Validation of a computerized decision support system to review pharmacotherapy treatment: scheduling guidelines.

BACKGROUND: The review of pharmacotherapy can be conceptualized as a service in which the drugs used by the patient are reviewed to control the risks as well as to improve the results of the drug therapy, detecting, solving, and preventing issues associated with the drug, readjusting the doses and times (schedule) so that the treatment is not incompatible or in duplicity. METHODS: The aim of the study was to validate an intelligent information system, which was developed to assist the scheduling activity in the pharmacotherapy review. The system used the concept of Genetic Algorithms. To validate the system, hypothetical cases were elaborated considering various aspects of pharmacotherapy such as underdose, overdose, drug interactions and contraindications. These cases were tested in the system and were also analyzed by pharmaceutical experts with clinical and research experience in the pharmacotherapy review process. The degree of agreement between the assessments of the appointments carried out by the pharmaceutical specialists and by the system were measured using the Kappa index with a 95% confidence interval. RESULTS: In detecting errors and make propositions, the system was able to identify 80% of errors, with pharmaceutical experts identifying between 20 and 70% of errors. In relation the results of kappa between the cases, the system had 87,3% of concordance, whereas the best pharmaceutical expert had 75,5% of concordance, considering the correct answer. CONCLUSION: It can be concluded that with the methodology used, the investigation met the objectives and confirmed the system is effective for pharmaceutical review process. There are indications that the system can help in the Pharmacotherapy review process, being able to find prescription errors as well as to establish times for the use of medications according to the patient's routine.

Regulatory reliance pathways during health emergencies: enabling timely authorizations for COVID-19 vaccines in Latin America / Mecanismos de utilización de las decisiones de autoridades regulatorias de otras jurisdicciones en las emergencias de salud: autorización oportuna de las vacunas contra la COVID-19 en América Latina / Uso de decisões regulatórias de outras autoridades durante emergências sanitárias e a tempestividade da autorização de vacinas contra a COVID-19 na América Latina

ABSTRACT Objectives. To map the timing and nature of regulatory reliance pathways used to authorize COVID-19 vaccines in Latin America. Methods. An observational study was conducted assessing the characteristics of all COVID-19 vaccine authorizations in Latin America. For every authorization it was determined whether reliance was used in the authorization process. Subgroups of reference national regulatory authorities (NRAs) and non-reference NRAs were compared. Results. 56 authorizations of 10 different COVID-19 vaccines were identified in 18 countries, of which 25 (44.6%) used reliance and 12 (21.4%) did not. For the remaining 19 (33.0%) it was not possible to determine whether reliance was used. Reference agencies used reliance less often (40% of authorizations with a known pathway) compared to non-reference agencies (100%). The median review time was just 15 days and does not meaningfully differ between reliance and non-reliance authorizations. Conclusions. This study demonstrated that for these vaccines, despite reliance pathways being associated with numerous rapid authorizations, independent authorization review times were not considerably longer than reliance reviews; reliance pathways were not a prerequisite for rapid authorization. Nevertheless, reliance pathways provided rapid authorizations in response to the COVID-19 emergency.

RESUMEN Objetivos. Determinar dónde y cuándo se usaron las decisiones de autoridades regulatorias de otras jurisdicciones y la naturaleza de estos mecanismos para autorizar vacunas contra la COVID-19 en América Latina. Métodos. Se realizó un estudio observacional para evaluar las características de todas las autorizaciones de vacunas contra la COVID-19 en América Latina. Para cada autorización se determinó si se emplearon las decisiones de autoridades regulatorias de otras jurisdicciones en el proceso de autorización. Se compararon subgrupos de autoridades regulatorias nacionales (ARN) consideradas de referencia con otras ARN no usadas como referencia. Resultados. Se determinó dónde se otorgaron 56 autorizaciones de 10 vacunas diferentes contra la COVID-19 en 18 países; de estas 56 autorizaciones, 25 (44,6%) hicieron uso de las decisiones de autoridades regulatorias de otras jurisdicciones y 12 (21,4%), no. Para las 19 restantes (33,0%) no fue posible determinar si se hizo uso de las decisiones de autoridades regulatorias de otras jurisdicciones. Los organismos de referencia utilizaron las decisiones de autoridades regulatorias de otras jurisdicciones con menos frecuencia (40% de las autorizaciones con un mecanismo conocido) en comparación con los organismos no usados como referencia (100%). El plazo medio de revisión fue de tan solo 15 días y no difiere significativamente entre las autorizaciones que emplearon decisiones de autoridades regulatorias de otras jurisdicciones y las que no las emplearon. Conclusiones. En este estudio se demostró que, a pesar de que los mecanismos de utilización de las decisiones de autoridades regulatorias de otras jurisdicciones se asocian en muchos casos con autorizaciones rápidas, para estas vacunas los plazos de revisión independiente para la autorización no fueron considerablemente mayores que los de las revisiones que emplearon decisiones de autoridades regulatorias de otras jurisdicciones. También se demostró que para obtener una autorización rápida no se requería la utilización de las decisiones de autoridades regulatorias de otras jurisdicciones. Sin embargo, estos mecanismos proporcionaron autorizaciones rápidas en respuesta a la emergencia por la COVID-19.

RESUMO Objetivos. Mapear a tempestividade e a natureza do uso de decisões regulatórias de outras autoridades (reliance regulatório) para autorização de vacinas contra a COVID-19 na América Latina. Métodos. Em um estudo observacional, foram avaliadas as características de todas as autorizações de vacinas contra COVID-19 na América Latina. Para cada autorização, foi determinado se foram utilizadas decisões de outras autoridades regulatórias para embasar o processo de autorização. Foram comparados subgrupos de autoridades reguladoras nacionais (ARN) de referência (ARNr) e ARN não consideradas de referência. Resultados. Foram identificadas 56 autorizações de 10 vacinas diferentes contra a COVID-19 em 18 países, das quais 25 (44,6%) utilizaram decisões de outras ARN como base para o registro e 12 (21,4%) não. Para as 19 (33,0%) autorizações restantes, não foi possível determinar se decisões de outras ARN foram utilizadas. As ARNr utilizaram decisões de outras autoridades com menos frequência (40% das autorizações com via regulatória conhecida) em comparação com as ARN não consideradas de referência (100%). A mediana do tempo de tramitação foi de apenas 15 dias, sem diferença significativa entre processos nos quais foram utilizadas decisões de outras agências e processos que não as utilizaram. Conclusões. Este estudo demonstrou que, para estas vacinas, apesar de o uso do reliance regulatório estar associado a várias autorizações rápidas, os tempos de tramitação não foram consideravelmente maiores em autorizações independentes do que quando foram utilizadas decisões de outras ARN; o reliance regulatório não foi um pré-requisito para autorização rápida. No entanto, o uso de tais processos viabilizou autorizações rápidas em resposta à emergência de COVID-19.

Severe Potential Drug-Drug Interactions and the Increased Length of Stay of Children in Intensive Care Unit.

Children are exposed to drug-drug interactions (DDI) risks due to their organism's complexity and the need for several medicines prescriptions in pediatric intensive care units (PICU). This study aimed to assess the prevalence of potential DDIs in a Brazilian PICU. We carried out a cross-sectional study at a pediatric teaching hospital from Rio de Janeiro (Brazil) over one year. Potential DDIs (pDDIs) between prescribed medicines for hospitalized children in PICU (n = 143) were analyzed according to severity using Micromedex®. Sex, age group, number of drugs prescribed, vasoactive amines use (a proxy of clinical complexity), and the PICU length of stay were summarized using descriptive statistics. Association between the PICU length stay, and variables sex, age, clinical condition complexity, number of drugs prescribed, and severity of pDDI were examined by univariate and multiple linear regression. Seventy percent of patients aged three days to 14 years old were exposed at least one potential DDIs during PICU stay. Two hundred eighty-four different types of pDDIs were identified, occurring 1,123 times. Nervous system drugs were implicated in 55% of the interactions, and fentanyl (10%) was most involving in pDDIs. Most pDDIs were classified as higher severity (56.2%), with reasonable documentation (64.6%) and unspecified onset time (63.8%). Worse clinical condition, ten or more drugs prescribed, and most severe pDDIs were associated with a longer PICU length of stay. Multiple linear regression analysis showed an increase of 9.83 days (95% confidence interval: 3.61-16.05; p = 0.002) in the PICU length of stay in children with major or contraindicated pDDIs. The results of this research may support the monitoring and prevention of pDDIs related to adverse events in children in intensive care and the design and conduction of new studies.

Surgical antibiotic prophylaxis: is the clinical practice based on evidence? / Antibioticoprofilaxia cirúrgica: sua prática clínica está baseada em evidências?

ABSTRACT Objective: To assess the surgical antibiotic prophylaxis. Methods: This was a descriptive study performed at a public tertiary care university hospital gathering prescription, sociodemographic and hospitalization data of inpatients admitted in 2014 who used antimicrobial drugs. This data were obtained from the hospital electronic database. The antimicrobial data were classified according to the anatomical, therapeutic chemical/defined daily dose per 1,000 inpatients. An exploratory analysis was performed using principal component analysis. Results: A total of 5,182 inpatients were prescribed surgical antibiotic prophylaxis. Of the total antimicrobial use, 11.7% were for surgical antibiotic prophylaxis. The orthopedic, thoracic and cardiovascular postoperative units, and postoperative intensive care unit comprised more than half of the total surgical antibiotic prophylaxis use (56.3%). The duration of antimicrobial use of these units were 2.2, 2.0, and 1.4 days, respectively. Third-generation cephalosporins and fluoroquinolones had the longest use among antimicrobial classes. Conclusion: Surgical antibiotic prophylaxis was inadequate in the orthopedic, postoperative intensive care, thoracic and cardiovascular postoperative, gynecology and obstetrics, and otolaryngology units. Therefore, the development and implementation of additional strategies to promote surgical antibiotic stewardship at hospitals are essential.

RESUMO Objetivo: Avaliar a utilização de antibioticoprofilaxia cirúrgica. Métodos: Foi realizado um estudo descritivo em um hospital universitário de cuidado terciário por meio de coleta de dados de prescrição, sociodemográficos e de hospitalização sobre todos os pacientes internados em 2014 que utilizaram pelo menos um medicamento antimicrobiano. Esses dados foram coletados da base de dados eletrônica do hospital. O consumo de antimicrobianos foi analisado de acordo com a classificação anatômica terapêutica e química/dose diária definida por mil pacientes-dia. Realizou-se uma análise exploratória por meio da análise de componentes principais. Resultados: Um total de 5.182 pacientes internados receberam prescrição de antibioticoprofilaxia cirúrgica, que corresponde a 11,7% do total de antibióticos utilizados no hospital. As unidades de ortopedia, pós-operatória de cirurgia torácica e cardiovascular e terapia intensiva pós-operatória foram responsáveis pela utilização de mais da metade (56,3%) da antibioticoprofilaxia cirúrgica. A duração de uso desses antimicrobianos nessas unidades foi 2,2, 2,0 e 2,4 dias, respectivamente. Cefalosporinas de terceira geração e fluoroquinolonas foram as classes de antimicrobianos com tempo de utilização mais longo. Conclusão: A utilização de antibioticoprofilaxia cirúrgica foi inadequada nas unidades de ortopedia, pós-operatória de cirurgia torácica e cardiovascular, terapia intensiva pós-operatória, ginecologia e obstetrícia e otorrinolarigonlogia. Portanto, são importantes o desenvolvimento e a implantação de estratégias que promovam o uso racional de antibioticoprofilaxia cirúrgica nos hospitais.

Comparing the Medicaid Prospective Drug Utilization Review Program Cost-Savings Methods Used by State Agencies in 2015 and 2016.

BACKGROUND: The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR process and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR involving ongoing, periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug-drug interaction, and medically unnecessary care, and implement corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure the prescription drug cost-savings generated from its DUR programs annually, but it provides no methodology for doing so. An earlier article compared the methodologies used by states to measure cost-savings in their retrospective DUR program in fiscal years 2014 and 2015. OBJECTIVE: To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid prospective DUR program in federal fiscal years 2015 and 2016. METHODS: For each state, we downloaded from Medicaid's website the cost-savings methodologies included in the Medicaid DUR 2015 and 2016 reports. We then reviewed and synthesized the reports. Methods described by the states were classified into a unique group based on the methodology used, except for Arkansas and Connecticut, which were classified in more than 1 category for the same period. RESULTS: Currently, 3 different methodologies are being used by states. In 2015 and 2016, the most common methodology used (by 18 states) was the calculation of total claim rejections and subtracting claim resubmissions at the amount actually paid. The comparisons of DUR program cost-savings among states are unreliable, because the states lack a common methodology in the way they measure their performance. CONCLUSIONS: Considering the lack of methodologic consistency among states in measuring the savings in the Medicaid DUR program shown in this analysis, the federal government must lead an effort to define a unique methodology to measure cost-savings in its entire DUR program. This will help to improve the measure of savings among states and understand how this program is performing in that matter.

The appropriate use of human albumin in a Brazilian University Hospital: therapeutic indication and dosage regimen

The objective of the study was to evaluate the use of human albumin in a Brazilian university hospital, in compliance with the institutional protocol and other clinical guidelines, taking into account the therapeutic indications and the dosage regimens. Data was obtained from the pharmacy dispensing records of human albumin, the requests for use it and, when available, the patient's records between January and October 2017. After evaluation the therapeutic indications and the dosage regimens were classified as "appropriate" and "inappropriate". The analysis of 98 requests showed that, when compared to the institutional protocol, 54 (55.1%) requests had an inappropriate therapeutic indication. However, when a comparison was made between 25 medical records (54 requests) and other clinical guidelines, it was observed that the therapeutic indication had none classified as inappropriate. In addition, 16 (29.7%) requests were considered inappropriate in relation to dosage regimens. From these results, it was possible to conclude that although the use of human albumin in the hospital was associated to a clinical protocol, it was outdated. Thus, it is possible to affirm that not only the adoption of a clinical protocol, but its periodical updating is an important strategy to promote the rational use of drugs.

Prescribing indicators in primary health care in Belo Horizonte, Brazil: associated factors.

Background The prescription is one of the factors that influences rational use of medicines. The evaluation of prescribing indicators should contribute to organization of primary health care services. Objective The aim of this study was to evaluate prescribing indicators and associated factors in primary health care in the northeast health district, Belo Horizonte, Brazil. Setting Twenty primary health care units in the Northeast Health District, Belo Horizonte, Brazil. Method The study was cross sectional. Indicators proposed by World Health Organization were used to evaluate rational use of medicines. Main outcome measure Indicators evaluated were average number of medicines per prescription, proportion of medicines with antibiotic, injectable, medicines prescribed by generic name and medicines present in the essential medicines list. Results Three hundred and ninety-nine patients were interviewed. The average number of medicines per prescription was 3.5 (SD 2.2). The proportion of medicines with antibiotic, injectable, medicines prescribed by generic name and medicines present in the essential medicines list was 17.8, 9.8, 94.9, 91.4%, respectively. Patient age ≥60 years was positively associated with number of medicines per prescription (P = 0.00). Conclusion In the northeast health district of Belo Horizonte, the proportion of prescriptions of antibiotics and injections, the adoption of prescribing by generic name and the prescribing of essential medicines were satisfactory in this study considering reference values for these indicators and international scientific literature. However, the mean number of prescribed medicines requires a more in-depth evaluation.

Comparing the Medicaid Retrospective Drug Utilization Review Program Cost-Savings Methods Used by State Agencies.

BACKGROUND: The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR and involves ongoing and periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug-drug interaction, or medically unnecessary care, implementing corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure prescription drug cost-savings generated from its DUR programs on an annual basis, but it provides no guidance or unified methodology for doing so. OBJECTIVES: To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid retrospective DUR program in federal fiscal years 2014 and 2015. METHOD: For each state, the cost-savings methodologies included in the Medicaid DUR 2014 and 2015 reports were downloaded from Medicaid's website. The reports were then reviewed and synthesized. Methods described by the states were classified according to research designs often described in evaluation textbooks. DISCUSSION: In 2014, the most often used prescription drugs cost-savings estimation methodology for the Medicaid retrospective DUR program was a simple pre-post intervention method, without a comparison group (ie, 12 states). In 2015, the most common methodology used was a pre-post intervention method, with a comparison group (ie, 14 states). Comparisons of savings attributed to the program among states are still unreliable, because of a lack of a common methodology available for measuring cost-savings. CONCLUSION: There is great variation among states in the methods used to measure prescription drug utilization cost-savings. This analysis suggests that there is still room for improvement in terms of methodology transparency, which is important, because lack of transparency hinders states from learning from each other. Ultimately, the federal government needs to evaluate and improve its DUR program.

Use of non-formulary drugs in children at a Brazilian teaching hospital: a descriptive study.

OBJECTIVE: To characterise the prescription of non-formulary drugs to children and neonates at a Brazilian teaching hospital and identify adverse drug reactions (ADRs), drug interactions, and prescription of potentially hazardous medicines. METHODS: A prospective exploratory study was carried out between January and May 2011 at the general paediatric wards and paediatric oncology, paediatric intensive care, and neonatal care units of the study hospital. Non-formulary drugs were categorised as approved, off-label, or not approved for use in children according to Brazilian compendia. Electronic health records were actively searched for ADRs and the possibility of moderate to severe interactions between non-formulary drugs and other medicines was determined with the Micromedex® database. RESULTS: Overall, 109 children or neonates received non-formulary drugs. Of these drugs, 54% were approved for use in children, 12.2% were used off-label, and 33.8% were not approved for use in children. Non-formulary drugs accounted for 13.4% of total prescriptions; 5.3% of drugs had a potential for interactions and five were possibly associated with ADRs. CONCLUSIONS: Prescription of non-formulary drugs not approved for use in children was common at the study hospital. Studies such as this provide information on the use of medicines for special indications and permit assessment of the relevance of hospital formularies for the paediatric population.

Calidad de prescripción de medicamentos en adultos mayores. EsSalud-2011

Objetivo: Evaluar la calidad de prescripción de medicamentos en adultos mayores, en el Hospital Nacional Almanzor Aguinaga Asenjo, en el periodo mayo-junio 2011. Material y Métodos: Descriptivo, Trasversal analítico. Población constituida por las prescripciones farmacológicas de los pacientes atendidos por consulta externa y/o hospitalización del servicio de Geriatría del Hospital Nacional Almanzor Aguinaga Asenjo. Se analizó los datos obtenidos por medio del software estadístico SPSS v 17.0, la calidad de prescripción de medicamentos se determinó utilizando la metodología del instrumento ACOVE modificado por Higashi y col. en el año 2004, el cual consta de 4 ejes, de los cuales para nuestro estudio se utilizó solo: 1) uso adecuado de medicamentos y 2) evitar medicación inadecuada. Resultados: La evaluación de la calidad de prescripción, mostró que los indicadores del eje 1 (uso de adecuado de medicamentos) presento 88% de cumplimiento y del eje 2 (evitar medicación inadecuada) fue del 66%. Conclusiones: La calidad de prescripción de medicamentos en adultos mayores, presenta porcentajes altos (>50%) de nivel adecuado de cumplimiento en la mayoría de los 26 indicadores de los Ejes 1 y 2, de la Metodología ACOVE (AssessingCare of Vulnerable Elder).(AU)

Objective: To evaluate the quality of drug prescription to elderly people at the Almanzor Aguinaga Asenjo National Hospital, during May ­ June, 2011. Material and Methods:Descriptive, Cross-sectional analytical. Population was constituted by the pharmacologic prescriptions of external consultation or hospitalized patients of the Geriatric service of the Almanzor Aguinaga Asenjo National Hospital. Obtained data was analyzed using the statistical software SPSS v17.0, the quality of drug prescription was determined using the instrument 'ACOVE', modified by Higashi and col., in the year 2004, which consists of 4 axis, from which we only used: 1) suitable usage of drugs and 2) avoiding unsuitable medication. Results: The evaluation of the prescription quality showed that the indicators of the axle 1 (use of adequate of medications) had 88 % of fulfillment and of the axle 2 (avoiding unsuitable medication) had 66 %. Conclusions: The quality of drug prescription in senior citizens presented high percentages (50 %) of an adequate level of fulfillment in most of the 26 indicators of the Axles 1 and 2 of the ACOVE (AssessingCare Vulnerable of Elder) Methodology.(AU)

Medicamentos e sondas de nutrição / Drugs and feeding tubes

OBJETIVO: Definir a prevalência de medicamentos incompatíveis com esta via em internados em instituição de longa permanência para idosos (ILPI) e em uso de sondas de nutrição. MÉTODOS: Análise de prescrições de internados em ILPI e em uso de sonda de nutrição há mais de 48 horas. Compararam-se os princípios ativos dos medicamentos prescritos, formas de apresentação e possibilidade de trituração com dados de literatura sobre viabilidade de fármacos por essa via. RESULTADOS: Observou-se sondas de nutrição em 57 pacientes (11,2 por cento do total de leitos), idade média de 65,6 ± 16,0 anos, 32 mulheres e 25 homens. Média de fármacos por via enteral: 5,6 ± 2,2. Itens medicamentosos nas prescrições: 316 divididos em 64 fármacos, sendo 129 itens (40,8 por cento do total) e 23 fármacos (35,4 por cento) impróprios para essa via. Medicamentos impróprios mais prescritos: captopril, fenitoína, ranitidina, omeprazol e complexo B. Apresentações alternativas foram encontradas para 15 (65,2 por cento) dos 23 fármacos inadequados por essa via. CONCLUSÃO: Sondas de nutrição, como via de administração medicamentosa em ILPI, apresentam significativo risco de prescrições incompatíveis com elas.

OBJECTIVE: Define the prevalence of drugs that are not compatible with this way of administration for inpatients in long term care facilities (LTCF), and their use in feeding tubes. METHODS: Analysis of prescriptions for LTCF inpatient who are using feeding tubes for more than 48 hours. The active ingredients, presentation and possibility of pulverizing drugs prescribed were compared to data in literature regarding the feasibility of enteral administration of drugs. RESULTS: Feeding tubes were observed in 57 patients (11.2 percent of the total of inpatients), mean age of 65.6 ± 16.0 years, 32 women and 25 men. Mean number of drugs administered enterally: 5.6 ± 2.2. Medication items in prescriptions: 316 divided into 64 drugs, with 129 items (40.8 percent of the total), and 23 drugs (35.4 percent) inappropriate for such administration. Inappropriate medications most often prescribed were: captopril, phenytoin, ranitidine, omeprazole, and B complex. Alternative presentations were found for 15 (65.2 percent) of the 23 drugs that were not appropriate for enteral administration CONCLUSION: Feeding tubes as a way of drug administration for LTCF have a significant risk of including prescriptions which are not compatible.

Avaliação de prescrições medicamentosas de um hospital universitário brasileiro / Evaluation of prescription data of a Brazilian teaching hospital

A prescrição é o ponto de partida para a utilização de medicamentos. O objetivo deste trabalho foi identificar a qualidade das informações presentes nas prescrições das enfermarias de um hospital universitário brasileiro. Foram coletadas 1.785 prescrições medicamentosas de pacientes maiores de 12 anos, de ambos os sexos, internados em enfermaria de 1º de janeiro a 30 de abril de 2004. A amostragem foi feita coletando-se todas as prescrições emitidas em um dia de cada semana durante o período de estudo, observando-se o intervalo de seis dias entre cada coleta. Foram avaliados dados relativos à identificação do paciente, do medicamento e do prescritor. Em 230 (12,9 por cento) prescrições não havia a idade do paciente. Em 224 (12 por cento) prescrições não constava à assinatura do prescritor. Em 16 por cento dos medicamentos prescritos foi detectada afalta de pelo menos uma informação relativa à posologia (dose, forma farmacêutica, via e/ou intervalo entre doses). Afalta destas informações é um obstáculo ao uso seguro de medicamentos, podendo levar ao uso inadequado e a reações adversas. Sugerimos intervenções educativas junto aos profissionais que lidam com o medicamento (desde a prescrição até sua utilização) e a implantação de monitoramento farmacoterapêutico dos pacientes. A participação mais ativa do farmacêutico na equipe de saúde também pode proporcionar tratamentos mais efetivos, seguros e convenientes aos pacientes hospitalizados. A assistência farmacêutica e a utilização de medicamentos em hospitais brasileiros precisam ser mais estudadas.

Prescription is the starting point for medicine use. The objective of this work was to identify the quality of the information contained in the prescriptions of a Brazilian university hospital. During the period January 1 to April 30,2004,1.785 drug prescriptions for inpatients older than 12 years were collected. The sample consisted of the total of prescriptions emitted on one day of each week during the study period, observing an interval of 6 days between each collection. Characteristics of the patient, the drug and the prescriber were evaluated. In 230 (12.9 percent) prescriptions the age of the patient was no mentioned. In 224 (12 percent) cases the prescriber had not signed the prescription. In 16 percent of prescriptions at least one item of the information regarding dosage (dosage, pharmaceutical form, route and/or time interval between doses) was missing. The lack of such information represents an obstacle for safe use of medicines and can lead to misuse and adverse reactions. We suggest educative interventions for the professionals who deal with medicines and pharmacotherapeutic monitoring of patients. The participation of the pharmacist in the health team can also contribute to more effective, safe and convenient therapies for the hospitalized patients. Pharmaceutical care and medicine use in Brazilian hospitals need further studies.

Esquizofrenia refratária / Refractory schizophrenia

OBJETIVO: O propósito deste artigo é o de revisar vários aspectos da esquizofrenia refratária levando em conta questões relacionadas à definição, aspectos clínicos, correlatos psicobiológicos, tratamentos farmacológicos e não farmacológicos, assim como preditores de resposta terapêutica. MÉTODO: Pesquisa no Medline, assim como artigos dos autores. RESULTADOS E CONCLUSÕES: Pelo menos um terço dos pacientes com esquizofrenia são refratários a tratamento com antipsicóticos e as evidências apontam a clozapina em monoterapia como a principal opção nesses casos. A politerapia com antipsicóticos não tem apoio em evidências. Ensaios clínicos recentes mostraram que a potencialização da clozapina com outros antipsicóticos não é superior ao placebo.

OBJECTIVE: The aim of the present paper is to review the various aspects of refractory schizophrenia regarding issues such as definitions, clinical aspects, psychobiological correlates, pharmacological and non-pharmacological treatment options and predictors of treatment response. METHOD: Medline search as well as articles of the authors. RESULTS AND CONCLUSIONS: Refractory schizophrenia affects at least one third of patients with schizophrenia and the best evidence shows that is monotherapy with clozapine remains the mainstay for the treatment of such condition. Antipsychotic polipharmacy is not supported by current evidence and recent clinical trials have shown that clozapine augmentation with antipsychotics has no benefit over placebo.

Reações adversas a medicamentos em uma população idosa hospitalizada / Adverse drug reactions among an elderly hospitalized population

Nesta pesquisa foram avaliados 186 idosos hospitalizados quanto ao aparecimento de reações adversas a medicamentos (RAM). Encontrou-se 199 RAM (1,07 por paciente). Para 11,3% dos idosos a RAM constituiu a causa da internação, para 17,2% estava presente à internação mas não como causa e 46,2% apresentaram RAM durante a hospitalização. As RAM sérias mais comuns foram a insuficiência renal aguda, a hipercalemia e a hipotensão postural. Concluiu-se que houve uma prevalência importante de RAM nesses pacientes, encontrando-se como fatores de risco significativos o número de diagnósticos, o número de medicamentos e o uso de medicamento inapropriado para idosos.

The present study evaluated the prevalence of adverse drug reactions (ADR) among 186 hospitalized elderly. A total of 199 ADR were founded (1.07 per patient). For 11.3% of the patients the ADR was the cause of hospitalization, for 17.2% the ADR was present at hospitalization but not as the cause and for 46.2% it was presented during hospitalization. The most common serious ADR were acute renal insufficiency, hyperkalemia and postural hypotension. We concluded that a significant prevalence of ADR was found among that patients, with the number of diagnosis, the number of drugs and the use of a drug considered to be inappropriate as risk factors.