Aude DESNOYER PharmD PhD student. Seminar M1 Wednesday, 25 March :00pm to 3:30pm Thursday, 26 March :00am to 10:30am
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1 Aude DESNOYER PharmD PhD student Seminar M1 Wednesday, 25 March :00pm to 3:30pm Thursday, 26 March :00am to 10:30am
2 Nothing to disclose Aude DESNOYER PharmD PhD student Seminar M1 Wednesday, 25 March :00pm to 3:30pm Thursday, 26 March :00am to 10:30am 2
3 An international prescribing screening tool for adults hospitalized in internal medicine Experts from Belgium, France, Quebec and Switzerland internists and clinical pharmacists Classified according to physiological-, pathological- and therapeutics-based systems Developed using a Delphi method Including all kinds of PIM (over-, under-use, interactions) and comprehensive conditions
4 2 nd step 1 st step 3 rd step Literature review: Published Explicit Criteria for older adults Literature review: Evidence based appropriate medication use according to the main medical field Draft criteria agreement: on a consensus basis among 6 members of the research group Delphi 1 st round Delphi 2 nd round May 2013 August Nov February 2014 May August 2014 Research group constitution Selection of themes to be addressed Semi-structured interviews: draft version of PIM-Check by compiling list of PIM proposed by 17 medical specialists Delphi preparation 1 st round results analysis PIM-check elaboration
5 01/14 Experts recruitement 40 Experts recruted recruited n = 40 02/14 tutorial and draft version of the list sent to experts 03/14 Delphi 1 st round Delphi 1 st round beginning 6 s or call reminders 04/14 05/14 06/14 1 st round results analysis Delphi 1st round ending Delphi 2 nd round beginning Participation rate = 97.5% 97,5% (39/40) Personalized report with quantitative group results sent to experts 07/14 Delphi 2 nd round 7 s or call reminders 08/14 09/14 2 nd round results analysis Delphi 2 nd round ending PIM-Check paper version Participation rate = 100% (39/39) Perspectives
6 Recommendations rating : two 5 points-lickert scales Strongly disagree Disagree Neither agree, nor disagree Agree Strongly agree Not useful at all Not very useful Potentially useful Useful Very useful No opinion Validation rule >65% of experts agree or strongly agree with statement Validation rule >75% of experts agree or strongly agree with statement 1st round 166 statements Results analysis 2 nd round 160 statements Results analysis PIM-Check 160 statements 6 statements removed 6 statements merged 3 statements added 77 statements modified
7 PIM-check Medical fields Sub-classes Cardiology 7 Angiology/Haemostasis 2 Endocrinology 3 Pneumology 3 Nephrology 2 Gastroenterology 5 Rheumatology 3 Neurology 2 Psychiatry 4 Pain/Analgesia 3 Infectiology 10 Ophthalmology 1 Dependencies 5 Obesity 1 Pharmacology/Toxicology 2 Transplants 1 Vaccination 1 17 medical fields 58 sub-classes 160 statements Hypertension Post-MI Heart failure Atrial fibrillation Diabetes Renal failure Gastric ulcer prevention Psychiatric diseases Pain management Alcoholism
8 PIM-check 17 medical fields 58 sub-classes 160 statements Medical fields Sub-classes Statements Cardiology 7 26 Angiology/Haemostasis 2 9 Endocrinology 3 16 Pneumology 3 9 Nephrology 2 7 Gastroenterology 5 11 Rheumatology 3 11 Neurology 2 5 Psychiatry 4 6 Pain/Analgesia 3 8 Infectiology Ophthalmology 1 2 Dependencies 5 9 Obesity 1 4 Pharmacology/Toxicology 2 8 Transplants 1 2 Vaccination 1 4 Platelet inhibitors, ACEI/sartans, betablockers, antihypertensives statins anticoagulants, heparin PPI Antidepressants, Neuroleptics Antalgesics and opiates Aminoglycosids
9 PIM-check Statements: 160 References: 333 Recommendations: 116 Comments: 93 Useful links: 29 Interactions statements Other 34 Overprescription 36 Underprescription 74
10 PIM-check PIM-Check Statements: 160 References: 333 Recommendations: 116 Comments: 93 Useful links: 29 STOPP-START Interactions statements OTHER 54% Other START 46% 34 Versus Underprescription STOPP 74 75% START 25% Overprescription (65%) totally new statements
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12 Website Webmobile App
13 Under-prescription statements Over-prescription statements CARDIOLOGY/HYPOLIPIDEMICS First line hypolipidemic: statins Prescribe a first line statin in case of mixed dyslipidaemia hypercholesterolemia, when pharmaceutical care is necessary* RATIONALE Prevention of heart disease. Allows a decrease in the LDL-c and triglycerides and an increase in the HDL-c. RECOMMANDATION *Suggested dosing regimen: maximum tolerated dose making it possible to achieve the target LDL- c level, based on the cardiovascular risk (*see item 5). OP GASTROENTEROLOGY/PROTON PUMP INHIBITORS PPI started during hospitalisation Stop PPI treatment before the patient is discharged, if that treatment was started during hospitalisation to prevent bleeding RATIONALE Avoid long-term treatments with no indication. Potential risk of pneumopathy, Clostridium difficile infection, osteoporosis and rebound effect upon stopping PPIs. RECOMMANDATION Gradual stopping of PPI's may be suggested in order to avoid rebound acidity, if the treatment has been extended. REFERENCES CCSG 2012 : Diagnosis and Treatment of Dyslipidemia for the PrevenKon of Cardiovascular Disease in the Adult ACC/AHA 2013 : Treatment of Blood Cholesterol to Reduce AtheroscleroKc Cardiovascular Risk in Adults ESC 2011 : Dyslipidaemias (Management of) REFERENCE HAS 2009 : Médicaments inhibiteurs de la pompe à protons chez l adulte : réévaluakon
14 Drug-Drug interactions statements Other kind of PMI DDI NEUROLOGY/EPILEPSY AND ANTI-EPILEPTICS Anti-epileptics and drug interactions Evaluate the risk of drug interactions and adapt the treatment in the event a new treatment is introduced in patients receiving anti-epileptics (in particular with CYP and/or Pgp inducers/inhibitors*) REMARKS Enzyme-inducing anti-epileptics: carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenytoin, primidone, topiramate, zonisamide. Enzyme-inhibiting anti-epileptics: valproic acid, topiramate, felbamate. USEFUL LINK HUG 2012: Drug interactions, cytochromes P450 and P-glycoprotein (Pgp) REFERENCES ILAE 2008 : Antiepileptic drugs best practice guidelines for therapeutic drug monitoring Patsalos P, et al. The importance of drug interactions in epilepsy therapy. Epilepsia 2002 Ot PNEUMOLOGY/CHRONIC RESPIRATORY DISEASES Inhalation chamber Favour the use of an inhalation chamber for the administration of products in inhalers in the event of worsening of chronic respiratory disease or poor hand-lung coordination RATIONALE Improves the intrapulmonary deposit and the efficacy of treatments. RECOMMANDATIONS Gradual stopping of PPI's may be suggested in order to avoid rebound acidity, if the treatment has been extended. REFERENCES NHLBI/NIH 2007 : Guidelines for the Diagnosis and Management of Asthma
15 Let s start to use it! 15
16 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) ² Physical examination ² Hyperthermia, tachycardia, hypotension ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Her current treatment is: Perindopril 10 mg Once a day Pravastatin 20 mg Once a day Aspirin 100 mg Once a day Beclometasone dipropionate INH 500 mcg Twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (160mg/day)
17 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) Over- prescrip3on Her current treatment is: Interac3ons ² Physical examination ² Hyperthermia, tachycardia, hypotension ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Under- prescrip3on Perindopril 10 mg Once a day Pravastatin 20 mg Once a day Aspirin 100 mg Once a day Beclometasone dipropionate INH 500 mcg Twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (160mg/day) Other PIM
18 PIM-Check Pathologies Therapeutic classes Key words search Patient profile Education Personal space
19 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) Her current treatment is: 1 st OPTION ² Physical examination Infec3ology ² Hyperthermia, tachycardia, hypotension Urinary infec3ons ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Cardiology STEMI & NSTEMI secondary preven3on Obesity Pneumology COPD Good use of medica3on in case of obesity Perindopril 10 mg Once a day Pravastatin 20 mg Once a day Aspirin 100 mg Once a day Beclometasone dipropionate INH 500 mcg Twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (160mg/day)
20 PIM-Check Pathologies Therapeutic classes Key words search Patient profile Education Education
21 PIM-Check Pathologies Therapeutic classes Key words search Patient profile Education Education
22 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) Infec3ous disease ² Physical examination Urinary infec3ons ² Hyperthermia, tachycardia, hypotension ² Cardiovascular Laboratory test system results STEMI ² Creatinin & NSTEMI secondary clearance : 72ml/min/1.73m 2 ² LDL-c: preven3on 2.4 mmol/l Respiratory system COPD Obesity Good use of medica3on in case of obesity Her current treatment is: 1 st OPTION Perindopril 10 mg Once a day Pravastatin 20 mg Once a day Aspirin 100 mg Once a day Beclometasone dipropionate INH 500 mcg Twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (160mg/day) + cardioselec3v betablocker + inhaled bronchodilator 130mg/day
23 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) ² Physical examination ² Hyperthermia, tachycardia, hypotension ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Her current treatment is: Acebutolol 400mg Once a day Perindopril 10 mg Once a day Pravastatin 20 mg Once a day Aspirin 100 mg Once a day Salmeterol INH 25 mcg 2 inhalations twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (130mg/day)
24 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) ² Physical examination ² Hyperthermia, tachycardia, hypotension ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Her current treatment is: Acebutolol 400mg Once a day Perindopril 10 mg Once a day ACEI Pravastatin 20 mg Once a day Sta3n 2 nd OPTION Aspirin 100 mg Once a day Salmeterol INH 25 mcg 2 inhalations twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (130mg/day) Beta- blocker Platelet inhibitor Inhaled bronchodilator An3bio3cs C3G An3bio3cs aminoglycosides
25 PIM-Check Pathologies Therapeutic classes Key words search Patient profile Education Personal space
26 PIM-Check Pathologies Key words search Education Therapeutic classes TherapeuKc classes Beta blocker ACEI StaKn Patient Platelet profile inhibitor Inhaled bronchodilator Cephalosporin ankbiokc Aminoglycosides Education CARDIOLOGY/SECONDARY PREVENTION OF ACUTE CORONARY SYNDROME WITH ST SEGMENT ELEVATION (STEMI) OR WITHOUT ST SEGMENT ELEVATION (NSTEMI) StaKns Prescribe or con3nue hypolipidemic treatment with sta3ns following a STEMI or NSTEMI RATIONALE Care for cardiovascular risk factors. RECOMMANDATION As First line: medium or high dose stakns combined with lifestyle and dietary measures. In case of intolerance: cholesterol absorpkon inhibitor, alone or in combinakon with a biliary acid or nicoknic acid sequestering agent. Therapeu3c goals: LDLc < 1.8 mmol/l or reduc3on 50% of the ini3al LDL- c level. REFERENCES ACC/AHA 2013 : Guideline on the Treatment of Blood Cholesterol to Reduce AtheroscleroKc Cardiovascular Risk in Adults ACCF/AHA 2013 : Guideline for the Management of ST- ElevaKon Myocardial InfarcKon ESC 2012 : Acute Myocardial InfarcKon in pakents presenkng with ST- segment elevakon (Management of) ESC 2011 : Acute Coronary Syndromes (ACS) in pakents presenkng without persistent ST- segment elevakon (Management of)
27 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) ² Physical examination ² Hyperthermia, tachycardia, hypotension ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Her current treatment is: Acebutolol 400mg Once a day Perindopril 10 mg Once a day ACEI Pravastatin 20 mg Once a day Sta3n 2 nd OPTION Aspirin 100 mg Once a day Salmeterol INH 25 mcg 2 inhalations twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (130mg/day) Beta- blocker Platelet inhibitor Inhaled bronchodilator An3bio3cs C3G An3bio3cs aminoglycosides
28 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) ² Physical examination ² Hyperthermia, tachycardia, hypotension ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Her current treatment is: Acebutolol 400mg Once a day Perindopril 10 mg Once a day ACEI Pravastatin 40 mg Once a day Sta3n 2 nd OPTION Aspirin 100 mg Once a day Salmeterol INH 25 mcg 2 inhalations twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (130mg/day) Beta- blocker Platelet inhibitor Inhaled bronchodilator An3bio3cs C3G An3bio3cs aminoglycosides
29 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) Infec3ous disease Urinary infec3ons Cardiovascular system ² Physical STEMI examination & NSTEMI secondary preven3on ² Hyperthermia, tachycardia, hypotension ² Laboratory Respiratory test results system ² Creatinin clearance : 72ml/min/1.73m 2 COPD ² LDL-c: 2.4 mmol/l Obesity Good use of medica3on in case of obesity Her current treatment is: Acebutolol 400mg Once a day Perindopril 10 mg Once a day ACEI Pravastatin 40 mg Once a day Sta3n Aspirin 100 mg Once a day Salmeterol INH 25 mcg 2 inhalations twice a day 1 st OPTION + 2 nd OPTION Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (130mg/day) Beta- blocker Platelet inhibitor Inhaled bronchodilator An3bio3cs C3G An3bio3cs aminoglycosides
30 With Mrs X, 55 years old ² Admission pattern ² Back pain, ² Fever for 5 days, ² Increased frequency of urination ² Medical diagnostic ² Acute pyelonephritis with sever sepsis ² Past medical history ² ST-elevation myocardial infarction (2012) ² Post-tabacco COPD ² Obesity with BMI = 31.2 kg/m 2 (80 kg; 160 cm) ² Physical examination ² Hyperthermia, tachycardia, hypotension ² Laboratory test results ² Creatinin clearance : 72ml/min/1.73m 2 ² LDL-c: 2.4 mmol/l Her current treatment is: Acebutolol 400mg Once a day 1 st OPTION + 2 nd OPTION - Inhaled cor3costeroids Perindopril 10 mg Once a day Pravastatin 40 mg Once a day Aspirin 100 mg Once a day Salmeterol INH 25 mcg 2 inhalations twice a day Ceftriaxone IV 2g Once a day Gentamicin IM 2mg/kg/day (130mg/day)
31 Thank you to all participants : Specialists, Delphi s experts, Members of the research group, etc audedesnoyer@gmail.com
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