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Hilmer SN, Johnell K, Mach J. Pre-clinical Models for Geriatric Pharmacotherapy. Drugs Aging 2024; 41:633-640. [PMID: 38982010 PMCID: PMC11322264 DOI: 10.1007/s40266-024-01129-6] [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] [Accepted: 06/16/2024] [Indexed: 07/11/2024]
Abstract
With ageing of the population worldwide and discovery of new medications for prevention and management of age-related conditions, there is increasing use of medications by older adults. There are international efforts to increase the representativeness of participants in clinical trials to match the intended real-world users of the medications across a range of characteristics including age, multimorbidity, polypharmacy and frailty. Currently, much of the data on medication-related harm in older adults are from pharmacovigilance studies. New methods in pre-clinical models have allowed for measurement of exposures (such as chronic exposure, polypharmacy and deprescribing) and outcomes (such as health span functional measures and frailty) that are highly relevant to geriatric pharmacotherapy. Here we describe opportunities for design and implementation of pre-clinical models that can better predict drug effects in geriatric patients. This could improve the translation of new drugs from bench to bedside and improve outcomes of pharmacotherapy in older adults.
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Affiliation(s)
- Sarah N Hilmer
- Kolling Institute, The University of Sydney and Northern Sydney Local Health District, St Leonards, NSW, Australia.
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - John Mach
- Kolling Institute, The University of Sydney and Northern Sydney Local Health District, St Leonards, NSW, Australia
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Wu YE, Zheng YY, Li QY, Yao BF, Cao J, Liu HX, Hao GX, van den Anker J, Zheng Y, Zhao W. Model-informed drug development in pediatric, pregnancy and geriatric drug development: States of the art and future. Adv Drug Deliv Rev 2024; 211:115364. [PMID: 38936664 DOI: 10.1016/j.addr.2024.115364] [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: 09/25/2023] [Revised: 06/09/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
The challenges of drug development in pediatric, pregnant and geriatric populations are a worldwide concern shared by regulatory authorities, pharmaceutical companies, and healthcare professionals. Model-informed drug development (MIDD) can integrate and quantify real-world data of physiology, pharmacology, and disease processes by using modeling and simulation techniques to facilitate decision-making in drug development. In this article, we reviewed current MIDD policy updates, reflected on the integrity of physiological data used for MIDD and the effects of physiological changes on the drug PK, as well as summarized current MIDD strategies and applications, so as to present the state of the art of MIDD in pediatric, pregnant and geriatric populations. Some considerations are put forth for the future improvements of MIDD including refining regulatory considerations, improving the integrity of physiological data, applying the emerging technologies, and exploring the application of MIDD in new therapies like gene therapies for special populations.
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Affiliation(s)
- Yue-E Wu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuan-Yuan Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiu-Yue Li
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing Cao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA; Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA; Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Yang Y, Wei S, Tian H, Cheng J, Zhong Y, Zhong X, Huang D, Jiang C, Ke X. Adverse event profile of memantine and donepezil combination therapy: a real-world pharmacovigilance analysis based on FDA adverse event reporting system (FAERS) data from 2004 to 2023. Front Pharmacol 2024; 15:1439115. [PMID: 39101151 PMCID: PMC11294921 DOI: 10.3389/fphar.2024.1439115] [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: 05/27/2024] [Accepted: 06/24/2024] [Indexed: 08/06/2024] Open
Abstract
Background Donepezil in combination with memantine is a widely used clinical therapy for moderate to severe dementia. However, real-world population data on the long-term safety of donepezil in combination with memantine are incomplete and variable. Therefore, the aim of this study was to analyze the adverse events (AEs) of donepezil in combination with memantine according to US Food and Drug Administration Adverse Event Reporting System (FAERS) data to provide evidence for the safety monitoring of this therapy. Methods We retrospectively analyzed reports of AEs associated with the combination of donepezil and memantine from 2004 to 2023 extracted from the FAERS database. Whether there was a significant association between donepezil and memantine combination therapy and AEs was assessed using four disproportionality analysis methods, namely, the reporting odds ratio, proportional reporting ratio, Bayesian confidence propagation neural network, and multi-item gamma Poisson shrinker methods. To further investigate potential safety issues, we also analyzed differences and similarities in the time of onset and incidence of AEs stratified by sex and differences and similarities in the incidence of AEs stratified by age. Results Of the 2,400 adverse drug reaction (ADR) reports in which the combination of donepezil and memantine was the primary suspected drug, most of the affected patients were female (54.96%) and older than 65 years of age (79.08%). We identified 22 different system organ classes covering 100 AEs, including some common AEs such as dizziness and electrocardiogram PR prolongation; fall, pleurothotonus and myoclonus were AEs that were not listed on the drug label. Moreover, we obtained 88 reports of AEs in men and 100 reports of AEs in women; somnolence was a common AE in both men and women and was more common in women, whereas pleurothotonus was a more common AE in men. In addition, we analyzed 12 AEs in patients younger than 18 years, 16 in patients between 18 and 65 years, and 113 in patients older than 65 years. The three age groups had distinctive AEs, but lethargy was the common AE among all age groups. Finally, the median time to AE onset was 19 days in all cases. In both men and women, most AEs occurred within a month of starting donepezil plus memantine, but some continued after a year of treatment. Conclusion Our study identified potential and new AEs of donepezil in combination with memantine; some of these AEs were the same as in the specification, and some of the AE signals were not shown in the specification. In addition, there were sex and age differences in some of the AEs. Therefore, our findings may provide valuable insights for further studies on the safety of donepezil and memantine combination therapy, which are expected to contribute to the safe use of this therapy in clinical practice.
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Affiliation(s)
- Yihan Yang
- The Institution of Rehabilitation Industry, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Sheng Wei
- Department of General Practice, The Second Affiliated Hospital of Wannan Medical College, Anhui, China
| | - Huan Tian
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
- School of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jing Cheng
- The First Clinical Medical College, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yue Zhong
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoling Zhong
- Guangdong Provincial Hospital of Chinese Medicine, The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dunbing Huang
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Cai Jiang
- Rehabilitation Medicine Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Xiaohua Ke
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
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González CP, Bardolia C, Pizzolato K, Amin NS. Utilizing Pharmacogenomics Results to Improve Statin-Associated Muscle Symptoms. Sr Care Pharm 2024; 39:151-158. [PMID: 38528333 DOI: 10.4140/tcp.n.2024.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The objective of this aims to demonstrate the advantage of a pharmacogenomics (PGx)-informed medication review in mitigating adverse drug events (ADEs) and optimizing therapeutic outcomes. PGx testing and PGx-informed medication reviews assist in mitigating ADEs. PGx testing was performed on a 68-year-old male presenting with uncontrolled chronic pain. The PGx results highlighted a drug-gene interaction, aiding in identification of the increased risk of statin-associated muscle symptoms (SAMS) attributing to uncontrolled chronic pain. This patient case report illustrates how incorporating PGx results can help improve chronic pain and mitigate ADEs, such as SAMS.
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Affiliation(s)
- Coral Perez González
- 1 Office of Translational Research and Residency Programs, Tabula Rasa HealthCare, Moorestown, New Jersey
| | - Chandni Bardolia
- 1 Office of Translational Research and Residency Programs, Tabula Rasa HealthCare, Moorestown, New Jersey
| | - Katie Pizzolato
- 1 Office of Translational Research and Residency Programs, Tabula Rasa HealthCare, Moorestown, New Jersey
| | - Nishita Shah Amin
- 1 Office of Translational Research and Residency Programs, Tabula Rasa HealthCare, Moorestown, New Jersey
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Iijima H, Shimizu H, Mori-Anai K, Kawaguchi A, Mochida Y, Yamauchi T, Kadowaki T. Evaluation of Age-Related Changes in Teneligliptin Pharmacokinetics in Japanese and European Descent Subjects Using a Physiologically Based Pharmacokinetic Model. Diabetes Ther 2024; 15:763-777. [PMID: 38117459 PMCID: PMC10951162 DOI: 10.1007/s13300-023-01514-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/17/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION Drugs often show differing pharmacokinetic (PK) profiles, such as higher plasma concentrations, in older people than in younger people owing to age-related decreases in physiological functions. However, it is difficult to evaluate the PK in older populations. Therefore, we simulated the plasma age-related changes in the PK of teneligliptin, a dipeptidyl peptidase-4 inhibitor, using physiologically based PK (PBPK) models. METHODS The previously developed PBPK model was revalidated by comparison between simulated data and clinical study data that included older subjects (up to 75 years old). We then simulated the plasma concentration-time profiles for teneligliptin at a dose of 20 mg (single and multiple doses) in virtual Japanese (20-70 years old) and European descent (20-98 years old) subjects. PK parameters were calculated by race and age group. RESULTS We confirmed the validity of the previous PBPK model by comparison between simulated data and clinical study data. In the evaluation of age-related changes in PK after single and multiple doses using the PBPK model, the area under the plasma concentration-time curve (AUC) of teneligliptin tended to increase slightly with age in both populations up to 70 years old. However, no clear age-related change in the maximum plasma concentration (Cmax) of teneligliptin was observed. In the European descent subjects aged ≥ 70 years, the AUC tended to increase but the ratio of the change in Cmax was smaller than that in AUC. In both populations, there were positive correlations between AUC and age, but not between Cmax and age. CONCLUSION The simulation using a PBPK model showed a tendency for the AUC of teneligliptin to increase with age, whereas Cmax was less affected by age than AUC.
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Affiliation(s)
- Hiroaki Iijima
- Medical Affairs Department, Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, 1-1-1, Marunouchi, Chiyoda-ku, Tokyo, 100-8205, Japan.
| | - Hidetoshi Shimizu
- Data Science Department, Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, 1-1-1, Marunouchi, Chiyoda-ku, Tokyo, 100-8205, Japan
| | - Kazumi Mori-Anai
- Medical Intelligence Department, Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, 1-1-1, Marunouchi, Chiyoda-ku, Tokyo, 100-8205, Japan
| | - Atsuhiro Kawaguchi
- Data Science Department, Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, 1-1-1, Marunouchi, Chiyoda-ku, Tokyo, 100-8205, Japan
| | - Yoji Mochida
- Medical Affairs Department, Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, 1-1-1, Marunouchi, Chiyoda-ku, Tokyo, 100-8205, Japan
| | - Toshimasa Yamauchi
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Takashi Kadowaki
- Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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Shin E, Leibovitch E, Nishimura Y, Bhagavathula AS. Long-term trends in mortality from adverse effects of medical treatment in older populations in the United States from 1990 to 2019. J Am Pharm Assoc (2003) 2024; 64:55-61. [PMID: 37734658 DOI: 10.1016/j.japh.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/21/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Adverse Effects of Medical Treatment (AEMT) refer to unintended harm caused by medical care and are a significant public health concern. OBJECTIVE This study utilizes the Global Burden of Disease database to investigate AEMT mortality trends among older adults in the United States from 1990 to 2019, focusing on crude mortality rates and age-standardized mortality rate trends by age group and sex. METHODS The study employs cause-of-death ensemble modeling and statistical analysis to examine crude and age-standardized mortality rates (ASRs) for AEMT in older age groups and identify trends in mortality due to AEMTs in those over 65 years of age in the United States. Trends in the ASR of AEMT were analyzed using the Joinpoint regression model. RESULTS AEMT mortality rates increased among older adults from 2012 to 2019, with the highest increase observed in the 95 years or older age group. Significant differences were noted in AEMT mortality rates between older men and women, with older men having higher rates and showing an upward trend, while rates among older women decreased from 1990 to 2019. CONCLUSION The study highlights an overall increase in ASR related to AEMT among older adults in the United States, with men shown to have a greater susceptibility to death from AEMT. Increased attention toward the detrimental impact of AEMT on our aging population, particularly for men, in conjunction with reinforcement of health policies and education, is warranted.
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Koehl JL. Adverse Drug Event Prevention and Detection in Older Emergency Department Patients. Clin Geriatr Med 2023; 39:635-645. [PMID: 37798069 DOI: 10.1016/j.cger.2023.04.008] [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] [Indexed: 10/07/2023]
Abstract
Older adults are given therapies to enhance the quality and longevity of life, but with the benefits of medication therapy also comes the potential for adverse drug events (ADEs). Avoiding ADEs has become a national health priority with substantial impact on health outcomes and health care costs. The presence of multimorbidity, changes in physiologic function, and polypharmacy make older adults more vulnerable to medication-related ADEs. Use of interactive support tools in the form of geriatric-friendly medication order sets and geriatric consultations along with pharmacist-led medication review and optimization are imperative to decrease the occurrence of ADEs and unnecessary prescribing cascades.
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Affiliation(s)
- Jennifer L Koehl
- Department of Pharmacy, Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Alsalemi N, Lafrance JP, Sadowski CA. Older age, kidney concordant diseases and the dilemma of adherence to guidelines: A narrative review. Res Social Adm Pharm 2023; 19:1018-1024. [PMID: 37055315 DOI: 10.1016/j.sapharm.2023.04.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
Evidence-based medicine is pivotal to contemporary clinical practice, and the excellence of a healthcare institution is measured by the adherence of its clinical staff to the clinical practice guidelines (CPGs) among other standards and policies. Following the recommendations of CPGs in older adults poses different challenges to prescribers. In this narrative review we explore research studies that assessed clinicians' adherence to CPGs when prescribing to older adults with chronic kidney disease and its concordant disorders, and to discuss the potential barriers and facilitators to better adherence to CPGs. Our review of the literature found that the adherence level to CPGs differed according to country, disease condition and healthcare setting. Clinicians' attitudes toward older adults and the CPGs, the unfamiliarity with the CPGs, and the lack of time, were commonly cited barriers. Interventions suggested to improve adherence to CPGs include direct mentoring, educational activities, and the integration of CPGs recommendations within hospital protocols and policies.
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Affiliation(s)
- Noor Alsalemi
- Département de pharmacologie et physiologie, Université de Montréal, Montréal, QC, Canada; Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada
| | - Jean-Philippe Lafrance
- Département de pharmacologie et physiologie, Université de Montréal, Montréal, QC, Canada; Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada; Service de néphrologie, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, QC, Canada
| | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.
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Helal NS, Omran Z, Moussa M. Assessment of survivin and p27 expression as potential prognostic markers in urothelial cell carcinoma of urinary bladder in Egyptian patients. AFRICAN JOURNAL OF UROLOGY 2022. [DOI: 10.1186/s12301-022-00315-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Bladder cancer (BC) is the tenth most common cancer worldwide with urothelial carcinoma (UC) being the main histologic subtype. Survivin is an apoptosis inhibitor that is associated with tumor proliferation and invasion. P27 is a cyclin-dependent kinase inhibitor that negatively regulates cell proliferation. The expression of both proteins was variable among different solid tumors including UC.
Methods
We aimed to investigate the expression of survivin and P27 in UC of urinary bladder and correlate their expressions with histopathological parameters in an attempt at studying the possibility of their use as targeted therapies. The investigation was performed through immunohistochemical staining for both proteins on sections belonging to 60 UCs and 12 mild chronic cystitis cases (controls). Immunopositivity (number of positive cases) and expression score (percentage of positive urothelial cells) were evaluated.
Results
Both survivin and P27 were absent in urothelial cells of mild chronic cystitis lesions while expressed in 60% and 43.3% of UCs, respectively. High score of survivin and low score of P27 were associated with poor prognostic factors of UC (solid pattern, high grade, and deep tumors). By logistic regression test, survivin expression can be a predictive risk factor associated with solid pattern and high-grade UC, while P27 expression can be a predictive risk factor associated low-grade UC.
Conclusion
High survivin and low P27 expression scores were associated with the studied prognostic factors of UC. Both proteins may play a role in UC progression and can have a value as prognostic and/or diagnostic markers of UC, as well as targeted therapies.
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Lee J, Singh N, Gray SL, Makris UE. Optimizing Medication Use in Older Adults With Rheumatic Musculoskeletal Diseases: Deprescribing as an Approach When Less May Be More. ACR Open Rheumatol 2022; 4:1031-1041. [PMID: 36278868 PMCID: PMC9746667 DOI: 10.1002/acr2.11503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 12/15/2022] Open
Abstract
The world population is aging, and the rheumatology workforce must be prepared to care for medically complex older adults. We can learn from our colleagues and experts in geriatrics about how to best manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older adults in the context of delivering care for rheumatic and musculoskeletal diseases (RMDs). Polypharmacy, a common occurrence in an aging population with multimorbidity, affects half of older adults with RMDs and is associated with increased risk of morbidity and mortality. In addition, potentially inappropriate medications that should be avoided under most circumstances is common in the RMD population. In recent years, deprescribing, known as the process of tapering, stopping, discontinuing, or withdrawing drugs, has been introduced as an approach to improve appropriate medication use among older adults and the outcomes that are important to them. As the rheumatology patient population ages globally, it is imperative to understand the burden of polypharmacy and the potential of deprescribing to improve medication use in older adults with RMDs. We encourage the rheumatology community to implement geriatric principles, when possible, as we move toward becoming an age-friendly health care specialty.
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Affiliation(s)
- Jiha Lee
- JUniversity of MichiganAnn Arbor
| | | | | | - Una E. Makris
- University of Texas Southwestern Medical Center and VA North Texas Health Care SystemDallas
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Yang L, Shen Q, Hu C, Wang Y, Zhu X, Shu S, Luo Z. Comparative Pharmacokinetics and Safety of Imrecoxib, a Novel Selective Cyclooxygenase-2 Inhibitor, in Elderly Healthy Subjects. Drug Des Devel Ther 2022; 16:3865-3876. [PMID: 36388081 PMCID: PMC9653025 DOI: 10.2147/dddt.s387508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022] Open
Abstract
Background Imrecoxib is a novel and moderately selective cyclooxygenase-2 inhibitor with properties of anti-inflammation and alleviating pain, which is widely applied in osteoarthritis patients. The pharmacokinetic data supporting imrecoxib’s rational use in elderly population are not available. Purpose The study aims to investigate the pharmacokinetics of imrecoxib and its main metabolites and explore the safety of imrecoxib in elderly healthy subjects. Methods A total of 19 healthy subjects including 10 non-elderly and 9 elderly subjects received single dose of 100 mg imrecoxib under fasting condition. Pharmacokinetics, safety and tolerability profiles were assessed. Results After oral administration of single dose of 100 mg imrecoxib, it was absorbed into plasma with median time to reach peak concentration (Tmax) around 2 hours. The concentration–time curves of imrecoxib (M0) showed higher interindividual variability in elderly subjects compared with non-elderly subjects. Peak concentration (Cmax) of M0, its hydroxyl metabolite M1 and carboxylated metabolite M2 in plasma increased by 39%, 21% and 17%, and area under concentration–time curve from time 0 to time t (AUC0-t) of M0, M1 and M2 in plasma increased by 34%, 13% and 27%, respectively, in elderly subjects compared with non-elderly subjects. The 90% CIs of geometric mean ratios of Cmax, AUC0-t and AUC0-∞ of M0, M1 and M2 between the two groups were not located within 80–125%, indicating Cmax, AUC0-t and AUC0-∞ were not completely equivalent between non-elderly and elderly healthy subjects. However, comparison of pharmacokinetic data of M0, M1 and M2 between the two groups showed no significant difference (P>0.05). Imrecoxib was well tolerated in both non-elderly and elderly healthy subjects, especially with favorable gastrointestinal and cardiovascular safety profiles. Conclusion Pharmacokinetic and safety profiles of imrecoxib in elderly healthy subjects indicated that no dose adjustment should be required for elderly population.
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Affiliation(s)
- Ling Yang
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, Chengdu, People’s Republic of China
| | - Qi Shen
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, Chengdu, People’s Republic of China
| | - Chao Hu
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, Chengdu, People’s Republic of China
| | - Ying Wang
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, Chengdu, People’s Republic of China
| | - Xiaohong Zhu
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, Chengdu, People’s Republic of China
| | - Shiqing Shu
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, Chengdu, People’s Republic of China
| | - Zhu Luo
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, Chengdu, People’s Republic of China
- Correspondence: Zhu Luo, Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital Sichuan University, No. 37 Guoxue Lane, Chengdu, Sichuan, 610044, People’s Republic of China, Tel +86 28 85422707, Email
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Ting AKY, Tay VSY, Chng HT, Xie S. A Critical Review on the Pharmacodynamics and Pharmacokinetics of Non-steroidal Anti-inflammatory Drugs and Opioid Drugs Used in Reptiles. Vet Anim Sci 2022; 17:100267. [PMID: 36043206 PMCID: PMC9420515 DOI: 10.1016/j.vas.2022.100267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are analgesics used for moderate to severe pain in many animals, including reptiles. However, reptilian dosing regimens are often extrapolated from other animal species. This is not ideal as inter- and intra-species variability in physiology may result in varied drug disposition. Therefore, this critical review aims to collate data from pharmacological studies of selected NSAIDs and opioids performed in reptile and provide an analysis and discussion on the existing pharmacodynamic knowledge and pharmacokinetic data of NSAIDs and opioids use in reptiles. Additionally, key pharmacokinetic trends that may aid dosing of NSAIDs and opioids in reptiles will also be highlighted. Most of the existing reports of NSAID used in reptiles did not observe any adverse effects directly associated to the respective NSAID used, with meloxicam being the most well-studied. Despite the current absence of analgesic efficacy studies for NSAIDs in reptiles, most reports observed behavioural improvements in reptiles after NSAID treatment. Fentanyl and morphine were studied in the greatest number of reptile species with analgesic effects observed with the doses used, while adverse effects such as sedation were observed most with butorphanol use. While pharmacokinetic trends were drug- and species-specific, it was observed that clearance (CL) of drugs tended to be higher in squamates compared to chelonians. The half-life (t1/2) of meloxicam also appeared to be longer when dosed orally compared to other routes of drug administration. This could have been due to absorption-rate limited disposition. Although current data provided beneficial information, there is an urgent need for future research on NSAID and opioid pharmacology to ensure the safe and effective use of opioids in reptiles.
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Mangoni AA, Jarmuzewska EA. Patient-Centricity: A Much-Needed Strategy to Enhance the Quality Use of Medicines in Older Patients. Curr Rev Clin Exp Pharmacol 2022; 17:1-2. [DOI: 10.2174/277243281701211223100004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elzbieta A. Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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14
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Hunt NJ, McCourt PAG, Kuncic Z, Le Couteur DG, Cogger VC. Opportunities and Challenges for Nanotherapeutics for the Aging Population. FRONTIERS IN NANOTECHNOLOGY 2022. [DOI: 10.3389/fnano.2022.832524] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Nanotherapeutics utilize the properties of nanomaterials to alter the pharmacology of the drugs and therapies being transported, leading to changes in their biological disposition (absorption, distribution, cellular uptake, metabolism and elimination) and ultimately, their pharmacological effect. This provides an opportunity to optimize the pharmacology of drugs, particularly for those that are dependent on hepatic action. Old age is associated with changes in many pharmacokinetic processes which tend to impair drug efficacy and increase risk of toxicity. While these age-related changes are drug-specific they could be directly addressed using nanotechnology and precision targeting. The benefits of nanotherapeutics needs to be balanced against toxicity, with future use in humans dependent upon the gathering of information about the clearance and long-term safety of nanomaterials.
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15
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Young JC, Dasgupta N, Chidgey BA, Stürmer T, Pate V, Hudgens M, Funk MJ. Impacts of Initial Prescription Length and Prescribing Limits on Risk of Prolonged Postsurgical Opioid Use. Med Care 2022; 60:75-82. [PMID: 34812786 PMCID: PMC8900903 DOI: 10.1097/mlr.0000000000001663] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND In response to concerns about opioid addiction following surgery, many states have implemented laws capping the days supplied for initial postoperative prescriptions. However, few studies have examined changes in the risk of prolonged opioid use associated with the initial amount prescribed. OBJECTIVE The objective of this study was to estimate the risk of prolonged opioid use associated with the length of initial opioid prescribed and the potential impact of prescribing limits. RESEARCH DESIGN Using Medicare insurance claims (2007-2017), we identified opioid-naive adults undergoing surgery. Using G-computation methods with logistic regression models, we estimated the risk of prolonged opioid use (≥1 opioid prescription dispensed in 3 consecutive 30-d windows following surgery) associated with the varying initial number of days supplied. We then estimate the potential reduction in cases of prolonged opioid use associated with varying prescribing limits. RESULTS We identified 1,060,596 opioid-naive surgical patients. Among the 70.0% who received an opioid for postoperative pain, 1.9% had prolonged opioid use. The risk of prolonged use increased from 0.7% (1 d supply) to 4.4% (15+ d). We estimated that a prescribing limit of 4 days would be associated with a risk reduction of 4.84 (3.59, 6.09)/1000 patients and would be associated with 2255 cases of prolonged use potentially avoided. The commonly used day supply limit of 7 would be associated with a smaller reduction in risk [absolute risk difference=2.04 (-0.17, 4.25)/1000]. CONCLUSIONS The risk of prolonged opioid use following surgery increased monotonically with increasing prescription duration. Common prescribing maximums based on days supplied may impact many patients but are associated with relatively low numbers of reduced cases of prolonged use. Any prescribing limits need to be weighed against the need for adequate pain management.
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Affiliation(s)
- Jessica C. Young
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC 27599
| | - Brooke A. Chidgey
- Department of Anesthesiology and Pain Management, University of North Carolina School of Medicine, Chapel Hill, NC 27599
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Michael Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
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16
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Ravari A, Mirzaei T, Hosieni F, Hassanshahi E. Comparison of The Effects of Cognitive Therapy and Logotherapy on Iranian Elderly People's General Health. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2021; 9:289-299. [PMID: 34604398 PMCID: PMC8479288 DOI: 10.30476/ijcbnm.2021.88217.1497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 06/02/2021] [Accepted: 06/12/2021] [Indexed: 11/19/2022]
Abstract
Background: Mental health promotion programs in the elderly are important. The main objective of the present study was to compare the effects of cognitive therapy and
logotherapy on the general health of elderly people who referred to health centers. Methods: This is a quasi-experimental study with pretest-posttest design using a control group. A sample of 90 elderly people was recruited from health centers located in Rafsanjan,
between April 2017 and June 2017. 30 participants were considered in each group, separately (cognitive therapy (N=30), logotherapy (N=30), and control (N=30)).
Cognitive therapy and logotherapy programs were implemented in eight 90-minute sessions, while people in the control group received neither cognitive therapy nor logotherapy.
The demographic questionnaire was used at baseline. The 28-item General Health Questionnaire (GHQ-28) was used in two steps of pre-test and post-test. The study data were analyzed
through independent t-test, Chi-square, one-way ANOVA, and the Tukey’s post hoc tests; SPSS 18 was used to analyze the data, and P<0.05 was considered as significant. Results: The mean GHQ-28 total scores before the intervention in the cognitive therapy and logotherapy groups and control group were 52.53±2.55,
52.63±5.64, and 52.26±4.09, respectively, which were not significantly different (P=0.94). However, after the intervention these scores were 41.60±3.31,
40.46±3.97 and 51.93±4.22, respectively, and the difference between the two intervention groups and control group was statistically significant (P<0.001).
There was no significant difference between the two intervention groups (P=0.49). Conclusions: Group cognitive therapy is as effective as logotherapy in improving the elderly people’s general health.
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Affiliation(s)
- Ali Ravari
- Deptartment of Medical Surgical Nursing, School of Nursing and Midwifery, Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Tayebeh Mirzaei
- Deptartment of Medical Surgical Nursing, School of Nursing and Midwifery, Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Fatemeh Hosieni
- Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Elham Hassanshahi
- Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
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17
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Ruangritchankul S, Chantharit P, Srisuma S, Gray LC. Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review. Ther Clin Risk Manag 2021; 17:927-949. [PMID: 34511919 PMCID: PMC8427072 DOI: 10.2147/tcrm.s323387] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.
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Affiliation(s)
- Sirasa Ruangritchankul
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prawat Chantharit
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sahaphume Srisuma
- Ramathibodi Poison Center and Division of Clinical Pharmacology and Toxicology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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18
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Franks PW, Melén E, Friedman M, Sundström J, Kockum I, Klareskog L, Almqvist C, Bergen SE, Czene K, Hägg S, Hall P, Johnell K, Malarstig A, Catrina A, Hagström H, Benson M, Gustav Smith J, Gomez MF, Orho-Melander M, Jacobsson B, Halfvarson J, Repsilber D, Oresic M, Jern C, Melin B, Ohlsson C, Fall T, Rönnblom L, Wadelius M, Nordmark G, Johansson Å, Rosenquist R, Sullivan PF. Technological readiness and implementation of genomic-driven precision medicine for complex diseases. J Intern Med 2021; 290:602-620. [PMID: 34213793 DOI: 10.1111/joim.13330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 03/21/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022]
Abstract
The fields of human genetics and genomics have generated considerable knowledge about the mechanistic basis of many diseases. Genomic approaches to diagnosis, prognostication, prevention and treatment - genomic-driven precision medicine (GDPM) - may help optimize medical practice. Here, we provide a comprehensive review of GDPM of complex diseases across major medical specialties. We focus on technological readiness: how rapidly a test can be implemented into health care. Although these areas of medicine are diverse, key similarities exist across almost all areas. Many medical areas have, within their standards of care, at least one GDPM test for a genetic variant of strong effect that aids the identification/diagnosis of a more homogeneous subset within a larger disease group or identifies a subset with different therapeutic requirements. However, for almost all complex diseases, the majority of patients do not carry established single-gene mutations with large effects. Thus, research is underway that seeks to determine the polygenic basis of many complex diseases. Nevertheless, most complex diseases are caused by the interplay of genetic, behavioural and environmental risk factors, which will likely necessitate models for prediction and diagnosis that incorporate genetic and non-genetic data.
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Affiliation(s)
- P W Franks
- From the, Department of Clinical Sciences, Lund University Diabetes Center, Lund University, Malmö, Sweden.,Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
| | - E Melén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - M Friedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Sundström
- Department of Cardiology, Akademiska Sjukhuset, Uppsala, Sweden.,George Institute for Global Health, Camperdown, NSW, Australia.,Medical Sciences, Uppsala University, Uppsala, Sweden
| | - I Kockum
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - L Klareskog
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Rheumatology, Karolinska Institutet, Stockholm, Sweden
| | - C Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - S E Bergen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - K Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - S Hägg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - P Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - K Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - A Malarstig
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Pfizer, Worldwide Research and Development, Stockholm, Sweden
| | - A Catrina
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - H Hagström
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden
| | - M Benson
- Department of Pediatrics, Linkopings Universitet, Linkoping, Sweden.,Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - J Gustav Smith
- Department of Cardiology and Wallenberg Center for Molecular Medicine, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M F Gomez
- From the, Department of Clinical Sciences, Lund University Diabetes Center, Lund University, Malmö, Sweden
| | - M Orho-Melander
- From the, Department of Clinical Sciences, Lund University Diabetes Center, Lund University, Malmö, Sweden
| | - B Jacobsson
- Division of Health Data and Digitalisation, Norwegian Institute of Public Health, Genetics and Bioinformatics, Oslo, Norway.,Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - J Halfvarson
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - D Repsilber
- Functional Bioinformatics, Örebro University, Örebro, Sweden
| | - M Oresic
- School of Medical Sciences, Örebro University, Örebro, Sweden.,Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, FI, Finland
| | - C Jern
- Department of Clinical Genetics and Genomics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Laboratory Medicine, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - B Melin
- Department of Radiation Sciences, Oncology, Umeå Universitet, Umeå, Sweden
| | - C Ohlsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, CBAR, University of Gothenburg, Gothenburg, Sweden.,Department of Drug Treatment, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - T Fall
- Department of Medical Sciences, Molecular Epidemiology, Uppsala University, Uppsala, Sweden
| | - L Rönnblom
- Department of Medical Sciences, Rheumatology & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - M Wadelius
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - G Nordmark
- Department of Medical Sciences, Rheumatology & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Å Johansson
- Institute for Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden
| | - R Rosenquist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - P F Sullivan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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19
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Neilson V, Palmer S. The effectiveness of a multidisciplinary frailty team in reducing anticholinergic burden in frail older patients: A quantitative service evaluation. Geriatr Nurs 2021; 42:943-947. [PMID: 34130126 DOI: 10.1016/j.gerinurse.2021.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Victoria Neilson
- Royal United Hospitals Bath NHS Foundation Trust, Bath, BA1 3NG, United Kingdom.
| | - Shea Palmer
- Musculoskeletal Rehabilitation, Faculty of Health and Applied Sciences University of West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol, BS16 1DD, UK
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20
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Trends and patterns in EU(7)-PIM prescribing to elderly patients in Germany. Eur J Clin Pharmacol 2021; 77:1553-1561. [PMID: 33938975 DOI: 10.1007/s00228-021-03148-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/20/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this study was to explore patterns and long-term development in prescribing potentially inappropriate medication (PIM) according to the EU(7)-PIM list to elderly patients in Germany. METHODS We analysed anonymized German claims data. The study population comprised 6.0 million insured individuals at least 65 years old, including all their prescriptions reimbursed in 2019. For the analysis of long-term development, we used data for the years 2009-2019. Factors associated with PIM prescribing were considered from two perspectives: patient-oriented analysis was performed with logistic regression and prescriber-oriented analysis was performed with multiple linear regression. RESULTS EU(7)-PIM prevalence was reduced from 56.9% in 2009 to 45.1% in 2019. Average annual volume (DDDs/insured) decreased from 145 in 2009 to 121 in 2019. These figures are substantially greater than those for the older PRISCUS list. The majority of investigated ATC level 2 groups with the highest EU(7)-PIM DDD volume exhibited substantial decreases; moderate increases were found for antihypertensive and urological drugs. Antithrombotics increased strongly with the introduction of direct oral anticoagulants. The most prevalent EU(7)-PIM medication was diclofenac; however, in the age group 85+ years, apixaban was twice as prevalent as diclofenac. Polypharmacy, female sex, age < 90 years, need for nursing care and living in Eastern regions were identified as risk factors. Prescriber specialty was the most marked factor in the prescriber-oriented analysis. CONCLUSION Although the use of EU(7)-PIMs has been declining, regional differences indicate considerable room for improvement. The comparison with PRISCUS highlights the necessity of regular updates of PIM lists.
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21
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Weersink RA, Alvarez-Alvarez I, Medina-Cáliz I, Sanabria-Cabrera J, Robles-Díaz M, Ortega-Alonso A, García-Cortés M, Bonilla E, Niu H, Soriano G, Jimenez-Perez M, Hallal H, Blanco S, Kaplowitz N, Lucena MI, Andrade RJ. Clinical Characteristics and Outcome of Drug-Induced Liver Injury in the Older Patients: From the Young-Old to the Oldest-Old. Clin Pharmacol Ther 2021; 109:1147-1158. [PMID: 33179256 DOI: 10.1002/cpt.2108] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/02/2020] [Indexed: 02/05/2023]
Abstract
Older patients with hepatotoxicity have been scarcely studied in idiosyncratic drug-induced liver injury (DILI) cohorts. We sought the distinctive characteristics of DILI in older patients across age groups. A total of 882 DILI patients included in the Spanish DILI Registry (33% ≥ 65 years) were categorized according to age: "young" (< 65 years); "young-old" (65-74 years); "middle-old" (75-84 years); and "oldest-old" (≥ 85 years). All elderly groups had an increasingly higher comorbidity burden (P < 0.001) and polypharmacy (P < 0.001). There was a relationship between jaundice and hospitalization (P < 0.001), and both were more prevalent in the older age groups, especially in the oldest-old (88% and 69%, respectively), and the DILI episode was more severe (P = 0.029). The proportion of females decreased across age groups from the young to the middle-old, yet in the oldest-old there was a distinct female predominance. Pattern of liver injury shifted towards cholestatic with increasing age among top culprit drugs amoxicillin-clavulanate, atorvastatin, levofloxacin, ibuprofen, and ticlopidine. The best cutoff point for increased odds of cholestatic DILI was 65 years. Older patients had increased non-liver-related mortality (P = 0.030) as shown by the predictive capacity of the Model for End-Stage Liver Disease score (odds ratio (OR) = 1.116; P < 0.001), and comorbidity burden (OR = 4.188; P = 0.001) in the 6-month mortality. Older patients with DILI exhibited an increasingly predominant cholestatic phenotype across a range of culprit drugs, other than amoxicillin-clavulanate, with increased non-liver-related mortality and require a different approach to predict outcome. The oldest DILI patients exhibited a particular phenotype with more severe DILI episodes and need to be considered when stratifying older DILI populations.
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Affiliation(s)
- Rianne A Weersink
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Department of Clinical Pharmacy, Deventer Hospital, Deventer, The Netherlands
| | - Ismael Alvarez-Alvarez
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Inmaculada Medina-Cáliz
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
| | - Judith Sanabria-Cabrera
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Platform for Clinical Research and Clinical Trials IBIMA, SCReN (Spanish Clinical Research Network), Madrid, Spain
| | - Mercedes Robles-Díaz
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
| | - Aida Ortega-Alonso
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Miren García-Cortés
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Elvira Bonilla
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Hao Niu
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - German Soriano
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio Aparato Digestivo, Hospital Santa Creu I Sant Pau, Barcelona, Spain
| | | | - Hacibe Hallal
- Servicio Aparato Digestivo, Hospital General Universitario J.M. Morales Meseguer, Murcia, Spain
| | - Sonia Blanco
- Servicio de Aparato Digestivo, Hospital Universitario Basurto, Bilbao, Spain
| | - Neil Kaplowitz
- Keck School of Medicine, University of Southern California Research Center for Liver Diseases, Los Angeles, California, USA
| | - M Isabel Lucena
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Platform for Clinical Research and Clinical Trials IBIMA, SCReN (Spanish Clinical Research Network), Madrid, Spain
| | - Raúl J Andrade
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
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22
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Mangoni AA, Jarmuzewska EA. Incorporating pharmacokinetic data into personalised prescribing for older people: challenges and opportunities. Eur Geriatr Med 2021; 12:435-442. [PMID: 33417165 DOI: 10.1007/s41999-020-00437-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE We discuss the known age-associated changes in drug metabolism and elimination, the potential use of this information when selecting specific therapeutic strategies in older patients, and the steps required to fill the knowledge gap in this field. METHODS We conducted a narrative review that encapsulates the current knowledge regarding the main age-associated changes in drug metabolism and elimination and discusses their possible inclusion in current and future personalised prescribing tools for the older patient population. RESULTS Despite some progress in this field, the lack of specific information regarding the impact of frailty, pharmacogenomics, and drug-drug, drug-disease, and organ-organ interactions, particularly in subjects > 80 years, currently prevents the routine incorporation of pharmacokinetic data, barring measures of renal function, into personalised prescribing tools. CONCLUSIONS The incorporation of pharmacokinetic data into personalised prescribing, an approach based on the consideration of a number of patient's characteristics when selecting the right drug(s) and dose regimen(s) to maximize effectiveness and limit toxicity, remains a hypothetical construct in geriatric care. Pending the inclusion of frail and complex older patients in pre- and post-marketing studies, a better understanding of the key pharmacokinetic alterations of common medications in "real-life" patients, together with the implementation of effective strategies tackling inappropriate prescribing, is likely to improve clinical outcomes and reduce healthcare utilization in the older population.
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Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Bedford Park, SA, 5042, Australia. .,Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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23
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Opioid prescribing and risk of drug-opioid interactions in older discharged patients with polypharmacy in Australia. Int J Clin Pharm 2020; 43:365-374. [PMID: 33206289 DOI: 10.1007/s11096-020-01191-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/28/2020] [Indexed: 01/19/2023]
Abstract
Background Opioids are commonly prescribed to managing chronic pain in older persons. However, these patients are often at risk of drug-opioid interactions due to polypharmacy. Objectives To identify the prevalence of opioid prescribing and drug-opioid interactions in poly-medicated older patients and factors associated with opioid prescribing. Setting Patients were included if they were admitted to the Royal Adelaide Hospital between September 2015 and August 2016, aged ≥ 75 years and took ≥ 5 medications at discharge. Methods After ethics approval, data of were retrospectively collected from case notes. The Charlson Comorbidity Index and Drug Burden Index were determined and opioids were classified as strong or weak. The association between opioid use and concurrent medications was computed using logistic regression and the results presented as odds ratios (OR) and 95% confidence intervals (95% CI), adjusted for age, sex, Charlson Comorbidity Index, number of prescribed medications and modified-Drug Burden Index. Main outcome measure Association between concurrent medications and opioid prescribing. Results 15,000 geriatric admissions were identified, of which 1192 were included. A total of 283 (23.7%) patients were prescribed opioids, with oxycodone accounting for 56% of these prescriptions. Opioid users were prescribed more medications (11.2 vs. 9.0, P < 0.001) and had higher Drug Burden Index (1.2 vs. 0.14, P < 0.001) compared to non-users. Opioid use was associated with concurrent prescription of antiepileptics (OR = 1.7, 95% CI 1.1-2.6), and negatively associated with Charlson Comorbidity Index (OR = 0.9, 95% CI 0.8-0.98) and concurrent use of antipsychotics (OR = 0.5, 95% CI 0.3-0.9) and beta blocking agents (OR = 0.4, 95% CI 0.3-0.6). Conclusions Strong opioids were prescribed more often than weak opioids and opioid users presented with characteristics and concurrent medications which increased the risk of opioid related adverse drug effects.
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Maher D, Ailabouni N, Mangoni AA, Wiese MD, Reeve E. Alterations in drug disposition in older adults: a focus on geriatric syndromes. Expert Opin Drug Metab Toxicol 2020; 17:41-52. [PMID: 33078628 DOI: 10.1080/17425255.2021.1839413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Age-associated physiological changes can alter the disposition of drugs, however, pathophysiological changes associated with geriatric syndromes in older adults may lead to even greater heterogeneity in pharmacokinetics. Geriatric syndromes are common health problems in older adults which have multifactorial causes and do not fit into distinct organ-based disease categories. With older adults being the greatest users of medications, understanding both age- and geriatric syndrome-related changes is important clinically to ensure safe and effective medication use. AREAS COVERED This review provides an overview of current evidence regarding pharmacokinetic alterations that occur with aging and in common geriatric syndromes, including frailty, sarcopenia, dementia, polypharmacy and enteral feeding. The evidence is presented according to the four primary pharmacokinetic processes (Absorption, Distribution, Metabolism and Excretion). EXPERT OPINION There is some evidence to inform our understanding of the impact of chronological aging and various geriatric syndromes on drug disposition. However, many areas require more research, including drug induced inhibition and induction of cytochrome P450 enzymes and the clinical utility of emerging methods for estimating renal function. There is a need to develop tools to predict alterations in drug disposition in subgroups of older adults, particularly where the currently available clinical information is sparse.
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Affiliation(s)
- Dorsa Maher
- Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia , Adelaide, Australia
| | - Nagham Ailabouni
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia , Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre , Bedford Park, Australia
| | - Michael D Wiese
- Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia , Adelaide, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia , Australia.,Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority , Halifax, Canada
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25
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Achterhof AB, Rozsnyai Z, Reeve E, Jungo KT, Floriani C, Poortvliet RKE, Rodondi N, Gussekloo J, Streit S. Potentially inappropriate medication and attitudes of older adults towards deprescribing. PLoS One 2020; 15:e0240463. [PMID: 33104695 PMCID: PMC7588126 DOI: 10.1371/journal.pone.0240463] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Multimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to assess patients' attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe. METHOD We analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness. RESULTS Data from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81). CONCLUSION The willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients' awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.
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Affiliation(s)
- Alexandra B. Achterhof
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Zsofia Rozsnyai
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
- Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Katharina Tabea Jungo
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Carmen Floriani
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
| | | | - Nicolas Rodondi
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - 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
| | - Sven Streit
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
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Drenth‐van Maanen AC, Wilting I, Jansen PAF. Prescribing medicines to older people-How to consider the impact of ageing on human organ and body functions. Br J Clin Pharmacol 2020; 86:1921-1930. [PMID: 31425638 PMCID: PMC7495267 DOI: 10.1111/bcp.14094] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 12/25/2022] Open
Abstract
Ageing is associated with several changes in human organs, which result in altered medication pharmacokinetics and pharmacodynamics. Ageing is also associated with changes in human body functions, such as impaired vision, hearing, swallowing, motor and cognitive functions, which can affect the adequate intake and administration of drugs. As a consequence, older people, and especially patients older than 75 years, are the main users of many drugs and they frequently use 5 drugs or more long-term (i.e. polypharmacy). All this increases the complexity of adequate drug intake, administration and adherence. However, there is a lack of evidence on the considerations that should be taken into account to ensure appropriate drug prescribing to older people. This review article summarizes the most clinically relevant changes in human organ and body functions and the consequential changes in pharmacokinetics and pharmacodynamics in older people, along with possible dosing consequences or alternatives for drugs frequently prescribed to this patient population. Recommendations are given on how ageing could be considered in clinical drug development, drug authorization and appropriate prescribing.
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Affiliation(s)
- A. Clara Drenth‐van Maanen
- Geriatric DepartmentUniversity Medical Center UtrechtThe Netherlands
- Expertise Centre Pharmacotherapy in Old Persons (Ephor), The Netherlands
| | - Ingeborg Wilting
- Department of Clinical PharmacyUniversity Medical Center Utrecht, The Netherlands
| | - Paul A. F. Jansen
- Geriatric DepartmentUniversity Medical Center UtrechtThe Netherlands
- Expertise Centre Pharmacotherapy in Old Persons (Ephor), The Netherlands
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Roberti R, Palleria C, Nesci V, Tallarico M, Di Bonaventura C, Cerulli Irelli E, Morano A, De Sarro G, Russo E, Citraro R. Pharmacokinetic considerations about antiseizure medications in the elderly. Expert Opin Drug Metab Toxicol 2020; 16:983-995. [DOI: 10.1080/17425255.2020.1806236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Roberta Roberti
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Caterina Palleria
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Valentina Nesci
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Martina Tallarico
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Carlo Di Bonaventura
- Neurology Unit, Department of Human Neurosciences, “Sapienza” University, Rome, Italy
| | | | - Alessandra Morano
- Neurology Unit, Department of Human Neurosciences, “Sapienza” University, Rome, Italy
| | | | - Emilio Russo
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Rita Citraro
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
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28
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Michels G, Sieber CC, Marx G, Roller-Wirnsberger R, Joannidis M, Müller-Werdan U, Müllges W, Gahn G, Pfister R, Thürmann PA, Wirth R, Fresenborg J, Kuntz L, Simon ST, Janssens U, Heppner HJ. [Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]. Med Klin Intensivmed Notfmed 2020; 115:393-411. [PMID: 31278437 DOI: 10.1007/s00063-019-0590-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.
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Affiliation(s)
- Guido Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Cornel C Sieber
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
| | - Gernot Marx
- Klinik für Operative Intensivmedizin und Intermediate Care, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | | | - Michael Joannidis
- Gemeinsame Einrichtung für Internistische Intensiv- und Notfallmedizin, Department Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Ursula Müller-Werdan
- Klinik für Geriatrie und Altersmedizin, Evangelisches Geriatriezentrum Berlin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Roman Pfister
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Petra A Thürmann
- Lehrstuhl für Klinische Pharmakologie, Helios Universitätsklinkum Wuppertal, Universität Witten/Herdecke, Wuppertal, Deutschland
| | - Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | - Jana Fresenborg
- Seminar für Allgemeine BWL und Management im Gesundheitswesen, Universität zu Köln, Köln, Deutschland
| | - Ludwig Kuntz
- Seminar für Allgemeine BWL und Management im Gesundheitswesen, Universität zu Köln, Köln, Deutschland
| | - Steffen T Simon
- Zentrum für Palliativmedizin, Uniklinik Köln, Köln, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital Eschweiler, Eschweiler, Deutschland
| | - Hans Jürgen Heppner
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
- Geriatrische Klinik und Tagesklinik, Lehrstuhl für Geriatrie, HELIOS Klinikum Schwelm, Universität Witten/Herdecke, Schwelm, Deutschland
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29
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Ye LX, Xu Y, Zhang SH, Cao DX, Chen LF, Su YP, Huang HH, Yu CX. Orally Administered Koumine Persists Longer in the Plasma of Aged Rats Than That of Adult Rats as Assessed by Ultra-Performance Liquid Chromatography-Tandem Mass Spectrometry. Front Pharmacol 2020; 11:1113. [PMID: 32792950 PMCID: PMC7385321 DOI: 10.3389/fphar.2020.01113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/08/2020] [Indexed: 12/28/2022] Open
Abstract
Aging leads to changes in nearly all pharmacokinetic phases. Koumine (KM), an alkaloid derived from Gelsemium elegans Benth., is effective against age-associated chronic diseases, but its dose proportionality following oral administration in aged individuals remains unknown. Herein, we established and validated a simple method that requires low sample volumes to determine KM concentration in rats using ultra-performance liquid chromatography-tandem mass spectrometry. The maximum plasma concentration (Cmax) of 7 mg·kg−1 KM was ~12-fold and ~24-fold higher than that of 0.28 mg·kg−1 KM in adult and aged rats, respectively (P < 0.01). Time to reach Cmax (Tmax) for 7 mg·kg−1 KM was 4-fold longer in aged rats (P < 0.05). The area under the curve (AUC) of 7 mg·kg−1 KM was >17-fold and >43-fold higher than those of 0.28 mg·kg−1 KM in adult and aged rats, respectively (P < 0.01). The half-life (t1/2) of 7 mg·kg−1 KM was over 4-fold longer than that of 0.28 mg·kg−1 KM in adult rats (P < 0.01). The t1/2 of 1.4 and 7 mg·kg−1 KM were 1.5~2-fold longer, than that of 0.28 mg·kg−1 KM in aged rats (P < 0.05). The clearance rate of 7 mg·kg−1 KM was significantly lower in aged than in adult rats (P < 0.05). For 7.0 mg·kg−1 KM, the Cmax in aged rats was higher than in adult rats during the Tmax period (P < 0.05). In aged rats, the AUC for KM was >2.5-fold higher (P < 0.05) and the t1/2 was >60% longer than in adult rats (P < 0.05). These results help interpret the pharmacokinetics of KM in aging-associated diseases.
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Affiliation(s)
- Li-Xiang Ye
- Fujian Center for Safety Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Ying Xu
- Department of Pharmacology, College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Shui-Hua Zhang
- Fujian Center for Safety Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Da-Xuan Cao
- Fujian Center for Safety Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Ling-Fan Chen
- Fujian Center for Safety Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Yan-Ping Su
- Department of Pharmacology, College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Hui-Hui Huang
- Department of Pharmacology, College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Chang-Xi Yu
- Department of Pharmacology, College of Pharmacy, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Natural Medicine Pharmacology, College of Pharmacy, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Drug Target Discovery and Structural and Functional Research, College of Pharmacy, Fujian Medical University, Fuzhou, China
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Reeve E, Jordan V, Thompson W, Sawan M, Todd A, Gammie TM, Hopper I, Hilmer SN, Gnjidic D. Withdrawal of antihypertensive drugs in older people. Cochrane Database Syst Rev 2020; 6:CD012572. [PMID: 32519776 PMCID: PMC7387859 DOI: 10.1002/14651858.cd012572.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Hypertension is an important risk factor for subsequent cardiovascular events, including ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Overall, the use of antihypertensive medications has led to reduction in cardiovascular disease, morbidity rates and mortality rates. However, the use of antihypertensive medications is also associated with harms, especially in older people, including the development of adverse drug reactions, drug-drug interactions and can contribute to increasing medication-related burden. As such, discontinuation of antihypertensives may be considered and appropriate in some older people. OBJECTIVES To investigate whether withdrawal of antihypertensive medications is feasible, and evaluate the effects of withdrawal of antihypertensive medications on mortality, cardiovascular outcomes, hypertension and quality of life in older people. SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to April 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 3), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also conducted reference checking, citation searches and, when appropriate, contacted study authors to identify any additional studies. The searches had no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) of withdrawal versus continuation of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults (defined as 50 years and over). Participants were eligible if they lived in the community, residential aged care facilities, or were based in hospital settings. We sought to include trials looking at the complete withdrawal of the antihypertensive medication, and those focusing on a dose reduction of the antihypertensive medicine. DATA COLLECTION AND ANALYSIS We compared the intervention of discontinuing or reducing antihypertensive medication to usual treatment using mean differences (MD) and 95% confidence intervals (95% CIs) for continuous variables and we used Peto odds ratios (ORs) and 95% CI for binary variables. Our primary outcomes included: mortality, myocardial infarction, development of adverse drug reactions or adverse drug withdrawal reactions. Secondary outcomes included: blood pressure, hospitalisation, stroke, success of withdrawing from antihypertensives, quality of life, and falls. Two authors independently, and in duplicate, conducted all stages of study selection, data extraction and quality assessment. MAIN RESULTS Six RCTs met the inclusion criteria and were included in the review (1073 participants). Study duration and follow-up ranged from 4 weeks to 56 weeks. Meta-analysis of studies showed that, in the discontinuation group compared to continuation, the odds for all-cause mortality were 2.08 (95% CI 0.79 to 5.46; low certainty of evidence), for myocardial infarction 1.86 (95% CI 0.19 to 17.98; very low certainty of evidence) and for stroke 1.44 (95% CI 0.25 to 8.35; low certainty of evidence). Blood pressure was higher in the discontinuation group than the continuation group (systolic blood pressure: MD = 9.75 mmHg, 95% CI 7.33 to 12.18; and diastolic blood pressure: MD = 3.5 mmHg, 95% CI 1.82 to 5.18; low certainty of evidence). For the development of adverse events, meta-analysis was not possible; antihypertensive discontinuation did not appear to increase the risk of adverse events and may lead to resolution of adverse drug reactions, although eligible studies had limited reporting of adverse effects of drug withdrawal (very low certainty of evidence). One study reported hospitalisation with an odds ratio of 0.83 for discontinuation compared to continuation (95% CI 0.33 to 2.10; low certainty of evidence). No studies were identified which reported falls. Between 10.5% and 33.3% of participants in the discontinuation group compared to 9% to 15% in the continuation group experienced raised blood pressure or other clinical criteria (as pre-defined by the studies) that would require restarting of therapy/removal from the study. The sources of bias included selective reporting (reporting bias), lack of blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and lack of blinding of participants and personnel (performance bias). AUTHORS' CONCLUSIONS There is no evidence of an effect of discontinuing compared with continuing antihypertensives used for hypertension or primary prevention of cardiovascular disease in older adults on all-cause mortality and myocardial infarction. The evidence was low to very low certainty mainly due to small studies and low event rates. These limitations mean that we cannot make any firm conclusions about the effect of deprescribing antihypertensives on these outcomes. Future research should focus on populations with the greatest uncertainty of the benefit:risk ratio for use of antihypertensive medications, such as those with frailty, older age groups and those taking polypharmacy, and measure clinically important outcomes such as falls, quality of life and adverse drug events.
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Affiliation(s)
- Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia
- College of Pharmacy, Dalhousie University, Halifax, Canada
- Geriatric Medicine Research, Nova Scotia Health Authority and Dalhousie University, Halifax, Canada
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Wade Thompson
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Mouna Sawan
- Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney University, Camperdown, Sydney, Australia
| | - Adam Todd
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK
| | | | - Ingrid Hopper
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, The Alfred, Melbourne, Australia
| | - Sarah N Hilmer
- Kolling Institute, Royal North Shore Hospital and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, St Leonards, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, and Charles Perkins Centre, University of Sydney, Sydney, Australia
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Abstract
Atrial fibrillation is the most common arrhythmia in clinical practice, and age is one of the strongest predictors/risk factors for ischemic stroke in patients with atrial fibrillation. Elderly patients, in particular patients aged 80 years and older, are at higher risk of both ischemic and bleeding events compared with younger patients. Vitamin K antagonists (VKAs) reduce the risk of ischemic stroke, especially in the elderly, but increase the bleeding risk. In addition, frequent international normalized ratio monitoring is needed to ensure the optimal level of anticoagulation. Furthermore, VKAs have multiple drug and food interactions. Direct oral anticoagulants (DOACs) have recently emerged as alternatives to VKAs and are gradually increasing their popularity mainly because of their fewer drug and food interactions and ease of use. Their effectiveness and safety have been well-established in the general population, but the benefit in the very elderly (≥80 years old) is still unclear. Data about the safety and the effectiveness of DOACs in patients older than 75 years are available in literature, but the evidences of the use of DOACs in patients aged 80 years and older are lacking. This review aims to give light to the differences, in terms of benefits and safety, of the DOACs in this subset of patients.
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32
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Fernández CS, Gullón A, Formiga F. The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation. J Comp Eff Res 2020; 9:509-523. [PMID: 32329353 DOI: 10.2217/cer-2019-0197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation.
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Affiliation(s)
| | - Alejandra Gullón
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain
| | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Mortsiefer A, Wilm S, Santos S, Löscher S, Wollny A, Drewelow E, Ritzke M, Thürmann P, Mann NK, Meyer G, Abraham J, Icks A, Montalbo J, Wiese B, Altiner A. Family conferences and shared prioritisation to improve patient safety in the frail elderly (COFRAIL): study protocol of a cluster randomised intervention trial in primary care. Trials 2020; 21:285. [PMID: 32197631 PMCID: PMC7082941 DOI: 10.1186/s13063-020-4182-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/18/2020] [Indexed: 01/19/2023] Open
Abstract
Background Frailty in elderly patients is associated with an increased risk of poor health outcomes, including falls, delirium, malnutrition, hospitalisation, and mortality. Because polypharmacy is recognised as a possible major contributor to the pathogenesis of geriatric frailty, reducing inappropriate medication exposure is supposed to be a promising approach to improve health-related quality of life and prevent adverse outcomes. A major challenge for the process of deprescribing of inappropriate polypharmacy is to improve the communication between general practitioner (GPs), patient and family carer. This study investigates the effects of a complex intervention in frail elderly patients with polypharmacy living at home. Methods This is a cluster randomised controlled trial including 136 GPs and 676 patients. Patients with a positive clinical screening for frailty are eligible if they are aged 70 years or older, receiving family or professional nursing care at home, and taking in five or more drugs per day. Exclusion criteria are higher grade of dementia and life expectancy of 6 months or less. The GPs of the intervention group receive an educational training promoting a deprescribing guideline and providing information on how to conduct a family conference focussing on prioritisation of treatment goals concerning drug therapy. During the 1-year intervention, GPs are expected to perform a total of three family conferences, each including a structured medication review with patients and their family carers. GPs of the control group will receive no training and will deliver care as usual. Geriatric assessment of all patients will be performed by study nurses during home visits at baseline and after 6 and 12 months. The primary outcome is the hospitalisation rate during the observation period of 12 months. Secondary outcomes are number and appropriateness of medications, mobility, weakness, cognition, depressive disorder, health-related quality of life, activities of daily living, weight, and costs of health care use. Discussion This study will provide evidence for a pragmatic co-operative and patient-centred educational intervention using family conferences to improve patient safety in frail elderly patients with polypharmacy. Trial registration German Clinical Trials Register, DRKS00015055 (WHO International Clinical Trials Registry Platform [ICTRP]). Registered on 6 February 2019.
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Affiliation(s)
- Achim Mortsiefer
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Stefan Wilm
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Sara Santos
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Susanne Löscher
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Anja Wollny
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Eva Drewelow
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Manuela Ritzke
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Nina-Kristin Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Gabriele Meyer
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Jens Abraham
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Andrea Icks
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Joseph Montalbo
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Birgitt Wiese
- WG Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Attila Altiner
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
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Dearing ME, Bowles S, Isenor J, Kits O, Kouladjian O'Donnell L, Neville H, Hilmer S, Toombs K, Sirois C, Hajizadeh M, Negus A, Rockwood K, Reeve E. Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis. BMJ Open 2020; 10:e035656. [PMID: 32086361 PMCID: PMC7044900 DOI: 10.1136/bmjopen-2019-035656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. METHODS AND ANALYSIS This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2, analysis of variance and unadjusted and adjusted regression methods. ETHICS AND DISSEMINATION Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences. TRIAL REGISTRATION NUMBER NCT03698487.
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Affiliation(s)
- Marci Elizabeth Dearing
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Susan Bowles
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Isenor
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Olga Kits
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Kouladjian O'Donnell
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Heather Neville
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sarah Hilmer
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Kent Toombs
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Universite Laval, Québec city, Quebec, Canada
- Centre for Excellence on Aging of Quebec, Quebec Integrated University Centre for Health and Social Services of the National Capital, Québec city, Québec, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Aprill Negus
- Department of Family Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Centre for Health Care of the Elderly, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Emily Reeve
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality Use of Medicines Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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Abstract
PURPOSE OF REVIEW With the growing of the aging population, increased and new methods of anesthesia and surgery allow for surgery and other interventions in older adults.Pharmacokinetics and pharmacodynamics of drugs in older adults differ from those in younger and middle-aged adults. However, the geriatric population is frequently neglected in the context of clinical trials. The present review focuses on the consequences of multimorbidity and pharmacokinetic and pharmacodynamic alterations and their implications on anesthesia. RECENT FINDINGS Physiologically based pharmacokinetic and pharmacodynamic modeling may serve as an option to better understand the influence of age on drugs used for anesthesia. However, difficulties to adequately characterize geriatric patients are described. SUMMARY Further research of drug effects in the aging population may include physiologically based pharmacokinetic and pharmacodynamic complex models and randomized controlled trials with thoroughly conducted geriatric assessments.
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[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]. Z Gerontol Geriatr 2019; 52:440-456. [PMID: 31278486 DOI: 10.1007/s00391-019-01584-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.
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Le Bosquet K, Barnett N, Minshull J. Deprescribing: Practical Ways to Support Person-Centred, Evidence-Based Deprescribing. PHARMACY 2019; 7:E129. [PMID: 31484305 PMCID: PMC6789835 DOI: 10.3390/pharmacy7030129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 08/14/2019] [Accepted: 08/22/2019] [Indexed: 12/20/2022] Open
Abstract
Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments and use of single disease model guidelines have led to a healthcare system geared towards prescribing, with deprescribing often seen as a separate activity. Deprescribing should be seen as part of prescribing, and is a key element in ensuring patients remain on the most appropriate medications at the correct doses for them. Due to the complex nature of polypharmacy, every patient experience and relationship with medications is unique. The individual's history must be incorporated into a patient-centred medication review, in order for medicines to remain optimal through changes in circumstance and health. Knowledge of the law and appropriate recording is important to ensure consent is adequately gained and recorded in line with processes followed when initiating a medication. In recent years, with the increase in interested clinicians globally, a number of prominent networks have grown, creating crucial links for both research and sharing of good practice.
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Affiliation(s)
| | - Nina Barnett
- NHS Specialist Pharmacy Service, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - John Minshull
- NHS Specialist Pharmacy Service, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
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Morin L, Wastesson JW, Laroche ML, Fastbom J, Johnell K. How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study. Palliat Med 2019; 33:1080-1090. [PMID: 31172885 PMCID: PMC6691599 DOI: 10.1177/0269216319854013] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. AIM To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. DESIGN Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. SETTING Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. RESULTS A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75-84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. CONCLUSION A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.
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Affiliation(s)
- Lucas Morin
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas W Wastesson
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie-Laure Laroche
- 3 Centre de pharmacovigilance et de pharmaco-épidémiologie, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, CHU Limoges, Limoges, France.,4 INSERM 1248, University of Limoges, CHU Limoges, Limoges, France
| | - Johan Fastbom
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Johnell
- 2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Chang Z, Ghirardi L, Quinn PD, Asherson P, D’Onofrio BM, Larsson H. Risks and Benefits of Attention-Deficit/Hyperactivity Disorder Medication on Behavioral and Neuropsychiatric Outcomes: A Qualitative Review of Pharmacoepidemiology Studies Using Linked Prescription Databases. Biol Psychiatry 2019; 86:335-343. [PMID: 31155139 PMCID: PMC6697582 DOI: 10.1016/j.biopsych.2019.04.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/02/2019] [Accepted: 04/07/2019] [Indexed: 12/24/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) medication is one of the most commonly prescribed medication classes in child and adolescent psychiatry, and its use is increasing rapidly in adult psychiatry. However, major questions and concerns remain regarding the benefits and risks of ADHD medication, especially in real-world settings. We conducted a qualitative systematic review of studies that investigated the effects of ADHD medication on behavioral and neuropsychiatric outcomes using linked prescription databases from the last 10 years and identified 40 studies from Europe, North America, and Asia. Among them, 18 used within-individual designs to account for confounding by indication. These studies suggested short-term beneficial effects of ADHD medication on several behavioral or neuropsychiatric outcomes (i.e., injuries, motor vehicle accidents, education, substance use disorder), with estimates suggesting relative risk reduction of 9% to 58% for these outcomes. The within-individual studies found no evidence of increased risks for suicidality and seizures. Replication studies are needed for several other important outcomes (i.e., criminality, depression, mania, psychosis). The available evidence from pharmacoepidemiology studies on long-term effects of ADHD medication was less clear. We discuss time-varying confounding and other limitations that should be considered when interpreting results from pharmacoepidemiology studies. Furthermore, we highlight several knowledge gaps to be addressed in future research and implications for research on mechanisms of outcomes of ADHD medications.
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Affiliation(s)
- Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Laura Ghirardi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN
| | - Philip Asherson
- Social Genetic and Developmental Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,School of Medical Sciences, Örebro University, Örebro, Sweden
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Sirois C, Ouali A, Simard M. Polypharmacy among Older Individuals with COPD: Trends between 2000 and 2015 in Quebec, Canada. COPD 2019; 16:234-239. [PMID: 31401851 DOI: 10.1080/15412555.2019.1646716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The treatment of chronic obstructive pulmonary disease (COPD) and concomitant diseases requires several medications. Yet there is little data on how the pharmacological burden progressed over time among older individuals with COPD. We aimed to: 1) describe the proportion of older adults with COPD in Quebec, Canada, that were exposed to polypharmacy (≥10, ≥15 or ≥20 medications/year) between 2000 and 2015; 2) calculate the proportion of individuals receiving specific prescriptions for COPD during this period. We conducted a population-based cohort study with the Quebec Integrated Chronic Disease Surveillance System. Individuals aged ≥66 years with COPD and covered by the universal public drug plan were included. We calculated the total number of drugs used at least once by each individual during each of the studied years, and used age-standardized proportions to compare proportions of users between the years. The average number of drugs used increased from 12.0 in 2000 to 14.8 in 2015. The proportion of individuals exposed to polypharmacy increased (≥10 drugs: 62.0% to 74.6%;≥15 drugs: 31.2% to 45.4%; ≥20 drugs: 12.3% to 22.4%). The proportion of individuals receiving long-acting bronchodilators increased from 18.7% in 2000 to 69.6% in 2015. The use of short-acting bronchodilators decreased from 81.5% to 67.9%, and that of inhaled corticosteroids from 60.6% to 26.0%. The proportion of users of methylxanthines decreased from 15.0% to 1.9%. Older individuals with COPD are increasingly exposed to polypharmacy. Identifying which polypharmacy is beneficial is a priority.
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Affiliation(s)
- Caroline Sirois
- Faculty of Medicine, Université Laval , Québec , Canada.,Institut national de santé publique du Québec , Québec , Canada.,Centre d'excellence sur le vieillissement de Québec , Québec , Canada
| | - Amina Ouali
- Faculty of Medicine, Université Laval , Québec , Canada
| | - Marc Simard
- Institut national de santé publique du Québec , Québec , Canada
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Ali I, Guidone D, Nicolazzo JA, Brouwer KLR. Impact of reduced P-glycoprotein function on digoxin concentrations in patients with dementia. Br J Clin Pharmacol 2019; 85:2351-2359. [PMID: 31269278 DOI: 10.1111/bcp.14049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/22/2019] [Accepted: 06/17/2019] [Indexed: 01/19/2023] Open
Abstract
AIMS Patients with Alzheimer's disease (AD), the most common form of dementia, have reduced P-glycoprotein (P-gp) function at the blood-brain barrier. However, the effect of AD on P-gp function in peripheral organs, and the impact on medication efficacy and toxicity is unknown. In this study, clinical chart review and physiologically based pharmacokinetic (PBPK) modelling were employed to determine whether disease-associated changes in P-gp could be assessed from clinically measured digoxin concentrations in patients without and with dementia. METHODS A retrospective chart review was conducted to compare digoxin dose and concentrations between cohorts. A PBPK model was developed to simulate changes in digoxin concentrations at single and multiple 62.5 and 125 μg/d doses due to reduced P-gp function in peripheral organs. RESULTS Digoxin concentrations were similar between the nondementia (n = 75) and dementia (n = 72) cohorts (mean ± standard deviation; 0.64 ± 0.31 and 0.60 ± 0.34 ng/mL, respectively; -0.06 to 0.15, 95% confidence interval of difference). PBPK simulations showed that reduced P-gp function resulted in a significant increase in digoxin exposure (AUC), but not in Cmax . For example, when a 2-fold reduction in P-gp function was simulated in older people following multiple 125 μg/d digoxin doses, the AUC over the last dosing interval was increased compared to baseline (24.29 ± 3.94 vs 17.04 ± 3.46 ng/mL*h; 4.52 to 9.98); however, Cmax was similar (1.38 ± 0.20 vs 0.99 ± 0.18 ng/mL; -2.33 to 3.13). CONCLUSION Clinically measured digoxin concentrations were not statistically different in patients with dementia. Based on PBPK simulations, digoxin AUC may need to be evaluated to adequately assess the impact of reduced P-gp function in peripheral organs.
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Affiliation(s)
- Izna Ali
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Joseph A Nicolazzo
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Kim L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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Biology of frailty: Implications for clinical pharmacology and drug therapy in frail older people. Mech Ageing Dev 2019; 181:22-28. [PMID: 31125572 DOI: 10.1016/j.mad.2019.111119] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/30/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
Abstract
Polypharmacy is very common in frail older people, although medications are rarely evaluated in this population. We conducted a narrative review of the effects of the biology of frailty on clinical pharmacology to inform the extrapolation of the results from clinical trials in robust people to the treatment of frail older people. Biological changes of frailty, such as changes in body composition, organ function and vulnerability to external stressors, are likely to impact on the pharmacokinetics and pharmacodynamics of drugs when used in frail older people. We considered whether these theoretical impacts were observed in the limited empirical data on pharmacokinetics in frail and robust older people. We applied what is known about the biology of frailty to interpret results of clinical trials that have conducted subgroup analyses of drug response by frailty status; and results of observational data on the safety of medications when used in frail older people. Synthesising the effects of the biology of frailty on clinical pharmacology is complicated by the use of different definitions of frailty, including a range of validated scales (that identify different people as frail), clinical judgement and residence in a nursing home.
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Nachtigall A, Heppner HJ, Thürmann PA. Influence of pharmacist intervention on drug safety of geriatric inpatients: a prospective, controlled trial. Ther Adv Drug Saf 2019; 10:2042098619843365. [PMID: 31019678 PMCID: PMC6469284 DOI: 10.1177/2042098619843365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 03/20/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Demographic shift leads to an increasing number of geriatric patients suffering from multimorbidity and resulting polypharmacy. Polypharmacy is shown to be associated with drug-related problems (DRPs) and increased morbidity. For Germany, a hospital-based intervention may be successful optimizing of polypharmacy. The aim of this study was to reduce DRPs in geriatric inpatients by a structured pharmacist's intervention and to measure the acceptance rate of pharmaceutical recommendations. METHODS This study followed an open, prospective, quasi-randomized, controlled design and was conducted in a geriatric department in a teaching hospital in Germany. Patients of all sexes were included, with a minimum age of 70 years, a written informed consent and a regular intake of at least five drugs daily. Primary outcome was the percentage of patients having a DRP at admission and discharge. A DRP was defined as a prescription without indication or a relevant drug-drug interaction or prescription of a potentially inappropriate medication or presence of an adverse drug reaction. Recommendations were classified and discussed face to face. Statistical analyses were performed using a full-set analysis and a matched-pairs design. RESULTS Within 12 months, 411 patients were recruited with median age of 82 years (intervention: n = 209; control: n = 202). Median number of drugs at admission was 10 (range 5-24), at discharge 9 (range 3-21). In the intervention group, the percentage of patients with a DRP was reduced from 86.6% to 56.0%; in the control group, from 76.7% to 76.2% (p value < 0.001). Medication appropriateness index score was reduced by 56% in the intervention group and by 0.2% in the control group (p value < 0.001). Implementation rate of the pharmaceutical recommendation was 80%. CONCLUSION This prospective controlled trial showed that a pharmacist's intervention was successful in optimizing polypharmacy in geriatric inpatients.
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Affiliation(s)
- Angela Nachtigall
- Department of Human Medicine, University of
Witten/Herdecke, Witten, Germany, Pharmacy, Helios Clinic Schwelm, Schwelm,
Germany
| | - Hans J. Heppner
- Department of Human Medicine, University of
Witten/Herdecke, Witten, Germany Department of Geriatric Medicine, Helios
Clinic Schwelm, Schwelm, Germany, Institute for Biomedicine of Ageing, FAU
Erlangen-Nuremberg, Nuremberg, Germany
| | - Petra A. Thürmann
- Department of Human Medicine, University of
Witten/Herdecke, Witten, Germany Department of Geriatric Medicine, Helios
Clinic Schwelm, Schwelm, Germany, Institute for Biomedicine of Ageing, FAU
Erlangen-Nuremberg, Nuremberg, Germany
- Department of Human Medicine, University of
Witten/Herdecke, Witten, Germany
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Mangoni AA, Bryant K, Jarmuzewska EA. Medication Management Issues in Old Age: A Call for Submissions to Current Clinical Pharmacology. ACTA ACUST UNITED AC 2019; 14:2-4. [PMID: 30968764 DOI: 10.2174/157488471401190301120237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia
| | - Kimberley Bryant
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia.,Department of Orthopaedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders, Medical Centre, Adelaide, Australia
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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Okeowo D, Patterson A, Boyd C, Reeve E, Gnjidic D, Todd A. Clinical practice guidelines for older people with multimorbidity and life-limiting illness: what are the implications for deprescribing? Ther Adv Drug Saf 2018; 9:619-630. [PMID: 30479737 PMCID: PMC6243426 DOI: 10.1177/2042098618795770] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/07/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The aim of this study was (1) to apply the current United Kingdom (UK) National Institute for Health and Care Excellence (NICE) clinical practice guidelines to a hypothetical older patient with multimorbidity and life-limiting illness; (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity; and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped. METHODS Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment-resistant model, and a last-line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI). RESULTS The majority of the guidelines recommended the initiation of medication in the hypothetical patient; if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication, with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day; for the treatment-resistant model, 6 separate medications (15 dosage units); and, for the last-line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication. CONCLUSIONS In a UK context, disease-specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life-limiting illness and multimorbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when and how the medications should be reduced or stopped.
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Affiliation(s)
- Daniel Okeowo
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Alastair Patterson
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily Reeve
- NHMRC-Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada College of Pharmacy, Faculty of Health, Dalhousie University, NS, Canada
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Adam Todd
- Faculty of Medical Sciences, School of Pharmacy, Newcastle University, Rm G.66, King George VI Building, Queen Victoria Road, Newcastle upon Tyne, NE1 7RU, UK
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Beauchet O. Medical cannabis use in older patients: Update on medical knowledge. Maturitas 2018; 118:56-59. [PMID: 30415756 DOI: 10.1016/j.maturitas.2018.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 10/22/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is increasing scientific data suggesting that cannabis is beneficial for a large range of medical conditions. Physicians need up-to-date medical knowledge (i.e., indications, dose and safety properties) before prescribing cannabis for older patients, who are, a priori, more prone to its adverse effects than younger patients. A mini-review was conducted to examine the evidence on medical cannabis use in older patients. METHODS An English and French systematic Medline (PubMed) search, from January 1, 2001 to October 15, 2018, was conducted using the MeSH terms "Cannabis"[Mesh] OR "Marijuana Abuse"[Mesh] OR "Medical Marijuana"[Mesh] OR "Marijuana Smoking"[Mesh] combined with the MeSH terms ("Aged"[Mesh]) OR "Aged, 80 and over"[Mesh]. A total of 451 abstracts were identified and full relevant articles were retrieved and analysed. RESULTS Even with a growing body of data showing positive effects of medical cannabis use, mixed results have been reported. Most clinical studies have had small samples and there are few randomized controlled trials. This lack of evidence on the positive clinical effects of medical cannabis use is especially marked for older patients, few of whom have been examined. CONCLUSIONS There is a lack of consistent data on the clinical effects of medical cannabis use in older patients to guide cannabis prescription for this group of patients.
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Affiliation(s)
- Olivier Beauchet
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis - Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Quebec, Canada; Dr. Joseph Kaufmann Chair in Geriatric Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Centre of Excellence on Longevity of McGill integrated University Health Network, Quebec, Canada; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
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Mangoni AA, Jarmuzewska EA. The influence of heart failure on the pharmacokinetics of cardiovascular and non-cardiovascular drugs: a critical appraisal of the evidence. Br J Clin Pharmacol 2018; 85:20-36. [PMID: 30194701 DOI: 10.1111/bcp.13760] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/21/2018] [Accepted: 09/03/2018] [Indexed: 12/12/2022] Open
Abstract
Prescribing in heart failure (HF), a common disease state that predominantly affects the older population, is often a challenging task because of the dynamic nature of the condition, requiring frequent monitoring and medication review, the presence of various comorbidities, and the frailty phenotype of many patients. The significant alterations in various organs and tissues occurring in HF, particularly the reduced cardiac output with peripheral hypoperfusion and the structural and functional changes of the gastrointestinal tract, liver and kidney, might affect the pharmacokinetics of several drugs. This review critically appraises the results of published studies investigating the pharmacokinetics of currently marketed cardiovascular and selected non-cardiovascular drugs in HF patients and control groups, identifies gaps in the current knowledge, and suggests avenues for future research in this complex patient population.
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Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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Khan MS, Roberts MS. Challenges and innovations of drug delivery in older age. Adv Drug Deliv Rev 2018; 135:3-38. [PMID: 30217519 DOI: 10.1016/j.addr.2018.09.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/31/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022]
Abstract
Both drug delivery performance and various age-related physical, mental and physiological changes can affect drug effectiveness and safety in elderly patients. The many drug delivery systems developed over the years include recent novel transdermal, nasal, pulmonary and orally disintegrating tablets that provide consistent, precise, timely and more targeted drug delivery. Certain drug delivery systems may be associated with suboptimal outcomes in the elderly because of the nature of drug present, a lack of appreciation of the impact of age-related changes in drug absorption, distribution and clearance, the limited availability of pharmacokinetic, safety and clinical data. Polypharmacy, patient morbidity and poor adherence can also contribute to sub-optimal drug delivery systems outcomes in the elderly. The development of drug delivery systems for the elderly is a poorly realised opportunity, with each system having specific advantages and limitations. A key challenge is to provide the innovation that best meets the specific physiological, psychological and multiple drug requirements of individual elderly patients.
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Krzyszczyk P, Acevedo A, Davidoff EJ, Timmins LM, Marrero-Berrios I, Patel M, White C, Lowe C, Sherba JJ, Hartmanshenn C, O'Neill KM, Balter ML, Fritz ZR, Androulakis IP, Schloss RS, Yarmush ML. The growing role of precision and personalized medicine for cancer treatment. TECHNOLOGY 2018; 6:79-100. [PMID: 30713991 PMCID: PMC6352312 DOI: 10.1142/s2339547818300020] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Cancer is a devastating disease that takes the lives of hundreds of thousands of people every year. Due to disease heterogeneity, standard treatments, such as chemotherapy or radiation, are effective in only a subset of the patient population. Tumors can have different underlying genetic causes and may express different proteins in one patient versus another. This inherent variability of cancer lends itself to the growing field of precision and personalized medicine (PPM). There are many ongoing efforts to acquire PPM data in order to characterize molecular differences between tumors. Some PPM products are already available to link these differences to an effective drug. It is clear that PPM cancer treatments can result in immense patient benefits, and companies and regulatory agencies have begun to recognize this. However, broader changes to the healthcare and insurance systems must be addressed if PPM is to become part of standard cancer care.
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Affiliation(s)
- Paulina Krzyszczyk
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Alison Acevedo
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Erika J Davidoff
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Lauren M Timmins
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Ileana Marrero-Berrios
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Misaal Patel
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Corina White
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Christopher Lowe
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Joseph J Sherba
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Clara Hartmanshenn
- Department of Chemical & Biochemical Engineering, Rutgers University, 98 Brett Road, Piscataway, NJ 08854, USA
| | - Kate M O'Neill
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Max L Balter
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Zachary R Fritz
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Ioannis P Androulakis
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
- Department of Chemical & Biochemical Engineering, Rutgers University, 98 Brett Road, Piscataway, NJ 08854, USA
| | - Rene S Schloss
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Martin L Yarmush
- Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA
- Department of Chemical & Biochemical Engineering, Rutgers University, 98 Brett Road, Piscataway, NJ 08854, USA
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Johnell K. The controversies surrounding polypharmacy in old age - where are we? Expert Rev Clin Pharmacol 2018; 11:825-827. [PMID: 30092160 DOI: 10.1080/17512433.2018.1510313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Kristina Johnell
- a Aging Research Center, Department of Neurobiology, Care Sciences and Society , Karolinska Institutet and Stockholm University , Stockholm , Sweden
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