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   2017| April-June  | Volume 6 | Issue 2  
    Online since May 31, 2017

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Initiatives to reduce nonprescription sales and dispensing of antibiotics: Findings and implications
Vanda Markovic-Pekovic, Nataša Grubiša, Johanita Burger, Ljubica Bojanić, Brian Godman
April-June 2017, 6(2):120-125
DOI:10.4103/jrpp.JRPP_17_12  PMID:28616436
Objective: Irrational use of antimicrobials is a major driver of antimicrobial resistance, exacerbated by dispensing antibiotics without a prescription. Our previous study suggested this was a problem in the Republic of Srpska despite legislation. Since then, a number of activities have been initiated. Consequently, the study aimed to ascertain whether these multiple initiatives had reduced this. Methods: Patients visiting all community pharmacies in the Republic from October 2014 to July 2015 presenting with symptoms typical of an acute, viral, and mostly uncomplicated upper respiratory tract infection, with results compared to the previous study. If an antibiotic was suggested, the maximum allowance was €3/pack. Findings: Self-medication with antibiotics significantly decreased from 58% to 18.5% of pharmacies. In both studies, most patients were offered over-the-counter medication. The most common reason for not dispensing an antibiotic was “antibiotics can be dispensed with a prescription only.” The penicillins were the most dispensed antibiotic. Fewer patients than the previous study were given instructions about antibiotic use and no discussion on their side effects. Conclusion: While encouraging that self-medication decreased significantly, 18.5% were disappointing given recent initiatives. Fewer instructions about antibiotics if an antibiotic was dispensed were also disappointing. This suggests the need for even stronger enforcement of the laws as well as further training of pharmacy personnel to ensure the future appropriate use of medicines.
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Severity of gastrointestinal side effects of metformin tablet compared to metformin capsule in type 2 diabetes mellitus patients
Mansour Siavash, Majid Tabbakhian, Ali Mohammad Sabzghabaee, Niloufar Razavi
April-June 2017, 6(2):73-76
DOI:10.4103/jrpp.JRPP_17_2  PMID:28616428
Objective: This study was designed to compare the severity of gastrointestinal (GI) side effects in Type 2 diabetes mellitus (DM) patients receiving tablet or capsule forms of metformin. Methods: In this prospective interventional study, patients were evaluated from June to November 2016 at DM clinics affiliated to Isfahan University of Medical Sciences, Isfahan, Iran. Adult patients with Type 2 DM who were eligible for inclusion criteria switched from metformin tablet to metformin capsule. Hemoglobin A1c (HbA1c), GI side effects, and patient satisfaction based on visual analog scale (VAS) were assessed during a 6-week follow-up of receiving metformin capsule. Findings: One hundred and three patients were evaluated, and 75 patients participated in this study. At the baseline, 40 patients (53.3%) had GI side effects due to metformin tablet which was reduced to 16 patients (21.3%) after switching to metformin capsule (P = 0.001). There was also an improvement in HbA1c (from 7 to 6.8,P < 0.0001). The results of patients' satisfaction based on VAS and numeric rating scale indicated that in 59 patients (78.67%), GI side effects were reduced after switching to metformin capsule (mean score: 7.2 with the range of 6–9) while 16 patients stated no treatment preference. Conclusion: Switching to metformin capsule may result in less GI side effects, with no further side effect complications.
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An audit of perioperative antimicrobial prophylaxis: Compliance with the international guidelines
Sarah Mousavi, Elham Zamani, Faranak Bahrami
April-June 2017, 6(2):126-129
DOI:10.4103/jrpp.JRPP_16_164  PMID:28616437
Objective: Antimicrobial prophylaxis has been demonstrated to lower the incidence of postoperative infection in nearly all types of surgery. The American Society of Health-System Pharmacists (ASHP) guideline summarizes current data on the appropriate use of antibiotic for surgical prophylaxis. The objective of this study was to assess and audit the use of antibiotics in a tertiary care center according to the recommendation of ASHP guideline. Methods: This cross-sectional study was performed using prospective data gathered from April to September 2015 in the surgical wards of Al Zahra Hospital, Isfahan, Iran. Antibiotic indication and choice, dose, dosing interval, route of administration, and timing of first administration and duration of prophylaxis were compared with the ASHP guideline recommendations. Findings: A total of 100 patients with the mean age of 49.8 ± 18.2 years were recruited for this study. About 22% of procedures had full compliance with all guideline recommendations. The most frequently encounter noncompliance type were the duration of prophylaxis (14%) and appropriate agent choice (35%). Timing of the initial dose was appropriate in most of the procedures (42%). Conclusion: This study revealed that most of the prescribed antibiotics for surgical prophylaxis are not in accordance with standard treatment guideline. The density of antimicrobial use for preoperative antimicrobial prophylaxis is very high. Furthermore, the hospital should develop a formal strategy, including a local guideline for antimicrobial prophylaxis in surgical procedures.
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Medication errors in patients with enteral feeding tubes in the intensive care unit
Seyed Mojtaba Sohrevardi, Mohammad Hossein Jarahzadeh, Ehsan Mirzaei, Mahtabalsadat Mirjalili, Arefeh Dehghani Tafti, Behrooz Heydari
April-June 2017, 6(2):100-105
DOI:10.4103/jrpp.JRPP_17_9  PMID:28616433
Objective: Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. Methods: A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Findings: Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. Conclusion: In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.
  6 2,429 434
Evaluation of the interaction of intravenous and oral voriconazole with oral cyclosporine in iranian HSCT patients
Hamidreza Taghvaye Masoumi, Molouk Hadjibabaie, Mohammad Vaezi, Ardeshir Ghavamzadeh
April-June 2017, 6(2):77-82
DOI:10.4103/jrpp.JRPP_16_163  PMID:28616429
Objective: Voriconazole as a triazole antifungal agent is widely used for prophylaxis or treatment of fungal infections in allogeneic hematopoietic stem cell transplantation (HSCT). It can increase blood concentrations of other medications including cyclosporine A (CsA) which are substrates for cytochrome P450 3A4. The aim of this study was to evaluate comparatively the interaction between oral/intravenous (IV) voriconazole and oral CsA. Methods: Twenty-nine recipients of allogeneic HSCT who had been already on a steady dose of CsA and were started on oral or IV voriconazole were evaluated in a prospective cohort study. Blood concentration of CsA was determined before and 5–8 days after voriconazole initiation. Plasma concentration of voriconazole was measured in steady state. The changes in blood concentration of CsA after administration of voriconazole were evaluated. Findings: The concentration/dose (C/D) ratio of CsA increased significantly (P < 0.001) after voriconazole initiation in both routes of administration (8.40%–174.10% increase in C/D ratio). The C/D ratio alteration of CsA did not differ significantly between oral and IV voriconazole group (P = 0.405). There was a significant correlation in all patients between plasma concentration of voriconazole and percentage of CsA C/D ratio increment (P = 0.046). Conclusion: There was a significant intrapatient variability in the magnitude of CsA blood concentration increment after voriconazole initiation. We also demonstrated that magnitude of drug interaction did not differ in IV and oral voriconazole administration. Furthermore, we found that the magnitude of drug interaction was correlated with plasma concentration of voriconazole.
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Training and validation of standardized patients for assessing communication and counseling skills of pharmacy students: A pilot study
Mahboobeh Khabaz Mafinejad, Mansoor Rastegarpanah, Fereshteh Moosavi, Mandana Shirazi
April-June 2017, 6(2):83-88
DOI:10.4103/jrpp.JRPP_17_20  PMID:28616430
Objective: The objective of this study is to describe the process of training valid simulated patients (SPs) for assessing communication and counseling skills of pharmacy students' performance. Methods: This is a cross-sectional and correlational study. Psychometric properties of checklist and SPs' portrayals and their filling of the checklist regarding assessing pharmacy students were assessed. Five SPs who were working in the simulated patient's pool were volunteered to take part in the project, which one of the SPs failed. Three scenarios, along with corresponding checklists, were developed based on the usual medications of different diseases consisting of asthma, respiratory infections, and osteoporosis. The SPs' role-play performance was video-recorded and rated independently by two experts according to an observational rating scale to assess validity. The role-play was repeated after 1 week with the same scenario and the same doctor, to assess test-retest reliability. The inter-rater agreement between SPs and experts was determined by calculating the intraclass correlation coefficient and kappa coefficient. Findings: The four eligible SPs were all women, with an average age of 37 years. The correlation between mean scores of raters and mean scores of SPs was 0.91 and 0.85, respectively. The Pearson's correlation between mean scores of raters with SPs was 0.75. The checklists' reliability, Cronbach's alpha, was calculated to be 0.72. The measured weighted Cohen's kappa for the ratings of by each SP, and the gold standard was between 0.53 and 0.57, indicating a moderate agreement. The inter-rater reliability kappa coefficient between raters was 0.75 (P = 0.01). Conclusion: The authors have demonstrated the technique of using standardized patients to evaluate communication and counseling skills of pharmacy students. The findings indicated that trained SPs can be used as an effective tool to assess pharmacy students' communication and counseling skills.
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Effect of pretreatment with omega-3 supplement on cardiac necrosis markers in chronic kidney disease patients undergoing elective percutaneous coronary intervention
Farzaneh Foroughinia, Maryam Foroozmehr
April-June 2017, 6(2):94-99
DOI:10.4103/jrpp.JRPP_17_24  PMID:28616432
Objective: Studies have demonstrated the direct relation between elevation in cardiac necrosis markers and increased risk of cardiovascular complications after percutaneous coronary intervention (PCI) in chronic kidney disease (CKD) patients. In this study, we sought to evaluate the effect of omega-3 on creatine kinase-MB (CK-MB) and troponin-I in CKD patients undergoing elective PCI. Methods: Eighty CKD patients, candidate for elective PCI, were randomly assigned into two groups: Group A – receiving omega-3 (2.5 g, 12 h before PCI) plus standard treatment (n = 37) and Group B – control group, receiving only standard therapy (aspirin 325 mg and clopidogrel 600 mg loading dose and weight-adjusted intravenous heparin) (n = 43). Blood samples were collected before and 24 h after PCI for measuring CK-MB and troponin-I. The primary endpoint was considered to be postprocedural variations of CK-MB and troponin-I levels in both groups. The secondary endpoint was the percentage of pre-procedural myocardial infarction (PMI) occurrence, defined as the elevation of post-PCI troponin-I, between study groups. Findings: Both the baseline and 24-h CK-MB were significantly higher in omega-3 group. Although 24-h troponin-I increased less in omega-3-treated arm compared to the control group, no statistically significant variation was observed between the two groups. With regard to PMI occurrence, no significant difference was detected among study groups. Conclusion: Despite the beneficial but nonsignificant effects of omega-3 on decreasing post-PCI elevation of troponin-I and PMI occurrence, further investigations with bigger study population, higher doses of omega-3 and longer duration of treatment, and long-term follow-up of patients are required to better test the potential effects of omega-3 in improving clinical outcomes in CKD patients undergoing PCI.
  2 1,664 209
Drug reaction with eosinophilia and systemic symptom in a patient with pneumonia and hyperthyroidism
Hualiang Jin, Limin Wang, Jian Ye
April-June 2017, 6(2):130-133
DOI:10.4103/jrpp.JRPP_17_23  PMID:28616438
Drug rash with eosinophilia and systemic symptoms syndrome is an idiosyncratic drug reaction characterized by fever, skin eruption, lymph node enlargement, and internal organ involvement. We report a case of a patient with pneumonia who developed clinical manifestations of fever, rash, lymphadenopathy, hypereosinophilia, and visceral involvement (renal failure and eosinophilic pneumonitis) caused by methimazole. The patient improved remarkably with drug withdrawal. A high index of clinical suspicion is emphasized to facilitate prompt diagnosis of medication-related adverse effect and its discontinuation.
  1 1,721 205
Developing an economic case of clinical pharmacists' interventions on venous thromboembolism prophylaxis through service evaluation
Eun Hee Lee, Victoria Bray, Robert Horne
April-June 2017, 6(2):106-113
DOI:10.4103/jrpp.JRPP_16_160  PMID:28616434
Objective: Venous thromboembolism (VTE) has become a huge health problem as well as a financial burden for the National Health Service. The objective of this study was to characterize current practice of VTE prophylaxis (VTEP) and evaluate the economic impact of clinical pharmacists' interventions (CPIs) on VTEP. Methods: A prospective service evaluation was conducted in a medical and surgical ward at a tertiary teaching hospital in London from 23 May to 08 June 2016. Appropriateness of risk assessment (RA) and VTEP and CPIs were categorized and assessed. Based on the results of the service evaluation, a pharmacoeconomic analysis was undertaken to estimate the cost savings by CPIs for inappropriate pharmacological VTEP. Findings: A total of 203 cases were analyzed. The rates of appropriateness for RA on admission, RA at 24 h and pharmacological VTEP were 58.6%, 39.7%, and 75.4%, respectively. In the medical ward, there was a significant difference of appropriate RAs between on admission and at 24 h (70.3% vs. 23.8%, respectively). Whereas, the rate of appropriate pharmacological VTEP accounted for 75.4% and the rate of appropriate prophylaxis was significantly higher in the medical ward than surgical ward (80.5% vs. 68.2%, P= 0.045). Of 50 cases of inappropriate pharmacological prophylaxis, 39 cases (78.0%) were corrected by clinical pharmacists. These CPIs resulted in £1,286.23 cost savings during the study and it was estimated to be £517,522/annum. Conclusion: CPIs had significant positive clinical and economic impacts on VTEP. There is more scope for the improvement of RA at 24 h through CPIs.
  1 1,811 203
Impact of pharmacist intervention on appropriate insulin pen use in older patients with type 2 diabetes mellitus in a rural area in Iran
Aida Sefidani Forough, Parsa Riazi Esfahani
April-June 2017, 6(2):114-119
DOI:10.4103/jrpp.JRPP_16_151  PMID:28616435
Objective: The aim of this study was to evaluate the impact of pharmacist-conducted educational intervention on reducing errors related to inappropriate insulin pen use.Methods: This was a prospective, before-after study with an educational intervention component. The study was conducted on 122 elderly diabetic patients. Data were collected through interviews using researcher-administered questionnaires as well as patients' medical records. Patients were asked about the preparation, injection, and storage techniques, they followed when using insulin pens. Blood glucose parameters were extracted from laboratory records. After the detection of errors, patients and their caregivers were instructed about the insulin pen use by the pharmacist. Patients were reevaluated after 12 weeks. Findings: Patients' mean age was 67.2 ± 3.5 with male: female ratio of 71:51. Mean diabetes duration was 7.1 ± 2.8 years. Fifty-four patients (44.2%) stated that they had received instructions for insulin pen use previously. The majority of this group (24 cases, 44.4%) reported that the instructions were given by a pharmacist. The mean number of errors decreased from 3.99 ± 0.22 errors per patient to 1.49 ± 0.13 errors (odds ratio: 0.28, 95% confidence interval: 0.23–0.33,P < 0.05). Of eleven evaluated insulin pen-related medication error items, nine items experienced a significant decrease after patient education. Fasting plasma glucose (FPG) levels decreased significantly from 161.7 ± 12.5 to 147.3 ± 13.1 mg/dL (P < 0.05). However, glycated hemoglobin levels did not change significantly after 3 months (P = 0.18). Controlled FPG had a significant rise from 45% before education to 63.9% postintervention (P < 0.05). Conclusion: Pharmacists can play an important role in safe and efficient use of insulin pen in elderly diabetic patients by minimizing the likelihood of medication errors associated with insulin pen use.
  1 1,583 238
Specific genes associated with adverse events of methylphenidate use in the pediatric population: A systematic literature review
Beinta Joensen, Morten Meyer, Lise Aagaard
April-June 2017, 6(2):65-72
DOI:10.4103/jrpp.JRPP_16_161  PMID:28616427
The aim of this study was to review empirical studies examining associations between candidate genes and adverse events (AEs) from methylphenidate (MPH) use in children and adolescents. The PubMed, EMBASE, CINAHL, and Web of Science databases were searched from their inception until March 2017. We included empirically based articles on pharmacogenetic studies in 0–17-year-old patients that investigated associations between specific candidate genes, their polymorphisms, and reported AEs. We extracted information about study design, setting, type of AE reporter, studied genes and their polymorphisms, age and gender, administered doses, method of genotyping, outcome measures, and main findings. A total of nine articles reporting information about four double-blind, placebo-controlled, cross-over studies and five open-label cohort studies were eligible for inclusion. Studies were published from 2006 onward and included a total of 998 patients (3–17-year-olds) diagnosed with attention-deficit hyperactivity disorder (ADHD). Studies predominantly involved males and lasted from 1 to 12 weeks. Studies used polymerase chain reaction and single nucleotide polymorphism genotyping methodology. Reported AEs were significantly associated with the following genes: appetite reduction (CES1*G); buccal-lingual movements (T1065G); diastolic blood pressure (ADRA2A Mspl C/C-GC); emotionality (DAT1*9/9); irritability (SNAP25 T1065G); picking (DRD4*7/DRD4*4); social withdrawal (DRD4*7/DRD4*4); somatic complaints (DAT1*10/10); tics (5-HTTLRP*S/L*L/L; SNAP25 T1065G); sadness (CES1*rsl12443580); and vegetative symptoms (5-HTTLPR). In conclusion, only few MPH pediatric pharmacogenetic studies were located, and large between-study heterogeneity was found. Studies were of naturalistic design and of short duration. They included small patient samples, poorly standardized treatment regimens, and limited outcome assessments. In the future, more pharmacogenomic studies in ADHD are needed, preferably using randomized, controlled study designs and of longer duration (more than 6 months).
  1 2,080 406
Erratum: A copmarative review of electronic prescription systems: Lessons learned from developed countries

April-June 2017, 6(2):134-134
DOI:10.4103/2279-042X.207363  PMID:28616439
  - 1,242 124
Comparing the effects of zinc sulfate, calcium pantothenate, their combination and minoxidil solution regimens on controlling hair loss in women: A randomized controlled trial
Mansour Siavash, Fereshteh Tavakoli, Fatemeh Mokhtari
April-June 2017, 6(2):89-93
DOI:10.4103/jrpp.JRPP_17_17  PMID:28616431
Objective: This study was conducted to evaluate the combination of oral supplements with 2% minoxidil solution in four groups of women with hair loss. Methods: A prospective, randomized controlled trial was conducted from July to December 2016 in dermatology clinics affiliated to Isfahan University of Medical Sciences. A total of 73, 15–45-year-old, women with hair loss participated in this 4-month study. Simple randomization using Random Allocation Software was done to put the participants in four groups to receive coadministration of zinc sulfate and calcium pantothenate, zinc sulfate, calcium pantothenate, and 2% minoxidil solution. The primary endpoint was the change in hair density and diameter measured by dermatoscope. Secondary endpoints included the researcher's evaluation, dermatologist's opinion - which was blinded to the study - from comparing the participants' photographs before and after treatment and finally, overall changes in hair density measured by participants' self-assessment. Findings: Seventy-three women participated in this study. Primary hair count and thickness were 118.5 ± 10 hairs/cm2 and 58.8 ± 5.8 μ that changed to 124 ± 11 hairs/cm2 and 62.3 ± 4.3 μ respectively (P < 0.001) which in the zinc plus pantothenate group these changes were from 118.6 ± 9.9 hairs/cm2 to 121.9 ± 11.1 hairs/cm2 (P = 0.042) and from 62.2 ± 6.6 μ to 64.0 ± 5.0 μ (P = 0.126), respectively. Hair density increments were more obvious in the minoxidil group, and hair thickness increments were more obvious in pantothenate group. Participants' satisfaction was 85% in the combination therapy which was more than other groups. Participants' satisfaction, author's and blind dermatologist's opinion showed a significant correlation (P = 0.0001). Conclusion: Based on the participants' satisfaction, the combination of zinc sulfate and calcium pantothenate when administered in a pulse therapy way could be a good choice for hair loss controlling in initial stages.
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