International Journal of Clinical Pharmacy最新文献

Introduction: Off-label prescribing, use of medications outside approved indications, dosages, administration routes, or age groups is common in pediatric clinical practice, largely because of the lack of high-quality clinical trials in children. Although such prescriptions can meet urgent therapeutic needs, particularly in complex or rare pediatric conditions, they also raise significant concerns regarding safety, effectiveness, and medicolegal liability. Limited research has examined the behavioral factors that influence pediatricians' decisions to prescribe off-label drugs.

Aim: This study aimed to identify the behavioral determinants of pediatricians' off-label drug use in Chinese hospitals by applying the Theory of Planned Behavior (TPB) to assess how behavior attitudes, subjective norms, and perceived behavioral control influence prescribing intentions and behaviors.

Method: A cross-sectional survey was conducted among pediatricians from 40 hospitals across seven provinces and municipalities in China. A TPB-based questionnaire was developed and refined through expert panel review and pilot testing. Structural equation modeling (SEM) was used to test the hypothesized relationships among the TPB constructs.

Results: A total of 350 questionnaires were distributed, of which 320 were returned (response rate: 91.4%). Most pediatricians acknowledged the necessity (82.4%) and risks (78.9%) of off-label use. Attitudes reflecting perceived benefits, safety concerns, and cost implications significantly predicted behavioral intention (β = 0.51, P < 0.01). Perceived behavioral control, including barriers such as outdated labeling, lack of pediatric formulations, and limited data, also predicted intention (β = 0.26, P < 0.01), but not behavior directly (β = 0.00, P = 0.12). Subjective norms such as institutional expectations and peer influence were positively associated with intention (β = 0.07, P < 0.01). Behavioral intention was the strongest predictor of actual off-label prescription behaviors (β = 0.16, P < 0.001). Most pediatricians (85.2%) supported pharmacists' involvement in evidence reviews, documentation, and prescription oversight.

Conclusion: Pediatric off-label prescribing in China is largely intention-driven and shaped by behavior attitudes, perceived control, and professional norms. Interventions targeting these behavioral domains, along with institutional policies and pharmacist collaboration, may enhance the safety, consistency, and regulatory oversight of off-label drug use in pediatric care.

Introduction: Medications with anticholinergic effects are widely used despite the mounting evidence of physical and cognitive impairment associated with their use among older adults.

Aim: A systematic review was conducted to describe the prevalence of anticholinergic medication use in community-dwelling older adults, document the factors associated with their use and describe the most frequently used medication classes.

Method: MEDLINE, Embase and CINAHL were searched from inception to May 2024. All study designs except case reports and case studies were eligible if they included community-dwelling older adults aged 65 and older and assessed the factors associated with anticholinergic medication use. An open-source artificial intelligence screening tool was used to optimise title and abstract screening. The subsequent review of the full texts of potentially eligible studies and data extraction were conducted in the Covidence systematic review tool using standardised data collection forms. Study quality was assessed with the Newcastle-Ottawa scale. The study selection, data extraction and quality assessment were conducted independently by two reviewers.

Results: From 4139 records of interest, the seven selected studies included five cross-sectional and two retrospective studies, published between 2014 and 2021. The risk of bias was assessed to be low in five studies and high in two studies. Greater anticholinergic burden was associated with female sex, lower socioeconomic status, higher co-morbidity score, higher frailty probability, specific diseases, polypharmacy and greater use of healthcare, while increasing age was associated with both increased and decreased anticholinergic burden. Anticholinergic exposure, varied from a low of 6.2% of medical visits in the United States between 2006 and 2015, assessed with the 2015 Beers Criteria and the Anticholinergic Risk Scale, to a high of 72.8% of medication claims (dispensed medications) in South Korea, over the year 2012, assessed with the 2015 Beers Criteria and the Anticholinergic Burden Scale. The use of six different anticholinergic scales and different evaluation periods did not allow a meaningful comparison of the prevalence of anticholinergic exposure across studies. Antidepressants, antihistamines and antimuscarinics were the most common medication classes in the two studies using this classification.

Conclusion: This systematic review documented key socioeconomic and health status factors to be targeted by interventions aimed at limiting the use of anticholinergic medications in community-dwelling older adults.

Introduction: Medication adherence is essential for the effective management of chronic diseases; however, adherence among patients remains suboptimal in China. Understanding the multidimensional determinants of adherence is critical in designing interventions to improve treatment outcomes. The health ecology model (HEM) provides a comprehensive framework that integrates individual, behavioral, social, and environmental influences on health behaviors.

Aim: This study aimed to identify the multilevel determinants of medication adherence among Chinese patients with chronic diseases using an ecological framework based on the HEM and to provide evidence to inform pharmacist- and policy-driven strategies to enhance adherence.

Method: Data were derived from the 2021 Psychology and Behavior Investigation of Chinese Residents, a nationally representative survey of 1162 adults with chronic diseases. Medication adherence was assessed using the Medication Adherence Rating Scale. Independent variables were categorized into five hierarchical levels according to the HEM: personal traits, behavioral characteristics, interpersonal networks, working and living conditions, and policy environment. Binary logistic regression analyses were performed sequentially to identify factors associated with good medication adherence.

Results: Among the participants, 23.8% demonstrated good adherence to medication. In the final regression model (AUC = 0.721; Hosmer-Lemeshow p = 0.790; R² = 0.168), higher adherence was significantly associated with older age (OR 1.616, p < 0.01), lower depression levels (OR 0.663-0.869, p < 0.05), absence of alcohol use (OR 1.485, p < 0.05), being married OR 1.829, p < 0.01), higher education (OR 1.784, p < 0.05), higher income (OR 1.679, p < 0.01), and eligibility for medical subsidies (OR 1.763, p < 0.01).

Conclusion: This nationwide study demonstrated that medication adherence among Chinese patients with chronic diseases is influenced by interconnected personal, psychosocial, and socioeconomic factors. Multifaceted interventions, including pharmacist involvement in adherence monitoring, family-based support, mental health screening, and the expansion of subsidy programs, may improve medication adherence and optimize chronic disease management.

Introduction: Antimicrobial resistance poses a growing global health threat and is largely driven by the inappropriate use of antibiotics. Primary healthcare institutions, particularly in low-resource settings, often face challenges, such as limited oversight and irrational prescribing practices. While progress has been made in improving antibiotic stewardship in higher-level hospitals, efforts to optimize prescription in primary healthcare institutions remain insufficient. The County Medical Community Central Pharmacy (CMCP) program was introduced as an integrated intervention to enhance pharmacy services and promote rational antibiotic use through centralized oversight, training, and pharmacist collaboration.

Aim: This multicenter quasi-experimental study aimed to evaluate the effectiveness of the CMCP program in reducing antibiotic misuse and improving prescribing rationality in primary healthcare institutions in Shandong Province, China.

Method: This multicenter quasi-experimental study was conducted between July and December 2023 in six geographically and economically diverse rural regions of Shandong Province. A total of 37 primary healthcare institutions were included, with 25 voluntarily implementing the CMCP program (intervention group) and 12 continuing routine practices (control group). Data were collected at two time points via structured questionnaires and reviews of 100 randomly selected outpatient prescriptions from each primary healthcare institution. A difference-in-differences (DID) regression model was applied to estimate the impact of the intervention on antibiotic usage and irrational prescribing, controlling for institutional and staffing characteristics.

Results: Antibiotic usage rates increased in both groups, but to a lesser extent in the intervention group (from 15.726 to 18.732%; P = 0.006) than in the control group (from 17.682 to 26.582%; P < 0.001). DID analysis showed a mitigating effect on antibiotic use (DID coefficient = - 0.061; P = 0.054). Irrational antibiotic use in the intervention group decreased from 50.660 to 27.655% (P < 0.001), whereas it remained largely unchanged in the control group (36.893% vs. 35.238%).

Conclusion: The CMCP program was effective in curbing unnecessary antibiotic prescriptions and enhancing prescription quality in primary healthcare institutions. These findings support the continued implementation and scale-up of CMCP as a strategy to strengthen antibiotic stewardship at the primary care level in resource-limited settings.

Introduction: Adherence to newly prescribed cardiometabolic medications is low. It is crucial to develop personalized behavioural interventions to address patients' specific medication adherence barriers.

Aim: The aim of this study was to develop a behavioural theory-based New Medicine Service (NMS) toolkit for use by community pharmacists in Türkiye to identify and address reasons for nonadherence in patients newly started on medications for hypertension, diabetes, or dyslipidemia.

Method: This multistage study used a literature search, expert panel, cognitive interviews, and survey with patients to identify reasons for nonadherence to include in the Turkish DOSE Nonadherence Scale. A short form of the toolkit was generated by asking the patients to select the most challenging reasons for nonadherence. To identify relevant pharmacist interventions, the theoretical domains framework (TDF-14) (v2) domains related to reasons for nonadherence were identified and matched with behavioural change techniques (BCTs). To assess the applicability of the proposed pharmacist interventions in daily practice, an online survey of community pharmacists was conducted using a modified Delphi study.

Results: The final list of reasons for nonadherence consisted of 31 items, of which 14 identified as most challenging by patients were selected for inclusion in the short form of the NMS toolkit. For the full 31 reasons, ten domains of TDF-14 and 18 BCTs were selected. In the Delphi study (response rate: 83.3%), 68 of the 81 (84.0%) pharmacist interventions were found to be applicable, corresponding to 15 BCTs.

Conclusion: The behavioural theory-based NMS toolkit was developed for use by community pharmacists to identify and address reasons for nonadherence in patients newly started on medications to manage hypertension, diabetes, or dyslipidemia. This toolkit will assist community pharmacists in developing personalized interventions to overcome nonadherence problems in patients who are newly starting medications. Future studies should be conducted to assess the impact of this new toolkit on patients' medication adherence levels and clinical outcomes.

Introduction: Drug-induced movement disorders (DIMDs) are often underrecognized and challenging to diagnose and manage in clinical practice. Sodium valproate (VPA), a widely prescribed antiepileptic drug, causes DIMDs. Predictive modeling based on electronic medical records and machine learning algorithms offers a promising approach to improve early identification of adverse drug reactions (ADRs) and enhance clinical safety.

Aim: This study aimed to conduct real-world active surveillance of VPA-associated DIMDs using hospital information system data, to identify independent risk factors, and to develop a clinically applicable prediction model for early warning and intervention.

Method: In this retrospective case-control study, data were collected from hospitalized patients prescribed sodium valproate between 2018 and 2022. DIMD cases were identified through automated alerts generated by the ADE Active Surveillance and Assessment System II, and subsequently confirmed using the Naranjo scale for manual causality assessment. A clinical prediction model was developed using LASSO logistic regression and was presented as a nomogram. Model performance was evaluated using area under the receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC).

Results: Of the 6692 patients screened, 98 were confirmed to have DIMDs, yielding an incidence rate of 1.46%. Four independent protective factors were identified: higher lymphocyte count, red blood cell count, serum sodium concentration, and co-administration of levetiracetam. The nomogram demonstrated good discrimination (AUC = 0.774), acceptable calibration (Brier score = 0.194), and strong clinical utility across a threshold probability range of 10-70%.The results of the external validation suggest that the efficiency of the model remained stable and showed no significant decline. It had better predictive ability in high- and medium-risk groups and had significant potential for clinical application. The incidence of DIMDs was significantly higher among patients receiving VPA for therapeutic purposes than among those receiving VPA prophylactically.

Conclusion: VPA-associated DIMDs are common in hospitalized patients. The prediction model based on routine clinical indicators enabled the identification of high- and middle-risk individuals, thereby facilitating timely monitoring and targeted interventions to reduce the burden of movement-related ADRs.

Introduction: Venous thromboembolism (VTE) is a common and preventable complication in orthopedic surgery, yet adherence to prophylaxis guidelines remains suboptimal. A pharmacist-led anticoagulation care model based on the Pharmacist Early Active Consultation (PEAC) framework may enhance the quality and safety of VTE prevention in surgical patients.

Aim: This study aimed to evaluate the impact of a pharmacist-led Venous Thromboembolism Clinical Pharmaceutical Care (VTE-CPC) model, derived from the PEAC framework, on VTE prevention and anticoagulation quality in orthopedic surgery patients.

Method: A retrospective cohort study was conducted at a tertiary hospital in China. Patients admitted between December 2023 and May 2024 received routine care (no VTE-CPC group), while those admitted between June and November 2024 received additional pharmacist-led interventions (VTE-CPC group). Multivariate logistic regression was used to identify independent risk factors for VTE. Propensity score matching (PSM) was performed to control baseline differences, resulting in a balanced cohort of 812 patients. Outcomes included VTE incidence, pharmacological prophylaxis practices, and safety endpoints.

Results: A total of 959 patients were included (no VTE-CPC: n = 531; VTE-CPC: n = 428). The incidence of VTE was significantly lower in the VTE-CPC group (3.74%) compared to the no VTE-CPC group (7.53%, p = 0.020). VTE-CPC remained an independent protective factor in multivariate analysis (OR = 0.45; 95% CI 0.23-0.84; p = 0.015). In the PSM matched cohort, patients in the VTE-CPC group had higher rates of postoperative pharmacological prophylaxis (22.66% vs. 16.26%, p = 0.027) and improved dosage appropriateness across all perioperative phases (p < 0.05). No significant differences were observed between groups in rates of bleeding events, thrombocytopenia, or hepatic/renal dysfunction.

Conclusion: A pharmacist-led anticoagulation management model based on the PEAC framework significantly reduced perioperative VTE incidence without increasing adverse events. These findings support broader implementation of proactive, pharmacist-driven strategies to improve thromboprophylaxis quality in orthopedic surgery.

Introduction: Depression affects approximately 5% of the global adult population, and its clinical and economic burden is particularly pronounced among individuals with chronic conditions such as diabetes mellitus, where it is frequently underdiagnosed and inadequately managed. Pharmacists play an important role in managing chronic diseases, including depression, through screening and medication management.

Aim: This systematic review aimed to critically appraise and synthesize evidence on pharmacist input in screening and managing depression among patients with diabetes, either as sole providers or as part of a multidisciplinary team, and assess their impact on clinical outcomes and quality of life.

Method: A systematic literature search was conducted in March 2023 and updated in March 2025 across Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and International Pharmaceutical Abstracts (IPA) databases, and reported in accordance with the PRISMA 2020 guidelines. Studies, irrespective of their design and published in English, reporting any pharmacist input in screening and managing depression among patients with diabetes, were included. No date restrictions were applied. Data extraction was based on Donabedian's quality-of-care model, which categorizes findings into structure, process, and outcome. The results were presented in both narrative and tabular formats. Quality was assessed by two independent researchers via the Mixed Methods Appraisal Tool.

Results: Among the 1,852 records screened, 10 studies met the inclusion criteria. The studies described pharmacist input in depression screening n = 4, medication therapy management n = 6, telehealth services n = 2, and shared medical appointments n = 1. The most reported setting was outpatient clinics, n = 5. All studies demonstrated the positive impact of pharmacists on depression screening, treatment initiation, and medication adherence., Some interventions failed to significantly improve clinical parameters such as HbA1c levels or depressive symptoms. Barriers included limited physicians' response to screening results and a lack of structured care models.

Conclusion: The positive impact of pharmacist interventions on this patient cohort is evident despite the variability across settings and intervention designs, reflecting the adaptability of pharmacist services. Results also suggest the need for standardized models of care and consistent outcome reporting.

Introduction: Daily intravenous dosing of cefepime, meropenem and ceftazidime/avibactam is recommended in patients receiving intermittent hemodialysis (IHD), but requires hospitalization or frequent clinic visits. High dose post-HD administration may offer a more convenient outpatient alternative, but supporting data is limited.

Aim: To evaluate the feasibility by assessing predicted pharmacokinetic/pharmacodynamic (PK/PD) target attainment and neurotoxicity risk of high-dose post-HD versus daily dosing strategies for cefepime, meropenem, and ceftazidime/avibactam in patients receiving thrice-weekly IHD, using the Monte Carlo simulation (MCS) techniques.

Method: One-compartment pharmacokinetic models were developed using published data to simulate drug exposure in anuric patients receiving 4-h IHD thrice-weekly. MCS (Crystal Ball, Oracle) assessed the probability of target attainment (PTA) and neurotoxicity risk of various post-HD and daily dosing regimens in 5,000 virtual cohorts for one week. The PK/PD targets were ≥ 60% fT > MIC for cefepime, ≥ 40% fT > MIC for meropenem and ≥ 50% fT > MIC for ceftazidime with ≥ 50% fT > 1 g/mL for avibactam, assuming Pseudomonas aeruginosa or Enterobactarales infections. A PTA ≥ 90% was considered optimal for PK/PD target attainment. Safety was also assessed using the neurotoxicity thresholds.

Results: All daily regimens achieved PTA ≥ 90% on all simulated days. High-dose post-HD cefepime (1-2 g) and meropenem (2 g) maintained acceptable PTA over 2-day interdialytic periods, but failed to sustain targets through the 3-day period. Ceftazidime/avibactam post-HD dosing (0.94 g-0.94 g-2.5 g) maintained ≥ 90% PTA for ceftazidime throughout the week, though avibactam fell slightly below target on the final day. Predicted neurotoxicity risk was negligible for meropenem and ceftazidime/avibactam, but elevated with higher cefepime doses (1-2 g post-HD and 1 g daily). Cefepime 0.5 g daily, meropenem 0.25-1 g daily, and ceftazidime/avibactam 0.94 g daily or 0.94 g-0.94 g-2.5 g post-HD attained both PK/PD targets and safety targets.

Conclusion: High-dose post-HD dosing appears feasible for ceftazidime/avibactam but may be inadequate for cefepime and meropenem over a 3-day interdialytic period. Elevated neurotoxicity risk predicted with higher cefepime doses highlights the importance of cautious dosing and consideration of therapeutic drug monitoring.

Introduction: Awareness of planetary health has grown across healthcare professions, and the pharmacy sector, responsible for the lifecycle of medicines from production to disposal, plays a significant role in both perpetuating and mitigating environmental harm. However, pharmacy education omits environmental sustainability as a structured component.

Aim: To explore pharmacy students' perceptions of environmental sustainability within their education and future professional roles, focusing on their awareness, attitudes, and perceived barriers or enablers to integrating sustainability in pharmacy education and practice.

Method: A qualitative study was conducted at a university in Northern Ireland, utilising semi-structured interviews with pharmacy students across all four years of their studies. Purposive sampling was used. Interviews were transcribed verbatim and analysed inductively using Braun and Clarke's six-phase approach to thematic analysis.

Results: Sixteen students were interviewed, with data saturation reached at the 14th interview and confirmed through researcher consensus and transcript review. Six themes emerged (mean interview length = 45 ± 10 min): (1) Sustainability as an overlooked area - limited or fragmented curricular coverage; (2) Narrow understanding of waste - awareness focused on disposal and packaging, with little recognition of wider pharmaceutical impacts; (3) Pharmacy as both waste generator and sustainability site - examples included medicines returns, digitalisation, and hospital "green teams"; (4) Integrating sustainability into education - preference for interactive, experiential learning (e.g., guest speakers, placements); (5) Barriers to change - patient resistance, behavioural inertia, and competing curricular demands; (6) Policy, incentives, and leadership as enablers - systemic and financial support deemed essential for sustainable practice.

Conclusion: Pharmacy students recognise the importance of environmental sustainability but perceive significant gaps in both education and practice. While they value opportunities for experiential learning and see potential for pharmacy to contribute positively, systemic barriers and limited curricular integration hinder progress. Embedding sustainability into pharmacy education, supported by leadership, policy, and incentives, will be critical to preparing future pharmacists as both healthcare providers and environmental stewards.