15 de junho de 2014

DRUG AND FOOD INTERACTIONS: A FIELD FOR PHARMACEUTICAL CARE INTERVENTION

CAMILA DE ALBUQUERQUE MONTENEGRO, IARA LEÃO LUNA DE SOUZA, RODRIGO DE OLIVEIRA FORMIGA, KATY LÍSIAS GONDIM DIAS DE ALBUQUERQUE, NADJA DE AZEVÊDO CORREIA AND DIEGO NUNES GUEDES

Industrial Pharmacist, Master in Pharmacology and student of Pharmaceutical Care and Clinical Pharmacotherapy Specialization,  Pharmacist,  Pharmacy graduating student,  Pharmacists, PhD Professors from Physiology and Patology Departament/CCS/Federal University of Paraíba

Drug administration with food is recommended by the possibility of greater drug or nutrient absorption, reducing the irritant effect of certain active substances in the gastrointestinal mucosa and assisting in adherence of therapy, being related to administration of a drug in the main meals.

However, such interaction might not be benefic, being crucial to suspend the intake of some nutrients during the treatment. Drugs, including antibiotics, antacids and laxatives may affect the nutrients absorption, and in some cases might constitute a Drug Related Problems (DRP) that occasionally generates a Negative Outcomes Associated with Medication (NOM).

In this way appears clinical pharmacist who together with other health professionals, interferes rationally in this occurrence pharmaceutical, resolving and preventing problem or even the co-morbidities appearance related to irrational use of medicines.

This study aimed to explore the interactions between drugs and food, their mechanisms, effects on organisms and risks for patients, through a literature review, using periodicals, journals and specialized books providing a critical analysis of these problematic, updating pharmacists and other health professionals.

Results were expressed on a table where it is presented the drugs, nutrients, mechanisms and effects of these associations. To illustrate, diazepam and high-fat nutrients administration can generate an interaction, because of renal drug excretion decreased, making the substance stays longer in the body, which enhances the effect of it, leading the user to intoxication.

An alkaline diet enhances the excretion of non-anti-inflammatory drugs (NSAIDs) causes an increase in urine pH and ionization of NSAIDs, resulting in a reduction of tubular drug reabsorption. Thus, we conclude that it is essential prior knowledge of these types of associations and guidance provided by a multidisciplinary team, in which clinical pharmacists excel to solve and prevent DRPs, NOMs, avoiding damage to treatment and/or nutritional individual’s status.

Rev.Bras. Farm. – 94 (4); 2013

18 de abril de 2014

CYTOTOXIC DRUGS WITH THE POTENTIAL TO PROLONG THE QT INTERVAL

M Morgado, L Lemos, R Oliveira, S Morgado.

Hospital Centre of Cova da Beira, Pharmaceutical Services, Covilhã, Portugal; University of Beira Interior, Health Sciences Faculty, Covilhã, Portugal

Background Regulation No. 173/CD/8.1.7. from the Portuguese Authority of Medicines and Health Products (INFARMED), issued on 2 August 2012 and titled ‘Ondansetron – dose constraint for injectable drugs’, recommends that ‘care must be taken when administering this antiemetic associated with other drugs that prolong the QT interval, namely several cytotoxic agents’. To effectively implement this recommendation, it was thought advisable to point out, in the computerised hospital drug database, all cytotoxic drugs that prolong the QT interval.

Purpose To review all cytotoxic drugs available in the Portuguese pharmaceutical market to identify those with the potential to prolong the QT interval, in order to allow hospital pharmacists to quickly and effi ciently implement the above-mentioned recommendation.

Materials and Methods Literature review based upon all summaries of product characteristics (SPCs) of cytotoxic drugs available in Portugal and 48 literature sources from PubMed, found by intersecting the terms ‘cytotoxic-induced prolongation of the QT interval’, ‘antineoplastic-induced prolongation of the QT interval’ and ‘druginduced prolongation of the QT interval’ and using the time limit interval from January/2003 to September/2012.

Results A total of 58 cytotoxic agents currently available in Portugal were investigated. Agents with the potential to prolong the QT interval are: arsenic trioxide, capecitabine, dasatinib, doxorubicin, epirubicin, eribulin, gefi tinib, lapatinib, nilotinib, sorafenib, sunitinib and vandetanib. Substantial evidence supports the conclusion that arsenic trioxide and vandetanib have a risk of torsades de pointes (TdP) when used as directed in SPC. Regarding eribulin, lapatinib, nilotinib and sunitinib, there is insuffi cient evidence that they may cause TdP when used as directed in the SPC. Note that the hormone antagonists bicalutamide and tamoxifen also have the potential to prolong the QT interval.

Conclusions The database produced is a valuable tool to Portuguese hospital pharmacists who dispense cytotoxic drugs, contributing to the implementation of one of the recommendations of
the above-mentioned regulation.

Reference Eur J Hosp Pharm 2013;20(Suppl 1):A1–A238

30 de março de 2014


1ª Ed. 2014 Editora Medfarma
ISBN 9788589248136
Nº de págs.: 962
Capa flexível
Formato: 16 x 23 cm

    Manual de Medicamentos Citostáticos é um livro com todos os fundamentos necessários para uso pela Equipe Multiprofissional que atuam em Unidades ou Centros de Assistência de Alta Complexidade em Oncologia (CACON), que apresenta informações sobre medicamentos citostáticos para todos os estudantes e profissionais da área de saúde, com o objetivo de complementar uma abordagem multiprofissional ao paciente oncológico. Livro contendo 184 medicamentos e com os seguintes capítulos: glossário farmacêutico, glossário de oncologia, lista de abreviaturas e siglas, tabela geral de diluição, manipulação de drogas citostáticas, PGRSS com pictogramas e símbolos de identificação de grupos de resíduos, medicamentos com resumo das toxicidades e as monografias dos medicamentos. Neste sentido, o livro aborda as seguintes informações:  nome genérico do produto,  nomes comerciais, sinonímia e outras denominações, forma farmacêutica, categoria terapêutica, farmacocinética, posologia, reações adversas, regimes especiais de posologia, alertas de administração, precauções, interações medicamentosas, condutas na superdose, medidas após a contaminação acidental, protocolo para extravasamento, biossegurança ocupacional, normas internacionais de transporte do produto, PGRSS, estabilidade da solução reconstituída no frasco de vidro, concentração após reconstituição no frasco de vidro,  vias e formas de administração, diluentes, volume final e tempo de infusão, compatibilidade com as soluções e com os equipamentos,  incompatibilidade com as soluções e com os equipamentos, estabilidade em seringa plástica, estabilidade em bolsa plástica de PVC, poliolefina, PEBD e de EVA. Considero este livro uma futura publicação multiprofissional indispensável para todos os profissionais da área de saúde, que necessitam de informações atualizadas e precisas, abordando de maneira clara, simples e objetiva os estudos, principalmente, sobre protocolos para extravasamento, em condutas na superdose e na contaminação acidental, normas do PGRSS, assim como a diluição, compatibilidade e estabilidade de medicamentos citostáticos.

5 de março de 2014

TAKING A LEAD IN WARD PATIENT SAFETY

EGM Ulgey. Konya Numune State Hospital, Pharmacy, Konya

Background The pharmacist workforce is limited in terms of patient safety due to the ‘one pharmacist to every one hundred beds’ rule in Turkish state hospitals. Our hospital is being rebuilt, and having fewer patients in wards has resulted in all departments working under capacity for a certain period.

Purpose To take advantage of this unique situation that allowed pharmacists to raise the standards of patient safety by using the extra time and workforce granted; and also to prove that good leadership in pharmacy care can result in better patient health.

Materials and Methods Pharmacists were encouraged to appraise the clinical skills of their department, determine the level of the need of ward patients for better patient safety and judge the resources currently available for implementation, before considering the potential sources of collaboration with other health professionals. ‘Rx Media Pharma’ software was used for gaining detailed results on patient chart evaluations. All documentation was performed online with ‘Google Docs’, allowing participants to share and make changes online directly with selected health professionals.

Results For 23 working days, 200 patient charts were reviewed. The average number of drugs used was 7.6 and the drug-drug interactions identified were 2.02 per patient. The importance of the interactions was evaluated in 3 levels; major (42.82%), moderate(51.23%) and minor (5.94%). The numbers of recommendations regarding the drug-drug interactions spotted were: 31 therapeutic exchange (7.67%), 88 dosage recommendation (21.78%), 4 adding drug to the treatment (0.99%), 99 proposal to withdraw a particular drug (24.50%), 182 monitoring (45.04%). Total number of food-drug interactions was 286 (1.43 per patient), with 118 instances of intravenous incompatibility warnings made to the ward nurses (0.59 per patient). 62 inappropriate drug dosages (0.31 per patient) and 3 drugs containing the same active substances in different formulations (0.015 per patient) were reported to the prescribing physicians. In 124 cases (0.62 per patient), pharmacists requested information about the use of the drugs prescribed for treatment. Upon discussion of the results, the physicians provided feedback and acted according to three options: (9.14%) the physician didn’t agree (they believed the situation didn’t require an intervention), (58.53%) the physician felt it was suffi cient to monitor the patient’s status, considering the suggested change in treatment, (32.31%) the physician agreed to a change in the patient’s treatment, applying the recommendation pharmacists made.

Conclusions Our pharmacy department discovered that continuous service at this level of quality is needed for ward patients. Similar studies should be encouraged by health care leaders in Turkey to
improve hospital care.

Reference Eur J Hosp Pharm 2013;20(Suppl 1):A1–238

WARD PHARMACIST: MANAGING INTERACTIONS IN THE DEPARTMENT OF HAEMATOLOGY AND BONE MARROW TRANSPLANTATION

G Saibene, F Brera, E Togliardi, G Antonacci, F Festinese, M Mazzer, V Di Mauro.
Fondazione IRCCS Istituto Nazionale Dei Tumori, Farmacia, Milano, Italy

Background The Milan National Cancer Institute Pharmacy began a collaboration with the haematology and bone marrow transplantation (ETMO) department, to optimise concomitant conditioning protocols of bone marrow transplants; the pharmacokinetics and pharmacodynamics are affected by the high doses of chemotherapy administered. The drugs analysed were those in the conditioning schedules used in accordance with international guidelines.

Purpose To provide a practical guide for managing drug interactions between the drugs commonly used by ETMO and those in the transplant conditioning schedules.

Materials and Methods The presence of the ward pharmacist, funded by the Italian Haematology Society, allowed the daily management of treatment to be investigated. Databases were used (Micromedex, Codifa) and literature meta-analyses were conducted, in order to obtain the pharmacokinetic and pharmacodynamic characteristics of these drugs and possible interactions.

Results Within our Institute, 72 transplants that used conditioning were performed in a year, 32 autologous and 40 allogeneic. In particular, 28 transplants used a high-dose melphalan scheme, 28 used thiotepa/fludarabine/cyclophosphamide, 4 used BEAM, 4 used TBI + fludarabine + cyclophosphamide and 8 used the KROGER scheme. Therefore the interactions between drugs used in the protocols themselves and the drugs commonly used within the department by transplant patients were analysed. For this purpose the following drugs were considered: ciclosporin, allopurinol, acetazolamide and IPP. Following this analysis, it was shown that there were signifi cant interactions between the drugs used in the conditioning scheme and drugs commonly used in patients with bone marrow transplants.

Conclusions The pharmacist set up a means of enabling a clinician to browse for a more informed choice: dedicated schemes are being developed, in which they report any interactions observed, associated with the treatment protocols. All this has therefore contributed to the rational use of the drugs and resources, for example the use of antifungals after transplantation and not before, and the introduction of pantoprazole instead of omeprazole. A future goal will be the analysis of the interactions between the drugs and concomitant haematology chemotherapy.

Reference Eur J Hosp Pharm 2013;20(Suppl 1):A1–A238

1 de fevereiro de 2014

PHARMACOKINETIC DRUG-DRUG INTERACTIONS DUE TO TREATMENT WITH AMIODARONE – A PRACTICAL APPROACH

N Carstens. Apotekene Vest, Sjukehusapoteket i Haugesund, Haugesund, Norway

Background: the drug amiodarone has a complex pharmacokinetic profi le and can be a challenge to use due to the high potential for drug-drug interactions.

Purpose: to identify and submit proposals for handling drug-drug interactions for patients treated with amiodarone. In addition we would like to highlight the fact that drug interactions can occur even if amiodarone is administered as only a single IV dose, and the effect on further treatment. The purpose was also to prepare proposals for management and follow ups of interactions in the clinic.

Materials and Methods: before the ward round the pharmacist carried out medicines reviews for the 25 patients who were included. They were all treated with amiodarone at admission or during hospitalisation. Input was given on the clinically signifi cant interactions identifi ed. For patients treated with warfarin in addition to IV amiodarone the INR values were observed through the entire hospital stay for any signs of a drug-drug interaction.

Results: the pharmacist had 54 inputs referring to interactions with amiodarone, of which 41 were taken into account. The inputs led to dose reductions, changes of drugs and monitoring of blood
values. Case reports showed that interactions do occur after IV amiodarone treatment and these lead to uncertain and variable drug effi cacy over time.

Conclusions: based on results from the study and a literature search, general advice for handling interactions due to amiodarone and further treatment were prepared. The recommendations were
endorsed by the consultant Cardiologist.

1. Advice for avoiding Drug-Related Problems DRPs due to treatment with amiodarone

Warfarin Reduce/give half-dose warfarin at start-up. Monitor the INR values (1)

Digitoxin Give half dose digitoxin/digoxin and monitor digitoxin/digoxin determined by procedure (2)

Simvastatin No doses above 20 mg or switch to another statin. (3)

Atorvastatin Note the dose! No clear recommendations, but maximum 40 mg

Metoprolol Bradycardia? The dose may be adjusted (4)

2. General advice: when admitted from other hospitals. Note in the drug curve if recently treated with amiodarone!

3. Discharge summaries: explain why the GP should follow up the blood values; INR, digitoxin/digoxin and possibly CK.

References:

1. Edvin SB et al, An evaluation of early pharmacodynamic response after simultaneous initiation
of warfarin and amiodarone.
2. Laer S et al, Digitoxin intoxication during concomitant use of amiodarone.
3. Marot A et al, Concomitant use of simvastatin and amiodarone resulting in severe
rhabdomyolysis: a case report and literature review
4. Fukumoto et al, Effect of amiodarone on the serum concentration/dose ratio of metoprolol in
patients with cardiac arrhythmias

Eur J Hosp Pharm 2013;20(Suppl 1):A1–238