MedsScan, Issue 2, 2026

These reviews provide updates on the international literature on therapeutics. Expert pharmacy practitioners — via AdPha’s Specialty Practice Groups — scan major peer-reviewed journals in areas relevant to Australian pharmacy practice and present precis on major clinical trials, important pharmacoepidemiology studies and pharmacoeconomic research, and other updates relevant to practice. Interested readers are encouraged to explore the original publications in greater detail.

Published online: 12 June 2026

CRITICAL CARE

MedsScan Editors for Critical care SPG: Melissa Faehrmann and Grainne Hughes

Digital software to reduce medication errors during ICU to ward transfers

Special contributor: Bridget Frain

Can the use of digital tools reduce medication errors when two electronic medication systems don’t talk to one another? Or are they just another screen?

This two-part mixed methods study, undertaken at two hospitals in NSW, explored whether the use of an electronic transfer of care (eTOC) system reduced medication errors at point of transfer from the intensive care unit (ICU) to a general ward when different prescribing software was used in the two areas. The eTOC tool facilitates unidirectional information transfer from the ICU to ward-based systems via a web application. Clinicians were also interviewed to assess the usability and practicality of the eTOC digital tool.

The study examined 200 patient transfers which included 2178 individual medicine transfers. There was no significant difference in the number of patient transfers containing medication errors (51% versus 46% pre-intervention and post-intervention respectively, Rao-Scott χ2 = 2.7, p = 0.1). The number of medication errors per patient (for those with errors) ranged between 1 and 11, and the use of the eTOC system more than halved the odds of a medication error occurring (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.27–0.71). However, the eTOC tool was inconsistently used post-implementation and some users described functionality issues that did not support work processes.

While the introduction of the eTOC system only led to a small (5%) reduction in the number of patient transfers affected by medication errors, chart reviews revealed that use of the eTOC system was associated with a 50% reduction in the number of medication errors that occurred during ICU to ward transfers.

Overall, the eTOC system did improve the safe transfer of medicines information between the ICU and a general ward, but improvements to the eTOC system, or similar digital tools, are likely necessary to improve usability and reduce the time required to perform a transfer with the eTOC system.

Baysari MT, Stanceski K, Van Dort BA, Raubenhiemer J, Pham L, Deidun D, et al. Mixed methods evaluation of a digital tool to support the transfer of medication information from ICU to ward. J Crit Care 2026; 91: 155219.

Is landiolol superior to esmolol for heart rate control in critically ill patients?

Tachycardia is common in critical illness and can be associated with poorer outcomes, including in septic shock. Esmolol and landiolol are short-acting, titratable, cardioselective intravenous betablockers. Both are registered by the Therapeutic Goods Administration (TGA) for rapid control of ventricular rate in patients with atrial fibrillation or flutter when short-term management is needed and for non-compensatory sinus tachycardia requiring specific intervention. Landiolol is also TGA-registered for supraventricular tachycardia. Landiolol has approximately seven-times greater β1 selectivity than esmolol. Whether one agent offers superior heart rate control or safety in the ICU setting remains uncertain.

This retrospective, observational study in China compared the safety and efficacy of landiolol and esmolol in critically ill adult patients with tachycardia. Propensity‑matched analysis included 438 ICU patients (n = 292 esmolol, n = 146 landiolol) treated between 2016–2022.

Landiolol achieved a greater reduction in mean heart rate than esmolol (4.7 beats per minute; p = 0.007) without increasing vasopressor requirements in the first 24 hours. Secondary outcomes also favoured landiolol, including shorter ICU length of stay (4.9 versus 6.7 days, p = 0.011) and hospital length of stay (26.5 versus 30.0 days, p = 0.044). Infusion doses used were lower than standard references; landiolol was started at 3.1 microgram/kg/min (usual dosing range 10–40 microgram/kg/min per product information) and esmolol was commenced at 5.5 microgram/kg/min (usual dosing range 50–200 microgram/kg/min).

Although the findings suggested modest advantages with landiolol, the retrospective, single‑centre design and subtherapeutic dosing limit generalisability. Prospective, adequately powered trials are required before landiolol can be recommended over esmolol in Australian ICUs or before beta‑blockade more broadly can be endorsed as standard care in this setting.

Tang Z, Sun Q, Xu J, Yang Y, Peng F. Comparison of esmolol versus landiolol on mortality in adult patients with sepsis: a systematic review and network meta-analysis. Crit Care Med 2026; 54: 324–334.

Sodium bicarbonate in severe metabolic acidaemia with acute kidney injury: no mortality benefit

Special contributor: Christy El-Khoury

Severe metabolic acidaemia in critically ill patients is associated with major physiological derangements and poor outcomes. Despite limited high-quality evidence, intravenous sodium bicarbonate is frequently used in this setting, particularly when acute kidney injury (AKI) is present. The BICARICU-2 trial aimed to determine whether this common practice improves survival.

This multicentre, open-label, randomised controlled trial was conducted across 43 French ICUs. A total of 640 adults with severe metabolic acidaemia (pH ≤7.20) and moderate-to-severe AKI were randomised to receive intravenous sodium bicarbonate, titrated to target an arterial pH ≥7.30, or no sodium bicarbonate. The primary outcome was day 90 all-cause mortality.

Of the 627 patients included in the primary analysis (n = 314 sodium bicarbonate, n = 313 control), 90-day mortality was high and similar between groups (62.1% versus 61.7%; absolute difference 0.4%, 95% CI -7.2 to 8.0; p = 0.91). There were no differences in mortality at day 28 or day 180, or in duration of organ support or length of stay. However, sodium bicarbonate therapy was associated with less use of kidney replacement therapy (35% versus 50%; absolute difference -15.5%, 95% CI -23.1 to -7.8) and delayed initiation. Adverse events were comparable between groups.

In contrast to earlier subgroup analyses suggesting benefit in AKI, this adequately powered trial demonstrated no mortality advantage with sodium bicarbonate. For critical care pharmacists, the reduction in dialysis use is clinically relevant given the risks, costs and infection burden associated with kidney replacement therapy. However, the open-label design and clinician-driven dialysis decisions may have influenced this outcome. In Australian practice, routine sodium bicarbonate use to improve survival is not supported, although it may remain a reasonable temporising strategy to delay dialysis in carefully selected patients with severe acidaemia.

Jung B, Jabaudon M, De Jong A, Bitker L, Audard J, Klouche K, et al. Sodium bicarbonate for severe metabolic acidemia and acute kidney injury: the BICARICU-2 randomized clinical trial. JAMA 2025; 334: 2000–2010.

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GERIATRIC MEDICINE

MedsScan Editors for Geriatric medicine SPG: Anna Jennings and Jess Coddo

A bigger dose, a bigger impact: boosting influenza protection in older adults

Special contributor: Madison Young

Influenza is a major global public health concern and adults aged 65 years and older (older adults) face a higher risk of severe complications than younger adults. A high-dose inactivated influenza vaccine (HD-IIV) has been developed, aiming to increase older adults’ protection against influenza. This pooled analysis of two large scale randomised controlled trials (RCTs) aimed to address the lack of high-quality evidence for the HD-IIV in older adults.

The DANFLU-2 and GALFLU trials compared the standard dose inactivated influenza vaccine (SD-IIV) with HD-IIV in older adults across 466 320 participants, during three influenza seasons and across two geographical locations, Denmark and Spain, respectively. Combined results found a reduction in the primary endpoint of influenza or pneumonia hospitalisation in the HD-IIV group (relative vaccine efficacy = 8.8%, 95% confidence interval [CI] 1.7–15.5, p = 0.0082). All-cause hospitalisation was also less among the HD-IIV participants (2.2% reduction, p = 0.012). These studies indicated for every 515 older adults given HD-IIV instead of SD-IIV, one hospitalisation could be prevented.

In Australia, older adults are recommended to receive either the adjuvanted influenza vaccine or HD-IIV in preference to SD-IIV. This study strengthens the existing recommendation, preferencing the use of HD-IIV over SD-IIV for older adults. It is worth noting that the adjuvanted influenza vaccine was not included in this study. In Australia, more than 3 million older adults were vaccinated against influenza in 2025. FLUNITY-HD provides pharmacists more confidence when recommending HD-IIV to our older adult patients.

Johansen ND, Modin D, Pardo-Seco J, Rodriguez-Tenreiro-Sánchez C, Loiacono MM, Harris RC, et al. Effectiveness of high-dose influenza vaccine against hospitalisations in older adults (FLUNITY-HD): an individual-level pooled analysis. Lancet 2025; 406: 2425–2434.

GLP-1 receptor agonist therapy in older adults with type 2 diabetes

Special contributor: Tiernan McDonough

Type 2 diabetes mellitus (T2DM) is a growing public health issue, with a range of well-described sequelae with significant morbidity, mortality and health economics implications. Evidence that agents such as glucagon-like peptide-1 receptor (GLP-1) agonists and sodium-glucose co-transport 2 (SGLT2) inhibitors improve cardiovascular and renal outcomes have drastically altered practice. Despite this, safety and efficacy data in patients aged over 80 years is lacking.  

This retrospective cohort study compared clinical outcomes amongst patients with T2DM, aged ≥80 years, and using GLP-1 agonists to those using dipeptidyl peptidase 4-inhibitors (DPP4is). After propensity score matching, each study arm contained 11 464 patients. Both cohorts had a mean age ± standard deviation of 81.6 ± 2.0 years.

Efficacy data demonstrated significantly lower rates of major adverse cardiovascular events (hazard ratio [HR] 0.86, 95% CI 0.81–0.91), major adverse kidney events (HR 0.86, 95% CI 0.82–0.91), all-cause hospitalisation (HR 0.91, 95% CI 0.84 – 0.97) and mortality (HR 0.82, 95% CI 0.77 – 0.88) for those treated with GLP-1 agonists. Major adverse effects such as hypoglycaemia and fracture risk did not increase amongst those using GLP-1 agonists. A slightly increased risk of gastrointestinal [GI] adverse effects was noted amongst GLP-1 agonist users.

Despite propensity matching, there was a higher body mass index in the GLP-1 agonist group, which may have had relevant clinical implications. This real-world data indicated that GLP-1 agonists may be safe and associated with reduced cardiorenal and mortality complications in adults aged 80 years and older.

Chen J-C, Fang Y-W, Liu Y-F, Chen M-T, Tsai M-H. GLP-1 receptor agonist therapy and cardiorenal outcomes in patients ≥ 80 years old with type 2 diabetes. J Am Geriatr Soc. 2026; 74: 96–106.

Prevalence of major bleeding in older patients on oral anticoagulants

Special contributor: Heather Forbes

Anticoagulation is the cornerstone of management of atrial fibrillation (AF) and has been shown to significantly decrease the risk of stroke, while increasing the risk of bleeding. A single centre, retrospective cohort study evaluated the prevalence of bleeding events in patients admitted to a Malaysian hospital from 2012–2023 with non-valvular AF (NVAF), who were taking either a direct-acting oral anticoagulant (DOAC) or warfarin. Patients were stratified by age into young-old (65-74 years), middle-old (75-84 years) and old-old (≥85 years). Bleeding events were verified by chart review and were classified as minor or major bleeding according to established criteria. A total of 886 patients were included, with a mean age of 78 years. 

A total of 63 patients (7.1%) experienced major bleeding. Major bleeding was non-significantly lower in the DOAC compared to the warfarin group (6.6% versus 10.5%). Each one-year increase in age was associated with 6% higher odds of major bleeding (p < 0.001). Patients with a history of major bleeding, or a HAS-BLED score ≥3, had significantly higher odds of major bleeding. Identification of risk factors for bleeding can help to balance the risk versus benefit of using anticoagulants for stoke prevention.

This study identified age and prior major bleeding as important risk factors and also reinforced HAS-BLED as a useful tool for predicting bleeding complications in older patients.1 In clinical practice, pharmacists can assess HASBLED scores to improve anticoagulant safety through identification of patients with high bleeding risk, and through recommendations for altering modifiable risk factors. 

References

  1. MD+CALC. HAS-BLED score for major bleeding risk. NY: MDCalc; 2026. Available from <https://www.mdcalc.com/calc/807/has-bled-score-major-bleeding-risk>.

Kwan HF, Mahadzir H, Tumian NR, Aizuddin AN, Kong SH. Prevalence of major bleeding in elderly patients on oral anticoagulants for non-valvular atrial fibrillation: a single-centre 12-year retrospective review. Geriatr 2025; 10: 165.

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ONCOLOGY AND HAEMATOLOGY

MedsScan Editor for Oncology and haematology SPG: Alborz Soroush

Daratumumab versus active monitoring for patients with high-risk smoldering multiple myeloma

Smoldering multiple myeloma (SMM) is an asymptomatic precursor plasma cell disorder that precedes the development of active multiple myeloma (MM). Approximately one-third of SMM patients are classified as having high-risk SMM and are at a 50% risk of developing symptomatic MM within two years.1 The standard of care for high-risk SMM is observation until disease progression. This phase 3 trial assessed the effect of early daratumumab versus observation, in an effort to prolong the time to the development of symptomatic MM.

AQUILA is an open-label, global, multicentre, randomised phase 3 study conducted at 124 sites in 23 countries. Three hundred and ninety patients with high-risk SMM were randomised 1:1 to subcutaneous daratumumab 1800 mg (n = 194) versus active monitoring (n = 196). Patients on daratumumab received the drug weekly during cycles 1 and 2, then every 2 weeks during cycles 3–6, then every 4 weeks thereafter for up to 36 months (39 cycles). The control arm was observational, with disease assessments performed every 12 weeks. The primary endpoint was progression-free survival (PFS) defined as the time to progression to active MM or death. The secondary endpoints included overall survival (OS), overall response rate (ORR), complete response rate, time to biochemical progression, and first-line MM treatment initiation and safety.

With a median follow up of 65.2 months, a significant benefit with daratumumab was observed. The risk of progression or death was reduced by 51% (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.36–0.67, p < 0.001). The estimated 5-year PFS rates were 63.1% (95% CI 58.4–67.8) with daratumumab and 40.8% (95% CI 33.5–48.4) with monitoring. The median time to progression was 44.1 months with daratumumab and 17.8 months with monitoring. Additionally, overall survival at 5 years was 93.0% with daratumumab compared to 86.9% with monitoring (HR 0.52).

Daratumumab was well tolerated. Adverse events were reported in 96.9% of patients in the daratumumab arm and in 82.7% of patients in the control arm and most were grade 1 or 2 adverse events. In the daratumumab group, the most common adverse events were fatigue (34.2%), upper respiratory tract infections (30.1%), diarrhoea (27.5%) and arthralgia (26.9%). Grade 3 or higher adverse events were reported in 40.4% of the patients in the daratumumab arm versus 30.1% in the control arm. Hypertension was the most frequent grade 3 or higher adverse event (5.7%). 

The AQUILA trial demonstrated early use of subcutaneous daratumumab delays the time to disease progression from asymptomatic high-risk SMM to symptomatic MM with a favourable safety profile, supporting a potential practice-changing strategy from watchful waiting to early treatment for selected high-risk SMM patients.

References

  1. Rajkumar SV, Kumar S, Lonial S, Mateos MV. Smoldering multiple myeloma current treatment algorithms. Blood Cancer J 2022; 12: 129.

Dimopoulos MA, Voorhees PM, Schjesvold F, Cohen YC, Hungria V, Sandhu I, et al. Daratumumab or active monitoring for high-risk smoldering multiple myeloma. N Eng J Med 2025; 392: 1777–1788.

Frontline daratumumab in patients with newly diagnosed transplant ineligible multiple myeloma

Special contributor: Maia Ismail

Daratumumab is an effective targeted therapy promoting myeloma cell death by binding to the CD38 (cluster of differentiation 38) protein expressed on myeloma cells. Previously, daratumumab was exclusively available as Pharmaceutical Benefits Scheme (PBS)-subsidised therapy in combination with standard of care treatment for relapsed or refractory MM only.

A phase 3 open label trial, the MAIA trial, was conducted to compare lenalidomide and dexamethasone (Rd) or daratumumab with lenalidomide and dexamethasone (D-Rd) in transplant-ineligible patients with newly diagnosed MM. Seven hundred and thirty-seven patients were included and randomised equally to receive either Rd or D-Rd.

The MAIA trial met its primary end point of PFS in the D‑Rd group compared to Rd alone, where long-term data (with an extended follow up) at 56.2 months showed a 47% (HR 0.53) reduction in the risk of disease progression in the D-Rd group. Secondary end points demonstrated higher complete response rates (51% versus 30%), tripled minimal residual disease‑negativity rates (31% versus 10%) as well as 32% relative reduction in the risk of death (HR 0.68, p<0.0013) in the D-Rd group compared to the control group, reflecting improved overall survival.

 No new safety signals have been identified with the use of daratumumab in combination with lenalidomide and dexamethasone after a follow-up period of over 56 months on patients from the D-Rd arm. While there was an increase in grade 3-4 neutropenia (54% vs 37%) and serious infections (41% vs 29%) with the D-Rd regimen, the difference in the proportion of these events leading to treatment discontinuation did not reach statistical significance between the two treatment arms.These findings demonstrated support for establishing D-Rd as frontline therapy for transplant‑ineligible MM, demonstrating improved disease control and survival outcomes. The recent PBS subsidy of daratumumab to frontline therapy in MM patients supports this updated standard of care.

Facon T, Kumar SK, Plesner T, Orlowski RZ, Moreau P, Bahlis N, et al. Daratumumab, lenalidomide, and dexamethasone versus lenalidomide and dexamethasone alone in newly diagnosed multiple myeloma (MAIA): overall survival results from a randomised, open-label, phase 3 trial. Lancet Oncol 2021; 22: 1582–1596.

Does CPX-351 benefit older adults with non-adverse risk acute myeloid leukaemia?

Special contributor: Alison Schroeder

Daunorubicin and cytarabine have been a staple of acute myeloid leukaemia (AML) treatment in older adults (aged ≥60 years) who are fit for intensive chemotherapy for many years. The NCRI AML16 trial showed that the addition of gemtuzumab ozogamicin (GO) to daunorubicin/cytarabine improved overall survival in patients with favourable risk cytogenetics.1 Evidence also showed that CPX-351, a liposomal formulation of daunorubicin, improves outcomes for older patients with secondary AML.2 The aim of the AML18 study was to investigate if the benefits seen with CPX-351 extended to older patients without adverse-risk genetics.

AML18 was an open label, randomised, multicentre trial across 87 centres within the United Kingdom and Denmark. Four hundred and thirty-nine previously untreated patients with AML, aged ≥60 years, without known adverse-risk cytogenetics were randomised 2:1 to receive CPX-351 or daunorubicin, cytarabine and fractionated GO (DA-GO2). Patients who did not enter measurable residual disease (MRD)-negative remission following course one could enter a second course randomisation for treatment intensification.

The initial primary outcome was overall survival (OS). However, due to impacts of the COVID-19 pandemic on recruitment, the primary end point was amended to event free survival (EFS). Both EFS (HR 0.73, 95% CI 0.57–0.93, P = 0.012) and OS (HR 0.62, 95% CI 0.46–0.83, P = 0.001) were better with the DA-GO2 arm (34% and 52% respectively) in comparison to CPX-351 (27% and 35% respectively). Median follow up was 35 months. The improvement in OS and EFS with DA-GO2 was felt to be due to higher rates of complete remission after the completion of the first course. There was no significant difference between the treatment arms in survival from remission or cumulative incidence of relapse.

AML18 showed, in older adults with non-adverse-risk AML, CPX-351 is inferior to DA-GO2, with lower remission rates and worse EFS and OS. These findings indicate that the survival advantage of CPX-351 in older adults with secondary AML should not be extrapolated to non-adverse-risk disease. CPX-351 remains on the Pharmaceutical Benefits Scheme for patients without favourable cytogenetics for newly diagnosed therapy-related AML or newly diagnosed AML with myelodysplasia-related changes. Further studies are warranted to investigate the ideal place for CPX-351 in non-adverse-risk AML treatment.

References

  1. Freeman SD, Thomas A, Thomas I, Hills RK, Vyas P, Gilkes A, et al. Fractionated vs single-dose gemtuzumab ozogamicin with determinants of benefit in older patients with AML: the UK NCRI AML18 trial. Blood 2023;142: 1697–1707.
  2. Lancet JE, Uy GL, Cortes JE, Newell LF, Lin TL, Ritchie EK, et al. CPX-351 (cytarabine and daunorubicin) liposome for injection versus conventional cytarabine plus daunorubicin in older patients with newly diagnosed secondary acute myeloid leukemia. J Clin Oncol 2018; 36: 2684–2692.

Knapper S, Dillon LW, Babu M, Thomas A, Thomas I, Hourigan CS, et al. CPX-351 vs daunorubicin, cytarabine, and gemtuzumab ozogamicin in older adults with non–adverse-risk AML: the NCRI AML18 trial. Blood 2026; 147: 1048–1057.

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PALLIATIVE CARE

MedsScan Editors for Palliative care SPG: Vicki Poulier and Annette Bush

Dexmedetomidine for end-of-life sedation: how does it compare?

Distress and delirium are common in palliative care patients at the end of life. Midazolam is widely used for these indications despite limited robust evidence and concerns about paradoxical agitation and delirium. This Australian trial investigated whether dexmedetomidine offers advantages over midazolam for the management of distress in the terminal phase.

The DREAMS trial was a randomised, controlled, non-blinded single-centre study conducted in hospitalised palliative care patients experiencing refractory distress and likely to die within seven days. Patients were randomised to receive a subcutaneous infusion of dexmedetomidine (0.5 microgram/kg/hour) or midazolam (0.25 mg/kg/day). Arm specific breakthrough doses were available for agitation and the management of other symptoms. The primary outcome was mean daily Richmond Agitation Sedation Scores - Palliative Version (RASS-PAL). Secondary outcomes included delirium severity and patient comfort.

Fifty-two patients consented, were randomised and included in the analysis. There was no significant difference in mean RASS-PAL scores between groups, with scores suggesting each group averaged light to moderate sedation. Dexmedetomidine was associated with a statistically significant reduction in delirium on day 1 compared to midazolam, although this difference was not sustained. Patient comfort scores were similar for both treatment arms, with a statistically significant improvement in patient comfort observed with dexmedetomidine only on day 3 of treatment.

This Australian study suggests dexmedetomidine and midazolam provided relief from distress and delirium in the terminal phase. The findings support dexmedetomidine as a viable alternative to midazolam and also raises questions about the adequacy of midazolam starting doses. Non-blinding, a small sample size, and a lack of dose escalation limited conclusions in this study and larger trials are needed before widespread practice change.  This study demonstrated that if appropriate safeguards can be maintained to protect this vulnerable population, there is appetite for patients to participate in research at the end of life.

Thomas B, Barclay G, Mansfield K, Mullan J, Wing-Shan AL. Dexmedetomidine versus midazolam for end-of-life sedation: the DREAMS non-blinded randomized clinical trial. J Pain Symptom Manage 2025; 70(5): 459–469.

Comparing opioid prescribing strategies for cancer-associated breathlessness in opioid-tolerant patients

Evidence supporting the use of opioids for breathlessness is largely derived from non-cancer populations, where low doses are recommended and dose escalation offers limited benefit. For patients with cancer already taking regular opioids, there is little data to guide clinicians for optimising management when breathlessness worsens.

This secondary analysis of an open-label observational study reviewed the records of 122 opioid-tolerant patients with cancer who additionally began requiring regular opioids for breathlessness. The patients were recruited from 12 palliative care services across Japan. Treatment groups were defined as increase (increased baseline dose) and switch/combination (rotation to a different opioid or use of combined opioids). Response was defined as decreased Numerical Rating Score (NRS) for dyspnoea by one or more from the previous score measured at baseline and every 24 hours for 72 hours.

No statistically significant difference was found in overall dyspnoea response at 72 hours between the increase or switch/combination groups (63% versus 73%, p = 0.33). When assessing selected opioid strategy, dose increase occurred in 91% of patients on baseline morphine and 68% each of patients on baseline oxycodone and hydromorphone. In contrast, 90% of patients on baseline fentanyl were switched to, or combined with, another opioid. Overall, all patients with dyspnoea NRS ³ 7 were more likely to experience improvement in breathlessness. For patients in the switch/combination group, patients with liver metastases or oral morphine equivalent (OME) ³ 90 mg were less likely to experience breathlessness relief.

The authors concluded that moderate to severe breathlessness in opioid-tolerant patients with cancer can be effectively managed by modifying baseline opioids. While dose escalation and opioid choice was left to individual clinical judgement, reflecting real-world practice, larger studies are needed to determine if individual opioids differ in relieving dyspnoea. The study was observational and open-label, risking bias in assessment of breathlessness response. The study suggests that dyspnoea management may differ significantly between cancer and non-cancer patients, with further research needed to explore best practice in these patient cohorts.

Suzuki K, Matsuda Y, Mori M, Tasaki J, Matsunuma R, Ikari T, et al. The effectiveness of regular opioids for dyspnea among opioid-tolerant patients with cancer: a comparison of increasing baseline opioids versus opioid switch/combination therapy. J Pall Med 2025; 28: 924–930.

Do distressing end of life symptoms worsen when antidepressants are discontinued without weaning?

When patients at end of life (EOL) can no longer swallow medicines, it is difficult to assess whether distressing symptoms such as agitation or restlessness occur due to disease progression or the sudden discontinuation of usual medicines, such as antidepressants. Although not a randomised trial, this study may allow us to consider how we optimise medicines discontinuation at EOL.

This retrospective American study reviewed hospice patients in the last week of life. Records for three groups of 12 patients were reviewed: patients prescribed antidepressants who did not receive them for 3–6 days before death (antidepressant disrupted [ADD]), patients prescribed antidepressants who were able to continue them until death (antidepressant continued [ADC]) and a matched cohort of patients who did not receive antidepressants (antidepressant naïve [ADN]). Patients receiving continuous infusions or with lengths of stay less than one week were excluded. Administration of oral morphine, lorazepam and haloperidol was assessed for 3 days prior to antidepressant discontinuation and 3 days post-discontinuation.

A significant increase in morphine and lorazepam total doses was found for both ADD and ADN groups, increasing to a greater extent after antidepressant disruption. There was no significant change in morphine and lorazepam doses in patients whose antidepressant continued. There was no significant change in haloperidol total doses for all three groups.

While the authors recognised that increased use of opioids and benzodiazepines occurs at EOL, they suggested discontinuation symptoms may further exacerbate EOL symptoms, but that opioids and benzodiazepines may also mask discontinuation symptoms with unnecessary sedation, which patients and families may not want. They recommend tapering antidepressants, which is not always feasible if trajectory changes rapidly.

The study has several limitations apart from its retrospective nature: small sample size, no data on specific symptoms for which morphine and lorazepam were administered and no data on which antidepressants were prescribed in the patient cohort, precluding consideration of potential differences in use of comfort medicines between antidepressants. The patient cohort may not reflect Australian practice, where patients in the last week of life would likely be prescribed subcutaneous anticipatory medicines. While not executed particularly well, this study may help us to reflect on our own practices and encourage our clinicians to more actively manage medication discontinuation as patients approach EOL.

Shanker M, Choi J, Weisse CS. Examining antidepressant discontinuation syndrome (ADS) among hospice patients in the last week of life. Am J Hosp Palliat Care 2025; (online ahead of print). https://doi.org/10.1177/10499091251381304

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RURAL AND REMOTE

MedsScan Editor for Rural and remote SPG: Kingston Yeung

Utilising a mobile telemedicine model to treat chronic hepatitis C in rural and remote settings

Special contributors: Simran Vaswani and Ujjwal Chaulagain

People who inject drugs in rural areas face substantial barriers to hepatitis C virus (HCV) care, including limited access to testing, direct-acting antiviral (DAA) therapy, specialist services and harm reduction programs. This American, randomised trial evaluated a mobile telemedicine model designed to overcome these barriers, improving treatment access and outcomes for people living in rural areas in New Hampshire and Vermont.

In total, 150 participants were randomised to either mobile telemedicine care (MTC) or enhanced usual care (EUC). The MTC intervention delivered HCV assessment and DAA treatment via telemedicine integrated with mobile syringe services. EUC participants received treatment referrals. Primary outcomes were treatment initiation and viral clearance at 12 weeks.

Treatment initiation was more than doubled in the MTC group compared with EUC (57.3% versus 26.7%, relative risk [RR] 2.2, 95% confidence interval [CI] 1.4–3.3). Viral clearance rates were also significantly higher (37.3% versus 18.7%, RR 2.0, 95% CI 1.2–3.5). Among those who initiated treatment, cure rates exceeded 60% in both groups, indicating strong treatment efficacy once treatment was initiated. No significant difference was observed in injection equipment sharing (RR 1.0).

These findings demonstrate that mobile telemedicine is an effective strategy for expanding access to HCV treatment among underserved rural populations. In the Australian context, similar outreach models could meaningfully advance national HCV elimination goals, particularly for rural and marginalised communities. However, implementation at scale would require sustained investment in workforce, mobile infrastructure and service integration.

Friedmann PD, Wilson D, de Gijsel D, Nolte K, Dejace J, Hoskinson R Jr, et al. Mobile telemedicine for treating chronic hepatitis C among rural people who inject drugs: a randomised clinical trial. JAMA Network Open 2026; 9: e2555125-e.

Implementing a Virtual Clinical Pharmacy Service in Rural and Remote Settings

Special contributors: Simran Vaswani and Ujjwal Chaulagain

Rural and remote hospitals often face significant resource constraints, including persistent workforce shortages. Many small rural and remote hospitals across Australia lack access to onsite pharmacy services. To address this gap, a randomised controlled trial was conducted across eight rural and remote hospitals in New South Wales to assess a virtual clinical pharmacy service (VCPS). The VCPS provided clinical pharmacy services via videoconferencing and documented all interventions within the patient’s electronic medical record.

A total of 1305 patients (n = 535 control, n = 527 intervention) were included. The intervention group demonstrated substantially higher rates of medication reconciliation on admission (85% versus 44%, odds ratio [OR] 11.2, 95% CI 5.6–22.3, p < 0.001). Improvements were also observed in discharge reconciliation (68% versus 38%, OR 4.07, 95% CI 2.4–7.0, p < 0.001), and best possible medication history documentation (82% versus 19%, OR 33.3, 95% CI 17.5–63.1, p < 0.001). Across the study, the VCPS identified 879 medication-related problems, of which 73% were accepted. Patient-reported experience surveys indicated that patients felt more confident in managing their medicines and reported high satisfaction with the virtual service.

Patients in rural and remote settings are at increased risk of medication-related harm due to reduced access to healthcare professionals. This study demonstrated that telehealth-enabled pharmacy services can meaningfully improve medication safety in settings where onsite pharmacists are not traditionally available. However, successful implementation requires reliable electronic medical record infrastructure, which remains a barrier in facilities still reliant on paper-based systems.

Nott S, Fleming C, Hawthorn G, Luscombe G, Allan J, Webster E, et al. A stepped wedge randomised controlled trial assessing the efficacy and patient acceptability of virtual clinical pharmacy in rural and remote Australian hospitals. BMC Health Services Research 2024; 24: 1375.

Residents and caregivers' experiences with medication communication in rural residential aged care facilities

Special contributors: Simran Vaswani and Ujjwal Chaulagain

Medication changes during transitions of care are common; yet these changes are often poorly communicated to residents of residential aged care facilities (RACF) and their caregivers. This communication gap reduces patient engagement and is particularly challenging in rural settings, where limited resources hinder continuity of care.

This qualitative study explored the perspectives of rural RACF residents and caregivers on engagement in medication communication during transitions of care in rural New South Wales and Victoria. Eligible participants included residents who had undergone at least one transition of care in the previous 12 months or a current caregiver. Qualitative interviews were conducted with nine residents and seven family caregivers.

Two major themes emerged: 1) medication communication during transitions into healthcare services and 2) influences shaping residents' and caregivers’ engagement in medication communication. Participants described a shift from being active members in their healthcare to adopting a more passive role. This shift reduced their engagement and understanding of medicine management. Staffing shortages and high turnover in rural RACFs contributed to fragmented care and inconsistent communication, making it difficult for residents and caregivers to build rapport and trust with healthcare providers.

This study highlighted a strong desire among residents and caregivers for greater involvement in medication-related decisions. The integration of aged care onsite pharmacists (ACOP) has the potential to address this need by providing accessible, ongoing medication support and empowering residents to participate more actively in their care.

Dowling A, Manias E. Engagement in medication communication during transitions of care for rural aged care residents and family caregivers: a qualitative study. J Clin Nurs 2026; 35: 850–865.

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SURGERY AND PERIOPERATIVE MEDICINE

MedsScan Editors for Surgery and perioperative medicine SPG: Abby Yu and Thuy Bui

Preoperative haemoglobin A1c as a predictor of general surgery outcomes

Dysglycaemia is a recognised risk factor for poor surgical outcomes, yet its significance in the general surgery population is less well defined than it is in other high‑risk specialties. The value of routine preoperative haemoglobin A1c (HbA1c) testing for identifying patients at increased perioperative risk, including those with undiagnosed diabetes, remains uncertain. This study evaluated associations between preoperative HbA1c levels and short‑term postoperative outcomes following general surgery.

This retrospective cohort study analysed data from the American College of Surgeons National Surgical Quality Improvement Program between 2021–2023. Adults undergoing general surgery with documented preoperative HbA1c were included. Glycaemic status was categorised by diabetes diagnosis and HbA1c level, ranging from normoglycaemia to very poor glycaemic control. Multivariable logistic regression adjusted for demographic, clinical and procedural factors.

The cohort included 282 131 patients, of whom 36% had diagnosed diabetes and 6.4% had HbA1c values in the diabetic range without a recorded diagnosis. Increasing HbA1c was associated with progressively higher risk of postoperative complications. Compared with healthy controls, those with very poor glycaemic control had higher odds of any complication (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.25–1.39, P < 0.001). Undiagnosed diabetes was also associated with increased medical complications (OR 1.11, 95% CI 1.04–1.18, P = 0.002) and 30day mortality (OR 1.24, 95% CI 1.07–1.42, P = 0.003).

This multicentre analysis demonstrated that dysglycaemia, including previously unrecognised diabetes, is common in general surgery populations and independently associated with worse outcomes. These findings support routine preoperative HbA1c screening and perioperative glycaemic assessment and optimisation in general surgery patients.

Schaschinger T, Niederegger T, Brandt J, Knoedler S, Knoedler L, Matar DY, et al. Preoperative hemoglobin A1C, glycemic status, and postoperative outcomes in general surgery. JAMA Surg 2026; 161: 39–49.

Prophylactic tranexamic acid in general surgery

Special contributor: Jesseca Eglington

Tranexamic acid is an antifibrinolytic agent that enhances the stability of fibrin clots promoting haemostasis, whilst its prothrombotic effect remains unknown. This systematic review and meta analysis assessed the effectiveness and safety of prophylactic tranexamic acid in reducing blood loss in the general surgery.

Three databases were searched for randomised clinical trials (RCTs) comparing intravenous tranexamic acid with placebo in adults undergoing general surgery, from database inception to April 2025. Twenty-six papers, including a total of 6976 patients, were included. Intravenous tranexamic acid regimens varied from bolus-only, bolus plus rescue or bolus plus continuous infusion, included fixed or weight-based dosing and administration time ranged from preoperative, intraoperative to combination regimens. 

The analysis found that tranexamic acid use was associated with lower intraoperative blood loss (mean differences [MD] -35.85 mL, 95% CI -57.20 to -14.51, P = 0.001), reduced need for transfusion (risk ratio [RR] 0.75, 95% CI 0.60 to 0.94, P = 0.01) and reduced major bleeding events (RR 0.72, 95% CI 0.59 to 0.89; P = 0.02). No statistically significant differences in venous thromboembolism, mortality or length of stay were found.

Overall, this study supports the use of prophylactic tranexamic acid in general surgery. Given the diversity of procedures within general surgery and the heterogeneity of the results, further research is required to be able to apply these findings to specific procedures and patient cohorts. Australian pharmacists should be prepared to see greater consideration of the use of prophylactic tranexamic acid, especially in the elective surgery setting, however more information on dosing and administration is required before including it in specific perioperative protocols.

Delgado LM, Pompeu BF, Martins GHA, Azevedo ML, Pasqualotto E, Chulam TC, et al. Perioperative use of tranexamic acid in general surgery: a systematic review and meta-analysis. JAMA Surg 2026; 161: 179–187.

Home-based prehabilitation for gastrectomy

Special contributor: Janelle Penno

Major surgery is often likened to a marathon; something you would not undertake without training. This is where prehabilitation comes in, it prepares patients through a multidisciplinary, multimodal program incorporating exercise, respiratory training, psychological support and optimisation of nutrition, haematinics, comorbidities and medicines.

This multicentre RCT included 347 frail older patients (median age 70 years, 27.4% female, 82.7% with multiple comorbidities) undergoing radical gastrectomy. Patients were randomised to prehabilitation or standard enhanced recovery after surgery (ERAS) care to reduce postoperative complications. Prehabilitation involved a two-week home-based intervention program.

Prehabilitation compliance was high (93.75%), with no related adverse events. The prehabilitation group had fewer intensive care unit (ICU) admissions (22.5% versus 32.6%, p = 0.04) and shorter mechanical ventilation (6 h versus 9h, p = 0.008) and ICU stays (24 h versus 38 h, p < 0.001). Postoperative complications were significantly lower with prehabilitation (17.2% versus 28.7%, p = 0.01), particularly medical complications such as pneumonia. Functional capacity was increased with prehabilitation by more than 20 m on a 6-min walk test which persisted post-surgery and was clinically significant.

This study strengthens evidence supporting surgical prehabilitation, with expected positive outcomes. Frailty was assessed using the Geriatric 8 score, one of several tools validated in surgical populations. Applicability may be limited by reliance on trained family members to support prehabilitation. Pharmacist involvement for medication optimisation and deprescribing would have been valuable given the comorbidity burden, but the short preoperative timeframe would limit benefits. Pharmacists’ roles in prehabilitation are emerging and compliment the comprehensive assessment undertaken as part of prehabilitation, particularly where longer surgical lead times allow for meaningful medicines optimisation.

Sun Y, Tian Y, Cao S, Li L, Yu W, Ding Y, et al. Supervised multimodal prehabilitation and clinical outcomes in older patients with frailty and gastric cancer: the GISSG+2201 randomized clinical trial. JAMA Surgery 2026; 161: 223–233.

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TECHNICIANS AND ASSISTANTS

MedsScan Editor for Technicians and assistants SPG: Bryan Walker

Empowering the pharmaceutical workforce for the digital future

The pharmaceutical industry is undergoing rapid operational and technological change. These changes are influencing pharmaceutical sciences, data sciences and automation engineering. But with all these advances, there are still significant gaps in sustaining innovation with these digital technologies. This review article explored shifting digital technologies and data science skills within the pharmaceutical industry to see how job roles are evolving and reshaping the industry across the United Kingdom and Europe.

The authors mapped broad changes already underway in the profession. In particular, the evolution of job roles and what it means to be a technician (and a pharmacist) are shifting. The increasing presence of artificial intelligence and other digital developments are creating new or expanded roles such as a pharmaceutical data scientist that applies data science methods to drug development and manufacturing data and a digital process engineer that is responsible for integrating automation and data analytics into manufacturing processes.

To support these evolving roles, university education programs must include data science and evidence-based practices to prepare future pharmacy technicians.  In addition to university education, CPD (continuing professional development) can also be used to prepare pharmacists and technicians by upskilling and reskilling teams to prepare them for the changing landscape.

The authors argue that preparing the technician and pharmacist workforce for their digital future requires an integrated approach from the beginning of a person’s journey from university and throughout their career. A combined effort from the political, industrial and academic sectors will be necessary to ensure growth and sustainability, but it is important to note that digital changes do not undermine the role of technicians but remind us they are more essential than ever.

This summary barely touches on all the changes that will shape the industry's future. Readers are strongly encouraged to read the entire review for more information.

Maclean N, Abrahmsén-Alami S, Clark C, Dörr F, Florence A, Ketolainen J, et al. Empowering the pharmaceutical workforce for the digital future. Eur J Pharm Sci 2026; 220: 107449.

Why are pharmacy technicians leaving? Factors contributing to turnover intention and strategies for retention

It is no secret that many pharmacy technicians and assistants leave the workforce. Many left during the COVID-19 pandemic, but even more left afterwards. Roles have been expanded but their responsibilities have not always been clarified. In some cases, the challenges of keeping up with training amid all the changes have made achieving goals difficult. Training inconsistencies contribute to pharmacists’ reluctance to delegate tasks, and technicians and assistants are unable to learn, grow and achieve.

In England, there are 22 119 registered pharmacy technicians as of September 2024. Estimates suggest a 9% vacancy rate across the acute and primary care sectors and private sector estimates suggest a minimum of 20%. There is growing concern that the pharmacy technician workforce will lack the skills needed to adapt to the evolving landscape.

This mixed-methods study surveyed and interviewed pharmacy technicians to understand their career and organisational commitment, job satisfaction, job stress and intention to leave the profession to identify problems in the workforce and determine steps to mitigate them.

Six hundred and three survey responses were received (response rate 5.2%) and 19 semi-structured interviews were conducted. Many of the respondents were women (n = 489, 86.9%), with only 61 (10.8%) male respondents included. The most common workplace setting was hospital pharmacy (26%). The most mentioned reason for departure was a lack of career progression. Some respondents felt the only way to move up in the profession was to leave the pharmacy technician field and seek something different, or to enter a field adjacent to pharmacy. Some participants felt they received little recognition for the work they did and there was a general lack of understanding of what pharmacy technicians do and a lack of professional acknowledgement.

Prioritising career development opportunities, such as mentorship, would demonstrate a commitment to developing pharmacy technicians. Cultivating supportive and inclusive work environments would be essential for the wellbeing of pharmacy technicians. This involves fostering a culture that supports and values the contributions of pharmacy technicians and promotes improved work-life balance.

McDermott I, Willis S, Hindi A, Schafheutle E. Why are pharmacy technicians leaving? Factors contributing to turnover intention and strategies for retention. Res Social Adm Pharm 2025; 21: 94–103.

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TRANSITIONS OF CARE AND PRIMARY CARE

MedsScan Editors for Transitions of care and primary care SPG: Kingston Yeung and Elizabeth Manias

Efficacy of a pharmacist-led transition of care program in the emergency department

Contributor: Elizabeth Manias

Medication-related adverse events frequently occur which contribute to patient harm, hospital readmissions and emergency department (ED) visits. Little is known about whether pharmacist-led programs in the ED setting impact the occurrence of medication-related events. The aim of this French study was to assess the efficacy of a pharmacist-led transition of care program compared to usual care, in reducing the proportion of patients with at least one identical medication-related event leading to an ED visit at six months.

A prospective, parallel-group randomised controlled trial was conducted, comprising adult patients with a medication-related event detected at ED admission. The intervention involved ED pharmacists making post-discharge telephone calls and sending letters to general practitioners (GPs) and community pharmacists, informing them about management recommendations. Information from ED pharmacists comprised the suspected medicine/s involved in the medication-related event and recommendations such as discontinuation of medicines, patient education or the need for specialised medical consultations.

In all, 167 patients were randomised to the intervention group and 163 to the control group. At six months, fewer people in the intervention group had ED visits related to the same medication-related event (n = 5, 3.0% versus n = 36, 22.1%). There was a decrease in all-cause ED visits in the intervention group compared to the control group at six months (n = 35, 21.0% versus n = 57, 35.0%). All-cause medical costs, hospitalisation and mortality were not significantly different between the two groups.

The authors concluded that there were potential benefits in a pharmacist-led transition of care with multidisciplinary collaboration. Limitations of the study related to it being conducted within a single university hospital and the self-reporting of health care utilisation costs by patients and GPs. While the study had a novel focus for the primary outcome relating to previously diagnosed medication-related events, further research is needed to evaluate the intervention in diverse healthcare systems.

Villiet M, Laureau M, Perier D, Pinzani V, Giraud I, Lohan L, et al. Emergency department visits for medication-related events with vs without pharmacist intervention: the URGEIM randomized clinical trial. JAMA Intern Med 2025; 185: 669–678.

Pharmacist-to-pharmacist transitions of care program

Special contributors: Simran Vaswani and Ujjwal Chaulagain

Transitions of care (TOC) are high-risk periods for medication-related problems (MRPs) and improving medication safety during these transitions has become a global priority. This pilot study evaluated the feasibility of a pharmacist-to-pharmacist TOC pilot program in the United States to support patients discharged from general medicine at hospital discharge. The program included inpatient pharmacists that identified patients at risk and referred them to an outpatient pharmacist for a comprehensive post-discharge medication review within 30 days of hospital admission.

A total of 25 patients were included. Patients had a mean age of 66 years, were predominantly male and were discharged on an average of 12 medicines. Of these, 10 patients were accepted by the outpatient clinic and received a post-discharge medication review, during which 41 MRPs were identified. The most common MRPs included medication access barriers, the need for counselling or education and risks of adverse drug reactions. Common interventions included patient counselling, discontinuing medicines and identifying opportunities for cost savings.

These findings underscore the need for coordinated communication between healthcare providers during transitions of care. The pharmacist-to-pharmacist model demonstrated a practical approach to facilitate timely follow up. This approach aligns well with the Australian context, where Home Medicine Reviews (HMRs) provide a federally funded mechanism for post-discharge medication review, however although inpatient pharmacists can recommend HMRs, they currently cannot refer patients directly. These pilot findings suggest that enabling pharmacist-initiated referrals may strengthen continuity of care and improve medication safety. Further research is needed to determine the applicability and sustainability of this model.

McDonnell J, Combs K, Dockery R. Optimizing healthcare: implementation of a pharmacist-to-pharmacist transitions of care pilot program. J Pharm Pract 2025; 38: 397–402.

Pharmacist-led GLP-1 agonists optimisation service

Special contributors: Simran Vaswani and Ujjwal Chaulagain

Glucagon-like peptide-1 receptor (GLP-1) agonists are increasingly used as adjunct therapy to metformin for type 2 diabetes mellitus (T2DM), offering benefits such as improved glycaemic control, reduced cardiovascular risk, weight loss and kidney protection. However, optimal use requires careful monitoring and dose titration, which may not be feasible given GP workforce shortages. This American pilot study evaluated a pharmacist-led GLP-1 agonists titration service, designed to optimise therapy and improve clinical outcomes.

Eligible patients were adults with T2DM, prescribed a GLP-1 agonist by their GP and referred to the outpatient pharmacist. Pharmacists monitored and titrated GLP-1 agonists according to the study protocol and provided regular follow up to assess tolerability, glycaemic control and adherence.

A total of 112 patients were included. The cohort had a mean age of 56 years, was predominantly male and had a mean baseline haemoglobin A1c (HbA1c) of 8.3% and a mean weight of 114.7 kg. Patients were taking an average of 2.5 diabetes medicines at baseline. Following pharmacist-led GLP-1 agonist optimisation, mean HbA1c decreased by 1.8% (8.3% to 6.4%, p < 0.001) at 3–6 months. Mean weight decreased by 8.1 kg (p < 0.001), representing approximately 6.5% mean weight loss. The average number of diabetes medicines decreased from 2.5 to 2.1. On average, patients required 6.5 pharmacist encounters, totalling 91 mins of pharmacist time.

These findings support the role pharmacists can play in supporting primary care and chronic disease management, particularly in optimising GLP-1 agonist therapy and reducing medication burden. In Australia, similar models could be integrated into general practice settings; however, current scope of practice restrictions may limit implementation. Further evaluation is needed to determine the feasibility, sustainability and health system impact within the Australian context.

Miller K, Carson E, Boothe K, Brown B. Implementation and evaluation of a pharmacist-led glucagon-like peptide-1 receptor agonist titration service in two primary care clinics. J Am Pharm Assoc 2025; 65: 102385.

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