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Arku D, Yousef C, Abraham I. Changing paradigms in detecting rare adverse drug reactions: from disproportionality analysis, old and new, to machine learning. Expert Opin Drug Saf 2022; 21:1235-1238. [PMID: 36181369 DOI: 10.1080/14740338.2022.2131770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PLAIN LANGUAGE SUMMARYYour physician, pharmacist, nurse, or even you can voluntarily report suspected adverse events associated with drugs. The FDA Adverse Reporting System (FAERS) and the WHO Vigibase are large databases that store individual reports of adverse drug reactions (ADRs). While some ADRs are very common, others are seen rarely. Detecting rare and very rare ADRs is extremely difficult but very important for the safe use of drugs. Databases such as FAERS and WHO Vigibase contain a large amount of data and are commonly used for analysis applying a statistical method called disproportionately analysis. This type of analysis determines whether there is a higher-than-expected number of adverse reactions for a particular drug. In the future, machine learning will complement this process by applying algorithms to the data, constructing and refining rules of inference, and building predictive models of ADRs. This paradigm change in testing for ADRs is expected to provide a better understanding of the factors impacting drug safety.
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Affiliation(s)
- Daniel Arku
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA
| | - Consuela Yousef
- Pharmaceutical Care Department, Ministry of National Guard - Health Affairs, Dammam, Saudi Arabia
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA.,Matrix45, Tucson, AZ, USA
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Jazbar J, Locatelli I, Kos M. The association between medication or alcohol use and the incidence of frailty: a retrospective cohort study. BMC Geriatr 2021; 21:25. [PMID: 33413145 PMCID: PMC7791729 DOI: 10.1186/s12877-020-01969-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/16/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Understanding potentially modifiable factors that influence the risk of frailty is a key concern for the management of this urgent contemporary public health challenge. This study evaluates the association between the use of various medications or alcohol and the incidence of frailty among older adults. METHODS This study was a retrospective cohort study on older adults (≥ 65 years) using data from the longitudinal Survey of Health, Ageing and Retirement in Europe (SHARE survey, 28 countries). Medication use was measured as taking several different groups of medications. Alcohol use was assessed with SHARE questions corresponding to AUDIT-C. The outcome measure was the incidence of frailty after two years, defined by frailty index (FI) and frailty phenotype (FP). A multiple logistic regression model was used to evaluate the association with adjustment for several potential confounding factors. RESULTS Of the 14,665 FI-population participants, 1800 (12.3%) developed frailty within two years. Of the 8133 FP-population participants, 2798 (34.4%) developed pre-frailty and 247 (3.0%) developed frailty within two years of baseline. After adjustment for potential confounding variables, non-hazardous alcohol use (adjusted OR; 95% CI for the FI-population: 0.68; 0.60-0.77) and hazardous alcohol use (0.80; 0.68-0.93) are associated with lower incidence of frailty compared to no alcohol use. The odds of frailty are increased when taking medications; the largest effect size was observed in older adults taking medication for chronic bronchitis (adjusted OR; 95% CI for the FI-population: 2.45; 1.87-3.22), joint pain and other pain medication (2.26; 2.00-2.54), medication for coronary and other heart disease (1.72; 1.52-1.96), medication for diabetes (1.69; 1.46-1.96), and medication for anxiety, depression and sleep problems (1.56; 1.33-1.84). Additionally, the risk of frailty was increased with stroke, Parkinson's disease and dementia. CONCLUSIONS Taking certain groups of medication was associated with increased incidence of frailty and pre-frailty, which might be due to either medication use or the underlying disease. Alcohol use was associated with a lower risk of pre-frailty and frailty compared to no alcohol use, which might be due to reverse causality or residual confounding. There was no significant interaction effect between medication groups and alcohol use on frailty incidence.
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Affiliation(s)
- Janja Jazbar
- University of Ljubljana, Faculty of Pharmacy, Askerceva cesta 7, 1000, Ljubljana, Slovenia
| | - Igor Locatelli
- University of Ljubljana, Faculty of Pharmacy, Askerceva cesta 7, 1000, Ljubljana, Slovenia
| | - Mitja Kos
- University of Ljubljana, Faculty of Pharmacy, Askerceva cesta 7, 1000, Ljubljana, Slovenia.
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Lopez-Rodriguez JA, Rogero-Blanco E, Aza-Pascual-Salcedo M, Lopez-Verde F, Pico-Soler V, Leiva-Fernandez F, Prados-Torres JD, Prados-Torres A, Cura-González I. Potentially inappropriate prescriptions according to explicit and implicit criteria in patients with multimorbidity and polypharmacy. MULTIPAP: A cross-sectional study. PLoS One 2020; 15:e0237186. [PMID: 32785232 PMCID: PMC7423095 DOI: 10.1371/journal.pone.0237186] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/21/2020] [Indexed: 01/25/2023] Open
Abstract
Background Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria. Objective To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria® (2015, 2019), the Screening Tool of Older Person’s Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care. Methods This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model. Results A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores. Conclusions The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.
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Affiliation(s)
- Juan A. Lopez-Rodriguez
- Primary Healthcare Center General Ricardos, Madrid, Spain
- Medical Specialties and Public Health Department, School of Health Sciences, University Rey Juan Carlos Alcorcón, Madrid, Spain
- Research Support Unit, Primary Care Management, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
| | - Eloísa Rogero-Blanco
- Primary Healthcare Center General Ricardos, Madrid, Spain
- Medical Specialties and Public Health Department, School of Health Sciences, University Rey Juan Carlos Alcorcón, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
- * E-mail:
| | | | - Fernando Lopez-Verde
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Distrito Málaga/Guadalhorce, Málaga, Spain
- Primary Healthcare Center Las Delicias, Málaga, Spain
| | - Victoria Pico-Soler
- Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
- EpiChron Research Group, IIS Aragón, Aragon Health Sciences Institute, Zaragoza, Spain
- Primary Healthcare Center Torrero-La Paz, Zaragoza, Spain
| | - Francisca Leiva-Fernandez
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Distrito Málaga/Guadalhorce, Málaga, Spain
- Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | - J. Daniel Prados-Torres
- Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Distrito Málaga/Guadalhorce, Málaga, Spain
- Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | - Alexandra Prados-Torres
- Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
- EpiChron Research Group, IIS Aragón, Aragon Health Sciences Institute, Zaragoza, Spain
- Miguel Servet University Hospital, Zaragoza, Spain
| | - Isabel Cura-González
- Medical Specialties and Public Health Department, School of Health Sciences, University Rey Juan Carlos Alcorcón, Madrid, Spain
- Research Support Unit, Primary Care Management, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
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Zhang H, Kang E, Ham YE, Chang JW. Disability and self-reported adverse drug events among patients with chronic diseases. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00733-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Singh JA. Response to: 'Correspondence to "Hypersensitivity reactions with allopurinol and febuxostat: a study using the Medicare claims data' by Ma et al. Ann Rheum Dis 2020; 81:e108. [PMID: 32561599 DOI: 10.1136/annrheumdis-2020-218149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Jasvinder A Singh
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA .,Medicine Service, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
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Dang TT, Nguyen TH, Ho TB. Causality Assessment of Adverse Drug Reaction: Controlling Confounding Induced by Polypharmacy. Curr Pharm Des 2020; 25:1134-1143. [PMID: 31038058 DOI: 10.2174/1381612825666190416115714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/01/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Post-marketing pharmaceutical surveillance, a.k.a. pragmatic clinical trials (i.e., PCT), plays a vital role in preventing accidents in practical treatment. The most important and difficult task in PCT is to assess which drug causes adverse reactions (i.e., ADRs) from clinical texts. The confounding (i.e., factors cause confusions in causality assessment) is generated by the polypharmacy (i.e., multiple drugs use), which makes most of existing methods poor for detecting drugs that capably cause observed ADRs. OBJECTIVE We aim to improve the performance of detecting drug-ADR causal relations from clinical texts. To this end, a mechanism for reducing the impact of confounding on the detecting process is needful. METHODS We proposed a novel model which is called the analogy-based active voting (i.e., AAV) for improving the ability of detecting causal drug-ADR pairs, in case multiple drugs are prescribed for treating the comorbidity. This model is inspired by the analogy principle which was proposed by Bradford Hill. RESULTS The experimental results show the improvement of recognizing causal relations between drugs and ADRs that are confirmed by the SIDER. In addition, the proposed model is promising to detect infrequently observed causal drug-ADR pairs when the drug is not commonly used. CONCLUSION The proposed model demonstrates its ability for controlling the polypharmacy-induced confounding, to improve the quality of causality assessment of ADRs. Additionally, this also shows that the analogy principle is applicable for the assessment.
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Affiliation(s)
- Tran-Thai Dang
- Japan Advanced Instiute of Science and Technology, 1 Chrome-1 Asahidia, Nomi, Ishikawa 92312211, Japan
| | | | - Tu-Bao Ho
- Japan Advanced Instiute of Science and Technology, 1 Chrome-1 Asahidia, Nomi, Ishikawa 92312211, Japan.,John von Neumann Institute, VNU-HCM, Phurong Linh Trung, Thu Durc, Ho Chi Minh City, Vietnam.,Vietnam Institute for Advanced Study in Mathematics, Hanoi, Vietnam
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Feng C, Le D, McCoy AB. Using Electronic Health Records to Identify Adverse Drug Events in Ambulatory Care: A Systematic Review. Appl Clin Inform 2019; 10:123-128. [PMID: 30786301 PMCID: PMC6382497 DOI: 10.1055/s-0039-1677738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE We identified the methods used and determined the roles of electronic health records (EHRs) in detecting and assessing adverse drug events (ADEs) in the ambulatory setting. METHODS We performed a systematic literature review by searching PubMed and Google Scholar for studies on ADEs detected in the ambulatory setting involving any EHR use published before June 2017. We extracted study characteristics from included studies related to ADE detection methods for analysis. RESULTS We identified 30 studies that evaluated ADEs in an ambulatory setting with an EHR. In 27 studies, EHRs were used only as the data source for ADE identification. In two studies, the EHR was used as both a data source and to deliver decision support to providers during order entry. In one study, the EHR was a source of data and generated patient safety reports that researchers used in the process of identifying ADEs. Methods of identification included manual chart review by trained nurses, pharmacists, and/or physicians; prescription review; computer monitors; electronic triggers; International Classification of Diseases codes; natural language processing of clinical notes; and patient phone calls and surveys. Seven studies provided examples of search phrases, laboratory values, and rules used to identify ADEs. CONCLUSION The majority of studies examined used EHRs as sources of data for ADE detection. This retrospective approach is appropriate to measure incidence rates of ADEs but not adequate to detect preventable ADEs before patient harm occurs. New methods involving computer monitors and electronic triggers will enable researchers to catch preventable ADEs and take corrective action.
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Affiliation(s)
- Chenchen Feng
- Tulane University School of Medicine, Tulane University, New Orleans, Louisiana, United States
| | - David Le
- Tulane University School of Medicine, Tulane University, New Orleans, Louisiana, United States
| | - Allison B McCoy
- Department of Global Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, United States
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Antimisiaris D, Cutler T. Managing Polypharmacy in the 15-Minute Office Visit. PHYSICIAN ASSISTANT CLINICS 2018. [DOI: 10.1016/j.cpha.2018.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yan M, Wu ZF, Tang D, Wang F, Xiao YW, Xu P, Zhang BK, Liu YP, Xiang DX, Banh HL. The impact of proton pump inhibitors on the pharmacokinetics of voriconazole in vitro and in vivo. Biomed Pharmacother 2018; 108:60-64. [PMID: 30216801 DOI: 10.1016/j.biopha.2018.08.121] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 11/26/2022] Open
Abstract
Voriconazole (VRC) and proton pump inhibitors (PPIs) have similar metabolic pathways. The objectives of the study are to evaluate the impact of PPIs on the pharmacokinetics of VRC. Human liver microsomes model was applied to assess the inhibitory effects of PPIs on the metabolism of VRC in vitro. A retrospective study was also carried out to explore the relationship between the plasma VRC trough concentrations and PPIs uses. Patients were divided into six groups: control (n = 166), lansoprazole (LAN, n = 38), esomeprazole (ESO, n = 19), omeprazole (OME, n = 45), pantoprazole (PAN, n = 43), and ilaprazole (ILA, n = 38) groups. All five PPIs showed concentration-dependent inhibitory effects on the VRC metabolism in human liver microsomes, among which LAN, OME and ESO were three of the most potent inhibitors. Consistently, co-administered with LAN, OME and ESO significantly increased the plasma VRC trough levels (p < 0.05), whereas there was no significant association between VRC concentrations and PAN or ILA use. Interestingly, patients in the PPIs groups were more likely to reach the therapeutic VRC range of 1-5.5 μg/mL in steady state when compared with control patients (75-81% VS 69%). In conclusion, although all PPIs showed inhibitory effects on the VRC metabolism in vitro, only LAN, OME and ESO significantly increased VRC plasma concentrations. This study should be helpful for choice of the type of PPIs for patients administered with VRC.
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Affiliation(s)
- Miao Yan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Zhu-Feng Wu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Dan Tang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu 211100, China
| | - Feng Wang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Yi-Wen Xiao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Ping Xu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Bi-Kui Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Yi-Ping Liu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Da-Xiong Xiang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China.
| | - Hoan Linh Banh
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. Tools for Assessment of the Appropriateness of Prescribing and Association with Patient-Related Outcomes: A Systematic Review. Drugs Aging 2018; 35:43-60. [PMID: 29350335 DOI: 10.1007/s40266-018-0516-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND There are tools and criteria in the literature aimed at distinguishing between appropriate and inappropriate medicines use. However, many have not been externally validated with regard to patient-related outcomes, potentially limiting their use in clinical practice. OBJECTIVES The aim of the study was to conduct a systematic review to summarise (1) available prescribing appropriateness assessment tools and criteria, and (2) their associations with patient-related outcomes (external validity). METHODS A systematic review was conducted using MEDLINE, EMBASE and Informit (Health Collection) databases to screen for articles in English that examined (1) tools to assess the appropriateness of prescribing and (2) associations of tools with patient-related outcomes, published between 2000 and 2016, without any limits placed on the study design, participant age or setting. RESULTS After screening 1710 articles, removing duplicates and shortlisting relevant articles, 42 prescribing assessment tools were identified. Out of the 42 tools, 78.6% (n = 33) provided guidance around stopping inappropriate medications, 28.6% (n = 12) around starting appropriate medications, 61.9% (n = 26) were explicit (criteria based) and 31.0% (n = 13) had been externally validated, with hospitalisation being the most commonly used patient-related outcome (n = 9, 21.4%). CONCLUSION The results of this systematic review highlight the need for evidence-based and externally validated tools, which combine the different aspects of medication management to optimise patient-related outcomes. PROSPERO registration number: CRD42017067233.
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Affiliation(s)
- Nashwa Masnoon
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia.
- Department of Pharmacy, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia.
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, SA, Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia
| | - Gillian E Caughey
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, SA, Australia
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Abstract
Polypharmacy is an underappreciated factor in undesirable patient outcomes. In older adults, polypharmacy is considered a syndrome of harm and presents a challenge to primary care providers. The United States has one of the highest medication use rates per capita in the world. With the aging population, and polypharmacy a significant part of the lives of older adults, management of polypharmacy poses both a growing challenge and an opportunity for all health care providers. This article provides an overview of skills to improve medication use management in older adults living with polypharmacy.
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Affiliation(s)
- Demetra Antimisiaris
- Pharmacy and Medication Management Program, Department of Pharmacology and Toxicology, University of Louisville, 501 East Broadway, Suite 240, Louisville, KY 40202, USA; Department of Neurology, University of Louisville, 501 East Broadway, Suite 240, Louisville, KY 40202, USA; Department of Family Medicine and Geriatrics, University of Louisville, 501 East Broadway, Suite 240, Louisville, KY 40202, USA.
| | - Timothy Cutler
- Department of Clinical Pharmacy, UCSF School of Pharmacy, 533 Parnassus Avenue U585, UCSF POBox 0622, San Francisco, CA 94117, USA
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12
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Evaluation of Drug-Disease Interactions and Their Association with Unplanned Hospital Readmission Utilizing STOPP Version 2 Criteria. Geriatrics (Basel) 2017; 2:geriatrics2040033. [PMID: 31011043 PMCID: PMC6371179 DOI: 10.3390/geriatrics2040033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/01/2017] [Accepted: 11/07/2017] [Indexed: 11/19/2022] Open
Abstract
Early hospital readmission is a common problem among geriatric patients, as they are more susceptible to adverse drug events, which are associated with increased hospital admission. The objective is to examine the association between exposure to potentially inappropriate medications under selected STOPP version 2 criteria related to drug-disease interactions and unplanned early hospitalization within 28 days of index admission in elderly patients prescribed a potentially inappropriate medication. This retrospective single-center study reviewed patients 75 years of age or older that were discharged with 5 or more medications, including at least one selected medication listed in the STOPP version 2 criteria relating to drug-disease interactions. 182 patients, with a mean age of 83.5 years, were included in the study, with anticholinergics being the most common potentially inappropriate medications (22.4%). Potentially inappropriate medications (57.1% vs. 17.1%, p < 0.001), gout (31% vs. 11.5%, p = 0.003), and gastrointestinal disease (11.9% vs. 2.5%, p = 0.026) were shown to increase risk of 28-day readmission, whereas no other factors assessed correlated with readmission. A rapid evaluation of elderly patient discharge medications and concomitant disease states with the aid of the STOPP version 2 criteria could potentially reduce hospital readmissions or emergency department visits.
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Hasan SS, Kow CS, Thiruchelvam K, Chong DWK, Ahmed SI. An Evaluation of the Central Nervous System Medication Use and Frailty among Residents of Aged Care Homes in Malaysia. Neuroepidemiology 2017; 49:82-90. [PMID: 28892805 DOI: 10.1159/000480433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/17/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND/AIMS Old age and institutionalization in care homes are associated with increased use of risk medications affecting the central nervous system (CNS). This study evaluated medication utilization and appropriateness; and assessed frailty among residents of Malaysian aged care homes. METHODS The subjects of this study included 202 elderly (≥65 years) residents of 17 aged care homes in suburban peninsular Malaysia. Frailty was measured using the Groningen Frailty Indicator (GFI) score and independence in daily living was measured as KATZ activity of daily living score. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI) and 2015 Beers' criteria for Potentially Inappropriate Medication (PIM). RESULTS CNS medications constituted about 16% of the total, with an average of 0.8 ± 1.1 medications per resident, which reduced to 0.5 ± 0.8 medications after 3 months. Frailty (154/202) and polypharmacy (90/202) were highly prevalent in study subjects. Subjects on CNS medications had significantly higher GFI score (7.1 vs. 5.9; p = 0.031), polypharmacy (57.8 vs. 35.3%; p = 0.002), number of PIMs (0.9 vs. 0.2; p = 0.001), and mean summed MAI score (3.6 vs. 2.6; p = 0.015) than subjects not on CNS medications. Medication number was also significantly correlated with GFI (r = 0.194; p = 0.006) and KATZ (r = 0.141; p = 0.046) scores. CONCLUSION Frailty and polypharmacy were highly prevalent among aged care home subjects taking CNS medications. These findings support the notion that periodic regular medication review should improve the overall use of medications in elderly patients.
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Affiliation(s)
- Syed Shahzad Hasan
- International Medical University, Jalan Jalil Perkasa, Bukit Jalil, Kuala Lumpur, Malaysia
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Hanlon JT, Perera S, Newman AB, Thorpe JM, Donohue JM, Simonsick EM, Shorr RI, Bauer DC, Marcum ZA. Potential drug-drug and drug-disease interactions in well-functioning community-dwelling older adults. J Clin Pharm Ther 2017; 42:228-233. [PMID: 28111765 DOI: 10.1111/jcpt.12502] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/20/2016] [Indexed: 12/17/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE There are few studies examining both drug-drug and drug-disease interactions in older adults. Therefore, the objective of this study was to describe the prevalence of potential drug-drug and drug-disease interactions and associated factors in community-dwelling older adults. METHODS This cross-sectional study included 3055 adults aged 70-79 without mobility limitations at their baseline visit in the Health Aging and Body Composition Study conducted in the communities of Pittsburgh PA and Memphis TN, USA. The outcome factors were potential drug-drug and drug-disease interactions as per the application of explicit criteria drawn from a number of sources to self-reported prescription and non-prescription medication use. RESULTS Over one-third of participants had at least one type of interaction. Approximately one quarter (25·1%) had evidence of had one or more drug-drug interactions. Nearly 10·7% of the participants had a drug-drug interaction that involved a non-prescription medication. % The most common drug-drug interaction was non-steroidal anti-inflammatory drugs (NSAIDs) affecting antihypertensives. Additionally, 16·0% had a potential drug-disease interaction with 3·7% participants having one involving non-prescription medications. The most common drug-disease interaction was aspirin/NSAID use in those with history of peptic ulcer disease without gastroprotection. Over one-third (34·0%) had at least one type of drug interaction. Each prescription medication increased the odds of having at least one type of drug interaction by 35-40% [drug-drug interaction adjusted odds ratio (AOR) = 1·35, 95% confidence interval (CI) = 1·27-1·42; drug-disease interaction AOR = 1·30; CI = 1·21-1·40; and both AOR = 1·45; CI = 1·34-1·57]. A prior hospitalization increased the odds of having at least one type of drug interaction by 49-84% compared with those not hospitalized (drug-drug interaction AOR = 1·49, 95% CI = 1·11-2·01; drug-disease interaction AOR = 1·69, CI = 1·15-2·49; and both AOR = 1·84, CI = 1·20-2·84). WHAT IS NEW AND CONCLUSION Drug interactions are common among community-dwelling older adults and are associated with the number of medications and hospitalization in the previous year. Longitudinal studies are needed to evaluate the impact of drug interactions on health-related outcomes.
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Affiliation(s)
- J T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, School of Pharmacy, Pittsburgh, PA, USA.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - S Perera
- Division of Geriatrics, Department of Medicine, School of Medicine, Pittsburgh, PA, USA.,Department of Biostatistics, Pittsburgh, PA, USA
| | - A B Newman
- Division of Geriatrics, Department of Medicine, School of Medicine, Pittsburgh, PA, USA.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - J M Thorpe
- Department of Pharmacy and Therapeutics, School of Pharmacy, Pittsburgh, PA, USA.,Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - J M Donohue
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - E M Simonsick
- Intramural Research Program, National Institute on Aging, Baltimore, MD, USA
| | - R I Shorr
- Geriatric Research, Education and Clinical Center, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, USA
| | - D C Bauer
- University of California at San Francisco, San Francisco, CA, USA
| | - Z A Marcum
- Division of Geriatrics, Department of Medicine, School of Medicine, Pittsburgh, PA, USA
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Riordan DO, Walsh KA, Galvin R, Sinnott C, Kearney PM, Byrne S. The effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: A systematic review. SAGE Open Med 2016; 4:2050312116652568. [PMID: 27354917 PMCID: PMC4910534 DOI: 10.1177/2050312116652568] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/04/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To evaluate studies of pharmacist-led interventions on potentially inappropriate prescribing among community-dwelling older adults receiving primary care to identify the components of a successful intervention. DATA SOURCES An electronic search of the literature was conducted using the following databases from inception to December 2015: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, MEDLINE (through Ovid), Trip, Centre for Reviews and Dissemination databases, Cochrane Database of Systematic Reviews, ISI Web of Science, ScienceDirect, ClinicalTrials.gov, metaRegister of Controlled Trials, ProQuest Dissertations & Theses Database (Theses in Great Britain, Ireland and North America). REVIEW METHODS Studies were included if they were randomised controlled trials or quasi-randomised studies involving a pharmacist-led intervention compared to usual/routine care which aimed to reduce potentially inappropriate prescribing in older adults in primary care. Methodological quality of the included studies was independently assessed. RESULTS A comprehensive literature search was conducted which identified 2193 studies following removal of duplicates. Five studies met the inclusion criteria. Four studies involved a pharmacist conducting a medication review and providing feedback to patients or their family physician. One randomised controlled trial evaluated the effect of a computerised tool that alerted pharmacists when elderly patients were newly prescribed potentially inappropriate medications. Four studies were associated with an improvement in prescribing appropriateness. CONCLUSION Overall, this review demonstrates that pharmacist-led interventions may improve prescribing appropriateness in community-dwelling older adults. However, the quality of evidence is low. The role of a pharmacist working as part of a multidisciplinary primary care team requires further investigation to optimise prescribing in this group of patients.
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Affiliation(s)
- David O Riordan
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland
| | - Kieran A Walsh
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland
| | - Rose Galvin
- Department of Clinical Therapies, Health Research Institute, University of Limerick, Limerick, Republic of Ireland
| | - Carol Sinnott
- Department of General Practice, University College Cork, Cork, Republic of Ireland
| | - Patricia M Kearney
- Department of Epidemiology and Public Health, University College Cork, Cork, Republic of Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland
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16
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Moss JM, Bryan WE, Wilkerson LM, Jackson GL, Owenby RK, Van Houtven C, Stevens MB, Powers JS, Vaughan CP, Hung WW, Hwang U, Markland AD, McGwin G, Hastings SN. Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department. J Manag Care Spec Pharm 2016; 22:74-80. [PMID: 27015054 PMCID: PMC10397930 DOI: 10.18553/jmcp.2016.22.1.74] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population. OBJECTIVES To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative. METHODS Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time. RESULTS At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period. CONCLUSIONS This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.
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American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2015; 63:2227-46. [PMID: 26446832 DOI: 10.1111/jgs.13702] [Citation(s) in RCA: 1747] [Impact Index Per Article: 194.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The 2015 American Geriatrics Society (AGS) Beers Criteria are presented. Like the 2012 AGS Beers Criteria, they include lists of potentially inappropriate medications to be avoided in older adults. New to the criteria are lists of select drugs that should be avoided or have their dose adjusted based on the individual's kidney function and select drug-drug interactions documented to be associated with harms in older adults. The specific aim was to have a 13-member interdisciplinary panel of experts in geriatric care and pharmacotherapy update the 2012 AGS Beers Criteria using a modified Delphi method to systematically review and grade the evidence and reach a consensus on each existing and new criterion. The process followed an evidence-based approach using Institute of Medicine standards. The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of those in palliative and hospice care. Careful application of the criteria by health professionals, consumers, payors, and health systems should lead to closer monitoring of drug use in older adults.
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18
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Aspinall SL, Zhao X, Semla TP, Cunningham FE, Paquin AM, Pugh MJ, Schmader KE, Stone RA, Hanlon JT. Epidemiology of drug-disease interactions in older veteran nursing home residents. J Am Geriatr Soc 2014; 63:77-84. [PMID: 25537124 DOI: 10.1111/jgs.13197] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe the prevalence of and factors associated with drug-disease interactions (DDIs) in older nursing home residents according to the American Geriatrics Society 2012 Beers Criteria. DESIGN Cross-sectional. SETTING Fifteen Veterans Affairs Community Living Centers. PARTICIPANTS Individuals aged 65 and older with a diagnosis of dementia or cognitive impairment, a history of falls or hip fracture, heart failure (HF), a history of peptic ulcer disease (PUD), or Stage IV or V chronic kidney disease (CKD). MEASUREMENTS Medications that could exacerbate the above conditions (DDIs). RESULTS Three hundred sixty-one of 696 (51.9%) eligible residents had one or more DDIs. None involved residents with a history of PUD, one involved a resident with CKD, and four occurred in residents with HF. Of 540 residents with dementia or cognitive impairment, 50.7% took a drug that could exacerbate these conditions; the most commonly involved medications were antipsychotics (35.4%) and benzodiazepines (14.4%). Of 267 with a history of falls or hip fracture, 67.8% received an interacting medication, with selective serotonin reuptake inhibitors (33.1%), antipsychotics (30.7%), and anticonvulsants (25.1%) being most commonly involved. Using separate multivariable logistic regression models, factors associated with DDIs in dementia or cognitive impairment and falls or fractures included age 85 and older (adjusted odds ratio (aOR) = 0.38, 95% confidence interval (CI) = 0.24-0.60 and aOR = 0.48, 95% CI = 0.24-0.96, respectively), taking five to eight medications (aOR = 2.06, 95% CI = 1.02-4.16 and aOR = 4.76, 95% CI = 1.68-13.5, respectively), taking nine or more medications (aOR = 1.99, 95% CI = 1.03-3.85 and aOR = 3.68, 95% CI = 1.41-9.61, respectively), and being a long-stay resident (aOR = 1.80, 95% CI = 1.04-3.12 and aOR = 2.35, 95% CI = 1.12-4.91, respectively). CONCLUSION DDIs were common in older nursing home residents with dementia or cognitive impairment or a history of falls or fractures.
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Affiliation(s)
- Sherrie L Aspinall
- Veterans Affairs Pharmacy Benefits Management Services, Hines, Illinois; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
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19
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Hanlon JT, Schmader KE. The medication appropriateness index at 20: where it started, where it has been, and where it may be going. Drugs Aging 2014; 30:893-900. [PMID: 24062215 DOI: 10.1007/s40266-013-0118-4] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAI's reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term 'medication appropriateness index'. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.
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Affiliation(s)
- Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA,
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20
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Liu F, Abdul-Hussain S, Mahboob S, Rai V, Kostrzewski A. How useful are medication patient information leaflets to older adults? A content, readability and layout analysis. Int J Clin Pharm 2014; 36:827-34. [PMID: 24986267 DOI: 10.1007/s11096-014-9973-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/10/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient information leaflets (PILs) are the most important information source for older patients to effectively manage their drug therapy. OBJECTIVE The objective of this study is to evaluate the appropriateness of current available PILs for use by older adults. METHODS The content of the PILs were assessed by checking the availability of information relevant to older patients including pharmacokinetics, safety and dose instructions. The layout of the PILs was evaluated using criteria derived from the relevant regulatory guidelines on the design of PILs. The Gunning Fog Index was used to determine the readability of the PILs to older adults. RESULTS Total of 48 PILs were analysed involving 25 drug substances for the treatment of cardiovascular disease and type 2 diabetes. One out of the 48 PILs contained information on pharmacokinetic changes in older patients and only 15 % of the PILs specified the age of the older person. Thirty-one percent of the PILs provided nonspecific warnings to the older population, while only 15 % included specific side effects that could occur in the older generation. Text font sizes of the PILs were generally too small for older adults to read, with only 9 % of the PILs used type size 12 or over. The readability of 63 % of the PILs had a score above 12, which is considered difficult for older people to understand. CONCLUSION Currently available medication PILs are inappropriate for use by older adults to manage their medications effectively, which could adversely affect patient safety and adherence to drug therapy.
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Affiliation(s)
- Fang Liu
- Department of Pharmacy, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, AL10 9AB, UK,
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21
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Salvi F, Marchetti A, D'Angelo F, Boemi M, Lattanzio F, Cherubini A. Adverse drug events as a cause of hospitalization in older adults. Drug Saf 2013; 35 Suppl 1:29-45. [PMID: 23446784 DOI: 10.1007/bf03319101] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Older adults are about four to seven times more likely than younger persons to experience adverse drug events (ADEs) that cause hospitalization, especially if they are women and take multiple medications. The prevalence of drug-related hospitalizations has been reported to be as high as 31%, with large heterogeneity between different studies, depending on study setting (all hospital admissions or only acute hospital admissions), study population (entire hospital, specific wards, selected population and/or age groups), type of drug-related problem measured (adverse drug reaction or ADE), method of data collection (chart review, spontaneous reporting or database research) and method and definition used to detect ADEs. The higher risk of drug-related hospitalizations in older adults is mainly caused by age-related pharmacokinetic and pharmacodynamic changes, a higher number of chronic conditions and polypharmacy, which is often associated with the use of potentially inappropriate drugs. Other factors that have been involved are errors related to prescription or administration of drugs, medication non-adherence and inadequate monitoring of pharmacological therapies. A few commonly used drugs are responsible for the majority of emergency hospitalizations in older subjects, i.e. warfarin, oral antiplatelet agents, insulin and oral hypoglycaemic agents, central nervous system agents. The aims of the present review are to summarize recent evidence concerning drug-related hospitalization in older adults, to assess the contribution of specific medications, and to identify potential interventions able to reduce the occurrence of these drug-related events, as they are, at least partly, potentially preventable.
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Affiliation(s)
- Fabio Salvi
- Geriatrics and Geriatric Emergency Care, Italian National Research Centres on Aging (INRCA), Via della Montagnola n. 81, 60127, Ancona, Italy
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22
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Gnjidic D, Johnell K. Clinical implications from drug-drug and drug-disease interactions in older people. Clin Exp Pharmacol Physiol 2013; 40:320-5. [DOI: 10.1111/1440-1681.12081] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 03/06/2013] [Accepted: 03/18/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Danijela Gnjidic
- Faculty of Pharmacy and Sydney Medical School; University of Sydney; Sydney; New South Wales; Australia
| | - Kristina Johnell
- Aging Research Center; Karolinska Institutet and Stockholm University; Stockholm; Sweden
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23
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An educational intervention to reduce the use of potentially inappropriate medications among older adults (EMPOWER study): protocol for a cluster randomized trial. Trials 2013; 14:80. [PMID: 23514019 PMCID: PMC3621099 DOI: 10.1186/1745-6215-14-80] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 03/01/2013] [Indexed: 12/16/2022] Open
Abstract
Background Currently, far too many older adults consume inappropriate prescriptions, which increase the risk of adverse drug reactions and unnecessary hospitalizations. A health education program directly informing patients of prescription risks may promote inappropriate prescription discontinuation in chronic benzodiazepine users. Methods/Design This is a cluster randomized controlled trial using a two-arm parallel-design. A total of 250 older chronic benzodiazepine users recruited from community pharmacies in the greater Montreal area will be studied with informed consent. A participating pharmacy with recruited participants represents a cluster, the unit of randomization. For every four pharmacies recruited, a simple 2:2 randomization is used to allocate clusters into intervention and control arms. Participants will be followed for 1 year. Within the intervention clusters, participants will receive a novel educational intervention detailing risks and safe alternatives to their current potentially inappropriate medication, while the control group will be wait-listed for the intervention for 6 months and receive usual care during that time period. The primary outcome is the rate of change in benzodiazepine use at 6 months. Secondary outcomes are changes in risk perception, self-efficacy for discontinuing benzodiazepines, and activation of patients initiating discussions with their physician or pharmacist about safer prescribing practices. An intention-to-treat analysis will be followed. The rate of change of benzodiazepine use will be compared between intervention and control groups at the individual level at the 6-month follow-up. Risk differences between the control and experimental groups will be calculated, and the robust variance estimator will be used to estimate the associated 95% confidence interval (CI). As a sensitivity analysis (and/or if any confounders are unbalanced between the groups), we will estimate the risk difference for the intervention via a marginal model estimated via generalized estimating equations with an exchangeable correlation structure. Discussion Targeting consumers directly as catalysts for engaging physicians and pharmacists in collaborative discontinuation of benzodiazepine drugs is a novel approach to reduce inappropriate prescriptions. By directly empowering chronic users with knowledge about risks, we hope to imitate the success of individually targeted anti-smoking campaigns. Trial registration ClinicalTrials.gov identifier: NCT01148186
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24
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Geller AI, Nopkhun W, Dows-Martinez MN, Strasser DC. Polypharmacy and the role of physical medicine and rehabilitation. PM R 2012; 4:198-219. [PMID: 22443958 DOI: 10.1016/j.pmrj.2012.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 02/08/2012] [Accepted: 02/10/2012] [Indexed: 02/07/2023]
Abstract
Polypharmacy and inappropriate prescribing practices lead to higher rates of mortality and morbidity, particularly in vulnerable populations, such as the elderly and those with complex medical conditions. Physical medicine and physiatrists face particular challenges given the array of symptoms treated across a spectrum of conditions. This clinical review focuses on polypharmacy and the associated issue of potentially inappropriate prescribing. The article begins with a review of polypharmacy along with relevant aspects of pharmacokinetics and pharmacodynamics in the elderly. The adverse effects and potential hazards of selected medications commonly initiated and managed by rehabilitation specialists are then discussed with specific attention to pain medications, neurostimulants, antipsychotics, antidepressants, antispasmodics, sleep medications, and antiepileptics. Of particular concern is the notion that an adverse effect of one medication can mimic an indication for another and lead to a prescribing cascade and further adverse medication events. Appropriate prescribing practices mandate an accurate, current medication list, yet errors and inaccuracies often plague such lists. The evidence to support explicit (medications to avoid) and implicit (how to evaluate) criteria is presented along with the role of physicians and patients in prescribing medications. A brief discussion of "medication debridement" or de-prescribing strategies follows. In the last section, we draw on the essence of physiatry as a team-based endeavor to discuss the potential benefits of collaboration. In working to optimize medication prescribing, efforts should be made to collaborate not only with pharmacists and other medical specialties but with members of inpatient rehabilitation teams as well.
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Affiliation(s)
- Andrew I Geller
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA, USA
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25
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Hutson JR, Fischer HD, Wang X, Gruneir A, Daneman N, Gill SS, Rochon PA, Anderson GM. Use of clarithromycin and adverse cardiovascular events among older patients receiving donepezil: a population-based, nested case-control study. Drugs Aging 2012; 29:205-211. [PMID: 22372724 DOI: 10.2165/11599090-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Donepezil is a commonly used drug in older people that due to its procholinergic effects can provoke bradycardia and neurocardiogenic syncope. Donepezil is metabolized by the cytochrome P450 isozyme 3A4 (CYP3A4). Clarithromycin is a potent inhibitor of CYP3A4, and patients taking both of these drugs may be at increased risk of cardiac adverse events. OBJECTIVE The aim of this study was to evaluate the association between recent use of clarithromycin and adverse cardiovascular events in elderly patients receiving donepezil. METHODS A population-based, nested case-control study using provincial healthcare databases was conducted. The base cohort was made up of persons 66 years of age or older who were prescribed donepezil and also were prescribed clarithromycin, erythromycin, azithromycin, cefuroxime, moxifloxacin or levofloxacin. Cases were those members of the base cohort hospitalized for bradycardia, syncope or complete atrioventricular block. For each case patient, five controls were matched according to age, sex and residence (community or long-term care). RESULTS Between July 2002 and March 2010, 17,712 patients continuously receiving donepezil were prescribed one of the antibacterials. In 1400 person-years of follow-up, 59 cases were identified. As compared with azithromycin, there was no statistically significant association between use of clarithromycin in donepezil users and subsequent adverse cardiovascular events (odds ratio 0.67; 95% CI 0.28, 1.63). There was no significant risk associated with exposure to either cefuroxime or respiratory quinolones. CONCLUSIONS The use of clarithromycin in elderly donepezil users did not significantly increase the risk of adverse cardiovascular outcomes. However, our study cannot rule out a possible small increase in risk. Although antibacterials can be beneficial, care should be taken in selecting antibacterials for use in older people receiving donepezil.
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Affiliation(s)
- Janine R Hutson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Hadas D Fischer
- Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Xuesong Wang
- Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Andrea Gruneir
- Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Nick Daneman
- Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Sudeep S Gill
- Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Paula A Rochon
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Geoffrey M Anderson
- Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Abstract
Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. PIMs now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults. This was accomplished through the support of The American Geriatrics Society (AGS) and the work of an interdisciplinary panel of 11 experts in geriatric care and pharmacotherapy who applied a modified Delphi method to the systematic review and grading to reach consensus on the updated 2012 AGS Beers Criteria. Fifty-three medications or medication classes encompass the final updated Criteria, which are divided into three categories: potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and finally medications to be used with caution in older adults. This update has much strength, including the use of an evidence-based approach using the Institute of Medicine standards and the development of a partnership to regularly update the Criteria. Thoughtful application of the Criteria will allow for (a) closer monitoring of drug use, (b) application of real-time e-prescribing and interventions to decrease ADEs in older adults, and (c) better patient outcomes.
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27
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Abstract
The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.
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Affiliation(s)
- Roschelle A Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt. Pleasant, Michigan 48859, USA.
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28
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Abstract
Pharmacotherapy of the elderly is very complex due to age-related physiologic changes, multiple comorbidities, multiple medications (prescription, over-the counter, and herbal), and multiple providers (prescribers and pharmacies). Age-related physiologic changes and disease-related changes in organ function affect drug handling (pharmacokinetics) and response (pharmacodynamics). In addition, patients' cognitive impairment, functional difficulties, as well as caregiver issues play a large role in errors and compliance. Many older adults have several chronic conditions, and they stand to benefit the most from best practice guidelines. However, they are also at risk of toxicity given our increasingly complex pharmacopoeia and potential adverse effects that can cause morbidity and mortality. It is imperative that physicians learn how to minimize side effects and interactions. Potentially inappropriate medications (medications that pose more risk than benefit to the patient) are among the most important causes of adverse drug reactions, independent of the number of medications and other confounding factors. Many of these adverse drug reactions could be predicted from the known pharmacology of the drug and therefore could be potentially avoidable. To prescribe appropriately, we need to consider not only the pharmacological properties of the drugs, but also clinical, epidemiological, social, cultural, and economic factors. Elders' adherence to prescribed medications is also complex and depends on medical, personal, and economic factors; cognitive status; and relationship with the physician. Detection of nonadherence is a necessary prerequisite for adequate treatment, and patient education is a cornerstone in achieving medication adherence. Finally, appropriate prescribing should include a consideration of life expectancy and goals of care.
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Hanlon JT, Schmader KE. How important are drug-drug interactions to the health of older adults? ACTA ACUST UNITED AC 2011; 9:361-3. [PMID: 22088796 DOI: 10.1016/j.amjopharm.2011.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/21/2011] [Indexed: 10/15/2022]
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Peron EP, Gray SL, Hanlon JT. Medication use and functional status decline in older adults: a narrative review. ACTA ACUST UNITED AC 2011; 9:378-91. [PMID: 22057096 DOI: 10.1016/j.amjopharm.2011.10.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Functional status is the cornerstone of geriatric care and serves as an indicator of general well-being. A decline in function can increase health care use, worsen quality of life, threaten independence, and increase the risk of mortality. One of several risk factors for decline in functional status is medication use. OBJECTIVE Our aim was to critically review published articles that have examined the relationship between medication use and functional status decline in the elderly. METHODS The MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to June 2011. Search terms included aged, humans, drug utilization, polypharmacy, inappropriate prescribing, anticholinergics, psychotropics, antihypertensives, drug burden index, functional status, function change or decline, activities of daily living, gait, mobility limitation, and disability. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to retrieve additional publications. Only articles that used rigorous observational or interventional designs were included. Cross-sectional studies and case series were excluded from this review. RESULTS Nineteen studies met the inclusion criteria. Five studies addressed the impact of suboptimal prescribing on function, 3 of which found an increased risk of worse function in community-dwelling subjects receiving polypharmacy. Three of the 4 studies that assessed benzodiazepine use and functional status decline found a statistically significant association. One cohort study identified no relationship between antidepressant use and functional status, whereas a randomized trial found that amitriptyline, but not desipramine or paroxetine, impaired certain measures of gait. Two studies found that increasing anticholinergic burden was associated with worse functional status. In a study of hospitalized rehabilitation patients, users of hypnotics/anxiolytics (eg, phenobarbital, zolpidem) had lower relative Functional Independence Measure motor gains than nonusers. Use of multiple central nervous system (CNS) drugs (using different definitions) was linked to greater declines in self-reported mobility and Short Physical Performance Battery (SPPB) scores in 2 community-based studies. Another study of nursing home patients did not report a significant decrease in SPPB scores in those taking multiple CNS drugs. Finally, 2 studies found mixed effects between antihypertensive use and functional status in the elderly. CONCLUSIONS Benzodiazepines and anticholinergics have been consistently associated with impairments in functional status in the elderly. The relationships between suboptimal prescribing, antidepressants, and antihypertensives and functional status decline were mixed. Further research using established measures and methods is needed to better describe the impact of medication use on functional status in older adults.
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Affiliation(s)
- Emily P Peron
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pennsylvania, USA.
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