JOURNAL OF PHARMACEUTICAL CARE
Year:2022 | Volume:10 | Issue:4|Papers Count:13

The world is ageing. Data from World Population Prospects: the 2019 Revision, states that by 2050, one in six people in the world will be over age 65 (16%), up from one in 11 in 2019 (9%) (1). Iran is ageing rapidly, too. The data from the Statistical Center of Iran states that currently 10% of the Iranian population is 65 years old or above, but this percentage soon reaches to around 20% by the year 2050 (2). There has been efforts in highlighting this concern like writing “, Sanad Melli Salmandan Keshvar”,or the National Document on the Elderly, in 1399, by The Ministry of Health and Medical Education, Planning and Budget Organization, and State Welfare Organization of Iran (3). Also, for the first time in 1392, medical residents were recruited but this program was discontinued after several years. Elderly population needs special attention both from the physicians and pharmacists. The clinical pharmacist can play a special role by educating these two groups of healthcare professionals. This segment of population have different pharmacokinetics and pharmacodynamics and have sensitive receptors. This leads into reducing dosage of drugs especially in the initiation phase. In addition, they tend to be more forgetful, and have reduced visual and auditory senses, making the medication consultation essential. Drug safety is very important, here. Need for reduced dosages and high chances of drug-drug interactions and side effects are enough reasons for a clinical pharmacist to monitor pharmacotherapy while educating patients, physicians and pharmacists. Mark H Beers from UCLA developed the first list of “, potentially inappropriate medication use in older adults”,in 1991. Since then, several revisions have occurred, the latest, in 2022, where the American Geriatrics Society updated the list by using an expert panel (4). Other countries such as Germany, France, Canada, England, and Sweden followed suit (5-9). In Iran, we do not have such a list. Maybe, a clinical pharmacist should make an effort to create this list by using physicians and clinical pharmacists as the panel of experts. Also, clinical pharmacists should be trained in geriatrics especially when we lack enough medical specialists to monitor the pharmacotherapy of Iranian elderlies.

Background: Pain is associated with increased prevalence of chronic diseases which adverselyaffects the quality of life of patients. This also leads to increased demand of drugs for chronic painrelief. Drug utilization pattern studies of pain clinic are therefore important to ascertain rational useof medicines in healthcare system. The study aims to evaluate drug utilization pattern in pain clinicof a tertiary care teaching hospital. Methods: A cross sectional study was done by analyzing prescriptions of patients at pain clinic ofMYH Hospital of Indore, MP, India, for a period of 3 months from November 2021 to January 2022. Total 260 prescriptions were analyzed on the basis of WHO core prescribing indicators, FDC (FixedDose Combinations) & NLEM (National List of Essential Medicines) list by using descriptivestatistics. Results: Study results showed that analgesics were most commonly prescribed in the age grou p41-60 years. Lower back pain (28. 8%) was the most common indication for prescribing analgesics inpain clinic with a female preponderance of 57. 7%. Out of total 639 drugs, Fixed Dose Combinations(FDC)(76. 2%) were more than single drugs (24. 8%). 59. 3% of drugs were concomitant medications. 80% (220) FDCs were generic and Gabapentin+Nortryptiline (31. 8%) was the commonest FDC. Pregabalin was the most commonly prescribed single drug preparation. Average number of drugs perencounter were 2. 45 and generic prescribing was 85. 7%. Total 46% of medicines were prescribedfrom NLEM. Conclusion: We found that FDC, generic prescribing and concomitant medications use was higher inour study. The study guides for rational prescribing of analgesics to maximize pain relief and minimizeadverse effects associated with it.

Background: Insulin resistance has been suggested as one of the known metabolic disorders duringcachexia. This study hypothesized that cachexia in cancer patients might be related to insulinresistance as early as cachexia development. Methods: This study was performed on 46 patients with metastatic gastrointestinal cancer. Anthropometric characteristics and biochemical markers were assessed at baseline, second andthird month. Insulin resistance was assessed using the homeostasis model assessment-estimatedinsulin resistance (HOMA IR) method. SFQ-36 questions were used to assess the patients’,qualityof life at baseline, second and third months. Results: Anthropometric characteristic was significantly associated between pre-cachectic and non-pre-cachectic patients in third month. Cholesterol (P-value = 0. 93), albumin (P-value: 0. 82), andserum creatinine (P-value = 0. 88) in pre-cachectic patients decreased over three months. There wasan increasing trend of insulin resistance between pre-cachectic and non-pre-cachectic patients in thirdmonth. Cholesterol had an upward trend with a significant relation in cachectic patients [(P-value =0. 00), (P-value = 0. 03), (P-value = 0. 01)]. We detected a decreasing trend of insulin resistance betweencachectic and non-cachectic patients from second to third month (P-value = 0. 04). SFQ evaluation hadno significant relation with cachectic status. Conclusion: Previous studies showed that the use of NSAIDs, progesterone’, s, corticosteroids, COX-2inhibitors, anabolic agents and drugs targeting inflammatory cytokines may be beneficial for improvingof symptoms of cachexia. Significant relation between anthropometric variables with pre-cachexiaand cachectic conditions was concluded. Patients’,outcome and its relation with insulin resistancedemonstrated a significant relation between the cachectic and non-cachectic patients in the third month. We also detected the increased serum cholesterol level in cachectic patients, moreover, higher cholesterollevels in expired cachectic patients than in the living.

Background: Varicella-Zoster virus (VZV) is the causative agent of herpes zoster, or “, shingles. ”, Most cases of acute herpes zoster are self-limiting, although the pain can cause significant suffering, and experience postherpetic neuralgia (PHN), particularly in older adults. Early treatment of herpeticneuralgia in the subacute phase may prevent PHN progression. This study aimed to evaluate theefficacy of memantine in the treatment of subacute neuropathic herpes zoster. Methods: This randomized clinical trial was performed on sixteen patients aged 18-75 years withsubacute herpetic neuralgia. Patients were randomly assigned to the intervention or control groupaccording to the inclusion and exclusion criteria (8 in each group). The duration of the study waseight weeks. Patients in the memantine group received Gabapentin 300 mg per day and memantine5 mg twice a day. Then, after one week, the memantine dose was tapered up to 10 mg twice a day. In the control group, patients received only Gabapentin from the first week to the end of the study. DN4 questionnaire is used to measure the severity of nerve pain. The patients of both control andintervention groups completed the questionnaire before starting the treatment and it was done againafter the end of the treatment period (8 weeks). Results: The results showed improvement in pain in patients who received Memantine along withGabapentin in comparison with Gabapentin alone (P =0. 001). Moreover, the DN4 questionnaire scoreevaluation indicated a significant difference only for the intervention group’, s Q1 variable in within-group analysis (P =0. 031). Conclusion: Co-administration of memantine with Gabapentin reduced the severity of subacuteneuropathic herpes. In addition, memantine is expected to be a viable option for treating and relievingsubacute and chronic nerve pain in patients.

Background: To study the drug utilization trends among patients with COVID-19 disease duringthe second wave in a tertiary care hospital. Methods: A retrospective cross-sectional study was conducted in patients admitted in COVID-19wards during second wave of SARS –,COVID-19 pandemic from 1st March 2021 to 30th June2021. A total of 300 prescriptions were analysed. Assessment of prescription patterns were done asper the WHO-The International Network for Rational Use of Drugs (INRUD)drug use indicators. Results: A total of 3106 drugs were analysed. The average number of drugs prescribed was 11±, 5. 1. The most frequent prescription was that of analgesic and antipyretic drug Paracetamol (95. 26%)followed by vitamin C (94. 74%) and multivitamins(87. 89%). Nearly all patients in this studyreceived antibacterials, 68% received antivirals. Antibacterials commonly used were cephalosporins, amoxicillin-clavulanic acid combination and pipercillin –, tazobactam combination. Antiviral drugRemdesivir was also used extensively in our study (54. 21%). Other class of drugs which werecommonly prescribed to more patients were Dalteparin (73. 16%) and corticosteroids like methylprednisolone (52. 63%) and dexamethasone (51. 05%). 35. 68% of the drugs were prescribed withgeneric name. 45. 43% of the drugs were injectables. 2. 96% of the drugs were prescribed as fixeddose combinations. Conclusion: In summary, the drug utilization for hospitalized patients with COVID-19 was diverse butgenerally complied with the ongoing guidelines. The drug were mostly prescribed from WHO essentialdrug list and percentage of fixed dose combination prescription was low. However not prescribing thedrugs by generic name and large encounters of injectable was matter of concern. To get a better glimpseof drug utilization a more extensive study needs to be undertaken.

Background: Non-alcoholic fatty liver disease (NAFLD) is one of the important health issueswith high prevalence worldwide. However, there is no approved medication for that. As one of theindicators of metabolic syndrome, uric acid might play a role in the pathogenesis of NAFLD. Inthis study, we aimed to determine the correlation between serum uric acid level, liver enzymes, andultrasonographic grading of NAFLD. Methods: This cross-sectional study included patients aged 18-65 with NAFLD. Patients with othermetabolic disorders and a history of using alcohol or medications that alter uric acid levels wereexcluded. The patients’,serum uric acid, alanine aminotransferase (ALT), aspartate aminotransferase(AST) levels, and ultrasonographic grading of NAFLD at baseline, third month, and sixth monthwere collected. Results: Of the 3000 patients, 500 patients met the eligibility criteria. The results showed that thereis a significant positive relationship between ALT and serum uric acid level at the first (P= 0. 01), third (P=0. 01), and sixth month (P=0. 01). Furthermore, there was a significant positive correlationbetween AST and serum uric acid level at the sixth month (P= 0. 001). The comparison of 249 patients’, ultrasonographic grading showed no significant correlation with serum uric acid levels. Conclusion: To conclude, the serum uric acid level significantly correlates with ALT and AST over sixmonths but not with the ultrasonographic grading. Further studies are required to determine the role ofuric acid-lowering agents in the treatment of NAFLD.

Background: Thalassemia is a congenital disease and Iran is as one of the countries in thethalassemia belt. It has a huge burden in Iranian national health budget. The aim of this study wasto develop a questionnaire to assess the knowledge and practice of thalassemia patients toward theirmedications. Methods: This is a methodological research, which was done from April 2020 to November2021 in Tehran, Iran, To develop a valid and reliable instrument for measuring major thalassemiapatients’,knowledge and practice regarding their medications, a questionnaire based on three ironchelating medications (deferoxamine, deferiprone, and deferasirox) developed. This process doneby holding several expert panel meetings. This questionnaire was consisting of some aspects suchas: administration, self-monitoring, miss dose, common interactions, and adverse events. Contentvalidity index (CVI) and internal consistency and reliability were calculated. Results: The CVI was as 0. 76 for deferoxamine, 0. 80 deferiprone and 0. 88 for deferasiroxquestionnaire. Further analysis for internal consistency demonstrated satisfactory results withCronbach’, s alpha coefficients ranging from 0. 743 to 0. 781. Results showed Thalassemia MedicationQuestionnaire (TMQ) demonstrated acceptable validity and reliability for application. Conclusion: It was concluded that TMQ could be a useful instrument to measure knowledge andpractice about iron chelation therapy. The reason is the diverse range of questions and the simplicity, validity, reliability, and the practicability.

Polypharmacy is a growing public health problem which is affecting multitudes worldwide. Thisemerging public health problem is defined as the routine use of five or more medicines by an individualpatient. Many researchers believe that the prevalence of polypharmacy is going to keep increasingsince more people are being diagnosed with chronic diseases. Polypharmacy is known to cause manyproblems such as adverse drug reactions, drug to drug interactions, wastage of resources and increasedtreatment costs. Countries should raise awareness of polypharmacy and find solutions to this problem. Healthcare professionals should be educated on the dangers of polypharmacy, medication safety andpolypharmacy management. Polypharmacy management means a whole systems approach whichavoids the use of unnecessary medication for multimorbid patients while maximizing pharmaceuticalcare. There is ongoing research to investigate polypharmacy because very little is known in the existingliterature. This article describes polypharmacy in detail, including the prevalence of polypharmacy, theeconomic impact of polypharmacy, medication safety and polypharmacy management. This article aims togive a much deeper insight into polypharmacy.

Background: Many medications are unlicensed for use in toddlers and many drugs are prescribed as off-label in this age group. Different studies showed high prevalence of prescribing such medications in children. Prescribing off-labeled or unlicensed drugs can cause adverse drug events (ADEs)and harm to the patients. We conducted this study to evaluate the rate of off-label and unlicensed drugs prescribed for toddlers. Methods: Out-patient prescriptions within the electronic database from a main governmental health insurance company in Tehran, Iran were evaluated for off-label and unlicensed drugs in a two-month period (November-December 2019). Results: 5358 prescriptions for toddlers reached to the insurance database, of these, 461 prescriptions were randomly selected. Three hundred and fifty prescriptions contained antibiotics and/or respiratory medications, from them, 183 (52. 3%) had at least one off-labeled or unlicensed medication. Conclusion: Our study showed high rates of off-label and/or unlicensed medication use in pediatric population.

Stevens Johnson Syndrome is a rare autoimmune disorder which includes skin and mucous membrane. In India, the incidence of Stevens Johnson Syndrome (SJS) is 1. 2 to 6 million patients per year. SJSis a very serious and life-threatening hypersensitivity reaction that can occurs due to infections(mycoplasma pneumonia) or as side effects of drugs (Sulfa Drugs, Phenytoin, Carbamazepine, Lamotrigine, Phenobarbital, Allopurinol, Piroxicam, Nevirapine and Diclofenac). Antibiotics cancause SJS and their contribution is around 40%. Fluoroquinolones are prescribed globally (11%) totreat lower respiratory tract infections, gastrointestinal and genitourinary infections. Norfloxacin andCiprofloxacin are rarely associated with drug induced SJS. Most of the informative data, availableon drugs induced SJS are based on case reports or case series. Here, we present three case reports ofFluoroquinolones induced SJS. In the following cases, patients had developed symptoms of SJS withintwo days. Whereas in Antibiotic induced SJS, it is reported that symptoms of SJS can appear withinfew days or even after a single dose of taking antibiotics. Therefore, we alleged that Fluoroquinolonecould be the possible causative agent in our cases. The causality assessment had done based on theWHO-UMC causality scale and it was probable in all three cases of Fluoroquinolone induced SJS. This assessment generates a strong evidence that Fluoroquinolone induced SJS in all three cases. These patients were treated symptomatically with corticosteroids, parenteral solution and other non-pharmacologic agents and discharged after complete recovery.

The brain is one of the most sensitive organs to hypoxia and the most vulnerable to ischemia andvascular events. Zolpidem, as a GABA-A receptor agonist, has an inhibiting effect on the centralnervous system. In this study, the possible side effects of zolpidem on brain perfusion were reported ina patient with zolpidem addiction. Moreover, the correlated literature has been reviewed. The patientwas a 33-year-old man who was referred with a complaint of cognitive impairment, gait disturbance, confusion, and seizure. The patient reported taking the daily dose of 270 mg of zolpidem. He developedacute dystonia, rigidity, and bradykinesia during treatment with haloperidol in the psychiatric ward. Brain MRI and EEG were requested due to the prolongation of cognitive impairment and parkinsonismsymptoms. The Neurologist utilized Brain MRA to determine the source of microvascular lesionsfound in the brain MRI. Unexpectedly, a reduction in Anterior Cerebral Artery (ACA) perfusionwas detected after a comprehensive evaluation by Brain MRA. In addition, impairment of severalcognitive domains was observed in the follow-up visit. Zolpidem could reduce cerebral perfusion invarious vascular territories. It seems that in patients who take zolpidem with higher than therapeuticdoses, vascular complications and a decreased cerebral perfusion have occurred, resulting in moreneurological complications, including cognitive disorders and vascular events. A holistic investigationof the patient with zolpidem abuse and neurological symptoms would be recommended to determinethe probable vascular complication of zolpidem.

The World Health Organization classifies cycloserine as a group four second line anti tubercular drugfor the treatment of drug resistant tuberculosis. Neuropsychiatric adverse drug reactions associatedwith cycloserine need more attention as they may compromise treatment success. Here, we reporta case of cycloserine induced psychosis, insomnia and suicidal attempts in a young female patientwith pre-extensively drug resistant tuberculosis (pre-XDR-TB). A 20-year-old female patientwas prescribed longer oral XDR-TB regimen (high dose of moxifloxacin, cycloserine, linezolid, clofazimine, bedaquiline and pyridoxine). After fifteen days of treatment, patient developed changes inbehaviour with frequent episodes of spontaneous and excessive laughing or crying. She also developedinsomnia, started to hear voices and made two attempts of suicide. Following this, cycloserine wasdiscontinued. Clonazepam and clomipramine were prescribed to her. Patient gradually recoveredover a period of one month. Extreme caution with regular and close monitoring should be exercisedwhile administering cycloserine because psychiatric adverse drug reactions could be associated withincreased risk of poor drug adherence in drug resistant tuberculosis.

Appropriate levothyroxine (LT4) dosing is essential in hypothyroid patients to maintain biochemical and clinical euthyroidism, but achieving appropriate plasma concentration of LT4 can be complicated by numerous disease states, foods, supplements, and commonly prescribed medications such as calcium supplements, pantoprazole etc. that potentially interfere with intestinal LT4 absorption. About one-third of treated patients are not receiving adequate treatment, leading to decreased quality of life, increased morbidity, and even increased mortality. Hypothyroid patients treated with LT4 must be careful to avoid concomitant ingestion of such medicines or optimal gap must be ensured between ingestions to prevent drug-drug interactions and reduce absorption of LT4. We describe two such real life cases managed in our clinical pharmacology consultation facility to highlight the importance of systematically evaluating the drug-drug interactions of levothyroxine with commonly used concomitant medications and how deprescribing of the same can result in attainment of optimum thyroid replacement with lesser doses of LT4 with better patient outcome.