Ischaemic heart disease is a leading cause of morbidity and mortality in haemodialysis patients, yet conventional therapies are often precluded due to increased perioperative risk and medication contraindications. Perhexiline, an antianginal agent, is contraindicated in renal impairment. Research has suggested therapy in kidney failure may be safe, but these studies excluded patients requiring haemodialysis.
We describe a novel case of safe and effective long-term perhexiline therapy in a patient requiring haemodialysis, with treatment guided by therapeutic drug monitoring and interpreted in the context of pharmacogenomic screening.
A male patient, aged 84 years, with an intermediate cytochrome P450 2D6 (CYP2D6) metaboliser phenotype, kidney failure (requiring haemodialysis) and ischaemic heart disease (quintuple coronary artery bypass grafting in 1999 with multiple occluded grafts), and intolerant of conventional antianginal therapy received perhexiline 50 mg, twice daily, for refractory symptomatic ischaemic heart disease for the past three years. [Correction added on 28 April 2025, after first online publication: Some text has been corrected in this section].
Perhexiline and metabolite levels remained within therapeutic range before and after dialysis, and clearance by haemodialysis was negligible. Pharmacogenomic screening and hydroxyperhexiline/perhexiline ratios were consistent with an intermediate CYP2D6 metaboliser phenotype. Therapy in this patient was effective with no adverse events identified.
This case, combined with existing literature, challenges the contraindication of perhexiline in kidney failure. Perhexiline's unique ability to relieve ischaemic symptoms without inducing intolerable blood pressure reduction makes it a therapy of interest in this patient population. Further studies are needed to definitively establish its long-term safety and efficacy in the kidney failure population.
Patients are often advised to withhold their medications prior to surgery. If the surgery date changes, a plan regarding medicine use needs to be communicated to the patient. Bulk cancellations of elective surgery due to the COVID-19 pandemic highlighted a gap in practice.
To report on intervention rate and time taken for pharmacist review of patient medications when bulk cancellations of elective surgery occurred.
A screening tool was developed for nursing staff to identify patients on high-risk medications. Medication plans were developed by the pharmacist, with input from the broader surgical team. Time spent was recorded by the pharmacist. Data were collected over a 3-week period in July 2022. This project was exempt due to the local policy requirements that constitute research by the Metro South Human Research Ethics Committee (Reference no: CM0602202402). The justification for this exemption was as follows: the study complied with Chapter 2.3 of the National statement of ethical conduct in human research and presented no foreseeable risk of patient harm.
The pharmacist reviewed 154 cancellations, of which 17% (n = 26) required intervention by the pharmacist as they met the high-risk criteria identified by the screening tool. Of these, 34% (n = 9) had not attended pre-admission clinic for an original medication plan. The time to conduct a pharmacist review ranged from 10–14 min. At the time of cancellation, 84% (n = 130) of patients were awaiting a new surgery date. Surgical specialties most implicated included orthopaedic surgery (36%, n = 55) and urology (17%, n = 26). The average time between the cancellation date and a new surgery date was 7 days.
A pharmacist-led process to review medication plans in patients whose elective surgery procedure date had been cancelled was developed. Communication of these plans is essential to ensure patient safety and reduce medication-related harm.
Medicine safety is a critical concern for Australia's growing aged-care population. Pharmacists play a vital role in improving medicines management, but their integration into aged-care settings requires careful planning.
To report on the outcomes of a national meeting of stakeholders in Australia exploring the integration of pharmacists into aged care to enhance medicine safety for aged-care residents.
A stakeholder meeting was held in July 2023 including 73 pharmacists, five general practitioners, three geriatricians, three industry stakeholders, three researchers, one student pharmacist, and one nurse. Four working groups focused on medicines management, pharmacist training, role description, and refining the vision for a Community of Practice. Ethical approval was granted by the University of Western Australian Human Research Ethics Committee (Reference no: 36895) and the study conforms with the National statement on ethical conduct in human research. Informed consent was obtained from all participants. At the start of the stakeholder meeting, attendees were informed about the project details, including the intended use of their data for publication. All participants were informed that participation was voluntary, and they could choose to exclude their data at any time. No participants requested withdrawal.
The medicines management working group highlighted areas for improvement in health policy, aged-care facility environment (resources, staff training, and cultural considerations) and broader healthcare sector collaboration. The training working group proposed a flexible, workplace-based program focusing on core competencies like communication, geriatric therapeutics and medication review skills, facilitated by mentorship, workshops, and peer review. The role description working group explored the responsibilities of aged-care pharmacists, including medication reviews, deprescribing, error reduction and contributing to care plans, with credentialling deemed essential. Finally, the Community of Practice working group envisioned a platform for knowledge sharing, professional development and workforce growth through virtual meetings, case studies, resource development, and mentorship opportunities.
This stakeholder meeti
Several questionnaires are available to evaluate immunosuppressant knowledge among kidney transplant recipients (KTRs). However, most contain a mixture of questions about different aspects of health management before and after kidney transplantation and do not specifically assess immunosuppressant knowledge.
This study aimed to generate preliminary items for a questionnaire to assess immunosuppressant knowledge among KTRs, validate the items, and translate the items into Malay.
Preliminary items were generated from domains and subdomains identified through a review of previous questionnaires. Then, the item content was validated in a three-round Delphi study by an expert panel of 11 renal pharmacists. The experts rated the relevance of the items and provided feedback on their comprehensibility and comprehensiveness. Items that attained ≥75% expert agreement on their relevance were considered relevant. Finally, the relevant items were translated into Malay through a forward–backward translation process by three external translators and two researchers. Ethical approval was granted by the Universiti Teknologi MARA Research Ethics Committee (Reference no: REC (PH)PG/027/2022) and the study conforms with the Declaration of Helsinki. Participants were approached electronically, and informed consent was obtained from all participants via distribution of a project information sheet, explaining their participation was voluntary and a gift card would be provided as an incentive upon completion of all three rounds of the Delphi study and completion of a written consent form.
A total of 24 preliminary items were generated. In Round 1 of the Delphi study, four items needed revision, and nine new items were suggested for Round 2 (n = 13). In Round 2, only five of the 13 items were carried forward to Round 3. In the final round, only one of the five items was relevant. The final experts' revision produced 27 items. A Malay-language questionnaire equivalent to the English version was produced.
A content-validated questionnaire consisting of 27 items in English and Malay was produced. This questionnaire serves as a reliable tool to identify immunosuppressant knowledge gaps and evaluate the impacts of educational interventions.
Warfarin therapy remains essential in anticoagulation management and its quality is measured by the time in therapeutic range (TTR). In Malaysia, some healthcare centres provide the Anticoagulation Medication Therapy Adherence Clinic (ACMTAC) service for warfarin management, which is managed by pharmacists.
To evaluate overall TTR and to analyse the occurrence of thromboembolic and bleeding complications in warfarin patients.
This cross-sectional, retrospective cohort study included patients who received warfarin treatment over a 3-year period (2019–2021). Data were collected from 49 healthcare centres in Malaysia with ACMTAC services. TTR was calculated using the Rosendaal method from international normalised ratio (INR) data acquired across these centres. TTR ≥ 65% was defined as good control of anticoagulation therapy. Ethical approval was granted by the Medical Research and Ethics Committee, Ministry of Health Malaysia (Reference no: NMRR- 21-779-59275) and the study conforms with the Declaration of Helsinki.
The mean age (±standard deviation [SD]) of the 1464 included patients was 60.3 (±13.1) years, and 732 (50.0%) were male. Atrial fibrillation (65.7%) and valve replacement (23.1%) were the main indications for warfarin therapy. From 2019 to 2021, the annual mean TTR (±SD) were 63.1% (±24.5%), 64.0% (±25.0%), and 64.1% (±26.3%) respectively. For three consecutive years, more than 49% of patients achieved good control of anticoagulation therapy. Among the 49 centres, over 24 (49.0%) achieved a mean TTR of ≥65%, and the mean TTR varied significantly between centres (p < 0.001). The occurrence of bleeding and thromboembolic events was 227 (15.5%) and 15 (1.0%) respectively.
In Malaysia, the anticoagulation control of warfarin under ACMTAC management is moderate, with about half of patients demonstrating good control levels. Over a 3-year observation period, there was variation in TTR among the centres.
A 2016 Australian hospital pharmacy technician workforce survey reported that pharmacy technicians seldom perform clinical support roles. Subsequently, the Society of Hospital Pharmacists of Australia extended their endorsement of pharmacy technicians performing clinical roles in the Standard of practice for pharmacy technicians to support clinical pharmacy services published in 2019. It is unknown if the roles undertaken by hospital pharmacy technicians have since evolved.
To compare and contrast trends in the uptake of hospital pharmacy technician roles between 2016–2022.
An electronic questionnaire comprising 97 questions was circulated to Australian hospital pharmacy departments in 2022 and the results were compared to those obtained from the 2016 questionnaire. Hospital pharmacy technicians' clinical support roles were categorised as ‘clinical tasks’ (n = 15) or ‘technical tasks’ (n = 34). Ethical approval was granted by the University of Technology Sydney Human Research Ethics Committee (Reference no: ETH21-6732) and the study conforms with the National statement on ethical conduct in human research. Informed consent was obtained from all participants via project information distributed to potential participants via email, indicating their participation would be voluntary and anonymous. Participants provided their consent by completing the questionnaire.
Responses were received from 54 of 273 pharmacy departments (response rate 20%) in 2022 compared to 154 responses from 308 pharmacy departments (response rate 50%) in 2016. Hospital pharmacy technicians performed a median of 0.5 ‘clinical tasks’ (interquartile range [IQR] 0–1.25) in 2022 and 1 ‘clinical tasks’ (IQR 0–3) in 2016. In contrast, hospital pharmacy technicians performed a median of 7 (IQR 3–12) and 8 (IQR 3–12) ‘technical tasks’ in 2022 and 2016, respectively. No significant changes were identified in the prevalence of hospital pharmacy technicians undertaking clinical tasks.
Despite publication of professional practice standards endorsing clinical roles for pharmacy technicians, clinical roles are still seldom performed. Interventions are required to address the barriers limiting the expansion of hospital pharmacy technician roles.
Failure to self-administer a medication is the most common reason for non-adherence. Dose administration aids (DAAs) are a simple and common solution to improve unintentional non-adherence for oral tablets. They range from compartmentalised pill boxes and automated medication dispensing devices to blister packs. The aim of this systematic review was to summarise the current literature assessing the impact of DAAs on medication adherence.
A search of MEDLINE, Embase, CINAHL, and the Cochrane Library was conducted from the beginning of each database until April 2023.
A search strategy and keywords list were developed with a medical research librarian. Two reviewers independently screened studies and extracted data. The primary outcome was to assess the effects of DAAs on medication adherence. The secondary outcome was to evaluate the changes in any health outcomes documented. The study was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) 2020 statement and registered with PROSPERO (Study registration: CRD42018096087).
Twenty-two randomised controlled trials were included. Median adherence improved within the intervention groups for self-reported (95.5%, range: 88%–100% vs 84.5%, range: 83%–98%) and non-self-reported (88%, range: 54%–100% vs 70%, range: 83%–98%) adherence compared to usual care. However, self-reported adherence was higher in both intervention and control groups than non-self-reported adherence. Measured changes to health outcomes included cardiovascular outcomes, plasma levels, cure rates for malaria, hospital admissions, venous thromboembolism, and anaemia. Even though self-reported adherence levels were high, included studies did not report many statistically significant improvements in health outcomes with DAAs.
The use of DAAs can considerably improve medication adherence, with limited data suggesting positive effects on patient outcomes. Healthcare providers should consider the use of these aids as part of a comprehensive treatment plan for patients who struggle with medication adherence.
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