Advanced pharmacist practice: where is the United Kingdom in pursuit of this ‘Brave New World’?

International Journal of Clinical Pharmacy - Pharmacy has developed many novel patient-facing roles across the globe, typically delivered through the lens of pharmaceutical care. The macro-level...     

Care of the stroke patient—communication between the community pharmacist and prescribers in the Republic of Ireland

Objective This study sought to examine the perceptions that community pharmacists have of communication with prescribers in both primary and secondary care in Ireland, with respect to care of stroke patients. Setting Community pharmacies across Ireland, stratified into the four representative administrative regions. Method Survey using a structured postal questionnaire. Main outcome measure Perceptions of communication with prescribers based in primary and secondary care; pharmacy and pharmacy premises demographics. Results A response rate of 52% (n = 314) was achieved. Community pharmacists’ perceptions of information provision from secondary care were low, the majority (83%) never received any information from the hospital, although they would welcome it. Communication with hospital based prescribers was considered by most (93%) to be poor. The majority (greater than 75%) of respondents expressed a desire for greater information provision concerning a stroke patient’s medication and diagnostic information. Pharmacists’ perceptions of interaction with general practitioners were generally regarded as good (63%) although information provision in both directions between pharmacist and general practitioner could be improved. Conclusion The findings of this study indicated that community pharmacists perceive that there is room for improvement in the communication between themselves and prescribers in the primary and secondary care settings, concerning the care of the stroke patient. This highlights the need for the development of formal communication channels between community pharmacists and other members of the healthcare team involved in the care of the stroke patient. However, the challenges of communicating patient information across healthcare sectors are recognized.     

Evaluation of the cost-effectiveness of rifaximin-α for the management of patients with hepatic encephalopathy in the United Kingdom

Objective: Rifaximin-α 550?mg twice daily plus lactulose has demonstrated efficacy in reducing recurrence of episodes of overt hepatic encephalopathy (OHE) and the risk of hepatic encephalopathy (HE)-related hospitalizations compared with lactulose alone. This analysis estimated the cost effectiveness of rifaximin-α 550?mg twice daily plus lactulose versus lactulose alone in United Kingdom (UK) cirrhotic patients with OHE.

Method: A Markov model was built to estimate the incremental cost-effectiveness ratio (ICER). The perspective was that of the UK National Health Service (NHS). Clinical data was sourced from a randomized controlled trial (RCT) and an open-label maintenance study in cirrhotic patients in remission from recurrent episodes of OHE. Health-related utility was estimated indirectly from disease-specific quality of life RCT data. Resource use data describing the impact of rifaximin-α on hospital admissions and length of stay for cirrhotic patients with OHE was from four single-center UK audits. Costs (2012) were derived from published sources; costs and benefits were discounted at 3.5%. The base-case time horizon was 5 years.

Results: The average cost per patient was £22,971 in the rifaximin-α plus lactulose arm and £23,545 in the lactulose arm, a saving of £573. The corresponding values for benefit were 2.35 quality adjusted life years (QALYs) and 1.83 QALYs per person, a difference of 0.52 QALYs. This translated into a dominant base-case ICER. Key parameters that impacted the ICER included number of hospital admissions and length of stay.

Conclusion: Rifaximin-α 550?mg twice daily in patients with recurrent episodes of OHE was estimated to generate cost savings and improved clinical outcomes compared to standard care over 5 years.     

Self-medication in Poland: the pharmacist’s advisory role in Warsaw

Background

Easy access favours the informative role that pharmacists play in Poland with regard to the proper use of medicinal products as well as preventing illness and promoting health.

Objective

The aim of the present study was to define situations in which patients ask a pharmacist for advice and to identify the most important factors that affect the patients’ decisions in seeking advice from a pharmacist.

Method

n all, 101 patients (69 women, 32 men) aged 19–67 years participated in the study. The study was conducted using a structured interview research method. Patients were asked to answer a set of closed-ended questions related to their habits regarding the purchase of medicines and the factors that affected their decision to seek the advice of a pharmacist.

Main outcome measure

Factors determining the choice to contact a pharmacy.

Results

Patients seldom asked pharmacists for advice: 77 of the patients “rarely” or “never” went to a pharmacy to consult the pharmacist. When patients did ask the pharmacist for advice, it was mainly concerning the choice of over-the-counter medicines. The most important reason for patients visiting a pharmacy for advice was the large number of pharmacies in Poland and their ease of access; the long queues of people in busy pharmacies and the lack of confidentiality in the pharmacy were considered negative factors.

Conclusion

The current advisory role of pharmacists in Poland seems of minimal importance to the public.     

Mental Health Curricula at Schools of Pharmacy in the United Kingdom and Recent Graduates’ Readiness to Practice

Objective. To assess mental health education in the undergraduate pharmacy curricula in the United Kingdom and gauge how well prepared graduates are to manage mental health patients.Method. The authors conducted semi-structured telephone interviews with pharmacy educators and administered an electronic self-administered survey instrument to pharmacy graduates.Results. The mental health conditions of depression, schizophrenia, bipolar disorder, and Parkinson disease were taught, in detail, by all schools, but more specialized areas of mental health (eg, personality disorder, autism) were generally not taught. Just 5 of 19 schools attempted to teach the broader social aspects of mental health. A third of the schools provided experiential learning opportunities. Graduates and recently registered pharmacists stated that undergraduate education had prepared them adequately with regard to knowledge on conditions and treatment options, but that they were not as well prepared to talk with mental health patients and deal with practical drug management-related issues.Conclusion. The mental health portion of the undergraduate pharmacy curricula in colleges and schools of pharmacy in the United Kingdom is largely theoretical, and pharmacy students have little exposure to mental health patients. Graduates identified an inability to effectively communicate with these patients and manage common drug management-related issues.     

An overview of the prevalence of 25‐hydroxy-vitamin D inadequacy amongst elderly patients with or without fragility fracture in the United Kingdom

ABSTRACT

Background: Many studies have investigated the prevalence of 25-hydroxy-vitamin D inadequacy throughout the world and found a high prevalence of 25-hydroxy-vitamin D inadequacy in older patients, particularly those with fragility fracture.

Scope: To review the findings from vitamin D audits from six units across the UK and compare with previously published data from around the world. Results from four units have been previously published (Belfast, Glasgow, London and Medway) and this paper presents new data from Southampton and Carshalton, and further sub-analysis of the data from Medway.

Findings: Three audits of patients attending metabolic bone clinics (Carshalton, Medway and Southampton) identified 954 patients, of which overall 49% had a prior fragility fracture. Mean 25‐hydroxy-vitamin D levels ranged from 47.7?nmol/L to 62.4?nmol/L. Of these patients 72.9–88.9% had a 25‐hydroxy-vitamin D level < 80?nmol/L, 68.8–83.3% < 70?nmol/L and 37.5–59.1% < 50?nmol/L. The mean age of patients ranged from 60.0 to 67.5 years. Sub-analysis of the data by fracture status revealed that patients with fracture had lower mean levels of 25‐hydroxy-vitamin D compared with patients without fracture. This was statistically significant in the sub-analysis of the Medway data (45.3?nmol/L versus 49.9?nmol/L, p < 0.005).

Three audits identified 330 patients with fragility fracture. Audits from Glasgow and Belfast specifically identified patients with fragility fracture. A subgroup of patients with fracture aged over 50 years from the Medway audit was also included in this group. Mean levels of 25‐hydroxy-vitamin D ranged from 40.0?nmol/L to 52.3?nmol/L. 83.7–96.4% of patients had a 25‐hydroxy-vitamin D level < 80?nmol/L, 73.3–89.7% < 70?nmol/L and 55.8–73.2% < 50?nmol/L. The mean age of patients ranged from 65.3 to 68.6 years.

The audits carried out in Belfast and Medway were also divided by supplementation status. Mean 25‐hydroxy-vitamin D levels were 48.1?nmol/L in Belfast and 40.5?nmol/L in Medway in the patients not receiving supplements and 53.8?nmol/L and 59.9?nmol/L, respectively in the patients receiving supplements. The difference was statistically significant in the Medway audit (?p < 0.0001), but not in the smaller Belfast audit (?p = 0.216). As would be expected, the prevalence of 25‐hydroxy-vitamin D inadequacy was higher in the patients not receiving supplements, for example at the 70?nmol/L threshold: 82.6% versus 67.1% in Belfast and 89.6% versus 72.7% in Medway.

Three audits specifically identified 694 patients with hip fracture (Belfast, Glasgow and London). Mean levels of 25‐hydroxy-vitamin D ranged from 24.7?nmol/L to 36.1?nmol/L. Of these patients 90.7–99.0% had a 25‐hydroxy-vitamin D level < 80?nmol/L, 88.4–98.0% < 70?nmol/L and 81.6–92.7% < 50?nmol/L. The mean age of patients ranged from 73.4 to 80.5 years.

Conclusion: Inadequate 25‐hydroxy-vitamin D levels are extremely common in the elderly and particularly so in patients with fragility fracture – specifically in those with hip fracture. Although the differing audit specifications and assay techniques used make direct comparisons difficult, the data do provide a snapshot of 25‐hydroxy-vitamin D status across the UK and are consistent with those previously observed elsewhere in Europe and the rest of the world.     

GPs’ views on patient drug use and the pharmacist’s role in DRP management

Objective The aim of this study was to examine general practitioners’ (GPs’) views on (1) patients’ drug-related problems (DRPs) and noncompliance and (2) the role of pharmacy practitioners in DRP management. Method A brief questionnaire was designed and distributed to 224 GPs in Sweden. Results Totally 152 GPs responded (68%). Most felt that pharmacy practitioners could improve patients’ drug use by identifying DRPs. A majority of the GPs also found presentations and analyses of their local pharmacies’ DRP documentation valuable. According to the GPs’ experiences, adverse drug effects and therapy failure were the most salient problems in patients’ drug use. Half of the doctors believed that 50–75% of their patients were compliant with their prescribed drug treatments. A majority of the GPs found a 75–95% degree of compliance acceptable. Conclusion The surveyed GPs demonstrated very positive attitudes towards the role of pharmacy practitioners in improving patients’ drug use and managing DRPs. The GPs realised that many patients were not compliant with their prescribed drug treatments and accepted an imperfect compliance.     

The pharmacist’s role in advocating for the health care of immigrants in detention centers

ObjectivesThe primary objectives of this commentary are to (1) summarize the role of pharmacists as an advocate for the health care and appropriate use of medications of migrants in immigration detention centers and (2) describe methods to advocate for this vulnerable population.SummaryThere is a current humanitarian crisis occurring within the United States that violates the responsibilities and values held by members of the profession of pharmacy. Reports by reputable news organizations and members of U.S. Congress have shared that there have been inappropriate distribution and use of medications in migrant detention centers along the southern border. Specific instances have been described, including lack of access to vaccinations and vital medications to control chronic conditions and treat acute conditions. The role of the pharmacist is to ensure safe and effective use of medications. This role is not being fulfilled at migrant detention centers in the United States. By advocating to elected leaders, the Department of Homeland Security, and Customs Border and Protection for legislation that ensures the appropriate use and access of medications for migrants in immigration detention centers, pharmacists can push for the appropriate care for this vulnerable patient population.ConclusionThe professional values of a pharmacist should not be hindered by a border or the citizenship of a patient. As is stated in the Oath of a Pharmacist, pharmacists must “consider the welfare of humanity and relief of suffering [their] primary concern.” Through advocacy, pharmacists and student pharmacists can uphold their professional ethics and roles on the health care team by advocating for the care of a patient population that needs the profession’s help.     

Premature cardiovascular events and mortality in south Asians with type 2 diabetes in the United Kingdom Asian Diabetes Study – effect of ethnicity on risk

Abstract

Background/Aim:

People of south Asian origin have an excessive risk of morbidity and mortality from cardiovascular disease. We examined the effect of ethnicity on known risk factors and analysed the risk of cardiovascular events and mortality in UK south Asian and white Europeans patients with type 2 diabetes over a 2 year period.     

‘Superbugs’: new antibacterials in the pipeline

‘Superbugs’ in the context discussed herein are Gram-positive pathogens that are multi-resistant to common antibiotic classes. Although many of these organisms were recently susceptible only to vancomycin, therapeutic options are now expanding with the recent approvals for the use of quinupristin-dalfopristin and linezolid against some of these pathogens. Compounds currently under development include cell-wall active agents, such as anti-MRSA cephalosporins, and the glycopeptide LY-333328 to treat resistant Gram-positive infections. More active topoisomerase inhibitors, such as gemifloxacin, sitafloxacin and non-fluoroquinolones, are being evaluated for treatment of multi-drug resistant streptococci, as is the penem faropenem. Novel protein synthesis inhibitors, such as new ketolides and the glycylcycline GAR-936, are also in development; in addition, the lipopeptides daptomycin and HMR-1043 are being evaluated. Safety and efficacy in the treatment of serious infections are two major issues that will determine the eventual success of these agents.     

Safety and efficacy of newly formulated selegiline orally disintegrating tablets as an adjunct to levodopa in the management of ‘off’ episodes in patients with Parkinson's disease

ABSTRACT

Objective: Patients receiving levodopa for Parkinson's disease experience motor fluctuations and immobility (‘off’ episodes) between doses. This study assessed adjunctive Zelapar^? (selegiline orally disintegrating tablet (ODT)) for managing off episodes and for long-term safety.

Methods: This open-label extension evaluated long-term safety, efficacy, and tolerability of adjunctive selegiline ODT 2.5?mg in patients who completed either of two large phase 3 double-blind studies. The study was to end after 12 months but was amended to be open-ended. Investigators could increase levodopa doses and introduce controlled-release formulations of levodopa or dopamine agonists if warranted. Additionally, results of a small randomized trial of open-label selegiline ODT 1.25?mg in comparison to conventional selegiline was added only to the safety analysis. Efficacy variables included changes in daily off time and Patient's Global Impression of Improvement (PGI-I) and Clinical Global Impressions Severity of Disease (CGI-S) ratings. Safety assessments included adverse events and oropharyngeal findings.

Results: This study enrolled 254 patients: 248 from the large phase 3 studies (efficacy analysis) and an additional six from the prior open-label comparison (safety analysis) in order to evaluate a larger population for safety purposes. Mean reduction from baseline in daily off time was 9.4% (1.6?h) for patients previously given selegiline ODT, 6.0% (1.2?h) for those switched from placebo, and 8.1% (1.4?h) overall. PGI-I and CGI-S ratings indicated little or no change from baseline. Treatment-related adverse events occurred in 132 (52%) patients. No severe oral irritations were attributed to selegiline ODT or prompted discontinuation.

Conclusions: Long-term selegiline ODT 2.5?mg/day was effective, safe, and well tolerated in patients with Parkinson's disease experiencing off episodes during levodopa therapy.     

Meeting Report: Metabolites in Safety Testing (MIST) Symposium—Safety Assessment of Human Metabolites: What’s REALLY Necessary to Ascertain Exposure Coverage in Safety Tests?

In the 2012 AAPS metabolites in safety testing (MIST) symposium held in Chicago, IL, USA, on October 15, 2012, regulatory experts and industrial scientists joined together to discuss their perspectives and strategies in addressing contemporary MIST recommendations (FDA 2008, International Conference on Harmonization (ICH) M3(R2), ICH M(R2) Q&A). Overall, these regulatory guidances indicate that metabolites identified in human plasma should circulate at similar or greater concentrations in at least one of the animal species used in nonclinical safety assessment of the parent drug. However, synthetic standards for the metabolites often do not exist or they are intractable to synthesize, thus introducing multiple challenges in drug development for the quantitative comparison of metabolites between human and animals. A tiered bioanalytical strategy for metabolite analysis is a prevalent approach to demonstrate coverage in animals. Recent developments in bioanalytical methodology have yielded several time- and resource-sparing strategies to provide fit-for-purpose approaches that can enable critical decisions related to metabolite quantification and monitoring in plasma. This report summarizes the presentations and panel discussions at the symposium.     

‘Ethnobotanicals’ and ‘Spice zombies’: new psychoactive substances in the mainstream media

Abstract

This paper observes and compares discursive framings of new psychoactive substances (NPS) in parts of the mainstream media in Romania and the United Kingdom. It assembles a corpus of about 800 news items and looks into samples of reporting from 2009 to 2017. In Romania, NPS or more generally ‘ethnobotanicals’ were first associated with gullible youths experimenting with what appeared to be synthetic cannabinoids only for public attention to briefly move on to stimulant powders displacing heroin among injecting users, later on. In the UK, the synthetic cathinone mephedrone was presented by tabloids as a ‘menace’ to teenagers and other young users, only for synthetic cannabinoids to eventually be linked with rough sleepers and other vulnerable groups. Through this, qualitative distinctions are shown in the portraying of a middle-class notion of naïve but ‘clean’ youth, valuable in itself, and the portraying of abject underclass users, mostly as a threatening and contagious presence. Beyond alarmism and exaggeration, drug news reporting thus also appears rooted in class politics and structural inequalities where NPS meet with the lived conditions and spoiled identities of disadvantaged groups.     

A comparison of ‘Integrin’ and ‘Tacitin’ in the treatment of anxiety neurosis in general practice

Summary

A double-blind trial was carried out in general practice over a 4-week period on 76 patients with anxiety neurosis to compare the efficacy of ‘Integrin’ (oxypertine) with that of ‘Tacitin’ (benzoctamine hydrochloride). A standard daily dose of 30?mg. of either drug was used. Patients were assessed on a modified Hamilton Anxiety Scale. Changes in total score and in specific scores for anxious and for depressed mood were examined. Both agents produced a highly significant improvement and were equally effective. Side-effects were acceptably low in both.