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Defieuw L, Hias J, Karapinar-Carkıt F, Forsyth P, Van der Linden LR. Empowering European hospital pharmacists in the face of heart failure. Eur J Hosp Pharm 2024:ejhpharm-2023-004068. [PMID: 38740548 DOI: 10.1136/ejhpharm-2023-004068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Affiliation(s)
- Lise Defieuw
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
| | - Julie Hias
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Flanders, Belgium
| | - Fatma Karapinar-Carkıt
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, The Netherlands
| | - Paul Forsyth
- Pharmacy, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Lorenz Roger Van der Linden
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Flanders, Belgium
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Van der Linden L, Hias J, Walgraeve K, Petrovic M, Tournoy J, Vandenbriele C, Van Aelst L. Guideline-Directed Medical Therapies for Heart Failure with a Reduced Ejection Fraction in Older Adults: A Narrative Review on Efficacy, Safety and Timeliness. Drugs Aging 2023; 40:691-702. [PMID: 37452262 DOI: 10.1007/s40266-023-01046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
Heart failure is a prevalent syndrome among older adults, with a major impact on morbidity and mortality. Higher age is correlated with underuse of guideline-directed medical therapies which, in turn, has been linked to worse clinical outcomes. Importantly, most evidence so far has been collected in adults who were younger, less multi-morbid and polymedicated compared with those who are commonly treated in daily clinical practice. Hence, we aimed to assess and describe the evidence base for pharmacotherapy in older adults with heart failure with a reduced ejection. First, a narrative review was undertaken using Medline, from inception to January 2023. Four foundational therapies were selected based on the latest European Society of Cardiology clinical practice guideline: angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Post hoc analyses from landmark heart failure drug trials were searched and included if they contained data on the impact of age on efficacy, safety and/or timeliness of therapies in the management of heart failure with a reduced ejection fraction. Second, a proposal was developed to support and promote the use of evidence-based heart failure pharmacotherapy in complex, older adults. In total, 11 articles were selected: 4 meta-analyses, 6 post hoc analyses and 1 review paper. No attenuation of efficacy for any of the foundational agents was found in older adults. Regarding safety, dedicated analyses showed that beta blockers, mineraloid receptor antagonists, sacubitril-valsartan, dapagliflozin and empagliflozin retained their overall benefit-risk profile regardless of age. Time to benefit was short and occurred generally within 1 month. Consensus was achieved on a five-step proposal to manage complex medication regimens in older adults suffering from heart failure. In conclusion, older adults suffering from heart failure with a reduced ejection fraction should not be denied treatment based on their age.
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Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karolien Walgraeve
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary care, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Adult intensive Care, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundations Trust, London, UK
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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Consensus validation of a screening tool for cardiovascular pharmacotherapy in geriatric patients: the RASP_CARDIO list (Rationalization of Home Medication by an Adjusted STOPP list in Older Patients). Eur Geriatr Med 2022; 13:1467-1476. [PMID: 36229756 DOI: 10.1007/s41999-022-00701-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/26/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Cardiovascular agents commonly used in geriatric patients, are linked to potentially avoidable harm and might hence be a suitable substrate for medication review practices. Therefore, we sought to update and validate the content of the cardiovascular segment of the previously published Rationalization of Home Medication by an Adjusted STOPP list in Older Patients (RASP) List. METHODS A three-step study was conducted by the pharmacy department in collaboration with the geriatric medicine and cardiology department at the University Hospitals Leuven, Belgium. First, the cardiovascular segment of the RASP list version 2014 was updated taking into account published research, other screening tools and the input of end-users. Secondly, this draft was reviewed during three panel discussions with five expert cardiologists and three clinical pharmacists, all of whom had relevant expertise in geriatric pharmacotherapy. Thirdly, the content was validated using a modified Delphi Technique by a panel of European hospital pharmacists, cardiologists, geriatricians and an internal medicine physician. RESULTS After the first and second step, the RASP_CARDIO list comprised 94 statements. Consensus (≥ 80% agreement) of all statements and one new statement about gliflozins in heart failure was achieved by a panel of seventeen experts across four European countries after two validation rounds. The final construct comprised a list of 95 statements related to potentially inappropriate prescribing of cardiovascular agents. CONCLUSION The RASP_CARDIO list is an updated and validated explicit screening tool to optimize cardiovascular pharmacotherapy in geriatric patients.
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Hias J, Hellemans L, Walgraeve K, Tournoy J, Van der Linden L. SGLT2 Inhibitors in Older Adults with Heart Failure with Preserved Ejection Fraction. Drugs Aging 2022; 39:185-190. [PMID: 35118602 DOI: 10.1007/s40266-022-00920-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
Heart failure is an important medical condition that is prevalent in older adults. Multiple therapies have been identified that improve clinical outcome in heart failure with a reduced ejection fraction. Conversely, this has not been the case in heart failure with preserved ejection fraction (HFpEF). Until now, empagliflozin is the first therapy that has convincingly been shown to improve clinical outcome in HFpEF. Importantly, some key points should be considered to better understand the impact of empagliflozin on the patient trajectory, particularly in older adults with HFpEF. In this current opinion article, we have therefore provided more information on how to translate the findings of the EMPEROR-Preserved trial to the setting of older adults, with a focus on the impact of empagliflozin on hospitalizations, both heart failure-related and all-cause. To better understand the importance of EMPEROR-Preserved findings, we compared these findings with previous relevant HFpEF and heart failure with reduced ejection fraction (HFrEF) trials and provided information on ongoing trials in the HFpEF setting.
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Affiliation(s)
- Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Laura Hellemans
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Geriatrics and Gerontology, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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Van Der Linden L, Hias J, Walgraeve K, Loyens S, Flamaing J, Spriet I, Tournoy J. Factors associated with the number of clinical pharmacy recommendations: findings from an observational study in geriatric inpatients. Acta Clin Belg 2021; 76:119-126. [PMID: 31642397 DOI: 10.1080/17843286.2019.1683128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives: Drug-related problems are prevalent in older inpatients and can be reduced by providing clinical pharmacy (CP) services. Details concerning implementation in clinical practice are frequently lacking. The aim was to describe the output of one such CP program and to identify factors associated with CP recommendations.Methods: A CP program was installed at three acute geriatric wards in a teaching hospital. A convenience sample was collected, consisting of inpatients who received a CP consultation at discharge. Medical conditions, patient demographics, and drug use were evaluated retrospectively. Number and type of the CP recommendations were determined. A Poisson regression analysis was performed to determine factors associated with the number of CP recommendations.Results: A cohort of 524 patients, aged 85 (interquartile range (IQR): 82-89) years was included. On admission, 10.31 (standard deviation: 4.49) drugs were taken. Three (IQR: 2-4) CP recommendations were provided per patient, of which 70.2% targeted drug discontinuation. A model was derived, containing the following factors: number of drugs on admission (incidence rate ratio (IRR): 1.063; 95% confidence interval (CI): 1.052-1.074), number of previous contacts with the geriatric department (IRR: 0.869; 95%CI: 0.816-0.926), presence of left-ventricular dysfunction (IRR: 1.179, 95% CI: 1.023-1.360), the number of new drugs (IRR: 1.046; 95% CI: 1.021-1.071) and use of colecalciferol (IRR: 1.22; 95% CI: 1.088-1.367).Conclusions: Five factors were associated with the number of CP recommendations at discharge. This could allow for further patient stratification to increase the efficiency of the CP program.
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Affiliation(s)
- Lorenz Van Der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | | | - Silke Loyens
- Faculty Of Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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Hias J, Walgraeve K, Tournoy J, Flamaing J, Spriet I, Van der Linden L. Physician's feedback on a clinical pharmacy program on geriatric wards. Acta Clin Belg 2020; 75:321-328. [PMID: 31179904 DOI: 10.1080/17843286.2019.1629054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES As clinical pharmacy (CP) services can improve drug use and clinical outcome in older inpatients, a dedicated CP program was installed at the geriatric wards of an academic hospital. The aim of this study was to evaluate and potentially improve the CP program, by obtaining physician's feedback. METHODS An anonymous e-questionnaire was sent to all physicians who were active between October 2014 and March 2018 on the acute geriatric wards (80 beds) of the University Hospitals Leuven, Belgium. Thematic content analysis was applied. Six themes were defined: satisfaction with the service, time allocation of the clinical pharmacists, content and clinical relevance of pharmaceutical interventions, communication, time savings for the treating physician and future perspectives. RESULTS A total of 45 physicians (59%) completed the e-questionnaire. All respondents were satisfied with the content of the provided pharmaceutical recommendations. A minority (44%) found that a 0.8 full-time equivalent clinical pharmacist presence was sufficient in terms of the expected workload. The provided CP interventions improved quality of care according to 38 (84%) physicians. Oral and written communication were considered necessary by 89% and 82% of physicians, respectively. On average, an estimated 30 minutes physician time (IQR: 15-60) per patient was saved as a result of the program. The majority (87%) preferred clinical pharmacist presence for discharge support in all geriatric patients. CONCLUSION Physician's satisfaction with the CP service was very high. CP services in geriatric inpatients were perceived to be clinically relevant as well as time-saving by the involved physicians.
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Affiliation(s)
- Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | | | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Abstract
BACKGROUND Hospital admissions in older adults are frequently drug related and avoidable. Clinical pharmacy interventions during hospital stay might reduce drug-related harm and reduce hospital visits. Moreover, several recent positive clinical pharmacy investigations incorporated a transitional care component to further improve medication use after discharge. It is currently unclear what the strength of evidence is and what the exact components should be of such clinical pharmacy interventions in older adults. OBJECTIVE An evidence-based review was performed to determine the status of the evidence and also to explore whether a clinical pharmacy intervention incorporating transitional care was associated with reduced hospital visits after discharge. METHODS Prospective controlled investigations were included if they contained a clinical pharmacy intervention that was initiated before discharge in older inpatients. Relevant quasi-experimental and randomized controlled trials were searched in MEDLINE. First, an evidence-based review was performed, including a description of the study design, characteristics, and outcomes. Major components of successful clinical pharmacy interventions were described and potential implications for clinical practice and research were determined. Second, the Fisher's exact test was used to explore the association between transitional care and reduced hospital visits. Third, based on these findings, a medication review proposal was developed to improve medication use in older adults. RESULTS Thirty-five studies were included, with 26 randomized controlled trials. Median patient follow-up after discharge was 90 days (interquartile range 37-180 days) and investigators enrolled a median of 210 (interquartile range 110-498) study participants. On average, patients were aged 77.5 years (interquartile range 73-82.2 years). Nine randomized controlled trials had sufficient power to detect a reduction in hospital visits after discharge; this was reduced in three randomized controlled trials. Post-discharge follow-up was not associated with reduced post-discharge hospital visits (20 randomized controlled trials: follow-up vs. no follow-up: 6/11 vs. 1/9, p = 0.070). There was a significant reduction in post-discharge hospital visits in patients aged 75 years or older (12 randomized controlled trials: follow-up vs. no follow-up: 5/7 vs. 0/5, p = 0.028). A medication review proposal was developed, consisting of six steps. CONCLUSIONS Three powered randomized controlled trials were identified that found a significant association between a pharmacist-led intervention in older adults and a reduction in post-discharge hospital visits. In clinical practice, an intervention consisting of medication reconciliation, review, counseling, and post-discharge follow-up should be provided to such high-risk inpatients. Regarding research priorities, large, multi-center randomized controlled trials should be performed to generate more evidence on the impact of clinical pharmacy interventions on the patient trajectory and economic outcomes.
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Van der Linden L, Hias J, Spriet I, Walgraeve K, Flamaing J, Tournoy J. Medication review in older adults: Importance of time to benefit. Am J Health Syst Pharm 2019; 76:247-250. [DOI: 10.1093/ajhp/zxy038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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Polypharmacy in older people: time to take action. Eur Geriatr Med 2018; 10:1-3. [PMID: 32720284 DOI: 10.1007/s41999-018-0140-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/20/2018] [Indexed: 01/22/2023]
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