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Background Fluid resuscitation is a central component of sepsis management, but which fluid should be used has remained controversally. The updated Survivng Sepsis Guidelines, published in 2016, recommends crystalloids as the initial choice for fluid resuscitation in sepsis with albumin as an adjuvant when patients require substantial ammounts of crystalloides. Purpose The aim was to compare the costs of using crystalloids alone vs. crystalloids and albumin, as they are commonly used in the treatment of sepsis. Material and methods The study was conducted from September 2016 to May 2017 in the Intensive Care Unit (ICU) of a tertiary university hospital. A group of 24 adult critically ill patients with sepsis who received crystalloids with 20% albumin (n=24), were included in the study. The control group consisted of age-, sex- and diagnosis-matched patients who were administered crystalloids alone (n=24). The cost of treatment, in the ICU, was calculated for both groups. Treatment outcomes were expressed in life-years gained (LYG) and quality-adjusted life-years (QALYs). LYG were adjusted for patients with sepsis (LYG/0.51). QALYs were obtained by multiplying adjusted LYGs with the utility value for sepsis 0.69. Student t-test was used for statistical analysis between groups. All costs are reported as median 95% confidence interval (CI). Results There were no statistical differences regarding LYG and QALYs between the two groups. Costs were higher in the group with added 20% albumin in comparison to patients treated with crystalloids for €170 (95% CI: €125 to 214). Conclusion The results showed that the use of 20% albumin, in critically ill patients with sepsis was associated with higher costs, with no differences in survival. Our results indicate that crystalloids alone should be the fluid of choice in patients with sepsis. Reference Rhodes A, Evans L, Alhazzai W, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med2017;45(3):?1–67. No conflict of interest

Summary What is known and Objective: Lamotrigine metabolism may be substantially altered with concomitant administration of valproic acid and/or carbamazepine. Such alterations may require the adjustment of lamotrigine dose to ensure optimal treatment efficacy and safety. Methods: The extent of lamotrigine interactions was investigated dependent on age, gender, weight and dose of concomitant carbamazepine and/or valproic acid in 65 patients with epilepsy. Lamotrigine plasma steady-state oral clearance (CLss/F) and area under the curve (AUCss) were calculated from the dose of drug, average steady-state concentration (Css) and interval of administration. Multiple regression analysis was used for the identification and quantification of factors that influenced lamotrigine pharmacokinetics. Results and Discussion: Age and dose of carbamazepine and valproic acid had significant influence on lamotrigine CLss/F and AUCss. Carbamazepine was associated with a dose-dependent increase and valproic acid with a dose-dependent decrease of lamotrigine metabolism rate. The effect of carbamazepine was more pronounced. Younger patients were expected to metabolize lamotrigine more rapidly whereas overweight patients may be less susceptible to interactions. Gender had no influence on lamotrigine pharmacokinetics. What is new and Conclusion: The efficacy and safety of lamotrigine may be altered by concomitant administration of carbamazepine and valproic acid. The models developed may be useful for estimating doses of lamotrigine for individual patients to minimize clinically significant interactions. Therapeutic monitoring is advisable when those drugs are used concomitantly.

Background People with chronic liver diseases constitute a group of patients who often have polypharmacy, comorbidities, and pharmacokinetic and pharmacodynamic changes, that cause an increase in the risk of drug-drug interactions. Purpose To identify and describe drug-drug interactions based on their clinical significance and predictors of their occurrence among patients with chronic liver diseases. To compare the results from two available electronic sources for interaction evaluation. Material and methods A study was conducted on a hepatology ward from May to July 2015, at the gastroenterology and hepatology clinic. Data were gathered through a prospective chart review performed by a clinical pharmacist during a 4 h visit once per week. An estimate of whether gender, age, liver disease, comorbidities, use of certain drugs and total number of drugs per patient influenced the occurrence of drug-drug interactions was made, using correlation and binary regression analysis. Two separate drug interaction programs (Lexi-Interact and Epocrates) were applied to provide the analysis. Results From medicines use review of 100 patients with chronic liver diseases, we identified 486 drug-drug interactions (DDIs) using the Lexi-Interact and 293 using the Epocrates database. The most common type of interaction was class C and monitor/mоdify, deemed as clinically significant (367 DDIs; at least one was found in 83.5% of patients). Acetylsalicylic acid had the highest risk of causing potentially serious (class D, major severity; Lexi-Interact) interactions (25.3%). Most common interacting drug pairs were hydrochlorothiazide/bisoprolol, hydrochlorothiazide/ibuprofen and furosemide/spironolactone. Predictors of DDIs were total number of drugs per patient, number of comorbidities and gender. Statistically significant correlation with occurrence of DDIs was observed for the following covariates: total number of drugs per patient (p = 0.049), number of comorbidities (p = 0.023) and patient age (p = 0.039). Conclusion Most DDIs in the study identified the need for monitoring/modifying therapy. Patients on hydrochlorothiazide, furosemide and bisoprolol were more likely to have DDIs. Lexi-Interact was shown to be the more sensitive source. We advocate that on-ward participation of a clinical pharmacist in a hepatology team may prevent/minimise the frequency and severity of DDIs, provide prompt solutions and enhance patient care. References and/or Acknowledgements lexi.com/PDA-Software-for-Pharmacists/Lexi-Drugs-Interact https://online.epocrates.com No conflict of interest.

Background Patient-centred clinical pharmacy is still in its early stages in _, despite its well evidenced positive impact worldwide. Studies show that clinical pharmacists are valuable members of the healthcare team in improving medicines outcomes in patients with liver disease and liver transplant recipients. Purpose To assess the results of the introduction of clinical pharmacy services on the hepatology ward of a tertiary care teaching hospital in _. Material and methods The prospective observational study was conducted on a hepatology ward from March to July 2014, at Gastroenterology and Hepatology Clinic, _. The clinical pharmacist evaluated medicines use during a 4 h visit once per week, and made recommendations to the prescribing physician. The interventions to optimise prescribing were classified according to type and acceptance by the physician. Results A total of 107 medicines-related interventions were made for 57 patients (investigated or treated for alcohol-related liver disease, non-alcohol-related steatohepatitis, viral hepatitis, autoimmune hepatitis, biliary cirrhosis, sclerosing cholangitis, liver transplant recipients), of which the clinical pharmacist initiated 84 (78.5%) interventions, while 23 (21.5%) interventions were initiated by other health care professionals. The most frequent drug related problems requiring interventions were: incorrect dose (14.7%), inappropriate choice of medicine (11.9%), adverse drug reaction (10.1%) and unavailability of necessary drug (8.9%). The most common type of recommendation was dose adjustment (22.7%), change (15.5%) or discontinuation (11.9%) of a drug, followed by a consultation with a healthcare professional regarding potential adverse drug reactions, interactions and other available treatment options (10.7%). Acceptance rate by physicians was 87.3%. Conclusion Involving a clinical pharmacist in a hepatology team led to clinically significant and embraced optimisation of medicines use. This approach may serve as a baseline and the support for further development of clinical pharmacy in References and/or Acknowledgements No conflict of interest.

Conclusion: There is increased risk of Vitamin D deficiency in patients with Intellectual Disability on carbamazepine. The doctors’ lack of knowledge and the cost of the test can have an impact on clinical practice. Online survey among the ID psychiatrists in North-West region is being conducted, awaiting results. Recommendations are made for local services to produce easy read information leaflets for patients and their carers, posters in waiting areas and reminders to be sent to GPs to carry out the test in remainder of the patients.