Pulmonary arterial hypertension is an infrequent but nevertheless serious life-threatening severe complication of HIV infection. It can be treated with bosentan and oral anticoagulants. Bosentan could induce the acenocoumarol metabolism and it increases the INR values. Until now, no study of interaction between bosentan and oral anticoagulants in HIV patients has reported. So we present a case of this interaction between these drugs and we reviewed MEDLINE to identify all the papers published so far. In our case, several weeks after increasing dose of bosentan acenocoumarol dose had to be progressively increased to 70 mg/week (+33%) without obtaining an adequate INR level (2.0–3.0). Forty-nine days later, we achieved a therapeutic INR with 90 mg/week of warfarin. The use of bosentan and oral anticoagulants together in these patients require a closer monitoring during first weeks of treatment, after increasing the bosentan dose and even during longer periods of time.

No abstract

Background Enoxaparin is a low molecular weight heparin used in the treatment and prophylaxis of thromboembolic disease. It is metabolised in the liver and its elimination is mainly renal. Renal impairment results in a decrease in its elimination and then in a higher anticoagulant response. In patients with severe renal impairment dosage adjustment is recommended. Purpose To analyse enoxaparin dose adjustment in patients with severe renal impairment based on clinical practice guideline recommendations. Materials and methods We carried out a three-month prospective study in a 250-bed hospital. Patients treated with less than 40 mg enoxaparin were reviewed. Creatinine clearance (CrCl) <30 ml/min triggered a pharmaceutical intervention (PI), recommending 30 mg of enoxaparin for prophylaxis and 1 mg/kg/day for treatment of venous thromboembolism, unstable angina and acute non-Q wave myocardial infarction. All interventions were reported to the relevant physician through the electronic prescribing program. PIs were not performed when anticoagulation was being monitored by the haematology department. Data were obtained from the electronic prescribing (Unidosis Farmatools software application Dominion), laboratory software (GIPI) and electronic medical records (Ariadna). Results During the study, enoxaparin was prescribed to 192 patients at doses higher than 40 mg/day. 12 (6.25%) had a CrCl < 30 ml/min. PIs were performed in 83.3% (10) of these renal cases, being accepted in 80% (8). No thromboembolic events were detected during the study. PIs not accepted were due to patient discharge or recovery of renal function. Conclusions PIs improved prescribing, promoting the safe and proper use of enoxaparin, improving patient safety and reducing the risk of complications associated with overdose, with the consequent impact on the efficiency and quality of care in hospitalised patients. No conflict of interest.

Background Currently, drugs for HIV treatment have an important financial impact in our hospital Pharmacy Department. Protease Inhibitor (PI) monotherapy is a useful tool that can be used for selected patients Purpose To determine the proportion of patients on antiretroviral therapy (ART) who could benefit from simplification to Darunavir/Ritonavir (DRV/r) and evaluate its financial impact Materials and Methods Retrospective study conducted in a primary hospital between September 2011 and September 2012. Patients included were those being treated for HIV infection. Simplification criteria [1] (CS) for DRV/r were the following: patients without a history of failure of Protease Inhibitors (PIs), undetectable viral load (VL < 50 c/mL) over the last 6 months, adherence to treatment >95% and/or intolerance to Nucleoside Reverse Transcriptase Inhibitors (NRTIs). We excluded HIV-2 patients, those co-infected with chronic hepatitis B virus or already treated with PI monotherapy (DRV/r). Clinical data were collected from medical and dispensing records from outpatients. Results Patients on ART: 346. Of those, 34 patients met the CS. Their previous ARTs were: 18 with 2 NRTI+ 1 PI, 7 with 2 NRTI + 1 Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) and 9 with other ART. The most prevalent NRTIs, PIs and NNRTIs were tenofovir (76%), lopinavir (38%) and efavirenz (14%). There were 14 patients with no response to PIs, 68 with detectable VL, 89 with adherence <95% and 69 with intolerance to NRTIs. Average savings per patient/year: €3,246. Total savings: €110,378 per year (4.7% of the total HIV cost) Conclusions Almost 10% of patients treated with HIV drugs could be on simplified treatment. 73% of previous ARTs were 2 NRTI plus 1 PI or NNRTI, which is consistent with reference clinical studies. Simplifying the treatment could improve adherence and tolerance in patients as well as cost effectiveness in the ambulatory management of these drugs. Reference  EACS Clinical Guidelines, October 2011 (v.6). No conflict of interest.

Background Amiodarone and dronedarone decrease the risk of recurrences in patients with paroxysmal or persistent atrial fibrillation or atrial flutter. Both drugs are P-glycoprotein inhibitors and they are substrate/inhibitor of CYP3A4. Purpose To assess the safety profile of amiodarone and dronedarone in patients treated with oral vitamin K antagonists. Materials and methods Prospective study in a hospital for 12 months. Data collected: demographics and INR levels. Patients included: age >18 treated with acenocoumarol who were started on dronedarone or amiodarone. In patients with AF an INR of 2.0–3.0 was considered as therapeutic. We included patients who had an INR stable for at least 3 months prior to starting treatment with either drug. We monitored the INR for a month after initiation of antiarrhythmic treatment. We considered the effect of other factors in altering the INR. Safety profile of the drugs: class A-mild (INR: 3–4), class B-moderate (INR: 4–5), class C-severe (INR: >5). We considered an INR <3 a lack of interaction. Results Patients included: 30. Patients treated with amiodarone: 18, 61.1% (11/18) females, mean age (years): 72 (range: 59–89). Patients treated with dronedarone: 12, 33.3% (4/12) females, mean age (years): 69 (range: 37–80). Patients treated with amiodarone, class A: 5 (27.8%), class B: 6 (33.3%), class C: 7 (38.9%). Patients treated with dronedarone, class A: 8 (66.7%), class B: 3 (25%), class C: 0, absence of interaction: 1 (8.3%). INR remained stable for at least 3 months in all cases after an alteration of INR had been detected and the pattern of acenocoumarol had been changed. No effects were observed due to other drugs, food or lifestyle changes in these patients. INR was altered only with the use of dronedarone or amiodarone. Conclusions Dronedarone had a better safety profile than amiodarone in elderly patients treated with acenocoumarol. However, further studies should provide a greater degree of evidence in this regard and clarify the mechanisms of action involved in this interaction. No conflict of interest.