Professional Interventions to Improve Rational Prescribing and Drug Utilization: Role of Pharmacists

Background: Radiotherapy as an important treatment modality in head and neck cancer diminishes reactive oxygen system which causes damages to the normal cell/tissue function and cell cycle regulation. Selenium involve in both antioxidant and anti-inflammatory systems. In this study, we aimed to investigate whether there is a difference between selenium levels before and after radiotherapy and the effects of serum selenium levels on radiotherapy oral mucositis (OM) patients undergoing radiation for head and neck cancer.
Methods:This prospective study includes 42 head and neck cancer patients treated by external beam radiotherapy at the Cancer Institution of Imam Khomeini Hospital, Tehran University of Medical Sciences. Plasma selenium concentrations were determined before and after RT. The grade of OM was evaluated weekly by the WHO oral toxicity scale.
Results: The mean patient age was 54.74 (range=18-81) years. For most of the patients, the histopathological diagnosis of cancer was squamous cell carcinoma (n=28 (66.7%)).  There was no significant difference in serum Se levels before and after RT (85.38±30.63 before radiation and 90.32±33.26 after radiation, p-value >0.05). ). Moreover, there was no significant difference between levels of Se after RT in patients who developed severe OM and who did not.
Conclusion: In our study, we couldn’t find any significant difference in the levels of Selenium before and after radiotherapy and also there was no association between Selenium levels and oral mucositis developing.

Background: Cardiovascular disease is a leading cause of morbidity and mortality among type 2 diabetes mellitus (T2DM) patients. It has been proved & recommended by most guidelines that statins are effective for primary or secondary cardiovascular diseases prophylaxis. The aim of the study was to assess the pattern of statin use among T2DM patients with high risk of cardiovascular diseases.
Methods: Hospital-based cross-sectional study was conducted among T2DM patients from February to April 2018 at Jimma University Medical Center. Patient-specific data including clinical characteristics, laboratory work ups and medication records were collected using a structured data collection tool.
Results: Mrom a total of 150 study participants, 93(62%) of them were males. Majority of the patient, 112(74.7%), were between age of 40-64 years (mean ± SD of 46.65±19.61 years). About 55(36.67%) of participants were on statin therapy for treatment & prophylaxis. Age between 65 to 74 years (AOR = 3.006; 95% CI: 1.440–6.277; P=0.003), disease co-morbidity (AOR 4.486; 95% CI: 2.080–9.673; P<0.001) & elevated blood cholesterol (AOR = 1. 422; 95% CI: 1.244–1.622; P=0.033), living with diabetes mellitus for more than 10 years (AOR=2.45; 95% CI: 1.524- 3.891; P=0.027) & uncontrolled blood sugar (AOR=2.127; 95% CI: 1.833–2.457; P=0.0241) were independent predictor of statin use.
Conclusion: The majority of patients with type 2 diabetes were not receiving statins. Further interventions to improve statin use should be considered for these high-risk patients

Background:  Drug interaction commonly occurred in critically ill patients and may increase hospital lengths of stay and total cost. The aim of the present study is to evaluate potential drug-drug interaction in critically ill patients.
Methods: In this cross-sectional study, medical records of critically ill patients admitted to the 16-bed intensive-care units of a teaching hospital were assessed according to the Micromedex® drug interaction and drug interaction fact®. The identified drug-drug interactions were categorized by level of severity. The agreement between two resources was assessed.
Results: Our survey found 915 and 564 paired DDIs according to the Micromedex® and drug interaction fact®, respectively, amongst 120 patients.  The prevalence of potential DDIs (pDDIs) was 87.7% and 91.7% with drug interaction Fact® and Micromedex®, respectively. Approximately, 80% of recruited patients, had at least three pDDIs based on Micromedex®. A significant moderate agreement between two drug interaction compendia was reported. (kappa= 0.41, 95% CI: 0.167-0.649, p<0.001). The serotonin syndrome, increasing the risk of bleeding and hyperkalemia were the major possible consequence of potential DDIs; but none of them occurred.
Conclusions: Most of the observed interactions were mild to moderate in nature. However, major and contraindicated interactions are possible in critically ill patients. Therefore, monitoring of patients with possible major or contraindicated drug interaction is recommended.

Background: Intravenous fluid therapy is frequently used for hospitalized patients but it is overused in many cases. This can lead to economic burden in addition to complications. Few studies have investigated fluid therapy cost-related errors. Drug Use Evaluation (DUE) can be used to evaluate these errors. The aim of our research is to evaluate fluid therapy errors in surgery ward of Imam Reza Hospital, Mashhad, Iran.
Methods: During this cross-sectional study, patients selected by simple randomization method from surgical ward of a teaching hospital in Mashhad, Iran. Intravenous fluid therapy information including indication, type, volume and rate of fluid administration was recorded for each patient. An internal protocol for intravenous fluid therapy was designed based on literature review and available recommendations by clinical pharmacists. The data related to patients’ fluid therapy were compared with this protocol. Main outcome measure of this study was any mistake in the selection of fluid type, content, volume and rate of administration.
Results: One hundred patients were observed during study. Errors in the rate of fluid administration (85%), incorrect fluid volume calculation (83%) and incorrect type of fluid selection (1%) were the most common types of errors.
Conclusion: Our result showed that intravenous fluid therapy errors occurred commonly in the hospitalized patients especially in the medical wards. Improvement in knowledge and attention of health-care workers about these errors are essential for preventing of medication errors in aspect of fluid therapy.

Background: Patients’ knowledge, attitude, and practice are essential factors for hypertension management. Therefore, the information that reflects the level of public awareness can affect health policies. The aim of this study is to assess the knowledge, attitude, and practice of the general population about different aspects of hypertension.
Method: In this pilot study, we totally include 198 adults with or without hypertension who came to the main teaching hospital in Mashhad city. Patients were randomly selected, and they filled a KAP questionnaire.
Results: Most of the participants were younger than 30 years old. The gender distribution consisted of 53.7% males and 45.8% females. The educational levels of participants were 13.8% primary or less, 33% secondary-tertiary and 53.2% academic. Severe headache and dizziness were the principal hypertension symptoms in participant perspectives. Most of the people had reported that salt intake and fatty foods may cause hypertension more than others. Majority of the responders considered low salt-fat diet and regular exercise were the main hypertension prevention. In the present study, participants believed that all the population can be at risk of hypertension, except primary or less educated who said low exercise and positive family history are the main causes.  All groups believed that hypertension risks are threatening both individual and society. In the presence of hypertension symptoms, referring to the nephrologist for initial evaluation was a priority for thirty percent of responders.
Conclusions: Our study concluded that the majority of the general population had good knowledge about hypertension. We found that attitude was satisfied, although the inappropriate practice was seen in participants.

Geriatric patients are at greater risk of drug related problems due to increased prevalence of chronic diseases and drug consumption. But at the same time, an important issue in the collaboration of pharmacists and physicians, is the acceptance of the pharmacist’s recommendations by other specialties. The present review summarizes the acceptance rate of nephrologists towards pharmacist recommendations. PubMed and google scholar were searched from 1979 to 2016. The key terms were: physician-pharmacist, physician acceptance, pharmacist intervention, elderly patients, nephrology, renal disorder, pharmacist assessment, geriatrics, physician pharmacist collaboration. The search for key terms in English and Persian resulted in 13 relevant literatures from 2011-2018. All of the studies demonstrated the positive effect of pharmacist interventions. The acceptance rate of nephrologists is over 60% (and sometimes as high as 84%) in different regions. This topic is relatively young and the specific collaboration of nephrologists and pharmacists has not been studied prior to 2011.

Thrombocytopenia has been reported as an adverse effect of numerous medicines including vancomycin. Due to contribution of other suspected causes and lack of a standard diagnostic test, vancomycin-induced thrombocytopenia has been less addressed in clinical practice. In the current study, we present a suspected case initially diagnosed as heparin-induced thrombocytopenia but further workup proposed vancomycin as the offending medicine. Following discontinuation of vancomycin, the thrombocytopenia resolved which confirmed the diagnosis of vancomycin induced thrombocytopenia. We tended to highlight vancomycin-induced thrombocytopenia which is usually not considered in differential diagnosis of thrombocytopenia in comparison with heparin induced thrombocytopenia which is well known for clinicians; a scenario commonly encountered in clinical practice. This is important regard to high possibility of concomitant use of vancomycin and heparin in every day clinical practice. In accordance with educational aims of the current case, differential diagnosis of thrombocytopenia and clinical approach to thrombocytopenia is well documented in this patient.

Sepsis-induced leukopenia occurs in critically ill patients and associated with negative clinical outcomes. A sixty years old patients with respiratory failure, decreased level of consciousness and pneumonia transferred to the intensive care unit. During intensive care stay patients developed late ventilator-associated pneumonia and severe neutropenia. Colony stimulating factor (filgrastim) was initiated for patients. Severe leukocytosis (leukocyte counts of 94000/mm3) was seen with no source of new infection was detected. After filgrastim discontinuation serum leukocyte counts returned to the normal limits with no sequel or complication. Although Hyperleukocytosis may increase the risk of thrombosis and pulmonary edema. Most cases of iatrogenic hyperleukocytosis are well tolerated with no complication.

Rare cases of akathisia have been reported with paroxetine in the literature. However, accurate diagnosis for early treatment is important since untreated akathisia can result in poor patient^’s compliance, treatment failure, aggressive or suicidal acts. We present a case of a 25-year- old female patient, suffering from akathisia, who was treated with paroxetine and olanzapine due to hypomania and general anxiety disorder. Our finding shows that side effects like akathisia could be addressed by the timing of the peak level of paroxetine. Thus, shifting the time of paroxetine consumption to reach its peak level at the sleeping period could be a rational approach for many patients.  More research is required to confirm that the observation of this case report was not accidental.