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Objective: Epilepsy is primarily treated with antiseizure medications (ASMs). The recommendations for first ASM in newly diagnosed epilepsy are inconsistently followed, and we sought to examine whether nonrecommended first ASM was associated with acute care utilization. Methods: We conducted a retrospective cohort study of adults (≥18 years old) with newly diagnosed epilepsy (identified using validated epilepsy/convulsion International Classification of Diseases, Clinical Modification codes) in 2015–2019, sampled from Marketscan's Commercial and Medicare Databases. Exposure of interest was receipt of a non‐guideline‐recommended ASM, and the primary outcome was acute care utilization (an emergency department visit or hospitalization after the first ASM claim). Descriptive statistics characterized covariates, and multivariable negative binominal regression models were built adjusting for age, sex, Elixhauser Comorbidity Index, comorbid neurologic disease (e.g., stroke), and ASM polypharmacy. Results: Approximately 14 681 people with new epilepsy were prescribed an ASM within 1 year. The three most prescribed medications were levetiracetam (54%, n = 7912), gabapentin (10%, n = 1462), and topiramate (7%, n = 1022). Approximately 4% (n = 648) were prescribed an ASM that should be avoided, and ~74% of people with new epilepsy had an acute care visit during the follow‐up period. Mean number of acute care visits during follow‐up was 3.34 for "recommended" ASMs and 4.42 for ASMs that "should be avoided." Prescription of a recommended/neutral ASM as compared to an ASM that should be avoided was associated with reduced likelihood of acute care utilization (incidence rate ratio [IRR] =.85, 95% confidence interval [CI] =.77–.94). The recommended/neutral category of ASMs was not statistically significantly associated with seizure‐ or epilepsy‐specific acute care utilization (IRR =.93, 95% CI =.79–1.09). Significance: Adults with new epilepsy are frequent users of acute care. There remain a proportion of persons with epilepsy prescribed ASMs that guidelines suggest avoiding, and these ASMs are associated with increased likelihood of emergency department visit or hospitalization. These findings reinforce the importance of optimizing the choice of first ASM in epilepsy. [ABSTRACT FROM AUTHOR]

Valproic acid (VPA) is used for epilepsy and bipolar disorder. It has near‐complete bioavailability and is primarily metabolized by glucuronosyltransferases and mitochondrial oxidation. This case highlights a 79‐year‐old male with bipolar disorder on VPA therapy that started with flucloxacillin for Staphylococcus aureus bacteraemia and exhibited significantly reduced VPA serum levels. During hospitalization, flucloxacillin treatment correlated with a sharp decline of 75% in VPA total serum levels, a novel drug–drug interaction not previously reported. Nonadherence and absorption issues of VPA were ruled out, confirming flucloxacillin's role in reducing VPA levels. Because free‐fraction serum levels of VPA remained within therapeutic range (5–25 mg/L) and our patient's bipolar disorder remained stable at 1000 mg twice daily, a dose increase was not necessary. Previous reports described cytochrome P450 enzyme induction as the mechanism of flucloxacillin lowering serum levels of immunosuppressants and antimycotics. Because only 10% of VPA is metabolized by cytochrome P450 enzymes, this is not plausible for this case. The proposed mechanism for the VPA–flucloxacillin drug–drug interaction is flucloxacillin as inducer of glucuronosyltransferase enzymes via the pregnane X receptor pathway, accelerating VPA metabolism. Because this case showed that free‐fraction serum levels remained within therapeutic range, it underscores the need for free‐fraction VPA monitoring in bipolar disorder and flucloxacillin therapy. When VPA is used for epilepsy, it is advised to consider alternative antibiotics to avoid this interaction. [ABSTRACT FROM AUTHOR]

Aims: Healthcare accounts for 5% of global greenhouse gas emissions, with medicines making a sizeable contribution. Product‐level medicine emission data is limited, hindering mitigation efforts. To address this, we created Medicine Carbon Footprint (MCF) Classifier, to estimate, standardize, stratify and visualize medicine carbon footprints. Methods: We used molecular weight and chemical structure to estimate the process mass intensity and global warming potential of the active pharmaceutical ingredient in small molecule medicines. This allowed us to estimate medicine carbon footprints per dose, which we categorized into MCF Ratings, accessible via a searchable web application, MCF Formulary. We performed comparison and sensitivity analyses to validate the ratings, and stratification analyses by therapeutic indication to identify priority areas for emission reduction interventions. Results: We generated standardized medicine carbon footprints for 2214 products, with 38% rated LOW, 35% MEDIUM, 25% HIGH and 2% VERY HIGH. These products represented 2.2 billion NHS England prescribed doses in January 2023, with a total footprint of 140 000 tonnes CO2e, equivalent to the monthly emissions of 940 000 cars. Notably, three antibiotics—amoxicillin, flucloxacillin and penicillin V—contributed 15% of emissions. We estimate that implementing the recommended 20% antibiotic prescription reduction could save 4200 tonnes CO2e per month, equivalent to removing 29 000 cars. Conclusions: Standardized medicine carbon footprints have utility in assessing and addressing the carbon emissions of medicines, and the potential to inform and catalyse changes needed to align better healthcare and net zero commitments. [ABSTRACT FROM AUTHOR]

Functional neurological disorder (FND) is common among children and adolescents, results in significant impairments in quality of life, and places a substantial burden on healthcare systems. Despite this, there is minimal literature to guide prescribing for this population. The purpose of this article is to provide common sense prescribing recommendations for providers who treat pediatric FND. A narrative review was conducted by searching PubMed using keywords related to FND and pharmacology. The narrative synthesis was guided by the objective of providing evidence for generally accepted practices and highlighting contributions and gaps in the literature. There is a dearth of evidence, and unique challenges exist in prescribing for pediatric patients with FND. Efforts should be made to limit prescribing and to discontinue, or de-prescribe, medications that may contribute to polypharmacy or overmedicalization of functional symptoms. Pediatric patients with FND require a thoughtful, multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Background: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, for which there are effective pharmacological treatments that improve symptoms and reduce complications. Guidelines published by the National Institute for Health and Care Excellence recommend that primary care practitioners prescribe medication for adult ADHD under shared-care agreements with Adult Mental Health Services (AMHS). However, provision remains uneven, with some practitioners reporting a lack of support. Aim: This study aimed to describe elements of support, and their availability/use, in primary care prescribing for adult ADHD medication in England to improve access for this underserved population and inform service improvement. Design and setting: Cross-sectional surveys were used to elicit data from commissioners, health professionals (HPs), and people with lived experience of ADHD (LE) across England about elements supporting pharmacological treatment of ADHD in primary care. Method: Three interlinked cross-sectional surveys were used to ask every integrated care board in England (commissioners), along with convenience samples of HPs and LEs, about prescribing rates, AMHS availability, wait times, and shared-care agreement protocols/policies for the pharmacological treatment of ADHD in primary care. Descriptive analyses, percentages, and confidence intervals were used to summarise responses by stakeholder group. Variations in reported provision and practice were explored and displayed visually using mapping software. Results: Data from 782 responders (42 commissioners, 331 HPs, 409 LEs) revealed differences in reported provision by stakeholder group, including for prescribing (95% of HPs versus 64% of LEs). In all, >40% of responders reported extended AMHS wait times of ≥2 years. There was some variability by NHS region – for example, London had the lowest reported extended wait time (25%), while East of England had the highest (55%). Conclusion: Elements supporting appropriate shared-care prescribing of ADHD medication via primary care are not universally available in England. Coordinated approaches are needed to address these gaps. [ABSTRACT FROM AUTHOR]

Background: Between 2003 and 2018, incident prescriptions of beta-blockers for anxiety increased substantially, particularly for young adults. National Institute for Health and Care Excellence guidance for anxiety does not recommend beta-blockers, probably due to a lack of evidence to support such use. Recent reports have highlighted the potential risks of beta-blockers. Aim: To understand when and why GPs prescribe beta-blockers for people with anxiety. Design and setting: In-depth interviews with 17 GPs in Bristol and the surrounding areas. Method: Interviews were held by telephone or video call. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Results: Many GPs viewed beta-blockers as 'low risk', particularly for young adults. Some GPs viewed beta-blockers as an alternative to benzodiazepines, acting quickly and not leading to dependence. GPs reflected that some patients appeared to want an 'immediate fix' to their symptoms, which GPs thought beta-blockers could potentially offer. This is salient in light of substantial waiting lists for talking therapies and delays in antidepressants taking effect. GPs described how some patients seemed more willing to try beta-blockers than antidepressants, as patients did not perceive them as 'mental health drugs' and therefore viewed them as potentially more acceptable and less stigmatising. Further, GPs viewed beta-blockers as 'patient-led', with patients managing their own dose and frequency, without GP input. Conclusion: Many GPs believe that beta-blockers have a role to play in the management of anxiety. Given recent increases in the prescribing of these drugs in primary care, there is a need to assess their safety and effectiveness as a treatment for people with anxiety disorders. [ABSTRACT FROM AUTHOR]

Background: Incident benzodiazepine prescriptions in primary care for anxiety decreased between 2003 and 2018. However, from 2008, incident prescribing of benzodiazepines for anxiety increased among those aged 18–34 years. There are increasing concerns around prescribing of benzodiazepines. Further, although guidelines state benzodiazepines should only be prescribed short term, in 2017, 44% of incident prescriptions were prescribed for longer than the recommended duration of 2–4 weeks. Aim: To understand when and why GPs prescribe benzodiazepines for anxiety in young adults. Design and setting: A qualitative study was undertaken using in-depth interviews with 17 GPs from 10 general practices in South West England. Method: Interviews were conducted by telephone or videocall. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and data analysed using reflexive thematic analysis. Results: GPs described caution in prescribing benzodiazepines for anxiety in young adults, but thought they had an important role in acute situations. GPs described caution in prescribing duration, but some thought longer-term prescriptions could be appropriate. In light of these views, some GPs questioned whether primary care needs to revisit how clinicians are using benzodiazepines. GPs perceived that some young adults requested benzodiazepines and suggested this might be because they wanted quick symptom relief. GPs noted that refusing to prescribe felt uncomfortable and that the number of young adults presenting to general practice, already dependent on benzodiazepines, had increased. Conclusion: Patient-driven factors for prescribing benzodiazepines suggest there are current unmet treatment needs among young adults with anxiety. Given increases in prescribing in this age group, it may be timely to revisit the role of benzodiazepines in the management of people with anxiety in primary care. [ABSTRACT FROM AUTHOR]

Global prevalence rates for transgender individuals vary with estimates ranging from 0.3% to 1%, translating to a potential global population of 24.3 million to 81 million. It is estimated that one in two people will develop cancer in their lifetime. Gender‐affirming hormone therapy (GAHT) is a common medical intervention for transgender and non‐binary individuals. GAHT requires careful consideration for concurrent medical care due to potential drug interactions and physiological changes. A multi‐disciplinary team with expertise in transgender health, oncology and pharmacy met to develop a document summarizing current knowledge on the topic for practical use. The team included trans and non‐binary authors who shaped the document's language and focus. The document gives a status update on the current understanding of GAHT and how this may intersect with the safe prescribing of systemic anti‐cancer therapies (SACT). The document underwent multiple review stages including internal review, review by the British Oncology Pharmacy Association (BOPA) EDI Subcommittee and, finally, BOPA Executive Committee review and final approval. Key recommendations of this document include the use of inclusive and effective communication, vigilant monitoring of kidney function and cardiovascular health, and considerations for hormone receptor‐positive cancers. The document also recognizes the multidisciplinary nature of transgender healthcare and where this relates to social prescribing. [ABSTRACT FROM AUTHOR]

Aims: Previous systematic reviews suggest that deprescribing may improve survival, particularly in frail older people. Evidence is rapidly accumulating, suggesting a need for an updated review of the literature. Methods: We updated a 2016 systematic review and meta‐analysis to include studies published from inception to 26 April 2024 from specified databases. Studies in which older people had at least one medication deprescribed were included and grouped by study designs and targeted medications. The risk of bias was assessed using the Cochrane tool and the Newcastle‐Ottawa tool. Odds ratios (OR) or mean differences were calculated as the effect measures using either the Mantel–Haenszel or generic inverse‐variance method with fixed‐ or random‐effects meta‐analyses. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, physical health, cognitive function, quality of life and effect on medication regimen. Subgroup analyses were performed based on age and intervention types. Results: A total of 259 studies (reported in 286 papers) were included in this updated review. Deprescribing polypharmacy did not result in a significant reduction in mortality in both randomized (OR 0.96, 95% confidence interval [CI] 0.84–1.09) and non‐randomized studies (OR 0.70, 95% CI 0.36–1.38). Further subgroup analyses of randomized studies on deprescribing polypharmacy demonstrated a significant reduction in mortality in the young old (aged 65–79) (OR 0.71, 95% CI 0.51–0.99) and when patient‐specific interventions were applied (OR 0.79, 95% CI 0.63–0.99). Conclusions: Deprescribing can be achieved with potentially important benefits in terms of improved survival, particularly when patient‐specific interventions are applied and initiated early in the young old. [ABSTRACT FROM AUTHOR]

Aims: The management of patients treated with direct oral anticoagulants (DOACs) during hospitalization is a common challenge in clinical practice. Although bridging is generally not recommended, too often DOACs are switched to parenteral therapy with low molecular weight heparins. Our objectives were to update a local guideline for perioperative DOAC management and to develop a guideline for the anticoagulation management in non‐surgical patients regarding temporary DOAC discontinuation. Methods: We executed a two‐step modified Delphi study in a 1000‐bed university hospital in Belgium. The Delphi questionnaires were developed based on a literature review and a telephone survey of prescribers. Two expert panels were established: one dedicated to perioperative DOAC management and the other to DOAC management in non‐surgical patients. Both panels completed two rounds, commencing with an individual and online round, followed by a face‐to‐face group session. Results: After the two‐round Delphi process, the updated perioperative guideline on DOAC management included reasons for delaying the resumption of DOACs following surgery, such as oral intake not possible, the probability of re‐intervention within 3 days, and insufficient haemostasis (e.g. active clinically significant haematoma, haemorrhagic drains or wounds). Furthermore, a guideline for non‐surgical hospitalized patients was developed, outlining possible reasons for interrupting DOAC therapy. Both guidelines offer clear anticoagulation therapy strategies corresponding to the identified scenarios. Conclusions: We have updated and developed guidelines for DOAC management in surgical and non‐surgical patients during hospitalization, which aim to support prescribers and to enhance targeted prescription review by hospital pharmacists. [ABSTRACT FROM AUTHOR]

Background: To be effective, interventions aimed at increasing the appropriateness of antibiotic use in primary care should consider the perspectives of prescribing physicians. Aim: To explore the decision making of general practitioners (GPs) when managing uncomplicated urinary tract infections (uUTIs) in women. Design & setting: A qualitative study using semi-structured interviews with 22 GPs in Bavaria and Baden-Württemberg (southern Germany). Method: Verbatim transcripts were analysed through inductive qualitative content analysis. Results: We generated the following three main themes: factors facilitating the decision making; factors complicating the decision making; and consultation modalities. According to participants, following evidence-based recommendations makes the prescription decision smoother. GPs' and patients' prior experiences and beliefs guides decisions towards certain antibiotics, even if those experiences and beliefs contradict evidence-based recommendations. Patient expectations and demands also condition antibiotic prescribing, favouring it. Organisational constraints, such as time pressure, the day of the week (for example, before weekends), and a lower cost of antibiotics for patients than alternative treatments favour the decision to prescribe antibiotics. Diagnostic and prognostic uncertainty complicates decision making, as does scepticism towards evidence-based recommendations. Discordance within the patient-doctor relationship contributed to this complexity. Regarding consultation modalities, a more in-depth consultation and shared decision making were seen as helpful in this process. Conclusion: We identified different factors as intervening against or for a straightforward management decision when dealing with women with uUTIs. They reveal the complexity behind the GPs' decision making. Providing GPs with easy-to- apply guidance while removing economic constraints to allocate sufficient consultation time, and supporting shared decision making may help GPs appropriately manage uUTIs in women. [ABSTRACT FROM AUTHOR]

Background Objectives Subjects Methods Results Conclusions and Clinical Importance Minimizing harm from antimicrobials requires use of the narrowest spectrum drug, at an effective dose for the minimum effective duration. Many prescribers are not currently following these guidelines. To address suboptimal antimicrobial use, the underlying reasons must be understood.To identify factors influencing choices of antimicrobial drug, dose, and duration for companion animals.Twenty‐two veterinarians treating companion animals in Australia. Diversity of participants was deliberately sought.Semistructured interviews were conducted online. Two case studies were discussed, and then a range of broader questions was posed. Transcripts were analyzed thematically, using an inductive approach.Few participants chose guideline‐concordant management for the case studies. Prescribing choices were influenced by a complex array of factors associated with the clinical case, pet owner, drug, veterinarian, veterinary colleagues, and external factors. Key factors driving broad‐spectrum antimicrobial use included a sense of safety, habit, ease of administering the drug (especially in cats), pharmaceutical marketing, and the self‐perpetuating dispensary cycle. Many participants were concerned about antimicrobial resistance, but insufficiently informed about how to minimize this risk. Several participants believed that longer duration of treatment and ensuring patients finish a predetermined course would decrease the risk of antimicrobial resistance and improve clinical outcomes.Veterinarians are engaged with the concept of antimicrobial stewardship, but face numerous practical barriers and require more information. In particular, improved education is needed on enhancing patient safety by minimizing both spectrum of activity and duration of treatment, and dispelling myths about “finishing the course.” [ABSTRACT FROM AUTHOR]

Aims: Pharmacogenetics (PGx) is increasingly recognized as a strategy for medicines optimisation and prevention of adverse drug reactions. According to guidelines produced by the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Dutch Pharmacogenetic Working Group (DPWG), most medicines with drug‐gene interactions (DGIs) are prescribed in primary care. This study aimed to estimate the prevalence of potential and actionable DGIs involving all medicines dispensed in Irish primary care. Methods: Dispensings of 46 drugs to General Medical Services (GMS) patients in the Health Service Executive Primary Care Reimbursement Service Irish pharmacy claims database from 01 January 2021 to 31 December 2021 were analysed to estimate the national prevalence of total dispensings and incidence of first‐time dispensings of drugs with potential DGIs according to the CPIC and/or DPWG guidelines. Phenotype frequency data from the UK Biobank and the CPIC were used to estimate the incidence of actionable DGIs. Results: One in five dispensings (12 443 637 of 62 754 498, 19.8%) were medicines with potential DGIs, 1 878 255 of these dispensed for the first time. On application of phenotype frequencies and linked guideline based therapeutic recommendations, 2 349 055 potential DGIs (18.9%) required action, such as monitoring and guarding against maximum dose, drug or dose change. One in five (369 700, 19.7%) first‐time dispensings required action, with 139 169 (7.4%) requiring a change in prescribing. Antidepressants, weak opioids and statins were most commonly identified as having actionable DGIs. Conclusions: This study estimated a high prevalence of DGIs in primary care in Ireland, identifying the need and opportunity to optimize drug therapy through PGx testing. [ABSTRACT FROM AUTHOR]

Abstract Background /Aims De-implementation, including the removal or reduction of unnecessary or inappropriate prescribing, is crucial to ensure patients receive appropriate evidence-based health care. The utilization of de-implementation efforts is contingent on the quality of strategy reporting. To further understand effective ways to de-implement medical practices, specification of behavioural targets and components of de-implementation strategies are required. This paper aims to critically analyse how well the behavioural targets and strategy components, in studies that focused on de-implementing unnecessary or inappropriate prescribing in secondary healthcare settings, were reported. Methods A supplementary analysis of studies included in a recently published review of de-implementation studies was conducted. Article text was coded verbatim to two established specification frameworks. Behavioural components were coded deductively to the five elements of the Action, Actor, Context, Target, Time (AACTT) framework. Strategy components were mapped to the nine elements of the Proctor’s ‘measuring implementation strategies’ framework. Results The behavioural components of low-value prescribing, as coded to the AACTT framework, were generally specified well. However, the Actor and Time components were often vague or not well reported. Specification of strategy components, as coded to the Proctor framework, were less well reported. Proctor’s Actor, Action target: specifying targets, Dose and Justification elements were not well reported or varied in the amount of detail offered. We also offer suggestions of additional specifications to make, such as the ‘interactions’ participants have with a strategy. Conclusion Specification of behavioural targets and components of de-implementation strategies for prescribing practices can be accommodated by the AACTT and Proctor frameworks when used in conjunction. These essential details are required to understand, replicate and successfully de-implement unnecessary or inappropriate prescribing. In general, standardisation in the reporting quality of these components is required to replicate any de-implementation efforts. Trial registration Not registered.

Objectives: To assess the prevalence of self-medication in urban Indian medical students and explore possible factors associated with this practice. Methods: After obtaining institutional ethics approval, 180 medical students from six medical colleges in Mumbai were recruited to participate via social media. They were administered a pre-validated questionnaire that assessed self-medication as a practice, along with the perceived stress scale (PSS-10) online. Anonymity and confidentiality were maintained Results: The prevalence of self-medication in medical students was found to be 83.9%, with no significant difference between genders or between academic years of medical education. The most used source of information for self-medicating was older prescriptions, and for procuring drugs was pharmacist stores. Common cold was the most cited indication. Anti-pyretics and anti-inflammatory drugs were the most commonly self-medicated drugs. It was found that 73.3% of medical students had self-medicated with non-over-the-counter (OTC) drugs. It was observed that 6.1% of medical students had experienced adverse drug reactions, and alarmingly, 0.6% of medical students continued self-medicating despite experiencing adverse drug reactions Conclusions: Most of the study participants admitted to having practised self-medication. It was alarming to find that an appreciable fraction of the study population had uncontrolled access to non-OTC drugs. Thus, there needs to be a greater emphasis on the education of medical students with respect to the problems encountered by self-medicating and a need to enforce stricter regulations, as well as to establish a more watertight monitoring system, to curb this hazardous practice.

Abstract Background Resistance to multiple antibiotics by several pathogens has been widely described in children and has become a global health emergency. This is due to increased use by parents, caregivers, and healthcare providers. This study aims to describe the prevalence rates of antibiotic prescribing, ascertain the impact of antimicrobial stewardship programs, and target improving the quality of antibiotic prescribing in the paediatric population over time in a hospital. Method A point prevalence survey of antibiotic use was performed yearly for 4 years to monitor trends in antibiotic prescribing. Data from all patients admitted before 8 a.m. on the day of the PPS were included. A web-based application designed by the University of Antwerp was used for data entry, validation, and analysis ( http://www.global-pps.com ). Results A total of 260 children, including 90 (34.6%) neonates and 170 (65.4%) older children, were admitted during the four surveys. Overall, 179 (68.8%) patients received at least one antibiotic. In neonates, the prevalence of antibiotic use increased from 78.9 to 89.5% but decreased from 100 to 58.8% in older children. There was a reduction in the use of antibiotics for prophylaxis from 45.7 to 24.6%. The most frequently prescribed antibiotic groups were third generation cephalosporins and aminoglycosides. The most common indications for antibiotic prescription were sepsis in neonates and central nervous system infection in older children. The documentation of reason in notes increased from 33 to 100%, while the stop-review date also increased from 19.4 to 70%. Conclusion The indicators for appropriate antibiotic prescription improved over time with the introduction of antibiotic stewardship program in the department.

Introduction: Adjusting drug dose levels based on equations that standardize the estimated glomerular filtration rate (eGFR) to a body surface area (BSA) of 1.73m2 can pose challenges, especially for patients with extremely high or low body mass index (BMI). The objective of the present study of patients with CKD and diabetes was to assess the impact of deindexing creatinine-based equations on estimates of kidney function and on the frequency of inappropriate prescriptions of oral antidiabetic drugs (OADs). Methods: The prospective CKD-REIN cohort is comprised of patients with eGFR <60 mL/min/1.73m². The inclusion criteria for this study were the use of OADs and the availability of data on weight, height and serum creatinine. We compared data for three BMI subgroups (group 1 <30 kg/m²; group 2 30-34.9 kg/m²; group 3 =35 kg/m²). Inappropriate prescriptions (contraindicated or over-dosed drugs) were assessed with regard to the summary of product characteristics and the patient's kidney function estimated with the 2009 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, the 2021 CKD-EPI equation, the Modification of Diet in Renal Disease (MDRD) equation, the European Kidney Function Consortium (EKFC) equation, their deindexed estimates, and the Cockcroft-Gault (CG) formula. The impact of deindexing the equations was evaluated by assessing 1) the difference between the indexed and deindexed eGFRs, and 2) the difference in the proportion of patients with at least one inappropriate OAD prescription between the indexed and deindexed estimates. Results: At baseline, 694 patients were receiving OADs. The median BMI was 30.7 kg/m², the mean BSA was 1.98m², and 90% of patients had a BSA >1.73m². Deindexing the kidney function estimates led to higher eGFRs, especially in BMI group 3. The proportion of patients with at least one inappropriate prescription differed greatly when comparing indexed and deindexed estimates. The magnitude of the difference increased with the BMI: when comparing BMI group 1 with BMI group 3, the difference was respectively -4% and -10% between deindexed 2021 CKD-EPI and indexed CKD-EPI. Metformin and sitagliptin were the most frequent inappropriately prescribed OADs. Conclusion: We highlight significant differences between the BSA-indexed and deindexed versions of equations used to estimate kidney function, emphasizing the importance of using deindexed estimates to adjust drug dose levels - especially in patients with an extreme BMI. [ABSTRACT FROM AUTHOR]

Aims: The COVID‐19 pandemic caused significant disruption to routine activity in primary care. Medication reviews are an important primary care activity ensuring safety and appropriateness of prescribing. A disruption could have significant negative implications for patient care. Using routinely collected data, our aim was first to describe codes used to record medication review activity and then to report the impact of COVID‐19 on the rates of medication reviews. Methods: With the approval of NHS England, we conducted a cohort study of 20 million adult patient records in general practice, in‐situ using the OpenSAFELY platform. For each month, between April 2019 and March 2022, we report the percentage of patients with a medication review coded monthly and in the previous 12 months with breakdowns by regional, clinical and demographic subgroups and those prescribed high‐risk medications. Results: In April 2019, 32.3% of patients had a medication review coded in the previous 12 months. During the first COVID‐19 lockdown, monthly activity decreased (−21.1% April 2020), but the 12‐month rate was not substantially impacted (−10.5% March 2021). The rate of structured medication review in the last 12 months reached 2.9% by March 2022, with higher percentages in high‐risk groups (care home residents 34.1%, age 90+ years 13.1%, high‐risk medications 10.2%). The most used medication review code was Medication review done 314530002 (59.5%). Conclusions: There was a substantial reduction in the monthly rate of medication reviews during the pandemic but rates recovered by the end of the study period. Structured medication reviews were prioritized for high‐risk patients. [ABSTRACT FROM AUTHOR]

Aims: Genetic testing can be used to improve the safety and effectiveness of commonly prescribed medicines—a concept known as pharmacogenetics. This study aimed to quantify members of the UK public's preferences for a pharmacogenetic service to be delivered in primary care in the National Health Service. Methods: Members of the UK population were surveyed via an online panel company. Respondents completed 1 of 2 survey versions, asking respondents to select their preferred pharmacogenetic testing service in the context of a presentation of low mood or pain. A conditional logit model was estimated, before the best functional form for the dataset was identified. Preference heterogeneity was identified via latent class analysis. Coefficients from the final selected models were used to estimate uptake in the context of different hypothetical pharmacogenetic services. Results: Responses from 1993 individuals were included in the analysis. There were no differences observed in preference between the 2 clinical scenarios. Conditional logit analysis, using maximum likelihood estimation, indicated that respondents preferred to have noninvasive tests and wanted their data to be shared between different healthcare organizations to guide future prescribing. There was a preference for regional over national data sharing initiatives, and respondents preferred to have access to their data. Predicted uptake varied considerably, ranging from 51% to >99%, depending on design of the service. Conclusion: This study identifies public preferences for a pharmacogenetic testing service and demonstrates how predicted uptake can be impacted by relatively minor adaptations. This highlights areas for prioritization during development of future pharmacogenetic services. [ABSTRACT FROM AUTHOR]

Background: In patients with infectious diseases, remote consultation (RC) may be questionable compared with face-to-face office consultation (OC), not only because of the lack of physical examination but also because of the risk of overprescribing antibiotics (ATBs). Aim: To analyse ATB prescription in OC versus RC in a sample of French GPs. Design & setting: This is a retrospective observational cohort study in general practice in 2021. Anonymised data were collected from voluntary GPs. Method: The influence of the mode of consultation on ATB prescription was analysed using a χ² test. A secondary multivariate analysis investigated the factors influencing the use of OC or RC in patients who received at least one ATB. Results: In total, 35 503 consultations with an identifiable rating were included, corresponding to seven doctors' activities, practising with five locums and three residents. ATBs were prescribed in 10.41% of RCs and 6.77% of OCs (P<0.01). RC was associated with more frequent prescription of ATBs for respiratory and ear, nose, and throat (ENT) viral infections and urinary tract infections. For patients aged 20–40 years, ATB prescription was more associated with RC. Conclusion: RC is associated with a more frequent ATB prescription than OC, mostly for patients aged 20–40 years, who are most likely to use new technologies; and for urinary tract infections or respiratory and ENT viral infections. Further studies on RC outcomes should be conducted to better analyse the impact of RC on the prescribing of ATBs. [ABSTRACT FROM AUTHOR]

Background: Patients with severe mental illness (SMI) die 10–20 years earlier than the general population. They have a higher risk of cardiovascular disease (CVD) yet may experience lower cardioprotective medication prescribing. Aim: To understand the challenges experienced by GPs in prescribing cardioprotective medication to patients with SMI. Design & setting: A qualitative study with 15 GPs from 11 practices in two Scottish health boards, including practices servicing highly deprived areas (Deep End). Method: Semi-structured one-to-one interviews with fully qualified GPs with clinical experience of patients with SMI. Interviews were transcribed verbatim and analysed thematically. Results: Participants aimed to routinely prescribe cardioprotective medication to relevant patients with SMI but were hampered by various challenges. These structural and contextual barriers included the following: lack of funding for chronic disease management; insufficient consultation time; workforce shortages; IT infrastructure; and navigating boundaries with mental health services. Patient-related barriers included patients’ complex health and social needs, their understandable prioritisation of mental health needs or existing physical conditions, and presentation during crises. Professional barriers comprised GPs' desire to practise holistic medicine rather than treating via cardioprotective prescribing in isolation, and concerns about patients' medication concordance if patients were not prioritising this aspect of their health care at that particular time. In terms of enablers for cardioprotective prescribing, participants emphasised continuity of care as fundamental in engaging this patient group in effective cardiovascular health management. A cross-cutting theme was the current GP workforce crisis leading to ‘firefighting’ and diminishing capacity for primary prevention. This was particularly acute in Deep End practices, which have a high proportion of patients with complex needs and greater resource challenges. Conclusion: Although participants aspire to prescribe cardioprotective medication to patients with SMI, professional-, system- and patient-level barriers often make this challenging, particularly in deprived areas owing to patient complexity and the inverse care law. [ABSTRACT FROM AUTHOR]

Background: Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for increasing OAC in patients with AF. However, prescribing DOACs for patients with established AF poses various challenges and general practice pharmacists may have an important role in supporting their management. Aim: To investigate the effectiveness of pharmacist-led interventions in general practice in optimising the use of OAC therapies in AF. Design & setting: A retrospective observational study in general practices in Bradford. Method: The data were collected retrospectively from 1 November 2018–31 December 2019 using electronic health record data. The data were analysed: 1) to identify patients with AF not on OAC; 2) to describe inappropriate DOAC prescriptions; and 3) to calculate HAS-BLED scores. Results: Overall, 76.3% (n = 470) of patients with AF received OAC therapy, and of these, 63.4% received DOACs. Pharmacist-led interventions increased DOAC prescribing by 6.0% (P = 0.03). Inappropriate DOAC use was identified in 24.5% of patients with AF, with underdosed and overdosed identified in 9.7% and 14.8%, respectively. Post-intervention, inappropriate prescribing was reduced to 1.7%. The mean HAS-BLED score decreased from 3.00 to 2.22 (P<0.01). Successful transition from vitamin K antagonist (VKA) therapy to DOACs was achieved in 25.7% of patients. Conclusion: Pharmacist-led interventions have successfully improved the use of OAC therapies in patients with AF, and effectively managed the bleeding risks and transition from VKA to DOAC therapy, in line with guidelines. [ABSTRACT FROM AUTHOR]

The past two decades will be remembered for the rapid advances in our understanding of the significant role that the human microbiome plays in health, illness and longevity, but it remains a vast concept, one that is largely uncharted. Its contribution to human health is brought about by a myriad microbiome-associated physiological mechanisms complemented by its genetic ability, which is around 150 times that of the human genome. Many strategies are being devised to 'engineer' or augment an unfavourable microbiome. The use of probiotic products represents one of these strategies since they can augment the gut microbiome and improve health. However, their correct, effective and safe use is clouded by many variables. Probiotic drugs are used for two main reasons: mostly to improve general health but also in some illnesses for which evidence has been generated. The use of probiotic products to maintain general health is in most instances not supported by scientific evidence. Precision in the reconstitution of an unfavourable microbiome as in disease or the maintenance of a favourable microbiome is the ultimate goal. This is not possible at the bedside because of an incomplete understanding of the human microbiome. This could lead in turn to the overuse of unregulated probiotic products which may be ineffective or even harmful, as in the case of immunocompromised individuals. The aim of this article is to offer guidance on current best practices in prescribing probiotic drugs. [ABSTRACT FROM AUTHOR]

Diseñar un protocolo asistencial en las artritis inflamatorias crónicas durante el período preconcepcional, el embarazo, el posparto y la lactancia. Este protocolo tiene como objetivo ser práctico y aplicable en las consultas donde se atienden a pacientes con enfermedades inflamatorias reumatológicas crónicas, ayudando así a un mejor control de estas pacientes. Asimismo, se ofrecen recomendaciones sobre en qué momento se podría consultar/remitir a las pacientes a un centro especializado por parte del facultativo. Un panel multidisciplinar de médicos expertos de diferentes especialidades identificó los puntos claves, analizó la evidencia científica y se reunió para elaborar el protocolo asistencial. Las recomendaciones elaboradas se han dividido en 3 bloques: reumatología, ginecología y pediatría. El primer bloque se ha dividido en visita pregestacional, gestación y posparto. Este protocolo intenta homogeneizar el seguimiento de las pacientes desde el momento del deseo gestacional hasta el año de vida de los lactantes. Es importante realizar análisis en las pacientes en edad fértil y usar fármacos compatibles con la gestación. Si procede, se debe derivar a la paciente a unidades especializadas. La multidisciplinariedad (reumatología, ginecología y pediatría) es fundamental para mejorar en el control y en el seguimiento de estas pacientes y sus recién nacidos. To design a care protocol in chronic inflammatory arthritis during the pre-conceptional period, pregnancy, postpartum and lactation. This protocol aims to be practical and applicable in consultations where patients with chronic inflammatory rheumatological diseases are treated, thus helping to better control these patients. Likewise, recommendations are offered on when patients could be consulted/referred to a specialized center by the physician. A multidisciplinary panel of expert physicians from different specialties identified the key points, analyzed the scientific evidence, and met to develop the care protocol. The recommendations prepared have been divided into three blocks: rheumatology, gynecology and pediatrics. The first block has been divided into pre-pregnancy, pregnancy and postpartum visits. This protocol tries to homogenize the follow-up of the patients from the moment of the gestational desire until the year of life of the infants. It is important to perform tests in patients of childbearing age and use drugs compatible with pregnancy. If appropriate, the patient should be referred to specialized units. Multidisciplinarity (rheumatology, gynecology and pediatrics) is essential to improve the control and monitoring of these patients and their offspring. [ABSTRACT FROM AUTHOR]

Background: Resistance to multiple antibiotics by several pathogens has been widely described in children and has become a global health emergency. This is due to increased use by parents, caregivers, and healthcare providers. This study aims to describe the prevalence rates of antibiotic prescribing, ascertain the impact of antimicrobial stewardship programs, and target improving the quality of antibiotic prescribing in the paediatric population over time in a hospital. Method: A point prevalence survey of antibiotic use was performed yearly for 4 years to monitor trends in antibiotic prescribing. Data from all patients admitted before 8 a.m. on the day of the PPS were included. A web-based application designed by the University of Antwerp was used for data entry, validation, and analysis (http://www.global-pps.com). Results: A total of 260 children, including 90 (34.6%) neonates and 170 (65.4%) older children, were admitted during the four surveys. Overall, 179 (68.8%) patients received at least one antibiotic. In neonates, the prevalence of antibiotic use increased from 78.9 to 89.5% but decreased from 100 to 58.8% in older children. There was a reduction in the use of antibiotics for prophylaxis from 45.7 to 24.6%. The most frequently prescribed antibiotic groups were third generation cephalosporins and aminoglycosides. The most common indications for antibiotic prescription were sepsis in neonates and central nervous system infection in older children. The documentation of reason in notes increased from 33 to 100%, while the stop-review date also increased from 19.4 to 70%. Conclusion: The indicators for appropriate antibiotic prescription improved over time with the introduction of antibiotic stewardship program in the department. [ABSTRACT FROM AUTHOR]

Background: Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder. UK guidance states that primary care has a vital role in effective ADHD management, including referral, medication prescribing and monitoring, and providing broader mental health and wellbeing support. However, many GPs feel unsupported to provide health care for young people with ADHD. Inadequate health care is associated with rising costs for patients and society. Aim: To investigate the experiences of young people with ADHD accessing primary care in England, from the perspectives of people with lived experience of ADHD and healthcare professionals (HCPs). Design and setting: A qualitative study. Interviews were conducted with HCPs (GPs, practice managers, and a wellbeing worker) and people with lived experience of ADHD (young people aged 16–25 years and their supporters) located in integrated care systems across England. Method: Semi-structured interviews were conducted with participants at five purposively selected general practices (varying by deprivation, ethnicity, and setting). Questions focused on experiences of accessing/providing health care for ADHD. Reflexive thematic analysis was undertaken within a critical realist framework to understand how provision works in practice and to explore potential improvements. Results: In total, 20 interviews were completed with 11 HCPs and nine people with lived experience. Three themes were generated: a system under stress, incompatibility between ADHD and the healthcare system, and strategies for change in ADHD primary care provision. Conclusion: Standardisation of ADHD management in primary care, providing better information and support for HCPs, and advising on reasonable adjustments for people with lived experience could help improve access to effective treatments for young people living with ADHD. [ABSTRACT FROM AUTHOR]

Background: To be effective, interventions aimed at increasing the appropriateness of antibiotic use in primary care should consider the perspectives of prescribing physicians. Aim: To explore the decision making of general practitioners (GPs) when managing uncomplicated urinary tract infections (uUTIs) in women. Design & setting: A qualitative study using semi-structured interviews with 22 GPs in Bavaria and Baden-Württemberg (southern Germany). Method: Verbatim transcripts were analysed through inductive qualitative content analysis. Results: We generated the following three main themes: factors facilitating the decision making; factors complicating the decision making; and consultation modalities. According to participants, following evidence-based recommendations makes the prescription decision smoother. GPs' and patients’ prior experiences and beliefs guides decisions towards certain antibiotics, even if those experiences and beliefs contradict evidence-based recommendations. Patient expectations and demands also condition antibiotic prescribing, favouring it. Organisational constraints, such as time pressure, the day of the week (for example, before weekends), and a lower cost of antibiotics for patients than alternative treatments favour the decision to prescribe antibiotics. Diagnostic and prognostic uncertainty complicates decision making, as does scepticism towards evidence-based recommendations. Discordance within the patient–doctor relationship contributed to this complexity. Regarding consultation modalities, a more in-depth consultation and shared decision making were seen as helpful in this process. Conclusion: We identified different factors as intervening against or for a straightforward management decision when dealing with women with uUTIs. They reveal the complexity behind the GPs’ decision making. Providing GPs with easy-to-apply guidance while removing economic constraints to allocate sufficient consultation time, and supporting shared decision making may help GPs appropriately manage uUTIs in women.

IntroductionThere are ongoing concerns about opioid prescribing for surgical and non-surgical dental needs among adolescent/young adult and adult patients. Although there are known differences in the overall opioid prescription rates in rural areas compared to urban areas, the contribution of dental opioid prescriptions is still unclear. This study aims to examine the factors associated with receiving an opioid prescription following a dental visit.Materials and methodsThis cross-sectional study utilized the 2021 Centers for Medicare & Medicaid Services unredacted Transformed Medicaid Statistical Information System Analytic Files to examine Medicaid and CHIP adolescent/young adult beneficiaries aged 12–20 and adults aged 21–64 who are non-dually eligible for Medicare and had a dental visit in 2021. Multilevel logistic regression models were used to predict the odds of receiving a dental opioid prescription.ResultsThe results of the adolescent/young adult models show that for every percentage point increase in the percentage of non-Hispanic Black residents in a county, the odds of receiving a dental opioid prescription increase by 0.8% in rural areas. However, with every percentage point increase in the Hispanic population, the odds of receiving a dental opioid prescription decrease by 0.3% in rural areas and 0.7% in urban areas. The adult models show that compared to non-Hispanic white beneficiaries, non-Hispanic Black beneficiaries are 8% more likely to receive a dental opioid prescription if they live in rural areas and 18% more likely if they live in urban areas, while all other racial and ethnic groups are significantly less likely to receive a dental opioid prescription. With every unit increase in the concentrated disadvantage index, the odds of receiving a dental opioid prescription increase by 17% among rural adults and 24% among urban adults.DiscussionOur findings on rural–urban disparities in opioid prescriptions suggest that prescription patterns in dental settings are significant and inequitable across various beneficiary- and county-level factors and areas of residence. These variations in prescription patterns highlight the known disparities in access to preventive dental care and the need for targeted interventions to address the healthcare needs of rural residents.

Background Recent changes to legislation in British Columbia (BC) have expanded the scope of pharmacist-provided services to include pharmacist prescribing for minor ailments and contraception (PPMAC). The purpose of this study was to gather community-based pharmacists’ perspectives on these changes to practice. Methods This was a cross-sectional online survey study. The study population was pharmacists practicing in community settings in BC. A 28-question survey was developed to capture the uptake of prescribing in the pharmacists’ practices, their views on PPMAC, educational supports, and workplace-specific questions. Invitations to participate were disseminated by using fax, social media platform posts, and email. Results A total of 246 participants completed all or part of the survey. A majority felt they should be able to assess and prescribe for minor ailments and contraception, and were satisfied with the regulatory changes. Pharmacists had varying degrees of comfort with prescribing for specific patient populations, with the highest for patients >75 years of age and lowest for patients with renal disease. Respondents felt that patients who were without a primary care provider or did not have easy access to walk-in clinics would benefit the most from PPMAC. Pharmacists expressed concerns about their workplace’s level of support for their providing these new services to patients. Discussion Most pharmacist respondents were supportive of and have begun prescribing for minor ailments and contraception in their practices. While they identified many perceived benefits to patient care, workplace barriers may hinder full provision of pharmacist prescribing in their practice.

BackgroundHospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use.MethodsThis was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge.ResultsThe cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs. ConclusionsHospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.

Abstract Introduction Problem-based learning (PBL) was introduced to address passive teaching limitations. However, it is not fully characterised as a teaching modality in pharmacology. The present study investigated the factors affecting pharmacology learning in an integrated PBL-based curriculum in diverse learners. Methods Year 1 undergraduate medical students from two cohorts at St. George’s University of London and University of Nicosia, participated. Statistical analysis of pharmacology knowledge scores, at the beginning (pre-test) and end of the academic year (post-test), investigated readiness to benefit from PBL based on diverse student characteristics (educational background, age, gender, country of origin, ethnicity, native language, PBL experience). Focus groups/interviews and a survey investigated aspects of integrated PBL impacting learning in depth. Results Pre- and post-test scores were positively correlated. Students with biomedical sciences degrees performed better at the pharmacology pre- and post-tests, while post-graduate degree holders performed better only at the pre-test. Effect size was of moderate magnitude. However, progress in learning (post-test performance after controlling for pre-test scores) was unaffected. Qualitative analysis revealed three major themes: 1) PBL as a learning environment; 2) PBL as a learning environment in pharmacology; and 3) PBL as a learning environment and confidence in prescribing. Under theme one, skill development, knowledge acquisition through collaboration and self-directed learning, group dynamics and preferred teaching methods were discussed. Under theme two, contextual learning, depth of knowledge and material correctness were raised. Under theme 3, students expressed variability in prescribing confidence. They perceived that learning could be improved by better integration, further references earlier on, more lectures and PBL facilitators with greater content expertise. The survey findings were consistent with those from focus groups/interviews. Conclusion Pharmacology learning in a PBL-based curriculum is facilitated by constructive, collaborative and contextual learning. While baseline pharmacology knowledge may be advantageous, the other aforementioned characteristics studied may not affect readiness to benefit from PBL. However, further instructional scaffolding is needed, for example through further resources, lectures and self-assessment. The results from our study can inform evidence-based curriculum reform to support student learning further. Addressing learning needs could ultimately contribute to reducing medication errors through effective training of future prescribers.

Summary: Background: Excessive use of antibiotics is a widespread problem. We aim to evaluate the efficacy of a multifaceted intervention for reducing antibiotic use in patients with respiratory tract infections (RTIs). Methods: In this two-arm cluster randomized controlled trial, we enrolled patients aged 18+ with symptomatic RTIs at 40 township health centers (THCs) selected from 10 counties in Anhui, China. The THCs were randomized using an online tool (‘Sealed Envelope’) to intervention or usual care (1:1 ratio), stratified by baseline antibiotic prescribing and with random block sizes (4 or 6). The intervention had five components: a half-day clinician training, a WeChat-based peer support group, a decision aid, a poster commitment letter and a patient leaflet. The primary outcome was whether antibiotics were prescribed at the index consultation. Secondary measures included defined daily dose (DDD), illness recovery rate, re-visits to other care-givers or retail pharmacies and incremental cost-effectiveness ratio (ICER). These measures were analyzed using generalized linear mixed modeling controlling for clustering. The study was registered as ISRCTN30652037. Findings: Between December 2021 and September 2022, 1053 patients were recruited (intervention, 21 THCs, n = 552; control, 19 THCs, n = 501), using consecutive sampling. Antibiotic prescribing rate was 55.25% and 66.67% in the intervention and control arms (Odds ratio 0.52, 95% confidence interval [CI]: 0.27, 0.98; p = 0.044). The intervention group also had lower, significant or non-significant, differences for other markers of antibiotic use: DDD (1.57 vs 2.75); prescriptions of two or more types of antibiotics (9.78% vs 11.58%); obtaining antibiotics from retail pharmacies (3.68% vs 5.78) or from other clinics (2.70% vs 4.05%). The intervention resulted in a cost reduction of 9.265 RMB (1.471 USD) per consultation episode and an ICER of −7769.98 RMB or −1233.33 USD/QALYs. The intervention did not encounter any major adverse event. Interpretation: The intervention package was effective and cost-effective in reducing antibiotics prescribing without adverse effects. Funding: The trial was supported by National Natural Science Foundation of China (No. 81861138049) and United Kingdom Research Innovation (No. MR/S013717/1).

Background: In the United States, the scheduling system for controlled substances was established by the Controlled Substance Act of 1970. In 2009, Parker et al. published the study “Physicians' knowledge and attitudes toward scheduling.” Since 2009, the opioid epidemic has gathered national attention from social and scientific perspectives as the number of drug overdose deaths in the United States has nearly tripled. Objective: To follow up on a 2009 survey by Parker, et al. to determine prescribers' knowledge and attitudes regarding the controlled substance scheduling system and assess the impact of the controlled substance scheduling system on providing optimal patient care. Methods: The cross-sectional survey was designed to assess prescribers' attitudes and mailed to 400 randomly selected physicians and 400 randomly selected nurse practitioners. Results: Prescribers across all groups provided consistent responses suggesting an overall lack of understanding of controlled substance regulations, a negative attitude towards the controlled substance scheduling system, and a detrimental effect on providing optimal patient care. Responses from nurse practitioners differed significantly from physicians in 75 % (3 of the 4) questions regarding regulations, suggesting nurse practitioners possess a greater understanding of pharmaceutical regulations. Specialists' responses demonstrated an enhanced level of dissatisfaction regarding the controlled substance scheduling system compared to primary care providers in 75 % (3 of the 4) questions. Questions regarding the impact of the scheduling system on prescribing patterns differed significantly across multiple demographic groups, notably between physicians and nurse practitioners, differences in practice setting, and primary state of practice for 75 % (3 of the 4) questions. Conclusions: The results of this survey confirm the findings of Parker, et al., and further display the need for investigation into how to improve the controlled substance scheduling system in the United States.

Background In recent decades, there has been an interest in clinical pharmacy practice in Türkiye with emerging studies in this area. Despite the recent emergence of diverse pharmacy practice studies in Türkiye, a comprehensive assessment of overall typology of studies and impact has not been conducted thus far.Objectives This systematic review aims to document and assess pharmaceutical policy and practice literature published within the last 5 years in Türkiye. The other aim is to summarise the expected impact of published studies on policy and practice research.Methods The systematic review was conducted according to the guidelines described in the PRISMA Statement. A comprehensive search approach, incorporating Medical Subject Headings (MeSH) queries and free-text terms was employed to locate pertinent literature related to pharmacy practice and policy in Türkiye. The search covered the period from January 1, 2019, to January 1, 2024, and involved electronic databases including PubMed, Medline Ovid, Scopus, ScienceDirect, Springer Link, PlosOne, and BMC.Results In the final grouping, 73 articles met the inclusion criteria and were selected for this review. Among the quantitative studies, majority studies were cross-sectional survey studies. Through the rigorous thematic content analysis seven research domains were developed from the selected literature: drug utilisation and rational drug use, the emerging role of pharmacist, access to medicines and generic medicines, community pharmacy practice, pharmacovigilance/adverse drug reactions, and pharmacoeconomic studies.Conclusions The pharmacist role is evolving; however, several challenges remain in fully realising the potential of pharmacists. These include regulatory barriers, limited public awareness of pharmacists’ expanded roles, workforce capacity issues, and the need for ongoing professional development and training. Research studies are needed in the areas of generic prescribing, medicine adherence, intervention studies in community and hospital pharmacy practice, and on pharmacoeconomics and pharmacovigilance.

A cross-sectional and retrospective study design and simple random sampling strategy was conducted in Gondar town veterinary clinic, northern Ethiopia with the aim of evaluating drug use pattern and show public health significance of irrational veterinary drug use. A total of 2117 drugs were prescribed to 1717 veterinary patients randomly selected from the case registry in this study. The result indicates average number of drugs prescribed per case was 1.23 and the maximum of three drugs was prescribed. The percentages of antimicrobial, anthelmintic, endectocide and other drugs prescribed were 1182 (55.7%), 481 (22.7%), 426 (20.1%), and 28 (1.3%), respectively. All patients were treated without correct laboratory support. As a result, antimicrobials were inappropriately prescribed in 1.4% of viral diseases, 0.2% of external parasitic diseases, 0.8% of internal parasitic diseases, 0.3% of metabolic diseases, 0.1% of fungal diseases, and anthelmintics in 0.1% of bacterial diseases and 0.5% of external parasitic diseases. 2013/2117 (95.1%) the route of administration of the prescribed drugs was not stated. Clinic professionals were 80% animal health assistants and 20% veterinarians. The results reveal problems with correct diagnosis, low level of education of prescribers, few essential drugs, absence of standard veterinary drug lists, and inappropriate drug use; these all principals to public health significance. Therefore, the availability of key essential drugs should improve and available drugs be prescribed with its appropriate doses, routes, and regimens. Veterinarians should be made aware of the irrational use of veterinary drugs and their public health implications. [ABSTRACT FROM AUTHOR]

Aim: The purpose of the current study was to develop and assess the psychometric properties of a measure that captures nursing behaviours that have the potential to influence the initiation of antibiotics in residential aged‐care facilities. Design: Cross‐sectional online survey. Method: One hundred and fifty‐seven nurses completed an online survey. The survey consisted of two clinical vignettes and measures of tolerance of uncertainty and anxiety. The vignettes consisted of the most common presentations (urinary tract infections and upper respiratory tract infections) of two hypothetical residents in aged‐care facilities. The vignettes provided participants with incremental information with varying levels of symptoms, input from other people and availability of test results. Both vignettes were subjected to exploratory factor analysis. Results: The results focus on the 16 items in the second vignette which resulted in the extraction of three factors. The derived factors were labelled as follows: (i) Noting and Calling GP, (ii) Consult a Colleague and (iii) Immediate Assessment and Antibiotics. Reliability analysis revealed excellent to satisfactory reliability. All three scales were significantly correlated with measures of clinical tolerance of uncertainty, and the 'noting and calling GP' scale was also negatively correlated with measures of anxiety and general tolerance of uncertainty. The measure showed satisfactory reliability and validity for capturing nursing behaviours that have the potential to influence decisions regarding antibiotics. As such, the current study provides a first step towards addressing the lack of ecologically valid measures that capture the complex and nuanced context of nurses' behaviours in RACF that have the potential to inform future stewardship interventions. [ABSTRACT FROM AUTHOR]

Background: Adherence to medications presents a significant challenge in healthcare. Statins, used in primary and secondary prevention of cardiovascular disease, are of particular importance for public health. The outbreak of the COVID-19 pandemic resulted in additional healthcare systemrelated barriers impeding the execution of therapies. This study aimed to assess the use of as well as adherence and persistence to statins in a national cohort of 38 million of Polish citizens during pandemic. Methods: A retrospective analysis of prescription and dispensation data for all statins users from the national payer organization covering the years 2020-2022 was conducted. Medication adherence was assessed using the Medication Possession Ratio, for persistence the 30-day cut-off was accepted. National data on COVID-19 cases and COVID-19 related deaths were obtained from ECDC. Results: The analysis identified 7,189,716 Polish citizens (approximately 19% of Polish population) who were dispensed at least 1 pack of statins within the study period. Over that time, there was a continuous significant increasing trend in prescribing and dispensing of statins. Despite a total increase of 18.9% in the number of prescribed tablets, the percentage of tablets dispensed remained similar, averaging 86%. Overall percentage of adherent patients was 48.2%. For a random sample of 100,000 patients, the mean period of continuous therapy in 2022 was 6.2+/- 5.3 months. During the lockdown period, the mean number of prescribed and dispensed tablets was lower by 6.8% and 5.9%, respectively (p < 0.05). However, fluctuations in the number of COVID-19 cases or COVID-19-related deaths per week had no major impact on the prescribing and dispensing of statins. Conclusion: Over the time of pandemic, there was a continuous increase in the number of statin tablets prescribed and dispensed in Poland. This suggests that, despite the potential limitations posed by COVID-19, access to statins remained easy, which may be attributed to the mass-scale implementation of the national e-prescription system. However, it is crucial to realise that approximately 1/7 of prescribed statin doses were never dispensed, and the overall levels of adherence and persistence were low. This underscores the necessity for concerted efforts to change this scenario in Poland. [ABSTRACT FROM AUTHOR]

Antibiotic resistance is a persistent and growing concern. Our objective was to analyze antibiotic prescribing in the United States (US) in the Medical Expenditure Panel System (MEPS) and to Medicaid patients. We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020. We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad-spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. Antibiotic prescriptions in MEPS decreased from 2013 to 2020 by 38.7%, with a larger decline for the broad (−53.7%) than narrow (−23.5%) spectrum antibiotics. Antibiotic prescriptions in Medicaid decreased by 6.7%. Amoxicillin was the predominant antibiotic, followed by azithromycin, cephalexin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, levofloxacin, and moxifloxacin. Substantial geographic variation in prescribing existed, with a 2.8-fold difference between the highest (Kentucky = 855/1000) and lowest (Oregon = 299) states. The South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). This study identified sizable disparities by geography in the prescribing rates of eight antibiotics with over three-fold state-level differences. Areas with high prescribing rates, particularly for outpatients, may benefit from stewardship programs to reduce potentially unnecessary prescribing. [ABSTRACT FROM AUTHOR]

Opioid prescribing and dispensing from emergency departments is a noteworthy issue given widespread opioid misuse and diversion in many countries, contributing both physical and economic harm to the population. High patient numbers and the stochastic nature of acute emergency presentations to emergency departments (EDs) introduce challenges for prescribers who are considering opioid stewardship principles. This study investigated the effect of changes to electronic prescribing software on prescriptions with an auto-populated quantity of oxycodone immediate release (IR) from an Australian tertiary emergency department following the implementation of national recommendations for reduced pack sizes. A retrospective review of oxycodone IR prescriptions over two six-month periods between 2019 and 2021 was undertaken, either side of a software adjustment to reduce the default quantities of tablets prescribed from 20 to 10. Patient demographic details were collected, and prescriber years of practice calculated for inclusion in linear mixed effects regression modelling. A reduction in the median number of tablets prescribed per prescription following the software changes (13.5 to 10.0, p < 0.001) with little change in the underlying characteristics of the patient or prescriber populations was observed, as well as an 11.65% reduction in the total number of tablets prescribed. The prescriber's years of practice, patient age and patient sex were found to influence increased prescription sizes. Reduced quantity of oxycodone tablets prescribed was achieved by alteration of prescribing software prefill parameters, providing further evidence to support systems-based policy interventions to influence health care providers behaviour and to act as a forcing function for prescribers to consider opioid stewardship principles. [ABSTRACT FROM AUTHOR]

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Aims Methods Results Conclusion This randomized controlled pilot study aimed to assess the differences in the frequency, type and severity of prescribing errors made by medical students when assessed in an electronic (e‐)prescribing system compared to a traditional prescribing method (e.g., typing out a prescription).Fourth year medical students in the period of 1 November to 31 July 2023, were asked to participate in this single‐centre prospective, randomized, controlled intervention study. Participants performed a prescribing assessment in either an e‐prescribing system (intervention group) or in a more traditional prescribing platform (control group). The prescriptions were checked for errors, graded and categorized. Differences in prescribing errors, error categories and severity were analysed.Out of 334 students, 84 participated in the study. Nearly all participants (98.8%) made 1 or more prescribing errors, primarily involving inadequate information errors. In the intervention group, more participants made prescribing errors involving the prescribed amount (71.4 vs. 19.0%; P < .01), but fewer involving administrative errors (2.4 vs. 19.0%; P = .03). Prescribing‐method‐specific errors were identified in 4.8 and 40.5% of the intervention and control group, respectively, with significant differences in overlapping errors as well.This pilot study shows the importance of training e‐prescribing competencies in medical curricula, in addition to traditional prescribing methods. It identifies prescribing‐method‐specific prescribing errors and emphasizes the need for further research to define e‐prescribing competencies. Additionally, the need for an accessible real‐life‐like e‐prescribing environment tailored to educators and students is essential for effective learning and incorporation of e‐prescribing into medical curricula. [ABSTRACT FROM AUTHOR]

Introduction: Problem-based learning (PBL) was introduced to address passive teaching limitations. However, it is not fully characterised as a teaching modality in pharmacology. The present study investigated the factors affecting pharmacology learning in an integrated PBL-based curriculum in diverse learners. Methods: Year 1 undergraduate medical students from two cohorts at St. George's University of London and University of Nicosia, participated. Statistical analysis of pharmacology knowledge scores, at the beginning (pre-test) and end of the academic year (post-test), investigated readiness to benefit from PBL based on diverse student characteristics (educational background, age, gender, country of origin, ethnicity, native language, PBL experience). Focus groups/interviews and a survey investigated aspects of integrated PBL impacting learning in depth. Results: Pre- and post-test scores were positively correlated. Students with biomedical sciences degrees performed better at the pharmacology pre- and post-tests, while post-graduate degree holders performed better only at the pre-test. Effect size was of moderate magnitude. However, progress in learning (post-test performance after controlling for pre-test scores) was unaffected. Qualitative analysis revealed three major themes: 1) PBL as a learning environment; 2) PBL as a learning environment in pharmacology; and 3) PBL as a learning environment and confidence in prescribing. Under theme one, skill development, knowledge acquisition through collaboration and self-directed learning, group dynamics and preferred teaching methods were discussed. Under theme two, contextual learning, depth of knowledge and material correctness were raised. Under theme 3, students expressed variability in prescribing confidence. They perceived that learning could be improved by better integration, further references earlier on, more lectures and PBL facilitators with greater content expertise. The survey findings were consistent with those from focus groups/interviews. Conclusion: Pharmacology learning in a PBL-based curriculum is facilitated by constructive, collaborative and contextual learning. While baseline pharmacology knowledge may be advantageous, the other aforementioned characteristics studied may not affect readiness to benefit from PBL. However, further instructional scaffolding is needed, for example through further resources, lectures and self-assessment. The results from our study can inform evidence-based curriculum reform to support student learning further. Addressing learning needs could ultimately contribute to reducing medication errors through effective training of future prescribers. [ABSTRACT FROM AUTHOR]

Background: The current utilization of neurokinin‐1 receptor antagonists (NK1RAs) and the impact of updated guidelines on prescription patterns of antiemetic drugs among Chinese patients receiving highly emetogenic chemotherapy (HEC) remain undetermined. This study aims to analyze the present situation of Chinese cancer patients using antiemetic drugs and assess the appropriateness of antiemetic regimens. Methods: Prescription data were collected between January 2015 and December 2020 from cancer patients receiving cisplatin‐based chemotherapy at 76 hospitals in six major cities in China. Trends in the use of antiemetic drugs, prescribing patterns and adherence to antiemetic guidelines were assessed. Results: Among the 108,611 patients included in this study, 6 classes and 17 antiemetic drugs were identified as monotherapy or combination therapy in 93,872 patients (86.4%), whereas 14,739 patients (13.6%) were administered no antiemetic treatment. 5‐hydroxytryptamine 3 receptor antagonists (5‐HT3RAs) and glucocorticoids were the two most frequently used classes of antiemetics, followed by metoclopramide. NK1RAs were underused across the six cities, only 9332 (8.6%) and 1655 (1.5%) cisplatin‐based treatments were prescribed aprepitant and fosaprepitant, respectively. Prescriptions of olanzapine and lorazepam were very low throughout the study period. In prescribing patterns of antiemetic drugs, dual combination regimens were the most common (40.0%), followed by triple combination therapy and monotherapy (25.8% and 15.1%, respectively). Overall, the adherence to antiemetic guidelines for patients undergoing cisplatin‐based regimens was only 8.1% due to inadequate prescription of antiemetic drugs. Finally, our study also revealed that 5‐HT3RAs and glucocorticoids were overprescribed in 8.8% and 1.6% of patients, respectively. Conclusions: The current study reveals suboptimal utilization of recommended antiemetic drugs for managing cisplatin‐based HEC‐induced nausea and vomiting in China. Improving the management of CINV is crucial, and these findings provide valuable insights into optimizing antiemetic drug practices. [ABSTRACT FROM AUTHOR]

Aims Methods Results Conclusion Since assessment of prescribing competence is a key promoter of student learning and achievement, we aim to summarize existing national‐level approaches, provide a systematic review of current literature, indicate the frequency of various methodologies, and make recommendations to promote and extend existing practice.Regulatory body websites were accessed for details of national examinations. PubMed, Embase, the Allied and Complementary Medicine, and CINAHL databases were systematically searched in August 2023 for studies in English from Europe, North America, Australia and New Zealand reporting assessment of prescribing competencies among students/practitioners. Additional articles were identified through citation tracking.National approaches are described for several jurisdictions. A total of 20 514 articles were retrieved, of which 54 met the inclusion criteria. Most articles came from the UK, with medical students and qualified doctors most frequently featured. Multiple choice formats were most common, with short answer questions, calculations and scenario‐based skills tests also featured. Direct observations of skills through Objective Structured Clinical Examinations and similar methods were less commonly described. Test reliability generally employed Classical Test Theory. Costs of developing and delivering assessments, differential attainment by demographics, and predictive validity were not indicated.We recommend measurement of the predictive validity of prescribing competence assessments, the routine inclusion of performance by demographic characteristics, extension of competence assessments to professions other than medicine, and structured reporting of methods and findings, including costs and cost‐effectiveness. Situational judgement tests would be a valuable addition to assessment practices. [ABSTRACT FROM AUTHOR]

Aims: To gain insight in the uptake and practice variation in the prescription of 2 new medicine groups for common conditions in primary care (direct‐acting oral anticoagulants [DOACs] and incretin‐based therapies) from introduction, around 2007, to 2019 and the correlation between the adoption of those medicines in primary care. Methods: Prescription data from general practices in the Dutch Nivel Primary Care Database from 2007 to 2019 were used. The percentage of patients with prescriptions for DOACs of all patients with prescriptions for DOACs and vitamin K antagonists was calculated per practice per year, as was the percentage of patients prescribed incretin‐based therapies as a proportion of all patients with diabetes medication. Multilevel models were used to estimate practice variation for DOACs and incretin‐based therapies, expressed as intraclass correlation coefficients. Linear regression analysis was used to study the association between the prescription of DOACs and incretin‐based therapies. Results: Per year, 46–424 general practices and 179 933–1 654 376 patients were included. In 2019, the mean percentage of patients per practice using DOACs or incretin‐based therapies was 54.9 and 9.7%, respectively. The intraclass correlation coefficient decreased from 0.75 to 0.024 for DOACs and from 0.33 to 0.074 for incretin‐based medicines during the study period. No clear correlation was found between the prescription of DOACs and incretin‐based therapies. Conclusion: DOACs and incretin‐based therapies have different adoption profiles and practice variation is large, especially in the years before these medicines were introduced in guidelines. Early adopters of both medicine classes differ. [ABSTRACT FROM AUTHOR]

Originally developed for use in type 2 diabetes mellitus (T2DM), sodium–glucose co-transporter-2 (SGLT2) inhibitors demonstrated diverse cardiovascular- and kidney-protective effects in large outcome trials. Their subsequent approval as a treatment for chronic kidney disease (CKD) marked a pivotal shift in the landscape of CKD management. Further to this, the approval of dapagliflozin and empagliflozin for use in patients with CKD with and without T2DM afforded new treatment opportunities for this population. SGLT2 inhibitors provide an effective treatment for CKD with a favorable safety profile. However, their uptake has been slow, especially among patients without T2DM, owing perhaps to a lack of certainty and familiarity among health care professionals. As the landscape of CKD management continues to evolve, health care professionals should remain knowledgeable about these changes, and implement new guideline recommendations promptly to avoid therapeutic inertia. SGLT2 inhibitors are recommended for patients with CKD with or without T2DM and are foundational agents to support cardiovascular, kidney, and metabolic health. In this review, we provide evidence-based answers to questions that may be asked in the clinic regarding the use of SGLT2 inhibitors to treat CKD.

Background: In patients with infectious diseases, remote consultation (RC) may be questionable compared with face-to-face office consultation (OC), not only because of the lack of physical examination but also because of the risk of overprescribing antibiotics (ATBs). Aim: To analyse ATB prescription in OC versus RC in a sample of French GPs. Design & setting: This is a retrospective observational cohort study in general practice in 2021. Anonymised data were collected from voluntary GPs. Method: The influence of the mode of consultation on ATB prescription was analysed using a χ² test. A secondary multivariate analysis investigated the factors influencing the use of OC or RC in patients who received at least one ATB. Results: In total, 35 503 consultations with an identifiable rating were included, corresponding to seven doctors' activities, practising with five locums and three residents. ATBs were prescribed in 10.41% of RCs and 6.77% of OCs (P

Background: Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for increasing OAC in patients with AF. However, prescribing DOACs for patients with established AF poses various challenges and general practice pharmacists may have an important role in supporting their management. Aim: To investigate the effectiveness of pharmacist-led interventions in general practice in optimising the use of OAC therapies in AF. Design & setting: A retrospective observational study in general practices in Bradford. Method: The data were collected retrospectively from 1 November 2018–31 December 2019 using electronic health record data. The data were analysed: 1) to identify patients with AF not on OAC; 2) to describe inappropriate DOAC prescriptions; and 3) to calculate HAS-BLED scores. Results: Overall, 76.3% (n = 470) of patients with AF received OAC therapy, and of these, 63.4% received DOACs. Pharmacist-led interventions increased DOAC prescribing by 6.0% (P = 0.03). Inappropriate DOAC use was identified in 24.5% of patients with AF, with underdosed and overdosed identified in 9.7% and 14.8%, respectively. Post-intervention, inappropriate prescribing was reduced to 1.7%. The mean HAS-BLED score decreased from 3.00 to 2.22 (P

Background: Patients with severe mental illness (SMI) die 10–20 years earlier than the general population. They have a higher risk of cardiovascular disease (CVD) yet may experience lower cardioprotective medication prescribing. Aim: To understand the challenges experienced by GPs in prescribing cardioprotective medication to patients with SMI. Design & setting: A qualitative study with 15 GPs from 11 practices in two Scottish health boards, including practices servicing highly deprived areas (Deep End). Method: Semi-structured one-to-one interviews with fully qualified GPs with clinical experience of patients with SMI. Interviews were transcribed verbatim and analysed thematically. Results: Participants aimed to routinely prescribe cardioprotective medication to relevant patients with SMI but were hampered by various challenges. These structural and contextual barriers included the following: lack of funding for chronic disease management; insufficient consultation time; workforce shortages; IT infrastructure; and navigating boundaries with mental health services. Patient-related barriers included patients’ complex health and social needs, their understandable prioritisation of mental health needs or existing physical conditions, and presentation during crises. Professional barriers comprised GPs’ desire to practise holistic medicine rather than treating via cardioprotective prescribing in isolation, and concerns about patients’ medication concordance if patients were not prioritising this aspect of their health care at that particular time. In terms of enablers for cardioprotective prescribing, participants emphasised continuity of care as fundamental in engaging this patient group in effective cardiovascular health management. A cross-cutting theme was the current GP workforce crisis leading to ‘firefighting’ and diminishing capacity for primary prevention. This was particularly acute in Deep End practices, which have a high proportion of patients with complex needs and greater resource challenges. Conclusion: Although participants aspire to prescribe cardioprotective medication to patients with SMI, professional-, system- and patient-level barriers often make this challenging, particularly in deprived areas owing to patient complexity and the inverse care law.

Introduction: Adjusting drug dose levels based on equations that standardize the estimated glomerular filtration rate (eGFR) to a body surface area (BSA) of 1.73 m2 can pose challenges, especially for patients with extremely high or low body mass index (BMI). The objective of the present study of patients with CKD and diabetes was to assess the impact of deindexing creatinine-based equations on estimates of kidney function and on the frequency of inappropriate prescriptions of oral antidiabetic drugs (OADs).Methods: The prospective CKD-REIN cohort is comprised of patients with eGFR 1.73 m2. Deindexing the kidney function estimates led to higher eGFRs, especially in BMI group 3. The proportion of patients with at least one inappropriate prescription differed greatly when comparing indexed and deindexed estimates. The magnitude of the difference increased with the BMI: when comparing BMI group 1 with BMI group 3, the difference was respectively −4% and −10% between deindexed 2021 CKD-EPI and indexed CKD-EPI. Metformin and sitagliptin were the most frequent inappropriately prescribed OADs.Conclusion: We highlight significant differences between the BSA-indexed and deindexed versions of equations used to estimate kidney function, emphasizing the importance of using deindexed estimates to adjust drug dose levels - especially in patients with an extreme BMI.