BACKGROUND: The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. OBJECTIVES: The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register in July 2002. SELECTION CRITERIA: Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto). MAIN RESULTS: We identified 110 trials; 96 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.74 (95% confidence interval 1.64 - 1.86), The odds ratios for the different forms of NRT were 1.66 for gum, 1.74 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 2.08 for nicotine sublingual tablet/lozenge. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 - 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo. REVIEWER'S CONCLUSIONS: All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.

Nicotine replacement therapy for smoking cessation.

Multimorbidity and the associated use of multiple medicines (polypharmacy), is common in the older population. Despite this, there is no consensus definition for polypharmacy. A systematic review was conducted to identify and summarise polypharmacy definitions in existing literature. The reporting of this systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. MEDLINE (Ovid), EMBASE and Cochrane were systematically searched, as well as grey literature, to identify articles which defined the term polypharmacy (without any limits on the types of definitions) and were in English, published between 1st January 2000 and 30th May 2016. Definitions were categorised as i. numerical only (using the number of medications to define polypharmacy), ii. numerical with an associated duration of therapy or healthcare setting (such as during hospital stay) or iii. Descriptive (using a brief description to define polypharmacy). A total of 1156 articles were identified and 110 articles met the inclusion criteria. Articles not only defined polypharmacy but associated terms such as minor and major polypharmacy. As a result, a total of 138 definitions of polypharmacy and associated terms were obtained. There were 111 numerical only definitions (80.4% of all definitions), 15 numerical definitions which incorporated a duration of therapy or healthcare setting (10.9%) and 12 descriptive definitions (8.7%). The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy, using descriptive definitions to make this distinction. Polypharmacy definitions were variable. Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting.

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What is polypharmacy? A systematic review of definitions

http://repositorio.inger.gob.mx/jspui/bitstream/20.500.12100/17171/1/PIIS0140673614613477.pdf

The burden of disease in older people and implications for health policy and practice

This month, the Clinical Practice Guideline (CPG) column reviews the recently published guideline, Treating Tobacco Use and Dependence. This set of recommendations is available in a quick reference format and a more comprehensive clinician's guide that includes detailed information on the methodology and references used to develop the guidelines. Both are available in electronic and hard copy versions through a variety of sources, including the National Guidelines Clearinghouse, the Centers for Disease Control and Prevention, and the National Cancer Institute.

Treating tobacco use and dependence.

Description: A multidisciplinary group of 34 experts from 15 countries developed this update and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding (UGIB) from 2003. Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews; randomized, controlled trials; and abstracts up to October 2008. Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Recommendations: Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermocoagulation, alone or with epinephrine injection, are effective methods; epinephrine injection alone is not recommended. Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. Preendoscopy proton-pump inhibitor (PPI) therapy may downstage the lesion; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding.

International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding

The prevalence of comorbidity is high, with 80% of the elderly population having three or more chronic conditions. Comorbidity is associated with a decline in many health outcomes and increases in mortality and use of health care resources. The aim of this study was to identify, review and summarise studies reporting the prevalence of comorbidity of chronic diseases in Australia. A systematic review of Australian studies (1996 – May 2007) was conducted. The review focused specifically on the chronic diseases included as national health priorities; arthritis, asthma, cancer, cardiovascular disease (CVD), diabetes mellitus and mental health problems. A total of twenty five studies met our inclusion criteria. Over half of the elderly patients with arthritis also had hypertension, 20% had CVD, 14% diabetes and 12% mental health problem. Over 60% of patients with asthma reported arthritis as a comorbidity, 20% also had CVD and 16% diabetes. Of those with CVD, 60% also had arthritis, 20% diabetes and 10% had asthma or mental health problems. There are comparatively few Australian studies that focused on comorbidity associated with chronic disease. However, they do show high prevalence of comorbidity across national health priority areas. This suggests integration and co-ordination of the national health priority areas is critical. A greater awareness of the importance of managing a patients' overall health status within the context of comorbidity is needed together with, increased research on comorbidity to provide an appropriate scientific basis on which to build evidence based care guidelines for these multimorbid patients.

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Prevalence of comorbidity of chronic diseases in Australia

OBJECTIVE: To examine the extent of drug-related hospital admissions in Australia by reviewing Australian studies published between 1988 and 1996. DATA SOURCES AND STUDY SELECTION: The terms "drug-related", "admissions", "readmissions", "hospitalisation", "hospitalization" and "iatrogenic" were used to search MEDLINE and Australian Public Affairs Information Service databases. The Australian Journal of Hospital Pharmacy and conference proceedings of the Society of Hospital Pharmacists and the Australasian Pharmaceutical Science Association were searched manually. Studies were included if they were Australian, had the primary aim of identifying drug-related admissions, and had at least one clinical pharmacist or medical practitioner review the admissions. DATA EXTRACTION: Total number of admissions assessed; proportion considered drug-related; drug groups implicated; and proportion considered avoidable. DATA SYNTHESIS: 14 studies were identified; 2.4%-3.6% of all hospital admissions were reported to be drug-related. 6%-7% of emergency admissions, 12% of all admissions to medical wards and 15%-22% of all emergency admissions among the elderly were drug related. Between 32% and 69% of drug-related admissions were reported as definitely or possibly preventable. Drug groups most commonly implicated were cytotoxics, cardiovascular agents, antihypertensives, anticoagulants and non-steroidal anti-inflammatory drugs. CONCLUSION: Drug-related hospital admissions are a significant and expensive public health problem in Australia, and approximately half were considered possibly or probably preventable.

Drug‐related hospital admissions: a review of Australian studies published 1988‐1996

Comorbidity in the elderly with diabetes: Identification of areas of potential treatment conflicts

Objective: To implement and evaluate a collaborative medication management service model. Design: Participatory action research. Setting and participants: The study was conducted from March 1999 to March 2000; 1000 patients, 63 pharmacists and 129 general practitioners from six Divisions of General Practice in South Australia participated. Interventions: A collaborative service delivery model, involving a preliminary case conference, a home visit and a second case conference, was agreed through discussions with medical and pharmacy organisations and then implemented. Outcome measures: Medication-related problems; actions recommended; actions implemented; and outcomes after actions taken. Results: Overall, 2764 problems were identified. The most common medicationrelated problem (17.5% of all problems) was the need for additional tests. Thirtyseven per cent of problems related to medicine selection, 20% to patient knowledge, and 17% to the medication regimen. Of 2764 actions recommended to resolve medication-related problems, 42% were implemented. Of the 978 problems for which action was taken and follow-up data were available, 81% were reported to be “resolved”, “well managed” or “improving”. Conclusion: This implementation model was successful in engaging GPs and

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Collaborative medication management services: improving patient care

Background— Randomized controlled trials have demonstrated that collaborative medication reviews can improve outcomes for patients with heart failure. We aimed to determine whether these results translated into Australian practice, where collaborative reviews are nationally funded. Methods and Results— This retrospective cohort study using administrative claims data included veterans 65 years and older receiving bisoprolol, carvedilol, or metoprolol succinate for which prescribing physicians indicated treatment was for heart failure. We compared those exposed to a general practitioner–pharmacist collaborative home medication review with those who did not receive the service. The service includes physician referral, a home visit by an accredited pharmacist to identify medication-related problems, and a pharmacist report with follow-up undertaken by the physician. Kaplan-Meier analyses and Cox proportional hazards models were used to compare time until next hospitalization for heart failure between the expo...

The Effectiveness of Collaborative Medicine Reviews in Delaying Time to Next Hospitalization for Patients With Heart Failure in the Practice Setting Results of a Cohort Study

Andrew L. Gilbert

Papers

Prevalence of comorbidity of chronic diseases in Australia

Drug‐related hospital admissions: a review of Australian studies published 1988‐1996

Comorbidity in the elderly with diabetes: Identification of areas of potential treatment conflicts

Collaborative medication management services: improving patient care

The Effectiveness of Collaborative Medicine Reviews in Delaying Time to Next Hospitalization for Patients With Heart Failure in the Practice Setting Results of a Cohort Study