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Krause O, Ziemann CT, Schulze Westhoff M, Schröder S, Krichevsky B, Greten S, Stichtenoth DO, Heck J. What do older patients know about their medication? A cross-sectional, interview-based pilot study. Eur J Clin Pharmacol 2023; 79:1365-1374. [PMID: 37561156 PMCID: PMC10501933 DOI: 10.1007/s00228-023-03548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/02/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE This study sought to analyze the medication knowledge and awareness of medication adjustment options during intercurrent illness (sick day rules) of patients ≥ 70 years treated at a hospital for geriatric medicine in northern Germany. METHODS The study was designed as a cross-sectional, interview-based pilot study, was approved by the Ethics Committee of Hannover Medical School (No. 10274_BO_K_2022; date of approval: 11 March 2022), and enrolled a convenience sample of 100 patients between May and December 2022. RESULTS The median of the average medication knowledge score in the study population (median age 82 years (IQR 75-87); 71% female) was 5 on a scale from 0 to 6 (IQR 3.8-5.6). Women achieved higher average medication knowledge scores than men (median 5.1 (IQR 4-5.6) vs. median 4.3 (IQR 3.6-5.1); p = 0.012), and patients < 80 years achieved higher average medication knowledge scores than patients ≥ 80 years (median 5.4 (IQR 4.9-5.7) vs. median 4.3 (IQR 3.2-5.3); p < 0.001). Sick day rules were known for only 1.1% of drugs for which sick day rules were applicable. Fifty-two percent of the patients reported that their general practitioner contributed most to their medication knowledge, and 66% considered their daily number of drugs to take adequate. CONCLUSION Our study showed that medication knowledge of older patients was overall satisfying. Awareness of sick day rules, however, was poor. Future studies should evaluate the clinical benefits of sick day rules and ways of better communicating sick day rules to patients. In this regard, general practitioners may play a decisive role.
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Affiliation(s)
- Olaf Krause
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
- Center for Geriatric Medicine, DIAKOVERE Henriettenstift, Hannover, Germany
| | - Corinna T Ziemann
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - Martin Schulze Westhoff
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Sebastian Schröder
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Benjamin Krichevsky
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - Stephan Greten
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Dirk O Stichtenoth
- Institute for Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Brennan V, Martin-Grace J, Greene G, Heverin K, Mulvey C, McCartan T, Lombard L, Walsh J, Hale EM, Srinivasan S, O'Reilly MW, Thompson CJ, Costello RW, Sherlock M. The Contribution of Oral and Inhaled Glucocorticoids to Adrenal Insufficiency in Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2614-2623. [PMID: 35697207 DOI: 10.1016/j.jaip.2022.05.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Exposure to any form of glucocorticoid preparation is associated with a risk of adrenal insufficiency (AI). OBJECTIVE To establish the contribution of oral corticosteroid (OCS) and inhaled corticosteroid (ICS) exposure to the risk of AI in a cohort of patients (n = 80) with severe, uncontrolled asthma. METHODS We compiled individualized cumulative OCS and ICS exposure data using a combination of health care records and electronic inhaler monitoring using an Inhaler Compliance Assessment device and estimated the risk of AI for each participant using a morning serum cortisol concentration. RESULTS The predicted prevalence of AI based on morning cortisol concentrations was 25% (20 of 80). Participants on maintenance OCS therapy had the highest risk of AI at 60% (6 of 10) compared with 17% (11 of 65) in those with no recent OCS exposure. Morning serum cortisol correlated negatively with both OCS exposure (mg/kg prednisolone) (r = -0.4; P < .0002) and ICS exposure (mg/kg fluticasone propionate) (r = -0.26; P = .019). Logistic regression of risk of AI against the number of standard treatment courses of OCS demonstrated a positive relationship although this did not reach statistical significance (odds ratio, 1.41; 95% CI, 0.97-2.05; P = .073). Logistic regression analysis, categorizing patients as high-risk AI (cortisol <130 nmol/L) or not (cortisol >130 nmol/L), showed that cumulative ICS exposure remained a significant predictor of AI, even when exposure to OCS was controlled for (odds ratio, 2.17 per 1 mg/kg increase in cumulative fluticasone propionate exposure; 95% CI, 1.06-4.42; P = .033). CONCLUSIONS Our data suggest that AI is common among patients with asthma and highlights that the risk of AI is associated with both high-dose ICS therapy and intermittent treatment courses of OCS.
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Affiliation(s)
- Vincent Brennan
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Julie Martin-Grace
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Garrett Greene
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Karen Heverin
- Department of Clinical Biochemistry, Beaumont Hospital, Dublin, Ireland
| | - Christopher Mulvey
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Tom McCartan
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Lorna Lombard
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Joanne Walsh
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Elaine Mac Hale
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Shari Srinivasan
- Department of Clinical Biochemistry, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Chris J Thompson
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Richard W Costello
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Gaw AG, Wemyss C, Bell A, Goodall CA. Management of patients at risk of adrenal crisis in the dental setting: a review of current practice in UK dental teaching hospitals. Br Dent J 2022:10.1038/s41415-022-4515-0. [PMID: 35931749 DOI: 10.1038/s41415-022-4515-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/06/2022] [Indexed: 11/09/2022]
Abstract
Introduction Patients with impaired corticosteroid response due to Addison's disease or systemic glucocorticoid use are at risk of adrenal crisis when undergoing dental treatment. There is a lack of conclusive evidence to support dental teams in identifying patients at risk and their management to prevent an adrenal crisis.Aim To review the current practice in UK dental teaching hospitals regarding the management of patients at risk of adrenal crisis in the dental setting.Methods An electronic survey focused on patients who may be at risk of adrenal crisis due to systemic glucocorticoid therapy was sent to all 18 UK dental teaching hospitals. Information on the use of a policy or guidance was requested. Responses were evaluated for clinical decision-making, patient risk assessment and steroid cover dosing regimens.Results A 78% response rate was achieved. Only 29% of institutions had a written policy or guidance document. Variation exists in the threshold of steroid dose and duration of treatment in identifying patients at risk of adrenal suppression. Furthermore, the dose regime for steroid cover varied.Conclusion Further evidence on the management of patients at risk of adrenal crisis is required to inform national guidance and reduce variation in patient management.
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Affiliation(s)
- A Gemma Gaw
- Dental Core Trainee in Oral and Maxillofacial Surgery, Forth Valley Royal Hospital, Larbert, UK.
| | - Callum Wemyss
- Speciality Registrar in Oral Surgery, Glasgow Dental Hospital and School, Glasgow, UK
| | - Aileen Bell
- Professor of Oral Surgery and Dental Education, Honorary Consultant in Oral Surgery and Head of Dental School, School of Medicine Dentistry and Nursing, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Christine A Goodall
- Professor of Oral Surgery and Violence Reduction, Honorary Consultant in Oral Surgery, School of Medicine Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Donald DM, Sherlock M, Thompson CJ. Hyponatraemia and the syndrome of inappropriate antidiuresis (SIAD) in cancer. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R78-R89. [PMID: 37435459 PMCID: PMC10259335 DOI: 10.1530/eo-22-0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/10/2022] [Indexed: 07/13/2023]
Abstract
Hyponatraemia is a common electrolyte abnormality seen in a wide range of oncological and haematological malignancies and confers poor performance status, prolonged hospital admission and reduced overall survival, in patients with cancer. Syndrome of inappropriate antidiuresis (SIAD) is the commonest cause of hyponatraemia in malignancy and is characterised by clinical euvolaemia, low plasma osmolality and concentrated urine, with normal renal, adrenal and thyroid function. Causes of SIAD include ectopic production of vasopressin (AVP) from an underlying tumour, cancer treatments, nausea and pain. Cortisol deficiency is an important differential in the assessment of hyponatraemia, as it has an identical biochemical pattern to SIAD and is easily treatable. This is particularly relevant with the increasing use of immune checkpoint inhibitors, which can cause hypophysitis and adrenalitis, leading to cortisol deficiency. Guidelines on the management of acute, symptomatic hyponatraemia recommend 100 mL bolus of 3% saline with careful monitoring of the serum sodium to prevent overcorrection. In cases of chronic hyponatraemia, fluid restriction is recommended as first-line treatment; however, this is frequently not feasible in patients with cancer and has been shown to have limited efficacy. Vasopressin-2 receptor antagonists (vaptans) may be preferable, as they effectively increase sodium levels in SIAD and do not require fluid restriction. Active management of hyponatraemia is increasingly recognised as an important component of oncological management; correction of hyponatraemia is associated with shorter hospital stay and prolonged survival. The awareness of the impact of hyponatraemia and the positive benefits of active restoration of normonatraemia remain challenging in oncology.
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Affiliation(s)
- D Mc Donald
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - M Sherlock
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - C J Thompson
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
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Mehta P, Meeran K, Macphie E, Abbas A, Rippin J, Jeffery RC, Reddy V, Leandro MJ, Ciurtin C, Simpson HL, Mackie SL. Variability in counselling for adrenal insufficiency in COVID-19 and beyond: a survey of rheumatology practice. LANCET RHEUMATOLOGY 2021; 3:e92-e94. [PMID: 33521672 PMCID: PMC7834225 DOI: 10.1016/s2665-9913(20)30389-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Puja Mehta
- Centre for Inflammation and Tissue Repair, UCL Respiratory, Division of Medicine, University College London Hospital, London WC1E 6JF, UK.,Department of Rheumatology, University College London Hospital, London WC1E 6JF, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College London, London, UK
| | - Elizabeth Macphie
- Rheumatology Service, Lancashire and South Cumbria NHS Foundation Trust, Preston, UK
| | - Afroze Abbas
- Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jonathan Rippin
- Department of Endocrinology, Northampton General Hospital, Northampton, UK
| | - Rachel C Jeffery
- Department of Endocrinology, Northampton General Hospital, Northampton, UK
| | - Venkat Reddy
- Department of Rheumatology, University College London Hospital, London WC1E 6JF, UK
| | - Maria J Leandro
- Centre for Adolescent Rheumatology, University College London Hospital, London WC1E 6JF, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London Hospital, London WC1E 6JF, UK
| | - Helen L Simpson
- Department of Endocrinology, University College London Hospital, London WC1E 6JF, UK
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Rushworth RL, Torpy DJ, Falhammar H. Adrenal crises in older patients. Lancet Diabetes Endocrinol 2020; 8:628-639. [PMID: 32559478 DOI: 10.1016/s2213-8587(20)30122-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/21/2022]
Abstract
Adrenal crises are severe manifestations of adrenal insufficiency that result in hospital admission and incur a risk of cardiovascular events, acute renal injury, and death. Evidence from population-based studies indicate that adults older than 60 years have the highest adrenal insufficiency incidence, contribute to the highest number of adrenal crises, and have the highest age-specific incidence of adrenal crisis, which doubles between the age groups of 60-69 years and 80 years or older. Older patients might be more susceptible to adrenal crises because of a higher prevalence of comorbidities and a consequently higher risk of acute illness. This susceptibility might be compounded by shortfalls in the implementation of prevention strategies for adrenal crisis, because of individual and social factors that increase with age. Although little research has focused on adrenal crisis prevention in older patients, it seems logical that a timely diagnosis of adrenal insufficiency and the use of consensus driven adrenal crisis prevention and attenuation strategies might reduce adrenal crises in patients older than 60 years old.
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Affiliation(s)
- Ruth L Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Dineen R, Martin-Grace J, Thompson CJ, Sherlock M. The management of glucocorticoid deficiency: Current and future perspectives. Clin Chim Acta 2020; 505:148-159. [DOI: 10.1016/j.cca.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
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Adrenal insufficiency: Physiology, clinical presentation and diagnostic challenges. Clin Chim Acta 2020; 505:78-91. [PMID: 32035851 DOI: 10.1016/j.cca.2020.01.029] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
Adrenal insufficiency (AI) is a serious condition, which can arise from pathology affecting the adrenal gland itself (primary adrenal insufficiency, PAI), hypothalamic or pituitary pathology (secondary adrenal insufficiency, SAI), or as a result of suppression of the hypothalamic-pituitaryadrenal (HPA) axis by exogenous glucocorticoid therapy (tertiary adrenal insufficiency, TAI). AI is associated with an increase in morbidity and mortality and a reduction in quality of life. In addition, the most common cause of PAI, autoimmune adrenalitis, may be associated with a variety of other autoimmune disorders. Untreated AI can present with chronic fatigue, weight loss and vulnerability to infection. The inability to cope with acute illness or infection can precipitate life-threatening adrenal crisis. It is therefore a critical diagnosis to make in a timely fashion, in order to institute appropriate management, aimed at reversing chronic ill health, preventing acute crises, and restoring quality of life. In this review, we will describe the normal physiology of the HPA axis and explain how knowledge of the physiology of this axis helps us understand the clinical presentation of AI, and forms the basis for the biochemical investigations which lead to the diagnosis of AI.
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Rushworth RL, Chrisp GL, Torpy DJ. The use of medical identification jewellery in adults with adrenal insufficiency in Australia. Clin Endocrinol (Oxf) 2019; 91:41-47. [PMID: 30963602 DOI: 10.1111/cen.13985] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/28/2019] [Accepted: 04/06/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Hydrocortisone stress dosing during illness can prevent adrenal crises (AC) in patients with adrenal insufficiency (AI). When patients cannot communicate, medical identification jewellery may facilitate parenteral hydrocortisone provision but patient adoption rates are not known. DESIGN A cross-sectional analysis of Australian medical identification jewellery subscription data. PATIENTS Patients with AI aged 20 years and over with an active subscription to a large medical jewellery provider. MEASUREMENTS Subscription rates by AI subtype, geographic area, age and gender. RESULTS There were 1955 patients with AI and an active subscription in the database, corresponding to a subscription rate of 105.79/million or approximately one-third of the AI population. The subscription rate was substantially higher in primary AI (60.72/million) than secondary AI (23.16/million), corresponding to approximately 60.7% and 11.6% of the estimated population prevalence of each disorder, respectively. There was substantial variation in use by state/territory, with the highest subscribing state having a rate of over four times that of the lowest (P < 0.001). Women comprised 64.8% (n = 1266) of the group. Subscription also varied by age, being highest in the 60-69 year age group (165.15/million) and lowest in those aged 30-39 years (47.23/million) (P < 0.001). Few patients (4.8%, n = 94) mentioned, either in their record or on their jewellery, the need for urgent parenteral hydrocortisone in the event of severe illness. CONCLUSIONS Medical jewellery is a component of AC risk reduction. However, subscription appears to be underutilised in the Australian AI population, especially among patients with secondary AI. Urgent treatment recommendations should be inscribed on the jewellery.
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Affiliation(s)
- Rosemary Louise Rushworth
- School of Medicine Sydney, The University of Notre Dame, Australia, Sydney, New South Wales, Australia
| | - Georgina L Chrisp
- School of Medicine Sydney, The University of Notre Dame, Australia, Sydney, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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A letter of reply to: Salehmohamed, M.R., Griffin, M., Branigan, T. et al. Patients treated with immunosuppressive steroids are less aware of sick day rules than those on endocrine replacement therapy and may be at greater risk of adrenal crisis. Ir J Med Sci (2017). doi: 10.1007/s11845-017-1607-y. Ir J Med Sci 2018; 187:541. [DOI: 10.1007/s11845-017-1656-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/04/2017] [Indexed: 11/27/2022]
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