Showing papers by "Thierry Christiaens published in 2018"
TL;DR: There is low-quality evidence that antipsychotics may be successfully discontinued in older people with dementia and NPS who have been taking antipsychotic drugs for at least three months, and that discontinuation may have little or no important effect on behavioural and psychological symptoms.
Abstract: Background: Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in people with dementia although there is uncertainty about the effectiveness of their long-term use for this indication and concern that they may cause harm, including higher mortality. When behavioural strategies have failed and treatment with antipsychotic drugs is instituted, regular attempts to withdraw them have been recommended in guidelines. Physicians, nurses and families of older people with dementia may be reluctant to stop antipsychotics, fearing deterioration of NPS. This is an update of a Cochrane Review published in 2013. Objectives: To evaluate whether withdrawal of antipsychotic agents is successful in older people with dementia and NPS in primary care or nursing home settings, to list the different strategies for withdrawal of antipsychotic agents in older participants with dementia and NPS, and to measure the effects of withdrawal of antipsychotic agents on participants' behaviour and assess safety. Search methods: We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), theCochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources up to 11 January 2018. Selection criteria: We included all randomised, controlled trials comparing an antipsychotic withdrawal strategy to continuation of antipsychotics in people with dementia who had been treated with an antipsychotic drug for at least three months. Data collection and analysis: We used standard methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions. We rated the quality of evidence for each outcome using the GRADE approach. Main results: We included 10 studies involving 632 participants. One new trial (19 participants) was added for this update. One trial was conducted in a community setting, eight in nursing homes and one in both settings. Different types of antipsychotics at varying doses were discontinued in the studies. Both abrupt and gradual withdrawal schedules were used. Reported data were predominantly from studies at low or unclear risk of bias. We included nine trials with 575 randomised participants that used a proxy outcome for overall success of antipsychotic withdrawal. Pooling data was not possible due to heterogeneity of outcome measures used. Based on assessment of seven studies, discontinuation may make little or no difference to whether or not participants complete the study (low-quality evidence). Two trials included only participants with psychosis, agitation or aggression who had responded to antipsychotic treatment. In these two trials, stopping antipsychotics was associated with a higher risk of leaving the study early due to symptomatic relapse or a shorter time to symptomatic relapse. We found low-quality evidence that discontinuation may make little or no difference to overall NPS, measured using various scales (7 trials, 519 participants). There was some evidence from subgroup analyses in two trials that discontinuation may reduce agitation for participants with less severe NPS at baseline, but may be associated with a worsening of NPS in participants with more severe NPS at baseline. None of the studies assessed withdrawal symptoms. Adverse effects of antipsychotics (such as falls) were not systematically assessed. Low-quality evidence showed that discontinuation may have little or no effect on adverse events (5 trials, 381 participants), quality of life (2 trials, 119 participants), or cognitive function (5 trials, 365 participants). There were insufficient data to determine whether discontinuation of antipsychotics has any effect on mortality (very low-quality evidence). Authors' conclusions: There is low-quality evidence that antipsychotics may be successfully discontinued in older people with dementia and NPS who have been taking antipsychotics for at least three months, and that discontinuation may have little or no important effect on behavioural and psychological symptoms. This is consistent with the observation that most behavioural complications of dementia are intermittent and often do not persist for longer than three months. Discontinuation may have little or no effect on overall cognitive function. Discontinuation may make no difference to adverse events and quality of life. Based on the trials in this review, we are uncertain whether discontinuation of antipsychotics leads to a decrease in mortality. People with psychosis, aggression or agitation who responded well to long-term antipsychotic drug use, or those with more severe NPS at baseline, may benefit behaviourally from continuation of antipsychotics. Discontinuation may reduce agitation for people with mild NPS at baseline. However, these conclusions are based on few studies or small subgroups and further evidence of benefits and harms associated with withdrawal of antipsychotic is required in people with dementia and mild and severe NPS. The overall conclusions of the review have not changed since 2013 and the number of available trials remains low.
80 citations
TL;DR: A blueprint of a European core curriculum describing when and how the learning outcomes might be acquired is provided and 252 learning outcomes should be included in undergraduate CPT curricula to ensure that European graduates are able to prescribe safely and effectively.
Abstract: Harmonizing clinical pharmacology and therapeutics (CPT) education in Europe is necessary to ensure that the prescribing competency of future doctors is of a uniform high standard. As there are currently no uniform requirements, our aim was to achieve consensus on key learning outcomes for undergraduate CPT education in Europe. We used a modified Delphi method consisting of three questionnaire rounds and a panel meeting. A total of 129 experts from 27 European countries were asked to rate 307 learning outcomes. In all, 92 experts (71%) completed all three questionnaire rounds, and 33 experts (26%) attended the meeting. 232 learning outcomes from the original list, 15 newly suggested and 5 rephrased outcomes were included. These 252 learning outcomes should be included in undergraduate CPT curricula to ensure that European graduates are able to prescribe safely and effectively. We provide a blueprint of a European core curriculum describing when and how the learning outcomes might be acquired.
38 citations
TL;DR: Although medication use was high, signs of deprescribing were noted when the physical and mental health of the residents declined, especially in pain and sleeping medications, while antipsychotics use increased.
18 citations
TL;DR: Medications for symptom relief increased in almost all medication groups and deprescribing was found in heart medication/anti-hypertensives and cancer therapy, although use of the latter remained relatively high.
Abstract: Background:Information on medication use in the last months of life is limited.Aim:To describe which medications are prescribed and deprescribed in advanced cancer patients receiving palliative care in relation to time before death and to explore associations with demographic variables.Design:Prospective study, using case report forms for monthly data collection. Medication included cancer treatment and 19 therapeutic groups, grouped into four categories for: (1) cancer therapy, (2) specific cancer-related symptom relief, (3) other symptom relief and (4) long-term prevention. Data were analysed retrospectively using death as the index date. We compared medication use at 5, 4, 3, 2 and 1 month(s) before death by constructing five cross-sectional subsamples with medication use during that month. Paired analyses were done on a subsample of patients with at least two assessments before death.Setting/participants:We studied the medication use of 720 patients (mean age 67, 56% male) in 30 cancer centres represe...
17 citations
TL;DR: To explore if the patients’ ideas, concerns and expectations (ICE) behind the reason for encounter (RFE) can be coded with the International Classification of Primary Care, version 2 (ICPC-2) and what kinds of codes are missing to be able to do so.
Abstract: BACKGROUND Family practice aims to recognize the health problems and needs expressed by the person rather than only focusing on the disease. Documenting person-related information will facilitate both the understanding and delivery of person-focused care. Aim To explore if the patients' ideas, concerns and expectations (ICE) behind the reason for encounter (RFE) can be coded with the International Classification of Primary Care, version 2 (ICPC-2) and what kinds of codes are missing to be able to do so. METHODS In total, 613 consultations were observed, and patients' expressions of ICE were narratively recorded. These descriptions were consequently translated to ICPC codes by two researchers. Descriptions that could not be translated were qualitatively analysed in order to identify gaps in ICPC-2. RESULTS In all, 613 consultations yielded 672 ICE expressions. Within the 123 that could not be coded with ICPC-2, eight categories could be defined: concern about the duration/time frame; concern about the evolution/severity; concern of being contagious or a danger to others; patient has no concern, but others do; expects a confirmation of something; expects a solution for the symptoms without specification of what it should be; expects a specific procedure; and expects that something is not done. Discussion Although many ICE can be registered with ICPC-2, adding eight new categories would capture almost all ICE.
15 citations
TL;DR: A Cochrane systematic review and meta-analysis revealed that there is low-quality evidence that long-term antipsychotic drugs for BPSD may be successfully discontinued in most adults aged 65 and older.
13 citations
TL;DR: In this paper, a European repository of explicit criteria on PIM lists, suitable for electronic assessment, was constructed, including medication description, medication information, clinical information and level of evidence.
Abstract: AIM Lack of electronic assessment of medication lists in electronic health records is a barrier for more generalized use of potentially inappropriate medications (PIM) lists, designed for older adults. The aim was to construct a European repository of explicit criteria on PIM, suitable for electronic assessment. METHODS PIM description, medication information, clinical information and level of evidence was entered. Criteria with unclear medication specifications were excluded. Too complex criteria were divided for more operable use. RESULTS We selected three lists: the European Union (7)-PIM (2015), STOPP/START (2014) and Beers criteria (2015). After exclusion and division, from 641 original criteria of the three PIM-lists, a total of 650 criteria were entered (n = 282 from European Union (7)-PIM, n = 201 from Beers and n = 167 from the STOPP/START list). Identification of the medication was possible with the Anatomical Therapeutic Chemical Classification System for practically all criteria, except for 23 (3.5%). From all criteria, 63.9% required only medication-related information. In 55.7% of the criteria, identification of the active substance(s) was the only medication data requirement and 8.2% required additional information (dose, duration, route of administration). From all criteria, 36.1% required clinical information, from which 17.8% requested disease information only, and 18.3% required additional information (indication, history of diseases, laboratory results or severity of diseases). CONCLUSIONS It was feasible to enter most of the original criteria of the three PIM lists into a repository of electronically applicable criteria. In the future, developers of new PIM lists should take into account semantic interoperability and consider the suitability of the criteria for electronic use. Geriatr Gerontol Int 2018; 18: 1293-1297.
11 citations
TL;DR: In this paper, the authors analyse the main themes that are used by the Belgian pharmaceutical industry to construct its reputational discourse, and focus on how this discourse is shaped by the Bad Pharma discourse.
Abstract: The pharmaceutical industry has been battling a negative reputation and has been confronted with accusations such as putting profits before patients and manipulating clinical trial results. In this study, we focus on how pharmaceutical companies address what we define as the Bad Pharma discourse. Drawing on interviews, press releases, corporate documentation and ethnographic fieldwork, we analyse the main themes that are used by the Belgian pharmaceutical industry to construct its reputational discourse, and we focus on how this discourse is shaped by the Bad Pharma discourse. Our results illustrate that on the one hand, the industry contests the Bad Pharma discourse by generating an alternative discourse. On the other hand, they also partly embrace and reframe this Bad Pharma discourse. This way, current societal debates are entextualised in the reputational discourses of the pharmaceutical industry.
10 citations
TL;DR: Data from the public and the private healthcare sectors were collected to examine the utilization of oncologic drugs in Ecuador over a 5‐year period (2010–2014).
Abstract: Objective: In Ecuador, a new constitutional mandate (2008) allowed the government to implement free universal access to health care, including oncologic drugs. As most Latin American countries, Ecuadorian healthcare system is fragmented between public and private providers, posing a special challenge to collect valid drug utilization data. Data from the public and the private healthcare sectors were collected to examine the utilization of oncologic drugs in Ecuador over a 5-year period (2010-2014).
Methods: Oncologic drugs were extracted from individual dispensing data collected in the six largest Ecuadorian cancer hospitals. Drug utilization indicators include the yearly proportion of patients using selected therapeutic groups (targeted drugs, chemotherapy and hormonal drugs), and the mean and total expenditures, by healthcare sector.
Key findings: Total number of patients ranged from 12 060 in 2010 to 12 769 in 2014. Median age was 56 years; 60.3% were women. Twenty-three drugs were classified as targeted (monoclonal antibodies, protein kinase inhibitor, vismodegib, vorinostat and abiraterone), 43 as chemotherapy and 11 as hormonal. Patients using chemotherapy decreased from 56% to 52%. Proportion of patients using chemotherapy drugs was 30% lower in the public than in the private sector. Total expenditures on cancer drugs showed a constant increase from USD 17 912 865 in 2010 to USD 40 514 947 in 2014. Patients using targeted drugs doubled from 8% to 14% in 5 years. Targeted drugs accounted for 76% of total expenditures in 2014.
Conclusion: Although only a small, but increasing proportion of patients used targeted drugs, it leads to a sharp rise in expenditures. In 2014, it represented three-quarters of the total oncologic drugs expenditures. Differences in chemotherapy consumption between public and private sectors could reflect difficulties in public procurement, shortages and a faster, poorly controlled adoption of new drugs. If unmanaged, this is a possible threat to the health budget in the coming years.
4 citations