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Spitz JA, Yang E, Blumenthal RS, Sharma G. Public Health Messaging to Older Adults About Hypertension. Clin Geriatr Med 2024; 40:669-683. [PMID: 39349039 DOI: 10.1016/j.cger.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2024]
Abstract
Hypertension is a major risk factor for cardiovascular disease, cognitive decline, and frailty. Given the increasing burden of hypertension in the aging population, it is imperative to improve hypertension management in that population. Apart from variations in treatment goals, challenges such as polypharmacy, medication side effects, and therapeutic inertia hinder adherence to guideline-directed medical therapies among older people. Effective public health messaging is essential for spreading evidence-based guidelines, raising awareness among clinicians, enhancing patient education and health literacy, and implementing community-based strategies to tackle hypertension. This review examines the current state of public messaging on hypertension in older adults.
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Affiliation(s)
- Jared A Spitz
- Inova Schar Heart and Vascular, Inova Health System, 8081 Innovation Park Drive, #700, Inova Specialty Center, Fairfax, VA 22031, USA.
| | - Eugene Yang
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA; UW Medicine Cardiovascular Wellness and Prevention Program, Medicine, UW Medicine - Eastside Specialty Center, Carl and Renée Behnke Endowed Professorship for Asian Health, 3100 Northup Way Box 356005 Bellevue, WA 98004, USA
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, 601 North Caroline Street, Suite 7200, Baltimore, MD 21287, USA
| | - Garima Sharma
- Inova Schar Heart and Vascular, Inova Health System, 8081 Innovation Park Drive, #700, Inova Specialty Center, Fairfax, VA 22031, USA; Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Gronich N, Saliba W, Schwartz JB. Prevalence and proportion by age and sex of chronic health conditions in a large healthcare system. PLoS One 2024; 19:e0308031. [PMID: 39325771 PMCID: PMC11426542 DOI: 10.1371/journal.pone.0308031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/16/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND Disease prevalence and distribution by patient characteristics data are needed to guide "representative" patient enrollment in clinical trials and assess relevance of results to patient populations. Our objective was to describe disease prevalence, and age/sex distribution of patients with common chronic conditions from a large population sample. METHODS A cross-sectional study of all members of Clalit Health Services, alive on January 1, 2020. Included were 26 chronic diseases, and 21 types of malignancies regarded as active by being diagnosed between January 1, 2018- to January 1, 2020, or by prescription of oncologic treatment medications January 1, 2018 and January 1, 2020. RESULTS Data from 4,627,183 individuals, 2,274,349 males and 2,352,834 females from newborn to 110 years. Obesity (19%), hypertension (13%), diabetes mellitus (9%), esophagitis-gastritis (5.5%), thyroid disease (5.3%), asthma (5.1%), ischemic heart disease (4.5%), depression (4.5%), osteoporosis (3.8%), and atopic dermatitis (3.6%) were the ten most prevalent conditions. Proportions of age groups varied between conditions (67% of hypertensives were ≥65 years old, 24% ≥80 years; 73% with ischemic heart disease were ≥65 years, 29% ≥80 years; 59% of diabetics were ≥65 years, 17% ≥80 years; 42% of atrial fibrillation patients were ≥80 years; 40% of heart failure patients were ≥80 years). Proportions of males and females for most conditions paralleled prevalence except proportions of women increased after age 80 for cardiovascular diseases, and for diabetes after age 75. The five most frequent active cancers were breast, prostate, colon/rectal, lymphoma and melanoma. The prevalence of cancers increased with age beginning in the middle-aged groups and peaking at very old ages. Women had lower prevalence of lung cancers and accounted for lower percentages of patients with lung cancers (45 vs 55%) but similar percentages for women and men were seen in the patients with colon and rectal cancer (50.4 vs. 49.6% in women) and lymphoma (50.7 vs. 49.3% in women). CONCLUSIONS Prevalence of medical conditions and distributions differ by age and sex. This information serves as an example and resource for data needed to describe a "representative" clinical population.
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Affiliation(s)
- Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Walid Saliba
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
- Translational Epidemiology Unit and Research Authority, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Janice B Schwartz
- Divisions of Geriatrics and Clinical Pharmacology, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
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3
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Qian L, Wang Z, Paine MF, Chan ECY, Zhou Z. Application of physiologically-based pharmacokinetic modeling to inform dosing decisions for geriatric patients. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 39291626 DOI: 10.1002/psp4.13241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/17/2024] [Accepted: 09/02/2024] [Indexed: 09/19/2024] Open
Affiliation(s)
- Lixuan Qian
- Department of Chemistry, York College, City University of New York, New York, New York, USA
| | - Ziteng Wang
- Department of Pharmacy and Pharmaceutical Sciences, National University of Singapore, Singapore, Singapore
| | - Mary F Paine
- Department of Pharmaceutical Sciences, Washington State University, Pullman, Washington, USA
| | - Eric Chun Yong Chan
- Department of Pharmacy and Pharmaceutical Sciences, National University of Singapore, Singapore, Singapore
| | - Zhu Zhou
- Department of Chemistry, York College, City University of New York, New York, New York, USA
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Duong MH, Gnjidic D, McLachlan AJ, Redston MR, Goyal P, Mathieson S, Hilmer SN. The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: A systematic review and meta-analysis. Br J Clin Pharmacol 2024. [PMID: 39285726 DOI: 10.1111/bcp.16223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 07/20/2024] [Accepted: 08/01/2024] [Indexed: 10/09/2024] Open
Abstract
The aim of this study was to investigate whether interventions to discontinue or down-titrate heart failure (HF) pharmacotherapy are feasible and associated with risks in older people. A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. Electronic databases were searched from inception to 8 March 2023. Randomized controlled trials (RCTs) and observational studies included people with HF, aged ≥50 years and who discontinued or down-titrated HF pharmacotherapy. Outcomes were feasibility (whether discontinuation or down-titration of HF pharmacotherapy was sustained at follow-up) and associated risks (mortality, hospitalization, adverse drug withdrawal effects [ADWE]). Random-effects meta-analysis was performed when heterogeneity was not substantial (Higgins I2 < 70%). Sub-analysis by frailty status was conducted. Six RCTs (536 participants) and 27 observational studies (810 499 participants) across six therapeutic classes were included, for 3-260 weeks follow-up. RCTs were conducted in patients presenting with stable chronic HF. Down-titrating a renin-angiotensin system inhibitor (RASI) in patients with chronic kidney disease was 76% more likely than continuation (risk ratio [RR] 1.76, 95% confidence interval [CI] 1.14-2.73), with no difference in mortality (RR 0.64, 95% CI 0.30-1.64). Discontinuation of beta-blockers were feasible compared to continuation in preserved ejection fraction (RR 1.00, 95% CI 0.68-1.47). Participants were 25% more likely to re-initiate discontinued diuretics (RR 0.75, 95% CI 0.66-0.86). Digoxin discontinuation was associated with 5.5-fold risk of hospitalization compared to continuation. Worsening HF was the most common ADWE. One observational study measured frailty but did not report outcomes by frailty status. The appropriateness and associated risks of down-titrating or discontinuing HF pharmacotherapy in people aged ≥75 years is uncertain. Evaluation of outcomes by frailty status necessitates investigation.
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Affiliation(s)
- Mai H Duong
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Mitchell R Redston
- St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Parag Goyal
- Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Stephanie Mathieson
- Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
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Hilmer SN, Schwartz J, Petrovic M, Walker LE, Thürmann P, Le Couteur DG. Addressing the gaps in evaluation of new drugs for older adults: Strategies from the International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee. J Am Geriatr Soc 2024; 72:2942-2950. [PMID: 38485461 DOI: 10.1111/jgs.18826] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 09/03/2024]
Abstract
The International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee aims to improve the use of drugs in older adults and develop new therapeutic approaches for the syndromes and diseases of old age through advocacy, education, and research. In the present paper, we propose strategies relevant to drug development and evaluation, spanning preclinical and the full range of clinical studies. Drugs for older adults need to consider not only age, but also other characteristics common in geriatric patients, such as multimorbidity, polypharmacy, falls, cognitive impairment, and frailty. The IUPHAR Geriatric Committee's position statement on 'Measurement of Frailty in Drug Development and Evaluation' is included, highlighting 12 key principles that cover the spectrum of translational research. We propose that where older adults are likely to be major users of a drug, that frailty is measured at baseline and as an outcome. Preclinical models that replicate the age, frailty, duration of exposure, comorbidities, and co-medications of the proposed patients may improve translation. We highlight the potential application of recent technologies, such as physiologically based pharmacokinetic-pharmacodynamic modeling informed by frailty biology, and Artificial Intelligence, to inform personalized medicine for older patients. Considerations for the rapidly aging populations in low- and middle-income countries related to health-care and clinical trials are outlined. Involving older adults, their caregivers and health-care providers in all phases of research should improve drug development, evaluation, and outcomes for older adults internationally.
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Affiliation(s)
- Sarah N Hilmer
- Kolling Institute, The University of Sydney and Northern Sydney Local Health District, St Leonards, New South Wales, Australia
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
| | - Janice Schwartz
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Divisions of Geriatrics and Clinical Pharmacology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Mirko Petrovic
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Lauren E Walker
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK
| | - Petra Thürmann
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Helios University Hospital Wuppertal, Chair of Clinical Pharmacology, University Witten/Herdecke, Witten, Germany
| | - David G Le Couteur
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Centre for Education and Research on Ageing, University of Sydney and Concord RG Hospital, Concord, New South Wales, Australia
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Schwartz JB. Current status of inclusion of older groups in evaluations of new medications: Gaps and implementation needs to fill them. J Am Geriatr Soc 2024; 72:2894-2902. [PMID: 38600697 DOI: 10.1111/jgs.18912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/16/2024] [Indexed: 04/12/2024]
Abstract
Under-representation of subgroups of the population in clinical trials has been and continues to be a problem despite goals of academia, industry, and government. Older adults are among the groups that are under-represented in trials of medications that they are likely to receive once marketing approval has been received. Recent legislation that mandates that clinical trial participants be representative of patient population has been passed and creates hope that greater numbers of older adults will be enrolled in clinical trials and that they will be representative of "typical" geriatric patients. However, there is the need for collection of current data on disease prevalences with granularity as to age, gender, and race as well as geriatric co-morbidities to assess the representativeness of clinical trial participants relative to patient populations. Consensus on definitions and collection of data relevant to geriatric patient populations are needed to evaluate effects of comorbidities, frailty, cognitive and physical function. There will also be a need for expansion of the geriatric research workforce, facilities for research both in academic centers but also in the community and long-term care facilities, and for engagement with and involvement of communities that have been traditionally under-represented to conduct clinical trials that enroll truly representative patient populations.
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Affiliation(s)
- Janice B Schwartz
- Department of Medicine, Divisions of Geriatrics and Clinical Pharmacology, University of California, San Francisco, San Francisco, California, USA
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Walker LE, Pirmohamed M. The status of drug evaluation in older adults in the United Kingdom: Bridging the representation gap. J Am Geriatr Soc 2024; 72:2933-2941. [PMID: 38393834 DOI: 10.1111/jgs.18817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
Older adults are persistently underrepresented in clinical drug trials worldwide, despite increasing multiple long-term conditions and significant prescribing in this demographic. We discuss systemic challenges such as the exclusion of people with comorbid conditions and the lack of assessment for comorbidities as modifiers of treatment effects and highlight the rising trend of polypharmacy, especially among the oldest age groups, which is linked to a significant percentage of unplanned hospitalizations and medication errors. The consequences of these trends prompted the United Kingdom National Overprescribing review, culminating in a set of recommendations for drug development tailored to older adults. Building on this, two critical reports released in April 2023 by the International Longevity Centre (ILC) and the Nuffield Council on Bioethics (NCOB) are discussed. These reports emphasize the importance of diversity and inclusion in clinical trials, advocating for ethical frameworks and methodologies that cater to the complex needs of older adults. The development of inclusive criteria, innovative statistical methodologies, and the integration of patient-reported outcomes are needed to address the persistent barriers to older adult participation in research, suggesting that pragmatic trials, exemplified by the UK's RECOVERY trial during the COVID-19 pandemic, could pave the way for more inclusive research practices.
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Affiliation(s)
- Lauren E Walker
- The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Munir Pirmohamed
- The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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8
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Lau SWJ, Liu Q, Madabushi R, Temple R. Closing the gap: A United States perspective on enhancing drug evaluation in older adults. J Am Geriatr Soc 2024; 72:2903-2906. [PMID: 38567777 DOI: 10.1111/jgs.18903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/08/2024] [Indexed: 09/03/2024]
Affiliation(s)
- S W Johnny Lau
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rajanikanth Madabushi
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Temple
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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9
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Rowland Yeo K, Gil Berglund E, Chen Y. Dose Optimization Informed by PBPK Modeling: State-of-the Art and Future. Clin Pharmacol Ther 2024; 116:563-576. [PMID: 38686708 DOI: 10.1002/cpt.3289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/17/2024] [Indexed: 05/02/2024]
Abstract
Model-informed drug development (MIDD) is a powerful quantitative approach that plays an integral role in drug development and regulatory review. While applied throughout the life cycle of the development of new drugs, a key application of MIDD is to inform clinical trial design including dose selection and optimization. To date, physiologically-based pharmacokinetic (PBPK) modeling, an established component of the MIDD toolkit, has mainly been used for assessment of drug-drug interactions (DDIs) and consequential dose adjustments in regulatory submissions. As a result of recent scientific advances and growing confidence in the utility of the approach, PBPK models are being increasingly applied to provide dose recommendations for subjects with differing ages, genetics, and disease states. In this review, we present our perspective on the current landscape of regulatory acceptance of PBPK applications supported by relevant case studies. We also discuss the recent progress and future challenges associated with expanding the utility of PBPK models into emerging areas for regulatory decision making, especially dose optimization in highly vulnerable and understudied populations and facilitating diversity in clinical trials.
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Affiliation(s)
| | - Eva Gil Berglund
- Certara Clinical Drug Development Solutions, Oss, The Netherlands
| | - Yuan Chen
- Department of Drug Metabolism and Pharmacokinetics, Genentech, Inc., South San Francisco, California, USA
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Hilmer SN, Johnell K, Mach J. Pre-clinical Models for Geriatric Pharmacotherapy. Drugs Aging 2024; 41:633-640. [PMID: 38982010 PMCID: PMC11322264 DOI: 10.1007/s40266-024-01129-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2024] [Indexed: 07/11/2024]
Abstract
With ageing of the population worldwide and discovery of new medications for prevention and management of age-related conditions, there is increasing use of medications by older adults. There are international efforts to increase the representativeness of participants in clinical trials to match the intended real-world users of the medications across a range of characteristics including age, multimorbidity, polypharmacy and frailty. Currently, much of the data on medication-related harm in older adults are from pharmacovigilance studies. New methods in pre-clinical models have allowed for measurement of exposures (such as chronic exposure, polypharmacy and deprescribing) and outcomes (such as health span functional measures and frailty) that are highly relevant to geriatric pharmacotherapy. Here we describe opportunities for design and implementation of pre-clinical models that can better predict drug effects in geriatric patients. This could improve the translation of new drugs from bench to bedside and improve outcomes of pharmacotherapy in older adults.
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Affiliation(s)
- Sarah N Hilmer
- Kolling Institute, The University of Sydney and Northern Sydney Local Health District, St Leonards, NSW, Australia.
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - John Mach
- Kolling Institute, The University of Sydney and Northern Sydney Local Health District, St Leonards, NSW, Australia
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Kim DH, Park CM, Ko D, Lin KJ, Glynn RJ. Assessing the Benefits and Harms of Pharmacotherapy in Older Adults with Frailty: Insights from Pharmacoepidemiologic Studies of Routine Health Care Data. Drugs Aging 2024; 41:583-600. [PMID: 38954400 DOI: 10.1007/s40266-024-01121-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 07/04/2024]
Abstract
The objective of this review is to summarize and appraise the research methodology, emerging findings, and future directions in pharmacoepidemiologic studies assessing the benefits and harms of pharmacotherapies in older adults with different levels of frailty. Older adults living with frailty are at elevated risk for poor health outcomes and adverse effects from pharmacotherapy. However, current evidence is limited due to the under-enrollment of frail older adults and the lack of validated frailty assessments in clinical trials. Recent advancements in measuring frailty in administrative claims and electronic health records (database-derived frailty scores) have enabled researchers to identify patients with frailty and to evaluate the heterogeneity of treatment effects by patients' frailty levels using routine health care data. When selecting a database-derived frailty score, researchers must consider the type of data (e.g., different coding systems), the length of the predictor assessment period, the extent of validation against clinically validated frailty measures, and the possibility of surveillance bias arising from unequal access to care. We reviewed 13 pharmacoepidemiologic studies published on PubMed from 2013 to 2023 that evaluated the benefits and harms of cardiovascular medications, diabetes medications, anti-neoplastic agents, antipsychotic medications, and vaccines by frailty levels. These studies suggest that, while greater frailty is positively associated with adverse treatment outcomes, older adults with frailty can still benefit from pharmacotherapy. Therefore, we recommend routine frailty subgroup analyses in pharmacoepidemiologic studies. Despite data and design limitations, the findings from such studies may be informative to tailor pharmacotherapy for older adults across the frailty spectrum.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Harvard Medical School, Boston, MA, USA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Harvard Medical School, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Boston, MA, USA
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Gronich N. Central Nervous System Medications: Pharmacokinetic and Pharmacodynamic Considerations for Older Adults. Drugs Aging 2024; 41:507-519. [PMID: 38814377 PMCID: PMC11193826 DOI: 10.1007/s40266-024-01117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/31/2024]
Abstract
Most drugs have not been evaluated in the older population. Recognizing physiological alterations associated with changes in drug disposition and with the ultimate effect, especially in central nervous system-acting drugs, is fundamental. While considering pharmacokinetics, it should be noted that the absorption of most drugs from the gastrointestinal tract does not change in advanced age. There are only few data about the effect of age on the transdermal absorption of medications such as fentanyl. Absorption from an intramuscular injection may be similar in older adults as in younger patients. The distribution of lipophilic drugs (such as diazepam) is increased owing to a relative increase in the percentage of body fat, causing drug accumulation and prolonged drug elimination following cessation. Phase I drug biotransformation is variably decreased in aging, impacting elimination, and hepatic drug clearance has been shown to decrease in older individuals by 10-40% for most drugs studied. Lower doses of phenothiazines, butyrophenones, atypical antipsychotics, antidepressants (citalopram, mirtazapine, and tricyclic antidepressants), and benzodiazepines (such as diazepam) achieve the same extent of exposure. For renally cleared drugs with no prior metabolism (such as gabapentin), the glomerular filtration rate appropriately estimates drug clearance. Important pharmacodynamic changes in older adults include an increased sedative effect of benzodiazepines at a given drug exposure, and a higher sensitivity to mu opiate receptor agonists and to opioid adverse effects. Artificial intelligence, physiologically based pharmacokinetic modeling and simulation, and concentration-effect modeling enabling a differentiation between the pharmacokinetic and the pharmacodynamic effects of aging might help to close some of the gaps in knowledge.
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Affiliation(s)
- Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, 7 Michal St, 3436212, Haifa, Israel.
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 3200003, Haifa, Israel.
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13
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Schwartz JB, Liu RY, Boscardin J, Liu Q, Lau SWJ, Khatri S, Tarn D. Attitudes on participation in clinical drug trials: A nationally representative survey of older adults with multimorbidity. J Am Geriatr Soc 2024; 72:1717-1727. [PMID: 38485469 PMCID: PMC11187642 DOI: 10.1111/jgs.18857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Older adults with multimorbidity are under-represented in clinical drug trials. Their inclusion will not increase unless they are willing and able to participate. Data on motivators and barriers to participation in trials of new medications of older adults with multimorbidity are needed. METHODS Cross-sectional internet and telephone survey of a nationally representative sample of adults ≥65 years with ≥3 chronic conditions (NORC University of Chicago Amerispeak Panel) conducted from March-April, 2023 to determine motivators and barriers to drug trial participation, described graphically and using statistics. RESULTS Surveyed 1318 (1142 Internet, 176 phone) with mean age 72.3 ± 6.3 (SD), 52% women; race: 83% White, 10% Black or African American, 5% Hispanic or Latino, 1.1% Asian; 4.4 ± 1.9 chronic conditions (of 16 queried), taking 7.5 ± 3.3 medications. Barriers included fear of side effects (48%), taking too many medications (44%), placebo (44%), mobility (33%), bathroom needs (25%), hearing (19%), eyesight (15%), video visits (33%; higher in women, Black or African-American respondents, and those ≥80 years). Sixty-five percent would join all in-person trials, 49% would join all-video trials. Travel >1 h was difficult for 66%, most difficult for women. Trust was a concern in 25% of Black respondents. Caregiving responsibilities or lack of time were not obstacles. Participants were most likely to consider a drug trial for a problem they have (63%) versus prevention (44%) and if invited by a physician (80%) or University healthcare system (58%). Getting better care was ranked very important (79%) followed by helping others (57%). CONCLUSIONS Major concerns of older patients with multimorbidity about participation in drug trials are potential side effects, taking too many medicines, and video visits. Physicians have the greatest influence on decisions and in-person visits are preferred. Proposed changes in trial design to increase enrollment of under-represented older adults may not align with patient-reported preferences.
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Affiliation(s)
- Janice B. Schwartz
- Department of Medicine, Division of Geriatrics and Division of Clinical Pharmacology, University of California, San Francisco, California, USA
| | - Ruey-ying Liu
- Department of Sociology, National Chengchi University, Taipei, Taiwan
| | - John Boscardin
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Qi Liu
- Center for Drug Evaluation and Research, Office of Translational Sciences and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - S. W. Johnny Lau
- Center for Drug Evaluation and Research, Office of Translational Sciences and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - Sadhna Khatri
- Center for Biologics Evaluation and Research, Office of Compliance Biologics Quality, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - Derjung Tarn
- Department of Family Medicine, University of California, Los Angeles, California, USA
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14
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Gosselin M, Baroud ML, Denis OR, Gagnon ME, Sirois C. Evidence-based data for newly approved medications' use in older adults: An analysis from clinical trials to monographs. J Am Geriatr Soc 2024; 72:1252-1262. [PMID: 38270204 DOI: 10.1111/jgs.18772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Older adults have historically been excluded from clinical trials, limiting evidence-based data. An updated picture of the situation with newly marketed medications is needed. We aimed to describe (1) the recommendations specific to older adults in monographs of newly marketed medications; (2) the representation of older adults in clinical trials of those medications. METHODS In November 2020, we listed all medications that received a notice of compliance from Health Canada between January 2006 and September 2020, excluding those with indications irrelevant to community-dwelling older adults and locally acting medications. We assessed the availability and clarity of recommendations in monographs regarding older adults. Using Clinicaltrials.gov, we identified randomized controlled double-blind Phase III-IV trials led in Canada/United States of a sample of 30 commonly used medications among those previously listed. We extracted information on study design, participants, and efficacy/safety analysis specific to older patients. We used simple linear regression and Chi-square/Fisher's exact tests to analyze time trends in the representation of older adults over different periods. RESULTS A total of 195 monographs were included. Of the 130 monographs reporting a dosing recommendation in older adults, 53 (41%) also reported limited/insufficient data in this population or its subgroups. Of the 373 trials included, 217 (58%) did not integrate a maximum age as an inclusion criterion. However, only 113 (30%) reported including a proportion of older adults representative (or over-representative) of the Canadian older population. Most trials (n = 289; 78%) did not provide efficacy or safety data specific to older adults. In our sample, the number/proportion of older adults in trials seemed to be increasingly reported over time, either explicitly or implicitly (e.g., inclusion criterion specifies <65 years old). CONCLUSIONS Newly marketed medications still appear to under-represent older adults. The resulting lack of clear recommendations in monographs compromises evidence-based practice, thereby perpetuating the risk to older adults' health.
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Affiliation(s)
- Maude Gosselin
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
| | | | | | - Marie-Eve Gagnon
- Faculty of Pharmacy, Université Laval, Quebec, Quebec, Canada
- Department of Health Sciences, Université du Québec à Rimouski, Rimouski, Quebec, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Université Laval, Quebec, Quebec, Canada
- Centre d'excellence sur le vieillissement de Québec, Quebec, Quebec, Canada
- VITAM, Sustainable Health Research Centre, Quebec, Quebec, Canada
- CHU de Québec-Université Laval Research Centre, Quebec, Quebec, Canada
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15
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Masnoon N, George C, Lo S, Tan E, Bordia A, Hilmer S. The outcomes of considering goals of care in medication reviews for older adults: a systematic review. Expert Rev Clin Pharmacol 2024; 17:33-56. [PMID: 38145414 DOI: 10.1080/17512433.2023.2286321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 11/17/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION This is a systematic review of prescribing, clinical, patient-reported, and health utilization outcomes of goal-directed medication reviews in older adults. METHODS A systematic review was conducted using MEDLINE, EMBASE, SCOPUS and CINAHL databases to identify studies examining outcomes of goal-directed medication reviews in humans, with mean/median age ≥ 60 years and in English. RESULTS Seventeen out of 743 articles identified were included. Whilst there were inconsistent findings regarding changes in the number of medications between groups or post-intervention in one group (n = 6 studies), studies found reductions in drug-related problems (n = 2) and potential to reduce anticholinergics and sedatives (n = 2). Two out of seven studies investigating clinical outcomes found improvements, such as reduced hospital readmissions and improved depression severity. One study found 75% of patients achieved ≥ 1 goals and another found 43% of goals were achieved at six months. Four out of five studies found significant improvements in patient-reported quality of life between groups (n = 2) or post-intervention in one group (n = 2). Both studies investigating cost-effectiveness reported the intervention was cost-effective. CONCLUSIONS There is evidence of positive impact on medication rationalization, quality of life and cost-effectiveness, supporting goal-directed medication reviews. Larger, longitudinal studies, exploring patient-focused outcomes may provide further insights into the ongoing impact of goal-directed medication reviews.
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Affiliation(s)
- Nashwa Masnoon
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Cristen George
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarita Lo
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Edwin Tan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Aagam Bordia
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah Hilmer
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, NSW, Australia
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16
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Denkinger M, Knol W, Cherubini A, Simonds A, Lionis C, Lacombe D, Petelos E, McCarthy M, Ouvrard P, Van Kerrebroeck P, Szymański P, Cupelli A, Laslop A, Koch A, Sepodes B, Torre C, Rönnemaa E, Bałkowiec-Iskra E, Herdeiro MT, Rosa MM, Trauffler M, Mirošević Skvrce N, Mayrhofer S, Berntgen M, Silva I, Cerreta F. Inclusion of functional measures and frailty in the development and evaluation of medicines for older adults. THE LANCET. HEALTHY LONGEVITY 2023; 4:e724-e729. [PMID: 37977177 DOI: 10.1016/s2666-7568(23)00208-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 11/19/2023] Open
Abstract
The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) E7, the guidance for the conduct of clinical trials in people older than age 65 years, dates from 1994. Since then, the inclusion of older people in clinical trials has hardly improved, particularly for the oldest old age group (individuals older than age 75 years), which is the fastest growing demographic bracket in the EU. Even though most medications are taken by this group, relevant endpoints and safety outcomes for this cohort are rarely included and reported, both in clinical trials and regulatory approval documents. To improve the critical appraisal and the regulatory review of medicines taken by frail older adults, eight recommendations are presented and discussed in this Health Policy. These recommendations are brought together from different perspectives and experience of the treatment of older patients. On one side, the perspective of medical practitioners from various clinical disciplines, with their direct experience of clinical decision making; on the other, the perspective of regulators assessing the data submitted in medicine registration dossiers, their relevance to the risk-benefit balance for older patients, and the communication of the findings in the product information. Efforts to improve the participation of older people in clinical trials have been in place for more than a decade, with little success. The recommendations presented here are relevant for stakeholders, authorities, pharmaceutical companies, and researchers alike, as the implementation of these measures is not under the capacity of a single entity. Improving the inclusion of frail older adults requires awareness, focus, and action on the part of those who can effect a much needed change.
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Affiliation(s)
- Michael Denkinger
- European Geriatric Medicine Society, Genoa, Italy; Institute for Geriatric Research, Ulm University Medical Center at Agaplesion Bethesda Ulm, Ulm, Germany.
| | - Wilma Knol
- European Geriatric Medicine Society, Genoa, Italy; Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Antonio Cherubini
- European Geriatric Medicine Society, Genoa, Italy; Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anita Simonds
- European Respiratory Society, Lausanne, Switzerland; NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Christos Lionis
- European Forum for Primary Care, Utrecht, Netherlands; Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Denis Lacombe
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Elena Petelos
- European Forum for Primary Care, Utrecht, Netherlands; Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece; European Public Health Association, Utrecht, Netherlands; Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Mary McCarthy
- European Union of General Practitioners/Family Physicians, Brussels, Belgium
| | - Patrick Ouvrard
- European Union of General Practitioners/Family Physicians, Brussels, Belgium; Société de Formation Thérapeutique du Généraliste, Paris, France
| | - Philip Van Kerrebroeck
- Department of Urology, Maastricht University, Maastricht, Netherlands; European Association of Urology, Arnhem, Netherlands
| | - Piotr Szymański
- European Society of Cardiology, Sophia Antipolis Cedex, France; Center for Clinical Cardiology, Structural and Rare Cardiovascular Diseases, National Institute of Medicine MSWiA, Warsaw, Poland
| | - Amelia Cupelli
- Pharmacovigilance Risk Assessment Committee, European Medicines Agency, Amsterdam, Netherlands; Pharmacovigilance Office, Italian Medicines Agency, Rome, Italy
| | - Andrea Laslop
- Pharmacovigilance Risk Assessment Committee, European Medicines Agency, Amsterdam, Netherlands; Scientific Office, Austrian Medicines and Medical Devices Agency, Federal Office for Safety in Health Care, Vienna, Austria
| | - Armin Koch
- Institut für Biometrie, Medizinische Hochschule Hannover, Hanover, Germany
| | - Bruno Sepodes
- Committee for Medicinal Products for Human Use, European Medicines Agency, Amsterdam, Netherlands; Departamento de Farmácia, Farmacologia e Tecnologias em Saúde, Faculdade de Farmácia, Universidade de Lisboa, Lisbon, Portugal
| | - Carla Torre
- Committee for Medicinal Products for Human Use, European Medicines Agency, Amsterdam, Netherlands; Departamento de Farmácia, Farmacologia e Tecnologias em Saúde, Faculdade de Farmácia, Universidade de Lisboa, Lisbon, Portugal
| | - Elina Rönnemaa
- Scientific Advice Working Party, European Medicines Agency, Amsterdam, Netherlands; Department of Public Health and Caring Sciences/Geriatrics, Uppsala, Sweden
| | - Ewa Bałkowiec-Iskra
- Committee for Medicinal Products for Human Use, European Medicines Agency, Amsterdam, Netherlands; Scientific Advice Working Party, European Medicines Agency, Amsterdam, Netherlands; Central Nervous System Working Party, European Medicines Agency, Amsterdam, Netherlands; The Office for Registration of Medicinal Products, Medical Devices and Biocidal Products, Warsaw, Poland; Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Maria Teresa Herdeiro
- Pharmacovigilance Risk Assessment Committee, European Medicines Agency, Amsterdam, Netherlands; Health Sciences Department Institute of Biomedicine, University of Aveiro, Aveiro, Portugal
| | - Mário Miguel Rosa
- Scientific Advice Working Party, European Medicines Agency, Amsterdam, Netherlands; Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Martine Trauffler
- Committee for Medicinal Products for Human Use, European Medicines Agency, Amsterdam, Netherlands; Division of Pharmacy and Medicines, Directorate of Health, Ministry of Health, Luxembourg
| | - Nikica Mirošević Skvrce
- Pharmacovigilance Risk Assessment Committee, European Medicines Agency, Amsterdam, Netherlands; Pharmacovigilance Department, Agency for Medicinal Products and Medical Devices, Zagreb, Croatia
| | - Sabine Mayrhofer
- Committee for Medicinal Products for Human Use, European Medicines Agency, Amsterdam, Netherlands; Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Michael Berntgen
- Scientific Evidence Generation Department, European Medicines Agency, Amsterdam, Netherlands
| | - Ivana Silva
- Public and Stakeholders Department, European Medicines Agency, Amsterdam, Netherlands
| | - Francesca Cerreta
- Scientific Evidence Generation Department, European Medicines Agency, Amsterdam, Netherlands
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17
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van Poelgeest E, Seppala L, Bahat G, Ilhan B, Mair A, van Marum R, Onder G, Ryg J, Fernandes MA, Cherubini A, Denkinger M, Eidam A, Egberts A, Gudmundsson A, Koçak FÖK, Soulis G, Tournoy J, Masud T, Wehling M, van der Velde N. Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper. Eur Geriatr Med 2023; 14:1195-1209. [PMID: 37812379 PMCID: PMC10754739 DOI: 10.1007/s41999-023-00872-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.
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Affiliation(s)
- Eveline van Poelgeest
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Lotta Seppala
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Liv Hospital Vadistanbul, Istanbul, Turkey
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
- Edinburgh Napier University, Edinburgh, UK
| | - Rob van Marum
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Graziano Onder
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Antonio Cherubini
- Geriatria Accettazione geriatrica e Centro di Ricerca per l'invecchiamento IRCCS INRCA, Ancona, Italy
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Annette Eidam
- Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Angelique Egberts
- Department of Hospital Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, The Netherlands
| | - Aðalsteinn Gudmundsson
- Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Fatma Özge Kayhan Koçak
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
- Hellenic Open University, Patras, Greece
| | - Jos Tournoy
- Department of Geriatric Medicine, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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18
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Alikhani R, Pai MP. Reconsideration of the current models of estimated kidney function-based drug dose adjustment in older adults: The role of biological age. Clin Transl Sci 2023; 16:2095-2105. [PMID: 37702349 PMCID: PMC10651638 DOI: 10.1111/cts.13643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
Human lifespan has increased from a median of 46.5 years in 1950 to 71.7 years in 2022. As people age, one of the inevitable consequences is a decline in kidney function and glomerular filtration rate (GFR) which can have direct or indirect effects on the pharmacokinetic and pharmacodynamic profiles of many drugs. Numerous equations have been developed to generate estimated GFR (eGFR) using the two principal biomarkers: serum creatinine and serum cystatin C. However, the trajectory of changes with aging is dissimilar in these equations. In addition, there is recognition that chronological age (lifespan) often does not reflect biological age (healthspan) as an essential parameter in kidney function equations. In the past decade, there has been an increasing interest in quantifying biological age and new commercially available assays have entered the marketplace. In this narrative review, we illustrate how dominant equations of eGFR model the fractional change in this parameter very differently across chronological age. In addition, we review various biological age indicators (aging clocks) and challenges to their application in clinical practice. Importantly, by comparing vancomycin's mean clearance as a drug with limited metabolism and unchanged elimination between two age milestones in some recent population pharmacokinetic models, we show how efforts to quantify kidney function in older adults optimally remain under-explored, particularly those at the upper end of their lifespan. We also propose considering new models that integrate biological age as a new pathway to improve precision drug dosing in older adults.
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Affiliation(s)
- Radin Alikhani
- Department of Clinical Pharmacy, College of PharmacyUniversity of MichiganAnn ArborMichiganUSA
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, College of PharmacyUniversity of MichiganAnn ArborMichiganUSA
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19
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Zhou Z, Slattum PW, Ke A, Zhang L. Managing Drug-Drug Interactions in Older Adults. J Clin Pharmacol 2023; 63:1083-1090. [PMID: 37408371 PMCID: PMC10529698 DOI: 10.1002/jcph.2299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Zhu Zhou
- Department of Chemistry, York College, City University of New York, Jamaica, NY
| | | | - Alice Ke
- Certara UK Limited (Simcyp Division), Sheffield, UK
| | - Lei Zhang
- Office of Research and Standards, Office of Generic Drugs, U.S. Food and Drug Administration, Silver Spring, MD
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20
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Hilmer SN. STOPP/START version 3: looks great, fits well, but itches. Eur Geriatr Med 2023; 14:639-641. [PMID: 37421573 DOI: 10.1007/s41999-023-00828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Affiliation(s)
- Sarah N Hilmer
- Kolling Institute, Northern Sydney Local Health District and The University of Sydney, St Leonards, NSW, Australia.
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21
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Schwartz JB. Representative enrolment of older adults in clinical trials: the time is now. THE LANCET. HEALTHY LONGEVITY 2023:S2666-7568(23)00088-0. [PMID: 37263282 DOI: 10.1016/s2666-7568(23)00088-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023] Open
Affiliation(s)
- Janice B Schwartz
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA 94143-1265, USA.
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22
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Cerreta F, Vučić K, Laslop A. Assessing Medicines for Use in the Geriatric Population. Clin Pharmacol Ther 2023; 113:536-540. [PMID: 36354419 DOI: 10.1002/cpt.2793] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/07/2022] [Indexed: 11/12/2022]
Abstract
The aging processes alter the body's response to a medicine's pharmacokinetics, pharmacodynamics, and susceptibility to adverse effects. In addition, older adults, especially the oldest age category (85+ years) or those with multiple chronic health conditions, polypharmacy, or frailty, are under-represented in clinical trials of new medicines. Evidence-based prescribing guidelines based on these trials might result in inappropriate prescription, increasing the risk of drug interactions and adverse drug reactions. Regulators face a conundrum between acquiring sufficient data and putting susceptible patients at risk in the early stages of a development program, when little is known about a medicine's effects. Healthcare professionals and patients deserve to have access to clear information on the knowledge and evidence gaps leading to the approval of a new medicinal product. This should also include proper consideration of the population of older patients. In the present article, we outline the approach taken by the European Medicines Agency (EMA) regulators in the assessment of a new medicine's dossier.
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Affiliation(s)
- Francesca Cerreta
- Scientific Evidence Generation Department, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Katarina Vučić
- Office of Therapies for Endocrine and Cardiovascular Diseases, Human Medicines Division, European Medicines Agency, Amsterdam, The Netherlands
| | - Andrea Laslop
- Scientific Office, Austrian Medicines and Medical Devices Agency, Federal Office for Safety in Health Care, Vienna, Austria
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23
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Then MI, Tümena T, Sledziewska A, Gaßmann KG, Maas R, Fromm MF. Development in Prescriptions of Contraindicated and Potentially Harmful QT Interval-Prolonging Drugs in a Large Geriatric Inpatient Cohort From 2011 to 2021. Clin Pharmacol Ther 2023; 113:435-445. [PMID: 36471654 DOI: 10.1002/cpt.2813] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
Regulatory authorities put major emphasis on QT (interval)-prolonging properties of new molecular entities. Product information/Summaries of Product Characteristics (SmPCs) of multiple drugs contain warnings or contraindications regarding QT prolongation, e.g., on coadministration of QT-prolonging drugs (QT drugs). To characterize the development of the QT drug burden, we performed a trend analysis of prescriptions and co-prescriptions of QT drugs in a large geriatric inpatient cohort. The German SmPCs (status of 2014 and of 2021) and the year-wise listings in the CredibleMeds® database from 2011 to 2021 were used as sources. There were 402,631 geriatric cases included. The group of QT drugs according to SmPCs in 2014, which must not be combined with other QT drugs, was less frequently involved in contraindicated co-prescriptions in 2021 compared with 2015 (3.0% (2.5-3.7%) of cases with at least one of those drugs in 2021 vs. 4.0% (3.5-4.5%) in 2015), with citalopram, escitalopram, and amiodarone involved in nearly 90% of the co-prescriptions. The number of CredibleMeds-QT-drugs per patient increased from 0.4 (SD=1.1) in 2011 to 1.8 (SD=3.9) in 2021. The percentage of contraindicated co-prescriptions of drugs with known risk for torsade de pointes according to CredibleMeds® listings at the beginning of the respective years increased from 1.7% in 2011 to 6.1% in 2021. Considering the regularly updated CredibleMeds® QT drugs list, the contraindicated co-prescriptions of QT drugs markedly increased in the last decade. If prescribers considered only the few most frequently (co-) prescribed QT drugs, then most of the medication errors regarding QT drugs could be prevented.
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Affiliation(s)
- Melanie I Then
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Anna Sledziewska
- Geriatrics Centre Erlangen, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Karl-Günter Gaßmann
- Geriatrics in Bavaria Database, Nürnberg, Germany.,Geriatrics Centre Erlangen, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Renke Maas
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Martin F Fromm
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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24
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van der Graaf PH. Diversity in Clinical Pharmacology Coming of Age. Clin Pharmacol Ther 2022; 112:191-193. [PMID: 35849717 DOI: 10.1002/cpt.2680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/05/2022] [Indexed: 11/06/2022]
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25
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Sukumar S, Orkaby AR, Schwartz JB, Marcum Z, Januzzi JL, Vaduganathan M, Warraich HJ. Polypharmacy in Older Heart Failure Patients: a Multidisciplinary Approach. Curr Heart Fail Rep 2022; 19:290-302. [PMID: 35723783 DOI: 10.1007/s11897-022-00559-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW We provide a review of considerations when applying principles of optimal pharmacotherapy to older adults with heart failure (HF), an analysis on the pivotal clinical trials focusing on applicability to older adults, and multi-disciplinary strategies to optimize the health of HF patients with polypharmacy. RECENT FINDINGS Polypharmacy is very common among patients with HF, due to medications for both HF and non-HF comorbidities. Definitions of polypharmacy were not developed specifically for older adults with HF and may need to be modified in order to meaningfully describe medication burden and promote appropriate medical therapy. This is because clinical practice guidelines for multi-drug HF regimens have unique considerations, given that they improve outcomes and symptoms of HF. Adults older than 65 years are well represented in contemporary clinical trials for HF with preserved ejection fraction (HFpEF) and guideline directed medical therapy (GDMT) for HF with reduced ejection fraction (HFrEF). While these trials did not have significant heterogeneity in safety or efficacy across a broad age spectrum, some may have limited representation of adults ≥ 80 years old, the sickest older adults, or those with decreased functional status. There is also a lack of data on the safety and efficacy of deprescribing HF medications, and deprescription in otherwise stable patients may lead to clinical destabilization or disease progression. There is therefore innate tension between the well-studied benefits of optimized HF therapy for older adults that must be weighed against the risks of polypharmacy and many unknowns that still exist. Given the strong evidence that optimized HF therapies confer symptomatic and mortality benefits for older adults, it is clear that polypharmacy in this context can be appropriate. A shift in paradigm is therefore needed when evaluating polypharmacy in patients with HF. Instead of assuming all polypharmacy is "good" or "bad," we propose a concerted move, using a multidisciplinary approach, to focus on the "appropriateness" of specific medications, in order to optimize HF medical therapy. Clinicians of all specialties caring for complex older adults with HF must consider goals of care, functional status, and new evidence-based therapies, in order to optimize this polypharmacy for older adults.
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Affiliation(s)
- Smrithi Sukumar
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ariela R Orkaby
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.,New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA.,Division of Aging, Brigham & Women's Hospital, Boston, MA, USA
| | | | - Zachary Marcum
- UW School of Pharmacy, University of Washington, Seattle, WA, USA
| | - James L Januzzi
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Muthiah Vaduganathan
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Haider J Warraich
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.,, Boston, MA, USA
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Wang Z, Chan ECY. Physiologically-Based Pharmacokinetic Modelling to Investigate Baricitinib and Tofacitinib Dosing Recommendations for COVID-19 in Geriatrics. Clin Pharmacol Ther 2022; 112:291-296. [PMID: 35380176 PMCID: PMC9087009 DOI: 10.1002/cpt.2600] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/27/2022] [Indexed: 01/02/2023]
Abstract
Janus kinase (JAK) inhibitors baricitinib and tofacitinib are recommended by the US National Institutes of Health as immunomodulatory drugs for coronavirus disease 2019 (COVID-19) treatment. In addition, baricitinib has recently received Emergency Use Authorization from the US Food and Drug Administration, although the instruction provided dosing information only for adults. Geriatrics with organ dysfunction are one of the most vulnerable cohorts when combating the pandemic. The aim of the present work was to evaluate current dosing strategies of baricitinib and tofacitinib for potential COVID-19 treatment for White and Chinese geriatric patients with chronic renal impairment. An established physiologically-based pharmacokinetic (PBPK) modeling framework for age-dependent simulations was utilized. PBPK drug models adopted from literature were first verified. Several population models representing different age groups, ethnicities, and stages of renal impairment were used for prospective simulations. Notwithstanding the increase in systemic exposure of both drugs resulting from renal dysfunction was more pronounced for geriatrics than general White populations, our simulations confirmed their current dosage adjustments based on renal functions are broadly adequate. The exception being White older subjects with mild renal impairment where current recommendation of 4 mg baricitinib yielded a 2.31-fold increase in systemic exposure, and reduction to 2 mg could mitigate the potential risk to an acceptable 1.15-fold. Comparable relationships between systemic exposure and renal dysfunction were observed for both drugs in the Chinese population. In summary, PBPK modeling of both JAK inhibitors supports the rational and prudent dose adjustments of these COVID-19 therapeutics among adult patients of different age groups and renal functions.
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Affiliation(s)
- Ziteng Wang
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Eric Chun Yong Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
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