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

Acute kidney injury and aging

Our aging population is growing and developing treatments for age-related diseases such as Alzheimer's and Parkinson's disease has taken on an increasing urgency and is accompanied by high public awareness. The already high and rising incidence of acute kidney injury (AKI) in the elderly, however, has received relatively little attention despite the potentially fatal outcomes associated with an episode of AKI in this age group. When discussing AKI and aging, one should consider two aspects: first, elderly patients have an increased susceptibility to an AKI episode, and second, they have decreased kidney repair after AKI given the high incidence of progression to chronic kidney disease (CKD). It is unclear if the same factors that drive the increased susceptibility to AKI could be playing a role in the decreased repair capacity or if they are totally different and unrelated. This review will examine current knowledge on the risk factors for the increased susceptibility to AKI in the elderly and will also explore potential aspects that might contribute to a decreased kidney repair response in this age group.

Polypharmacy, hospitalization, and mortality risk: a nationwide cohort study

Polypharmacy is a growing and major public health issue, particularly in the geriatric population. This study aimed to examine the association between polypharmacy and the risk of hospitalization and mortality. We included 3,007,620 elderly individuals aged ≥ 65 years who had at least one routinely-prescribed medication but had no prior hospitalization within a year. The primary exposures of interest were number of daily prescribed medications (1–2, 3–4, 5–6, 7–8, 9–10, and ≥ 11) and presence of polypharmacy (≥ 5 prescription drugs per day). The corresponding comparators were the lowest number of medications (1–2) and absence of polypharmacy. The study outcomes were hospitalization and all-cause death. The median age of participants was 72 years and 39.5% were men. Approximately, 46.6% of participants experienced polypharmacy. Over a median follow-up of 5.0 years, 2,028,062 (67.4%) hospitalizations and 459,076 (15.3%) all-cause deaths were observed. An incrementally higher number of daily prescribed medications was found to be associated with increasingly higher risk for hospitalization and mortality. These associations were consistent across subgroups of age, sex, residential area, and comorbidities. Furthermore, polypharmacy was associated with greater risk of hospitalization and death: adjusted HRs (95% CIs) were 1.18 (1.18–1.19) and 1.25 (1.24–1.25) in the overall and 1.16 (1.16–1.17) and 1.25 (1.24–1.25) in the matched cohorts, respectively. Hence, polypharmacy was associated with a higher risk of hospitalization and all-cause death among elderly individuals.

Machine Learning for Identifying Medication-Associated Acute Kidney Injury

One of the prominent problems in clinical medicine is medication-induced acute kidney injury (AKI). Avoiding this problem can prevent patient harm and reduce healthcare expenditures. Several researches have been conducted to identify AKI-associated medications using statistical, data mining, and machine learning techniques. However, these studies are limited to assessing the impact of known nephrotoxic medications and do not comprehensively explore the relationship between medication combinations and AKI. In this paper, we present a population-based retrospective cohort study that employs automated data analysis techniques to identify medications and medication combinations that are associated with a higher risk of AKI. By integrating multivariable logistic regression, frequent itemset mining, and stratified analysis, this study is designed to explore the complex relationships between medications and AKI in such a way that has never been attempted before. Through an analysis of prescription records of one million older patients stored in the healthcare administrative dataset at ICES (an independent, non-profit, world-leading research organization that uses population-based health and social data to produce knowledge on a broad range of healthcare issues), we identified 55 AKI-associated medications among 595 distinct medications and 78 AKI-associated medication combinations among 7748 frequent medication combinations. In addition, through a stratified analysis, we identified 37 cases where a particular medication was associated with increasing the risk of AKI when used with another medication. We have shown that our results are consistent with previous studies through consultation with a nephrologist and an electronic literature search. This research demonstrates how automated analysis techniques can be used to accomplish data-driven tasks using massive clinical datasets.

Community-Acquired Acute Kidney Injury Induced By Drugs In Older Patients: A Multifactorial Event

Purpose

Community-acquired acute kidney injury (CA-AKI) is a frequent and severe adverse drug reaction (ADR) among older patients. The combination of drugs and other CA-AKI risk factors was barely evaluated. The objectives of our study were to both accurately identify CA-AKI induced by drugs in older patients, and to describe their combination with other risk factors.

Patients and methods

We conducted a retrospective, single-center study in a general hospital over a two-year period. An automated detection identified CA-AKI according to KDIGO criteria, amongst 4,767 eligible inpatient stays among patients aged 75 years or older. Two independent experts reviewed all CA-AKI events to adjudicate drug involvement (Naranjo scale), identify inappropriate prescriptions (STOPP criteria), evaluate avoidability (Hallas criteria) and identify combined risk factors.

Results

An expert review confirmed 713 CA-AKI (15.0% of inpatient stays) and determined that 419 (58.8%) CA-AKI were induced by drugs. A multifactorial cause (i.e., at least one drug with a precipitating factor) was found in 63.2% of drug-induced CA-AKI. Most of the drug-induced events were avoidable (66.8%), mainly in relation to a multifactorial cause.

Conclusion

Drug-induced CA-AKI were frequent, multifactorial events in hospitalized older patients and their prevention should focus on combinations with precipitating factors.

Addressing the Challenge of Polypharmacy

Polypharmacy describes the concomitant use of multiple medicines and represents a growing global challenge attributable to aging populations with an increasing prevalence of multimorbidity. Polypharmacy can be appropriate but is problematic when the increased risk of harm from interactions between drugs or between drugs and diseases or the burden of administering and monitoring medicines outweighs plausible benefits. Polypharmacy has a substantial economic impact in service demand and hospitalization as well as a detrimental impact on patients' quality of life. Apart from causing avoidable harm, polypharmacy can also lead to therapeutic failure, with up to 50% of patients who take four or more medications not taking them as prescribed. Guidance is needed to support patients and clinicians in defining and achieving realistic goals of drug treatment, and system change is necessary to aid implementation. This article outlines lessons from two programs that aim to address these challenges: the Scottish polypharmacy guidance on realistic prescribing and the European Union SIMPATHY project.

Risk of Kidney Dysfunction from Polypharmacy among Older Patients: A Nested Case-Control Study of the South Korean Senior Cohort

Polypharmacy, the concurrent use of multiple medicines, could increase the risk of kidney dysfunction among older adults because it likely burdens the aging kidneys to excrete multiple pharmaceutical ingredients and their metabolites. This study aimed to examine the relation between polypharmacy and kidney dysfunction among older patients. A nested case-control study was conducted using the National Health Insurance Service - Senior Cohort (NHIS-SC, 2009-2013), representative of the Korean senior population. It consisted of all health insurance claims linked to records of mandatory health examination. Kidney dysfunction was defined as having an eGFR lower than 60, with a decline rate of 10% or more compared to the baseline eGFR. Polypharmacy was defined based on daily counts of pharmaceutical ingredients during one year prior to the case's event date. It was classified into polypharmacy (five to 10 ingredients) and excessive polypharmacy (10 or more ingredients). After matching case and control groups based on a range of potential confounders, conditional logistic regression was performed incorporating adjustments on disease-specific, medication-specific, and lifestyle-related risk factors. The matching resulted in 14,577 pairs of cases and controls. Exposure to polypharmacy was significantly associated with increase in the risk of kidney dysfunction; i.e., crude model (polypharmacy: OR = 1.572, 95% CI = 1.492-1.656; excessive polypharmacy: OR = 2.069, 95% CI = 1.876-2.283) and risk adjustment model (polypharmacy: OR = 1.213, 95% CI = 1.139-1.292; excessive polypharmacy: OR = 1.461, 95% CI = 1.303-1.639). The significant associations were robust across different definitions of kidney dysfunction. These findings inform healthcare providers and policy makers of the importance of polypharmacy prevention to protect older adults from kidney dysfunction.

Chronotherapies for Parkinson's disease

Parkinson's disease (PD) is the second-most common progressive neurodegenerative disorder. Although the clinical diagnosis of PD is still based on its cardinal motor dysfunctions, several non-motor symptoms (NMS) have been established as integral part of the disease. Unlike motor disorders, development of therapies against NMS are still challenging and remain a critical unmet clinical need. During the last decade, several studies have characterised the molecular, physiological and behavioural alterations of the circadian system in PD patients. As a consequence, and given the ubiquitous nature of circadian rhythms in the entire organism, the biological clock has emerged as a potential therapeutic target to ease suffering from both motor and NMS in PD patients. Here we discuss the emerging field of using bright light, physical exercise and melatonin as chronotherapeutic tools to alleviate motor disorders, sleep/wake alterations, anxiety and depression in PD patients. We also highlight the potential of these readily available therapies to improve the general quality of life and wellbeing of PD patients. Finally, we provide specific data- and mechanisms-driven recommendations that might help improve the therapeutic benefit of light and physical exercise in PD patients.

Characteristics of doctor-shoppers: a systematic literature review

Objective: Doctor-shopping has significant consequences for patients and payers and can indicate misuse of drugs, polypharmacy, less continuity of care, and increased medical expenses. This study reviewed the literature describing doctor-shoppers in the adult population. Methods: A systematic literature review was performed in PubMed and supplemented by a Google search of grey literature. Overall, 2885 records were identified; 43 papers served as a source of definition of a doctor-shopper, disease, treatment, patient characteristics, patient special needs, country. Results: Definitions of doctor-shopping were heterogeneous. Overall, 40% of studies examined the use of opioids, antidepressants, or psychoactive drugs, while the others focused on chronic or frequent diseases. Most studies were conducted in countries with easy access to healthcare resources (USA, France, Taiwan, Hong Kong). The prevalence of doctor-shopping ranged from 0.5% among opioid users in the USA to 25% of patients registered at general practices in Japan. Comorbidities, active substance abuse, greater distance from healthcare facility, younger age, longer disease and poor patient satisfaction increased doctor-shopping. Conclusions: Knowing the characteristics of doctor-shoppers may help identify such patients and reduce the associated waste of medical resources, but concerns about the misuse of drugs or healthcare resources should not prevent proper disease management.

An update on the clinical consequences of polypharmacy in older adults: a narrative review

INTRODUCTION

Polypharmacy, the use of multiple medications by one individual, is increasingly common among older adults. Caring for the growing number of older people with complex drug regimens and multimorbidity presents an important challenge in the coming years.

AREAS COVERED

This article reviews the international trends in the prevalence of polypharmacy, summarizes the results from previous reviews on polypharmacy and negative health outcomes, and updates a previous review on the clinical consequences of polypharmacy by focusing on studies published after 2013. This narrative review, which is based on a literature search in MEDLINE and EMBASE from January 1990 to June 2018, was undertaken to identify relevant articles. Search terms included variations of polypharmacy and multiple medications.

EXPERT OPINION

The prevalence of polypharmacy is increasing worldwide. More than half of the older population is exposed to polypharmacy in some settings. Polypharmacy is associated with a broad range of clinical consequences. However, methods to assess the dangers of polypharmacy should be refined. In our opinion, the issue of 'confounding by multimorbidity' has been underestimated and should be better accounted for in future studies. Moreover, researchers should develop more clinically relevant definitions of polypharmacy, including measures of inappropriate or problematic polypharmacy.

Medication Exposure and Health Outcomes in Older Patients with End-Stage Kidney Disease: A Prospective Study Undertaken in New Zealand

BACKGROUND

The impact of multiple medication exposure on health outcomes among older patients with end-stage kidney disease (ESKD) is unknown.

OBJECTIVE

The objective of this study was to identify the impact of medicine exposure on hospitalisation rates and mortality in a prospective longitudinal observational study of older dialysis patients.

METHODS

Patient demographics, medication use, hospitalisation, mortality and co-morbidity data were collected through the prospective longitudinal cohort study DOS65 + (Dialysis Outcomes in those aged ≥ 65 years Study) (n = 225). Medication exposure was measured by the total number of individual medications and the number of predetermined 'medication groups'. Associations between medications prescribed at recruitment and health outcomes as measured by hospitalisation and mortality were assessed by univariate and multivariable regression analyses.

RESULTS

Older ESKD patients were exposed to a median of ten (0-20) medications and eight (0-15) medication groups. Multivariate analyses estimate each additional medication increased mortality risk by 8% (relative risk [RR] = 1.08; 95% confidence interval [CI] 1.07-1.09); each medication group increased mortality risk by 11% (RR = 1.11; 95% CI 1.09-1.12). Similar trends were observed for hospitalisation. Certain medication groups were associated with reduced hospitalisation rates, namely angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (RR = 0.62; 95% CI 0.53-0.72) and dihydropyridines (RR = 0.64; 95% CI 0.54-0.76). Warfarin, gastric acid suppressants, diuretics and β-blockers were associated with increased hospitalisation rates. Warfarin was associated with an increased mortality rate (RR = 1.40; 95% CI 1.19-1.65).

CONCLUSIONS

Multiple medication exposure was prevalent in this older ESKD population, and was associated with an increased risk of mortality and hospitalisation. While this study is not able to determine the cause of these relationships, review of medication use is warranted in this population.

TRIAL REGISTRATION

ACTRN12611000024943.

Drug-Induced Kidney Injury in the Elderly

The incidence of acute kidney injury in the elderly has grown over the past decade. One of the primary drivers is drug-induced nephrotoxicity, which is the result of a combination of the unique susceptibilities to kidney injury and the increased use of medications in the elderly population. Specific drug classes are associated with increased rates of kidney injury including agents that block the renin angiotensin system, antimicrobials, and chemotherapeutic agents. Mechanistically, injury may be due to hemodynamic effects, tubular or glomerular toxicity, and interstitial nephritis. Early recognition of nephrotoxicity is critical, as are preventative steps when applicable. Unfortunately, treatment for established drug-induced kidney injury is limited and supportive care is required. Limiting exposure to nephrotoxic drugs is critical in decreasing the incidence of acute kidney injury in the elderly patient.

Is Excessive Polypharmacy a Transient or Persistent Phenomenon? A Nationwide Cohort Study in Taiwan

Objectives: Target populations with persistent polypharmacy should be identified prior to implementing strategies against inappropriate medication use, yet limited information regarding such populations is available. The main objectives were to explore the trends of excessive polypharmacy, whether transient or persistent, at the individual level. The secondary objectives were to identify the factors associated with persistently excessive polypharmacy and to estimate the probabilities for repeatedly excessive polypharmacy.

Methods: Retrospective cohort analyses of excessive polypharmacy, defined as prescription of ≥ 10 medicines at an ambulatory visit, from 2001 to 2013 were conducted using a nationally representative claims database in Taiwan. Survival analyses with log-rank test of adult patients with first-time excessive polypharmacy were conducted to predict the probabilities, stratified by age and sex, of having repeatedly excessive polypharmacy.

Results: During the study period, excessive polypharmacy occurred in 5.4% of patients for the first time. Among them, 63.9% had repeatedly excessive polypharmacy and the probabilities were higher in men and old people. Men versus women, and old versus middle-aged and young people had shorter median excessive polypharmacy-free times (9.4 vs. 5.5 months, 5.3 vs. 10.1 and 35.0 months, both p < 0.001). Overall, the probabilities of having no repeatedly excessive polypharmacy within 3 months, 6 months, and 1 year were 59.9, 53.6, and 48.1%, respectively.

Conclusion: Although male and old patients were more likely to have persistently excessive polypharmacy, most cases of excessive polypharmacy were transient or did not re-appear in the short run. Systemic deprescribing measures should be tailored to at-risk groups.

What is polypharmacy? A systematic review of definitions

BACKGROUND

Multimorbidity and the associated use of multiple medicines (polypharmacy), is common in the older population. Despite this, there is no consensus definition for polypharmacy. A systematic review was conducted to identify and summarise polypharmacy definitions in existing literature.

METHODS

The reporting of this systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. MEDLINE (Ovid), EMBASE and Cochrane were systematically searched, as well as grey literature, to identify articles which defined the term polypharmacy (without any limits on the types of definitions) and were in English, published between 1st January 2000 and 30th May 2016. Definitions were categorised as i. numerical only (using the number of medications to define polypharmacy), ii. numerical with an associated duration of therapy or healthcare setting (such as during hospital stay) or iii. Descriptive (using a brief description to define polypharmacy).

RESULTS

A total of 1156 articles were identified and 110 articles met the inclusion criteria. Articles not only defined polypharmacy but associated terms such as minor and major polypharmacy. As a result, a total of 138 definitions of polypharmacy and associated terms were obtained. There were 111 numerical only definitions (80.4% of all definitions), 15 numerical definitions which incorporated a duration of therapy or healthcare setting (10.9%) and 12 descriptive definitions (8.7%). The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy, using descriptive definitions to make this distinction.

CONCLUSIONS

Polypharmacy definitions were variable. Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting.

The drugs that mostly frequently induce acute kidney injury: a case - noncase study of a pharmacovigilance database

AIMS

Acute kidney injury (AKI) is associated with a high hospitalization rate, accelerated long-term decline in kidney function and a high mortality rate. Adverse drug reactions (ADRs) constitute one of the most important modifiable factors in the context of AKI. Most studies of drug-induced AKI have focused on a sole drug class. The objective of the present study was to establish a comprehensive overview of drug-induced AKI on the basis of spontaneously reported ADRs in the French national pharmacovigilance database (FPVD).

METHODS

We performed a case-noncase study of drug-induced AKI. Cases corresponded to the reports of AKI recorded in the FPVD between 1 January 2015 and 31 December 2015. The noncases corresponded to all other spontaneously reported ADRs (excluding AKI) recorded in the FPVD during the same period. Data were expressed as the reporting odds ratio (ROR) and the 95% confidence interval.

RESULTS

Of the 38 782 ADRs recorded in the FPVD during the study period, 3.2% were classified as cases of AKI. A total of 1254 patients experienced AKI (males: 55%; mean age ± standard deviation: 68.7 ± 15.0 years). Overall, 15.2% of the patients required renal replacement therapy. Two or more concomitantly administered drugs were involved in 66% of the cases of AKI. The most frequently implicated drug classes were antibacterial agents for systemic use (29.5%), diuretics (18.5%), agents acting on the renin-angiotensin system (16.3%), antineoplastic agents (10.2%) and anti-inflammatory agents (5.4%). Gentamicin, eplerenone, spironolactone, candesartan, cisplatin and acyclovir had the highest RORs (>10).

CONCLUSION

A comprehensive study of a national pharmacovigilance database enabled us to identify the drug classes that most frequently induced AKI. Even though most of the identified drugs were already known to induce AKI, the present work should raise physicians' awareness of the compounds responsible for triggering this potentially life-threatening condition.

Polypharmacy and Renal Failure in Nursing Home Residents: Results of the Inappropriate Medication in Patients with Renal Insufficiency in Nursing Homes (IMREN) Study

BACKGROUND

Polypharmacy has become an emerging public health issue in recent years, since use of multiple medications or polypharmacy is beneficial for many conditions, but may also have negative effects like adverse drug reactions. The risk further increases in patients with chronic renal failure, a comorbidity very frequent in nursing home residents. Since more than 50% of all drugs were renally excreted, dose adjustments in patients with renal failure are required.

OBJECTIVE

To assess polypharmacy in German nursing homes, in particular in residents with renal failure.

METHODS

Multi-center cross-sectional study in 21 nursing homes in Bremen and Lower Saxony/Germany. Baseline data were analysed using descriptive statistics. Multivariable logistic regression model and 95% confidence intervals were used to study the association of renal failure and polypharmacy.

RESULTS

Of all 852 residents, the analysis comprised those 685 with at least one serum creatinine value so that the estimated creatinine clearance could be calculated. Of those, 436 (63.6%) had a severe or moderate renal failure, defined as estimated creatinine clearance <60 mL/min. Polypharmacy (5-9 drugs) was found in 365 (53.3%) and excessive polypharmacy (≥10 drugs) in 112 (16.4%) residents. Diuretics and psycholeptics were the most commonly used drug classes. Severe renal failure (estimated creatinine clearance <30 mL/min) was associated with polypharmacy (OR: 2.8, 95% CI 1.4-5.7).

CONCLUSION

Both, polypharmacy and renal failure are common in German nursing home residents and an association of both could be found. Further studies are needed to assess the appropriateness of polypharmacy in these patients.

The perfect storm: older adults and acute kidney injury

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

Multiple medication (polypharmacy) and chronic kidney disease in patients aged 60 and older: a pharmacoepidemiologic perspective

BACKGROUND

Few studies have examined whether there was an independent association between multiple medication use and risk of chronic kidney disease (CKD), with adjustment for cardiometabolic factors. In the study, we aimed to examine this association using a nationally representative sample in CKD patients aged 60 and older.

METHODS

In the study, subjects aged ⩾60 years (n = 1306) who participated in the 2011-2012 National Health and Nutrition Examination Survey were analyzed cross-sectionally. CKD was defined using the CKD Epidemiology Collaboration (CKD-EPI) equation i.e. estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m(2). Patients with multiple medications were classified as those having five or more prescription medications per day. All data analysis was performed using SAS 9.3 version.

RESULTS

The prevalence of CKD among age group ⩾80 years, age group 70-79 years and age group 60-69 years were 73.26%, 55.76% and 27.03% respectively (p < 0.001). About half of hypertension (HTN) and diabetic patients aged ⩾60 years had CKD. The prevalence of CKD in patients with cardiovascular disease (CVD) was 60.57%. The logistic regression model without adjustment reflects that those on multiple medications (⩾5 medications/day) had 1.53 (1.02-2.31) times as likely (53% increase) to have CKD compared with those on <5 medications/day. After adjustment for age, CVD, HTN and diabetes mellitus (DM), the odds of CKD for multiple medications appeared to have a protective effect, although it did not reach statistical significance. The adjusted odds ratio [95% confidence interval (CI)] was 0.89 (95% CI: 0.60-1.34); it showed an 11% decreased odds of CKD in patients who were taking multiple medications. The adjusted odds ratio for patients with CVD was 1.38 (95% CI: 0.97-1.98), HTN 1.13 (95% CI: 0.80-1.6), DM 1.78 (95% CI: 1.26-2.51) in age group 70-79 years 3.2 (95% CI: 2.1-4.87) and in age ⩾80 years 6.98 (95% CI: 4.02-12.11) compared with age group 60-69 years old, respectively.

CONCLUSION

We did not find significant independent association between use of multiple medications and CKD. The switchover of odds for multiple medication suggested a confounding effect of covariates; further prospective studies are required to find the individualized effect of multiple medications on CKD.

The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study

BACKGROUND

Multimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. Chronic kidney disease (CKD) is common but often considered in isolation. The extent and prognostic significance of its comorbidities is not well understood. This study aimed to assess the extent and prognostic significance of 11 comorbidities in people with CKD stage 3.

METHODS

A prospective cohort of 1741 people with CKD stage 3 was recruited from primary care between August 2008 and March 2010. Participants underwent medical history, clinical assessment, blood and urine sampling. Comorbidity was defined by self-reported doctor-diagnosed condition, disease-specific medication or blood results (hemoglobin), and treatment burden as number of ongoing medications. Logistic regression was used to identify associations with greater treatment burden (taking >5 medications) and greater multimorbidity (3 or more comorbidities). Kaplan Meier plots and multivariate Cox proportional hazards models were used to investigate associations between multimorbidity and all-cause mortality.

RESULTS

One thousand seven hundred forty-one people were recruited, mean age 72.9 +/-9 years. Mean baseline eGFR was 52 ml/min/1.73 m(2). Only 78/1741 (4 %) had no comorbidities, 453/1741 (26 %) had one, 508/1741 (29 %) had two and 702/1741 (40 %) had >2. Hypertension was common (88 %), 30 % had 'painful condition', 24 % anemia, 23 %, ischaemic heart disease, 17 % diabetes and 12 % thyroid disorders. Median medication use was 5 medications (interquartile range 3-8) and increased with degree of comorbidity. Greater treatment burden and multimorbidity were independently associated with age, smoking, increasing body mass index and decreasing eGFR. Treatment burden was also independently associated with lower education status. After median 3.6 years follow-up, 175/1741 (10 %) died. Greater multimorbidity was independently associated with mortality (hazard ratio 2.81 (95 % confidence intervals 1.72-4.58), p < 0.001) for 3 or more comorbidities vs 0 or 1).

CONCLUSIONS

Isolated CKD was rare and multimorbidity the norm in this cohort of people with moderate CKD. Increasing multimorbidity was associated with greater medication burden and poorer survival. CKD management should include consideration of comorbidities.

Cumulative Cardiovascular Polypharmacy Is Associated With the Risk of Acute Kidney Injury in Elderly Patients

Polypharmacy is common in the elderly due to multimorbidity and interventions. However, the temporal association between polypharmacy and renal outcomes is rarely addressed and recognized. We investigated the association between cardiovascular (CV) polypharmacy and the risk of acute kidney injury (AKI) in elderly patients.We used the Taiwan National Health Insurance PharmaCloud system to investigate the relationship between cumulative CV medications in the 3 months before admission and risk of AKI in the elderly at their admission to general medical wards in a single center. Community-dwelling elderly patients (>60 years) were prospectively enrolled and classified according to the number of preadmission CV medications. CV polypharmacy was defined as use of 2 or more CV medications.We enrolled 152 patients, 48% with AKI (based upon Kidney Disease Improving Global Outcomes [KDIGO] classification) and 64% with CV polypharmacy. The incidence of AKI was higher in patients taking more CV medications (0 drugs: 33%; 1 drug: 50%; 2 drugs: 57%; 3 or more drugs: 60%; P = 0.05) before admission. Patients with higher KDIGO grades also took more preadmission CV medications (P = 0.04). Multiple regression analysis showed that patients who used 1 or more CV medications before admission had increased risk of AKI at admission (1 drug: odds ratio [OR] = 1.63, P = 0.2; 2 drugs: OR = 4.74, P = 0.03; 3 or more drugs: OR = 5.92, P = 0.02), and that CV polypharmacy is associated with higher risk of AKI (OR 2.58; P = 0.02). Each additional CV medication increased the risk for AKI by 30%.We found that elderly patients taking more CV medications are associated with risk of adverse renal events. Further study to evaluate whether interventions that reduce polypharmacy could reduce the incidence of geriatric AKI is urgently needed.

Evaluation of a health-promoting school program to enhance correct medication use in Taiwan

This study was an evaluation of the Health Promoting School (HPS) program in Taiwan and its effectiveness in enhancing students’ knowledge and abilities with regard to correct medication usage. In 2011, baseline and follow-up self-administered online surveys were received from 3520 middle-school and primary students from intervention schools, and 3738 students from comparison primary and secondary schools completed the same survey. The results indicated that after implementing the correct medication use HPS program, students’ knowledge and abilities concerning correct medication usage (i.e., the need to express clearly personal conditions to physicians, to check information on the medication packages, to take medication correctly and adhere to prescribed medication regimens, not to buy or acquire medication from unlicensed sources, and to consult pharmacists/physicians) were significantly increased among the students in the intervention schools (p < 0.001). In addition, students’ knowledge and abilities concerning correct medication usage were significantly higher in the intervention schools compared with the comparison schools (p < 0.001). In conclusion, the correct medication use HPS program significantly enhanced students’ knowledge and abilities concerning correct medication usage.

Factors affecting the development of adverse drug reactions (Review article)

OBJECTIVES

To discuss the effect of certain factors on the occurrence of Adverse Drug Reactions (ADRs).

DATA SOURCES

A systematic review of the literature in the period between 1991 and 2012 was made based on PubMed, the Cochrane database of systematic reviews, EMBASE and IDIS. Key words used were: medication error, adverse drug reaction, iatrogenic disease factors, ambulatory care, primary health care, side effects and treatment hazards.

SUMMARY

Many factors play a crucial role in the occurrence of ADRs, some of these are patient related, drug related or socially related factors. Age for instance has a very critical impact on the occurrence of ADRs, both very young and very old patients are more vulnerable to these reactions than other age groups. Alcohol intake also has a crucial impact on ADRs. Other factors are gender, race, pregnancy, breast feeding, kidney problems, liver function, drug dose and frequency and many other factors. The effect of these factors on ADRs is well documented in the medical literature. Taking these factors into consideration during medical evaluation enables medical practitioners to choose the best drug regimen.

CONCLUSION

Many factors affect the occurrence of ADRs. Some of these factors can be changed like smoking or alcohol intake others cannot be changed like age, presence of other diseases or genetic factors. Understanding the different effects of these factors on ADRs enables healthcare professionals to choose the most appropriate medication for that particular patient. It also helps the healthcare professionals to give the best advice to patients. Pharmacogenomics is the most recent science which emphasizes the genetic predisposition of ADRs. This innovative science provides a new perspective in dealing with the decision making process of drug selection.