Polypharmacy: the cure becomes the disease

Drug use survey to identify significant drug-drug interactions and assess clinical importance in the outpatient setting of a tertiary care hospital

OBJECTIVES

Drug-drug interactions (DDIs) are a common problem in pharmacotherapy, particularly in situations where multiple disorders must be treated at the same time. We conducted a drug use survey in the general medicine outpatient department of a tertiary care hospital with the objective of assessing the potential for DDI in individual prescriptions for adult patients.

MATERIALS AND METHODS

Drugs prescribed in the current physician-patient encounter were considered in conjunction with medicines already being received by the patient as well as those discontinued in the past 1 month. Free online DDI checkers (available at https://www.drugs.com/drug_interactions.html and https://reference.medscape.com/) were used to identify potential DDI and categorize them into mild, moderate, and severe categories. We did not consider food, alcohol, or smoking-related interactions.

RESULTS

A total of 153 prescriptions, having two or more drugs, were collected, and they accounted for 1052 prescribed drugs. Among them, 613 (58.27%) were prescribed in index visits, and the rest 438 (41.63%) were preexisting medication. The number of drugs prescribed in index visits ranged from 1 to 9 (mean ± standard deviation [SD] 4.0 ± 1.86; median 4). Potential DDIs were identified in 103 (67.32%) instances. The total number of interactions identified was 412. Of these, 19.66% had minor, 77.67% moderate, and 7.19% major clinical implications. Potential DDI count in each prescription was found from 0 to 13 in number (mean ± SD 2.7 ± 3.12; median 2.0). This number correlated strongly with the number of drugs being received by individual subjects (Rho 0.744; P < 0.001).

CONCLUSIONS

Potential DDIs are a reality in day to day prescribing practice. Substantial proportion of these DDIs may have significant clinical implications. Prescribers need to be sensitized to this issue. Combining human expertise with technological solutions such as automated drug interaction alerts can help rectify the situation. Similar surveys are needed on a periodic basis to improve medication safety for patients.

Enhancing Primary Care for Nursing Home Patients with an Artificial Intelligence-Aided Rational Drug Use Web Assistant

Polypharmacy can result in drug-drug interactions, severe side-effects, drug-disease interactions, inappropriate medication use in the elderly, and escalating costs. This study aims to evaluate nursing home residents' medication regimens using a rational drug use web assistant developed by researchers to mitigate unnecessary medication usage. This analytical, cross-sectional study included data from nursing home residents recently recorded in a training family health center. Sociodemographic information, medical conditions, and prescribed medications of all patients in the nursing home (n = 99) were documented. Medications were assessed using an artificial intelligence-aided rational drug use web assistant. Instances of inappropriate drug use and calculations of contraindicated drug costs were also recorded. The study revealed that 88.9% (n = 88) of patients experienced polypharmacy, with a mean value of 6.96 ± 2.94 drugs per patient. Potential risky drug-drug interactions were present in 89.9% (n = 89) of patients, contraindicated drug-drug interactions in 20.2% (n = 20), and potentially inappropriate drug use in 86.9% (n = 86). Plans to discontinue 83 medications were estimated to reduce total direct medication costs by 9.1% per month. After the assessment with the rational drug use web assistant, the number of drugs that patients needed to use and polypharmacy decreased significantly. This study concludes that the rational drug use web assistant application, which is more cost-effective than the traditional manual method, assisted by artificial intelligence, and integrated into healthcare services, may offer substantial benefits to family physicians and their geriatric patients.

Artificial intelligence-supported web application design and development for reducing polypharmacy side effects and supporting rational drug use in geriatric patients

Introduction

The main complications of polypharmacy, which is known as the simultaneous use of more than five drugs, are potentially inappropriate medicines(PIMs), drug–drug, and drug-disease interaction. It is aimed to prepare an auxiliary tool to reduce the complications of polypharmacy and to support rational drug use(RDU), by evaluating the patient with age, drugs, and chronic diseases in this study.

Materials and methods

In the first phase of this study, as methodological research, an up-to-date and comprehensive auxiliary tool as a reference method was generated with a database containing interaction information of 430 most commonly used drug agents and chronic diseases in geriatrics in the light of current and valid 6 PIM criteria for geriatric patients, and medication prospectuses, relevant current articles, and guidelines. Then, an artificial intelligence(AI) supported web application was designed and developed to facilitate the practical use of the tool. Afterward, the data of a cross-sectional observational single-center study were used for the rate and time of PIM and drug interaction detection with the web application. The proposed web application is publicly available at https://fastrational.com/.

Results

While the PIM coverage rate with the proposed tool was 75.3%, the PIM coverage rate of EU(7)-PIM, US-FORTA, TIME-to-STOPP, Beers 2019, STOPP, Priscus criteria in the web application database respectively(63.5%–19.5%) from the highest to the lowest. The proposed tool includes all PIMs, drug–drug, and drug-disease interaction information detected with other criteria. A general practitioner detects interactions for a patient without the web application in 2278 s on average, while the time with the web application is decreased to 33.8 s on average, and this situation is statistically significant.

Discussion

In the literature and this study, the PIM criteria alone are insufficient to include actively used medicines and it shows heterogeneity. In addition, many studies showed that the biggest obstacle to drug regulation in practice is “time constraints.” The proposed comprehensive auxiliary tool analyzes age, drugs, and diseases specifically for the patient 60 times faster than the manual method, and it provides quick access to the relevant references, and ultimately supports RDU for the clinician, with the first and only AI-supported web application.

Pharmacotherapeutic challenges for treating the baby boomer cohort

As the baby boomer cohort ages, they have an ever-increasing number of comorbidities and associated poly-pharmaceutical treatment needs. The challenge for healthcare providers is to stay current of advancements in providing for this aging population. Baby boomers can expect a longer life expectancy than any previous generation. Yet, longevity has not correlated with better health. This cohort is noted for being goal driven and more self-assured than younger generations. They are resourceful and will often attempt to fix things themselves, including their healthcare. They believe hard work deserves justifiable rewards and relaxation. These beliefs have resulted in baby boomers utilizing more alcohol and illicit drugs. Altogether this means today's healthcare providers must be aware of potential interactions from the polypharmacy of prescribed medication, and they must include and understand additional complications associated with supplemental medications and illegal drugs.

Aging and the Prevalence of Polypharmacy and Hyper-Polypharmacy Among Older Adults in South Korea: A National Retrospective Study During 2010–2019

Background: Polypharmacy has become a global health problem and is associated with adverse health outcomes in the elderly. This study evaluated the prevalence of polypharmacy and hyper-polypharmacy in elderly patients in South Korea during 2010–2019.

Methods: We analyzed the outpatient care of persons aged ≥65 years covered by National Health Insurance (NHI) using NHI claims data from 2010 to 2019. Polypharmacy was defined as the use of ≥5 medications, and hyper-polypharmacy was defined as the use of ≥10 medications, and we examined them over periods of ≥90 days and ≥180 days. The average annual percent change (AAPC) was calculated using Joinpoint statistical software.

Results: The prevalence of polypharmacy among ≥90 days of medication use elderly decreased from 42.5% in 2010 to 41.8% in 2019, and the prevalence of hyper-polypharmacy for ≥90 days increased from 10.4% to 14.4%. The prevalence of polypharmacy for ≥180 days increased from 37.8% in 2010 to 38.1% in 2019, and the prevalence of hyper-polypharmacy for ≥180 days increased from 6.4% to 9.4%. The prevalence of polypharmacy for ≥90 days and ≥180 days steadily increased among elderly patients, with AAPCs of 3.7 and 4.5, respectively.

Conclusion: The prevalence of polypharmacy for ≥90 days and ≥180 days remained stably high, with rates of about 42 and 38%, respectively, and hyper-polypharmacy increased over the past 10 years in South Korea. Therefore, strategies to address polypharmacy need to be implemented. Further research is also required to identify the clinical outcomes (including mortality risks) associated with polypharmacy.

An Initiative to Reduce Insulin-Related Adverse Drug Events in a Children's Hospital

OBJECTIVES

Adverse drug events (ADEs) during hospitalization are common. Insulin-related events, specifically, are frequent and preventable. At a tertiary children's hospital, we sought to reduce insulin-related ADEs by decreasing the median event rate of hyper- and hypoglycemia over a 12-month period.

METHODS

Using Lean 6 σ methodology, we instituted a house-wide process change from a single-order ordering process to a pro re nata (PRN) standing order process. The standardized process included parameters for administration and intervention, enabling physician and nursing providers to practice at top of licensure. Automated technology during dose calculation promoted patient safety during dual verification processes. Control charts tracked rates of insulin-related ADEs, defined as hyperglycemia (glucose level >250 mg/dL) or hypoglycemia (glucose level <65 mg/dL). Events were standardized according to use rates of insulin on each nursing unit. The rates of appropriately timed insulin doses (within 30 minutes of a blood sugar check) were assessed.

RESULTS

Baseline median house-wide frequencies of hyperglycemic and hypoglycemic episodes were 55 and 6.9 events (per 100 rapid-acting insulin days), respectively. The median time to insulin administration was 32 minutes. The implementation of the PRN process reduced the median frequencies of hyperglycemic and hypoglycemic episodes to 45 and 3.8 events, respectively. The median time to insulin administration decreased to 18 minutes.

CONCLUSIONS

A PRN ordering process and education decreased insulin-associated ADEs and the time to insulin dosing compared with single-entry processes. Engaging bedside providers was instrumental in reducing insulin-related ADEs. Strategies that decrease the time from patient assessment to drug administration should be studied for other high-risk drugs.

Therapeutic duplication on the general surgical wards

Therapeutic duplication is the practice of prescribing multiple medications for the same indication or purpose without a clear distinction of when one agent should be administered over another. This is a problem that occurs frequently, especially on electronic prescribing records (EPR) as the medication chart is not always reviewed before prescribing. The aim of this Quality Improvement Project (QIP) was to reduce therapeutic duplication to 0% through educating the general surgical team. Prescriptions of all general surgical patients in the surgical wards were reviewed daily for a month. EPR was used to check if there were any duplications or identical class of drug prescribed. Patient documentation was thoroughly checked to rule out if the duplication was intentional. Following this, if duplication was still unclear, the relevant teams would be contacted for clarification. Any unintentional error was removed, and data was collected. The QIP results were presented to the local general surgical meeting and our fellow colleagues were educated on the importance of safe prescribing and on how to prevent prescribing errors. The baseline of therapeutic duplications on the general surgical wards was 9% prior to our first cycle. Following the presentation of data and educating the surgical team at the surgical meeting, the number of errors seemingly reduced, however, there was a jump to 22% of therapeutic duplication on a particular Friday which brought the average of therapeutic duplication to 8.77%. The team was reminded again about the importance of correct prescribing and after the second cycle, the number of errors reduced to 5.29%. For the third audit cycle, the team was presented with the reaudited data and following this, the number of errors dropped down to 3.12%. Therapeutic duplication should never occur as this could cause a risk to patient harm. Through educating the surgical team and reminding our team regularly, the average number of errors reduced by more than half of the original number. In our hospital, the main source of safety net is through pharmacists and nurses, however as shown, this is not enough to prevent all therapeutic errors. A more sustainable intervention such as an alert on EPR prior to prescribing may be required to maintain a low therapeutic duplication average and prevent patient harm.

Assessing polypharmacy in the older population: Comparison of a self-reported and prescription based method

PURPOSE

To explore differences in the prevalence and determinants of polypharmacy in the older general population in Belgium between self-reported and prescription based estimates and assess the relative merits of each data source.

METHODS

Data were used from participants aged ≥65 years of the Belgian national health survey 2013 (n = 1950). Detailed information was asked on the use of medicines in the past 24 h and linked with prescription data from the Belgian compulsory health insurance (BCHI). Agreement between polypharmacy (use or prescription ≥5 medicines) and excessive polypharmacy (≥10 medicines) between both sources was assessed with kappa statistics. Multinomial logistic regression was used to study determinants of moderate (5-9 medicines) and excessive polypharmacy (≥10 medicines) and over- and underestimation of prescription based compared to self-reported polypharmacy.

RESULTS

Self-reported and prescription based polypharmacy prevalence estimates were respectively 27% and 32%. Overall agreement was moderate, but better in men (kappa 0.60) than in women (0.45). Determinants of moderate polypharmacy did not vary substantially by source of outcome indicator, but restrictions in activities of daily living (ADL), living in an institution and a history of a hospital admission was associated with self-reported based excessive polypharmacy only.

CONCLUSIONS

Surveys and prescription data measure polypharmacy from a different perspective, but overall conclusions in terms of prevalence and determinants of polypharmacy do not differ substantially by data source. Linking survey data with prescription data can combine the strengths of both data sources resulting in a better tool to explore polypharmacy at population level.

The effects of in-hospital deprescribing on potential prescribing omission in hospitalized elderly patients with polypharmacy

No studies to investigate the effect of a deprescribing intervention on the occurrence of potential prescribing omissions (PPOs) among elderly patients with polypharmacy have been conducted. Therefore, the effect of deprescribing on PPOs among elderly patients with polypharmacy was investigated. All 121 consecutive elderly patients who received in-hospital deprescribing interventions were evaluated. The primary outcome was any occurrence of PPOs based on the 2015 STOPP/START criteria. The proportion of patients who had any PPOs significantly increased after the deprescribing interventions (52.9% vs 77.7%, p < 0.001). In the multivariable analysis, older age was the only independent risk factor associated with an increased risk of any PPOs after the deprescribing interventions (OR 1.08, 95% CI 1.01 to 1.16). In-hospital deprescribing interventions for elderly patients with polypharmacy may increase the occurrence of PPOs. Further study is warranted to investigate the effects on clinical outcomes of the increased occurrence of PPOs due to the deprescribing intervention.

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

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

3D Printing of Solid Oral Dosage Forms: Numerous Challenges With Unique Opportunities

Since the FDA approval of Spritam, there has been a growing interest in the application of 3D printing in pharmaceutical science. 3D printing is a method of manufacturing involving the layer-by-layer deposition of materials to create a final product according to a digital model. There are various techniques used to achieve this method of printing including the SLS, SLA, FDM, SSE and PB-inkjet printing. In biomanufacturing, bone and tissue engineering involving 3D printing to create scaffolds, while in pharmaceutics, 3D printing was applied in drug development, and the fabrication of drug delivery devices. This paper aims to review the use of some 3D printing techniques in the fabrication of oral solid dosage forms. FDM, SLA SLS, and PB-Inkjet printing processes were found suitable for the fabrication of oral solid dosage forms, though a great deal of the available research was focused on fused deposition modelling due to its availability and flexibility. Process parameters as well as strategies to control the characteristics of printed dosage forms are analysed and discussed. The review also presents the advantages and possible limitations of 3D printing of medicines.

The federal standard medication plan in practice: An observational cross-sectional study on prevalence and quality

BACKGROUND

Medication plans are instruments used to document drug therapies, guide patients, and ensure medication safety. In Germany, patients who take at least 3 long-term medications are eligible to receive a medication plan. It has been statutory to use the federal standard layout (German: "Bundeseinheitlicher Medikationsplan") since April 2017.

OBJECTIVES

This study explores the prevalence, availability, medication discrepancies, and conformance with statutory regulations of medication plans since the introduction of the format of the federal standard medication plan in Germany.

METHODS

Medication reconciliation was performed for hospitalized patients according to the Best Possible Medication History principle. The collected medication lists were analyzed for medication discrepancies and conformance with the statutory regulations. The medication discrepancies were (1) omitted drugs, (2) additional drugs, and (3) dosing errors.

RESULTS

After hospitalization, 524 patients taking drugs were included. The majority (n = 424 patients) were eligible for a medication plan. While 241 medication lists were present, only 24.1% (n = 58) matched the federal standard format. The mean number of drugs was 6.3 ± 3.6, with 3315 medications (3046 long-term and 269 as needed) reconciled totally. The 84 medication lists with omitted or additional drugs included 166 medication discrepancies upon 774 drugs listed. Of the 253 patients with dosing errors, 146 had a medication list. Inappropriate dosages were due to single dose (n = 195), daily dose (n = 225) or frequency of application (n = 255).

CONCLUSION

Medication plans are valuable tools for patients and health care providers. This study shows that the introduced paper-based federal standard medication plan in Germany falls short of its expectations regarding availability and correctness. Switching to an electronic patient record system may overcome some of the current pitfalls.

Physicians' role in the development of inappropriate polypharmacy among older adults in Iran: a qualitative study

OBJECTIVES

The use of unnecessary or excessive medications (inappropriate polypharmacy) is a major health challenge among older adults which is driven by several factors. This study aims to provide in-depth descriptions of the physician's role in the development of inappropriate polypharmacy among older adults in Iran.

DESIGN

Qualitative content analysis of interviews, field notes and other relevant documents available (eg, medical records). Data collection and analyses were done concurrently to guide the sampling process.

SETTING

Three purposively selected referral hospitals in Tehran, Iran.

PARTICIPANTS

A total of 7 physicians, 10 older adults, 3 caregivers and 3 pharmacists with a median age of 54 (IQR 23) years were recruited through convenience sampling.

RESULTS

Emerged categories included misdiagnosis, inappropriate prescribing, insufficient patient education, poor communication, unprofessional behaviour and limited perspectives which highlight the role of physicians in the development of inappropriate polypharmacy among older adults in Iran under the main concept of poor medical practice.

CONCLUSION

This study provides valuable insight on the role of physicians in the development of inappropriate polypharmacy among the elderly in the healthcare setting in Iran by exploring the viewpoints of physicians, patients, caregivers and pharmacists. Physicians can be an influential factor in tackling this challenge through proper diagnosis, prescription, patient education and follow-up. In Iran, physicians' practice styles are affected by potentially adverse factors such as the novelty of geriatric medicine, lack of a referral system, patient unfamiliarity with the system and lack of a monitoring system for multiple prescriptions. Furthermore, clinics tend to be overcrowded and visit fees can be low; in this setting, lack of physician assistants leads to limited time allocation to each patient and physician dissatisfaction with their income.

Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders

BACKGROUND

Psychotropic polypharmacy is a concern in the management of pediatric mental disorders due to the lack of pediatric data to support the practice. Although seeing multiple providers has been identified as an important predictor of polypharmacy, no study has yet assessed the effect of care coordination between providers on receipt of psychotropic polypharmacy.

OBJECTIVE

To examine the association between the intensity of care coordination within a patient's care team and the likelihood of the patient receiving multiclass psychotropic polypharmacy.

METHODS

A retrospective study was conducted using the 2013-2015 administrative claims data from a Medicaid managed care organization (Texas Children's Health Plan). Children and adolescents aged 18 years or younger with a diagnosis of a mental/behavioral disorder and receipt of psychotropic prescriptions from multiple prescribers were included in the study. Psychotropic polypharmacy was defined as the receipt of 2 or more psychotropic medications from different drug classes concurrently for 60 days or more. Care coordination was measured using social network analysis (SNA), a new technique included in the Agency for Healthcare Research and Quality Care Coordination Measures Atlas. Care density, an SNA surrogate for care coordination, was calculated as the ratio of the sum of patients shared by physician pairs within a patient's care team to the total number of physician pairs. The Andersen behavioral model was used to guide multivariate logistic regression analyses conducted to assess the association between care density and the likelihood of patients receiving psychotropic polypharmacy after controlling for predisposing and need factors.

RESULTS

A total of 24,147 children and adolescents diagnosed with a mental/behavioral disorder were identified. About 34.0% (n = 8,092) of these individuals received psychotropic medications from multiple prescribers who were either primary care physicians (PCPs) or specialists. Logistic regression analysis showed a significant association between care density and the use of psychotropic polypharmacy. However, the direction of this relationship varied depending on the composition of the patient's care team. Among patients with only PCPs involved in their care team, patients in the higher care-density group were 28% less likely to receive psychotropic polypharmacy (OR = 0.72; 95% CI = 0.62-0.96) than those in the lower care-density group. In contrast, among patients who had both PCPs and specialists involved in their care team, those in the higher care-density group were 2 times more likely to experience psychotropic polypharmacy (OR = 2.01; 95% CI = 1.68-2.40). Care density was not significantly associated with the receipt of psychotropic polypharmacy in the specialist-only group.

CONCLUSIONS

This study found significant associations between care density and prescription of psychotropic polypharmacy. This relationship varied depending on the patient's diagnosis, disease complexity, and composition of the patient's care team.

DISCLOSURES

No outside funding supported this study. The authors do not have any financial relationships or potential conflicts of interest relevant to this article to disclose. The abstract for part of this study, titled "Association Between Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders," was selected as a silver medal abstract and was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2017; March 27-30, 2017; Denver, CO.

Association between prescribed antidepressants and other prescribed drugs differ by gender: a nationwide register-based study in Sweden

BACKGROUND

People with depression are prescribed more drugs than people in general, partly due to comorbidity with other conditions. However, little research has been done on depression-related drug use from a gender perspective.

AIM

Examine the association between antidepressants, other types of prescribed drugs, and polypharmacy, by gender.

METHODS

Data on drugs dispensed October to December 2016 to all Swedish citizens aged 18-84 years were collected from the Swedish prescribed drug register. Logistic regression analyses were performed to examine the associations between antidepressants and other drugs, by gender.

RESULTS

For both men and women, associations were found between antidepressants and drugs for alimentary tract problems, respiratory problems, blood, nervous system, analgesics, and polypharmacy. However, for women, but not men, associations were also found for drugs for diabetes, musculoskeletal problems, dermatological problems, and systemic hormones.

CONCLUSIONS

Associations were found between antidepressants and many other types of drugs for both men and women; indicating comorbidity between depression and other conditions. Further, some of the associations between antidepressants and other drugs were found to be specific among women. Whether this indicates that men and women differ in comorbidity between depression and other conditions cannot be concluded based on this cross-sectional study. However, comorbidity impairs the possibility of recovery; in the somatic condition as well as the depression. Thus, physicians need to be aware that the association between antidepressants and other types of drugs are more common among women than men.

Polypharmacy in the Older Patient with Cancer

Background

Elderly patients – those aged 65 years and over – use more medications than their younger counterparts and experience higher risks for polypharmacy, drug interactions, adverse drug reactions, and noncompliance for this age-group.

Methods

The data on polypharmacy in the aged is reviewed, supplemented with preliminary information from studies performed on elderly patients with cancer at our institution.

Results

Polypharmacy occurs in ambulatory, extended care, and institutional settings. Over-the-counter medications are underreported. The number of potential drug-related problems is related to the total number of prescriptions. Methods for evaluating the extent of polypharmacy include the “brown-bag” technique and careful medication histories.

Conclusions

The risks of polypharmacy may be reduced with patient and physician education, intervention, and drug monitoring. Further pharmacokinetic investigations of anticancer medications are needed to recognize the potential for harmful drug interactions, to understand their toxicity profiles, and to avoid the clinical implications of drug interactions.

Prescription Assistance for Older Adults with Limited Incomes: Client and Program Characteristics

Objective:

To describe the sociodemographic, medication-related, health services utilization and health characteristics of the community-dwelling senior citizens (≥65 y) with limited incomes who enrolled in Senior PHARM Assist, a community-based prescription assistance program.

Patients:

Senior citizens (n = 387) enrolled in the program between June 1994 and May 1996. All eligible participants were 65 years of age or older, had incomes below 140% of the federal poverty level, but were not enrolled in Medicaid. All the patients were living in Durham County and were taking prescription medications.

Measurements:

Self- or caregiver-reported. In addition to demographic characteristics, polypharmacy (taking ≥5 prescription medications in the last month), medication adherence (adherence to directions on the medication container), medication knowledge (client or caregiver stated appropriate purpose for taking the medication), adverse effects from medications, and activities of daily living and instrumental activities of daily living limitations were measured.

Results:

Eighty percent of the senior citizens lived below the federal poverty level, 82% were women, 53% were African-American, 53% lived alone, and the mean monthly income for a single person was $595 and for a couple was $939. They were taking, on average, 8.9 medications, were adherent with 71% of their medications, knew the purpose of 69% of their medications, and reported adverse effects from 10% of their prescription medications.

Conclusions:

This population of community-dwelling seniors takes, on average, a higher number of prescription medications than previously reported, posing a higher risk for the hazards associated with polypharmacy and uncoordinated prescribing, such as nonadherence, drug interactions, and adverse effects. There may be a greater need for future intervention programs to include a comprehensive educational component, such as a coordinated medication review, in addition to financial assistance.

Education and Assessment of Pharmacists on the Use of the Drug Burden Index in Older Adults Using a Continuing Professional Development Education Method

Objective. To educate pharmacists and assess their knowledge of and ability to calculate the Drug Burden Index (DBI) using a continuing professional development (CPD) intervention. Methods. The intervention included designing education surrounding the DBI and its application in practice and assessing knowledge in the form of a CPD education article with four multiple-choice questions (MCQs). Deidentified demographic data on participants were collected. Results. Multiple-choice questions were completed by 2522 pharmacist participants: 97.9% of participants successfully completed the CPD assessment (answered three or four MCQs correctly), and 76.5% of participants achieved a perfect score (answered four MCQs correctly). The question that required calculation of the DBI for a fictional patient was answered correctly least often (81.8%). Conclusion. Pharmacist participants had good knowledge of using DBI in practice; difficulty was observed in calculating the DBI for a hypothetical patient. This CPD intervention provided a practical medium for educating and assessing pharmacists' knowledge of the DBI.

The perfect storm: older adults and acute kidney injury

Older adults have a high risk for acute kidney injury (AKI), often necessitating critical care admission. The majority of older adults live with 1 or more chronic conditions requiring multiple medications, and when faced with acute illness increased vulnerability can lead to poor health outcomes. When combined with circumstances that exacerbate chronic conditions, clinicians may witness the perfect storm. Some factors that contribute to AKI risk include the aging kidney, sepsis, polypharmacy, and nephrotoxic medications and contrast media. This paper discusses specific risks and approaches to care for older adults with AKI who are in critical care.

Polypharmacy and potentially inappropriate prescriptions identified by Beers and STOPP criteria in co-morbid older patients at hospital discharge

RATIONALE, AIMS AND OBJECTIVES

The objective of this study was to evaluate the prevalence of potentially inappropriate prescriptions (PIP) and the association with polypharmacy (more than six drugs prescribed) in co-morbid older patients in a critical moment of care transition such as hospital discharge by means of two explicit criteria (Beers 2012 and STOPP 2008).

METHOD

Cross-sectional study carried out in an older patients' population (≥65 years old) discharged from a university hospital in Spain. We recorded patients' information regarding demographics, diagnosis, drugs prescribed and associated pathological conditions and calculated the Charlson co-morbidity index. Data were obtained from the electronic medical records of hospital discharge. Beers (2012) and STOPP criteria (2008) were applied for PIP detection. The strength of association between polypharmacy and the presence of PIP was assessed by calculating the crude and adjusted odds ratio and its 95% confidence interval.

RESULTS

From 1004 patients of a 15% random sample, just 624 that fulfilled the inclusion criteria were included in the study. The number of prescribed drugs was a risk factor for PIP according to both criteria, even after adjusting for confounding variables. PIP frequency was higher in patients who received more than 12 medications (Beers: 34.8%, STOPP: 54.4%). Each additional medication increased the risk of PIP by 14 or 15% (Beers or STOPP).

CONCLUSIONS

Our results suggest that the strategies used for PIP reduction in co-morbid older patients should focus on the management of polypharmacy. Medication review at hospital discharge is highly recommended for patients taking more than six drugs.

Discrepancies on Medication Plans detected in German Community Pharmacies

RATIONALE, AIMS AND OBJECTIVES

A current medication plan was identified as important patient safety factor. Information is needed on how many patients possess such a plan and what problems can be identified with its use. This study tried to define factors that influence accuracy of medication plans and to detect discrepancies from planned and actually administered medication in polypharmacy patients.

METHODS

Participants of the 'Apo-AMTS' course in Germany evaluated medication plans from their patients during performing medication reviews in community pharmacies. Discrepancies were defined as additional or missing drugs and deviations in dosage and drug names for Rx drugs and missing or additional self-medication.

RESULTS

Eighty per cent of the patients possessed a medication plan mainly written by general practitioners. Only 6.5% of the plans showed no discrepancies. Most discrepancies were seen on medication plans written by medical specialists and general practitioners, mainly name aberrations (41%) followed by additional drugs taken (30%) and prescribed drugs no longer taken (18%). Dosage variance was seen in 11% of all discrepancies. Deviations from the plan were observed frequently with antihypertensives (31.4%), analgesics (11.3%) and antidepressants/hypnotics as well as lipid-lowering drugs (6.7%). Four hundred thirty-three OTC drugs were not listed, mainly analgesics, mineral supplements and laxatives.

CONCLUSION

Many patients possess a medication plan but most of these plans showed discrepancies which limits the use as patient safety indicator. Community pharmacies offering medication reviews have an essential position to use the medication plan as a central link between patients and their prescribers, and therefore improve patient safety.

Add-On Pregnenolone with L-Theanine to Antipsychotic Therapy Relieves Negative and Anxiety Symptoms of Schizophrenia: An 8-Week, Randomized, Double-Blind, Placebo-Controlled Trial

AIMS

Pregnenolone (PREG) and L-theanine (LT) have shown ameliorative effects on various schizophrenia symptoms. This is the first study to evaluate the efficacy and safety of augmentation of antipsychotic treatment among patients with chronic schizophrenia or schizoaffective disorder with PREG-LT.

METHODS

Double-blind, placebo-controlled trial of PREG-LT or placebo augmentation was conducted for eight weeks with 40 chronic DSM-IV schizophrenia and schizoaffective disorder patients with suboptimal response to antipsychotics. Oral PREG (50 mg/day) with LT (400 mg/day) or placebo were added to a stable regimen of antipsychotic medication from March 2011 to October 2013. The participants were rated using the Scale for the Assessment of Negative Symptoms (SANS), the Hamilton Scale for Anxiety (HAM-A), and the Positive and Negative Syndrome Scale (PANSS) scales bi-weekly. The decrease of SANS and HAM-A scores were the co-primary outcomes. Secondary outcomes included assessments of general functioning and side effects.

RESULTS

Negative symptoms such as blunted affect, alogia, and anhedonia (SANS) were found to be significantly improved with moderate effect sizes among patients who received PREG-LT, in comparison with the placebo group. Add-on PREG-LT also significantly associated with a reduction of anxiety scores such as anxious mood, tension, and cardiovascular symptoms (HAM-A), and elevation of general functioning (GAF). Positive symptoms, antipsychotic agents, concomitant drugs, and illness duration did not associate significantly with effect of PREG-LT augmentation. PREG-LT was well-tolerated.

CONCLUSIONS

Pregnenolone with L-theanine augmentation may offer a new therapeutic strategy for treatment of negative and anxiety symptoms in schizophrenia and schizoaffective disorder. Further studies are warranted.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01831986.

Association between Total Daily Doses with duration of hospitalization among readmitted patients in a multi-ethnic Asian population

Increased length of stay (LOS) in the hospital incurs substantial financial costs on the healthcare system. Multiple factors are associated with LOS. However, few studies have been done to associate the impact of Total Daily Doses (TDD) and LOS. Hence, the aim of this study is to examine the association between patients’ LOS upon readmission and their TDD before readmission. A retrospective cross-sectional study of readmission cases occurring from 1st January to 31st March 2013 was conducted at a regional hospital. Demographics and clinical variables were collected using electronic medical databases. Univariable and multiple linear regressions were used. Confounders such as comorbidities and drug related problems (DRP) were controlled for in this study. There were 432 patients and 649 readmissions examined. The average TDD and LOS were 18.04 ± 8.16 and 7.63 days ± 7.08 respectively. In the univariable analysis, variables that were significantly associated with the LOS included age above 75 year-old, race, comorbidity, number of comorbidities, number of medications, TDD and thrombocytopenia as DRPs. In the multiple linear regression, there was a statistically significant association between TDD (β = 0.0733, p = 0.030) and LOS. Variables that were found significant were age above 75 year-old (β = 1.5477, p = 0.008), Malay (β = −1.5123, p = 0.033), other races (β = −2.6174, p = 0.007), depression (β = 2.1551, p = 0.031) and thrombocytopenia as a type of DRP (β = 7.5548, p = 0.027). When TDD was replaced with number of medications, number of medications (β = 0.1487, p = 0.021), age of 75 year-old (β = 1.5303, p = 0.009), Malay (β = −1.4687, p = 0.038), race of others (β = −2.6499, p = 0.007), depression (β = 2.1951, p = 0.028) and thrombocytopenia as a type of DRP (β = 7.5260, p = 0.028) were significant. In conclusion, a significant relationship between TDD and number of medications before readmission and the LOS upon readmission was established. This finding highlights the importance of optimizing patients’ TDD in the attempt of reducing their LOS.

Polypharmacy in the Elderly: A Marker of Increased Risk of Mortality in a Population-Based Prospective Study (NEDICES)

BACKGROUND

Little information is available on the potential association between polypharmacy and risk of mortality.

OBJECTIVE

To determine in a population-based study whether polypharmacy is associated with increased risk of mortality in elderly persons.

METHODS

In this population-based, prospective study of 5,052 people aged 65 years and older (Neurological Disorders in Central Spain), current medications were recorded. Cox proportional hazards models, adjusted for sociodemographics and comorbidity factors, were used to assess the risk of death up to 13.3 years later, comparing the polypharmacy group (≥6 drugs) to those who were taking 1-5 drugs and those in a nonmedicated group (0 drugs).

RESULTS

Out of 5,052 participants, 2,550 (50.5%) died over a median follow-up of 6.5 years, including 361 (28.8%) deaths among 931 nonmedicated participants, 1,946 (51.4%) deaths among 3,787 participants taking 1-5 drugs daily, and 243 (72.8%) among 334 participants on polypharmacy. In an unadjusted Cox model, risk of mortality was increased in participants on polypharmacy [hazard ratio (HR) = 2.78, 95% confidence interval [CI]: 2.36-3.27, p < 0.001) and in those taking between 1 and 5 drugs (HR = 1.47, 95% CI: 1.31-1.64, p < 0.001) versus those who were nonmedicated (reference group). In a Cox model that adjusted for a variety of demographic factors and comorbidities, HR remained increased in participants on polypharmacy (HR = 1.83, 95% CI: 1.51-2.21, p < 0.001).

CONCLUSION

This study provides evidence that polypharmacy is associated with increased risk of mortality in elderly people. The extent to which polypharmacy is the proximate cause rather than a marker of this increase risk remains to be determined.

Growth in the concurrent use of antipsychotics with other psychotropic medications in Medicaid-enrolled children

OBJECTIVE

Second-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children; however, there is limited understanding of the frequency of concurrent SGA prescribing with other psychotropic medications. This study describes the epidemiology of concurrent SGA use with 4 psychotropic classes (stimulants, antidepressants, mood stabilizers, and α-agonists) among a national sample of Medicaid-enrolled children and adolescents 6 to 18 years old between 2004 and 2008.

METHOD

Repeated cross-sectional design was used, with national Medicaid Analytic eXtract data (10.6 million children annually). Logit and Poisson regression, standardized for year, demographics, and Medicaid eligibility group, estimated the probability and duration of concurrent SGA use with each medication class over time and examined concurrent SGAs in relation to clinical and demographic characteristics.

RESULTS

While SGA use overall increased by 22%, 85% of such use occurred concurrently. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. Concurrent SGA use occurred for long durations (69%-89% of annual medication days). Although the highest users of concurrent SGA were participants in foster care and disability Medicaid programs or those with behavioral hospitalizations, the most significant increases over time occurred among participants who were income-eligible for Medicaid (+13%), without comorbid ADHD (+15%), were not hospitalized (+13%), and did not have comorbid intellectual disability (+45%).

CONCLUSION

Concurrent SGA use with other psychotropic classes increased over time, and the duration of concurrent therapy was consistently long term. Concurrent SGA regimens will require further research to determine efficacy and potential drug-drug interactions, given a practice trend toward more complex regimens in less-impaired children/adolescents.

Medication safety in residential aged-care facilities: a perspective

Medication safety must be tailored to the distinctive issues in residential aged-care facilities (RACFs). The health and functional characteristics of their residents are different to those of hospital inpatients and community-dwelling older adults, and there are unique staffing and management issues. Understanding the aetiology and epidemiology of drug-related problems is vital in developing methods to improve patient safety. In this perspective review, we discuss tools that are used to quantify exposure to 'high-risk' medications and their evaluation in residential aged-care settings. Drug withdrawal interventions are described as a potential way to reduce adverse drug events in RACFs. Multidisciplinary professional interventions, education programs and improved communication between health professionals have been shown to improve medication safety in RACFs. Technological advances and other administrative strategies may also improve resident safety. This perspective addresses issues in medication safety facing RACFs and methods to improve the safety of medicines for their residents.

Prevalence and associated factors of polypharmacy among adult Saudi medical outpatients at a tertiary care center

Objective:

The objective of this study was to assess the prevalence of polypharmacy (PP) and the associated factors in medical outpatients.

Materials and Methods:

A cross-sectional, observational, descriptive study was carried out in adult medical outpatients attending internal medicine clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia from 1 March 2009 to 31 December 2009. PP was defined as the concomitant use of ≥5 medications daily. The number of medications being currently taken by patient was recorded. Effect of patients’ age, gender, educational level, number of prescribers, disease load and disease type on PP was assessed by multivariate analysis using Statistical Package for Social Sciences Incorporated (SPSS Inc) Version 18.

Results:

Out of 766 patients included in the study, 683 (89%) had PP. The mean number of prescribed medications, oral pills and doses was 8.8, 9.6 and 12.1, respectively. Factors significantly associated with PP included age (≥61 years), disease load and the number of prescribers. Gender had no impact on PP while education beyond primary education significantly decreased PP. Hypertension, diabetes mellitus and dyslipidemia alone and as a cluster increased PP.

Conclusion:

We found an extremely high level of PP in medical outpatients at our tertiary care center. The impact of PP on medication compliance and control of underlying diseases in Saudi Arabia is unknown and needs to be studied at different levels of care.

Rates, variability, and associated factors of polypharmacy in nursing home patients

Objectives

To determine the rate and variability of polypharmacy in nursing home (NH) residents and investigate its relationship to age, sex, functional status, length of stay, and comorbidities.

Methods

We conducted a cross sectional, multicenter study that included six nursing homes. Demographic, clinical characteristics, Charlson comorbidity index (CCI), the number and classes of chronic medications, rate of polypharmacy >5 drugs (per day) and polypharmacy >7 drugs (per day) were recorded.

Results

Nine hundred and ninety-three residents were included; 750 (75.5%) fully dependent residents and 243 (24.5%) mobile demented residents requiring institutional care. The mean age was 85.04±7.55 (65–108) years. The mean rates of polypharmacy >5 drugs and polypharmacy >7 drugs were 42.6% and 18.6%, respectively. Differences in polypharmacy >5 drugs and polypharmacy >7 drugs were observed in NHs 24.7%–56% and 4.9%–30.4%, respectively (P<0.001). Mean number of chronic drugs per resident was 5.14±2.60 from 3.81±2.24 to 5.95±2.73 (P<0.001). No differences in polypharmacy were found between sex and fully dependent versus mobile demented residents. The most common medications taken were for gastrointestinal, neurological, and cardiovascular disorders. Regression analysis revealed four independent variables for polypharmacy >5 drugs: groups aged 75–84 and >85 relative to 65–74, odds ratio (OR) 0.46 (95% confidence interval [CI] 0.27–0.78) P=0.004, OR 0.35 (95% confidence interval 0.19–0.53), respectively, P<0.001; length of stay >2 years, OR 0.51 (95% CI 0.36–0.73) P<0.001; CCI, OR 1.58 (95% CI 1.42–1.75) P<0.001; and feeding tube versus normal feeding, OR 0.27 (95% CI 0.12–0.60) P=0.001.

Conclusion

Rates of polypharmacy in NHs are high with significant variability. Variability rates of polypharmacy, distinct residents’ characteristics, and excessive use of certain drug groups may indicate that a decrease in medication is potentially feasible.

Prescribing practices of topical corticosteroids in the outpatient dermatology department of a rural tertiary care teaching hospital

Background:

Inappropriate or excessive use of topical corticosteroids can lead to cutaneous and systemic adverse effects which occur more commonly with the use of very potent steroids. Monitoring and analysis of the prescription practices of topical steroids can help to achieve rational prescription of these drugs.

Aim:

The present study was carried out to study and analyze the pattern of prescribing topical corticosteroids among outpatients attending the dermatology clinic in a rural tertiary care and teaching hospital, Ambajogai, Maharashtra.

Materials and Methods:

A cross-sectional descriptive study was conducted for a duration of two months from August 2011 to September 2011, and 500 prescriptions were randomly collected from the dermatology pharmacy and analyzed.

Results:

About 66% of the prescriptions contained four to five drugs per prescription. Topical steroids were given in 28.4% of all the prescriptions. In almost all the prescriptions, strength, quantity of the steroid to be used, frequency, site, and duration of application was not mentioned. The chief complaints and diagnoses were not mentioned in about 85% of the prescriptions for topical corticosteroids. About 94.36% of the prescriptions contained very potent steroids.

Conclusion:

Inadequate prescribing information is a clear characteristic of the dermatological prescriptions containing topical corticosteroids. Doctors should be educated about the importance of giving patients sufficient information regarding the use of steroids. There is a need to revise hospital formulary where low-potency steroids can also be included along with potent ones so that the latter can be avoided in conditions where they are unnecessary.

Clinical consequences of polypharmacy in elderly

INTRODUCTION

Polypharmacy, defined as the use of multiple drugs or more than are medically necessary, is a growing concern for older adults. MEDLINE and EMBASE databases were searched from January 1, 1986 to June 30, 2013) to identify relevant articles in people aged > 65 years.

AREAS COVERED

We present information about: i) prevalence of polypharmacy and unnecessary medication use; ii) negative consequences of polypharmacy; and iii) interventions to improve polypharmacy.

EXPERT OPINION

International research shows that polypharmacy is common in older adults with the highest number of drugs taken by those residing in nursing homes. Nearly 50% of older adults take one or more medications that are not medically necessary. Research has clearly established a strong relationship between polypharmacy and negative clinical consequences. Moreover, well-designed interprofessional (often including clinical pharmacist) intervention studies that focus on enrolling high-risk older patients with polypharmacy have shown that they can be effective in reducing aspects of unnecessary prescribing with mixed results on distal health outcomes.

The next therapeutic challenge in HIV: polypharmacy

With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.

Gender and polypharmacotherapy in the elderly: a clinical challenge

Polypharmacotherapy is a major concern in the elderly and especially in older women after the age of 80. It results from the intake of prescription and non-prescription drugs, being often a problem of evidence-based therapy. Besides the fact that women live longer than men and outnumber them, reasons for polypharmacy in women are diverse and include a different attitude towards intake of drugs between men and women, the propensity of women to rather see a physician and talk about their problems, the load of family responsibility as women are the main caregivers within a family, the influence of physician sex on patient care, the level of education, social deprivation and self-rated health. Women are more often prescribed potentially inappropriate medication and more often become victims of adverse drug reactions. This is not only due to the number and quality of drugs prescribed but also to differences in pharmacokinetics and - dynamics which make them more vulnerable to drug exposure. Thus, inappropriate prescribing contributes to hospitalization, poor quality of life, costs, compliance issues and poor outcomes. More preclinical and clinical studies with elderly patients and especially elderly women are needed to study the underlying mechanisms of the pharmacologic differences and obtain more insight into the difference in risk between men and women. Attention to prescribing of medications, consistent review of medication lists, and reevaluation of indications and outcomes of prescribing are essential to ensure that drugs are used appropriately in elderly women, polypharmacy is minimized and safety for patients is maximized.

Rethinking adherence: a health literacy-informed model of medication self-management

Medication adherence has received a great deal of attention over the past several decades; however, its definition and measurement remain elusive. The authors propose a new definition of medication self-management that is guided by evidence from the field of health literacy. Specifically, a new conceptual model is introduced that deconstructs the tasks associated with taking prescription drugs; including the knowledge, skills and behaviors necessary for patients to correctly take medications and sustain use over time in ambulatory care. This model is then used to review and criticize current adherence measures as well as to offer guidance to future interventions promoting medication self-management, especially among patients with low literacy skills.

Management of anxiety and sleep disorders: role of complementary and alternative medicine and challenges of integration with conventional orthodox care

There is renewed attention and greater focus on anxiety and sleep- sleep-related disturbances because of the high prevalence, complexity, and their health related implications. The role of complementary and alternative medicine (CAM), which refers to therapeutic approaches that are "complementary to the end goals of decreasing illness and enhancing wellness, but are alternative to conventional medical treatment" is also increasingly recognized. In this review, we considered CAM approach to the management of anxiety and sleep disorders and discussed a few challenges associated with the effective integration of alternative therapy with conventional orthodox medical care.

Potential benefits of reducing medication-related anticholinergic burden for demented older adults: a prospective cohort study

AIM

Medication-related anticholinergic burden is a quality indicator for geriatric pharmacotherapy; however, little is known regarding the benefits of reducing anticholinergic burden for demented patients

METHODS

Demented residents in a Veteran Home were enrolled for this study and an educational program was held for primary care physicians providing services at the Veterans Home. Residents were assigned to the intervention group if the primary care team could adhere to the research protocol and the remaining residents were assigned to the reference group receiving conventional care. Anticholinergic burden was estimated by Clinician-Rated Anticholinergic Score (CR-ACHS). Healthcare outcomes; for example, hospitalizations, mortality, cognitive and physical function, were compared between groups.

RESULTS

Overall, 53 of the 67 demented residents (mean age 83.4 ± 4.4 years) completed this study. Anticholinergic exposure was found in 38 participants (56.7%) at baseline, in which antipsychotics (n=29, 76.3%) and antidepressants (n=19, 50%) were the most common agents. Compared with participants in the reference group, CR-ACHS was significantly reduced in the intervention group at 12-week follow up (intervention group vs reference group=0.5 ± 1.1 vs 1.1 ± 1.3, P=0.021), whereas the mean Mini-Mental State Examination and Barthel Index were similar between groups. In contrast, no clinical complication was observed regarding medication adjustments during the study period.

CONCLUSIONS

Anticholinergic burden can be successfully and safely reduced through an educational program for primary care physicians, but the benefit of reducing anticholinergic burden remained unclear within the first 12 weeks. Further investigation is required to evaluate the long-term benefits of reducing anticholinergic burden for demented older adults.

The impact of increasing polypharmacy on prescribed drug expenditure-a register-based study in Sweden 2005-2009

OBJECTIVES

To analyse the impact of the observed increase in the prevalence in polypharmacy on the development of prescribed drug expenditure (PDE) in a national population during five years.

METHODS

A register-based study of all prescribed drugs and PDE for the entire Swedish population during a 3-month period in 2005 and 2009, respectively. The prevalence of "polypharmacy" and "excessive polypharmacy" was defined as the proportion of patients receiving five or more (PD≥5) and ten or more (PD≥10) prescribed drugs during a 3-month period, respectively.

RESULTS

Between 2005 and 2009, the prevalence of polypharmacy increased by 8.3% (from 11.1% to 12.0%), and the prevalence of excessive polypharmacy by 9.9% (from 2.4% to 2.6%). Total PDE increased by 4.8% in real prices. For the group of patients with polypharmacy and excessive polypharmacy, PDE increased by 6.2%, and 7.3%, respectively. A simulation, in which the increase in polypharmacy was neutralised, resulted in no increase in total PDE.

CONCLUSIONS

The increase in the prevalence of polypharmacy has a substantial impact on the increase in PDE and can explain the entire increase in PDE in Sweden during 2005 to 2009. For clinicians and healthcare stakeholders, it is important to monitor and guidance the further development in multiple medication therapy, so that the cost associated with increasing polypharmacy will not exceed its benefits.

Effect of coexisting chronic obstructive pulmonary disease and cognitive impairment on health outcomes in older adults

OBJECTIVES

To determine the extent to which the co-occurrence of chronic obstructive pulmonary disease (COPD) and cognitive impairment affect adverse health outcomes in older adults.

DESIGN

Multicenter longitudinal cohort study.

SETTING

California, Pennsylvania, Maryland, and North Carolina.

PARTICIPANTS

Three thousand ninety-three community-dwelling adults aged 65 and older from the Cardiovascular Health Study. Four hundred thirty-one had chronic obstructive pulmonary disease (COPD) at study baseline.

MEASUREMENTS

Follow-up began at the second CHS visit and continued for 3 years. Spirometric criteria for airflow limitation served to establish COPD using the Lambda-Mu-Sigma method, which accounts for age-related changes in lung function. Cognitive impairment was evaluated using the modified Mini-Mental State Examination and claims data. Outcomes were respiratory-related and all-cause hospitalizations and death.

RESULTS

Participants with coexisting COPD and cognitive impairment had the highest rates of respiratory-related (adjusted hazard ratio (aHR) = 4.10, 95% confidence interval (CI) = 1.86-9.05) and all-cause hospitalizations (aHR = 1.34, 95% CI = 1.00-1.80) and death (aHR = 2.29, 95% CI = 1.18-4.45). In particular, individuals with both conditions had a 48% higher rate of all-cause hospitalizations (adjusted synergy index (aSI) = 1.48, 95% CI = 0.19-11.31) and a rate of death nearly three times as high (aSI = 2.74, 95% CI = 0.43-17.32) as the sum of risks for each respective outcome associated with having COPD or cognitive impairment alone. Nevertheless, tests for interaction were not statistically significant for the presence of synergism between the two conditions contributing to each of the outcomes. Therefore, it cannot be concluded that the combined effect of COPD and cognitive impairment is greater than additive.

CONCLUSION

Coexisting COPD and cognitive impairment have an additive effect on respiratory-related and all-cause hospitalizations and death. Optimizing outcomes in older adults with COPD and cognitive impairment will require that how to improve concurrent management of both conditions be determined.

A population-based study on the association between acute renal failure (ARF) and the duration of polypharmacy

BACKGROUND

Because of the rapid growth in elderly population, polypharmacy has become a serious public health issue worldwide. Although acute renal failure (ARF) is one negative consequence of polypharmacy, the association between the duration of polypharmacy and ARF remains unclear. We therefore assessed this association using a population-based database.

METHODS

Data were collected from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 through 2006. The case group included patients hospitalized for ARF during 2006, but not admitted due to trauma, surgery, burn trauma, car accident, transplantation, or infectious diseases; the control group included patients hospitalized without ARF. The cumulative number of days of polypharmacy (defined as more than 5 prescriptions per day) for 1 year prior to admission was determined, with patients further subdivided into 4 categories: less than 30 days, 31-90 days, 91-180 days, and over 181 days. The dependent variable was ARF, and the control variables were age, gender, comorbidities in patients hospitalized for ARF, stay in ICUs during ARF hospitalization and site of operation for prior admissions within one month of ARF hospitalization.

RESULTS

Of 20,790 patients who were admitted to hospitals for ARF in 2006, 12,314 (59.23 %) were male and more than 60 % were older than 65 years. Of patients with and without ARF, 16.14 % and 10.61 %, respectively, received polypharmacy for 91-180 days and 50.22 % and 24.12 %, respectively, for over 181 days. A statistical model indicated that, relative to patients who received polypharmacy for less than 30 days, those who received polypharmacy for 31-90, 91-180 and over 181 days had odds ratios of developing ARF of 1.33 (p<0.001), 1.65 (p<0.001) and 1.74 (p<0.001), respectively.

CONCLUSIONS

We observed statistically significant associations between the duration of polypharmacy and the occurrence of ARF.

Is drug utilization in Greece sex dependent? A population-based study

Despite scarce data pertaining to prescription drug sales in Greece, the lack of large-scale epidemiological studies has made it difficult to elaborate on putative differences regarding drug consumption patterns between the two sexes. Herein, we sought to investigate whether sex may have an impact on medication trends of the Greek population. The data reported are part of a survey conducted under the auspices of the National Center for Social Research. Information was collected from 2499 Athenian citizens. Probability of drug use was assessed through Pearson chi-square (χ(2) ) test and logistic regression was implemented to clarify whether sex or other socio-economic and morbidity factors may influence drug utilization. Women consumed more drugs as compared to men. Sex proved to be a differentiating factor influencing the use of analgesic/non-steroidal anti-inflammatory drugs, cardiovascular, anxiolytic and antidepressant drugs, as well as drugs for the treatment of thyroid diseases and osteoporosis. Present results further implicate other socio-economic factors (e.g. education, employment and financial status) in the harnessing of drug use in Greece. To the best of our knowledge, this is the largest pharmacoepidemiological study to report that Greek women consume more drugs and present different medication patterns, as compared to men. Further research is considered imperative in order for the awareness of prescribers, policy-makers and the general public on this sensitive matter to be increased.

Personalized medicine: the impact on chemistry

An effective strategy for personalized medicine requires a major conceptual change in the development and application of therapeutics. In this article, we argue that further advances in this field should be made with reference to another conceptual shift, that of network pharmacology. We examine the intersection of personalized medicine and network pharmacology to identify strategies for the development of personalized therapies that are fully informed by network pharmacology concepts. This provides a framework for discussion of the impact personalized medicine will have on chemistry in terms of drug discovery, formulation and delivery, the adaptations and changes in ideology required and the contribution chemistry is already making. New ways of conceptualizing chemistry's relationship with medicine will lead to new approaches to drug discovery and hold promise of delivering safer and more effective therapies.

[Development and validation of a prediction model to identify HIV+ patients with drug-related problems. A prediction study]

OBJECTIVE

To develop and validate a prediction model for the detection of drug-related problems (DRP) in patients on antiretroviral treatment during their regular monitoring in Pharmaceutical Care Clinics before dispensing drugs. MEHOD: Open multicentre prospective study. HIV patients with and without DRP were included. Demographic, clinical and pharmacotherapy variables (related and unrelated to antiretroviral treatment) were included in the model design. To find prognostic factors for DRP, a binary logistic regression model was created after performing a univariate analysis that identified independent variables related to DRP these variables were introduced in the multivariate model for the final selection. Model validity was determined by the shrinkage method and the discriminatory power by Harrell's C-index.

RESULTS

733 patients were included. The variables "adherence", "prescription of drugs needing dosage adjustment", and "total number of drugs prescribed (apart from the antiretroviral treatment)" were independently related to the appearance of DRP. Probabilities predicted by the model, customising the coefficients using the uniform shrinkage method, showed a R(2)=0.962 for the construction sample and a R(2)=0.872 for the validation sample. The discriminatory capacity of the model was 0.816 for the construction sample and 0.779 for the validation sample.

CONCLUSIONS

The developed and validated model enables detection of patients on antiretroviral treatment who are at a higher risk for experiencing a DRP. The prediction variables employed are commonly used in patient's pharmacotherapy record, allowing the model to be used in routine clinical practice.

Polypharmacy, adverse drug reactions, and geriatric syndromes

The elderly are at risk for polypharmacy, which is associated with significant consequences such as adverse effects, medication nonadherence, drug-drug and drug-disease interactions, and increased risk of geriatric syndromes. Providers should evaluate all existing medications at each patient visit for appropriateness and weigh the risks and benefits of starting new medications to minimize polypharmacy.

Non-adherence to drug therapy and drug acquisition costs in a national population--a patient-based register study

Background

Patients' non-adherence to drug therapy is a major problem for society as it is associated with reduced health outcomes. Generally, approximately only 50% of patients with chronic disease in developed countries adhere to prescribed therapy, and the most common non-adherence refers to chronic under-use, i.e. patients use less medication than prescribed or prematurely stop the therapy. Patients' non-adherence leads to high additional costs for society in terms of poor health. Non-adherence is also related to the unnecessary sale of drugs. The aim of the present study was to estimate the drug acquisition cost related to non-adherence to drug therapy in a national population.

Methods

We constructed a model of the drug acquisition cost related to non-adherence to drug therapy based on patient register data of dispensed out-patient prescriptions in the entire Swedish population during a 12-month period. In the model, the total drug acquisition cost was successively adjusted for the assumed different rates of primary non-adherence (prescriptions not being filled by the patient), and secondary non-adherence (medication not being taken as prescribed) according to the patient's age, therapies, and the number of dispensed drugs per patient.

Results

With an assumption of a general primary non-adherence rate of 3%, and a general secondary non-adherence rate of 50%, for all types of drugs, the acquisition cost related to non-adherence totalled SEK 11.2 billion (€ 1.2 billion), or 48.5% of total drug acquisition costs in Sweden 2006.

With the assumption of varying primary non-adherence rates for different age groups and different secondary non-adherence rates for varying types of drug therapies, the acquisition cost related to non-adherence totalled SEK 9.3 billion (€ 1.0 billion), or 40.2% of the total drug acquisition costs.

When the assumption of varying primary and secondary non-adherence rates for a different number of dispensed drugs per patient was added to the model, the acquisition cost related to non-adherence totalled SEK 9.9 billion (€ 1.1 billion), or 42.6% of the total drug acquisition costs.

Conclusions

Our estimate indicates that drug acquisition costs related to non-adherence represent a substantial proportion of the economic resources in the health care sector. A low rate of primary non-adherence, combined with a high rate of secondary non-adherence, contributes to a large degree of unnecessary medical spending. Thus, efforts of different types of interventions are needed to improve secondary adherence.

Adverse drug events in U.S. adult ambulatory medical care

OBJECTIVE

To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings.

DATA SOURCE

We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys.

STUDY DESIGN

Secondary data analysis.

PRINCIPAL FINDINGS

An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]).

CONCLUSIONS

Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.

Adherence, therapeutic intensity, and the number of dispensed drugs

PURPOSE

To estimate non-adherence in relation to the therapeutic intensity (TI) and the number of dispensed drugs per individual and study whether the TI can be used as an estimator of non-adherence with an increasing number of drugs.

METHODS

The study comprised an individual-based register of all dispensed outpatient prescriptions in Sweden in 2006, including 6.2 million individuals. The applied definition of drug was the chemical entity or substance comprising the fifth level in the World Health Organisation's Anatomic, Therapeutic, Chemical classification. The defined daily dosage per individual during 12 months was applied as an indicator of the TI.

RESULTS

We found a positive linear relation between the TI and the increasing number of dispensed drugs per individual, both for men and women. We found a slightly diminishing TI with an increasing number of drugs only for the age groups above 70 years, at a level above 13 drugs per individual.

CONCLUSIONS

The linear relationship between the TI and the increasing number of dispensed drugs per individual provides poor support for using decreasing TI as an estimator of non-adherence. The low rate of cost-related non-adherence in Sweden might contribute to explaining the linear relationship.