Chinese Clinical Trial Registry to COVID-19, Where is the Way Out to the Diagnosis and Treatment Therapy
YaYun Wu1, HuaYe Jiang1, Xun Huang1*
1Departments of Infection Control, Xiangya Hospital, Central South University, Changsha，HuNan 410008,China
*Corresponding author:Xun Huang，MD, Department of Infection Control, Xiangya Hospital, Central South University, Changsha ， HuNan 410008,China (Email: huangxun@mail.csu.edu.cn)
To the Editor:
During the epidemic period of Coronavirus Disease 2019 (COVID-19), many doctors and researchers conducted clinical trial on COVID-19 in China. Until 04:00 am 16 April , 2020, there were 598 clinical trials on COVID-19 registered in Chinese Clinical Trial Register (ChiCTR), including 309 (51.67%) interventional trials and 248 (41.47%) observational trials and 41 （6.86%） diagnostic trials. There were 43 studies have been withdrawn1.We analyze the data for the period, 6 clinical trials were registered in January (1.23-1.31), all of them were interventional studies.There were 291 clinical trials registered in February (2.1-2.29), including 193 (66.32%) interventional studies， 83 (28.52%) observational studies and 15 (5.16%) diagnostic studies.There were 254 clinical trials registered in March (3.1-3.31), including 93 (36.61%) interventional studies,138 (54.33%) observational studies and 23 (9.06%) diagnostic studies. There were 47 clinical trials registered in Apri...
Chinese Clinical Trial Registry to COVID-19, Where is the Way Out to the Diagnosis and Treatment Therapy
YaYun Wu1, HuaYe Jiang1, Xun Huang1*
1Departments of Infection Control, Xiangya Hospital, Central South University, Changsha，HuNan 410008,China
*Corresponding author:Xun Huang，MD, Department of Infection Control, Xiangya Hospital, Central South University, Changsha ， HuNan 410008,China (Email: huangxun@mail.csu.edu.cn)
To the Editor:
During the epidemic period of Coronavirus Disease 2019 (COVID-19), many doctors and researchers conducted clinical trial on COVID-19 in China. Until 04:00 am 16 April , 2020, there were 598 clinical trials on COVID-19 registered in Chinese Clinical Trial Register (ChiCTR), including 309 (51.67%) interventional trials and 248 (41.47%) observational trials and 41 （6.86%） diagnostic trials. There were 43 studies have been withdrawn1.We analyze the data for the period, 6 clinical trials were registered in January (1.23-1.31), all of them were interventional studies.There were 291 clinical trials registered in February (2.1-2.29), including 193 (66.32%) interventional studies， 83 (28.52%) observational studies and 15 (5.16%) diagnostic studies.There were 254 clinical trials registered in March (3.1-3.31), including 93 (36.61%) interventional studies,138 (54.33%) observational studies and 23 (9.06%) diagnostic studies. There were 47 clinical trials registered in April (4.1-4.16), including 17 (36.17%) interventional studies, 27 (57.45%) observational studies and 3 (6.38%) diagnostic studies. The purpose of these interventional clinical trials is to explore the effects of different therapies on COVID-19, while the purpose of these observational clinical trials is to summarize the epidemiological characteristics,clinical symptoms and prognosis of COVID-19.
From January to February, the number of people infected with the novel coronavirus (SARS-CoV-2) increased rapidly in China and the most important task is to treat the patients, so the researchers pay more attention to interventional clinical trials. COVID-19 was gradually controlled in China after March ,thus more efforts were made to summarize the epidemiological characteristics, clinical manifestations and prognosis of COVID-19 by china experts. Therefore, clinical trials in March and April focused on observational studies mostly.Changes in the types and quantities of clinical trials from January to April also reflect the trend of COVID-19 in China.
There were 95 clinical trials about severe and critical cases, 8 clinical trials about deaths, 12 clinical trials about newborn and children, 5 clinical trials about the elderly among the 598 studies.Relevant literature showed that the newborn can be infected by pregnant women with COVID-192. And there were two clinical trials on mother-to-child transmission of COVID-19.
The minimum duration of these clinical trials was 6 days and the maximum duration was 3 years. Most of them were short-term trials and many studies last 1 to 6 months because it is not easy to find patients with COVID-19 and collect specimens when COVID-19 is controlled.There was no gender requirement for participants.Patients specimens included respiratory tract specimens (sputum, throat swab), saliva, blood, feces, urine, tissue specimens.Among these clinical trials, the minimum number of subjects was 8, which reflected the insufficient sample size of some trials.Clinical trials are usually exclusive, and if a patient participates in one intervention trial, he or she cannot join in another study.With the control of COVID-19 in China, the number of people infected goes down. Therefore, some clinical trials may not be able to recruit enough patients and researchers can not draw reliable conclusions without sufficient sample size.
COVID-19 was confirmed by fluorescent reverse transcription polymerase chain reaction (RT-PCR) detection of positive nucleic acid of SARS-CoV-2, however, this technique is time-consuming and laborious. If there are a large number of suspected patients, the detection speed may be slow when use PCR technique only.The lung CT scan of patients with COVID-19 showed lesions, therefore, artificial intelligence imaging system can also play a role in diagnosis. It can complete the screening of suspected cases in a short time, and assists the imaging diagnosis under high intensity work.And there were two studies about the application of artificial intelligence imaging system in the diagnosis of COVID-19.
According to the Chinese COVID-19 Diagnosis and Treatment Protocol (7th edition) 3, symptomatic support therapy and antiviral therapy are the most important treatment .Among the clinical trials of antiviral drugs, there were 16 studies on chloroquine phosphate, 6 studies on interferon ,11 studies on lopinavir/ritonavir, 1 studies on ribavirin, 4 studies on azvudine and 4 studies on abidor.Among the clinical trials of treatment options in severe and critical cases, there were 4 studies on extracorporeal membrane oxygenation(ECMO) techniques, 11 studies on convalescent patients’ plasma therapy, 2 studies on blood purification therapy, 4 studies on glucocorticoid therapy, 6 studies on monoclonal antibody therapy, and 22 studies on stem cell therapy.People died from COVID-19 were severe and critical patients usually,so we want to find appropriate treatment through the studies of severe and critical cases and reduce the mortality.COVID-19 can not only injure the body of patients but also affect their psychological state. People often feel anxiety and fear during outbreaks of infectious disease, so the study of psychology is important too. There were 37 studies on psychologic status of health care workers and patients. With these psychological studies and guidance, fear and anxiety of patients may be reduced.There were 126 studies about Traditional Chinese Medicine and it also played an important role in the treatment of COVID-19.
At present, the spread of COVID-19 are controlled basically in China, but the situation is getting worse in other countries.The imported transmission between different countries will make the epidemic difficult to control, so it is urgent to develop an effective and safe vaccine.There were 5 clinical trials on COVID-19 vaccine registered in ChiCTR. One of which has completed phase I clinical trial, conducted by Institute of biological engineering, academy of military sciences.108 subjects have been vaccinated, including three groups: low-dose group, medium-dose group and high-dose group (36 subjects each group).And the researchers started phase Ⅱ clinical trial already, this is the first COVID-19 vaccine project which has started phase Ⅱ clinical trial in the world.In addition to China, the process of vaccine research is also under way in other countries and it is hopeful to develop an effective vaccine in the near future.
Although COVID-19 has been basically controlled in China, these clinical trials can provide experience for future recurrence and provide reference for the diagnosis and treatment in other countries.The concept of Community of Shared Future for Mankind (CSFM) tell us that only if COVID-19 is under control in all countries can we get out of current predicament. It is hopeful that the results of these clinical trials will play a role in the control of COVID-19 and bring us normal life as soon as possible.
References
1.Index of clinical trials on COVID-19（Updated to 04:00 AM Beijing time, 16 April , 2020)
(http://www.chictr.org.cn/uploads/documents/2020/04/16/88f0c7bb71dc44efb5...)
2.Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records[J]. Lancet,2020,395(10226):809-815.
3.Notice on the issuance about diagnosis and treatment protocol of COVID-19 (7th edition):General office of the national health commission [2020] No.184(http://www.gov.cn/zhengce/zhengceku/2020-03/04/content_5486705.htm)
I) We agree with Dr. Van den Eynde that since tedizolid is a more potent inhibitor than linezolid, it is administered at lower doses. Thus, the MAO inhibition would be lower. This is probably the reason why there have been no reports regarding serotoninergic toxicity. However, the possibility of MAO inhibition cannot be ruled out, especially when tedizolid is administered together with serotoninergic drugs. We would like to emphasize that the spontaneous reporting of suspected adverse reactions is useful to identify potential signals that suggest a causal association between a medicinal product and a previously unknown reaction. Whether this suspected adverse reaction is a signal, it should be confirmed by further reports.
II) In our article we do not affirm that it is a serotonin syndrome or a serotonin toxicity, since, in fact, we do not have enough clinical information to confirm it. We only discuss the possibility that the hypertensive crisis could be related to the co-administration of tedizolid and other serotoninergic drugs. Our position is well defined in the following paragraph of the article: “The causality of hypertension as an adverse drug reaction due to the co-administration of tedizolid and other serotonergic treatments was evaluated using the algorithm of Naranjo et al, obtaining a final score of 3. According to this value, the relationship between tedizolid and the hypertensive crisis should be classified as possible, as we were not able to rule ou...
I) We agree with Dr. Van den Eynde that since tedizolid is a more potent inhibitor than linezolid, it is administered at lower doses. Thus, the MAO inhibition would be lower. This is probably the reason why there have been no reports regarding serotoninergic toxicity. However, the possibility of MAO inhibition cannot be ruled out, especially when tedizolid is administered together with serotoninergic drugs. We would like to emphasize that the spontaneous reporting of suspected adverse reactions is useful to identify potential signals that suggest a causal association between a medicinal product and a previously unknown reaction. Whether this suspected adverse reaction is a signal, it should be confirmed by further reports.
II) In our article we do not affirm that it is a serotonin syndrome or a serotonin toxicity, since, in fact, we do not have enough clinical information to confirm it. We only discuss the possibility that the hypertensive crisis could be related to the co-administration of tedizolid and other serotoninergic drugs. Our position is well defined in the following paragraph of the article: “The causality of hypertension as an adverse drug reaction due to the co-administration of tedizolid and other serotonergic treatments was evaluated using the algorithm of Naranjo et al, obtaining a final score of 3. According to this value, the relationship between tedizolid and the hypertensive crisis should be classified as possible, as we were not able to rule out the involvement of other factors.”
References
1. Flanagan S, Bartizal K, Minassian SL, et al. In vitro, in vivo, and clinical studies of tedizolid to assess the potential for peripheral or central monoamine oxidase interactions. Antimicrob Agents Chemother 2013;57:3060–6.
2. Moore N, Berdaï D, Blin P, Droz C. Pharmacovigilance - The next chapter. Therapie. 2019 Dec;74(6):557-567.
3. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239–45.
4. de Castro Julve M, Miralles Albors P, Ortonobes Roig S, et al. Hypertensive crisis following the administration of tedizolid: possible serotonin syndrome. Eur J Hosp Pharm 2018;0:1-3.
We note, upon critical appraisal of this case report, two shortcomings:
(I) the authors provide a one-sided and inaccurate extrapolation to clinical practice from the literature data on tedizolid;
(II) the authors do not adhere to well-established ‘diagnostic decision rules for serotonin toxicity’: the Hunter criteria.<1>
I. In gauging the MAO-inhibiting potential of both antibiotics, de Castro Julve et al. rightly note that ‘tedizolid appears to be a more potent inhibitor in vitro of MAO-A than linezolid’ <2>– but neglect to mention (a) that tedizolid is also four to sixteen (or – depending on the source – ‘two to eight’)<3> times more potent than linezolid at treating most gram-positive infections;<4> and (b) that tedizolid is therefore administered at a lower dose than is linezolid (200mg/day vs. 600mg/12 hours).<3> This likely leads, in practice, to less tedizolid-induced (vs. linezolid-induced) MAO-inhibition<3>, as evidenced by the clinically insignificant potentiation of the tyramine pressor response (TYR30)<2>, and to less potential for serotonergic drug interactions<5>, as further evidenced by the fact that no changes in the murine head twitch response occur, even at plasma tedizolid concentrations which exceed – ‘by up to ~25-fold’ – the Cmax observed in humans at the clinical dose of 200mg/day.<3>
II. The detection in their patient of a hypertensive crisis ‘suspected to be an adverse r...
We note, upon critical appraisal of this case report, two shortcomings:
(I) the authors provide a one-sided and inaccurate extrapolation to clinical practice from the literature data on tedizolid;
(II) the authors do not adhere to well-established ‘diagnostic decision rules for serotonin toxicity’: the Hunter criteria.<1>
I. In gauging the MAO-inhibiting potential of both antibiotics, de Castro Julve et al. rightly note that ‘tedizolid appears to be a more potent inhibitor in vitro of MAO-A than linezolid’ <2>– but neglect to mention (a) that tedizolid is also four to sixteen (or – depending on the source – ‘two to eight’)<3> times more potent than linezolid at treating most gram-positive infections;<4> and (b) that tedizolid is therefore administered at a lower dose than is linezolid (200mg/day vs. 600mg/12 hours).<3> This likely leads, in practice, to less tedizolid-induced (vs. linezolid-induced) MAO-inhibition<3>, as evidenced by the clinically insignificant potentiation of the tyramine pressor response (TYR30)<2>, and to less potential for serotonergic drug interactions<5>, as further evidenced by the fact that no changes in the murine head twitch response occur, even at plasma tedizolid concentrations which exceed – ‘by up to ~25-fold’ – the Cmax observed in humans at the clinical dose of 200mg/day.<3>
II. The detection in their patient of a hypertensive crisis ‘suspected to be an adverse reaction to tedizolid’<2> on the fourth day of treatment, is not a valid diagnostic criterion for even a tentative assessment of ‘serotonin syndrome’ – note, furthermore, that this nomenclature is increasingly considered outmoded: serotonin surplus occurs on a toxicity spectrum<1>, and is preferably consistently referred to as ‘serotonin toxicity’. The absence of observed spontaneous/inducible/ocular clonus or hyperreflexia in the patient, precludes – by all recognized criteria – a diagnosis of possible serotonin toxicity.<1>
Van den Eynde Vincent (first author) has nothing to disclose.
Gillman Peter Kenneth (second/corresponding author: ken.psychotropical@gmail.com) has nothing to disclose.
---
Bibliography (<endnotes>):
1 Dunkley ECJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. Q J Med 2003;96:635-42.
2 de Castro Julve M, Miralles Albors P, Ortonobes Roig S, et al. Hypertensive crisis following the administration of tedizolid: possible serotonin syndrome. Eur J Hosp Pharm 2018;0:1-3.
3 Rybak JM, Roberts K. Tedizolid Phosphate: a Next-Generation Oxazolidinone. Infect Dis Ther 2015;4:1-14.
4 Flanagan S, Bartizal K, Minassian SL, et al. In Vitro, In Vivo, and Clinical Studies of Tedizolid To Assess the Potential for Peripheral or Central Monoamine Oxidase Interactions. Antimicrob Agents Chemother 2013;57:3060-6.
5 Burdette SD, Trotman R. Tedizolid: The First Once-Daily Oxazolidinone Class Antibiotic. Clin Infect Dis 2015;61:1315-21.
The section in this paper which says pharmacists could prescribe controlled drugs from 2012 with the exception of schedule 1 and 2 CDs for drug misuse is misleading. Schedule 1 cannot be prescribed by anyone without out a licence to do so (this includes doctors) and schedule 1 contains substances of no medicinal use. Schedule 2 CDs can be prescribed by pharmacists for drug misuse, the only exception is diamorphine (and technically cocaine and dipipanone although these are not used). Diamorphine is prescribed as an injectable by prescribers on the Dept of Health approved list to do so and this list is restricted to medical doctors. Other schedule 2 drugs for addiction such as methadone and morphine (unlicensed) can be prescribed by pharmacist prescribers.
Monitored dosage systems (or dose administration aids) are widely used but it is important to reduce their inappropriate use by ensuring they are only issued on a case-by-case basis to address specific practical problems of medicines adherence. It should be assumed that patients can manage their medicines unless indicated otherwise. NICE guidance (1) states monitored dosage systems should be considered as an option to improve adherence on a case-by-case basis, and only if there is a specific need to overcome practical problems. This should follow a discussion with the patient to explore possible reasons for nonadherence and the options available to improve adherence, if that is their wish.
• The inappropriate use of monitored dosage systems can make patients and carers less familiar with their medicines. Health literacy including awareness of medicines should be promoted.
• Transferring medicines to monitored dosage systems carries the risk of human error. The stability of many medicines cannot be guaranteed outside their original packaging.
• Patients who may benefit from monitored dosage systems include patients who have less ability to read or understand the instructions on standard medicines packaging, but who have the dexterity to use the devices and who wish to adhere to their medicines regimen.
• Pharmacists should check compliance issues and provide a monitored dosage system only if compliance cannot be addressed by other methods a...
Monitored dosage systems (or dose administration aids) are widely used but it is important to reduce their inappropriate use by ensuring they are only issued on a case-by-case basis to address specific practical problems of medicines adherence. It should be assumed that patients can manage their medicines unless indicated otherwise. NICE guidance (1) states monitored dosage systems should be considered as an option to improve adherence on a case-by-case basis, and only if there is a specific need to overcome practical problems. This should follow a discussion with the patient to explore possible reasons for nonadherence and the options available to improve adherence, if that is their wish.
• The inappropriate use of monitored dosage systems can make patients and carers less familiar with their medicines. Health literacy including awareness of medicines should be promoted.
• Transferring medicines to monitored dosage systems carries the risk of human error. The stability of many medicines cannot be guaranteed outside their original packaging.
• Patients who may benefit from monitored dosage systems include patients who have less ability to read or understand the instructions on standard medicines packaging, but who have the dexterity to use the devices and who wish to adhere to their medicines regimen.
• Pharmacists should check compliance issues and provide a monitored dosage system only if compliance cannot be addressed by other methods and the patient has the dexterity and health literacy to use the monitored dosage system.
• Patients may only be able to have part of their medication regimen supplied in a monitored dosage system with other medications provided in their original containers, leading to confusion and the risk of non adherence.
• Patients who use monitored dosage systems some of which are stored in the fridge and some out of the fridge may be at risk of non adherence if either is overlooked, forgotten etc
• Examples of problems which may affect compliance and solutions should be considered before a decision is made to supply a monitored dosage system (2) . The patient should be involved in any decisions and their preferences should be explored.
• The level of support available to the patient should be understood. Does the patient self administer? Is the patient supported by family and / or trained/registered staff?
• Patients using a monitored dosage system should be assessed regularly for appropriate and safe use.
(1)National Institute for Health and Clinical Excellence, 2009.Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. NICE Guideline CG76
(2) NHS Tayside, Compliance Needs Assessment Background Notes
Comment 1: In case of stable patient, the priority of management for
extremity fracture in emergency department would be early reduction with
immobilization, pain relief is not the primary concern, on the other hand,
early pain relief might put the patient in a risk of delayed reduction
trial . As we know neurovascular compromise around fracture site is
critical for fracture management, and so, instead of decreasing time...
Comment 1: In case of stable patient, the priority of management for
extremity fracture in emergency department would be early reduction with
immobilization, pain relief is not the primary concern, on the other hand,
early pain relief might put the patient in a risk of delayed reduction
trial . As we know neurovascular compromise around fracture site is
critical for fracture management, and so, instead of decreasing time to
pain relief, I would rather suggest decreasing time to early reduction and
immobilization. That is more meaningful and practical for orthopedic
surgeon
Comment 2: If early pain relief is the main issue for concern, why
not IV or IM analgesic instead of oral administration, the former
treatment will relatively not influence the anesthesia procedure (due to
inadequate NPO time).
Reading the editorial – “Value or cost: looking for the wider perspective”,the one thing that struck us the most was,when pharmacists determine value,one of the most important variables that they take into account is the monetary cost of the intervention,say antibiotics.This raised several questions in our minds.What if the antibiotics on the hospital formulary were priced at a point that their use in certain situations seemed unjustified to pharmacists,but would seem perfectly justified at lower price points?What if generics,available at a fraction of the price of the branded variety,were used in place of the brands?It seems to us that they would most certainly impact the way that “value” is calculated for that particular scenario.What if the pharmacist knew a perfectly good enough generic,but hospital policy allowed procurement,and hence prescribing of,only a more expensive brand?
When hospital pharmacists try to assess the value of a new health technology,we feel that they would be well served if they took a long,hard look at the evidence.Sometimes claims might not be very genuine.And this could place heavy costs on the patients.A very contemporary example would be the pricing of cardiac stents. Cardiac stents are sold at a 300 to 400 percent mark up to Indian patients.A stent that costs Rs.20,000(Euro 284) if bought from a vendor would miraculously cost Rs.160,000(Euro 2273)at the hospital pharmacy,all other charges being separate.1The patient is not given the o...
Reading the editorial – “Value or cost: looking for the wider perspective”,the one thing that struck us the most was,when pharmacists determine value,one of the most important variables that they take into account is the monetary cost of the intervention,say antibiotics.This raised several questions in our minds.What if the antibiotics on the hospital formulary were priced at a point that their use in certain situations seemed unjustified to pharmacists,but would seem perfectly justified at lower price points?What if generics,available at a fraction of the price of the branded variety,were used in place of the brands?It seems to us that they would most certainly impact the way that “value” is calculated for that particular scenario.What if the pharmacist knew a perfectly good enough generic,but hospital policy allowed procurement,and hence prescribing of,only a more expensive brand?
When hospital pharmacists try to assess the value of a new health technology,we feel that they would be well served if they took a long,hard look at the evidence.Sometimes claims might not be very genuine.And this could place heavy costs on the patients.A very contemporary example would be the pricing of cardiac stents. Cardiac stents are sold at a 300 to 400 percent mark up to Indian patients.A stent that costs Rs.20,000(Euro 284) if bought from a vendor would miraculously cost Rs.160,000(Euro 2273)at the hospital pharmacy,all other charges being separate.1The patient is not given the option of purchasing the stent from anywhere but the pharmacy of the hospital conducting the procedure.The number of angioplasties performed in India is 420,000 every year1.Estimates say 80% of these are in private hospitals1..No comprehensive data exists on stent pricing by hospitals,but assuming an average “excess” profit of Rs.50,000(Euro 710) per stent for the estimated 336,000 angioplasties carried out in private hospitals,which seems reasonable in the given pricing landscape1,the potential for savings works out to 1,680 crore rupees(Euro 238 million) a year.And this is not the end of the story.Drug eluting and bio-absorbable stents are priced significantly higher than the bare metal stents,with companies claiming superiority of the drug eluting and bioabsorbable stents,but not being able to produce evidence of it.1The government of India has now capped the price of the metal stents at under 8,000 rupees(Euro 114) and the drug eluting and bioabsorbable stents at under 30,000 rupees(Euro 426).
In this case,government intervention in pricing seems to us to have made the greatest impact in delivering “value”.Similar government interventions in the pricing of antibiotics,anti HIV drugs and anti-cancer drugs could help pharmacists make more patient-centric decisions keeping in mind the value that patients are looking for.
The population with intellectual disabilities are vulnerable in the prescribing and the deprescribing process.
In the population with intellectual disabilities compared to the general population, the multi-morbidity burden is greater, occurs at much earlier age, and the profile of health conditions differs [1].
People with intellectual disabilities use multiple medications and may have been taking them for many years. Extreme care in required when de- prescribing many medications in this population group. The principles of good de-prescribing during medication review in the population with intellectual disabilities, based on the British Pharmacological Society’s Principles for Good Prescribing 2010, provide a template for quality de-prescribing in this vulnerable population group.
Principles of Good De-prescribing during Medication Review in the Population with Intellectual Disabilities and Behaviour Disorders. Based on the British Pharmacological Society’s Principles for Good Prescribing 2010
1. Be clear about the reasons for de-prescribing.
2. Take into account the patient with intellectual disabilities and behaviour disorders medication history before de-prescribing.
3. Take into account other factors that might alter the benefits and risks of de-prescribing treatment in the patient with intellectual disability and behaviour disorders.
4. Take into account the patient’s/carer’s/families/advocates ideas, concerns, and expec...
The population with intellectual disabilities are vulnerable in the prescribing and the deprescribing process.
In the population with intellectual disabilities compared to the general population, the multi-morbidity burden is greater, occurs at much earlier age, and the profile of health conditions differs [1].
People with intellectual disabilities use multiple medications and may have been taking them for many years. Extreme care in required when de- prescribing many medications in this population group. The principles of good de-prescribing during medication review in the population with intellectual disabilities, based on the British Pharmacological Society’s Principles for Good Prescribing 2010, provide a template for quality de-prescribing in this vulnerable population group.
Principles of Good De-prescribing during Medication Review in the Population with Intellectual Disabilities and Behaviour Disorders. Based on the British Pharmacological Society’s Principles for Good Prescribing 2010
1. Be clear about the reasons for de-prescribing.
2. Take into account the patient with intellectual disabilities and behaviour disorders medication history before de-prescribing.
3. Take into account other factors that might alter the benefits and risks of de-prescribing treatment in the patient with intellectual disability and behaviour disorders.
4. Take into account the patient’s/carer’s/families/advocates ideas, concerns, and expectations.
5. Ensure all medicines are effective, safe, cost-effective in appropriate form individualised for the patient with intellectual disability, behaviour disorders and other conditions such as dysphagia, autism.
6. Adhere to national guidelines and local formularies where appropriate. Use caution where the population with intellectual disability have not been considered in the guideline development process.
7. Write unambiguous correct documentation detailing reason for de-prescribing.
8. Monitor the beneficial and adverse effects of de-prescribing medicines and any effects on behaviour.
9. Communicate and document all de-prescribing decisions and the reasons for them such as transferred to appropriate personnel such as GP, pharmacist, psychiatrist, epileptologist, carer and patient.
10. De - prescribe within the limitations of your knowledge, skills and experience of the population with intellectual disabilities and behaviour disorders.
1. Cooper S-A, McLean G, Guthrie B, et al. Multiple physical and mental health comorbidity in adults with intellectual disabilities: population-based cross-sectional analysis. BMC Family Practice. 2015;16:110. doi:10.1186/s12875-015-0329-3.
Vulnerable populations are vulnerable because they are susceptible to
harm in health care environments. It is important that the healthcare
issues specific to the population with learning/intellectual disabilities
are considered when prescribing and deprescribing.
Deprescribing tools must be validated in the population with
learning/intellectual disabilities to ensure safety and quality care.
People with learn...
Vulnerable populations are vulnerable because they are susceptible to
harm in health care environments. It is important that the healthcare
issues specific to the population with learning/intellectual disabilities
are considered when prescribing and deprescribing.
Deprescribing tools must be validated in the population with
learning/intellectual disabilities to ensure safety and quality care.
People with learning/intellectual disabilities and behaviour disorders
provide particular challenges.
In the population with learning/intellectual disabilities compared
to the general population, the multi-morbidity burden is greater, occurs
at much earlier age, and the profile of health conditions differs [1].
People with learning/intellectual disabilities use multiple
medications and may have been taking them for many years. Extreme care in
required when de- prescribing many medications in this population group.
The principles of good de-prescribing during medication review in the
population with learning/intellectual disabilities, based on the British
Pharmacological Society's Principles for Good Prescribing 2010, provide a
template for quality de-prescribing in this population group.
Principles of Good De-prescribing during Medication Review in the
Population with Learning/Intellectual Disabilities (and Behaviour
Disorders). Based on the British Pharmacological Society's Principles for
Good Prescribing 2010
1. Be clear about the reasons for de-prescribing.
2. Take into account the patient with learning/intellectual disabilities
and behaviour disorders medication history before de-prescribing.
3. Take into account other factors that might alter the benefits and risks
of de-prescribing treatment in the patient with learning/intellectual
disability and behaviour disorders.
4. Take into account the patient's/carer's/families/advocates ideas,
concerns, and expectations.
5. Ensure all medicines are effective, safe, cost-effective in appropriate
form individualised for the patient with learning/intellectual disability,
behaviour disorders and other conditions such as dysphagia, autism.
6. Adhere to national guidelines and local formularies where appropriate.
Use caution where the population with learning/intellectual disability
have not been considered in the guideline development process.
7. Write unambiguous correct documentation detailing reason for de-
prescribing.
8. Monitor the beneficial and adverse effects of de-prescribing medicines
and any effects on behaviour.
9. Communicate and document all de-prescribing decisions and the reasons
for them such as transferred to appropriate personnel such as GP,
pharmacist, psychiatrist, epileptologist, carer and patient.
10. De - prescribe within the limitations of your knowledge, skills and
experience of the population with learning/intellectual disabilities and
behaviour disorders.
1. Cooper S-A, McLean G, Guthrie B, et al. Multiple physical and
mental health comorbidity in adults with intellectual disabilities:
population-based cross-sectional analysis. BMC Family Practice.
2015;16:110. doi:10.1186/s12875-015-0329-3.
Wright and colleagues report on a single centre survey of inpatient
perceptions and experiences of the current discharge process, and identify
improvement opportunities in relation to waiting for medicines, and lack
of counselling by pharmacists.(1) Problems such as low awareness among
inpatients of pharmacy services, or pharmacists citing challenges to
achieving patient medication counselling have b...
Wright and colleagues report on a single centre survey of inpatient
perceptions and experiences of the current discharge process, and identify
improvement opportunities in relation to waiting for medicines, and lack
of counselling by pharmacists.(1) Problems such as low awareness among
inpatients of pharmacy services, or pharmacists citing challenges to
achieving patient medication counselling have been reported
internationally.(2,3)
In summer 2015 we undertook a similar small survey (building on our
previous work from 20124) at our 600 bedded teaching hospital. A Patient
Ambassador approached 33 patients (22 aged over 60 years) to ask questions
about their knowledge of their medicines. Thirty (90%) patients were
taking regular medicines prior to admission. Of these 30, 22 patients
recognised that their existing medicines had been changed whilst in
hospital, one did not know, and 7 claimed that there had been no changes.
Seventeen (77%) of the 22 patients reported that medication changes had
been explained to them, though in only 2 instances did the patient
acknowledge that the pharmacist undertook this counselling. Of the 26
patients commenced on new medicines during their stay only 6 (23%)
received information on side effects. Despite this, 18 of all 33
participants indicated that they received enough information about their
medication during their stay, though only 3 of these patients responded
that this information had been provided by the pharmacist.
Wright et al quite correctly reference the importance attached to the
National NHS Inpatient Survey which assesses patient experience at
hospitals across England, and results from the medicines related questions
section of this survey form part of the Hospital Pharmacy and Medicines
Optimisation project. They also argue for the development of a new model
of care for patient discharge. As an enhancement to discharge medicines
counselling provided by pharmacy, we are utilising a checklist for nursing
staff to follow when discharging patients which requires the nurse to
explain the medication and side effects. We have also very recently moved
from a faxing system to an electronic referral system (Pharmoutcomes) for
sending critical clinical information to a patient's regular community
pharmacy to enable the community pharmacist to offer on-going support and
advice on medication-related issue that may have arisen during the
admission.
Ensuring that all hospital processes around discharge and all
hospital staff involved with the discharge process are aligned with such a
new model of care for patient discharge may benefit from adopting the
Always Event approach.(5)
Yours sincerely
Mike Wilcock
Sally Miles
Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall
REFERENCES
1. Wright S, Charles W, Morecroft CW, Mullen R, Ewing AB. UK hospital
patient discharge: the patient perspective. Eur J Hosp Pharm
doi:10.1136/ejhpharm-2016-001134
2.King PK, Martin SJ, Betka EM. Patient awareness and expectations of
pharmacist services during hospital stay. J Pharm Pract 2016 Aug 31. pii:
0897190016665541
3. Chevalier BA, Watson BM, Barras MA, Cottrell WN. Hospital pharmacists'
perceptions of medication counseling: A focus group study. Res Social Adm
Pharm. 2016 Sep-Oct;12(5):756-71.
4. Wilcock M, Lawrence J. Patients' experience of the hospital pharmacy
team - still further work to be done! Pharmacy Management 2015;31(1):15-
20.
5. NHS England. Always event (cited 18 January 2017)
https://www.england.nhs.uk/ourwork/pe/always-events/
Chinese Clinical Trial Registry to COVID-19, Where is the Way Out to the Diagnosis and Treatment Therapy
Show MoreYaYun Wu1, HuaYe Jiang1, Xun Huang1*
1Departments of Infection Control, Xiangya Hospital, Central South University, Changsha，HuNan 410008,China
*Corresponding author:Xun Huang，MD, Department of Infection Control, Xiangya Hospital, Central South University, Changsha ， HuNan 410008,China (Email: huangxun@mail.csu.edu.cn)
To the Editor:
During the epidemic period of Coronavirus Disease 2019 (COVID-19), many doctors and researchers conducted clinical trial on COVID-19 in China. Until 04:00 am 16 April , 2020, there were 598 clinical trials on COVID-19 registered in Chinese Clinical Trial Register (ChiCTR), including 309 (51.67%) interventional trials and 248 (41.47%) observational trials and 41 （6.86%） diagnostic trials. There were 43 studies have been withdrawn1.We analyze the data for the period, 6 clinical trials were registered in January (1.23-1.31), all of them were interventional studies.There were 291 clinical trials registered in February (2.1-2.29), including 193 (66.32%) interventional studies， 83 (28.52%) observational studies and 15 (5.16%) diagnostic studies.There were 254 clinical trials registered in March (3.1-3.31), including 93 (36.61%) interventional studies,138 (54.33%) observational studies and 23 (9.06%) diagnostic studies. There were 47 clinical trials registered in Apri...
I) We agree with Dr. Van den Eynde that since tedizolid is a more potent inhibitor than linezolid, it is administered at lower doses. Thus, the MAO inhibition would be lower. This is probably the reason why there have been no reports regarding serotoninergic toxicity. However, the possibility of MAO inhibition cannot be ruled out, especially when tedizolid is administered together with serotoninergic drugs. We would like to emphasize that the spontaneous reporting of suspected adverse reactions is useful to identify potential signals that suggest a causal association between a medicinal product and a previously unknown reaction. Whether this suspected adverse reaction is a signal, it should be confirmed by further reports.
II) In our article we do not affirm that it is a serotonin syndrome or a serotonin toxicity, since, in fact, we do not have enough clinical information to confirm it. We only discuss the possibility that the hypertensive crisis could be related to the co-administration of tedizolid and other serotoninergic drugs. Our position is well defined in the following paragraph of the article: “The causality of hypertension as an adverse drug reaction due to the co-administration of tedizolid and other serotonergic treatments was evaluated using the algorithm of Naranjo et al, obtaining a final score of 3. According to this value, the relationship between tedizolid and the hypertensive crisis should be classified as possible, as we were not able to rule ou...
Show MoreWe note, upon critical appraisal of this case report, two shortcomings:
Show More(I) the authors provide a one-sided and inaccurate extrapolation to clinical practice from the literature data on tedizolid;
(II) the authors do not adhere to well-established ‘diagnostic decision rules for serotonin toxicity’: the Hunter criteria.<1>
I. In gauging the MAO-inhibiting potential of both antibiotics, de Castro Julve et al. rightly note that ‘tedizolid appears to be a more potent inhibitor in vitro of MAO-A than linezolid’ <2>– but neglect to mention (a) that tedizolid is also four to sixteen (or – depending on the source – ‘two to eight’)<3> times more potent than linezolid at treating most gram-positive infections;<4> and (b) that tedizolid is therefore administered at a lower dose than is linezolid (200mg/day vs. 600mg/12 hours).<3> This likely leads, in practice, to less tedizolid-induced (vs. linezolid-induced) MAO-inhibition<3>, as evidenced by the clinically insignificant potentiation of the tyramine pressor response (TYR30)<2>, and to less potential for serotonergic drug interactions<5>, as further evidenced by the fact that no changes in the murine head twitch response occur, even at plasma tedizolid concentrations which exceed – ‘by up to ~25-fold’ – the Cmax observed in humans at the clinical dose of 200mg/day.<3>
II. The detection in their patient of a hypertensive crisis ‘suspected to be an adverse r...
The section in this paper which says pharmacists could prescribe controlled drugs from 2012 with the exception of schedule 1 and 2 CDs for drug misuse is misleading. Schedule 1 cannot be prescribed by anyone without out a licence to do so (this includes doctors) and schedule 1 contains substances of no medicinal use. Schedule 2 CDs can be prescribed by pharmacists for drug misuse, the only exception is diamorphine (and technically cocaine and dipipanone although these are not used). Diamorphine is prescribed as an injectable by prescribers on the Dept of Health approved list to do so and this list is restricted to medical doctors. Other schedule 2 drugs for addiction such as methadone and morphine (unlicensed) can be prescribed by pharmacist prescribers.
Monitored dosage systems (or dose administration aids) are widely used but it is important to reduce their inappropriate use by ensuring they are only issued on a case-by-case basis to address specific practical problems of medicines adherence. It should be assumed that patients can manage their medicines unless indicated otherwise. NICE guidance (1) states monitored dosage systems should be considered as an option to improve adherence on a case-by-case basis, and only if there is a specific need to overcome practical problems. This should follow a discussion with the patient to explore possible reasons for nonadherence and the options available to improve adherence, if that is their wish.
Show More• The inappropriate use of monitored dosage systems can make patients and carers less familiar with their medicines. Health literacy including awareness of medicines should be promoted.
• Transferring medicines to monitored dosage systems carries the risk of human error. The stability of many medicines cannot be guaranteed outside their original packaging.
• Patients who may benefit from monitored dosage systems include patients who have less ability to read or understand the instructions on standard medicines packaging, but who have the dexterity to use the devices and who wish to adhere to their medicines regimen.
• Pharmacists should check compliance issues and provide a monitored dosage system only if compliance cannot be addressed by other methods a...
Comment 1: In case of stable patient, the priority of management for extremity fracture in emergency department would be early reduction with immobilization, pain relief is not the primary concern, on the other hand, early pain relief might put the patient in a risk of delayed reduction trial . As we know neurovascular compromise around fracture site is critical for fracture management, and so, instead of decreasing time...
Reading the editorial – “Value or cost: looking for the wider perspective”,the one thing that struck us the most was,when pharmacists determine value,one of the most important variables that they take into account is the monetary cost of the intervention,say antibiotics.This raised several questions in our minds.What if the antibiotics on the hospital formulary were priced at a point that their use in certain situations seemed unjustified to pharmacists,but would seem perfectly justified at lower price points?What if generics,available at a fraction of the price of the branded variety,were used in place of the brands?It seems to us that they would most certainly impact the way that “value” is calculated for that particular scenario.What if the pharmacist knew a perfectly good enough generic,but hospital policy allowed procurement,and hence prescribing of,only a more expensive brand?
Show MoreWhen hospital pharmacists try to assess the value of a new health technology,we feel that they would be well served if they took a long,hard look at the evidence.Sometimes claims might not be very genuine.And this could place heavy costs on the patients.A very contemporary example would be the pricing of cardiac stents. Cardiac stents are sold at a 300 to 400 percent mark up to Indian patients.A stent that costs Rs.20,000(Euro 284) if bought from a vendor would miraculously cost Rs.160,000(Euro 2273)at the hospital pharmacy,all other charges being separate.1The patient is not given the o...
The population with intellectual disabilities are vulnerable in the prescribing and the deprescribing process.
In the population with intellectual disabilities compared to the general population, the multi-morbidity burden is greater, occurs at much earlier age, and the profile of health conditions differs [1].
People with intellectual disabilities use multiple medications and may have been taking them for many years. Extreme care in required when de- prescribing many medications in this population group. The principles of good de-prescribing during medication review in the population with intellectual disabilities, based on the British Pharmacological Society’s Principles for Good Prescribing 2010, provide a template for quality de-prescribing in this vulnerable population group.
Principles of Good De-prescribing during Medication Review in the Population with Intellectual Disabilities and Behaviour Disorders. Based on the British Pharmacological Society’s Principles for Good Prescribing 2010
Show More1. Be clear about the reasons for de-prescribing.
2. Take into account the patient with intellectual disabilities and behaviour disorders medication history before de-prescribing.
3. Take into account other factors that might alter the benefits and risks of de-prescribing treatment in the patient with intellectual disability and behaviour disorders.
4. Take into account the patient’s/carer’s/families/advocates ideas, concerns, and expec...
Vulnerable populations are vulnerable because they are susceptible to harm in health care environments. It is important that the healthcare issues specific to the population with learning/intellectual disabilities are considered when prescribing and deprescribing.
Deprescribing tools must be validated in the population with learning/intellectual disabilities to ensure safety and quality care. People with learn...
Dear Editor
Wright and colleagues report on a single centre survey of inpatient perceptions and experiences of the current discharge process, and identify improvement opportunities in relation to waiting for medicines, and lack of counselling by pharmacists.(1) Problems such as low awareness among inpatients of pharmacy services, or pharmacists citing challenges to achieving patient medication counselling have b...