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Background Electronic prescription was traditionally used in our country by primary health centres but it has also been progressively introduced into hospitals. This has had an economic impact on some products, such as those used in artificial home nutrition. Purpose To assess the economic impact arising from electronic prescription of diet products at a specialty hospital. To establish effective measures to compensate for the economic impact resulting from the transfer of responsibilities from primary health care to hospital care. Material and methods Retrospective observational study of the increase in spending and number of prescriptions for diet products in outpatient clinics and on hospital discharge. The period from November 2014 to October 2015 was compared with an equivalent period from the previous year. These data were then correlated with percentage of implementations of the electronic prescription module. Prescription details, number of prescriptions and costs were retrieved from the Microstrategy assistance application. The data were broken down by medical service, prescriber and product. Results After analysing the data, an increase in home prescriptions for diet products was found: the number of prescriptions rose by 45.24%, which caused a total increase in costs of 55.14%. These data are explained by a higher degree of implementation of the electronic prescription module (88% in 2014 vs 98.28% in 2015), as well as greater flexibility in computer based procedures for visa issuance. The endocrinology department was responsible for 66.9% of diet product spending. We observed a greater increase in prescription of complete formulae for diabetics (99.08%); polymeric, normoproteic, normocaloric, fibre-free formulae (538.46%), and hypercaloric, fibre-rich formulae (149.36%). A project was developed to incorporate the pharmacist into the visa circuit, in order to ensure efficient management of diet products in compliance with national legislation. To accomplish this goal, the unit of clinical management of pharmacy undertakes the management of visa approval for diet products. Conclusion Prescribing via electronic prescription has involved an increase in spending on artificial home diet at our centre. Incorporating a hospital pharmacist into the visa circuit might optimise usage of dietary therapeutic products, thereby ensuring compliance with safety and efficacy criteria, as well as appropriateness of treatment and patient follow-up. No conflict of interest

Background Iron deficiency (ID) is an important comorbidity associated with chronic heart failure. This often leads to worsening functional class, quality of life and poor prognosis. Diagnosis and prompt treatment of ID are essential. Purpose The aim of this study was to analyse compliance with a new protocol for intravenous ferric carboxymaltose (FCM) in the heart failure unit and the short term safety and analytical profile of intravenous FCM. Material and methods A review was conducted by a multidisciplinary team (MT). After review, the MT decided to implement a new protocol using FCM in a definite group of patients. Absolute ID was defined as ferritin Results 62 patients were analysed in this retrospective observational study. Mean age was 65.2±12.9 years, and patients were predominantly men (70%). Relevant laboratory parameters before and after treatment with intravenous FCM were requested and analysed according to the protocol. Haematological and iron status parameters: haemoglobin (13.04 vs 13.78 mg/dL), haematocrit (38.5 vs 41.6), blood iron level (67.85 vs 109.11 mg/dL), ferritin (79.65 vs 424.62 mg/dL) and TSAT (17.23% vs 33.64%) improved significantly (p Conclusion In our study, this therapy safely and effectively corrected deficient iron stores in the short term. Studies that analysed the effects of intravenous iron treatment in patients with heart failure have demonstrated improved quality of life and functional capacity. The intravenous FCM protocol had an acceptable degree of compliance but the importance of diagnosis and monitoring patients must be stressed as the long term effects of intravenous iron therapy are not yet well defined. No conflict of interest

Background When both HIV and hepatitis C virus (HCV) treatments are indicated, the antiretroviral therapy (ART) may need to be modified before HCV treatment is initiated to reduce the potential for drug-drug interactions and overlapping toxicities that may develop during the period of concurrent treatment. Purpose To describe the modifications on ART when HIV/HCV co-infected patients start HCV therapy with new direct acting antivirals (DAA) in our healthcare area and evaluate its economic impact on ART regimen costs. Material and methods Observational, retrospective study. Gender, ART regimen and its cost per month (previous/after starting HCV therapy) and HCV regimen chosen were recorded for every HIV/HCV co-infected patient who started therapy with new DAA agents (simeprevir, sofosbuvir, ledipasvir, daclatasvir, ombitasvir/paritaprevir/ritonavir and dasabuvir). Patient data, regimens prescribed and treatment cost were collected from external patients and management pharmacy´s database and analysed using the SPSS statistical package. Results 47 patients (15% female) started therapy with DAA agents during the time of the study. ART was modified in 26 (55.3%) patients. 27 antiretroviral drugs were changed (in 1 patient, two modifications were needed), 12 (44.4%) due to the substitution of one non-nucleoside reverse transcriptase inhibitor (NNRTI) and the other 15 (55.6%) corresponded to a change in a protease inhibitor (PI) of the original regimen. The modifications from a NNRTI to avoid interactions with DAAs resulted in the prescription of another not contraindicated NNRTI (rilpivirine) in 8 (66.7%) cases, an integrase strand transfer inhibitor (INSTI) in 3 (25%) and a PI (darunavir/r) in 1 case (8.3%). The modifications from an original PI resulted in the replacement by another not contraindicated PI in 5 patients, to an INSTI in 5 and to a NNRTI in another 5 (33.3% each). The average ART cost per patient was 632.68€ monthly before starting HCV therapy, and 667.40€ later (variations from -169.73€ to +388.67€), which means an increase of 5.5% in the monthly cost per patient. Conclusion Original ART had to be modified in a high proportion of patients (more than half in our series) when starting HCV therapy. All modifications were due to NNRTI and PI interactions with current DAA agents. These changes have led to a slight increase in the ART cost per patient, which can be considered acceptable for public spending. No conflict of interest.

Background Pharmacists prescribe and monitor, in consensus with Oncology, individualised Post-Chemotherapy antiemetic regimes for all patients in our Hospital. Purpose To evaluate the quality and the acceptance of the antiemetic treatment prescribed to breast cancer (BC) patients in the last five years. Material and methods Retrospective observational study of BC patients treated with standard chemotherapy who received antiemetic treatment between 2008 and 2013. Depending on the emetogenic potential (EP) of the chemotherapy scheme, the pharmacist assigned and explained to the patient/family the most suitable antiemetic regime as: Low EP: metoclopramide 10–20 mg tds as needed (PRN). Moderate EP (Kit-1): dexamethasone 4 mg tds 2 days, then 4 mg bid 2 days, then 4 mg od 2 days, and metoclopramide 10–20 mg tds PRN. High EP (Kit-3): Kit-1 plus granisetron 1 mg in the evening following chemotherapy. If the patient had no emesis on the previous cycle, the regime was reduced, but if nausea/vomiting were felt, the regime was stepped up. Patient/family was always involved in treatment decisions. Patient data, prescriptions and monitoring were collected from the Oncofarm application and Pharmacy Database and analysed using SPSS. Results 93 BC patients (all female) received a total of 400 chemotherapy cycles. 357 antiemetic prescriptions were dispensed, so 89.25% of the time a patient received chemotherapy, came to pharmacy for antiemetic drugs. 87.3% of anti-emesis patients started with Kit-3, and 12.9% with kit-1. Antiemetics were reduced in 63.4% of patients, 15.1% continued with the same regime and 21.5% required reinforcement: taking metoclopramide around-the-clock (16.1%), stepping up from kit-1 to kit-3 (3.2%) or adding lorazepam due to anticipatory nausea/vomiting (2.2%). Conclusion The large number of antiemetic prescriptions states the good acceptance from patients of the healthcare provided by the pharmacy. Progressive reduction of antiemetics in more than 60% of patients shows the good control and monitoring of nausea/vomiting with the antiemetic treatment prescribed. References and/or Acknowledgements No conflict of interest.

Background An association between sitagliptin and myopathy is exceptional, although four cases of rhabdomyolysis caused by a statin-sitagliptin interaction have been already reported, one of them with atorvastatin. Purpose To present a case of rhabdomyolysis with hypomagnesemia and acute kidney failure possibly caused by an interaction between sitagliptin and atorvastatin. Materials and methods Description of the clinical picture, physical examination and laboratory data: serum electrolytes, kidney function blood test, creatine phosphokinase (CPK) and lactic dehydrogenase (LDH). Use of the Drug Interaction Probability Scale (DIPS) to establish a possible interaction between the two drugs. Results An 80-year-old man with hypertension, diabetes treated with metformin, dyslipidaemia, myocardial infarction and recent stroke, admitted because of asthenia, confusional syndrome, myalgia, muscle cramps and fasciculations. Chronic medicines included furosemide 40 mg od, manidipine 10 mg od, famotidine 20 mg od and zolpidem 10 mg nocte. The patient became unwell after atorvastatin was increased from 40 to 80 mg/day because of the stroke, and after adding sitagliptin to metformin because poor glycaemic control. Laboratory data: urea 49.3 mg/dL; creatinine 1.45 mg/dL; sodium 145.2 mg/dL; potassium 3.3 mg/dL; calcium 4.9 mg/dL; P 5.1 mg/dL; magnesium 0.9 mg/dL; CPK 1253 IU/L; LDH 352 mg/dL; albumin 2.6 mg/dL; uric acid 9.2 mg/dL; D-vitamin 43.0 ng/mL. Calcium gluconate 10% (IV) and oral magnesium lactate (60 mg/day) were prescribed. When blood calcium levels reached 8–9 mg/dL, treatment was switched to oral. Clinical and analytical improvements were observed seven days after sitagliptin and atorvastatin were interrupted. Atorvastatin (40 mg/day) was reintroduced later. Calcium, magnesium, uric acid, CPK and LDH went back to normality. By contrast, kidney function has not completely recovered. DIPS indicated a possible interaction (score of 4) between sitagliptin and atorvastatin. Conclusions There was a possible interaction between sitagliptin and atorvastatin. The atorvastatin dose had been increased from 40 to 80 mg, so it cannot be assumed that the clinical profile was entirely caused by the introduction of sitagliptin. Furthers studies are needed about the effect of sitagliptin on the cytochrome P4503A4 system. Meanwhile, this interaction should be taken into account by prescribers and pharmacists. No conflict of interest.

Background In order to bring prescriptions for the use of direct-acting antiviral agents (DAAs) for the treatment of HCV genotype 1 infection in mono and co-infected patients in line with the recommendations of the Spanish Health System under the current economic conditions, a local committee formed by an Infectious Disease specialist, a Gastroenterologist and a Hospital Pharmacist was created in our Health Care Area. Purpose To evaluate the economic impact of prioritising treatments with DAAs decided by a local committee in a Health Care Area over 18 months. Materials and methods Observational, retrospective study from April 12 to September 13. Viral genotype was ascertained, as well as liver stiffness by ultrasound-based transient elastography (FibroScan) and IL-28 polymorphism. Patients were classified based on previous treatment with peginterferon-ribavirin (treatment-naive, relapser, partial-responder, non-responder or with unknown previous response). By agreement between the Medical Director, Pharmacy, Gastroenterology and Infectious Disease Services, patients considered eligible for treatment with DAAs were those with stage F3-F4 fibrosis and those relapsers whose liver stiffness was >8.5 kpa. Medical records and laboratory data of all patients with a request for treatment with DAAs were reviewed as well as the decision taken by the Commission (accepted/denied). The cost with triple therapy in HCV genotype 1 was estimated to be 40,000 € per patient (treatment and supportive treatment). Data was analysed using SPSS. Results 56 treatment requests were finally evaluated. Depending on previous treatment, patients were treatment-naive (46.42%), relapsers (37.5%), partial-responders (10.71%) and non-responders (5.35%). Classed by stage of fibrosis, they were F0-F2 (25%), F3-F4 (57.14%), and 17.85% had no recent fibrosis test (neither FibroScan nor biopsy). 93.9% of accepted prescriptions corresponded to F3-F4 patients and the remaining 6.1% were two exceptions to the current HCV therapy recommendations of the Spanish Health System (one F2 treatment-naive woman with childbearing intentions and one F2 treatment-naive man with special working conditions). 23 (41.1%) patients were considered not eligible for triple therapy with DAAs. That resulted in a cost saving of 880,000 € (one of them had no indication for treatment (F0-F1), so was not included). Conclusions The creation of a local committee with powers to prioritise triple therapy with DAAs to those patients with more advanced liver disease and to defer such treatment of those in the early stages (hoping for new, better and safer drugs) has already generated important cost savings in our Health Care Area. No conflict of interest.

Background According to current clinical guidelines developed from evidence-based medicine, heart failure with ventricular dysfunction needs to be treated with the combination of an ACE inhibitor and a beta blocker. An aldosterone antagonist should be added in the more advanced stages of heart failure or recent myocardial infarction. Purpose To review the treatment of patients diagnosed with heart failure in order to evaluate whether they were properly treated according to current clinical guidelines. Materials and methods In 2012 we conducted a retrospective review of the medical records of all patients admitted to the Internal Medicine Service of a second level hospital with a discharge diagnosis (principal diagnosis or comorbidity) of heart failure. 100 paper medical charts were randomly selected from a total of 521 found and clinical, laboratory and echocardiographic data and patient’s medicines at discharge were collected and analysed using the SPSS statistical package. Results With regard to cardiovascular drugs, discharge treatment included diuretics (85%), ACE inhibitors (42%), statins (39%), digoxin (35%), ARBs (30%), calcium antagonists (24%) and beta blockers (24%). Unfortunately no distinction was made in the data collection between different types of diuretics, so analysis of aldosterone antagonist therapy was missed. 65% of the patients had heart failure with systolic dysfunction, of which 68% were female and had a mean age of 74.6 years. The primary reasons for admission were: respiratory infection (31%), cardiac arrhythmia (28%) and cardiac ischemia (20%). Comorbidities associated with heart failure were hypertension (70%), diabetes mellitus (52%), atrial fibrillation (33%), COPD (15%) and chronic renal failure (10%). 28% of patients didn’t received any drug blocking the renin angiotensin system, and an even higher percentage, 76%, no beta blocker, although both groups of drugs are well known for improving survival. Of those patients prescribed an ARB antagonist or an ACE inhibitor, a higher percentage of patients received an ARB inhibitor (42%) than was felt justified. Conclusions The data indicate that, according to current recommendations, a significant percentage of patients are undertreated. The high percentage of patients prescribed diuretics suggests the focus is on symptom relief, rather than on prognosis. These findings are consistent with the literature and indicate that there are legitimate reasons for undertreatment by general physicians, such as the concern of adding a hypotensive drug or a potentially nephrotoxic drug in elderly patients with multiple significant comorbidities. A specialist heart failure team in our area would benefit patients by minimising unnecessary drugs (including diuretics) and initiating and uptitrating ACE inhibitors and beta blockers in these patients. No conflict of interest.

Background The Andalusian Public Health Care Service have developed some indicators based on the selection of drugs for which there is better evidence of efficiency within several therapeutic groups, in areas of prescribing in which more deviations were detected in the past. Purpose To improve the prescribing in a rheumatology team, in terms of efficiency, through the implementation of three quality prescribing indicators, and to measure its degree of compliance after completion of an educational program. Materials and methods Retrospective observational study that measures the percentage of prescriptions meeting three quality indicators before and after an educational program consisting of clinical sessions, meetings with the head of the rheumatology team and/or meetings with medical direction and management direction. Doctors also had information on their results every three months. The three indicators measured were: percentage of generic-name prescriptions versus total prescriptions, percentage of first-line NSAIDs (naproxen, diclofenac and ibuprofen) prescribed versus total NSAIDs and percentage of alendronate, Calcium and Vitamin D versus total of drugs approved for fracture prevention. The prescription rates were measured in October 2012, before the beginning of the educational program, and in August 2013, when it had ended. Prescribing data were obtained from the pharmacy’s computerised reimbursed drugs records (Microstrategy) of all physicians who belonged to the rheumatology team for at least one month during the time studied. Results The initial team of six doctors was monitored. At the end of the study no one had left and no new doctors were incorporated. Three clinical sessions were given by the pharmacist in charge, plus two meetings between him and the chief doctor, and another two between the pharmacist, Chief Doctor and Medical Director. Generic prescription was 72.02% at the beginning and had increased to 83.77% ten months later. First-line NSAIDs prescribing also increased from 18.23% to 46.06%, and the percentage of first-line drugs for fracture prevention (Ca, vit. D and alendronate) rose from 27.05% to 42.50% at the end of the study. Conclusions Prescription of generic-name drugs, first-choice NSAIDs and first-line drugs for fracture prevention improved in a Rheumatology Unit due to an educational prescribing course based on clinical evidence guidelines. The initiative was popular with the doctors, and the commitment of the Medical Director was important to obtain these results. No conflict of interest.