Cathal A. Cadogan

Many guidelines recommend deprescribing benzodiazepines and z-drugs in most long-term users. Due to physical dependence in those using medication as prescribed (distinct from addiction), discontinuation can be difficult and is often unsuccessful, as withdrawal symptoms can be severe and long-lasting, especially after long-term use. There is a lack of clarity on how to taper patients in a tolerable manner that minimizes discomfort. Current guidelines vary with some suggesting linear reductions (e.g. 1 mg every 1–4 weeks) and some proportionate reductions (e.g. 5%–10% of the most recent dose per month, with smaller reductions as the dose decreases). The shape of the relationship between dose of benzodiazepine and activity at gamma-aminobutyric acid-A (GABA-A) receptors is hyperbolic: steeply inclining at low doses, flattening at higher doses. Consequently, linear dose reductions produce increasingly large changes in receptor occupancy, predicting escalating withdrawal effects, while hyperbolic or proportionate dose reductions produce linear reductions in pharmacological effect. Slower tapering (over months and years) may be more successful than tapering over days or weeks. In practice, rate of tapering should be adjusted according to severity of withdrawal effects. Final doses for some people will need to be very small (equivalent to as little as 0.2 mg of diazepam, or less) so that the last ‘step down’ to zero is not larger than prior tolerated reductions in terms of pharmacological effects. Liquids or compounded formulations of medication can be helpful at low doses to make small reductions. Guidelines should recommend hyperbolic tapering while awaiting randomized trials comparing linear with hyperbolic tapering.

Objective: The objective of this scoping review is to map and synthesize current literature and policy related to covert medication administration in vulnerable groups across all settings. Introduction: Covert medication administration refers to administrating medication in a disguised way without the knowledge of the person receiving it. This practice occurs among vulnerable groups, including children, people with intellectual disabilities, people experiencing mental ill-health, and older people, particularly those living with dementia. Given the sensitive nature of this practice, a scoping review can provide insight into how health professionals navigate these challenges and where support or reform is needed. Eligibility criteria: This scoping review will consider primary research studies, evidence synthesis, discussion articles, and policy documents focusing on covert medication administration relating to individuals of any age across various conditions. The context may include hospitals, long-term care settings, nursing homes, residential settings, respite settings, and family home settings. Methods: This review will follow JBI methodology for scoping reviews and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A literature search will be conducted across MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science Core Collection. A gray literature search will also be performed. Screening of titles, abstracts, and full-text articles will be conducted by 2 reviewers independently. Extracted data will be analyzed and presented in a descriptive manner, with the use of tables, accompanied by a narrative summary describing how the results relate to the review objective and questions. Review registration: OSF osf.io/y9z48

Objectives: To describe and assess the appropriateness of prescribing for older adults with atrial fibrillation (AF) presenting to a multidisciplinary outpatient clinic. Methods: Retrospective observational study of medical records of patients who attended a specialist AF outpatient clinic over a 1-year period. Prescribing was assessed using the STOPP/START Criteria (Version 2). Direct oral anticoagulant prescribing was assessed separately. Risk factors for Potentially Inappropriate Medications (PIM) and Potential Prescribing Omissions (PPO) were assessed through multivariable logistic regression. Key findings: One hundred and sixty-eight patients (median age: 74 years; range: 65–94 years; 59.4% male) were included. Patients had a median of six comorbidities (IQR 4–9) and were prescribed a median of six medications (IQR 4–9). Minor polypharmacy (5–9 medications) was found in 53.0% (n = 89), and major polypharmacy (>9 medications) was found in 21.4% (n = 36). Potentially inappropriate prescribing was present in 75.6% (n = 127). The majority (60.1%, n = 101) had at least one potentially inappropriate medication, and 46.4% (n = 78) had a potential prescribing omission. Anticoagulants were inappropriately dosed in 11.6% (n = 13) of patients. There were positive associations between number of medications prescribed and PIM (P = < .001), and number of comorbidities and PPO (P = < .001). Conclusions: Polypharmacy and potentially inappropriate prescribing were prevalent in this population of older adults with AF. Interventions are needed to optimize prescribing in this cohort.

Introduction Discontinuation of psychotropic medication is associated with considerable clinical challenges, including withdrawal symptoms and relapse. Pharmacogenomic testing is increasingly used in clinical practice to optimise pharmacotherapy by guiding drug selection and dosing, however, its role in informing medication discontinuation and tapering strategies remains underexplored. Understanding the influence of genetic variability on withdrawal symptoms could support safer, individualised discontinuation practices. Objective This scoping review aims to map the available evidence on the role of pharmacogenomics on the discontinuation of psychotropic medications. Methods The review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and reported using the PRISMA-ScR checklist. Comprehensive searches will be performed in MEDLINE, EMBASE, CINAHL, Web of Science, and PsycINFO. Studies exploring gene polymorphisms relevant to the discontinuation of psychotropic medications (antidepressants, antipsychotics, mood stabilisers, anxiolytics, hypnotics, stimulants, and opioids) will be considered. Following screening, data will be extracted, and a narrative synthesis will be undertaken to map characteristics of included studies, genes studied, medication classes involved, reported outcomes, and knowledge gaps. Conclusion This review will provide an overview of existing evidence and identify gaps regarding the role of pharmacogenomics in psychotropic medication discontinuation. The findings will help to inform future research on the integration of pharmacogenomics into individualised tapering strategies.

Introduction Discontinuation of psychotropic medication is associated with considerable clinical challenges, including withdrawal symptoms and relapse. Pharmacogenomic testing is increasingly used in clinical practice to optimise pharmacotherapy by guiding drug selection and dosing, however, its role in informing medication discontinuation and tapering strategies remains underexplored. Understanding the influence of genetic variability on withdrawal symptoms could support safer, individualised discontinuation practices. Objective This scoping review aims to map the available evidence on the role of pharmacogenomics on the discontinuation of psychotropic medications. Methods The review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and reported using the PRISMA-ScR checklist. Comprehensive searches will be performed in MEDLINE, EMBASE, CINAHL, Web of Science, and PsycINFO. Studies exploring gene polymorphisms relevant to the discontinuation of psychotropic medications (antidepressants, antipsychotics, mood stabilisers, anxiolytics, hypnotics, stimulants, and opioids) will be considered. Following screening, data will be extracted, and a narrative synthesis will be undertaken to map characteristics of included studies, genes studied, medication classes involved, reported outcomes, and knowledge gaps. Conclusion This review will provide an overview of existing evidence and identify gaps regarding the role of pharmacogenomics in psychotropic medication discontinuation. The findings will help to inform future research on the integration of pharmacogenomics into individualised tapering strategies.

Introduction: Despite significant increases in the prescribing of psychiatric medication in recent years, many uncertainties exist regarding the process of reducing and stopping these medications. A James Lind Alliance Priority Setting Partnership (PSP) study was conducted to identify the top 10 research priorities on reducing and stopping psychiatric medication. As part of the PSP study, an online survey was conducted, which asked respondents to submit their views and experiences of reducing and/or stopping psychiatric medication as free‐text comments. This study aimed to conduct a descriptive analysis on these free‐text survey responses. Methods: A qualitative descriptive analysis was undertaken on responses submitted to the online survey, which was disseminated using social media, newsletters and emails. Responses were submitted by three stakeholder groups (i.e., people with lived experience of taking and/or stopping psychiatric medication, family members/carers/supporters and healthcare professionals). All survey responses were downloaded, screened and analysed using template analysis. A coding template was iteratively developed using samples of responses and then applied to the responses by the researchers working independently. Results: In total, 705 responses contained free‐text additional comments, of which 483 responses were considered in‐scope. Six main themes were identified: (1) experiences of psychiatric medication, (2) challenges to reducing/stopping psychiatric medication, (3) strategies used to reduce/stop psychiatric medication, (4) outcomes of reducing/stopping psychiatric medication, (5) emotional context and (6) areas for improvement. Conclusion: This study identified numerous challenges faced by respondents when discontinuing psychiatric medication, the uncertainty that prevails in terms of the best tapering strategy and the emotional impact of taking and/or stopping psychiatric medication. The findings also highlight the importance of support during the discontinuation process, in particular psychosocial supports, and areas that could be targeted to improve the withdrawal process. Patient or Public Contribution: An international Steering Group was established to oversee and guide the PSP study in accordance with the James Lind Alliance guidance and Patient and Public Involvement principles. Patient and public groups were represented on the Steering Group and were among the three key stakeholder groups (i.e., people with lived experience of taking and/or stopping psychiatric medication, family members/carers/supporters and healthcare professionals) engaged with throughout.

Objective Antimicrobial resistance is a significant global health challenge, exacerbated by unnecessary antibiotic prescribing. Respiratory tract infections (RTIs) are common reasons for antibiotic prescribing in primary care, despite most being viral or bacterial infections that are self-limiting. C-reactive protein (CRP) point-of-care tests (POCTs) are promising tools to support antibiotic stewardship by guiding the management of lower RTIs (LRTIs). The aim of this study was to develop best practice guidance for using CRP POCT in the management of LRTIs in primary care. Design Scoping review findings informed guidance statements, which were then evaluated through a three-round Delphi process with an expert panel via web-based questionnaires. Statements focused on intended use, detection of bacterial LRTIs, communication strategies, device features, performance and ease of use of CRP POCT. Setting and participants The panel of experts included 19 healthcare professionals across several specialties, including general practitioners, community pharmacists, hospital pharmacists and respiratory physicians. Main outcome measures Panellists rated each guidance statement using a 5-point Likert scale, with acceptance, revision or rejection determined using predefined cut-off scores for medians and interquartile ranges. Statements were revised between rounds using the feedback provided by panellists. Results In the first round, 49 statements were evaluated; 16 were accepted, nine removed and 24 revised for the second round. Of the 24 statements evaluated in the second round, 17 were accepted and seven were revised. In the third round, consensus was reached on four of the seven statements presented, resulting in 37 final guidance statements. These statements covered key areas, including the appropriate use of CRP POCTs to guide antibiotic prescribing, CRP cut-off values, integration with clinical decision rules, device performance and operational considerations, training requirements and financial reimbursement. The panel emphasised the need for structured guidelines to align CRP POCT use with clinical context and highlighted its role in improving diagnostic confidence while supporting antibiotic stewardship. Conclusions This study provides a set of best practice guidance statements to support the use of CRP POCT in the management of LRTIs in primary care. Dissemination and further research are required to assess their impact.

Aims: To identify, evaluate and summarize all published literature that investigated manipulations to pharmaceutical dosage forms of psychotropic medications that could be used for the purposes of tapering. Methods: A systematic literature review was carried out of the available published literature on manipulations performed to psychotropic medications to obtain a decreased dose of the active pharmaceutical ingredient. All studies that involved the manipulation of pharmaceutical dosage forms of antidepressants or benzodiazepine receptor agonists and subsequent pharmaceutical analysis of active pharmaceutical ingredient content were eligible for inclusion. The electronic databases searched were: MEDLINE, Web of Science, EMBASE, PsycINFO and CINAHL. Results: Sixteen studies met inclusion criteria. The manipulation methods carried out in the identified studies involved tablet splitting (4 studies), formulation of liquid suspensions (8 studies) and diluting existing marketed liquid formulations (4 studies). Ten of the included studies reported a mean target dose recovery within the 95–105% range after the manipulation was performed. All studies in which a dilution was performed to an oral liquid formulation ( n = 4) reported results within this percentage recovery range. None of the included studies investigated the accuracy of manipulations across the full dose range of a tapering schedule. Conclusion: This review identified a limited amount of published research on the accuracy of different methods of manipulating psychotropic medications. Diluting liquid formulations to achieve lower doses merits further investigation. Further research comparing different manipulation methods is also required to determine the best approach for tapering to lower doses.

Background Antimicrobial resistance is a significant global health challenge, exacerbated by inappropriate antibiotic prescribing, particularly in primary care where up to 50% of antibiotic prescriptions prescribed by general practitioners (GPs) and dispensed by community pharmacists (CPs) are deemed inappropriate. Respiratory tract infections (RTIs) are among the most common conditions leading to GP consultations and subsequent antibiotic prescribing, much of which is inappropriate as most RTIs are viral in nature or self-limiting bacterial infections. Point-of-care tests (POCTs) have emerged as tools to improve the diagnosis and appropriate treatment of RTIs. Objective This study aims to develop and test an intervention to improve the use of POCTs in managing RTIs involving GPs and CPs in Irish primary care, following the UK’s Medical Research Council’s (MRC) framework for complex intervention development, involving five work-packages (WPs). Methods WP1 involves creating best practice guidance for using POCT in managing RTIs, informed by a scoping review and validated with an expert Delphi panel. This guidance will be used to define target behaviour(s) for GPs and CPs related to POCT use. WP2 explores GP and CP perceived barriers and facilitators to these behaviours using the Theoretical Domains Framework, mapping influential domains to Behaviour Change Techniques to develop draft interventions. WP3 gathers patients’ perspectives on using POCTs for RTIs. In WP4, a task group will review and finalise the intervention(s). They will consider patients’ perspectives from WP3 and assess feasibility of the intervention(s). WP5 involves a proof-of-concept study to test the feasibility of the newly developed intervention(s). Conclusion A theoretically informed intervention(s) for using POCT(s) in the management of RTIs in primary care in Ireland will be developed and tested in a proof-of-concept study, following MRC guidance. Further refinement and larger studies will be needed to determine its effectiveness before widespread implementation.