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Kim E, Kim S, Suh HS. Use of gastrointestinal prokinetics and the risk of parkinsonism: A population-based case-crossover study. Pharmacoepidemiol Drug Saf 2023; 32:1378-1386. [PMID: 37491627 DOI: 10.1002/pds.5668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 05/03/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND The disease burden of parkinsonism is extremely costly in the United States. Unlike Parkinson's disease, drug-induced parkinsonism (DIP) is acute and reversible; exploring the causative drug is important to prevent DIP in patients at high-risk of parkinsonism. OBJECTIVE To examine whether the use of gastrointestinal (GI) prokinetics is associated with an increased risk of parkinsonism. METHODS We conducted a case-crossover study using nationally representative data. We included patients who were newly diagnosed with parkinsonism (ICD-10 G20, G21.1, G25.1) between January 1, 2007 and December 1, 2015. The first prescription date of G20, G21.1, or G25.1 diagnoses was defined as the index date (0 day). Patients with prior extrapyramidal and movement disorders or brain tumors were excluded. We assessed the exposure within the risk (0-29 days) and control periods (60-89 days), before or on the index date. Conditional logistic regression estimated the adjusted odds ratio (aOR) for parkinsonism. RESULTS Overall, 2268 and 1674 patients were exposed to GI prokinetics during the risk and control periods, respectively. The use of GI prokinetics significantly increased the occurrence of parkinsonism (aOR = 2.31; 95% Confidence Interval [CI], 2.06-2.59). The use of GI prokinetics was associated with a higher occurrence of parkinsonism in elderly patients (≥65 years old; aOR = 2.69; 95% CI, 2.30-3.14) than in younger patients (aOR = 1.90; 95% CI, 1.59-2.27). CONCLUSIONS The use of GI prokinetics was significantly associated with higher occurrences of parkinsonism, necessitating close consideration when using GI prokinetics.
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Affiliation(s)
- Eunji Kim
- Department of Pharmacy, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Siin Kim
- College of Pharmacy, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation through Science (IRIS), Kyung Hee University, Seoul, Republic of Korea
| | - Hae Sun Suh
- College of Pharmacy, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation through Science (IRIS), Kyung Hee University, Seoul, Republic of Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
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Adrien O, Mohammad AK, Hugtenburg JG, McCarthy LM, Priester-Vink S, Visscher R, van den Bemt PMLA, Denig P, Karapinar-Carkıt F. Prescribing Cascades with Recommendations to Prevent or Reverse Them: A Systematic Review. Drugs Aging 2023; 40:1085-1100. [PMID: 37863868 PMCID: PMC10682291 DOI: 10.1007/s40266-023-01072-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND To reduce prescribing cascades occurring in clinical practice, healthcare providers require information on the prescribing cascades they can recognize and prevent. OBJECTIVE This systematic review aims to provide an overview of prescribing cascades, including dose-dependency information and recommendations that healthcare providers can use to prevent or reverse them. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Relevant literature was identified through searches in OVID MEDLINE, OVID Embase, OVID CINAHL, and Cochrane. Additionally, Web of Science and Scopus were consulted to analyze reference lists and citations. Publications in English were included if they analyzed the occurrence of prescribing cascades. Prescribing cascades were included if at least one study demonstrated a significant association and were excluded when the adverse drug reaction could not be confirmed in the Summary of Product Characteristics. Two reviewers independently extracted and grouped similar prescribing cascades. Descriptive summaries were provided regarding dose-dependency analyses and recommendations to prevent or reverse these prescribing cascades. RESULTS A total of 95 publications were included, resulting in 115 prescribing cascades with confirmed adverse drug reactions for which at least one significant association was found. For 52 of these prescribing cascades, information regarding dose dependency or recommendations to prevent or reverse prescribing cascades was found. Dose dependency was analyzed and confirmed for 12 prescribing cascades. For example, antipsychotics that may cause extrapyramidal syndrome followed by anti-parkinson drugs. Recommendations focused on dosage lowering, discontinuing medication, and medication switching. Explicit recommendations regarding alternative options were given for three prescribing cascades. One example was switching to ondansetron or granisetron when extrapyramidal syndrome is experienced using metoclopramide. CONCLUSIONS In total, 115 prescribing cascades were identified and an overview of 52 of them was generated for which recommendations to prevent or reverse them were provided. Nonetheless, information regarding alternative options for managing prescribing cascades was scarce.
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Affiliation(s)
- Oriane Adrien
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Atiya K Mohammad
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Lisa M McCarthy
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Leslie Dan Faculty of Pharmacy and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Robbert Visscher
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Fatma Karapinar-Carkıt
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands.
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, The Netherlands.
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Chen Z, Liu Z, Zeng L, Huang L, Zhang L. Research on prescribing cascades: a scoping review. Front Pharmacol 2023; 14:1147921. [PMID: 37465527 PMCID: PMC10350531 DOI: 10.3389/fphar.2023.1147921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
Background: The concept of prescribing cascades has been proposed for more than 20 years, but the research progress and cognitive level varied in different countries. The aim of this study was to systematically evaluate the current status of relevant original research on prescribing cascades, and to provide references for further research and continuous improvement in clinical practice. Methods: We searched three English databases and four Chinese databases from inception until January 2022. Relevant studies about prescribing cascades meeting the eligibility criteria were extracted independently by two reviewers, and a descriptive analysis was conducted to compare the methods and outcomes of the included studies. Results: A total of 32 studies involving 7,075,200 patients in 11 countries were included, including 13 cross-sectional studies, 11 case reports, 7 cohort studies, and 1 case-control study. The target population was mainly elderly people (24 studies). The purpose of the included studies could be divided into three categories: prevention (4 studies), identification (17 studies), and resolution (11 studies) of prescribing cascades. 49 prescribing cascade routes were identified and mainly attributed to the cardiovascular system, most primary diseases of which were dementia, the initial medications of prescribing cascades were mainly calcium channel blockers, and two to six drugs were involved in the prescribing cascade routes. Conclusion: Prescribing cascades have attracted more attention internationally and current studies have mainly focused on the elderly and their cardiovascular diseases and nervous diseases, but still not yet formed integral research in other special populations of drug use, such as children and pregnant women. It is necessary to further conduct in-depth studies with a broader range, and to establish a series of effective measures to decrease the incidence of prescribing cascades in the high-risk group of drug use.
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Affiliation(s)
- Zhe Chen
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Zheng Liu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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Doherty AS, Shahid F, Moriarty F, Boland F, Clyne B, Dreischulte T, Fahey T, Kennelly SP, Wallace E. Prescribing cascades in community-dwelling adults: A systematic review. Pharmacol Res Perspect 2022; 10:e01008. [PMID: 36123967 PMCID: PMC9485823 DOI: 10.1002/prp2.1008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/15/2022] Open
Abstract
The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.
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Affiliation(s)
- Ann S. Doherty
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Faiza Shahid
- Institute of General Practice and Family MedicineUniversity Hospital of Ludwig‐Maximilians‐University MunichMunichGermany
| | - Frank Moriarty
- School of Pharmacy and Biomolecular SciencesRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Fiona Boland
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
- Data Science CentreRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Barbara Clyne
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Tobias Dreischulte
- Institute of General Practice and Family MedicineUniversity Hospital of Ludwig‐Maximilians‐University MunichMunichGermany
| | - Tom Fahey
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Seán P. Kennelly
- Department of Medical GerontologyTrinity College DublinDublin 2Ireland
- Department of Age‐related HealthcareTallaght University HospitalDublin 24Ireland
| | - Emma Wallace
- Department of General PracticeUniversity College CorkCorkIreland
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Trenaman SC, Harding A, Bowles SK, Kirkland SA, Andrew MK. A Prescribing Cascade of Proton Pump Inhibitors Following Anticholinergic Medications in Older Adults With Dementia. Front Pharmacol 2022; 13:878092. [PMID: 35814221 PMCID: PMC9257131 DOI: 10.3389/fphar.2022.878092] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/30/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction: Prescribing cascade refers to use of a medication to treat a drug-related adverse event. Prescribing cascades increase medication use, cost, and risk of adverse events. Objective: Our objective was to use administrative health data to identify whether use of medications from the anticholinergic cognitive burden scale was associated with proton pump inhibitor (PPI) prescribing consistent with a prescribing cascade in older adults with dementia. Method: The cohort was comprised of Nova Scotia Seniors’ Pharmacare beneficiaries identified to have dementia and medication dispensation data recorded between 1 April 2010, or cohort entry and 31 March 2015. Anticholinergic medications from the anticholinergic cognitive burden scale (ACB) were abstracted. A look back period of 365 days identified if a PPI had been dispensed preceding anticholinergic dispensation. PPI initiation within 30, 60, 90, or 180 days of the anticholinergic medication was assessed. Demographic description of those dispensed anticholinergic medications or PPIs were reported. Risk factors for the prescribing cascade were investigated with logistic regression and Cox proportional hazards modelling including a sex-stratified analysis. Results: We identified 28,952 Nova Scotia Seniors’ Pharmacare beneficiaries with dementia and prescription dispensation data. Anticholinergic medications were frequently dispensed with 63.4% of the cohort dispensed at least one prescription for an anticholinergic medication. The prescribing cascade defined as up to 180-days between anticholinergic medication inititation and PPI dispensation, occurred in 1,845 Nova Scotia Seniors’ Pharmacare beneficiaries with dementia (incidence 6.4%). Multivariate regression showed those experiencing the prescribing cascade after initiating any anticholinergic were younger (OR 0.98, 95%CI [0.97–0.98]), less likely to live in an urban location (OR 0.82, 95%CI [0.74–0.91]), or to be men (OR 0.74, 95%CI [0.67–0.82]). Cox regression demonstrated an increased risk of starting a PPI within 180 days when initiating any medication from the ACB (HR 1.38, 95%CI [1.29–1.58]). Discussion: Regression modelling suggested that anticholinergic medications increased the risk of PPI dispensation consistent with a prescribing cascade in the cohort. The identification of the prescribing cascade in this population of older Nova Scotia Seniors’ Pharmacare Program beneficiaries with dementia using administrative health data highlights how routinely collected health data can be used to identify prescribing cascades.
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Affiliation(s)
- Shanna C. Trenaman
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
- *Correspondence: Shanna C. Trenaman,
| | | | - Susan K. Bowles
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Susan A. Kirkland
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Melissa K. Andrew
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
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Gareri P, Cotroneo AM, Pontieri MT, Palleria C, De Sarro G. The risk of polypharmacy and potentially inappropriate drugs in residential care dementia patients: tips from the PharE study. Aging Clin Exp Res 2021; 33:1909-17. [PMID: 33226608 DOI: 10.1007/s40520-020-01719-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/16/2020] [Indexed: 02/03/2023]
Abstract
AIMS The aims of the present study, conducted in two regions of Italy, Calabria and Piedmont, were to assess the use of inappropriate drugs according to the Beers Criteria and to study the possible drug-drug interactions. METHODS Data were obtained retrospectively from 972 residential care patients between 2016 and 2018. Mean age was 82.4 ± 8.4 years, with a prevalence of women (64.8%). Activities of daily living, instrumental activities of daily living, Mini-Mental State Examination, Cumulative Illness Rating Scale, Neuropsychiatric Inventory Scale and number and kind of drugs were recorded. A classification of potential inappropriate drugs was made according to the Beers criteria. Data were collected through an Excel file able to gather the main information. In the case of suspected adverse event, Naranjo Scale was applied. The study of possible drug-drug interactions was made by Micromedex 2.0. RESULTS Functional and cognitive impairments, comorbidities and number of drugs were assessed. The bivariate relationship between number of drugs and glomerular filtration rate assessed by CKD-EPI showed that the higher was the number of drugs used, the worst was kidney function assessment (p = 0.0001). The most frequent inappropriate drugs were anticholinergic drugs, tricyclics antidepressants, long-half-life benzodiazepines, antipsychotics and proton pump inhibitors. CONCLUSIONS These data are very interesting and show the need for an accurate choice of drugs in elderly people and for starting a wise deprescribing procedure.
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Trenaman SC, Bowles SK, Kirkland S, Andrew MK. An examination of three prescribing cascades in a cohort of older adults with dementia. BMC Geriatr 2021; 21:297. [PMID: 33964882 PMCID: PMC8106136 DOI: 10.1186/s12877-021-02246-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/27/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prescribing cascades are a source of inappropriate prescribing for older adults with dementia. We aimed to study three prescribing cascades in older Nova Scotians with dementia using administrative databases. METHODS Cohort entry for Nova Scotia Seniors' Pharmacare Program beneficiaries was the date of dementia diagnosis. Prescription drug dispensing data was extracted for inciting medication and second treatment (cholinesterase inhibitor and bladder anticholinergic, metoclopramide and Parkinson's disease medication, or calcium channel blocker (CCB) and diuretic) over the six-year period April 1, 2009 to March 31, 2015. In three separate analyses, dispensing an inciting medication signaled a look back of 365 days from the date of first dispensing to confirm that the second treatment was started after the inciting medication. The prescribing cascade was considered when the second treatment was started within 180 days of the inciting treatment. Sex differences in the prescribing cascade were tested using t-tests or chi square tests as appropriate. Both univariate (unadjusted) and multivariate (adjusted) logistic regression (adjusted for age, rurality, and sex) and Cox proportional hazards regression was used to identify risk factors for the prescribing cascade. RESULTS From March 1, 2005 to March 31, 2015, 28,953 Nova Scotia Seniors' Pharmacare beneficiaries with dementia (NSSPBD) were identified. There were 60 cases of bladder anticholinergics following cholinesterase inhibitors, 11 cases of Parkinson's disease medication following metoclopramide, and 289 cases of a diuretic following CCB in the cohort. Regression analysis demonstrated that risk of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were associated with female sex. Cox regression suggested that bladder anticholinergics were less often used by those on cholinesterase inhibitors and did not identify CCB use as leading more frequently to diuretic use. CONCLUSIONS The combination of diuretics following CCB was the most common prescribing cascade and bladder anticholinergics following cholinesterase inhibitors the second most common. However, exposure to the inciting medications did not increase risk of exposure to the second treatments. Combinations of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were more common for women raising concern that women may be at increased risk of these prescribing cascades.
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Affiliation(s)
- Shanna C Trenaman
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Susan K Bowles
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan Kirkland
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melissa K Andrew
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
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Singh S, Cocoros NM, Haynes K, Nair VP, Harkins TP, Rochon PA, Platt R, Dashevsky I, Reynolds J, Mazor KM, Bloomstone S, Anzuoni K, Crawford SL, Gurwitz JH. Identifying prescribing cascades in Alzheimer's disease and related dementias: The calcium channel blocker-diuretic prescribing cascade. Pharmacoepidemiol Drug Saf 2021; 30:1066-1073. [PMID: 33715299 DOI: 10.1002/pds.5230] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Prescribing cascades occur when a physician prescribes a new drug to address the side-effect of another drug. Persons with Alzheimer's disease and related dementias (ADRD) are at increased risk for prescribing cascades. Our objective was to develop an approach to estimating the proportion of calcium channel blocker-diuretic (CCB-diuretic) prescribing cascades among persons with ADRD in two U.S. health plans. METHODS We identified patients aged ≥50 on January 1, 2017, dispensed a drug to treat ADRD in the 365-days prior to/on cohort entry date. Patients had medical/pharmacy coverage for 1 year before and through cohort entry. We excluded individuals with an institutional stay encounter in the 45 days prior to cohort entry and censored patients based on: disenrollment from coverage, death, or end of data. We identified incident and prevalent CCB use in the 183-days following cohort entry, and identified subsequent incident diuretic use among incident and prevalent CCB-users within 365-days from cohort entry. RESULTS There were 121 538 eligible patients. Approximately 62% were female, with a mean age of 79.5 (SD ±8.6). Overall 2.1% of the cohort experienced a prevalent CCB-diuretic prescribing cascade with 1586 incident diuretic-users among 36 462 prevalent CCB-users (4.3%, 95% CI 4.1-4.6%]); and there were161 incident diuretic-users among 3304 incident CCB-users (4.9%, 95% CI 4.2-5.7%) (incident CCB-diuretic cascade). CONCLUSIONS We describe an approach to identify prescribing cascades in persons with ADRD, which can be used to assess the proportion of prescribing cascades in large cohorts. We determined the proportion of CCB-diuretic prescribing cascades was low.
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Affiliation(s)
- Sonal Singh
- Department of Family Medicine and Community Health, University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | | | - Vinit P Nair
- Humana Healthcare Research Inc. (Humana), Louisville, Kentucky, USA
| | | | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Inna Dashevsky
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Juliane Reynolds
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Kathleen M Mazor
- Department of Family Medicine and Community Health, University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Sarah Bloomstone
- Department of Family Medicine and Community Health, University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Kathryn Anzuoni
- Department of Family Medicine and Community Health, University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Sybil L Crawford
- Department of Family Medicine and Community Health, University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Jerry H Gurwitz
- Department of Family Medicine and Community Health, University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
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Singh S, Cocoros NM, Haynes K, Nair VP, Harkins TP, Rochon PA, Platt R, Dashevsky I, Reynolds J, Mazor KM, Bloomstone S, Anzuoni K, Crawford SL, Gurwitz JH. Antidopaminergic-Antiparkinsonian Medication Prescribing Cascade in Persons with Alzheimer's Disease. J Am Geriatr Soc 2021; 69:1328-1333. [PMID: 33432578 DOI: 10.1111/jgs.17013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Persons living with Alzheimer's disease (AD) may be at increased risk for prescribing cascades due to greater multimorbidity, polypharmacy, and the need for more complex care. Our objective was to assess the proportion of the antidopaminergic-antiparkinsonian medication prescribing cascades among persons living with Alzheimer's disease. SETTING Two large administrative claims databases in the United States. PARTICIPANTS We identified patients aged ≥50 on January 1, 2017, who were dispensed a drug used to treat Alzheimer's disease for at least 1 day in the 365 days prior to or on cohort entry date and who had medical and pharmacy coverage in the 365 days prior to the cohort entry date. We excluded individuals with a recent institutional stay. We identified incident antidopaminergic (antipsychotic/metoclopramide) use in the 183 days following cohort entry and identified subsequent incident antiparkinsonian drug use within 8 to 365 days. RESULTS There were 121,538 patients with Alzheimer's disease eligible for inclusion. Approximately 62% were women with a mean age of 79.5 (SD ± 8.6). The mean number of drugs dispensed was 9.2 (SD ± 4.9). There were 36 incident antiparkinsonian users among 4,534 incident antipsychotic/metoclopramide users (0.8%). CONCLUSION We determined that the proportion of antidopaminergic-antiparkinsonian medication prescribing cascades, widely considered as high-priority, was low. Our approach can be used to assess the proportion of prescribing cascades in populations considered to be at high risk and to prioritize system-level interventional efforts to improve medication safety in these patients.
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Affiliation(s)
- Sonal Singh
- University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | | | - Vinit P Nair
- Humana Healthcare Research Inc., (Humana), Louisville, Kentucky, USA
| | | | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Inna Dashevsky
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Juliane Reynolds
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Kathleen M Mazor
- University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Sarah Bloomstone
- University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Kathryn Anzuoni
- University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Sybil L Crawford
- University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - Jerry H Gurwitz
- University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA
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Farrell BJ, Jeffs L, Irving H, McCarthy LM. Patient and provider perspectives on the development and resolution of prescribing cascades: a qualitative study. BMC Geriatr 2020; 20:368. [PMID: 32977743 DOI: 10.1186/s12877-020-01774-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/15/2020] [Indexed: 01/19/2023] Open
Abstract
Background Prescribing cascades occur when the side effect of a medication is treated with a second medication. The aim of the study was to understand how prescribing cascades develop and persist and to identify strategies for their identification, prevention and management. Method This qualitative study employed semi-structured interviews to explore the existence of prescribing cascades and to gather patients', caregivers' and clinicians’ perspectives about how prescribing cascades start, persist and how they might be resolved. Participants were older adults (over age 65) at an outpatient Geriatric Day Hospital (GDH) with possible prescribing cascades (identified by a GDH team member), their caregivers, and healthcare providers. Data were analyzed using an inductive content analysis approach. Results Fourteen participants were interviewed (eight patients, one family caregiver, one GDH pharmacist, three GDH physicians and one family physician) providing a total of 22 interviews about patient-specific cases. The complexity and contextually situated nature of prescribing cascades created challenges for all of those involved with their identification. Three themes impacted how prescribing cascades developed and persisted: varying awareness of medications and cascades; varying feelings of accountability for making decisions about medication-related care; and accessibility to an ideal environment and relevant information. Actions to prevent, identify or resolve cascades were suggested. Conclusion Patients and healthcare providers struggled to recognize prescribing cascades and identify when they had occurred; knowledge gaps contributed to this challenge and led to inaction. Strategies that equip patients and clinicians with resources to recognize prescribing cascades and environmental and social supports that would help with their identification are needed. Current conceptualizations of cascades warrant additional refinement by considering the nuances our work raises regarding their appropriateness and directionality.
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