Inappropriate use of digoxin in the elderly: how widespread is the problem and how can it be solved?

Utilization of potentially inappropriate medications in elderly patients in a tertiary care teaching hospital in India

Aim:

To evaluate the use of potentially inappropriate medicines in elderly inpatients in a tertiary care teaching hospital.

Materials and Methods:

Retrospective analysis was performed for cases of elderly patients admitted between January 2010 and December 2010. Data on age, gender, diagnosis, duration of hospital stay, treatment, and outcome were collected. Prescriptions were assessed for the use of potentially inappropriate medications in geriatric patients by using American Geriatric Society Beer's criteria (2012) and PRISCUS list (2010).

Results:

A total of 676 geriatric patients (52.12% females) were admitted in the medicine ward. The average age of geriatric patients was 72.69 years. According to Beer's criteria, at least one inappropriate medicine was prescribed in 590 (87.3%) patients. Metoclopramide (54.3%), alprazolam (9%), diazepam (8%), digoxin > 0.125 mg/day (5%), and diclofenac (3.7%) were the commonly used inappropriate medications. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in heart and renal failure patients was the commonly identified drug–disease interaction. According to PRISCUS list, at least one inappropriate medication was prescribed in 210 (31.06%) patients.

Conclusion:

Use of inappropriate medicines is highly prevalent in elderly patients.

Contemporary Considerations for the Use of Digoxin for Heart Failure in Older Patients

Background:

Digoxin has been used in older people for over 200 years to treat heart failure. Research over the past 15 years has caused the place of digoxin in therapy to evolve. This review was conducted in order to describe the role of digoxin in the care of older patients with heart failure.

Methods:

This review was conducted by systematically searching the literature using MEDLINE via Ovid, Cochrane Library, Pub Med and EMBASE, with the search terms “heart failure” and “digoxin.” Studies published after publication of the Digitalis Investigation Group (DIG) trial (conducted from February 1997 to October 2010) were selected for possible inclusion in the review.

Results:

The majority of data regarding the use of digoxin for heart failure in older people originates from the DIG trial and the various post-hoc analyses of this dataset. When considered in unison with evidence for other heart failure therapies (e.g., angiotensin-converting enzyme inhibitors), the place of digoxin is clear, in that it should be used for patients in sinus rhythm who are symptomatic despite therapy with first-line agents or for those with concomitant atrial fibrillation whose heart rate is not well controlled by, or cannot tolerate, beta-adrenergic blockers. There are various safety and monitoring parameters that should be considered in older people when using this drug.

Conclusions:

Digoxin is a drug that still demonstrates value for heart failure in older patients when used appropriately, and after first-line agents have been maximized.

Polypharmacy in elderly patients at discharge from the acute care hospital

OBJECTIVE

To investigate correlates of polypharmacy at discharge from wards of general medicine and geriatrics.

POPULATION

2465 patients enrolled in the Gruppo Italiano di Farmacovigilanza nell'Anziano (GIFA) study.

MAIN OUTCOME MEASURE

Polypharmacy, ie having more than 6 drugs prescribed at discharge.

METHODS

Data on drugs prescribed at home, during hospital stay, and at discharge were collected according to a validated procedure. Logistic regression analysis was used to identify independent correlates of polypharmacy at discharge. The adherence to current therapeutic guidelines was assessed for selected drugs (digitalis, diuretics, antithrombotics, bronchodilators)

RESULTS

The median number of prescribed drugs was 3.0 before admission and 4.0 at discharge (p < 0.001). Polypharmacy prior to admission (Odds Ratio [OR] 4.32, 95% Confidence Interval [CI] 3.13-5.96), cumulative comorbidity (OR 1.81, 95% CI 1.40-2.32) and selected chronicconditions (diabetes, heart failure, chronic obstructive pulmonary disease, renal insufficiency, and depression) were significant correlates of polypharmacy at discharge. Negative correlate of the outcome was the occurrence of adverse drug reactions prior to admission (OR 0.22, 95% CI 0.09-0.51). The rate of appropriate prescription reached 80% only for antithrombotics either at home or in hospital and at discharge.

CONCLUSIONS

Hospitalization increases drug prescription at discharge in elderly patients. Efforts are needed to identify the determinants and to assess the quality of this prescription practice, with the final aim of contrasting polypharmacy.

A population-based study on well-being in the very old: the role of cardiovascular diseases and drugs

Cardiovascular diseases constitute the most common health problems in very old people. Consequently, cardiovascular drugs are the medicines that are most frequently used by elderly subjects. Although many studies have examined the physiological effect and adverse reactions of these drugs, knowledge on their effect on emotional well-being is missing. The present study aims to examine the association between cardiovascular diseases and their medical treatment on the emotional well-being of very old people. We investigated a representative group of elderly subjects gathered from a population-based study (n=235). Participants were 84 years or older and cognitively intact (mini-mental state examination (MMSE) > or =24 points). Well-being was assessed with the positive and negative affect schedule (PANAS), measuring different mood categories. Cardiovascular diseases were diagnosed following the International Classification of Diseases. In this population the prevalence of cardiovascular diseases was high (62%). Multivariate regression analysis showed that while being affected by a cardiovascular disease did not affect the emotional well-being of the subjects (PANAS-PA, p=0.171; PANAS-NA, p=0.209), the use of some cardiovascular drugs showed an association. Cardiac glycosides (p=0.006) and nitrates (p=0.008) were associated with increased negative feelings. Due to high prevalence of cardiovascular diseases and use of cardiovascular medicines, this finding has relevance on the quality of life of elderly people. However, due to the nature of this study we cannot assess cause-effect relationship of this positive association. Therefore, the present findings suggest that there is a need for clinical studies in this increasing and limited studied age group.

The relationship of medication regimen to hospital readmissions for older adults with heart failure

The purpose of this part of a longitudinal study was to examine whether medication therapy for older adults with heart failure predicted days to readmission post-hospital discharge. Using a prospective, predictive design, a convenience sample included 127 older adults with heart failure who had been recently discharged from two hospitals in northeastern Ohio. One hundred five patients were prescribed diuretics, 49 angiotensin-converting enzyme inhibitors, 23 b blockers, and 47 digoxin. There were no significant differences between readmitted and non-readmitted patients with regard to the use of the specific classes of cardiac medications. None of the specific classes of cardiac medications predicted the number of days between the initial hospital discharge and readmission 3 months later. The use of a small, non-probability sample and exclusion of variables limit the results of the study. Effective case management with teaching about heart failure must address changes involved with heart failure and the use of medication therapy. More research is needed about treatment protocols in various regions of the United States.

[Study of drug prescribing in patients older than 65 in Languedoc-Roussillon]

PURPOSE

To analyse the medical prescriptions reimbursed by the Languedoc-Roussillon health care to the patient above 65 years old and analyse potential drugs interactions. To deduct the presenting actual educational modalities and information needed to ameliorate the quality of prescriptions for the elderly.

METHODS

The data from the second trimester 1999 were taken from the LR health care data base on pharmaceutical agents which records the prescriptions dispensed in the pharmacies by teletransmission of codes CIP (Club International Pharmaceutique). The drug interactions of the prescriptions for the elderly of 65 or above in January 1999 by the LR health care Gard region.

RESULTS

The prescriptions differ according to the sex and age. The drugs of psychotrope family and veinotonics (10% more) laxatives and NSAID's (2 to 3% more) for women. The majority of prescribed drugs diminish after a pick at the age of 85. The antihyperlipidemic drugs are an exception because their prescription diminishes immediately after 70's. The analyse of medical interactions shows lots of problem: sulfonylureas with fibrates (533 prescriptions), oral anticoagulant and fibrates (23), between sulfomylureas (273), or NSAID's (174) and a lot of contraindicated drugs (Ozidia 37).

CONCLUSIONS

Some medical treatments because of their large number of prescription need to be continually educated to the practitioners. Some drugs which are inadvisable because of their adverse effects have had an individual treatment. This database is a good way to analyse the drug iatrogeny and its prevention.

Inappropriate use of digoxin in older hospitalized heart failure patients

BACKGROUND

Older adults are more likely to suffer from the adverse effects of digoxin. Studies have described the inappropriate use of digoxin in various populations. The objective of this study was to determine the correlates of inappropriate digoxin use in older heart failure patients.

METHODS

We studied older hospitalized heart failure patients with documented left ventricular (LV) function evaluation and electrocardiography. Digoxin use was considered inappropriate if patients had preserved LV systolic function (ejection fraction greater > or =40%) or if they had no atrial fibrillation (AF). We compared baseline patient characteristics by indication for digoxin and tested statistical significance using Pearson's chi-square analysis and Student's t tests. Using logistic regression, we determined the correlates of inappropriate use and initiation of digoxin.

RESULTS

Subjects (N = 603) had a mean age of 79 (+/-7) years; 59% were women, and 18% were African American. A total of 376 patients (62%) were discharged on digoxin, and 223 (37%) had no indication for its use. Half of the patients without an indication for digoxin received the drug. Of 132 patients without an indication and not already on digoxin, 38 (29%) were initiated on it. After adjustment for various patient and care characteristics, prior digoxin use (adjusted odds ratio [OR] 11.47, 95% confidence interval [CI] 5.72-23.02) and pulse > or =100/min (adjusted OR 2.33, 95% CI 1.10-4.94) were associated with inappropriate digoxin use. Pulse > or =100/min was also associated with inappropriate initiation of the drug (adjusted OR 2.95, 95% CI 1.28-6.78).

CONCLUSIONS

Inappropriate use of digoxin was common and was associated with prior use. Tachycardia was associated with inappropriate use and initiation. Electrocardiography and echocardiography should be performed in all older heart failure patients. Digoxin therapy should not be initiated or continued in patients without any evidence of LV systolic dysfunction or chronic AF.