIONS: This study provides insight into the various barriers and enablers faced by NHPs and pharmacists when deprescribing in nursing homes. Specific for this population, deprescribing barriers focus on communication (with residents and their relatives, and also with medical specialists) and resources, while knowledge and expertise are mentioned as enablers.

The impact of polypharmacy on 30-day COVID-related mortality in nursing home residents: a multicenter retrospective cohort study.

PURPOSE: Both the coronavirus (COVID-19) disease and polypharmacy pose a serious threat to nursing home (NH) residents. This study aimed to assess the impact of polypharmacy on 30-day COVID-related mortality in NH residents with COVID-19. METHODS: Multicenter retrospective cohort study including NH residents from 15 NHs in the Netherlands. The impact of polypharmacy on 30-day COVID-related mortality was evaluated and assessed using multivariable logistic regression analyses with correction for age, sex, CCI, BMI and vaccination status. RESULTS: In total, 348 NH residents were included, with a mean age of 84 years (SD = 8); 65% were female, 70% lived in a psychogeriatric ward, with a main diagnosis of dementia. 30-day COVID-related mortality was 27.3%. We found a significant, positive association between the total number of medications and 30-day COVID-related mortality (OR 1.09; 95% CI 1.001-1.20, p = 0.046), after adjustment for age, sex, Charlson Comorbidity Index (CCI), Body Mass Index (BMI) and vaccination status. After additional correction for dementia (model 2) and use of PPI, vitamin D, antipsychotics and antithrombotics (model 3), this effect remained positive, but was no longer significant. CONCLUSION: Nursing home residents with a higher number of medications and who were not vaccinated, had a higher 30-day COVID-related mortality. These findings have important implications for the management of COVID-19 in the frail NH population. As such they underline the importance of deprescribing on the one hand, but also of improving vaccination rates on the other.

How to select a best-value biological medicine? A practical model to support hospital pharmacists.

PURPOSE: With the growing availability of biosimilars on the global market, clinicians and pharmacists have multiple off-patent biological products to choose from. Besides the competitiveness of the product's price, other criteria should be considered when selecting a best-value biological. This article aims to provide a model to facilitate transparent best-value biological selection in the off-patent biological medicines segment. SUMMARY: The presented model was developed on the basis of established multicriteria decision analysis tools for rational and transparent medicine selection, ie, the System of Objectified Judgement Analysis and InforMatrix. Criteria for the model were informed by earlier research, a literature search, and evaluation by the authors. The developed model includes up-to-date guidance on criteria that can be considered in selection and provides background on the allocation of weights that may aid hospital pharmacists and clinicians with decision-making in practice. Three main categories of criteria besides price were identified and included in the model: (1) product-driven criteria, (2) service-driven criteria, and (3) patient-driven criteria. Product-driven criteria include technical product features and licensed therapeutic indications. Service-driven criteria consist of supply conditions, value-added services, and environment and sustainability criteria. Patient-driven criteria contain product administration elements such as ease of use and service elements such as patient support programs. Relative weighting of the criteria is largely context dependent and should in a given setting be determined at the beginning of the process. CONCLUSION: The practical model described here may support hospital pharmacists and clinicians with transparent and evidence-based best-value biological selection in clinical practice.

Deprescribing Statins and Proton Pump Inhibitors in Nursing Home Residents; a Pragmatic Exploratory Study.

INTRODUCTION: Polypharmacy is common in the frail nursing home population and associated with an increased risk of adverse events, unplanned hospitalizations, and increased all-cause mortality. Deprescribing using a deprescribing algorithm might reduce unnecessary polypharmacy. This exploratory study was performed to determine the effect of this implicit deprescribing algorithm in deprescribing statins and proton pump inhibitors (PPIs) in nursing home residents. METHOD: Multicenter, longitudinal, single-arm exploratory study. All participants received the same deprescribing intervention to identify and deprescribe potentially inappropriate statins and/or PPIs. Residents across 10 nursing homes in the Netherlands were included if they used a statin and/or PPI. Residents in hospices or short-stay wards were excluded. The intervention involved a deprescribing algorithm in which nursing home physicians identified and, if possible, deprescribed potentially inappropriate statins and/or PPIs. RESULTS: Sixty-seven residents participated in the study. At 3 months, deprescribing was successful in 52% of the residents. Six months after the intervention, all these residents still had their medication sustainably deprescribed. CONCLUSION: Based on this study, deprescribing statins and PPIs using an implicit deprescribing algorithm is possible in a considerable number of nursing home residents.

Cotreatment with methotrexate in routine care patients with rheumatoid arthritis receiving biological treatment yields better outcomes over time.

Objectives: We aimed to evaluate the effects of methotrexate (MTX) comedication added to biological disease-modifying antirheumatic drugs (bDMARD) on disease activity measures in patients with rheumatoid arthritis (RA) in routine care. Methods: Patients with RA on treatment with either bDMARDs or conventional synthetic DMARDs were included in this prospective cohort study. The effect of (time-varying) combination therapy with bDMARD and MTX compared with bDMARD monotherapy was tested in longitudinal generalised estimating equation models using as outcomes: (1) the likelihood to be in remission according to the 28-joint Disease Activity Score (DAS28) erythrocyte sedimentation rate (ESR) (<2.6) and to the Routine Assessment of Patient Index Data 3 (RAPID3) (0-30; ≤3), a patient-reported outcome measure about RA symptoms; and (2) DAS28-ESR and RAPID3 as continuous variables. All models were adjusted for potential confounders: age, gender, drugs for comorbidities (yes/no), oral steroids (yes/no) and non-steroidal anti-inflammatory drug (yes/no). Results: In total, 330 patients were included (mean (SD) follow-up; 10.7 (9.7) months). Compared with bDMARD monotherapy, MTX combination therapy was significantly associated with a 55% higher likelihood to be in DAS28 remission, but not RAPID3 remission, over time. Combination therapy resulted in slightly, but statistically significant, lower levels of DAS28-ESR over time (ß=-0.42 (95% CI -0.67 to - 0.17)), but not RAPID3 (ß=-0.58 (95% CI -0.65 to 0.49)). The effect on DAS28-ESR was entirely explained by lower swollen joint counts and was persistent after correction for confounders. Conclusion: These results give support to the policy that MTX should be continued in routine care patients with RA on biological therapy since this leads to better objective but not subjective clinical outcomes.

Routine Assessment of Patient Index Data 3 (RAPID3) alone is insufficient to monitor disease activity in rheumatoid arthritis in clinical practice.

Objective: To test the longitudinal association between patient-reported outcome, Routine Assessment of Patient Index Data 3 (RAPID3) and the Disease Activity Score in 28 joints that includes the erythrocyte sedimentation rate (DAS28-ESR) in routine-care patients with rheumatoid arthritis (RA). Methods: Patients with RA treated with disease-modifying antirheumatic drugs were included in this prospective observational cohort. The longitudinal association between RAPID3 (0-10) and DAS28-ESR and its individual components (swollen joint count (SJC), erythrocyte sedimentation rate (ESR) (mm/hour), tender joint count (TJC) and patient global assessment (PGA)) was tested using generalised estimating equations in patients with more than two consecutive visits with data on RAPID3 and DAS28-ESR. Interactions between RAPID3 and gender, pain, PGA and age at baseline were tested, and if significant (p<0.20) and clinically relevant, models were fit in the corresponding strata. Results: In total, 330 patients were included (mean follow-up 10.7 (SD 9.7) months, female gender 67.9%). The longitudinal association between RAPID3 and DAS28-ESR was weak (ß=0.29 (95% CI 0.24 to 0.35), n=207), meaning that one unit increase in RAPID3 corresponded to a 0.29 unit increase in Disease Activity Score in 28 joints (DAS28). RAPID3 was most strongly associated with subjective (TJC: ß=0.89 (95% CI 0.61 to 1.17); PGA: ß=0.94 (95% CI 0.84 to 1.04)) and not with objective components of DAS28 (SJC: ß=0.29 (95% CI 0.17 to 0.41), n=172). The association between RAPID3 and ESR was poor but modified by gender, being only significant in men (ß=0.37 (95% CI 0.08 to 0.67)). Conclusions: These data suggest that RAPID3 does not sufficiently capture changes in objective inflammatory signs. Monitoring by RAPID3 alone is therefore insufficient to follow disease activity in patients wth RA in clinical practice.

Validation of an automated delirium prediction model (DElirium MOdel (DEMO)): an observational study.

OBJECTIVES: Delirium is an underdiagnosed, severe and costly disorder, and 30%-40% of cases can be prevented. A fully automated model to predict delirium (DEMO) in older people has been developed, and the objective of this study is to validate the model in a hospital setting. SETTING: Secondary care, one hospital with two locations. DESIGN: Observational study. PARTICIPANTS: The study included 450 randomly selected patients over 60 years of age admitted to Zuyderland Medical Centre. Patients who presented with delirium on admission were excluded. PRIMARY OUTCOME MEASURES: Development of delirium through chart review. RESULTS: A total of 383 patients were included in this study. The analysis was performed for delirium within 1, 3 and 5 days after a DEMO score was obtained. Sensitivity was 87.1% (95% CI 0.756 to 0.939), 84.2% (95% CI 0.732 to 0.915) and 82.7% (95% CI 0.734 to 0.893) for 1, 3 and 5 days, respectively, after obtaining the DEMO score. Specificity was 77.9% (95% CI 0.729 to 0.882), 81.5% (95% CI 0.766 to 0.856) and 84.5% (95% CI 0.797 to 0.884) for 1, 3 and 5 days, respectively, after obtaining the DEMO score. CONCLUSION: DEMO is a satisfactory prediction model but needs further prospective validation with in-person delirium confirmation. In the future, DEMO will be applied in clinical practice so that physicians will be aware of when a patient is at an increased risk of developing delirium, which will facilitate earlier recognition and diagnosis, and thus will allow the implementation of prevention measures.

Supporting clinical rules engine in the adjustment of medication (SCREAM): protocol of a multicentre, prospective, randomised study.

BACKGROUND: In the nursing home population, it is estimated that 1 in every 3 patients is polymedicated and given their considerable frailty, these patients are especially prone to adverse drug reactions. Clinical pharmacist-led medication reviews are considered successful interventions to improve medication safety in the inpatient setting. Due to the limited available evidence concerning the benefits of medication reviews performed in the nursing home setting, we propose a study aiming to demonstrate a positive effect that a clinical decision support system, as a health care intervention, may have on the target population. The primary objective of this study is to reduce the number of patients with at least one event when using the clinical decision support system compared to the regular care. These events consist of hospital referrals, delirium, falls, and/or deaths. METHOD/DESIGN: This study is a multicentre, prospective, randomised study with a cluster group design. The randomisation will be per main nursing home physician and stratified per ward (somatic and psychogeriatric). In the intervention group the clinical decision support system will be used to screen medication list, laboratory values and medical history in order to obtain potential clinical relevant remarks. The remarks will be sent to the main physician and feedback will be provided whether the advice was followed or not. In the control group regular care will be applied. DISCUSSION: We strongly believe that by using a clinical decision support system, medication reviews are performed in a standardised way which leads to comparable results between patients. In addition, using a clinical decision support system eliminates the time factor to perform medication reviews as the major problems related to medication, laboratory values, indications and/or established patient characteristics will be directly available. In this way, and in order to make the medication review process complete, consultation within healthcare professionals and/or the patient itself will be time effective and the medication surveillance could be performed around the clock. TRIAL REGISTRATION: The Netherlands National Trial Register NTR5165 . Registered 2nd April 2015.

The support of medication reviews in hospitalised patients using a clinical decision support system.

OBJECTIVES: First, to estimate the added value of a clinical decision support system (CDSS) in the performance of medication reviews in hospitalised elderly. Second, to identify the limitations of the current CDSS by analysing generated drug-related problems (DRPs). METHODS: Medication reviews were performed in patients admitted to the geriatric ward of the Zuyderland medical centre. Additionally, electronically available patient information was introduced into a CDSS. The DRP notifications generated by the CDSS were compared with those found in the medication review. The DRP notifications were analysed to learn how to improve the CDSS. RESULTS: A total of 223 DRP strategies were identified during the medication reviews. The CDSS generated 70 clinically relevant DRP notifications. Of these DRP notifications, 63 % (44) were also found during the medication reviews. The CDSS generated 10 % (26) new DRP notifications and conveyed 28 % (70) of all 249 clinically relevant DRPs that were found. Classification of the CDSS generated DRP notifications related to 'medication error type' revealed that 'contraindications/interactions/side effects' and 'indication without medication' were the main categories not identified during the manual medication review. The error types 'medication without indication', 'double medication', and 'wrong medication' were mostly not identified by the CDSS. CONCLUSIONS: The CDSS used in this study is not yet sufficiently advanced to replace the manual medication review, though it does add value to the manual medication review. The strengths and weaknesses of the current CDSS can be determined according to the medication error types.

The development of an automated ward independent delirium risk prediction model.

Background A delirium is common in hospital settings resulting in increased mortality and costs. Prevention of a delirium is clearly preferred over treatment. A delirium risk prediction model can be helpful to identify patients at risk of a delirium, allowing the start of preventive treatment. Current risk prediction models rely on manual calculation of the individual patient risk. Objective The aim of this study was to develop an automated ward independent delirium riskprediction model. To show that such a model can be constructed exclusively from electronically available risk factors and thereby implemented into a clinical decision support system (CDSS) to optimally support the physician to initiate preventive treatment. Setting A Dutch teaching hospital. Methods A retrospective cohort study in which patients, 60 years or older, were selected when admitted to the hospital, with no delirium diagnosis when presenting, or during the first day of admission. We used logistic regression analysis to develop a delirium predictive model out of the electronically available predictive variables. Main outcome measure A delirium risk prediction model. Results A delirium risk prediction model was developed using predictive variables that were significant in the univariable regression analyses. The area under the receiver operating characteristics curve of the "medication model" model was 0.76 after internal validation. Conclusions CDSSs can be used to automatically predict the risk of a delirium in individual hospitalised patients' by exclusively using electronically available predictive variables. To increase the use and improve the quality of predictive models, clinical risk factors should be documented ready for automated use.

Evaluating patient reported outcomes in routine practice of patients with rheumatoid arthritis treated with biological disease modifying anti rheumatic drugs (b-DMARDs).

OBJECTIVES: In this study the concordance between the Routine Assessment of Patient Index Data 3 (RAPID3) and the Disease Activity Score 28-joint count (DAS28) was investigated in a clinical routine outpatient setting. PATIENTS AND METHODS: A sample of 150 adult patients with stable RA treated with biological DMARDs (bDMARDs) was asked to complete the RAPID3 (digital or on paper) just before their outpatient routine visit during which DAS28 assessment took place. The RAPID3 correlation with and the agreement in four DAS28 categories was studied using Spearman's rank order and Cohen's observed kappa statistics respectively. The positive (PPV) and negative (NPV) predictive values were calculated to test whether RAPID3 could make distinction in active disease (DAS28 >3.2) or not. RESULTS: A moderate correlation (ρ 0.576) and a poor kappa value of 0.13 were found in the whole study population. Patients reported a higher disease severity than was measured by DAS28. The PPV of RAPID3 for active disease by DAS28 was 0.59 (95 % CI 0.50-0.68) and the NPV was 0.91 (95 % CI 0.75-0.98) with a sensitivity and specificity of 96 and 40 % respectively. DISCUSSION: While RAPID3 correlates to some extent with DAS28 at the group level, agreement between RAPID3 and DAS28 at the individual patient level is to poor to rely on RAPID3 results in monitoring patients with RA. RAPID3 tends to over-report disease activity as assessed by DAS28.

To what extent is clinical and laboratory information used to perform medication reviews in the nursing home setting? the CLEAR study.

BACKGROUND: The aim of this study was to evaluate to what extent laboratory data, actual medication, medical history, and/or drug indication influence the quality of medication reviews for nursing home patients. METHODS: Forty-six health care professionals from different fields were requested to perform medication reviews for three different cases. Per case, the amount of information provided varied in three subsequent stages: stage 1, medication list only; stage 2, adding laboratory data and reason for hospital admission; and stage 3, adding medical history/drug indication. Following a slightly modified Delphi method, a multidisciplinary team performed the medication review for each case and stage. The results of these medication reviews were used as reference reviews (gold standard). The remarks from the participants were scored, according to their potential clinical impact, from relevant to harmful on a scale of 3 to -1. A total score per case and stage was calculated and expressed as a percentage of the total score from the expert panel for the same case and stage. RESULTS: The overall mean percentage over all cases, stages, and groups was 37.0% when compared with the reference reviews. For one of the cases, the average score decreased significantly from 40.0% in stage 1, to 30.9% in stage 2, and 27.9% in stage 3; no significant differences between stages was found for the other cases. CONCLUSION: The low performance, against the gold standard, of medication reviews found in the present study highlights that information is incorrectly used or wrongly interpreted, irrespective of the available information. Performing medication reviews without using the available information in an optimal way can have potential implications for patient safety.

Evaluation of clinical rules in a standalone pharmacy based clinical decision support system for hospitalized and nursing home patients.

OBJECTIVES: To improve the current standalone pharmacy clinical decision support system (CDSS) by identifying and quantifying the benefits and limitations of the system. METHODS: Alerts and handling of the executed clinical rules were extracted from the CDSS from the period September 2011 to December 2011. The number of executed clinical rule alerts, number of actions on alerts, and the reason why alerts were classified as not relevant were analyzed. The alerts where considered clinically relevant when the pharmacist needed to contact the physician. RESULTS: The 4065 alerts have been separated into: 1137 (28.0%) new alerts, 2797 (68.8%) repeat alerts and 131 (3.2%) double alerts. When the alerts were analyzed, only 3.6% were considered clinically relevant. Reasons why alerts were considered as not to be relevant were: (a) the dosage was correct or already adjusted, (b) the drug was (temporarily) stopped and (c) the monitored laboratory value or drug dosage had already reverted to be within the reference limits. The reasons for no action were linked to three categorical limitations of the used system: 'algorithm alert criteria', 'CDSS optimization', and 'data delivery'. CONCLUSION: This study highlighted a number of ways in which the CDSS could be improved. These different aspects have been identified as important for developing an efficient CDSS.

Development of a computer system to support medication reviews in nursing homes.

The frail elderly populations of nursing homes frequently use drugs and suffer from considerable comorbidities. Medication reviews are intended to support evidence based prescribing and optimise therapy. However, literature is still ambiguous regarding the optimal method and the effects of medication reviews. Innovative computerised systems may support the medication reviews in the future. We are developing a clinical decision support system (CDSS) that, independently of the prescribing software, continuously monitors all prescribed drugs while taking into account co-medication, laboratory-data and co-morbidities. The CDSS will be developed in five phases: (1) development of the computerised system, (2) development of the clinical rules, (3) validation of the CDSS, (4) randomised controlled trial, and (5) feasibility for implementation in different nursing homes. The clinical decision support system aims at supporting the traditional medication review.

Medication surveillance on intravenous cytotoxic agents: a retrospective study.

BACKGROUND: Medication surveillance is not commonly performed for cytotoxic agents. Cytotoxic agents generally have a narrow therapeutic range and therefore it might be necessary to adjust the dose. Interactions may not only cause supratherapeutic ranges, but can also lead to subtherapeutic levels. Up till now, only a few studies have demonstrated the value and importance of medication surveillance in ambulatory cancer patients. OBJECTIVE: The objective of this study is to determine the prevalence and relevance of interactions with cytotoxic agents in ambulant cancer patients receiving one or more intravenous cytotoxic administrations. SETTING: This retrospective study was undertaken in the Orbis Medical Centre in Sittard, the Netherlands. METHODS: All ambulatory cancer patients receiving one or more intravenous cytotoxic treatments during the period October 2008 to April 2010 were included. Cytotoxic agent related information was determined using the hospital information system and medication history was determined using the Electronic Prescribing System (EPS) and an open care information system. Medication was entered into the EPS and medication surveillance was performed electronically using the G-standard. All alerts were generated retrospectively. MAIN OUTCOME MEASURE: The prevalence and relevance of interactions between cytotoxic agents and other drugs in ambulatory cancer patients. RESULTS: A total of 527 ambulatory cancer patients was enrolled. The mean age of the patients was 63.6 years and 303 were female (55 %). In 24 patients a total of 58 cytotoxic agent-related interactions was detected of whom five were clinically relevant. The most frequent cytotoxic agent-related interaction was with acenocoumarol; the most relevant interactions were with antiepileptic drugs. CONCLUSION: A total of 58 potential cytotoxic agent-related interactions was found. This corresponds to 11 cytotoxic agent-related interactions per 100 ambulatory cancer patients, of which one was indicated clinically relevant and should have required an intervention. The most frequently involved drug was acenocoumarol. Most drug-related interactions with cytotoxic agents are manageable and can be monitored. Prospective studies are needed to confirm the relevance of medication surveillance on cytotoxic agents.

Failure of vancomycin treatment for meningitis caused by vancomycin-susceptible Enterococcus faecium.

This case report describes a nosocomial vancomycin-sensitive Enterococcus faecium meningitis with poor response to vancomycin. E. faecium infections continue to represent a therapeutic challenge in Europe, even in countries where vancomycin resistance is still rare. In the case of vancomycin-sensitive E. faecium meningitis, intravenous chloramphenicol should be considered as a treatment option.

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol.

BACKGROUND: The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy? METHODS: In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year. DISCUSSION: We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.

The association between antidepressant use and disturbances in glucose homeostasis: evidence from spontaneous reports.

OBJECTIVES: Depression is common in patients with diabetes, and the use of antidepressants may impair glycaemic control. We assessed the association between antidepressant use and hyper- and hypoglycaemia. METHODS: Based on spontaneous reports listed in the World Health Organization (WHO) Adverse Drug Reaction Database, a case-control study was conducted. The study base consisted of all adverse drug reactions (ADRs) ascribed to antidepressants, antipsychotics and benzodiazepines between 1969 and 2005. Cases were defined as reported ADRs classified as hyper- or hypoglycaemia and separated in different study populations. All other reports were considered as controls. Exposure to antidepressants was the primary determinant investigated. Benzodiazepines and antipsychotics were chosen as reference groups. Potential confounding factors, namely, age, gender, use of antidiabetic medication, use of hyper- or hypoglycaemia-inducing comedication and reporting year, were determined on the index date. Multivariate logistic regression was used to evaluate the strength of the association, which was expressed as reporting odds ratios (RORs) with 95% confidence intervals (95% CI). RESULTS: Overall, the use of antidepressants was associated with hyperglycaemia [ROR 1.52 (95% CI: 1.20-1.93)] and of hypoglycaemia [ROR 1.84 (95% CI: 1.40-2.42)]. The association with hyperglycaemia was most pronounced for antidepressants with affinity for the 5-HT(2c) receptor, histamine-(1) receptor and norepinephrinic (NE) reuptake transporter. The association with hypoglycaemia was most pronounced for antidepressants with affinity for the serotonin reuptake transporter. CONCLUSION: The results of this study strengthen the findings in individual case reports that the use of antidepressants is associated with disturbances in glucose homeostasis.

Electronic monitoring of adherence as a tool to improve blood pressure control. A randomized controlled trial.

BACKGROUND: Poor adherence to antihypertensive drug regimens is believed to be a major contributor to treatment failure. Electronic monitoring of adherence may improve adherence and allow differentiation between those who are nonadherent and those who are pharmacologically nonresponsive. This study was designed to evaluate the effectiveness of electronic monitoring of adherence in lowering blood pressure (BP) in comparison with usual care. METHODS: A total of 258 patients with high BP despite use of antihypertensive medication were randomly assigned to either continuation of usual care (with adjustment in antihypertensive medication if necessary) or to the introduction of electronic monitoring. Adherence to antihypertensive medication was monitored for 2 months without medication changes. The primary outcome measure was the proportion of patients who reached target BP levels after a 5-month follow-up period. RESULTS: At 5 months, 50.6% of the patients in the usual care group reached adequate BP, v 53.7% in the electronic monitoring group (P = .73). The percentages of patients with drug additions or increases in dosage were higher in the usual care group compared with those in whom adherence was monitored (P < .01). CONCLUSION: These data show that electronic monitoring in comparison to usual care results in similar BP control but leads to fewer drug changes and less drug use. This result is likely to be achieved by improving adherence. Hence a strategy that includes electronic monitoring has the potential to prevent unnecessary treatment escalation in patients with poor adherence.