Psychotropic drugs in the elderly. Selection of the appropriate agent

Anti-seizure medications-associated bladder and urethral symptoms: a pharmacovigilance analysis based on the FAERS database

BACKGROUND

In clinical practice, observations have been made regarding bladder and urethral symptoms (BUS), notably urinary frequency and urgency, among patients prescribed the anti-seizure medication (ASM) lacosamide. However, the precise association between ASMs and BUS events in real-world settings remains elusive.

RESEARCH DESIGN AND METHODS

Data from the FDA Adverse Event Reporting System (FAERS) database were employed and the analysis focused on ASMs-associated BUS events utilizing disproportionality analysis methods, including the reporting odds ratio (ROR) and the proportional reporting ratio (PRR). Furthermore, co-administration, time to onset of ASMs-associated BUS events, and severity assessments were conducted.

RESULTS

Several ASMs demonstrated statistically meaningful associations with BUS signals, notably ezogabine, valproic acid/valproate sodium, and clorazepate (p < 0.05). And ASMs-associated BUS events predominantly occurred within the first week and persisted for more than 180 days afterward. Diazepam, gabapentin, and brivaracetam exhibited distinct risk profiles for severe BUS events compared to valproic acid/sodium valproate (p < 0.05). And the nomogram constructed in this study exhibited robust predictive performance.

CONCLUSION

This study yields valuable insights into the association between ASMs and BUS events, but several limitations warrant consideration. Nonetheless, these findings emphasize the significance of vigilance and proactive management of ASMs-associated BUS events.

Safety profile of high-dose statin therapy in geriatric patients with stroke

OBJECTIVES

Use of high-dose statin therapy (HDST) in patients with stroke became standard clinical practice after the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study, in which the mean age of the study population was approximately 63 years. Little data are available on the adverse effects of statins when used in high doses in adults older than 65 years. The objective of this study was to assess the magnitude of adverse effects of HDST in geriatric patients.

METHODS

This single-center, retrospective, case-control study was conducted at Upstate Medical University, Syracuse, New York. All patients older than 65 years admitted between 2008 and 2011 to the hospital's Upstate Stroke Center with acute stroke were eligible. Electronic medical records of 200 eligible patients were reviewed to collect demographic, clinical, and laboratory data. Patients on HDST (cases) were compared with those on low doses (controls) using the χ, Fisher exact (two-sided), and Student t tests.

RESULTS

One hundred cases (mean age 80.5 ± 7.7 years) were compared with 100 controls (mean age 78.9 ± 6.4 years). Sixty-seven percent were taking simvastatin. Ninety percent of the cases compared with 81% of the controls had ischemic stroke. The prevalence of elevated alanine aminotransferase (13%) and myositis (4%) was significantly higher in the cases than in the controls. Fourteen percent of the cases reported myalgias, 9% had nausea, and 6% had diarrhea. Seventy-three cases had low-density lipoprotein levels <100 mg% and 41% of the cases had mean glycated hemoglobin levels ≥ 6.5%.

CONCLUSIONS

The use of HDST in older adult patients with acute stroke is associated with a significantly increased burden of liver enzyme elevation and myalgias.

Pharmacokinetic and pharmacodynamic factors that can affect sensitivity to neurotoxic sequelae in elderly individuals

Early-life exposure to agents that modulate neurologic function can have long-lasting effects well into the geriatric period. Many other factors can affect neurologic function and susceptibility to neurotoxicants in elderly individuals. In this review we highlight pharmacokinetic and pharmacodynamic factors that may increase geriatric susceptibility to these agents. There is a decreasing trend in hepatic metabolizing capacity with advancing years that can affect the ability to clear therapeutic drugs and environmental chemicals. This factor combined with decreased renal clearance causes prolonged retention of numerous drugs in elderly individuals. A geriatric pharmacokinetic database was developed to analyze changes in drug clearance with advancing age. This analysis shows that the half-life of drugs processed by hepatic cytochrome P450 enzymes or via renal elimination is typically 50-75% longer in those older than 65 than in young adults. Liver and kidney diseases are more common in elderly individuals and can further decrease the clearance function of these organs. Polypharmacy, the administration of numerous drugs to a single patient, is very common in elderly individuals and increases the risks for drug interaction and side effects. With advancing age the nervous system undergoes a variety of changes, including neuronal loss, altered neurotransmitter and receptor levels, and decreased adaptability to changes induced by xenobiotics. These changes in the central nervous system can make elderly individuals more susceptible to neurologic dysfunction when confronted with single pharmacologic agents, polypharmacy, or environmental toxicants. The many factors that affect elderly responses to neuroactive agents make environmental risk assessment for this age group a special concern and present a unique challenge.

Risk management for extrapyramidal symptoms

Extrapyramidal symptoms (EPS), the side effects of antipsychotic medications, have become the focus of much attention from clinical researchers, the courts, consumer groups, and even the U.S. Congress. The major clinical manifestations of EPS, the etiology, symptoms, and treatments are reviewed. The literature identified risk factors for EPS--those specific to the patient, to the particular antipsychotic agent used, and to the nature of the ongoing treatment for EPS. By quantifying these factors, weighting them according to the known risks, a risk management tool is developed for use in predicting which patients are at higher risks for EPS, in evaluating treatment, and in assessing the responses of patients to changes in their condition and to the subsequent adjustments in treatment. The risk management tool provides guidelines for the continual evaluation of these changes, with the goal of minimizing the risks for EPS.