A cross sectional survey of the views of newly registered pharmacists in Great Britain on their potential prescribing role: a cautious approach

AIM

To investigate newly registered pharmacists'' awareness of pharmacist prescribing and views on potential future roles as prescribers.

METHODS

A mailed questionnaire was sent to all 1658 pharmacists joining the Pharmacist Register in 2009.

RESULTS

The response rate was 25.2% (n = 418). While most (86.4%) expressed interest in prescribing training, they acknowledged training needs in clinical examination, patient monitoring and medico-legal aspects of prescribing. Two thirds of respondents (66.3%) thought the current requirement of being registered as a pharmacist for 2 years prior to commencing prescribing training was appropriate.

CONCLUSION

Newly registered pharmacists are cautious in their approach to taking on prescribing training and roles.     

Effects of angiotensin receptor blockers on endothelial nitric oxide release: the role of eNOS variants

AIM

Angiotensin II receptor blockers (ARBs) improve endothelial cell (EC)-dependent vasodilation in patients with hypertension through suppression of angiotensin II type 1 receptors but may have additional and differential effects on endothelial nitric oxide (NO) synthase (eNOS) function. To investigate this question, we tested the effects of various ARBs on NO release in ECs from multiple donors, including those with eNOS genetic variants linked to higher cardiovascular risk.

METHODS

The effects of ARBs (losartan, olmesartan, telmisartan, valsartan), at 1 µm, on NO release were measured with nanosensors in human umbilical vein ECs obtained from 18 donors. NO release was stimulated with calcium ionophore (1 µm) and its maximal concentration was correlated with eNOS variants. The eNOS variants were determined by a single nucleotide polymorphism in the promoter region (T-786C) and in the exon 7 (G894T), linked to changes in NO metabolism.

RESULTS

All of the ARBs caused an increase in NO release as compared with untreated samples (P < 0.01, n = 4–5 in all eNOS variants). However, maximal NO production was differentially influenced by eNOS genotype. Olmesartan increased maximal NO release by 30%, which was significantly greater (P < 0.01, n = 4–5 in all eNOS variants) than increases observed with other ARBs.

CONCLUSIONS

The ARBs differentially enhanced NO release in ECs in a manner influenced by eNOS single nucleotide polymorphisms. These findings provide new insights into the effects of ARBs on EC-dependent vasodilation and eNOS function.     

The renal protective effect of angiotensin receptor blockers depends on intra-individual response variation in multiple risk markers

Aims

Angiotensin receptor blockers (ARBs) are renoprotective and targeted to blood pressure. However, ARBs have multiple other (off-target) effects which may affect renal outcome. It is unknown whether on-target and off-target effects are congruent within individuals. If not, this variation in short term effects may have important implications for the prediction of individual long term renal outcomes. Our aim was to assess intra-individual variability in multiple parameters in response to ARBs in type 2 diabetes.

Methods

Changes in systolic blood pressure (SBP), albuminuria, potassium, haemoglobin, cholesterol and uric acid after 6 months of losartan treatment were assessed in the RENAAL database. Improvement in predictive performance of renal outcomes (ESRD or doubling serum creatinine) for each individual using ARB-induced changes in all risk markers was assessed by the relative integrative discrimination index (RIDI).

Results

SBP response showed high variability (mean –5.7 mmHg, 5^th to 95^th percentile –36.5 to +24.0 mmHg) between individuals. Changes in off-target parameters also showed high variability between individuals. No congruency was observed between responses to losartan in multiple parameters within individuals. Using individual responses in all risk markers significantly improved renal risk prediction (RIDI 30.4%, P < 0.01) compared with using only SBP changes. Results were successfully replicated in two independent trials with irbesartan, IDNT and IRMA-2.

Conclusions

In this post hoc analysis we showed that ARBs have multiple off-target effects which vary between and within individuals. Combining all ARB-induced responses beyond SBP provides a more accurate prediction of who will benefit from ARB therapy. Prospective trials are required to validate these findings.     

Inpatient prescribing errors and pharmacist intervention at a teaching hospital in Saudi Arabia

Background

Prescribing errors phenomena are very common within health care practice. These errors could result in adverse events and harm to patients. Pharmacist has an identified role in minimizing and preventing such errors.

Objectives

To detect the incidence of prescribing errors for hospitalized patient, to evaluate the clinical impact of pharmacist intervention on the detection of these errors, and to propose a program to overcome this problem in a teaching hospital.

Methods

For one month period starting November until December 2009, the inpatient medication charts and orders were identified and rectified by ward and practicing pharmacists within inpatient pharmacy services in a teaching hospital at King Khalid University Hospital (KKUH) at King Saud University, Riyadh, Kingdom of Saudi Arabia on routine daily activities. Data were collected and evaluated. The causes of this problem were identified.

Results

Approximately 113 (7.1%) prescribing errors were detected during the study period out of 1580 medication orders. Wrong strength and wrong administration frequency of the prescribed drug were the most errors encountered in the study, which were 35%, and 23%, respectively. Other errors such as wrong patient, wrong drug, and wrong dose were also encountered. Lack of knowledge of prescribing skill was the main cause of such errors.

Conclusion

Prescribing errors in teaching hospital within inpatient pharmacy services were noticed. The applied method in this project might be implemented as part of pharmacy quality assurance program for ongoing detection and monitoring of such errors. Technology in prescribing process will support the practitioner to reduce the incidence of these errors. Forcing ongoing professional communication and education within the medical team about prescribing errors now appear warranted.     

Implementation of a Standardized Discharge Time-out Process to Reduce Prescribing Errors at Discharge

Background:

To reduce prescribing errors occurring on discharge from the hospital, a standardized discharge time-out process was implemented on a general medicine service at Wake Forest Baptist Medical Center. In the time-out process, the multidisciplinary care team reviewed the patient’s medical records together to determine the optimal discharge medication regimen. This regimen was recorded on a time-out form and then was used to develop the patient’s discharge documents.

Objective:

To evaluate the impact of a standardized discharge time-out process on prescribing errors that occur as patients are discharged from a general medicine service.

Methods:

The medical records of all patients discharged from a general medicine service during 60-day periods before (“pre-group”) and after (“post-group”) implementation of a standardized discharge time-out process were retrospectively reviewed by an internal medicine physician to determine the presence of discharge prescribing errors.

Results:

There were 142 and 124 evaluable patients in the pre- and post-groups, respectively. Compliance with the time-out process was 93% in the post-group. At least 1 prescribing error was detected in 49 (34.5%) of the discharges in the pre-group and 17 (13%) of the discharges in the post-group (P < .0001). All of the errors noted in the post-group occurred in discharges in which a clinical pharmacist was not involved.

Conclusions:

A multidisciplinary, standardized discharge time-out process was associated with a dramatic reduction in prescribing errors when patients were discharged from a general medicine service. The time-out process is one strategy to improve patient safety at hospital discharge.     

A signal of increased risk of hypoglycaemia with angiotensin receptor blockers caused by confounding

AIMS

To study reporting of hypoglycaemia in angiotensin receptor blocker (ARB) users, and to investigate the possibility of confounding.

METHODS

The French pharmacovigilance database was examined for an association between hypoglycaemia and ARBs or other drugs using reports notified between 1996 and 2005. This association was also tested in patients taking or not taking antidiabetic agents (ADAs) using reporting odds ratios (ROR).

RESULTS

Hypoglycaemia was mentioned in 807 of the 174 595 reports entered during the study period. Overall hypoglycaemia was associated with the use of ARBs [ROR 2, 95% confidence interval (CI) 1, 3] and with the use of ADAs (ROR 32, 95% CI 27, 37). Moreover, the use of ARBs was associated with the use of ADAs (OR 7, 95% CI 6, 8). Considering separately reports with and without ADA, the association of ARB use with a higher risk of hypoglycaemia disappeared (OR 0.4, 95% CI 0.2, 0.8 and OR 2, 95% CI 1, 3, respectively).

CONCLUSION

A signal indicating an association between ARB use and hypoglycaemia was found in the French pharmacovigilance database. This signal disappeared after stratification on ADA use, thus suggesting confounding by indication. Moreover, the association between ARB use and hypoglycaemia was negative in ADA users.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• Spontaneous reporting is a valuable way to provide early detection for safety signals related to drug use.
• Due to the increasing size of pharmacovigilance databases, data-mining and other automated methods for signal generation are more and more often used.
• Even if these methods are very useful, they do not allow, for every particular association, an automated exploration of the multiple sources of confounding.

WHAT THIS STUDY ADDS

• An association between angiotensin receptor blockers use and hypoglycaemia was found in the French pharmacovigilance database.
• This signal disappeared after stratification on antidiabetic drug use, suggesting confounding by indication.
• The association between hypoglycaemia and angiotensin receptor blocker use was actually less than expected in concomitant antidiabetic drug users.

     

Telmisartan protects central neurons against nutrient deprivation-induced apoptosis in vitro through activation of PPARγ and the Akt/GSK-3β pathway

Aim： To determine whether angiotensin II receptor blockers （ARBs） could protect central neurons against nutrient deprivation-induced apoptosis in vitro and to elucidate the underlying mechanisms.
Methods： Primary rat cerebellar granule cells （CGCs） underwent B27 （a serum substitute） deprivation for 24 h to induce neurotoxicity, and cell viability was analyzed using LDH assay and WST-1 assay. DNA laddering assay and TUNEL assay were used to detect cell apoptosis. The expression of caspase-3 and Bcl-2, and the phosphorylation of Akt and GSK-3β were detected using Western blot analysis. AT1a mRNA expression was determined using RT-PCR analysis.
Results： B27 deprivation significantly increased the apoptosis of CGCs, as demonstrated by LDH release, DNA laddering, caspase-3 activation and positive TUNEL staining. Pretreatment with 10 μmol/L ARBs （telmisartan, candesartan or losartan） partially blocked B27 deprivation-induced apoptosis of CGCs with telmisartan being the most effective one. B27 deprivation markedly increased the expression of AT1a receptor in CGCs, inhibited Akt and GSK-3β activation, decreased Bcl-2 level, and activated caspase-3, which were reversed by pretreatment with 1 μmol/L telmisartan. In addition, pretreatment with 10 μmol/L PPARγ agonist pioglitazone was more effective in protecting CGCs against B27 deprivation-induced apoptosis, whereas pretreatment with 20 μmol/L PPARγ antagonist GW9662 abolished all the effects of telmisartan in CGCs deprived of B27.
Conclusion： ARBs, in particular telmisartan, can protect the nutrient deprivation-induced apoptosis of CGCs in vitro through activation of PPARγ and the Akt/GSK-3β pathway.     

Use of evidence-based therapy at discharge for patients with acute myocardial infarction: retrospective audit of medical records

Background:

Various guidelines are available outlining optimal therapy for patients with acute myocardial infarction. Canadian institutions providing care for such patients have been encouraged to evaluate their care processes using specific indicators.

Objective:

To determine the proportion of patients with acute myocardial infarction discharged from a single health authority for whom acetylsalicylic acid (ASA), adrenergic β-receptor antagonists (β-blockers), angiotensin-converting enzyme (ACE) inhibitors, or 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) had been prescribed.

Methods:

Patients treated over a 12-month period (April 1, 2004, to March 31, 2005) for whom the most responsible diagnosis was acute myocardial infarction were eligible for inclusion in this review. Retrieved data included diagnosis, demographic information, comorbidities, and medications at the time of admission and discharge. Rates of discharge prescribing for the 4 drug classes were calculated for all patients and for “ideal” patients (those without documented contraindications). Rates were compared with published benchmark values.

Results:

Medical records for a total of 346 eligible patients were reviewed. Mean age was 65.3 years (standard deviation 13.4 years), and 226 (65.3%) of the patients were male. The coded diagnosis was ST-elevation myocardial infarction for 91 patients (26.3%), non-ST-elevation myocardial infarction for 164 (47.4%), and myocardial infarction not specified for 91 (26.3%). For “ideal” patients, the prescribing rates were 99.0% (308 of 311 patients) for ASA, 96.3% (310 of 322 patients) for β-blockers, 90.4% (264 of 292 patients) for ACE inhibitors, and 88.8% (278 of 313 patients) for statins.

Conclusions:

Rates of prescribing of ASA, β-blockers, ACE inhibitors, and statins for “ideal” patients discharged after treatment for acute myocardial infarction exceeded the published Canadian benchmark rates (≥ 90% for ASA, ≥ 85% for β-blockers and ACE inhibitors, ≥ 70% for statins).     

A point prevalence survey of antibiotic prescriptions: benchmarking and patterns of use

AIM

The aim of the study was to assess current patterns of antibiotic prescribing and the impact of a hospital antibiotic policy on these practices.

METHODS

The study involved collecting information regarding hospitalized patients utilizing the ESAC audit tool.

RESULTS

In the study site hospital, the use of the restricted agents was low whilst the use of the non-restricted agents was high. Compliance with the hospital antibiotic guidelines was 70%.

DISCUSSION

The findings identified monitoring non-restricted antibiotics and compliance with guidelines as targets for quality improvements in our hospital. Point prevalence surveys may offer a simple method of monitoring antibiotic policies, thus, informing antibiotic stewardship.