Drug interactions and adverse drug reactions in the older patients admitted to the emergency department

A meta-analysis assessing the prevalence of drug-drug interactions among hospitalized patients

PURPOSE

Drug-drug interactions (DDIs), particularly in hospitalized patients can result in adverse drug events and unfavorable health consequences. The aim of this meta-analysis is to provide up-to-date evidence on the prevalence of clinically evident adverse drug events due to DDIs in hospitalized patients.

METHODS

Data from Scopus, PubMed, Cochrane and Web of Science were extracted using these keywords (Drug interaction/drug-drug interactions, Hospital/ hospitals, Adverse drug event, Hospitalized patients, inpatient, Department, Hospital stay, Harm, Mortality, death). The studies that include Observational studies on hospitalized patients, reporting potential DDIs using an electronic database, and reporting the clinically observed adverse drug interactions (ADI) through symptoms, signs or Laboratory tests are included. Using Open meta-Software (version 12.11.14), the incidence of clinically evident DDIs among hospitalized patients was determined and shown in a forest plot.

RESULTS

Only 15 of the 8261 articles found through a literature search met the inclusion criteria and reported the desired outcome. The pooled prevalence of potential drug-drug interactions is 64.9% (CI 95% 0.618-0.736). While clinically evident DDIs have a pooled frequency of 17.17% (CI 95% 0.133-0.256).

CONCLUSION

The issue of DDIs remains a significant concern in hospitalized patients, with a notable rise in their prevalence. This meta-analysis encompassed a greater quantity of studies and demonstrated a heightened proportion of drug-drug interaction prevalence in comparison to the percentages reported in the previously published meta-analysis.

Potentially clinically significant drug-drug interactions in older patients admitted to the hospital: A cross-sectional study

Background: An international consensus list of potentially clinically significant drug-drug interactions (DDIs) in older people has been recently validated. Our objective was to describe the prevalence and characteristics of drug combinations potentially causing clinically significant DDIs identified in the medication history of older patients admitted to the hospital and the prevalence and characteristics of manifest DDIs-DDIs involved in adverse drug events present at hospital admission, DDIs that contributed to ADE-related hospital admissions, and DDIs involved in drug-related laboratory deviations. Methods: The data were obtained from our previous study that examined the drug-relatedness of hospital admissions to University Hospital Hradec Králové via the department of emergency medicine in the Czech Republic. Patients ≥ 65 years old were included. Drug combinations potentially causing clinically significant DDIs were identified using the international consensus list of potentially clinically significant DDIs in older people. Results: Of the 812 older patients admitted to the hospital, 46% were exposed to drug combinations potentially causing clinically significant DDIs. A combination of medications that affect potassium concentrations accounted for 47% of all drug combinations potentially causing clinically significant DDIs. In 27 cases, potentially clinically significant DDIs were associated with drug-related hospital admissions. In 4 cases, potentially clinically significant DDIs were associated with ADEs that were present at admissions. In 4 cases, the potentially clinically significant DDIs were associated with laboratory deviations. Manifest DDIs that contributed to drug-related hospital admissions most frequently involved antithrombotic agents and central nervous system depressants. Conclusion: The results confirm the findings from the European OPERAM trial, which found that drug combinations potentially causing clinically significant DDIs are very common in older patients. Manifest DDIs were present in 4.3% of older patients admitted to the hospital. In 3.3%, manifest DDIs contributed to drug-related hospital admissions. The difference in the rates of potential and manifest DDIs suggests that if a computerized decision support system is used for alerting potentially clinically significant DDIs in older patients, it needs to be contextualized (e.g., take concomitant medications, doses of medications, laboratory values, and patients' comorbidities into account).

Predictors of hospital-acquired adverse drug reactions: a cohort of Ugandan older adults

Background

Globally, it is estimated that the number of older adults will become 2 billion by 2050. The identification of the predictors of adverse drug reaction (ADR) in hospitalized older patients is crucial to the development of prediction tools and preventive strategies to mitigate the burden of ADRs. This study aimed to determine the predictors of hospital-acquired ADR occurrence among hospitalized older adults in a low-income country.

Methods

We conducted a prospective cohort of older adults admitted to medical, oncology, and surgery wards at Mbarara Regional Referral Hospital (MRRH) for a consecutive 6 months where each patient was followed up daily from admission to discharge. We used Edwards and Aronson’s definition of ADR and the Naranjo ADR Causality Scale. We employed Beer’s criteria and Lexicomp to determine potentially inappropriate medications, and drug interactions, respectively. We conducted univariate and multivariable logistic regression using Statistical Package for the Social Science (SPSS) Version 23.0.

Results

Out of 523 participants with median (Inter Quartile Range) age of 67 (62–76) years, 256 (48.9%) experienced at least one ADR. Independent predictors of occurrence of hospital acquired ADRs included age of 60–75 (Adjusted odds ratio (AOR) = 1.97, 95% C.I: 1.14–3.41; p value = 0.015) compared to > 75 years, previous ADR in 1 year (AOR = 2.43, 95% C.I: 1.42–4.17; p value = 0.001), potentially inappropriate medication (AOR = 4.56, 95% C.I: 2.70–7.70; p value< 0.001), polypharmacy (AOR = 3.29, 95% C.I: 1.98–5.46; p value< 0.001)), having a Charlison Comorbidity Index (CCI) ≥ 6 (AOR = 8.47, 95% C.I: 4.85–14.99; p value< 0.001), having heart failure (AOR = 2.83, 95% C.I: 1.34–6.02; p value = 0.007) or kidney disease (AOR = 1.95, 95% C.I: 1.05–3.61; p value = 0.034) and a hospital stay > 10 days (AOR = 3.53, 95% C.I: 1.89–6.61; p value< 0.001) compared to < 5 days.

Conclusion

The current prevalence of ADR is higher than previously reported in high-income countries. Disease-related factors followed by medication-related factors were shown to be the most important predictors of hospital-acquired ADRs. CCI and PIM showed the strongest association with ADR. The predictors of ADRs identified in our study were generally comparable with those reported by previous studies.

Plain language title

Conditions that predispose older patients to experience harmful effects from their medications while in hospital.

Plain language summary

Identifying the conditions that predispose older adults to incur harmful effects of their medications helps to plan on how best to predict, take precautions and closely follow up on them and thus, to prevent these undesirable outcomes. This study aimed to identify these conditions which determine which older adults are higher risk to incur these harmful undesirable effects of medicines. Everydayduring their hospital stay, we closely followed older patients who were 60 years and above from their entry to the hospital wards until they left the hospital. We interviewed the participants, reviewed their medication files and we also examined them physically to identify any unwanted and harmful outcome from their current medications. Out of 523 participants, almost half of them experienced at least one harmful or undesired effect related to their medicine. Conditions which predisposed them to experience a harmful effect from their medicines included being in age bracket of 60–75 years, having a history of experiencing harmful outcomes from medicines in the previous 1 year, taking a medication which was listed as potentially inappropriate for older adults, taking 5 or more medications concurrently, having a lower 10 years survival chance, having heart or kidney disease and a hospital stay > 10 days.

Drug-related hospital admissions in older adults: comparison of the Naranjo algorithm and an adjusted version of the Kramer algorithm

PURPOSE

Drug-related admissions (DRAs) are an important cause of preventable harm in older adults. Multiple algorithms exist to assess causality of adverse drug reactions, including the Naranjo algorithm and an adjusted version of the Kramer algorithm. The performance of these tools in assessing DRA causality has not been robustly shown. This study aimed to evaluate the ability of the adjusted Kramer algorithm to adjudicate DRA causality in geriatric inpatients.

METHODS

DRAs were assessed in a convenience sample of patients admitted to the acute geriatric wards of an academic hospital. DRAs were identified by expert consensus and causality was evaluated using the Naranjo and the adjusted Kramer algorithms. Positive agreement with expert consensus was calculated for both algorithms. A multivariable logistic regression analysis was performed to explore determinants for a DRA.

RESULTS

A total of 218 geriatric inpatients was included of whom 65 (29.8%) experienced a DRA. Positive agreement was 72.3% (95% confidence interval (CI), 59.6-82.3%) and 100% (95% CI, 93.0-100%) for the Naranjo and the adjusted Kramer algorithm, respectively. Diuretics were the main culprits and most DRAs were attributed to a fall (n = 18; 27.7%). A fall-related principal diagnosis was independently associated with a DRA (odds ratio 20.11; 95% CI, 5.60-72.24).

CONCLUSION

The adjusted Kramer algorithm demonstrated a higher positive agreement with expert consensus in assessing DRA causality in geriatric inpatients compared to the Naranjo algorithm. Our results further support implementation of the adjusted Kramer algorithm as part of a standardized DRA assessment in older adults.

The impact of treatment choices on potential drug-drug interactions in hypertensive patients

AIMS

The aim of this study was to analyse potential drug-drug interactions (pDDIs) and their potential adverse drug reactions (ADRs) among hypertensive patients. Moreover, we investigated the possibility of reducing pDDIs with different treatment choices.

METHODS

This was a cross-sectional study including all outpatients with hypertension and two or more medications, treated in a university hospital in Serbia. Lexicomp Interact (Lexi-Comp, Inc., Hudson, OH) was used for identification of pDDIs and potential ADRs. Treatment choices were explored according to patient characteristics, treatment guidelines and the interacting potential of drugs. Data were analysed using descriptive analysis and multiple logistic regression.

RESULTS

A total of 350 patients were included in this study, with average age (77 [36-98] years and 6.1 [2.5]) medications. The majority of patients (86.0%) had at least one clinically significant pDDI, and the average was 3.78 (3.90) (range 1-25). Suggestions for treatment change aimed mainly at eliminating drug duplications, reducing the use of thiazide diuretics, sulfonylureas, alpha-lipoic acid and pentoxifylline and increasing the use of calcium-channel blockers, when appropriate. pDDIs would have decreased to 2.10 (2.52), P <.001, yet male gender, ≥6 medications, cardiovascular diseases, diabetes, benign prostatic hyperplasia, would be predictive of two or more pDDIs. The main potential adverse outcomes of pDDIs were hypotension, renal failure, hypoglycaemia, bradycardia and lactic acidosis.

CONCLUSION

Careful choice of drugs can reduce but not eliminate pDDIs and their potential ADRs in hypertensive patients. Close monitoring for hypotension, renal failure, hypoglycaemia, bradycardia and lactic acidosis is necessary.

Prevalence, Incidence, and Characteristics of Adverse Drug Reactions Among Older Adults Hospitalized at Mbarara Regional Referral Hospital, Uganda: A Prospective Cohort Study

Background

Adverse drug reactions (ADRs) are associated with significant clinical and economic effects. Among the elderly population, the risk for ADRs is even higher. Data of ADR prevalence and incidence among the elderly population in Uganda and many low- and middle-income countries are lacking.

Objective

This study determined the prevalence, incidence, and characteristics of ADRs among hospitalized elderly patients at Mbarara Regional Referral Hospital (MRRH), Uganda.

Methods and Materials

We conducted a prospective cohort of older adults admitted to medical, oncology, and surgery wards at MRRH for consecutive 6 months. The primary data were obtained by interviewing patients and caregivers and reviewing patient medication charts, taking vital signs, and physical examinations. We used Edwards and Aronson’s definition of ADR and the Naranjo ADR Causality Scale. We conducted descriptive statistics and the Kolmogorov–Smirnov test using SPSS Version 23.0.

Results

We studied a total of 523 older adults 60 to 103 years of age. During their hospital stay, 256 (48.9%) of the patients experienced at least one ADR. A total of 365 ADRs were identified during 4702 person-days of follow-up. The incidence of ADRs was 78 ADRs/1000 person-days. ADRs affecting the gastrointestinal tract were the most frequently (40.6%) identified categories. Probable and type A ADRs accounted for 260 (71.2%) and 305 (83.6%) of the total incidents, respectively. Overall, 237 (64.9%) of the ADRs were rated as mild, whereas 10 (2.8%) of them as severe. Lastly, 165 (45.2%) of the ADRs were categorized as preventable.

Conclusion

Almost half of the hospitalized patients aged 60 to 103 years experienced at least one ADR during their hospital stay, which is higher than has been previously documented. Almost three-thirds of the ADRs were probable, about 4 out of 5 were type A and almost two-thirds were mild. Nearly half of the ADRs were preventable.

Prevalence, characteristics and predicting risk factors of adverse drug reactions among hospitalized older adults: A systematic review and meta-analysis

BACKGROUND

Occurrence of adverse drug reactions is a major global health problem mostly affecting older adults. Identifying the magnitude and predictors of adverse drug reactions is crucial to developing strategies to mitigate the burden of adverse drug reactions. This study's objectives were to estimate and compare the prevalences of adverse drug reactions, to characterize them and to identify the predictors among hospitalized older adults.

METHODS

A comprehensive systematic literature search including both prevalence and risk factors of adverse drug reactions in hospitalized older adults was conducted using PubMed, Scopus and Google Scholar, involving all articles published in English. Descriptive statistics and comparison of means was performed using SPSS version 20.0 and metaprop command was performed in STATA version 13.0. Heterogeneity was assessed using I 2 statistic.

RESULTS

A total of 18 studies, involving 80,695 participants with a median age of 77 years, were included in this study. The pooled prevalence of adverse drug reaction was 22% (95% confidence interval: 17%, 28%; I 2 = 99.23%). Among high-income countries, the prevalence of adverse drug reactions was 29% (95% confidence interval: 16%, 42%) as compared to 19% (95% confidence interval: 14%-25%) in low and middle-income countries (p value = 0.176). Of the 620 adverse drug reactions categorized, most were type A (89%), which are generally predictable and preventable. Two-thirds (795, 67%) of the adverse drug reactions were probable and most (1194, 69%) were mild or moderate. The majority (60%) of the categorized adverse drug reactions were preventable and less than one-third (31%) were severe. The most consistently reported predictors of adverse drug reactions in hospitalized older patients were medication-related factors, including polypharmacy and potentially inappropriate medications followed by disease-related factors-renal failure, complex comorbidity, heart failure and liver failure.

CONCLUSION

Almost one-quarter of all hospitalized older adults experienced at least one adverse drug reaction during their hospital stay. The majority of the adverse drug reactions were preventable. Medication-related factors were the most consistently reported predictors of adverse drug reactions followed by disease-related factors.

Prevalence of clinically manifested drug interactions in hospitalized patients: A systematic review and meta-analysis

AIMS

This review aims to determine the prevalence of clinically manifested drug-drug interactions (DDIs) in hospitalized patients.

METHODS

PubMed, Scopus, Embase, Web of Science, and Lilacs databases were used to identify articles published before June 2019 that met specific inclusion criteria. The search strategy was developed using both controlled and uncontrolled vocabulary related to the following domains: "drug interactions," "clinically relevant," and "hospital." In this review, we discuss original observational studies that detected DDIs in the hospital setting, studies that provided enough data to allow us to calculate the prevalence of clinically manifested DDIs, and studies that described the drugs prescribed or provided DDI adverse reaction reports, published in either English, Portuguese, or Spanish.

RESULTS

From the initial 5,999 articles identified, 10 met the inclusion criteria. The pooled prevalence of clinically manifested DDIs was 9.2% (CI 95% 4.0-19.7). The mean number of medications per patient reported in six studies ranged from 4.0 to 9.0, with an overall average of 5.47 ± 1.77 drugs per patient. The quality of the included studies was moderate. The main methods used to identify clinically manifested DDIs were evaluating medical records and ward visits (n = 7). Micromedex® (27.7%) and Lexi-Comp® (27.7%) online reference databases were commonly used to detect DDIs and none of the studies evaluated used more than one database for this purpose.

CONCLUSIONS

This systematic review showed that, despite the significant prevalence of potential DDIs reported in the literature, less than one in ten patients were exposed to a clinically manifested drug interaction. The use of causality tools to identify clinically manifested DDIs as well as clinical adoption of DDI lists based on actual adverse outcomes that can be identified through the implementation of real DDI notification systems is recommended to reduce the incidence of alert fatigue, enhance decision-making for DDI prevention or resolution, and, consequently, contribute to patient safety.

Use of prescription drugs in the older adult population-a nationwide pharmacoepidemiological study

PURPOSE

Multi-morbidity and polypharmacy are common among older people. It is essential to provide a better understanding of the complexity of prescription drug use among older adults to optimise rational pharmacotherapy. Population-based utilisation data in this age group is limited. Using the Danish nationwide health registries, we aimed to characterise drug use among Danish individuals ≥ 60 years.

METHODS

This is a descriptive population-based study assessing drug prescription patterns in 2015 in the full Danish population aged ≥ 60 years. The use of specific therapeutic subgroups and chemical subgroups and its dependence on age were described using descriptive statistics. Profiles of drug combination patterns were evaluated using latent class analysis.

RESULTS

We included 1,424,775 residents (median age 70 years, 53% women). Of all the older adults, 89% filled at least one prescription during 2015. The median number of drug groups used was five per person. The most used single drug groups were paracetamol and analogues (34%), statins (33%) and platelet aggregation inhibitors (24%). Eighteen drug profiles with different drug combination patterns were identified. One drug profile with expected use of zero drugs and 11 drug profiles expected to receive more than five different therapeutic subgroup drugs were identified.

CONCLUSION

The use of drugs is extensive both at the population level and increasing with age at an individual level. Separating the population into different homogenous groups related to drug use resulted in 18 different drug profiles, of which 11 drug profiles received on average more than five different therapeutic subgroup drugs.

Understanding adverse drug-related emergency department visits: development of a conceptual model through a systematic review

Background

The burden of adverse drug event (ADE)-related emergency department (ED) visits is increasing despite several preventive measures. The objective of this paper was to develop and validate a conceptual model for a better understanding of ADE-related ED visits and to guide the design and implementation of effective interventions.

Methods

The development of the model involved a systematic review of the literature using PubMed and Embase databases. Studies reporting the risk factors associated with ADE-related ED visits were included. The methodological qualities of the included studies were assessed using the Mixed Methods Appraisal Tool (MMAT). The model was mapped and validated using face and content validity by an expert panel. Deficiencies and targeted interventions were identified, and steps for the design and implementation were recommended.

Results

The literature search generated 1361 articles, of which 38 were included in the review; 41 risk factors associated with ADE-related ED visits were identified. All factors were mapped, and the model was validated through face and content validity. The model consisted of six concepts related to sociodemographic factors, clinical factors, ADE-related to ED visits, ADE while in the ED, outcomes, and consequences. Interventions could be targeted at the factors identified in each concept to prevent ADE-related ED burden.

Conclusion

A conceptual model to guide the successful design and implementation of strategies to prevent ADE-related ED visits and the occurrence of ADE at ED was developed. Clinicians should take these factors into consideration to prevent untoward events, especially when treating high-risk patients.

Descriptive study of drug-drug interactions attributed to prescriptions written upon discharge from the emergency department

OBJECTIVE

The primary purpose of this study was to identify the most common drug-drug interactions (DDI'S) in patients prescribed medications upon discharge from the emergency department.

METHODS

We conducted a respective chart review of patients discharged home with a prescription from an academic emergency department. The study period was from August 1, 2015 to August 31, 2015. Patients will be excluded if they meet the following criteria: age under 20 years; discharge home without a prescription; inpatient hospital admission; transfer to another inpatient facility; or sign out against medical advice. The primary endpoint is the identification and characterization of drug-drug interactions caused by discharge prescriptions written by the treating physician.

RESULTS

A total of 500 patient charts were included, with 38% having at least one DDI. Overall, there were 429 DDIs among 858 prescriptions written. 15.6% (n = 67) of the DDI's were classified as B, no modification of therapy needed. 60% (n = 260) of the DDIs were risk-rating category C, requiring monitoring of therapy. 22% (n = 95) of the DDI's identified were category D, which are consider modification of therapy. Lastly, we identified 1.6% (n = 7) category X DDI's. The top 3 most commonly associated drugs were oxycodone/acetaminophen, ibuprofen, and ciprofloxacin.

CONCLUSION

DDIs are occurring upon discharge from a large, urban, tertiary care, academic medical center. Many of the DDI's identified do not require any modification to therapy. However, 23.6% of identified DDI's required modification or were contraindicated. A majority of the category X drug interactions involved QT prolongation.

Adverse Drug Reaction-Related Hospitalizations in Elderly Australians: A Prospective Cross-Sectional Study in Two Tasmanian Hospitals

INTRODUCTION

Adverse drug reactions (ADRs) have been commonly cited as a major cause of hospital admissions in older individuals. However, despite the apparent magnitude of this problem, there are limited prospective data on ADRs as a cause of hospitalization in elderly medical patients.

OBJECTIVES

The objective of this study was to evaluate the proportion, clinical characteristics, causality, severity, preventability, and outcome of ADR-related admissions in older patients admitted to two Tasmanian hospitals.

METHODS

We conducted a prospective cross-sectional study at the Royal Hobart and Launceston General Hospitals in Tasmania, Australia. A convenience sample of patients, aged 65 years and older, undergoing unplanned overnight medical admissions was screened. ADR-related admissions were determined through expert consensus from detailed review of medical records and patient interviews. The causality, preventability and severity of each ADR-related admission were assessed.

RESULTS

Of 1008 admissions, the proportion of potential ADR-related medical admissions was 18.9%. Most (88.5%) ADR-related admissions were considered preventable. Cardiovascular complaints (29.3%) represented the most common ADRs, followed by neuropsychiatric (20.0%) and renal and genitourinary disorders (15.2%). The most frequently implicated drug classes were diuretics (23.9%), agents acting on the renin angiotensin system (16.4%), β-blocking agents (7.1%), antidepressants (6.9%), and antithrombotic agents (6.9%). Application of the Naranjo algorithm found 5.8% definite, 70.1% probable, and 24.1% possible ADRs. ADR severity was rated moderate and severe in 97.9% and 2.1% of admissions, respectively. For most (93.2%) ADR-related admissions the ADR resolved and the patient recovered.

CONCLUSION

Hospitalization due to an ADR is a common occurrence in this older population. There is need for future studies to implement and evaluate interventions to reduce the risk of ADR-related admissions in elderly populations.

Physicians' Non-Uniform Approach to Prescribing Drugs to Older Patients - A Qualitative Study

Multi-morbidity and polypharmacy are common in older patients and increase their susceptibility to adverse drug events and hospitalizations. Rational drug prescription is critical; however, little is known about physicians' perspectives on how to prescribe drugs for older patients. The aim of this study was to explore physicians' approach to prescribe drugs to older patients, including identifying the drugs that physicians perceive to be risk drugs for older patients and comparing them with established lists of potentially inappropriate medications. Short semi-structured interviews were conducted with 50 medical specialists in 23 different specialities throughout Denmark who had contact with older patients. Content analysis was performed to identify the relevant themes. Regardless of their medical or surgical background and how often they prescribed drugs for older patients in daily work, all physicians expressed a cautious approach when prescribing risk drugs. Despite their shared caution, physicians had different strategies for prescribing drugs to older patients. The following strategies were identified: (1) 'Start low, go slow', (2) 'Trial and error', (3) 'Dose reduction', and (4) 'Never prescribe'. The most frequently mentioned risk drugs considered to cause hospitalization were vitamin K antagonists, opioids and diuretics; these drugs are relatively highly consistent with established lists of PIMs. Physicians were relatively knowledgeable about risk drugs. Although the physicians agreed that a cautious approach was needed when prescribing drugs for older people, there was no consensus about how to best accomplish this in practice.

Adverse Drug reactions in an Ageing PopulaTion (ADAPT) study protocol: a cross-sectional and prospective cohort study of hospital admissions related to adverse drug reactions in older patients

INTRODUCTION

Older people experience greater morbidity with a corresponding increase in medication use resulting in a potentially higher risk of adverse drug reactions (ADRs). The aim of this study is to determine the prevalence and characteristics of ADR-related hospital admissions among older patients (≥65 years) and their associated health and cost outcomes.

METHODS AND ANALYSIS

The proposed study will include a cross-sectional study of ADR prevalence in all patients aged ≥65 years admitted acutely to a large tertiary referral hospital in Ireland over a 9-month period (2016-2017) and a prospective cohort study of patient-reported health outcomes and costs associated with ADR-related hospital admissions. All acute medical admissions will be screened for a suspected ADR-related hospital admission. A number of validated algorithms will be applied to assess the type, causative medications, preventability and severity of each ADR. ADRs will be determined, using a consensus method, by an expert panel. Patients who provide consent will be followed up 3 months post-discharge to establish patient-reported health outcomes (health service use, health-related quality of life, adherence) and costs associated with ADR-related hospital admissions. A random sample of patients admitted to hospital without a suspected ADR will be invited to take part in the study as a control group.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Beaumont Hospital Ethics Committee. Findings will be disseminated through presentations and peer-reviewed publications.

Comparative analysis of three drug-drug interaction screening systems against probable clinically relevant drug-drug interactions: a prospective cohort study

PURPOSE

Drug-drug interaction (DDI) screening systems report potential DDIs. This study aimed to find the prevalence of probable DDI-related adverse drug reactions (ADRs) and compare the clinical usefulness of different DDI screening systems to prevent or warn against these ADRs.

METHODS

A prospective cohort study was conducted in patients urgently admitted to medical departments. Potential DDIs were checked using Complete Drug Interaction®, Lexicomp® Online™, and Drug Interaction Checker®. The study team identified the patients with probable clinically relevant DDI-related ADRs on admission, the causality of which was assessed using the Drug Interaction Probability Scale (DIPS). Sensitivity, specificity, and positive and negative predictive values of screening systems to prevent or warn against probable DDI-related ADRs were evaluated.

RESULTS

Overall, 50 probable clinically relevant DDI-related ADRs were found in 37 out of 795 included patients taking at least two drugs, most common of them were bleeding, hyperkalemia, digitalis toxicity, and hypotension. Complete Drug Interaction showed the best sensitivity (0.76) for actual DDI-related ADRs, followed by Lexicomp Online (0.50), and Drug Interaction Checker (0.40). Complete Drug Interaction and Drug Interaction Checker had positive predictive values of 0.07; Lexicomp Online had 0.04. We found no difference in specificity and negative predictive values among these systems.

CONCLUSION

DDI screening systems differ significantly in their ability to detect probable clinically relevant DDI-related ADRs in terms of sensitivity and positive predictive value.

Hospital admissions due to adverse drug reactions in the elderly. A meta-analysis

INTRODUCTION

It is currently admitted that adverse drug reactions (ADRs) account for a great burden of disease. Of particular concern are ADR-induced hospital admissions, particularly in the elderly; they receive most of the medications and they are the most prone to develop ADRs. Therefore, our aim was to carry out a study of ADR-induced hospital admissions focused on the elderly population.

METHODS

For the purpose, a systematic review and meta-analysis was performed of those studies addressing ADR-induced hospital admissions in patients over 60 years of age. A computerized search of the literature was carried out in the main databases. The search spans from 1988 to 2015. A pooled prevalence figure was calculated with 95% CIs; heterogeneity was also explored.

RESULTS

The final number of selected articles was 42; all of them were published between January 1988 and August 2015. The overall average percentage of hospital admissions was 8.7% (95% CI, 7.6-9.8%). NSAIDs are one of the medication classes more frequently related to these admissions (percentages range from 2.3 to 33.3%). Inappropriate medication as a risk factor was studied in nine studies, four found a statistically significant relationship between those medications and hospital admissions.

CONCLUSIONS

Circa one in ten hospital admissions of older patients are due to ADRs. A great burden of disease is due to a few and identifiable medication classes; in most of the cases, the reactions are well known and probably preventable. A sense of purpose and determination is needed by health authorities to face this problem. Doctors, on their part, should be aware when prescribing some specific identifiable medications to these patients.

KEY POINTS

1. One in ten hospital admissions in older patients are due to ADRs; NSAIDs are the medications the most related with these admissions, followed by other common medications used in patients of this age, such as beta-blockers. 2. A great burden of disease is due to medications that are intended to cure or alleviate disease; this burden of disease is not only painful for the patients but also costly. 3. Identified risk factors are particular medication classes and polymedication. In most of the cases, reactions are probably preventable.

Emergency department visits caused by adverse drug reactions: results of aTurkish university hospital

BACKGROUND/AIM

We aimed to evaluate adverse drug reaction (ADR)-related emergency department (ED) visits in the ED of the Dokuz Eylül University Hospital prospectively.

MATERIALS AND METHODS

Patients who were admitted to the ED during 1-week periods of four different seasons between July 2010 and April 2011 were enrolled. Demographics of patients, previous ADR history, clinical progress, and outcomes were recorded. Causality assessment was done according to World Health Organization Uppsala Monitoring Centre categories. ADRs were categorized as certain, probable, or possible.

RESULTS

Patients who were on medications (26.5%, n = 1838) were evaluated for ADR-related ED admissions. ADRs accounted for 5.9% of cases (n = 108). The most frequently affected systems were the gastrointestinal (35.2%, n = 38), dermatological (23.1%, n = 25), and hematological (10.2%, n = 11) systems (7.4%, n = 8). The most common causes of ADRs were antiinfectives (31.6%, n = 33). Amoxicillin, Coumadin, and paracetamol were the most common medications that caused ADRs.

CONCLUSION

Nearly 6% of the admissions were ADR-related. ADRs should always be considered when patients who are on medication are admitted to the ED. Multicenter epidemiologic studies are required to know the real rates of ADR cases in EDs in Turkey.

Drug-induced diseases (DIDs): An experience of a tertiary care teaching hospital from India

Background & objectives:

Drug-induced diseases (DIDs) are well known but least studied. Data on DIDs from India are not available. Hence, this retrospective cross-sectional study was undertaken using suspected adverse drug reaction (ADR) data collected form Pharmacovigilance Programme of India (PvPI) to evaluate profile of DIDs over two years, in a tertiary care teaching hospital from north India.

Methods:

The suspected ADRs in the form of DID were evaluated for drug and disease related variables and were classified in terms of causality.

Results:

DID rate was 38.80 per cent. Mean duration of developing DIDs was 26.05 ± 9.6 days; 25.16 per cent had more than one co-morbid condition. Geriatric population (53.99%) accounted for maximum DIDs followed by adult (37.79%) and paediatric (8.21%). Maximum events were probable (93.98%) followed by possible (6.04%). All DIDs required intervention. Gastritis (7.43%), diarrhoea (5.92%), anaemia (4.79%), hypotension (2.77%), hepatic dysfunction (2.69%), hypertension (1.51%), myalgia (1.05%), and renal dysfunction (1.01%) were some of the DIDs. Anti tubercular treatment (ATT), anti retroviral treatment (ART), ceftriaxone injection, steroids, non-steroidal anti-inflammatory drugs, antimicrobials and anticancer drugs were found as commonly offending drugs.

Interpretation & conclusions:

Our findings show that DIDs are a significant health problem in our country, which need more attention.

Prevalence of Drug-Related Emergency Department Visits at a Teaching Hospital in Malaysia

BACKGROUND

Data on the prevalence of adverse drug event (ADE)-related emergency department (ED) visits in developing countries are limited. Malaysia is located in South-East Asia, and, to our knowledge, no information exists on ADE-related ED visits.

OBJECTIVE

The objective of this study was to determine the prevalence, preventability, severity, and outcome of drug-related ED visits.

METHODOLOGY

A cross-sectional study was conducted in consenting patients who visited the ED of Hospital Universiti Sains Malaysia over a 6-week period. The ED physician on duty determined whether or not the visit was drug related according to set criteria. Other relevant information was extracted from the patient's medical folder by a clinical pharmacist.

RESULTS

Of the 434 consenting patients, 133 (30.6 %; 95 % confidence interval [CI] 26-35 %) visits were determined to be ADE related; 55.5 % were considered preventable, 11.3 % possibly preventable, and 33.1 % not preventable. Severity was classed as mild in 1.5 %, moderate in 67.7 %, and severe in 30.8 %. The most common ADEs reported were drug therapeutic failure (55.6 %) and adverse drug reactions (32.3 %). The most frequently implicated drugs were antidiabetics (n = 31; 23.3 %), antihypertensives (n = 28; 21.1 %), antibiotics (n = 13; 9.8 %), and anti-asthmatics (n = 11; 8.3 %). A total of 93 patients (69.9 %) were admitted to the ED for observation, 25 (18.8 %) were discharged immediately after consultation, and 15 (11.3 %) were admitted to the ward through the ED.

CONCLUSION

The prevalence of ADE-related ED visits was high; more than one-half of the events were considered preventable and one-third was classed as severe. As such, preventive measures will minimize future occurrences and increase patient safety.

A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting

Adverse drug reactions (ADRs) are an important health issue. While prevalence and risk factors associated with ADRs in the general adult population have been well documented, much less is known about ADRs in the elderly population. The aim of this study was to review the published literature to estimate the prevalence of ADRs in the elderly in the acute care setting and identify factors associated with an increased risk of an ADR in the elderly. A systematic review of studies published between 2003 and 2013 was conducted in the Cochrane Database of Systematic Reviews, EMBASE, Google Scholar and MEDLINE. Key search terms included: “adverse drug reactions”, “adverse effects”, “elderly patients and hospital admission”, “drug therapy”, “drug adverse effects”, “drug related”, “aged”, “older patients”, “geriatric”, “hospitalization”, and “emergency admissions”. For inclusion in the review, studies had to focus on ADRs in the elderly and had to include an explicit definition of what was considered an ADR and/or an explicit assessment of causality, and a clear description of the method used for ADR identification, and had to describe factors associated with an increased risk of an ADR. Fourteen hospital-based observational studies exploring ADRs in the elderly in the acute care setting were eligible for inclusion in this review. The mean prevalence of ADRs in the elderly in the studies included in this review was 11.0% (95% confidence interval [CI]: 5.1%–16.8%). The median prevalence of ADRs leading to hospitalization was 10.0% (95% CI: 7.2%–12.8%), while the prevalence of ADRs occurring during hospitalization was 11.5% (95% CI: 0%–27.7%). There was wide variation in the overall ADR prevalence, from 5.8% to 46.3%. Female sex, increased comorbid complexity, and increased number of medications were all significantly associated with an increased risk of an ADR. Retrospective studies and those relying on identification by the usual treating team reported lower prevalence rates. From this review, we can conclude that ADRs constitute a significant health issue for the elderly in the acute care setting. While there was wide variation in the prevalence of ADRs in the elderly, based on the findings of this study, at least one in ten elderly patients will experience an ADR leading to or during their hospital stay. Older female patients and those with multiple comorbidities and medications appear to be at the highest risk of an ADR in the acute care setting.

Comparison of delivery strategies for pharmacogenetic testing services

The number and use of pharmacogenetic tests to assess a patient's likelihood of response or risk of an adverse event is expanding across medical specialties and becoming more prevalent. During this period of development and translation, different approaches are being investigated to optimize delivery of pharmacogenetic services. In this paper, we review pre-emptive and point-of-care delivery approaches currently implemented or being investigated and discuss the advantages and disadvantages of each approach. The continued growth in knowledge about the genetic basis of drug response combined with development of new and less expensive testing technologies and electronic medical records will impact future delivery systems. Regardless of delivery approach, the currently limited knowledge of health professionals about genetics generally or PGx specifically will remain a major obstacle to utilization.