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Jamil YA, Cohen R, Alameddine DK, Deo SV, Kumar M, Orkaby AR. Cholesterol Lowering in Older Adults: Should We Wait for Further Evidence? Curr Atheroscler Rep 2024; 26:521-536. [PMID: 38958924 DOI: 10.1007/s11883-024-01224-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies. RECENT FINDINGS The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.
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Affiliation(s)
- Yasser A Jamil
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Dana K Alameddine
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Salil V Deo
- Cleveland VA Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Manish Kumar
- Albert Einstien College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Ariela R Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, 150 S Huntington St, Boston, MA, 02130, USA.
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Denig P, Stuijt PJC. Perspectives on deprescribing in older people with type 2 diabetes and/or cardiovascular conditions: challenges from healthcare provider, patient and caregiver perspective, and interventions to support a proactive approach. Expert Rev Clin Pharmacol 2024; 17:637-654. [PMID: 39119644 DOI: 10.1080/17512433.2024.2378765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION For people with type 2 diabetes and/or cardiovascular conditions, deprescribing of glucose-lowering, blood pressure-lowering and/or lipid-lowering medication is recommended when they age, and their health status deteriorates. So far, deprescribing rates of these so-called cardiometabolic medications are low. A review of challenges and interventions addressing these challenges in this population is pertinent. AREAS COVERED We first provide an overview of relevant deprescribing recommendations. Next, we review challenges for healthcare providers (HCPs) to deprescribe cardiometabolic medication and provide insight in the patient and caregiver perspective on deprescribing. We summarize findings from research on implementing deprescribing of cardiometabolic medication and reflect on strategies to enhance deprescribing. We have used a combination of methods to search for relevant articles. EXPERT OPINION There is a need for rigorous development and evaluation of intervention strategies aimed at proactive deprescribing of cardiometabolic medication. To address challenges at different levels, these should be multifaceted interventions. All stakeholders must become aware of the relevance of deintensifying medication in this population. Education and training for HCPs and patients should support patient-centered communication and shared decision-making. Development of procedures and tools to select eligible patients and conduct targeted medication reviews are important for implementation of deprescribing in routine care.
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Affiliation(s)
- Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Di Palo KE, Feder S, Baggenstos YT, Cornelio CK, Forman DE, Goyal P, Kwak MJ, McIlvennan CK. Palliative Pharmacotherapy for Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2024; 17:e000131. [PMID: 38946532 DOI: 10.1161/hcq.0000000000000131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Cardiovascular disease exacts a heavy toll on health and quality of life and is the leading cause of death among people ≥65 years of age. Although medical, surgical, and device therapies can certainly prolong a life span, disease progression from chronic to advanced to end stage is temporally unpredictable, uncertain, and marked by worsening symptoms that result in recurrent hospitalizations and excessive health care use. Compared with other serious illnesses, medication management that incorporates a palliative approach is underused among individuals with cardiovascular disease. This scientific statement describes palliative pharmacotherapy inclusive of cardiovascular drugs and essential palliative medicines that work synergistically to control symptoms and enhance quality of life. We also summarize and clarify available evidence on the utility of guideline-directed and evidence-based medical therapies in individuals with end-stage heart failure, pulmonary arterial hypertension, coronary heart disease, and other cardiomyopathies while providing clinical considerations for de-escalating or deprescribing. Shared decision-making and goal-oriented care are emphasized and considered quintessential to the iterative process of patient-centered medication management across the spectrum of cardiovascular disease.
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Peixoto C, Choudhri Y, Francoeur S, McCarthy LM, Fung C, Dowlatshahi D, Lemay G, Barry A, Goyal P, Pan J, Bjerre LM, Thompson W. Discontinuation versus continuation of statins: A systematic review. J Am Geriatr Soc 2024. [PMID: 39051828 DOI: 10.1111/jgs.19093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/23/2024] [Accepted: 06/27/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Clinicians and patients often face a decision to continue or discontinue statins. We examined the impact of discontinuation of statins compared with continuation on clinical outcomes (all-cause mortality, cardiovascular [CV] mortality, CV events, and quality of life). METHODS We conducted a systematic review. Randomized controlled trials (RCTs), cohort studies, case-control studies, and quasi-randomized studies among people ≥18 years were eligible. We searched MEDLINE, Embase, and Cochrane Central Registry (inception to August 2023). Two independent reviewers performed screening and extracted data. Quality assessment was performed by one author and verified by another. We summarized results narratively, performed meta-analysis for a subset of studies, and used GRADE to assess certainty of evidence. We summarized findings in the subgroup of persons ≥75 years. RESULTS We retrieved 8369 titles/abstracts; 37 reports from 36 studies were eligible. This comprised 35 non-randomized studies (n = 1,708,684) and 1 RCT (n = 381). The 1 RCT was conducted among persons with life expectancy <1 year and showed there is probably no difference in 60-day mortality (risk difference = 3.5%, 90% CI -3.5 to 10.5) for statin discontinuation compared with continuation. Non-randomized studies varied in terms of population and setting, but consistently suggested that statin discontinuation might be associated with a relative increased risk of mortality (hazard ratio (HR) 1.92, 95% CI 1.52 to 2.44, nine studies), CV mortality (HR 1.63, 95% CI 1.27 to 2.10, five reports), and CV events (HR 1.31, 95% CI 1.23 to 1.39, eight reports). Findings in people ≥75 years were consistent with main results. There was a high degree of uncertainty in findings from non-randomized studies due to methodological limitations. CONCLUSIONS Statin discontinuation does not appear to affect short-term mortality near end-of-life based on one RCT. Outside of this population, findings from non-randomized studies consistently suggested statin discontinuation may be associated with worse outcomes, though this is uncertain.
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Affiliation(s)
| | | | | | - Lisa M McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- Women's College Research Institute, Toronto, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Celeste Fung
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Geneviève Lemay
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Arden Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Parag Goyal
- Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Jeffrey Pan
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lise M Bjerre
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Ortonobes S, Herranz S, Lleal M, Sevilla-Sánchez D, Jordana R, Mascaró O, Ferrández O, de Jaime E, Estrada R, Nazco GJ, Baré M. Multidisciplinary medication review during older patient hospitalization according to STOPP/START criteria reduces potentially inappropriate prescriptions: MoPIM cohort study. BMC Geriatr 2024; 24:584. [PMID: 38978009 PMCID: PMC11232270 DOI: 10.1186/s12877-024-05185-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/28/2024] [Indexed: 07/10/2024] Open
Abstract
PURPOSE Multimorbidity and polypharmacy in older adults converts the detection and adequacy of potentially inappropriate drug prescriptions (PIDP) in a healthcare priority. The objectives of this study are to describe the clinical decisions taken after the identification of PIDP by clinical pharmacists, using STOPP/START criteria, and to evaluate the degree of accomplishment of these decisions. METHODS Multicenter, prospective, non-comparative cohort study in patients aged 65 and older, hospitalized because of an exacerbation of their chronic conditions. Each possible PIDP was manually identified by the clinical pharmacist at admission and an initial decision was taken by a multidisciplinary clinical committee. At discharge, criteria were re-applied and final decisions recorded. RESULTS From all patients (n = 674), 493 (73.1%) presented at least one STOPP criteria at admission, significantly reduced up to 258 (38.3%) at discharge. A similar trend was observed for START criteria (36.7% vs. 15.7%). Regarding the top 10 most prevalent STOPP criteria, the clinical committee initially agreed to withdraw 257 (34.2%) prescriptions and to modify 93 (12.4%) prescriptions. However, the evaluation of final clinical decisions revealed that 503 (67.0%) of those STOPP criteria were ultimately amended. For the top 10 START criteria associated PIDP, the committee decided to initiate 149 (51.7%) prescriptions, while a total of 198 (68.8%) were finally introduced at discharge. CONCLUSIONS The clinical committee, through a pharmacotherapy review, succeeded in identifying and reducing the degree of prescription inadequacy, for both STOPP and START criteria, in older patients with high degree of multimorbidity and polypharmacy. TRIAL REGISTRATION NCT02830425.
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Affiliation(s)
- Sara Ortonobes
- Pharmacy Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, 08208, Sabadell, Spain.
| | - Susana Herranz
- Acute Care Geriatric Unit, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, 08208, Sabadell, Catalonia, Spain
- Research Network On Health Services in Chronic Patients (REDISSEC), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | - Marina Lleal
- Clinical Epidemiology and Cancer Screening Department, Parc Taulí Hospital Universitari, Institut d'Investigació I Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, 08208, Sabadell, Spain
- Department of Paediatrics, Obstetrics and Gynaecology, Preventive Medicine and Public Health, Autonomous University of Barcelona (UAB), 08193, Bellaterra, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | | | - Rosa Jordana
- Internal Medicine Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, 08208, Sabadell, Spain
| | - Oscar Mascaró
- Internal Medicine Department, University Hospital of Vic, Multidisciplinary Inflamation Research Group (MIRG), Facultat de Medicina, Universitat de Vic, Universitat Central de Catalunya, 08500, Vic, Spain
| | - Olivia Ferrández
- Pharmacy Department, Consorci Parc de Salut Mar, 08003, Barcelona, Spain
| | - Elisabet de Jaime
- Geriatrics Department, Consorci Parc de Salut Mar, 08003, Barcelona, Spain
| | - Rafael Estrada
- Internal Medicine, Hospital Galdakao-Usansolo, 48960, Galdakao, Spain
| | - Gloria Julia Nazco
- Pharmacy Department, Hospital Universitario de Canarias, 38320, La Laguna, Spain
| | - Marisa Baré
- Research Network On Health Services in Chronic Patients (REDISSEC), Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Primary Care Center, CAP Can Rull, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), 08206, Sabadell, Spain.
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Stone J, Kumar M, Orkaby AR. The role of statin therapy in older adults: best practices and unmet challenges. Expert Rev Cardiovasc Ther 2024; 22:301-311. [PMID: 38940676 PMCID: PMC11331431 DOI: 10.1080/14779072.2024.2371968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/20/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is associated with significant morbidity, functional decline, and mortality in older adults. The role of statins for primary CVD prevention in older adults remains unclear, largely due to systematic exclusion of these individuals in trials that inform current practice guidelines, leading to conflicting national and international practice recommendations for statin use for primary prevention of CVD in adults aged 75 and older. AREAS COVERED In this narrative review, we performed a literature review utilizing PubMed, and ultimately focus on seven major national and international guidelines of lipid lowering therapy. Through the lens of two clinical cases, we review physiologic changes in lipid metabolism with aging, discuss the relationship between cholesterol and cardiovascular events in older adults, examine the national and international guidelines and the available evidence informing these guidelines for statin use in primary prevention of CVD in older adults. Finally we review practical clinical considerations for drug monitoring and deprescribing in this population. EXPERT OPINION Guidelines for the use of statins for primary CVD prevention in older adults is conflicting. Collectively, evidence to date suggests statin therapy may be beneficial for primary CVD prevention in older adults free of life-limiting comorbidities. Randomized controlled trials are currently underway to address current evidence gaps.
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Affiliation(s)
- John Stone
- Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Manish Kumar
- Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Ariela R Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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Japelj N, Horvat N, Knez L, Kos M. Deprescribing: An umbrella review. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2024; 74:249-267. [PMID: 38815201 DOI: 10.2478/acph-2024-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 06/01/2024]
Abstract
This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.
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Affiliation(s)
- Nuša Japelj
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Nejc Horvat
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Lea Knez
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
- 2University Clinic Golnik 4204 Golnik, Slovenia
| | - Mitja Kos
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
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Densham E, Youssef E, Ferguson O, Winter R. The effect of statins on falls and physical activity in people aged 65 and older: A systematic review. Eur J Clin Pharmacol 2024; 80:657-668. [PMID: 38353691 DOI: 10.1007/s00228-024-03632-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/18/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Statins are commonly prescribed medications with recognised side effects including muscle weakness. Despite this, little is known about their effect on the physical activity and falls risk in the older population. This paper aims to explore the relationship between statin use and the physical activity and falls risk in adults aged 65 and older. METHODS MEDLINE, Embase, CINAHL and PsycINFO were searched on 21/11/2022 to obtain relevant articles. Data considered appropriate included that relating to muscle strength, grip strength, gait speed, balance and falls incidence. Reference and citation searches were performed to identify further relevant papers, and all eligible articles were subject to a Critical Appraisal Skills Programme (CASP) to assess potential bias. With the data being highly heterogeneous, no attempt to measure effect size was made and a narrative synthesis approach was used. The review proposal was registered with PROSPERO: CRD42022366159. RESULTS Twenty articles were included. Data were inconsistent throughout, with the overall trend suggesting no significant negative effects of statins on the parameters of physical activity, or on falls risk. This was especially true in matched and adjusted cohorts, where potential confounders had been accounted for. CONCLUSION This review did not identify a relationship between statin use and physical activity and falls risk in people aged 65 years and older. Ultimately, the risks and benefits of every medication should be considered in the context of each individual.
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Affiliation(s)
| | | | | | - Rebecca Winter
- Brighton and Sussex Medical School, Brighton, UK
- University Hospitals Sussex, Brighton, UK
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Liau SJ, Zhao M, Hamada S, Gutiérrez-Valencia M, Jadczak AD, Li L, Martínez-Velilla N, Sakata N, Fu P, Visvanathan R, Lalic S, Roncal-Belzunce V, Bell JS. Deprescribing Opportunities for Frail Residents of Nursing Homes: A Multicenter Study in Australia, China, Japan, and Spain. J Am Med Dir Assoc 2024; 25:876-883. [PMID: 38423513 DOI: 10.1016/j.jamda.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Deprescribing opportunities may differ across health care systems, nursing home settings, and prescribing cultures. The objective of this study was to compare the prevalence of STOPPFrail medications according to frailty status among residents of nursing homes in Australia, China, Japan, and Spain. DESIGN Secondary cross-sectional analyses of data from 4 cohort studies. SETTING AND PARTICIPANTS A total of 1142 residents in 31 nursing homes. METHODS Medication data were extracted from resident records. Frailty was assessed using the FRAIL-NH scale (non-frail 0-2; frail 3-6; most-frail 7-14). Chi-square tests and prevalence ratios (PRs) were used to compare STOPPFrail medication use across cohorts. RESULTS In total, 84.7% of non-frail, 95.6% of frail, and 90.6% of most-frail residents received ≥1 STOPPFrail medication. Overall, the most prevalent STOPPFrail medications were antihypertensives (53.0% in China to 73.3% in Australia, P < .001), vitamin D (nil in China to 52.7% in Australia, P < .001), lipid-lowering therapies (11.1% in Japan to 38.9% in Australia, P < .001), aspirin (13.5% in Japan to 26.2% in China, P < .001), proton pump inhibitors (2.1% in Japan to 32.0% in Australia, P < .001), and antidiabetic medications (12.3% in Japan to 23.5% in China, P = .010). Overall use of antihypertensives (PR, 1.15; 95% CI, 1.06-1.25), lipid-lowering therapies (PR, 1.78; 95% CI, 1.45-2.18), aspirin (PR, 1.31; 95% CI, 1.04-1.64), and antidiabetic medications (PR, 1.31; 95% CI, 1.00-1.72) were more prevalent among non-frail and frail residents compared with most-frail residents. Antihypertensive use was more prevalent with increasing frailty in China and Japan, but less prevalent with increasing frailty in Australia. Antidiabetic medication use was less prevalent with increasing frailty in China and Spain but was consistent across frailty groups in Australia and Japan. CONCLUSIONS AND IMPLICATIONS There were overall and frailty-specific variations in prevalence of different STOPPFrail medications across cohorts. This may reflect differences in prescribing cultures, application of clinical practice guidelines in the nursing home setting, and clinician or resident attitudes toward deprescribing.
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Affiliation(s)
- Shin J Liau
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.
| | - Meng Zhao
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Shota Hamada
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan; Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Marta Gutiérrez-Valencia
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Navarre, Spain; Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain
| | - Agathe D Jadczak
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Aged and Extended Care Services and the Basil Hetzel Institute, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Li Li
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Nicolás Martínez-Velilla
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Navarrabiomed, Public University of Navarra (UPNA), Pamplona, Navarre, Spain; Department of Geriatrics, Hospital Universitario de Navarra (HUN), Pamplona, Navarre, Spain
| | - Nobuo Sakata
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Heisei Medical Welfare Group Research Institute, Tokyo, Japan
| | - Peipei Fu
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Renuka Visvanathan
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Aged and Extended Care Services and the Basil Hetzel Institute, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia; Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | - Victoria Roncal-Belzunce
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Navarrabiomed, Public University of Navarra (UPNA), Pamplona, Navarre, Spain
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
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Hanna M, Wabnitz A, Grewal P. Sex and stroke risk factors: A review of differences and impact. J Stroke Cerebrovasc Dis 2024; 33:107624. [PMID: 38316283 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors. METHODS We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review. RESULTS Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels. CONCLUSIONS By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.
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Affiliation(s)
- Mckay Hanna
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Ashley Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Parneet Grewal
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States.
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O'Sullivan DT, Walsh DJ, Goggin C, Horgan AM. Statin use in older adults with cancer - Experience from a dedicated geriatric oncology service. J Geriatr Oncol 2024; 15:101722. [PMID: 38461641 DOI: 10.1016/j.jgo.2024.101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/05/2024] [Accepted: 02/07/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION The increase in statin use, since their introduction, has been rapid and the broadening of indications has occurred seemingly without restriction. Once established on statin therapy, there is sparse research on discontinuation. Trials do not often address benefit in later life, or the impact of a life-limiting diagnosis. Data on primary prevention suggest that 100 patients need treatment for 2.5 years to prevent one major adverse cardiovascular event. Acknowledging this, we sought to determine the use of statins in a cohort of older adults with cancer, to highlight prevalence, and suggest a role for deprescribing. MATERIALS AND METHODS Data were retrospectively collected from a prospectively maintained database of patients attending a single centre Geriatric Oncology clinic. Data collected included sex, age, cancer type and stage, systemic anti-cancer therapy (SACT) recommendation, comorbidities, non-SACT medications, and overall survival. For those receiving statin therapy, data were separated into primary prevention and stage IV cancer. RESULTS In the group studied (n = 230), 135 (59%) were prescribed a statin, with 79 (58%) for primary prevention. Ninety-three (40%) had stage IV cancer. Of the 230 patients, 134 (58%) were recommended SACT. Within the primary prevention group, the median age was 79 years. Twenty-seven patients (34%) had stage III disease, while 36 (46%) had stage IV disease. Thirteen (16%) had diabetes mellitus. The median number of medications was seven (Interquartile range 5). Fifty patients (63%) were recommended SACT. In terms of survival, 31 (50%) were alive at one year, 18 (29%) alive at two years, and 14 (23%) alive beyond two and a half years. Within the stage IV disease group, 59 out of 93 (63%) were receiving statin therapy; 35 (59%) for primary prevention and seven (8%) for diabetes mellitus. Fifty-eight (63%) were recommended SACT. Twenty-four (29%) were alive at one year, 17 (21%) alive at two years, and 13 (16%) alive beyond two and a half years. DISCUSSION Statin therapy is prevalent and continues into older age. Available data regarding statin therapy in older adults and survival seen in this study support deprescribing in primary prevention and life-limiting illness, such as stage IV cancer.
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Affiliation(s)
| | - Darren J Walsh
- University Hospital Waterford, Waterford, Ireland; School of Pharmacy, University College Cork, Ireland
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Orkaby AR, Lu B, Ho YL, Treu T, Galloway A, Wilson PW, Cho K, Gaziano JM, Alexander KP, Gagnon DR, Djousse L, Forman DE, Driver JA. New statin use, mortality, and first cardiovascular events in older US Veterans by frailty status. J Am Geriatr Soc 2024; 72:410-422. [PMID: 38055194 PMCID: PMC10922314 DOI: 10.1111/jgs.18700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Statins are part of long-term medical regimens for many older adults. Whether frailty modifies the protective relationship between statins, mortality, and major adverse cardiovascular events (MACE) is unknown. METHODS This was a retrospective study of US Veterans ≥65, without CVD or prior statin use seen in 2002-2012, followed through 2017. A 31-item frailty index was used. The co-primary endpoint was all-cause mortality or MACE (MI, stroke/TIA, revascularization, or cardiovascular death). Cox proportional hazards models were developed to evaluate the association of statin use with outcomes; propensity score overlap weighting accounted for confounding by indication. RESULTS We identified 710,313 Veterans (mean age (SD) 75.3(6.5), 98% male, 89% white); 86,327 (12.1%) were frail. Over mean follow-up of 8 (5) years, there were 48.6 and 72.6 deaths per 1000 person-years (PY) among non-frail statin-users vs nonusers (weighted Incidence Rate Difference (wIRD)/1000 person years (PY), -24.0[95% CI, -24.5 to -23.6]), and 90.4 and 130.4 deaths per 1000PY among frail statin-users vs nonusers (wIRD/1000PY, -40.0[95% CI, -41.8 to -38.2]). There were 51.7 and 60.8 MACE per 1000PY among non-frail statin-users vs nonusers (wIRD/1000PY, -9.1[95% CI, -9.7 to -8.5]), and 88.2 and 102.0 MACE per 1000PY among frail statin-users vs nonusers (wIRD/1000PY, -13.8[95% CI, -16.2 to -11.4]). There were no significant interactions by frailty for statin users vs non-users by either mortality or MACE outcomes, p-interaction 0.770 and 0.319, respectively. Statin use was associated with lower risk of all-cause mortality (HR, 0.61 (0.60-0.61)) and MACE (HR 0.86 (0.85-0.87)). CONCLUSIONS New statin use is associated with a lower risk of mortality and MACE, independent of frailty. These findings should be confirmed in a randomized clinical trial.
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Affiliation(s)
- Ariela R. Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 S Huntington St, Boston, MA 02130
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Bing Lu
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
- Department of Public Health, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030
| | - Yuk-Lam Ho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
| | - Timothy Treu
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
| | - Ashley Galloway
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
| | - Peter W.F. Wilson
- Atlanta VA Healthcare System, 1670 Clairmont Road, Decatur, GA 30033
- Emory Clinical Cardiology Research Institute, 1462 Clifton Rd NE, 5 Floor, Atlanta, GA 30322
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
- Department of Public Health, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030
| | - J. Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
- Department of Public Health, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030
| | - Karen P. Alexander
- Division of Cardiology, Duke University Medical Center, 10 Duke Medicine Cir, Durham, NC 27710
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC 27701
| | - David R. Gagnon
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
| | - Luc Djousse
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 2 2 Avenue de Lafayette, Boston, MA 02111
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Daniel E. Forman
- Section of Geriatric Cardiology, University of Pittsburgh Medical Center, 3471 Fifth Ave, Ste 500 Pittsburgh, PA 15213
- Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, 4100 Allequippa St, Pittsburgh, PA 15240
| | - Jane A. Driver
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 S Huntington St, Boston, MA 02130
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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13
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Kulkarni S, Watts MM, Kostapanos M. Statins. BMJ 2024; 384:e072584. [PMID: 38267068 DOI: 10.1136/bmj-2022-072584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Spoorthy Kulkarni
- Clinical Pharmacology Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michaela M Watts
- Clinical Pharmacology Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Lipid clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust
| | - Michalis Kostapanos
- Clinical Pharmacology Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Lipid clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust
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Brunner L, Mooser B, Spinewine A, Rodondi N, Aubert CE. Older Adult Perspectives on Statin Continuation and Discontinuation in Primary Cardiovascular Disease Prevention: A Mixed-Methods Study. Patient Prefer Adherence 2024; 18:15-27. [PMID: 38196947 PMCID: PMC10773265 DOI: 10.2147/ppa.s432448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/10/2023] [Indexed: 01/11/2024] Open
Abstract
Background and Purpose Evidence for statin use for primary cardiovascular disease prevention in older adults is limited. When evidence on risk-benefit profile of a medication is uncertain, using it or not becomes a preference-sensitive decision. We aimed to assess and explore patient perspectives on continuation and discontinuation of statins used for primary cardiovascular prevention in older adults. Patients and Methods We used a convergent mixed-methods design, conducting in parallel a survey among 47 patients and three focus groups (FGs) with 14 patients total. We recruited patients aged ≥65 years and taking a statin for primary cardiovascular prevention. The survey and FGs aimed to assess and explore patient experiences of statin use, and views on statin continuation and discontinuation, including patient decision-making. Quantitative and qualitative data were first analyzed separately - descriptive statistics for quantitative data and thematic analysis for qualitative data - and then integrated to create metainferences, using joint displays. Results Forty-one percent of patients (N=19) were reluctant to discontinue the statin, whereas 22% (N=10) were willing to try discontinuing it. A reason to continue the statin was its perceived necessity, while self-estimated low cardiovascular risk and wish to reduce medication burden were given as reasons to discontinue it. Lack of expertise assumed by the patients to decide about statin continuation or discontinuation, uncertainty about statin indication, and fear of having a cardiovascular event after discontinuation made many patients uncertain about deciding to continue or discontinue the statin. In this context, 70% (N=33) would rather have their physician choose for them, and 94% (N=44) would continue taking the statin for as long as their physician told them to do so. Conclusion This study highlights factors that influence patient willingness to continue or discontinue statins, patient uncertainty about statin continuation or discontinuation, and the important role physicians play in the decision-making process.
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Affiliation(s)
- Laureline Brunner
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Blandine Mooser
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Spinewine
- Université catholique de Louvain, Louvain Drug Research Institute, Clinical Pharmacy Research Group, Brussels, Belgium; Department of Pharmacy, Centre Hospitalier Universitaire (CHU) UCL Namur, Yvoir, Belgium
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carole Elodie Aubert
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Adam L, Baretella O, Feller M, Blum MR, Papazoglou DD, Boland B, Aujesky D, Baggio S, Rodondi N. Statin therapy in multimorbid older patients with polypharmacy- a cross-sectional analysis of the Swiss OPERAM trial population. Front Cardiovasc Med 2023; 10:1236547. [PMID: 37808883 PMCID: PMC10551156 DOI: 10.3389/fcvm.2023.1236547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Statin therapy in multimorbid older individuals with polypharmacy is controversial, particularly in primary prevention of cardiovascular disease. Thereby, physicians must weigh potential benefits against potential side effects, drug-drug interactions, and limited life expectancy. Aim To assess the prevalence and determinants of potentially inappropriate statin therapy in multimorbid older patients. Methods We conducted a cross-sectional analysis of patients aged ≥70 years with multimorbidity and polypharmacy in the Swiss study center of OPERAM, a cluster-randomized trial on pharmacotherapy optimization to reduce drug-related hospital admissions. We assessed potential underuse (no statin but formal indication) and potential overuse (statin but no formal indication, including predicted >60% one-year mortality based on the Walter Score) based on current guidelines for patients in secondary and primary cardiovascular prevention. We assessed the association of potential statin overuse and underuse with six patient characteristics (age, gender, number of diagnoses, number of medications, mental impairment, being housebound) in LASSO-selection analyses. Results Of 715 multimorbid older adults (79.7 ± 6.5 years, 39.9% women), 337 (47%) were on statin. Statin therapy was appropriate in 474 (66.3%), underused in 130 (18.2%), and overused in 111 (15.5%) patients. In participants in secondary cardiovascular prevention (n = 437), being female (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.67-4.22) was significantly associated with potential underuse while being housebound (OR 3.53, 95%CI 1.32-9.46) and taking ≥10 medications (OR 1.95,95%CI 1.05-3.67) were associated with potential overuse. In participants in primary cardiovascular prevention (n = 278), 28.1% were potentially under- (9%) or overusing (19%) a statin, with no identified risk factor. Conclusion A third of hospitalized multimorbid older patients with polypharmacy potentially (either) overused or underused statin therapy. Among patients in secondary cardiovascular prevention, women were at risk for potential statin underuse. Housebound patients and those taking ≥10 medications were at risk for potential overuse of a statin. Physicians should carefully evaluate the indication for statin prescription in multimorbid older patients with polypharmacy.
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Affiliation(s)
- Luise Adam
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Angiology, Gefässzentrum, Kantonsspital Baden, Baden, Switzerland
| | - Oliver Baretella
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Manuel Raphael Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dimitrios David Papazoglou
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Benoit Boland
- Geriatric Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Health Science Research Institute, UCLouvain, Louvain, Belgium
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stéphanie Baggio
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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16
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Jepsen DB, Bergen ES, Pan J, van Poelgeest E, Osman A, Burghle A, Ryg J, Thompson W, Lundby C. Recommendations on deprescribing of bisphosphonates in osteoporosis guidelines: a systematic review. Eur Geriatr Med 2023; 14:747-760. [PMID: 37393587 DOI: 10.1007/s41999-023-00820-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 06/14/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE Advancing age, declining health status, and a shift in benefit/risk balance warrant judicious use of preventive medications in older persons, including consideration of deprescribing. Lack of guidance on deprescribing is a major barrier for prescribers to consider deprescribing in daily practice. The aim of this review was to evaluate to what extent osteoporosis guidelines include bisphosphonate deprescribing recommendations. METHODOLOGY We conducted a systematic review, searching PubMed, Embase, and grey literature. We included guidelines on treatment of osteoporosis with bisphosphonates. Two independent reviewers screened titles, abstracts, and full texts. Recommendations for deprescribing were extracted, and quality of guidelines were assessed. RESULTS Among 9345 references, 42 guidelines were included. A total of 32 (76%) guidelines included deprescribing recommendations: 29 (69%) guidelines included non-specific deprescribing recommendations framed as a drug holiday, of which 2 (5%) also included specific deprescribing recommendations based on individual health context (e.g. life expectancy, frailty, function, preferences/goals). Twenty-four (57%) guidelines included practical deprescribing recommendations, and 27 (64%) guidelines included recommendations for when deprescribing should not be considered. CONCLUSION Bisphosphonate deprescribing recommendations in osteoporosis guidelines were primarily framed as drug holidays, with limited guidance on how to make individualized deprescribing decisions based on individual health context. This suggests a need for additional focus on deprescribing in osteoporosis guidelines.
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Affiliation(s)
- Ditte Beck Jepsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark.
| | - Emilie Sofie Bergen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jeffrey Pan
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Eveline van Poelgeest
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Abdiaziz Osman
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Alaa Burghle
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology and Therapeutics, Therapeutics Initiative, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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van Eijk E, van der Spek YM, van Deudekom FJA, van den Bos F, Mooijaart SP, Trompet S. Temporal changes in characteristics and external validity of randomized controlled trials in older people from 2012 to 2019. BMC Geriatr 2023; 23:324. [PMID: 37226093 PMCID: PMC10207774 DOI: 10.1186/s12877-023-04018-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 05/04/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Older individuals are often underrepresented in clinical trials. In 2012 only 7% of RCT's specifically studied older people and their geriatric characteristics were poorly reported. The aim of this review was to investigate temporal changes in characteristics and external validity of randomized controlled trials in older people from 2012 to 2019. METHODS PubMed was searched for randomized clinical trials (RCTs) published in 2019. Firstly, the proportion of RCTs specially designed for older people were determined by the following criteria: a reported mean age of ≥ 70 years or a lower age cutoff of ≥ 55. Secondly, the trials with a majority of older people, defined by a reported mean age of ≥ 60 years, were screened for reporting of geriatric assessments. Both parts were compared with identical reviews performed in 2012. RESULTS From a 10% random sample, 1446 RCTs were included in this systematic review. First, 8% of trials were specifically designed for older people in 2019 compared to 7% in 2012. Secondly, 25% of the trials included a majority of older people in 2019, compared to 22% in 2012. Thirdly, in 52% of these trials in 2019 one or more of the geriatric assessments were reported compared to 34% in 2012. CONCLUSIONS Although in 2019 the proportion of published RCTs specifically designed for older people remains low, more characteristics on geriatric assessments were reported compared to 2012. Continued efforts should be paid to increase both the number and the validity of trials for older people.
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Affiliation(s)
- Estelle van Eijk
- Section of Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Yanna M van der Spek
- Section of Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | | | - Frederiek van den Bos
- Section of Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Simon P Mooijaart
- Section of Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden, The Netherlands
| | - Stella Trompet
- Section of Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands.
- LUMC Center for Medicine for Older People, Leiden, The Netherlands.
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Igho-Osagie E, Puenpatom A, Williams MG, Song Y, Yi D, Wang J, Berman R, Gu M, He C. Prevalence of potential drug-drug interactions with ritonavir-containing COVID-19 therapy. J Manag Care Spec Pharm 2023; 29:509-518. [PMID: 36989455 PMCID: PMC10394216 DOI: 10.18553/jmcp.2023.22366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND: Patients with COVID-19 receiving ritonavir-containing therapies are at risk of potential drug-drug interactions (pDDIs) because of ritonavir's effects on cytochrome P450 3A4. OBJECTIVE: To assess the prevalence of pDDIs with ritonavir-containing COVID-19 therapy in adults with COVID-19 using the Optum Clinformatics Data Mart database. METHODS: In this retrospective, observational cohort study, patients with COVID-19 aged 18 years or older prescribed cytochrome P450 3A4-mediated medications with supply days overlapping the date of COVID-19 diagnosis between January 1, 2020, and June 30, 2021, were classified as having pDDIs. pDDI was classified as contraindicated, major, moderate, or mild using established drug interaction resources. Prevalence of pDDIs with ritonavir-containing COVID-19 therapy was estimated for the entire cohort and in patient groups with high risk of severe COVID-19 progression or pDDIs. Actual COVID-19 treatments received by the patients, if any, were not considered. Outcomes were presented descriptively without adjusted comparisons. RESULTS: A total of 718,387 patients with COVID-19 were identified. The age-sex standardized national prevalence of pDDIs of any severity was estimated at 52.2%. Approximately 34.5% were at risk of contraindicated or major pDDIs. Compared with patients without pDDI, patients exposed to pDDIs were older and more likely to be female, reside in long-term care facilities, and have risk factors for progression to severe COVID-19. Higher prevalence of major/contraindicated pDDIs was observed in older patients (76.1%), female patients (65.0%), and patients with multiple morbidities (84.6%). CONCLUSIONS: Study findings demonstrate that more than one-third of patients with COVID-19 were at risk of significant pDDIs if treated with ritonavir-containing COVID-19 therapy and highlight the need to assess all patients with COVID-19 for pDDIs. Ritonavir-based therapies may not be appropriate for certain patient groups, and alternative therapies should be considered. DISCLOSURES: Drs Igho-Osagie, Puenpatom, and Grifasi Williams are employees of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc. Dr Song and Ms He are employees of Analysis Group, Inc., and served as paid consultants for Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc. Drs Yi and Wang, and Mr Berman, and Ms Gu were employees of Analysis Group, Inc., at the time of study conduct. Financial support for this study was provided by Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc. The study sponsor was involved in the design and conduct of the study; collection, management, analysis, interpretation of data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Affiliation(s)
| | | | | | - Yan Song
- Analysis Group, Inc., Boston, MA
| | | | | | | | - Miley Gu
- Analysis Group, Inc., Boston, MA
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19
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Licher S. Lifetime perspectives on dementia prevention: The role of 'preventive' polypharmacy. Maturitas 2023; 168:92-93. [PMID: 35725685 DOI: 10.1016/j.maturitas.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Silvan Licher
- Department of Epidemiology, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Alaa Eddine N, Schreiber J, El-Yazbi AF, Shmaytilli H, Amin MEK. A pharmacist-led medication review service with a deprescribing focus guided by implementation science. Front Pharmacol 2023; 14:1097238. [PMID: 36794277 PMCID: PMC9922726 DOI: 10.3389/fphar.2023.1097238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
Background: Little research addressed deprescribing-focused medication optimization interventions while utilizing implementation science. This study aimed to develop a pharmacist-led medication review service with a deprescribing focus in a care facility serving patients of low income receiving medications for free in Lebanon followed by an assessment of the recommendations' acceptance by prescribing physicians. As a secondary aim, the study evaluates the impact of this intervention on satisfaction compared to satisfaction associated with receiving routine care. Methods: The Consolidated Framework for Implementation Research (CFIR) was used to address implementation barriers and facilitators by mapping its constructs to the intervention implementation determinants at the study site. After filling medications and receiving routine pharmacy service at the facility, patients 65 years or older and taking 5 or more medications, were assigned into two groups. Both groups of patients received the intervention. Patient satisfaction was assessed right after receiving the intervention (intervention group) or just before the intervention (control group). The intervention consisted of an assessment of patient medication profiles before addressing recommendations with attending physicians at the facility. Patient satisfaction with the service was assessed using a validated translated version of the Medication Management Patient Satisfaction Survey (MMPSS). Descriptive statistics provided data on drug-related problems, the nature and the number of recommendations as well as physicians' responses to recommendations. Independent sample t-tests were used to assess the intervention's impact on patient satisfaction. Results: Of 157 patients meeting the inclusion criteria, 143 patients were enrolled: 72 in the control group and 71 in the experimental group. Of 143 patients, 83% presented drug-related problems (DRPs). Further, 66% of the screened DRPs met the STOPP/START criteria (77%, and 23% respectively). The intervention pharmacist provided 221 recommendations to physicians, of which 52% were to discontinue one or more medications. Patients in the intervention group showed significantly higher satisfaction compared to the ones in the control group (p < 0.001, effect size = 1.75). Of those recommendations, 30% were accepted by the physicians. Conclusion: Patients showed significantly higher satisfaction with the intervention they received compared to routine care. Future work should assess how specific CFIR constructs contribute to the outcomes of deprescribing-focused interventions.
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Affiliation(s)
- Nada Alaa Eddine
- Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon,*Correspondence: Nada Alaa Eddine, ; Mohamed Ezzat Khamis Amin,
| | - James Schreiber
- School of Nursing, Duquesne University, Pittsburgh, PA, United States
| | - Ahmed F. El-Yazbi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt,Faculty of Pharmacy, Alamein International University, El Alamein, Egypt
| | - Haya Shmaytilli
- Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon
| | - Mohamed Ezzat Khamis Amin
- Faculty of Pharmacy, Alamein International University, El Alamein, Egypt,*Correspondence: Nada Alaa Eddine, ; Mohamed Ezzat Khamis Amin,
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Nanna MG, Abdullah A, Mortensen MB, Navar AM. Primary prevention statin therapy in older adults. Curr Opin Cardiol 2023; 38:11-20. [PMID: 36598445 PMCID: PMC9830552 DOI: 10.1097/hco.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to assess the evidence for primary prevention statin treatment in older adults, within the context of the most recent guideline recommendations, while also highlighting important considerations for shared decision-making. RECENT FINDINGS As the average lifespan increases and the older adult population grows, the opportunity for prevention of morbidity and mortality from cardiovascular disease is magnified. Randomized trials and meta-analyses have demonstrated a clear benefit for primary prevention statin use through age 75, with uncertainty beyond that age. Despite these data supporting their use, current guidelines conflict in their statin treatment recommendations in those aged 70-75 years. Reflecting the paucity of evidence, the same guidelines are equivocal around primary prevention statins in those beyond age 75. Two large ongoing randomized trials (STAREE and PREVENTABLE) will provide additional insights into the treatment benefits and risks of primary prevention statins in the older adult population. In the meantime, a holistic approach in treatment decisions remains paramount for older patients. SUMMARY The benefits of primary prevention statin treatment are apparent through age 75, which is reflected in the current ACC/AHA and USPSTF recommendations. Ongoing trials will clarify the utility in those beyond age 75.
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Affiliation(s)
- Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ahmed Abdullah
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Ann Marie Navar
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas, USA
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Aeschbacher‐Germann M, Kaiser N, Speierer A, Blum MR, Bauer DC, Del Giovane C, Aujesky D, Gencer B, Rodondi N, Moutzouri E. Lipid-Lowering Trials Are Not Representative of Patients Managed in Clinical Practice: A Systematic Review and Meta-Analysis of Exclusion Criteria. J Am Heart Assoc 2022; 12:e026551. [PMID: 36565207 PMCID: PMC9973576 DOI: 10.1161/jaha.122.026551] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Randomized clinical trials (RCTs) might not be representative of the real-world population because of unreasonable exclusion criteria. We sought to determine which groups of patients are excluded from RCTs that included lipid-lowering therapy. Methods and Results We retrieved all trials from the Cholesterol Treatment Trialists Collaboration and systematically searched for large (≥1000 participants) lipid-lowering therapy RCTs, defined as statins, ezetimibe, and PCSK9 inhibitors. We predefined groups: older adults (>70 or >75 years), women, non-Whites, chronic kidney failure, heart failure, immunosuppression, cancer, dementia, treated thyroid disease, chronic obstructive pulmonary disease, mental illness, atrial fibrillation, multimorbidity (≥2 chronic diseases), and polypharmacy. We counted the number of RCTs excluding patients of the predefined groups and meta-analyzed the prevalence of included patients to obtain pooled estimates with a random-effects model. We included 42 RCTs (298 605 patients). Eighty-one percent of trials excluded patients with severe and 76% those with moderate kidney failure. Seventy-one percent of trials excluded groups of women, 64% excluded patients with moderate to severe heart failure, 64% those with immunosuppressant conditions, 48% those with cancer, 29% those with dementia, and 29% of trials excluded older adults. The pooled prevalence for patients >70 years of age was 25% (95% CI, 0%-49%), 11% (3%-18%) for >75 years of age, and 51% (38%-63%) for multimorbidity. Conclusions The majority of lipid-lowering therapy trials excluded patients with common diseases, such as moderate-to-severe kidney disease or heart failure or with immunosuppression. Underrepresenting certain populations, including women and older adults, might lead to limited transportability of study results and uncertainty on possible side-effects and efficacy in these groups. Future trials should promote diversity in the recruitment strategies and improve equity in cardiovascular research. Registration URL: ClinicalTrials.gov; Unique Identifier: CRD42021253909.
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Affiliation(s)
- Martina Aeschbacher‐Germann
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland,Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Nathalie Kaiser
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland,Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Alexandre Speierer
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
| | - Manuel R. Blum
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland,Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Douglas C. Bauer
- Departments of Medicine and Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCA
| | | | - Drahomir Aujesky
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
| | - Baris Gencer
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland,Division of CardiologyGeneva University HospitalsGenevaSwitzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland,Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Elisavet Moutzouri
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland,Institute of Primary Health Care (BIHAM)University of BernSwitzerland
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23
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Sarraju A, Spencer-Bonilla G, Chung S, Gomez S, Li J, Heidenreich P, Palaniappan L, Rodriguez F. Statin Use in Older Adults for Primary Cardiovascular Disease Prevention Across a Spectrum of Cardiovascular Risk. J Gen Intern Med 2022; 37:2642-2649. [PMID: 34505981 PMCID: PMC9411428 DOI: 10.1007/s11606-021-07107-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/19/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND There remains uncertainty regarding optimal primary atherosclerotic cardiovascular disease (ASCVD) prevention practices for older adults. OBJECTIVE To assess statin treatment patterns and incident ASCVD among older patients for primary prevention across the spectrum of ASCVD risk. DESIGN Retrospective cohort study of participants without ASCVD aged 65-79 years. Patients were stratified by age (65-69, 70-75, > 75 years) and 10-year ASCVD risk category (low/borderline, intermediate, high) based on the Pooled Cohort Equations. Multivariable logistic regressions were used to identify predictors of moderate- or high-intensity statin prescriptions. Cox proportional models were used to estimate hazard ratios (HRs) for incident ASCVD. PARTICIPANTS Patients aged 65-79 years without ASCVD from a Northern California health system. MAIN MEASURES Statin prescriptions and incident ASCVD events. KEY RESULTS There were 54,066 patients, with 10,288 (19%) aged > 75 years and 57% women. Compared with younger groups, adults > 75 years were less likely to be prescribed moderate- or high-intensity statin prescriptions across ASCVD risk groups (all p < 0.001); this persisted after multivariable adjustment including for ASCVD risk (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86). Adults > 75 years were more likely to experience incident ASCVD (HR 1.42, 95% CI 1.23-1.63). Women (OR 0.85, 95% CI 0.81-0.89) and underweight older adults (OR 0.45, 95% CI 0.33-0.61) were also less likely to receive moderate- or high-intensity statins. CONCLUSIONS Among older adults aged 65-79 years without prior ASCVD, those > 75 years of age were less likely to receive moderate- or high-intensity statins regardless of ASCVD risk compared with their younger counterparts, while experiencing more incident ASCVD. Efforts are warranted to study the reasons for age-based differences in statin use in older adults, particularly those at highest ASCVD risk.
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Affiliation(s)
- Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, 870 Quarry Road, Falk CVRC, Stanford, CA, 94305-5406, USA.
| | | | - Sukyung Chung
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sofia Gomez
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jiang Li
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Paul Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Latha Palaniappan
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, 870 Quarry Road, Falk CVRC, Stanford, CA, 94305-5406, USA
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24
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Role of Traditional Cardiovascular Risk Factors after Initiation of Statin Therapy: A PharmLines Inception Cohort Study. Cardiovasc Ther 2022; 2022:6587165. [PMID: 35676913 PMCID: PMC9155967 DOI: 10.1155/2022/6587165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background Multiple studies and meta-analyses examined the role of traditional risk factors for cardiovascular events in statin treatment-naive patients. Nowadays, millions receive such therapy for the primary prevention of cardiovascular events (CVE). Objective CVEs still occur in patients on primary preventive statin therapy. Therefore, further risk stratification within these patients is urgently needed. Methods Using the unique linkage between biomedical data and prescription data from the PharmLines Initiative, we assessed the role of several risk factors used in cardiovascular risk models, using a time-dependent Cox PH model, in the occurrence of drug treatment of CVEs after initiation of statin therapy. Results Among 602 statin therapy starters, 11% received drug treatment for CVE within an average follow-up period of 832 days. After multivariable modelling, cholesterol levels and blood pressure at baseline were no longer associated, whereas self-reported diabetes and increasing age were highly associated with the outcome when on statin therapy (hazard ratio (HR): 3.01, 95% confidence interval (95% CI): 1.48-6.12 and 1.04; 95% CI: 1.01-1.07, respectively). Males, smokers, and nonadherent patients had increased risks (HR 1.6, 1.12, and 1.18, resp.), though not statistically significant. Conclusion Drug treatment for CVEs after statin initiation is increased in patients with diabetes type 2, in aged patients, males, smokers, and those with poor adherence, while there was no association with baseline cholesterol levels and blood pressure. These factors should be taken into account during the monitoring of statin therapy and may lead to changes in statin treatment or risk-related lifestyle factors.
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25
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van der Ploeg MA, Poortvliet RKE, Achterberg WP, Mooijaart SP, Gussekloo J, Drewes YM. Assessment of the appropriateness of cardiovascular preventive medication in older people: using the RAND/UCLA Appropriateness Method. BMC Geriatr 2022; 22:394. [PMID: 35513798 PMCID: PMC9069851 DOI: 10.1186/s12877-022-03082-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 04/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background In clinical practice and science, there is debate for which older adults the benefits of cardiovascular preventive medications (CPM) still outweigh the risks in older age. Therefore, we aimed to assess how various clinical characteristics influence the judgement of appropriateness of CPM in older adults. Method We assessed the appropriateness of CPM for adults ≥75 years with regard to clinical characteristics (cardiovascular variables, complexity of health problems, age, side effects and life expectancy) using the RAND/ University of California at Los Angeles Appropriateness Method. A multidisciplinary panel, including 11 medical professionals and 3 older representatives of the target population, received an up-to-date overview of the literature. Using 9-point Likert scales (1 = extremely inappropriate; 9 = extremely appropriate), they assessed the appropriateness of starting and stopping cholesterol lowering medication, antihypertensives and platelet aggregation inhibitors, for various theoretical clinical scenarios. There were two rating rounds, with one face-to-face discussion in between. The overall appropriateness judgments were based on the median panel ratings of the second round and level of disagreement. Results The panelists emphasized the importance of the individual context of the patient for appropriateness of CPM. They judged that in general, a history of atherosclerotic cardiovascular disease strongly adds to the appropriateness of CPM, while increasing complexity of health problems, presence of hindering or severe side effects, and life expectancy < 1 year all contribute to the inappropriateness of CPM. Age had only minor influence on the appropriateness judgments. The appropriateness judgments were different for the three types of CPM. The literature, time-to-benefit, remaining life expectancy, number needed to treat, and quality of life, were major themes in the panel discussions. The considerations to stop CPM were different from the considerations not to start CPM. Conclusion Next to the patients’ individual context, which was considered decisive in the final decision to start or stop CPM, there were general trends of how clinical characteristics influenced the appropriateness, according to the multidisciplinary panel. The decision to stop, and not start CPM, appeared to be two distinct concepts. Results of this study may be used in efforts to support clinical decision making about CPM in older adults. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03082-8.
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Affiliation(s)
- Milly A van der Ploeg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.,Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M Drewes
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands.
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26
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Jansen SA, Huiskens B, Trompet S, Jukema JW, Mooijaart SP, Willems van Dijk K, van Heemst D, Noordam R. Classical risk factors for primary coronary artery disease from an aging perspective through Mendelian Randomization. GeroScience 2021; 44:1703-1713. [PMID: 34932184 PMCID: PMC9213623 DOI: 10.1007/s11357-021-00498-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/11/2021] [Indexed: 11/25/2022] Open
Abstract
The significance of classical risk factors in coronary artery disease (CAD) remains unclear in older age due to possible changes in underlying disease pathologies. Therefore, we conducted Mendelian Randomization approaches to investigate the causal relationship between classical risk factors and primary CAD in different age groups. A Mendelian Randomization study was conducted in European-ethnicity individuals from the UK Biobank population. Analyses were performed using data of 22,313 CAD cases (71.6% men) and 407,920 controls (44.5% men). Using logistic regression analyses, we investigated the associations between standardized genetic risk score and primary CAD stratified by age of diagnosis. In addition, feature importance and model accuracy were assessed in different age groups to evaluate predictive power of the genetic risk scores with increasing age. We found age-dependent associations for all classical CAD risk factors. Notably, body mass index (OR 1.22 diagnosis < 50 years; OR 1.02 diagnosis > 70 years), blood pressure (OR 1.12 < 50 years; OR 1.04 > 70 years), LDL cholesterol (OR 1.16 < 50 years; OR 1.02 > 70 years), and triglyceride levels (OR 1.11 < 50 years; 1.04 > 70 years). In line with the Mendelian Randomization analyses, model accuracy and feature importance of the classical risk factors decreased with increasing age of diagnosis. Causal determinants for primary CAD are age dependent with classical CAD risk factors attenuating in relation with primary CAD with increasing age. These results question the need for (some) currently applied cardiovascular disease risk reducing interventions at older age.
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Affiliation(s)
- Swetta A Jansen
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
- Data Science Lab, Amsterdam, the Netherlands
| | | | - Stella Trompet
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - JWouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - Ko Willems van Dijk
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Leiden Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Diana van Heemst
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - Raymond Noordam
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands.
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Cobos-Palacios L, Sanz-Cánovas J, Muñoz-Ubeda M, Lopez-Carmona MD, Perez-Belmonte LM, Lopez-Sampalo A, Gomez-Huelgas R, Bernal-Lopez MR. Statin Therapy in Very Old Patients: Lights and Shadows. Front Cardiovasc Med 2021; 8:779044. [PMID: 34912868 PMCID: PMC8667269 DOI: 10.3389/fcvm.2021.779044] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022] Open
Abstract
Atherosclerotic cardiovascular diseases (ASCVD) are the leading cause of death worldwide. High levels of total cholesterol—and of low-density lipoprotein cholesterol in particular—are one of the main risk factors associated with ASCVD. Statins are first-line treatment for hypercholesterolemia and have been proven to reduce major vascular events in adults with and without underlying ASCVD. Findings in the literature show that statins reduce coronary and cerebrovascular morbidity and mortality in middle-aged people, but their benefits in older adults are not as well-established, especially in primary prevention. Furthermore, many particularities must be considered regarding their use in old subjects, such as age-related changes in pharmacokinetics and pharmacodynamics, comorbidities, polypharmacy, and frailty, which decrease the safety and efficacy of statins in this population. Myopathy and a possible higher risk of falling along with cognitive decline are classic concerns for physicians when considering statin use in the very old. Additionally, some studies suggest that the relative risk for coronary events and cardiovascular mortality associated with high levels of cholesterol decreases after age 70, making the role of statins unclear. On the other hand, ASCVD are one of the most important causes of disability in old subjects, so cardiovascular prevention is of particular interest in this population in order to preserve functional status. This review aims to gather the current available evidence on the efficacy and safety of statin use in very old patients in both primary and secondary prevention.
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Affiliation(s)
- Lidia Cobos-Palacios
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
| | - Jaime Sanz-Cánovas
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
| | - Mónica Muñoz-Ubeda
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
| | - María Dolores Lopez-Carmona
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
| | - Luis Miguel Perez-Belmonte
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
| | - Almudena Lopez-Sampalo
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
| | - Ricardo Gomez-Huelgas
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain.,CIBER Fisiopatología de la Obesidad y la Nutrición, Carlos III Health Institute, Madrid, Spain
| | - Maria Rosa Bernal-Lopez
- Department of Internal Medicine, Regional University Hospital of Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain.,CIBER Fisiopatología de la Obesidad y la Nutrición, Carlos III Health Institute, Madrid, Spain
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28
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Thompson W, Morin L, Jarbøl DE, Andersen JH, Ernst MT, Nielsen JB, Haastrup P, Schmidt M, Pottegård A. Statin Discontinuation and Cardiovascular Events Among Older People in Denmark. JAMA Netw Open 2021; 4:e2136802. [PMID: 34854906 PMCID: PMC8640890 DOI: 10.1001/jamanetworkopen.2021.36802] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/05/2021] [Indexed: 12/16/2022] Open
Abstract
Importance Statin use is common in older persons. Given uncertainties in ongoing benefit, changes in health status, and shifting goals of care and preferences, statin discontinuation may be considered in some older persons, although there is currently little evidence to guide this decision. Objective To evaluate the association between statin discontinuation and the rate of major adverse cardiovascular events (MACE) among people aged 75 years or older who receive long-term statin treatment. Design, Setting, and Participants This cohort study included all persons in Denmark aged 75 years or older who were treated with statins for at least 5 consecutive years as of January 1, 2011. Participants were followed up until December 31, 2016. Data were analyzed from July to November, 2020. Exposure Statin discontinuation. Main Outcomes and Measures Rate of occurrence of MACE and its components (myocardial infarction, ischemic stroke or transient ischemic attack, coronary revascularization, and death due to myocardial infarction or ischemic stroke) in persons continuing statins compared with those discontinuing statins. Confounding adjustment was done using inverse probability of treatment weighting. Analyses were conducted separately for primary prevention (no history of cardiovascular disease) and secondary prevention (history of cardiovascular disease). Results The study included 67 418 long-term statin users, including 27 463 in the primary prevention analysis (median age, 79 years [IQR, 77-83 years]; 18 134 [66%] female) and 39 955 in the secondary prevention analysis (median age, 80 years [IQR, 77-84 years]; 18 717 [47%] female). In both primary and secondary prevention analyses, the rate of MACE was higher among persons who discontinued statins compared with those who continued statins. In the primary prevention cohort, the weighted rate difference was 9 per 1000 person-years (95% CI, 5-12 per 1000 person-years) and the adjusted sub-hazard ratio was 1.32 (95% CI, 1.18-1.48), corresponding to 1 excess MACE per 112 persons who discontinued statins per year. In the secondary prevention cohort, the weighted rate difference was 13 per 1000 person-years (95% CI, 8-17 per 1000 person-years) and the adjusted sub-hazard ratio was 1.28 (95% CI, 1.18-1.39), corresponding to 1 excess MACE per 77 persons who discontinued statins per year. Conclusions and Relevance In this cohort study, among older adults receiving long-term statin treatment, discontinuation of statins was associated with a higher rate of MACE compared with statin continuation in both the primary and the secondary prevention cohorts. These findings suggest a need for robust evidence from randomized clinical trials.
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Affiliation(s)
- Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Fyn, Odense University Hospital, Odense, Denmark
| | - Lucas Morin
- Inserm CIC 1431, Clinical Investigation Unit, University Hospital of Besançon, Besançon, France
- Inserm 1018, High-Dimensional Biostatistics for Drug Safety and Genomics, Centre de Recherche en Épidémiologie et Santé des Populations, Villejuif, France
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jacob Harbo Andersen
- Research Unit of Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Martin Thomsen Ernst
- Research Unit of Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Bo Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Peter Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Fyn, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Banach M, Burchardt P, Chlebus K, Dobrowolski P, Dudek D, Dyrbuś K, Gąsior M, Jankowski P, Jóźwiak J, Kłosiewicz-Latoszek L, Kowalska I, Małecki M, Prejbisz A, Rakowski M, Rysz J, Solnica B, Sitkiewicz D, Sygitowicz G, Sypniewska G, Tomasik T, Windak A, Zozulińska-Ziółkiewicz D, Cybulska B. PoLA/CFPiP/PCS/PSLD/PSD/PSH guidelines on diagnosis and therapy of lipid disorders in Poland 2021. Arch Med Sci 2021; 17:1447-1547. [PMID: 34900032 PMCID: PMC8641518 DOI: 10.5114/aoms/141941] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/03/2021] [Indexed: 12/18/2022] Open
Abstract
In Poland there are still nearly 20 million individuals with hypercholesterolaemia, most of them are unaware of their condition; that is also why only ca. 5% of patients with familial hypercholesterolaemia have been diagnosed; that is why other rare cholesterol metabolism disorders are so rarely diagnosed in Poland. Let us hope that these guidelines, being an effect of work of experts representing 6 main scientific societies, as well as the network of PoLA lipid centers being a part of the EAS lipid centers, certification of lipidologists by PoLA, or the growing number of centers for rare diseases, with a network planned by the Ministry of Health, improvements in coordinated care for patients after myocardial infarction (KOS-Zawał), reimbursement of innovative agents, as well as introduction in Poland of an effective primary prevention program, will make improvement in relation to these unmet needs in diagnostics and treatment of lipid disorders possible.
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Affiliation(s)
- Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Lodz, Poland
- Cardiovascular Research Center, University of Zielona Gora, Zielona Gora, Poland
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother’s Memorial Hospital Research Institute (PMMHRI) in Lodz, Lodz, Poland
| | - Paweł Burchardt
- Department of Hypertensiology, Angiology, and Internal Medicine, K. Marcinkowski Poznan University of Medical Science, Poznan, Poland
- Department of Cardiology, Cardiovascular Unit, J. Strus Hospital, Poznan, Poland
| | - Krzysztof Chlebus
- First Department and Chair of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Dyrbuś
- 3 Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases in Zabrze, Poland
| | - Mariusz Gąsior
- 3 Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases in Zabrze, Poland
| | - Piotr Jankowski
- Department of Internal Medicine and Geriatric Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Cardiology and Arterial Hypertension, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Jóźwiak
- Department of Family Medicine and Public Health, Institute of Medical Sciences, Faculty of Medicine, University of Opole, Opole, Poland
| | | | - Irina Kowalska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Bialystok, Bialystok, Poland
| | - Maciej Małecki
- Department and Chair of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Michał Rakowski
- Department of Molecular Biophysics, Institute of Biophysics, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - Jacek Rysz
- Chair of Nephrology, Arterial Hypertension, and Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Bogdan Solnica
- Chair of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - Dariusz Sitkiewicz
- Department of Clinical Chemistry and Laboratory Diagnostics, Medical University of Warsaw, Warsaw, Poland
| | - Grażyna Sygitowicz
- Department of Clinical Chemistry and Laboratory Diagnostics, Medical University of Warsaw, Warsaw, Poland
| | - Grażyna Sypniewska
- Department of Laboratory Medicine, L. Rydygier Medical College in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Tomasz Tomasik
- Chair of Family Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Adam Windak
- Chair of Family Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Dorota Zozulińska-Ziółkiewicz
- Department and Chair of Internal Medicine and Diabetology, K. Marcinkowski Poznan University of Medical Sciences, Poznan, Poland
| | - Barbara Cybulska
- National Institute of Public Health NIH – National Research Institute, Warsaw, Poland
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Hsu J, Iversen T, Price M, Moger TA, Tevis D, Hagen TP, Dow WH. Myocardial Infarction Care Among The Elderly: Declining Treatment With Increasing Age In Two Countries. Health Aff (Millwood) 2021; 40:1483-1490. [PMID: 34495733 PMCID: PMC10909380 DOI: 10.1377/hlthaff.2021.00108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The elderly account for the majority of medical spending in many countries, raising concerns about potentially unnecessary spending, especially during the final months of life. Using a well-defined starting point (hospitalization for an initial acute myocardial infarction) with evidence-based postevent treatments, we examined age trends in treatments in the US and Norway, two countries with high levels of per capita medical spending. After accounting for comorbidities, we found marked decreases within both countries in the use of invasive treatments with age (for example, less use of percutaneous coronary interventions and surgery) and the use of relatively inexpensive medications (for example, less use of anticholesterol [statin] drugs for which generic versions are widely available). The treatment decreases with age were larger in Norway compared with those in the US. The less frequent treatment of the oldest of the old, without even use of basic medications, suggests potential age-related bias and a disconnect with the evidence on treatment value. Hospital organization and payment in both countries should incentivize greater equity in treatment use across ages.
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Affiliation(s)
- John Hsu
- John Hsu is director of the Clinical Economics and Policy Analysis Program at the Mongan Institute Health Policy Center, Massachusetts General Hospital, and an associate professor in the Department of Medicine and the Department of Health Care Policy, Harvard Medical School, both in Boston, Massachusetts
| | - Tor Iversen
- Tor Iversen is a professor in the Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, in Oslo, Norway
| | - Mary Price
- Mary Price is a senior consulting data analyst at the Mongan Institute Health Policy Center, Massachusetts General Hospital
| | - Tron Anders Moger
- Tron Anders Moger is a professor in the Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo
| | - Delaney Tevis
- Delaney Tevis is a research assistant in the Mongan Institute Health Policy Research Center, Massachusetts General Hospital
| | - Terje P Hagen
- Terje P. Hagen is professor and the head of the Institute of Health and Society, University of Oslo
| | - William H Dow
- William H. Dow is a professor in the Division of Health Policy and Management, School of Public Health, University of California Berkeley, in Berkeley, California
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31
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De Spiegeleer A, Van Migerode J, Bronselaer A, Wynendaele E, Peelman M, Vandaele F, Byttebier G, De Tré G, Belmans L, Van De Wiele C, Sathekge M, Van Dijck D, Saxberg B, Alexander M, Fedson D, Elewaut D, Van Den Noortgate N, De Spiegeleer B. Statin Intake and All-Cause Mortality among Older Nursing Home Residents. Gerontology 2021; 68:407-411. [PMID: 34134106 DOI: 10.1159/000516862] [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: 01/08/2021] [Accepted: 04/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Statins are progressively accepted as being associated with reduced mortality. However, few real-world statin studies have been conducted on statin use in older people and especially the most frail, that is, the nursing home residents. OBJECTIVE The aim of this study was to evaluate the impact of statin intake in nursing home residents on all-cause mortality. METHOD This is a cross-sectional study of 1,094 older people residing in 6 nursing homes in Flanders (Belgium) between March 1, 2020 and May 30, 2020. We considered all residents who were taking statins for at least 5 days as statin users. All-cause mortality during the 3 months of data collection was the primary outcome. Propensity score overlap-weighted logistic regression models were applied with age, sex, functional status, diabetes, and cardiac failure/ischemia as potential confounders. RESULTS 185 out of 1,094 residents were on statin therapy (17%). The statin intake was associated with decreased all-cause mortality: 4% absolute risk reduction; adjusted odds ratio 0.50; CI 0.31-0.81, p = 0.005. CONCLUSIONS The statin intake was associated with decreased all-cause mortality in older people residing in nursing homes. More in-depth studies investigating the potential geroprotector effect of statins in this population are needed.
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Affiliation(s)
- Anton De Spiegeleer
- Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium, .,Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium, .,VIB-Center for Inflammation Research, Ghent, Belgium,
| | | | - Antoon Bronselaer
- Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium
| | | | - Milan Peelman
- Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium
| | | | | | - Guy De Tré
- Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium
| | - Luc Belmans
- Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | | | - Mike Sathekge
- Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | - Bo Saxberg
- DDO Strategic Services, Oro Valley, Arizona, USA
| | | | | | - Dirk Elewaut
- VIB-Center for Inflammation Research, Ghent, Belgium
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32
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Tsu LV, Carroll K, Kindler K, Early N. Pharmacological Management of Hyperlipidemia in Older individuals. Sr Care Pharm 2021; 36:284-303. [PMID: 34016226 DOI: 10.4140/tcp.n.2021.284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To provide an up-to-date review of current hyperlipidemia guidelines and discuss pharmacotherapeutic management of hyperlipidemia in older individuals. DATA SOURCES A PubMed search of articles published through October 2020 was performed using a combination of the following words: older adults, hyperlipidemia, statin, ezetimibe, fibrate, fish oil, niacin, bile acid sequestrant, and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor. STUDY SELECTION/DATA EXTRACTION Relevant original research, review articles, and guidelines were assessed for the management of hyperlipidemia in the older individuals. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS Hyperlipidemia is a common chronic disease state in the elderly population, though there is limited evidence for clinical outcomes in older people when compared withwith the general adult population. Statins have the most evidence for primary and secondary prevention of cardiovascular disease in older people, though ezetimibe and PCSK9 inhibitors have a role as add-on or monotherapy in patients who do not tolerate statins. CONCLUSION Optimal management of hyperlipidemia in older people is important in order to avoid further complications and improve outcomes. Pharmacists can help improve management in the elderly by incorporating up-to-date evidence from guidelines and providing medication education specifically for this population.
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Affiliation(s)
- Laura V Tsu
- 1Chapman University School of Pharmacy, Irvine, California
| | - Kacey Carroll
- 2Butler University College of Pharmacy, Indianapolis, Indiana
| | | | - Nicole Early
- 4Midwestern University College of Pharmacy - Glendale, Glendale, Arizona
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33
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Brouwer JMJL, Olde Hengel E, Risselada AJ, van Roon EN, Mulder H. Applicability of somatic monitoring instructions in clinical practice guidelines on antipsychotic drug use. BMC Psychiatry 2021; 21:189. [PMID: 33845804 PMCID: PMC8042861 DOI: 10.1186/s12888-021-03162-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 03/11/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) recommend the monitoring of somatic parameters in patients treated with antipsychotic drugs in order to detect adverse effects. The objective of this study was to assess, in adult and (frail) elderly populations, the consistency and applicability of the somatic monitoring instructions recommended by established CPGs prior to and during antipsychotic drug use. METHODS A search for national and international CPGs was performed by querying the electronic database PubMed and Google. Somatic monitoring instructions were assessed for adult and (frail) elderly populations separately. The applicability of somatic monitoring instructions was assessed using the Systematic Information for Monitoring (SIM) score. Somatic monitoring instructions were considered applicable when a minimum SIM score of 3 was reached. RESULTS In total, 16 CPGs were included, with a total of 231 somatic monitoring instructions (mean: 14; range: 0-47). Of the somatic monitoring instructions, 87% were considered applicable, although critical values and how to respond to aberrant values were only present in 28 and 52% of the available instructions respectively. Only 1 CPG presented an instruction specifically for (frail) elderly populations. CONCLUSIONS We emphasize the need for a guideline with somatic monitoring instructions based on the SIM definition for both adult and (frail) elderly populations using antipsychotic drugs. In addition, CPGs should state that clear agreements should be made regarding who is responsible for interventions and somatic monitoring prior to and during antipsychotic drug use.
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Affiliation(s)
- Jurriaan M J L Brouwer
- Department of Clinical Pharmacy, Wilhelmina Hospital Assen, Mailbox: 30.001, Assen, Drenthe, 9400 RA, The Netherlands.
- GGZ Drenthe Mental Health Services Drenthe, Assen, Drenthe, The Netherlands.
- Department of Psychiatry, Research School of Behavioural and Cognitive Neurosciences, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
| | - Erien Olde Hengel
- Department of Pharmacotherapy, -Epidemiology & -Economics, Pharmacy and Pharmaceutical Sciences, University of Groningen, Groningen, Groningen, The Netherlands
| | - Arne J Risselada
- Department of Clinical Pharmacy, Wilhelmina Hospital Assen, Mailbox: 30.001, Assen, Drenthe, 9400 RA, The Netherlands
| | - Eric N van Roon
- Department of Pharmacotherapy, -Epidemiology & -Economics, Pharmacy and Pharmaceutical Sciences, University of Groningen, Groningen, Groningen, The Netherlands
- Department of Clinical Pharmacy and Clinical Pharmacology, Medical Centre Leeuwarden, Leeuwarden, Friesland, The Netherlands
| | - Hans Mulder
- Department of Clinical Pharmacy, Wilhelmina Hospital Assen, Mailbox: 30.001, Assen, Drenthe, 9400 RA, The Netherlands
- GGZ Drenthe Mental Health Services Drenthe, Assen, Drenthe, The Netherlands
- Department of Pharmacotherapy, -Epidemiology & -Economics, Pharmacy and Pharmaceutical Sciences, University of Groningen, Groningen, Groningen, The Netherlands
- Department of Psychiatry, Interdisciplinary Centre for Psychopathology and Emotion Regulation, University of Groningen, University Medical Centre Groningen, Groningen, Groningen, The Netherlands
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34
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Affiliation(s)
- Guy G De Backer
- Department of Public Health and Primary Care, Ghent University, University Hospital, C. Heymanslaan, 9000 Gent, Belgium
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35
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Thompson W, Jarbøl DE, Nielsen JB, Haastrup P, Pottegård A. Statin use and discontinuation in Danes age 70 and older: a nationwide drug utilisation study. Age Ageing 2021; 50:554-558. [PMID: 32936863 DOI: 10.1093/ageing/afaa160] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/19/2020] [Accepted: 06/13/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There is limited evidence on the clinical effects of statins in older persons. We aimed to explore statin use and discontinuation patterns in Danes age 70 and older. DESIGN Register-based drug utilisation study. SETTING Danish nationwide health registries. SUBJECTS All Danish persons aged ≥70 years between 2011 and 2016. MEASUREMENTS (1) Monthly prevalence and (2) quarterly incidence of statin use, (3) characteristics of new users, (4) total amount of statin redeemed, (5) statin discontinuation rate between 2014 and 2016 in long-term statin users and (6) factors associated with discontinuation. RESULTS We identified 395,279 unique older statin users between 2011 and 2016. The prevalence increased from 30% in 2011 to 33% in 2016 (23% for primary prevention and 56% for secondary prevention in 2016). The quarterly incidence fell from 11 per 1,000 persons in 2011 to 7 per 1,000 persons in 2016. The prevalence was generally stable in those 70 to 79 years. In those aged ≥80 years, the prevalence increased despite decreasing incidence. The proportion of persons initiating for primary prevention decreased from 58% in 2011 to 52% in 2016. Approximately 19% of long-term statin users discontinued therapy between 2014 and 2016. Increasing age was the strongest predictor of statin discontinuation. CONCLUSIONS Approximately one in three Danes age ≥ 70 years were taking statins in 2016. The characteristics of incident users shifted between 2011 and 2016, with less people age 80 and older starting on statins and fewer people starting for primary prevention.
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Affiliation(s)
- Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
| | - Jesper Bo Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
| | - Peter Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Denmark
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36
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López-Lluch G. Coenzyme Q homeostasis in aging: Response to non-genetic interventions. Free Radic Biol Med 2021; 164:285-302. [PMID: 33454314 DOI: 10.1016/j.freeradbiomed.2021.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/30/2020] [Accepted: 01/11/2021] [Indexed: 12/28/2022]
Abstract
Coenzyme Q (CoQ) is a key component for many essential metabolic and antioxidant activities in cells in mitochondria and cell membranes. Mitochondrial dysfunction is one of the hallmarks of aging and age-related diseases. Deprivation of CoQ during aging can be the cause or the consequence of this mitochondrial dysfunction. In any case, it seems clear that aging-associated CoQ deprivation accelerates mitochondrial dysfunction in these diseases. Non-genetic prolongevity interventions, including CoQ dietary supplementation, can increase CoQ levels in mitochondria and cell membranes improving mitochondrial activity and delaying cell and tissue deterioration by oxidative damage. In this review, we discuss the importance of CoQ deprivation in aging and age-related diseases and the effect of prolongevity interventions on CoQ levels and synthesis and CoQ-dependent antioxidant activities.
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Affiliation(s)
- Guillermo López-Lluch
- Universidad Pablo de Olavide, Centro Andaluz de Biología Del Desarrollo, CABD-CSIC, CIBERER, Instituto de Salud Carlos III, Carretera de Utrera Km. 1, 41013, Sevilla, Spain.
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37
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Lefeber GJ, Knol W, Souverein PC, Bouvy ML, de Boer A, Koek HL. Statins After Ischemic Stroke in the Oldest: A Cohort Study Using the Clinical Practice Research Datalink Database. Stroke 2021; 52:1244-1252. [PMID: 33563018 DOI: 10.1161/strokeaha.120.030755] [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] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Geert J Lefeber
- Department of Geriatrics, University Medical Center Utrecht (G.J.L., W.K., H.L.K.), Utrecht University, the Netherlands.,Expertise Centre Pharmacotherapy in Old Persons (EPHOR), Utrecht, the Netherlands (G.J.L., W.K., H.L.K.)
| | - Wilma Knol
- Department of Geriatrics, University Medical Center Utrecht (G.J.L., W.K., H.L.K.), Utrecht University, the Netherlands.,Expertise Centre Pharmacotherapy in Old Persons (EPHOR), Utrecht, the Netherlands (G.J.L., W.K., H.L.K.)
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS) (P.C.S., M.L.B., A.d.B.), Utrecht University, the Netherlands
| | - Marcel L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS) (P.C.S., M.L.B., A.d.B.), Utrecht University, the Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS) (P.C.S., M.L.B., A.d.B.), Utrecht University, the Netherlands
| | - Huiberdina L Koek
- Department of Geriatrics, University Medical Center Utrecht (G.J.L., W.K., H.L.K.), Utrecht University, the Netherlands.,Expertise Centre Pharmacotherapy in Old Persons (EPHOR), Utrecht, the Netherlands (G.J.L., W.K., H.L.K.)
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38
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Mack DS, Baek J, Tjia J, Lapane KL. Statin Discontinuation and Life-Limiting Illness in Non-Skilled Stay Nursing Homes at Admission. J Am Geriatr Soc 2020; 68:2787-2796. [PMID: 33270223 PMCID: PMC8127623 DOI: 10.1111/jgs.16777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness. DESIGN Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files. SETTING U.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092). PARTICIPANTS Medicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247). MEASUREMENTS Residents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission. RESULTS Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status. CONCLUSION Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.
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Affiliation(s)
- Deborah S Mack
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jonggyu Baek
- Division of Biostatistics and Health Services Research, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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39
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White AMB, Mishcon HR, Redwanski JL, Hills RD. Statin Treatment in Specific Patient Groups: Role for Improved Cardiovascular Risk Markers. J Clin Med 2020; 9:E3748. [PMID: 33233352 PMCID: PMC7700563 DOI: 10.3390/jcm9113748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 01/17/2023] Open
Abstract
Ample evidence supports the use of statin therapy for secondary prevention in patients with a history of atherosclerotic cardiovascular disease (ASCVD), but evidence is wanting in the case of primary prevention, low-risk individuals, and elderly adults 65+. Statins are effective in lowering low-density lipoprotein (LDL), which has long been a target for treatment decisions. We discuss the weakening dependence between cholesterol levels and mortality as a function of age and highlight recent findings on lipoprotein subfractions and other superior markers of ASCVD risk. The efficacy of statins is compared for distinct subsets of patients based on age, diabetes, ASCVD, and coronary artery calcium (CAC) status. Most cardiovascular risk calculators heavily weight age and overestimate one's absolute risk of ASCVD, particularly in very old adults. Improvements in risk assessment enable the identification of specific patient populations that benefit most from statin treatment. Derisking is particularly important for adults over 75, in whom treatment benefits are reduced and adverse musculoskeletal effects are amplified. The CAC score stratifies the benefit effect size obtainable with statins, and forms of coenzyme Q are discussed for improving patient outcomes. Robust risk estimator tools and personalized, evidence-based approaches are needed to optimally reduce cardiovascular events and mortality rates through administration of cholesterol-lowering medications.
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Affiliation(s)
- Alyssa M. B. White
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
| | - Hillary R. Mishcon
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
| | - John L. Redwanski
- Department of Pharmacy Practice, School of Pharmacy, University of New England, Portland, ME 04103, USA;
| | - Ronald D. Hills
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
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40
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Thorpe CT, Sileanu FE, Mor MK, Zhao X, Aspinall S, Ersek M, Springer S, Niznik JD, Vu M, Schleiden LJ, Gellad WF, Hunnicutt J, Thorpe JM, Hanlon JT. Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life. J Am Geriatr Soc 2020; 68:2609-2619. [PMID: 32786004 DOI: 10.1111/jgs.16727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING VA NHs, known as community living centers (CLCs). PARTICIPANTS Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Sherrie Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Veterans Experience Center and the Center for Health Equity Research and Promotion; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sydney Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of New England College of Pharmacy, Portland, Maine
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michelle Vu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Clough AJ, Hilmer SN, Naismith SL, Gnjidic D. The Feasibility of Using N-Of-1 Trials to Investigate Deprescribing in Older Adults with Dementia: A Pilot Study. Healthcare (Basel) 2019; 7:healthcare7040161. [PMID: 31842475 PMCID: PMC6955788 DOI: 10.3390/healthcare7040161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/05/2019] [Accepted: 12/09/2019] [Indexed: 01/27/2023] Open
Abstract
N-of-1 trials may provide insights into the impact of deprescribing medications in populations where evidence is currently lacking, such as the effect of statins on cognition in people with dementia. For this pilot, N-of-1, double-blinded, deprescribing trial, adults over 80 years of age with dementia taking statins for at least 6-months were recruited from a hospital’s geriatric medicine outpatient clinic in Sydney, Australia. Participants discontinued and restarted statins over the study period. At enrolment, the hospital pharmacy—using a random number generator, randomised recruited participants to their usual statin or placebo regimen, with assessment and switching of treatment every 5 weeks from baseline (0-weeks) until Visit 4 (15-weeks). Primary outcome was measured using the rate of change in Alzheimer’s Disease Assessment Score-Cognitive Subscale (ADAS-CoG). Over 6-months, 81 participants were screened, 14 were eligible, and four were randomised. One participant (female, 88 years) completed all four assessments with no major harms reported. Cognitive impairment, as measured by ADAS-CoG score, was similar on placebo (15.5/70) compared to statin (15/70). This study suggests there are significant challenges in performing N-of-1 trials and recruiting people with dementia into deprescribing trials from outpatient settings.
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Affiliation(s)
- Alexander J. Clough
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia;
- Correspondence: ; Tel.: +61-2-9351-8073
| | - Sarah N. Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, St Leonards, NSW 2064, Australia;
| | - Sharon L. Naismith
- Charles Perkins Centre, University of Sydney, Camperdown, NSW 2006, Australia;
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia;
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