Background Changing demographics across the UK has led to general practitioners (GPs) managing increasing numbers of older patients with multi-morbidity and resultant polypharmacy. Through government led initiatives within the National Health Service, an increasing number of GP practices employ pharmacist support. The purpose of this study is to evaluate the impact of a medicines optimisation intervention, delivered by GP practice-based pharmacists, to patients at risk of medication-related problems (MRPs), on patient outcomes and healthcare costs. Methods A multi-centre, randomised (normal care or pharmacist supplemented care) study in four regions of the UK, involving patients (n = 356) from eight GP practices, with a 6-month follow-up period. Participants were adult patients who were at risk of MRPs. Results Median number of MRPs per intervention patient were reduced at the third assessment, i.e. 3 to 0.5 (p < 0.001) in patients who received the full intervention schedule. Medication Appropriateness Index (MAI) scores were reduced (medications more appropriate) for the intervention group, but not for control group patients (8 [4–13] to 5 [0–11] vs 8 [3–13] to 7 [3–12], respectively; p = 0.001). Using the intention-to-treat (ITT) approach, the number of telephone consultations in intervention group patients was reduced and different from the control group (1 [0–3] to 1 [0–2] vs 1 [0–2] to 1 [0–3], p = 0.020). No significant differences between groups were, however, found in unplanned hospital admissions, length of hospital stay, number of A&E attendances or outpatient visits. The mean overall healthcare cost per intervention patient fell from £1041.7 ± 1446.7 to £859.1 ± 1235.2 (p = 0.032). Cost utility analysis showed an incremental cost per patient of − £229.0 (95% CI − 594.6, 128.2) and a mean QALY gained of 0.024 (95% CI − 0.021 to 0.065), i.e. indicative of a health status gain at a reduced cost (2016/2017). Conclusion The pharmacist service was effective in reducing MRPs, inappropriateness of medications and telephone consultations in general practice in a cost-effective manner. Trial registration: ClinicalTrials.Gov, NCT03241498. Registered 7 August 2017—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03241498

Objective: This study aimed at analyzing drug-related problems (DRPs) in hospitalized geriatric patients with diabetes mellitus. Methods:We prospectively collected data of 26 hospitalized geriatric patients at the Gatot Soebroto Army Hospital (age, >60 year) who underwent inpatient treatment for at least 1 month between February and April 2015. Readable data were obtained from prescriptions, medical records, and index card/nurses records. We obtained data on 299 drug treatments for 26 patients and identified 166 DRPs. These were analyzed based on the Pharmaceutical Care Network Europe Version 6.2. Results:The percentage of treatment effectiveness (50.6%) and adverse drug reactions (49.4%) was predominantly due to an inappropriate drugdrug or drug-food combination, including the incidence of drug interactions (20.4%).

Objective: To quantify 4-hydroxycyclophosphamide in cancer patients' plasma for therapeutic drug monitoring of cyclophosphamide. Methods:The blood was collected at 0.5 and 1 h after administration of chemotherapy. Prior to analysis, 4-OHCP in plasma was derivatized with semicarbazide HCl, then was extracted using 4 ml ethyl acetate and finally was determined by Ultra High-Performance Liquid Chromatographytandem mass spectrometry. Chromatographic separation was conducted using waters acquity BEH C18 column (1.7 μm; 50 mm x 2.1 mm). The mobile phase consisted of formic acid 0.1% and methanol (50: 50, v/v), column temperature 30 °C and flow rate of 0.3 ml/min. Mass detection was performed on waters xevo TQD equipped with an electrospray ionization (ESI) source at positive ion mode in the multiple reaction monitoring (MRM). Cyclophosphamide was detected at m/z 260.968>139.978, 4-hydroxycyclophosphamide-semicarbazide at m/z 338.011>224.97, and hexamethylphosphoramide as internal standard at m/z 180.17>92.08. Results:The method was linear in the range of 5-1000 ng/ml for cyclophosphamide and also for 4-hydroxycyclophosphamide. The results showed that the level of 4-OHCP in 39 cancer patients was in the range of 5.02 ng/ml to 832.44 ng/ml.Conclusion: 4-hydroxycyclophosphamide was detected on 39 patient samples with the lowest level of 5.40ng/ml and the highest level was 832.44 ng/ml. This can be a parameter that the regiment of cyclophosphamide was effective.

Objective: This study aimed to evaluate the use and potential drug interactions of proton-pump inhibitor (PPI) in outpatients.Methods: This study is a retrospective descriptive analysis of prescriptions and medical records from outpatients in Gatot Soebroto Army Hospitalselected by purposive sampling who received PPI with one or more other drugs from July to December 2015. The analysis was conducted on 400prescriptions from 192 patients.Results: Data showed that 100% of the PPI therapy utilized was appropriate for the patients’ condition, 79.00% was appropriate for the indication,79.00% was appropriate for the dosage, 79.00% had an appropriate administration duration, and 83.75% was given the appropriate drug. Thepotential of PPI interactions with other drugs was found in 324 prescriptions (81.00%) from 475 cases. Of all the cases, 42 were considered majorinteractions, 138 were moderate interactions, and 295 cases had minor interactions. There were 14 drugs that could potentially interact with PPI, suchas mycophenolate mofetil, clopidogrel, cilostazol, warfarin, iron, levothyroxine, propranolol, cyclosporine, simvastatin, atorvastatin, cyanocobalamin,sucralfate, theophylline, and antacids.Conclusion: PPI use in outpatients at the Gatot Soebroto Army Hospital was not entirely appropriate and had a large number of potential druginteractions with concurrent drugs.