Are traditional NSAIDs prescribed appropriately among French elderly with osteoarthritis? Results from the CADEUS cohort

Prescription of potentially inappropriate medicines and comparison with lists of essential medicines for treatment of chronic disorders in older patients

OBJECTIVES

To examine the current situation of potentially inappropriate medicines (PIM) for treatment of chronicity in older patients and whether the inappropriate medicines were included in the 22nd World Health Organization (WHO) Model List of Essential Medicines (EMLs), China National Model list of Essential Medicines (China EMLs), or supplementary list of essential medicines in Guizhou Province 2018 (Guizhou EMLs) through real world data, so as to promote the development of lists of essential medicines suitable for older patients and provide a reference for the revision of lists of essential medicines to reduce adverse effects, drug-induced diseases and even possible death due to use of inappropriate medicines existing in lists of essential medicines.

METHODS

A retrospectively study was conducted. Dispensing records of patients aged ≥ 65 admitted to convenience clinic of a tertiary hospital from January 1, 2021 to December 31, 2021 were extracted through electronic information system. Then, we merged dispensing records of the same patient on the same date as one record and patients with at least one chronic disease were included. The American Geriatrics Society(AGS)/Beers Criteria 2019 (Beers 2019) was used to evaluate the PIM status. Thereafter, the inappropriate medicines were compared with WHO EMLs, China EMLs, and Guizhou EMLs to find out percentages of drugs of PIMs existing in above lists of essential medicines in all drugs of PIMs. The above evaluation was conducted using Excel software (version 2019).

RESULTS

A total of 5314 dispensing reports were included in this study. 5.95% (316/5314), 7.88% (419/5314) of PIMs met Table 2 (medicines that are potentially inappropriate in most older adults), Table 4 (medicines that should be used with caution) of Beers 2019, respectively. Among PIM drugs which met Table 2 of Beers 2019, 47.37%, 78.95%, and 78.95% were respectively included in WHO EMLs, China EMLs, and Guizhou EMLs, and that was 47.06%, 76.47%, and 82.35% for Table 4 of Beers 2019.

CONCLUSIONS

PIM in older patients is common in clinical practice. Patients with diabetes, hypertension, arthritis, depression and/or anxiety and Parkinson' diseases were more frequently prescribed drugs of PIM according to Beers 2019. Take older patients into consideration and formulate List of essential medicines special for older patients may be a key way to reduce PIM.

Utilization of gastroprotective strategies for nonsteroidal anti-inflammatory drug-induced gastrointestinal events in a major teaching hospital

Background and purpose

Clinical guidelines recommend the prescribing of gastroprotective strategies in nonsteroidal anti-inflammatory drug (NSAID) users with risk factors for gastrointestinal (GI) ulcer or ulcer complications. However, these guidelines are not often translated into clinical practice. Therefore, the aim of this study was to investigate the utilization of gastroprotective strategies for NSAID-induced upper GI events in at-risk users in a major teaching hospital.

Patients and methods

A cross-sectional, observational, pharmacy-based study was conducted in a major Asian institution with both primary and secondary health care services. This study involved the screening of prescriptions for regular NSAIDs, and patients who met the inclusion criteria were recruited and interviewed using a questionnaire.

Results

Of the 409 participants recruited, 83.1% had at least one GI risk factor, of whom 70.3% did not receive appropriate gastroprotection. The most common GI risk factor was the use of high-dose NSAIDs (69.2%), followed by participants aged 65 years and older (22%) and concomitant use of low-dose aspirin (11.7%). Appropriate gastroprotective strategies utilized consisted of the use of a cyclooxygenase (COX)-2 inhibitor alone or a nonselective NSAID plus a proton pump inhibitor (PPI) in the moderate-risk group and a COX-2 inhibitor plus a PPI in the high-risk group. Gastroprotective strategies were underutilized in 67.1% of at-risk participants and overutilized in 59.4% of those without risk factors. Co-prescription of a histamine-2 receptor antagonist at lower-than-recommended doses constituted 59% of the inappropriate gastroprotective agents used. Logistic regression analysis revealed patients aged 65 years and older (odds ratio, 1.89; 95% CI =1.15–3.09) as a predictor for the prescribing of gastroprotection by the clinicians.

Conclusion

Approximately 70% of at-risk NSAID users, mainly on high-dose NSAIDs, were not prescribed appropriate gastroprotective strategies. Further measures are warranted to improve the safe prescribing of regular NSAIDs.

Uso de anti-inflamatórios e analgésicos por uma população de idosos atendida na Estratégia Saúde da Família

ResumoEste estudo objetivou analisar a prevalência do uso de anti-inflamatórios e analgésicos em idosos da Estratégia Saúde da Família de Porto Alegre-RS, bem como investigar fatores associados: dados sociodemográficos e de saúde; uso contínuo ou se necessário da medicação; indicação médica ou automedicação. A coleta de dados ocorreu entre março de 2011 e dezembro de 2012. Os agentes de saúde comunitários aplicaram um questionário com dados sociodemográficos, de saúde e uso de medicamentos. Foram estudados os anti-inflamatórios não esteroidais, glicocorticoides, analgésicos não opioides e opioides de uso oral. Foram incluídos 758 idosos e o uso de anti-inflamatórios e analgésicos era feito por 28,8%. O paracetamol e o ibuprofeno foram os mais utilizados. No que diz respeito à autopercepção de saúde, quanto pior a saúde relatada, maior o uso da terapêutica (p<0,001). A doença hepática e artrose/artrite/reumatismo mostraram estar associadas ao uso de anti-inflamatórios e analgésicos (p<0,001). A prevalência de uso de anti-inflamatórios e analgésicos foi considerada moderada quando comparada a estudos prévios (28,8%). Além disso, a maioria dos idosos fazia uso desses medicamentos quando era preciso, provavelmente porque sentia dores leves a moderadas, não sendo necessário o uso contínuo da medicação ou também por sofrer com os efeitos adversos desses medicamentos, optando por usá-los esporadicamente.

Co-prescription of gastroprotective agents and their efficacy in elderly patients taking nonsteroidal anti-inflammatory drugs: a systematic review of observational studies

BACKGROUND & AIMS

Guidelines recommend prescribing gastroprotective agents (proton pump inhibitors, misoprostol) to older patients (primarily ≥65 years old) taking nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal ulcers. Older individuals are underrepresented in clinical trials of these agents. We systematically reviewed evidence from observational studies on the use of gastroprotective agents in elderly patients and their ability to prevent NSAID-related ulcers in this population.

METHODS

We performed a systematic search of Embase and MEDLINE and identified 23 observational studies that focused on elderly patients and reported data on co-prescription of gastroprotective agents and NSAIDs and/or the effectiveness of the agents in preventing gastrointestinal events in NSAID users. We collected data on rates of co-prescription and NSAID-related gastrointestinal events in patients with and without gastroprotection.

RESULTS

A median of 24% (range, 10%-69%) of elderly patients taking NSAIDs received a co-prescription for gastroprotective agents; this percentage was only slightly higher in the oldest age groups. All studies of efficacy showed a positive effect of gastroprotection. However, the adjusted results were not suitable for synthesis, and the 5 studies reporting unadjusted results were too heterogeneous for meta-analysis (I(2) = 97%). The studies differed in outcomes, definitions of co-prescription, and differences in baseline risk factors between patients with and without gastroprotection. None of the studies assessed adverse effects of gastroprotective agents. The 2 cost-effectiveness studies reached opposing conclusions.

CONCLUSIONS

In a systematic review, the observational evidence for the efficacy of gastroprotective agents in preventing NSAID-associated gastrointestinal events was in agreement with results of randomized controlled trials. However, because of heterogeneity of included studies, it is not clear what the effect would be if more patients were treated, or at what age gastroprotection should be recommended. We offer suggestions to facilitate comparison with other work and address the questions of risk and benefit in relation to age.

Potentially inappropriate medications in the elderly: a comprehensive protocol

Elderly patients are at increased risk of drug-related morbidity and mortality. Avoiding the use of potentially inappropriate medications (PIMs) is one of the strategies that has been widely adopted to reduce the harmful consequences of drug use. There are several PIM screening tools available. In this review, we provide an overview of existing screening tools to detect PIMs in the elderly, emphasizing the advantages and disadvantages of each. Combining previously published and adopted tools (adjusted Beers list, French consensus panel, McLeod's list, and Lindblad's list of clinically important drug-disease interactions), we develop a new comprehensive tool that also includes the adjusted Hanlon's and Malone's lists of potentially serious drug-drug interactions in the elderly. In addition to listed PIMs and clinically important drug-drug interactions, alternative therapeutic solutions are suggested. The new protocol differentiates: drugs with an unfavorable benefit/risk ratio (to be avoided regardless of the underlying disease/condition), drugs with a questionable efficacy, and drugs to be avoided with certain diseases/conditions, and provides a list of potentially serious drug-drug interactions. A tool consisting of PIMs and potential drug-drug interactions within the same protocol provides more comprehensive quality assessment of drug-prescribing behavior to the elderly, which in turn may lead to better prescribing practices.