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Aims: The contemporary prescription patterns of antidiabetic drugs following guideline changes recommending metformin as first‐line gestational diabetes (GDM) pharmacotherapy is underexplored. We aimed to examined use of metformin and insulin during pregnancy among women with GDM over 20 years in the United Kingdom. Methods: We conducted a population‐based cohort study using linked data from the Clinical Practice Research Datalink, its pregnancy register and Hospital Episode Statistics from 1998 to 2017. We included pregnancies of women without prior diabetes history who received GDM diagnosis or initiated an antidiabetic drug after 20 weeks gestation. Patient‐level and practice‐level characteristics were compared between metformin initiators and insulin initiators. We described trends of initiating metformin as first‐line treatment and described time to initiation of rescue insulin overall, and by body mass index among metformin initiators. Results: Our cohort included 5633 pregnancies from 5393 women with GDM, of whom 38.9% initiated pharmacotherapy (41% insulin, 59% metformin). Metformin prescriptions (as opposed to insulin) increased substantially, from <5% of pregnancies before 2007 to 42.5% in 2008. Over 85% of pregnancies that were prescribed pharmacotherapy were prescribed metformin as first‐line treatment in 2015. Among metformin initiators, 16% initiated rescue insulin, typically occurring within 40 days of metformin initiation. Choice of GDM pharmacotherapy varied by characteristics, including smoking, obesity, race/ethnicity and general practice regions. Conclusions: Metformin was the most prescribed medication for GDM, with large increases over the past 2 decades. The increasing use of oral‐antidiabetic drugs during pregnancy, consistent with other regions, highlights the need for future studies examining effectiveness and safety of antidiabetic drug use during pregnancy. [ABSTRACT FROM AUTHOR]

Aims: The combined oral contraceptive (COC) is the most commonly used hormonal contraceptive in Aotearoa New Zealand (Aotearoa/NZ). Currently there is limited data available on who uses COC in Aotearoa/NZ. The aims were to (i) define the population of reproductive‐aged females in Aotearoa/NZ in 2018 and identify the rate of COC use among this group and (ii) describe the sociodemographic and geographic characteristics of the population of COC users compared to the general population of reproductive‐aged females in 2018. Methods: This whole‐of‐population cross‐sectional study used the Integrated Data Infrastructure, a large research database managed by Statistics New Zealand. Females aged 16–50 years with complete sociodemographic and geographic information in 2018 from Aotearoa/NZ's estimated resident population were included. COC dispensing records to this cohort were identified from the national Pharmaceutical Collection. This paper reports descriptive counts of COC use and employs generalised linear regression with a binomial distribution and a log link to estimate adjusted risk ratios (aRR) of COC use for key sociodemographic and geographic subgroups. Results: Of 1 113 750 individuals in the study, 159 789 (14.3%) were dispensed as COC in 2018. European/other individuals were most likely to use COC (aRR: 2.72, 2.67–2.78), and Pacific Peoples were least likely (aRR: 0.56, 0.55–0.58) to use COC. Individuals residing in the most deprived quintile had less COC use than individuals in the least deprived quintile (aRR: 0.73, 0.72–0.74). Conclusion: Our study is able to highlight significant disparities in use by ethnicity, area‐level deprivation, and geographic factors. [ABSTRACT FROM AUTHOR]

Background and aim: From 1 February 2018, codeine was rescheduled from an over‐the‐counter (OTC) to a prescription‐only medicine in Australia. We used wastewater‐based epidemiology to measure changes in population codeine consumption before and after rescheduling. Methods: We analysed 3703 wastewater samples from 48 wastewater treatment plants, taken between August 2016 and August 2019. Our samples represented 10.6 million people, 45% of the Australian population in state capitals and regional areas in each state or territory. Codeine concentrations were determined by liquid chromatography–tandem mass spectrometry and converted to per‐capita consumption estimates using the site daily wastewater volume, catchment populations and codeine excretion kinetics. Results: Average per‐capita consumption of codeine decreased by 37% nationally immediately after the rescheduling in February 2018 [95% confidence interval (CI) = 35.3–39.4%] and substantially in all states between 24 and 51% (95% CI = 22.4–27.0% and 41.8–59.4%). The decrease was sustained at the lower level to August 2019. Locations with least pharmacy access decreased by 51% (95% CI = 41.7–61.7%), a greater decrease than 37% observed for those with greater pharmacy access (95% CI = 35.1–39.4%). Regional areas decreased by a smaller margin to cities (32 versus 38%, 95% CI = 30.2–34.1% versus 34.9–40.4%, respectively) from a base per‐capita usage approximately 40% higher than cities. Conclusion: Wastewater analysis shows that codeine consumption in Australia decreased by approximately 37% following its rescheduling as a prescription‐only medicine in 2018. Wastewater‐based epidemiology can be used to evaluate changes in population pharmaceutical consumption in responses to changes in drug scheduling. [ABSTRACT FROM AUTHOR]

Background: Antipsychotics and sedatives are used to treat agitation in the emergency department (ED) but carry significant risk in older adults. Our objective was to determine factors associated with their administration to older ED patients. Methods: This was an observational study using data from the 2014–2017 National Hospital Ambulatory Medical Care Survey. We identified ED visits for patients aged ≥65 years and determined whether an antipsychotic or sedative was administered. Visits related to substance use/withdrawal, other psychiatric complaints, and intubation were excluded. We performed multivariable logistic regression to identify risk factors for antipsychotic or sedative administration. Results: Of the 78.7 million ED visits that met inclusion criteria, 3.5% involved at least one dose of antipsychotic or sedative medication; 13% involved an antipsychotic and 92% a sedative. Factors associated with antipsychotic administration included nursing home residence (adjusted odds ratio [aOR]: 2.67; 95% CI: 1.05–6.80), dementia (aOR: 5.62; 95% CI: 2.44–12.94), and delirium (aOR: 7.33; 95% CI: 2.21–24.32). Sedative administration was positively associated with CT or MR imaging (aOR: 1.86; 95% CI: 1.42–2.43), urbanicity of ED (aOR: 1.46; 95% CI: 1.02–2.08), and female gender (aOR: 1.47; 95% CI: 1.08–1.99) and negatively associated with older age (age: 75–84; aOR: 0.67; 95% CI: 0.49–0.91; age: 85+; aOR: 0.63; 95% CI: 0.45–0.88; reference age: 65–74 years). Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission. Conclusion: We identified patient‐ and facility‐level factors associated with sedative and antipsychotic administration in older ED patients. Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission. See related editorial by Lee. in this issue. [ABSTRACT FROM AUTHOR]

Background: Central nervous system (CNS)‐active medication use is an important modifiable risk factor for falls in older adults. A fall‐related injury should prompt providers to evaluate and reduce CNS‐active medications to prevent recurrent falls. We evaluated change in CNS‐active medications up to 12 months following a fall‐related injury in community‐dwelling older adults compared with a matched cohort without fall‐related injury. Methods: Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall‐related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall‐related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS‐active medication use at 3, 6, and 12 months post‐index according to the presence or absence of CNS‐active medication use before index. Results: One thousand five hundred sixteen participants with fall‐related injury index encounters (449 CNS‐active users, 1067 nonusers) were matched to 7014 index encounters from people without fall‐related injuries (1751 users, 5236 nonusers). Among CNS‐active users at the index encounter, those with fall‐related injury had an average decrease in standard daily doses (SDDs) at 12 months (−0.43; 95% CI: −0.63 to −0.23), and those without injury had a greater (p = 0.047) average decrease (−0.66; 95% CI: −0.78 to −0.55). Among nonusers at index, those with fall‐related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005). Conclusions: The differences in CNS‐active medication use change over 12 months between those with and without fall‐related injury were small and unlikely to be clinically significant. These results suggest that fall risk‐increasing drug use is not reduced following a fall‐related injury, thus opportunities exist to reduce CNS‐active medications, a potentially modifiable risk factor for falls. [ABSTRACT FROM AUTHOR]

The Child and Family Services Improvement and Innovation Act (2011) mandated states to monitor psychotropic medication usage in foster care systems. In response to that legislation, the Deputy Director of the Alabama Department of Human Resources developed the Alabama Psychiatric Medication Review Team (APMRT). To date, our team has engaged in actions to target relevant personnel in foster care systems including caseworkers, foster parents, biological parents, and prescribers of psychotropic medication. One component of APMRT services involves tracking psychotropic medication prescriptions in Alabama foster care through our state Medicaid base. This process led the APMRT to include residential facilities as a target for services. What follows is a detailed account of the steps the APMRT initiated within a specific inpatient residential facility to improve (a) behavior tracking systems and (b) staff members' implementation of general behavior interventions. [ABSTRACT FROM AUTHOR]

Aim: To assess the role of momentary pain on opioid craving and illicit opioid use among individuals receiving opioid agonist treatment. Design Observational study using ecological momentary assessment. Setting: The National Institute of Drug Abuse Intramural Research Program in the United States. Participants: Fifty‐six adults who qualified for opioid agonist treatment. Measurements Participants completed randomly prompted assessments of pain severity, stress, negative mood, opioid craving and illicit opioid use for a mean of 66 days [standard deviation (SD) = 27]. Urine samples were collected two to three times/week throughout. Findings Almost 70% of participants reported moderate average pain severity in the past 24 hours at intake and 35% of participants reported chronic pain. There were no significant differences in percent of opioid‐positive urine samples (P = 0.73) and average level of opioid craving during the study period (P = 0.91) among opioid agonist treatment only patients versus opioid agonist treatment patients with chronic pain. However, momentary pain severity significantly predicted concurrent opioid craving [B = 0.02, 95% confidence interval (CI) = 0.01, 0.04], over and above stress and negative mood. Momentary opioid craving, in turn, significantly predicted illicit opioid use that was assessed in the next moment [odds ratio (OR) = 1.72, 95% CI = 1.12, 2.64), while controlling for autocorrelation and the effects of pain, negative mood and stress. Momentary opioid craving significantly mediated the prospective association between momentary pain and illicit opioid use (95% CI = 0.003, 0.032). Exploratory analysis revealed that momentary pain severity also significantly moderated the momentary association between stress and opioid craving (B = 0.02, 95% CI = 0.00, 0.04), such that when momentary pain severity increased, the association between the two intensified. Conclusions: Among people receiving opioid agonist treatment, momentary pain appears to be indirectly associated with illicit opioid use via momentary opioid craving. [ABSTRACT FROM AUTHOR]

Objective: We compared the incremental effects of adding acceptance and commitment therapy (ACT) to pharmacological treatment as usual (TAU) in a sample of patients with high frequency episodic migraine without aura (HFEM), assessing impact on a spectrum of measures across multiple domains. Background: Patients with HFEM are at risk of developing chronic migraine and medication overuse headache. ACT has been shown to be effective for the treatment of various chronic pain conditions, but little attention has been given to its therapeutic value in the management of recurring headaches. Methods: In this single‐blind (masking for outcome assessor), open‐label, randomized clinical trial, 35 patients with HFEM, with a monthly headache frequency ranging from 9 to 14 days, were recruited at the headache center of C. Besta Neurological Institute and randomized to either TAU (patient education and pharmacological prophylaxis; n = 17) or TAU + ACT (n = 18). Patients assigned to the combined treatment arm additionally received six 90‐min weekly group sessions of ACT therapy and two supplementary "booster" sessions. All patients were on a stable course of prophylactic medication in the 3 months prior to initiating either treatment. Monthly headache frequency served as the primary outcome measure, with all other data collected being considered as secondary measures (medication intake, disability, headache impact, anxiety and depression, catastrophizing, allodynia, cognitive inflexibility, pain acceptance, mindful attention and awareness). Results: A total of 35 patients were enrolled: 17 randomized to TAU, of whom three dropped out, and 18 to TAU + ACT (no dropouts in this group). Headache frequency and medication intake decreased in both groups over 12 months, with patients in the TAU + ACT group showing statistically significant reduction earlier, that is, by month 3. Headache frequency was reduced by 3.3 days (95% CI: 1.4 to 5.2) among those randomized to ACT + TAU, whereas it increased by 0.7 days (95% CI: −2.7 to 1.3) among those randomized to TAU only (p = 0.007, partial η2 = 0.21), the difference being 4 days (95% CI: 1.2 to 6.8). Medication intake was reduced by 4.1 intakes (95% CI: 2.0 to 6.3) among those randomized to ACT + TAU and by 0.4 intakes (95% CI: −1.8 to 2.5) among those randomized to TAU only (p = 0.016; partial η2 = 0.17), the difference being 3.8 intakes (95% CI: 0.7 to 6.8). At 6 and 12 months, the variations were not different between the two groups for headache frequency and medication intake. The opposite was found for measures of headache impact and pain acceptance, where the differences over time favored patients allocated to TAU. Both groups improved with regard to measures of disability, anxiety and depression, catastrophizing, and cognitive inflexibility, whereas measures of allodynia and pain acceptance were stable over time. Conclusions: Our preliminary findings indicate that supplementing TAU with ACT can enhance the main clinical outcomes, namely headache frequency and medication intake of patients with HFEM. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Inappropriate prescribing of medications is common in health care, and is an important safety concern, especially for older adults, who have a high burden of comorbidity and are at greater risk for medication‐related adverse events. This study aims to estimate the extent and cost of potentially inappropriate prescribing of medications to older adults in the United States. DESIGN: A cross‐sectional study. SETTING: Medicare Part D Prescription Drug Program data set (2014–2018). PARTICIPANTS: Older adults who were enrolled in Medicare Part D Prescription Drug Program between 2014 and 2018. MEASUREMENTS: Potentially inappropriate medications were identified using the 2019 American Geriatrics Society Beers Criteria®. RESULTS: In 2018, 7.3 billion doses of potentially inappropriate medications were dispensed. The most common medications by number of doses dispensed were proton pump inhibitors, benzodiazepines, and tricyclic antidepressants, and the top five unique medications by reported spending were dexlansoprazole, esomeprazole, omeprazole, dronedarone, and conjugated estrogens. From 2014 to 2018, 43 billion doses of potentially inappropriate medications were dispensed, with a reported spending of $25.2 billion. CONCLUSION: Potentially inappropriate medication use among older adults is both common and costly. Careful attention to potentially inappropriate medication use and deprescribing when clinically appropriate could reduce costs and potentially improve outcomes among older adults. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate outcomes associated with pharmacist‐led medication reviews in residential aged care facility (RACF) residents with dementia. Methods: Six scientific databases were searched. All study designs investigating pharmacist‐led medication reviews in RACF residents with dementia were considered. The protocol was registered with PROSPERO (CRD42019121681). Results: One randomised controlled trial (RCT) and five observational studies were identified. Two studies reported reductions in medication usage per resident, and one study reported improved appropriateness of psychotropic use following reviews as part of multi‐faceted, collaborative interventions. In three studies, reviews undertaken as an isolated intervention or by a visiting pharmacist with minimal collaboration with physicians were associated with low implementation rates of recommendations to alter therapy. Conclusion: Pharmacist‐led medication reviews, when conducted collaboratively, may improve the use of medicines in RACF residents with dementia. However, robust conclusions cannot be drawn, largely due to the low quality of evidence available, including only one RCT. [ABSTRACT FROM AUTHOR]

Objective: To identify factors associated with incidence of medication reviews (MRs), particularly in women with dementia and in residential aged care (RAC). Methods: Data from 10 359 women in the 1921‐1926 cohort of the Australian Longitudinal Study on Women's Health were linked to Medicare Benefits Schedule data to identify MRs for each year from 2003 to 2015. Results: Incidence of MR increased from 2003 to 2013 (age 87‐92 years) when 37.1% of women with dementia had a MR compared to 19.8% of women without dementia. Adjusting for time and other factors, the odds of having a MR were higher for women with dementia (AOR = 1.18, 95% CI: 1.06‐1.32) and women in RAC (AOR = 3.61, 95% CI: 3.28‐3.98). Conclusions: Although higher in women with dementia and those in RAC, utilisation of MR was modest. System‐level interventions may be required to ensure the use and benefits of MRs. [ABSTRACT FROM AUTHOR]

Background: Pre‐race screening and risk stratification in recreational endurance runners may predict adverse events (AEs) during a race. Aim: To determine if pre‐race screening and risk stratification predict AEs during a race. Methods: A total of 29 585 participants (Male 71.1%, average age = 42.1 years; Female 28.9%, average age = 40.2 years) at the Two Oceans ultra‐marathon races (56 km) completed a pre‐race medical screening questionnaire and were risk stratified into four pre‐specified groups [very high risk (VHR; existing cardiovascular disease–CVD:3.2%), high risk (HR; risk factors for CVD:10.5%), intermediate risk (IR; existing other chronic disease, medication use or injury:53.3%), and low risk (LR:33.0%)]. Race starters, finishers, and medical encounters (ME) were recorded. Did‐not‐start (DNS) rate (per 1000 entrants that did‐not‐start), did‐not‐finish (DNF) rate (per 1000 starters that did‐not‐finish), AE rate [per 1000 starters that either DNF or had an ME], and ME rate (per 1000 starters with an ME) were compared across risk categories. Results: Adverse events were significantly higher (per 1000 starters; 95%CI) in the VHR (68.9; 52.4‐89.9:P =.0407) compared with the LR (51.3; 46.5‐56.7). The DNS rate was significantly different between the IR (190.3; 184.0‐196.9) and LR (207.4; 199.2‐216.0: P =.0011). DNF rates were not different in the VHR (56.4; 41.9‐75.9) compared to LR (44.2; 39.7‐49.1: P =.1295), and ME rate was also not different between risk categories, however, VHR (12.9; 7.0‐23.9) was approaching significance compared to LR (6.9; 5.2‐9.1: P =.0662). Conclusion: Pre‐race medical screening and risk stratification may identify athletes at higher risk of AEs. Further studies should be performed in larger cohorts to clarify the role of pre‐race medical screening in reducing AEs in endurance runners. [ABSTRACT FROM AUTHOR]

Background: Given the potential hazards of teratogenic medicines, to a fetus exposed in utero, monitoring their use around pregnancy is imperative. Aim: To measure utilisation of teratogenic medicines (Therapeutic Goods Administration's category D or X) in women who gave birth in New South Wales, Australia, during pregnancy and the 24 months prior. Materials and Methods: We used linked population‐based datasets including dispensing and perinatal data for all deliveries in NSW between 2005 and 2012. We included pregnancies among concessional beneficiaries only, with complete ascertainment of dispensing claims. Pre‐pregnancy and during‐pregnancy periods were based on birth dates and gestational age. We determined prevalence of exposure using percent of pregnancies in which women had at least one dispensed teratogenic medicine in three‐month time periods. Results: The study included 191 588 pregnancies (145 419 women). Prevalence of exposure to D/X medicines anytime during pregnancy was 2.0% (<20 pregnancies category X), decreasing from pre‐pregnancy (3.8–6.0%) to first trimester (1.5%), further decreasing in second and third trimesters (0.8% and 0.6% respectively). We observed large reductions in antibiotic prevalence but only modest reductions for psychotropics and antilipidemic agents (all category D). Our results suggest higher use of potentially teratogenic medicines (category D) than those strictly contraindicated for use (category X), during pregnancy. Overall, use was higher in the first trimester than the rest of pregnancy. The high prevalence of potentially contraindicated psychotropics in all three trimesters may suggest a higher benefit‐to‐risk ratio and warrants future research focusing on the reasons for their prescribing to pregnant women. [ABSTRACT FROM AUTHOR]

The article offers information on medicines use evaluation guidelines. Topics include Australia's National Medicines Policy defines quality use of medicines (QUM) as ‘selecting management options wisely; a Medicines Use Evaluation (MUE) activity estimating the extent of the appropriate use of medicines; and the objective of MUE Guideline to provide pharmacists with a process to follow in order to implement an MUE within a healthcare organisation.

Objective: To clarify whether the clinical response after the first 2 cycles with Onabotulinumtoxin A can accurately predict the long‐term response. Background: Onabotulinumtoxin‐A (OBT‐A) is an approved preventive treatment option for chronic migraine (CM). Nowadays, it remains to be clarified if the treatment has to be prolonged for at least an entire year (4 injections every 3 months – ie, quarterly, as proposed in the PREEMPT trials) or it can be halted after the second or third injection if not clinically effective. Design and Methods: We conducted a multicenter observational cohort study based on real‐life data on the usage of OBT‐A in CM patients from 2 Italian headache centers, Roma Campus Bio‐Medico and Milano Besta, adopting the whole 4‐injections protocol. We performed a retrospective analysis of medical records of consecutive patients treated in the 2 centers. The main statistical analysis aimed to evaluate longitudinal measures related to headache (monthly headache frequency, monthly number of analgesic drugs, MIDAS). We hypothesized from our clinical practice with OBT‐A that only 2 cycles of treatment were not enough to actually define the non‐responder status to botulinum toxin A and that probably a longer time of treatment is needed to get the condition of long‐term (delayed) responder. Results: We considered 115 patients from the 2 centers: 53 in Roma and 62 in Milano. Regarding the main analysis, a clear improvement in each measure was obtained at the 6 months assessment and maintained up to 12 months. Comparing patients with <30% and ≥30% reduction in headache frequency between T0 and T2 or T4 (respectively, "Non‐Responders" and "Responders"), we found that the agreement between the classification Responders/Non‐Responders at T2 and T4 was not very high (79/104 = 76.0%, with a "moderate" Cohen's Kappa of 0.51), suggesting that the status at T4 is not fully predictable by the status at T2 (λ = 0.47). Responders for headache frequency at T4 were 54.8%. Among Responders at T2, Responders at T4 were 47/62 = 75.8% (95% CI: 64.5%, 85.5%), while among Non‐Responders at T2, Responders at T4 were 10/42 = 23.8% (95% CI: 11.9%, 38.1%). Similarly, even when considering the 50% reduction in painkillers consumption or in MIDAS total score between T0 and T2 as possible prognostic factors, the changes occurring at T4 are not strongly predictable by those at T2. Conclusions: A ≥30% reduction in headache frequency at T2 cut‐off is not adequate in predicting a late response to treatment: more than a quarter of excluded patients would miss a clinical improvement with an ongoing treatment, while in a similar percentage of Responders the treatment would lose efficacy. Results from our real‐life study suggest that we possibly have to postpone the definition of Responder/Non‐Responder to OBT‐A at least after 1 year of treatment (4 cycles). [ABSTRACT FROM AUTHOR]

Off‐label or unlicensed medicines use is extremely common in obstetric and paediatric clinical practice and necessitates greater emphasis on the underlying evidence of a medicines safety or efficacy. This creates significant challenges for pharmacists relating to the supply and use of medicines in this setting. Understanding how and why unlicensed or off‐label medicine use occurs, together with the underlying evidence base, is critical for supporting the quality use of medicines. Addressing issues surrounding unlicensed or off‐label medicine use in a collaborative manner with prescribers and patients can help reduce unnecessary patient concern, possible non‐adherence and risk of suboptimal treatment outcomes. This review summarises current evidence and challenges surrounding off‐label and unlicensed medicine use in the obstetric and paediatric clinical setting from the perspective of key stakeholders. It aims to support pharmacists in their evaluation of the appropriateness of off‐label and unlicensed medicine use, and provide strategies to help manage these challenging medicines management decisions. [ABSTRACT FROM AUTHOR]

Background: Bacterial and viral meningitis are two life‐threatening diseases that pose a socioeconomic burden on many developing countries such as Egypt. Inappropriate management is the main factor contributing to this burden. Aim: Assess the appropriateness of management of bacterial and viral meningitis in accordance with the Infectious Diseases Society of America guidelines and to evaluate the drugs used. Methods: A prospective observational audit study was conducted in a teaching hospital in Egypt to evaluate the appropriateness of meningitis management as part of implementing a proposed institutional antibiotic stewardship program. Fifty‐eight patients met the inclusion criteria. A threshold between 90 and 100% was considered to measure the appropriateness as according to the World Health Organization drug use evaluation guidelines. Results: Viral meningitis affected more than 60% of patients. The empirical regimen consisted primarily of penicillin, ceftriaxone and dexamethasone. The mean duration of the first antimicrobial and antiviral doses were 1.55h and 19–22h respectively. Non‐compliance with standard practice guidelines due to wrong regimen selection was detected in more than 60% of patients. Fewer than 10% of patients received the correct dexamethasone regimen and fewer than 20% of patients had a follow‐up lumbar puncture. The mean length of stay was 9–12 days. Non‐compliance with guidelines resulted in extra charges for more than 70% of patients. Conclusions: Overall compliance with standard practice guidelines was below the proposed thresholds and misuse of drugs, especially antibiotics, was obvious. Institutional antimicrobial stewardship programs are essential to improve the quality of care and to limit medication misuse. [ABSTRACT FROM AUTHOR]

The article focuses on changes in use of high-priced new drugs and drug costs among residents of long-term care facilities under a bundled payment system. Topics include the Geriatric Health Services facilities in Japan follow has bundled payment system for most routine care services, the changes in medications and an associated reduction in drug costs after the admission of residents, resulting from the discontinuation of drugs and replacement of branded drugs with generic drugs.

Objective: The aim of this study was to investigate the impact of the use of crack and other illicit drugs on oral health‐related quality of life (OHRQoL) in young adults. Methods: This cross‐sectional study evaluated 106 crack users at a public treatment center for drug addiction and 106 controls matched for gender, age, and use of tobacco. Clinical examinations were performed for dental caries and periodontal disease. The outcome was OHRQoL, which was determined using the Oral Health Impact Profile (OHIP‐14). The association between OHRQoL and illicit drugs was modeled using conditional Poisson regression. Results: Users of crack and other illicit drugs had a poorer OHRQoL than the controls (p < .001). Among the crack users, the odds ratio to yield high OHIP‐14 was 3.40 (95% confidence interval, 1.91–6.08). Adjustment for sex, age, schooling, income, smoking, dental caries, and periodontal disease did not change such an estimate considerably. The functional limitation and psychological discomfort domains were associated with the use of illicit drugs. Conclusion: Users of crack and other illicit drugs exerted a negative impact on OHRQoL independently of socio‐demographic characteristics and tobacco use, suggesting the need for special attention regarding the specific oral health needs of this population as well as drug prevention and treatment strategies. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, aims, and objectives: Despite proven benefits for reducing incidence of major cardiac events, antihypertensive drug therapy remains underutilized in the United States. This analysis assesses antihypertensive drug adherence, utilization predictors, and associations between adherence and outcomes (a composite of cardiovascular events, Medicare inpatient payments, and inpatient days). Methods: The sample consisted of Atherosclerosis Risk in Communities Study cohort participants reporting hypertension without prevalent cardiovascular disease during 2006 to 2007 annual follow‐up calls. Atherosclerosis Risk in Communities records were linked to Medicare claims through 2012. Antihypertensive medication adherence was measured as more than 80% proportion days covered by using Medicare Part D claims. Standard and hierarchical regression models were used to evaluate adjusted associations between person characteristics and adherence and between adherence and outcomes. Results: Among 1826 hypertensive participants with Part D coverage, 31.5% had no antihypertensive class with more than 80% proportion days covered in the 3 months preceding the report of hypertension in 2006 to 2007. After adjustment for confounders, positive predictors of use included female gender and diabetes; negative predictors were African‐American race and current smoking. Adjusted association between receiving no therapy and a composite endpoint of cardiovascular outcomes through 2012 was not statistically significant (hazard ratio: 0.93; 95% confidence interval: 0.72, 1.22) nor was the adjusted association with Medicare inpatient days or payments (incremental difference at 48 months in payments: $1217; 95% CI: −$2030, $4463). Conclusions: Despite having medical and prescription coverage, nearly a third of hypertensive participants were not adherent to antihypertensive drug therapy. Differences in clinical outcomes associated with nonadherence, though not statistically significant, were consistent with results from randomized trials. The approach provides a model framework for rigorous assessment of detailed data that are increasingly available through emerging sources. [ABSTRACT FROM AUTHOR]

The article offers a perspective on future directions for the proposed the International Cannabis Toolkit (iCannToolkit), a hierarchical framework of measurement tools that consolidates input from global leaders in cannabis research. It discusses the challenge of defining a unit of safe cannabis exposure and mentions a proposed standard tetrahydrocannabinol (THC) unit. It raises concerns on the iCannToolkit's biological assessments and the therapeutic versus harmful effects of cannabis.

Background Quality use of medicines ( QUM) has been identified as a priority in Sri Lanka. Aim To identify opportunities to optimise QUM, and evaluate medication appropriateness and medication information exchanged with patients and carers on discharge in a Sri Lankan tertiary care hospital. Methods An observational, prospective, cohort study of patients systematically sampled from two medical wards. A research pharmacist determined their pre-admission medication regimen via interview at time of discharge. Issues of poor adherence and discrepancies between the pre- and post-admission medication regimens were recorded. Drug-related problems were categorised into opportunities to optimise drug therapy. The appropriateness of discharge medications was evaluated using a validated tool. The patient or carer was interviewed after discharge regarding the quality of medicine information exchanged in hospital. Results The 578 recruited patients were taking 1756 medications prior to admission, and 657 (37.4%) of these medications were not continued during admission. Opportunities to optimise drug therapy were identified on 1496 occasions during admission (median, 2.0 opportunities/patient), 215 opportunities, (14.4%) were resolved spontaneously by the medical team prior to discharge. The median score for appropriateness of medications on discharge was 1.5 per patient (interquartile range, 0.0-3.5). Of 427 patients surveyed after discharge, 52% recalled being asked about their medications on admission to hospital, 75% about previous adverse medication reactions and 39% recalled being informed about changes to their medications on discharge. Conclusion Significant opportunities exist for pharmacists to enhance quality use of medicines for patients in the current hospital-based healthcare system in Sri Lanka. [ABSTRACT FROM AUTHOR]

Objectives To explore barriers to anticoagulation in older adults with atrial fibrillation ( AF) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants ( OACs). Design Retrospective cohort study. Setting Two large community-based AF cohorts. Participants Individuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79). Measurements Using structured chart review, reasons for nonuse of OAC were identified, and 1-year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse. Results Median CHA2 DS2- VASc score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most-frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio ( OR) = 8.96, 95% confidence interval ( CI) = 5.01-16.04 for aged ≥85 vs <65) and disability ( OR = 12.58, 95% CI = 5.82-27.21 for severe vs no deficit) were the most-important independent predictors of nonuse of OACs. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC ( P < .001), far higher than recurrent stroke rates. Conclusion Despite very high stroke risk, more than 40% of participants were not discharged with an OAC. Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals' high 1-year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF, and determine whether newer anticoagulants are safer in complex elderly and frail individuals. [ABSTRACT FROM AUTHOR]

This study examined warfarin usage for elderly Medicare beneficiaries with atrial fibrillation (AF) who suffered traumatic brain injury (TBI), hip fracture, or torso injuries. Using the 5% Chronic Condition Data Warehouse administrative claims data, this study included fee-for-service Medicare beneficiaries who had a single injury hospitalization (TBI, hip fracture, or major torso injury) between 1/1/2007 and 12/31/2009, with complete Medicare Parts A, B (no Medicare Advantage), and D coverage 6 months before injury, and who were aged 66 years or older and diagnosed with AF at least 1 year before injury. About 45% of the AF patients were using warfarin before TBI or torso injury, and 35% before hip fracture. After injury, there was a dramatic and persistent decrease in warfarin use in TBI and torso injury groups (30% for TBI and 37% for torso injury at 12 months after injury). Warfarin usage in hip fracture patients also dropped after injury but returned to pre-injury level within 4 months. TBI and torso injury lead to significant decreases in warfarin usage in elderly AF patients. Further research is needed to understand reasons for the pattern and to develop evidence-based management strategies in the post-acute setting. [ABSTRACT FROM AUTHOR]

Despite rigorous expert review, medications often fall into routine use with unrecognized and unwanted complications. Use of some medications remains controversial because information to support efficacy is conflicting, scant, or nonexistent. Medication use evaluation ( MUE) is a performance improvement tool that can be used when there is uncertainty regarding whether a medication will be beneficial. It is particularly useful when limited evidence is available on how best to choose between two or more medications. MUEs can analyze the process of medication prescribing, preparation, dispensing, administration, and monitoring. MUEs can be part of a structured or mandated multidisciplinary quality management program that focuses on evaluating medication effectiveness and improving patient safety. Successful MUE programs have a structure in place to support completion of rapid-cycle data collection, analysis, and intervention that supports practice change. [ABSTRACT FROM AUTHOR]

Management of psoriasis is based on a stepwise approach that includes a wide variety of treatment options. Our Drug review focusses on key points and recent advances in the management of psoriasis, followed by a review of the prescription data and sources of further information. [ABSTRACT FROM AUTHOR]

Objectives To determine whether excessive and often inappropriate or dangerous psychotropic drug dispensing to older adults is unique to care homes or is a continuation of community treatment. Design Population-based data-linkage study using prescription drug information. Setting Northern Ireland's national prescribing database and care home information from the national inspectorate. Participants Two hundred fifty thousand six hundred seventeen individuals aged 65 and older. Measurements Prescription information was extracted for all psychotropic drugs included in the British National Formulary ( BNF) categories 4.1.1, 4.1.2, and 4.2.2 (hypnotics, anxiolytics, and antipsychotics) dispensed over the study period. Repeated cross-sectional analysis was used to monitor changes in psychotropic drug dispensing over time. Results Psychotropic drug use was higher in care homes than the community; 20.3% of those in care homes were dispensed an antipsychotic in January 2009, compared with 1.1% of those in the community. People who entered care had higher use of psychotropic medications before entry than those who did not enter care, but this increased sharply in the month of admission and continued to rise. Antipsychotic drug dispensing increased from 8.2% before entry to 18.6% after entering care (risk ratio ( RR) = 2.26, 95% confidence interval ( CI)=1.96-2.59) and hypnotic drug dispensing from 14.8% to 26.3% ( RR=1.78, 95% CI=1.61-1.96). Conclusion A continuation of high use before entry cannot wholly explain the higher dispensing of psychotropic drugs to individuals in care homes. Although drug dispensing is high in older people in the community, it increases dramatically on entry to care. Routine medicine reviews are necessary in older people and are especially important during transitions of care. [ABSTRACT FROM AUTHOR]

Objective: To examine the real-world role of tricyclic antidepressants (TCAs) in fibromyalgia (FM) treatment. Methods: Using privately insured U.S. administrative claims data, this study examined TCA use for newly diagnosed FM patients. Patients ages 18 to 64 years with ≥ 2 FM diagnoses (ICD-9-CM: 729.1) during Q1:2007 to Q1:2009, no previous FM diagnosis, and continuous eligibility for insurance during the year before and after the first FM diagnosis ('study period') were identified as newly diagnosed ( N = 10,129). Treatment with TCAs was examined over the first treatment episode (allowing up to a 45-day gap between refills). A sensitivity analysis was performed excluding patients with depression/anxiety diagnoses during the study period. Results: During the study period, 8.9% of patients with FM used TCAs at anytime, 5.0% used TCAs during the year before FM diagnosis, and 7.2% used TCAs during the year after. The mean (median) duration of the first treatment episode was 150 (58) days. During this episode, 84.0% used other medications concomitantly, with 60.3% using analgesics and 39.6% using other antidepressants. Additionally, 60.8% augmented TCA use with other drugs, 61.8% switched to another drug at the end of their TCA episode, and 22.8% discontinued TCAs without switching. Similar patterns were observed for the subset of patients with no depression or anxiety ( N = 7,655). Discussion: Research covering 1999 to 2005 using the same methods found that 15.9% of patients with FM used TCAs during the year before FM diagnosis and 20.7% used TCAs during the year after. These findings suggest that TCA use among the patients with FM is uncommon and may be declining in real-world practice. [ABSTRACT FROM AUTHOR]

The objectives of this study were to determine whether Drug Burden Index (DBI), a measure of individuals’ exposure to anticholinergic and sedative drugs, and Beers criteria, an explicit measure of potentially inappropriate drug use, are associated with function in older adults living in low-level care facilities; and to compare DBI with Beers criteria as a predictor of function in older people. The study population consisted of 115 residents living in low-level care facilities in Sydney, Australia. Data on demographics, drugs, and comorbidities were collected. Outcomes included objective measures of physical function Short Performance Physical Battery (SPPB) and grip strength. In total, 50 (44%) participants were exposed to DBI drugs, 51 (44%) participants received at least 1 Beers criteria drug, and 30 (26%) were exposed to both. After adjusting for confounders, for every unit increase in DBI, the SPPB score decreased by 1.3 (P = .04). DBI was not associated with weaker grip strength. Beers criteria were not associated with any of the outcomes. In older adults living in self-care retirement villages, DBI was associated with impairments in physical functioning. Exposure to Beers criteria drugs was common; however, Beers criteria did not predict functional outcomes in this population of older adults. [ABSTRACT FROM PUBLISHER]

Background: The emergence of antimicrobial resistance reinforces the need for antimicrobial stewardship to promote the appropriate and judicious use of antimicrobials. Aim: To quantify restricted antimicrobial use among intensive care unit (ICU) discharges to general wards, and to review appropriateness of antimicrobial use. Method: A prospective clinical audit was conducted over a 2- week period. Medical records for ICU discharges were reviewed, with relevant data extracted (patient characteristics, antimicrobial therapy prescribed, treatment instructions). Appropriateness of restricted antimicrobials used was gauged in accordance with hospital policies and the Therapeutic Guidelines: Antibiotic. Results: 98 patients were discharged from the ICU - 74 (76%) discharged to general wards were on antimicrobials, 15 discharged to general wards were not on antimicrobials and 9 discharged out of the hospital. Of these 74 patients, 31 (42%) were prescribed a total of 57 restricted antimicrobials; only 11 of these 31 (36%) patients had documented approval (from microbiology/infectious diseases teams) for use of restricted antimicrobials. 46 restricted antimicrobials (n = 57; 81%) were deemed clinically appropriate and the remaining 11 were prescribed outside guideline-recommended indications. Conclusion: While most restricted antimicrobials were prescribed according to national guidelines, in only one-third of patients were the restricted antimicrobials 'approved' for use according to hospital policies. Better clinical documentation on treatment plans and review processes for restricted antimicrobial use is needed during the transition from ICU to general wards. INSET: Antimicrobials restricted by the hospital formulary. [ABSTRACT FROM AUTHOR]

Aim: To investigate complementary and alternative medicines (CAM) knowledge and use in patients on warfarin and matched controls, and the association between CAM use and adverse events (bleeding or clotting). Method: A retrospective cohort study was undertaken in the emergency department of a Melbourne hospital. Patients in the warfarin and control groups were those taking/not taking warfarin, respectively (groups matched for age and gender). An investigator-administered questionnaire was used to collect data on CAM knowledge and use, and bleeding/clotting events during the previous 6 months. The international normalised ratio (INR) data during the previous 6 months were obtained from medical and pathology records. Results: 246 warfarin and 246 control group patients were enrolled. Approximately 50% in each group indicated that they knew of the potential for CAM-drug interactions. Only 60 (24%) patients in the warfarin group reported having been advised about CAM use. Compared to controls, a similar proportion of warfarin patients reported CAM use (29% vs 37%; p = 0.07) and significantly fewer used a CAM known to interact with warfarin ('interacting CAM') (11% vs 19%; p = 0.03). In the warfarin group, CAM users and non-users reported a similar number of events below and above their therapeutic INR range and when the INR exceeded 5. CAM users in the warfarin group tended to have more abnormal bleeding events (42% vs 30%; p = 0.06) but a similar number of clotting events (9% vs 10%; p = 0.8) than CAM non-users. Warfarin patients who used 'interacting CAM' had significantly more clotting events than those who used CAM not known to interact with warfarin (18% vs 2%; p = 0.02). Conclusion: CAM knowledge in people on warfarin was poor. 'Interacting CAM' used concomitantly with warfarin may be associated with increased rates of clotting events. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes. DESIGN: Systematic review. SETTING: Medline search of the peer-reviewed literature from January 1, 2006, to October 8, 2010. PARTICIPANTS: Medicare beneficiaries who obtained drug insurance from the Part D program. MEASUREMENTS: The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer-reviewed articles. RESULTS: Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined. CONCLUSION: Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use. [ABSTRACT FROM AUTHOR]

Objectives: This study was to develop a version of the Pain Medication Questionnaire (PMQ) specific to the elderly chronic pain population and to identify relevant subscales and items for that population. Exploratory factor analysis (EFA) was conducted to assess the factor structure of the PMQ, to eliminate items that are not appropriate for this population, and to improve ease of administration in the elderly population. Methods: Data were obtained through a survey administered to older adults with chronic pain who consumed opioid medications in a cross-sectional study at outpatient clinics affiliated with the Baltimore Veterans Affairs Medical Center and the University of Maryland Medical System. EFA was conducted on the PMQ in the geriatric chronic pain population, which was compared with the PMQ studies from the general chronic pain population. Results: A two-factor solution yielded Factor 1 with four items and Factor 2 with three items; 18 items did not load significantly on either factor, and only seven items loaded significantly on either factor. All of the chosen factor loadings ranged from 0.41 to 0.88. Conclusion: The findings suggest that, although a small number of the items were identified from the overall scale, they adequately explain two relatively unique factors pertaining to pain management among older adults. This preliminary study suggests that the seven-item PMQ may be useful in assessing opioid medication misuse in community-dwelling older adults with chronic pain. Future studies are needed to confirm the reliability, validity, and factor structure of this modified PMQ in the geriatric population. [ABSTRACT FROM AUTHOR]

The objective of this study was to compare population pharmacokinetic models of escitalopram developed from dosage times recorded by a medication event monitoring system (MEMS) versus the reported times from patients with diagnosed depression. Seventy-three patients were prescribed doses of 10, 15, or 20 mg escitalopram daily. Sparse blood samples were collected at weeks 4, 12, 24, and 36 with 185 blood samples obtained from the 73 patients. NONMEM was used to develop a population pharmacokinetic model based on dosing records obtained from MEMS prior to each blood sample time. A separate population pharmacokinetic analysis using NONMEM was performed for the same population using the patientreported last dosing time and assuming a steady-state condition as the model input. Objective function values and goodness-of-fit plots were used as model selection criteria. The absolute mean difference in the last dosing time between MEMS and patient-reported times was 4.48 ± 10.12 hours. A 1-compartment model with first-order absorption and elimination was sufficient for describing the data. Estimated oral clearance (CL/F) to escitalopram was statistically insensitive to reported dosing methods (MEMS vs patient reported: 25.5 [7.0%] vs 26.9 [6.6%] L/h). However, different dosing report methods resulted in significantly different estimates on the volume of distribution (V/F; MEMS vs patient reported: 1000 [17.3%] vs 767 [17.5%] L) and the absorption rate constant K[suba] (MEMS vs patient reported: 0.74 [45.7%] vs 0.51 [35.4%] h[sup-1]) for escitalopram. Furthermore, the parameters estimated from the MEMS method were similar to literature reported values for V/F (∼1100 L) and K[suba] (∼0.8-0.9 h[sup-1]) arising fromtraditional pharmacokinetic approaches. [ABSTRACT FROM AUTHOR]

Introduction and Aims. To examine age-related differences in drug use and risk among regular injecting drug users (IDU) in Australia. Design and Methods. Cross-sectional data from the 2006 Illicit Drug Reporting System were examined for age-related differences in demographic characteristics, drug use history and current use patterns and self-reported risk behaviours. Results. IDU under 25 years of age were more likely to have initiated injecting at a younger age, to identify as Aboriginal and/or Torres Strait Islander, and to be injecting daily or more often than their older counterparts. They reported more frequent heroin use in the preceding 6 months, and were more likely to report morphine as the first drug injected than were IDU aged 35 years or over. Younger IDU were also more likely to report providing used needles to others, engaging in recent property crime and drug dealing and arrest in the last year. Conclusions. Younger IDU reported significantly different drug use patterns and higher rates of risk behaviours than their older counterparts. Treatment services need to ensure that harm and demand reduction services deliver messages to new cohorts of IDU, particularly given that their drug use patterns may be different to those of older users. [Degenhardt L, Kinner SA, Roxburgh A, Black E, Bruno R, Fetherston J, Fry CL. Drug use and risk among regular injecting drug users in Australia: does age make a difference?Drug Alcohol Rev 2008;27:357-360] [ABSTRACT FROM AUTHOR]

Background: I. v. paracetamol has recently become available in Australia for the treatment of pain when the oral or rectal administration route is not accessible. Our primary aim was to assess compliance with prescribing guidelines and our secondary aim to evaluate the safety of i.v. paracetamol use (4 g/day) and the effect of patient comorbidities on drug safety. Methods: Eighty-five consecutive patients were identified through the pharmacy dispensing system at a 900-bed, metropolitan, primary care and tertiary referral hospital over a period of 7 months from December 2005 to June 2006. Cross-sectional evaluation by patient interview, review of medical records and pathology parameters were carried out. The study has been approved by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee. Results: I.v. paracetamol was given for pain following abdominal surgery (90%) and musculoskeletal pain (10%). The comorbid conditions included severe renal impairment (9.4%), alcohol dependence (3.5%), pre-existing liver failure (2.4%) and malnutrition (18.8%). Prescribing guidelines were not adhered to in 25% of patients. The main cause for discordance observed in 90% of this group was the administration of i.v. paracetamol despite the presence of an alternative route of administration. Eight patients received i.v. paracetamol despite not having had a surgical procedure. Twelve patients received i.v. paracetamol for longer than 48 h; no injection site reactions or toxicity were noted. Conclusion: A lack of concordance between i.v. paracetamol use and prescribing guidelines was identified. There were no new safety concerns. [ABSTRACT FROM AUTHOR]

Background: Gentamicin, an aminoglycoside antibiotic, is used to treat gram-negative bacterial infections. In the current Therapeutic Guidelines: Antibiotic, the recommendations for gentamicin have changed, i.e. the initial dose for empirical treatment, subsequent dose calculations and maximum duration of therapy. Aim: To investigate the pattern of gentamicin utilisation and adherence to local gentamicin dosing guidelines. Method: A cross-sectional audit was conducted of available medication charts for inpatients (n = 51) administered gentamicin at a Sydney hospital over a 2 month period. For comparison, patients were stratified according to age into younger (18 to 59 years) or older (≥ 60 years) groups. Results: Of the 51 patients evaluated, only 11 (8 younger, 3 older) had their weight recorded and they received significantly lower gentamicin doses than the recommended dose based on their age and weight. 11 patients received multiple doses of gentamicin with an average of 2.6 (range 2 to 4) days of therapy. The most common dose was gentamicin 240 mg. Conclusion: There was significant under-dosing of gentamicin in patients of all ages who had their weight recorded. Future studies are needed to investigate the impact of gentamicin underdosing on clinical outcomes. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with harm caused by discrepancies in medication histories in hospital and pharmacy records.

Part of NHS England's Quality Premium is to reduce the number of antibiotics prescribed. A targeted approach, timelier diagnostics and tailored prescribing are just some of the issues we need to address to tackle the complexities surrounding this problem. [ABSTRACT FROM AUTHOR]

An introduction to the issue is presented in which the author discusses topics within the issue such as medicines optimisation, polypharmacy, and guidelines for drug administration to patients.

The author reflects on the use of medication use evaluation (MUE) or drug utilization evaluation (DUE) or drug utilization review (DUR) in understanding how medications are being used. Topics discussed include the goals of MUE to assess a medication process, practice or change within an organization and the 2 categories under which most MUEs generally fall into including one that determine the basis for using a medication and one that determine whether a formula change impacted an outcome.

Objectives: Several pharmacologic therapies have been recommended for managing fibromyalgia. However, the factors associated with each treatment initiation have not been well established. This study assessed factors that were associated with the use of duloxetine vs. other pain medications among patients with fibromyalgia. Research Design and Methods: Administrative claims from a large, U.S. commercially insured population were analyzed using a retrospective cohort design. Patients with fibromyalgia who were 18 to 64 years old and initiated duloxetine vs. selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), venlafaxine, gabapentin, pregabalin, tramadol, or nontramadol opioids between January 1, 2007 and December 12, 2008 were selected. Treatment initiation was defined as no access to the same medication over the previous 90 days, with the most recent initiation date as the index date. All patients selected had at least one fibromyalgia diagnosis (ICD-9-CM: 729.1) in the 12 months prior to initiation of each study medication. Multiple logistic regression models were estimated to assess the predictors of initiating duloxetine vs. each of the other medications. Results: The study included 117,305 patients with fibromyalgia (48 years of age on average; 76% women) who initiated duloxetine ( n = 5,827), SSRIs ( n = 8,620), TCAs ( n = 5,424), venlafaxine ( n = 2,038), gabapentin ( n = 5,733), pregabalin ( n = 11,152), tramadol ( n = 7,312), or nontramadol opioids ( n = 71,199). Common fibromyalgia-related comorbidities were low back pain (31% to 49%), osteoarthritis (14% to 21%), and sleep disturbance (10% to 15%). Controlling for demographic and clinical characteristics, patients who received pregabalin in the prior 12-month period were more likely to initiate duloxetine. Patients from other treatment cohorts, except for those in the pregabalin and nontramadol opioid cohorts, were more likely to re-initiate the same prior medication than to begin treatment with duloxetine. Other predictors of duloxetine initiation included history of rheumatoid and sleep disturbance. Conclusions: The presence of select comorbidities and prior use of certain medications were associated with the duloxetine initiation among working-age, commercially insured patients with fibromyalgia. [ABSTRACT FROM AUTHOR]

Reports on the development and testing of an instrument that attempts to uncover the subjective reasons underlying noncompliance with maintenance drug treatment. Major problem in treatment of schizophrenia; Use of the Rating of Medication Influences (ROMI); Reliability and validity of the instrument.