Background A significant gap exists between recommended low-density lipoprotein cholesterol (LDL-C) treatment goals and the achievement of these goals in clinical practice. In addition, there remains suboptimal utilization of lipid-lowering therapies (LLT). This study examines the prescribing pattern of LLT and the level of LDL-C goal achievement among Irish adults in a primary care setting. In addition, it identifies patient factors associated with the prescribing of LLT and LDL-C goal achievement. Methods This was a cross-sectional analysis of rescreen data from the Mitchelstown Cohort Study. Demographic, medication and diagnosis data were obtained from participant electronic health records. Cardiovascular risk was assessed using the SCORE tool. LDL-C goal achievement was determined using the LDL-C goals set out in the 2011 ESC/EAS guidelines for the management of dyslipidemia. Results Among 1,183 participants (median age = 65 years), 48.5% were prescribed LLT, 42% of whom attained their LDL-C goal. Only 17.5% were prescribed high-intensity statin therapy and 13% were prescribed combination therapy. In multivariable analysis, diabetes history, polypharmacy, and hyper-polypharmacy were associated with prescribing LLT. Being male or ≤59 years of age was associated with lower likelihood of LLT prescription. Target LDL-C goal achievement was associated with male sex and age ≤64 or ≥70 years, while BMI 25 – 29kg/m2 was associated with lower LDL-C goal achievement. Conclusion Dyslipidemia is undertreated in this Irish primary care population with limited use of high-intensity statins. This study highlights the gap between guideline recommendations for LLT prescription and LDL-C target goals and real-world implementation of guidelines.

Direct Healthcare Professional Communications (DHPCs) alert healthcare professionals of important safety information relating to medication(s) and of the need to adapt practices with respect to these. International evidence suggests that their implementation varies in clinical practice. To date, few studies have examined implementation of DHPCs in primary care. To examine how general practitioners (GPs) and community pharmacists implement DHPCs in Ireland and their preferences for receiving medication safety updates. A national cross-sectional survey of GPs and pharmacists in collaboration with the Irish Health Products Regulatory Authority (HPRA), was conducted in June 2024. GPs and CPs were invited to participate via national gatekeepers (Irish College of GPs, Pharmaceutical Society of Ireland). Following piloting, the questionnaire were administered via email using Qualtrics. Data was analysed using R and R Studio. A total of 277 GPs and 219 pharmacists completed the questionnaire, a response rate of 6

Medicines reviews by general practice pharmacists improve patient outcomes, but little is known about the associated economic outcomes, particularly in patients at higher risk of medicines-related harm. To conduct an economic cost-benefit analysis of pharmacists providing person-centred medicines reviews to patients with hyperpolypharmacy (prescribed ≥ 10 regular medicines) and/or at high risk of medicines-related harm across multiple general practice settings. Service delivery costs were calculated based on the pharmacist’s salary, recorded timings, and a general practitioner fee. Direct cost savings were calculated from the cost change of patients’ medicines post review, projected over 1 year. Indirect savings were calculated using two models, a population-based model for avoidance of hospital admissions due to adverse drug reactions and an intervention-based model applying a probability of adverse drug reaction avoidance. Sensitivity analyses were performed using varying workday scenarios. Based on 1471 patients (88.4

Mental disorders are estimated to affect one in seven people globally and are often linked to premature mortality. Psychotropic medicines play an important role in the management of many mental health conditions particularly where symptoms are moderate to severe, persistent, or complex. Pharmacists are increasingly recognised as key members of multidisciplinary mental health teams, with their role focusing on safe and effective use of psychotropic medicines. Mental healthcare is increasingly delivered in outpatient settings, however, the impact of pharmacists on these services remains underexplored. To systematically review and evaluate the impact of pharmacist-led or pharmacist-involved interventions specifically within outpatient mental health settings globally, across the full spectrum of mental disorders. A systematic search of five electronic databases (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO) was conducted from inception to October 2025. Grey literature sources including ClinicalTrials.gov and Google Scholar were also searched. Inclusion criteria were: (i) evaluation of a pharmacist-led or pharmacist-involved intervention with a measurable outcome; (ii) conducted in an outpatient mental health setting involving adults with a diagnosed mental disorder classified according to ICD (up to and including ICD-11) or DSM criteria (up to and including DSM-5), excluding dementia; and (iii) inclusion of a comparator or control group. Study screening, data extraction, and quality appraisal, were performed independently by two reviewers. Due to heterogeneity in study design and outcomes, a narrative synthesis was conducted. Twenty-three studies met the inclusion criteria: 11 randomised controlled trials and 12 non-randomised studies. Pharmacist interventions varied, but most commonly included medication reviews, psychoeducation, adherence support and monitoring for side effects or drug interactions. Outcomes were grouped into seven domains: patient-reported, symptom-related, treatment-related, medication adherence, cost, monitoring and hospitalisations. Pharmacist impact was associated with improvements across multiple domains, particularly in medication adherence, treatment-related and symptom-related outcomes. While outcome measures varied between studies, a majority (82.6

Medication adherence following myocardial infarction (MI) is essential for effective secondary prevention, yet adherence rates remain suboptimal. Healthcare professionals (HCPs) are central to promoting adherence through clinical decision-making, patient education, and ongoing behavioural support. Understanding how HCPs perceive and experience the factors' influencing adherence is key to developing effective, context-specific interventions. This study explored HCPs' perspectives on medication adherence post-MI and identified behavioural determinants influencing medication management across the care pathway. A qualitative descriptive study was conducted using semi-structured interviews with HCPs in the southwest of Ireland. Participants included hospital pharmacists, community pharmacists, general practitioners (GPs), cardiologists, and nurses, recruited through purposive, convenience, and snowball sampling. Interviews were recorded, transcribed verbatim, and analysed using directed content analysis guided by the Theoretical Domains Framework (TDF). Twelve HCPs (eight female) were interviewed between December 2024 and May 2025, including four pharmacists, two GPs, three cardiologists and three nurses. Interviews lasted 30-50 min (mean 41 min). Analysis identified 15 facilitators, 13 barriers, and 7 dual-role determinants across 10 TDF domains. Novel contributions include demonstrating how HCPs' real-world experiences contextualise adherence issues in the distinct post-MI setting characterised by abrupt care transitions, polypharmacy, and emotional vulnerability and identifying where HCPs feel most constrained and where their expertise could directly inform targeted intervention design. HCPs' insights reveal complex, context-specific behavioural determinants influencing post-MI medication adherence and highlight the need for multidisciplinary, tailored, and system-level solutions. Enhancing collaboration, supporting patient-centred communication, and addressing resource barriers could empower HCPs to deliver more effective, personalised adherence support and inform the development of targeted intervention strategies.

Background With pharmacist roles in general practices not widely implemented, it is not clear what interventions are undertaken as part of patient-centred medicines reviews in that setting. Objectives To describe the types of general practice pharmacist interventions from person-centred medicines reviews with patients with hyperpolypharmacy (on ≥10 regular medicines) and/or at high risk of medicines-related harm, and evaluate their significance, rates of acceptance and implementation, and resulting changes in medicines numbers. Methods Four pharmacists were integrated into ten general practice settings, who conducted medicines reviews following the ‘7 Steps to Appropriate Polypharmacy’ approach, and liaised with general practitioners, other healthcare professionals, and patients to make review-related interventions and follow up. Intervention significance was classified using Eadon grading. General practitioner acceptance and implementation of recommendations to alter prescriptions was recorded. Descriptive and inferential statistics were performed on summary data. Results Between January 2021 and December 2022, 1471 patients consented to data collection (mean age: 76 years, 88.3% with hyperpolypharmacy). A mean of twelve interventions/patient was made. For patients with complete intervention data (n = 1181), 38.7% of 14,592 interventions were recommendations to alter prescriptions; of these with known outcomes (n = 5537), 95% were accepted and 82.7% implemented. Prescription alterations comprised stops (55.9%), decreased doses (19.0%), starts (18.9%), and increased doses (6.2%). Nearly all interventions were deemed ‘significant’ (98.4%); 29% of patients had ≥1 ‘very significant’ intervention, of which 75% related to stopping a medicine. Patients had a mean of 13.8 pre-review medicines and 12.3 post-review medicines (mean difference − 1.5 [SD 2.0], p < 0.0001), with an 11.2% reduction in medicines and 11.6% fewer patients with hyperpolypharmacy post review. Conclusion Pharmacist interventions from person-centred medicines reviews in general practice were highly accepted, generating substantial medicines reductions and improved care for patients at high risk of medicines-related harm. Future research should explore the longer-term sustainment of these reviews in more diverse healthcare contexts.

Over three million people annually experience myocardial infarction (MI). As MI survival rates increase, so does the importance of secondary prevention medications. International guidelines recommend using several medications to prevent further morbidity. To synthesise the qualitative literature on the facilitators and barriers faced by MI survivors and their families/caregivers regarding medication management and, thus, medication adherence post-discharge. This systematic review was conducted and reported following the PRISMA-2020 guidelines. Five databases were searched from inception until the 13th of August 2024. The inclusion criteria were articles focused on people aged 18 years or older who experienced MI and were discharged from acute care settings to home settings, as well as caregivers of individuals who met the above-mentioned criteria. Qualitative and mixed-methods studies with qualitative elements were deemed eligible for inclusion. The theoretical domain framework was used to analyse the findings. The quality of the included studies was assessed using the JBI Critical Appraisal tool for qualitative research. The Confidence in the Evidence from the reviews of qualitative research approach was applied to assess confidence in qualitative evidence synthesis. Of the 14,002 titles, 11,354 remained after duplicates were removed. Of the 234 full-text screenings, fifteen were included. A total of 533 people who experienced MI and 25 spouses from eight different countries were included. The most prominent facilitator that emerged was “beliefs about consequences”, whilst “lack of knowledge” and “environmental context and resources” were the most prominent barriers to medication management reported. Patients face multiple challenges that affect their medication adherence post-MI. These findings highlight important considerations for creating an individualised, tailored approach to enhance medication adherence post-MI. Systematic review registration: PROSPERO CRD42023424844.

The aim of this study was to investigate the impact of pharmacist-led person-centred medicines reviews in general practices on medicines appropriateness, polypharmacy indicators (high-risk prescribing markers), and patient-reported outcome measures (PROMs). Four pharmacists conducted person-centred medicines reviews in ten general practices between January 2021 and December 2022 for patients with hyperpolypharmacy (prescribed ≥10 regular medicines) and/or at high risk of medicines-related harm. Prescribing recommendations were provided to the general practitioner and followed up with patients and/or healthcare professionals. In this single arm study, pre and post intervention: (1) polypharmacy indicators were documented, and for a sample of patients, the (2) Person-Centred Medication Appropriateness Index (PC-MAI) scores and (3) PROMs were gathered. Of the 1471 included patients, the mean age was 76 years, 88.4% had hyperpolypharmacy, whilst the mean number of medicines was 13.8 pre and 12.3 post review. Of the 1056 polypharmacy indicator occurrences identified, 70.7% were resolved post review. Of the 194 patients with pre-review and post-review PC-MAI scores, 99% had a reduction; the mean reduction was 17.3 (95% confidence interval [CI] 15.8–18.8, P  < .0001) per patient and 1.2 (95% CI 1.0–1.3, P  < .0001) per medicine. PROMs were collected for 179 patients; 87.7% reported the review helped their medicines understanding, 63.1% their experience of side effects, 36.9% their ability to take medicines correctly, and 30.5% the impact of medicines on their daily activities. General practice pharmacist-led person-centred medicines reviews for patients with hyperpolypharmacy and/or at high risk of medicines-related harm delivered substantial improvements in medicines appropriateness and patient-reported outcomes, thus providing evidence to support their wider implementation.

AIM:The aim of this study was to investigate the impact of pharmacist-led person-centred medicines reviews in general practices on medicines appropriateness, polypharmacy indicators (high-risk prescribing markers), and patient-reported outcome measures (PROMs). METHODS:Four pharmacists conducted person-centred medicines reviews in ten general practices between January 2021 and December 2022 for patients with hyperpolypharmacy (prescribed ≥10 regular medicines) and/or at high risk of medicines-related harm. Prescribing recommendations were provided to the general practitioner and followed up with patients and/or healthcare professionals. In this single arm study, pre and post intervention: (1) polypharmacy indicators were documented, and for a sample of patients, the (2) Person-Centred Medication Appropriateness Index (PC-MAI) scores and (3) PROMs were gathered. RESULTS:Of the 1471 included patients, the mean age was 76 years, 88.4% had hyperpolypharmacy, whilst the mean number of medicines was 13.8 pre and 12.3 post review. Of the 1056 polypharmacy indicator occurrences identified, 70.7% were resolved post review. Of the 194 patients with pre-review and post-review PC-MAI scores, 99% had a reduction; the mean reduction was 17.3 (95% confidence interval [CI] 15.8-18.8, P < .0001) per patient and 1.2 (95% CI 1.0-1.3, P < .0001) per medicine. PROMs were collected for 179 patients; 87.7% reported the review helped their medicines understanding, 63.1% their experience of side effects, 36.9% their ability to take medicines correctly, and 30.5% the impact of medicines on their daily activities. CONCLUSIONS:General practice pharmacist-led person-centred medicines reviews for patients with hyperpolypharmacy and/or at high risk of medicines-related harm delivered substantial improvements in medicines appropriateness and patient-reported outcomes, thus providing evidence to support their wider implementation.

BACKGROUND: In hospital practice, atypical antipsychotics are often used to manage delirium, sleep problems, agitation, or behavioural and psychological symptoms of dementia, while evidence remains uncertain regarding effectiveness and safety for those off-label indications. While guidelines to reduce inappropriate prescribing have been published, prescribing patterns in older multimorbid patients are not well understood. We thus aimed to investigate the patterns of prescribing and deprescribing of atypical antipsychotics over one year following an acute hospitalisation, as well as the appropriateness of prescriptions. METHODS: We conducted a longitudinal analysis using data from the OPERAM trial, a European multicentre study assessing hospital pharmacotherapy optimisation in multimorbid older patients aged 70 years or older in Switzerland, Ireland, Belgium and the Netherlands between 2016 and 2019. Data were collected at different time points: admission, discharge, two months post-discharge and one year post-discharge. Atypical antipsychotic prescriptions were classified as appropriate, off-label but accepted, or potentially inappropriate. Outcomes included the prevalence of atypical antipsychotic use at the different time points, deprescribing rates for appropriate and inappropriate prescriptions, and the incidence of new atypical antipsychotic prescriptions among patients not previously treated. RESULTS: The number of patients prescribed atypical antipsychotics increased from 88/2005 (4.4%) at admission to 116/1980 (5.9%) at discharge. At admission, 62.5% of these prescriptions were classified as potentially inappropriate. During hospitalisation, 20/53 (37.7%) patients with potentially inappropriate prescriptions either had the medication discontinued or were assigned a new diagnosis that justified the use under an off-label but accepted or otherwise appropriate indication. Additionally, 47 (2.5%) of the 1917 antipsychotic-naïve patients received a new prescription during index admission, with one third (36.2%) lacking a clear indication. Among those newly prescribed atypical antipsychotics without an appropriate indication during hospitalisation, only 58.3% had the medication discontinued within one year of follow-up. CONCLUSIONS: This study highlights the substantial prevalence of potentially inappropriate atypical antipsychotic prescribing in older multimorbid patients, with no clearly documented indication in almost half of the prescriptions initiated during hospitalisation and slow deprescribing efforts leading to long-term medication risks. Improving prescribing practices through education, protocol-driven deprescribing, and post-discharge follow-up is essential to reduce inappropriate use, and ultimately enhance patient safety.

Older patients with multimorbidity and polypharmacy experience excess adverse drug reactions which contribute to frequent emergency department (ED) attendance, unscheduled readmission and increased mortality. Implementing medication optimization strategies through STOPP/START criteria and drug-drug interaction (DDI) avoidance could mitigate these adverse clinical outcomes. We designed a comprehensive medication-optimizing definitive intervention (DI) based on STOPP/STARTv3 criteria and Stockley’s®DDI checker and evaluated it by randomized clinical trial in 3 large university hospitals. We enrolled 636 older patients (mean age=80.3, 49.5% female) with ≥3 chronic conditions and polypharmacy (≥5 daily medications) admitted acutely in 2023-24. Patients were randomized to standard pharmaceutical care arm (n=217), physician-delivered-DI arm (n=210) or pharmacist-delivered-DI arm (n=209). For DI patients, written and verbal medication optimization advice was delivered to senior attending doctors at admission and pre-discharge. Prioritized STOPP/STARTv3/Stockley’s®DDI medication advice was further discussed with DI-arm patients’ general practitioners at 10+/-3 days post-discharge. Primary endpoints determined at 30+/-7 days (T4) and 90-180 days (T5) post-discharge were ED attendance, readmission and all-cause mortality. Composite endpoints included (i) ED attendance, readmission or all-cause mortality, and (ii) ED attendance or readmission. Data were evaluated by logistic regression analysis with results expressed as odds ratios (OR’s) with 95% confidence intervals (CI’s). Both composite endpoints (i) and (ii) were significantly reduced in the combined DI arms versus controls (adjusted OR=0.68 [95%CI 0.46-0.99], p<0.05; adjusted OR = 0.65 [95%CI 0.44-0.96], p=0.03 respectively). Composite endpoint (i) was also significantly reduced in the pharmacist-delivered DI arm versus controls at T5 (adjusted OR=0.59 [95%CI 0.37-0.94], p=0.03). ED attendance was significantly reduced at T4 in the physician-delivered DI arm versus controls (adjusted OR=0.53 [95%CI 0.28-0.98], p<0.05). We found no significant endpoint differences between the two DI arms. Implementing clinically relevant STOPP/STARTv3 inappropriate prescribing criteria and Stockley’s® DDI recommendations reduced adverse clinical outcomes in older multimorbid patients with polypharmacy.

INTRODUCTION:Prescribing cascades are important medication-related issues to be aware of, particularly for multimorbid older adults with polypharmacy. These cascades were initially defined as phenomena where side effect misinterpretation results in the prescribing of additional medications. This definition has been debated though, particularly on whether side effects may be misinterpreted or recognised/unrecognised, and consequently whether cascades are intentional/unintentional. Given these inconsistencies, this scoping review aimed to map how prescribing cascades have been defined and described in the published literature. METHODS:Seven electronic databases were searched from inception to October 2024. Full-text publications in English that mentioned prescribing cascade (or a synonym) in the title or abstract and provided a prescribing cascade definition/description in the full text were included. Specific terminology and images used to define/describe prescribing cascades were extracted, and the findings were narratively synthesised. RESULTS:Of the 139 included publications, less than half directly aligned with the original definition by containing descriptions of prescribing cascades that indicated side effect misinterpretation (48.9%). One quarter indicated side effects could be recognised or unrecognised (24.5%), 37.4% addressed cascade appropriateness or inappropriateness, and 8.6% referenced their intentional or unintentional nature. One fifth (20.9%) included an image or map to describe a prescribing cascade. CONCLUSION:This review has uniquely mapped how prescribing cascades have been described in the literature, finding substantial heterogeneity between publications. By highlighting this inconsistent terminology use, this review emphasises the need to develop consensus definitions to aid in the future recognition, measurement, education, and prevention of prescribing cascades.

Background:The appropriate treatment high blood pressure (BP) and low-density lipoprotein cholesterol.(LDL-C), according to clinical guidelines, reduces a patient's risk of a cardiovascular event. Aim:This systematic review aims to evaluate the attainment of BP and LDL-C goals among the Irish population in both primary and secondary prevention of cardiovascular diseases, the level of adherence to prescribing guidelines by doctors and the level of medication adherence among patients. Methods:Five databases were searched in March 2024. Quantitative articles reporting levels of goals attainment, medication adherence or guideline adherence for LDL-C and BP among Irish adults aged ≥18 years were included. The proportion of patients attaining their LDL-Cor BP goals were statistically combined using the random effect model. Results:Following screening, 23 eligible articles were identified. The achievement of LDL-C <1.8 mmol/L was 41 % (95 % CI 31,52), compared to 69 % of people (95 % CI 62,76) reported to have achieved the less stringent goal of LDL-C < 3 mmol/L. The achievement of BP < 140/90 mmHg was 56 % (95 % CI 46,65). Medication adherence levels ranged between 27 % and 92 %. Guideline adherence findings demonstrated that not all patients who should be on lipid-lowering therapy are and that choice of antihypertensive is not always in line with the guidelines. Conclusion:Approximately one-third of deaths in Ireland annually are caused by cardiovascular disease, despite being preventable. There is room for improvement in goal attainments in people at risk of CVDs and optimization of medication adherence and guideline adherence may be beneficial in this population.