Recently, clinical pharmacists have contributed to medication consultation and inpatient pharmaceutical services in hospitals. However, there are few reports investigating the effects of an ambulatory care pharmacy for cardiovascular disease in Japan. Here we examined whether an ambulatory care pharmacy improves patient care in the clinical pathway for cardiovascular diseases in North Shinshu. We retrospectively investigated the number of patients in possession of drug profile books from June 2009 to March 2014. Among 175 patients, the rate of carrying drug profile books significantly increased from 85.6％ to 96.6％ (P < 0.01). According to the guidelines for cardiovascular disease in Japan, we checked the prescriptions from April 2015 to March 2016 to review the appropriate use of medications. We consulted 147 patients and successfully reduced the cost of medicines to 731,132 yen per year by discontinuing the medicines that the doctor and pharmacist considered unnecessary at the time. The ambulatory care pharmacy demonstrated an increase in the number of patients having a drug profile book and a decrease in the cost of medicines associated with cardiovascular diseases. The development of an ambulatory care pharmacy might have the potential to improve the quality of pharmaceutical care in cardiovascular disease.
Fatigue is a frequent side effect in patients undergoing cancer chemotherapy. Patients may experience insomnia and pain, which are risk factors for fatigue, and have more severe fatigue after the introduction of chemotherapy. The present prospective cohort study included 59 patients who had been newly introduced to chemotherapy. We investigated the incidence of the severe fatigue and the influencing factors after the introduction of chemotherapy in patients with insomnia or pain prior to the introduction of chemotherapy. Patients with Visual Analog Scale (VAS) scores of < 20 mm and ≥ 20 mm were categorized into the "- group" and "+ group," respectively. A VAS score of ≥ 80 mm was considered to indicate severe fatigue, which was the primary endpoint of this study. Statistical analyses were performed using the log-rank test and the Cox proportional hazards model. The incidence of severe fatigue in the + group was always high (P = 0.011). Four factors: insomnia (adjusted HR = 17.721; P < 0.0001), cigarette smoking (adjusted HR = 31.602; P < 0.0001), alcohol use (adjusted HR = 0.119; P = 0.002), sleep-inducing drug use (adjusted HR = 0.054; P = 0.016) have been identified as risk factors contributing to the occurrence of severe fatigue. The results of the present study suggest the possibility that severe fatigue in cancer patients can be prevented by evaluating and treating symptoms such as insomnia, etc., which are risk factors for severe fatigue, prior to the introduction of chemotherapy.
Most esophageal cancer patients have difficulty swallowing medications due to their narrowing esophagus. Therefore, oral antiemetics are often unacceptable when these patients undergo chemotherapy. Fosaprepitant is a prodrug of aprepitant, and the first injectable neurokinin-1 (NK-1) receptor antagonist. When it became available on the market, we modified our antiemetic prophylaxis for 5-fluorouracil plus cisplatin (FP) therapy, a standard chemotherapy for esophageal cancer, replacing aprepitant with fosaprepitant. In the present study, we compared the previous prophylaxis with the modified one in effectiveness and adverse events.
We retrospectively reviewed medical records of patients who received FP therapy. The patients were divided into two groups: Group A, those who received the previous prophylaxis consisting of aprepitant (Days 1-3), palonosetron (Day 1) and dexamethasone (Days 1-3); and Group F, those who received modified prophylaxis consisting of fosaprepitant (Day 1), palonosetron (Day 1) and dexamethasone (Days 1-4). We evaluated complete response (CR; no emesis and no rescue therapy) rate, (NV; no vomiting) rate, and adverse events related to antiemetics.
There were no significant differences in CR rate and NV rate between Group A and Group F (CR rate: 58.3％ vs 61.4％, P = 0.895; NV rate: 100.0％ vs 97.1％, P = 0.271). The incidence of ALT elevation was significantly higher in Group A than Group F (Grade 1: 52.0％ vs 25.7％, Grade 2: 4.1％ vs 8.5％, Grade 3: 0.0％ vs 2.8％; P = 0.018).
For esophageal cancer patients with dysphagia, it is sensible to replace fosaprepitant with aprepitant in antiemetic prophylaxis when used with palonosetron.
The absorption of gefitinib is dependent on gastric pH. However, an increase in gastric pH via the use of antacids such as proton pump inhibitors (PPI) and histamine H2 receptor antagonists may reduce the bioavailability and efficacy of gefitinib.
In this study, we report the influence of the concurrent use of antacids with gefitinib on the efficacy in epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC). Our subjects were 68 patients with NSCLC who were treated with gefitinib at our hospital between 2008 and 2015.
In the study, we compared time to treatment failure (TTF), overall survival (OS), response rate, disease control rate and adverse effect rates in patients receiving antacids in combination as well as (AC; n = 29) with those only receiving gefitinib (no AC; n = 34).
The patients in the AC group exhibited a significant difference in TTF (409 days (95％CI: 1.00-4.22) vs 901 days (95％CI: 0.24-0.99), P = 0.0492) as compared to the no AC group. But then the OS, response rate, disease control rate and adverse effects rate were not significant between each group. Therefore, this study suggests that, as long as the combination of gefitinib with antacids is avoided, the combination with antacids should not impair the clinical efficacy of gefitinib. From the results of the sub-analysis, this study suggests that, in particular men, less than 75 years old, PS≧2, pulmonary metastasis, it is preferable to avoid the combination of gefitinib and antacids.
Oxaliplatin (L-OHP) was approved for the treatment of gastric cancer in 2015 in Japan. Cisplatin (CDDP) and L-OHP are used as the first-line therapy for unresectable advanced or recurrent gastric cancer. Compared with CDDP, L-OHP has fewer adverse effects such as nausea and vomiting. Moreover, L-OHP does not need a large amount of hydration. Many outpatients with gastric cancer can use L-OHP. L-OHP is used with S-1 (SOX) for unresectable advanced or recurrent gastric cancer. However, some patients need to take a reduced dose or discontinue therapy. Thus, we evaluated the factors that influence the tolerance to SOX, to improve treatment safety and predict adverse events. The study included 22 patients who were treated with SOX. Intolerant patients were defined as those who required a reduced dose or discontinuation of therapy. Eight patients were defined as intolerant. The factors that influenced tolerance included surgical history of gastric cancer (P = 0.018), body mass index < 18.5 (P = 0.039), low neutrophil count (P = 0.039), low platelet count (P = 0.039), and high aspartate transaminase level (P = 0.036). All intolerant patients underwent surgery for gastric cancer. The duration from surgery to the initiation of SOX in intolerant patients was shorter than that for tolerant patients (P = 0.021). In conclusion, the factors that influence tolerance in patients receiving SOX were short duration from surgery to SOX, low body mass index, low neutrophil count, low platelet count and high aspartate transaminase level. Therefore, patients who have these factors require careful monitoring for adverse events.
Warfarin is a useful and effective oral anticoagulant. The management of the prothrombin time-international normalized ratio (PT-INR) is important for ensuring appropriate warfarin-based anticoagulation therapy. Here, we developed an anticoagulation management support (ACMS) system involving self-monitoring of the PT-INR and an Internet-based reporting system for outpatients. In the ACMS system, outpatients monitor their own PT-INR values using a CoaguChek® XS rapid measuring device and report the data to medical staff via a website. Then, the medical staff reply to the patients with information about their next dosage of warfarin based on the reported PT-INR data. We employed protocol-based pharmacotherapy management (PBPM), which was conducted by pharmacists, linked to the ACMS system to treat outpatients who received combination therapy involving warfarin and drugs that can have drug-drug interactions with warfarin, such as rifampicin, miconazole, 5-FU, and S-1. In the present study, we investigated the safety and efficacy of PBPM in 6 patients. There were no major discrepancies between the PT-INR values measured by self-monitoring and those obtained at hospital, and the patients did not make any errors when inputting their data via the website. By applying PBPM, anticoagulation therapy with warfarin was found to be safe and effective, and the time in therapeutic range was 82.1 ± 7.3％ (mean ± SD). No major adverse events, such as bleeding or embolisms, occurred in any patient during the observation period. These results suggest that PBPM linked to the ACMS has beneficial effects on warfarin-based anticoagulation therapy in outpatients.
Kobe University Hospital has set up “Pharmaceutical Outpatient Clinics” for outpatients of the Departments of General Internal Medicine and Cardiovascular Surgery included in each ambulatory medical practice. Before the medical examination, the pharmacist in charge interviews each patient about medications in a separate room. Thereafter, the pharmacist participates in the medical examination for each patient, and intervenes in the prescription process by discussing with the medical doctor and each patient in the Departments of General Internal Medicine. In this study, the effects of the pharmacist's intervention in the “Pharmaceutical Outpatient Clinic” on the changes of prescribed drugs were evaluated. A total of 517 patients visited the “Pharmaceutical Outpatient Clinics” from May 2014 to March 2015. The pharmacist intervened in the prescriptions of drugs in patients visiting the “Pharmaceutical Outpatient Clinics” at a rate of 12.4％ (64 cases) and the doses were reduced at a rate of 5.6％ (29 cases), and both rates were significantly higher than those in patients without pharmacist's interventions (P < 0.01). No significant differences were observed in the frequency of adverse events due to the changed prescriptions with and without pharmacist's interventions (4.1％ vs 4.7％). The most frequent reason for the pharmacist's intervention was “an improvement of symptoms” in the outpatients of General Internal Medicine and “adaptation to the drug indication” in the outpatients of Cardiovascular Surgery, respectively. In conclusion, the “Pharmaceutical Outpatient Clinic,” in cooperation with medical doctors, helps to promote appropriate drug usage.