AREAS COVERED: A review of articles that evaluated the cost of prescribing conventional (e.g. vitamin K antagonists) and NOACs (e.g. direct thrombin inhibitors and direct factor Xa inhibitors) in older adults.
EXPERT COMMENTARY: While the use of NOACs significantly increases the cost of the initial treatment for thromboembolic disorders, they are still considered cost-effective relative to warfarin since they offer reduced risk of intracranial haemorrhagic events. The optimum anticoagulation with warfarin can be achieved by providing specialised care; clinics managed by pharmacists have been shown to be cost-effective relative to usual care. There are suggestions that genotyping the CYP2C9 and VKORC1 genes is useful for determining a more appropriate initial dose and thereby increasing the effectiveness and safety of warfarin.
AREAS COVERED: We discussed various aspects of pharmacotherapeutic management in hospitalized patients with COVID-19: (i) susceptibility and severity of COVID-19 among individuals with diabetes, (ii) glycemic goals for hospitalized patients with COVID-19 and concurrent diabetes, (iii) pharmacological treatment considerations for hospitalized patients with COVID-19 and concurrent diabetes.
EXPERT OPINION: The glycemic goals in patients with COVID-19 and concurrent type 1 (T1DM) or type 2 diabetes (T2DM) are to avoid disruption of stable metabolic state, maintain optimal glycemic control, and prevent adverse glycemic events. Patients with T1DM require insulin therapy at all times to prevent ketosis. The management strategies for patients with T2DM include temporary discontinuation of certain oral antidiabetic agents and consideration for insulin therapy. Patients with T2DM who are relatively stable and able to eat regularly may continue with oral antidiabetic agents if glycemic control is satisfactory. Hyperglycemia may develop in patients with systemic corticosteroid treatment and should be managed upon accordingly.
AIMS: This study aimed to determine common combinations of medications used among women aged 77-96 years and to describe characteristics associated with these combinations.
METHODS: A cohort study of older women enroled in the Australian Longitudinal Study on Women's Health over a 15-year period was used to determine combinations of medications using latent class analysis. Multinomial logistic regression was used to determine characteristics associated with these combinations.
RESULTS: The highest medication users during the study were for the cardiovascular (2003: 80.28%; 2017: 85.63%) and nervous (2003: 66.03%; 2017: 75.41%) systems. A 3-class latent model described medication use combinations: class 1: 'Cardiovascular & neurology anatomical group' (27.25%) included participants using medications of the cardiovascular and nervous systems in their later years; class 2: 'Multiple anatomical group' (16.49%) and class 3: 'Antiinfectives & multiple anatomical group' (56.27%). When compared to the reference class (class 1), the risk of participants being in class 3 was slightly higher than being in class 2 if they had > 4 general practitioner visits (RRR 2.37; 95% CI 2.08, 2.71), Department of Veterans Affairs' coverage (RRR 1.59; 95% CI 1.36, 1.86), ≥ 4 chronic diseases (RRR 3.16; 95% CI 2.56, 3.90) and were frail (RRR 1.47; 95% CI 1.27, 1.69).
CONCLUSION: Identification of combinations of medication use may provide opportunities to develop multimorbidity guidelines and target medication reviews, and may help reduce medication load for older individuals.
METHODS: A cross-sectional study design with mixed qualitative and quantitative approaches was employed and data collection was carried out primarily using self-administered questionnaire.
RESULTS: Approximately half (52.5%, n = 74) of all respondents (n = 141) reported having personally encountered at least one case of academic dishonesty involving their peers. The results also revealed the significantly higher prevalence of various forms of academic misconduct among healthcare academics compared to their non-healthcare counterparts. Although respondents were generally conscious of the negative implications associated with academic dishonesty, more than half of all cases of misconduct were not reported due to the indifferent attitude among academics. Low levels of self-discipline and integrity were found to be the major factors leading to academic misdeeds and respondents opined that university managements should be more proactive in addressing this issue.
CONCLUSIONS: The outcome of this study should serve as a clarion call for all relevant stakeholders to start making immediate amends in order to improve the current state of affairs in academia.
METHODS: Prescriptions and costs data from Prescription Cost Analysis database and Interactive Drug Analysis Profiles presenting all suspected ADRs reported for each drug were examined. Pharmacy level prices were also obtained. Linear regression analysis was used to investigate the trends in prescribing and costs.
RESULTS: Prescribing and costs of metformin-based single pill drug combinations (as a percent mean change per year) saw an increase of 8.78% (95% Cl: 7.45%, 10.11%, p = 0.001) and 5.17% (95% Cl: 2.13%, 8.22%, p = 0.009) on average each year, respectively. Metformin was the most prescribed monotherapy drug between 2015 and 2020. The cost of prescribing metformin (as a proportion of total oral hypoglycaemic agents) has been reduced from 30% in 2015 to 17% in 2020. Metformin-dipeptidyl peptidase-4 inhibitor (e.g., metformin-sitagliptin) combination was the most popular metformin-based single pill drug combination. The number of adverse drug reactions per million items dispensed shows that metformin has the lowest adverse drug reactions per million items compared to other oral hypoglycaemic drugs.
CONCLUSIONS: Overall, an increase in prescription items can be seen for metformin-based single pill drug combinations along with an increase in their costs in primary care in England between 2015 and 2020. There was a declining trend for the number of ADRs reported per million prescription items dispensed for metformin-containing single pill combinations, even though their prescription rate increased.
Methods: This retrospective, multicenter, descriptive study enrolled consecutive hospitalized patients with COVID-19 who were admitted between March 1, 2021, and April 30, 2021, from three District Headquarter Hospitals in the Punjab province of Pakistan. We described patient and clinical characteristics and medications, stratified by COVID-19 severity during hospitalization: mild, moderate, and severe. In addition, an analytical study of drug utilization was conducted.
Findings: A total of 444 hospitalized patients with COVID-19 were included. Remdesvir, corticosteroids, antibiotics, and antithrombotics were administered to 45.0%, 93.9%, 84.9%, and 60.1% of patients, respectively. Specifically, dexamethasone was the most commonly used corticosteroid among the included patients (n = 405; 91.2%), irrespective of their clinical severity. Only 60.1% of patients hospitalized with COVID-19 in our cohort received antithrombotic therapy, and the prevalence of use was especially low (27.8%) in patients with mild illness. Of 444 patientsscreened, 399 (89.9%) patients had been discharged, and 45 patients (10.1%) died.
Implications: We provided an important glimpse into the utilization patterns of several medications of interest for the treatment of COVID-19 in Pakistan, which had not been entirely evidence-based, especially concerning systemic corticosteroids and antibiotics.
METHODS: The subjects of this study included 202 elderly (≥65 years) residents of 17 aged care homes in suburban peninsular Malaysia. Frailty was measured using the Groningen Frailty Indicator (GFI) score and independence in daily living was measured as KATZ activity of daily living score. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI) and 2015 Beers' criteria for Potentially Inappropriate Medication (PIM).
RESULTS: CNS medications constituted about 16% of the total, with an average of 0.8 ± 1.1 medications per resident, which reduced to 0.5 ± 0.8 medications after 3 months. Frailty (154/202) and polypharmacy (90/202) were highly prevalent in study subjects. Subjects on CNS medications had significantly higher GFI score (7.1 vs. 5.9; p = 0.031), polypharmacy (57.8 vs. 35.3%; p = 0.002), number of PIMs (0.9 vs. 0.2; p = 0.001), and mean summed MAI score (3.6 vs. 2.6; p = 0.015) than subjects not on CNS medications. Medication number was also significantly correlated with GFI (r = 0.194; p = 0.006) and KATZ (r = 0.141; p = 0.046) scores.
CONCLUSION: Frailty and polypharmacy were highly prevalent among aged care home subjects taking CNS medications. These findings support the notion that periodic regular medication review should improve the overall use of medications in elderly patients.
Methods: A qualitative research methodology was adopted to explore HIV/AIDS patients' views about disease screening. A semi-structured interview guide was used for in-depth patient interviews. All interviews were audio-recorded and were subjected to a standard content analysis framework for data analysis.
Results: Most patients were positive about screening and the value of knowing about their status early. However, fear of social stigma, discrimination, lack of support system and lack of public understanding were identified as major concerns affecting their willingness to be screened. They were concerned about mandatory screening being implemented without improvement in support system and public education.
Conclusions: Reluctance to seek HIV screening is an important factor contributing to transmission in developing countries. In the Malaysian context, efforts should be made to strengthen screening strategies especially in the most-at-risk populations to monitor the epidemic and target prevention strategies.
Practice implications: In a multicultural context, HIV preventive strategies must include disease awareness, including measure to tackle barriers towards screening.
STUDY DESIGN AND SETTING: Scientific databases were systematically searched to identify relevant trials of HCQ/CQ for the treatment of COVID-19 published up to 10 September 2020. The Cochrane risk-of-bias tools for randomized trials and non-randomized trials of interventions were used to assess risk of bias in the included studies. A 10-item Consolidated Standards of Reporting Trials (CONSORT) harm extension was used to assess quality of harm reporting in the included trials.
RESULTS: Sixteen trials, including fourteen randomized trials and two non-randomized trials, met the inclusion criteria. The results from the included trials were conflicting and lacked effect estimates adjusted for baseline disease severity or comorbidities in many cases, and most of the trials recruited a fairly small cohort of patients. None of the clinical trials met the CONSORT criteria in full for reporting harm data in clinical trials. None of the 16 trials had an overall 'low' risk of bias, while four of the trials had a 'high', 'critical', or 'serious' risk of bias. Biases observed in these trials arise from the randomization process, potential deviation from intended interventions, outcome measurements, selective reporting, confounding, participant selection, and/or classification of interventions.
CONCLUSION: In general, the quality of currently available evidence for the effectiveness of CQ/HCQ in patients with COVID-19 is suboptimal. The importance of a properly designed and reported clinical trial cannot be overemphasized amid the COVID-19 pandemic, and its dismissal could lead to poorer clinical and policy decisions, resulting in wastage of already stretched invaluable health care resources.
METHODS: Electronic databases and country-specific healthcare databases were searched to identify relevant studies/reports. The quality assessment of individual studies was conducted using the Newcastle-Ottawa Scale. Country-specific proportion of individuals with COVID-19 who developed ARDS and reported death were combined in a random-effect meta-analysis to give a pooled mortality estimate of ARDS.
RESULTS: The overall pooled mortality estimate among 10,815 ARDS cases in COVID-19 patients was 39% (95% CI: 23-56%). The pooled mortality estimate for China was 69% (95% CI: 67-72%). In Europe, the highest mortality estimate among COVID-19 patients with ARDS was reported in Poland (73%; 95% CI: 58-86%) while Germany had the lowest mortality estimate (13%; 95% CI: 2-29%) among COVID-19 patients with ARDS. The median crude mortality rate of COVID-19 patients with reported corticosteroid use was 28.0% (lower quartile: 13.9%; upper quartile: 53.6%).
CONCLUSIONS: The high mortality in COVID-19 associated ARDS necessitates a prompt and aggressive treatment strategy which includes corticosteroids. Most of the studies included no information on the dosing regimen of corticosteroid therapy, however, low-dose corticosteroid therapy or pulse corticosteroid therapy appears to have a beneficial role in the management of severely ill COVID-19 patients.