International Journal of Clinical Pharmacy最新文献

Introduction: Medication-related harm (is a challenge globally and contributes to emergency department (ED) presentations. Accurate medication histories are essential to identify whether medication-related harm contributed to an ED presentation.

Aim: The aim of this study was to explore the perspectives of ED clinicians on prioritising ED patients admitted due to potential medication-related harm.

Method: We conducted semi-structured qualitative interviews with purposively selected ED doctors, pharmacists, and nurses from a hospital and health service in Southeast Queensland, which includes both a tertiary and secondary ED. Participants were interviewed face-to-face May-July 2023. Interviews were guided by a piloted interview guide with seven open-ended questions focusing on clinicians' views of medication management and prioritisation in suspected medication-related harm cases.

Results: Fifteen clinicians with varying ED experience levels were interviewed: five doctors, five pharmacists, five nurses. Average interview time was 19 min (9-44 min). Thematic analysis of the interview data identified two key themes and six subthemes related to the prioritisation of patients with suspected medication-related harm and the role of ED clinicians in medication management. ED clinicians used varied and inconsistent processes to identify and flag patients who were either admitted with or suffered potential medication-related harm during admission and identified a need for a strategic structured process. The value of ED pharmacists was highlighted by all non-pharmacist participants.

Conclusion: Findings indicate that, in the absence of standardised prioritisation processes, ED clinicians rely heavily on individual clinical judgement. This underscores the need for the development of a tool specifically designed for the ED context to guide patient prioritisation.

Introduction: The standard treatment for Hormone Receptor-Positive breast cancer (BC) is Oral Endocrine Therapy (OET). OET reduces BC recurrence rates by ~ 50%, and non-adherence to OET leads to worse outcomes. However, OET adherence remains suboptimal, particularly among low socioeconomic status populations.

Aim: This study assessed 12-month OET adherence and identified factors associated with non-adherence among BC patients at a multispecialty hospital in Edinburg, Texas in the Rio Grande Valley region.

Method: A 12-month single-center retrospective study of BC patients taking OET was conducted. Information on patient demographics, tumor characteristics, and prescription details was gathered from electronic medical records. Inclusion criteria included patients 18 years or older who filled at least one OET prescription. OET adherence was assessed using the proportion of Days Covered. Differences between the adherent and non-adherent groups were analyzed using chi-square and Student's t-tests, while multivariable logistic regression was employed to identify factors associated with non-adherence.

Results: Of the total 346 adult female patients, 322 (93%) were Hispanic/Latino. The mean age was 60.8 years, and the mean body mass index was 30.7. Only 122 (35.3%) patients were adherent at 12 months. Patients with diabetes were less likely to be adherent (odds ratio, 0.44; 95% confidence interval: 0.25-0.80). Longer duration of therapy was associated with higher OET adherence, which was estimated to increase 1.84-fold with each additional year of therapy.

Conclusion: Approximately two-thirds of BC patients were non-adherent to OET. Diabetes and shorter time on therapy predicted poorer adherence. These results present the urgent need to address barriers to OET adherence among BC patients in the underserved area of South Texas.

Background: People who inject drugs (PWID) are at high risk of acquiring hepatitis C virus (HCV) infection, yet many remain undiagnosed due to testing barriers. Pharmacy-based point-of-care testing could improve access; however, little is known about its acceptability among PWID.

Aim: To explore the experiences of PWID with HCV testing and their perceptions of a pharmacy-based HCV testing option.

Method: A qualitative study involving interviews with eleven PWID between June and August 2022. Participants were asked about their perceptions and experiences about HCV testing as well as their views on a proposed pharmacy-based HCV testing model which was being proposed for a separate research study. Data were analyzed using reflexive thematic analysis.

Results: Regarding their experiences with HCV testing, participants recognized the importance of testing to know their status both for their health and that of others. Several challenges to testing were described, and participants described the impact of the primary care provider on testing. It was suggested that opioid agonist therapy programs were a missed opportunity for testing, and many potential advantages to pharmacy testing were described. Privacy and confidentiality within the pharmacy, as well as the impact of the relationship with pharmacists and staff were key factors influencing uptake.

Conclusion: Pharmacy-based HCV testing is viewed by participants as a convenient and acceptable testing option. Addressing stigma, ensuring privacy, and building trust with pharmacy staff appear to be critical for uptake. This approach may help to engage PWID in HCV testing as part of HCV elimination efforts.

Introduction: The development of anti-drug antibodies against tumor necrosis factor inhibitors, such as infliximab and adalimumab, is a major cause of therapeutic failure in patients with immune-mediated inflammatory diseases (IMIDs). However, immunogenicity responses are heterogeneous, and drug exposure can be restored in selected cases through individualized management.

Aim: To evaluate the clinical management and pharmacokinetic (PK) outcomes of immunogenicity in IMIDs treated with infliximab or adalimumab, by assessing its prevalence and phenotypes, associated factors, and the effectiveness of therapeutic interventions in reversing its PK impact.

Method: This retrospective cohort study included 997 patients treated with infliximab (n = 278) or adalimumab (n = 719). Immunogenicity was defined by detectable anti-drug antibodies and/or undetectable serum drug levels. Patients were stratified into three phenotypes based on anti-drug antibody titers and serum concentrations. Therapeutic drug monitoring guided clinical decision-making in cases of suspected treatment failure, immunogenicity, or subtherapeutic exposure, in accordance with institutional protocols. PK reversal was defined as the reappearance of detectable drug levels after intervention without switching therapy.

Results: Immunogenicity was identified in 240 patients (24.1%), more frequently among those treated with infliximab (28.4%) than with adalimumab (22.4%; p = 0.064). Multivariable analysis confirmed treatment with infliximab (OR: 1.43; 95% CI: 1.04-1.97) and prior immunogenicity (OR: 3.69; 95% CI: 1.50-9.11) as risk factors, while concomitant immunosuppressants were protective (OR: 0.62; 95% CI: 0.45-0.84). Among 77 patients managed actively, PK reversal was achieved in 76.7%. The rate of reversal was higher with adalimumab (80.0%) than with infliximab (62.5%; p = 0.039), and in patients with undetectable antibodies and low drug concentrations (Group 3) than in those with low-level antibodies (77.5% vs 50.0%; p = 0.024). Dose intensification and supervised administration were effective in achieving PK reversal (79.2% and 70.8%, respectively). Median serum drug concentrations increased significantly after intervention in both groups (p < 0.001).

Conclusion: Therapeutic drug monitoring-guided interventions tailored to immunogenicity phenotype can restore drug exposure in a substantial proportion of patients treated with tumor necrosis factor inhibitors. Recognition of reversible immunogenicity is essential for optimizing long-term therapeutic success and avoiding premature drug discontinuation.

Introduction: First line treatment of cerebral edema or elevated intracranial pressure involves hyperosmolar therapy.

Aim: The purpose of this study was to identify risk factors associated with hypertonic saline solutions (HTS) non-responders post HTS bolus for treatment of cerebral edema.

Method: This single center, retrospective cohort study included neurocritical care patients who received one bolus dose of 3% NaCl (> 100 mL) or 23.4% NaCl (30 mL) and obtained one serum sodium level between one and eight hours after administration. The primary outcome was to determine the incidence of HTS non-responders, defined as a serum sodium response of < 5 mEq/L on repeat lab draw, and to identify risk factors associated with HTS non-response (sodium < 5 mEq/L) within 8 h after a HTS bolus dose.

Results: A total of 200 patients were included. The primary neurologic injuries included were acute ischemic stroke (41.5%) and intracerebral hemorrhage (35.5%). For the primary outcome, 127 (63.5%) patients were HTS non-responders. Risk factors associated with HTS non-response, included patients who did not receive mannitol prior to HTS (OR 3.31, 95% CI 1.34-8.17; p = 0.009), male sex (OR 2.43; 95% CI 1.27-4.63; p = 0.007), and patients without intraventricular hemorrhage (IVH) (OR 2.12; 95% CI 1.11-4.06; p = 0.024).

Conclusion: Overall, 63.5% patients were non-responders to HTS. Risk factors for non-response to HTS included no prior mannitol therapy, male sex, and patients without IVH. Further studies are warranted to assess the impact these risk factors have on HTS dosing and the treatment of cerebral edema.

Introduction: The Aged Care Onsite Pharmacist (ACOP) program was recently launched in Australia to enable pharmacists to deliver clinical governance, clinical pharmacy and education services on the ground in residential aged care homes (RACHs). As the program is now being scaled up nationally, it is crucial to understand the complex interactions between various factors at the individual and organisational levels to ensure the program is successfully implemented and achieves its ultimate goal of improving the quality use of medicines in RACHs.

Aim: This qualitative study aimed to explore stakeholders' perspectives on medication management, perceived value of onsite pharmacists, and key considerations for successful program implementation in RACHs.

Method: We employed a qualitative approach and conducted semi-structured interviews (n = 61) with residents/families, pharmacists, medical practitioners, RACH staff, and individuals involved in policy and planning. Participants with experience working in both metropolitan and rural areas were included. The interviews were audio-recorded, transcribed, and thematically analysed, both inductively and deductively. The Consolidated Framework for Implementation Research informed the design of the study, developing interview schedules and data analysis.

Results: Factors influencing the program implementation were grouped into five themes: (1) Individuals: factors concerning individuals involved in the program; (2) Innovation: factors related to the program design; (3) Process: implementation process actions; (4) Inner setting: factors relating to the organisational context; and (5) Outer setting: factors pertaining to the policy context. Most participants valued the potential contribution of onsite pharmacists. Program flexibility was noted as essential to increase its acceptability, uptake and adoptability. A desire for implementation strategies was evident. Workforce, organisational leadership, infrastructure and resources, and broader policy support were noted as critical for the program's success.

Conclusion: The ACOP program represents a promising strategy to enhance medication management in RACHs. However, implementation on a large scale necessitates a thoughtful consideration of various interconnected factors at the individual, organisation and policy levels that may affect its uptake, adoptability, and long-term sustainability. This has implications for policymakers and providers at the scale up phase to ensure the program achieves its ultimate goal of enhancing residents' health outcomes.

Background: The roles of community pharmacists have evolved from dispensing medications to clinical decision makers. This shift requires a clearer understanding of pharmacists' clinical reasoning. Managing hospital discharge prescriptions requires analytical reasoning to ensure patient safety through medication reconciliation and patient education.

Aim: This study assessed community pharmacists' practices and their clinical reasoning towards hospital discharge prescriptions.

Method: This mixed-method study consisted of two phases. First, community pharmacists participated in a simulated encounter in their pharmacy, where a patient presented a discharge prescription. Their practices and the structure of the encounter were assessed using a structured checklist of practices adapted from the MEDICODE checklist. Following the simulation, participants verbalised their thought processes in a retrospective think-aloud session. These semi-structured interviews were transcribed and analysed using both inductive and deductive qualitative methods. Charlin et al.'s model was used to assess clinical reasoning, while the Calgary-Cambridge model evaluated communication structure.

Results: Among 14 participating pharmacists, 13 performed medication reconciliation, and 10 contacted the simulated prescriber to address discrepancies. While most provided adherence aids, only seven assessed non-adherence, and five actively collaborated with the patient. Pharmacists exhibited diverse interview structures, often revisiting previous discussion points. Clinical reasoning misconceptions, such as assumptions or premature closure, were observed at multiple stages of the clinical reasoning process.

Conclusion: Community pharmacists demonstrate strong medication-related skills but face challenges in clinical reasoning for discharge prescriptions. Clinical reasoning training, semi-structured consultations, and greater patient engagement would help tailor and improve post-discharge care.