Epistaxis and atorvastatin: is there an association and are clinicians aware? A retrospective audit of 100 patients

ObjectiveEpistaxis is a common ENT presentation. The British National Formulary lists epistaxis as a common side effect of atorvastatin. This study aimed to better understand the relationship between epistaxis and atorvastatin use, and determine whether ENT doctors are aware of its side effect profile.MethodsA retrospective analysis over 10 months identified 100 individuals who presented to hospital with epistaxis. A questionnaire of 24 ENT registrars was undertaken.ResultsOf the 100 patients admitted with epistaxis, 27 were receiving atorvastatin and 21 simvastatin. None of the 24 ENT registrars were aware that epistaxis was a listed common side effect of atorvastatin.ConclusionThere was no apparent difference in the proportion of patients admitted with epistaxis taking atorvastatin versus simvastatin. Epistaxis is an unknown side effect of atorvastatin; doctors have an obligation to be aware of the pharmaceutical literature and to consider alternatives, particularly in re-admissions cases.

ANALISIS PENGGUNAAN OBAT GASTROESOPHAGEAL REFLUX DISEASE (GERD) PADA PASIEN RAWAT JALAN DI RUMAH SAKIT UMUM DAERAH KARAWANG

ABSTRAK Gastroesophageal Reflux Disease (GERD) adalah suatu kondisi refluksnya HCL dari gaster ke esofagus, mengakibatkan gejala klinis dan komplikasi yang menurunkan kualitas hidup seseorang. Angka pravalensi di Indonesia dari tahun ke tahun meningkat yaitu sebanyak 25,18% pada tahun 2002, peningkatan ini terjadi akibat adanya perubahan gaya hidup yang dapat meningkatkan faktor risiko GERD seperti merokok dan minum kopi. Penelitian ini menggunakan rancangan penelitian analis kuantitatif untuk mengetahui angka kejadian, kerasionalan penggunaan obat dan faktor hubungan penyakit sedangkan kualitatif untuk mengetahui gambaran pola penggunaan obat dan karateristik pasien GERD dengan metode observasional. Hasil penelitian angka kejadian GERD di RSUD Karawang adalah 68 pasien, pada pasien perempuan lebih tinggi sebesar 51,5% (35 pasien) dan Kerasionalan terapi pada pasien GERD di RSUD Karawang menggunakan tiga literatur yaitu Pharmacotherapy Handbook, British National Formulary edition 70 dan Konsensus GERD di Indonesia edisi tahun 2013 diperoleh hasil rata-rata: tepat indikasi sebesar 80,4%, tepat obat sebesar 59,3%, tepat pasien sebesar 89,7% dan tepat dosis sebesar 64%. Pada analisis bivariat menggunakan analisis Kruskal Wallis nilai p sebesar 0,014 menunjukkan jenis kelamin adalah faktor resiko tanda dan gejala Gastroesophageal Reflux Disease (GERD). Kata Kunci : Gastroesophageal Reflux Disease (GERD), Prevalensi, Rasionalitas terapi, Pasien Rawat Jalan. ABSTRACT Gastroesophageal Reflux Disease (GERD) is a condition of HCL reflux from gastric to esophagus, resulting in clinical symptoms and complications that reduce a person's quality of life. The pravalence rate in Indonesia has increased from year to year by as much as 25.18% in 2002, this increase is due to lifestyle changes that can increase GERD risk factors such as smoking and drinking coffee. This study uses a quantitative analyst research design to determine the incidence, rational use of drugs and disease relationship factors while qualitative to describe the pattern of drug use and characteristics of GERD patients with observational methods. The results of the study of the incidence of GERD in RSUD Karawang were 68 patients, in female patients higher by 51.5% (35 patients) and rationality of therapy in GERD patients in RSUD Karawang using three literature namely Pharmacotherapy Handbook, British National Formulary edition 70 and GERD Consensus in the 2013 edition of Indonesia the average results were obtained: the exact indication was 80.4%, the exact drug was 59.3%, the exact patient was 89.7% and the exact dose was 64%. In the bivariate analysis using the Kruskal Wallis analysis the p value of 0.014 indicates gender is a risk factor for signs and symptoms of Gastroesophageal Reflux Disease (GERD). Keywords : Gastroesophageal Reflux Disease (GERD), Prevalence, Rationality of therapy, Outpatients.

Evaluation of instructions in patient information leaflets for the use of intranasal corticosteroid sprays: an observational study

ObjectivesIn this study, we analysed patient information leaflets (PILs) of intranasal corticosteroid sprays (INCS) of different manufacturers in the UK to determine if instructions for the use of INCS are complete and uniform.SettingPILs of all INCS of all manufacturers, available for patients in the UK, were collected from the British National Formulary website and the Medicines and Healthcare products Regulatory Agency website. All instructions in these PILs were analysed.ParticipantsWe identified PILs of INCS from 21 different manufacturers, available for patients in the UK.ResultsWe analysed the instructions for the use of INCS in 21 different PILs and there is large variation in the PIL instructions for the technique of using INCS across PILs.ConclusionComplete and uniform instructions for the use of INCS are lacking in PILs for registered preparations in the UK. Structured and standardised instructions to be used by both professionals and patients are essential in order to optimise daily use of INCS.

P27 Impact of new vancomycin dosing and monitoring guideline

The Neonatal and Paediatric Pharmacists Group (NPPG) released a report which carried out a vancomycin in paediatric audit (VIPA). This report reviewed the effectiveness of currently employed intravenous vancomycin dosing regimens. It stated that British National Formulary for Children (BNFC) vancomycin dosing was not sufficient for achieving the target therapeutic range in typical patients and higher, more frequent dosing is required to reach target levels quicker.1,2Based on this report, we amended our dosing guidelines to the following empirical starting doses for children with normal or mildly impaired renal function:Infant 1–6 months: 10 mg/kg 6 hourlyInfant > 6 month: 15 mg/kg 6 hourlyTo evaluate if the new guidelines achieve target therapeutic levels quicker without increasing toxicity or incidence of adverse effects an audit was carried out. The results were then compared to an audit carried out in 2009 using the old vancomycin pathway which based doses on BNFC dosing of 15 mg/kg every eight hours.3The main objectives were to determine the number of patients that achieved target therapeutic range at steady state, and the dose required to achieve this, the time taken to achieve target therapeutic range, the number of patients that achieved levels <10 mg/L (sub-therapeutic) and >20 mg/L (toxic) and the frequency of adverse effects.MethodData was collected for all patients who had been started on vancomycin from 14th September 2016 to 5th December 2016. Using our electronic prescribing system, a daily report identified patients who had vancomycin prescribed. The data collected was compared to the data collected from the 2009 audit.Results23 patients had been commenced on vancomycin during the audit time frame. 20 of these patients (87%) were started on the correct frequency of 6 hourly dosing, and 13 of these patients (65%) were started on the correct frequency and dose of 15 mg/kg/dose.Of the 13 patients started on the correct dose and frequency, only 6 patients (46%) had their first level taken at the correct time. 4 of these patients (67%) achieved the therapeutic target range of 10–15 mg/L. This has improved from 2009, when an audit completed on the old guidelines showed that 1 patient (7%) reached therapeutic levels without having to adjust dose.No patients’ reached a trough level greater than 20 mg/L and additionally no patients’ had a 50% or greater increase of serum creatinine, suggesting the change to guidelines does not negatively impact on toxicity or acute kidney risk.The mean time to achieve therapeutic dose has decreased from 3.6 days in 2009 to 1.4 days in 2016.There was a correlation between age and vancomycin levels-with the average level for patients between 1–6 months being 10.67 mg/L (therapeutic). Whereas the average vancomycin level for patients over 6 months was 8.14 mg/L (sub- therapeutic). This suggests the new guidelines are more effective for the lower age range group.ConclusionThe new guidelines have helped to achieve target levels quicker, with no increase in toxicity. However, there are still areas for improvement for older paediatric patients; reinforcing the idea of aged based dosing.ReferencesCole C, Shepard M. A review of the trust’s paediatric vancomycin guidelines. Neonatal and Paediatric Pharmacists Group2015;1(1):46. http://adc.bmj.com/content/100/6/e1.50 [Accessed: 22nd August 2016].Nash C, Gooding N, Muller H. Intermittent intravenous vancomycin in children aged over 1 month: Empirical dosing for optimum trough levels. Report to the Neonatal and Paediatric Pharmacist Group January 2016 Neonatal and Paediatric Pharmacists Group2016;1–40. [Accessed: 2nd September 2016].British National Formulary. 2014th–5th ed. BMJ group, Pharmaceutical Press 2015. [Accessed: 2nd September 2016].

Did the accuracy of oral amoxicillin dosing of children improve after British National Formulary dose revisions in 2014? National cross-sectional survey in England

ObjectivesInaccurate antibiotic dosing can lead to treatment failure, fuel antimicrobial resistance and increase side effects. The British National Formulary for Children (BNFC) guidance recommends oral antibiotic dosing according to age bands as a proxy for weight. Recommended doses of amoxicillin for children were increased in 2014 ‘after widespread concerns of under dosing’. However, the impact of dose changes on British children of different weights is unknown, particularly given the rising prevalence of childhood obesity in the UK. We aimed to estimate the accuracy of oral amoxicillin dosing in British children before and after the revised BNFC guidance in 2014.Setting and participantsWe used data on age and weights for 1556 British children (aged 2–18 years) from a nationally representative cross-sectional survey, the Health Survey for England 2013.InterventionsWe calculated the doses each child would receive using the BNFC age band guidance, before and after the 2014 changes, against the ‘gold standard’ weight-based dose of amoxicillin, as per its summary of product characteristics.Primary outcome measureAssuming children of different weights were equally likely to receive antibiotics, we calculated the percentage of the children who would be at risk of misdosing by the BNFC age bands.ResultsBefore 2014, 54.6% of children receiving oral amoxicillin would have been underdosed and no child would have received more than the recommended dose. After the BNFC guidance changed in 2014, the number of children estimated as underdosed dropped to 5.8%, but 0.5% of the children would have received too high a dose.ConclusionsChanges to the BNFC age-banded amoxicillin doses in 2014 have significantly reduced the proportion of children who are likely to be underdosed, with only a minimal rise in the number of those above the recommended range.

Therapy-related issues: malignant diseases and immunosuppression

This chapter outlines information relevant to clinical pharmacists related to malignant disease and immunosuppression and is loosely based on the British National Formulary, Chapter 8. In particular, this chapter covers administration and handling of cytotoxic drugs, clinical screening of chemotherapy prescriptions, chemotherapy dosing and toxicity, antiemetics for chemotherapy-induced nausea and vomiting, extravasation, and intrathecal administration of chemotherapy.