Background In renal failure, alteration in the pharmacokinetics increases the frequency of overdoses. Purpose To evaluate pharmaceutical care using a computer programme for drug dose adjustment in renal failure. Materials and Methods The study period lasted from September 2011 to January 2012 (inclusive), in a 420-bed hospital. Every day creatinine values over 130 mmol/l were filtered. Treatment was reviewed and we obtained creatinine clearance values (Crockcoft & Gault) of selected patients. After consulting the drug dose adjustment on the sheet and in Micromedex, a report was sent with the pharmaceutical recommendation. ResultsThere were 68 interventions for the 2147 patients studied: Internal Medicine (34) Cardiology (1), Short Stay Unit (5), Orthopaedics (7), Urology (5), Haematology (7) Surgery (5), Neurology (1), Intensive Care Unit (ICU) (2) Oncology (1). 55.9% of notifications were for changes in the dose of enoxaparin (38), 11.8% of amoxicillin-clavulanic acid (8), piperacillin-tazobactam 14.7% (10), 8.8% levofloxacin (6), 2.9% meropenem (2), 2.9% ciprofloxacin (2), 1.5% imipenem (1) and 1.5% aztreonam (1). The proportion of suggested changes accepted was 58.8% (40). 5.9% (4) discontinued treatment, 5.9% (4) were discharged and 29.4% (20) not changed. Of the latter, five were for changes in the pattern of enoxaparin in trauma patients, another 5 from Internal Medicine and 2 more from Haematology and ICU. The rest of them were changes in the pattern of antibiotics (imipenem 1, 2 levofloxacin, 1 meropenem, 1 ciprofloxacin, piperacillin-tazobactam 3) that were given out in the different services. Conclusions A high percentage of doctors followed the recommendations. Part of the unaccepted tally corresponds to trauma patients whose prophylactic regimen of enoxaparin (40 mg/24 h) was not modified due to the service criteria. Some of the antibiotic prescriptions were not changed because of the severity of the patient’s illness (1 levofloxacin and 1 Internal Medicine Meropenem Imipenem Oncology and 1). The rest were rejected without explanation. No conflict of interest.

Background Pain is a common symptom that leads terminally ill patients to an emergency department. Opioids have a critical place in the management of terminal pain. Purpose To investigate the characteristics of patients admitted for palliative care and treatments prescribed for making pain bearable and to develop query tables on the dosage and exchange of opioids. Materials and methods The data of all the patients admitted to the hospital for palliative care from January to May 2012 (32 patients) were examined in order to study their demographics, admission date, sex, age, length of hospitalisation, reason for admission, the main disease, comorbidities, treatment used for pain and frequency of rescue from pain. Finally, we undertook a bibliographic review of the use of opioids for pain. Results 68.7% of enrolled patients were men, with a mean age of 75.87 years overall. 75% of patients admitted had cancer, the other patients (25%) had chronic obstructive pulmonary disease. The most common comorbidities were hypertension (27%), type II diabetes (17%), heart disease (16%) and dyslipidaemia (13%). 47% of patients experienced pain during admission, which was controlled in 67% of cases with strong opioids, 27% with NSAIDs, and 6% with weak opioids. 33% of patients required rescue medicines, with an average of less than two rescues a day. Three tables were developed showing doses, exchange and opioid rescue and were distributed throughout the hospital. Conclusions Most of the patients admitted had cancer and their pain was controlled with morphine. On average they needed fewer than two daily rescues, which could indicate that the pain was controlled. The proposed dosing and opioid exchange tables, and with the Palliative Care Unit agreement, helping to better management and safety in the administration of these drugs in the hospital. No conflict of interest.

Background Inappropriate prescribing is highly prevalent in older people and has become a global healthcare concern. Purpose To detect inappropriate prescriptions for patients hospitalised in the Internal Medicine Ward according to STOPP/START criteria. To define the profile of patients who would benefit more from a pharmaceutical intervention. Materials and methods Observational and retrospective study of drugs prescribed to patients who were admitted and discharged from the Internal Medicine Ward of a second-level university hospital from October 2012 to February 2013. Patients were over the age of 65 and prescribed ≥5 drugs. The data were obtained from the patients’ medical records. STOPP and START criteria were applied to the drugs prescribed upon hospital admission and discharge. Results A group of 50 patients were studied at the time. The average age was: 80.4 (65–96). According to STOPP/START criteria 32 patients (64%) with inappropriate prescriptions were detected upon hospital admission and 18 (36%) upon hospital discharge. Regarding the age of the sample group, patients were classified into the following groups: 65–70 years old (8%), 71–80 years old (48%), 81–90 years old (30%), >90 (12%). According to STOPP criteria there were 45 non-recommended prescriptions upon hospital admission and 21 upon hospital discharge: NSAIDs with mild/severe hypertension (15% admission, 19% discharge) and duplicate drug class prescriptions (13% admission, 9% discharge). According to START criteria there were 59 cases upon hospital admission in which a non-prescribed drug had to be added and 30 on discharge, pointing out: ACE inhibitors in chronic heart failure (14% admission, 30% discharge) and ACE inhibitors or ARBsII in diabetes with nephropathy (12% admission, 13% discharge). Conclusions There was a high percentage of patients with inappropriate prescriptions. 48% of inappropriate prescriptions were corrected according to STOPP criteria and 53% according to START criteria during hospitalisation. As described by Sevilla-Sánchez et al (2012) the cardiovascular system group of medicines was the most frequently inappropriately prescribed. Patients between 81–90 years old would benefit more from a pharmaceutical intervention. As Lee et al (2013) prove, START/STOPP criteria can help doctors and pharmacists to prescribe properly in clinical practice. No conflict of interest.

Background Spanish laws include the special availability situation of drugs that can be used for ‘off label’ indications. Off-label use is regulated by the RD 1015/2009 from 19th June law. Purpose To study the drugs prescribed to be used for off-label indications. Materials and methods Observational and retrospective study of the drugs prescribed for ‘off label’ indications to patients who were admitted to a second level university hospital from January 2013 to June 2013. To evaluate the evidence level of each drug indication we reviewed the Micromedex online data base. Patients’ data were obtained from their medical records and were treated as anonymous. We evaluated the economic impact of the drugs, the average number of treatment doses given to patients and the possible adverse effects of the drugs, the effect of those drugs on each patient and the final outcomes. Results The hospital pharmacy was asked for 29 drugs for off-label indications, for 36 pathologies. 63 reports were sent to the medical manager, and 100% were approved. The most-prescribed drugs were Avastin (bevacizumab) (11 patients) and Abraxane (paclitaxel formulated as albumin-bound nanoparticles)(5 patients). The total cost of these drugs was 107,588 €. The wards that requested more off-label drugs were Oncology (14 patients) and Haematology (12 patients), with a spend of 27,276 € and 24,008 €. The pathologies that were most treated with off-label drugs were endometrial and pancreatic cancer. The most expensive drug per dose was plerixafor. Evidence about the majority of indications was low (11 indications were found on the Micromedex database). Finally 53 patients were treated with the off-label indications drugs. Currently there are 18 patients still getting treatment. 7 patients’ conditions clearly improved and 5 worsened after treatment. 12 patients had adverse effects due to these drugs. Conclusions Off-label drugs are a very important element of oncohaematology treatments. These drugs can have an important effect on patient health and treatment cost, and therefore should be tightly controlled. No conflict of interest.