Preventable ADRs leading to hospitalization - results of a long-term prospective safety study with 6,427 ADR cases focusing on elderly patients

Deep mutational scanning of CYP2C19 in human cells reveals a substrate specificity-abundance tradeoff

The cytochrome P450s enzyme family metabolizes ∼80% of small molecule drugs. Variants in cytochrome P450s can substantially alter drug metabolism, leading to improper dosing and severe adverse drug reactions. Due to low sequence conservation, predicting variant effects across cytochrome P450s is challenging. Even closely related cytochrome P450s like CYP2C9 and CYP2C19, which share 92% amino acid sequence identity, display distinct phenotypic properties. Using variant abundance by massively parallel sequencing, we measured the steady-state protein abundance of 7,660 single amino acid variants in CYP2C19 expressed in cultured human cells. Our findings confirmed critical positions and structural features essential for cytochrome P450 function, and revealed how variants at conserved positions influence abundance. We jointly analyzed 4,670 variants whose abundance was measured in both CYP2C19 and CYP2C9, finding that the homologs have different variant abundances in substrate recognition sites within the hydrophobic core. We also measured the abundance of all single and some multiple wild type amino acid exchanges between CYP2C19 and CYP2C9. While most exchanges had no effect, substitutions in substrate recognition site 4 reduced abundance in CYP2C19. Double and triple mutants showed distinct interactions, highlighting a region that points to differing thermodynamic properties between the 2 homologs. These positions are known contributors to substrate specificity, suggesting an evolutionary tradeoff between stability and enzymatic function. Finally, we analyzed 368 previously unannotated human variants, finding that 43% had decreased abundance. By comparing variant effects between these homologs, we uncovered regions underlying their functional differences, advancing our understanding of this versatile family of enzymes.

Frequency, Characteristics, and Preventability of Adverse Drug Reactions in Perioperative Neurosurgery: Analysis Over 11 Years

OBJECTIVE

Despite the importance of adverse drug reactions (ADRs), little is known about their role in perioperative neurosurgery. This study aimed to determine the prevalence of ADRs in perioperative neurosurgery and clarify the characteristics, severity, preventability, and risk factors of ADRs.

METHODS

Data for all patients who underwent neurosurgical procedures over an 11-year period were analyzed. During the study period, 3648 surgical procedures were performed for 2695 patients. Demographic and clinical information documented included medical history, allergic history, diagnosis, surgical method, suspected drugs, concomitant medications, and drug details. Multivariate logistic regression analyses were performed to identify independent parameters that were correlated with ADRs.

RESULTS

In total, 467 ADRs (18.3% ADRs/all neurosurgical procedures) were experienced by 401 patients. Anticonvulsants were associated with the highest number of ADRs (16.0%), followed by antibiotics (14.7%). Patients with ADRs were older than patients without ADRs (P < 0.01). The total number of drugs in patients with ADRs was 8.8 ± 3.6, compared to 5.2 ± 2.4 for patients without ADRs (P < 0.01). There were no significant differences in sex, allergic history, severe renal dysfunction (estimated glomerular filtration rate < 30 ml/min/1.73 m2), hypertension, diabetes, urgency of surgery, and type of surgery. Multivariate analysis showed that a high total number of drugs (odds ratio=3.2; 95% confidence interval 1.9-5.1) and older age (odds ratio=2.1; 95% confidence interval 1.3-3.8) were independent risk factors for ADRs.

CONCLUSIONS

The frequency of suspected and severe ADRs was higher than expected. Polypharmacy and older age were independent risk factors for ADRs in perioperative neurosurgery. To decrease ADRs during perioperative neurosurgery, polypharmacy must be discouraged, especially among older adult 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.

[INTERPOLAR-prospective, interventional studies as part of the Medical Informatics Initiative to improve medication therapy safety in healthcare]

Medication analyses by ward pharmacists are an important measure of drug therapy safety (DTS). Medication-related problems (MRPs) are identified and resolved with the attending clinicians. However, staff resources for extended medication analyses and complete documentation are often limited. Until now, data required for the identification of risk patients and for an extended medication analysis often had to be collected from various parts of the institution's internal electronic medical record (EMR). This error-prone and time-consuming process is to be improved in the INTERPOLAR (INTERventional POLypharmacy-Drug interActions-Risks) project using an IT tool provided by the data integration centers (DIC).INTERPOLAR is a use case of the Medical Informatics Initiative (MII) that focuses on the topic of DTS. The planning phase took place in 2023, with routine implementation planned from 2024. DTS-relevant data from the EMR is to be presented and the documentation of MRPs in routine care is to be facilitated. The prospective multicenter, cluster-randomized INTERPOLAR‑1 study serves to evaluate the benefits of IT support in routine care. The aim is to show that more MRPs can be detected and resolved with the help of IT support. For this purpose, six normal wards will be selected at each of eight university hospitals, so that 48 clusters (with a total of at least 70,000 cases) are available for randomization.

Digital Medication Management in Polypharmacy—Findings of a Cluster-Randomized, Controlled Trial With a Stepped-Wedge Design in Primary Care Practices (AdAM)

BACKGROUND

Inappropriate drug prescriptions for patients with polypharmacy can have avoidable adverse consequences. We studied the effects of a clinical decision-support system (CDSS) for medication management on hospitalizations and mortality.

METHODS

This stepped-wedge, cluster-randomized, controlled trial involved an open cohort of adult patients with polypharmacy in primary care practices (=clusters) in Westphalia-Lippe, Germany. During the period of the intervention, their medication lists were checked annually using the CDSS. The CDSS warns against inappropriate prescriptions on the basis of patient-related health insurance data. The combined primary endpoint consisted of overall mortality and hospitalization for any reason. The secondary endpoints were mortality, hospitalizations, and high-risk prescription. We analyzed the quarterly health insurance data of the intention- to-treat population with a mixed logistic model taking account of clustering and repeated measurements. Sensitivity analyses addressed effects of the COVID-19 pandemic and other effects.

RESULTS

688 primary care practices were randomized, and data were obtained on 42 700 patients over 391 994 quarter years. No significant reduction was found in either the primary endpoint (odds ratio [OR] 1.00; 95% confidence interval [0.95; 1.04]; p = 0.8716) or the secondary endpoints (hospitalizations: OR 1.00 [0.95; 1.05]; mortality: OR 1.04 [0.92; 1.17]; high-risk prescription: OR 0.98 [0.92; 1.04]).

CONCLUSION

The planned analyses did not reveal any significant effect of the intervention. Pandemicadjusted analyses yielded evidence that the mortality of adult patients with polypharmacy might potentially be lowered by the CDSS. Controlled trials with appropriate follow-up are needed to prove that a CDSS has significant effects on mortality in patients with polypharmacy.

Potentially Inappropriate Prescribing and Potential Prescribing Omissions and Their Association with Adverse Drug Reaction-Related Hospital Admissions

BACKGROUND

This study aimed to determine the prevalence of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) and their association with ADR-related hospital admissions in patients aged ≥ 65 years admitted acutely to the hospital.

METHODS

Information on medications and morbidities was extracted from the Adverse Drug Reactions in an Ageing Population (ADAPT) cohort (N = 798: N = 361 ADR-related admissions; 437 non-ADR-related admissions). PIP and PPOs were assessed using Beers Criteria 2019 and STOPP/START version 2. Multivariable logistic regression (adjusted odds ratios (aOR), 95%CI) was used to examine the association between PIP, PPOs and ADR-related admissions, adjusting for covariates (age, gender, comorbidity, polypharmacy).

RESULTS

In total, 715 (90%; 95% CI 87-92%) patients had ≥1 Beers Criteria, 555 (70%; 95% CI 66-73%) had ≥ 1 STOPP criteria and 666 patients (83%; 95% CI 81-86%) had ≥ 1 START criteria. Being prescribed at least one Beers (aOR = 1.66, 95% CI = 1.00-2.77), or meeting STOPP (aOR = 1.07, 95% CI = 0.79-1.45) or START (aOR = 0.72; 95%CI = 0.50-1.06) criteria or the number of PIP/PPO criteria met was not significantly associated with ADR-related admissions. Patients prescribed certain drug classes (e.g., antiplatelet agents, diuretics) per individual PIP criteria were more likely to have an ADR-related admission.

CONCLUSION

There was a high prevalence of PIP and PPOs in this cohort but no association with ADR-related admissions.

Drug-related hospitalizations - insights from the Czech Republic

Drug-related hospitalizations - insights from the Czech Republic Background and objective: Drug-related hospitalizations represent a significant burden on healthcare. The aim of the study was to determine the prevalence of drug-related hospitalizations and identify medications and clinical manifestations associated with drug-related hospitalizations in patients admitted to hospital through the emergency department.

METHODS

This cross-sectional study examined unplanned hospitalizations at the University Hospital Hradec Kralove through the Department of Emergency Medicine between August and November 2018. Data were obtained from electronic health records. The methodology for identifying drug-related hospitalizations was based on the guideline of the European project OPERAM. This article focuses on a subgroup of drug-related problems related to the medication safety.

RESULTS

Of the total 1252 hospitalizations analyzed, 145 cases were identified as drug-related. The prevalence of drug-related hospitalizations was 12% (95% confidence interval 10-13). In 62% of cases, medications only contributed to the cause of hospitalization. Antithrombotics, cytostatics, diuretics, and systemic corticosteroids were the most common medication classes leading to drug-related hospitalizations. Gastrointestinal bleeding was the most common cause of drug-related hospitalizations. The potential preventability of drug-related hospitalizations was 34%.

CONCLUSION

Drug-related hospitalizations remain relatively common, while some of them could be potentially prevented. Pharmacists can contribute to enhancing patient safety by detecting drug-related problems and proposing measures to minimize risks.

[Scoring tool to identify patients at increased risk for drug-related problems: results of a point prevalence study at hospital admission]

INTRODUCTION

Drug therapy is a high-risk process and requires special attention, especially at sectoral borders. Pharmaceutical services such as medication review are appropriate measures to identify drug-related problems and thus improve the safety of drug therapy. Risk-scoring tools have been described in the literature as helpful for prioritizing medication reviews for patients at high risk for drug-related problems.

METHODS

In a multi-centre point prevalence study, we identified patients at increased risk for medication-related problems at hospital admission using the medication risk tool. In addition, the current level of implementation of pharmacy services was surveyed.

RESULTS

A total of 11 (58%; 11/19) hospital pharmacies in Saxony participated in the point prevalence survey. The scoring tool identified 32% (279/875) of patients at increased risk for medication-related problems (Meris score >12 group) at admission. Thereby, the number of drugs in the Meris score >12 group was 10.6 (average; standard deviation 3.5; n=279), while in the Meris score ≤12 group it was only five drugs per patient (average 4.6; standard deviation 2.8; n=596). The age of patients in the Meris score >12 group averaged 75.9 ± 11 years, while the age of patients in the Meris score ≤12 group averaged 60.6 ± 17.9 years.

DISCUSSION

Prioritization with the help of a risk-scoring tool is essential as pharmacy services in Saxon hospitals still need to be regularly established and in order to identify patients with an increased risk for drug-related problems at an early stage.

Haefeli W, M. Seidling H. Mortality and Hospitalizations Among Patients Enrolled in an Interprofessional Medication Management Program

BACKGROUND

Measures for improving medication safety in outpatient care are often complex and involve medication reviews. Over the period 2016-2022 (with a preceeding one-year pilot phase), an interprofessional medication management program- the Medicines Initiative Saxony-Thuringia (Arzneimittelinitiative Sachsen-Thüringen, ARMIN)-was implemented in two German federal states. More than 5000 patients received a medication review by the end of 2019 by a team composed of physicians and pharmacists and were provided with joint, continuous care thereafter.

METHODS

In the framework of a retrospectively registered cohort study, the mortality and hospitalizations of this population (5033 patients) were studied using routine data from a statutory health insurer (observation period 2015-2019) and compared with those of a control group (10 039 patients) determined from the routine data by propensity score matching. Mortality was compared by survival analysis (Cox regression), and hospitalization rates were compared in terms of event probabilities within two years of enrollment in the medication management program. Robustness was tested in multiple sensitivity analyses.

RESULTS

Over the observation period, 9.3% of the ARMIN participants and 12.9% of persons in the control group died (hazard ratio of the adjusted Cox regression, 0.84; 95% confidence interval [0.76; 0.94], P = 0.001). In the first two years after inclusion, the ARMIN participants were hospitalized just as often as the persons in the control group (52.4% versus 53.4%; odds ratio from the adjusted model, 1.04 [0.96; 1.11], P = 0.347). The effects were consistent in sensitivity analyses.

CONCLUSION

In this retrospective cohort study, participation in the ARMIN program was associated with a lower risk of death. Exploratory analyses provide clues to the potential origin of this association.

[Polypharmacy in nursing homes: options to improve drug therapy safety]

Patients in need of care usually suffer from multiple chronic conditions and therefore receive a high number of drugs. Polypharmacy involves multiple risks, for example, drug-drug and drug-disease interactions, adverse effects and potentially inappropriate medication (PIM), more hospital admissions, and increased mortality.Residents in long-term care facilities are particularly sensitive to adverse drug reactions because of age-related changes, frailty, and the high prevalence of dementia. Numerous drugs have side effects that lead to sedation, particularly in old age, and increase the risk of falls. In addition, anticholinergic effects negatively modify cognition. These PIMs are frequently prescribed to nursing home residents.The medication process in long-term care facilities is complex and requires numerous coordinated processes. In addition to the correct administration, the nursing staff have other important tasks such as monitoring the effects and potential adverse drug reactions and communicating their observations to the prescribing physicians and home-supplying pharmacists. The nursing staff therefore play a crucial role in the prescription of psychotropic drugs and contribute to the medication quality for nursing home residents. National and international studies indicate that improvements of polypharmacy and drug therapy safety in nursing homes can only be achieved by interprofessional collaboration.

Detection of Drug-Related Problems through a Clinical Decision Support System Used by a Clinical Pharmacy Team

Clinical decision support systems (CDSSs) are intended to detect drug-related problems in real time and might be of value in healthcare institutions with a clinical pharmacy team. The objective was to report the detection of drug-related problems through a CDSS used by an existing clinical pharmacy team over 22 months. It was a retrospective single-center study. A CDSS was integrated in the clinical pharmacy team in July 2019. The investigating clinical pharmacists evaluated the pharmaceutical relevance and physician acceptance rates for critical alerts (i.e., alerts for drug-related problems arising during on-call periods) and noncritical alerts (i.e., prevention alerts arising during the pharmacist’s normal work day) from the CDSS. Of the 3612 alerts triggered, 1554 (43.0%) were critical, and 594 of these 1554 (38.2%) prompted a pharmacist intervention. Of the 2058 (57.0%) noncritical alerts, 475 of these 2058 (23.1%) prompted a pharmacist intervention. About two-thirds of the total pharmacist interventions (PI) were accepted by physicians; the proportion was 71.2% for critical alerts (i.e., 19 critical alerts per month vs. 12.5 noncritical alerts per month). Some alerts were pharmaceutically irrelevant—mainly due to poor performance by the CDSS. Our results suggest that a CDSS is a useful decision-support tool for a hospital pharmacist’s clinical practice. It can help to prioritize drug-related problems by distinguishing critical and noncritical alerts. However, building an appropriate organizational structure around the CDSS is important for correct operation.

Which Adverse Events and Which Drugs Are Implicated in Drug-Related Hospital Admissions? A Systematic Review and Meta-Analysis

Adverse drug events (ADEs) and adverse drug reactions (ADRs) are leading causes of iatrogenic injury, which can result in emergency department (ED) visits or admissions to inpatient wards. The aim of this systematic review and meta-analysis was to provide up-to-date estimates of the prevalence of (preventable) drug-related ED visits and hospital admissions, as well as the type and prevalence of implicated ADRs/ADEs and drugs. A literature search of studies published between January 2012 and December 2021 was performed in PubMed, Medline, EMBASE, Cochrane Library, and Web of Science. Retrospective and prospective observational studies investigating acute admissions to EDs or inpatient wards due to ADRs or ADEs in the general population were included. Meta-analyses of prevalence rates were conducted using generalized linear mixed models (GLMM) with the random-effect method. Seventeen studies reporting ADRs and/or ADEs were eligible for inclusion. The prevalence rates of ADR- and ADE-related admissions to EDs or inpatient wards were estimated at 8.3% ([95% CI, 6.4-10.7%]) and 13.9% ([95% CI, 8.1-22.8%]), respectively, of which almost half (ADRs: 44.7% [95% CI: 28.1; 62.4]) and more than two thirds (ADEs: 71.0% [95% CI, 65.9-75.6%]) had been classified as at least possibly preventable. The ADR categories most frequently implicated in ADR-related admissions were gastrointestinal disorders, electrolyte disturbances, bleeding events, and renal and urinary disorders. Nervous system drugs were found to be the most commonly implicated drug groups, followed by cardiovascular and antithrombotic agents. Our findings demonstrate that ADR-related admissions to EDs and inpatient wards still represent a major and often preventable health care problem. In comparison to previous systematic reviews, cardiovascular and antithrombotic drugs remain common causes of drug-related admissions, while nervous system drugs appear to have become more commonly implicated. These developments may be considered in future efforts to improve medication safety in primary care.

Safety of Mexidol® (ethylmethylhydroxypyridine succinate) in adult patients of different age groups

To reduce the risk of developing adverse events (AEs) and increase the adherence of elderly patients to treatment, it is recommended to limit maximally the total number of prescribed drugs (DR), using one drug for the treatment of two or more pathologies if possible. The drugs that meet the criteria for use in elderly patients and / or patients with comorbidity include the original Russian drug Mexidol® (ethylmethylhydroxypyridine succinate), which has a multimodal mechanism of action and has multiple pharmacological effects. In order to study the safety of Mexidol in comparison with placebo in different age groups of patients with chronic cerebral ischemia, a post hoc analysis of the international multicenter, randomized, double-blind, placebo-controlled MEMO study with an adaptive design was carried out, which assessed the efficacy and safety of sequential therapy with Mexidol®, a solution for intravenous and intramuscular injection, 50 mg/ml (NPK PHARMASOFT, Russia) and Mexidol® FORTE 250 film-coated tablets, 250 mg (NPK PHARMASOFT, Russia) in patients with chronic cerebral ischemia. The study involved 318 patients aged from 40 to 90 years.

Comparable safety and tolerability of Mexidol was demonstrated in middle-aged and elderly people with chronic cerebral ischemia, including patients over 75 years of age. 

Drug-Related Hospital Admissions via the Department of Emergency Medicine: A Cross-Sectional Study From the Czech Republic

Background: Drug-related hospital admissions (DRAs) represent a significant problem affecting all countries worldwide. This study aimed to determine the prevalence and preventability of DRAs, identify the most common medications involved in DRAs, the most common clinical manifestations of DRAs and describe the preventability aspects of DRAs.

Methods: This cross-sectional study examined unplanned hospital admissions to the University Hospital Hradec Králové via the department of emergency medicine in August–November 2018. Data were obtained from electronic medical records. The methodology of DRA identification was adapted from the OPERAM DRA adjudication guide.

Results: Out of 1252 hospital admissions, 195 DRAs have been identified (145 related to treatment safety, 50 related to treatment effectiveness). The prevalence of DRAs was 15.6% (95% CI 13.6–17.6). The most common medication classes involved in DRAs related to treatment safety were Antithrombotic agents, Antineoplastic agents, Diuretics, Corticosteroids for systemic use, and Beta blocking agents. The most common medication classes involved in DRAs related to treatment effectiveness included Diuretics, Antithrombotic agents, Drugs used in diabetes, Agents acting on the renin-angiotensin system, and Lipid modifying agents. Gastrointestinal disorders were the leading causes of DRAs related to treatment safety, while Cardiac disorders were the leading causes of DRAs related to treatment effectiveness. The potential preventability of DRAs was 51%. The highest share of potential preventability in medication classes repeatedly involved in DRAs related to treatment safety was observed for Anti-inflammatory and antirheumatic products, Psycholeptics, and Drugs used in diabetes. Potentially preventable DRAs related to treatment safety were most commonly associated with inappropriate drug selection, inappropriate monitoring, inappropriate dose selection, and inappropriate lifestyle measures. On the contrary, DRAs related to treatment effectiveness were more commonly associated with medication nonadherence.

Conclusion: It should be emphasized that in most DRAs, medications were only a contributory reason of hospital admissions and that benefits and risks have to be carefully balanced. It is highlighted by the finding that the same medication classes (Antithrombotic agents and Diuretics) were among the most common medication classes involved in DRAs related to treatment safety and simultaneously in DRAs related to treatment effectiveness. The study highlighted that apart from problems related to prescribing, problems related to monitoring and patient-related problems represent significant preventability aspects.

Healthcare Professionals' Views on the Management of Medication Complexities in the Elderly With Mental Health Disorders: A Cross-Sectional Study

Background

Many challenges in elderly pharmacotherapy are identified, including the use of Potentially Inappropriate Medications (PIMs) which may increase the odds of adverse events, especially in elderly patients with mental health disorders (e. g., behavioral, and psychological symptoms of dementia-BPSD, schizophrenia, bipolar disorder). However, information on the knowledge and practice of healthcare professionals (HCPs) about this topic is still scarce.

Methods

A cross-sectional study was undertaken from July-October 2019. An online questionnaire was specifically designed and validated for this study. We sought HCPs (physicians, pharmacists, and nurses) worldwide, using (a) social media, via Facebook, Twitter, and LinkedIn; and (b) email contacts of the research team (convenience sample). Either way participants were asked to share on their social media or via e-mail the questionnaires with other HCPs (snowballing sample). The survey assessed two main domains: knowledge and practice. Knowledge was evaluated by self-report (perceived knowledge by a 5-item Likert confidence scale) and using three clinical cases, scored between 0 and 30 points (each one rated from 0 to 10 points; real knowledge). Barriers in clinical practice were evaluated using a 5-item Likert scale judging practitioners' opinion.

Results

A total of 165 questionnaires were collected. HCPs were mainly female (n = 114; 69.1%), with a mean age of 35.3 ± 11.3 years old. Seventy-two percent (n = 118) were pharmacists, 21.1% (n = 35) were physicians, and 7.3% (n = 12) nurses. There was a weak correlation, albeit significant, between perceived and real knowledge (r = 0.199; p = 0.001). The mean score of the clinical vignettes regarding elderly patients with dementia and bipolar disorder were 4.59 ± 4.08 and 4.86 ± 2.97 points, respectively. Most HCPs were classified as having an intermediate knowledge (n = 100; 60.6%) about medication complexities in the elderly with mental disorders. Most HCPs agreed that lack of time (81.6%; n = 138), lack of education and training on elderly pharmacotherapy (72.2%; n = 122), and lack of tools adapted to daily practice (61.8%; n = 105) were the main barriers.

Conclusions

Most of the HCPs felt confident to manage medication complexities in elder patients with mental disorders, but only a minority obtained a good score in the knowledge assessment test. The main barriers identified included structural barriers (tools unfit for practice) and process barriers (time).

Fatal Events Associated with Adverse Drug Reactions in the Korean National Pharmacovigilance Database

Adverse drug reactions (ADRs) pose a global public health threat, substantially contributing to death. Due to the relative paucity of clinical evidence regarding fatal ADRs, this study was performed to characterize the epidemiology of fatal ADRs in Korea. This was a retrospective, cross-sectional analysis of ADR cases reported to the Korea Adverse Event Reporting System from 2010 to 2019. All ADRs were coded using the World Health Organization-Adverse Reaction Terminology system and classified as either fatal or non-fatal events. Logistic regression was performed to identify factors associated with fatal events. Among 289,756 ADR records, 629 fatal events (0.2%) occurred. The most common causative agent of fatal ADRs was antibacterials (20.3%), followed by antimycobacterials (5.4%), analgesics (4.0%), and contrast media (1.9%). Among antimicrobials, vancomycin was most frequently implicated without significantly increasing the risk of fatal events. The risk for fatal ADRs was significantly increased with male sex; advanced age; polypharmacy; piperacillin/β-lactamase inhibitor; cefotetan; ceftriaxone; combination antimycobacterial therapy consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol; morphine; and iopromide (reporting odds ratio > 1, p < 0.05 for all). Although fatal ADRs are uncommon (<1%) in Korea, they are primarily caused by commonly used medications including antibiotics, analgesics, and contrast media.

Trampisch H, Timmesfeld N, Thürmann P, Hackmann E, Barkhausen T, Junius-Walker U, Wilm S. Reduction of Potentially Inappropriate Medication in the Elderly

BACKGROUND

Medications with an unfavorable risk-benefit profile in the elderly, and for which there are safer alternatives, are designated as potentially inappropriate medications (PIM). The RIME trial (Reduction of Potentially Inappropriate Medication in the Elderly) was based on PRISCUS, a list of PIM that was developed in 2010 for the German pharmaceuticals market. In this trial, it was studied whether special training and the PRISCUS card could lessen PIM and undesired drug-drug interactions (DDI) among elderly patients in primary care.

METHODS

A three-armed, cluster-randomized, controlled trial was carried out in two regions of Germany. 137 primary care practices were randomized in equal numbers to one of two intervention groups-in which either the primary care physicians alone or the entire practice team received special training-or to a control group with general instructions about medication. The primary endpoint was the percentage of patients with at least one PIM or DDI (PIM/DDI) per practice. The primary hypothesis was that at 1 year this endpoint would be more effectively lowered in the intervention groups compared to the control group.

RESULTS

Among 1138 patients regularly taking more than five drugs, 453 (39.8%) had at least one PIM/DDI at the beginning of the trial. The percent - ages of PIM/DDI at the beginning of the trial and 1 year later were 43.0% and 41.3% in the intervention groups and 37.0% and 37.6% in the control group. The estimated intervention effect of any intervention (69 practices) versus control (68 practices) was 2.3% (p = 0.36), while that of team training (35 practices) versus physician training (34 practices) was 4.3% (p = 0.22).

CONCLUSION

The interventions in the RIME trial did not significantly lower the percentage of patients with PIM or DDI.

Prescription of Potentially Inappropriate Medication in Older Inpatients of an Internal Medicine Ward: Concordance and Overlap Among the EU(7)-PIM List and Beers and STOPP Criteria

Background: Age-related comorbidities prone older adults to polypharmacy and to an increased risk of potentially inappropriate medication (PIM) use. This work aims to analyze the concordance and overlap among the EU(7)-PIM list, 2019 Beers criteria, and Screening Tool of Older Person’s Prescriptions (STOPP) version 2 criteria and also to analyze the prevalence of PIM.

Methods: A retrospective cohort study was conducted on older inpatients of an internal medicine ward. Demographic, clinical, and pharmacological data were collected, during March 2020. After PIM identification by the EU(7)-PIM list, Beers criteria, and STOPP v2 criteria, the concordance and overlap between criteria were analyzed. A descriptive analysis was performed, and all the results with a p-value lower than 0.05 were considered statistically significant.

Results: A total of 616 older patients were included in the study whose median age was 85 (Q1–Q3) (78–89) years. Most of the older patients were male (51.6%), and the median (Q1–Q3) number of days of hospitalization was 17 (13–22) days. According to the EU(7)-PIM list, Beers criteria, and STOPP criteria, 79.7, 92.0, and 76.5% of older adults, respectively, used at least one PIM. A poor concordance (<63.4%) among criteria was observed. An association between PIM and the number of prescribed medicines was found in all applied criteria. Moreover, an association between the number of PIMs and diagnoses of endocrine, nutritional, and metabolic diseases, mental, behavioral, and neurodevelopmental disorders, and circulatory system diseases and days of hospitalization was observed according to Beers criteria, and that with diseases of the circulatory system and musculoskeletal system and connective tissue was observed according to STOPP criteria.

Conclusion: Despite the poor concordance between the EU(7)-PIM list, 2019 Beers, and STOPP v2 criteria, this work highlights the need for more studies in inpatients to develop strategies to facilitate the identification of PIM to decrease the high prevalence of PIM in hospitalized patients. The poor concordance among criteria also highlights the need to develop new tools adapting the existing criteria to medical ward inpatients.

REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors (REMEDI[e]S): French implicit and explicit criteria

PURPOSE

To establish a consensus on both explicit and implicit criteria in order to identify potentially inappropriate prescribing (PIP) in French older people aged 75 years and over or 65 years and over with multimorbidity.

METHODS

Fifteen experts in geriatrics, general practice, pharmacy, and clinical pharmacology were involved in a two-round Delphi survey to assess preliminary explicit and implicit criteria based on an extensive literature review and up-to-date evidence data. Experts were asked to rate their level of agreement using a 5-level Likert scale for inclusion of criteria and also for rationale and therapeutic alternatives. A consensus was considered as reached if at least 75% of the experts rated criteria as "strongly agreed" or "agreed."

RESULTS

The new tool included a seven-step algorithm (implicit criteria) encompassing the three main domains that define PIP (i.e. overprescribing, underprescribing, and misprescribing) and 104 explicit criteria. Explicit criteria were divided into 6 tables related to inappropriate drug duplications (n = 7 criteria), omissions of medications and/or medication associations (n = 16), medications with an unfavourable benefit/risk ratio and/or a questionable efficacy (n = 39), medications with an unsuitable dose (n = 4) or duration (n = 6), drug-disease (n = 13), and drug-drug interactions (n = 19).

CONCLUSION

The REMEDI[e]S tool (REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors) is an original mixed tool, adapted to French medical practices, aimed at preventing PIP both at the individual level in clinical practice and the population level in large-scale studies. Therefore, its use could contribute to an improvement in healthcare professionals' prescribing practices and safer care in older adults.

Trends and patterns in EU(7)-PIM prescribing to elderly patients in Germany

PURPOSE

The aim of this study was to explore patterns and long-term development in prescribing potentially inappropriate medication (PIM) according to the EU(7)-PIM list to elderly patients in Germany.

METHODS

We analysed anonymized German claims data. The study population comprised 6.0 million insured individuals at least 65 years old, including all their prescriptions reimbursed in 2019. For the analysis of long-term development, we used data for the years 2009-2019. Factors associated with PIM prescribing were considered from two perspectives: patient-oriented analysis was performed with logistic regression and prescriber-oriented analysis was performed with multiple linear regression.

RESULTS

EU(7)-PIM prevalence was reduced from 56.9% in 2009 to 45.1% in 2019. Average annual volume (DDDs/insured) decreased from 145 in 2009 to 121 in 2019. These figures are substantially greater than those for the older PRISCUS list. The majority of investigated ATC level 2 groups with the highest EU(7)-PIM DDD volume exhibited substantial decreases; moderate increases were found for antihypertensive and urological drugs. Antithrombotics increased strongly with the introduction of direct oral anticoagulants. The most prevalent EU(7)-PIM medication was diclofenac; however, in the age group 85+ years, apixaban was twice as prevalent as diclofenac. Polypharmacy, female sex, age < 90 years, need for nursing care and living in Eastern regions were identified as risk factors. Prescriber specialty was the most marked factor in the prescriber-oriented analysis.

CONCLUSION

Although the use of EU(7)-PIMs has been declining, regional differences indicate considerable room for improvement. The comparison with PRISCUS highlights the necessity of regular updates of PIM lists.

Hospital admissions to geriatric ward related to adverse drug events: a cross-sectional study from the Czech Republic

Background Geriatric patients represent a vulnerable population in terms of adverse drug events (ADEs). Objective The aims of this study were to determine the prevalence and preventability of hospital admissions to a geriatric ward related to ADEs, to identify medications involved in these ADEs and to describe potential preventability aspects of ADE-related admissions. Setting University Hospital Hradec Králové, Czech Republic. Methods This cross-sectional study evaluated acute hospital admissions to the geriatric ward of University Hospital Hradec Králové over a period of nine months (April-December 2017). Medication reviews were performed in order to identify ADE-related hospital admissions. Causality was assessed using the World Health Organization-Uppsala Monitoring Centre criteria. Modified Schumock-Thornton algorithm was used to assess the preventability of ADEs. Main outcome measure 9-month-prevalence of ADE-related hospital admissions. Results A total of 366 hospital admissions were included. The 9-month-prevalence of ADE-related hospital admissions was 11.75% [95% confidence interval 8.45-15.05]. Antithrombotic agents and diuretics represented the most common medication classes associated with ADEs (30.2% each). Electrolyte disturbances and gastrointestinal haemorrhages and ulcerations were the most frequently observed ADEs associated with hospital admission. Out of 43 ADE-related hospitalisations, 23 (53.5%) were considered potentially preventable. Conclusion The contribution of ADEs to hospital admission to the geriatric ward was not negligible. Our results also suggest that 53.5% of identified ADE-related admissions could be potentially prevented. This finding demonstrates just how important the research on the preventability of medication-related hospitalisations is. Further studies and implementations are still needed aiming to minimize the risk of medication-related harm.

Antibiotic allergy as a cause of hospitalization in adults: a hospital-based study in Ukraine

Background:

Antibiotic allergy is an important clinical and social-economical issue.

Objective:

The main objectives of this study were to determine the incidence, causative drugs, and risk groups of antibiotic allergy as a reason for hospitalization. The secondary objective was to evaluate the treatment of antibiotic allergy through the identification of drug related problems (DRPs).

Methods:

This retrospective hospital-based study was carried out in one of Lviv city hospitals (Ukraine) from January 2015 to December 2017. Patients with antibiotic allergy as a cause for hospitalization were included in this study.

Results:

In this study the incidence of antibiotic allergy was 2.0% (95%CI 1.6:2.4) of all admissions to the Unit that provides special medical care for adult inpatients with allergy diseases and allergy reactions. The mean age of patients was 48.5 years (SD=17.0; range 18-83 years) with female predominance (78.2%; 95%CI 68.9:85.2). Antibiotic hypersensitivity reactions manifested as urticaria with angioedema (52.5%; 95%CI 42.3:62.5), urticaria (36.6%; 95%CI 27.8:46.8) or angioedema (10.9%; 95%CI 5.6:18.7). Beta-lactams (48.5%; 95%CI 38.5:58.7), fluoroquinolones (13.9%; 95%CI 7.8%:22.2%) and macrolides (7.9%; 95%CI 3.5:15.0) were specified as the main causative drugs. All patients during hospitalization (a mean of 8.2 days; SD=2.2; range 2-13 days) took at least 3 medicines (a mean of 5.4 medicines per patient; SD=1.2; range 3-12 medicines). The total number of identified DRPs was 400, a mean of 4.0 DRPs per patient (SD=1.8). The most frequently identified type of DRPs was inappropriate route of drug administration (25.0%; 95%CI 20.8:29.5). This was followed by duplicate prescriptions (23.5%; 95%CI 19.4:28.0) and insufficient frequency of drug administration (19.0%; 95%CI 15.3:23.2). Potential drug-drug interactions and inappropriate drug prescriptions each accounted for 16.0% (95% CI 12.6:20.0) of all DRPs. Comparing all above items in 2015, 2016 and 2017 showed no statistically significant changes (p>0.05).

Conclusions:

Antibiotic allergy is a common reason for admissions. The treatment of antibiotic allergy is associated with numerous DRPs. Our results could be useful for development of strategies for improving the safety and quality of pharmacotherapy.

Investigation of the characteristics of medication errors and adverse drug reactions using pharmacovigilance data in China

The aim of this study was to investigate the characteristics of medication errors (MEs) and adverse drug reactions (ADRs) using data from the spontaneous reporting system, which is helpful to understand the actual situation of MEs in China. Data from 2015 in a south distinct in Shanghai were gathered from the spontaneous reporting system and analyzed. The general information, cause of errors, severity, primary diseases, involved system and organs, symptoms, and suspected drugs were investigated. A total of 1290 adverse drug events (ADEs), including 1079 ADRs and 211 MEcs (MEs causing ADE), were reported. Older patients suffered from both ADRs and MEcs (age distribution and dosage form were different between ADRs and MEcs). The main causes of errors were inappropriate usage and dosage of drugs and inappropriate indication selection. Most ADR and MEc cases were mild; the possibility of developing a severe adverse event was quite low. The distribution of the top 10 system and organs, and symptoms involved was significantly different between ADRs and MEcs, with J01 drugs (antibacterials for systemic use) being the leading cause in both. Our results suggested that a direct analysis of data from the spontaneous reporting system is a reliable, and convenient method to investigate MEs and ADRs, despite the existing limitations, and contributes to further understanding the current situation of MEs and ADRs in China.

Risk factors associated with potential cardiovascular and cerebrovascular adverse events in elderly individuals assisted at secondary level

SUMMARY OBJECTIVE To identify the use of Potentially Inappropriate Medications with imminent risk of Cardiovascular and Cerebrovascular Adverse Events (PIM-CCVAE), in addition to the factors associated with a group of elderly individuals undergoing therapeutic care in a Brazilian public service. METHODS A cross-sectional retrospective study conducted at a secondary level service located in Carapicuíba, SP, Brasil. Only elderly individuals (≥60 years) who were treated in one of the outpatient departments were included. The use of PIM-CCVAE was defined based on the PIM-CCVAEs list. In this research, we used descriptive statistics and logistic regression to identify and track possible predictors of MPI use. All statistical analyses were performed using Stata software version 15.1 (Stata Corporation). RESULTS The sample included 233 elderly individuals, with a mean age of 74.9 (± 9.4) years. Of these, 74.2% used at least one PIM-CCVAE, with an average daily intake of 1.3 (± 1) PIM/elderly. The presence of comorbidities, diseases of the circulatory system, polypharmacy, and low to moderate scores in morbidity and mortality were important factors associated with an increased odds ratio for the consumption of PIM-CCVAE. It is also emphasized that the presence of neurological symptoms proved to be a protective factor for this outcome. CONCLUSION Given the clinical severity and imminent risk of CCVAE in the researched group, preventive measures should be instituted to minimize health problems related to medication in the public network.

Potentially Inappropriate Prescribing and Potential Prescribing Omissions in 82,935 Older Hospitalised Adults: Association with Hospital Readmission and Mortality Within Six Months

Polypharmacy with “potentially inappropriate medications” (PIMs) and “potential prescribing omissions” (PPOs) are frequent among those 65 and older. We assessed PIMs and PPOs in a retrospective study of 82,935 patients ≥ 65 during their first admission in the period March 2013 through February 2018 to the four acute-care Calgary hospitals. We used the American Geriatric Society (AGS) and STOPP/START criteria to assess PIMs and PPOs. We computed odds ratios (ORs) for key outcomes of concern to patients, their families, and physicians, namely readmission and/or mortality within six months of discharge, and controlled for age, sex, numbers of medications, PIMs, and PPOs. For readmission, the adjusted OR for number of medications was 1.09 (1.09–1.09), for AGS PIMs 1.14 (1.13–1.14), for STOPP PIMs 1.15 (1.14–1.15), for START PPOs 1.04 (1.02–1.06), and for START PPOs correctly prescribed 1.16 (1.14–1.17). For mortality within 6 months of discharge, the adjusted OR for the number of medications was 1.02 (1.01–1.02), for STOPP PIMs 1.07 (1.06–1.08), for AGS PIMs 1.11 (1.10–1.12), for START PPOs 1.31 (1.27–1.34), and for START PPOs correctly prescribed 0.97 (0.94–0.99). Algorithm rule mining identified an 8.772 higher likelihood of mortality with the combination of STOPP medications of duplicate drugs from the same class, neuroleptics, and strong opioids compared to a random relationship, and a 2.358 higher likelihood of readmission for this same set of medications. Detailed discussions between patients, physicians, and pharmacists are needed to improve these outcomes.

Urgent Hospital Admissions Caused by Adverse Drug Reactions and Medication Errors-A Population-Based Study in Spain

BACKGROUND

Adverse drug reactions (ADR) are a public health issue, due to their great impact on morbidity, mortality, and economic cost.

OBJECTIVE

We aimed to study the percentage of patients admitted urgently as a result of an ADR, considered serious adverse event, or medication error. Also, we intended to identify possible risk factors which would lead to improvements in the prescription and use of medications.

METHODS

This is a retrospective observational study conducted during February 2019, including patients admitted through the emergency department in our hospital. We evaluated the medical records of those with suspected ADR diagnoses to perform a descriptive analysis of the demographic characteristics. Moreover, after applying the Spanish Pharmacovigilance System causality algorithm, we performed a descriptive analysis of the identified ADR and the drugs involved. We also investigated those cases suspected of being a medication error.

RESULTS

During the study period, 847 patients were urgently hospitalized. From those, 71 (29 women and 42 men) were admitted due to an ADR (8.4%, 95% CI 6.5%-10.3%). The mean age was 73 ± 15.9 years old and the mean number of prescribed medications was 7.3 ± 3.6 drugs/patient on admission. The most frequent ADR were opportunistic infections due to antineoplastic and immunomodulator drugs, and bleeding due to antiaggregants and anticoagulants. Five suspected medication errors occurred, being the incidence 0.6% (95% CI 0.08%-1.12%) of total admissions.

CONCLUSIONS

8.4% of urgent admissions were attributed to an ADR. Age (75% of patients were ≥ 65 years old), comorbidities and polymedication were the main risk factors. Although medication errors had a very low incidence (0.6% of urgent admissions), they were preventable and should be considered as a focus for action.

Reduction of potentially inappropriate medication in the elderly: design of a cluster-randomised controlled trial in German primary care practices (RIME)

Background:

Potentially inappropriate medication (PIM) is considered to have potentially more harmful than beneficial health effects in elderly patients. A German example for a PIM list is the PRISCUS list that has been available since 2010. PIMs are associated with an increased risk of hospitalisation and adverse health outcomes. Furthermore, drug–drug interactions (DDI) may pose additional risks to patients. It is not yet clear how numbers of PIM and DDI can be reduced in community-dwelling seniors in primary care; nor is it clear whether patients would benefit from such deprescribing.

Methods:

The cluster-randomised controlled study on the “Reduction of potentially Inappropriate Medication in the Elderly” (RIME study) is designed to examine whether an intervention based on the PRISCUS list can lower the proportion of community-dwelling people of ⩾70 years taking at least one PIM and/or medication inducing at least one dangerous DDI. The intervention consists of professional education and training on the reduction of PIM and DDI, and will be offered to either general practitioners (GPs) alone or GPs and their office staff in the experimental study arm. The control group will be offered professional education and training on more general issues of prescribing in the elderly, not specifically addressing PIM or DDI. The primary endpoint is the difference in the proportion of patients with at least one PIM or DDI between the start of the study and study closure after 12 months as compared between intervention and control group. Secondary endpoints include overall mortality, number of hospitalisations during the course of the study, quality of life and costs. Secondary analyses will be explorative, with the cluster randomisation being factored in.

Discussion:

The RIME study will contribute to answering the question of whether an intervention based on the PRISCUS list can reduce the proportion of community-dwelling seniors aged ⩾70 years with at least one PIM and/or DDI, and whether this will result in positive health effects, for example, as regards hospitalisations.

Trial registration

The Study has been registered in the German Clinical Trials Register (DRKS) under the number DRKS00003610.

Influence of metabolic profiles on the safety of drug therapy in routine care in Germany: protocol of the cohort study EMPAR

INTRODUCTION

Pre-emptive testing of pharmacogenetically relevant single-nucleotide polymorphisms can be an effective tool in the prevention of adverse drug reactions and therapy resistance. However, most of the tests are not used as standard in routine care in Germany because of lacking evidence for the clinical and economical benefit and their impact on the usage of healthcare services. We address this issue by investigating the influence of pharmacogenetic profiles on the use of healthcare services over an extended period of several years using routine care data from a statutory health insurance company. The goal is to provide clinical evidence whether pre-emptive pharmacogenetic testing of metabolic profiles in routine care in Germany is beneficial and cost-effective.

METHODS AND ANALYSIS

The EMPAR (Einfluss metabolischer Profile auf die Arzneimitteltherapiesicherheit in der Routineversorgung) study is a non-interventional cohort study conducted to analyse pharmacogenetic risk factors that are important for drug therapy by means of endpoints relevant for healthcare. The analysis is based on pharmacogenetic profiles and statutory health insurance data. We perform pharmacogenetic, pharmacoepidemiological and pharmacoeconomic analyses using health care utilisation scores and machine learning techniques. Therefore, we aim to include about 10 000 patients (≥18 years) insured by the health insurance provider Techniker Krankenkasse. The study focuses on patients with prescriptions of anticoagulants and prescriptions of cholesterol-lowering drugs. Also, a screening for special pharmacogenetic characteristics will be performed in patients with at least one Y57.9! diagnosis (Complication of medical and surgical care: drug or medicament, unspecified). Outcomes include the utilisation of health insurance services, the incidence of incapacity for work and costs for drugs and treatment.

ETHICS AND DISSEMINATION

The protocol was approved by the Ethics Committee of the Medical Faculty, University of Bonn (Lfd. Nr. 339/17). The results of this research project will be published in scientific open access journals and at conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register, DRKS00013909.

Analysis of spontaneous reporting of suspected adverse drug reactions for non-analgesic over-the-counter drugs from 2008 to 2017

BACKGROUND

Adverse drug reaction (ADR) reporting practices by health care professionals remain poor. Over-the-counter (OTC) drugs are perceived as safe; however, they can also cause ADRs. The objective of this study was to analyze ADR reporting for OTC drugs in a 10-year period, in order to evaluate frequency of ADRs, population that ADRs most affect and reporters of ADRs of OTC drugs in Croatia.

METHODS

Spontaneously reported ADRs of non-analgesic OTC drugs, collected from January 2008 to December 2017 were analyzed. Data was obtained from Agency for Medicinal Products and Medical Devices of Croatia (HALMED).

RESULTS

There were 547 ADRs of OTC drugs reported in total and an increase in number of reports through the years was observed. Pharmacists reported 45.4% of all ADRs, and were most frequent reporters (p < 0.001). In 2017 majority of reports, 62 (49.2%), were obtained from consumers. ADRs were most frequently observed in patients aged 70 years and older (15% of ADRs). Five percent of all reports were accidental exposures among children.

CONCLUSIONS

Pharmacists most frequently reported ADRs of OTC drugs and consumers' awareness of ADR reporting has risen. Other health care professionals (e.g., nurses and dentists) must be offered proper education in order to improve reporting practice of ADRs. Health care professionals should address concerns about OTC drug safety in elderly and children.

Medication reconciliation: time to save? A cross-sectional study from one acute hospital

PURPOSE

Medication errors during transitional care are an important patient safety issue. Medication reconciliation is an established intervention to reduce such errors. Current evidence has not demonstrated an associated reduction in healthcare costs, however, with complexity and resource intensity being identified as issues. The aims of this study were to examine an existing process of medication reconciliation in terms of time taken, to identify factors associated with additional time, and to determine if additional time is associated with detecting errors of clinical significance.

METHODS

A cross-sectional study was conducted. Issues arising during medication reconciliation incurring a time burden additional to the usual process were logged and quantified by pharmacists. Regression analyses investigated associations between patient characteristics and clinically significant errors and additional time. Cost for additional time in terms of hospital pharmacist salary was calculated.

RESULTS

Eighty-nine patients were included. Having a personal record of medication at admission (OR 3.30, 95% CI: (1.05 to 10.42), p = 0.004) was a significant predictor of additional time. No significant associations were found between the occurrence of clinically significant error and additional time (p > 0.05). The most common reason for additional time was clarifying issues pertaining to primary care medication information. Projected annual 5-year costs for the mean additional time of 3.75 min were €1.8-1.9 million.

CONCLUSIONS

Spending additional time on medication reconciliation is associated with economic burden and may not yield benefit in terms of capturing clinically significant errors. There is a need to improve communication of medication information between primary and secondary care.

Identification of potentially inappropriate medications with risk of major adverse cardiac and cerebrovascular events among elderly patients in ambulatory setting and long-term care facilities

PURPOSE

Cardiovascular diseases (CVDs) are extremely common among the elderly, but information on the use of potentially inappropriate medications (PIMs) with cardiovascular risk is scarce. We aimed to determine the prevalence of PIMs with risk of cardiac and cerebrovascular adverse events (CCVAEs), including major adverse cardiac and cerebrovascular events (MACCE).

PATIENTS AND METHODS

A cross-sectional study was performed using a convenience sample from four long-term care facilities and one community pharmacy in Portugal. Patients were included if they were aged 65 or older and presented at least one type of medication in their medical and pharmacotherapeutic records from 2015 until December 2017. The main outcome was defined as the presence of PIMs with risk of MACCE and was assessed by applying a PIM-MACCE list that was developed from a previous study. All medications included in this list were assessed for their availability in Portugal.

RESULTS

A total of 680 patients were included. Of those, 428 (63%) were female with a mean age of 78.4±8.1 years. Four-hundred and four (59.4%) patients were taking medications associated with CCVAEs risk (mean =1.7±1.0 drugs/patient), including 264 patients (38.8%) who used drugs with MACCE risk (mean =1.4±0.8 drugs/patient). Fifty percent of patients with a previous history of CVD (n=521) were taking PIMs with risk of CCVAEs, including 30.0% with risk of MACCE.

CONCLUSION

Our findings show that 50% of patients with previous history of CVD were taking drugs with risk of CCAVEs and 30% with risk of MACCE. More tailored tools for the management of drug therapy in elderly patients with CVD are of major importance in clinical practice.

[Electronically supported co-operation of physicians and pharmacists to improve medication safety in the ambulatory setting : The "Arzneimittelinitiative Sachsen-Thüringen" (ARMIN)]

In Germany, the number of drugs dispensed, prescription as well as drugs that are sold without a prescription (over-the-counter drugs), is rising continuously. As a consequence, the proportion of patients with polymedication and the risk for adverse drug events is rising as well.The ABDA - Federal Union of German Associations of Pharmacists and the Federal Association of Statutory Health Insurance Physicians developed a comprehensive concept based on an interdisciplinary approach. Overall, the concept aims to improve both the effectiveness and safety of pharmacotherapy. The program consists of three components: (1) preferred generic prescribing (instead of brand name products), (2) preferred prescribing of first-line drugs according to a medication catalogue, and (3) medication management (MM). In ARMIN (Arzneimittelinitiative Sachsen-Thüringen), a contract signed in 2014, this concept was implemented for the first time.Datasets were developed and integrated into the local software of physicians and pharmacies to establish the prescription of active ingredients and dispensing the appropriate product as well as the medication catalogue. For MM, processes and responsibilities were developed as well as a technical infrastructure to enable an electronic exchange of patients' medication data.By December 2017, 546 physicians and 969 pharmacists participated in ARMIN, of which 297 physicians and 285 pharmacists were technically able to offer MM, and approximately 3200 patients had signed up for the MM service.In ARMIN, a promising interdisciplinary concept has been developed and implemented. Defining responsibilities and integrating the components into the local software of the physicians and pharmacists facilitated implementation. Future evaluation will show to what extent this concept can contribute to medication safety.