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   Table of Contents - Current issue
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January-March 2020
Volume 9 | Issue 1
Page Nos. 1-60

Online since Saturday, March 28, 2020

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EDITORIAL  

The second Euro-Asian congress of pharmacoepidemiology recently held in Tehran 2019 p. 1
Sten Olsson
DOI:10.4103/jrpp.JRPP_20_22  
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ORIGINAL ARTICLES Top

Pharmacist interventions in improving clinical outcomes in patients with type 2 diabetes mellitus among the underrepresented population: A collaborative ambulatory care pharmacy practice (CAPP) approach p. 3
Mok Thoong Chong
DOI:10.4103/jrpp.JRPP_19_75  
Objective: The objective of this study was to evaluate the impact of pharmacist's interventions through a collaborative ambulatory care pharmacy practice (CAPP) model in patients with type 2 diabetes mellitus (T2DM) among the underrepresented population. Methods: Eligible patients were 18 years and older with a diagnosis of T2DM with or without comorbid cardiovascular disease risk factors. Patients were enrolled through routine primary care provider referrals. During a one-on-one, face-to-face scheduled clinic visit, the pharmacist provided a comprehensive medication management by reviewing vital signs and laboratory values, provided medication reconciliation and management, followed by medication counseling through a CAPP approach in a primary care setting. The pharmacist worked in close collaboration with the primary care provider to intervene on medication therapy through recommendations to initiate, adjust, modify, or discontinue drug therapy and order laboratory tests and drug concentration levels as appropriate. Each visit was documented as a “PharmD Progress Note” in the patient's electronic medical record. Follow-up visits were scheduled until patients' targeted treatment goals were achieved. Primary and secondary outcome data were collected and then analyzed. Findings: A pharmacist saw 47 patients over 12 months. Sixty-four percent of the participating patients were able to achieve targeted treatment goals. A statistically significant decrease in the mean change in hemoglobin A1c, diastolic blood pressure, fasting blood glucose, and triglyceride levels was observed from the baseline which was −2.3%, −7.75 mmHg, −76.1 mg/dL, and −55.5 mg/dL, respectively. No significant changes in other clinical outcomes were observed. Conclusion: The CAPP model demonstrated a significant reduction in clinical endpoints in patients with T2DM among the high-risk underrepresented population.
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Recurrence rate and clinical outcome of amniotic membrane transplantation combined with mitomycin c in pterygium surgery: Two-year follow-up p. 10
Hasan Razmjoo, Seyed-Abolfazl Kashfi, Majid Mirmohammadkhani, Mohsen Pourazizi
DOI:10.4103/jrpp.JRPP_19_127  
Objective: To evaluate the recurrence rate and outcome of pterygium surgery with amniotic membrane transplantation (AMT) and intraoperative mitomycin C (MMC). Methods: This prospective clinical study included patients with pterygium who were candidates for pterygium excision. After the surgical excision, intraoperative local MMC were applied in the standard protocol followed by AMT. The outcome measures were recurrence and the size change of lesion. Kaplan-Meier estimation and regression analyses were performed. Findings: Fifty five eyes of 55 consecutive patients including 30 male (54.5%) and 25 female (45.5%) with mean age of 47.12 ± 15.95 years were operated. The mean follow-up period was 15.21 ± 2.67 months. The overall recurrence rate was 34.5% (19/55 cases). The estimated recurrence time for larger size of pterygium before surgery was short and marginally significant (17.14 ± 0.58 month in size of ≤3.0 mm versus. 18.56 ± 0.60 month in size of <3 mm; P= 0.06). A statistically significant association was found in reduced model among the size change of the pterygium and standardized coefficient was −0.012 (P = 0.044) and −0.743 (P < 0.001) for age and size of lesion before surgery, respectively. Conclusion: Our findings suggest that increasing age and pterygial tissue are the risk factors for recurrence and pterygium has a substantial recurrence rate even after AMT combined with MMC.
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Glycemic control after initiating direct-acting antiviral agents in patients with hepatitis C virus and type 2 diabetes mellitus using the united states integrated healthcare system p. 16
Alicia Halim Wong, John Sie, Angela Chen, Basuki Gunawan, Joanie Chung, Nazia Rashid
DOI:10.4103/jrpp.JRPP_19_110  
Objective: Hepatitis C virus (HCV) has an increased risk of Type 2 diabetes mellitus (T2DM). Prior studies found that the eradication of HCV with direct-acting antiviral (DAA) agents led to improved glycemic control in patients with T2DM. We aimed to identify the association between HCV eradication and glycemic control in patients diagnosed with HCV and T2DM. Methods: A retrospective observational study was conducted to identify adult patients diagnosed with HCV from January 1, 2014, to August 31, 2017. Patients were included if they were initiated on one of the following DAA agents within the study period: Sofosbuvir/velpatasvir, sofosbuvir/ledispavir, elbasvir/grazopevir. Patients were also required to have the diagnosis of T2DM. The primary outcome of this study was the average change in glycosylated hemoglobin (HbA1c) pre- versus post-DAA agents. Findings: Our final cohort consisted of 996 patients diagnosed with HCV and T2DM: Patients who achieved sustained virologic response (SVR) (n = 937, 94%) and those who did not achieve SVR (n = 59, 6%). In the SVR group, there was a 0.3950% reduction in HbA1c (P < 0.0001) and in those who did not achieve SVR group, there was 0.3532% reduction in HbA1c (P = 0.0051). In the overall study population, SVR group had 0.04% more reduction in HbA1c but was not statistically significant (P = 0.7441). Conclusion: Both groups had statistically significant reductions in HbA1c when comparing the mean change in average HbA1c pre-versus post-DAA agent. Patients who achieved SVR had a greater absolute reduction in HbA1c by 0.04%; however, this was not statistically significant.
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Adaptation and validation of the screening tool of older people's prescriptions instrument for the Indonesian population p. 24
Siti Fauziyah, Retnosari Andrajati, Ratu Ayu Dewi Sartika, Maksum Radji
DOI:10.4103/jrpp.JRPP_19_106  
Objective: In this study, we aimed to prepare and validate an Indonesian version for the Screening Tool of Older People's Prescriptions (STOPP), which is an instrument to identify inappropriate medications for elderly patients. Methods: The Indonesian version of STOPP (STOPP_INA) was developed using modified transcultural adaptation guidelines from the American Academy of Orthopedic Surgeons. Our method consisted of translating original STOPP into Indonesian (forwardly translation), synthesis of forward translation, translation into English and synthesis of back translation, a review by the copyright holder of STOPP, a review by the expert team, pretest, revision of STOPP_INA, field test, and psychometric analysis of the final version of the questionnaire. The study design for this part was quasi-experimental with purposive sampling for members of the translator's team, expert's team, and respondents in the pretest, but they were different from field testing that used purposive and postsurvey sampling for respondents. Content validity and face validity were used to construct the validity of STOPP_INA by assessing item-level content validity and correlation between items and total values. Internal consistency was measured with Cronbach's alpha coefficient. Findings: The expert panel agreed on a list of 81 criteria. Five (62.50%) of expert team members agreed and could be continued to the field test without revision of STOPP_INA and 3 (37.50%) agreed with a revision. The research subjects in the psychometric test had 230 respondents, 5 (2.17%) resigned, with an average of item-level content validity index of 0.99. The construct validity analysis showed that 5-item criteria are “not valid,” namely in A1, A3, B7, B10, and C3. Reliability analysis showed the Cronbach's Alpha and Cronbach's Alpha Based on Standardized Items were 0.978 and 0.979. Conclusion: The expert team was be agreed on 81 criteria (100%) of adaptation of STOPP version 2 criteria. There were 5 criteria that not valid statistically, they could not be removed from the instrument because they can influence content and construct of the instrument. The STOPP_INA has been developed for the Indonesian population, currently being tested in clinical practice against elderly patients undergoing hospitalization.
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Thiamine for prevention of postoperative delirium in patients undergoing gastrointestinal surgery: A randomized clinical trial p. 30
Rohollah Moslemi, Hossein Khalili, Mostafa Mohammadi, Zeinab Mehrabi, Niayesh Mohebbi
DOI:10.4103/jrpp.JRPP_19_124  
Objective: Postoperative delirium is a common complication after gastrointestinal surgery that is associated with adverse outcomes. Thiamine is an essential cofactor for the glycolysis, oxidative metabolism, production of neurotransmitters in the crebs cycle. In this study, efficacy of thiamine was assessed as a preventive strategy of delirium in patients undergoing gastrointestinal surgery. Methods: In this randomized clinical trial, 96 adult patients admitted to the intensive care unit (ICU) following gastrointestinal surgery were included. Patients were allocated to receive either 200 mg intravenous thiamine daily or an equal volume of 0.9% saline for 3 days. Delirium was evaluated twice daily based on the confusion assessment method-ICU. The incidence of postoperative delirium was considered as the primary outcome, and total analgesic use and ventilation days has been defined as secondary outcomes of the study. Findings: The incidence rate of delirium was significantly lower in the thiamine group than the placebo group on the first day (8.3% vs. 25%; Odds ratio: 0.27 [95% confidence interval (CI): 0.08–0.92]; P= 0.026) and on the second day (4.2% vs. 20.8%; or: 0.16 [95% CI: 0.03–0.81]; P= 0.014). No adverse effect related to thiamine was detected during the study course. Conclusion: Study results suggest that thiamine is a safe option for the prevention of postoperative delirium in patients after gastrointestinal surgery.
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Reducing missed medication doses in intensive care units: A pharmacist-led intervention p. 36
Mukhtar Jawad Alomar, Sohail Ahmad, Yahya Moustafa, Lafi Salim Alharbi
DOI:10.4103/jrpp.JRPP_19_95  
Objective: The objectives of this study were to investigate the frequency and reasons for missing doses and impact of a pharmacist-led intervention to reduce the missed doses in intensive care units. Methods: This study was completed in two phases. In the first phase, a retrospective quality assurance audit was conducted to quantify the problem of missed doses from the pharmacist/nurse communication slip record. The frequency and potential reasons for missing dose occurrences were identified and listed, and respective solutions were finalized by a joint health-care team. In the second phase of the study, post-intervention analysis was done for a period of 1 month to check the impact of intervention. The data were recorded from pharmacy/nursing communication forms for medication, dosage form, route of administration (ROA), frequency of missed doses, and underlying reasons for missing doses. Findings: There was a substantial reduction in the number of incidences of missed doses in post-intervention phase. The number of events decreased from 190 (pre-intervention; 2 months) to 11 (post-intervention; 1 month), 389 to 87, and 133 to 12 for automatic stop order, unknown reason, and late mix medication, respectively. No missed dose event was recorded secondary to order overseen and inactive patient status in post-intervention phase. Moreover, identified reasons, ROA, frequency, and the system status were the significant predictors of missing doses. Conclusion: The findings of this study emphasized the need to introduce better documentation procedures and continuous surveillance system to decrease the number of missing doses and further improve already established drug distribution service.
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Pediatric toxicoepidemiology of tramadol intoxication in Iran: A 5-year cross-sectional study p. 44
Mohaddeseh Hedayati Goudarzi, Nastaran Eizadi-Mood, Marjan Mansourian, Soroush Mohammadi-Jouabadi, Payam Peymani, Ali Mohammad Sabzghabaee
DOI:10.4103/jrpp.JRPP_20_4  
Objective: We aimed to find the toxicoepidemiological indicators of tramadol poisoning in children and also the relationship of these indicators (such as demographic characteristics, and referral time) with the final therapeutic outcome. Methods: In this cross-sectional study with retrospective data collection, we included the records for all the patients under 18 that have been admitted due to tramadol poisoning between 2010 and 2015 to Noor and Ali-Asghar (PBUH) University hospital which serves as the referral medical center for acute poisonings management in the central part of Iran and is located in Isfahan. Demographic characteristics, ingested dose, dosage forms, clinical manifestations, coingested drugs, and the outcome of treatment for all pediatric patients were documented and descriptively analyzed. Findings: Demographic and clinical data of a total of 189 patients including 101 male (53.4%) with a mean age of 16.66 ± 2.64 years were abstracted and included in this study. The average time between tramadol ingestion and hospital admission was 3.39 ± 3.23 h. Mean duration of hospitalization was 12.3 ± 10.7 h. In all cases, the route of drug exposure was oral, and the most common form of drug dosage form was 100 mg tablets (n = 122) proceeded by 200 mg tablets (n = 32). The mean estimated dose of ingested tramadol was 1126 ± 1061 mg (median, 900 range, 50–7000 mg). 43.9% of the poisoned patients were high school students, and 23.3% had a high school diploma. Intentional intoxications were reported in 93.1% cases and 42.9% had coingestions. Activated charcoal (87.3%), gastric lavage (59.3%), oxygen therapy with mask (46.6%), naloxone (11.6%), anticonvulsants (13.2%), and intubation and ventilation (5.3%) were done as first-line therapeutic measures. Conclusion: Our results suggest that the trend of acute tramadol poisoning among children is decreasing, mostly accidental in adolescents and commonly intentional among young children. Proper education to improve emotional intelligence for young adults and to keep drugs out of reach of the children and safer packaging is recommended to reduce tramadol poisoning incidence in the pediatric population.
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Prospective study of irrational prescription of teicoplanin in a large academic hospital: A dilemma of antimicrobial resistance p. 50
Masoud Hajialigol, Shadi Farsaei, Kiana Shirani
DOI:10.4103/jrpp.JRPP_19_104  
Objective: Teicoplanin is an antibiotic used to treat severe Gram-positive infections, especially those caused by methicillin-resistant Staphylococcus aureus(MRSA). In this study, we aimed to evaluate the pattern of teicoplanin rational prescribing to identify the factors which affected rational utilization. In addition, the teicoplanin minimum inhibitory concentration (MIC) was assessed in randomly selected isolates. Methods: In this descriptive-analytical prospective study, a total of 256 patients were randomly selected to evaluate the pattern of teicoplanin use. The required data were gathered to assess the appropriateness of teicoplanin usage. Also, 100 teicoplanin Etests were used for measuring the MIC. Findings: The results showed that the appropriateness rate of teicoplanin usage was 21.9%. The mean MIC was 2.24 ± 5.47 mg/L for the MRSA cultures (33 cultures), including 32 sensitive cultures (97%). In addition, the mean MIC was 28.71 ± 8.29 mg/L for the vancomycin-resistant enterococci (VRE) cultures (67 cultures), including five sensitive cultures (7.5%). Moreover, the analysis revealed that only the hospitalization ward was statistically significantly related to irrational usage (P = 0.014). Conclusion: The high prevalence of the inappropriate use of teicoplanin will lead to the development of antimicrobial resistance. Furthermore, the high rate of VRE cultures resistant to teicoplanin proves that teicoplanin has no advantage over vancomycin for treating VRE infections. Finally, we recommend guidelines' development for the appropriate administration of teicoplanin.
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BRIEF COMMUNICATION Top

Reduced weekly subcutaneous doses of bortezomib in combination with cyclophosphamide and dexamethasone for newly diagnosed multiple myeloma p. 56
Farzaneh Ashrafi, Azadeh Moghaddas, Ali Darakhshandeh
DOI:10.4103/jrpp.JRPP_18_82  
Objective: A combination of bortezomib, cyclophosphamide, and dexamethasone is highly effective in the treatment of newly diagnosed multiple myeloma. Neuropathy is a dose-limiting adverse effect of this regimen. Subcutaneous and weekly injection instead of biweekly intravenous administration are used to reduce neuropathy. In this study, patients treated with subcutaneous weekly reduced the dose of bortezomib to reduce neuropathy and cost of treatment. Methods: This is an interventional study, including 16 patients. Enrolled patients received bortezomib 1 mg/m2 subcutaneously, cyclophosphamide 300 mg/m2 intravenously, and dexamethasone 40 mg intravenously days 1, 8, 15, and 22 of a 28 cycle. Findings: The overall response rate (≥partial response [PR]) was 93.8%. Thirteen of 16 patients (81.3%) were in an acceptable PR and complete response. Two patients (12.5%) achieving a PR. Meantime to achievement, the best response was 71 (55–87) days. Median progression-free survival was 33 (2–56) months, and autologous stem cell transplantation was performed for 68.8% of patients. Five patients (31.25%) experienced Grade I and one patient (6.25%) Grade III (no Grade 2 or 4) of peripheral neuropathy. Dose reduction and drug discontinuation was required in one patient (6.25%). Conclusion: A reduced subcutaneous, weekly dose of bortezomib in combination with cyclophosphamide and dexamethasone is effective with manageable profile toxicity and acceptable cost.
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LETTER TO THE EDITOR Top

The necessity of an aseptic environment for the preparation of enteral feeding solutions in iranian hospitals p. 60
Ali Rismanbaf
DOI:10.4103/jrpp.JRPP_20_1  
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