No abstract

Proton pump inhibitors (PPIs) are widely used in the elderly. Recent studies have suggested that long-term PPI therapy is associated with fractures in the elderly, however the mechanism remains unknown. We investigated the association between long-term PPI therapy !1 year and fracture risk factors including bone structure, falls, and balance-related function in a post hoc analysis of a longitudinal population-based prospective cohort of elderly postmenopausal women and replicated the findings in a second prospective study of falling in elderly postmenopausal women. Long-term PPI therapy was associated with increased risk of falls and fracture-related hospitalizations; adjusted odds ratio (AOR) 2.17; 95% CI, 1.25-3.77; p ¼ 0.006 and 1.95; 95% CI, 1.20-3.16; p ¼ 0.007, respectively. In the replication study, long-term PPI use was associated with an increased risk of self-reported falling; AOR, 1.51; 95% CI, 1.00-2.27; p ¼ 0.049. No association of long-term PPI therapy with bone structure was observed; however, questionnaire-assessed falls-associated metrics such as limiting outdoor activity (p ¼ 0.002) and indoor activity (p ¼ 0.001) due to fear of falling, dizziness (p < 0.001) and numbness of feet (p ¼ 0.017) and objective clinical measurement such as Timed Up and Go (p ¼ 0.002) and Romberg eyes closed (p ¼ 0.025) tests were all significantly impaired in long-term PPI users. Long-term PPI users were also more likely to have low vitamin B12 levels than non-users (50% versus 21%, p ¼ 0.003). In conclusion, similar to previous studies, we identified an increased fracture risk in subjects on long-term PPI therapy. This increase in fracture risk in elderly women, already at high risk of fracture, appears to be mediated via increased falls risk and falling rather than impaired bone structure and should be carefully considered when prescribing long-term PPI therapy.

Accessibility, availability and frequent public contact place community pharmacists in an ideal position to provide medically necessary, intensive health education and preventive health services to diabetes patients, thus reducing physician burden. We assessed the cost-effectiveness of reducing glycaemic episodes in patients with type 2 diabetes mellitus through a pharmacist-led Diabetes Management Education Program (DMEP) compared to standard care. We recruited eight metropolitan community pharmacies in Perth, Western Australia for the study. We paired them based on geographical location and the socioeconomic status of the population served, and then randomly selected one pharmacy in each pair to be in the intervention group, with the other assigned to the control group. We conducted an incremental cost-effectiveness analysis to compare the costs and effectiveness of DMEP with standard pharmacy care. Cost per patient of implementing DMEP was AU$394 (US$356) for the 6-month intervention period. Significantly greater reductions in number of hyperglycaemic and hypoglycaemic episodes occurred in the intervention relative to the control group [OR 0.34 (95 % CI 0.22, 0.52), p = 0.001; OR 0.54 (95 % CI 0.34, 0.86), p = 0.009], respectively, with a net reduction of 1.86 days with glycaemic episodes per patient per month. The cost-effectiveness of DMEP relative to standard pharmacy care was AU$43 (US$39) per day of glycaemic symptoms avoided. Patients with type 2 diabetes in three surveys were willing to pay an average of 1.9 times that amount to avoid a hypoglycaemic day. We conclude that DMEP decreased days with glycaemic symptoms at a reasonable cost. If a larger-scale replication study confirms these findings, widespread adoption of this approach would improve diabetes health without burdening general practitioners.

The documentation system allowed for the determination of the frequency and types of DRPs, as well as the recommendations made to resolve them in community pharmacy practice. Use of the software, including its electronic prompts, significantly increased the documentation of interventions by pharmacists.