Evaluation of potentially inappropriate medication in older patients with cardiovascular diseases-STOPP/START-based study

Inappropriate medication prescribing, polypharmacy, potential drug-drug interactions and medication regimen complexity in older adults attending three referral hospitals in Asmara, Eritrea: a cross-sectional study

BACKGROUND

Older adults often face several chronic illnesses that require them to take multiple medications. The increased number of prescribed medications has led to more complex medication regimens, putting older adults at a higher risk of potential drug-drug interactions, inappropriate medication prescribing, and adverse events. This study aimed to assess inappropriate prescribing practices, polypharmacy, medication regimen complexity, and their determinants in older adults.

METHODS

A cross-sectional study was conducted among older adults (aged 65 years and above) who visited three referral hospitals in Asmara, Eritrea, between June and August, 2023. A stratified random sampling technique was used, and data were collected from patient prescriptions, medical cards, and through interviews with a questionnaire. Inappropriate medication prescribing was evaluated using STOPP (Screening Tool of Older Person's Prescriptions)/ START (Screening Tool to Alert to Right Treatment) criteria version 3. Potential drug-drug interactions (pDDIs) and medication regimen complexity (MRC) were assessed using Lexi-comp drug interaction checker and MRC index, respectively. Descriptive statistics, logistic regression, Pearson's correlation coefficient, independent samples t-test, one-way Analysis of Variance, and paired t-test were employed using IBM SPSS (version-26.0).

RESULTS

A total of 430 respondents, with a similar male to female ratio, were included. The prevalence of polypharmacy was 5.3% (95%CI: 3.2, 7.5). Moreover, the prevalence of clinically significant pDDI was 51% (95%CI: 46, 56). The most common medicines involved in clinically significant pDDIs were enalapril (n = 179) and acetylsalicylic acid (n = 124). The presence of chronic illness (AOR = 7.58, 95%CI: 3.73, 15.39) and the number of drugs prescribed (AOR = 2.80, 95%CI: 1.91, 4.10) were predictors of clinically significant pDDIs. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were 27.4% (95% CI: 23.4, 31.8) and 13.3% (95% CI: 10.3, 16.7), respectively. The most common PIMs were long-acting sulfonylureas (n = 63) and aldosterone antagonists (n = 19). Besides, proton pump inhibitors (PPIs) (n = 41) and cardio-selective beta-blockers (n = 14) were the most common PPOs identified. Age (AOR: 0.95, 95% CI: 0.92, 0.98), presence of chronic illness (AOR: 1.51, 95% CI: 0.81, 2.80), and number of drugs prescribed (AOR: 2.01, 95% CI: 1.51, 2.69) were significant factors associated with PIM. MRCI score was a significant determinant of PPO (AOR: 1.25, 95% CI: 1.14, 1.38). The mean (SD) of the overall MRCI score was 9.1 (3.7), with dose frequency being the major contributor. The number of drugs prescribed was a determinant of MRCI score (r = 0.625, p < 0.001).

CONCLUSION

Inappropriate medication prescribing and clinically significant drug-drug interactions were common among older adults, highlighting the need for immediate attention from policymakers, program managers, and healthcare professionals.

Application of STOPP/START criteria in older patients in primary care using RStudio®

OBJECTIVES

To estimate the frequency of potentially inappropriate prescribing (PIP) in outpatients according to STOPP/START criteria, and to identify risk factors. For this purpose, an algorithm was developed and validated in RStudio® based on the information collected in the electronic prescription.

METHODS

The data corresponds to dispensations from two pharmacies in Spain made to patients over 18 years, over 4 years. For the analysis, only patients aged ≥ 65 years who are targeted by the STOPP/START criteria are included. The statistical programming language RStudio® was used to develop the algorithm. The STOPP criteria used as models for the implementation of the method were L2 and B12. A logistic regression analysis was performed.

RESULTS

A total of 15,601 treatment plans were obtained from 2312 patients ≥ 65 years (56% women), of whom 46.6% had polypharmacy (≥ 5 drugs) and 9.3% had excessive polypharmacy (≥ 10 drugs). In this group, PIPs were detected in 57% of patients and in 38% of their treatment plans; of these PIPs the most common were those related to the use of benzodiazepines for more than 28 days (D5 criterion) in 25.9% of patients, followed by the use of opioids prescribed without an associated laxative (L2 criterion) in 13.8% and finally, drugs duplication (A3 criterion) in 5.7%. The most numerous duplications related to criterion A3 were benzodiazepines (39%) and non-steroidal anti-inflammatory drugs (37.4%).

CONCLUSIONS

The method developed and validated in RStudio® with different STOPP criteria allows us to analyse the pharmacological treatment of many patients using different databases and to identify those at risk of suffering a PIP according to the STOPP criteria. Our results indicate a high prevalence of PIPs in patients ≥ 65 years, with polypharmacy being the most common risk factor affecting PIP.

Evaluation of medication safety assessment tools for pharmacist-led medication reviews: the Eastern European pilot project

Background: Pharmacist-led medication reviews (MR) are one of the key methods to support medication safety in polypharmacy patients. The aims of this study were to pilot MRs in Eastern European community pharmacies, describe medication use in polypharmacy patients, and evaluate the usability of medication safety assessment tools. Methods: The MR pilot was undertaken in Estonia, Latvia, Poland, Hungary, Romania, and Bulgaria. Patients who used at least five medicines were directed to the service by their GPs. Data on drug-related problems (DRPs) and adherence were collected by pharmacists through structured patient interviews. Databases for identification of potential drug-drug interactions (pDDIs) and adverse drug reactions (ADRs) named Inxbase/Riskbase, as well as an integrated tool comprising potentially inappropriate medicines (PIMs) lists EU(7)-PIM and EURO-FORTA, were applied retroactively to the MR pilot data to investigate possibilities for their use and to describe medication use and potential risks in the study population. Results: A total of 318 patients were included in the study, 250 of them elderly (≥65 years). One hundred and eighty (56.6%) participants had a total of 504 pDDIs based on Inxbase analysis. On average, there were 1.6 pDDIs per participant. Twenty-five (5.0%) of the 504 pDDIs were in a high-risk category. A total of 279 (87.7%) participants had a potential ADR in at least one of 10 Riskbase categories. One hundred and fifty-four (20.8%) of the potential ADRs were in a high-risk category. Twenty-seven pDDIs and 68 ADRs documented as DRPs during the service were not included in the databases. Using the integrated EU(7)-PIM/EURO-FORTA PIM list, a total of 816 PIMs were found in 240 (96%) of the 250 elderly participants (on average 3.4 PIMs per elderly participant). Seventy-one (29.6%) of the participants were using high-risk PIMs. Twenty-one percent of high-risk PIMs and 13.8% of medium-risk PIMs were documented as DRPs by the pharmacists during the pilot. Conclusion: Medication safety assessment tools can be useful in guiding decision-making during MRs; however, these tools cannot replace patient interviews and monitoring. Tools that include a thorough explanation of the potential risks and are easy to use are more beneficial for MRs.

Prevalence and prognostic value of malnutrition in patients with acute coronary syndrome and chronic kidney disease

Background

Malnutrition is a rising global health issue associated with unfavorable outcomes of a variety of disorders. Currently, the prevalence and prognostic significance of malnutrition to patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) remained largely unclear.

Methods

A total of 705 patients diagnosed with ACS and CKD in the First Affiliated Hospital of Wenzhou Medical University between 2013 and 2021 were included in this retrospective cohort study. Malnutrition was assessed by the Controlling Nutritional Status (CONUT), the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI), respectively. The relationships between malnutrition and all-cause mortality and major cardiovascular events (MACEs) were analyzed.

Results

During a median follow-up of 31 months, 153 (21.7%) patients died, and 165 (23.4%) had MACEs. The prevalence of malnutrition was 29.8, 80.6, and 89.8% for the PNI, CONUT, and GNRI, respectively. All the malnutrition indexes were correlated with each other (r = 0.77 between GNRI and PNI, r = -0.72 between GNRI and CONUT, and r = -0.88 between PNI and CONUT, all p < 0.001). Compared with normal nutrition, malnutrition was independently associated with an increased risk for all-cause mortality (adjusted hazard ratio for moderate and severe degrees of malnutrition, respectively: 7.23 [95% confidence interval (CI): 2.69 to 19.49] and 17.56 [95% CI: 5.61 to 55.09] for the CONUT score, 2.18 [95% CI: 0.93 to 5.13] and 3.16 [95% CI: 1.28 to 7.79] for the GNRI, and 2.52 [95% CI: 1.62 to 3.94] and 3.46 [95% CI: 2.28 to 5.25] for the PNI score. p values were lower than 0.05 for all nutritional indexes, except for moderate GNRI p value = 0.075). As for MACEs, similar results were observed in the CONUT and PNI. All the risk scores could improve the predictive ability of the Global Registry of Acute Coronary Events (GRACE) risk score for both all-cause mortality and MACEs.

Conclusion

Malnutrition was common in patients with ACS and CKD regardless of the screening tools used, and was independently associated with all-cause mortality and MACEs. Malnutrition scores could facilitate risk stratification and prognosis assessment.

Potentially Inappropriate Medications Use among Older Adults with Dyslipidaemia

BACKGROUND

Since older patients with dyslipidemia frequently receive many prescriptions, medication errors are typical and expected in this population. This risk has increased by using potentially inappropriate medications. The 2019 Beers criteria were used in this study to investigate potentially inappropriate medication use among older individuals with dyslipidemia.

METHODS

A cross-sectional retrospective analysis used data from electronic medical records from an ambulatory-care environment. Patients with dyslipidemia who were older adults (>65 years old) were included. To describe and find potential determinants of potentially inappropriate medication usage, descriptive statistics and logistic regression were employed.

RESULTS

This study included 2209 older adults (age ≥ 65) with dyslipidemia. The mean age was 72.1 ± 6.0 years, and the majority of the study sample had hypertension (83.7%) and diabetes (61.7%), and around 80.0% were using polypharmacy. The prevalence of potentially inappropriate medications to be avoided among older adults with dyslipidemia was 48.6%. A high risk of potentially inappropriate medication usage was found in older patients with dyslipidemia who had polypharmacy and comorbid diabetes, ischemic heart disease, and anxiety.

CONCLUSIONS

This study showed that the number of medications prescribed and the presence of concurrent chronic health conditions are important indicators of the risk of potentially inappropriate medications in ambulatory older patients with dyslipidemia.

Gender Differences in Potentially Inappropriate Medication Use among Older Adults

BACKGROUND

Use of potentially inappropriate medication (PIMs) is a prominent concern that leads to significant medication-related issues among older adults. Notably, older women tend to utilize more medicines than men; older women frequently take more drugs. In addition, some evidence suggests that prescription PIMs vary by gender. This study examines the gender-based variation in prescribing PIM among older adults in Saudi Arabia.

METHODS

A cross-sectional retrospective analysis of electronic medical records from a large hospital in Saudi Arabia was carried out. Patients over the age of 65 who received ambulatory treatment were included in the study. The utilization of PIM was assessed based on Beers criteria. Descriptive statistics and logistic regression were employed to describe patterns of PIM utilization and identify factors associated with their use. All statistical analyses were performed using Version 9.4 of the Statistical Analysis Software (SAS^® 9.4).

RESULTS

The study comprised 4062 older people (age 65) who visited ambulatory care clinics; the average age was (72.6 ± 6.2) years. The majority of the study sample was women (56.8%). Among older adults, 44.7% of older men and 58.3% of older women reported having PIMs that should be avoided, indicating a higher prevalence of PIMs among women compared to men. In terms of the PIM categories used, women had a much higher utilization rate of cardiovascular and gastrointestinal drugs than men. In men, the use of PIMs was frequently associated with hypertension, ischemic heart disease, asthma, osteoarthritis, and cancer, while in women PIM use was associated with age, dyslipidemia, chronic kidney disease, and osteoporosis.

CONCLUSIONS

This study revealed sex differences in PIM prescribing among older adults; PIM use is more common among women. Sex differences exist in clinical and socioeconomic characteristics and factors related to using potentially inappropriate medications. This study revealed essential areas that could be targeted by further interventions to improve drug-prescribing practices among older adults at risk of PIM.