Adverse drug reactions in elderly patients

Many studies from around the world show a correlation between increasing age and adverse drug reaction (ADR) rate, at least for some medical conditions. More than 80% of ADRs causing admission or occurring in hospital are type A (dose-related) in nature, and thus predictable from the known pharmacology of the drug and therefore potentially avoidable. Frail elderly patients appear to be particularly at risk of ADRs and this group is also likely to be receiving several medicines. The toxicity of some drug combinations may sometimes be synergistic and be greater than the sum of the risks of toxicity of either agent used alone. In order to recognize and to prevent ADRs (including drug interactions), good communication is crucial, and prescribers should develop an effective therapeutic partnership with the patient and with fellow health professionals. Undergraduate and postgraduate education in evidence-based therapeutics is also vitally important. The use of computer-based decision support systems (CDSS) and electronic prescribing should be encouraged, and when problems do occur, health professionals need to be aware of their professional responsibility to report suspected adverse drug events (ADEs) and ADRs. "Rational" or "obligatory" polypharmacy is becoming a legitimate practice as increasing numbers of individuals live longer and the range of available therapeutic options for many medical conditions increases. The clear risk of ADRs in this situation should be considered in the context that dose-related failure of existing therapy to manage the condition adequately may be one of the most important reasons for admission of the elderly to hospital. Thus, age itself should not be used as a reason for withholding adequate doses of effective therapies.

Mechanisms of prescription drug diversion among drug-involved club- and street-based populations

OBJECTIVE

Prescription drug diversion involves the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace, and can occur along all points in the drug delivery process, from the original manufacturing site to the wholesale distributor, the physician's office, the retail pharmacy, or the patient. However, empirical data on diversion are limited.

METHOD

In an attempt to develop a better understanding of how specific drug-using populations are diverting prescription opioids and other medications, or obtaining controlled drugs that have already been diverted, qualitative interviews and focus group data were collected on four separate populations of prescription drug abusers in Miami, Florida--club drug users, street-based illicit drug users, methadone maintenance patients, and HIV positive individuals who abuse and/or divert drugs.

RESULTS

Sources of abused prescription drugs cited by focus group participants were extremely diverse, including their physicians and pharmacists; parents and relatives; "doctor shopping"; leftover supplies following an illness or injury; personal visits to Mexico, South America and the Caribbean; prescriptions intended for the treatment of mental illness; direct sales on the street and in nightclubs; pharmacy and hospital theft; through friends or acquaintances; under-the-door apartment flyers advertising telephone numbers to call; and "stealing from grandma's medicine cabinet."

CONCLUSION

While doctor shoppers, physicians and the Internet receive much of the attention regarding diversion, the data reported in this paper suggest that there are numerous active street markets involving patients, Medicaid recipients and pharmacies as well. In addition, there are other data which suggest that the contributions of residential burglaries, pharmacy robberies and thefts, and "sneak thefts" to the diversion problem may be understated.

Patients, society, and the increase in self medication

Self medication with over the counter medicines has long been a feature of the lay health system. With the reclassification of certain drugs, the public can buy preparations that were previously available only prescription. Sales of over the counter medicines are now equivalent to a third of the NHS drugs bill; governments throughout the world see self medication as a way of shifting some of the cost of health care onto consumers. The trend towards increased self care and with it the increasing empowerment of patients has many potential benefits; collaboration between doctors and pharmacists will be critical.

Environmental contamination and assessment of exposure to antineoplastic agents by determination of cyclophosphamide in urine of exposed pharmacy technicians: is skin absorption an important exposure route?

In the Netherlands, special guidelines and safety precautions were introduced about 10 y ago for preparation and administration of antineoplastic agents. However, little is known about the effectiveness of these measures. In this study, occupational exposure to antineoplastic agents of nine pharmacy technicians who were involved in drug preparation was investigated. Cyclophosphamide, 5-fluorouracil, and methotrexate accounted for 95% of the antineoplastic agents prepared; therefore, the presence of these compounds was monitored. During preparation, cyclophosphamide was detected in the air of the work environment (< 0.04-10.1 micrograms/m3). Contamination of and permeation through latex gloves were found for each of the three compounds. The uptake of cyclophosphamide was assessed by the determination of cyclophosphamide in urine. The drug was found in urine samples of six pharmacy technicians, including three persons who were not directly involved in the preparation of cyclophosphamide. The amounts excreted ranged from 0.2 to 19.4 micrograms/24 h. The results strongly suggest that inhalation is of minor importance for internal exposure, compared with other, presumably dermal, routes.

Agenda for an anthropology of pharmaceutical practice

Over the last two decades, patterns of pharmaceutical-related behavior and the cultural interpretation of medicines have been examined by anthropologists in several cultural settings. In this paper the authors identify additional issues warranting study so as to broaden the scope of pharmaceutical anthropology, utilizing as a unifying focus the examination of pharmaceutical use in the context of social transformation. Ten interactive themes are presented which bridge micro-level and macro-level investigations of pharmaceutical use. The discussion moves from the discourse on 'rational drug use' to the rationales which underscore drug prescription, manufacture, and demand.

Prevalence of off-label use and spending in 2010 among patent-protected chemotherapies in a population-based cohort of medical oncologists

PURPOSE

The prevalence of off-label anticancer drug use is not well characterized. The extent of off-label use is a policy concern because the clinical benefits of such use to patients may not outweigh costs or adverse health outcomes.

METHODS

Prescribing data from IntrinsiQ Intellidose data systems, a pharmacy software provider maintaining a population-based cohort database of medical oncologists, was analyzed. Use of the most commonly prescribed anticancer drugs ("chemotherapies") that were patent protected and administered intravenously to patients in 2010 was examined. Use was classified as "on-label" if the cancer site, stage, and therapy line met the US Food and Drug Administration (FDA)-approved indication. All other use was "off-label." Off-label use was divided by whether it conformed to National Comprehensive Care Network (NCCN) Compendium recommendations, a basis of insurer coverage policies. IMS Health National Sales Perspectives was used to estimate national spending by use category.

RESULTS

Ten chemotherapies met inclusion criteria. On-label use amounted to 70%, and off-label use amounted to 30%. Fourteen percent of use conformed to an NCCN-supported off-label indication, and 10% of off-label use was associated with an FDA-approved cancer site, but an NCCN-unsupported cancer stage and/or line of therapy. Total national spending on these chemotherapies amounted to $12 billion (B; $7.3B on-label, $2B off-label and NCCN supported; $2.5B off-label and NCCN unsupported).

CONCLUSION

Commonly used, novel chemotherapies are more often used on-label than off-label in contemporary practice. Off-label use is composed of a roughly equal mix of chemotherapy applied in clinical settings supported by the NCCN and those that are not.

Pharmacy-based assessment of adherence to HAART predicts virologic and immunologic treatment response and clinical progression to AIDS and death

Although adherence to HAART at a level above 95% has been associated with optimal viral suppression, the impact of different levels of adherence on long-term clinical outcomes has not been determined. We used an objective pharmacy-based measure to examine the association between three levels of adherence to HAART and disease progression among a population-based cohort of HIV-infected patients attending an urban HIV specialty clinic. Higher levels of adherence to HAART were significantly associated with longer time to virologic failure ( P < 0.001), greater increase in CD4 cell count ( P = 0.04), and lower risk of progression to clinical AIDS or death ( P < 0.007). After controlling for other factors, patients with low adherence had over five times the risk of disease progression than patients with moderate adherence ( P = 0.007) or patients with high adherence ( P = 0.001). There was no significant difference in the risk of progression between patients with moderate and high levels of adherence ( P > 0.2). Patients who progressed to AIDS or death had significantly higher viral loads ( P = 0.01) and lower CD4 cell counts ( P = 0.03) than patients who experienced virologic failure, but did not progress.

An eleven-year review of the pharmacy literature: documentation of the value and acceptance of clinical pharmacy

The primary objectives of the article were accomplished by providing both a bibliography of articles dealing with clinical pharmacy services in acute-care facilities and summaries of those constituting original research reports on clinical pharmacy services. However, in the process, we made the following interesting observations. We found that articles reporting impacts on cost, quality, and attitude numbered 48, 58, and 24, respectively. Most articles relating to drug therapy monitoring, with minor exceptions, dealt with either the quality or cost-savings impact or a combination of both. Also, articles concerning drug therapy monitoring comprised almost half of all those summarized (40 articles). Articles detailing drug information and education (category 2) numbered 28 and dealt mainly with attitudes or quality impacts with minor reference to cost-savings. It was also interesting, albeit expected, to observe that the bulk of attitudinal studies fell in category 2. We found category 5, controlling medication administration, had 13 articles, primarily concerned with cost and or quality. Category 4, reporting and detection of adverse drug reactions, contained a total of eight articles mainly studying the impact on quality. The other categories contained very few, if any, articles. From these results, it is evident that the profession has made significant strides in building a strong scientific data base to support the value of its clinical services. However, there is ample room for additional original research reports. Although it can be argued that alone many of the studies could not justify clinical pharmacy as cost-effective, organized as one reference they provide an invaluable resource. Although it might be unreasonable to expect each pharmacy department to be able to cost-justify its existence, this work presents the background data needed to begin or develop such efforts.

Exposure of pharmacy technicians to antineoplastic agents: reevaluation after additional protective measures

In the past, special guidelines and protective measures have been introduced to protect hospital workers during the handling of antineoplastic agents; nevertheless, it was found that they did not prevent the uptake of these toxic compounds. In response, additional protective measures were introduced, including adaptations of the laminar downflow hood, use of special masks, use of double pairs of gloves, and replacement of ampules with vials. In the current study, the authors compared the effects in these additional measures with results of a previous study. Cyclophosphamide, 5-fluorouracil, and methotrexate constituted 81% of the antineoplastic agents prepared; therefore, the investigators monitored these compounds again by personal air sampling and by determining the levels of contamination on masks and gloves. Cyclophosphamide in the urine of workers was also measured. During preparation, investigators concluded that there were lower concentrations of cyclophosphamide in the air than had occurred in the previous study. Replacement of ampules with vials (i.e., 5-fluorouracil) resulted in a significantly diminished contamination of latex gloves. Cyclophosphamide was detected in urine samples provided by six of nine technicians; the maximum amount excreted over 5 d was 2.6 microg. The mean cyclophosphamide excretion/d was not significantly lower than that found in the previous study (0.16 microg and 1.44 microg, respectively). Despite an intensified hygienic regimen, exposure to antineoplastic agents cannot be reduced if the reasons for exposure remain unknown.

Over the counter drugs. The future for self medication

The increasing trend towards deregulation of more medicines to over the counter status has implications for the primary health care team as well as for consumers and patients. Better information for patients could improve the safety of over the counter medicines, but better systems need to be devised for reporting adverse reactions. "Collaborative care" could bring financial benefits. Doctors, nurses, and pharmacists need to discuss how they will respond to self medication practices, and ways of rewarding pharmacists for advising patients need to be found. Improved communication between doctors and pharmacists and the involvement of nurses could bring health care professionals into a new and more constructive interaction with each other and with the patient--or the changes required could split the professions as they each try to keep control of medicines.