Potentially inappropriate prescribing to hospitalised patients

Prevalence of potentially inappropriate prescribing in older adults in Central and Eastern Europe: a systematic review and synthesis without meta-analysis

We aimed to systematically review the prevalence of potentially inappropriate prescribing (PIP) in older adults in Central and Eastern Europe (CEE) in all care settings. We searched Embase and MEDLINE (up to June 2019) and checked the reference lists of the included studies and relevant reviews. Eligible studies used validated explicit or implicit tools to assess the PIP prevalence in older adults in CEE. All study designs were considered, except case‒control studies and case series. We assessed the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal Tool and the certainty of evidence using the GRADE approach. Meta-analysis was inappropriate due to heterogeneity in the outcome measurements. Therefore, we used the synthesis without meta-analysis approach-summarizing effect estimates method. This review included twenty-seven studies with 139,693 participants. Most studies were cross-sectional and conducted in high-income countries. The data synthesis across 26 studies revealed the PIP prevalence: the median was 34.6%, the interquartile range was 25.9-63.2%, and the range was 6.5-95.8%. The certainty of this evidence was very low due to the risk of bias, imprecision, and inconsistency. These findings show that PIP is a prevalent issue in the CEE region. Further well-designed studies conducted across countries are needed to strengthen the existing evidence and increase the generalizability of findings.

Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study

Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.

Prevalence of drug interactions in hospitalised elderly patients: a systematic review

BACKGROUND

The prevalence of drug-drug interactions (DDIs) in hospital settings is variable, and elderly patients are considered a high risk population for DDIs. There are no systematic reviews describing the prevalence of DDIs in hospitalised elderly patients.

OBJECTIVES

To assess and summarise the available data on the prevalence of DDIs in hospitalised elderly patients and to describe which drugs, drug classes and drug combinations are most commonly involved in DDIs.

DATA SOURCE

A systematic electronic literature search was conducted on Medline/PubMed, Embase, Lilacs, SciElo, Web of Science, Cinahl, Scopus, Cochrane, OpenGrey, Capes Thesis Bank, OasisBR, OpenAire and abstracts from scientific events, without limitation on language or period of publication. Study selection was completed on 21 September 2018.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Original observational studies that reported the prevalence of actual or potential DDIs during hospitalisation in patients aged 60 years or older were included. The main outcome measure was prevalence of DDIs and number of DDIs per patient. Subgroup analysis was performed in studies that reported the prevalence of DDIs in geriatric units.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was assessed using the Agency for Healthcare Research and Quality methodological checklist for cross sectional and prevalence studies.

RESULTS

34 studies were included, involving 9577 patients. The prevalence of DDIs ranged from 8.34% to 100%. In studies conducted in geriatric units, the prevalence ranged from 80.5% to 90.5%. The number of DDIs per patient ranged from 1.2 to 30.6. Single drugs most commonly involved in DDIs were furosemide, captopril, warfarin and dipyrone. Drug classes mostly involved were potassium sparing diuretics and angiotensin converting enzyme inhibitors.

LIMITATIONS

The main limitation is the heterogeneity between the included studies that precluded a meta-analysis. Several different methods were used to identify DDIs, majorly, and potential DDIs. Few studies have reported measures to control the quality of the collected data.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The prevalence of DDIs ranged widely, and the variation may reflect differences in the conditions of the elderly patients and level of attention (or complexity of care), as well as methodological differences, especially the methods and/or software used to identify DDIs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42018096720.

Drug-drug interactions and their harmful effects in hospitalised patients: a systematic review and meta-analysis

PURPOSE

Drug-drug interactions (DDIs) are often avoidable and, if undetected, can lead to patient harm. This review aimed to determine the prevalence of potential DDIs (pDDIs), clinically relevant DDIs (DDIs that could lead to measurable patient harm, taking into account the patient's individual clinical profile) and DDIs that resulted in actual patient harm during hospitalisation.

METHOD

Four databases were scanned for English papers published from 2000 to 2016. Papers that reported prevalence of DDIs in the outpatient setting, at admission or discharge, involving only specific drugs, or in specific disease populations or age groups were excluded.

RESULTS

Twenty-seven papers met the inclusion criteria and were graded for quality using the Critical Appraisal Skills Programme (CASP) cohort study checklist. Ten papers were rated as 'poor', 14 as 'fair' and only three papers as 'good'. Overall, the meta-analysis revealed that 33% of general patients and 67% of intensive care patients experienced a pDDI during their hospital stay. It was not possible to determine the prevalence of clinically relevant DDIs or DDIs that resulted in actual patient harm as data on these categories were limited. Of the very few studies that reported on harm, only a small proportion of DDIs were found to have resulted in actual patient harm.

CONCLUSIONS

Standardisation of DDI definitions and research methods are required to allow meaningful prevalence rates to be obtained and compared. Studies that go further than measuring pDDIs are critically needed to determine the impact of DDIs on patient safety.

Prevalence of QT interval prolonging drug-drug interactions (QT-DDIs) in psychiatry wards of tertiary care hospitals in Pakistan: a multicenter cross-sectional study

Background QT prolongation and associated arrhythmias, torsades de pointes (TdP), are considerable negative outcomes of many antipsychotic and antidepressant agents frequently used by psychiatric patients. Objective To identify the prevalence, levels, and predictors of QT prolonging drug-drug interactions (QT-DDIs), and AZCERT (Arizona Center for Education and Research on Therapeutics) classification of drugs involved in QT-DDIs. Setting Psychiatry wards of three major tertiary care hospitals of Khyber-Pakhtunkhwa, Pakistan. Method This was a multicenter cross-sectional study. Micromedex DrugReax was used for identification of QT-DDIs. TdP risks were identified by the AZCERT classification. Multivariate logistic regression analysis was performed to identify predictors of QT-DDIs. Main outcome measure Prevalence of QT-DDIs (overall, age-wise and gender-wise) and their levels of severity and documentation; AZCERT classes of drugs involved in QT-DDIs; and odds ratios for predictors of QT-DDIs. Results Of 600 patients, 58.5% were female. Median age was 25 years (IQR = 20-35). Overall 51.7% patients had QT-DDIs. Of total 698 identified QT-DDIs, most were of major-severity (98.4%) and fair-documentation (93.7%). According to the AZCERT classification, 36.4% of the interacting drugs were included in list-1 (known risk of TdP), 26.9% in list-2 (possible risk of TdP) and 27.5% in list-3 (conditional risk of TdP). Drugs commonly involved in QT-DDI were olanzapine (n = 146), haloperidol (138), escitalopram (122), risperidone (91), zuclopenthixol (87), quetiapine (n80) and fluoxetine (74). In multivariate logistic regression analysis, QT-DDIs were significantly associated with 6-7 prescribed medications (p = 0.04) and >7 medications (p = 0.03). Similarly, there was significant association of occurrence of QT-DDIs with 2-3 QT drugs (p < 0.001) and >3 QT drugs (p < 0.001). Conclusion A considerable number of patients are exposed to QT-DDIs in psychiatry. There is a need to implement protocol for monitoring the outcomes of QT-DDIs.

Clinical-pharmacist intervention reduces clinically relevant drug-drug interactions in patients with heart failure: A randomized, double-blind, controlled trial

BACKGROUND

Incidence of drug-drug interactions (DDIs) increases with complexity of treatment and comorbidities, as in heart failure (HF). This randomized, double-blind study evaluated the intervention of the pharmacist on prevalence of clinically relevant DDIs (NCT01855165).

METHODS

Patients admitted with HF were screened for clinically relevant DDIs, and randomized to control or intervention. All attending physicians received standard advice about pharmacological therapy; those in the intervention group also received alerts about clinically relevant DDIs. Primary endpoint was DDI at discharge and secondary were re-hospitalization or death during follow-up.

RESULTS

Of 213 patients, 51 (mean age, 79 ± 6 years; male, 47%) showed 66 clinically relevant DDIs and were randomized. For intervention (n=26) versus control (n=25), the number of patients with and the number of DDIs were significantly lower at discharge: 8 vs. 18 and 10 vs. 31; p=0.003 and 0.0049, respectively. Over a 6 month follow-up period, 11 control and 9 intervention patients were re-hospitalized or died (p>0.2 for all). No significant differences were seen between control and intervention for patients with eGFR <60 mL/min/1.73 m(2) (78%) for re-hospitalization or death (10 vs. 7; p=0.74).

CONCLUSIONS

Pharmacist intervention significantly reduces the number of patients with clinically relevant DDIs, but not clinical endpoints 6 months from discharge.

Conceptualizing and measuring potentially inappropriate drug therapy

WHAT IS KNOWN AND OBJECTIVE

Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice.

METHODS

A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT.

RESULTS AND DISCUSSION

From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1  = 0·479) and substantial for abstracts (κ2  = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature.

WHAT IS NEW AND CONCLUSION

This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.

Potential drug-drug interactions in hospitalized patients with chronic heart failure and chronic obstructive pulmonary disease

INTRODUCTION

Polypharmacy is common in patients with chronic heart failure (HF) and/or chronic obstructive pulmonary disease (COPD), but little is known about the prevalence and significance of drug-drug interactions (DDIs). This study evaluates DDIs in hospitalized patients.

MATERIAL AND METHODS

We retrospectively screened medical charts over a 6-month period for diagnosis of chronic HF and/or COPD. Potential DDIs were evaluated using Lexi-Interact software.

RESULTS

Seven hundred and seventy-eight patients were included in the study (median age 75 years, 61% men). The median number of drugs on admission and discharge was 6 (interquartile range (IQR) 4-9) and 7 (IQR 5-), respectively (p = 0.10). We recorded 6.5 ±5.7 potential DDIs per patient on admission and 7.2 ±5.6 on discharge (p = 0.2). From admission to discharge, type-C and type-X potential DDIs increased (p < 0.05 for both). Type X interactions were rare (< 1%), with the combination of a β-blocker and a β2 agonist being the most common (64%). There were significantly more type-C and type-D potential DDIs in patients with chronic HF as compared to patients with COPD (p < 0.001). Patients with concomitant chronic HF and COPD had more type-C and type-X potential DDIs when compared to those with individual disease (p < 0.005). An aldosterone antagonist and ACE inhibitor/ARB were prescribed to 3% of chronic HF patients with estimated glomerular filtration rate < 30 ml/(min × 1.73 m(2)).

CONCLUSIONS

The DDIs are common in patients with chronic HF and/or COPD, but only a few appear to be of clinical significance. The increase in potential DDIs from admission to discharge may reflect better guideline implementation rather than poor clinical practice.

Why is your patient sedated?

PURPOSE

The purpose of this paper is to examine the recording of clinical indication for prescribed sedative/hypnotic (SH) medications in a large, acute tertiary referral hospital.

DESIGN/METHODOLOGY/APPROACH

All hospital inpatients' medications (n = 367) were audited for prescription details regarding SH medications. Medical notes were then examined for evidence of a recorded indication for such medications.

FINDINGS

SH medications were prescribed to many hospital inpatients (42.5 per cent) during admission. An indication was documented in the nursing or medical records for 24.4 per cent of patients who were prescribed such medications. Nurses rather than by doctors prescribed most SH medications (74 vs 26 per cent, respectively, p = 0.003). Some patients receiving SH medications were both over 65 and impaired in their mobility (19.2 per cent). The treatment indication was documented in 47 per cent.

PRACTICAL IMPLICATIONS

Most patients prescribed SH medications have nothing in their medical record explaining why these drugs are being used, including half of the elderly, less mobile patients. All health professionals dealing with SH medications and doctors in particular need to justify the use of such medications in the medical record. For the particularly high-risk groups where SH medications are potentially more dangerous, explicit guidance on why and how such medications are to be used must be provided by prescribers.

ORIGINALITY/VALUE

For the first time, data are presented on documentation rates for clinical indication of prescribed SH medications across a large acute hospital, and highlights significant shortcomings in practice. This study should inform other organisations of the need to be mindful of facilitating greater compliance with good prescribing practice.

Prevention of inappropriate prescribing in hospitalized older patients using a computerized prescription support system (INTERcheck(®))

BACKGROUND

Polypharmacy is very common among older adults and can lead to inappropriate prescribing, poor adherence to treatment, adverse drug events and the prevalence of potential drug-drug interactions (DDIs). Electronic prescription database software may help to prevent inappropriate prescribing and minimize the occurrence of adverse drug reactions. INTERcheck(®) is a Computerized Prescription Support System (CPSS) developed in order to optimize drug prescription for elderly people with multimorbidity.

OBJECTIVES

The objectives of this study were (i) to evaluate the applicability of INTERcheck(®) as a means of reviewing the pharmacological profiles of elderly patients hospitalized in an acute geriatric ward in Northern Italy; and (ii) to evaluate the effectiveness of INTERcheck(®) in reducing potentially inappropriate medications (PIMs), potentially severe DDIs and the anticholinergic burden in daily practice.

METHODS

Two samples of elderly patients (aged 65+ years) hospitalized in a geriatric ward in Italy were enrolled throughout 2012. During the first (observation) phase, medications prescribed to 74 patients at admission and discharge were analyzed with INTERCheck(®) without any kind of interference based on information obtained from the software. During the second (intervention) phase, the treatment of 60 patients was reviewed and changed at discharge according to INTERCheck(®) suggestions.

RESULTS

In the observational period, the number of patients exposed to at least one PIM remained unchanged on both admission (n = 29; 39.1 %) and discharge (n = 28; 37.8 %). In the intervention phase, 25 patients (41.7 %) were exposed to at least one PIM at admission and 7 (11.6 %) at discharge (p < 0.001). The number of patients exposed to at least one potentially severe DDI decreased from 27 (45.0 %) to 20 (33.3 %), although the difference was not statistically significant (p = 0.703), while the number of new-onset potentially severe DDIs decreased from 37 (59.0 %) to 9 (33.0 %) [p < 0.001].

CONCLUSIONS

The use of INTERCheck(®) was associated with a significant reduction in PIMs and new-onset potentially severe DDIs. CPSSs combining different prescribing quality measures should be considered as an important strategy for optimizing medication prescription for elderly patients.

Anti-hypertensive medicines prescribing for medical outpatients in a premier teaching hospital in Nigeria: a probable shift of paradigm

BACKGROUND

Previous studies of anti-hypertensive medicines utilization pattern in Nigeria showed that Angiotensin converting enzyme inhibitors (ACEIs) were often the least prescribed. However, the appropriate use of ACEIs in the black population achieves good blood pressure control and provides additional long term cardio- and renovascular protection benefits.

OBJECTIVE

To assess the current utilization pattern of antihypertensive medicines with specific emphasis on identifying possible shift in the frequency of use of ACEIs.

METHODS

A prospective cross-sectional assessment of the current utilization pattern of anti-hypertensive medicines was conducted among 300 randomly selected cohort at a 900-bed premier Teaching Hospital located in Ibadan, Southwestern Nigeria. The current utilization pattern was compared with the results of a study conducted at the same site and published 10 years ago.

RESULTS

Of the 300 random cohorts, a majority (79%) were females (237) with mean age 58.7 years (SD=2.81 years. Stage 2 hypertension was the most frequent diagnosis (54.3%). The utilization of ACEIs and long acting CCB (amlodipine) significantly increased from 8.6% and 21% (Ten years ago) to 29.93% and 36.68% respectively (p < 0.0001). The use of thiazide diuretic and methyldopa declined significantly from 39.4% and 23.3% (Ten years ago) to 16.12% and 9.7% respectively (p < 0.0001). Adverse drug reactions due to ACEIs were documented in 1.5% (3), while laboratory monitoring of serum potassium, urea and creatinine was conducted in only 37% (111) of cohort. Potentially harmful drug-drug interactions were identified in 25% (75) of cohorts, and the most frequent were ACEIs + NSAIDs (53.3%), ACEIs + amiloride / hydrochlorothiazide (22.6%).

CONCLUSIONS

Anti-hypertensive medicines utilization has significantly shifted towards the increased use of ACEIs and long acting dihydropyridine CCBs. The use of thiazides and methyldopa has declined significantly. Physicians appeared more cognizant of the long term cardio- and renovascular benefits inherent in using ACEIs in a high cardiovascular risk group such as black hypertensive.

Frequency of inappropriate medication prescription in hospitalized elderly patients in Italy

Background

Older people often need comprehensive treatment, including many medications, and polypharmacy is common. The aims of this cross-sectional investigation were to examine the potentially inappropriate medication during the hospitalization and to identify the factors that may influence such inappropriateness among elderly in Italy.

Methods

A sample of 605 individuals aged 65 years and older admitted in non-academic public acute care hospitals was randomly selected. Prescription of inappropriate medications were evaluated during the period from the day of admission to a randomly preselected day (index day). Beers Criteria were used to evaluate appropriateness.

Results

At least one potentially inappropriate medication prescription from the day of hospital admission to the index day has been observed in 188 patients (31.1%), and respectively 84.1% and 15.9% of them had received one or two inappropriate medications. A total of 15 medications was prescribed inappropriately to these 188 patients, for 215 times with a total of 1143 doses. The multivariate logistic regression analysis revealed that the significant predictors for having at least one potentially inappropriate medication prescription during the hospitalization were: patients having an elementary education level, a lower pre-admission performance-based measure of basic activities of daily living, having received an inappropriate drug before the hospitalization, a hospital stay in the general and in the specialties surgical wards, a longer length of hospital stay from the admission to the index day, and having received a higher number of drugs from the day of the hospital admission to the index day. The most prevalent inappropriate medications administered were ketorolac (27.4%), amiodarone (19.1%), and clonidine (11.2%).

Conclusions

This study supports the need for clinical guidelines implementation to assist physicians in choosing the most appropriate drugs for the elderly and for effective education of all physicians.

Drug-drug interactions in a cohort of hospitalized elderly patients

PURPOSE

The aim of this study is to assess the prevalence of patients exposed to potentially severe drug-drug interactions (DDIs) at hospital admission and discharge and the related risk of in-hospital mortality and adverse clinical events, readmission, and all-cause mortality at 3 months.

METHODS

This cross-sectional, prospective study was held in 70 Italian internal medicine and geriatric wards. Potentially severe DDIs at hospital admission and discharge; risk of in-hospital mortality and of adverse clinical events, readmission, and all-cause mortality at 3-month follow-up.

RESULTS

Among 2712 patients aged 65 years or older recruited at hospital admission, 1642 (60.5%) were exposed to at least one potential DDI and 512 (18.9%) to at least one potentially severe DDI. Among 2314 patients discharged, 1598 (69.1%) were exposed to at least one potential DDI and 1561 (24.2%) to at least one potentially severe DDI. Multivariate analysis found a significant association with an increased risk of mortality at 3 months in patients exposed to at least two potentially severe DDIs (Odds ratio 2.62; 95% confidence interval, 1.00-6.68; p = 0.05). Adverse clinical events were potentially related to severe DDIs in two patients who died in the hospital, in five readmitted, and one who died at 3 months after discharge.

CONCLUSIONS

Hospitalization was associated with an increase in potentially severe DDIs. A significant association was found for mortality at 3 months after discharge in patients with at least two potentially severe DDIs. Careful monitoring for potentially severe DDIs, especially those created at discharge or recently generated, is important to minimize the risk of harm.

Drug-drug interactions contributing to QT prolongation in cardiac intensive care units

PURPOSE

To determine the most common drug-drug interaction (DDI) pairs contributing to QTc prolongation in cardiac intensive care units (ICUs).

MATERIALS AND METHODS

This retrospective evaluation included patients who were admitted to the cardiac ICUs between January 2009 and July 2009 aged ≥ 18 years with electrocardiographic evidence of a QTc ≥ 500 ms. Patients receiving at least two concomitant drugs known to prolong the QT interval were considered to experience a pharmacodynamic DDI. Drugs causing CYP450 inhibition of the metabolism of QT prolonging medications were considered to cause pharmacokinetic DDIs. The causality between drug and QTc prolongation was evaluated with an objective scale.

RESULTS

One hundred eighty-seven patients experienced QT prolongation out of a total of 501 patients (37%) admitted during the study period. Forty-three percent and 47% of patients experienced 133 and 179 temporally-related pharmacodynamic and pharmacokinetic interactions, respectively. The most common medications related to these DDIs were ondansetron, amiodarone, metronidazole, and haloperidol.

CONCLUSION

DDIs may be a significant cause of QT prolongation in cardiac ICUs. These data can be used to educate clinicians on safe medication use. Computerized clinical decision support could be applied to aid in the detection of these events.

Prevalence of drug interactions in hospital healthcare

AIM OF THE REVIEW

To study the prevalence of drug interactions in hospital healthcare by reviewing literature.

METHOD

A review was carried out of studies written in Spanish and English on the prevalence of drug interactions in hospital care published in Pubmed between January 1990 and September 2008. The search strategy combined free text and MeSH terms, using the following keywords: "Drug interaction", "prevalence" and "hospital". For each article, we classified independent variables (pathology, age of population, whether patients were hospitalized or not, geographical location, etc.) and dependent variables (number of interactions per 100 patients studied, prevalence of patients with interactions, most common drug interactions, and others).

RESULTS

The search generated 436 articles. Finally, 47 articles were selected for the study, 3 provided results about drug interactions with real clinical consequences, 42 about potential interactions, and 2 described both. The prevalence of patients with interactions was between 15 and 45 % and the number of interactions per 100 patients was between 37 and 106, depending on the group of studies analyzed. There was a considerable increase in these rates in patients with heart diseases and elderly persons.

CONCLUSION

There is a large number of studies on the prevalence of drug interactions in hospitals but they report widely varying results. The prevalence is higher in patients with heart diseases and elderly people.

Electronic prescribing and other forms of technology to reduce inappropriate medication use and polypharmacy in older people: a review of current evidence

This review provided an overview of the current evidence in relation to the use of e-prescribing and other forms of technology, such as CDSS, to reduce inappropriate prescribing in older people. The evidence indicates that various types of e-prescribing and CDSS interventions have the potential to reduce inappropriate prescribing and polypharmacy in older people, but the magnitude of their effect varies according to study design and setting. There was significant heterogeneity in the studies reported in terms of study designs, intervention design, patient settings, and outcome measures with patient outcomes seldom reported. Widespread diffusion of these interventions has not occurred in any of the health care settings examined. Overall, health care providers report being satisfied with e-prescribing systems and see the systems as having a positive impact on the safety of their prescribing practices, yet the problem of overriding or ignoring alerts persists. The problem of large numbers of inaccurate and insignificant alerts and this issue, along with the other barriers that have been identified, warrant further investigation.

Evaluation of drug-drug interaction screening software combined with pharmacist intervention

BACKGROUND

Drug-drug interactions (DDI) in hospitalized patients are highly prevalent and an important source of adverse drug reactions. DI computerized screening system can prevent the occurrence of some of these events.

OBJECTIVE

To evaluate the impact of drug-drug interaction (DDI) screening software combined with active intervention in preventing drug interactions.

SETTING

The study was conducted at General Hospital of Vitória da Conquista (HGVC), Brazil.

METHOD

A quasi-experimental study was used to evaluate the impact of IM-Pharma, a locally developed drug-drug interaction screening system, coupled with pharmacist intervention on adverse drug events in the hospital setting.

MAIN OUTCOME MEASURE

The proportion of patients co-prescribed two interacting drugs were measured in two phases, prior the implementation of IM-Pharma and during the intervention period. DDI rates per 100 patient days were calculated before and after implementation. Risk ratios were estimated by Poisson regression models.

RESULTS

A total of 6,834 instances of drug-drug interactions were identified; there was an average of 3.3 DDIs per patient in phase one and 2.5 in phase two, a reduction of 24 % (P = 0.03). There was a 71 % reduction in high-severity drug-drug interaction (P < 0.01). The risk for all DDIs decreased 50 % after the implementation of IM-Pharma (P < 0.01), and for those with high-severity, the reduction was 81 % (P < 0.01).

CONCLUSION

The performance of IM-Pharma combined with pharmacist intervention was positive with an expressive reduction in the risk of DDIs.

Comparison of published explicit criteria for potentially inappropriate medications in older adults

Several sets of explicit criteria for potentially inappropriate medications (PIMs) have been developed by expert consensus. The purpose of this review is to summarize and compare existing criteria to enable more informed choices about their use. After a systematic literature search was conducted, seven examples of criteria published between 1991 and 2009 were included in the review and their individual characteristics are presented. Common medications listed in the majority of these criteria are also summarized. PIMs listed regardless of co-morbidities in all seven criteria sets were long-acting benzodiazepines and tricyclic antidepressants. PIMs regardless of co-morbidities were most similar among the Beers, Rancourt and Winit-Watjana criteria. Several drug-disease interactions such as benzodiazepines and falls were cited in most criteria. With respect to drug-drug interactions, most criteria agreed that concomitant use of warfarin and NSAIDs should be avoided. The prevalence of PIMs varied with patient population, availability of medications in local markets, the specialties of the prescribing physicians and the assessment instruments used. The associations between PIMs use and health outcomes were largely inconclusive because of limited data. Further research is necessary to validate these published criteria in terms of reducing the incidence of adverse drug reactions and improving health outcomes among older adults. Incorporation of these criteria into computer-assisted order entry systems would increase their utilization in daily practice.

Use of potentially inappropriate medicines in elderly: A prospective study in medicine out-patient department of a tertiary care teaching hospital

Objective:

The present study was undertaken with the aim to detect extent of drug use in elderly at medicine outpatient department at tertiary care hospital and to evaluate inappropriate prescribing with the help of Beers' criteria 2002.

Materials and Methods:

The study was carried out at medicine out patient department of our hospital. 407 geriatric patients were included during the study period of three and half months. The data was collected in a proforma which included the patients' details and the prescriptions.

Results:

The results reveal that 7.42% of total drugs were prescribed in an inappropriate manner and 23.59% of total patients received at least one inappropriate drug prescription. Administration of a drug which is avoided in elderly forms a common category of inappropriate drug use. Antihistamines, anticholinergic, sedatives and hypnotics and cardiac glycosides are the most common drug groups prescribed in inappropriate manner.

Conclusion:

To conclude, this study shows high prevalence of inappropriate use of drugs in geriatric practice suggesting urgent need for sincere efforts to improve the situation.

Prevalence of potentially hazardous drug interactions amongst Australian veterans

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT * Up to 21% of adverse drug event related hospital admissions are due to drug interactions. Clinical significance of drug interactions varies. * Studies which only identified drug interactions of potentially major clinical significance found lower prevalence, of between 2 and 16%. * Prevalence of drug interactions defined 'potentially hazardous' has had limited study, with no publications identified for the Australian population. WHAT THIS STUDY ADDS * In the study population of 287 074, 1.5% of subjects were dispensed potentially hazardous interacting drug pairs. * However, limited to populations on specific medicines, it was found that for patients dispensed verapamil, methotrexate, amiodarone, lithium, warfarin, cyclosporin and itraconazole, potentially hazardous interactions occurred at a rate greater than 5%. * These patients should be the focus of medication review programmes to avoid potentially serious adverse drug events. BACKGROUND Up to 21% of adverse drug event-related hospital admissions are due to drug interactions. Clinical significance of drug interactions varies, and drug interactions defined 'potentially hazardous' are more likely to contribute to morbidity and mortality. AIM The aim of this study was to assess the prevalence of potentially hazardous drug interactions in an elderly Australian veteran population. METHODS This study assessed the prevalence of potentially hazardous drug interactions, where hazardous was defined in three or more international drug interaction references, using Repatriation Pharmaceutical Benefits Scheme pharmacy claims data. Analysis was limited to patients who received regular concurrent dispensings of potentially hazardous interacting medicines. RESULTS Of the 287 074 subjects included in the study, 1.5% were dispensed potentially hazardous interacting drug pairs. For patients dispensed cyclosporin, concomitant use of a statin was common (47%); as was statin use with those dispensed itraconazole (31%). Of those dispensed methotrexate, 24% also received a non-steroidal anti-inflammatory drug; of those on lithium, 18% also received an ACE inhibitor or angiotensin 2 receptor blocker; of those on warfarin, 7.2% and 5.9% were co-dispensed an non-steroidal anti-inflammatory drugs or antiplatelets respectively; for those on verapamil, 5.3% were co-dispensed a beta-blocker, while for those on amiodarone 6.2% were co-dispensed digoxin. CONCLUSIONS Overall prevalence of potentially serious drug interactions appears to be low in the Australian veteran population. However, patients taking cyclosporine, itraconazole, methotrexate, lithium, warfarin, verapamil and amiodarone appear to be most at risk and their medicine use should be regularly reviewed to prevent potentially hazardous drug interactions.

The incidence of potential drug-drug interactions in elderly patients with arterial hypertension

OBJECTIVE

To assess the incidence and type of potential, clinically significant drug-drug interactions in elderly outpatients with arterial hypertension.

SETTING

Three community pharmacies in Croatia.

METHOD

Eligible patients were aged 65 or older, treated for arterial hypertension and received 2 or more drugs. Potential interactions were identified by Lexi-Interact software. The software categorized each potential interaction according to clinical significance in five groups: (A) No known interaction; (B) Specified agents may interact, but there is little to no evidence of clinical concern; (C) Specified agents may interact in a clinically significant manner. Monitoring therapy is suggested; (D) The two medications may interact in a clinically significant manner. Modification of therapy is suggested; (X) Contraindicated combination. Interactions of level C, D and X were considered clinically significant.

MAIN OUTCOME MEASURE

The incidence and type of potential drug-drug interactions.

RESULTS

There were 265 patients included in the study. Potential, clinically significant drug interactions were identified in 240 (90.6%) patients, out of which 97.9% had interactions with clinical significance C, 20.4% D, and 0.8% X. The median number of drug interactions per patient was 4. We identified 215 drug combinations with the potential to cause clinically significant interaction, out of which 83.3% had clinical significance C, 16.3% clinical significance D, and 0.4% clinical significance X.

CONCLUSION

Drug-drug interactions are common in elderly hypertensive patients. Computer-based screening could help pharmacists and physicians to recognize potential, clinically significant interactions.

Polypharmacy in older adults with cancer

The definition of "polypharmacy" ranges from the use of a large number of medications; the use of potentially inappropriate medications, which can increase the risk for adverse drug events; medication underuse despite instructions to the contrary; and medication duplication. Older adults are particularly at risk because they often present with several medical conditions requiring pharmacotherapy. Cancer-related therapy adds to this risk in older adults, but few studies have been conducted in this patient population. In this review, we outline the adverse outcomes associated with polypharmacy and present polypharmacy definitions offered by the geriatrics literature. We also examine the strengths and weaknesses of these definitions and explore the relationships among these definitions and what is known about the prevalence and impact of polypharmacy.

Trends of benzodiazepine prescribing and the risk of hip fracture in elderly patients in Taiwan: A population-based study

Abstract Objective. The aim of this study was to explore the trends of prescribing potentially inappropriate benzodiazepine use (PIBU) and the risk of fractures in an elderly population in Taiwan. Methods. Retrospective administrative database analysis was conducted. Outpatient claim data were retrieved from the Longitudinal Health Insurance Database (LHID) between 2000 and 2003, which contains all inpatient and outpatient medical claims of approximately 23 million patients in Taiwan. All patients with the diagnosis of hip fractures (ICD codes) were identified from the database. The inappropriate use for the elderly was defined as a prescription with the dose of short- and long-acting BZD according to the 2003 version of Beers' criteria. Multiple logistic regressions were used to determine the association of PIBU with fractures. Results. A total of 62,023 elderly patients aged ≧65 years were retrieved from the database. The proportion of elderly patients taking short-and long-acting benzodiazepines declined significantly from 28.1 to 25% and 19.5 to 14.5% from 2000 to 2003, respectively (P<0.001). After adjustment for age, sex, co-morbidity, other medications in one prescription and all of the covariates, the risk of hip fractures (∼50%) was still statistically significant (adjusted OR in the four years studied: 1.57, 1.38, 1.68, 1.45) for elderly patients taking benzodiazepines in Taiwan. Conclusion. These findings suggest that the inappropriate use of benzodiazepine may be associated with the risk of fractures. Physicians should prescribe benzodiazepines appropriately for the elderly to minimize the risk of hip fractures.