You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Statin treatment and risk of developing diabetes

27 Jun, 13 | by kuppell

A study looking into whether there is an association between statin use and new onset diabetes found that patients treated with atorvastatin, rosuvastatin, or simvastatin were at an increased risk of new onset diabetes compared with those treated with pravastatin.

Researchers conducted a population-based retrospective cohort study in patients aged 66 years and older in Ontario, Canada who started treatment with a statin from 1 August 1997 to 31 March 2010. They examined the healthcare records of more than 1.5 million older people. The analysis was restricted to new users who had not been prescribed a statin in at least the preceding year and patients with established diabetes before the start of treatment were excluded. The primary outcome was incident diabetes. Over the 14 year study period, the researchers identified 471,250 patients with no history of diabetes who were newly treated with a statin. Of these patients, 227,994 (48.3%) received a statin for primary prevention, while 243,256 (51.7%) received a statin for secondary prevention.

Reporting their findings in the British Medical Journal the researchers say that, compared with pravastatin, there was an increased risk of incident diabetes with atorvastatin (adjusted HR 1.22, 95% CI 1.15 to 1.29), rosuvastatin (1.18, 1.10 to 1.26) and simvastatin (1.10, 1.04 to 1.17). There was no significantly increased risk among patients who received fluvastatin or lovastatin and the risk of incident diabetes was similar whether statins were used for primary or secondary prevention. BMJ 2013;346:f2610.

Short-term course of glucocorticoids for COPD

18 Jun, 13 | by kuppell

A short-term 5-day, rather than 14-day, course of glucocorticoid treatment should be used for acute exacerbations of chronic obstructive pulmonary disease (COPD) according to a study published in JAMA. The Reduction in the Use of Corticosteroids in Exacerbated COPD (REDUCE) study was a randomised, non-inferiority Swiss trial which enrolled 314 patients (from March 2006 to February 2011) presenting to the emergency departments of five hospitals with acute COPD exacerbations. Patients were past or present smokers (≥20 pack-years) without a history of asthma.

Patients received 40mg of prednisone daily for either 5 or 14 days in a placebo-controlled double-blind manner. The main outcome was time to next COPD exacerbation during a follow-up of 6 months.

Of the 314 patients, 311 were included in the intention-to-treat analysis and 296 in the per-protocol analysis. Hazard ratios (HRs) for the short-term versus 14-day treatment group were 0.95 (90% CI, 0.70 to 1.29; p=0.006 for non-inferiority) in the intention-to-treat analysis and 0.93 (90% CI, 0.68 to 1.26; p=0.005 for non-inferiority) in the per-protocol analysis, meeting the researchers non-inferiority criterion. In the 5-day treatment group, 56 patients (35.9%) reached the primary end point and 57 (36.8%) in the 14-day group. Estimates of reexacerbation rates within 6 months were 37.2% (95% CI, 29.5% to 44.9%) in the short-term group with median time to event being 43.5 days and were 38.4% (95% CI, 30.6% to 46.3%) in the 14-day treatment group with median time to event of 29 days.

The authors conclude that: ‘In patients presenting to the emergency department with acute exacerbations of COPD, 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure. These findings support the use of a 5-day glucocorticoid treatment in acute exacerbations of COPD.’ JAMA 2013;309:2223-31.

Continuous infliximab treatment rather than intermittent for plaque psoriasis

11 Jun, 13 | by kuppell

Continuous therapy with infliximab is more effective than intermittent therapy and is associated with fewer side effects in patients with moderate to severe plaque-type psoriasis according to a study published in the British Journal of Dermatology.

Eligible patients for inclusion in the extension study, RESTORE2, had received infliximab for 26 weeks and achieved Psoriasis Area and Severity Index (PASI) score of 75 in the initial RESTORE1 study. Of these, 222 patients were randomised to receive continuous infliximab treatment (5mg/kg every 8 weeks) and 219 received intermittent treatment (no infliximab until >50% loss of PASI improvement). The researchers say that more serious infusion-related reactions occurred with intermittent treatment (8/219 patients, 4%) than with continuous treatment (1/222 patients, <1%) which lead to termination of the study.  Although no formal efficacy analyses were conducted, continuous therapy led to greater PASI 75 at week 52 in the continuous group (81/101, 80%) than in the intermittent group (39/83, 47%).

‘For patients with moderate-to-severe plaque-type psoriasis, continuous therapy with infliximab may be more effective than intermittent therapy. The incidence of serious infusion-related reactions in the intermittent group suggests that clinicians should avoid intermittent therapy in this population,’ advise the researchers. Br J of Dermatol 2013;168:1325-34.

Changes Needed to Improve the Diagnosis and Management of CDI in Europe

22 May, 13 | by kuppell

Urgent action is needed to improve the diagnosis and management of clostridium difficile infection (CDI) in Europe according to a new report. CDI is the main cause of healthcare-associated diarrhoea in Europe and the CDI in Europe report hopes to help change the way CDI is managed across Europe at a policy level.

Written by a group of European infectious disease experts, with the support of Astellas Pharma Europe Ltd, the report points out that hospital patients with CDI are up to three times more likely to die in hospital (or within a month of infection) than those without CDI.  “CDI has an enormous impact on healthcare systems and infected patients can stay in hospital an extra 1-3 weeks at an additional cost of up to €14,000, compared with patients without CDI,” it adds.

 A number of reasons why CDI is not being well managed is identified by the report. In many countries there is an inadequate level of awareness of CDI among doctors and other healthcare workers, resulting in under-diagnosis. Where this happens treatment is delayed or omitted, leading to increased morbidity and complications in the treatment of co-existing diseases. Proactive infection control measures may also be delayed, risking further outbreaks. Additionally, only a third of European countries have a nationally recommended diagnostic test algorithm for CDI, with testing in nursing homes and the community being particularly limited.      

The report demonstrates how CDI threatens patient safety and the quality of care provided. It makes recommendations to improve CDI management, within the context of current EU policy initiatives, which call for increased awareness of the signs and symptoms of CDI to improve rates of testing and diagnosis as well as improved awareness of and compliance with guidelines for CDI therapy and infection control. The report also makes a case for the introduction of national-level surveillance systems in all Member States and increased patient education and awareness.

“It’s vital that governments see CDI management as a key indicator of patient safety and quality of care, and ensure that robust systems are in place to address it,” comments Professor Mark Wilcox, Professor of Medical Microbiology, University of Leeds and one of the CDI in Europe report authors. “CDI is a problem in hospitals and nursing homes and can be a major drain on healthcare resources. I believe implementation of the recommendations made in this Report will help improve the recognition of CDI and subsequently lead to a reduction in its incidence and impact on patients’ lives.”

A full copy of the report is available from http://www.epgonline.org/anti-infectives-knowledge-network/index.cfm.

 

EAHP launch search for good practice initiatives

1 May, 13 | by kuppell

The European Association of Hospital Pharmacists (EAHP) has launched a search for examples of successful European initiatives to improve hospital pharmacy practice. The exercise is part of a project led by the EAHP Scientific Committee to create an inventory map of good practice initiatives, which they hope will provide practical support and inspiration for hospital pharmacists in EAHP member countries to embark on fresh improvement projects of their own.

The EAHP says a good practice initiative is any service improvement or innovation in hospital pharmacy conducted in the past ten years that has the possibility of transfer to other hospital pharmacy settings in Europe and encourage hospital pharmacists to take part.

Launching the exercise, Prof. Dr. Cees Neef, Chairman of the EAHP Scientific Committee, said: ‘By creating a European map of completed service development initiatives, we believe we can go some way to inspiring the next generation of innovation and improvement in hospital pharmacy across the continent. We hope all hospital pharmacies that have implemented change and improvement in the past ten years will give consideration to making a short submission for inclusion and help to build an open and accessible database of lasting value in terms of both developing new services, and enhancing the quality and safety of existing services.’

Two examples of good practice initiatives can be found on the EAHP website, one relating to a pharmacogenetics education programme in Leiden, and another a parenteral drug compounding initiative in Maastricht. The EAHP says that all examples of good practice initiatives submitted will be considered for inclusion in the inventory map, although some category areas hospital pharmacists may wish to consider include: 

  • clinical pharmacy and other HP role development 
  • clinical trials and research 
  • communication and leadership 
  • compounding/medicines production
  • education and training  
  • inter-professional and inter-sector collaboration 
  • patient safety 
  • pharmacotherapy 
  • process improvement
  • procurement, logistics and distribution 
  • resource management
  • use of technology  

The EAHP requests that initial submissions be made via their website (www.eahp.eu) by close of Friday 7th June 2013. 

 

Triple therapy with antihypertensives and NSAIDs linked to acute kidney injury

19 Apr, 13 | by kuppell

Triple therapy combination consisting of diuretics with angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and NSAIDs is associated with an increased risk of acute kidney injury according to a UK study.

In a retrospective cohort study researchers assessed whether double therapy consisting of a diuretic or an ACE inhibitor or an ARB with the addition of a NSAID, and triple therapy consisting of a diuretic plus an ACE inhibitor or an ARB in addition to a NSAID increased the risk of acute kidney injury. A total of 487 372 people using antihypertensive drugs between 1 January 1997 and 31 December 2008 were identified from the UK Clinical Practice Research Datalink (CPRD). Reporting their finding in the British Medical Journal the researchers say that during a mean follow-up of 5.9 years, 2215 cases of acute kidney injury were identified (incidence rate 7/10 000 person years). ‘Current use of a triple therapy combination was associated with an increased rate of acute kidney injury (rate ratio 1.31, 95% confidence interval 1.12 to 1.53). In secondary analyses, the highest risk was observed in the first 30 days of use (rate ratio 1.82, 1.35 to 2.46),’ say the researchers. However, double therapy combination was not associated with an increased rate of acute kidney injury.

The researchers say that, to their knowledge, it is the first large population based study of patients using antihypertensive drugs to have investigated the association between the use of different combinations of antihypertensive drugs with NSAIDs on the risk of acute kidney injury. ‘Increased vigilance may be warranted when diuretics and ACE inhibitors or ARBs are used concurrently with NSAIDs. In particular, major attention should be paid early in the course of treatment, and a more appropriate use and choice among the available anti-inflammatory or analgesic drugs could therefore be applied in clinical practice,’ they suggest. BMJ 2013;346:e8525.

 

EJHP launches podcasts

12 Apr, 13 | by BMJ

In a new initiative for the journal, EJHP is now publishing podcasts. The first set were recorded at the 18th EAHP Congress in Paris, and include a selection of interviews with speakers from the Congress. In an introductory podcast Phil Wiffen, editor in chief of EJHP, explains the thinking behind the podcasts, outlines the direction the journal is heading in and encourages those thinking of writing for the Journal to contact him.

One of the keynotes at the Congress, on the topic of multidisciplinary teams, was given by Dr Fiona Reynolds (pediatric intensivist and deputy chief medical officer at Birmingham Children’s Hospital) and in a podcast interview she discusses how a multidisciplinary team can be set up, how it can work in practice and what benefits it can bring to hospital pharmacy. In another podcast Joanna Correa West, medicines management nurse from Birmingham Children’s Hospital Foundation Trust considers how hospital pharmacists and nurses can work better together and ways in which they can help and support each other.

Following on from their seminar at the Congress entitled ‘Team challenges in cancer: from cytotoxics to supportive care’ Jørn Herrstedt, professor in clinical oncology, Odense University Hospital, Denmark, and João Oliveira, medical director, Instituto Portugues de Oncologia, Lisbon, share their thoughts about oncology pharmacy, improving patient safety and the role pharmacists can have in supportive care. Medication errors occur in all health settings, but there is particular vulnerability at the interface between care settings, especially at the time of admission to hospital. In an interview Jean-Hughes Dalle (professor in pediatrics, Robert-Debré Hospital, Paris) Julie Rouprêt-Serzec (clinical pharmacist, Robert-Debré Hospital) and Anthony Sinclair (director of pharmacy, Birmingham Children’s Hospital) share their thoughts  about how to improve patient safety in this area.

More needs to be done to tackle TB

27 Mar, 13 | by kuppell

European healthcare system managers and policy makers need to take proactive measures to meet the growing problem of multidrug-resistant tuberculosis (MDR-TB) and the emergence of extensively drug-resistant TB (XDR-TB) warns Dr Roberto Frontini, President of the European Association of Hospital Pharmacists (EAHP). Following on from World TB Day (March 24th) Dr Frontini said it was a time to pause and reconsider the policy options and highlighted five hospital pharmacy related measures currently available to policy-makers:

  1. Ensure hospital pharmacists are involved in medicines counselling for tuberculosis patients starting new courses of treatment in order to improve adherence
  2. Expand the role of hospital pharmacists in Therapeutic Drug Monitoring for patients with drug-resistant TB on long term courses of treatment
  3. Concentrate efforts on improving the systems for communication between hospital and community based healthcare professionals to deliver integrated and joined up care for TB patients
  4. Give hospital pharmacists a leading role in antimicrobial stewardship to help prevent further resistance to existing antibiotic treatments
  5. Redouble attention on the provision of fresh incentives for the development of new antibiotic treatments for the treatment of TB

‘The evidence is stark. There are over 380,000 reported new cases of TB in Europe each year, and the growing problem of multi-drug resistant TB is exacerbated by people not continuing their treatment for the full six months. By ensuring all professions are able to maximise the contribution of their expertise, we can reverse some of the concerning trends in the area of tuberculosis’, said Dr Frontini.

In support of the fight against TB, the BMJ Group has made its latest tuberculosis related content and products free until the end of April (www.rebelmouse.com/Thorax). 

 

Impact of benzodiazepines on pneumonia

13 Mar, 13 | by kuppell

Benzodiazepines are associated with an increased risk of, and mortality from, community-acquired pneumonia (CAP) suggesting further research is required into the immune safety profile of benzodiazepines, according to a study published in Thorax. Using data from The Health Improvement Network (THIN) database, British researchers identified 29,697 controls and 4964 cases of CAP. They used conditional logistic regression to investigate the association between benzodiazepines and pneumonia occurrence, and Cox regression to determine the impact of benzodiazepines on mortality in the 4964 cases of CAP.

The researchers report that: ‘Exposure to benzodiazepines was associated with an increased risk of pneumonia (OR 1.54, 95% CI 1.42 to 1.67). Individually diazepam, lorazepam and temazepam, but not chlordiazepoxide, were associated with an increased incidence of CAP’. They also found that, as a class, benzodiazepines were associated with increased 30-day (HR 1.22 [95% CI 1.06 to 1.39]) and long-term mortality (HR 1.32 [95% CI 1.19 to 1.47]) in patients with a prior diagnosis of CAP. Individually diazepam, chlordiazepoxide, lorazepam and temazepam affected long-term mortality in these patients. ‘Given the widespread use of benzodiazepine drugs, further studies are required to evaluate their safety in the context of infection’, add the researchers. Thorax 2013;68:163-170.

Statin therapy and reduction in recurrent pulmonary embolism

13 Mar, 13 | by kuppell

A study carried out in the Netherlands suggests that statin treatment could decrease the risk of recurrent pulmonary embolism (PE) and might be an alternative to anticoagulant treatment in the long-term treatment of PE. Researchers identified patients hospitalized with an acute episode of PE between 1998 and 2008 by using data from a Dutch population-based registry of pharmacy records linked with hospital discharge records. Prescription-based use of statins and vitamin K antagonist (VKA) were identified starting at hospital discharge and during follow-up.  The researchers used Cox regression analysis to assess the incidence of recurrences, cardiovascular events and death.

The median duration of VKA treatment after acute PE was 199 (45–3793) days. Twenty-four per cent of the patients (n = 737) had at least one prescription of statins during the follow-up period and the median duration of statin therapy was 1557 (5–4055) days.

Reporting their findings in the European Heart Journal the researchers say that during a median follow-up of 1529 (1–4155) days, 285 (9.2%) patients experienced a recurrence. Treatment with statins was associated with a reduced risk of recurrent PE (adjusted hazard ratio [HR] 0.50, 95% CI: 0.36–0.70), both during and after stopping VKA treatment. A dose–response relationship was shown for potency, with the largest reduction in those with the most potent statins. ’Statin treatment also reduced the risk for cardiovascular events and all-cause mortality’, add the researchers. Eur Heart J (2013)doi: 10.1093/eurheartj/eht046.

Latest from European Journal of Hospital Pharmacy

Latest from European Journal of Hospital Pharmacy