More than 2,600 delegates from 51 countries attended the 14th congress of the EAHP in Barcelona in March 2009. Genomics, infectious disease, IT and automation were key topics.
Clinical trial data rarely provide answers to questions such as “Will this drug work for me?” or “Will this drug harm me” But genomics might provide real opportunities to improve effective use of medicines, Lawrence Lesko (director, Office of Clinical Pharmacology, Food and Drug administration, USA) told the audience. Genomics offers the opportunity to improve dosing by personalising pharmacokinetic and pharmacodynamic information, to improve safety by using risk markers and to improve efficacy by restricting eligibility to those patients who are likely to benefit from a specific treatment, he argued.
Warfarin is a good example of a drug for which genomic information would be helpful. It is the most widely used oral anticoagulant, with 30 million new prescriptions each year. It is the second-leading drug causing serious adverse events – accounting for 4% of all serious adverse drug events worldwide. A recent study in a long-term care facility showed that patients receiving warfarin spent 54% of their time in the therapeutic range, 35% below it and 11% above it. The pharmacogenetics of warfarin are well understood – specific polymorphisms of CYP2C9 and VKORC1 (vitamin K epoxide reductase complex 1) both reduce warfarin requirements. Studies have shown that the average stable dose of warfarin is inversely proportional to the number of variant CYP2C9 and VKORC1 alleles, explained Professor Lesko.
Algorithms have been devised to help to translate genetic information into initial doses of warfarin. The benefits of this approach include a shorter time to a stable international normalised ratio (INR), fewer episodes of overanticoagulation and less frequent dose adjustments.
Genetic testing can help to identify “the outliers”, – those who need lower or higher doses than the average. Testing is not complex to carry out or to interpret, and hospital pharmacists are ideally placed to demonstrate its value, said Professor Lesko.
Combinations of drugs and specific genetic tests may help to develop “precision medicines” in future. For example, a trial of bucindolol postmyocardial infarction showed no difference in 24-month survival compared with placebo. Later work showed that there are two genetic variants of beta-1-adrenergic receptors – ARG389 and GLY389; patients with the ARG389 variant had a 38% lower death rate. A diagnostic test to identify ARG389 patients in advance could ensure that only the appropriate patients receive the drug. Other drug test combinations include both new drugs such as maraviroc and dasatinib and older drugs such as codeine and panitumumab.
Professor Lesko said that pharmacists are the ideal healthcare professionals to identify gaps in good pharmacotherapy, He recommended that they should learn to interpret genetic tests, become “genetic trend watchers” and provide advice to patients and other healthcare professionals.
Global warming and infectious disease
The world is now committed to a 2 degrees temperature increase limit on global warming, but as the average temperature increases there will be more episodes of extremes of weather – unusually hot or cold – said Rainer Sauerborn (Heidelberg University, Germany), describing the impact of this on new infectious diseases.
By 2050 annual average river runoff and water availability are projected to increase by 10-40% at high latitudes and decrease by 10-30% over some dry regions at mid-latitudes and in the dry tropics, he continued. Developed countries produce highest emissions of greenhouse gases, but health impacts of climate change are likely to be felt most strongly in developing countries.
Two concepts important in the discussion of climate change are mitigation and adaptation, explained Professor Sauerborn. Mitigation is concerned with efforts to reverse or reduce factors that could make the situation worse, and could involve, for example, reducing carbon dioxide emissions. Adaptation is concerned with adapting to the new climate and the changes that it will bring.
Turning to the impact of climate change on health, he said that a number of factors could lead to temperature-related illness and deaths. Microbial changes are likely to lead to water- and food-borne disease along with diseases carried by rodent and insect vectors. Changes in agro-systems could lead to food shortages and malnutrition – “malnutrition and infectious disease are like bother and sister”, he emphasised. Socioeconomic and demographic disruption could lead to mental health problems, he warned.
A ranking order of infectious (viral) diseases has been constructed by WHO according to global death rates. HIV is ranked highest, followed by hepatitis B (HBV) and C (HCV). Measles, flu and dengue fever are in the next group, and the lowest group comprises SARS, ebola, polio and hantavirus. Other, nonviral leading causes of death are tobacco, malaria and road traffic accidents.
Some diseases are likely to re-emerge as the climate becomes warmer. In high-income countries these are likely to include tick-borne encephalitis, borreliosis, dengue fever and hantavirus infections. Lowand middle-income countries are likely to be affected by a longer list of infectious diseases, including parasitic diseases such as malaria, schistosomiasis, leishmaniasis and trypanosomiasis. Dengue fever is likely to affect a wide area that now includes Spain.
“It will come to Europe – it is just a question of when,” said Professor Sauerborn.
Studies are already beginning to show some shifting patterns of disease. For example, tick-borne encephalitis has become more common in Sweden over the past 30 years, and Lyme borreliosis has increased in Belgium over the past decade. Schistosomiasis has spread northwards in China as the winter freezing zone has moved northward: the intermediate hosts for the parasite (a variety of water snail) now survive the winter, allowing the parasite to complete its lifecycle.
The world needs research in this area, and Professor Sauerborn urged the healthcare community not to lag behind here but to get involved.
Preparation of chemotherapy agents
The introduction of the CytoCare robot into chemotherapy preparation has increased safety for staff by reducing the risks of repetitive strain injury, exposure to cytostatic agents and needlestick injury, according to Ann Jacklin (director of Pharmacy and Therapies, Imperial College NHS Trust, London). Excessive workloads and the resultant stress have also been reduced and staff satisfaction has increased, she continued.
A total of 29,500 doses of chemotherapy drugs are made each year in aseptic units in two of her hospitals (Charing Cross Hospital and Hammersmith Hospital).
Automated preparation of chemotherapy doses was “the next logical step” for her department, as all the other possible measures to streamline preparation had already been implemented, said Professor Jacklin. These included centralised preparation of doses in the pharmacy, dose-banding, use of standardised doses, purchase of ready-to-use products and use of oral chemotherapy when possible. Professor Jacklin concluded that the process is now more efficient and is delivered by staff who are less pressured and more flexible.
In Sweden, some 340,000 doses of chemotherapy drugs are made annually in 29 different hospitals, AnnSofie Fyhr (deputy director, University Hospital of Lund, Sweden) explained. A recent survey had found that the people involved in this type of work felt stressed by high workloads and experienced problems with finger and thumb grips. They also complained of problems with noise and felt they had poor job satisfaction.
Manual systems for preparation of chemotherapeutic doses increase the risk of occupational exposure and repetitive strain injury for the operators and the risk of medication errors to patients, she said.
Cathy Mooney (director of Governance and Corporate Affairs, Chelsea and Westminster Hospital, London) emphasised the importance of patient safety and the prevention of adverse events or errors. Medicines always appear in the top-three most commonly reported incident categories – they are recognised to be one of the highest-risk areas in healthcare. Errors are costly both financially and in terms of reputation. Technological solutions are highly effective barriers to patient harm, whereas systems that rely on revised procedures and staff training tend to be weak barriers to harm, she said.
At an ARX-sponsored satellite symposium three speakers described how robotic dispensing systems had been installed to solve problems in three very different situations, in three European countries.
The outpatient pharmacy at the Hospital Clinic in Barcelona deals with 3,000 patients and processes 9,000 prescription items each month. This workload presented a significant challenge, according to Ramon Casabona (area manager of the pharmacy, Hospital Clinic, Barcelona). In 2005, a decision was made to automate the outpatient pharmacy. Key considerations were to:
- Make optimum use of the stock management
- Increase space efficiency in the department.
- Provide additional time for patient counselling.
- Find a system that had a large capacity for refrigerated storage.
Rowa dispensing robots were purchased; one was located in the outpatient dispensary, and the other was located in a cold store as almost half of the items dispensed required refrigerated storage. In addition, anexpress unit was added to allow multiple packs of a single line to be delivered to a dispensing station. An automatic loading system was also purchased. The entire system serviced four dispensing stations in the outpatient pharmacy. Mr Casabona concluded that he was able to achieve a significant reduction in stockholding and at the same time improve stock control and security. A major benefit is improved space efficiency, resulting in the release of additional space for patient counselling. Other benefits are faster dispensing and shorter patient waiting times.
The pharmacy at Ealing Hospital in the UK issues a total of 37,000 items per month. Jatinder Harchowal (chief pharmacist and assistant director of operations, Ealing Hospital NHS Trust, London) explained that key elements of the case for automation in his pharmacy were to:
- Reduce dispensing error rates to below 16 per 100,000 items.
- Improve space and time utilisation.
- Release staff to support direct patient care.
- Ensure earlier finishing times for the staff.
“Automation was a large investment for a small trust, and so we had to maximise the benefits,” said Mr Harchowal.
A Rowa dispensing robot with three picking heads was purchased. An automatic loading system and refrigerated unit were included. The robot is located on the floor below the dispensary. Picked items are taken up on a lift and delivered via a conveyor to six dispensing stations and the out-of-hours drop off point.
“We are now able to meet our targets on waiting times, and dispensing errors have been reduced by 50%,” said Mr Harchowal. Finishing times are now earlier for staff, but the robot continues to work overnight putting away new stock and picking orders for the next morning. The financial benefits have been considerable, with a £150,000 reduction in stockholding and reductions in the amount of expired stock. In addition, staff are used more efficiently and overtime costs have been reduced.
The outpatient pharmacy at the Hotel Dieu hospital in Paris processes prescriptions for 160 patients per day. The medicines issued include treatments for HIV and cancer, antihaemophilic drugs and clinical trial products. A robot designed to issue original packs appeared to be the ideal tool for the outpatient service, explained François Chast (head of pharmacy, pharmacology and toxicology services, Hotel Dieu, Paris). It was important that it would interface with both the financial management system and the clinical management system. As the outpatient pharmacy consultation rooms are 30 metres away from the central pharmacy, speed was also a critical consideration. It takes 12-19 seconds to deliver medicines from the robot to the consultation rooms.
The major benefit conferred by the robot is that now the whole of the consultation time is devoted to direct contact with the patient, whereas previously the pharmacist would have to leave the patient to retrieve the medicines. This provides the opportunity for full discussion on all aspects of the treatment. Other outcomes included a 50% reduction in dispensing errors and the loss of five posts.