Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States

Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans

OBJECTIVES

To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics.

DESIGN

Retrospective cohort.

SETTING

Veterans Affairs Medical Centers.

PARTICIPANTS

Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006.

MEASUREMENTS

Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications).

RESULTS

Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio (AOR) = 3.90, 95% confidence interval (CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively).

CONCLUSION

ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy.

Prescribing for older adults

Pharmacotherapy of the elderly is very complex due to age-related physiologic changes, multiple comorbidities, multiple medications (prescription, over-the counter, and herbal), and multiple providers (prescribers and pharmacies). Age-related physiologic changes and disease-related changes in organ function affect drug handling (pharmacokinetics) and response (pharmacodynamics). In addition, patients' cognitive impairment, functional difficulties, as well as caregiver issues play a large role in errors and compliance. Many older adults have several chronic conditions, and they stand to benefit the most from best practice guidelines. However, they are also at risk of toxicity given our increasingly complex pharmacopoeia and potential adverse effects that can cause morbidity and mortality. It is imperative that physicians learn how to minimize side effects and interactions. Potentially inappropriate medications (medications that pose more risk than benefit to the patient) are among the most important causes of adverse drug reactions, independent of the number of medications and other confounding factors. Many of these adverse drug reactions could be predicted from the known pharmacology of the drug and therefore could be potentially avoidable. To prescribe appropriately, we need to consider not only the pharmacological properties of the drugs, but also clinical, epidemiological, social, cultural, and economic factors. Elders' adherence to prescribed medications is also complex and depends on medical, personal, and economic factors; cognitive status; and relationship with the physician. Detection of nonadherence is a necessary prerequisite for adequate treatment, and patient education is a cornerstone in achieving medication adherence. Finally, appropriate prescribing should include a consideration of life expectancy and goals of care.

Healthcare professional students' knowledge of drug-drug interactions

OBJECTIVES

To evaluate changes in medical, pharmacy, and nurse practitioner students' drug-drug interaction (DDI) knowledge after attending an educational program.

DESIGN

A DDI knowledge assessment containing 15 different drug pairs was administered to participants before and after a 45-minute educational session.

EVALUATION

Pharmacy, medical, and nursing students scored significantly higher on the posttest assessment for DDI recognition (median change 3, 9, and 8, respectively) and management strategy (median change 5, 9, 8, respectively), indicating a significant improvement in DDI knowledge as a result of the educational session. Pharmacy students scored significantly higher on the pretest; however, no difference was observed between the students' posttest scores. Posttest scores for all student groups were significantly greater than their respective pretest scores (p < 0.001).

CONCLUSIONS

Significant improvement in healthcare professional students' DDI knowledge was observed following participation in the educational session.

Potentially serious drug-drug interactions among community-dwelling older adult dental patients

OBJECTIVES

Reducing adverse drug events, including those resulting from drug-drug interactions, will be a health safety issue of increasing importance for dental practitioners in the coming decades as greater numbers of older adults seek oral health care. The purpose of this study was to identify prescription drugs with the potential for serious interactions and estimate prevalent use among older adults visiting the dentist.

STUDY DESIGN

The Medicare Current Beneficiary Survey is an ongoing series of nationally representative surveys of Medicare beneficiaries. Potentially serious drug interactions were selected with the use of published work by Partnership to Prevent Drug-Drug Interactions. Drug interactions were identified and prevalence estimates made for community-dwelling older adults visiting the dentist. Analyses were completed to test associations between sociodemographic and health-related variables and the use of prescription drugs with the potential for serious interactions.

RESULTS

Overall, 3.4% of those visiting the dentist were estimated to have been prescribed drugs with the potential for a serious drug interaction. Drugs commonly prescribed in dentistry with the potential for serious interactions include the benzodiazepines, macrolide antibiotics, and nonsteroidal antiinflammatory analgesics.

CONCLUSIONS

Understanding potentially harmful drug combinations, their clinical consequences, and the frequency with which implicated drugs are being prescribed will assist practitioners in clinically managing patients and avoiding inappropriate prescribing.

Potentially harmful drug-drug interactions in the elderly: a review

BACKGROUND

Elderly patients are vulnerable to drug interactions because of age-related physiologic changes, an increased risk for disease associated with aging, and the consequent increase in medication use.

OBJECTIVE

The purpose of this narrative review was to describe findings from rigorously designed observational cohort and case-control studies that have assessed specific drug interactions in elderly patients.

METHODS

The PubMed and International Pharmaceutical Abstracts databases were searched for studies published in English over the past 10 years (December 2000-December 2010) using relevant Medical Subject Headings terms (aged; aged, 80 and over; and drug interactions) and search terms (drug interaction and elderly). Search strategies were saved and repeated through September 2011 to ensure that the most recent relevant published articles were identified. Additional articles were found using a search of review articles and reference lists of the identified studies. Studies were included if they were observational cohort or case-control studies that reported specific adverse drug interactions, included patients aged ≥65 years, and evaluated clinically meaningful end points. Studies were excluded if they used less rigorous observational designs, assessed pharmacokinetic/pharmacodynamic properties, evaluated drug-nutrient or drug-disease interactions or interactions of drug combinations used for therapeutic benefit (eg, dual antiplatelet therapy), or had inconclusive evidence.

RESULTS

Seventeen studies met the inclusion criteria. Sixteen studies reported an elevated risk for hospitalization in older adults associated with adverse drug interactions. The drug interactions included: angiotensin-converting enzyme (ACE) inhibitors and potassium-sparing diuretics, ACE inhibitors or angiotensin receptor blockers and sulfamethoxazole/trimethoprim, benzodiazepines or zolpidem and interacting medications, calcium channel blockers and macrolide antibiotics, digoxin and macrolide antibiotics, lithium and loop diuretics or ACE inhibitors, phenytoin and sulfamethoxazole/trimethoprim, sulfonylureas and antimicrobial agents, theophylline and ciprofloxacin, and warfarin and antimicrobial agents or nonsteroidal anti-inflammatory drugs. One study reported the risk for breast cancer-related death as a function of paroxetine exposure among women treated with tamoxifen.

CONCLUSIONS

Several population-based studies have reported significant harm associated drug interactions in elderly patients. Increased awareness and interventions aimed at reducing exposure and minimizing the risks associated with potentially harmful drug combinations are needed.

Hypertension Secondary to Ingestion of Licorice Root Tea

Objective:

To report a case of hypertension secondary to ingestion of licorice root tea.

Case Summary:

A 46-year-old African American female with newly diagnosed stage 1 hypertension presented with a blood pressure measurement of 144/81 mm Hg and a reduced plasma potassium level of 3.2 mEq/L. The patient attempted lifestyle modifications prior to initiating an antihypertensive agent, but at a follow-up appointment, her blood pressure remained elevated. A current laboratory panel revealed a depressed morning plasma aldosterone concentration (PAC) of 5 ng/dL and low morning plasma renin activity (PRA) of 0.13 ng/mL/h. Later it was revealed that the patient regularly (1–2 cups/day) consumed “Yogi Calming” tea, a blend of herbs, including licorice root. The patient was advised to discontinue consumption of the herbal tea, and at a subsequent appointment, her blood pressure was 128/73 mm Hg and her laboratory panel had improved, including serum potassium concentration of 4.1 mEq/L, PAC of 6 ng/dL, and PRA of 0.19 ng/mL/h.

Discussion:

Excessive consumption of licorice has been well documented to cause pseudohyperaldosteronism, characterized by hypertension, hypokalemia, and suppressed plasma renin and aldosterone levels. Glycyrrhizin, the active ingredient in licorice, inhibits 11β-hydroxysteroid dehydrogenase type 2, an oxidase responsible for the conversion and inactivation of cortisol to cortisone. Chronic ingestion of licorice-containing foods has been demonstrated to cause pseudohyperaldosteronism. These include soft candies, lozenges, and dietary supplements, but licorice-containing teas have been infrequently described. Based on the Naranjo probability score, our patient's hypertension appears to have been a probable licorice-induced reaction secondary to a licorice-containing tea.

Conclusions:

Herbal and dietary supplements are frequently consumed by patients without full knowledge of the contents of the products or the impact on their health. In clinical practice, when hypertension is accompanied by hypokalemia and reduced PRA and PAC, licorice consumption should be investigated and causal hypertension ruled out.

Assessing the usability of a telemedicine-based Medication Delivery Unit for older adults through inspection methods

Polypharmacy and medication non-adherence are common in older adults, potentially leading to medication-related problems and increased healthcare expenditures. Medication Delivery Units (MDUs) may improve adherence, but their interfaces may present usability challenges for older adults with age-related impairments. We used a combination of three inspection methods - heuristic evaluation, cognitive walkthrough, and simulated elderly interaction, to identify potential concerns with the usability of a commercially available telemedicine MDU. Each method revealed different problems, with repeated discoveries via different methods providing triangulated evidence. Despite the MDU's general usability, issues of varying severity were discovered. Significant usability issues associated with physical interactions with the MDU included loading and unloading the medication blister packs, and opening the delivered medication prior to administration. Less severe issues centered on small text sizes and poor user feedback. Further usability testing, involving older adults with a variety of impairments, is needed to validate findings.

Impact of the geriatric medication game on pharmacy students' attitudes toward older adults

OBJECTIVE

To examine the impact of participation in the Geriatric Medication Game on pharmacy students' perceptions of and attitudes toward older adults and familiarity with common disabilities that affect them and the process of seeking health care.

DESIGN

In the game, first-year pharmacy students "became" older adults during a 3-hour pharmacy practice laboratory. They were given aging-related challenges (eg, impaired vision or mobility) and participated as patients in simulated healthcare scenarios, such as a visit to a physician's office and a pharmacy.

ASSESSMENT

After playing the game, students completed a 5-question reflection about their experiences and attitudes toward older adults. Content analysis was performed to identify themes from 4 years of student (n = 625) reflections. Predominant themes included: improved attitudes toward older adults, better understanding of patient experiences, and increased willingness to provide assistance.

CONCLUSIONS

Incorporating the Geriatric Medication Game into the pharmacy curriculum may facilitate students' understanding of the challenges that older adults face and improve future interactions.

Vitamin, mineral, and specialty supplements and risk of hematologic malignancies in the prospective VITamins And Lifestyle (VITAL) study

BACKGROUND

Increasing evidence suggests that nutrients from fruits and vegetables have chemoprotective effects on various cancers including hematologic malignancies, but the effects of nutritional supplements are poorly examined.

METHODS

Herein, we prospectively evaluated the association of vitamin, mineral, and specialty supplements with incident hematologic malignancies in 66,227 men and women aged 50 to 76 years from Washington State recruited from year 2000 to 2002 to the VITamins And Lifestyle (VITAL) cohort study. Hematologic malignancies cases (n = 588) were identified through December 2008 by linkage to the Surveillance, Epidemiology, and End Results (SEER) cancer registry. HRs and 95% CIs associated with supplement use were estimated with Cox proportional hazards models.

RESULTS

After adjustment, high use of garlic supplements [≥4 days per week for ≥3 years; HR = 0.55 (95% CI = 0.34-0.87); P(trend) = 0.028] and ever use of grape seed supplements [HR = 0.57 (95% CI = 0.37-0.88)] were inversely associated with hematologic malignancies in our models. In addition, high use (8-10 pill-years) of multivitamins was suggestive of an inverse association [HR = 0.80 (95% CI = 0.64-1.01)]. In contrast, no associations were observed for the remaining supplements.

CONCLUSIONS

These data indicate that the use of garlic and grape seed may be associated with reduced risk of hematologic malignancies.

IMPACT

This is the first cohort study to suggest a possible role of these supplements in the chemoprevention of hematologic malignancies.

Quality Improvement Pilot Program for Vulnerable Elderly Surgical Patients

The elderly are a growing surgical population with more comorbidities and less physiological reserve compared with nonelderly patients. The objective of our study was to implement a quality improvement pilot program targeting the specific needs of the elderly. We prospectively enrolled consecutive patients aged 65 years or older undergoing inpatient general or vascular surgery operations. Patients completed a preoperative assessment including the Vulnerable Elder Survey (VES) to determine baseline functional status and incidence of polypharmacy (five or more medications). They were interviewed postdischarge Day 2 and Day 30 for changes in functional status. An intervention was implemented consisting of an elderly-specific postoperative order set and preoperative risk reports sent to the surgical team with instructions to order physical therapy consults and home health nursing on discharge for VES 3 or greater and geriatrics consults for patients with polypharmacy. The elderly-specific order set was used for 71 per cent of the post-intervention group. There were no differences in the percentage of participants receiving physical therapy, geriatric, or home health nursing consults between the two groups. The postintervention group had significantly better functional status on postdischarge Day 30 ( P < 0.01). Our preliminary data suggest that individualizing care for elderly patients is feasible and may improve postoperative outcomes.

Nature and frequency of drug-related problems in self-medication (over-the-counter drugs) in daily community pharmacy practice in Germany

PURPOSE

To quantify drug-related problems (DRPs) in self-medication (over-the-counter [OTC] drug use) identified by community pharmacists (CPs) in Germany at the time the drug is dispensed.

METHODS

One hundred CPs were asked to document 100 consecutive customers presenting symptoms or requesting OTC drugs using a standardized documentation form. The number of 10,000 encounters seemed reasonable to evaluate the set objective. For each encounter, data such as age, sex, and first or repeated request and the availability of a patient file in the pharmacy including drug history were documented. Furthermore, identified DRPs, problem descriptions, and solutions were documented. Data were transcribed electronically, coded, checked for validity, and analyzed.

RESULTS

In total, 109 CPs documented 12,567 encounters identifying DRPs in 17.6% of all cases. Four indications comprised more than 70% of all DRPs: pain, respiratory, gastrointestinal, and skin disorders. Four DRPs were responsible for almost 75% of all DRPs identified: self-medication inappropriate (29.7%), requested product inappropriate (20.5%), intended duration of drug use too high including abuse (17.1%), and wrong dosage (6.8%). If a drug history was available, significantly more cases with wrong dosage (p < 0.05) and drug-drug interactions (p < 0.001) were detected. All patients with identified DRPs were counseled accordingly. Furthermore, the most frequent interventions were referral to a physician (39.5%) and switching to a more appropriate drug (28.1%).

CONCLUSIONS

In nearly one of five encounters, a direct pharmacist-patient interaction about self-medication revealed relevant DRPs. Having access to patient files including data on prescription and OTC drugs may increase patient safety.

Economic impact of potential CYP450 pharmacokinetic drug-drug interactions among chronic low back pain patients taking opioids

Chronic low back pain (cLBP) patients who take at least 1 CYP450-metabolized opioid analgesic agent concurrent with at least 1 other CYP450-metabolized medication experience a drug-drug exposure (DDE), which puts them at risk for a pharmacokinetic drug-drug interaction (PK DDI). This study compared utilization of healthcare resources and associated payments in cLBP patients with and without incident DDEs with the potential to cause PK DDIs. A retrospective database analysis examined the associated clinical events, healthcare utilization (measured in terms of claims for office visits, outpatient visits, emergency department visits, and hospitalization), and cost to the health plan, as defined as the sum of health plan payments for resources used. Patients were grouped into 2 cohorts by age (those under 65 and those 65 years and over). In the 6 months after exposure, total healthcare payments were significantly higher for DDE patients than those without DDEs (no-DDE), in both in the younger ($7,086, SD = $8,370) and $6,353, SD = $8,352, respectively, P < 0.001) and the older cohorts ($7,806 vs. $7,043, respectively, P = 0.013). Younger and older patients with DDE had significantly higher prescription payments than those without DDE ($2,041, SD = $2,706 vs. $1,565, SD = $2,349, respectively, P < 0.001 for younger and $2,482, SD = $2,481 vs. $2,286, SD = $2,521, respectively, P = 0.044 for older patients). Both older and younger patients with DDE had significantly more claims for office visits and higher associated payments than similar patients without DDE. Patients in the study who experienced DDEs that placed them at risk for PK DDIs had significantly greater utilization rates of healthcare resources and higher associated payments in the 6-month observation period following exposure.

Prospective evaluation of analgesic use and risk of renal cell cancer

BACKGROUND

Epidemiologic data suggest that analgesic use increases the risk of renal cell cancer (RCC), but few prospective studies have been published. We investigated the association between analgesic use and RCC in 2 large prospective studies.

METHODS

We examined the relationship between analgesic use and RCC risk in the Nurses' Health Study and the Health Professionals Follow-up Study. Use of aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen was ascertained in 1990 in the Nurses' Health Study and in 1986 in the Health Professionals Follow-up Study, and every 2 years thereafter. We evaluated baseline and duration of use of analgesics.

RESULTS

During follow-up of 16 years among 77,525 women and 20 years among 49,403 men, we documented 333 RCC cases. Aspirin and acetaminophen use were not associated with RCC risk. However, regular use of nonaspirin NSAIDs was associated with an increased RCC risk; the pooled multivariate relative risk was 1.51 (95% confidence interval, 1.12-2.04) at baseline. The absolute risk differences for users vs nonusers of nonaspirin NSAIDs were 9.15 per 100 000 person-years in women and 10.92 per 100,000 person-years in men. There was a dose-response relationship between duration of nonaspirin NSAID use and RCC risk; compared with nonregular use, the pooled multivariate relative risks were 0.81 (95% confidence interval, 0.59-1.11) for use less than 4 years, 1.36 (0.98-1.89) for 4 to less than 10 years, and 2.92 (1.71-5.01) for use for 10 or more years (P < .001 for trend).

CONCLUSION

Our prospective data suggest that longer duration of use of nonaspirin NSAIDs may increase the risk of RCC.

In Connecticut: improving patient medication management in primary care

Medications are a cornerstone of the management of most chronic conditions. However, medication discrepancies and medication-related problems-some of which can cause serious harm-are common. Pharmacists have the expertise to identify, resolve, monitor, and prevent these problems. We present findings from a Centers for Medicare and Medicaid Services demonstration project in Connecticut, in which nine pharmacists worked closely with eighty-eight Medicaid patients from July 2009 through May 2010. The pharmacists identified 917 drug therapy problems and resolved nearly 80 [corrected] percent of them after four encounters. The result was an estimated annual saving of $1,123 per patient on medication claims and $472 per patient on medical, hospital, and emergency department expenses-more than enough to pay for the contracted pharmacist services. We recommend that the Center for Medicare and Medicaid Innovation support the evaluation of pharmacist-provided medication management services in primary care medical homes, accountable care organizations, and community health and care transition teams, as well as research to explore how to enhance team-based care.

The epidemiology of sarcopenia in community living older adults: what role does lifestyle play?

BACKGROUND: Sarcopenia, the age-related decline in skeletal muscle mass and function, is a relatively poorly understood process which may play an important role in the incidence of physical disability and falls in older adults. Evidence demonstrates that both genetic and environmental factors contribute to increased susceptibility for sarcopenia development, yet some of these factors may represent unavoidable consequences of ageing. METHODS: A review of literature, generally from epidemiological research, was performed to examine the influence that potentially modifiable lifestyle factors (general physical activity, dietary nutrient intake and sun exposure), as well as chronic disease and medication use, may have on sarcopenia progression. RESULTS: The review demonstrated that while physical activity, nutrient intake and sun exposure often decline during ageing, each may have important but differing benefits for the prevention of muscle mass and functional declines in older adults. Conversely, age-related increases in the prevalence of chronic diseases and the subsequent prescription of pharmacotherapy may exacerbate sarcopenia progression. CONCLUSIONS: The prevalence of poor physical activity, diet and sun exposure, as well as chronic disease and medication use, within older adult populations may be modifiable through simple lifestyle and health care interventions. As such, these factors may represent the most effective targets for sarcopenia prevention during the ageing process.

Pharmacy students' retention of knowledge of drug-drug interactions

OBJECTIVES

To evaluate pharmacy students' drug-drug interaction (DDI) knowledge retention over 1 year and to determine whether presenting DDI vignettes increased knowledge retention.

METHODS

A knowledge assessment tool was distributed to fourth-year pharmacy students before and after completing a DDI educational session. The questionnaire was re-administered after 1 year to assess knowledge retention. During the intervening year, students had the option of presenting DDI case vignettes to preceptors and other health professionals as part of their advanced pharmacy practice experiences (APPEs).

RESULTS

Thirty-four of 78 pharmacy students completed both the post-intervention and 1-year follow-up assessments. Students' knowledge of 4 DDI pairs improved, knowledge of 3 DDI pairs did not change, and knowledge of the remainder of DDI pairs decreased. Average scores of the 18 students who completed all tests and presented at least 1 vignette during their APPEs were higher on the 1-year follow-up assessment than students who did not, suggesting greater DDI knowledge retention (p = 0.04).

CONCLUSION

Although pharmacy students' overall DDI knowledge decreased in the year following an educational session, those who presented vignettes to health professionals retained more DDI knowledge, particularly on those DDIs for which they gave presentations. Other methods to enhance pharmacy students' retention of DDI knowledge of clinically important DDIs are needed.

Review: Health Care Utilization and Costs of Elderly Persons With Multiple Chronic Conditions

This systematic literature review identified and summarized 35 studies that investigated the relationship between multiple chronic conditions (MCCs) and health care utilization outcomes (i.e. physician use, hospital use, medication use) and health care cost outcomes (medication costs, out-of-pocket costs, total health care costs) for elderly general populations. Although synthesis of studies was complicated because of ambiguous definitions and measurements of MCCs, and because of the multitude of outcomes investigated, almost all studies observed a positive association of MCCs and use/costs, many of which found that use/costs significantly increased with each additional condition. Several studies indicate a curvilinear, near exponential relationship between MCCs and costs. The rising prevalence, substantial costs, and the fear that current care arrangements may be inappropriate for many patients with MCCs, bring about a multitude of implications for research and policy, of which the most important are presented and discussed.

A survey on the knowledge, beliefs and behaviour of a general adult population in Malaysia with respect to the adverse effects of medicines

OBJECTIVE

The aim of the study was to explore, in the Malaysian general population: knowledge and beliefs of the characteristics in general of medication-related side effects and side effects associated with different types of medicines; behaviour related to the safe use of drugs before and after taking a medication; and behaviour in the event of a medication-related side effect.

METHODS

A 24-item self-administered questionnaire was developed and used to survey the general public living or working in suburban Kuala Lumpur, Malaysia. Eight hundred questionnaires were distributed, face to face, by researchers using quota sampling. Respondents' knowledge, belief and behaviour were analysed and correlated with demographics, medical history and experience of side effects.

KEY FINDINGS

Six hundred and ten respondents completed the questionnaire giving a response rate of 76.3%. The mean knowledge score for the respondents was 18.4±3.6 out of the maximum possible score of 26. Educational level and experience of side effect had an influence on the knowledge score obtained. Respondents had misconceptions regarding the safety of complementary and alternative medicines (CAMs) and over-the-counter medications. Medication history and previous experience with side effects had a significant influence on the higher behaviour score obtained.

CONCLUSION

The survey has shown moderate results with regard to the knowledge of public regarding safety of medications, and there was evidence of under-estimating the risk of medications, especially CAMs. The misconceptions among the public, and inappropriate behaviour on drug safety-related aspects, is a concern which needs to be addressed in the interventions designed.

Dietary supplement use within a multiethnic population as measured by a unique inventory method

Use of dietary supplements is widespread, yet intakes from supplements are difficult to quantify. The Supplement Reporting study utilized a unique inventory method to quantify dietary supplement use across 1 year in a sample of 397 supplement users. Interviewers visited participants' homes in 2005-2006 to record supplement purchases and the number of pills in each supplement bottle every 3 months. Total use for the year was calculated from these inventories. Participants in this observational study were older adults (average age 68 years) from the Multiethnic Cohort in Hawaii and Los Angeles, CA, with approximately equal representation of men and women and six ethnic groups (white, Japanese American, Hawaiian, African American, Latinos born in the United States, and Latinos born elsewhere). The most commonly used supplement type was one-a-day multivitamins/minerals, which were taken at least once during the year by 83% of men and 73% of women. Other common supplements were vitamin C, fish oil, vitamin E, and bone or joint supplements. Participants used a median of seven (women) and five and a half (men) different supplements during the year. There were few differences in supplement use across ethnic groups for men, but use tended to be highest for white and Japanese-American women. Use of nonvitamin/nonmineral supplements was common among these older adults, sometimes at high doses. When assessing intakes, supplement use should be correctly quantified because users tend to take many different supplements and nutrient intakes from supplements can be substantial. The inventory method may help improve the measurement of supplement use.

Psychotropic medication discussions in older adults' primary care office visits: So much to do, so little time

OBJECTIVES

To examine discussions of psychotropic medications during the older patient's visit to primary care physicians, identify how physician's competing demands influence these discussions, describe different scenarios physicians utilize to address mental health complaints of older adults, and recommend best practices for diagnosing and treating such patients.

METHOD

Convenience sample of 59 videotapes of primary care office visits involving mental health discussions in the United States complemented by patient and physician surveys. Videotaped visits were examined using logistic regression for grouped-level data to explore contributions of physician's competing demands to the likelihood of having psychotropic medication discussions. Tape transcripts were selected to provide examples of prescribing and referral behaviors.

RESULTS

One-third of these visits contained no psychotropic medication discussions despite its important role in treating mental illnesses. When prescribing psychotropic medicines, physicians presented information about the medication's purpose and brand name more often than adverse effects or usage. More competing demands (i.e., more topics discussed or more leading causes of disability addressed during the visit) were associated with less psychotropic medication discussions. Selected case scenarios illustrate the importance of acknowledging mental illness, prescribing psychotropic medications, explaining the medications, and/or referring patients to mental health providers to address their mental health complaints.

CONCLUSION

Competing demands may constrain discussions of psychotropic medications. Given the seriousness of mental illness in late life, system-level changes may be needed to correctly diagnose mental illness, take more proactive actions to improve mental health, and enhance information exchange concerning psychotropic medication in a manner that meets patients' needs.

Use of glucosamine and chondroitin and lung cancer risk in the VITamins And Lifestyle (VITAL) cohort

OBJECTIVE

Inflammation plays an important role in lung carcinogenesis. Epidemiologic studies have reported inverse associations of non-steroidal anti-inflammatory drug (NSAID) use and lung cancer risk. Previously, we found that ever use of glucosamine and chondroitin, which have anti-inflammatory properties, were inversely associated with lung cancer risk. After an additional year of follow-up, we further examined the association including frequency/duration of use, interaction with factors associated with inflammation, and lung cancer histology.

METHODS

Participants were members of the VITamins And Lifestyle cohort. Adults, aged 50-76 years, who were residents of western Washington State, completed a baseline questionnaire in 2000-2002 (n = 76,904). Participants were queried on their use of glucosamine and chondroitin, over the 10 years prior to baseline, and categorized as nonuser, low use < 4 days/week or < 3 years, or high use ≥ 4 days/week and ≥ 3 years. Lung cancer cases (n = 808) were ascertained through linkage to the Surveillance, Epidemiology, and End Results cancer registry.

RESULTS

High 10-year use of glucosamine [hazard ratio (HR), 0.77; 95% CI: 0.56-1.07; p trend = 0.04] but not chondroitin was associated with a reduction in lung cancer risk. The association with glucosamine was limited to adenocarcinoma (HR, 0.49; 95% CI: 0.27-0.90; p trend <0.01) and was not modified by NSAID use or smoking status.

CONCLUSIONS

Our results for glucosamine use are similar to the prior human studies of NSAID use and lung cancer, both in magnitude and the limitation of the association to adenocarcinoma. Unlike NSAIDs, glucosamine has no known adverse effects. Although confirmatory studies are needed, glucosamine is an attractive candidate for lung cancer chemoprevention.

From hospital to home healthcare: the need for medication reconciliation

Medication reconciliation is a process of comparing medications being used by a client to a current list of prescribed medications to verify its accuracy, and is a best-practice strategy to reduce medication errors. In home healthcare, medication reconciliation includes comparing medications specified in hospital discharge instructions, those taken before the hospitalization, and those now taken by the client, and documenting action taken to resolve discrepancies noted. This exploratory study was designed to describe the adequacy of medication reconciliation in a Midwestern home healthcare agency.

The medication experience: preliminary evidence of its value for patient education and counseling on chronic medications

OBJECTIVE

To describe medication therapy management (MTM) pharmacists' encounters with patients' medication experiences, to examine the utility of the medication experience in practice, and to explore the value of the medication experience in patient education and counseling on medications.

METHODS

A focus group of 10 MTM pharmacists, and 1 pharmacist's 9-month practice diary were analyzed to reveal patients' medication experiences and the utility and value of the medication experience in practice.

RESULTS

MTM pharmacists commonly encountered patients' medication experiences in their practices. The medication experience was often at the root of drug therapy problems (DTPs) the practitioners identified. The pharmacists identified several examples of drug therapy problems with an associated medication experience at the root. The medication experience was a meaningful construct to guide patient education and counseling on new chronic medications to ultimately prevent DTPs, and valuable for tailoring patient education and counseling on medications to resolve DTPs.

CONCLUSION

Our study provides preliminary evidence of the value of the medication experience for patient education and counseling on chronic medications in practice.

PRACTICE IMPLICATIONS

The medication experience is a valuable tool for practitioners to understand patients' needs, identify and resolve DTPs, and tailor patient education and counseling for chronic medications.

Reducing Adverse Self-Medication Behaviors in Older Adults with Hypertension: Results of an e-health Clinical Efficacy Trial

A randomized controlled efficacy trial targeting older adults with hypertension (age 60 and over) provided an e-health, tailored intervention with the "next generation" of the Personal Education Program (PEP-NG). Eleven primary care practices with advanced practice registered nurse (APRN) providers participated. Participants (N = 160) were randomly assigned by the PEP-NG (accessed via a wireless touchscreen tablet computer) to either control (entailing data collection and four routine APRN visits) or tailored intervention (involving PEP-NG intervention and four focused APRN visits) group. Compared to patients in the control group, patients receiving the PEP-NG e-health intervention achieved significant increases in both self-medication knowledge and self-efficacy measures, with large effect sizes. Among patients not at BP targets upon entry to the study, therapy intensification in controls (increased antihypertensive dose and/or an additional antihypertensive) was significant (p = .001) with an odds ratio of 21.27 in the control compared to the intervention group. Among patients not at BP targets on visit 1, there was a significant declining linear trend in proportion of the intervention group taking NSAIDs 21-31 days/month (p = 0.008). Satisfaction with the PEP-NG and the APRN provider relationship was high in both groups. These results suggest that the PEP-NG e-health intervention in primary care practices is effective in increasing knowledge and self-efficacy, as well as improving behavior regarding adverse self-medication practices among older adults with hypertension.

Influence of dietary substances on intestinal drug metabolism and transport

Successful delivery of promising new chemical entities via the oral route is rife with challenges, some of which cannot be explained or foreseen during drug development. Further complicating an already multifaceted problem is the obvious, yet often overlooked, effect of dietary substances on drug disposition and response. Some dietary substances, particularly fruit juices, have been shown to inhibit biochemical processes in the intestine, leading to altered pharmacokinetic (PK), and potentially pharmacodynamic (PD), outcomes. Inhibition of intestinal CYP3Amediated metabolism is the major mechanism by which fruit juices, including grapefruit juice, enhances systemic exposure to new and already marketed drugs. Inhibition of intestinal non-CYP3A enzymes and apically-located transport proteins represent recently identified mechanisms that can alter PK and PD. Several fruit juices have been shown to inhibit these processes in vitro, but some interactions have not translated to the clinic. The lack of in vitroin vivo concordance is due largely to a lack of rigorous methods to elucidate causative ingredients prior to clinical testing. Identification of specific components and underlying mechanisms is challenging, as dietary substances frequently contain multiple, often unknown, bioactive ingredients that vary in composition and bioactivity. A translational research approach, combining expertise from clinical pharmacologists and natural products chemists, is needed to develop robust models describing PK/PD relationships between a given dietary substance and drug of interest. Validation of these models through well-designed clinical trials would facilitate development of common practice guidelines for managing drug-dietary substance interactions appropriately.

Sorafenib and sunitinib, two anticancer drugs, inhibit CYP3A4-mediated and activate CY3A5-mediated midazolam 1'-hydroxylation

Sorafenib and sunitinib are novel small-molecule molecularly targeted anticancer drugs that inhibit multiple tyrosine kinases. These medicines have shown survival benefits in advanced renal cell carcinomas as well as in advanced hepatocellular carcinomas and gastrointestinal stromal tumors, respectively. The effects of sorafenib and sunitinib on midazolam 1'-hydroxylation catalyzed by human CYP3A4 or CYP3A5 were investigated. Sorafenib and sunitinib inhibited metabolic reactions catalyzed by recombinant CYP3A4. Midazolam hydroxylation was also inhibited in human liver microsomes harboring the CYP3A5*3/*3 genotype (poor CYP3A5 expressor). In contrast, midazolam 1'-hydroxylation catalyzed by recombinant CYP3A5 was enhanced by the coexistence of sorafenib or sunitinib in a concentration-dependent manner, with saturation occurring at approximately 10 μM. Midazolam hydroxylation was also enhanced in human liver microsomal samples harboring the CYP3A5*1/*1 genotype (extensive CYP3A5 expressor). Sorafenib N-oxidation and sunitinib N-deethylation, the primary routes of metabolism, were predominantly catalyzed by CYP3A4 but not by CYP3A5. The preincubation period of sorafenib and sunitinib before the midazolam addition in the reaction mixture did not affect the enhancement of CYP3A5-catalyzed midazolam hydroxylation, indicating that the enhancement was caused by parent sorafenib and sunitinib. Docking studies with a CYP3A5 homology model based on the structure of CYP3A4 revealed that midazolam closely docked to the heme of CYP3A5 compared with sorafenib or sunitinib, suggesting that these anticancer drugs act as enhancers, not as substrates. Our results thus showed that sorafenib and sunitinib activated midazolam 1'-hydroxylation by CYP3A5 but inhibited that by CYP3A4. Unexpected drug interactions involving sorafenib and sunitinib might occur via heterotropic cooperativity of CYP3A5.

Medication Assessments by Care Managers Reveal Potential Safety Issues in Homebound Older Adults

Background

Over-the-counter (OTC) medications, benzodiazepines, and barbiturates are not covered under many Medicare drug benefit plans; hence, their use by homebound older adults is largely unreported. Furthermore, the tiered design of Medicare drug formularies may in fact promote the use of older but potentially inappropriate medications. Little is known about the use of these medications in the homebound older adult population.

Objective:

To determine the prevalence of the use by homebound older adults of OTC drugs, dietary supplements (vitamins, minerals, and herbal products), Part D-excluded medications (benzodiazepines and barbiturates), and potentially inappropriate medications (according to Beers criteria).

Methods:

Patients were enrollees in a home and community-based Medicaid waiver provider. All clients were older than 65 and were dually eligible for Medicare and Medicaid. All clients met Florida Medicaid's medical and financial criteria for nursing home placement. The medication list was obtained by geriatric care managers during a home assessment.

Results:

A total of 3911 older adults (mean [SD] age 83.6 [8.0] years) were taking an average of 9.9 [4.8] drugs. Of these individuals. 74.5% were using an OTC medication, 41.9% were using a dietary supplement, 29.6% were using a benzodiazepine or barbiturate, and 25.2% were using at least 1 potentially inappropriate medication.

Conclusions:

Based on data gathered by a geriatric care management assessment, we found that most of the homebound older adults enrolled in our study used medications not included in their Medicare drug benefit. The use of potentially inappropriate medications was also common in this population. Future drug safety initiatives involving the elderly will benefit from engaging care managers in identifying and addressing the potential hazards posed by commonly used prescribed and nonprescribed medications.

Warfarin-associated bleeding events and concomitant use of potentially interacting medicines reported to the Norwegian spontaneous reporting system

AIMS

To study warfarin associated bleeding events reported to the Norwegian spontaneous reporting system and evaluate the differences in assessment of potentially interacting medicines between reporters and evaluators.

METHODS

Data on bleeding events on warfarin were retrieved from the Norwegian spontaneous reporting system database. Key measurements were time to bleeding, use of concomitant medications and the evaluation done by reporters.

RESULTS

In 289 case reports a total of 1261 medicines (median 4.0 per patient, range 1-17) was used. The evaluators (authors of this article) identified 546 medicines including warfarin (median 2.0 per patient, range 1-7) that could possibly cause bleeding alone or in combination. Reporters assessed 349 medicines (median 1.0 per patient, range 1-4) as suspect. Evaluators identified 156 pharmacokinetic and 101 pharmacodynamic interactions, compared with 19 pharmacokinetic and 56 pharmacodynamic interactions reported as suspected by the reporters. Time to bleeding was stated in 224 reports. Among the early bleeding events, the reports on warfarin without interacting medicines showed the highest INR (international normalized ratio). Heparin was used in 17/21 reported bleeding events during the first week on warfarin. Among the late bleeding events, reports with pharmacokinetic interacting medicines had the highest INR.

CONCLUSIONS

Concomitant use of potentially interacting medicines was involved in the majority of the warfarin-associated bleeding events reported to the Norwegian spontaneous reporting system. Reporters assessed mostly warfarin as the only contributor to bleeding. In particular, pharmacokinetically interacting medicines were not suspected as contributing to bleeding.

Vitamin status and needs for people with stages 3-5 chronic kidney disease

Patients with chronic kidney disease (CKD) often experience a decline in their nutrient intake starting at early stages of CKD. This reduction in intake can affect both energy-producing nutrients, such as carbohydrates, proteins, and fats, as well as vitamins, minerals, and trace elements. Knowledge of the burden and bioactivity of vitamins and their effect on the health of the patients with CKD is very incomplete. However, without sufficient data, the use of nutritional supplements to prevent inadequate intake may result in either excessive or insufficient intake of micronutrients for people with CKD. The purpose of this article is to briefly summarize the current knowledge regarding vitamin requirements for people with stages 3, 4, or 5 CKD who are not receiving dialysis.

Improved preclinical safety assessment using micro-BAL devices: the potential impact on human discovery and drug attrition

Hepatotoxicity is often unpredictable in the early phase of drug discovery and leads to drug attrition in preclinical and clinical development. Here, we discuss the conventional preclinical liver models that do not mimic in vivo livers. We focus on key components such as new sources of hepatocyte-derived human stem cells, enhanced direct oxygenation, defined biocompatibility nanoscaffolds, organotypical cellular models, dynamic culture, and metabolite status inside and outside the cell for effective configuration for the development of a bioartificial liver (BAL) device to mimic the in vivo liver microenvironment. The potential for development of BAL devices could open up new avenues in: (i) hepatotoxicity assessment for selecting drug candidates during preclinical screening; and (ii) therapeutic approaches for liver cell therapy at the clinical stage.

Acute kidney injury in older adults

Aging kidneys undergo structural and functional changes that decrease autoregulatory capacity and increase susceptibility to acute injury. Acute kidney injury associates with duration and location of hospitalization, mortality risk, progression to chronic kidney disease, and functional status in daily living. Definition and diagnosis of acute kidney injury are based on changes in creatinine, which is an inadequate marker and might identify patients when it is too late. The incidence of acute kidney injury is rising and increases with advancing age, yet clinical studies have been slow to address geriatric issues or the heterogeneity in etiologies, outcomes, or patient preferences among the elderly. Here we examine some of the current literature, identify knowledge gaps, and suggest potential research questions regarding acute kidney injury in older adults. Answering these questions will facilitate the integration of geriatric issues into future mechanistic and clinical studies that affect management and care of acute kidney injury.

Racial and ethnic disparities in cardiovascular medication use among older adults in the United States

BACKGROUND

Despite persistent racial/ethnic disparities in cardiovascular disease (CVD) among older adults, information on whether there are similar disparities in the use of prescription and over-the-counter medications to prevent such disease is limited. We examined racial and ethnic disparities in the use of statins and aspirin among older adults at low, moderate, and high risk for CVD.

METHODS AND RESULTS

In-home interviews, including a medication inventory, were administered between June 2005 and March 2006 to 3005 community-residing individuals, ages 57-85 years, drawn from a cross-sectional, nationally-representative probability sample of the United States. Based on a modified version of the Adult Treatment Panel III (ATP III) risk stratification guidelines, 1066 respondents were at high cardiovascular risk, 977 were at moderate risk, and 812 were at low risk. Rates of use were highest among respondents at high cardiovascular risk. Racial differences were highest among respondents at high risk with blacks less likely than whites to use statins (38% vs. 50%, p = 0.007) and aspirin (29% vs. 44%, p = 0.008). After controlling for age, gender, comorbidity, and socioeconomic, and access to care factors, racial/ethnic disparities persisted. In particular, blacks at highest risk were less likely than their white counterparts to use statins (odds ratio (OR) 0.65, confidence interval (CI) 0.46-0.90) or aspirin (OR 0.61, CI 0.37-0.98).

CONCLUSIONS

These results, based on an in-home survey of actual medication use, suggest widespread underuse of indicated preventive therapies among older adults at high cardiovascular risk in the United States. Racial/ethnic disparities in such use may contribute to documented disparities in cardiovascular outcomes.

Predictors of C-reactive protein in the national social life, health, and aging project

OBJECTIVE

Inflammation plays an important role in many chronic degenerative diseases associated with aging, and social, economic, and behavioral factors that contribute to inflammation may lead to differential burdens of morbidity and mortality in later life. This study examines socioeconomic status and race/ethnicity as predictors of C-reactive protein (CRP) among older adults in the United States and considers the degree to which health behaviors, medical conditions and medication use, and psychosocial factors account for these associations.

METHODS

Multiple linear regression analysis of survey data for 1,580 participants, 57-85 years of age, in a population-based nationally representative sample of community-residing older adults in the United States.

RESULTS

Educational attainment, household wealth, and race/ethnicity were independently associated with CRP, with limited evidence for interactions with age. Health-related behaviors and usage of medications related to inflammation accounted for substantial proportions of these associations.

DISCUSSION

These results highlight the fundamental causes of inflammation among older adults and suggest pathways through which social disparities in inflammation may be reduced.

Economic impact of potential drug-drug interactions in opioid analgesics

OBJECTIVE

Patients managing chronic non-cancer pain with cytochrome P450 (CYP450)-metabolized opioid analgesics who concurrently take another CYP450-metabolized medication experience a drug-drug exposure (DDE), which puts them at risk for a pharmacokinetic drug-drug interaction (PK DDI). This study examined the economic impact of incident DDEs with the potential to cause PK DDIs compared to similar patients without such exposure.

STUDY DESIGN

This retrospective analysis used paid claims from a large, commercially insured population during January 1, 2004 through December 31, 2008.

METHODS

Propensity matching was used to control for baseline differences in comparisons between 85,043 exposed and 85,043 non-exposed patients.

RESULTS

Comparisons yielded mean total costs 6 months after the DDEs that were significantly higher in subjects with DDE versus matched subjects without DDE [$8165 (SD $11,357) vs. $7498 (SD $11,668), respectively, p<0.01] resulting in a difference of $667. This was driven by medical costs [$5520 (SD $10,505) vs. $5222 (SD $10,689), respectively, p<0.01] a $298 difference, and total prescription costs [$2646 (SD $3262) vs. $2276 (SD $3907), respectively, p<0.01] a $369 difference.

LIMITATIONS

The study design demonstrates associations only and cannot establish causal relationships. Further, relevant DDEs were not included if concurrent consumption occurred outside the index period and when CYP450 substances were consumed that are not reflected in pharmacy claims (herbals, over-the-counter medications).

CONCLUSION

Since concurrent exposure to DDEs with the potential to cause PK DDIs may be relatively common, policy decisions-makers should consider the use of long-acting opioids that are not metabolized through the CYP450 pathway.

Optimizing chemotherapy: concomitant medication lists

Identifying sources of variability in the response to cancer chemotherapy requires knowledge of all variables, including concomitant medications, that can alter the metabolism and pharmacokinetics of chemotherapy. This study investigated the accuracy of the lists of concomitant medications in the charts of cancer patients. Information collated from a questionnaire, patient interview, and the patient's medical chart was used to obtain validated medication lists. Patients took an average of 4.8 prescription drugs, 1.6 nonprescription drugs, and 1.6 other remedies within the 3 days prior to chemotherapy. Of the concomitant drugs actually taken, the medical records did not report 24% of prescription drugs, 84% of nonprescription drugs, and 83% of other remedies. Electronic medical records (EMRs) were more complete than paper charts, but even these omitted >75% of nonprescription drugs and other remedies. Potential drug interactions were noted in this study. This study documents the extent and complexity of the concomitant drugs taken by patients undergoing chemotherapy and the deficiencies in recording this information in medical charts.

Concomitant use of prescription medications and dietary supplements in menopausal women: an approach to provider preparedness

Dietary supplements are becoming increasingly popular as therapies for symptom relief among menopause-age women in the United States. However, a large gap exists between research in the concomitant use of prescription medications and dietary supplements and provider preparedness to guide patient decision making. Many menopausal women take prescription medications, over the counter medications, and herbs and dietary supplements for climactic symptoms or other health conditions. With any drug, there is the potential for interactions. Women taking medications with a narrow therapeutic index, such as anticoagulants, anticonvulsants, and drugs for the treatment of chronic diseases, are at particular risk. Patients should be queried regarding their use of dietary supplements when starting or stopping a prescription drug, or if unexpected reactions occur. When counseling patients, one must carefully consider the risks and benefits of each supplement and medication being taken by each individual.

An instrument to evaluate pharmacists' patient counseling on herbal and dietary supplements

OBJECTIVE

To develop a measure of pharmacists' patient counseling on herbal and dietary supplements.

METHODS

A systematic process was used for item generation, testing, and validation of a measure of pharmacists counseling on herbal and dietary supplements. Because a pharmacist-patient encounter may or may not identify an indication for taking an herb or dietary supplement, the instrument was bifurcated into 2 distinct components: (1) patient counseling in general; and (2) patient counseling related to herbal and dietary supplements.

RESULTS

The instrument demonstrated high reliability and desirable construct validity. After adjusting for item difficulty, we found that pharmacists tended to provide more general patient counseling than counseling related to herbal and dietary supplements.

CONCLUSION

This instrument can be applied to assess the quality of counseling provided by pharmacists and pharmacy students, and the outcomes of pharmacist and pharmacy student education on herbal and dietary supplements.