- What are the most efficacious pharmacological strategies to incorporate into patient’s acute asthma action plans to prevent premature mortality?
Asthma is a highly prevalent chronic respiratory disease that affects more than five million adults and children in the UK and is associated with acute exacerbations that are responsible for an estimated 1000 premature deaths per year (Mukherjee et al., 2016). Notably, most of these deaths are considered preventable with optimal management regimes and stringent adherence to pharmacological agents (Torjesen, 2014). This has been recognised in a recent confidential enquiry into UK asthma deaths, where major contributing factors were found to be inappropriate prescribing and a lack of asthma action plans (Levy, 2015). In a small but significant proportion of cases, 3-10% of patients have severe asthma, who observe a more severe disease course with greater disability and impaired quality of life (D'Amato et al., 2016). After observation of a patient admitted to the Emergency Department with near fatal asthma, the role of acute management using a range of pharmacological interventions was fundamental to preventing death from respiratory failure. Given that UK hospitals receive a high proportion of patients with acute asthma exacerbations, this represents an opportunity to not only apply acute pharmacological strategies, but to also review and optimise patient’s regular asthma medications and acute management options, in order to promote more desirable outcomes. The focus of the dissertation would be upon the medications used in the self-management of acute asthma and their evidence base and effects upon outcomes.
Cazzola, M., Page, C. P., Calzetta, L. and Matera, M. G. (2012) Pharmacology and therapeutics of bronchodilators. Pharmacol Rev, 64 (3), 450-504. Available from: https://doi.org/10.1124/pr.111.004580 [accessed 27/08/2018].
D'Amato, G., Vitale, C., Molino, A., Stanziola, A., Sanduzzi, A., Vatrella, A., Mormile, M., Lanza, M., Calabrese, G., Antonicelli, L. and D'Amato, M. (2016) Asthma-related deaths. Multidiscip Respir Med, 11 37-41. Available from: https://doi.org/10.1186/s40248-016-0073-0 [accessed 25/08/2018].
Israel, E. and Reddel, H. K. (2017) Severe and Difficult-to-Treat Asthma in Adults. New England Journal of Medicine, 377 (10), 965-976. Available from: https://www.nejm.org/doi/full/10.1056/NEJMra1608969 [accessed 27/08/2018].
Levy, M. L. (2015) The national review of asthma deaths: what did we learn and what needs to change? Breathe, 11 (1), 14-24. Available from: https://doi.org/10.1183/20734735.008914 [accessed 28/08/2018].
Mukherjee, M., Stoddart, A., Gupta, R. P., Nwaru, B. I., Farr, A., Heaven, M., Fitzsimmons, D., Bandyopadhyay, A., Aftab, C., Simpson, C. R., Lyons, R. A., Fischbacher, C., Dibben, C., Shields, M. D., Phillips, C. J., Strachan, D. P., Davies, G. A., McKinstry, B. and Sheikh, A. (2016) The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases. BMC Medicine, 14 (1), 113-118. Available from: https://doi.org/10.1186/s12916-016-0657-8 [accessed 28/08/2018].
Patel, M. and Shaw, D. (2015) A review of standard pharmacological therapy for adult asthma – Steps 1 to 5. Chronic Respiratory Disease, 12 (2), 165-176. Available from: https://doi.org/10.1177/1479972315573529 [accessed 27/08/2018].
Torjesen, I. (2014) Two thirds of deaths from asthma are preventable, confidential inquiry finds. BMJ, 348 1-3. Available from: https://www.bmj.com/content/bmj/348/bmj.g3108.full.pdf [accessed 28/08/2018].
- What are the most effective education strategies for patients requiring long-term oral anticoagulation and overcoming the barriers to achieving therapeutic anticoagulation?
Anticoagulants are required for thromboprophylaxis in a range of diseases and conditions, which if left untreated, can lead to the development of thromboembolic complications and excess morbidity and mortality (Yeh et al., 2015). However, the use of conventional anticoagulants with narrow therapeutic indices, such as warfarin, are associated with considerable adverse effects, such as haemorrhage or sub-therapeutic concentrations, leaving patients vulnerable to complications (Harter et al., 2015). It is estimated that anticoagulants are responsible for 10% of all medication incidents causing severe harm or death, and efforts to promote safety rely upon effective patient education strategies (Fattah, 2013). Notably, in recent times the emergence of novel oral anticoagulants with more favourable pharmacological profiles, such as dabigatran and rivaroxaban, has seen reductions in adverse effects and requirements for drug level monitoring, however, problems such as limited reversal agents, among other reasons, mean that continued use of warfarin is required to protect patients’ future wellbeing (Arepally and Ortel, 2015). This dissertation will focus upon the education strategies that can be applied by pharmacists or other health professionals and reviewing the evidence base to evaluate their efficacy in preventing adverse effects and complications, as well as how they can help to overcome the barriers to achieving therapeutic anticoagulation.
Arepally, G. M. and Ortel, T. L. (2015) Changing Practice of Anticoagulation: Will Target-Specific Anticoagulants Replace Warfarin? Annual Review of Medicine, 66 (1), 241-253. Available from: https://www.annualreviews.org/doi/abs/10.1146/annurev-med-051113-024633 [accessed 27/08/2018].
Fattah, L. (2013). Anticoagulation [online]. Available from: https://www.cppe.ac.uk/learningdocuments/pdfs/fp_anticoagulation_book%201(final).pdf [accessed 27/08/2018].
Harter, K., Levine, M. and Henderson, S. O. (2015) Anticoagulation drug therapy: a review. West J Emerg Med, 16 (1), 11-17. Available from: https://doi.org/10.5811/westjem.2014.12.22933 [accessed 28/08/2018].
Hawes, E. M. (2018) Patient Education on Oral Anticoagulation. Pharmacy, 6 (2), 1-10. Available from: https://doi.org/10.3390/pharmacy6020034 [accessed 28/08/2018].
Moore, S. J., Blair, E. A., Steeb, D. R., Reed, B. N., Hull, J. H. and Rodgers, J. E. (2015) Impact of video technology on efficiency of pharmacist-provided anticoagulation counseling and patient comprehension. Ann Pharmacother, 49 (6), 631-638. Available from: https://doi.org/10.1177/1060028015575352 [accessed 28/08/2018].
Winans, A. R., Rudd, K. M. and Triller, D. (2010) Assessing anticoagulation knowledge in patients new to warfarin therapy. Ann Pharmacother, 44 (7-8), 1152-1157. Available from: https://doi.org/10.1345/aph.1P092 [accessed 28/08/2018].
Wofford, J. L., Wells, M. D. and Singh, S. (2008) Best strategies for patient education about anticoagulation with warfarin: a systematic review. BMC Health Serv Res, 8 40-52. Available from: https://doi.org/10.1186/1472-6963-8-40 [accessed 28/08/2018].
Yeh, C. H., Hogg, K. and Weitz, J. I. (2015) Overview of the new oral anticoagulants: opportunities and challenges. Arterioscler Thromb Vasc Biol, 35 (5), 1056-1065. Available from: https://doi.org/10.1161/ATVBAHA.115.303397 [accessed 27/08/2018].
- What are the most efficacious and safe pharmacological interventions that should be considered for patients presenting with insomnia in primary care settings?
In the last decade, studies from around the world have shown that there have been increases in insomnia and insomnia-related symptoms, particularly among persons of working age (Kronholm et al., 2016). In a cross-sectional study in the UK, Calem et al. (2012) found that the prevalence of insomnia had increased over the past 15 years among the general population, despite not observing changes in the reasons for sleep disturbances during this period. It is estimated that insomnia affects 10% of the adult population but almost half of the population will experience insomnia symptoms during their lifetime (Morgan and Sharman, 2017). Notably, insomnia can adversely impact on quality of life but effective management using pharmacological agents has been shown to confer benefits to physical, social and emotional functioning (Kyle et al., 2010). Moreover, the effects of acute and chronic sleep insufficiency have received growing attention, due to evidence reporting its negative impact upon cardiovascular and metabolic health and all-cause mortality (Kurina et al., 2013). Recent research discussing topical issues related to the de-pharmaceuticalisation of insomnia through the negative influence of media has led to patients being more reluctant to seek or obtain pharmacological options (Gabe et al., 2017). Thus, this dissertation will involve exploring the evidence base regarding the most effective and safe drugs that can be recommended for use in primary care settings.
Calem, M., Bisla, J., Begum, A., Dewey, M., Bebbington, P. E., Brugha, T., Cooper, C., Jenkins, R., Lindesay, J., McManus, S., Meltzer, H., Spiers, N., Weich, S. and Stewart, R. (2012) Increased prevalence of insomnia and changes in hypnotics use in England over 15 years: analysis of the 1993, 2000, and 2007 National Psychiatric Morbidity Surveys. Sleep, 35 (3), 377-384. Available from: https://doi.org/10.5665/sleep.1700 [accessed 28/08/2018].
Gabe, J., Williams, S. J. and Coveney, C. M. (2017) Prescription hypnotics in the news: A study of UK audiences. Social Science & Medicine, 174 43-52. Available from: http://www.sciencedirect.com/science/article/pii/S0277953616306487 [accessed 28/08/2018].
Kripke, D. F. (2016) Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit. F1000Res, 5 918-922. Available from: https://doi.org/10.12688/f1000research.8729.1 [accessed 27/08/2018].
Kronholm, E., Partonen, T., Härmä, M., Hublin, C., Lallukka, T., Peltonen, M. and Laatikainen, T. (2016) Prevalence of insomnia-related symptoms continues to increase in the Finnish working-age population. Journal of Sleep Research, 25 (4), 454-457. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jsr.12398 [accessed 28/08/2018].
Kurina, L. M., McClintock, M. K., Chen, J. H., Waite, L. J., Thisted, R. A. and Lauderdale, D. S. (2013) Sleep duration and all-cause mortality: a critical review of measurement and associations. Ann Epidemiol, 23 (6), 361-370. Available from: https://doi.org/10.1016/j.annepidem.2013.03.015 [accessed 27/08/2018].
Kyle, S. D., Morgan, K. and Espie, C. A. (2010) Insomnia and health-related quality of life. Sleep Med Rev, 14 (1), 69-82. Available from: https://doi.org/10.1016/j.smrv.2009.07.004 [accessed 27/08/2018].
Morgan, K. and Sharman, R. (2017). Clinical review: insomnia [online]. Available from: https://www.gponline.com/clinical-review-insomnia/article/1166560 [accessed 28/08/2018].
Neubauer, D. N. (2014) New and emerging pharmacotherapeutic approaches for insomnia. Int Rev Psychiatry, 26 (2), 214-224. Available from: https://doi.org/10.3109/09540261.2014.888990 [accessed 27/08/2018].
Shahid, A., Chung, S. A., Phillipson, R. and Shapiro, C. M. (2012) An approach to long-term sedative-hypnotic use. Nat Sci Sleep, 4 53-61. Available from: https://doi.org/10.2147/NSS.S28362 [accessed 27/08/2018].
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