Adverse drug reactions in older adults: a narrative review of the literature

Psychedelic interventions for major depressive disorder in the elderly: Exploring novel therapies, promise and potential

The global population is ageing rapidly, with the number of individuals aged 60 and older reaching 1 billion in 2019 and expected to double by 2050. As people age, neuropsychological health often deteriorates, leading to a higher prevalence of age-related depression. Symptoms may include anxiety, apathy, mood instability, sadness, and, in severe cases, suicidal thoughts. Depression in the elderly is a widespread concern, and conventional treatments such as antidepressants are often limited by side effects, reduced efficacy, and complications arising from polypharmacy. In response, novel therapeutic approaches are being explored, including psychedelic interventions. Recent clinical and preclinical studies suggest that psychedelics could offer a promising treatment for major depressive disorder (MDD) in older adults. These compounds, known for their profound neurobiological effects, have gained attention for their potential to address depression where traditional therapies fall short. This review aims to examine the therapeutic promise of psychedelic substances, focusing on those that show potential for treating MDD in the elderly. We also explore the underlying mechanisms through which psychedelics may exert their effects and highlight the preclinical models that support their use. Finally, we address safety considerations and propose strategies to enhance the effectiveness and safety of psychedelics in future clinical trials, offering new hope for treating age-related depressive disorders.

Employing bibliometrics and natural language processing (NLP) to analyse real-world applications of adverse drug reaction

Introduction

Adverse Drug Reactions (ADRs) pose significant health and economic burdens, yet underreporting and inconsistent standards persist. Digital health innovations, particularly mobile and web-based ADR reporting applications, offer potential to enhance pharmacovigilance by improving data accuracy and patient-reported outcomes.

Objectives

The study provides a comprehensive mapping of ADR mobile and web application literature, analysing publication trends, key contributors, and core themes through bibliometric and NLP-based content analysis.

Methods

A systematic two-stage approach was applied to 289 Web of Science articles on ADR reporting applications. Bibliometric analysis explored publication trends, co-authorship networks, and keyword occurrences, while NLP-based topic modelling identified prevalent themes, ensuring thematic coherence and interpretability.

Results

Bibliometric analysis showed a rise in ADR application-related publications, primarily from the United Kingdom, United States of America, and Switzerland. Content analysis identified ten key themes, including pharmacovigilance, chemotherapy adherence, and psychiatry research. A distinct focus on digital tools in ADR reporting and management was evident, with keywords such as "mobile," "application," and "patient" becoming increasingly prominent in recent years. Co-authorship and collaboration networks, however, showed limited cross-national research partnerships.

Discussion

The study highlights the transformative role of digital solutions in pharmacovigilance, demonstrating the potential of ADR applications to enhance reporting accuracy and improve patient safety. However, adoption remains early-stage and fragmented by regional affiliations. Future research should focus on patient-centric app development, effectiveness assessment, and fostering global collaboration. Strengthening digital literacy and robust investment in ADR reporting applications is crucial for optimizing their impact in healthcare.

Analysis of medication management system data to determine potentially inappropriate medication use and hospitalization among older adults living in residential care homes for the elderly population

OBJECTIVES

Many older adults living in Resident Care Homes for the Elderly (RCHEs) are at risk of polypharmacy and the use of potentially inappropriate medication (PIM). Few studies have evaluated the prevalence and consequences of PIM use among older adults living in RCHEs. The objectives of this study are (1) to evaluate the prevalence of PIM use in 29 RCHEs in Hong Kong, and (2) to investigate the association between PIM use and hospitalization in this population.

METHODS

This is a prospective, observational, cohort study which utilized final-administered medication data from RCHEs that participated in a medication management program. Data on the medications administered to all residents living in the participating RCHEs were extracted from the SafeMed Medication Management System (SMMS®), which is a purpose-built Information Technology supporting the entire medication management process at RCHEs. The outcome of interest is the 12-month period prevalence of PIM use (January 1 to December 31, 2023), which was obtained by comparing the medication data with the 2023 Beers criteria. Hospital admissions during the study period were extracted from the SMMS®.Multivariable logistic regression was conducted to investigate the association between PIM use and hospital admissions.

RESULTS

We included 6,346 residents (age 82.9 ± 8.6 years; female 61.9%). The average number of current medications was 6.8 ± 7.4. Over half (51.5%) of residents had polypharmacy (≥ 5 medications). The 12-month period prevalence of PIM use was 34.5%. Among the residents with PIMs, 65.1%, 25.5% and 9.4% used 1, 2 and > 2 PIMs, respectively. Residents with PIMs were associated with higher rates of hospitalization (Odds Ratio [OR] 1.73, 95% confidence interval [CI] 1.54 to 1.69), after adjusting for age, sex and comorbidities. The number of PIMs was significantly associated with higher risk of hospitalization (OR: 2.17, 95% CI: 1.82 to 2.59 for > 1 PIMs vs. 0).

CONCLUSIONS

The use of PIM was observed in one-third of older adults living in RCHEs, and was associated with an increased risk of hospitalization. Our findings highlighted the urgent need for strategies to improve clinicians' awareness of PIMs and their adverse impact, and to implement pharmacist-led medication reviews in RCHEs.

Association of potentially inappropriate medications with frailty and frailty components in community-dwelling older women in Japan: The Otassha Study

AIM

The use of potentially inappropriate medications (PIMs) in older adults can increase the risk of drug-related adverse events. We aimed to examine the associations between PIMs, frailty, and each frailty component in community-dwelling older women.

METHODS

This cross-sectional study included participants aged ≥65 years from a prospective cohort of older Japanese women. Frailty was classified using the Japanese version of Fried's Frailty Criteria, comprising five components. PIMs were identified using a screening tool for Japanese among regular prescription medications collected from participants' prescription notebooks. Multivariable logistic regression models adjusted for age and comorbidities were used to examine the association between PIMs (0, 1, 2, ≥3), frailty, and each component. The possible interactions between age groups (65-74 and ≥75 years) and PIMs were investigated. Age-stratified analyses were also performed.

RESULTS

We analyzed 530 older women (median age [interquartile range], 71 [68, 75] years) with a frailty prevalence of 5.5%. Three or more PIMs were associated with frailty and weight loss (adjusted odds ratio [95% confidence interval], 3.80 [1.23, 11.80], 2.53 [1.15, 5.39]). In age-stratified analyses, ≥3 PIMs were associated with weight loss (8.39 [1.79, 48.98]) in women aged ≥75 years, whereas 1 or 2 PIMs were associated with frailty (4.52 [1.17, 19.08]) or weakness (3.13 [1.22, 7.78]) in those aged 65-74 years.

CONCLUSIONS

Our results may suggest that the number of PIM prescriptions is associated with frailty and frailty components in older women. Longitudinal studies are required to clarify the causality between the number of PIMs and frailty. Geriatr Gerontol Int 2025; 25: 686-693.

Potential inappropriate medications and drug-drug interactions in adverse drug reactions in the elderly: a retrospective study in a pharmacovigilance database

Introduction

Potential inappropriate medications (PIMs) and potential drug-drug interactions (pDDIs) are important factors leading to adverse drug reactions (ADRs) in the elderly. This study aimed to evaluate the incidence and pattern of PIMs and pDDIs in the elderly based on a real-world pharmacovigilance database and identify the variables associated with them.

Methods

This retrospective study evaluated PIMs and pDDIs by updated Beers criteria and Lexi-Interact online, respectively, using ADRs reported for those aged ≥65 years submitted between 2011 and 2023 from a real-world database of a tertiary care teaching hospital. Correlation factors were investigated by binary and multiple logistic regression analyses.

Results

A total of 1,423 ADRs were included and involved 2,238 prescribed drugs; 54.11% of the total were men, and 23.47% were classified as serious. The most commonly implicated pharmacological group was antimicrobial agents. Aspirin and clopidogrel emerged as the drugs causing the majority of ADRs. PIMs were detected in 32.04% of all ADR reports. Aspirin and diclofenac were the most common active pharmaceutical ingredients involved, and gastrointestinal bleeding was the primary clinical manifestation of severe ADRs caused by PIMs or involved in PIM-related risk factors. Age, number of diagnosed diseases and prescribed drugs, ADR severity and preventability, hypertension, coronary heart disease, and arthritis were independent influencing factors of PIMs. Among 498 ADR reports with ≥2 prescribed drugs, 202 cases (14.20%) had pDDIs. Blood and hematopoietic organ and cardiovascular agents were the most commonly involved categories. The most frequent drug combinations in classes C, D, and X were aspirin-clopidogrel, aspirin-heparin, and potassium chloride-promethazine, respectively. The majority of pDDIs increased the risk of bleeding through pharmacodynamic mechanisms. The number of prescribed drugs and diagnosed diseases, ADR severity and preventability, stroke, diabetes, and coronary heart disease, along with PIM use, were independent predictors of pDDIs.

Conclusion

The incidence of PIMs and pDDIs was found to be relatively high in the elderly, especially in the treatment of cardiovascular and cerebrovascular diseases and non-steroidal anti-inflammatory drugs (NSAIDs), and relevant factors have been identified. Healthcare institutions should reinforce the management of rational drug use in the elderly to mitigate the occurrence of PIMs and pDDIs, thereby enhancing medication safety.

The Mediating Role of Emotional Self-Efficacy in the Relationship Between the Number of Medications and Psychological Distress Among Older Adults with Chronic Illness

PURPOSE

The present study aimed to examine the associations between the number of medications, emotional self-efficacy, and psychological distress in older adults with chronic illness.

DESIGN

A cross-sectional study was conducted with a convenience sample of 191 older adults in Anhui, China.

METHODS

Those participants completed a structured questionnaire that included sociodemographic data, medications, emotional self-efficacy, and psychological distress status. Pearson correlation analysis was used to examine the correlation between study variables. The bootstrap method was employed to analyze the mediating role of emotional self-efficacy.

FINDINGS

The results showed that 10.5% and 14.1% of the participants might be experiencing symptoms of anxiety and depression, respectively. Correlation analysis revealed that emotional self-efficacy was negatively correlated with anxiety and depression. The results showed that emotional self-efficacy partially mediated the relationship between the number of medications and depression, accounting for 51.9% of the total effect. Additionally, emotional self-efficacy partially mediated the relationship between the number of medications and anxiety, accounting for 50.8% of the total effect. However, a suppressor effect was established for the relationship between the number of medications and polypharmacy-related psychological distress.

CONCLUSIONS

The findings suggested that emotional self-efficacy might play an important role in the relationship between the number of medications and psychological distress in Chinese older adults with chronic illness.

Characteristics and patterns of adverse event reports in the Japanese Adverse Drug Event Report database over two decades (2004-2023): Exploring findings on sexes and age groups

Recently, increased attention has been paid to the consideration of individual characteristics, including sex and age, in the context of medication use and adverse events. However, the characteristics and patterns of adverse events reported in the Japanese Adverse Drug Event Report (JADER) database stratified by sex and age have not yet been clarified. This study aimed to clarify the characteristics and patterns of adverse event reports in the JADER database over a 20-year period (April 2004-March 2024). Data were stratified into 20 groups based on sex and age (aged 0-9 years, 10-19 years, 20-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, 70-79 years, 80-89 years, and ≥90 years). The female/male ratio of adverse event reports in JADER was 0.95. The largest group comprised males in their 70s. Adjusting for the proportion of adverse event reports in each group according to the demographic composition in 2015 highlighted that the reporting rates of adverse events were higher in people aged ≥70 years and that females aged 20-49 years reported more adverse events than males. Medical history, causative drugs, and adverse events reported to JADER were characterized by combinations of sex and age. Our results provide additional insights into the interpretation of previous studies using JADER. In addition, the results of this study will help understand the characteristics of adverse event reports contained in JADER and conduct appropriate subgroup and sensitivity analyses.

Analgesic effect of simultaneously targeting multiple pain processing brain circuits in an aged humanized mouse model of chronic pain by transcranial focused ultrasound

Low-intensity transcranial focused ultrasound (tFUS) has recently been shown to noninvasively and non-pharmacologically modulate pain hypersensitivity with high spatial specificity and deep brain penetration. However, the lack of knowledge about its effectiveness for pain management in older subjects vulnerable to severe pain who are also at increased risk of cognitive impairment, presents significant challenges. Additionally, current opioid pain treatments require hospital visits, limiting unwanted serious side effects with multiple liabilities, and device-based pain treatments are typically administered at medical facilities with bulky and expensive equipment, limiting accessibility and thus highlighting the need for at-home non-pharmacological treatment options. Here, we present a more accessible, noninvasive tFUS pain treatment strategy for senior subjects. This approach involves simultaneously targeting multiple pain-processing circuits using a battery-powered, compact, and low-cost ultrasound analog front end (UAFE). We developed and evaluated the performance of the UAFE capable of generating sufficiently high-amplitude output with significantly lower noise levels compared to a commercial transmitter. Using a humanized sickle mouse model of chronic hyperalgesia, we found that tFUS stimulation targeting multiple pain-processing circuits effectively reduces heat hyperalgesia in aged female mice. In addition to its efficacy, our behavioral-based safety assessment revealed no adverse effects on motor functions. These results suggest that using a battery-powered, compact UAFE to simultaneously target multiple pain-processing circuits can effectively suppress heat pain-related behaviors in aged female sickle mice without negatively impacting motor coordination and balance. This highlights the potential for further development of fully home-based tFUS pain treatment for seniors.

Auriculotherapy and pain intensity and functional disability in older adults with chronic low back pain: randomised single-blind clinical trial

INTRODUCTION

Considering the importance of chronic low back pain in disability in older adults, the present study aimed to investigate the effect of auriculotherapy on pain intensity and functional disability in this group.

MATERIALS AND METHODS

This single-blind clinical trial was conducted on older adults with chronic low back pain in Kashan, Iran, 2019-2020. Seventy eligible older people were allocated to the intervention and sham groups via block randomisation. In the intervention group, pressure was applied using Varcaria seeds on the Shenmen, sympathetic, nerve subcortex and low back points. The visual analogue scale was completed at the beginning (T0), weekly (T1-T4) and 1 month after intervention (T5). Functional disability was assessed using Oswestry Disability Index at T0, T4 and T5. Data were analysed in per-protocol and intention-to-treat designs using repeated measures analysis of variance and analysis of covariance.

RESULTS

There was a significant difference between the two groups regarding disease duration (p=0.012). The interaction effect of time and intervention was significant on pain intensity and functional disability (effect size (ES)=0.858 and ES=0.789, p<0.0001). The pain intensity in the intervention group was significantly lower than in the sham group at T2-T5 (p<0.0001). The functional disability score in the intervention group was significantly lower than in the sham group at T4 and T5 (p<0.0001).

CONCLUSION

Auriculotherapy can reduce pain intensity and functional disability in older adults with chronic low back pain; it can be used as a complementary medicine in care programmes for older adults with chronic low back pain.

Comparative Analysis of Adverse Drug Reactions Associated with Fluoroquinolones and Other Antibiotics: A Retrospective Pharmacovigilance Study

Background

Fluoroquinolones (FQs) are among the most popular antimicrobials that are highly effective against various infections. Although FQs are the most frequently used and generally tolerated, there are issues with their safety. This study assessed the rate, severity, seriousness, outcomes, and types of FQs adverse drug reactions (ADRs) in reports submitted to a regional spontaneous ADR database.

Methods

This was a retrospective cross-sectional observational study involving all patients with reported ADRs related to FQs or other antibiotics (ABs) that were submitted to the Regional Pharmacovigilance Center (PVC) database between January 2019 and December 2022. Data were extracted in the form of Saudi ADR from the PVC database, which is consistent with the MedWatch ADR form of the U.S Food and Drug Authority (FDA).

Results

In total, 605 ADRs related to antibiotic use were reported. ADRs caused by FQs use were the most frequently reported (177; 29.3%), followed by penicillin (100; 23.4%) and cephalosporin (90; 21%). There was no significant difference in ADRs caused by FQs between men (104; 58%) and women (OR 1.17, 95% CI 0.82-1.67, p=0.386). FQ-related ADRs were more frequent among those over 40 years-old (OR 1.56, 95% CI 1.09-2.22, p=0.015). Most of the detected FQ-related ADRs were of moderate severity (157; 88.7%), required interventions (83; 46.9%), and recovered after receiving medical interventions (154; 87%). Patients who received FQs were fourfold more likely to experience neurological adverse events (OR 4.15, 95% CI 2.48-6.93, p <0.001).

Conclusion

The FQs drug class exhibited a higher incidence of ADRs than other ABs. Regularly assessing the safety of ABs is crucial to improve public and healthcare providers' awareness of the correct utilization of ABs and to limit the use of FQs to infections that cannot be effectively managed with alternative ABs.

Real-World Utilization of Medications With Pharmacogenetic Recommendations in Older Adults: A Scoping Review

Pharmacogenetic testing provides patient genotype information which could influence medication selection and dosing for optimal patient care. Insurance coverage for pharmacogenetic testing varies widely. A better understanding of the commonly used medications with clinically important pharmacogenetic recommendations can inform which medications and/or genes should be prioritized for coverage and reimbursement in the context of finite healthcare resources. The aim of this scoping review was to collate previous studies that investigated the utilization rate of medications that could be guided by pharmacogenetic testing. Included studies utilized electronic medical records or claims data to assess pharmacogenetic medication prescription rates for older adults (≥ 65 years old). Identified pharmacogenetic medications were classified according to therapeutic class and assessed for actionability based on the Clinical Pharmacogenetics Implementation Consortium guidelines. Across the 31 included studies, analgesic (n = 29), psychotropic (n = 29), and cardiovascular (n = 27) therapeutic classes were most commonly investigated. Study populations were primarily generalized (48%); however, some studies focused on specific populations, such as, cancer (n = 6), mental health (n = 1), and nursing home (n = 2) cohorts. A total of 215 unique pharmacogenetic medications were reported, of which, 82 were associated with actionable pharmacogenetic recommendations. The most frequent genes implicated in potential drug-gene interactions with these actionable pharmacogenetic drugs were CYP2D6 (25.6%), CYP2C19 (18.3%), and CYP2C9 (11%). Medications most frequently prescribed included pantoprazole (range 0%-49.6%), simvastatin (range 0%-54.9%), and ondansetron (range 0.1%-62.6%). Overall, the frequently prescribed medications and associated genes identified in this review could guide pharmacogenetic testing implementation into clinical practice, including insurer subsidization.

Pharmacotherapeutic actions related to drug interaction alerts - a questionnaire study among Swedish hospital interns and residents in family medicine

PURPOSE

To explore how hospital interns and residents specialising in family medicine act on drug interaction alerts in a specific patient case, and on interaction alerts in general.

METHODS

A 4-page questionnaire, including a fictional patient case (73-year-old woman; 10 drugs in the medication list triggering 11 drug interaction alerts) and questions regarding the use of interaction alerts in general, was distributed to interns and residents during educational sessions (November‒December 2023). The respondents were instructed to consider what actions they would take "a normal day at work" due to the risk of interactions between the patients' drugs. In the general questions, the respondents were asked how often they access the detailed interaction information (from 1 = never to 5 = always) provided by the knowledge resource, in relation to the alert classification (D = clinically significant, should be avoided; C = clinically significant, can be handled by, e.g., dose adjustment).

RESULTS

The questionnaire was completed by 55 interns and 69 residents (response rate: 98%). In the patient case, the respondents acted on a median of 4 (range: 0‒8) drugs, most often concerning repaglinide (in a D interaction alert with clopidogrel; 96% of the interns and 96% of the residents suggested action), and omeprazole (in three C interaction alerts with citalopram, clopidogrel, and levothyroxine, respectively; 71% and 83% suggested action). Among the respondents who answered the questions about how often (rated 4/5) they access more detailed information about interactions, 56 (59%) did so for D versus 29 (31%) for C alerts (P < 0.001).

CONCLUSION

Physicians act on drug interaction alerts selectively, and the alert classifications seem to guide how they are used.

Cross-Cultural Adaptation and Clinical Validation of TIME Criteria to Detect Potentially Inappropriate Medication Use in Older Adults: Methodological Report from the TIME International Study Group

BACKGROUND

Various explicit screening tools, developed mostly in central Europe and the USA, assist clinicians in optimizing medication use for older adults. The Turkish Inappropriate Medication use in oldEr adults (TIME) criteria set, primarily based on the STOPP/START criteria set, is a current explicit tool originally developed for Eastern Europe and subsequently validated for broader use in Central European settings. Reviewed every three months to align with the latest scientific literature, it is one of the most up-to-date tools available. The tool is accessible via a free mobile app and website platforms, ensuring convenience for clinicians and timely integration of updates as needed. Healthcare providers often prefer to use their native language in medical practice, highlighting the need for prescribing tools to be translated and adapted into multiple languages to promote optimal medication practices.

OBJECTIVE

To describe the protocol for cross-cultural and language validation of the TIME criteria in various commonly used languages and to outline its protocol for clinical validation across different healthcare settings.

METHODS

The TIME International Study Group comprised 24 geriatric pharmacotherapy experts from 12 countries. In selecting the framework for the study, we reviewed the steps and outcomes from previous research on cross-cultural adaptations and clinical validations of explicit tools. Assessment tools were selected based on both their validity in accurately addressing the relevant issues and their feasibility for practical implementation. The drafted methodology paper was circulated among the study group members for feedback and revisions leading to a final consensus.

RESULTS

The research methodology consists of two phases. Cross-cultural adaptation/language validation phase follows the 8-step approach recommended by World Health Organization. This phase allows regions or countries to make modifications to existing criteria or introduce new adjustments based on local prescribing practices and available medications, as long as these adjustments are supported by current scientific evidence. The second phase involves the clinical validation, where participants will be randomized into two groups. The control group will receive standard care, while the intervention group will have their treatment evaluated by clinicians who will review the TIME criteria and consider its recommendations. A variety of patient outcomes (i.e., number of hospital admissions, quality of life, number of regular medications [including over the counter medications], geriatric syndromes and mortality) in different healthcare settings will be investigated.

CONCLUSION

The outputs of this methodological report are expected to promote broader adoption of the TIME criteria. Studies building on this work are anticipated to enhance the identification and management of inappropriate medication use and contribute to improved patient outcomes.

Safety of sarilumab in a Japanese population with rheumatoid arthritis by age group: Data from an interim analysis of a postmarketing surveillance study

OBJECTIVES

Using data from a postmarketing surveillance, this interim subgroup analysis investigated the safety of sarilumab in younger (<65 years) and older patients (≥65 and ≥75 years) with rheumatoid arthritis.

METHODS

During this interim analysis, patients who were treated with sarilumab in Japan were enrolled between June 2018 and 2021. Data collected by 12 January 2022 were analysed, with adverse drug events monitored over 52 weeks.

RESULTS

Of 972 patients with available data, the proportion of patients aged <65 years, ≥65 years, and ≥75 years was 40.8%, 59.2%, and 27.8%, respectively. Most patients (95.5%) received the standard 200 mg dose of sarilumab as the initial dose. Adverse drug reactions were reported in 24.6% of patients, with serious events accounting for 6.4% of cases. No malignancy and low incidences of adverse drug reactions of special interest were reported across all age groups (<65 years, 7.8%; ≥65 years, 8.2%; ≥75 years, 8.5%). When stratified by absolute neutrophil count above and below the lower limit of normal, there were no numerical differences in incidences of serious and non-serious infections between age groups.

CONCLUSIONS

Regardless of age, sarilumab therapy was well tolerated by patients with rheumatoid arthritis, with no new safety signals reported in this study.

High- versus low-dose ketamine for analgesia in older adults in the emergency department

BACKGROUND AND OBJECTIVES

Ketamine is increasingly being utilized in the management of acute pain in the emergency department (ED), including for older adults, a population at increased risk of adverse effects from medications. We aimed to compare the safety and analgesic effects of high-dose (≥0.3mg/kg) to low-dose (<0.3mg/kg) intravenous (IV) ketamine among older ED patients.

METHODS

Multi-center, retrospective cohort study of adults ≥60years who received IV ketamine for pain between 2018 and 2021. The primary outcome was pain improvement as measured by the Numerical Rating Scale (NRS) pain score within 60min after administration. Secondary outcomes included adverse effects (early discontinuation, nausea, rescue benzodiazepines and intubation) and the need for rescue analgesia. Linear regression was used to assess the association between the change in NRS pain scores and dose after adjusting for baseline pain, requiring an additional dose of ketamine, and receiving an opioid.

RESULTS

A total of 130 older adults received ketamine as an analgesic (37 high-dose, 93 low-dose). Median age was 69.2years, 52 % were women, 40 % had a history of substance use disorder. Prior to ketamine, 76 % received alternate analgesics and 23 % antiemetics. Baseline mean pain score was lower in the high-dose group (6.7 vs. 8.3, difference -1.7 [95 % CI -2.6 to -0.7], p = 0.013). Change in NRS pain scores were similar between the high-dose and low-dose groups (-2.4 [95 % CI -3.6 to -1.3] vs -1.6 [95 % CI -2.2 to -0.9], p = 0.27). After adjustment for baseline pain score, the high-dose group had a larger reduction in pain scores (-1.3 [95 % CI -2.6 to -0.1], p = 0.042) and percent change of pain (-23.8 % [95 % CI -42.1 % to -5.4 %], p = 0.012). There was no significant difference in rates of rescue analgesia (35.1 % vs. 44.1 %, p = 0.35) or early discontinuation (29.7 % vs. 32.3 %, p = 0.78). Rates of adverse effects were similar.

CONCLUSION

High-dose and low-dose ketamine reduced pain scores in older adults. High-dose ketamine led to a greater reduction in pain scores, and there was no observed difference in adverse effects or the need for rescue analgesia. One-third needed discontinuation of ketamine in both groups.

Graph neural network-based subgraph analysis for predicting adverse drug events

PURPOSE

Adverse drug events (ADEs) are a significant global public health concern, and they have resulted in high rates of hospital admissions, morbidity, and mortality. Prior to the use of machine learning and deep learning methods, ADEs may not become well recognized until long after a drug has been approved and is widely used, which poses a significant challenge for ensuring patient safety. Consequently, there is a need to develop computational approaches for earlier identification of ADEs not detected during pre-registration clinical trials.

METHODS

This paper presents a state-of-the-art network-based approach that models patients as subgraphs composed of nodes of International Classification of Diseases (ICD) codes and directed edges illustrating disease progression. Four Graph Neural Network (GNN) variants were employed to make sub-graph level predictions that answer three Research Questions (RQ): 1) whether ADE(s) would occur given a patient's prior diagnoses history, 2) when an ADE would occur, and 3) which ADE would occur. The first and second RQs were addressed using a binary classification approach. The third RQ was addressed using a multi-label classification model.

RESULTS

The proposed network-based approach demonstrated superior performance in predicting ADEs, with the GraphSage model exhibiting the highest accuracy for both RQ 1 (0.8863) and RQ 3 (0.9367), while the Graph Attention Networks (GAT) model was found to perform best for RQ 2 (0.8769). Furthermore, an analysis segmented by ADE classification revealed that while RQs 1 and 3 exhibited minimal variance across different ADE categories, a distinct advantage was observed for categories B, C, and E in the context of RQ 2 when applying this sub-graph method.

CONCLUSION

The network-based approach demonstrates the potential of GNNs in supporting the early detection and prevention of ADEs. Accurately predicting ADEs could enable healthcare professionals to make informed clinical decisions, take preventive measures and adjust medication regimens before serious adverse events occur. The proposed prediction method could also lead to optimized usage of healthcare resources by preventing hospital admissions and reducing the overall burden of adverse drug events on the healthcare systems.

Deprescribing Cardiovascular Medications in Older Adults Living with Frailty

Certain medications have shown significant effectiveness in reducing the incidence of cardiovascular events and mortality, leading them to be among those that are prescribed most commonly for Canadian seniors. However, polypharmacy, which disproportionately affects older adults, is particularly concerning for frail individuals who are at higher risk for adverse medication-related events. The deprescribing process is the discontinuation, either immediate or gradual, of inappropriate medications, to address polypharmacy and improve outcomes. Nonetheless, the incorporation of deprescribing principles into clinical practice present challenges, including the limited amount of data available on the clinical benefits of deprescription, and a lack of consensus on how to deprescribe. The current narrative review explores frailty as a basis for deciding to deprescribe medication. The evidence regarding the benefits of use of medications prescribed for common cardiovascular conditions (including acetylsalicylic acid, statins, and antihypertensives) in older adults with frailty is reviewed. The review also examines the issue of who should initiate the deprescribing process, and the associated psychological implications. Although no one-size-fits-all approach to deprescription is available, patient goals should be prioritized. For older adults with frailty, healthcare professionals must consider carefully whether the benefits of use of a cardiovascular medication outweighs the potential harms. Ideally, the deprescribing process should involve shared decision-making among physicians, other health professionals, and patients and/or their substitute decision-makers, with the common goal of improving patient outcomes.

Managing drug therapy-related problems and assessment of chronic diabetic wounds

Type 2 diabetes mellitus (T2DM), responsible for most diabetes cases recorded worldwide, increases the risk of chronic wounds and amputation. Patients with T2DM appear to be more susceptible to delayed wound healing due to their treatment adherence. This review explores the specifics of polypharmacy, side effects, possible drug interactions and the importance of medication adherence for therapeutic efficacy. We discuss the effects of anti-diabetes medications on wound healing as well as the role that biofilms and microbial infections play in diabetic wounds. Inconsistent use of medications can lead to poor glycaemic control, which negatively affects the healing process of diabetic foot ulcers. Managing chronic wounds represents a substantial portion of healthcare expenditures. Biofilm-associated infections are difficult for the immune system to treat and respond inconsistently to antibiotics as these infections are slow growing and persistent. Additionally, we emphasize the critical role pharmacists play in enhancing patient adherence and optimizing diabetes treatment by offering comprehensive coverage of drugs associated with problems related to pharmacological therapy in type 2 diabetes.

Applying the Andersen behavioral model to the medication therapy management program: an approach for improving medication safety in older adults

Medication therapy problems (MTPs) are common among older adults and are associated with considerable morbidity, mortality, and healthcare costs. The Medicare Part D Medication Therapy Management (MTM) program, which includes Comprehensive Medication Reviews (CMRs), Targeted Medication Reviews (TMRs), and guidance on safe medication disposal, is designed to optimize therapeutic outcomes and reduce adverse events by addressing MTPs. Although this program has demonstrated success in reducing MTPs, its utilization remains low, with ongoing concerns about service access disparities, patient satisfaction, and long-term health outcomes. This perspective paper applies the Andersen Behavioral Model (ABM) to the Medicare Part D MTM program to enhance understanding of factors influencing service utilization and impact among older adults. The ABM provides a structured framework to examine how macro-and micro-level factors shape health behaviors and outcomes. By applying ABM framework to MTM, this paper highlights essential research directions to generate rigorous evidence for program evaluation, inform policy adjustments, and make targeted recommendations for improving MTM within the U.S. healthcare system. Furthermore, this work has potential implications for global programs aimed at enhancing medication safety by addressing MTPs and optimizing medication use.

Can the integration of new rules into a clinical decision support system reduce the incidence of acute kidney injury and hyperkalemia among hospitalized older adults: a protocol for a stepped-wedge, cluster-randomized trial (DETECT-IP)

BACKGROUND

Clinical decision support systems (CDSSs) enable the automated, real-time detection of situations associated with a risk of adverse drug events (ADEs). However, the effectiveness of CDSS in reducing ADEs has yet to be demonstrated. We have chosen to focus on the detection of ADE such as hyperkalemia and/or acute kidney injury (AKI), which are common among hospitalized older adults. The present study's primary objective is to use a CDSS to reduce the number of ADEs (such as AKI and/or hyperkalemia) that occur in hospitalized older adults.

METHODS

This is a multicenter, stepped-wedge, cluster-randomized study involving five hospitals. Each hospital will start with a control period (i.e., routine care, during which each center's CDSS is deactivated) and then switch to an intervention period (during which the CDSS is activated). The intervention will be the use of a CDSS and a strategy for managing and transmitting alerts to clinical pharmacists. The rules concerning AKI and hyperkalemia have been drafted and reviewed by a multidisciplinary group. Each rule created in the CDSS is associated with a standardized procedure, based on a review of the literature. Older patients (aged 65 or over) admitted to a participating general medicine ward, a surgical ward, or obstetrics ward will be eligible for inclusion after the provision of verbal informed consent.

DISCUSSION

This study will assess the effectiveness of the CDSS in reducing the incidence of AKI and hyperkalemia. The implementation of the CDSS can assist clinical pharmacists in their daily work and is expected to prevent ADEs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05923983. Registered February 02, 2023.

Adverse drug reactions and its associated factors among geriatric hospitalized patients at selected comprehensive specialized hospitals of the Amhara Region, Ethiopia: a multicenter prospective cohort study

BACKGROUND

Adverse drug reactions are more prevalent in geriatric patients and are frequently associated with a range of polypharmacy-related issues as well as some physiological aging-related alterations. These affect the pharmacokinetic and pharmacodynamic properties of drugs. This study aimed to assess the magnitude of ADRs and their contributing factors among geriatric patients admitted at Comprehensive Specialized Hospitals of the Amhara Region.

METHODS

A multicenter prospective cohort study was carried out from May 2023 to August 2023 on geriatric patients admitted to four randomly selected comprehensive hospitals in the Amhara region. We used logistic regression to find the factors influencing the occurrence of ADRs. A P value of less than 0.05 was deemed statistically significant.

RESULTS

During the study's follow-up period, 373 patients in total were included. An incidence rate of 31.10% (95% CI: 26.38-35.82) was obtained from the identification of 121 ADRs in total. The organ most frequently affected by ADRs was the gastrointestinal tract (28.92%), followed by the cardiovascular system (19.01%), and the drug class most often implicated in ADRs was antibiotics (21.49%), then anticoagulants (12.40%). ADRs were substantially linked to being overweight (P < 0.001), having been hospitalized in the previous six months (P = 0.000), and hyperpolypharmacy (p = 0.047). 93.39% of all ADRs received the interventions. 85.12% of the adverse drug reactions were successfully resolved.

CONCLUSIONS

This study found that over one-third of older people and individuals admitted to the hospital experienced ADRs. Overweight, hyperpolypharmacy, and patients who had previously been admitted during the preceding six months were significantly linked with the occurrence of ADRs. Improving the drug safety of elderly patients, particularly those who are admitted, should be a greater priority for healthcare professionals.

Twelve hot questions in the management of hypertension in patients aged 80+ years and their answers with the help of the 2023 European Society of Hypertension Guidelines

Arterial hypertension is a major risk factor for cardiovascular morbidity and mortality, and highly prevalent in older age, underscoring the importance of its appropriate management. The population is ageing at an increasing rate, with those aged 80+ years being the fastest growing population characterized by high heterogeneity in terms of functionality and autonomy. The prevalence of hypertension rises with increasing age, due to a significant increase in SBP largely as a result of age-related stiffening of the aorta and other large arteries, affecting almost 80% of those aged 80+ years. Appropriate management of blood pressure in this population is a priority for clinicians. Frailty is a condition characterized by marked vulnerability to adverse health outcomes and is common among older adults including those with hypertension. Hypertension increases frailty level and at the same time, individuals with increasing frailty present with more drug-related adverse effects meaning they are less tolerant to blood pressure lowering by medication. Thus, frailty is a factor that should be integrated when treating hypertension in this population. The European Society of Hypertension 2023 Guidelines on the management of Hypertension are the first international guidelines to integrate the concept of adapting blood pressure management in older adults according to their frailty/functionality level, and to propose practical tools for the application of this concept in the daily practice of physicians and other healthcare professionals. The present article prepared by the European Society of Hypertension Working Group on Hypertension in Older Adults aims to further address some important aspects mentioned concisely in the 2023 European Society of Hypertension guidelines, in order to help physicians and other healthcare professionals including those practicing in primary care. To this end, this study discusses 12 'hot questions' which are answered with the help of the 2023 European Society of Hypertension Guidelines. We hope the present article and Working Group's actions will contribute to understanding and applying the ideal management of hypertension in this most vulnerable population.

Efficacy and Safety of Fixed-Dose Combinations for Pain in Older Adults

Pain is common in older adults and managing pain in this population can be challenging owing to altered pharmacokinetics, multimorbidity, polypharmacy, cognitive impairment, and physical frailty. A fixed-dose combination (FDC) analgesic contains two or more pharmaceutical ingredients in a single pill and may offer more benefits when compared with loose-dose formulations. The benefits include reduced pill burden and better adherence, a broader analgesic spectrum well-suited to multimechanistic pain conditions and more predictable pharmacokinetic and pharmacodynamic properties. These advantages may outweigh disadvantages such as reduced flexibility in dose adjustment. Most of the commonly used FDC analgesics are made up of a combination of paracetamol, muscle relaxant, nonsteroidal anti-inflammatory drug or opioid. They have been shown to have better efficacy and similar safety profiles compared with individual drugs. Adverse effects from the use of FDC analgesics in older patients were comparable with that observed in younger populations. With proper patient selection and continuous surveillance, FDC analgesics will likely benefit older adults by simplifying dosing regimen and improving compliance.

Assessing the Association of Pain Intensity Scales on Quality of Life in Elderly Patients with Chronic Pain: A Nursing Approach

BACKGROUND

Chronic pain is prevalent among the elderly and significantly affects their quality of life (QoL). Pain intensity scales are crucial tools in evaluating the severity of pain and tailoring management strategies. This study investigates the relationship between various pain intensity scales and QoL among elderly patients with chronic pain, highlighting the implications for nursing practice.

METHODS

A cross-sectional study was conducted with 150 elderly patients (aged 65 and above) in Riyadh, Saudi Arabia. Participants were assessed using the Numeric Rating Scale (NRS), Visual Analog Scale (VAS), and McGill Pain Questionnaire (MPQ) alongside the 36-Item Short-Form Health Survey (SF-36) to evaluate QoL. Data analysis involved Pearson correlation and multiple regression to explore the association of pain intensity on QoL.

RESULTS

All pain scales showed significant negative correlations with QoL. The MPQ exhibited a significant association, suggesting its comprehensive nature captures the multidimensional association of pain more effectively. Regression analysis identified pain intensity, age, and duration of chronic pain as significant predictors of reduced QoL.

CONCLUSIONS

The findings emphasize the importance of selecting appropriate pain assessment tools that reflect the complex nature of pain in elderly patients. Implementing comprehensive pain assessments like the MPQ can enhance individualized care strategies and potentially improve the QoL in this population. This study underscores the role of nurses in optimizing pain management approaches tailored to the elderly.

Acute Coronary Syndrome in Elderly Patients: How to Tackle Them?

Elderly patients diagnosed with acute coronary syndromes (ACS) represent a growing demographic population. These patients typically present more comorbidities and experience poorer outcomes compared to younger patients. Furthermore, they are less frequently subjected to revascularization procedures and are less likely to receive evidence-based medications in both the short and long-term periods. Assessing frailty is crucial in elderly patients with ACS because it can influence management decisions, as well as risk stratification and prognosis. Indeed, treatment decisions should consider geriatric syndromes, frailty, polypharmacy, sarcopenia, nutritional deficits, prevalence of comorbidities, thrombotic risk, and, at the same time, an increased risk of bleeding. Rigorous clinical assessments, clear revascularization criteria, and tailored approaches to antithrombotic therapy are essential for guiding personalized treatment decisions in these individuals. Assessing frailty helps healthcare providers identify patients who may benefit from targeted interventions to improve their outcomes and quality of life. Elderly individuals who experience ACS remain significantly underrepresented and understudied in randomized controlled trials. For this reason, the occurrence of ACS in the elderly continues to be a particularly complex issue in clinical practice, and one that clinicians increasingly have to address, given the general ageing of populations. This review aims to address the complex aspects of elderly patients with ACS to help clinicians make therapeutic decisions when faced with such situations.

Identifying and presenting key country-specific indicators related to medication adherence: a comprehensive study across European countries

This study tackles the critical challenge of medication non-adherence in healthcare by pinpointing indicators related to medication adherence (IRMAs) across 39 European countries and Israel. Utilizing a structured expert survey methodology within the European Network to Advance Best Practices and Technology on Medication Adherence (ENABLE; COST Action CA19132), our research identified key country-specific IRMAs and collected data on these indicators to understand the multifaceted nature of medication adherence. The research was conducted in two phases: firstly, defining key IRMAs through a two-round expert survey, and secondly, gathering country-specific data on these IRMAs through literature reviews and additional expert surveys. The study revealed a diverse range of 26 top-ranked IRMAs, including six related to country characteristics, four to social/economic factors, three each to therapy-related and patient-related factors, one to condition-related factors, and nine to healthcare system-related factors. The availability of country-specific data on these IRMAs varied among the countries, highlighting the need for more comprehensive data collection and research. The findings from this study not only underscore the complexity of predicting medication adherence but also lay the groundwork for developing targeted, country-specific interventions to improve adherence. Moreover, this research offers valuable insights for policymakers, highlighting the importance of understanding the multifaceted nature of medication adherence and offering a valuable resource in formulating targeted health policies to enhance health outcomes and reduce the economic burden associated with medication non-adherence.

Association between tricyclic antidepressants and health outcomes among older people: A systematic review and meta-analysis

Tricyclic antidepressants are effective for managing depression and other disorders. However, they can cause adverse reactions due to their anticholinergic properties, with the risk of such events increasing with age. This study identifies and describes clinical studies that evaluate associations between the use of tricyclic antidepressants and adverse health outcomes (falls, fractures, and mortality) among older people. A systematic search of the literature in English, Spanish, and French was conducted using the electronic databases PubMed, ISI Web of Science, PsycINFO, and Cochrane. The systematic review included a total of 18 studies. The meta-analysis examined the 14 studies that investigated the association between the use of tricyclic antidepressants and the risk of falls and fractures (4 of the 18 studies focused on mortality and so were excluded from the meta-analysis). The odds ratio (OR) was 1.40 (95 % CI = 1.27-1.53, p < 0.001). The Cochran Q test was significant (X2 = 79.72, p < 0.001), indicating high heterogeneity (I2 = 84.9 %). An additional meta-analysis was conducted on studies reporting hazard ratios (HRs), yielding an HR of 1.21 (95 % CI = 0.93-1.58, p = 0.16). Meta-regression analysis indicated that the years of follow-up could have a significant effect on the association studied (p = 0.008). In conclusion, enhancing our understanding of the use of antidepressants and the associated risk of adverse events in older adults will enable the identification of the most appropriate type of antidepressant for each clinical situation.

A descriptive analysis of drug-drug interactions and corresponding adverse drug reactions in multimorbid older inpatients: findings from the SENATOR trial

PURPOSE

Drug-drug interactions (DDIs) are prevalent among multimorbid and polymedicated older adults and can increase the risk of adverse drug reactions (ADRs), hospital admissions, and mortality. This study describes the incidence and prevalence of 66 clinically relevant DDIs and analyses the occurrence of 12 corresponding predefined ADRs in older inpatients enrolled in the SENATOR trial.

METHODS

The sub-study of the SENATOR trial that involved 1537 multimorbid older inpatients, recruited from 2016 to 2018 in six academic teaching hospitals in Belgium, Iceland, Ireland, Italy, Scotland, and Spain respectively, and analysed 66 potentially clinically significant DDIs. Descriptive analysis determined DDI and corresponding ADR prevalence/incidence.

RESULTS

At baseline (median age: 78 [72, 84], 52.8% male), the prevalence of patients with DDIs was high (50.9%), increased during hospitalisation (55.2%) and reduced to 49.7% after 12 weeks. The most common DDIs were: ≥ 2 potassium reducing drugs (17.1%), ≥ 3 centrally acting drugs (9.0%), and SSRI + loop/thiazide diuretic (7.2%). Of all participants, one-third experienced a prevalent (36.6%)/incident (35.8%) ADR. Major serum electrolyte disturbance had the highest incidence (10.7%)/prevalence (11.5%). Incident ADRs were more common in patients with DDIs (p = 0.013). A higher prevalence of new onset falls (p = 0.013), major constipation (p = 0.004), and major serum electrolyte disturbances (p = 0.006) was observed in patients with related and thus potentially causal DDIs.

CONCLUSIONS

Clinicians should, be aware of DDIs and the involved drug classes that can lead to an increased rate of ADRs in older multimorbid inpatients. Regularly reevaluating the appropriateness of the frequently prescribed drug classes and initiating judicious deprescribing is recommended.

Constipation: a neglected condition in older emergency department patients

Constipation and fecal impaction are common issues with the potential for significant morbidity in older people presenting to the Emergency Department (ED). While many of these patients present with classical symptoms of constipation or fecal impaction, atypical presentations are also frequent. These atypical presentations may include paradoxical diarrhea, fecal incontinence, urinary retention or overflow incontinence, hyperactive or hypoactive delirium, anorexia/dysphagia, and syncope. In addition, various clinical conditions (such as dementia, Parkinson's disease, dehydration, and hypothyroidism) and medications (such as opiate analgesics, anticholinergics, diuretics, calcium channel blockers, anti-parkinsonian drugs, and oral iron supplements) are associated with constipation and should be considered during the diagnostic process in the ED. This narrative review specifically focuses on the prevalence, presentation, diagnoses, and management of constipation in older ED patients.

[Delayed hypersensitivity reactions to drugs: Group Report of the Drug Allergy Committee of the Mexican College of Clinical Immunology and Allergy (CMICA).]

BACKGROUND

Adverse drug reactions are defined as unexpected reactions, either derived from the pharmacokinetics of the treatment (Type A) or as a host immune response (Type B), resulting in harmful or undesirable manifestations in the patient following the administration of pharmacological therapy. Type B reactions are less defined and are considered a result of hypersensitivity to pharmacological treatment, categorized as immediate (within 1 to 6 hours after exposure) and delayed or non-immediate (occurring 6 hours after exposure).

OBJECTIVE

A review to describe the immunological mechanisms of delayed hypersensitivity reactions to drugs.

METHODS

A search of major medical databases on delayed hypersensitivity reactions to drugs was conducted. The review was limited to articles published in the period between 2013 and 2023, taking into consideration articles written in English and Spanish.

RESULTS

The terms defining delayed hypersensitivity reactions to drugs, their classification, clinical manifestations, diagnosis, treatment algorithms, and prognosis.

CONCLUSIONS

Adverse drug reactions represent a challenge for the specialist physician, with a complex pathophysiology. A prompt diagnosis and treatment focused on the drug phenotype and its immunological expression are required to provide a multidisciplinary approach.

Is Dosage Adjustment Based on Age Necessary for Intravenous Lidocaine in Patients Undergoing General Anesthesia: A Prospective Multi-Arm Comparative Study

It remains unclear whether dosage adjustment of intravenous lidocaine is necessary during general anesthesia for elderly patients over 75 years old. This study aimed to investigate the effects of age on the pharmacokinetics (PK) and safety of intravenous lidocaine in patients undergoing general anesthesia. A total of 599 plasma samples were collected from 76 general anesthesia patients across three age groups: 18-64, 65-74, and ≥ 75 years. Lidocaine was administered intravenously at a dose of 1.5 mg/kg for the 18-64 and 65-74 years groups, while the dose was adjusted to 1.0 mg/kg for the ≥ 75 years group. The plasma concentrations of lidocaine and its active metabolites were measured using a validated ultra-performance liquid chromatography-tandem mass spectrometry assay, and the data were analyzed using a noncompartmental analysis. The results revealed no significant age-related differences in the PK of lidocaine and its metabolites. Among the three age groups, over 90 % of patient achieved a lidocaine concentration within a safe and effective range when the dosage was normalized to 1.5 mg/kg. In conclusion, age-based dosage adjustment was unnecessary for intravenous lidocaine in patients below 86 years undergoing general anesthesia.

A Pharmacogenetic Panel-Based Prediction of the Clinical Outcomes in Elderly Patients with Coronary Artery Disease

Clinical annotations for the actionable pharmacogenetic variants affecting the efficacy of cardiovascular drugs have been collected, yet their impacts on elderly patients with coronary artery disease (CAD) undergoing polypharmacy remain uncertain. We consecutively enrolled 892 elderly patients (mean age 80.7 ± 5.2) with CAD and polypharmacy. All the included patients underwent genotyping for 13 variants in 10 pharmacogenes (CYP2C19, CYP2C9, CYP4F2, CYP2D6, VKORC1, SLCO1B1, APOE, ACE, ADRB1, and MTHFR), which have the clinical annotations for 12 drugs that are commonly prescribed for patients with CAD. We found that 80.3% of the elderly CAD patients had at least one drug-gene pair associated with a therapeutical drug change. After adjusting for covariates, the number of drug-gene pairs was independently associated with a decreased risk of both major cardiovascular events (MACEs) (adjusted hazard ratio [HR]: 0.803, 95% confidence interval [CI]: 0.683-0.945, p = 0.008) and all-cause mortality (adjusted HR: 0.848, 95% CI: 0.722-0.996, p = 0.045), but also with an increased risk of adverse drug reactions (ADRs) (adjusted HR: 1.170, 95% CI: 1.030-1.329, p = 0.016). The Kaplan-Meier survival curves showed that compared to patients without a drug-gene pair, a significantly lower risk of MACEs could be observed in patients with a drug-gene pair during a 4-year follow-up (HR: 0.556, 95% CI: 0.325-0.951, p = 0.013). In conclusion, the carrier status of the actionable drug-gene pair is predictive for the clinical outcomes in elderly patients with CAD and polypharmacy. Implementing early or preemptive pharmacogenetic panel-guided polypharmacy holds the potential to enhance clinical outcomes for these patients.

Long-term effects of mepolizumab in patients with severe eosinophilic asthma: a 6-year real-life experience

Background

Severe eosinophilic asthma (SEA) is often linked to a dysregulation in the Interleukin-(IL)-5 axis. Mepolizumab, a humanized monoclonal antibody, reduces eosinophils by directly binging to IL-5, potentially restoring homeostatic eosinophil biology, with a significant impact on quality of life, acute exacerbations and oral corticosteroids (OCS) elimination in SEA patients. While its short- and middle-term effects are well described, no study has so far investigated its long-lasting effects in SEA patients. The aim of our study was therefore to explore the effects of a long-term, six-year continuous treatment with mepolizumab on clinical control and clinical remission in a cohort of SEA patients.

Methods

We conducted a retrospective review of clinical records of patients who were prescribed mepolizumab between June 2017 and April 2018. We collected demographical, functional, and clinical data from visits performed at baseline and then at the specified timepoints and checked if patients had reached clinical remission after 6 years. We assessed asthma control test (ACT), exacerbation rate, and OCS elimination dose at 6 years. Clinical Remission (CR) was defined on the basis of the elimination of OCS and the contemporary presence of all the following: 1) stable lung function; 2) no exacerbation in the previous 12 months; 3) acceptable symptom control (ACT ≥ 20).

Results

Of 86 patients screened, 62 were included in the final analysis. Our study suggests that mepolizumab is effective and well tolerated after a six-year course of continuous treatment in patients with SEA. We reported a prevalence of 28 (46.8%) patients who reached complete CR at 72 months from the treatment start. 75% of patients eliminated the maintenance OCS already after 1 year of treatment; this proportion reached the 87% within the sixth year of treatment.

Conclusion

Mepolizumab proved to be effective in real-life after 6 years of treatment, inducing a complete clinical remission in the 46.8% of patients, with sustained improvements in quality of life, exacerbation rate, OCS intake and lung function.

The adverse inpatient medication event and frailty (AIME-frail) risk prediction model

BACKGROUND

Medication harm affects between 5 and 15% of hospitalised patients, with approximately half of the harm events considered preventable through timely intervention. The Adverse Inpatient Medication Event (AIME) risk prediction model was previously developed to guide a systematic approach to patient prioritisation for targeted clinician review, but frailty was not tested as a candidate predictor variable.

AIM

To evaluate the predictive performance of an updated AIME model, incorporating a measure of frailty, when applied to a new multisite cohort of hospitalised adult inpatients.

METHODS

A retrospective cohort study was conducted at two tertiary Australian hospitals on patients discharged between 1st January and April 31, 2020. Data were extracted from electronic medical records (EMRs) and clinical coding databases. Medication harm was identified using ICD-10 Y-codes and confirmed by senior pharmacist review of medical records. The Hospital Frailty Risk Score (HFRS) was calculated for each patient. Logistic regression analysis was used to construct a modified AIME model. Candidate variables of the original AIME model, together with new variables including HFRS were tested. Performance of the final model was reported using area under the curve (AUC) and decision curve analysis (DCA).

RESULTS

A total of 4089 patient admissions were included, with a mean age ± standard deviation (SD) of 64 years (±19 years), 2050 patients (50%) were males, and mean HFRS was 6.2 (±5.9). 184 patients (4.5%) experienced one or more medication harm events during hospitalisation. The new AIME-Frail risk model incorporated 5 of the original variables: length of stay (LOS), anti-psychotics, antiarrhythmics, immunosuppressants, and INR greater than 3, as well as 5 new variables: HFRS, anticoagulants, antibiotics, insulin, and opioid use. The AUC was 0.79 (95% CI: 0.76-0.83) which was superior to the original model (AUC = 0.70, 95% CI: 0.65-0.74) with a sensitivity of 69%, specificity of 81%, positive predictive value of 0.14 (95% CI: 0.10-0.17) and negative predictive value of 0.98 (95% CI: 0.97-0.99). The DCA identified the model as having potential clinical utility between the probability thresholds of 0.05-0.4.

CONCLUSION

The inclusion of a frailty measure improved the predictive performance of the AIME model. Screening inpatients using the AIME-Frail tool could identify more patients at high-risk of medication harm who warrant timely clinician review.

Interaction of age and CYP2C19 genotypes on voriconazole steady-state trough concentration in Chinese patients

OBJECTIVES

Both age and CYP2C19 genotypes affect voriconazole plasma concentration; the interaction of age and CYP2C19 genotypes on voriconazole plasma concentration remains unknown. This study aims to investigate the combined effects of age and CYP2C19 genotypes on voriconazole plasma concentration in Chinese patients.

METHODS

A total of 480 patients who received voriconazole treatment were recruited. CYP2C19*2 (rs4244285) and CYP2C19*3 (rs4986893) polymorphisms were genotyped. Patients were divided into the young and the elderly groups by age of 60 years old. Influence of CYP2C19 genotype on steady-state trough concentration (C ss-min ) in overall patients and in age subgroups was analyzed.

RESULTS

Voriconazole C ss-min correlated positively with age, and mean voriconazole C ss-min was significantly higher in the elderly group ( P  < 0.001). CYP2C19 poor metabolizers showed significantly increased mean voriconazole C ss-min in the young but not the elderly group. The percentage of patients with subtherapeutic voriconazole C ss-min (<1.0 mg/l) was higher in the young group and that of supratherapeutic voriconazole C ss-min (>5.5 mg/l) was higher in the elderly patients. When the average C ss-min in the CYP2C19 normal metabolizer genotype was regarded as a reference, CYP2C19 genotypes showed greater impact on voriconazole C ss-min in the young group, while the influence of age on voriconazole C ss-min exceeded CYP2C19 genotypes in the elderly.

CONCLUSION

CYP2C19 genotypes affects voriconazole exposure is age dependent. Influence of CYP2C19 poor metabolizer genotype on increased voriconazoleexposure is prominent in the young, while age is a more important determinant factor for increased voriconazole exposure in the elderly patients.

Predictors of Adverse Drug Reaction-Related Hospitalisations Among People with Dementia: A Retrospective Case-Control Study

INTRODUCTION

Adverse drug reactions (ADRs) are common among people with dementia; however, little is known about the magnitude and predictors associated with ADR-related hospitalisation among these individuals. This study aimed to determine the magnitude, types, drugs implicated and predictors of ADRs associated with hospitalisation among people with dementia.

METHODS

This retrospective case-control study analysed medical records of individuals aged ≥ 65 years with dementia admitted to major public hospitals in Tasmania, Australia, from July 2010 to July 2021. Adverse drug reactions and implicated drugs were identified using administrative data and cross-checked with hospital medical records, with consensus reached among the research team.

RESULTS

Of the 7928 people admitted to hospital at least once within the study period, 1876 (23.7%) experienced at least one ADR-related hospitalisation. Of these, 300 case patients with 311 ADRs and 300 control patients were randomly selected. The most common types of ADRs were renal (acute kidney injury; AKI) (36.0%), followed by neuropsychiatric (17.6%), cardiovascular (16.0%) and haematological (13.1%). Diuretics, renin-angiotensin system (RAS) inhibitors and anti-thrombotics constituted the main implicated drug classes. The ADR-related hospitalisation was associated with: chronic kidney disease (CKD) (OR 8.00, 95% CI 2.63-24.28, p < 0.001), Australian-born (OR 1.62, 95% CI 1.08-2.43, p = 0.019), hypertension (OR 1.48, 95% CI 1.01-2.17, p = 0.044) and the number of medicines (OR 1.06, 95% CI 1.00-1.12, p = 0.022). Potentially inappropriate medication use and anticholinergic burden did not predict ADR-related hospitalisation.

CONCLUSIONS

These predictors could help identify the individuals at the highest risk and enable targeted interventions to be designed.

Chronic pain in older adults with disabilities is associated with fall-related injuries: a prospective cohort study

PURPOSE

Previous studies have shown an association between chronic pain and the occurrence of falls in community-dwelling older adults; however, the association between chronic pain and fall-related injuries in older adults with disabilities is unclear. This study aimed to determine the association between chronic pain and fall-related injuries in older adults with disabilities.

METHODS

This 24-month prospective cohort study included older adults aged 65 years or older using Japanese long-term care insurance services. Chronic pain, defined as "pain that has persisted for more than three months to date," was assessed using a face-to-face questionnaire. Fall-related injuries, defined as "injuries requiring hospitalization or outpatient treatment due to a fall," were assessed using a fall calendar. Data were analyzed using a Cox proportional hazards model, with fall-related injury as the dependent variable, chronic pain as the independent variable, and confounders as covariates.

RESULTS

Among 133 included participants, 15 experienced fall-related injuries. After adjusting for age and sex as covariates, chronic pain was significantly associated with fall-related injuries (hazard ratio: 5.487, 95% confidence interval: 1.211-24.853, p = 0.027).

CONCLUSIONS

Chronic pain was associated with fall-related injuries in older adults with disabilities. In this population, a greater focus should be placed on treating chronic pain to reduce the occurrence of falls.

The temporal association between adverse drug reactions and antirheumatic drugs utilisation in Western Australia: a retrospective study from real-world data (1995-2015)

BACKGROUND/OBJECTIVES

Adverse drug reactions (ADRs) can result in morbidity, mortality, and higher healthcare costs. Given the limited information available on ADRs associated with antirheumatic medications, this study aims to analyse and compare ADR reporting for these drugs in the pharmacovigilance datasets of Western Australia (WA) and the United States (US).

METHODS

Therapeutic Goods Administration provided WA pharmacovigilance data of selected antirheumatic drugs to from 1995 to 2015. The proportional reporting ratio (PRR) for WA case reports was compared to corresponding USA pharmacovigilance data by assessing the disproportionality of each ADR. clinically significant or true ADRs were determined using the Evans 2001 criteria (n > 2, chi-square > 4, PRR > 2).

RESULTS

A total of 232 reports were found in WA, mostly on sixty-nine women aged 45 to 69. Methotrexate, leflunomide, azathioprine, sulfasalazine, and infliximab had the highest reported ADRs, related to gastrointestinal disorders. Patients who used biological agents in WA had 2.7 times the likelihood of reporting true ADRs compared to conventional antirheumatic drugs. The ADR rates in the two datasets were comparable over the study period.

CONCLUSIONS

The PRR values of ADRs were consistent between WA and US databases. Methotrexate and infliximab use were commonly associated with ADR reports in WA females, with incidence rates comparable to the US; while patients using biological agents were more likely to report true ADRs than those on conventional antirheumatic drugs in WA.

Analysis of a Serious Adverse Reaction of Pulmonary Fibrosis Caused by Dronedarone

Objective

This study aims to analyze a severe adverse reaction of pulmonary fibrosis induced by dronedarone hydrochloride tablets, and to provide a reference for clinical rational medication through drug precautions.

Methods

A case of pulmonary fibrosis induced by dronedarone hydrochloride tablets, along with related literature was retrospectively analyzed.

Results

Patients over 65 years old with a history of exposure to amiodarone may increase the incidence of pulmonary toxicity induced by dronedarone, and dronedarone should not be selected as a substitute treatment drug for patients with amiodarone-induced pulmonary toxicity.

Conclusions

It is recommended that clinicians monitor the diffusion capacity of carbon monoxide and lung ventilation function of patients before and after using dronedarone for treatment. For patients with a history of amiodarone exposure, intermittent monitoring of chest X-rays and lung function is necessary. If lung function decreases, dronedarone should be immediately discontinued.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis

BACKGROUND

There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability.

AIMS

To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective.

METHODS

A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations.

RESULTS

The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised.

CONCLUSIONS

The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

'It's a job to be done'. Managing polypharmacy at home: A qualitative interview study exploring the experiences of older people living with frailty

INTRODUCTION

Many older people live with both multiple long-term conditions and frailty; thus, they manage complex medicines regimens and are at heightened risk of the consequences of medicines errors. Research to enhance how people manage medicines has focused on adherence to regimens rather than on the wider skills necessary to safely manage medicines, and the older population living with frailty and managing multiple medicines at home has been under-explored. This study, therefore, examines in depth how older people with mild to moderate frailty manage their polypharmacy regimens at home.

METHODS

Between June 2021 and February 2022, 32 patients aged 65 years or older with mild or moderate frailty and taking five or more medicines were recruited from 10 medical practices in the North of England, United Kingdom, and the CARE 75+ research cohort. Semi-structured interviews were conducted face to face, by telephone or online. The interviews were recorded, transcribed verbatim and analysed using reflexive thematic analysis.

FINDINGS

Five themes were developed: (1) Managing many medicines is a skilled job I didn't apply for; (2) Medicines keep me going, but what happened to my life?; (3) Managing medicines in an unclear system; (4) Support with medicines that makes my work easier; and (5) My medicines are familiar to me-there is nothing else I need (or want) to know. While navigating fragmented care, patients were expected to fit new medicines routines into their lives and keep on top of their medicines supply. Sometimes, they felt let down by a system that created new obstacles instead of supporting their complex daily work.

CONCLUSION

Frail older patients, who are at heightened risk of the impact of medicines errors, are expected to perform complex work to safely self-manage multiple medicines at home. Such a workload needs to be acknowledged, and more needs to be done to prepare people in order to avoid harm from medicines.

PATIENT AND PUBLIC INVOLVEMENT

An older person managing multiple medicines at home was a core member of the research team. An advisory group of older patients and family members advised the study and was involved in the first stages of data analysis. This influenced how data were coded and themes shaped.

Diabetes mellitus increases risk of adverse drug reactions and death in hospitalised older people: the SENATOR trial

PURPOSE

Adverse drug reactions (ADRs) are a major cause of morbidity and mortality, especially in older people. Older people with diabetes mellitus may be at especially high risk of ADRs but this risk has not been well studied. This study aimed to compare severity and type of ADRs in hospitalised, multimorbid older people with and without diabetes and secondly to assess the impact of ADRs on mortality, rehospitalisation and length of stay.

METHODS

Participants in the SENATOR (Software Engine for the Assessment and optimization of drug and non-drug Therapy in Older peRsons) trial were assessed for 12 common and 'other' prevalent and incident adverse drug reactions using a blinded end-point adjudication process. Descriptive analyses, logistic regression and mediation analyses were undertaken.

RESULTS

Of 1537 people in the SENATOR trial, 540 (35.1%) had diabetes mellitus (mean age 77.4 ± 7.3 years, 58.5% male). In the total population, 773 prevalent and 828 incident ADRs were reported. Both prevalent and incident symptomatic hypoglycaemia and incident acute kidney injury (AKI) were significantly more common in people with diabetes (p < 0.05). Patients with diabetes had higher all-cause mortality at 12 weeks than those without (9.1% vs 6.3%, p = 0.04). Mediation analysis revealed that mortality was significantly higher (OR = 1.43, Sobel test p = 0.048) in people with diabetes and ADRs causing AKI.

CONCLUSIONS

Older multimorbid people with diabetes presenting to hospital with acute illness have significantly more ADRs than those without, and a significantly higher mortality that is mediated by medication-associated AKI and poorer renal function.

Potentially inappropriate prescriptions of antibiotics in geriatric psychiatry-a retrospective cohort study

Introduction

Older patients are frequently affected by infectious diseases and adverse drug reactions (ADRs) of consecutively prescribed antibiotics. Particularly within geriatric psychiatry, high rates of potentially inappropriate prescriptions (PIPs) have been described, significantly complicating pharmacological treatment. Therefore, this study aimed to investigate the frequency and characteristics of antibiotic PIPs in geriatric psychiatry.

Methods

Medication charts of 139 patient cases (mean age 78.8 years; 69.8% female) receiving antibiotic treatment on a geriatric psychiatric ward were analyzed. Utilizing previously published definitions of antibiotic PIPs, adequacy of the antibiotic prescriptions was subsequently assessed.

Results

16.3% of all screened patient cases (139/851) received an antibiotic treatment during their inpatient stay. 59.5% of antibiotic prescriptions were due to urinary tract infections, followed by pulmonary (13.3%) and skin and soft tissue infections (11.3%). 46.7% of all antibiotic prescriptions fulfilled at least one PIP criterium, with the prescription of an antibiotic course for more than seven days as the most common PIP (15.3%).

Discussion

Antibiotic PIPs can be considered as a frequent phenomenon in geriatric psychiatry. Especially the use of fluoroquinolones and cephalosporins should be discussed critically due to their extensive side effect profiles. Due to the special characteristics of geriatric psychiatric patients, international guidelines on the use of antibiotics should consider frailty and psychotropic polypharmacy of this patient population more closely.

Immunological Mechanisms in Cutaneous Adverse Drug Reactions

Adverse drug reactions (ADRs) are an inherent aspect of drug use. While approximately 80% of ADRs are predictable, immune system-mediated ADRs, often unpredictable, are a noteworthy subset. Skin-related ADRs, in particular, are frequently unpredictable. However, the wide spectrum of skin manifestations poses a formidable diagnostic challenge. Comprehending the pathomechanisms underlying ADRs is essential for accurate diagnosis and effective management. The skin, being an active immune organ, plays a pivotal role in ADRs, although the precise cutaneous immunological mechanisms remain elusive. Fortunately, clinical manifestations of skin-related ADRs, irrespective of their severity, are frequently rooted in immunological processes. A comprehensive grasp of ADR morphology can aid in diagnosis. With the continuous development of new pharmaceuticals, it is noteworthy that certain drugs including immune checkpoint inhibitors have gained notoriety for their association with ADRs. This paper offers an overview of immunological mechanisms involved in cutaneous ADRs with a focus on clinical features and frequently implicated drugs.

Associations among frailty status, hypertension, and fall risk in community-dwelling older adults

Objectives

Frailty and hypertension often coexist in older adults, which may lead to fall risks. This study aimed to examine the relationship between frailty status, hypertension, and fall risk.

Methods

In this cross-sectional study, a total of 401 older adults were conveniently recruited from communities in Wuxi, China, between September 2022 and November 2022. The fall risk self-assessment checklist from the Stopping Elderly Accidents, Deaths & Injuries (STEADI) Toolkit was used to evaluate their fall risks. The FRAIL scale questionnaire was used to assess frailty status. Participants' demographic information and comorbidities were collected. Multivariate logistic regression, generalized additive model, and smooth curve fitting were used to analyze the association between frailty, hypertension, and fall risk.

Results

Frailty had a strong association with increased prevalence of fall risk among the participants (OR 8.52, 95% CI 3.21-22.57; P < 0.001). Hypertension significantly increased the fall risk among older adults (OR 1.87, 95% CI 1.11-3.13; P = 0.019). The group with hypertension and frailty had the highest prevalence of fall risk (OR 12.24, 95% CI 3.51-42.65). Smooth curve fitting showed a nonlinear association between frailty and fall risk in hypertension status. In the progress of pre-frailty to frailty status, a higher tendency to fall was found among older adults with hypertension.

Conclusions

Frailty status and hypertension independently and jointly influenced the increased prevalence of fall risk. Enhanced frailty and hypertension management may help decrease fall risk among this population.

Prevalence of and Risk Factors for Drug-Related Readmissions in Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Older adults are at an increased risk of drug-related problems, especially following discharge from hospital. Drug-related readmissions place a large burden on the patient and the healthcare system. However, previous studies report inconsistent results on the prevalence and associated risk factors for drug-related hospital readmissions in older adults.

OBJECTIVES

We aimed to assess the prevalence of drug-related readmissions in older adults aged 65 years and older and investigate the drug classes, preventability and risk factors most associated with these readmissions.

METHODS

A systematic review and meta-analysis were undertaken to answer our objectives. A search of four databases (MEDLINE, Embase, CINAHL and Scopus) was conducted. Three authors independently performed title and abstract screening, full-text screening and data extraction of all included studies. A meta-analysis was conducted to calculate the pooled prevalence of drug-related readmissions across all studies, and a subgroup analysis was performed to explore heterogeneity among studies reporting on adverse drug reaction-related readmissions.

RESULTS

A total of 1978 studies were identified in the initial search, of which four studies were included in the final synthesis. Three studies focused on readmissions due to adverse drug reactions and one study focused on readmissions due to drug-related problems. A pooled prevalence of 9% (95% confidence interval 2-18) was found for drug-related readmissions across all studies, and a pooled prevalence of 6% (95% confidence interval 4-10) was found for adverse drug reaction-related readmissions. Three studies explored the preventability of readmissions and 15.4-22.2% of cases were deemed preventable. The drug classes most associated with adverse drug reaction readmissions included anticoagulants, antibiotics, psychotropics and chemotherapy agents. Polypharmacy (the use of five or more medications) and several comorbidities such as cancer, liver disease, ischaemic heart disease and peptic ulcer disease were identified as risk factors for drug-related readmissions.

CONCLUSIONS

Almost one in ten older adults discharged from hospital experienced a drug-related hospital readmission, with one fifth of these deemed preventable. Several comorbidities and the use of polypharmacy and high-risk drugs were identified as prominent risk factors for readmission. Further research is needed to explore possible causes of drug-related readmissions in older adults for a more guided approach to the development of effective medication management interventions.

Incidence and Severity of Adverse Drug Reactions in Medical Intensive Care Unit

BACKGROUND

Adverse drug reactions (ADRs) curtail patients' quality of life by virtue of increasing therapeutic complexity and rising multimorbidity. In India, the frequency of ADRs for individual drugs and their economic burdens are rarely evaluated. This study aimed at identifying the incidence and severity of ADRs leading to hospitalization (ADRA) and occurring during a hospital stay (ADRH).

OBJECTIVE

The objective of this study is to evaluate the incidence the incidence and severity of ADRs in the ICU and their impact on the duration of hospitalization, along with the cost incurred to treat ADRs in the ICU.

METHODS

Demographic, clinical, and pharmacological data on patients admitted to the ICU were collected, analyzed and evaluated for ADRs. According to the setting analyzed, a descriptive analysis of the reactions, suspected medicines, and associated factors was undertaken.

RESULTS

A total of 208 patients were admitted to the ICU during the study period, of which ADRA contributed 9.1% of the incidence rate and 8.1% of ADRH in 36 patients. Males had a higher incidence of ADRs than females. Patients who had ADRs had a substantially longer length of stay than those who did not. Electrolyte disturbance was the most commonly found ADR. According to the Hartwig scale and WHO-causality scale, 88.9% were moderate, and 97.2% were possible ADRs, respectively.

CONCLUSION

In this study, a similar incidence rate of ADRA and ADRH was observed. The average cost for treating ADRA was higher than that for treating ADRH. As a result, identifying and preventing these reactions is critical, as they cause the patient greater suffering.