Polypharmacy definition and prevalence in heart failure: a systematic review

Medication burden and anticholinergic use are associated with overt HE in individuals with cirrhosis

BACKGROUND

Polypharmacy and anticholinergic medications are associated with cognitive decline in elderly populations. Although several medications have been associated with HE, associations between medication burden, anticholinergics, and HE have not been explored. We examined medication burden and anticholinergics in patients with cirrhosis and their associations with HE-related hospitalization.

METHODS

We conducted a retrospective cohort study of patients aged 18-80 with cirrhosis seen in hepatology clinics during 2019. The number of chronic medications (medication burden) and anticholinergic use were recorded. The primary outcome was HE-related hospitalization.

RESULTS

A total of 1039 patients were followed for a median of 840 days. Thirty-seven percent had a history of HE, and 9.8% had an HE-related hospitalization during follow-up. The mean number of chronic medications was 6.1 ± 4.3. Increasing medication burden was associated with HE-related hospitalizations in univariable (HR: 1.09, 95% CI: 1.05-1.12) and multivariable (HR: 1.07, 95% CI: 1.03-1.11) models. This relationship was maintained in those with baseline HE but not in those without baseline HE. Twenty-one percent were taking an anticholinergic medication. Anticholinergic exposure was associated with increased HE-related hospitalizations in both univariable (HR: 1.68, 95% CI: 1.09-2.57) and multivariable (HR: 1.71, 95% CI: 1.11-2.63) models. This relationship was maintained in those with baseline HE but not in those without baseline HE.

CONCLUSIONS

Anticholinergic use and medication burden are both associated with HE-related hospitalizations, particularly in those with a history of HE. Special considerations to limit anticholinergics and minimize overall medication burden should be tested for potential benefit in this population.

Polypharmacy, anticholinergic burden and drug-drug interaction assessment in people with four-class-resistant HIV: data from the PRESTIGIO registry

OBJECTIVES

To evaluate polypharmacy, anticholinergic burden (ACB) and drug-drug interactions (DDIs) in people with four-class-resistant HIV (4DR-PWH).

METHODS

We performed a cross-sectional study, including 4DR-PWH from the PRESTIGIO Registry taking at least one non-antiretroviral drug. Polypharmacy was defined as taking five or more non-antiretroviral drugs. ACB was calculated using the ACB scale: 0 = no AC effect, 1-2 = low/moderate risk, ≥3 = high AC risk. Participants' characteristics by ACB score were compared using the Kruskal-Wallis test, and Spearman's correlation coefficient was used to assess linear relationships. DDIs were evaluated using the Liverpool database.

RESULTS

Overall, 172 4DR-PLWH were evaluated: 75.6% males, median age 49.9 years (IQR = 45.6-56), 62 (27.1%) on polypharmacy, 124 (72.1%) using a boosting agent and 72 (41.8%) with four or more antiretrovirals. Based on ACB, 128 (74.45%), 33 (19.2%) and 11 (6.4%) had a no, low/moderate and high AC risk, respectively. The most common AC drugs were β-blockers (12.2%), diuretics (8.7%) and antidepressants (8.7%). The high ACB was significantly related to the number of drugs/person (r = 0.33, P < 0.0001) and the number of clinical events (r = 0.222, P = 0.004). Overall, 258 DDIs were found between antiretrovirals and co-medications in 115 (66.8%) PWH, and 14 (8.1%) PWH received contraindicated drug combinations.

CONCLUSIONS

In 4DR-PWH, polypharmacy, DDIs and the proportion of people with moderate/high AC burden were high. In 4DR-PWH undetectability achievement and maintenance is the priority and use of boosted PIs is common. A strict collaboration (infectious diseases specialists, virologists, pharmacologists) is needed to limit the risk of ACB and DDIs and to explore the advantages of new antiretrovirals.

Impact of polypharmacy on 3-year mortality in patients with heart failure: a retrospective study

BACKGROUND

Guideline-directed medical therapy (GDMT) is important in heart failure management; however, polypharmacy itself may impact heart failure. Although measures against polypharmacy are needed, current discussion on unilateral drug tapering (including the drugs that should be tapered) is insufficient. In this study, we investigated the relationship between the number of prescribed GDMT drugs and prognosis in patients with heart failure.

METHODS

In this single-centre retrospective study, 3,146 eligible patients with heart failure were included and divided into four groups based on the median number of prescribed GDMT drugs and the median number of drugs not included in the GDMT (ni-GDMT) at the time of hospital discharge. The definition of GDMT was based on various Japanese guidelines. The primary outcome was all-cause mortality within 3 years of hospital discharge.

RESULTS

A total of 252 deaths were observed during the 3-year follow-up period. Kaplan-Meier analysis revealed that groups with GDMT drug count ≥ 5 and ni-GDMT drug count < 4 had the lowest mortality, and those with GDMT drug count < 5 and ni-GDMT drug count ≥ 4 had the highest mortality (log-rank, P < 0.001). Cox regression analysis revealed a significant association between ni-GDMT drug count and all-cause mortality, even after adjustment for number of GDMT medications, age, male, left ventricular ejection function < 40%, hemoglobin, albumin levels, and estimated glomerular filtration rate [HR = 1.06 (95% CI: 1.01-1.11), P = 0.020]. Conversely, the GDMT drug count was not associated with increased mortality rates.

CONCLUSIONS

The ni-GDMT drug count was significantly associated with 3-year mortality in patients with heart failure. Conversely, the GDMT drug count did not worsen the prognosis. Polypharmacy measures should consider ni-GDMT drug quantity to improve the prognosis and outcomes in patients with heart failure.

Prognostic impact of polypharmacy and discharge medications in octogenarians and nonagenarian patients with acute heart failure

With the increasing frequency of heart failure (HF) in elderly patients, polypharmacy has become a major concern owing to its adverse outcomes. However, reports on the clinical impact of polypharmacy and discharge medications in hospitalized super-aged patients with acute HF are rare. Data from 682 patients aged 80 years or older, hospitalized for treating acute HF, were analyzed. We recorded the number of medications at discharge and classified them into three groups: HF, non-HF cardiovascular, and non-cardiovascular medications. We investigated the correlation of polypharmacy, defined as daily administration of 10 or more medications at discharge, and the use of discharge medications with post-discharge prognosis. Polypharmacy was recorded in 24.3% of enrolled patients. Polypharmacy was not an independent predictor of all-cause mortality, the incidence of cardiac-related death, or HF-associated rehospitalization; however, the number of non-cardiovascular medications, multiple usage of potentially inappropriate medications, use of mineralocorticoid receptor antagonists, and doses of loop diuretics were associated with poor prognosis. Polypharmacy was significantly associated with higher mortality in patients with Barthel index ≥ 60 at discharge; hence, physical function at discharge was useful for the stratification of prognostic impacts of polypharmacy. The current study demonstrated that polypharmacy was not essentially associated with poor prognosis in super-aged patients with acute HF. Appropriate medications that consider the patient's physical function, rather than polypharmacy itself, are important for the management of HF.

Machine Learning-Based Mortality Prediction in Chronic Kidney Disease among Heart Failure Patients: Insights and Outcomes from the Jordanian Heart Failure Registry

Background and Objectives: Heart failure (HF) is a prevalent and debilitating condition that imposes a significant burden on healthcare systems and adversely affects the quality of life of patients worldwide. Comorbidities such as chronic kidney disease (CKD), arterial hypertension, and diabetes mellitus (DM) are common among HF patients, as they share similar risk factors. This study aimed to identify the prognostic significance of multiple factors and their correlation with disease prognosis and outcomes in a Jordanian cohort. Materials and Methods: Data from the Jordanian Heart Failure Registry (JoHFR) were analyzed, encompassing medical records from acute and chronic HF patients attending public and private cardiology clinics and hospitals across Jordan. An online form was utilized for data collection, focusing on three kidney function tests, estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN), and creatinine levels, with the eGFR calculated using the Cockcroft-Gault formula. We also built six machine learning models to predict mortality in our cohort. Results: From the JoHFR, 2151 HF patients were included, with 644, 1799, and 1927 records analyzed for eGFR, BUN, and creatinine levels, respectively. Age negatively impacted all measures (p ≤ 0.001), while smokers surprisingly showed better results than non-smokers (p ≤ 0.001). Males had more normal eGFR levels compared to females (p = 0.002). Comorbidities such as hypertension, diabetes, arrhythmias, and implanted devices were inversely related to eGFR (all with p-values <0.05). Higher BUN levels were associated with chronic HF, dyslipidemia, and ASCVD (p ≤ 0.001). Higher creatinine levels were linked to hypertension, diabetes, dyslipidemia, arrhythmias, and previous HF history (all with p-values <0.05). Low eGFR levels were associated with increased mechanical ventilation needs (p = 0.049) and mortality (p ≤ 0.001), while BUN levels did not significantly affect these outcomes. Machine learning analysis employing the Random Forest Classifier revealed that length of hospital stay and creatinine >115 were the most significant predictors of mortality. The classifier achieved an accuracy of 90.02% with an AUC of 80.51%, indicating its efficacy in predictive modeling. Conclusions: This study reveals the intricate relationship among kidney function tests, comorbidities, and clinical outcomes in HF patients in Jordan, highlighting the importance of kidney function as a predictive tool. Integrating machine learning models into clinical practice may enhance the predictive accuracy of patient outcomes, thereby supporting a more personalized approach to managing HF and related kidney dysfunction. Further research is necessary to validate these findings and to develop innovative treatment strategies for the CKD population within the HF cohort.

Colchicine for the Prevention of Cardiovascular Disease: Potential Global Implementation

PURPOSE OF REVIEW

Targeting traditional cardiovascular risk factors is effective in reducing recurrent cardiovascular events, yet the presence of residual cardiovascular risk due to underlying systemic inflammation is a largely unaddressed opportunity. This review aims to comprehensively assess the evolving role of colchicine as a therapeutic approach targeting residual inflammatory risk in the context of those with coronary artery disease (CAD).

RECENT FINDINGS

Inflammation plays a significant role in promoting atherosclerosis, and targeting anti-inflammatory pathways has the potential to decrease cardiovascular events. Low-dose colchicine (0.5 mg/day orally), when added to guideline-directed medical care for CAD, safely decreases major adverse cardiovascular events (MACE) by 31% in stable atherosclerosis patients and 23% in those after recent myocardial infarctions. Meta-analyses of recent randomized control trials further support both the efficacy and safety of colchicine, particularly when added to other standard cardiovascular therapies, including statin therapy. The European Society of Cardiology and other national guidelines endorse the use of low-dose colchicine in patients across the spectrum of CAD. Recently, colchicine was FDA-approved in the United States as the first anti-inflammatory therapy for the reduction of cardiovascular events. In a period of a rising incidence of CAD across the globe, colchicine represents a unique opportunity to decrease MACE due to its large magnitude of benefits and general affordability. However, challenges with drug interactions must be addressed, especially in those regions where HIV, hepatitis, and tuberculosis are prevalent. Colchicine is safe and effective at reducing cardiovascular events across a broad spectrum of coronary syndromes. The ability to simultaneously target traditional risk factors and mitigate residual inflammatory risk marks a substantial advancement in cardiovascular prevention strategies, heralding a new era in the global battle against CAD.

Definition of Polypharmacy in Heart Failure: A Scoping Review of the Literature

Patients with heart failure (HF) have a high prevalence of polypharmacy, which can lead to drug interactions, cognitive impairment, and medication non-compliance. However, the definition of polypharmacy in these patients is still inconsistent. The aim of this scoping review was to find the most common definition of polypharmacy in HF patients. We conducted a scoping review searching Medline, Embase, CINAHL, and Cochrane using terms including polypharmacy, HF and deprescribing, which resulted in 7,949 articles. Articles without a definition of polypharmacy in HF patients and articles which included patients < 18 years of age were excluded; only 59 articles were included. Of the 59 articles, 49% (n = 29) were retrospective, 20% (n = 12) were prospective, 10% (n = 6) were cross-sectional, and 27% (n = 16) were review articles. Twenty percent (n = 12) of the articles focused on HF with reduced ejection fraction, 10% (n = 6) focused on HF with preserved ejection fraction and 69% (n = 41) articles either focused on both diagnoses or did not clarify the specific type of HF. The most common cutoff for polypharmacy in HF was five medications (59%, n = 35). There was no consensus regarding the inclusion or exclusion of over-the-counter medications, supplements, or vitamins. Some newer studies used a cutoff of 10 medications (14%, n = 8), and this may be a more practical and meaningful definition for HF patients.

What is the association of polypharmacy with frailty in heart failure? A systematic review and meta-analysis

This systematic review and meta-analysis aimed to explore the differences in the number of prescribed medications and polypharmacy risk between patients with heart failure (HF) and frailty vs. those with HF but without frailty. Eligible studies included observational or experimental studies in patients aged ≥50 years. Thirteen studies met the criteria and were included in the final analysis. Patients with frailty and HF exhibited a higher risk of polypharmacy (OR: 1.87, 95% CI 1.72 - 2.04, I2 = 0%, P < 0.01) compared to those without frailty. Results remained significant after adjusting for comorbidity status. Additionally, patients with frailty and HF were prescribed more medications compared to those without (k = 6; MD: 1.43, 95% CI 0.31 - 2.55, I2 = 94%, P = 0.01), with a high degree of heterogeneity. However, results were non-significant after adjustment for comorbidity status. Patients with HF and frailty have a higher need of polypharmacy compared to those without frailty, which may increase the risk of potentially inappropriate medications (PIM). Investigating the real-world prevalence of PIM may support clinicians in their routine assessment as part of a comprehensive management strategy in patients with HF and frailty.

Considerations Regarding Management of Heart Failure in Older Adults

Understanding noncardiovascular comorbidities and geriatric syndromes in elderly patients with heart failure (HF) is important as the average age of the population increases. Healthcare professionals need to consider these complex dynamics when managing older adults with HF, especially those older than 80. A number of small studies have described associations between HF and major geriatric domains. With information on patients' cognitive, functional decline, and ability to adhere to therapy, physicians can plan for individualized treatment goals and recommendations for these patients.

Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation

Objective

This study explored whether anticoagulation is safe for frail and non-frail elderly patients who have nonvalvular atrial fibrillation (NVAF).

Methods

At hospital discharge, the anticoagulant regimen and frailty status were recorded for 361 elderly patients (aged ≥75 y) with NVAF. The patients were followed for 12 months. The endpoints included occurrence of thrombosis; bleeding; all-cause death; and cardiovascular events.

Results

At hospital discharge, frailty affected 50.42% of the population and the anticoagulation rate was 44.04%. At discharge, age (OR 0.948, P = 0.006), paroxysmal NVAF (OR 0.384, P < 0.001), and bleeding history (OR 0.396, P = 0.001) were associated with a decrease in rate of receiving anticoagulation, while thrombotic events during hospitalization (OR 2.281, P = 0.021) were associated with an increase. Relative to non-frail patients, those with frailty showed a higher rate of ischemic stroke (5.33% cf. 3.01%), bleeding (P = 0.006) events, and all-cause mortality (P = 0.001). Relative to the group without anticoagulation, in those with anticoagulation the rate of thrombotic events was lower (6.99 cf. 10.98%) and bleeding events were higher (20.98 cf. 12.72%), but the risk of major bleeding was comparable.

Conclusion

In the elderly patients with NVAF, the decision toward anticoagulation therapy at hospital discharge was influenced by age, bleeding history, paroxysmal atrial fibrillation diagnosis, and absence of thrombosis. Frail patients were at greater risk of bleeding and all-cause mortality. Anticoagulation tended to reduce the risk of thrombotic events.

Oral anticoagulation in heart failure complicated by atrial fibrillation: A nationwide routine data study

BACKGROUND

This nationwide routine data analysis evaluates if oral anticoagulant (OAC) use in patients with heart failure (HF) and atrial fibrillation (AF) leads to a lower mortality and reduced readmission rate. Superiority of new oral anticoagulants (NOACs), compared to vitamin K antagonists (VKA), was analyzed for these endpoints.

METHODS

Anonymous data of patients with a health insurance at the Allgemeine Ortskrankenkasse and a claims record for hospitalization with the main diagnosis of HF and secondary diagnosis of AF (2017-2019) were included. A hospital stay in the previous year was an exclusion criterion. Mortality and readmission for all-cause and stroke/intracranial bleeding (ICB) were analyzed 91-365 days after the index hospitalization. Kaplan-Meier survival curves and multivariable Cox regression models were used to evaluate the impact of medication on outcome.

RESULTS

180,316 cases were included [81 years (IQR 76-86), 55.6% female, CHA2DS2-VASc score ≥ 2 (96.81%)]. In 80.6%, OACs were prescribed (VKA: 21.7%; direct factor Xa inhibitors (FXaI): 60.0%; direct thrombin inhibitors (DTI): 3.4%; with multiple prescriptions per patient included). Mortality rate was 19.1%, readmission rate was 29.9% and stroke/ICB occurred in 1.9%. Risk of death was lower with any OAC (HR 0.77, 95% CI [0.75-0.79]) but without significant differences in OAC type (VKA: HR 0.73, [0.71-0.76]; FXaI: HR 0.77, [0.75-0.78]; DTI: HR 0.71, [0.66-0.77]). The total readmission rate (HR 0.97, [0.94 to 0.99]) and readmission for stroke/ICB (HR 0.71, [0.65-0.77]) was lower with OAC.

CONCLUSIONS

Nationwide data confirm a reduction in mortality and readmission rate in HF-AF patients taking OACs, without NOAC superiority.

Use of different anticholinergic scales and their correlation with anticholinergic symptom burden in a cohort of people living with HIV

OBJECTIVES

How to detect the clinical impact of anticholinergic (AC) burden in people with HIV (PWH) remains poorly investigated. We cross-sectionally described the prevalence and type of AC signs/symptoms and the screening accuracy of three AC scales in detecting their presence in a modern cohort of PWH.

METHODS

We calculated AC Burden Scale (ABS), AC Risk Score (ARS) and AC Drug Score (ADS) in 721 adult PWH and recorded the presence of AC signs/symptoms over the previous 3 months. High AC risk was defined by ABS score ≥2, and ARS or ADS score ≥3. Comparisons among the scale were based on Cohen's inter-rater agreement, and their screening accuracy was assessed by receiver operating characteristics (ROC) curves and performance measures.

RESULTS

We enrolled 721 PWH, of whom 72.0% of participants were male; the median age was 53 years, and 164 participants (22.7%) were on at least one AC drug. Among these, 28.6% experienced at least one AC sign/symptom. Agreement in AC risk classification was substantial only between ARS and ADS (k = 0.6). Lower and higher risk of AC signs/symptoms was associated with dual regimens [adjusted OR (aOR) = 0.12 versus three-drug regimens, P = 0.002] and increasing number of AC drugs (aOR = 12.91, P < 0.001). Depression and COPD were also associated with higher risk of AC signs/symptoms in analysis unadjusted for number of AC drugs. ABS and ADS showed the best area under the ROC curve (AUROC) of 0.85 (0.78-0.92) and 0.84 (0.75-0.92; P < 0.001 for both). However, at the cut-off used for the general population, the sensitivity of all three scales was very low (34.0%, 46.8% and 46.8%).

CONCLUSIONS

Up to one-fourth of participants in our cohort were exposed to at least one AC drug, and among them AC signs/symptoms affected more than one-fourth. Both polypharmacy (as number of antiretrovirals and of co-medications with AC properties) and to a lesser extent specific comorbidities shaped the risk of developing AC signs/symptoms. Sensitive screenings for AC risk in PWH should prefer ABS or ADS based on lower cut-offs than those suggested for the general population.

Tacrolimus and Cyclosporin Pharmacotherapy, Detection Methods, Cytochrome P450 Enzymes after Heart Transplantation

BACKGROUND

Advances in organ transplantation were made after the discovery of the pure form of cyclosporine by Dr Jean Borel in the 1970s. In fact, in clinical practice achieving a delicate balance in circulating immunosuppressive necessitate focus on the difficult task of posttransplant therapeutic drug monitoring.

OBJECTIVE

The purpose of this study was to determine the pharmacologic properties of cyclosporine- tacrolimus, detection methods, and the effects on the activity of cytochrome P450 enzymes when prescribing the most efficient treatments in forms of polypharmacy for the recipients of heart transplantation.

METHODS

Scientific literature on the interactions of tacrolimus and cyclosporine with human cytochrome P450 enzymes was searched using PUBMED.Gov (https://pubmed.ncbi.nlm.nih.gov/), Web of Science, and Scopus.

RESULTS

Prescription immunosuppressive drugs based on polypharmacy accompanied by induction agents could result in hidden neurotoxicity and nephrotoxicity. A literature search shows that cyclosporine prescription with antihypertensives drugs needs close monitoring. Co-administration of tacrolimus and diltiazem or verapamil needs a decrease in the tacrolimus dose by 20-50%. Vigilant attention to the lowest possible statin dose is needed when coadministered with fluvastatin or pravastatin. Polypharmacy based on ticlopidine, clopidogrel, and cyclosporine or tacrolimus needs monitoring of immunosuppressive drug levels for several months. A prescription with clotrimazole or fluconazole needs close monitoring, and itraconazole or ketoconazole needs to reduce the initial dose by 50%. Combination with nefazodone needs to be avoided, and alternative drugs such as sertraline or citalopram could be prescribed in addition to further monitoring consideration. In prescription with phenytoin, the bound and free phenytoin levels need close monitoring.

CONCLUSION

Polypharmacy based on tacrolimus or cyclosporine needs vigilant therapeutic drug monitoring due to the cytochrome P450 enzymes associated with biochemical variables in metabolic pathways. Further attention to polypharmacy should be given to circulate drugs that could hide pharmacokinetics interactions associated with infections, malignancies, chronic kidney disease, and rejection after organ transplantation.

The Interplay of Comorbidities in Chronic Heart Failure: Challenges and Solutions

BACKGROUND

Chronic heart failure (HF) is frequently associated with various comorbidities. These comorbid conditions, such as anemia, diabetes mellitus, renal insufficiency, and sleep apnea, can significantly impact the prognosis of patients with HF.

OBJECTIVE

This review aims to synthesize current evidence on the prevalence, impact, and management of comorbidities in patients with chronic HF.

METHODS

A comprehensive review was conducted, with a rigorous selection process. Out of an initial pool of 59,030 articles identified across various research modalities, 134 articles were chosen for inclusion. The selection spanned various research methods, from randomized controlled trials to observational studies.

RESULTS

Comorbidities are highly prevalent in patients with HF and contribute to increased hospitalization rates and mortality. Despite advances in therapies for HF with reduced ejection fraction, options for treating HF with preserved ejection fraction remain sparse. Existing treatment protocols often lack standardization, reflecting a limited understanding of the intricate relationships between HF and associated comorbidities.

CONCLUSION

There is a pressing need for a multidisciplinary, tailored approach to manage HF and its intricate comorbidities. This review underscores the importance of ongoing research efforts to devise targeted treatment strategies for HF patients with various comorbid conditions.

Polypharmacy prevalence and associated factors in patients with systemic lupus erythematosus: A single-centre, cross-sectional study

OBJECTIVES

This study aimed to clarify factors associated with polypharmacy among patients with systemic lupus erythematosus.

METHODS

This single-centre cross-sectional study was conducted by reviewing the medical records and questionnaire data of 261 systemic lupus erythematosus patients at a teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as the regular administration of five or more oral medications; excessive polypharmacy consisted of the regular use of 10 or more oral medications. This study investigated (1) the prevalence of polypharmacy and excessive polypharmacy, (2) the distribution of medication types, and (3) the factors associated with polypharmacy and excessive polypharmacy.

RESULTS

The proportions of patients who exhibited polypharmacy and excessive polypharmacy were 70% and 19%, respectively. Polypharmacy was associated with older age, long duration of systemic lupus erythematosus, high disease activity, and administration of glucocorticoids or immunosuppressive agents. Excessive polypharmacy was associated with a higher updated Charlson comorbidity index, history of visits to multiple internal medicine clinics, and presence of public assistance.

CONCLUSIONS

Polypharmacy and excessive polypharmacy in patients with systemic lupus erythematosus are related to medical aspects such as disease severity and comorbidities in addition to social aspects such as hospital visitation patterns and economic status.

Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines?

Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.

Polypharmacy and Optimization of Guideline-Directed Medical Therapy in Heart Failure: The GUIDE-IT Trial

BACKGROUND

Polypharmacy is common among patients with heart failure with reduced ejection fraction (HFrEF). However, its impact on the use of optimal guideline-directed medical therapy (GDMT) is not well established.

OBJECTIVES

This study sought to evaluate the association between polypharmacy and odds of receiving optimal GDMT over time among patients with HFrEF.

METHODS

The authors conducted a post hoc analysis of the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment) trial. Polypharmacy was defined as receiving ≥5 medications (excluding HFrEF GDMT) at baseline. The outcome of interest was optimal triple therapy GDMT (concurrent administration of a renin-angiotensin-aldosterone blocker and beta-blocker at 50% of the target dose and a mineralocorticoid receptor antagonist at any dose) achieved over the 12-month follow-up. Multivariable adjusted mixed-effect logistic regression models with multiplicative interaction terms (time × polypharmacy) were constructed to evaluate how polypharmacy at baseline modified the odds of achieving optimal GDMT on follow-up.

RESULTS

The study included 891 participants with HFrEF. The median number of non-GDMT medications at baseline was 4 (IQR: 3-6), with 414 (46.5%) prescribed ≥5 and identified as being on polypharmacy. The proportion of participants who achieved optimal GDMT at the end of the 12-month follow-up was lower with vs without polypharmacy at baseline (15% vs 19%, respectively). In adjusted mixed models, the odds of achieving optimal GDMT over time were modified by baseline polypharmacy status (P for interaction < 0.001). Patients without polypharmacy at baseline had increased odds of achieving GDMT (OR: 1.16 [95% CI: 1.12-1.21] per 1-month increase; P < 0.001) but not patients with polypharmacy (OR: 1.01 [95% CI: 0.96-1.06)] per 1-month increase).

CONCLUSIONS

Patients with HFrEF who are on non-GDMT polypharmacy have lower odds of achieving optimal GDMT on follow-up.

Association between number of medications and hip fractures in Japanese elderly using conditional logistic LASSO regression

To examine the association between hip fracture and associated factors, including polypharmacy, and develop an optimal predictive model, we conducted a population-based matched case-control study using the health insurance claims data on hip fracture among Japanese patients. We included 34,717 hospitalized Japanese patients aged ≥ 65 years with hip fracture and 34,717 age- and sex- matched controls who were matched 1:1. This study included 69,434 participants. Overall, 16 variable comorbidities and 60 variable concomitant medications were used as explanatory variables. The participants were added to early elderly and late elderly categories for further analysis. The odds ratio of hip fracture increased with the number of medications only in the early elderly. AUC was highest for early elderly (AUC, 0.74, 95% CI 0.72-0.76). Use of anti-Parkinson's drugs had the largest coefficient and was the most influential variable in many categories. This study confirmed the association between risk factors, including polypharmacy and hip fracture. The risk of hip fracture increased with an increase in medication number taken by the early elderly and showed good predictive accuracy, whereas there was no such association in the late elderly. Therefore, the early elderly in Japan should be an active target population for hip fracture prevention.

Discovering Distinct Phenotypical Clusters in Heart Failure Across the Ejection Fraction Spectrum: a Systematic Review

REVIEW PURPOSE

This systematic review aims to summarise clustering studies in heart failure (HF) and guide future clinical trial design and implementation in routine clinical practice.

FINDINGS

34 studies were identified (n = 19 in HF with preserved ejection fraction (HFpEF)). There was significant heterogeneity invariables and techniques used. However, 149/165 described clusters could be assigned to one of nine phenotypes: 1) young, low comorbidity burden; 2) metabolic; 3) cardio-renal; 4) atrial fibrillation (AF); 5) elderly female AF; 6) hypertensive-comorbidity; 7) ischaemic-male; 8) valvular disease; and 9) devices. There was room for improvement on important methodological topics for all clustering studies such as external validation and transparency of the modelling process. The large overlap between the phenotypes of the clustering studies shows that clustering is a robust approach for discovering clinically distinct phenotypes. However, future studies should invest in a phenotype model that can be implemented in routine clinical practice and future clinical trial design. HF = heart failure, EF = ejection fraction, HFpEF = heart failure with preserved ejection fraction, HFrEF = heart failure with reduced ejection fraction, CKD = chronic kidney disease, AF = atrial fibrillation, IHD = ischaemic heart disease, CAD = coronary artery disease, ICD = implantable cardioverter-defibrillator, CRT = cardiac resynchronization therapy, NT-proBNP = N-terminal pro b-type natriuretic peptide, BMI = Body Mass Index, COPD = Chronic obstructive pulmonary disease.

Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction According to Polypharmacy Status

BACKGROUND

Patients with heart failure (HF) have a high burden of multimorbidity, often necessitating numerous medications. There may be clinical concern about introducing another medication, especially among individuals with polypharmacy.

OBJECTIVES

This study examined the efficacy and safety of addition of dapagliflozin according to the number of concomitant medications in HF with mildly reduced or preserved ejection fraction.

METHODS

In this post hoc analysis of the DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trial, 6,263 participants with symptomatic HF with left ventricular ejection fraction >40% were randomized to dapagliflozin or placebo. Baseline medication use (including vitamins and supplements) was collected. Efficacy and safety outcomes were assessed by medication use categories ("nonpolypharmacy": <5 medications; "polypharmacy": 5 to 9 medications; and "hyperpolypharmacy": ≥10 medications) and continuously. The primary outcome was worsening HF or cardiovascular death.

RESULTS

Overall, 3,795 (60.6%) patients met polypharmacy and 1,886 (30.1%) met hyperpolypharmacy criteria. Higher numbers of medications were strongly associated with higher comorbidity burden and increased rates of the primary outcome. Compared with placebo, dapagliflozin similarly reduced the risk of the primary outcome irrespective of polypharmacy status (nonpolypharmacy HR: 0.88 [95% CI: 0.58-1.34]; polypharmacy HR: 0.88 [95% CI: 0.75-1.03]; hyperpolypharmacy HR: 0.73 [95% CI: 0.60-0.88]; Pinteraction = 0.30). Similarly, benefits with dapagliflozin were consistent across the spectrum of total medication use (Pinteraction = 0.06). Although adverse events increased with higher number of medications, they were not more frequent with dapagliflozin, regardless of polypharmacy status.

CONCLUSIONS

In the DELIVER trial, dapagliflozin safely reduced worsening HF or cardiovascular death across a broad range of baseline medication use, including among individuals with polypharmacy (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).

Near-death experiences are associated with rapid eye movement (REM) sleep intrusions in migraine patients, independent of migraine aura

BACKGROUND AND PURPOSE

Migraine aura, near-death experiences (NDEs), and rapid eye movement (REM) sleep intrusions might share common mechanisms. Here, we investigated the prevalence of NDEs and REM sleep intrusions in people with migraine. We hypothesized that NDEs and REM sleep intrusions are more prevalent in migraine patients with aura than in those without.

METHODS

We conducted a prospective cross-sectional cohort study at a tertiary headache center, based on a prespecified sample size (n = 808). Migraine patients completed a series of questionnaires, including questions about demographic and headache characteristics, the 16-item Greyson NDE scale, four questions about REM sleep intrusions, and the Depression, Anxiety, and Stress Scale 21 (DASS-21).

RESULTS

Of 808 migraine patients (mean age 44.4 ± 13.3 years, 87.0% women), 353 (43.7%) had a current or previous history of migraine aura. Prevalence of NDE was 2.7% and not different in patients with and without aura (2.8% vs. 2.6%; p > 0.999). REM sleep intrusions were reported by 5.4% of participants and in a similar proportion of patients with and without aura (6.3% vs. 4.9%; p = 0.43). However, participants with REM sleep intrusions had had an NDE more often than participants without REM sleep intrusions (n = 5/44, 11.4% vs. n = 17/754, 2.2%; p = 0.005). Higher DASS-21 scores were associated with REM sleep intrusions (p < 0.001).

CONCLUSIONS

In this tertiary center cohort study, the prevalence of NDE and REM sleep intrusions was not influenced by migraine aura status. However, we identified an association between NDE and REM sleep intrusions, which corroborates the notion that they might share pathophysiological mechanisms.

Effect and usability of mobile health applications for medication adherence in patients with heart failure: A systematic review

BACKGROUND

This review aimed to evaluate the effect of mobile health applications (apps) use on medication adherence in heart failure (HF) patients, and to verify their quality of use.

METHODS

We searched MEDLINE, Embase, Web of Science, Scopus, CINAHL, LILACS, Cochrane, Clinical Trial Registries, Google Scholar, ProQuest, Open Access Theses and dissertations (OATD), Annual Symposium Proceedings of the American Medical Informatics Association (AMIA).

RESULTS

Of the 836 records identified, eight studies (five randomized clinical trials (RCTs) and three observational studies) were included, totaling 484 participants, with a mean age ranging from 51.1 to 72 years and 65% were male. The apps improved medication adherence when compared with their comparators in only two RCTs (n = 111, Cohen d = 3.23, 95% confidence interval (CI) 2.66; 3.80 and n = 80, d = 1.20, 95% CI 0.71; 1.66), and two observational studies, one of them with large effect size (n = 142, Cohen d = 1.51, 95% CI 1.12; 1.90). Apps proved to be more effective interventions than their comparators allowed continuous monitoring of patients. All included studies used self-report measures to assess medication adherence behaviors and their results should be interpreted with caution, as such tools may cause social desirability bias or recall bias.

CONCLUSION

The included studies indicate a possible outcome in favor of the use of apps to improve medication adherence in HF patients, but with very low quality level of evidence. Further studies are needed to investigate the effects of the use of apps, optimal frequency and duration of its use in HF patients.

Heart Failure in the Elderly: the Role of Biological and Sociocultural Aspects Related to Sex

PURPOSE OF REVIEW

Heart failure (HF) entails poor prognosis, with high morbidity and mortality burden, particularly in elderly patients. Notably, important sex differences have been described between men and women with HF. In this regard, some biological and sociocultural aspects related to sex may play a key role in the different development and prognosis of HF in elderly men and women.

RECENT FINDINGS

Important differences between men and women with HF, especially in the elderly population, have been specifically addressed in recent studies. Consequently, specific differences in biological and sociocultural aspects have been found to associate differences in pathophysiology, baseline clinical profile, and prognosis according to sex. Moreover, differences in comorbidities and frailty and other geriatric conditions, frequent in elderly population with HF, have also been described. Biological and sociocultural differences related to sex are key in the different clinical presentation and prognosis of heart failure in elderly women. Further studies will be required to better understand some other underlying reasons that may differently impact prognosis in elderly patients with HF.

Prevalence and factors associated with polypharmacy among patients with rheumatoid arthritis: a single-centre, cross-sectional study

OBJECTIVE

This study aimed to identify factors associated with polypharmacy, including social aspects, among patients with rheumatoid arthritis.

METHODS

We conducted this single-centre, cross-sectional study at a 715-bed regional tertiary care teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as having five or more medications administered orally regularly, and excessive polypharmacy was defined as having 10 or more medications administered orally regularly. The prevalence of polypharmacy and excessive polypharmacy, distribution of medication types, and factors associated with polypharmacy and excessive polypharmacy were investigated among patients with rheumatoid arthritis.

RESULTS

The proportions of polypharmacy and excessive polypharmacy were 61% and 15%, respectively, in 991 patients. Polypharmacy and excessive polypharmacy were associated with older age (odds ratio, 1.03 and 1.03, respectively), high Health Assessment Questionnaire Disability Index (odds ratio, 1.45 and 2.03, respectively), medication with glucocorticoids (odds ratio, 5.57 and 2.42, respectively), high Charlson comorbidity index (odds ratio, 1.28 and 1.36, respectively), and a history of hospitalisation in internal medicine (odds ratio, 1.92 and 1.87, respectively) and visits to other internal medicine clinics (odds ratio, 2.93 and 2.03, respectively). Moreover, excessive polypharmacy was associated with the presence of public assistance (odds ratio, 3.80).

CONCLUSIONS

Considering that polypharmacy and excessive polypharmacy are associated with a history of hospitalisation and glucocorticoid medication in patients with rheumatoid arthritis, medications during hospitalisation should be monitored, and glucocorticoids should be discontinued. Key points • The proportion of polypharmacy (five or more medications administered orally regularly) was 61%. • The proportion of excessive polypharmacy (10 or more medications administered orally regularly) was 15%. • Medications during hospitalisation should be reviewed and examined, and glucocorticoids should be discontinued.

Prognostic Role of Contraindicated Drugs in Hospitalized Patients with Decompensated Heart Failure

Due to the ageing population, patients often present to the hospital with a high burden of comorbidities and polypharmacy. For patients admitted with decompensated heart failure (HF), the evidence on the effects of contraindicated drugs on long-term mortality is scarce. Therefore, we aimed to investigate the effect of contraindicated medications on outcomes of patients admitted with decompensated HF. We analyzed all consecutive patients from the National Heart Failure Audit admitted to two tertiary centers with acutely decompensated HF between April 2020 and October 2021. We included medication classes listed as contraindicated (class III) in the most recent European and American guidelines on the management of HF. The primary outcome measure was in-hospital mortality. The secondary outcome measure was overall mortality. Overall, 716 patients admitted with acute HF were included. One-fifth (n = 156, 21.8%) were on at least one contraindicated medication at admission. The prevalence of comorbidities was comparable between medication groups. During hospitalization, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with increased in-hospital mortality (29% versus 9%, P = 0.013). On multivariable analyses, NSAID use was independently associated with worse in-hospital mortality (hazard ratio, 6.86; 95% confidence interval, 1.61-25.5; P = 0.005). However, other contraindicated medications were not associated with adverse outcomes. Postdischarge, the use of erythropoietin during admission was associated with increased mortality (54% versus 31%, P = 0.031). NSAID use is associated with increased in-hospital mortality for patients admitted with acute HF. However, inpatient use of other contraindicated medications was not associated with adverse in-hospital outcomes. Further studies are needed to confirm these results in larger and prospective cohorts. SIGNIFICANCE STATEMENT: Use of nonsteroidal anti-inflammatory drugs is associated with a worse in-hospital mortality in patients with decompensated heart failure. The prognostic role of other contraindicated medications remains still uncertain.

Prevalence and trends of polypharmacy in U.S. adults, 1999-2018

BACKGROUND

Polypharmacy is one of the most important health issues for its potential impacts on disease burden and healthcare costs. The aim of this study was to update a comprehensive picture of prevalence and trends in polypharmacy over 20 years in U.S. adults.

METHODS

Participants included 55,081 adults aged ≥ 20 from the National Health and Nutrition Examination Survey, January 1, 1999, through December 31, 2018. The simultaneously use of ≥ 5 drugs in one individual was defined as polypharmacy. National prevalence and trends in polypharmacy were evaluated among U.S. adults within different demo-socioeconomic status and pre-existing diseases.

RESULTS

From 1999-2000 to 2017-2018, the overall percentages of adults with polypharmacy remained on the rise, increasing from 8.2% (7.2-9.2%) to 17.1% (15.7-18.5%) (average annual percentage change [AAPC] = 2.9%, P = .001). The polypharmacy prevalence was considerably higher in the elderly (from 23.5% to 44.1%), in adults with heart disease (from 40.6% to 61.7%), and in adults with diabetes (from 36.3% to 57.7%). Also, we observed a greater increase rate of polypharmacy in men (AAPC = 4.1%, P < .001), in the Mexican American (AAPC = 6.3%, P < .001), and in the non-Hispanic Black (AAPC = 4.4%, P < .001).

CONCLUSIONS

From 1999-2000 to 2017-2018, the prevalence of polypharmacy is continually increasing in U.S. adults. The polypharmacy was especially higher in the older, in patients with heart disease, or diabetes. The high prevalence urges the healthcare providers and health policymakers to manage polypharmacy among specific population groups.

Geriatric Pharmacotherapy Case Series: Heart Failure With Reduced Ejection Fraction Pharmacotherapy Optimization in Older People

This case illustrates the pharmacist's role in the outpatient management of heart failure with reduced ejection fracture in a community-dwelling older person. In this case, the patient has a long-standing history of heart failure because of ischemic causes. Relatively active and working full-time, he presented to the pharmacist clinic for optimization of heart failure therapy. This case focuses on the role of mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors in heart failure with reduced ejection fraction management.

Polypharmacology: promises and new drugs in 2022

Polypharmacology is an emerging strategy of design, synthesis, and clinical implementation of pharmaceutical agents that act on multiple targets simultaneously. It should not be mixed up with polytherapy, which is based on the use of multiple selective drugs and is considered a cornerstone of current clinical practice. However, this 'classic' approach, when facing urgent medical challenges, such as multifactorial diseases, increasing resistance to pharmacotherapy, and multimorbidity, seems to be insufficient. The 'novel' polypharmacology concept leads to a more predictable pharmacokinetic profile of multi-target-directed ligands (MTDLs), giving a chance to avoid drug-drug interactions and improve patient compliance due to the simplification of dosing regimens. Plenty of recently marketed drugs interact with multiple biological targets or disease pathways. Many offer a significant additional benefit compared to the standard treatment regimens. In this paper, we will briefly outline the genesis of polypharmacology and its differences to polytherapy. We will also present leading concepts for obtaining MTDLs. Subsequently, we will describe some successfully marketed drugs, the mechanisms of action of which are based on the interaction with multiple targets. To get an idea, of whether MTDLs are indeed important in contemporary pharmacology, we also carefully analyzed drugs approved in 2022 in Germany: 10 out of them were found multi-targeting, including 7 antitumor agents, 1 antidepressant, 1 hypnotic, and 1 drug indicated for eye disease.

Sleep disturbances and their correlation with cardiovascular risk, obesity, and mood disorders in people with HIV

BACKGROUND

The relationship between sleep disorders (SDs), cardiovascular risk (CVR), and mood disorders (MDs) has been studied in detail in the general population, but far less in people with HIV (PWH).

METHODS

Cross-sectional analysis in single centre cohort of PWH. Sleep quality was assessed using by Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), Berlin Questionnaire (BQ), Pittsburgh Sleep Quality Index (PSQI); anxiety and depression were evaluated by the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9. Demographic, clinical and HIV-related data were collected, and Framingham and Data collection on Adverse effects of anti-HIV Drugs (DAD)-10 scores were computed in modelling associations with each SDs scale.

RESULTS

Data were collected for 721 PWH on stable combination antiretroviral therapy (cART) (median age of 53 years, 71.8% males, 96% with undetectable HIV RNA, 50.3% on cART potentially affecting sleep, and 20.4% on hypno-inducing drugs), 76.9% had SDs 60.3, 31.3, 31.1, and 7.9% at PSQI, BQ, ISI, and ESS, respectively. Anxiety and depression were detected in 28.3 and 16.1% participants, respectively. BQ score was independently associated with high BMI ( P  < 0.001), Framingham risk >10% ( P  < 0.001), and both DAD-10R and -10F score >10% ( P  < 0.001 and P  = 0.031). PSQI and ISI scores were independently associated with depression and anxiety ( P  < 0.001). No association between SDs and specific antiretroviral regimens, nor HIV-related parameters was detected.

CONCLUSIONS

In our cohort of PWH on stable ART, despite the alarmingly higher prevalence, SDs were associated with the same determinants (cardiovascular risk factors and MDs) observed in the general population.

Prognostic impact of cardiovascular polypharmacy on octogenarians with heart failure with preserved ejection fraction

BACKGROUNDS

Drug treatments of heart failure with preserved ejection fraction (HFpEF) have a little clinical benefit, but cardiovascular polypharmacy (CP) trend is observed in elderly HFpEF. We investigated the impact of CP on octogenarian with HFpEF.

METHODS

We examined 783 consecutive octogenarians (≥80 years) enrolled in the PURSUIT-HFpEF registry. We defined medications for hypertension, dyslipidemia, heart failure (HF), coronary artery disease, stroke, peripheral artery disease, and atrial fibrillation as cardiovascular medications (CM). In this study, we defined CP as ≥5 CM. We investigated whether CP was correlated with the composite end point (CE) of all-cause mortality and HF rehospitalization.

RESULTS

The proportion with CP was 51.9% (n = 406). Background characteristics correlated with CP were frailty, history of coronary artery disease, atrial fibrillation and left atrial dimension. Multivariable Cox proportional hazards analysis showed CP was significantly and independently correlated with CE (hazard ratio (HR): 1.31; 95% confidence Interval (CI): 1.01-1.70) in addition to age, clinical frailty scale, history of HF admission and N-terminal pro brain natriuretic peptide. Kaplan-Meier curve analysis showed that, compared with the non-CP group, the CP group had significantly higher risk of CE and HF (HR: 1.27; 95%CI: 1.04-1.56; P = 0.02 and HR: 1.46; 95%CI: 1.13-1.88; P < 0.01, respectively), but not any-cause death. In addition, diuretics were correlated with CE (HR: 1.61; 95%CI: 1.17-2.22; P < 0.01), but antithrombotic drugs and HFpEF medications were not.

CONCLUSIONS

CP at discharge is a prognostic factor driven by HF rehospitalization in octogenarians with HFpEF. In these patients, diuretics may be correlated with the prognosis.

Efficacy of surgical treatment on polypharmacy of elderly patients with lumbar spinal canal stenosis: retrospective exploratory research

BACKGROUND

Polypharmacy is a growing public health problem occurring in all healthcare settings worldwide. Elderly patients with lumbar spinal canal stenosis (LSS) who manifest low back and neuropathic pain and have a high frequency of comorbidity are predicted to take many drugs. However, no studies have reported polypharmacy in elderly patients with LSS. Thus, we aimed to review the polypharmacy among elderly LSS patients with elective surgeries and examine how the surgical treatment reduces the polypharmacy.

METHODS

We retrospectively enrolled all the patients aged ≥ 65 years who underwent spinal surgery for LSS between April 2020 and March 2021. The prescribed drugs of participants were directly checked by pharmacists in the outpatient department preoperatively and 6-month and 1-year postoperatively. The baseline characteristics were collected beside the patient-based outcomes including Roland-Morris Disability Questionnaire, Zurich Claudication Questionnaire, and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The cutoff number of drugs for polypharmacy was defined as 6. The prescription drugs were divided into 9 categories: drugs for neuropsychiatric, cardiovascular, respiratory, digestive, endocrine metabolic, and urinary renal diseases; blood products; pain relief medication; and others.

RESULTS

A total of 102 cases were finally analyzed, with a follow-up rate of 78.0%. Of the participants, the preoperative polypharmacy prevalence was 66.7%. The number of drugs 6-month and 1-year postoperatively was significantly less than the preoperative one. The proportions of polypharmacy at 6 months and 1 year after surgery significantly decreased to 57.8% and 55.9%, respectively. When the prescribed drugs were divided into 9 categories, the number of drugs for pain relief and digestive diseases was significantly reduced after surgery. The multi-variable analysis revealed that a higher score in the psychological disorder of JOABPEQ was associated with 3 or more drugs decreased 1-year postoperatively (OR, 2.5; 95% CI: 1.0-6.1).

CONCLUSION

Polypharmacy prevalence was high among elderly LSS patients indicated for lumbar spinal surgery. Additionally, our data showed that lumbar spinal surgery was effective in reducing polypharmacy among elderly LSS patients. Finally, the multi-variable analysis indicated that better psychological condition was associated with the reduction of prescribed drugs after lumbar spinal surgery.

Holistic approach to drug therapy in a patient with heart failure

Heart failure (HF) is a growing global public health problem affecting at least 26 million people worldwide. The evidence-based landscape for HF treatment has changed at a rapid rate over the last 30 years. International guidelines for the management of HF now recommend the use of four pillars in all patients with reduced ejection fraction: angiotensin receptor neprilysin inhibitors or ACE inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors. Beyond the main four pillar therapies, numerous further pharmacological treatments are also available in specific patient subtypes. These armouries of drug therapy are impressive, but where does this leave us with individualised and patient-centred care? This paper reviews the common considerations needed to provide a holistic, tailored and individual approach to drug therapy in a patient with HF with reduced ejection fraction, including shared decision making, initiating and sequencing of HF pharmacotherapy, drug-related considerations, polypharmacy and adherence.

Effect of polypharmacy on plasma bepridil concentration in patients with heart failure: a multicenter retrospective study

BACKGROUND

Polypharmacy, defined as the concurrent use of over six drugs, is common in the treatment of heart failure (HF); however, unpredictable drug interactions with bepridil may occur. In this study, we have elucidated the influence of polypharmacy on plasma bepridil concentrations in patients with HF.

METHODS

We conducted a multicenter retrospective study involving 359 adult patients with HF who received oral bepridil. Because QT prolongation is an adverse effect following plasma bepridil concentrations ≥800 ng/mL, the risk factors for patients achieving these concentrations at steady state were elucidated via multivariate logistic regression. The correlation between bepridil dose and plasma concentration was examined. The effect of polypharmacy on the value of the concentration-to-dose (C/D) ratio was investigated.

RESULTS

A significant relationship was observed between bepridil dose and plasma concentration (p <  0.001), and the intensity of the correlation was moderate (r = 0.503). Based on multivariate logistic regression, the adjusted odds ratios for a daily dose of bepridil ≥1.6 mg/kg, polypharmacy, and concomitant of aprindine, a cytochrome P450 2D6 inhibitor, were 6.82 (95% coefficient interval: 2.104-22.132, p = 0.001), 2.96 (95% coefficient interval: 1.014-8.643, p = 0.047), and 8.63 (95% coefficient interval: 1.684-44.215, p = 0.010), respectively. Despite the moderate correlation in non-polypharmacy, the correlation was not observed in polypharmacy. Therefore, inhibiting metabolism, along with other mechanisms, may contribute to the polypharmacy-induced increase in plasma bepridil concentrations. Moreover, the C/D ratios in the groups receiving 6-9 and 10≤ concomitant drugs were 1.28- and 1.70-fold higher than in those receiving <6 drugs, respectively.

CONCLUSIONS

Plasma bepridil concentrations may be influenced by polypharmacy. Moreover, the plasma bepridil concentration increased in correlation with the number of concomitant drugs used. Although the mechanism of this increase could not be determined, plasma bepridil concentrations should be periodically monitored for safe use in patients with HF.

TRIAL REGISTRATION

Retrospectively registered.

Prevalence and global trends of polypharmacy in patients with chronic kidney disease: A systematic review and meta-analysis

Background and objectives: Polypharmacy and chronic kidney disease (CKD) are becoming increasingly common due to an ageing population and the rise of multimorbidity. In line with the therapeutic guidelines, managing CKD and its complications necessitates prescribing multiple medications, which predisposes patients to polypharmacy. The aim of this systematic review and meta-analysis is to describe the prevalence of polypharmacy in patients with CKD and to explore the global trends of factors driving any apparent variability in prevalence estimates. Methods: PubMed, Scopus, the Cochrane Database of Systematic Reviews (CDSR), and Google Scholar were searched from 1999 to November 2021. Study selection, data extraction, and critical appraisal were conducted by two independent reviewers. The pooled prevalence of polypharmacy was estimated utilizing the random effects model using the default double arcsine transformation. Results: This review involved 14 studies comprising of 17 201 participants, a significant proportion of which were males (56.12%). The mean age of the review population was 61.96 (SD ± 11.51) years. The overall pooled prevalence of polypharmacy amongst patients with CKD was 69% (95% CI: 49%-86%) (I² = 100%, p < 0.0001), with a proportionately higher prevalence in North America and Europe as compared to Asia. Conclusion: The results from this meta-analysis showed a high pooled prevalence estimates of polypharmacy amongst patient cohorts with CKD. The exact interventions that are likely to significantly mitigate its effect remain uncertain and will need exploration by future prospective and systematic studies. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022306572].

Potentially inappropriate medication among older patients with diabetic kidney disease

Objective: Potentially inappropriate medications (PIM) contribute to poor outcomes in older patients, making it a widespread health problem. The study explored the occurrence and risk factors of PIM in older diabetic kidney disease (DKD) patients during hospitalization and investigated whether polypharmacy was associated with it. Methods: Retrospective analysis of the patients ≥ 65 years old diagnosed with DKD from July to December 2020; the PIM was evaluated according to the American Beers Criteria (2019). Factors with statistical significance in univariate analysis were included in Logistic multivariate analysis to explore the potential risk factors related to PIM. Results: Included 186 patients, 65.6% of patients had PIM, and 300 items were confirmed. The highest incidence of PIM was 41.7% for drugs that should be carefully used by the older, followed by 35.3% that should be avoided during hospitalization. The incidence of PIM related to diseases or symptoms, drug interactions to avoid, and drugs to avoid or reduce dose for renal insufficiency patients were 6.3%, 4.0% and 12.7%, respectively. The medications with a high incidence of PIM were diuretics (35.0%), benzodiazepines (10.7%) and peripheral ɑ1 blockers (8.7%). Compared with hospitalization, there were 26% of patients had increased PIM at discharge. Multivariate Logistic regression analysis showed that polypharmacy during hospitalization was an independent risk factor for PIM, OR = 4.471 (95% CI: 2.378, 8.406). Conclusion: The incidence of PIM in hospitalized older DKD patients is high; we should pay more attention to the problem of polypharmacy in these patients. Pharmacists identifying the subtypes and risk factors for PIM may facilitate risk reduction for older DKD patients.

Polypharmacy, chronic kidney disease, and mortality among older adults: A prospective study of National Health and nutrition examination survey, 1999-2018

Introduction

Polypharmacy might contribute to a range of adverse outcomes, which could get worse in the elderly with chronic kidney disease (CKD). Evidence on polypharmacy, CKD, and mortality is scarce. We aimed to investigate the prospective association between polypharmacy, CKD and all-cause and cause-specific mortality in adults aged ≥65 years.

Methods

A total of 13,513 adults from the National Health and Nutrition Examination Surveys were included, following up from 1999 to 2018 until December 31, 2019. The simultaneous use of ≥5 medications by one individual was defined as polypharmacy. Survey-weighted Cox proportional hazard models were used to estimate the hazard ratio (HRs) for mortality from all-cause, cardiovascular diseases (CVD), and cancer after adjusting for potential confounding factors.

Results

Among the elderly with CKD, we identified 3,825 total deaths (1,325 CVD and 714 cancer) during a median follow-up of 7.7 years. Participants with polypharmacy had a 27% (HR = 1.27 [1.15, 1.39]) and 39% (HR = 1.39 [1.19, 1.62]) higher risk of all-cause and CVD mortality, respectively, but not for cancer mortality. Compared with the elderly with no polypharmacy and no CKD, the corresponding HRs (95%CIs) for all-cause mortality were 1.04 (0.96, 1.14) for those with no polypharmacy but CKD, 1.24 (1.11, 1.39) for with polypharmacy but no CKD, and 1.34 (1.21, 1.49) for those with both polypharmacy and CKD. A similar pattern was detected for CVD mortality.

Discussion

Polypharmacy was associated with elevated risks of all-cause and CVD mortality among the elderly CKD patients. More evidence-based approaches should be promoted for the appropriate deprescribing in the older adults with CKD.

Hyperpolypharmacy is a predictor of mortality after left ventricular assist device (LVAD) implantation

Background

The prevalence of (hyper)polypharmacy in patients on left ventricular assist device (LVAD) support and its effect on clinical outcomeis unknown. Therefore, we aimed to determine the prevalence of (hyper)polypharmacy in LVAD patients and evaluate its association with mortality and complications.

Materials and methods

210 patients aged ≥40 years who received a primary LVAD implantation between 2011 and 2019 were included for analysis. Polypharmacy and hyperpolypharmacy were defined as the concomitant use of 5-9 and ≥10 medications at discharge after LVAD implantation, respectively. Cause specific cox regression was used to assess the association of ≥10 medications with mortality, cardiac arrhythmia, driveline infection and major bleeding.

Results

The median age of the patients was 57.5 years, and 35.7 % were female. The average number of discharge medications was 8.8 ± 2.3 per patient. The prevalence of patients with 5-9 medications and ≥10 medications was 62.9 % and 34.8 %, respectively. The median follow-up duration was 948 days (interquartile range 874 days). The prescription of ≥10 medications was significantly associated with a higher risk of mortality (HR 2.03; 95 % CI 1.15-3.6, p-value 0.02) adjusted for sex, age, comorbidity and stratified for device type. The prescription of ≥10 medications was not associated with a higher risk of major bleeding, cardiac arrhythmia or driveline infection.

Conclusions

(Hyper)polypharmacy is highly prevalent in LVAD patients and is independently associated with a higher risk of mortality. Future research is needed to assess the efficacy of individual risk-benefit profiling of (cardiovascular) medication to ensure appropriate polypharmacy and to decrease negative health outcomes.

Drug-related problems and its predictors among hospitalized heart failure patients at Jimma Medical Center, South West Ethiopia: prospective interventional study

Background

Drug-related problems are associated with high mortality, complications, prolonged hospital stay, compromised quality of life, and increased healthcare costs. This problem is high in patients hospitalized with chronic conditions such as heart failure. However, there are limited studies conducted on this area, particularly in Ethiopia.

Objective

To evaluate drug-related problems, their predictors, and clinical pharmacist intervention among hospitalized heart failure patients at Jimma Medical Center, Ethiopia.

Methods and participants

A prospective interventional study was conducted among hospitalized heart failure patients from September 30, 2020, to May 28, 2021, at Jimma Medical Center. Drug-related problems were sorted based on the Pharmaceutical Care Network Europe drug classification tool version 9.0. Patient's specific data were collected using a structured questionnaire. Data was analyzed using statistical software package version 23.0. Multivariate logistic regression analysis was used to identify independent predictors of drug-related problems occurrence and statistical significance was considered at a p value < 0.05.

Results

A total of 237 heart failure patients were included in this study. The mean (SD) age was 49.06 + 17.79. About two-thirds (66.2%) of study patients had at least one drug-related problem during their hospital stay. A total of 283 drug-related problems were identified among 157 patients. Treatment effectiveness-related problem (55.48%) was the most common observed drug-related problem. The independent predictors of drug-related problems were khat chewing [AOR = 3.25, 95% CI = (1.46–7.23)], hospital stay > 18 days [AOR = 3.77, 95% CI = (1.93–7.37)]; presence of comorbid condition [AOR = 2.59, 95% CI = (1.35–4.96)] and polypharmacy [AOR = 2.94, 95% CI = (1.54–5.61)].

Conclusion

The prevalence of drug-related problems was high among hospitalized heart failure patients in the study area. Chewing khat, prolonged hospital stay, comorbidity, and polypharmacy were the predictors of drug-related problems. Hence, to overcome these problems, clinical pharmacists, physicians, and other health professionals have to work in collaboration.

Polypharmacy in Older Heart Failure Patients: a Multidisciplinary Approach

PURPOSE OF REVIEW

We provide a review of considerations when applying principles of optimal pharmacotherapy to older adults with heart failure (HF), an analysis on the pivotal clinical trials focusing on applicability to older adults, and multi-disciplinary strategies to optimize the health of HF patients with polypharmacy.

RECENT FINDINGS

Polypharmacy is very common among patients with HF, due to medications for both HF and non-HF comorbidities. Definitions of polypharmacy were not developed specifically for older adults with HF and may need to be modified in order to meaningfully describe medication burden and promote appropriate medical therapy. This is because clinical practice guidelines for multi-drug HF regimens have unique considerations, given that they improve outcomes and symptoms of HF. Adults older than 65 years are well represented in contemporary clinical trials for HF with preserved ejection fraction (HFpEF) and guideline directed medical therapy (GDMT) for HF with reduced ejection fraction (HFrEF). While these trials did not have significant heterogeneity in safety or efficacy across a broad age spectrum, some may have limited representation of adults ≥ 80 years old, the sickest older adults, or those with decreased functional status. There is also a lack of data on the safety and efficacy of deprescribing HF medications, and deprescription in otherwise stable patients may lead to clinical destabilization or disease progression. There is therefore innate tension between the well-studied benefits of optimized HF therapy for older adults that must be weighed against the risks of polypharmacy and many unknowns that still exist. Given the strong evidence that optimized HF therapies confer symptomatic and mortality benefits for older adults, it is clear that polypharmacy in this context can be appropriate. A shift in paradigm is therefore needed when evaluating polypharmacy in patients with HF. Instead of assuming all polypharmacy is "good" or "bad," we propose a concerted move, using a multidisciplinary approach, to focus on the "appropriateness" of specific medications, in order to optimize HF medical therapy. Clinicians of all specialties caring for complex older adults with HF must consider goals of care, functional status, and new evidence-based therapies, in order to optimize this polypharmacy for older adults.

Assessment and Management of Older Patients With Transthyretin Amyloidosis Cardiomyopathy: Geriatric Cardiology, Frailty Assessment and Beyond

Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is commonly diagnosed in older adults, in particular the wild-type (ATTRwt), which is regarded as an age-related disease. With an aging population and improved diagnostic techniques, the prevalence and incidence of ATTR-CM will continue to increase. With increased availability of mortality reducing ATTR-CM therapies, patients are living longer. The predominant clinical manifestation of ATTR-CM is heart failure, while other cardiovascular manifestations include arrhythmia and aortic stenosis. Given their older age at diagnosis, patients often present with multiple age-related comorbidities, some of which can be exacerbated by ATTR, including neurologic, musculoskeletal, and gastrointestinal problems. Considerations related to older patient care, such as frailty, cognitive decline, polypharmacy, falls/mobility, functional capacity, caregiver support, living environment, quality of life and establishing goals of care are particularly important for many patients with ATTR-CM. Furthermore, the high cost ATTR treatments has increased interest in establishing improved predictors of response to therapy, with assessment of frailty emerging as a potentially important determinant. Multidisciplinary care inclusive of collaboration with geriatric and elder care medicine specialists, and others such as neurology, orthopedic surgery, electrophysiology and transcatheter aortic valve replacement clinics, is now an important component of ATTR-CM management. This review will examine current aspects of the management of older ATTR-CM patients, including shared care with multiple medical specialists, the emerging importance of frailty assessment and other considerations for using ATTR therapies.

Polypharmacy in Older People With Heart Failure: Roles of the Geriatrician and Pharmacist

Heart failure (HF) is a common health condition that typically affects older adults. Many people with HF are cared for on an inpatient basis, by noncardiologists, such as acute medical physicians, geriatricians and other physicians. Treatment options for HF are ever increasing, and adherence to guidelines for prognostic therapy contributes to polypharmacy, which is very familiar to clinicians who care for older people. This article explores the recent trials in both HF with reduced ejection fraction and HF with preserved ejection fraction and the limitations of international guidance in their management with respect to older people. In addition, this article discusses the challenge of managing polypharmacy in those with advanced age, and the importance of involving a geriatrician and pharmacist in the HF multidisciplinary team to provide a holistic and person-centred approach to optimisation of HF therapies.