Potential drug-drug and drug-disease interactions in well-functioning community-dwelling older adults

Perspective of older people on which medicines they need to report to healthcare professionals as part of a medicines history: a qualitative descriptive study

BACKGROUND

The medicines that older people consider relevant as part of their medicine regime may be reflected in their reporting of medicines to healthcare professionals during a medicine history.

AIM

This study aimed to understand the perspectives of people, aged 65 or older, on which medicine(s) they reported as part of their medicine regimen.

METHOD

A qualitative descriptive study was conducted in Australia using semi-structured interviews to investigate the perspectives of which medicines were reported in a medicines history by people aged 65 years or older, taking at least one medicine. Participants were recruited until data saturation was reached. The interviews were audio recorded, transcribed, and thematically analysed using the Framework Method.

RESULTS

Six main themes emerged from sixteen participants: reporting medicines that solved a medical condition, medicines recommended by healthcare professionals, regular medicines, route of administration, combination products, and multiple tablets, doses, or part doses. Participants' beliefs and experiences impacted whether they included a medicine in their regimen. Participants inconsistently reported infrequent medicines, varying formulations, and multiple doses. Non-oral and over-the-counter medicines were commonly included if a healthcare professional recommended them. In contrast, supplements were seldom included.

CONCLUSION

This study highlights the variation between participants' perspectives in reporting medicines, suggesting that older people's self-reporting of medicines is generally inconsistent. Our findings encourage clinicians to specifically enquire about medicines for acute health conditions, medicines commonly not prescribed by healthcare professionals, irregular medicines, and non-oral medicines to improve reporting by older people, to obtain the Best Possible Medication History.

Prevalence and risk factors of self-reported adverse drug events in elderly co-morbid patients in northeastern China: a cross-sectional study

BACKGROUND

Older adults are vulnerable to adverse drug events given the pharmacokinetic and pharmacodynamic changes that coming with ageing, as well as they often take multiple medications for their chronic health conditions, especially older co-morbidities. ADEs can cause unnecessary emergency department visits and hospitalization, which contribute to financial burden and decreased quality of life. This study aims to investigate the prevalence of adverse drug events in elderly co-morbid patients in Liaoning province and explore its risk factors, in order to ensure medication safety in elderly patients.

METHODS

This was a cross-sectional study that enrolled elderly patients with co-morbidities, and the data were collected by nurses using a structured interview method for elderly patients with multimorbidity. Risk factors for patient-reported adverse drug events were identified by univariate and logistic regression analyses.

RESULTS

A total of 329 elderly patients were enrolled, among whom 169 were females, with an age ranging from 61 to 90 years. 205 participants (62.3%) had 462 "possible-probable-certain" adverse drug events, and 156 (47.4%) experienced two or more self-reported adverse drug events concurrently. The logistic regression analysis included four variables: female (OR = 2.194, 95% confidence interval 1.281-3.760, P = 0.004), numbers of daily drugs > 12 (OR = 2.257, 95% confidence interval 1.254-4.061, P = 0.007), history of fall within 1 year (OR = 3.106, 95% confidence interval 1.112-8.674, P = 0.031), and medication noncompliance (OR = 3.768, 95% confidence interval 1.535-9.249, P = 0.004).

CONCLUSION

Patient-reported adverse drug events are more prevalent in older co-morbid patients in Liaoning province. Female, numbers of daily drugs, fall history with 1 year and poor medication compliance were significantly and independently associated with adverse drug events. These findings may provide informative interventions for the medication management in elderly patients living with multimorbidity.

Seasonal monitoring, ecological risk assessment, and prioritization of pharmaceuticals in a tropical semi-enclosed bay (Santos, São Paulo coast, Brazil)

Research on the occurrence and seasonal monitoring of pharmaceutically active compounds (PhACs) in estuarine and coastal waters has intensified recently. However, few studies have been conducted with PhACs flowing into the marine waters of South America (such as Brazil). Against this backdrop, the aims of this study were: (i) evaluate, for the first time, the seasonal occurrence throughout a year and the potential ecological risks of ten selected PhACs in marine bathing waters from Santos Bay, São Paulo, Brazil (a tropical low-wave energy semi-closed bay); and (ii) develop a list of high-priority PhACs for the monitoring based on "occurrence, persistence, bioaccumulation, and toxicity" criteria (OPBT). Four water sampling campaigns were carried out throughout the four seasons of the year. The results showed that: (i) ten PhACs (namely, caffeine/CAF (87.20-567.23 ng/L); carbamazepine/CAR [below the limit of quantification ( ACE > DIC and CAR to algae, crustaceans, and fishes; (iv) Finally, regarding the OPBT ranking, the DIC was the highest-priority PhAC in Santos Bay, followed by: ORP > LOS > CIT > CAR > FUR > ATE > CAF > ACE > ENA.

Evaluation of medication appropriateness index in cardiovascular outpatient clinic: A cross-sectional study

BACKGROUND

Older adults often have polypharmacy and multimorbidity. Cardiovascular diseases (CVDs) are the most common multimorbidities in older adults and are linked to wide range of adverse drug effects and drug-related problems. The medication appropriateness index (MAI) has been widely used in several patient settings to assess Potentially Inappropriate Medication (PIM) prescribing in older adults.

OBJECTIVES

The purpose of this study was to evaluate PIM prescribing in cardiovascular disease outpatient clinic. It also aimed at assessing the validity of the MAI to detect and quantify PIMs specifically in CVD outpatient clinics.

METHODS

This was a cross-sectional, single-center study in cardiovascular outpatient setting. Demographic, clinical, and medication information from older adults (≥ 65 years old) were collected and reviewed. Two clinical pharmacists randomly selected 70 patients, evaluated 539 medications, and assessed their appropriateness using the MAI. The Statistical Package for the Social Sciences (SPSS) descriptive and logistic regression analyses was to calculate the number of PIMs, the MAI scores, and factors associated with PIM prescribing.

RESULTS

Our data showed that 87.1 % of patients had at least one PIM and the number of PIMs per patient was 2.10. Approximately 60 % of the patients had an MAI weighted score of zero (no prescription error). The mean MAI score per patient was 17.61 and the mean MAI score per medication was 2.72. The overall agreement between the two raters was 87.3 % with moderate chance-adjusted agreement as indicated by the kappa static of 0.43. The factors that were associated with increased PIM prescribing were the total number of medications and being ≥85 years old.

CONCLUSION

A relatively high prevalence of PIMs was found in the studied population. The MAI is a reliable and valid tool to detect PIM prescribing in CVD outpatient clinics. It mandates implementing specific measures to reduce PIMs.

The European Drug-Drug Interaction (EuroDDI) Study Protocol: A Cross-Country Comparison of Drug-Drug Interaction Prevalence in the Older Community-Dwelling Population

BACKGROUND

Drug-drug interactions (DDIs), highly prevalent amongst the elderly, can lead to avoidable medication-related harm. Cardiovascular and central nervous system (CNS) drugs are commonly implicated. To date, there is no consensus on how to measure DDIs, making comparisons across countries challenging.

OBJECTIVE

To (i) establish a common data model (CDM) to measure DDI prevalence in the older (aged ≥ 70 years) community-dwelling population of three European countries and (ii) compare and describe cardiovascular and CNS DDI prevalence rates across these countries.

METHODS

This cross-country study will apply a harmonised method of DDI identification and analysis using the WHO ATC classification system and national pharmacy claims data from three European countries (Ireland, Italy, Spain). Patients aged ≥ 70 years dispensed ≥ 2 medications during 2016 will be identified from each country's national database. 'Severe' cardiovascular and CNS DDIs (i.e., may result in a life-threatening event/permanent detrimental effect) will be identified using the British National Formulary and Stockley's Drug Interactions. Two separate lists of 'severe' DDIs, per medications reimbursed, will be applied to each database: (i) DDIs relevant to each individual country and (ii) DDIs relevant to all three countries. DDIs will be defined as co-dispensed (same day) and concomitantly (±7 days) dispensed.

RESULTS

Descriptive statistics, including DDI prevalence and 95% confidence intervals, will be reported for each country. Prevalence will be pooled and compared across countries using random effects models and meta-regression, where feasible.

CONCLUSION

The EuroDDI study will develop a harmonised method to measure and compare DDI prevalence across health-related databases in Europe.

Temporal variability and ecological risks of pharmaceuticals and cocaine during the Christmas and New Year holidays in a beach area of North Coast of São Paulo, Brazil

This study assessed the occurrence and ecological potential risk of nine selected pharmaceuticals in water samples from the Juquehy River. The river flows continuously to Juquehy Beach, known as "the jewel of the north coast" of São Paulo, Brazil. Samples were collected during Christmas and the New Year (period of December 2023-January 2024), in addition to a previous baseline weekend, to compare the loads during "celebratory parties" versus "normal operational conditions." The findings indicated that the "mass gathering" during Christmas and New Year holidays contributed significantly to an increase of the mass load of the nine pharmaceuticals flowing along to the Juquehy River, i.e., caffeine (14.40-633.00 ng/L) > losartan ( furosemide (< LOQ to 9.16 ng/L) > diclofenac (0.61-4.55 ng/L) > carbamazepine (< LOQ to 0.73 ng/L) > orphenadrine (< LOQ to 0.11 ng/L) showed higher concentrations during the New Year holiday. Conversely, atenolol (< LOQ to 13.10 ng/L) > benzoylecgonine (0.33-7.23 ng/L) > cocaine (0.12-6.59 ng/L) showed higher concentrations during the Christmas day. The individual ecological risk assessment in the Juquehy River revealed a clear environmental concern for the aquatic ecosystem. The threat to the aquatic biota is significant, with caffeine and losartan presenting a moderate level of risk. Moreover, the mixture ecological risk assessment of nine compounds indicates acute moderate risks to algae, crustaceans, and fishes, as well as chronic low risks to fishes.

Epidemiology of potential drug- drug interactions in hospitalized patients with type 2 diabetes mellitus in China: a retrospective study

Background

Combination therapy was associated with an increased risk of drug- drug interactions (DDIs) in patients with type 2 diabetes mellitus (T2DM). The present study aimed to investigate the epidemiology of potential DDIs (pDDIs), including potential chemical drug-drug interactions (pCDIs) and potential herb-drug interactions (pHDIs), and classify the influencing factors of pDDIs in these patients.

Methods

A retrospective study of the epidemiology of pDDIs among T2DM hospitalized patients older than 18 years and treated with at least two drugs during hospitalization was conducted over a 12-month period in 2019. PDDIs were identified with C (monitor therapy), D (consider therapy modification), and X (avoid combination) risk ratings. Binary logistic regression was used to analyze the risk factors of pDDIs.

Results

A total of 6796 pDDIs were identified from 737 T2DM hospitalized patients during hospitalization, with 0.87% classified as X risk rating, 13.39% as D risk rating. Additionally, 1753 pDDIs were identified after discharge, with 0.11% as X and 25.73% as D risk rating. The drug-drug association networks showed that the majority of pCDIs were associated with cardiovascular system drugs. Chlorphenamine-potassium chloride and danshen-warfarin were the most prevalent interacting pairs of pCDIs and pHDIs with X rating during hospitalization. Multivariate analysis indicated that the likelihood of developing over 4 pDDIs was significantly higher among T2DM patients who had received over 8 medications. The presence of pDDIs after discharge was strongly associated with the complications of T2DM and the number of discharge medications.

Conclusions

T2DM patients were frequently exposed to pDDIs, including pCDIs and pHDIs, both during hospitalization and after discharge. Multi-drug combination was the primary risk factor for pDDIs. Strategies such as enhancing the monitoring and warning for pDDIs, increasing clinical pharmacological experience, as well as developing universally applicable clinical guidelines for pDDIs may be beneficial in reducing the incidence of potentially harmful drug-combinations.

Prevalence and differences in the co-administration of drugs known to interact: an analysis of three distinct and large populations

BACKGROUND

The co-administration of drugs known to interact greatly impacts morbidity, mortality, and health economics. This study aims to examine the drug-drug interaction (DDI) phenomenon with a large-scale longitudinal analysis of age and gender differences found in drug administration data from three distinct healthcare systems.

METHODS

This study analyzes drug administrations from population-wide electronic health records in Blumenau (Brazil; 133 K individuals), Catalonia (Spain; 5.5 M individuals), and Indianapolis (USA; 264 K individuals). The stratified prevalences of DDI for multiple severity levels per patient gender and age at the time of administration are computed, and null models are used to estimate the expected impact of polypharmacy on DDI prevalence. Finally, to study actionable strategies to reduce DDI prevalence, alternative polypharmacy regimens using drugs with fewer known interactions are simulated.

RESULTS

A large prevalence of co-administration of drugs known to interact is found in all populations, affecting 12.51%, 12.12%, and 10.06% of individuals in Blumenau, Indianapolis, and Catalonia, respectively. Despite very different healthcare systems and drug availability, the increasing prevalence of DDI as patients age is very similar across all three populations and is not explained solely by higher co-administration rates in the elderly. In general, the prevalence of DDI is significantly higher in women - with the exception of men over 50 years old in Indianapolis. Finally, we show that using proton pump inhibitor alternatives to omeprazole (the drug involved in more co-administrations in Catalonia and Blumenau), the proportion of patients that are administered known DDI can be reduced by up to 21% in both Blumenau and Catalonia and 2% in Indianapolis.

CONCLUSIONS

DDI administration has a high incidence in society, regardless of geographic, population, and healthcare management differences. Although DDI prevalence increases with age, our analysis points to a complex phenomenon that is much more prevalent than expected, suggesting comorbidities as key drivers of the increase. Furthermore, the gender differences observed in most age groups across populations are concerning in regard to gender equity in healthcare. Finally, our study exemplifies how electronic health records' analysis can lead to actionable interventions that significantly reduce the administration of known DDI and its associated human and economic costs.

Identification of Drugs Acting as Perpetrators in Common Drug Interactions in a Cohort of Geriatric Patients from Southern Italy and Analysis of the Gene Polymorphisms That Affect Their Interacting Potential

BACKGROUND

Pharmacogenomic factors affect the susceptibility to drug-drug interactions (DDI). We identified drug interaction perpetrators among the drugs prescribed to a cohort of 290 older adults and analysed the prevalence of gene polymorphisms that can increase their interacting potential. We also pinpointed clinical decision support systems (CDSSs) that incorporate pharmacogenomic factors in DDI risk evaluation.

METHODS

Perpetrator drugs were identified using the Drug Interactions Flockhart Table, the DRUGBANK website, and the Mayo Clinic Pharmacogenomics Association Table. Allelic variants affecting their activity were identified with the PharmVar, PharmGKB, dbSNP, ensembl and 1000 genome databases.

RESULTS

Amiodarone, amlodipine, atorvastatin, digoxin, esomperazole, omeprazole, pantoprazole, simvastatin and rosuvastatin were perpetrator drugs prescribed to >5% of our patients. Few allelic variants affecting their perpetrator activity showed a prevalence >2% in the European population: CYP3A4/5*22, *1G, *3, CYP2C9*2 and *3, CYP2C19*17 and *2, CYP2D6*4, *41, *5, *10 and *9 and SLC1B1*15 and *5. Few commercial CDSS include pharmacogenomic factors in DDI-risk evaluation and none of them was designed for use in older adults.

CONCLUSIONS

We provided a list of the allelic variants influencing the activity of drug perpetrators in older adults which should be included in pharmacogenomics-oriented CDSSs to be used in geriatric medicine.

Prevalence of Drug-Drug Interactions in Older Community-Dwelling Individuals: A Systematic Review and Meta-analysis

BACKGROUND

Drug-drug interactions (DDIs) can lead to medication-related harm, and the older population is at greatest risk. We conducted a systematic review and meta-analysis to estimate DDI prevalence and identify common DDIs in older community-dwelling adults.

METHODS

PubMed and EMBASE were searched for observational studies published between 01/01/2010 and 10/05/2021 reporting DDI prevalence in community-dwelling individuals aged ≥ 65 years. Nursing home and inpatient hospital studies were excluded. Study quality was assessed using the Joanna Briggs Institute critical appraisal tool. Meta-analysis was performed using a random-effects model with logit transformation. Heterogeneity was evaluated using Cochran's Q and I². DDI prevalence and 95% confidence intervals (CIs) are presented. All analyses were performed in R (version 4.1.2).

RESULTS

There were 5144 unique articles identified. Thirty-three studies involving 17,011,291 community-dwelling individuals aged ≥ 65 years met inclusion criteria. Thirty-one studies reported DDI prevalence at the study-participant level, estimates ranged from 0.8% to 90.6%. The pooled DDI prevalence was 28.8% (95% CI 19.3-40.7), with significant heterogeneity (p < 0.10; I² = 100%; tau² = 2.13) largely explained by the different DDI identification methods. Therefore, 26 studies were qualitatively synthesised and seven studies were eligible for separate meta-analyses. In a meta-analysis of three studies (N = 1122) using Micromedex^®, pooled DDI prevalence was 57.8% (95% CI 52.2-63.2; I² = 69.6%, p < 0.01). In a meta-analysis of two studies (N = 809,113) using Lexi-Interact^®, pooled DDI prevalence was 30.3% (95% CI 30.2-30.4; I² = 6.8%). In a meta-analysis of two studies (N = 947) using the 2015 American Geriatrics Society Beers criteria^®, pooled DDI prevalence was 16.6% (95% CI 5.6-40.2; I² = 97.5%, p < 0.01). Common DDIs frequently involved cardiovascular drugs, including ACE inhibitor-potassium-sparing diuretic; amiodarone-digoxin; and amiodarone-warfarin.

CONCLUSIONS

DDIs are prevalent among older community-dwelling individuals; however, the methodology used to estimate these events varies considerably. A standardised methodology is needed to allow meaningful measurement and comparison of DDI prevalence.

Prevalence and associated factors of drug-drug interactions in elderly outpatients in a tertiary care hospital: a cross-sectional study based on three databases

Background

Drug-drug interactions (DDIs) are factors of adverse drug reactions and are more common in elderly patients. Identifying potential DDIs can prevent the related risks. Fewer studies of potential DDIs in prescribing for elderly patients in outpatient clinics. This study aimed to investigate the prevalence and associated factors with potential DDIs and potentially clinically significant DDIs (csDDIs) among elderly outpatients based on 3 DDIs databases.

Methods

A cross-sectional study was carried out on outpatients (≥65 years old) of a tertiary care hospital in China between January and March 2022. Patients' prescriptions, including at least 1 systemic drug, were consecutively collected. The potential DDIs were identified by Lexicomp^®, Micromedex^®, and DDInter. Patient-related clinical parameter recorded at the prescriptions and DDIs with higher risk rating was analyzed. Variables showing association in univariate analysis (P<0.2) were included in logistic regression analysis. Weighted kappa analysis was used to analyze the consistencies of different databases.

Results

A total of 19,991 elderly outpatients were involved in the study, among whom 21,527 drug combinations including 486 drugs occurred. Lexicomp^®, Micromedex^®, and DDInter respectively identified 32.22%, 32.93%, and 22.62% of patients have at least one potential DDIs, meanwhile, 9.16%, 14.53%, and 4.56% of patients have at least one potential csDDIs. Under any evaluation criteria, polypharmacy and neurology visits were risk factors for csDDIs. Lexicomp^® has the highest coverage rate (87.86%) for drugs. Micromedex^® identified the most csDDIs (740 drug combinations). Drugs used in diabetes and psycholeptics were frequently found in the csDDIs of 2 commercial databases. The consistency between Lexicomp^® and Micromedex^® was moderate (weighted kappa 0.473). DDInter had fair consistencies with the other databases.

Conclusions

This study showed the prevalence of potential DDIs is high in elderly outpatients and potential csDDIs were prevalent. Considering the relative risk, pre-warning of potential DDIs before outpatient prescribing is necessary. As the consistencies among identification criteria are not good, more research is needed to focus on actual adverse outcomes to promote accurate prevention of csDDIs.

Exploring Older Adult Health Literacy in the Day-to-Day Management of Polypharmacy and Making Decisions About Deprescribing: A Mixed Methods Study

BACKGROUND

Polypharmacy use in older adults is increasing and sometimes leads to poor health outcomes. The influence of health literacy in managing polypharmacy and making decisions about stopping medication has received limited attention.

OBJECTIVE

A mixed methods design was used to measure and investigate the influence of health literacy in the management of polypharmacy and decisions about deprescribing. Phase 1 involved two cross-sectional surveys, one with older adults using five or more medications and the other with general practitioners (GPs).

METHODS

Older adult health literacy was measured using the All Aspects of Health Literacy Scale. Phase 2 employed individual interviews with both older adults and GPs and further explored the reported use of health literacy in practice. SPSS version 24 was used to conduct descriptive statistical analysis of the Phase 1 survey responses and Phase 2 interviews were analyzed using thematic analysis with the assistance of NVivo 12.

KEY RESULTS

Phase 1 survey responses were received from 85 GPs and 137 older adults. Phase 2 interviews were conducted with 16 GPs and 25 older adults. Phase 1 results indicated that self-reported older adult health literacy was high, and that GPs believed older patients could engage in decisions about deprescribing. Phase 2 findings showed that older adults developed and employed complex health literacy practices to manage medications between consultations; however, few reported using their health literacy skills in consultations with their GPs. GPs noted that older adult involvement in decision-making varied and generally thought that older adults had low health literacy.

CONCLUSION

Older adults reported using health literacy practices in the management of their sometimes-complex medication regimens. However, the role of health literacy in deprescribing decision-making was limited. The mixed methods approach allowed greater insight into older adult and GP practices that influence the acquisition and use of health literacy. [HLRP: Health Literacy Research and Practice. 2023;7(1):e14-e25.] Plain Language Summary: This report explores health literacy in the use of multiple medications and decisions to stop using medication/s in older age. Older adults reported good heath literacy and practiced many health literacy skills in the management of their medications. However, they did not always report the use of their health literacy skills when discussing their medications with their family doctor.

Occurrence, ecological risk assessment and prioritization of pharmaceuticals and abuse drugs in estuarine waters along the São Paulo coast, Brazil

The pollution of the surface waters by pharmaceuticals and personal care products (PPCPs) has attracted worldwide attention, but data regarding their occurrence and potential risks for the aquatic biota on tropical coastal rivers of South America are still scarce. In this context, the occurrence and the preliminary ecological risk assessment of eleven pharmaceuticals of various therapeutic classes (including cocaine and its primary metabolite, benzoylecgonine) were investigated, for the first time, in five rivers of São Paulo, southeast Brazil, covering a coastline of about 140 km, namely Perequê River, Itinga River, Mongaguá River, Itanhaém River and Guaraú River. Although these five rivers are born in well-preserved areas of the Atlantic rainforest biome, on its way to sea and when they cross the urban perimeter, they receive untreated sewage discharges containing a complex mixture of contaminants. In addition, a "persistence, bioaccumulation and toxicity" (PBT) approach allowed to pre-select the priority PPCPs to be monitored in this coastline. Identification of several PPCPs in the samples was done using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Ten PPCPs were successfully quantified in all five rivers, namely caffeine (9.00-560.00 ng/L), acetaminophen ( Collapse

Key Words

• Coastal rivers
• Domestic sewage
• Illicit drugs
• Pharmaceuticals
• Prioritization
• Risk assessment
• Subtropical ecosystem

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MESH Headings

• Environmental Monitoring/methods
• Water Pollutants, Chemical/analysis
• Chromatography, Liquid
• Caffeine/analysis
• Brazil
• Diclofenac
• Ecosystem
• Atenolol
• Orphenadrine/analysis
• Acetaminophen
• Losartan
• Furosemide
• Tandem Mass Spectrometry
• Rivers/chemistry
• Illicit Drugs/analysis
• Cocaine/analysis
• Risk Assessment
• Carbamazepine/analysis
• Pharmaceutical Preparations

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Affiliation(s)

Vinicius Roveri Universidade Metropolitana de Santos (UNIMES), Avenida Conselheiro Nébias, 536 - Encruzilhada, 11045-002, Santos, São Paulo, Brazil Centro Interdisciplinar de Investigação Marinha e Ambiental (CIIMAR/CIMAR), Avenida General Norton de Matos S/N, 4450-208, Matosinhos, Portugal
Luciana Lopes Guimarães Laboratório de Pesquisa em Produtos Naturais, Universidade Santa Cecília, Rua Cesário Mota 8, F83A, 11045-040 Santos, São Paulo, Brazil
Walber Toma Laboratório de Pesquisa em Produtos Naturais, Universidade Santa Cecília, Rua Cesário Mota 8, F83A, 11045-040 Santos, São Paulo, Brazil
Alberto Teodorico Correia Centro Interdisciplinar de Investigação Marinha e Ambiental (CIIMAR/CIMAR), Avenida General Norton de Matos S/N, 4450-208, Matosinhos, Portugal. Faculdade de Ciências da Saúde da Universidade Fernando Pessoa (FCS-UFP), Rua Carlos da Maia 296, 4200-150, Porto, Portugal. Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto (ICBAS-UP), Rua de Jorge Viterbo Ferreira 228, 4050-313, Porto, Portugal.

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Disease-Drug Interactions Requiring Special Attention

This short review addresses disease-drug interactions requiring special attention, namely interactions between common conditions and over-the-counter medication and interactions between rare conditions and drugs that are absolutely contraindicated. We specifically examine over-the-counter analgesics, antiemetics and drugs used to treat allergy symptoms and underlying disease conditions they can exacerbate. Resources for avoiding disease-drug interactions in patients with rare conditions, such as myasthenia gravis, glucose-6-phosphate deficiency, mitochondriopathies and long QT-syndrome are given. We also discuss methods for avoiding disease-drug interactions in clinical practice. These include awareness, regular diagnosis- and drug-history taking, consulting the product information, good communication between healthcare providers and patient education. Furthermore, pharmacovigilance activities help in the early identification and characterization of adverse drug reactions resulting from disease-drug interactions.

Occurrence of pharmaceuticals and cocaine in the urban drainage channels located on the outskirts of the São Vicente Island (São Paulo, Brazil) and related ecological risk assessment

"Wealth by the sea and poverty away from the sea breeze" is a metaphor that mirrors what happens along the Brazilian coastal zone, namely in São Vicente Island, São Paulo, Brazil. Due to the high cost of the properties on this shore, the impoverished population started to migrate to the northern outskirts of the island (away from the tourist beaches), potentiating the emergence of poor housing conditions, namely stilt-house slums. Consequently, the urban drainage channels across these outskirts neighbourhoods are potentially contaminated by human wastes. In this context, the occurrence and preliminary ecological risk assessment of eleven pharmaceuticals of various therapeutic classes (including cocaine and its primary metabolite, benzoylecgonine) were investigated, for the first time, in five urban drainage channels whose diffuse loads flow continuously to the estuarine waters of São Vicente Island. The results showed the widespread presence of these environmental stressors in all urban channels analysed, namely losartan (7.3-2680.0 ng/L), caffeine (314.0-726.0 ng/L), acetaminophen (7.0-78.2 ng/L), atenolol (6.2-23.6 ng/L), benzoylecgonine (10.2-17.2 ng/L), furosemide (1.0-7.2 ng/L), cocaine (2.3-6.7 ng/L), carbamazepine (0.2-2.6 ng/L), diclofenac (1.1-2.5 ng/L), orphenadrine (0.2-1.1 ng/L) and chlortalidone (0.5-1.0 ng/L). The overall total estimated load of pharmaceuticals and personal care products flowing to the estuarine waters of São Vicente Island is on the order of 41.1 g/day. The ecological risk assessment revealed a great environmental concern for São Vicente Island, ranging between low (e.g. carbamazepine and cocaine) and moderate to high (e.g. caffeine, acetaminophen and losartan) threats for the aquatic biota. Therefore, initiatives promoting basic sanitation, land-use regularisation and population awareness are highly recommended.

Potentially Harmful Medication Dispenses After a Fall or Hip Fracture: A Mixed Methods Study of a Commonly Used Quality Measure

BACKGROUND

High-risk medication dispenses to patients with a prior fall or hip fracture represent a potentially dangerous disease-drug interaction among older adults. The research team quantified the prevalence, identified risk factors, and generated patient and provider insights into high-risk medication dispenses in a large, community-based integrated health system using a commonly used quality measure.

METHODS

This was a mixed methods study with a convergent design combining a retrospective cohort study using electronic health record (EHR) data, individual interviews of primary care physicians, and a focus group of patient advisors.

RESULTS

Of 113,809 patients ≥ 65 years with a fall/fracture in 2009-2015, 35.4% had a potentially harmful medication dispensed after their fall/fracture. Most medications were prescribed by primary care providers. Older age, male gender, and race/ethnicity other than non-Hispanic White were associated with a reduced risk of high-risk medication dispenses. Patients with a pre-fall/fracture medication dispense were substantially more likely to have a post-fall/fracture medication dispense (hazard ratio [HR] = 13.26, 95% confidence interval [CI] = 12.91-13.61). Both patients and providers noted that providers may be unaware of patient falls due to inconsistent assessments and patient reluctance to disclose falls. Providers also noted the lack of a standard location to document falls and limited decision support alerts within the EHR.

CONCLUSION

High-risk medication dispenses are common among older patients with a history of falls/fractures. Future interventions should explore improved assessment and documentation of falls, decision support, clinician training strategies, patient educational resources, building trusting patient-clinician relationships to facilitate long-term medication discontinuation among persistent medication users, and a focus on fall prevention.

Racial and ethnic disparities associated with the measure for drug-drug interactions among Medicare beneficiaries

BACKGROUND

Drug-drug interactions (DDIs) cause many preventable hospitalizations and admissions. Efforts have been made to raise DDI awareness and reduce DDI occurrence; for example, Medicare Part D Star Ratings, a health plan quality assessment program, included a DDI measure. Previous research reported racial and ethnic disparities in health services utilization and that racial and ethnic minorities, compared with non-Hispanic whites (whites), may be less likely to be targeted for a similar measure, a Star Ratings adherence measure for diabetes medications.

OBJECTIVE

This study aimed to investigate whether any racial and ethnic disparities are associated with the DDI measure in Part D Star Ratings among Medicare populations with diabetes, hypertension, and hyperlipidemia.

METHODS

This cross-sectional study analyzed a 2017 Medicare Part D data sample, including 3,960,813 beneficiaries. Because the inclusion in the denominator of the Star Ratings DDI measure was determined by the use of a list of target medications, the likelihood of using a listed target medication was compared between racial and ethnic minorities and whites. Individuals with diabetes, hypertension, and hyperlipidemia were included in the analysis owing to the high prevalence of these conditions. Patient- and community-level characteristics were adjusted by logistic regression.

RESULTS

Of the entire study sample, 26.2% used a target medication. Compared with whites, most racial and ethnic minorities were less likely to use a target medication. For example, among individuals with diabetes, blacks, Hispanics, Asians/Pacific Islanders, and others had, respectively, 14% (odds ratio 0.86 [95% CI 0.84-0.88]), 5% (0.95 [0.93-0.98]), 12% (0.88 [0.84-0.92]), and 10% (0.90 [0.87-0.93]) lower odds compared with whites. Findings were similar among hypertension and hyperlipidemia cohorts, except that Hispanics had similar odds of use as whites.

CONCLUSION

Most racial and ethnic minorities may have lower likelihood of being targeted for the DDI measure compared with whites. Future studies should examine whether these disparities affect health outcomes and devise new DDI measures for racial and ethnic minorities.

Statins affect cancer cell plasticity with distinct consequences for tumor progression and metastasis

Statins are among the most commonly prescribed drugs, and around every fourth person above the age of 40 is on statin medication. Therefore, it is of utmost clinical importance to understand the effect of statins on cancer cell plasticity and its consequences to not only patients with cancer but also patients who are on statins. Here, we find that statins induce a partial epithelial-to-mesenchymal transition (EMT) phenotype in cancer cells of solid tumors. Using a comprehensive STRING network analysis of transcriptome, proteome, and phosphoproteome data combined with multiple mechanistic in vitro and functional in vivo analyses, we demonstrate that statins reduce cellular plasticity by enforcing a mesenchymal-like cell state that increases metastatic seeding ability on one side but reduces the formation of (secondary) tumors on the other due to heterogeneous treatment responses. Taken together, we provide a thorough mechanistic overview of the consequences of statin use for each step of cancer development, progression, and metastasis.

Prevalence and Factors Associated with Potential Drug-Drug Interactions in Older Community-Dwelling Adults: A Prospective Cohort Study

BACKGROUND

Older patients are at increased risk of drug-drug interactions (DDIs) due to polypharmacy. Cardiovascular and central nervous system (CNS) drugs are commonly implicated in serious DDIs.

OBJECTIVES

This study aimed to determine the prevalence and factors associated with potential 'severe' cardiovascular and CNS DDIs among older (≥ 70 years) community-dwellers.

METHODS

This was a prospective cohort study using linked data from a national pharmacy claims database and waves 1 and 2 of The Irish LongituDinal study on Ageing (TILDA). 'Severe' cardiovascular and CNS DDIs were identified using the British National Formulary 77 and Stockley's Drug Interactions. The prevalence of 'severe' DDIs (any DDI vs. none) was calculated. Logistic regression was used to examine the association between sociodemographic, functional ability, and medication-related factors and the risk of DDI exposure between waves 1 and 2.

RESULTS

A total of 1466 patients were included [mean age (standard deviation) = 78 (5.5) years; female n = 795, 54.2%]. In total, 332 community-dwellers aged ≥ 70 years [22.65%, 95% confidence interval (CI) 20.58-24.86] were potentially exposed to at least one 'severe' cardiovascular or CNS DDI, with more than half (54.82%) of this cohort dispensed the same DDI for a prolonged time (≥ 3 consecutive claims). Aspirin-warfarin was the most frequently dispensed (co-prescribed) DDI (n = 34, 10.24%, 95% CI 7.39-14.00), followed by atorvastatin-clarithromycin (n = 19, 5.72%, 95% CI 3.64-8.81). Polypharmacy [≥ 10 vs. < 5 drugs, odds ratio (OR) 13.40, 95% CI 8.22-21.85] and depression (depressed vs. not, OR 2.12, 95% CI 1.34-3.34) were significantly associated with these DDIs, after multivariable adjustment.

CONCLUSION

'Severe' cardiovascular and CNS DDIs are prevalent in older community-dwellers in Ireland, and those with polypharmacy and depression are at a significantly increased risk.

A Shared Decision-making Tool for Drug Interactions Between Warfarin and Nonsteroidal Anti-inflammatory Drugs: Design and Usability Study

Background

Exposure to life-threatening drug-drug interactions (DDIs) occurs despite the widespread use of clinical decision support. The DDI between warfarin and nonsteroidal anti-inflammatory drugs is common and potentially life-threatening. Patients can play a substantial role in preventing harm from DDIs; however, the current model for DDI decision-making is clinician centric.

Objective

This study aims to design and study the usability of DDInteract, a tool to support shared decision-making (SDM) between a patient and provider for the DDI between warfarin and nonsteroidal anti-inflammatory drugs.

Methods

We used an SDM framework and user-centered design methods to guide the design and usability of DDInteract—an SDM electronic health record app to prevent harm from clinically significant DDIs. The design involved iterative prototypes, qualitative feedback from stakeholders, and a heuristic evaluation. The usability evaluation included patients and clinicians. Patients participated in a simulated SDM discussion using clinical vignettes. Clinicians were asked to complete eight tasks using DDInteract and to assess the tool using a survey adapted from the System Usability Scale.

Results

The designed DDInteract prototype includes the following features: a patient-specific risk profile, dynamic risk icon array, patient education section, and treatment decision tree. A total of 4 patients and 11 clinicians participated in the usability study. After an SDM session where patients and clinicians review the tool concurrently, patients generally favored pain treatments with less risk of gastrointestinal bleeding. Clinicians successfully completed the tasks with a mean of 144 (SD 74) seconds and rated the usability of DDInteract as 4.32 (SD 0.52) of 5.

Conclusions

This study expands the use of SDM to DDIs. The next steps are to determine if DDInteract can improve shared decision-making quality and to implement it across health systems using interoperable technology.

Association of Hyper-Polypharmacy With Clinical Outcomes in Heart Failure With Preserved Ejection Fraction

BACKGROUND

Polypharmacy is associated with a poor prognosis in the elderly, however, information on the association of polypharmacy with cardiovascular outcomes in heart failure with preserved ejection fraction is sparse. This study sought to investigate the relationship between polypharmacy and adverse cardiovascular events in patients with heart failure with preserved ejection fraction.

METHODS

Baseline total number of medications was determined in 1758 patients with heart failure with preserved ejection fraction enrolled in the Americas regions of the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist), by 3 categories: nonpolypharmacy (<5 medications), polypharmacy (5-9), and hyper-polypharmacy (≥10). We examined the relationship of polypharmacy status with the primary outcome (cardiovascular death, HF hospitalization, or aborted cardiac arrest), hospitalizations for any reason, and serious adverse events.

RESULTS

The proportion of patients taking 5 or more medications was 92.5% (inclusive of polypharmacy [38.7%] and hyper-polypharmacy [53.8%]). Over a 2.9-year median follow-up, compared with patients with polypharmacy, hyper-polypharmacy was associated with an increased risk for the primary outcome, hospitalization for any reason and any serious adverse events in the univariable analysis, but not significantly associated with mortality. After multivariable adjustment for demographic and comorbidities, hyper-polypharmacy remained significantly associated with an increased risk for hospitalization for any reason (hazard ratio, 1.22 [95% CI, 1.05-1.41]; P=0.009) and any serious adverse events (hazard ratio, 1.23 [95% CI, 1.07-1.42]; P=0.005), whereas the primary outcome was no longer statistically significant.

CONCLUSIONS

Hyper-polypharmacy was common and associated with an elevated risk of hospitalization for any reason and any serious adverse events in patients with heart failure with preserved ejection fraction. There were no significant associations between polypharmacy status and mortality.

Prevalence of drug-drug interactions in older people before and after hospital admission: analysis from the OPERAM trial

Background

Drug-drug interactions (DDIs) are highly prevalent in older patients but little is known about prevalence of DDIs over time. Our main objective was to assess changes in the prevalence and characteristics of drug-drug interactions (DDIs) during a one-year period after hospital admission in older people, and associated risk factors.

Methods

We conducted a sub-study of the European OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people), which assessed the effects of a structured medication review (experimental arm) compared to usual care (control arm) on reducing drug-related hospital readmissions. All OPERAM patients (≥70 years, with multimorbidity and polypharmacy, hospitalized in four centers in Bern, Brussels, Cork and Utrecht between December 2016 and October 2018, followed over 1 year) who were alive at hospital discharge and had full medication data during the index hospitalization (at baseline i.e., enrolment at admission, and at discharge) were included. DDIs were assessed using an international consensus list of potentially clinically significant DDIs in older people. The point-prevalence of DDIs was evaluated at baseline, discharge, and at 2, 6 and 12 months after hospitalization. Logistic regression models were performed to assess independent variables associated with changes in DDIs 2 months after baseline.

Results

Of the 1950 patients (median age 79 years) included, 1045 (54%) had at least one potentially clinically significant DDI at baseline; point-prevalence rates were 58, 57, 56 and 57% at discharge, and 2, 6 and 12 months, respectively. The prevalence increased significantly from baseline to discharge (P < .001 [significant only in the control group]), then remained stable over time (P for trend .31). The five most common DDIs –all pharmacodynamic in nature– accounted for 80% of all DDIs and involved drugs that affect potassium concentrations, centrally-acting drugs and antithrombotics. At 2 months, DDIs had increased in 459 (27%) patients and decreased in 331 (19%). The main factor predictive of a change in the prevalence of DDIs was hyperpolypharmacy (≥10 medications).

Conclusions

DDIs were very common; their prevalence increased during hospitalization and tended to remain stable thereafter. Medication review may help control this increase and minimize the risk of adverse drug events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02532-z.

Cardiovascular care of older adults

Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.

Based on the Beers Criteria 2019 Edition Over-the-Counter Drugs Risk Confirmation of Elderly Chinese

OBJECTIVE

To explore OTC (over-the-counter drugs) in Chinese community pharmacies often causes ADE (adverse drug event) in elderly patients.

METHODS

Use the drugs in the Beers Criteria 2019 potentially inappropriate medication use (PIM) list as search terms. Search for drugs registered on the National Medical Products Administration of China website before December 2019 to determine the drugs containing PIM active ingredients and, then, search the Chinese OTC selection and conversion catalog database to determine it as OTC. Two databases are considered to be the same drug if they have the same drug composition.

RESULTS

The incidence of PIM in elderly patients in our community is relatively high, and the management of OTC may be related to risk factors. Statistics found that 71 OTC contained the Beers Criteria ingredients, including 65 chemicals and six Chinese patent medicines. Varieties of compound preparations accounted for 78.9% and cold medicines accounted for 47.9%.

CONCLUSIONS

The high detection rate of the Beers Criteria in Chinese OTC suggests that medical practitioners in China, especially community pharmacists, should pay attention to the rational use of OTC in the elderly.

Research priorities to address polypharmacy in older adults with cancer

Polypharmacy poses a significant public health problem that disproportionately affects older adults (≥65 years) since this population represents the largest consumers of medications. Clinicians caring for older adults with cancer must rely on evidence to understand polypharmacy and its implications, not only to communicate with patients and other healthcare providers, but also because of the significant interplay between polypharmacy, cancer, cancer-related treatment, and clinical outcomes. Interest in polypharmacy is rising because of its prevalence, the origins and facilitating factors behind it, and the direct and indirect clinical outcomes associated with it. The growing body of publications focused on polypharmacy in older adults with cancer demonstrates that this is a significant area of research; however, limited evidence exists to guide medication use (e.g., prescribing, administration) in this population. Currently, research priorities aimed at polypharmacy in the field of geriatric oncology lack clarity. We identified current gaps in the literature in order to establish research priorities for polypharmacy in older adults with cancer. The five research priorities-Polypharmacy Methodology and Definitions, Suboptimal Medication Use, Comorbidities and Geriatric Syndromes, Underrepresented Groups, and Polypharmacy Interventions-highlight critical areas for future research to improve outcomes for older adults with cancer.

An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People

OBJECTIVES

We aimed to establish an explicit list of potentially clinically significant drug-drug interactions (DDIs) in people aged ≥65 years.

DESIGN

A preliminary list of potentially clinically significant DDIs was compiled, based on 154 DDIs identified from literature review. Subsequently, a 2-round online Delphi survey was undertaken with a multidisciplinary expert panel. A consensus meeting and a final round were conducted to validate the final DDI list and the scope of information provided.

SETTING AND PARTICIPANTS

Twenty nine experts, including geriatricians and clinical pharmacists from 8 European countries.

MEASURES

For each DDI, in the first 2 rounds, experts were asked to score the severity of potential harm on a 5-point Likert-type scale. DDIs were directly included on the final list if the median score was 4 (major) or 5 (catastrophic). DDIs with a median score of 3 (moderate) were discussed at a consensus meeting and included if ≥75% of participants voted for inclusion in the final round.

RESULTS

Consensus was achieved on 66 potentially clinically significant DDIs (28 had a median score of 4/5 and 48 of 3 in the Delphi survey). Most concerned cardiovascular, antithrombotic, and central nervous system drugs. The final list includes information on the mechanism of interaction, harm, and management. Treatment modification is recommended for three-quarters of DDIs.

CONCLUSION AND IMPLICATIONS

We validated a list of potentially clinically significant DDIs in older people, which can be used in clinical practice and education to support identification and management of DDIs or to assess prevalence in epidemiologic and intervention studies.

Polypharmacy and Potential Drug-Drug Interactions in Home-Dwelling Older People - A Cross-Sectional Study

Background

Risks associated with polypharmacy and drug-drug interactions represent a challenge in drug treatment, especially in older adults. The aim of the present study was to assess the use of prescription and non-prescription drugs and the frequency of potential drug-drug interactions in home-dwelling older individuals.

Methods

A cross-sectional study design was applied. Data were collected during preventive home visits among individuals aged ≥75 in three separate communities of Western Norway. A questionnaire, which was filled out by the individual, their next-of-kin, and the nurse performing the home visit was used for the collection of demographic and clinical data (age, sex, medication use, diagnoses, need of assistance with drug administration). Potential drug-drug interactions were identified electronically by IBM Micromedex Drug Interaction Checking. Point prevalence of potential drug-drug interactions and polypharmacy (≥5 drugs) were calculated. Binary logistic regression analyses were performed to assess factors potentially associated with polypharmacy or potential drug-drug interactions.

Results

Among the 233 individuals (mean age 78±3 years, 46% male) included in the study, 43% used ≥5 drugs, 3.4% ≥10 drugs, while 4.3% used no drugs. In 54% of the 197 individuals using two or more drugs, at least one potential drug-drug interaction was detected. Low-dose aspirin and simvastatin were most frequently involved in potential drug-drug interactions. In total, 25% of the individuals reported current use of drugs sold over the counter of which more than 95% were analgesic drugs. Potential drug-drug interactions involving ibuprofen were identified in nine of 11 (82%) individuals using over-the-counter ibuprofen.

Conclusion

The study revealed a high prevalence of polypharmacy and potential drug-drug interactions with both prescription and non-prescription drugs in older home-dwelling individuals. Close monitoring of the patients at risk of drug-drug interactions, and increased awareness of the potential of over-the-counter drugs to cause drug-drug interactions, is needed.

Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study

Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.

Comparing the Prevalence of Polypharmacy and Potential Drug-Drug Interactions in Nursing Homes and in the Community Dwelling Elderly of Emilia Romagna Region

Backround: We aimed at assessing the prevalence of polypharmacy and potential drug-drug interactions (DDIs) with clinical relevance in elderly patient on Emilia Romagna area. Both outpatients and residents in nursing homes were assessed, with only partially overlapping strategies.

Methods: We defined a list of 190 pairs of potentially interacting drugs, based on literature appraisal and availability of therapeutic alternatives. January-June 2018 data on drug use in patients over 65 years-old were collected from nine Local Health Authorities of Emilia Romagna: data on community-dwelling subjects were extracted from archives of reimbursed prescriptions, while drug use in a sample of nursing homes was recorded from clinical charts in one index day within the same semester. The frequency of polypharmacy (at least five or at least 10 concurrent drugs) and of each DDI was calculated.

Results: In line with different rates of polypharmacy (80% vs 16%), the risk of exposure to at least one interaction was 53.7% in nursing homes and 26.4% in outpatients. Among DDIs, in nursing homes antidepressants—anxiolytics (11.9%) ranked first, followed by antidepressants—aspirin (7.4%). In outpatients, ACE-inhibitors—non-steroidal anti-inflammatory drugs (NSAIDs) reached 7.2% followed by the calcium channel blockers—α-blockers (2.4%).

Discussion: Polypharmacy and risk of DDIs appeared very different in the two settings, due to both technical and clinical reasons. In order to reduce use of benzodiazepines, NSAIDs, antidepressants and relevant DDIs, 1) defining alternative options for pain relief in elderly outpatients, and 2) implementing non-pharmacological management of insomnia and anxiety in nursing homes should be prioritized.

Low-Dose Aspirin Use Among African American Older Adults

OBJECTIVES

Existing epidemiologic information shows disparities in low-dose aspirin use by race. This study investigates the frequency, pattern, and correlates of both self- and clinician-prescribed low-dose aspirin use among underserved African Americans aged 55 years and older.

METHODS

This cross-sectional study conducted a comprehensive evaluation of all over-the-counter and prescribed medications used among 683 African American older adults in South Central Los Angeles, California. Correlation between use of low-dose aspirin and sociodemographic variables, health care continuity, health behaviors, and several major chronic medical conditions were examined. In addition, the use of low-dose aspirin as self prescribed versus clinician prescribed was examined. Multivariate logistic regression was performed to examine correlates of low-dose aspirin use.

RESULTS

Overall, 37% of participants were taking low-dose aspirin. Sixty percent of low-dose aspirin users were taking low-dose aspirin as self prescribed and 40% were taking it as prescribed by a clinician. Major aspirin-drug interactions were detected in 75% of participants who used low-dose aspirin, but no significant differences in aspirin-drug interactions were found between those who used aspirin as self prescribed and those who used it as clinician prescribed. No negative association between being diagnosed with gastrointestinal conditions and aspirin used was detected. Being diagnosed with diabetes mellitus or a heart condition was associated with higher use of aspirin. However, only 50% with high risk of cardiovascular took prescribed (38%) or self-prescribed (62%) low-dose aspirin. One third of participants aged 70 years and older with low risk of cardiovascular were using aspirin.

CONCLUSIONS

Among underserved African-American middle-aged and older adults, many who could potentially benefit from aspirin are not taking it; and many taking aspirin have no indication to do so and risk unnecessary side effects. Compared with non-Hispanic Whites, African Americans are more likely to be diagnosed with diabetes, hypertension, and heart conditions at earlier stages of life; as a result, the role of preventive intervention, including safe and appropriate use of low-dose aspirin among this segment of our population, is more salient. Interventional studies are needed to promote safe and effective use of low-dose aspirin among underserved African-American adults.

Drug-disease interactions in Swedish senior primary care patients were dominated by non-steroid anti-inflammatory drugs and hypertension - a population-based registry study

OBJECTIVE

Drug-disease interactions (DDSIs) are present when a drug prescribed for one disease worsens a concomitant disease. The prevalence of DDSIs in older patients in primary care is largely unknown, as well as to what extent physicians individualize drug prescribing in relation to concomitant diseases. We therefore analysed the prevalence of DDSIs in older patients in primary care and explored to what extent physicians take possible DDSIs into account when prescribing. Design and Setting: Cross-sectional population-based register study in primary care in Region Stockholm, Sweden. Thirty-one DDSIs derived from Irish STOPP-START-Criteria were assessed. We derived data from a regional administrative healthcare database including information on all healthcare consultations and dispensed prescription drugs in the region. Data on demography, diagnoses, drug dispensations and healthcare consumption were extracted. Drugs were assessed during 2016.

SUBJECTS

A total of 336,295 patients aged ≥65 registered with one of the 206 primary care practices in Region Stockholm.

MAIN OUTCOME MEASURES

Prevalence and prevalence differences for DDSIs.

RESULTS

In 10.8% of older patients, at least one DDSI was observed. Non-steroidal anti-inflammatory drugs (NSAIDs) were implicated in more than 75% of cases. The most common DDSI was NSAID/hypertension (8.1%), followed by NSAID/cardiovascular disease and loop diuretics/urinary incontinence (both 0.7%). The use of NSAIDs among patients with heart failure or impaired renal function was 15% lower than among patients without these diseases.

CONCLUSION

DDSIs were present in every tenth older patient in primary care. Patients with cardiovascular disease receive NSAIDs to a lower extent, possibly indicating physician awareness of DDSI. Key points Evidence on the prevalence of drug-disease interactions in older patients in primary care is sparse despite their potential to cause harm. In this study, we found that every 10th older patient attending primary care had at least one drug-disease interaction. Interactions with NSAIDs were far more common than interactions with other drugs. The use of NSAIDs among patients with heart failure or impaired renal function was 15% lower than among patients without these diseases.

Prescribing potentially inappropriate medications for the elderly according to Beers Criteria: systematic review

The study aimed to perform a systematic review to identify and evaluate the prevalence of potentially inappropriate medicines (PIM) prescriptions for the elderly, according to Beers Criteria, in hospitalized elderly individuals aged 65 years or older. Five databases consulted: VHL; Cochrane Library; CINAHL; MEDLINE and Web of Science. Nineteen articles identified, selected based on eligibility criteria. The mean age was 78.2 years and the most used criterion for the identification of PIM for the elderly was Beers 2015 (57.9%). A total of 221,879 elderly received a prescription for PIM, the mean prevalence was 65.0%, for the gastrointestinal system (15.3%) and proton-pump inhibitors (27.7%) highlighted as the main class of medicine prescribed. It concluded that the Beers Criteria have made it possible to identify the high prevalence in the prescription of PIM. The results of this review may help in the decision making of health professionals, to avoid the administration of PIM and to propose best practices to ensure the safety of the elderly hospitalized.

The Development of Practice Recommendations for Drug-Disease Interactions by Literature Review and Expert Opinion

Background

Drug-disease interactions negatively affect the benefit/risk ratio of drugs for specific populations. In these conditions drugs should be avoided, adjusted, or accompanied by extra monitoring. The motivation for many drug-disease interactions in the Summary of Product Characteristics (SmPC) is sometimes insufficiently supported by (accessible) evidence. As a consequence the translation of SmPC to clinical practice may lead to non-specific recommendations. For the translation of this information to the real world, it is necessary to evaluate the available knowledge about drug-disease interactions, and to formulate specific recommendations for prescribers and pharmacists. The aim of this paper is to describe a standardized method how to develop practice recommendations for drug-disease interactions by literature review and expert opinion.

Methods

The development of recommendations for drug-disease interactions will follow a six-step plan involving a multidisciplinary expert panel (1). The scope of the drug-disease interaction will be specified by defining the disease and by describing relevant effects of this drug-disease interaction. Drugs possibly involved in this drug-disease interaction are selected by checking the official product information, literature, and expert opinion (2). Evidence will be collected from the official product information, guidelines, handbooks, and primary literature (3). Study characteristics and outcomes will be evaluated and presented in standardized reports, including preliminary conclusions on the clinical relevance and practice recommendations (4). The multidisciplinary expert panel will discuss the reports and will either adopt or adjust the conclusions (5). Practice recommendations will be integrated in clinical decision support systems and published (6). The results of the evaluated drug-disease interactions will remain up-to-date by screening new risk information, periodic literature review, and (re)assessments initiated by health care providers.

Actionable Recommendations

The practice recommendations will result in advices for specific DDSI. The content and considerations of these DDSIs will be published and implemented in all Clinical Decision Support Systems in the Netherlands.

Discussion

The recommendations result in professional guidance in the context of individual patient care. The professional will be supported in the decision making in concerning pharmacotherapy for the treatment of a medical problem, and the clinical risks of the proposed medication in combination with specific diseases.

[Specificity of the management of metastatic renal cancer in the older patient]

AIM

To define the necessary arrangements of medical treatment with anti-angiogenics, mTOR inhibitor or systemic immunotherapies in the management of metastatic renal cell carcinoma in elderly patients.

METHOD

Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: metastatic renal cell carcinoma, elderly, treatment.

RESULTS

The selection criteria for the medical treatment of metastatic renal cell carcinoma in elderly patients are the IMDC score, necessarily complemented by performance status, the tolerability profile of treatments, more frequent drug interactions, treatment adherence, management capacity of side effects, and patient preference. Each of these criteria is detailed in critical ways.

CONCLUSION

The efficacy and tolerability of medical treatments for metastatic renal cancer have not been reported as different depending on age. No dosage adjustment is recommended in principle. However, prevention and early treatment of side effects of treatment should be strengthened in elderly patients.

Potential and clinical relevant drug-drug interactions among elderly from nursing homes: a multicentre study in Murcia, Spain

This study purposes to determine the prevalence of potential and clinical relevant Drug-Drug-Interactions (pDDIs) in institutionalized older adults and to identify the pertinent factors associated. We conduct an observational, multicenter and cross-sectional study during the last quarter of 2010. We selected a sample of 275 subjects (aged ≥ 65 years) from 10 nursing homes of Murcia (Spain) by a two-stage complex sampling. pDDIs were identified using the College of Pharmacists Database. We only considered pDDIs of clinical relevance, and thereafter the relevant factors were identified through uni-level and multi-level regression analyses. A total of 210 pDDIs were identified, 120 of which were considered clinically relevant (57.1%), affecting a total of 70 elderly (25.8%). Eight pharmacological groups made up 70.2% of the clinically relevant pDDIs. More clinically relevant DDIs were found in people suffering several pathologies (OR = 2.3; 95%CI = 1.4-4.5), and also in people who take ten or more drugs daily (OR = 9.6; 95%CI = 4.8-19.1), and people who take anti-inflammatory drugs (OR = 3.9; 95%CI = 1.4-10.4). This study reveals that clinically relevant pDDIs are very common in institutionalized elderly people, and that caregivers should aim at improving their practice in order to reduce the prevalence of this phenomenon.

Prevalence of cytochrome P450-mediated potential drug-drug interactions in residents of intermediate care facilities for older adults in Japan

AIM

Limited information is available on the prevalence of drug-drug interactions (DDI) in residents of long-term care facilities who often receive multiple drugs. This study aimed to evaluate the prevalence of clinically relevant cytochrome P450-mediated potential DDI in residents of intermediate care facilities for older adults (called Roken) in Japan.

METHODS

A nationwide drug utilization study was carried out for Roken residents in 2015 (up to five residents per facility). Potential DDI were identified with an explicit list of drugs that can be involved in clinically relevant cytochrome P450-mediated DDI in Japan. Logistic regression was used to evaluate the association of the number of drugs prescribed with the presence of potential DDI, adjusted for age, sex and long-term care needs level.

RESULTS

The study included 1222 residents of 348 Roken who were prescribed two or more active drug substances. The participants who received ≥6 and ≥10 drugs represented 49% and 10% of total participants, respectively. In total, 42 two-drug combinations involving potential DDI were identified in 33 participants (2.7%) - benzodiazepines, proton pump inhibitors, calcium channel blockers and anti-epileptic drugs were frequently involved. The adjusted odds ratios for potential DDI were 2.84 (95% confidence interval 1.15-7.02) or 7.82 (95% confidence interval 2.96-20.70) in residents receiving six to nine drugs or ≥10 drugs, compared with those receiving two to five drugs.

CONCLUSIONS

Approximately 3% of Roken residents were at risk for clinically relevant DDI. Reducing the number of drugs prescribed through medication reviews would mitigate the potential risk. Geriatr Gerontol Int 2019; 19: 513-517.

Spironolactone and Outcomes in Older Patients with Heart Failure and Reduced Ejection Fraction

BACKGROUND

The efficacy of mineralocorticoid receptor antagonists or aldosterone antagonists in heart failure with reduced ejection fraction (HFrEF) is well known. Less is known about their effectiveness in real-world older patients with HFrEF.

METHODS

Of the 8206 patients with heart failure and ejection fraction ≤35% without prior spironolactone use in the Medicare-linked OPTIMIZE-HF registry, 6986 were eligible for spironolactone therapy based on serum creatinine criteria (men ≤2.5 mg/dL, women ≤2.0 mg/dL) and 865 received a discharge prescription for spironolactone. Using propensity scores for spironolactone use, we assembled a matched cohort of 1724 (862 pairs) patients receiving and not receiving spironolactone, balanced on 58 baseline characteristics (Creatinine Cohort: mean age, 75 years, 42% women, 17% African American). We repeated the above process to assemble a secondary matched cohort of 1638 (819 pairs) patients with estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m² (eGFR Cohort: mean age, 75 years, 42% women, 17% African American).

RESULTS

In the matched Creatinine Cohort, spironolactone-associated hazard ratios (95% confidence intervals) for all-cause mortality, heart failure readmission, and combined endpoint of heart failure readmission or all-cause mortality were 0.92 (0.81-1.03), 0.87 (0.77-0.99), and 0.87 (0.79-0.97), respectively. Respective hazard ratios (95% confidence intervals) in the matched eGFR Cohort were 0.87 (0.77-0.98), 0.92 (0.80-1.05), and 0.91 (0.82-1.02).

CONCLUSIONS

These findings provide evidence of consistent, albeit modest, clinical effectiveness of spironolactone in older patients with HFrEF regardless of renal eligibility criteria used. Additional strategies are needed to improve the effectiveness of aldosterone antagonists in clinical practice.

Pharmacotherapy in Older Adults with Cardiovascular Disease: Report from an American College of Cardiology, American Geriatrics Society, and National Institute on Aging Workshop

OBJECTIVES

To identify the top priority areas for research to optimize pharmacotherapy in older adults with cardiovascular disease (CVD).

DESIGN

Consensus meeting.

SETTING

Multidisciplinary workshop supported by the National Institute on Aging, the American College of Cardiology, and the American Geriatrics Society, February 6-7, 2017.

PARTICIPANTS

Leaders in the Cardiology and Geriatrics communities, (officers in professional societies, journal editors, clinical trialists, Division chiefs), representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration; Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, pharmaceutical industry, and trainees and early career faculty with interests in geriatric cardiology.

MEASUREMENTS

Summary of workshop proceedings and recommendations.

RESULTS

To better align older adults' healthcare preferences with their care, research is needed to improve skills in patient engagement and communication. Similarly, to coordinate and meet the needs of older adults with multiple comorbidities encountering multiple healthcare providers and systems, systems and disciplines must be integrated. The lack of data from efficacy trials of CVD medications relevant to the majority of older adults creates uncertainty in determining the risks and benefits of many CVD therapies; thus, developing evidence-based guidelines for older adults with CVD is a top research priority. Polypharmacy and medication nonadherence lead to poor outcomes in older people, making research on appropriate prescribing and deprescribing to reduce polypharmacy and methods to improve adherence to beneficial therapies a priority.

CONCLUSION

The needs and circumstances of older adults with CVD differ from those that the current medical system has been designed to meet. Optimizing pharmacotherapy in older adults will require new data from traditional and pragmatic research to determine optimal CVD therapy, reduce polypharmacy, increase adherence, and meet person-centered goals. Better integration of the multiple systems and disciplines involved in the care of older adults will be essential to implement and disseminate best practices. J Am Geriatr Soc 67:371-380, 2019.

Profile of drugs used for self-medication by elderly attended at a referral center

OBJECTIVE

To determine the profile of medications used for self-medication by the elderly.

METHODS

A cross-sectional study based on interviews with elderly seen at a reference center for Elderly Health of a teaching hospital, from July 2014 to July 2015. Clinical, demographic and pharmacotherapeutic data were collected.

RESULTS

A total of 170 elderly were interviewed, 85.9% female, and the median age was 76 years. The frequency of self-medication was 80.5%. The most used medications for self-medication were central acting muscle relaxants, analgesics and antipyretics, non-steroidal anti-inflammatory and antirheumatic agents. Among the elderly who practiced self-medication, 55.5% used drugs that were inappropriate for the elderly, according to Beers criteria of 2015, and 56.9% used medications that showed therapeutic duplicity with the prescribed drugs. We identified 57 drugs used for self-medication, of which 30 (52.6%) were classified as over-the-counter and 27 (47.4%) as prescription drugs. Approximately 68.6% of elderly had at least one interaction involving drugs prescribed and those used for self-medication.

CONCLUSION

The practice of self-medication was frequent in the elderly studied. The widespread use of over-the-counter drugs and/or potentially inappropriate medications for elderly increases the risk of drug interactions and adverse events.

Characterization of drug-drug interactions in patients whose substance intake was objectively identified by detection in urine

BACKGROUND

Identification of drug-drug interactions (DDIs) typically relies on patient medication lists which are prone to inaccuracies. This study describes use of a mass spectrometry test to detect recently ingested substances in urine with subsequent identification of DDIs.

RESEARCH DESIGN AND METHODS

This was a retrospective analysis of the prevalence of DDIs identified in patients with chronic pain, addiction and/or behavioral health conditions in the U.S. Relationships between patient demographics, polypharmacy and the occurrence of DDIs were also described.

RESULTS

Of 15,004 patients, 2964 (20%) had a DDI identified. There was a positive association between the number of substances detected in urine and the number of interactions identified (r = 0.5033, p-value = 0.0001). Of patients with polypharmacy, 15.6% had contraindicated or severe interactions identified compared to only 3.2% of those without polypharmacy. For polypharmacy patients, the youngest population studied had a much higher likelihood of having one or more DDIs identified compared to the other age groups (p-value = 0.0002).

CONCLUSIONS

By utilizing a mass spectrometry test to objectively detect recently ingested substances followed by identification of DDIs, healthcare providers may be able to better characterize the true incidence of DDIs. Study findings may not be generalizable to healthcare populations outside of pain management, addiction treatment, and behavioral health.

[Diseases as a 'Stumbling Block' - a Case of Multimorbidity in Clinical Practice]

Diseases as a `Stumbling Block` - a Case of Multimorbidity in Clinical Practice Abstract. Here we report on a 83 year-old patient with cardiac syncope and consecutive traumatic brain injury with intracranial haemorrhage receiving anticoagulation for recurrent pulmonary embolism: a 'medical dilemma' due to the syncope with consecutive traumatic event and the underlying condition. A pre-existing underlying cardiac disease was identified as the cause of the syncope and the intracranial haemorrhage was most likely due to oral anticoagulation for recurrent pulmonary embolisms. The intracranial bleeding inhibited an optimal management of the underlying cardiac condition and the patient deceased shortly thereafter.

Statin drug interactions and related adverse reactions: an update

INTRODUCTION

Statins reduce the risk of cardiovascular morbidity and mortality in patients with or at risk for cardiovascular disease and their use is expanding, especially in elderly. Statins are prescribed on a long-term basis and may undergo drug-drug interactions (DDIs) with other drugs. Statins have different safety and tolerability, and this might affect the possibility of DDIs with other cardiovascular drugs, increasing the risk of statin-associated myopathy and hepatotoxicity. Polypharmacy and pharmacogenetic variability are potential causes of statin DDIs. Thus, the safety and adverse effects of statins, particularly in patients receiving multiple medications at risk of DDIs, are a matter of special concern.

AREAS COVERED

The purpose of this manuscript is to give an update on the potential statin DDIs and related adverse drug reactions (myopathy and hepatotoxicity), with special considerations on polypharmacy in elderly population, HIV patients, cardiovascular drugs and liver toxicities. The potential DDIs among statins and monoclonal antibodies including the recently approved PCSK9 inhibitors are also extensively discussed in the present review.

EXPERT OPINION

A better understanding of the incidence and clinical significance of statin DDIs will help physicians in fine-tuning the lipid-lowering therapeutic interventions thus providing their patients with an evidence-based, safe and cost-effective clinical support.