H2 inhalation therapy in patients with moderate COVID-19 (H2COVID): a prospective ascending-dose phase I clinical trial.

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has triggered a serious global health crisis, resulting in millions of reported deaths since its initial identification in China in November 2019. The global disparities in immunization access emphasize the urgent need for ongoing research into therapeutic interventions. This study focuses on the potential use of molecular dihydrogen (H2) inhalation as an adjunctive treatment for COVID-19. H2 therapy shows promise in inhibiting intracellular signaling pathways associated with inflammation, particularly when administered early in conjunction with nasal oxygen therapy. This phase I study, characterized by an open-label, prospective, monocentric, and single ascending-dose design, seeks to assess the safety and tolerability of the procedure in individuals with confirmed SARS-CoV-2 infection. Employing a 3 + 3 design, the study includes three exposure durations (target durations): 1 day (D1), 3 days (D2), and 6 days (D3). We concluded that the maximum tolerated duration is at least 3 days. Every patient showed clinical improvement and excellent tolerance to H2 therapy. To the best of our knowledge, this phase I clinical trial is the first to establish the safety of inhaling a mixture of H2 (3.6%) and N2 (96.4%) in hospitalized COVID-19 patients. The original device and method employed ensure the absence of explosion risk. The encouraging outcomes observed in the 12 patients included in the study justify further exploration through larger, controlled clinical trials. CLINICAL TRIALS: This study is registered with ClinicalTrials.gov as NCT04633980.

Much ado about nothing? Discrepancy between the available data on the antiviral effect of hydroxychloroquine in March 2020 and its inclusion in COVID-19 clinical trials and outpatient prescriptions.

OBJECTIVES: Many of the 2020 COVID-19 clinical trials included an (hydroxy)chloroquine ((H)CQ) arm. We aimed to juxtapose the state of science before April 2020 regarding the benefits of (H)CQ for viral infections with the number and size of the clinical trials studying (H)CQ and the volume of (H)CQ dispensed in France. STUDY DESIGN: We identified and analysed published scientific material regarding the antiviral activity of (H)CQ and publicly available data regarding clinical trials and drug dispensation in France. METHODS: We conducted a review of scientific publications available before April 2020 and a systematic analysis of COVID-19 clinical trials featuring (H)CQ registered on clinicaltrials.gov. RESULTS: Before April 2020, 894 scientific publications mentioning (H)CQ for viruses other than coronaviruses were available, including 35 in vitro studies (reporting an inconstant inhibition of viral replication), 11 preclinical studies (reporting no or disputable positive effects), and 32 clinical trials (reporting no or disputable positive effects). Moreover, 67 publications on (H)CQ and coronavirus infections were available, including 12 in vitro studies (reporting an inconstant inhibition of viral replication), two preclinical studies (reporting contradictory results), and no clinical trials. Meanwhile, 253 therapeutic clinical trials featuring an HCQ arm were registered in 2020, intending to enrol 246,623 patients. CONCLUSIONS: The number and size of (H)CQ clinical trials for COVID-19 launched in 2020 were not supported by the literature published before April 2020.

[Review of parenteral nutrition practices in four university hospital's pharmacies in Auvergne-Rhône-Alpes region]. / État des lieux des pratiques de nutrition parentérale dans quatre pharmacies à usage intérieur de centre hospitalier et universitaire de la région Auvergne-Rhône-Alpes.

OBJECTIVES: To carry out an assessment of parenteral nutrition (PN) practices in hospital pharmacies of the Auvergne-Rhône-Alpes region in order to explore a harmonisation of practices and a collaboration between the different centres. METHODS: Status of practices was carried out on the basis of an observational study inspired by the survey of the General Inspectorate of Social Affairs. It was carried out in Auvergne-Rhône-Alpes region in four university hospital pharmacies with a production unit of PN. It focused on the different stages of the PN process: prescription, formulation, compounding and quality control. It also covered the support processes such as the quality assurance system and the management of premises and equipment. RESULTS: Most preparations made in the region are individualized parenteral nutritional admixtures for paediatric and neonatal hospitalization departments. The production units of PN of each centre are located in premises in compliance with Good Preparation Practices. However, compounding equipment and raw materials used are heterogeneous in the four centres. All centres control the quality of their finished preparations. But, the performance of analytical control is disparate in terms of equipment and specifications. CONCLUSION: This assessment explains the similarities and differences in PN practices between various university hospitals in the Auvergne-Rhône-Alpes region and thus makes possible to provide a collective regional work to harmonise practices.

[What is the impact of changes in the drug circuit on dispensing activity during pharmaceutical duty?] / Quel impact des évolutions du circuit du médicament sur l'activité de dispensation durant la permanence pharmaceutique ?

INTRODUCTION: Pharmaceutical permanence (PP), outside the working hours of an in-house pharmacy (PUI), allows to guarantee the continuity of care in health-care institutions. A retrospective review of urgent drug dispensing was carried out in the light of changes in the drug circuit. MATERIALS AND METHOD: The analysis of drug dispensations was performed over a period from 2011 to 2019. The average number of drugs dispensed per shift, annual dispensations, and their variation by day of the week were studied. The increase is statistically significant and is found on both weekdays and weekends. Each drug was identified according to its Anatomical Therapeutic Chemical (ATC) classification. Data on the activities of our institution (number of hospitalizations, average length of stay) were also collected. RESULTS: In 2011, an average of 36 medications were dispensed per on-call period, compared with 77 in 2019 (a doubling of activity). The increase is statistically significant and is found on both weekdays and weekends. Neurological drugs and anti-infectives represent on average 43 % of the drugs dispensed. At the same time, there was a decrease in average length of stay and an increase in hospitalizations (-10 % and +16 % respectively). DISCUSSION: The increase in the average number of medications dispensed per shift is notable. It reflects a strong and gradual increase in activity, which was increased when the full vacuum cabinets (FVCs) were introduced, which improved the quality and safety of the pharmaceutical circuit. The revision of the allocations and the information of prescribers on the drug circuit will optimize the activity and refocus it on the pharmaceutical analysis of urgent needs.

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.

Validation of a tool for reporting pharmacists' interventions in everyday community pharmacy.

WHAT IS KNOWN AND OBJECTIVE: The French Society of Clinical Pharmacy (SFPC) asked a group of experts to adapt the SFPC hospital pharmacists' interventions reporting tool for use in community pharmacy practice. This study aimed to develop and validate a tool for the routine reporting of pharmacists' interventions in French community settings. METHODS: Two groups of community pharmacists coded reports of 60 typical pharmacists' interventions. One group was "experts" (n = 4) who had participated in the development of the tool (internal validation) and the other were "external" community pharmacists (n = 6), naïve to the tool (external validation). The Kappa coefficient was used to assess the inter-reliability of classification between participants. A 4-level Likert scale was used to evaluate ease of use and acceptability. RESULTS AND DISCUSSION: The tool we developed for recording and classifying PIs has 19 items; 11 non-ordered categories describing drug-related problems; and 7 items describing interventions. Two tables of definitions were provided to help community pharmacists in the classification. The mean κ statistic was (i) 0.63 for experts and 0.73 for external community pharmacists in categorizing drug-related problems and (ii) 0.69 for experts and 0.75 for external community pharmacists in categorizing interventions. WHAT IS NEW AND CONCLUSION: A specific tool for the documentation of pharmacists' interventions in community pharmacies is now available in French. Besides being useful to describe pharmacists' interventions in studies in community settings, it can be used to document the pharmaceutical patient record and to support the traceability process.

[Which useful Apps are installed on my smartphone as a clinical pharmacist?] / Quelles Apps utiles sur mon smartphone de pharmacien clinicien ?

Since the advent of PDAs (Personal Digital Assistants), smartphones and Apps have been widely adopted by medical professionals. This craze has increased since 2007 and the first generation iPhone. In this context, 3 questions emerged for the pharmacist that we studied in this review: (1) What Apps are available for practice and how to find them? (2) What is useful for practice? (3) What precautions should be taken?

[How to act when an alpha-blocker is associated with a potent inhibitor of CYP3A4]. / Conduite à tenir en cas d'association d'un alpha-bloquant et d'un inhibiteur puissant du cytochrome 3A4.

OBJECTIVE: Combination of alpha-blockers with potent CYP3A4 inhibitors is either contra-indicated or not recommended. We searched data supporting this classification and guiding prescribers when such an interaction occurs. METHODS: We analyzed reports published by the French agency for drug safety, reference books and performed search in databases of pharmacokinetics studies and case or case series related with these interactions. RESULTS: The classification of the potential severity of these interactions defined by the French agency for drug safety evolved over time. Our literature search did not identify any cases or case series reporting serious clinical consequences of such interactions and no pharmacoepidemiological studies on the association between alpha-blockers and inhibitors of CYP3A4. The content of the summaries of product characteristics indicate that the combination of ketoconazole with alfuzosin, silodosin and tamsulosin increases the area under the curve of the alpha-blocker 3 fold. CONCLUSION: Data demonstrating the clinical consequences of an association between alpha-blocker and a potent CYP3A4 inhibitor are lacking. The 3 fold increase of the area under the curve for alfuzosin, silodosin and tamsulosin associated with ketoconazole while the association with the two first is contra-indicated and is not recommended with the third raises questions. This lack of data leaves doctors and pharmacists in a situation of uncertainty on how to proceed when such an interaction occurs.

[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.

Trends in pharmacists' medication order review in French hospitals from 2006 to 2009: analysis of pharmacists' interventions from the Act-IP© website observatory.

WHAT IS KNOWN AND OBJECTIVES: The French Society of Clinical Pharmacy has developed a website, named Act-IP©, enabling hospital pharmacists to document and analyse pharmacists' interventions (PIs) proposed during medication order review when a drug-related problem is detected. This study analyses PIs documented in Act-IP© and assesses factors associated with physicians' acceptance of PIs. METHODS: PIs documented into Act-IP© over a 30-month period were analysed. Independent predictors of physicians' acceptance were assessed using multiple logistic regression. RESULTS AND DISCUSSION: A total of 34,522 PIs were registered by 201 pharmacists working in 59 hospitals. PIs were mostly related to 'dose adjustment' (25%), 'drug discontinuation' (20%) and 'drug switch' (19%). Of the 43,343 medications involved, 28% targeted drugs acting on the central nervous system, 17% anti-infective drugs and 16% cardiovascular drugs. Sixty-eight per cent of PIs were accepted by physicians (15% refusals and 17% non-assessable). Physicians' acceptance was significantly associated with 1/ drug group: antineoplastics and immunomodulators (OR = 2.29, CI 95[1.94-2.69]), anti-infectives (OR = 1.19, CI 95 [1.11-1.28]); 2/ type of intervention: drug switch (OR = 1.54, CI 95 [1.43-1.65]), drug discontinuation (OR = 1.38, CI 95 [1.29-1.48]), administration modality optimization (OR = 1.19, CI 95 [1.11-1.29]), addition of a new drug (OR = 1.12, CI 95 [1.00-1.24]); 3/ ward specialty: paediatrics (OR = 1.83, CI 95 [1.24-2.70]) and intensive care (OR = 1.34, CI 95 [1.10-1.64]); 4/ level of pharmacist integration in the ward: higher when the pharmacist is regularly in the ward compared with occasionally (OR = 0.74, CI 95 [0.70-0.79]) or never (OR = 0.68, CI 95 [0.60-0.75]) present. WHAT IS NEW AND CONCLUSION: This study highlights the role of routine pharmacist review of medication orders to prevent drug-related problems and gives new insights for a successful collaboration between physicians and pharmacists.

[Pharmacists' interventions conducted by hospital pharmacists on psychotropic drugs pharmacotherapy]. / Interventions pharmaceutiques émises par les pharmaciens sur les médicaments psychotropes.

INTRODUCTION: The French Society of Clinical Pharmacy (SFPC) through the special interest group "standardization and optimization of clinical pharmacy activities" stated that the study of pharmacists' interventions (PIs) conducted during prescription analysis was a priority. The SFPC developed an internet website named Act-IP(®) (http://www.sfpc.eu/fr/) where French speaking pharmacists were able to document PIs using a normalized codification. The objective of this study was to analyze medication-related problems linked to psychotropic drugs in hospital and to investigate PIs performed during prescription analysis. MATERIALS AND METHODS: This is a multicenter, retrospective, observational study using PIs involving psychotropic medications recorded between September 2006 and February 2009 on the Act-IP(®) website. RESULTS: Four thousand six hundred and twenty PIs recorded by 165 pharmacists in 57 hospitals were related to psychotropic drugs. Patients concerned by these drug-related problems were 64 years old on average. Seven categories of medication-related problems represented more than 69% of PIs (1.1-Non Conformity of the drug choice compared to the formulary; 4.1 Supratherapeutic dose; 5.3 Therapeutic redundancy; 6.2 Drug interaction (all levels of severity); 7.0 Adverse drug reaction; 8.3 Inappropriate drug form; 8.5 Inappropriate timing of administration). The PIs related to 9.2 Patient's non compliance, 2.0 Untreated indication and 3.2 Length of the treatment too short were infrequent (less than 1%). The most common type of intervention was the dose adjustment. Almost 45% of these PIs involved Zopiclone or Zolpidem prescription in elderly patients. Seven hundred and nine drug interactions were identified by pharmacists. The most common type of drug interaction considered the risk of cardiac arrhythmias due to antipsychotic medications. One hundred and thirty-three PIs concerned adverse drug reaction. The most frequent adverse drug reactions were a fall (36 PIs), hemorrhage/bleeding (32 PIs), drowsiness (12 PIs) and extrapyramidal syndrome (12 PIs). Antidepressant drugs were the greatest pharmacological class concerning adverse drug reaction. The overall acceptance rate was 57%. Eight hundred and seventy-four PIs (19%) were refused and 1111 (24%) were non-assessable. DISCUSSION: PIs avoids drug-related problems, such as the polyprescription of benzodiazepine or supratherapeutic dose. However, few PIs concern compliance to therapy or polyprescription of antipsychotic drugs. These two categories of medication-related problems are known to be an issue in mental health therapy. The lack of guidelines describing mental health pathology (such as the HAS guideline) is an obstacle for performing evidence-based PIs. The lack of information describing the context of the prescription is a limitation of this study. In order to improve their practice, pharmacists have to focus more on the context in which patients are evolving, and to take into account its entire situation based on Anglo-Saxon approaches. A second way is to identify clinical settings where PIs are useful and to describe PIs needed. Doctors and pharmacists should get together and talk about these clinical situations and PIs, because some may be misunderstood or disapproved by prescribers. This collaboration could take the form of a thesaurus combining clinical situation and PIs. CONCLUSION: It appears important for pharmacists to show their daily involvement in the quality of medical care. This feedback on medication problems encountered and PIs proposed should help prescribers to identify clinical situations at risk. Nevertheless, this study also suggests that progress is possible. Dialogue must allow pharmacists and physicians to delete misunderstandings about their practices.

Illness representation and treatment beliefs in liver transplantation: an exploratory qualitative study.

BACKGROUND: The objective of this study was to gain detailed insight concerning liver transplanted patients' representations about transplantation, graft rejection and immunosuppressive drugs to adapt the educational follow-up. PATIENTS AND METHODS: Semi-structured interviews were conducted with 8 patients. Each interview was recorded and fully transcribed. The verbatim was first coded according to the themes of the Common Sense Model and an inductive approach for the remaining text. RESULTS: Transplantation is perceived both as a recovery and a new chronic condition. Participants feel powerless in the face of the risk of graft rejection. This risk is perceived as out of control as it is not associated with specific symptoms and external causes. The individual knowledge gained about transplantation relies on real-life experience shared between patients. Many participants feel anxiety. It responds to stress caused by immunosuppressant medication intake, routine check-ups, potential side effects and chronicity of immunodepression. Messages stressing the importance of the tacrolimus in the medication therapy are strengthened by a pre-discharge pharmaceutical consultation. DISCUSSION AND CONCLUSIONS: This study suggests that healthcare providers should systematically seek to determine illness representations to optimize the educational follow-up. The patient education program for liver transplanted patients should include three types of intervention: individualized education, behavioral intervention and psychological support. It should provide a support for stress management and acceptance of the new chronic condition. The involvement of a clinical pharmacist is relevant.

Overdosed paracetamol (acetaminophen) prescriptions and subsequent pharmacist interventions in French hospitals.

INTRODUCTION: Little is known about the manner in which hospital pharmacists intervene for overdosed paracetamol prescriptions. The aim of this retrospective study was to describe the number and nature of pharmacists' interventions (PIs) for overdosed paracetamol adult prescriptions in hospitals. METHODS: We studied PIs that had been documented by pharmacists on the French Society of Clinical Pharmacy website tool between 2007 and 2010. We identified PIs that were related to paracetamol-containing prescriptions of one brand name only (type 1) particularly for patients with body weight ≤ 50 kg who were prescribed 4 g/day, and PIs that concerned the co-prescription of two paracetamol-containing products (type 2). RESULTS: Among 60 hospitals, seven did not report any paracetamol overdose-related PIs. Of the 53 hospitals that had at least one PI, 16 did not report any type 1 PIs. Bodyweight, liver disease, cirrhosis and chronic alcoholism were absent recorded criterion by most of the hospitals included in this study. DISCUSSION: Previously published studies have highlighted that the most frequent PIs are type 1, especially for patients whose body weight is ≤ 50 kg. We observed a broad variability in the number or type of PI that were related to overdosed paracetamol prescriptions compared with the total of all recorded types of PI. These data suggest that a significant number of hospital pharmacists are unaware of the risks that adult patients with low body weight are exposed to when receiving four grams paracetamol/day over several days. CONCLUSION: Pharmacist educational programs are needed.

[How can we evaluate medication adherence? What are the methods?]. / Comment évaluer l'adhésion médicamenteuse? Le point sur les méthodes.

INTRODUCTION: Identifying the difficulties of the patient towards following his medication regimen remains complex for the healthcare provider. This can be explained by the multidimensional character of medication adherence and, actually, the evaluation of this phenomenon. The objective of this work was to review the various methods to measure medication adherence. METHODS: We performed a search on PubMed completed by a manual one. RESULTS: Two types of measure are described. The "direct" methods are based on the measurement of the level of medicine or metabolite in blood or urine, measurement of biologic markers in blood or measurement of physiologic or clinical markers. The "indirect" methods are represented by the analysis of the administrative databases (prescription, rate of prescription refills); pill counts; electronic medication monitors; the self-reported measures by the patient or his close relations (questionnaires, diaries, interviews); the opinion of the healthcare provider. DISCUSSION: None of these tools supplants the others, each having limits either of feasibility, or reliability. In the end, it is the crossing of the information stemming from these various equipments that allows an idea on the adherence behavior of the patient and especially, dimensions on which he is most in trouble. CONCLUSION: The identification of these difficulties can allow the healthcare provider to develop behavioral and organizational skills tailored to the patient follow-up.

[Opportunities for medication errors and pharmacist's interventions in the context of computerized prescription order entry: a review of data published by French hospital pharmacists]. / Opportunités d'erreurs médicamenteuses et interventions pharmaceutiques dans le cadre de la prescription informatisée : revue des données publiées par les pharmaciens hospitaliers français.

INTRODUCTION: Computerized prescription order entry (CPOE) is accelerating in France. CPOE has been shown to reduce the occurrence of some medication errors, but evidence of a beneficial effect on clinical outcomes remains limited. In some cases, new error types have arisen with its use. The aim of this study was to investigate the French data on the nature and frequency of medication errors opportunities generated by the computer use, which led pharmacists to alert prescribers. METHODS: We performed a search on PubMed and CAT-INIST databases completed by a manual one. RESULTS: Ten publications, 11 abstracts and three personal communications were analysed. As part of the analysis of computerized prescriptions, the rate of pharmaceutical interventions due to CPOE ranges from 5.9 to 35% depending on the study. Duplicate orders, unit errors, the use of free text, parameterization flaws and poor usability of software are probably the root of many prescribing errors. Errors generated by the tool can have serious potential consequences. DISCUSSION: Pharmacist's interventions due to CPOE are common. It is not known whether variability of the percentage of pharmacist's interventions is due to software used or to conditions by witch studies were carried out. With implementation of CPOE in hospital, pharmacists must acquire new knowledge and new skills in order to prevent prescription errors generated by these tools and its misuse. CONCLUSION: Studies are urgently needed in order to identify the safest tools and to discard the most dangerous.

Management of voriconazole hepatotoxicity in a lung transplant patient.

Lung allograft airway colonization by Aspergillus species is common among lung transplant recipients. We report the case of a 46-year-old female lung transplant outpatient diagnosed with persistent pulmonary Aspergillus colonization (>50 colonies of Aspergillus terreus) 3 months after lung transplantation. Oral voriconazole 200 mg twice a day (b.i.d) was initiated shortly after diagnosis. Two days after voriconazole initiation, alkaline phosphatase (ALP), alanine transaminase (ALT), and aspartate transaminase (AST) were normal or slightly elevated (79, 37, and 21 UI/L, respectively). Ten days after the first voriconazole administration, these values started to increase. Maximum levels were reached after 20 days for ALP (369 UI/L) and at around 30 days for ALT and AST (223 and 188 UI/L, respectively). Instead of discontinuing antifungal therapy, it was decided to reduce the voriconazole dose to 100 mg b.i.d. This asymptomatic progressive cholestatic hepatitis resolved, and 10 days after dose reduction ALP, ALT, AST were at 136, 53, and 28 UI/L, respectively. Finally, therapeutic drug monitoring revealed adequate voriconazole plasma trough concentrations (0.98 mg/L) 30 days after dose reduction and no more colonies of Aspergillus were observed. Voriconazole-induced hepatotoxicity is a well known dose-dependent adverse drug reaction. This experience confirms the appropriateness of voriconazole dose reduction instead of therapy interruption in dose-dependent moderate liver toxicity. Voriconazole therapeutic drug monitoring before and after dose reduction may help to avoid drug accumulation and inappropriately low drug exposure, respectively.

Drug-related problems in medical wards with a computerized physician order entry system.

OBJECTIVE: Identification and estimation, by clinical pharmacists participating in routine medical rounds, of drug-related problems (DRPs), arising despite the use of a computerized physician order entry (CPOE) system. METHODS: An 18-month prospective study of DRPs through a CPOE was conducted by seven clinical pharmacists participating in ward activity. DRPs were identified by two independent pharmacists using a structured order review (French Society of Clinical Pharmacy instrument). RESULTS: A total of 29 016 medication orders relating to 8152 patients were analysed, and 2669 DRPs, involving 1564 patients (56% female; mean age 72.6 years), were identified representing 33 DRPs per 100 admissions. The most commonly identified DRPs were non-conformity to guidelines or contra-indication (29.5%), improper administration (19.6%), drug interaction (16.7%) and overdosage (12.8%). There were 429 different drugs associated with these DRPs. Cardiovascular drugs were the most frequently implicated (22.2%), followed by antibiotics/anti-infectives (13.3%) and analgesics/antiinflammatory drugs (11.3%). Different types of DRPs were closely associated with specific classes of drugs. CONCLUSIONS: Drug-related problems are common even after implementation of CPOE. In this context, routine participation of clinical pharmacists in clinical medical rounds may facilitate identification of DRPs. Pharmacists should be able to enhance patient safety through such involvement.

[Designing a tool to describe drug interactions and adverse events for learning and clinical routine]. / Développement d'un outil d'aide à la description des interactions et des effets indésirables médicamenteux pour la formation et la routine clinique.

Pharmacists play an important role in prescription analysis. They are involved in therapeutic drug monitoring, particularly for drugs with a narrow therapeutic index, prevention and management of drug interactions, and may be called in to identify side effects and adverse events related to drug therapy. For the polymedicated patient, the medical file, the list of prescribed drugs and the history of their administration may be insufficient to adequately assign the responsibility of a given adverse effect to one or more drugs. Graphical representations can sometimes be useful to describe and clarify a sequence of events. In addition, as part of their academic course, students have many occasions to hear about "side effects" and "drug interactions". However, in the academic setting, there are few opportunities to observe the evolution and the consequences of these events. In the course of their hospital training, these students are required to perform patient follow-up for pharmacotherapeutic or educational purposes and to comment case reports to physicians. The aim of this paper is to present a tool facilitating the graphic display of drug interaction consequences and side effects. This tool can be a useful aid for causality assessment. It structures the students' training course and helps them better understand the commentaries pharmacists provide for physicians. Further development of this tool should contribute to the prevention of adverse drug events.

[Drug supply chain safety in hospitals: current data and experience of the Grenoble university hospital]. / La sécurisation du circuit du médicament dans les établissements de santé : données actuelles et expérience du centre hospitalier universitaire de Grenoble.

Drug supply chain safety has become a priority for public health which implies a collective process. This process associates all health professionals including the pharmacist who plays a major role. The objective of this present paper is to describe the several approaches proven effective in the reduction of drug-related problem in hospital, illustrated by the Grenoble University Hospital experience. The pharmacist gets involved first in the general strategy of hospital drug supply chain, second by his direct implication in clinical activities. The general strategy of drug supply chain combines risk management, coordination of the Pharmacy and Therapeutics Committee, selection and purchase of drugs and organisation of drug supply chain. Computer management of drug supply chain is a major evolution. Nominative drug delivering has to be a prior objective and its implementation modalities have to be defined: centralized or decentralized in wards, manual or automated. Also, new technologies allow the automation of overall drug distribution from central pharmacy and the implementation of automated drug dispensing systems into wards. The development of centralised drug preparation allows a safe compounding of high risk drugs, like cytotoxic drugs. The pharmacist should develop his clinical activities with patients and other health care professionals in order to optimise clinical decisions (medication review, drug order analysis) and patients follow-up (therapeutic monitoring, patient education, discharge consultation).