Predicting risk of adverse drug reactions in older adults

Association of Sex, Age, and Comorbidities with Mortality in COVID-19 Patients: A Systematic Review and Meta-Analysis

INTRODUCTION

Although severe acute respiratory syndrome coronavirus-2 infection is causing mortality in considerable proportion of coronavirus disease-2019 (COVID-19) patients, however, evidence for the association of sex, age, and comorbidities on the risk of mortality is not well-aggregated yet. It was aimed to assess the association of sex, age, and comorbidities with mortality in COVID-2019 patients.

METHODS

Literatures were searched using different keywords in various databases. Relative risks (RRs) were calculated by RevMan software where statistical significance was set as p < 0.05.

RESULTS

COVID-19 male patients were associated with significantly increased risk of mortality compared to females (RR 1.86: 95% confidence interval [CI] 1.67-2.07; p < 0.00001). Patients with age ≥50 years were associated with 15.4-folds significantly increased risk of mortality compared to patients with age <50 years (RR 15.44: 95% CI 13.02-18.31; p < 0.00001). Comorbidities were also associated with significantly increased risk of mortality; kidney disease (RR 4.90: 95% CI 3.04-7.88; p < 0.00001), cereborovascular disease (RR 4.78; 95% CI 3.39-6.76; p < 0.00001), cardiovascular disease (RR 3.05: 95% CI 2.20-4.25; p < 0.00001), respiratory disease (RR 2.74: 95% CI 2.04-3.67; p < 0.00001), diabetes (RR 1.97: 95% CI 1.48-2.64; p < 0.00001), hypertension (RR 1.95: 95% CI 1.58-2.40; p < 0.00001), and cancer (RR 1.89; 95% CI 1.25-2.84; p = 0.002) but not liver disease (RR 1.64: 95% CI 0.82-3.28; p= 0.16).

CONCLUSION

Implementation of adequate protection and interventions for COVID-19 patients in general and in particular male patients with age ≥50 years having comorbidities may significantly reduce risk of mortality associated with COVID-19.

Identifying side effects of commonly used drugs in the treatment of Covid 19

To increase the success in Covid 19 treatment, many drug suggestions are presented, and some clinical studies are shared in the literature. There have been some attempts to use some of these drugs in combination. However, using more than one drug together may cause serious side effects on patients. Therefore, detecting drug-drug interactions of the drugs used will be of great importance in the treatment of Covid 19. In this study, the interactions of 8 drugs used for Covid 19 treatment with 645 different drugs and possible side effects estimates have been produced using Graph Convolutional Networks. As a result of the experiments, it has been found that the hematopoietic system and the cardiovascular system are exposed to more side effects than other organs. Among the focused drugs, Heparin and Atazanavir appear to cause more adverse reactions than other drugs. In addition, as it is known that some of these 8 drugs are used together in Covid-19 treatment, the side effects caused by using these drugs together are shared. With the experimental results obtained, it is aimed to facilitate the selection of the drugs and increase the success of Covid 19 treatment according to the targeted patient.

Emergency Room Visit Prevention for Older Patients with Parkinsonism in a Geriatric Clinic

BACKGROUND

Older persons with parkinsonism (PWP) are at high risk for hospitalization and adverse outcomes. Few effective strategies exist to prevent Emergency Department (ED) visits and hospitalization. The interdisciplinary Geriatrics Clinic for Parkinson's ("our clinic") was founded to address the complexity of parkinsonism in older patients, supported by a pharmacist-led telephone intervention (TI) service. Our primary objective was to study whether TI could avert ED visits in older PWP.

METHODS

Using a prospective, observational cohort, we collected data from all calls in 2016, including who initiated and reasons for the calls, patient demographics, number of comorbidities and medications, diagnoses, duration of disease, and intervention provided. Calls with intention to visit ED were classified as "crisis calls". Outcome of whether patients visited ED was collected within 1 week, and user satisfaction by anonymous survey within 3 weeks.

RESULTS

We received 337 calls concerning 114 patients, of which 82 (24%) were "crisis calls". Eighty-one percent of calls were initiated by caregivers. Ninety-three percent of "crisis calls" resolved without ED visit after TI. The main reasons for "crisis calls" were non-motor symptoms (NMS) (39%), adverse drug effects (ADE) (29%), and motor symptoms (18%). Ninety-seven percent of callers were satisfied with the TI.

CONCLUSION

Pharmacist-led TI in a Geriatrics Clinic for Parkinson's was effective in preventing ED visits in a population of older PWP, with high user satisfaction. Most calls were initiated by caregivers. Main reasons for crisis calls were NMS and ADE. These factors should be considered in care planning for older PWP.

Prevalence and Associated Factors of Drug-Related Problems Among Older People: A Cross-Sectional Study at King Chulalongkorn Memorial Hospital in Bangkok

BACKGROUND AND OBJECTIVE

The use of multiple medications and altered pharmacokinetics/pharmacodynamics may lead to drug-related problems in members of the older population. The aim of this study is to evaluate the prevalence of, and factors related to, drug-related problems in older urban-living Thai people.

METHODS

We conducted a cross-sectional study involving 466 participants (aged ≥ 65 years) whose first-time health screening at the Geriatric Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok was between May and October 2019. Participants were interviewed and assessed for drug-related problems by clinical pharmacists.

RESULTS

In total, 54.5% (254) of the participants were aged 65-69 years and 77.0% (359) of the participants were women. Of the participants, 56.7% had three or more health conditions such as hyperlipidemia (62%), hypertension (46%), and cataract (18%). Fifty-five percent of the participants took five or more health products (polypharmacy) and 16% took ten or more products on a regular basis. Of the 2633 products used, 68% were prescription drugs and 32% were over-the-counter products. The prevalence of drug-related problems according to the criteria suggested by Cipolle-Strand-Morley (2012) was 63.3% (587 drug-related problems). Most of the problems came from: (a) non-adherence (28.6%); (b) needs for additional drug therapy (26.4%); and (c) adverse drug reactions (17.4%). Factors associated with drug-related problems were polypharmacy (odds ratio 2.50, 95% confidence interval 1.60-3.89) and multiple comorbidities [three or more conditions] (odds ratio 2.20, 95% confidence interval 1.41-3.43).

CONCLUSIONS

The prevalence of drug-related problems in urban-living older people at King Chulalongkorn Memorial Hospital in Bangkok was high. Polypharmacy and multiple comorbidities were significantly related to drug-related problems. To decrease the number of drug-related problems, pharmacists should collaborate with healthcare teams and suggest how to correctly reduce the number of health products being consumed by older people.

Development of cardiotoxicity model using ligand-centric and receptor-centric descriptors

Background:

Bioinformatics and statistical analysis have been employed to develop a classification model to distinguish toxic and non-toxic molecules.

Aims:

The primary objective of this study is to enumerate the cut-off values of various physico-chemical (ligand-centric) and target interaction (receptor-centric) descriptors which forms the basis for classifying cardiotoxic and non-toxic molecules. We also sought correlation of molecular docking, absorption, distribution, metabolism, excretion, and toxicology (ADMET) parameters, Lipinski rules, physico-chemical parameters, etc. of human cardiotoxicity drugs.

Methods:

A training and test set of 91 compounds were applied to linear discriminant analysis (LDA) using 2D and 3D descriptors as discriminating variables representing various molecular modeling parameters to identify which function of descriptor type is responsible for cardiotoxicity. Internal validation was performed using the leave-one-out cross-validation methodology ensuing in good results, assuring the stability of the discriminant function (DF).

Results:

The values of the statistical parameters Fisher Discriminant Analysis (FDA) and Wilk’s λ for the DF showed reliable statistical significance, as long as the success rate in the prediction for both the training and the test set attained more than 93% accuracy, 87.50% sensitivity and 94.74% specificity.

Conclusion:

The predictive model was built using a hybrid approach using organ-specific targets for docking and ADMET properties for the FDA (Food and Drug Administration) approved and withdrawn drugs. Classifiers were developed by linear discriminant analysis and the cut-off was enumerated by receiver operating characteristic curve (ROC) analysis to achieve reliable specificity and sensitivity.

Antidepressant use and orthostatic hypotension in older adults living with mild-to-moderate Alzheimer disease

OBJECTIVES

Antidepressant use is often reported as a risk factor for Orthostatic Hypotension (OH), however this relationship has never been explored in those with mild/moderate Alzheimer Disease (AD), who may represent a particularly vulnerable cohort.

METHODS

We performed a cross-sectional analysis of baseline data from the NILVAD study. Participants with mild-moderate AD were recruited from 23 centres in nine countries. Systolic and Diastolic Blood Pressure (SBP/DBP) was recorded in the seated position and after both 1 and 5 minutes of standing. OH was defined as a drop of ≥20 mmHg SBP/≥10 mmHg DBP. We examined the relationship between antidepressant use, orthostatic BP drop and the presence of OH, controlling for important covariates.

RESULTS

Of 509 participants (72.9 ± 8.3 years, 61.9% female), two-fifths (39.1%; 199/509) were prescribed a regular antidepressant. Antidepressant use was associated with a significantly greater SBP and DBP drop at 5 minutes (β: 1.83, 0.16-3.50, P = .03 for SBP; β: 1.13, 0.02-2.25, P < .05 for DBP). Selective Serotonin Reuptake Inhibitor (SSRI) use was associated with a significantly greater likelihood of OH (OR 2.0, 1.1-3.6, P = .02). Both findings persisted following robust covariate adjustment.

CONCLUSIONS

In older adults with AD, antidepressants were associated with a significantly greater SBP/DBP drop at 5 minutes. SSRI use in particular may be a risk factor for OH. This emphasises the need to screen older antidepressant users, and particularly those with AD, for ongoing orthostatic symptoms in order to reduce the risk of falls in this vulnerable cohort.

The phenotype of adverse drug effects: Do emergency visits due to adverse drug reactions look different in older people? Results from the ADRED study

AIMS

Older patients in particular suffer from adverse drug reactions (ADR) when presenting in the emergency department. We aimed to characterise the phenotype of those ADRs, to be able to recognise an ADR in older patients.

METHODS

Cases of ADRs in emergency departments collected within the multicentre prospective observational study (ADRED) were analysed (n = 2215). We analysed ADR-associated diagnoses, symptoms and their risk profiles. We present frequencies and odds ratios (OR) with 95% confidence intervals for adults (18-64 years) compared to older adults (≥65 years; young-old 65-79, old-old ≥80 years) and regression coefficients (B) for each year of age.

RESULTS

Most prominent differences were seen for drug-associated confusion, dehydration, and bradycardia (OR 6.70 [1.59-28.27], B .054; OR 6.02 [2.41-15.03], B .081, and 4.82 [2.21-10.54], B .040), more likely seen in older adults. Bleedings were reported in all age groups, but gastrointestinal bleedings occurred with more than doubled chance in older adults (OR 2.46 [1.77-3.41], B .030), likewise did other bleedings such as haemorrhage from respiratory passages (OR 2.89 [1.37-6.11], B.036). Falls were more likely in older adults (OR 2.84 [1.77-4.53], B .030), while dizziness was frequent in both age groups.

CONCLUSION

Our data point to differences in symptoms of ADRs between adults and older individuals, with dangerous drug-associated phenomena in the older adult such as bleedings or falls. Physicians should consider drug-associated origins of symptoms in older adults with an increased risk for serious health problems.

Considering additive effects of polypharmacy : Analysis of adverse events in geriatric patients in long-term care facilities

Background

Potential additive effects of polypharmacy are rarely considered in adverse events of geriatric patients living in long-term care facilities. Our aim, therefore, was to identify adverse events in this setting and to assess plausible concomitant drug causes.

Methods

A cross-sectional observational study was performed in three facilities as follows: (i) adverse event identification: we structurally identified adverse events using nurses’ interviews and chart review. (ii) Analysis of the concomitantly administered drugs per patient was performed in two ways: (ii.a) a review of summary of product characteristics for listed adverse drug reactions to identify possible causing drugs and (ii.b) a causality assessment according to Naranjo algorithm.

Results

(i) We found 424 adverse events with a median of 4 per patient (range 1–14) in 103 of the 104 enrolled patients (99%). (ii.a) We identified a median of 3 drugs (range 0–11) with actually occurring adverse events listed as an adverse drug reaction in the summary of product characteristics. (ii.b) Causality was classified in 198 (46.9%) of adverse events as “doubtful,” in 218 (51.2%) as “possible,” in 7 (1.7%) as “probable,” and in 1 (0.2%) adverse event as a “definitive” cause of the administered drugs. In 340 (80.2%) of all identified adverse events several drugs simultaneously reached the highest respective Naranjo score.

Conclusion

Patients in long-term facilities frequently suffer from many adverse events. Concomitantly administered drugs have to be frequently considered as plausible causes for adverse events. These additive effects of drugs should be more focused in patient care and research.

The Double Burden of the COVID-19 Pandemic and Polypharmacy on Geriatric Population - Public Health Implications

COVID-19 pandemic is inducing acute respiratory distress syndrome, multi-organ failure, and eventual death. Respiratory failure is the leading cause of mortality in the elderly population with pre-existing medical conditions. This group is particularly vulnerable to infections due to a declined immune system, comorbidities, geriatric syndrome, and potentially inappropriate polypharmacy. These conditions make the elderly population more susceptible to the harmful effects of medications and the deleterious consequences of infections, including MERS-CoV, SARS-CoV, and SARS-CoV-2. Chronic diseases among elderlies, including respiratory diseases, hypertension, diabetes, and coronary heart diseases, present a significant challenge for healthcare professionals. To comply with the clinical guidelines, the practitioner may prescribe a complex medication regimen that adds up to the burden of pre-existing treatment, potentially inducing adverse drug reactions and leading to harmful side-effects. Consequently, the geriatric population is at increased risk of falls, frailty, and dependence that enhances their susceptibility to morbidity and mortality due to SARS-CoV-2 respiratory syndrome, particularly interstitial pneumonia. The major challenge resides in the detection of infection that may present as atypical manifestations in this age group. Healthy aging can be possible with adequate preventive measures and appropriate medication regimen and follow-up. Adherence to the guidelines and recommendations of WHO, CDC, and other national/regional/international agencies can reduce the risks of SARS-CoV-2 infection. Better training programs are needed to enhance the skill of health care professionals and patient’s caregivers. This review explains the public health implications associated with polypharmacy on the geriatric population with pre-existing co-morbidities during the COVID-19 pandemic.

Polypharmacy among adult and older adult users of primary care services delivered through the Unified Health System in Minas Gerais, Brazil

OBJECTIVES

To estimate the prevalence of polypharmacy (≥5 drugs) among adults and to analyze related factors.

METHODS

Cross-sectional study with 1,159 interviewees distributed across 104 cities and 253 primary healthcare services delivered through the Brazilian Unified Health System. Polypharmacy-related factors were identified using logistic regression model.

RESULTS

949 (81.8%) interviewees were using at least one medication and were included in this analysis. The prevalence of polypharmacy among them was 13.7% (95%CI:11.7-16.0%) in the general population and 33.3%(95%CI:26.1-41.4%) in older adults(≥65 years). Polypharmacy was positively associated with age (45 to 64 years, OR=2.02; 95%CI:1.03-3.94; ≥65 years, OR=4.17; 95%CI:1.92-9.17) and the following chronic diseases: stroke (OR=4.20; 95%CI:1.53-11.55); diabetes mellitus (OR=4.03; 95%CI:2.43-6.68); heart disease (OR=3.18; 95%CI:1.92-5.29); depression (OR=2.85; 95%CI:1.80-4.53); hypertension (OR=2.13; 95%CI:1.17-3.86); and dyslipidemia (OR=1.73; 95%CI:1.07-2.80).

CONCLUSION

This study revealed that polypharmacy is a real concern in primary health care and affects older and middle-aged adults alike. Groups of patients that are more likely to experience polypharmacy were identified. Our findings emphasize the relevance of an appropriate approach to polypharmacy driven by aging and multimorbidity.

Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital

Tuberculosis (TB) in the elderly (>65 years old) has increasingly become a global health problem. It has long been recognized that older people are vulnerable to developing tuberculosis. We retrospectively evaluated data from patients older than 65 years diagnosed with pulmonary TB admitted to the National Institute for Infectious Diseases L. Spallanzani, Rome, Italy, from 1 January 2016 to 31 December 2019. One hundred and six consecutive patients were diagnosed with pulmonary TB and 68% reported at least one comorbidity and 44% at least one of the TB risk-factors. Out of the 26 elderly patients who reported an adverse event, having risk factors for TB (O.R. (Odds Ratios) = 1.45; 95% CI 1.12-3.65) and the presence of cavities on Chest X-rays (O.R. = 1.42; 95% CI 1.08-2.73) resulted in being more likely to be associated with adverse events in elderly patients. Having weight loss (O.R. = 1.31; 95% CI 1.08-1.55) and dyspnea (O.R. = 1.23; 95% CI 1.13-1.41) resulted in being significant predictors of unsuccessful treatment outcome in elderly patients. Older people with TB represent a vulnerable group, with high mortality rate, with a challenging diagnosis. Hospitalizations in tertiary referral hospital with clinical expertise in TB management can be useful to improve the outcome of these fragile patients.

Impact of oral anticoagulation choice on healthcare utilization for the primary treatment of venous thromboembolism

Little is known about the impact of oral anticoagulation (OAC) choice on healthcare encounters during venous thromboembolism (VTE) primary treatment. Among anticoagulant-naïve patients with VTE, we tested the hypotheses that healthcare utilization would be lower among users of direct OACs (DOACs; rivaroxaban or apixaban) than among users of warfarin. MarketScan databases for years 2016 and 2017 were used; healthcare utilization was identified in the first 6 months after initial VTE diagnoses. The 23,864 patients with VTE had on average 0.2 ± 0.5 hospitalizations, spent 1.3 ± 5.2 days in the hospital, had 5.7 ± 5.1 outpatient encounters, and visited an emergency department 0.4 ± 1.1 times. As compared to warfarin, rivaroxaban and apixaban were associated with fewer hospitalizations, days hospitalized, outpatient office visits, and emergency department visits after accounting for age, sex, comorbidities, and medications. Hospitalization rates were 24% lower (incidence rate ratio (IRR): 0.76; 95% CI: 0.69, 0.83) with rivaroxaban and 22% lower (IRR: 0.78; 95% CI: 0.71, 0.87) with apixaban, as compared to warfarin (IRR: 1.00 (reference)). Healthcare utilization was similar between apixaban and rivaroxaban users. Patients with VTE prescribed rivaroxaban and apixaban had lower healthcare utilization than those prescribed warfarin, while there was no difference when comparing apixaban to rivaroxaban. These findings complement existing literature supporting the use of DOACs over warfarin.

Quality indicators for a geriatric emergency care (GeriQ-ED) - an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department

Introduction

In emergency care, geriatric requirements and risks are often not taken sufficiently into account. In addition, there are neither evidence-based recommendations nor scientifically developed quality indicators (QI) for geriatric emergency care in German emergency departments. As part of the GeriQ-ED© research project, quality indicators for geriatric emergency medicine in Germany have been developed using the QUALIFY-instruments.

Methods

Using a triangulation methodology, a) clinical experience-based quality aspects were identified and verified, b) research-based quality statements were formulated and assessed for relevance, and c) preliminary quality indicators were operationalized and evaluated in order to recommend a feasible set of final quality indicators.

Results

Initially, 41 quality statements were identified and assessed as relevant. Sixty-seven QI (33 process, 29 structure and 5 outcome indicators) were extrapolated and operationalised. In order to facilitate implementation into daily practice, the following five quality statements were defined as the GeriQ-ED© TOP 5: screening for delirium, taking a full medications history including an assessment of the indications, education of geriatric knowledge and skills to emergency staff, screening for patients with geriatric needs, and identification of patients with risk of falls/ recurrent falls.

Discussion

QIs are regarded as gold standard to measure, benchmark and improve emergency care. GeriQ-ED© QI focused on clinical experience- and research-based recommendations and describe for the first time a standard for geriatric emergency care in Germany. GeriQ-ED© TOP 5 should be implemented as a minimum standard in geriatric emergency care.

Prevalence and Seriousness of Analgesic-Induced Adverse Events in Korea: A 10-Year Nationwide Surveillance

OBJECTIVES

The objectives of this study were to describe the prevalence and seriousness of analgesic-induced adverse events (AEs) and to identify factors associated with serious analgesic-related AEs in Korea.

METHODS

Voluntarily reported analgesic-induced AEs to the Korea Adverse Event Reporting System from 2007 to 2016 were retrospectively reviewed. Analgesic medications were classified into nonopioids and opioids based on the Anatomical Therapeutic Chemical classification system. All AEs were grouped using System Organ Classes according to the World Health Organization-Adverse Reaction Terminology. Logistic regression was performed to identify factors associated with serious AEs.

RESULTS

Overall, 194,566 AEs (32.2% for nonopioids, 67.8% for opioids) were included in this analysis. The most common causative nonopioid and opioid analgesics was ketorolac (n = 10,789) and tramadol (n = 53,727), respectively. The most frequent AEs were skin and appendage disorders for nonopioids (31.8%) and gastrointestinal disorders (59.5%) for opioids. Serious AEs occurred in 6102 (9.7%) and 3326 (2.5%) cases of the nonopioid and opioid groups, respectively. The most common serious AEs were skin and appendage disorders (33.2%) for nonopioids and neurologic disorders (19.3%) for opioids. Serious AEs were significantly associated with male (odds ratio [OR] = 1.423), advanced age (OR = 1.570), certain causality (OR = 2.304), nonopioid analgesics (OR = 4.182), and polypharmacy (OR = 1.009; P <0.001 for all).

CONCLUSIONS

In Korea, analgesic-induced AEs are prevalent with opioids more commonly implicated. Tramadol is the most common etiologic medication. Serious AEs are more frequently caused by nonopioids with skin and appendage disorders most common.

Frailty and the Risk of Polypharmacy in the Older Person: Enabling and Preventative Approaches

Frail older people have an inherent risk of polypharmacy due to the need to treat multiple comorbidities, thus leading to various negative effects on their health due to the adverse actions from the drugs. This issue was discussed from a person-centered perspective, highlighting the category of frail older adults who are at a higher risk. Appropriate medication reconciliation in this population with useful prescribing tools (Beers and START/STOPP criteria) to minimize polypharmacy and to provide alternative prescriptive intervention could go alongside primary care to reduce the extent of frailty and polypharmacy. Reducing delayed referrals and extended hospitalization with electronic health record systems and using the signs of frailty from the Electronic Frailty Index (EFI) to predict polypharmacy for frail older persons are preventative approaches that proactively respond to frailty associated with the risk of polypharmacy.

Tolerability of high-dose ceftriaxone in CNS infections: a prospective multicentre cohort study

BACKGROUND

Ceftriaxone is widely used to treat community-acquired CNS bacterial infections. French guidelines for meningitis in adults promote 75-100 mg/kg/day ceftriaxone without an upper limit for dosage, yet little is known about the pharmacology and tolerability of such regimens.

PATIENTS AND METHODS

A multicentre prospective cohort study was conducted in adult patients to assess the adverse drug reactions (ADRs) of high-dose ceftriaxone (i.e. daily dosage ≥4 g or ≥75 mg/kg) in CNS infections and to analyse their related factors. Drug causality was systematically assessed by an expert committee who reviewed the medical charts of all included patients.

RESULTS

A total of 196 patients were enrolled over a 31 month period. Median dosage and duration of ceftriaxone were 96.4 mg/kg/day (7 g/day) and 8 days, respectively. Nineteen ceftriaxone-related ADRs (mainly neurological) occurred in 17 patients (8.7%), with only one case of treatment discontinuation (biliary pseudolithiasis). In univariate analysis, older age, male gender, renal impairment and high trough ceftriaxone plasma concentration were associated with ceftriaxone-related ADRs.

CONCLUSIONS

High-dose ceftriaxone for CNS infection administered as recommended by French guidelines in adults was well tolerated overall, suggesting these recommendations could be applied and generalized. In patients with advanced age or renal insufficiency, prescription should be done with caution and therapeutic drug monitoring could be useful.

The development of a scoring and ranking strategy for a patient-tailored adverse drug reaction prediction in polypharmacy

Only few applications are currently dealing with personalized adverse drug reactions (ADRs) prediction in case of polypharmacy. The study aimed to develop a patient-tailored ADR web application, considering characteristics from 734 drugs and relevant patient related factors. The application was designed in Python using a scoring and ranking system based on frequency and severity, computed for each ADR and expressed through an online platform. A neural networks algorithm was used for predicting the severity of ADRs. The application inputs are: age, gender, drugs, relevant pathologies. The outputs are: an overall severity profile (hospitalization and mortality risk), a stratified risk on specific ADR groups and a sorted list of the most important ADRs depending on frequency and severity. The Severity prediction model validation resulted in 79.7–85.1% Area Under the Receiver Operating Characteristic Curve Score, which lies in the good cut-off of 75–90%. The program offers a complex view regarding the ADR profile of a given patient and could be used by the physician and clinical pharmacist during patient safety monitoring, for a coherent therapy choice or medication adjustment, due to the good therapy coverage and the inclusion of relevant patient comorbidities.

Development of an adverse drug event network to predict drug toxicity

Despite of their therapeutic effects, drug's exposure may have negative effects on human health such as adverse drug reaction (ADR) and side effects (SE). Adverse drug events (ADEs), that correspond to an event occurring during the drug treatment (i.e. ADR and SE), is not necessarily caused by the drug itself, as this is the case with medical errors and social factors. Due to the complexity of the biological systems, not all ADEs are known for marketed drugs. Therefore, new and effective methods are needed to determine potential risks, including the development of computational strategies. We present an ADE association network based on 90,827 drug-ADE associations between 930 unique drug and 6221 unique ADE, on which we implemented a scoring system based on a pull-down approach for prediction of drug-ADE combination. Based on our network, ADEs proposed for three drugs, safinamide, sonidegib, rufinamide are further discussed. The model was able to identify, already known drug-ADE associations that are supported by the literature and FDA reports, and also to predict uncharacterized associations such as dopamine dysregulation syndrome, or nicotinic acid deficiency for the drugs safinamide and sonidegib respectively, illustrating the power of such integrative toxicological approach.

Drug Safety in Geriatric Patients: Current Status and Proposed Way Forward

Elderly patients are the main users of drugs and they differ from younger patients. They are a heterogeneous population that cannot be defined only by age but should rather be stratified based on their frailty. The elderly have distinctive pharmacokinetic and pharmacodynamic characteristics, are frequently polymorbid, and are therefore treated with multiple drugs. They may experience adverse reactions that are difficult to recognize, since some of them present non-specific symptoms easily mistaken for geriatric conditions. Paradoxically, the elderly are underrepresented in clinical trials, especially the frail individuals whose pharmacological response and expected treatment outcome can be different from those of non-frail patients. This means that the benefit-risk balance of drugs used in frail elderly patients is frequently unknown. We present some proposals to overcome the barriers preventing the enrollment of frail elderly patients in clinical trials, and strategies for monitoring their therapy to minimize the risk of adverse reactions. Automated alerts for drug and drug-disease interactions could help appropriate prescribing but should flag only clinically relevant interactions. Pharmaceutical forms should be designed to allow easy dose adjustment and, together with packaging and labeling, should account for the physical and cognitive limitations of frail elderly patients. Aggregate pharmacovigilance reports should summarize the safety profile in the elderly, but rather than presenting the results by age they should focus on patients' frailty, perhaps using the number of comorbidities as a proxy when information on frailty is not available.

Chronic polypharmacy impairs explorative behavior and reduces synaptic functions in young adult mice

A major challenge in the health care system is the lack of knowledge about the possible harmful effects of multiple drug treatments in old age. The present study aims to characterize a mouse model of polypharmacy, in order to investigate whether long-term exposure to multiple drugs could lead to adverse outcomes. To this purpose we selected five drugs from the ten most commonly used by older adults in Sweden (metoprolol, paracetamol, aspirin, simvastatin and citalopram). Five-month-old wild type male mice were fed for eight weeks with control or polypharmacy diet. We report for the first time that young adult polypharmacy-treated mice showed a significant decrease in exploration and spatial working memory compared to the control group. This memory impairment was further supported by a significant reduction of synaptic proteins in the hippocampus of treated mice. These novel results suggest that already at young adult age, use of polypharmacy affects explorative behavior and synaptic functions. This study underlines the importance of investigating the potentially negative outcomes from concomitant administration of different drugs, which have been poorly explored until now. The mouse model proposed here has translatable findings and can be applied as a useful tool for future studies on polypharmacy.

Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients

BACKGROUND

Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood.

OBJECTIVES

To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada.

METHODS

A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed.

RESULTS

Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001).

CONCLUSIONS

BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.

Prescribing for geriatrics in Tehran; is it appropriate and rational?

Background: The world’s population is growing older. Inappropriate and irrational use of drugs in the elderly is a considerable health concern due to consequences such as increased morbidity and adverse drug events. This study aimed to evaluate the rationality of prescribing and determining the extent of inappropriate prescribing in a sample of geriatric patients in Tehran.

Methods: This cross sectional study was performed on 1512 prescriptions of patients aged ≥ 65 years from 5 pharmacies affiliated to Tehran University of Medical Sciences in 2014. Prescription of potentially inappropriate medications (PIMs) was investigated using the Beers Criteria along with WHO prescribing indices. Date were analyzed using SPSS software, and significance level was set at less than 0.05.

Results: Mean (SD) age of patients was 73.9(6.7) years. A total of 472 (31.2%) patients received at least 1 PIM. Benzodiazepines were the most frequent drug class and general practitioners (GPs) were the most frequent prescriber of PIMs. The highest and the lowest percentage of prescriptions containing brand-names were prescribed by subspecialists (62.5%) and GPs (42.2%), respectively. Antibiotics and injectable medications were prescribed for 26.8% and 28.5% of patients by GPs. Mean (SD) number of drugs per prescription was 3.57 (1.92). Prescriptions containing systemic antibiotics and PIMs had significantly higher mean number of drugs compared to those without these items (both P < 0.001).

Conclusion: There is a need for interventions to improve the quality of prescribing for elderly patients, especially by GPs. Also, there are still some problems in rational use of drugs based on prescribing indices, especially, prescribing brand-names and injectable medications.

The Effects of Opioids on Cognition in Older Adults With Cancer and Chronic Noncancer Pain: A Systematic Review

CONTEXT

Opioids are prescribed to manage moderate-to-severe pain and can be used with older adults; however, they may lead to several adverse effects, including cognitive impairment.

OBJECTIVES

To identify, appraise, and synthesize evidence on the impact of opioids on cognition in older adults with cancer/chronic noncancer pain, and screening tools/neuropsychological assessments used to detect opioid-induced cognitive impairment.

METHODS

A systematic literature review following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (international prospective register of systematic reviews registration: CRD42018092943). MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Library, and Web of Science were searched up to December 2018. Randomized controlled trials, quasi-experimental studies, and observational studies of adults aged 65 years and older with cancer/chronic noncancer pain taking opioids were included. A narrative synthesis was conducted.

RESULTS

From 4036 records, 10 met inclusion criteria. Five studies used one screening tool, and five studies used a range of neuropsychological assessments; assessing 14 cognitive domains. Most studies demonstrated no effect of opioid use on cognitive domains, whereas four studies showed mixed effects. In particular, attention, language, orientation, psychomotor function, and verbal working/delayed episodic memory were worsened. Changes to cognitive function were predominantly observed in studies with higher mean doses of opioids (120-190.7mg oral morphine equivalent daily dose).

CONCLUSION

Both improvements and impairments to cognition were observed in studies with higher mean opioid doses. In clinical practice, a brief screening tool assessing attention, language, orientation, psychomotor function, and verbal working/delayed episodic memory may be beneficial to detect worsening cognition in older adults with chronic pain using opioids.

Adverse drug reactions in older adults: a retrospective comparative analysis of spontaneous reports to the German Federal Institute for Drugs and Medical Devices

BACKGROUND

Older adults are more prone to develop adverse drug reactions (ADRs) since they exhibit numerous risk factors. The first aim was to analyse the number of spontaneous ADR reports regarding older adults (> 65) in the ADR database of the German Federal Institute for Drugs and Medical Devices (BfArM) and to set them in relation to i) the number of ADR reports concerning younger adults (19-65), and ii) the number of inhabitants and assumed drug-exposed inhabitants. The second aim was to analyse, if reported characteristics occurred more often in older vs. younger adults.

METHODS

All spontaneous ADR reports involving older or younger adults within the period 01/01/2000-10/31/2017 were identified in the ADR database. Ratios concerning the number of ADR reports/number of inhabitants and ADR reports/drug-exposed inhabitants were calculated. The reports for older (n = 69,914) and younger adults (n = 111,463) were compared using descriptive and inferential statistics.

RESULTS

The absolute number of ADR reports involving older adults increased from 1615 (2000) up to 5367 ADR reports (2016). The age groups 76-84 and 70-79 had the highest number of ADR reports with 25 ADR reports per 100,000 inhabitants and 27 ADR reports per 100,000 assumed drug-exposed inhabitants. For both ratios, the number of reports was higher for males (26 and 28 ADR reports) than for females (24 and 26 ADR reports). Fatal outcome was reported almost three times more often in older vs. younger adults. Six out of ten drug substances most frequently suspected were antithrombotics (vs. 1/10 in younger adults). For some drug substances (e.g. rivaroxaban) the ADRs reported most frequently differed between older (epistaxis) and younger adults (menorrhagia).

CONCLUSIONS

There is a need to further investigate ADRs in older adults since they occurred more frequently in older vs. younger adults and will likely increase in future. Physicians should be aware of different ADRs being attributed to the same drug substances which may be more prominent in older adults. Regular monitoring of older adults taking antithrombotics is recommended.

The Contribution of Ototoxic Medications to Hearing Loss Among Older Adults

BACKGROUND

Ototoxicity may interact with the effects of aging, leading to a more severe hearing loss than that associated with age alone. The purpose of this study was to explore the associations between ototoxic medication use and the incidence and progression of hearing loss in older adults with a population-based longitudinal study.

METHODS

Epidemiology of Hearing Loss Study participants (n = 3,753) were examined. Medication use was assessed using a standardized questionnaire by the examiners at each examination every 5 year. The ototoxic medications include loop diuretics, nonsteroidal anti-inflammatory drugs, antibiotics, chemotherapeutic agents, quinine, and acetaminophen in this study. Generalized estimating equations model was used as a proportional hazard discrete time analysis.

RESULTS

Number of ototoxic medications was associated with the risk of developing hearing loss during the 10-year follow-up period (hazard ratio [HR] = 1.15, 95% confidence interval [CI] = 1.06, 1.25) after adjusting for age, sex, smoking, and body mass index. Loop diuretics (HR = 1.40, 95% CI = 1.05, 1.87) were associated with the 10-year incidence of hearing loss. Nonsteroidal anti-inflammatory drugs (HR = 1.45, 95% CI = 1.22, 1.72) and loop diuretics (HR = 1.33 95% CI = 1.08, 1.63) were associated with risk of progressive hearing loss over 10 years.

CONCLUSION

These ototoxic medications are commonly used in older adults and should be considered as potentially modifiable contributors to the incidence and severity of age-related hearing loss.

High-risk medication in community care: a scoping review

PURPOSE

To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care.

METHODS

Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions.

RESULTS

Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: "High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications". A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care.

CONCLUSION

The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.

Polypharmacy in elderly patients in Japan: Analysis of Japanese real-world databases

WHAT IS KNOWN AND OBJECTIVE

Polypharmacy is associated with an increased risk of adverse drug reactions (ADRs) and drug interactions, decreased adherence to medication and increased medical cost. Recently, polypharmacy has become a major problem in medical care in Japan as a result of the increase in the ageing population. The purpose of this study was to investigate the current situation of polypharmacy and the association between polypharmacy and adverse events.

METHODS

A retrospective data analysis was performed using two different real-world data from 2007 to 2015 in Japan. The Japanese Adverse Drug Event Report (JADER), a public spontaneous adverse drug reaction database constructed by the Pharmaceuticals and Medical Devices Agency (PMDA), and a large prescription database constructed by a database vendor (Japan Medical Information Research Institute, Inc Japan [JMIRI]) were analysed. Trends of polypharmacy during the study period were investigated.

RESULTS AND DISCUSSION

The mean number of drugs per report in the JADER database and per prescription in the JMIRI databases during the study period ranged from 4.8 to 5.6 and 3.5 to 3.7, respectively. The mean number of drugs increased with age in both the JADER and JMIRI databases, and the peak of the mean number of drugs was at 80-89 years (5.74 drugs) in the JADER database and at 90-99 years (4.97 drugs) in the JMIRI database.

WHAT IS NEW AND CONCLUSIONS

The number of drugs increased until age 90 years or more, even though adverse events are more likely to occur after the age of 80 in Japan. Therefore, polypharmacy in the elderly should be focused on the patients aged ≥80 years rather than patients aged ≥65 years from the viewpoint of the prevention of adverse events.

Analyses of Respiratory Depression Associated with Opioids in Cancer Patients Based on the Japanese Adverse Drug Event Report Database

Opioid-induced respiratory depression is a potentially life-threatening adverse drug event. The purpose of this study was to evaluate the incidence of respiratory depression using the Japanese Adverse Drug Event Report (JADER) Database to obtain data to promote proper use of opioids. The JADER database from April 2004 to March 2017 was obtained from the Pharmaceuticals and Medical Devices Agency. We calculated the reporting odds ratios (RORs) of suspected opioids (morphine, fentanyl, oxycodone, tapentadol, methadone, tramadol, pentazocine, buprenorphine, and codeine phosphate hydrate), analyzed the daily dose at first appearance and the time-to-onset profile, and assessed the hazard type using the Weibull shape parameter. ROR analysis detected adverse event signals for all opioids. Morphine showed a large ROR value with statistical significance in elderly (≥70 years old) patients. The median daily doses of oral morphine and oxycodone for inducing respiratory depression were comparably low (30 mg/d as oral morphine equivalent dose), while that of transdermal fentanyl was 120 mg/d (oral morphine equivalent dose). On time-to-onset analysis using the Weibull distribution, those opioids were classified as the early failure type. The median time-to-onset of oral morphine, oral oxycodone and transdermal fentanyl was 5.5, 11 and 12.5 d, respectively, and almost 50% of cases were reported within 30 d. Taken together, our results suggest that it is important to monitor patients carefully for at least the first one week to one month, even if opioids are administered at a relatively low dose, especially in elderly patients administered morphine.

Community-Acquired Acute Kidney Injury Induced By Drugs In Older Patients: A Multifactorial Event

Purpose

Community-acquired acute kidney injury (CA-AKI) is a frequent and severe adverse drug reaction (ADR) among older patients. The combination of drugs and other CA-AKI risk factors was barely evaluated. The objectives of our study were to both accurately identify CA-AKI induced by drugs in older patients, and to describe their combination with other risk factors.

Patients and methods

We conducted a retrospective, single-center study in a general hospital over a two-year period. An automated detection identified CA-AKI according to KDIGO criteria, amongst 4,767 eligible inpatient stays among patients aged 75 years or older. Two independent experts reviewed all CA-AKI events to adjudicate drug involvement (Naranjo scale), identify inappropriate prescriptions (STOPP criteria), evaluate avoidability (Hallas criteria) and identify combined risk factors.

Results

An expert review confirmed 713 CA-AKI (15.0% of inpatient stays) and determined that 419 (58.8%) CA-AKI were induced by drugs. A multifactorial cause (i.e., at least one drug with a precipitating factor) was found in 63.2% of drug-induced CA-AKI. Most of the drug-induced events were avoidable (66.8%), mainly in relation to a multifactorial cause.

Conclusion

Drug-induced CA-AKI were frequent, multifactorial events in hospitalized older patients and their prevention should focus on combinations with precipitating factors.

Advances in pain management for older patients with cancer

The population of older patients is growing with a rising prevalence of cancer diagnoses and cancer-related pain syndromes. Older patients are also vulnerable to misleading pain evaluations and under treatment with opioids. Barriers to the effective and safe management of analgesics include pain assessments and the complex management of the best analgesic choice and dose-titration while achieving the fewest side effects. In this review, we will provide an overview of the challenges present in assessment and treatment choices, along with practical tips for routine clinical practice.

Longitudinal Investigation of Older Adults' Ability to Self-Manage Complex Drug Regimens

OBJECTIVES

We sought to investigate older patients' ability to correctly and efficiently dose multidrug regimens over nearly a decade and to explore factors predicting declines in medication self-management.

DESIGN

Longitudinal cohort study funded by the National Institute on Aging.

SETTING

One academic internal medicine clinic and six community health centers.

PARTICIPANTS

Beginning in 2008, 900 English-speaking adults, aged 55 to 74 years, were enrolled in the study, completing a baseline (T1) assessment. To date, 303 participants have completed the same assessment 9 years postbaseline (T4).

MEASUREMENTS

At T1, subjects were given a standardized, seven-drug regimen and asked to demonstrate how they would take medicine over 24 hours. The number of dosing errors made and times per day that a participant would take medicine were recorded. Health literacy was measured via the Newest Vital Sign, and cognitive decline was measured by the Mini-Mental State Examination.

RESULTS

Participants on average made 2.9 dosing errors (SD = 2.5 dosing errors; range = 0-21 dosing errors) of 21 potential errors at T1 and 5.0 errors (SD = 2.1 errors; range = 1-18 errors; P < .001) at T4. In a multivariate model, limited literacy (β = .69; 95% confidence interval [CI] = .18-1.20; P = .01), meaningful cognitive decline (β = 1.72; 95% CI = .70-2.74; P = .01), number of chronic conditions (β = .21; 95% CI = .07-.34; P = .01), and number of baseline dosing errors (β = -.76; 95% CI = -.85 to -.67; P < .001) were significant, independent predictors of changes in dosing errors. Most patients overcomplicated their daily medication schedule; no sociodemographic characteristics were predictive of poor regimen organization in multivariate models. In a multivariate model, there were no significant predictors of changes in regimen consolidation over time, except regimen consolidation at T1.

CONCLUSIONS

Older patients frequently overcomplicated drug regimens and increasingly made more dosing errors over 9 years of follow-up. Patients with limited literacy, cognitive decline, and multimorbidity were at greatest risk for errors. J Am Geriatr Soc 68:569-575, 2020.

Mapping the perturbome network of cellular perturbations

Drug combinations provide effective treatments for diverse diseases, but also represent a major cause of adverse reactions. Currently there is no systematic understanding of how the complex cellular perturbations induced by different drugs influence each other. Here, we introduce a mathematical framework for classifying any interaction between perturbations with high-dimensional effects into 12 interaction types. We apply our framework to a large-scale imaging screen of cell morphology changes induced by diverse drugs and their combination, resulting in a perturbome network of 242 drugs and 1832 interactions. Our analysis of the chemical and biological features of the drugs reveals distinct molecular fingerprints for each interaction type. We find a direct link between drug similarities on the cell morphology level and the distance of their respective protein targets within the cellular interactome of molecular interactions. The interactome distance is also predictive for different types of drug interactions.

Our understanding of the mechanisms of drug interactions remains limited. Here the authors introduce a framework to study how complex cellular perturbations induced by different drugs affect each other in morphological feature space.

Photosensitivity reactions in the elderly population: questionnaire-based survey and literature review

Purpose

Older people are at risk of developing adverse drug reactions, including photosensitivity reactions. Therefore, the aim of the study was to assess the use of potentially photosensitizing medications and photoprotection in the elderly population.

Patients and methods

Three hundred and fifty-six respondents (223 [63%] women and 133 [37%] men) aged ≥65 years filled in the original questionnaire concerning photosensitivity reactions to drugs. The diagnosis of drug-induced photosensitivity was based on medical history and clinical examination.

Results and conclusion

We found that drugs potentially causing phototoxic/photoallergic reactions comprised more than one fifth of all drugs used by the participants. The most numerous group was patients treated with 3–5 drugs potentially causing phototoxic/photoallergic reactions simultaneously. Of all drugs, ketoprofen was found to cause the highest number of photosensitivity reactions. Cutaneous adverse reactions were also observed for hydrochlorothiazide, atorvastatin, simvastatin, telmisartan, and metformin. Moreover, it was found that the incidence of photosensitivity reactions can be significantly reduced by using proper photoprotection.

Nurse-led medicines' monitoring in care homes, implementing the Adverse Drug Reaction (ADRe) Profile improvement initiative for mental health medicines: An observational and interview study

Introduction

Preventable adverse effects of medicines often pass unnoticed, but lead to real harm.

Intervention

Nurse-led monitoring using the structured Adverse Drug Reaction (ADRe) Profile identifies and addresses adverse effects of mental health medicines.

Objectives

This study investigated the implementation and clinical impact of ADRe, and barriers to and facilitators of sustained utilisation in routine practice.

Methods

Administration of ADRe was observed for 30 residents prescribed mental health medicines in ten care homes. The study pharmacist reviewed completed ADRes against medication records. Policy context was explored in 30 interviews with service users, nurse managers and strategic leads in Wales.

Results

Residents were aged 60–95, and prescribed 1–17 (median 9 [interquartile range (IQR) 7–13]) medicines. ADRe identified a median of 18 [IQR 11.5–23] problems per resident and nurses made 2 [1–2] changes to care per resident. For example: falls were reported for 9 residents, and care was modified for 5; pain was identified in 8 residents, and alleviated for 7; all 6 residents recognised as dyspnoeic were referred to prescribers. Nurses referred 17 of 30 residents to prescribers. Pharmacists recommended review for all 30. Doubts about administering ADRe, sometimes expressed by people who had not yet used it, diminished as it became familiar. ADRe was needed to bridge communication between resident, nurses and prescribers. When barriers of time, complacency, and doctors’ non-availability were overcome, reporting with ADRe made prescribers more likely to heed nurses’ concerns regarding residents’ welfare. Clinical gains were facilitated by one-to-one time, staff-resident relationships, and unification of documentation.

Implications

To our knowledge, ADRe is the only instrument that brings a full account of patients’ problems to medication reviews. This juxtaposition of signs and symptoms against prescriptions facilitates dose adjustments and de-prescribing and leads to: reduced pain and sedation; early identification of problems linked to ADRs, such as falls; and timely medication reviews e.g. for dyspnoea.

'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial

INTRODUCTION

Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy.

METHODS AND ANALYSIS

Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed.

ETHICS AND DISSEMINATION

The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal.

MAIN FUNDING

Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'.

TRIAL REGISTRATION NUMBERS

Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).

Predictors of adverse drug reactions in geriatric patients: An exploratory study among cancer patients

Objectives:

The objective of this study was to study the predictors of adverse drug reactions (ADRs) among geriatric patients in the Department of Medical Oncology.

Methods:

A hospital-based prospective observational study was carried out among 153 inpatients in the Department of Medical Oncology for 6 months. Patients above 60 years of age with a confirmed history of malignancy were included in the study. The potential risk factors for ADR were defined in relation to the patient and chemotherapeutic regimen and relationship between them was assessed by univariate and multivariate logistic regression analysis.

Results:

Among 153 patients, 94 (64.43%) experienced ADRs. The mean ADR per patient was 0.88 ± 1.2. The common ADRs found were alopecia (30.18%) and diarrhea (28.68%). Risk estimates revealed that there was a significant association between smokers (odds ratio [OR] = 10.326; 95% confidence interval [CI] 2.345–45.47, P = 0.001), alcoholics (OR = 10.897; 95% CI 2.479–47.902, P = 0.001), increasing age (OR = 2.22; 95% CI 1.698–2.909, P = 0.001), overweight (OR = 16.68; 95% CI 2.179–127.741, P = 0.001), and male participants (OR = 0.143; 95% CI 0.05–0.390 P = 0.001) with the development of ADRs. The risk of carboplatin (OR = 13.359; 95% CI 3.056–58.406 P = 0.001) and 5-fluorouracil (OR = 1.938 95% CI 1.266–2.935 P = 0.001) use and occurrence of ADRs were also found to be high.

Conclusion:

The study findings showed that smoking, alcohol consumption, age more than 70 years, and overweight had a high risk for developing ADRs in geriatric patients who underwent chemotherapy. The independent risk factors identified should be targeted for preventive measures to improve anticancer agent prescription and reduce the risk of ADRs.

Pharmacomicrobiomics: The Holy Grail to Variability in Drug Response?

The human body, with 3.0 × 10¹³ cells and more than 3.8 × 10¹³ microorganisms, has nearly a one-to-one ratio of resident microbes to human cells. Initiatives like the Human Microbiome Project, American Gut, and Flemish Gut have identified associations between microbial taxa and human health. The study of interactions between microbiome and pharmaceutical agents, i.e., pharmacomicrobiomics, has revealed an instrumental role of the microbiome in modulating drug response that alters the therapeutic outcomes. In this review, we present our current comprehension of the relationship of the microbiome, host biology, and pharmaceutical agents such as cardiovascular drugs, analgesics, and chemotherapeutic agents to human disease and treatment outcomes. We also discuss the significance of studying diet-gene-drug interactions and further address the key challenges associated with pharmacomicrobiomics. Finally, we examine proposed models employing systems biology for the application of pharmacomicrobiomics and other -omics data, and provide approaches to elucidate microbiome-drug interactions to improve future translation to personalized medicine.

Burden of Exposure to Potential Interactions Between Antiretroviral and Non-Antiretroviral Medications in a Population of HIV-Positive Patients Aged 50 Years or Older

BACKGROUND

As HIV-infected patients aged 50 years or older are at increased risk of comorbidities and multidrug treatments, we examined their exposure to the potential drug-drug interactions (PDDIs) of antiretroviral (ARV) and other medications.

METHODS

This cross-sectional study involved the patients aged 50 years or older receiving ARV and non-ARV medications at our clinic. PDDIs were identified using the University of Liverpool HIV Drug Interaction Checker. Logistic regression models were used to assess risk factors for PDDIs. The American Geriatrics Society Beers Criteria were used to identify potentially inappropriate medications (PIMs).

RESULTS

A total of 395 (53.9%) of 744 patients showed ≥1 PDDI: 47.4% ≥ 1 amber-PDDI (comedications requiring appropriate management) and 5.6% ≥ 1 red-PDDI (contraindicated comedications). A higher risk of PDDIs was associated with the use of ≥5 medications (P < 0.001), of antiosteoporotics (P < 0.001), calcium channel blockers (P < 0.001), anti-benign prostatic hypertrophy agents (P < 0.001), hypnotics/sedatives (P = 0.022), and anticoagulants (P = 0.006). A higher risk of red-PDDIs was associated with the use of antacids (P < 0.001), anti-benign prostatic hypertrophy agents (P < 0.001) and antipsychotics (P = 0.023). The use of nucleoside reverse transcriptase inhibitor + nonnucleoside reverse transcriptase inhibitor and nucleoside reverse transcriptase inhibitor + integrase strand transfer inhibitor rather than protease inhibitor-based regimens was associated with a reduced risk of PDDIs (P < 0.001). Overall, 119 (16.0%) patients were receiving PIMs (mainly hypnotics/sedatives) and 49 (41.2%) of them had PDDIs able to increase the blood levels of these medications.

CONCLUSIONS

Older patients with HIV are highly exposed to PDDIs between ARVs and comedications. The knowledge of their complete medication regimens and the screening for PDDIs and PIMs is therefore crucial to prevent drug-related adverse outcomes in this population.

Aging and Direct-to-Consumer Prescription Drug Television Ads: The Effects of Individual Differences and Risk Presentation

To determine how individual difference (age, cognition, and hearing) and risk presentation (audio frequency, speed, and organization) variables affect viewing of direct-to-consumer (DTC) prescription drug television ads, participants (N = 1,075) from four age groups across the adult lifespan took an in-person hearing examination, watched a DTC television ad, and responded to survey questions. Results showed that increased age was related to reduced cognition and hearing ability, as well as lower ad comprehension and risk recall. Greater speed and more complex organization of the ad's risk information lowered risk recall and claim recognition. Audio frequency had no effect. Cognitive abilities mediated the relationship between age and risk recall. Our findings suggest that older adults are likely to have more difficulty recalling and understanding the risks presented in DTC television ads. Risk information can be presented in ways that facilitate or inhibit recall and recognition among individuals across the lifespan.

Adverse Reactions to Medications: Concept Analysis and Development of a New Risk Nursing Diagnosis

PURPOSE

To analyze the concept of adverse reaction to medications and to develop the new nursing diagnosis Risk for Adverse Reactions to Medications.

METHODS

Concept analysis using Walker and Avant's eight step method.

FINDINGS

Thirty-three articles indexed in four databases were included. The components of the new nursing diagnosis were determined, including possible nursing outcomes and interventions.

CONCLUSIONS

The concept analysis supported the development of the new nursing diagnosis Risk for Adverse Reactions to Medications, which may help nurses to evaluate and identify patients susceptible to adverse reactions.

IMPLICATIONS FOR NURSING PRACTICE

The establishment of this nursing diagnosis will provide nurses an opportunity to implement interventions to anticipate and effectively intervene with patients at risk for this condition.

Description of an Innovative Pediatric Individualized Therapeutics Clinic: Working toward Precision Drug Therapy

The GOLDILOKs^® (Genomic and Ontogeny-Linked Dose Individualization and cLinical Optimization for KidS) Clinic aims to provide families and physicians with data to make more informed decisions with regard to pharmacological therapy by using innovative therapy and genomic technologies. The objectives are two-fold: (1) To describe the utility of the GOLDILOKs^® Clinic to referring prescribers by evaluating the type of referrals made to the GOLDILOKs^® Clinic and (2) to assess the most often utilized technologies (e.g., genotyping) completed to formulate therapy recommendations. Patient data from July 2010 to June 2016 was retrospectively reviewed following Institutional Review Board (IRB) approval. The GOLDILOKs^® Clinic evaluated 306 patients and had increases in annual referrals from 14 in 2010–2011 to 84 in 2016–2017. The children that were referred were predominately Caucasian (82%) and male (59%) with an average age of 12.4 ± 5.9 years. Subspecialty versus primary care referrals accounted for 82% and 18% of referrals, respectively. Adverse drug reactions (n = 166) and poor medication response (n = 179) were the major reasons for referral. However, it must be noted that patients could have multiple reasons for referral. Pharmacogenetic results were extensively used to provide guidance for future therapy in patients with medication-related problems. Genotyping of drug metabolizing enzymes and drug target receptors was performed in 221 patients (72.2%). Recommendations were fully accepted by 63% and partially accepted by 22% of internal provider referrals.

Risk Factors of QTc Prolongation in Women With Hormone Receptor‒positive/Human Epidermal Growth Factor Receptor 2‒negative Metastatic Breast Cancer: A Retrospective Analysis of Health Care Claims Data

PURPOSE

In addition to biomarker status, treatment selection for metastatic breast cancer (mBC) includes individual patient and clinical characteristics such as tumor burden, timing of disease recurrence, and comorbidities. Women with mBC may take medications that can increase the risk of drug-induced toxicities, including prolongation of cardiac repolarization (prolongation of QT interval). Corrected QT (QTc) prolongation, a toxicity associated with many cancer treatments, can lead to potentially life-threatening ventricular arrhythmias. As such, it is important to identify patients at risk for QTc prolongation due to comorbid conditions, concomitant medications, or electrolyte abnormalities. This real-world study estimated the proportion of women with hormone receptor‒positive (HR+)/human epidermal growth factor receptor 2‒negative (HER2‒) mBC who may be at risk of developing QTc prolongation. Results in the elderly are also included.

METHODS

This retrospective, cross-sectional cohort study used the Truven Health MarketScan and Optum Clinformatics administrative claims databases. Patients' medical and pharmacy data were evaluated to assess the risk of QTc prolongation. Prescription and medication administration claims were evaluated during the 7-day period before the index date (ie, first secondary neoplasm diagnosis). In addition, International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification, codes were evaluated 12 months before the index date to describe congenital long QT syndrome, cardiac disease, and electrolyte abnormalities.

FINDINGS

A cohort of 24,340 women with HR+/HER2‒ mBC were identified, including 5059 women aged 65-74 years and 4851 aged ≥75 years. Based on an overall analysis of risk factors (congenital long QT syndrome, cardiovascular disease, electrolyte abnormalities, or concomitant medications), 29.5% of all patients, 33.2% of patients aged 65-74 years, and 40.5% of patients aged ≥75 years had risk factors for QTc prolongation.

IMPLICATIONS

This analysis of real-world data indicates that almost 1 in 3 women with HR+/HER2‒ mBC had congenital long QT syndrome, cardiovascular disease, and/or electrolyte abnormalities or received a concomitant medication that could increase the risk of developing QTc prolongation. The risk factors for congenital long QT syndrome, cardiovascular disease, or electrolyte abnormalities were more common in older patients. This analysis emphasizes the importance of individualized benefit/risk assessment during treatment decisions, especially when considering drugs with known or possible QTc prolongation risk.