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Serina PT, Bounds M, Dandapani H, Carnes TC, Linnebur SA, Gomez Picazo J, Keene SE, Goldberg EM. Could digital pills improve medication adherence in persons living with dementia? A qualitative study. J Am Geriatr Soc 2024. [PMID: 38651668 DOI: 10.1111/jgs.18932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Peter T Serina
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Brown University, Center for Gerontology and Healthcare Research Providence, Rhode Island, USA
| | - Megan Bounds
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hari Dandapani
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Sunny A Linnebur
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jonathan Gomez Picazo
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sarah E Keene
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Orth LE, Feudtner C, Kempe A, Morris MA, Colborn KL, Gritz RM, Linnebur SA, Begum A, Feinstein JA. A coordinated approach for managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication Therapy Management (pMTM) randomized controlled trial. BMC Health Serv Res 2023; 23:414. [PMID: 37120509 PMCID: PMC10148507 DOI: 10.1186/s12913-023-09439-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] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Children with medical complexity (CMC) often rely upon the use of multiple medications to sustain quality of life and control substantial symptom burden. Pediatric polypharmacy (≥ 5 concurrent medications) is prevalent and increases the risk of medication-related problems (MRPs). Although MRPs are associated with pediatric morbidity and healthcare utilization, polypharmacy is infrequently assessed during routine clinical care for CMC. The aim of this randomized controlled trial is to determine if a structured pharmacist-led Pediatric Medication Therapy Management (pMTM) intervention reduces MRP counts, as well as the secondary outcomes of symptom burden and acute healthcare utilization. METHODS This is a hybrid type 2 randomized controlled trial assessing the effectiveness of pMTM compared to usual care in a large, patient-centered medical home for CMC. Eligible patients include all children ages 2-18 years old, with ≥ 1 complex chronic condition, and with ≥ 5 active medications, as well as their English-speaking primary caregivers. Child participants and their primary parental caregivers will be randomized to pMTM or usual care before a non-acute primary care visit and followed for 90 days. Using generalized linear models, the overall effectiveness of the intervention will be evaluated using total MRP counts at 90 days following pMTM intervention or usual care visit. Following attrition, a total of 296 CMC will contribute measurements at 90 days, which provides > 90% power to detect a clinically significant 1.0 reduction in total MRPs with an alpha level of 0.05. Secondary outcomes include Parent-Reported Outcomes of Symptoms (PRO-Sx) symptom burden scores and acute healthcare visit counts. Program replication costs will be assessed using time-driven activity-based scoring. DISCUSSION This pMTM trial aims to test hypotheses that a patient-centered medication optimization intervention delivered by pediatric pharmacists will result in lower MRP counts, stable or improved symptom burdens, and fewer cumulative acute healthcare encounters at 90 days following pMTM compared to usual care. The results of this trial will be used to quantify medication-related outcomes, safety, and value for a high-utilization group of CMC, and outcomes may elucidate the role of integrated pharmacist services as a key component of outpatient complex care programs for this priority pediatric population. TRIAL REGISTRATION This trial was prospectively registered at clinicaltrials.gov (NCT05761847) on Feb 25, 2023.
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Affiliation(s)
- Lucas E Orth
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Departments of Pediatrics and Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Allison Kempe
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Megan A Morris
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn L Colborn
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - R Mark Gritz
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sunny A Linnebur
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anowara Begum
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
| | - James A Feinstein
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA.
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Pearson SM, Osbaugh NA, Linnebur SA, Fixen DR, Brungardt A, Marcus AM, Lum HD. Implementation of Pharmacist Reviews to Screen for Potentially Inappropriate Medications in Patients With Cognitive Impairment. Sr Care Pharm 2021; 36:508-522. [PMID: 34593093 DOI: 10.4140/tcp.n.2021.508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To describe two pharmacist-led initiatives aimed to reduce potentially inappropriate medication (PIM) use in community-dwelling patients with dementia or cognitive impairment. Design: Retrospective, descriptive analysis of two clinical initiatives. Setting: Academic geriatric primary care clinics. Participants: Patients were included if they received a Memory Clinic pharmacist review May 1, 2017, to December 31, 2019, or a Living with Dementia (LWD) program pharmacist review November 15, 2018 to December 31, 2019 with provider follow-up within 6 months. Interventions: Both initiatives involved medication review by a clinical pharmacist to identify and make recommendations regarding medications that may contribute to cognitive impairment. The Memory Clinic served patients with concerns of cognitive impairment; whereas, the LWD program enrolled patients with an established diagnosis of dementia. Main Outcome Measure: Number of PIMs that could negatively impact cognition within each cohort. Additionally, 6-month implementation rates were analyzed for actionable pharmacist recommendations. RESULTS: Memory Clinic patients (n = 110) were taking an average of 2.4 PIMs; whereas, LWD patients (n = 40) were taking an average of 1.5 PIMs. Six-month implementation rates for all actionable pharmacist recommendations were 61.0% for the Memory Clinic and 42.4% for the LWD program. Specifically evaluating deprescribing recommendations, the 6-month PIM discontinuation rate was 63.6% for the Memory Clinic group and 60.0% for the LWD group. Conclusion: Pharmacists routinely identified PIMs during medication reviews, which led to successful recommendation implementation throughout multiple stages of cognitive decline. Both programs will continue to be adapted to ensure maximal impact.
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Bishop MM, Fixen DR, Linnebur SA, Pearson SM. Cognitive effects of vortioxetine in older adults: a systematic review. Ther Adv Psychopharmacol 2021; 11:20451253211026796. [PMID: 35186260 PMCID: PMC8851129 DOI: 10.1177/20451253211026796] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/02/2021] [Indexed: 11/17/2022] Open
Abstract
Many older adults experience a deterioration in cognitive function with aging, and this can have a negative impact on quality of life. Late-life depression has been linked to mild cognitive impairment and dementia, and treating depression with an agent that has procognitive effects could be beneficial. Vortioxetine is a novel antidepressant with a multimodal mechanism of action that works primarily via serotonin transporter inhibition, 5-HT1A receptor agonism and 5-HT3 receptor antagonism. A recent systematic review demonstrated procognitive effects of vortioxetine when indirectly compared with selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in adults aged 18-65 years with major depressive disorder. While this systematic review demonstrated promising procognitive effects from vortioxetine, the included studies did not enroll older adults, who are at the highest risk of cognitive impairment. Therefore, our systematic review sought to investigate the effects of vortioxetine on cognitive functioning in patients over the age of 65 years. Three studies met the prespecified search criteria and were evaluated. Overall, these preliminary data suggest that vortioxetine has promising effects in improving cognition in older adults with depressive symptoms and may have a place in therapy in older adults with depression and/or cognitive impairment, including Alzheimer's disease. Additional long-term studies that include more diverse populations with comorbidities and direct comparisons with other antidepressants are needed to fully understand the potential cognitive benefits in older adults.
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Affiliation(s)
- Makenna M Bishop
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Danielle R Fixen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Sunny A Linnebur
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Scott M Pearson
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Boulevard; Mail Stop C238, Aurora, CO 80045, USA
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Osbaugh NA, Pearson SM, Fixen DR, Hartley K, Parnes BL, Linnebur SA. Implementation of an interprofessional approach to assessment and care planning in ambulatory older adults with cognitive impairment. Alzheimers Dement 2020. [DOI: 10.1002/alz.041501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nicole A Osbaugh
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora CO USA
| | - Scott M Pearson
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora CO USA
- University of Colorado Health Seniors Clinic Aurora CO USA
| | - Danielle R Fixen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora CO USA
- University of Colorado Health Seniors Clinic Aurora CO USA
| | - Kirbie Hartley
- University of Colorado Health Seniors Clinic Aurora CO USA
| | - Bennett L Parnes
- University of Colorado Health Seniors Clinic Aurora CO USA
- University of Colorado School of Medicine Aurora CO USA
| | - Sunny A Linnebur
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora CO USA
- University of Colorado Health Seniors Clinic Aurora CO USA
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Berquist K, Linnebur SA, Fixen DR. Incorporation of Clinical Pharmacy Into a Geriatric Transitional Care Management Program. J Pharm Pract 2020; 33:661-665. [DOI: 10.1177/0897190019830502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Transitional care management (TCM) programs have been shown to decrease hospital readmission rates, health-care costs, and medication-related errors and adverse drug events. Pharmacists have been utilized during the medication reconciliation process, during admission, and after hospital discharge to prevent readmission and identify medication discrepancies. There is a lack of data utilizing clinical pharmacists in the geriatric patient population transitional care process after hospital discharge. Less is known about the depth of professional services a pharmacist can perform in the geriatric setting. We analyzed the scope of pharmacist-assisted implementation of transitional care. A total of 365 patients received the clinical pharmacist comprehensive medication review during a 14-month time period. During these reviews, clinical pharmacists identified more than 600 medication discrepancies and offered more than 1000 recommendations to the primary care physician. Additionally, specific medication classes that have been identified to increase the risk of adverse drug events, specifically in older adults, were identified and used to screen for adverse drug events. Using this list, clinical pharmacists were able to identify 39 adverse drug events. The implementation of clinical pharmacists into the TCM program was successful; however, full salary compensation is unlikely with TCM reimbursement alone.
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Affiliation(s)
- Karly Berquist
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Sunny A. Linnebur
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Danielle R. Fixen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Pearson SM, Tandon A, Fixen DR, Linnebur SA, Orosz GM, Parnes BL, Marcus AM, Billups SJ. Pharmacist-Led Transition of Care Pilot Targeting Older People After Emergency Department Discharge. Sr Care Pharm 2020; 35:273-282. [PMID: 32456757 DOI: 10.4140/tcp.n.2020.273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: To evaluate the impact of a pharmacist-led transitional care intervention targeting high-risk older people after an emergency department (ED) visit.<br/> DESIGN: Retrospective cohort study of older people with ED visits prior to and during a pharmacist-led intervention.<br/> SETTING: Patients receiving primary care from the University of Colorado Health Seniors Clinic.<br/> PARTICIPANTS: The intervention cohort comprised 170 patients with an ED visit between August 18, 2018, and February 19, 2019, and the historical cohort included 166 patients with an ED visit between August 18, 2017, and February 19, 2018. All included patients either had a historical diagnosis of heart failure or chronic obstructive pulmonary disease, or they had an additional ED visit in the previous six months.<br/> INTERVENTIONS: The pilot intervention involved postED discharge telephonic outreach and assessment by a clinical pharmacist, with triaging to other staff if necessary.<br/> MAIN OUTCOME MEASURE: The primary outcome was the proportion of patients with at least one repeat ED visit, hospitalization, or death within 30 days of ED discharge. Outcome rates were also assessed at 90 days postdischarge.<br/> RESULTS: The primary outcome occurred in 21% of the historical cohort and 25% of the intervention cohort (adjusted P-value = 0.48). The incidence of the composite outcome within 90 days of ED discharge was 43% in the historical group compared with 38% in the intervention group (adjusted P-value = 0.29).<br/> CONCLUSION: A pharmacist-led telephonic intervention pilot targeting older people did not appear to have a significant effect on the composite of repeat ED visit, hospitalization, or death within 30 or 90 days of ED discharge. A limited sample size may hinder the ability to make definitive conclusions based on these findings.
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Snellings MS, Linnebur SA, Pearson SM, Wallace JI, Saseen JJ, Fixen DR. Effectiveness of Methenamine for UTI Prevention in Older Adults. Ann Pharmacother 2019; 54:359-363. [DOI: 10.1177/1060028019886308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Methenamine is a drug used for the prevention of lower urinary tract infections (UTIs). However, efficacy has not been established in older adults or patients with varying degrees of kidney function. Objective: To evaluate the effectiveness of methenamine for the prevention of UTI in adults 60 years and older. Methods: This was a retrospective, pre-post, observational study. The study included primary care patients 60 years and older who were taking methenamine between January 1, 2015, and September 30, 2018. The primary outcome was the time to first UTI after methenamine initiation compared with the average time between UTIs in the 12 months prior to methenamine initiation. Results: Of 434 patients reviewed, 150 met inclusion criteria. The average time to UTI was 3.3 months prior to methenamine initiation compared with 5.5 months after methenamine initiation ( P = 0.0004). There were 33 patients (22%) who did not have a UTI after methenamine initiation. Also, 14 patients (9.3%) had a calculated CrCl <30 mL/min at baseline. The average time to UTI in these patients was 3.3 months prior to methenamine initiation compared with 12.7 months after initiation ( P < 0.0001). Conclusion and Relevance: Methenamine use was associated with a longer time to UTI in older adults with varying degrees of kidney function. The effectiveness of methenamine appeared to be similar regardless of kidney function, which is new evidence. Because of a lack of acquired resistance, methenamine may be an effective option for UTI prophylaxis in older adults.
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Boxer R, Norman M, Abadir P, Beizer JL, Dierich M, Lau S, Linnebur SA, Lundebjerg NE, Naik AD, Schreiber R, Unroe K, Mikhailovich AL, Goldstein AC. When Women Rise, We All Rise: American Geriatrics Society Position Statement on Achieving Gender Equity in Geriatrics. J Am Geriatr Soc 2019; 67:2447-2454. [PMID: 31573074 DOI: 10.1111/jgs.16195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 11/28/2022]
Abstract
Supporting gender equity for women working in geriatrics is important to the growth of geriatrics across disciplines and is critical in achieving our vision for a future in which we are all able to contribute to our communities and maintain our health, safety, and independence as we age. Discrimination can have a negative impact on public health, particularly with regard to those who care for the health of older Americans and other vulnerable older people. Women working in the field of geriatrics have experienced implicit and explicit discriminatory practices that mirror available data on the entire workforce. In this position article, we outline strategic objectives and accompanying practical recommendations for how geriatrics, as a field, can work together to achieve a future in which the rights of women are guaranteed and women in geriatrics have the opportunity to achieve their full potential. This article represents the official positions of the American Geriatrics Society. J Am Geriatr Soc 67:2447-2454, 2019.
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Affiliation(s)
- Rebecca Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | | | - Peter Abadir
- Division of Geriatrics Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judith L Beizer
- St John's University College of Pharmacy and Health Science, Queens, New York
| | - Mary Dierich
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Samantha Lau
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sunny A Linnebur
- University of Colorado Skaggs School of Pharmacy, Aurora, Colorado
| | | | - Aanand D Naik
- DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas
| | | | - Kathleen Unroe
- Indiana University School of Medicine, Indianapolis, Indiana
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Abstract
OBJECTIVE: To review clinical studies evaluating melatonin doses and their effects on sleep in adults 65 years of age and older. DATA SOURCES: The MEDLINE databases were searched (1946 to October 10, 2018) using the following Medical Subject Heading terms: melatonin and: sleep initiation and maintenance disorders, dyssomnia, sleep wake disorders, insomnia, sleep disorders intrinsic, and sleep disorders circadian rhythm. Sources were limited to English and human data. STUDY SELECTION/DATA EXTRACTION: An initial search resulted in 144 publications, with 25 included in this review. Studies were selected for full review based on design, mean age of participants, use of exogenous melatonin, and reports on any sleep-related outcome. DATA SYNTHESIS: Because of the side effect profiles of most prescription and nonprescription sleep aids, safe and effective alternative therapies are necessary. Based on the current literature, no dose-related response to sleep improvement has been identified for melatonin in older adults. Variations in melatonin formulation and dosages, as well as available tools to measure sleep outcomes, make it challenging to compare studies. CONCLUSIONS: This review evaluated a variety of melatonin doses, 0.5 mg to 10 mg, and their effects on sleep in older adults. The results varied, with some studies finding no difference in sleep outcomes when compared with placebo, while other studies found statistically significant improvements in sleep outcomes. Doses of melatonin between 1 mg and 6 mg appear to be effective for improving sleep in older adults; however, further studies are needed to find the optimal minimum effective dose.
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Huntsberry AM, Linnebur SA, Fixen DR, Saba LM, Saseen JJ. Effects of Chronic Proton-Pump Inhibitor Use on Kidney Function in Older Adults. Sr Care Pharm 2019; 34:325-333. [PMID: 31054591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE: Proton-pump inhibitors (PPIs) have been associated with adverse renal outcomes in older adults; however, there are little data regarding the magnitude of the change in renal function in this population. The objective of this study was to quantify the change in kidney function associated with chronic PPI therapy at two years in older adults using estimated glomerular filtration rate (eGFR).<br/> DESIGN: The study was a retrospective, pre/post, observational cohort.<br/> SETTING/PATIENTS/INTERVENTIONS/MAIN OUTCOME MEASURE(S): The study included University of Colorado Health primary care patients 60 to 89 years of age who were newly initiated on a PPI between August 1, 2012, and March 1, 2015, and remained on therapy for at least two years. The primary outcome was the change in kidney function, measured by eGFR, two years after starting PPI therapy. Secondary outcomes included change in kidney function and incidence of reduction in eGFR to < 60 mL/min/1.73 m² two years post-index date between patients with and without diabetes mellitus.<br/> RESULTS: Of 877 electronic health records reviewed, 100 patients met inclusion criteria. The mean change in eGFR was -6.15 mL/min/1.73 m² (standard error of the mean = 1.03) at two years compared with baseline<br/> (95% confidence interval -8.20 to -4.10; P < 0.0001). There were no differences in the secondary outcomes based on concomitant diabetes mellitus.<br/> CONCLUSIONS: Chronic PPI use was associated with a significant reduction in eGFR in ambulatory older adults at two years, beyond that expected based on increased age alone. Prescribers should be aware of the potential adverse renal effects of chronic PPI use.
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Huntsberry AM, Linnebur SA, Fixen DR, Saba LM, Saseen JJ. Effects of Chronic Proton-Pump Inhibitor Use on Kidney Function in Older Adults. Sr Care Pharm 2019. [DOI: 10.4140/tcp.n.2019.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: Proton-pump inhibitors (PPIs) have been associated with adverse renal outcomes in older adults; however, there are little data regarding the magnitude of the change in renal function in this population. The objective of this study was to quantify the change in kidney
function associated with chronic PPI therapy at two years in older adults using estimated glomerular filtration rate (eGFR).<br/> DESIGN: The study was a retrospective, pre/post, observational cohort.<br/> SETTING/PATIENTS/INTERVENTIONS/MAIN OUTCOME MEASURE(S): The
study included University of Colorado Health primary care patients 60 to 89 years of age who were newly initiated on a PPI between August 1, 2012, and March 1, 2015, and remained on therapy for at least two years. The primary outcome was the change in kidney function, measured by eGFR, two
years after starting PPI therapy. Secondary outcomes included change in kidney function and incidence of reduction in eGFR to < 60 mL/min/1.73 m2 two years post-index date between patients with and without diabetes mellitus.<br/> RESULTS: Of 877 electronic health
records reviewed, 100 patients met inclusion criteria. The mean change in eGFR was -6.15 mL/min/1.73 m2 (standard error of the mean = 1.03) at two years compared with baseline<br/> (95% confidence interval -8.20 to -4.10; P < 0.0001). There were no differences in
the secondary outcomes based on concomitant diabetes mellitus.<br/> CONCLUSIONS: Chronic PPI use was associated with a significant reduction in eGFR in ambulatory older adults at two years, beyond that expected based on increased age alone. Prescribers should be aware of the potential
adverse renal effects of chronic PPI use.
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Tandon A, Linnebur SA, Vejar MV. Identifying Cognitive Impairment in an Older Adult Using Two Different Screening Tools. ACTA ACUST UNITED AC 2018. [PMID: 30545433 DOI: 10.4140/tcp.n.2018.702.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A 78-year-old Hispanic woman presented to an ambulatory care clinic for older adults describing memory impairment and requesting an assessment of her cognitive status. A Mini-Mental State Examination (MMSE) was performed and found to be 29/30 (normal). One year later, the same situation occurred and her MMSE was again found to be 29/30 (normal). However, a Saint Louis University Mental Status (SLUMS) examination administered that same day demonstrated a different result: a score of 19/30 (dementia). Fourteen months later, the patient returned again and scored 26/30 (normal) on the MMSE and 22/30 (mild neurocognitive disorder) on the SLUMS. Our patient case illustrates inherent differences between the MMSE and SLUMS in the ability to detect mild cognitive impairment and dementia, along with the variability that may occur with testing.
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Tandon A, Linnebur SA, Vejar MV. Identifying Cognitive Impairment in an Older Adult Using Two Different Screening Tools. Consult Pharm 2018; 33:702-705. [PMID: 30545433 DOI: 10.4140/tcp.n.2018.702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A 78-year-old Hispanic woman presented to an ambulatory care clinic for older adults describing memory impairment and requesting an assessment of her cognitive status. A Mini-Mental State Examination (MMSE) was performed and found to be 29/30 (normal). One year later, the same situation occurred and her MMSE was again found to be 29/30 (normal). However, a Saint Louis University Mental Status (SLUMS) examination administered that same day demonstrated a different result: a score of 19/30 (dementia). Fourteen months later, the patient returned again and scored 26/30 (normal) on the MMSE and 22/30 (mild neurocognitive disorder) on the SLUMS. Our patient case illustrates inherent differences between the MMSE and SLUMS in the ability to detect mild cognitive impairment and dementia, along with the variability that may occur with testing.
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Fixen DR, Linnebur SA, Parnes BL, Vejar MV, Vande Griend JP. Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic. Am J Health Syst Pharm 2018; 75:1805-1811. [DOI: 10.2146/ajhp170723] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Danielle R. Fixen
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Sunny A. Linnebur
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Bennett L. Parnes
- Division of Geriatrics, University of Colorado School of Medicine, Aurora, CO
| | - Maria V. Vejar
- Division of Geriatrics, University of Colorado School of Medicine, Aurora, CO
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Reynolds IR, Fixen DR, Parnes BL, Lum HD, Shanbhag P, Church S, Linnebur SA, Orosz G. Characteristics and Patterns of Marijuana Use in Community-Dwelling Older Adults. J Am Geriatr Soc 2018; 66:2167-2171. [PMID: 30291748 PMCID: PMC6476562 DOI: 10.1111/jgs.15507] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 02/12/2018] [Accepted: 05/18/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To understand patterns of marijuana use in community-dwelling older adults in Colorado. DESIGN Anonymous survey. SETTING Two academic geriatric primary care clinics. PARTICIPANTS English-speaking individuals. MEASUREMENTS We assessed self-reported characteristics and patterns of marijuana use and effect on targeted symptoms. Survey analysis focused on current users, defined as individuals who had used marijuana in the past 3 years. RESULTS Three hundred forty-five individuals completed the survey (55% response rate); 113 (32%) had used marijuana in the past, of whom 55 (16%) had used since legalization. More than half of current users were aged 75 and older, and one-quarter were aged 85 and older. Most current users were white women. Of current users, 44% used marijuana products at least weekly for common conditions including chronic pain, depression, anxiety, and insomnia, and most found marijuana helpful for these conditions. Most respondents reported obtaining marijuana recreationally (67%) without a prescription. Nine respondents reported negative side effects attributable to marijuana use. CONCLUSION To our knowledge, this is the first study to characterize marijuana use of older adults in a state in which it is legal for medical and recreational use. Marijuana was used for several common geriatric conditions, and respondents reported few side effects. The small number of survey respondents, the lack of generalizability in states where marijuana sales are illegal, and participation bias were the main study limitations. Further research is needed to better understand useful or harmful effects in this population. J Am Geriatr Soc 66:2167-2171, 2018.
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Affiliation(s)
- Ian R. Reynolds
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Danielle R. Fixen
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bennett L. Parnes
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Hillary D. Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Skotti Church
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Sunny A. Linnebur
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gretchen Orosz
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Abstract
An 84-year-old woman presented to her primary care physician with an unexplained 4-month history of weight and appetite loss after initiation of dofetilide 125 mcg orally twice daily for atrial fibrillation. She was noted to have lost 2.5 kg, which was a 3.6% decrease from her initial body weight of 69.4 kg. After excluding other etiologies for her anorexia, such as medication changes or changes in other diseases or conditions, her primary care physician and cardiologists elected to continue dofetilide but monitor the patient's appetite and body weight. After 7 months of dofetilide use with persistent appetite loss, the cardiology team discontinued dofetilide. Continued weight loss was observed until approximately 1 month after stopping dofetilide, with a maximum weight loss of 2.9 kg or a 4.2% decrease. Improvements in appetite were reported 2 months after discontinuing dofetilide, with minor increases in weight that eventually stabilized. In this case, while taking dofetilide, the patient experienced anorexia leading to weight loss that subsided after discontinuation of the drug. Based on the temporal association between the patient's changes in appetite and body weight and treatment with dofetilide, the drug was most likely the cause of the patient's anorexia. We are unaware of other reports of anorexia associated with dofetilide, but clinicians may want to consider the drug as a potential cause for otherwise unexplained changes in appetite or body weight.
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Affiliation(s)
- Jerald V Felipe
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Danielle R Fixen
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, 12850 E. Montview Blvd (C238), Aurora, CO 80045, USA
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Abstract
An increased risk of bacterial resistance toward fluoroquinolones and the increased risk of disabling and serious adverse effects prompted the US Food and Drug Administration to recommend limiting fluoroquinolone use to the treatment of community-acquired pneumonia, skin and skin-structure infections, bacterial sinusitis, plague, chronic bronchitis exacerbations, and complicated intra-abdominal infections. We report a case of moxifloxacin-induced tinnitus in an older adult prescribed oral moxifloxacin 400 mg for 5 days for the treatment of acute diverticulitis, due to allergies to nonfluoroquinolone preferred agents. A thorough literature review provided few other reported incidents of this rare and serious adverse event.
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Affiliation(s)
- Amber Onoh
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Sunny A Linnebur
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Danielle R Fixen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Mail Stop C-238, V20-2127, Aurora, CO 80045, USA
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Affiliation(s)
| | - Joseph T Hanlon
- Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania
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Wettergreen SA, Brunner J, Linnebur SA, Borgelt LM, Saseen JJ. Comparison of faculty assessment and students' self-assessment of performance during clinical case discussions in a pharmacotherapy capstone course. Med Teach 2018; 40:193-198. [PMID: 29117750 DOI: 10.1080/0142159x.2017.1397271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The primary objective of this study was to compare faculty assessment and third year students' self-assessment of performance in clinical case discussions. The secondary objective was to evaluate if student characteristics influence self-assessments. METHODS This retrospective analysis compared faculty and student self-assessment scores for two clinical case discussions using Spearman's correlation and Wilcoxon's signed ranks test. Chi-squared test was used to compare frequency of faculty and student self-assessments indicating the highest possible rating for the pooled score and for each individual component. The pooled score included three individual components: level of engagement, quality of contribution, and professionalism. RESULTS Pooled faculty and student self-assessments correlated for both the first (r = 0.41, p < 0.001) and second (r = 0.35; p < 0.001) clinical case discussions. The frequency that faculty and student self-assessment ratings were the highest possible pooled score was similar for both the first (51.3% vs. 44.7%, respectively, p = 0.25) and second (58.6% vs. 47.4%, p = 0.05) clinical case discussions. Student characteristics (age, gender, and grade point average at graduation) did not influence self-assessments. CONCLUSIONS Students' self-assessment correlated with faculty assessment of performance during clinical case discussions. Increased use of self-assessments for professional development in pharmacy and other healthcare professional curricula should be considered.
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Affiliation(s)
- Sara A Wettergreen
- a Department of Pharmacotherapy , University of North Texas System College of Pharmacy , Fort Worth , TX , USA
| | - Jason Brunner
- b Department of Clinical Pharmacy , Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Sunny A Linnebur
- b Department of Clinical Pharmacy , Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Laura M Borgelt
- b Department of Clinical Pharmacy , Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Joseph J Saseen
- b Department of Clinical Pharmacy , Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus , Aurora , CO , USA
- c Department of Family Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
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Xu D, Anderson HD, Tao A, Hannah KL, Linnebur SA, Valuck RJ, Culbertson VL. Assessing and predicting drug-induced anticholinergic risks: an integrated computational approach. Ther Adv Drug Saf 2017; 8:361-370. [PMID: 29090085 PMCID: PMC5638173 DOI: 10.1177/2042098617725267] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/19/2017] [Indexed: 11/17/2022] Open
Abstract
Background: Anticholinergic (AC) adverse drug events (ADEs) are caused by inhibition of muscarinic receptors as a result of designated or off-target drug–receptor interactions. In practice, AC toxicity is assessed primarily based on clinician experience. The goal of this study was to evaluate a novel concept of integrating big pharmacological and healthcare data to assess clinical AC toxicity risks. Methods: AC toxicity scores (ATSs) were computed using drug–receptor inhibitions identified through pharmacological data screening. A longitudinal retrospective cohort study using medical claims data was performed to quantify AC clinical risks. ATS was compared with two previously reported toxicity measures. A quantitative structure–activity relationship (QSAR) model was established for rapid assessment and prediction of AC clinical risks. Results: A total of 25 common medications, and 575,228 exposed and unexposed patients were analyzed. Our data indicated that ATS is more consistent with the trend of AC outcomes than other toxicity methods. Incorporating drug pharmacokinetic parameters to ATS yielded a QSAR model with excellent correlation to AC incident rate (R2 = 0.83) and predictive performance (cross validation Q2 = 0.64). Good correlation and predictive performance (R2 = 0.68/Q2 = 0.29) were also obtained for an M2 receptor-specific QSAR model and tachycardia, an M2 receptor-specific ADE. Conclusions: Albeit using a small medication sample size, our pilot data demonstrated the potential and feasibility of a new computational AC toxicity scoring approach driven by underlying pharmacology and big data analytics. Follow-up work is under way to further develop the ATS scoring approach and clinical toxicity predictive model using a large number of medications and clinical parameters.
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Affiliation(s)
- Dong Xu
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, 1311 East Central Drive, Meridian, ID 83642, USA
| | - Heather D Anderson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Aoxiang Tao
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, ID, USA
| | - Katia L Hannah
- School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert J Valuck
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vaughn L Culbertson
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, Idaho State University, 1311 East Central Drive, Meridian, ID 83642, USA
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Norman JL, Fixen DR, Saseen JJ, Saba LM, Linnebur SA. Zolpidem prescribing practices before and after Food and Drug Administration required product labeling changes. SAGE Open Med 2017; 5:2050312117707687. [PMID: 28515934 PMCID: PMC5423710 DOI: 10.1177/2050312117707687] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/10/2017] [Indexed: 11/24/2022] Open
Abstract
Background: Women have higher morning serum zolpidem concentrations than men after taking an evening dose, potentially leading to increased risk of harm. On 19 April 2013, the United States Food and Drug Administration required labeling changes for zolpidem, recommending an initial dose of no greater than 5 mg (immediate release) or 6.25 mg (controlled release) per night in women. Objectives: The primary objective of this study was to compare prescribing practices before and after the 2013 zolpidem labeling change. A secondary objective was to evaluate serious adverse events potentially related to zolpidem. Methods: Electronic medical records of adults receiving care through the University of Colorado Health system were accessed for study inclusion if patients were provided a first-time prescription for zolpidem either prior to or after the Food and Drug Administration labeling change. Patients were randomly chosen from eight strata based on age, gender, and date of zolpidem initiation (before/after the labeling change). Demographic and zolpidem prescribing data were collected. Low-dose zolpidem was considered 5 mg (immediate release) or 6.25 mg (controlled release) daily or less. Documentation of potentially related serious adverse events within the patients’ records was also evaluated. Results: A total of 400 patients were included in the study. The overall percentage of patients prescribed low-dose zolpidem increased from 44% to 58% after the labeling change (p = 0.0020). In a pre-specified subgroup analysis, the percentage of patients prescribed low-dose zolpidem increased in all groups, including young men (38%–50%, p = 0.23), elderly men (34%–40%, p = 0.53), and elderly women (60%–74%, p = 0.14), but the change was only significant in young women (42%–70%, p = 0.0045). Conclusion: After Food and Drug Administration–mandated labeling changes for zolpidem in 2013, the percentage of overall patients in our health system, and specifically young women, with initial prescriptions for low-dose zolpidem significantly increased as compared to before the labeling change.
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Affiliation(s)
| | - Danielle R Fixen
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Joseph J Saseen
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura M Saba
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Cobretti MR, Page RL, Linnebur SA, Deininger KM, Ambardekar AV, Lindenfeld J, Aquilante CL. Medication regimen complexity in ambulatory older adults with heart failure. Clin Interv Aging 2017; 12:679-686. [PMID: 28442898 PMCID: PMC5396835 DOI: 10.2147/cia.s130832] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in "young-old" (60-74 years) versus "old-old" (75-89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM). PATIENTS AND METHODS Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60-89 years with heart failure. Medications were categorized into three types - heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications - and scored using the pMRCI tool. RESULTS The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3-84) and total medication counts (13.3±4.8, range 2-30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications. CONCLUSION Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population.
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Affiliation(s)
| | - Robert L Page
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | | | - Amrut V Ambardekar
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, CO
| | - JoAnn Lindenfeld
- Advanced Heart Failure and Cardiac Transplant Program, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA
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Saseen JJ, Linnebur SA, Borgelt LM. A Pharmacotherapy Capstone Course to Target Student Learning and Programmatic Curricular Assessment. Am J Pharm Educ 2017; 81:45. [PMID: 28496265 PMCID: PMC5423061 DOI: 10.5688/ajpe81345] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/11/2016] [Indexed: 05/22/2023]
Abstract
Objective. To describe how a pharmacotherapy capstone course was used for student learning and programmatic curricular assessment. Design. A pharmacotherapy capstone course was included in the University of Colorado curriculum for 13 years from 2002 through 2014. This 9-credit hour course was the last course prior to Advanced Pharmacy Practice Experiences (APPEs). Students were held accountable for prior learning using complex patient cases and other activities that are seen in APPEs. Application of knowledge, skills, and critical thinking were integrated in this course using exclusively active learning methodologies. Students were expected to actively participate and learn independently, from peers and through self-assessment. Assessment. Evidence of student learning was demonstrated based on student performance on written and verbal evaluations analyzed from 2012 to 2014. Survey and self-evaluation data indicated that students learned within the course. An increase in student confidence in critical thinking, problem-solving, decision making, and lifelong learning was also seen during APPEs. Student performance in this course prompted changes to prerequisite courses and guided development of a renewed curriculum. Conclusion. The University of Colorado pharmacotherapy capstone course prepared students for the rigor of APPEs, provided insight that facilitated improvements in prerequisite courses, and was a nexus for the development of a renewed curriculum, which includes a new clinical capstone course.
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Trujillo JM, McNair CD, Linnebur SA, Valdez C, Trujillo TC. The Impact of a Standalone, Patient-centered Communication Course Series on Student Achievement, Preparedness, and Attitudes. Am J Pharm Educ 2016; 80:174. [PMID: 28179723 PMCID: PMC5289730 DOI: 10.5688/ajpe8010174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/22/2016] [Indexed: 06/06/2023]
Abstract
Objective. To evaluate the impact of a standalone, patient-centered communication (PCC) course series on student achievement of and perceived preparedness for PCC skills and to assess student attitudes regarding learning methods used. Design. During curriculum renewal, a standalone PCC course series that integrated horizontally and vertically within the curriculum was developed. Student achievement of outcomes was evaluated by aggregate performance on simulated evaluations. Students who completed the PCC series were surveyed to assess preparedness and attitudes. Students in the prior curriculum were also surveyed. Assessment. The majority of students who completed the PCC series met or exceeded expectations for the simulated evaluations. Preparedness responses were more positive from students who completed the PCC series than from those who completed the prior curriculum. Student attitudes about the learning methods use in the courses also were more positive. Conclusion. The standalone PCC course series effectively achieved PCC outcomes and improved student preparedness for communication-based activities.
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Affiliation(s)
- Jennifer M Trujillo
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Chelsea D McNair
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Sunny A Linnebur
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Connie Valdez
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Toby C Trujillo
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
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Abstract
Objective: To describe a case of a patient experiencing testicular pain on 3 occasions after taking 3 different statins. Case Summary: A 54-year-old man with hyperlipidemia was started on lovastatin therapy. His other medications included aspirin, levothyroxine, buspirone, and atenolol. Seven months after starting lovastatin, the patient experienced testicular discomfort that resolved upon discontinuation of the drug. Afterward, he started simvastatin and again experienced testicular discomfort. The simvastatin was changed to atorvastatin, and the pain resolved. However, 3 months after starting atorvastatin, the patient developed testicular pain, which resolved after the drug was stopped. During each of the episodes, the patient's pain increased when he was sitting, driving, or wearing tight clothing. The Naranjo probability scale indicates that statins probably caused the patient's pain. Discussion: Testicular pain is rarely caused by medications. Product labeling for statins does not list urinary adverse events as common. However, labeling for atorvastatin and pravastatin lists rare urologic adverse effects. A literature search did not reveal any previously reported cases of testicular adverse effects from statins. However, statins have been shown to inhibit cholesterol synthesis in the testis. Some data indicate that statins reduce serum testosterone concentrations, but other data indicate that statins have no effect on sex hormones or spermatogenesis. Data are also available indicating that aspirin might affect testosterone concentrations and testicular function. It is difficult to know whether either of the above hormonal mechanisms was associated with our patient's testicular discomfort, but the time course and challenge/rechallenge aspects of the case suggest that the statins were the cause. Conclusions: Urologic adverse effects of statins rarely occur but should not be overlooked by medical providers.
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Affiliation(s)
- Sunny A Linnebur
- Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262, USA.
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28
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Abstract
The “Newest Vital Sign” (NVS) is a validated health literacy assessment tool typically administered by clinicians. The objective of this study was to assess if the NVS could be self-administered in adolescents to measure health literacy. Sixth graders in a Colorado middle school were provided a self-administered survey containing the NVS, a section for parent permission, and a section for the student’s age, gender, grade, and previous elementary school. In all, 167 sixth graders returned usable surveys (45% return rate), and the average health literacy score was 3.75 ± 1.70. Almost two thirds (62.9%) of the students scored in the adequate health literacy range, while only 12.6% scored in the limited health literacy range. Health literacy scores were similar when evaluated based on gender. However, when students were grouped based on prior elementary school attendance, students who matriculated from one elementary school had an average NVS score significantly lower than two other elementary schools (p < .001 and p < .05). Self-administration of the NVS was successful and showed similar health literacy scores compared to other studies in adolescents. Using the NVS as a self-administered tool could greatly increase its function as a quick health literacy assessment for adolescents, both in clinical practice and in school-based health education.
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Ginde AA, Blatchford P, Breese K, Zarrabi L, Linnebur SA, Wallace JI, Schwartz RS. High-Dose Monthly Vitamin D for Prevention of Acute Respiratory Infection in Older Long-Term Care Residents: A Randomized Clinical Trial. J Am Geriatr Soc 2016; 65:496-503. [PMID: 27861708 DOI: 10.1111/jgs.14679] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the efficacy and safety of high-dose vitamin D supplementation for prevention of acute respiratory infection (ARI) in older long-term care residents. DESIGN Randomized controlled trial investigating high-dose vs standard-dose vitamin D from 2010 to 2014. SETTING Colorado long-term care facilities. PARTICIPANTS Long-term care residents aged 60 and older (n = 107). INTERVENTION The high-dose group received monthly supplement of vitamin D3 100,000 IU, the standard-dose group received a monthly placebo (for participants taking 400-1,000 IU/d as part of usual care) or a monthly supplement of 12,000 IU of vitamin D3 (for participants taking <400 IU/d as part of usual care). MEASUREMENTS The primary outcome was incidence of ARI during the 12-month intervention. Secondary outcomes were falls and fractures, 25-hydroxyvitamin D levels, hypercalcemia, and kidney stones. RESULTS Participants (55 high dose, 52 standard dose) were randomized and included in the final analysis. The high-dose group had 0.67 ARIs per person-year and the standard-dose group had 1.11 (incidence rate ratio (IRR) = 0.60, 95% confidence interval (CI) = 0.38-0.94, P = .02). Falls were more common in the high-dose group (1.47 per person-year vs 0.63 in standard-dose group; IRR = 2.33, 95% CI = 1.49-3.63, P < .001). Fractures were uncommon and similar in both groups (high dose 0.10 vs standard dose 0.19 per person-year; P = .31). Mean trough 25-hydroxyvitamin D levels during the trial were 32. ng/mL in the high-dose group and 25.1 ng/mL in the standard-dose group. There was no hypercalcemia or kidney stones in either group. CONCLUSION Monthly high-dose vitamin D3 supplementation reduced the incidence of ARI in older long-term care residents but was associated with a higher rate of falls without an increase in fractures.
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Affiliation(s)
- Adit A Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Patrick Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado.,Geriatric Research, Education and Clinical Center, Eastern Colorado Department of Veterans Affairs, Denver, Colorado
| | - Keith Breese
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Lida Zarrabi
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado.,Division of Geriatric Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jeffrey I Wallace
- Division of Geriatric Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Robert S Schwartz
- Geriatric Research, Education and Clinical Center, Eastern Colorado Department of Veterans Affairs, Denver, Colorado.,Division of Geriatric Medicine, School of Medicine, University of Colorado, Aurora, Colorado
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Hess C, Linnebur SA, Rhyne DN, Valdez CA. Over-the-Counter Drugs to Avoid in Older Adults with Kidney Impairment. Nephrol Nurs J 2016; 43:389-400. [PMID: 30550067] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Older adults (age 65 years or older) are at especially high risk of having adverse events from over-the-counter (OTC) drugs, and older adults who have kidney disease are at an even higher risk. These older adults with kidney impairment may need to completely avoid, or at the least reduce, their exposure to certain OTC products, such as nonsteroidal inhibitors. When older adults with kidney impairment are counseled about the safety of OTC drugs, they need to be made aware that some drugs may also require dose adjustments. Several categories of drugs that commonly require dosage changes include antihistamines, histamine-2 receptor antagonists, oral decongestants, codeine, and a few gastrointestinal drugs. Another concern is for the possibility of there being a drug-drug interaction between an OTC medication and a prescription drug. Careful consideration needs to be paid to the choice of drugs given to older adults. Patient education is essential to reduce the occurrence of adverse events.
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Affiliation(s)
- Chelsey Hess
- Fourth-Year Pharmacy Student, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, at the time of this writing
| | - Sunny A Linnebur
- Professor, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Danielle N Rhyne
- Assistant Professor, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Connie A Valdez
- Associate Professor, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
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Abstract
As the number of unused household medications within the United States continues to rise, so does the need for proper education among patients and health care professionals on proper drug disposal. Consumers have been provided conflicting directions on how to properly dispose of medications; as a result, harmful and unsafe disposal practices have been used that increased the risk for diversion and environmental damage. Recently, several governmental agencies have published recommendations for household medication disposal, and the number of national and statewide drug take-back programs has increased. Although these programs now have taken hold, consumers are often unaware of their presence or benefit. Pharmacists have a unique opportunity to educate the public and themselves on the importance of proper medication disposal as well as the programs available for patients to access.
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Affiliation(s)
- Kathleen M Athern
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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Abstract
OBJECTIVE To describe the prevalence of hyponatremia in older adults related to antidepressive agents and identify potential alternative options in older adults with a low-baseline serum sodium concentration and/or when a patient has experienced hyponatremia as a result of taking an antidepressant. DATA SOURCES A PubMed search was conducted on November 10, 2015. Search terms included: antidepressive agents, antidepressive agents second-generation, bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, hyponatremia, milnacipran, mirtazapine, paroxetine, reboxetine, syndrome of inappropriate antidiuretic hormone, sertraline, trazodone, venlafaxine, and vilazodone. Filters included English language. A search of product labeling was also conducted. STUDY SELECTION Out of 363 results, 124 publications were identified and reviewed along with 11 additional references. Publications were chosen based on relevance to the review: case reports of patients 60 years of age or older or clinical investigations of the association between hyponatremia and antidepressants in older adults. DATA EXTRACTION Hyponatremia was counted as an adverse effect if an antidepressant was the likely cause of hyponatremia, and hyponatremia was resolved after withdrawal. DATA SYNTHESIS Antidepressant-induced hyponatremia in older adults is fairly common. Selective serotonin reuptake inhibitors, serotonin/norepinephrine reuptake inhibitors, and mirtazapine were implicated in the majority of the case reports and clinical studies evaluating older adults. Bupropion, trazodone, and tricyclic antidepressants were implicated less often in the same literature. CONCLUSION Given its unique mechanism of action, bupropion may be the most appropriate antidepressant for older adults at risk for antidepressant-induced hyponatremia.
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Fixen CW, Saseen JJ, Vande Griend JP, Linnebur SA. Assessment of blood pressure in patients with hypertension aged 60-79 years before and after the publication of the 2014 Eighth Joint National Committee report. Ther Adv Cardiovasc Dis 2015; 10:67-73. [PMID: 26680558 DOI: 10.1177/1753944715621000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES In late 2013, the Joint National Committee (JNC 8) published hypertension treatment recommendations endorsing a goal blood pressure (BP) of < 150/90 mmHg starting at age 60 years. This was in contrast to other cardiovascular groups recommending age 80 years for this BP goal. This study examined mean BP in patients from age 60 years to 79 years with hypertension before and after publication of the JNC 8 recommendations. METHODS This retrospective cohort study examined mean BP and number of antihypertensives for a period of 1 year before and after the release of the JNC 8 report. Patients aged 60-79 years with hypertension receiving care at a University of Colorado Hospital primary care clinic were included. Patients with diabetes, chronic kidney disease, or kidney transplant were excluded. A total of 150 BP measurements were included in each of the before and after time frames. The primary outcomes were change in mean BP and number of antihypertensives. RESULTS A total of 171 patients met the criteria and were included in the study. Most had BPs in both the before and after time frames. Mean BP values were similar in the before and after groups (130.2/75.9 mmHg versus 131.5/76.6, respectively; p = 0.27/p = 0.46). Mean number of antihypertensives were similar in the before and after groups (1.95 versus 1.93, respectively; p = 0.79). CONCLUSIONS Over 1 year at an academic health system, new recommendations from the JNC 8 did not affect mean BP or number of antihypertensives in older patients with hypertension. A similar investigation after more time or in patients with newly diagnosed hypertension may help determine the full impact.
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Affiliation(s)
- Cy W Fixen
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Joseph J Saseen
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences and Department of Family Medicine, School of Medicine, Aurora, CO, USA
| | - Joseph P Vande Griend
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences and Department of Family Medicine, School of Medicine, Aurora, CO, USA
| | - Sunny A Linnebur
- University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Mailstop C238, Aurora, CO 80045, USA
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Abstract
Purpose The purpose of this study is to describe a case report of a patient experiencing hyponatremia from trimethoprim–sulfamethoxazole (TMP–SMX) upon initial use and subsequent rechallenge. Summary An 82-year-old woman presented to the emergency department with altered mental status thought to be due to complicated cystitis and was treated with TMP–SMX 160 mg/800 mg orally twice daily for 7 days. Her basic metabolic panel prior to initiation of TMP–SMX was within normal limits, with the exception of her serum sodium of 132 mmol/L (range 133–145 mmol/L). The day after completing her 7-day course of TMP–SMX therapy the patient was evaluated by her primary care provider and another basic metabolic panel revealed a reduction in the serum sodium to 121 mmol/L. The patient’s serum sodium concentrations increased to baseline 7 days after completion of the TMP–SMX therapy, and remained normal until she was treated in the emergency department several months later for another presumed urinary tract infection. She was again started on TMP–SMX therapy empirically, and within several days her serum sodium concentrations decreased from 138 mmol/L to a low of 129 mmol/L. The TMP–SMX therapy was discontinued upon negative urine culture results and her serum sodium increased to 134 mmol/L upon discharge. Based upon the Naranjo probability scale score of 9, TMP–SMX was the probable cause of the patient’s hyponatremia. Conclusion Our patient developed hyponatremia from TMP–SMX therapy upon initial use and rechallenge. Although hyponatremia appears to be rare with TMP–SMX therapy, providers should be aware of this potentially life-threatening adverse event.
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Affiliation(s)
- Ashley M Huntsberry
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Sunny A Linnebur
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Maria Vejar
- Division of Geriatrics, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Hildreth KL, Van Pelt RE, Moreau KL, Grigsby J, Hoth KF, Pelak V, Anderson CA, Parnes B, Kittelson J, Wolfe P, Nakamura T, Linnebur SA, Trujillo JM, Aquilante CL, Schwartz RS. Effects of pioglitazone or exercise in older adults with mild cognitive impairment and insulin resistance: a pilot study. Dement Geriatr Cogn Dis Extra 2015; 5:51-63. [PMID: 25852732 PMCID: PMC4361908 DOI: 10.1159/000371509] [Citation(s) in RCA: 30] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIMS To examine the effects of pioglitazone or endurance exercise training on cognitive function in older adults with mild cognitive impairment (MCI) and insulin resistance. METHODS Seventy-eight adults (mean age ± SD: 65 ± 7 years) with central obesity and MCI were randomized to 6 months of endurance exercise, pioglitazone or control. RESULTS Sixty-six participants completed the study. Exercise training did not significantly increase peak oxygen uptake compared to control (p = 0.12). Compared to control, insulin resistance improved in the pioglitazone group (p = 0.002) but not in the exercise group (p = 0.25). There was no measureable effect of pioglitazone or exercise on cognitive performance compared to control. CONCLUSION In this pilot study, pioglitazone improved insulin resistance but not cognitive performance in older adults with MCI and insulin resistance.
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Affiliation(s)
- Kerry L Hildreth
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Rachael E Van Pelt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Kerrie L Moreau
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Jim Grigsby
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Karin F Hoth
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Victoria Pelak
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - C Alan Anderson
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Bennett Parnes
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - John Kittelson
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Pamela Wolfe
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Tammie Nakamura
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Sunny A Linnebur
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Jennifer M Trujillo
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Christina L Aquilante
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Robert S Schwartz
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., USA
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Jankowski CM, Shea K, Barry DW, Linnebur SA, Wolfe P, Kittelson J, Schwartz RS, Kohrt WM. Timing of Ibuprofen Use and Musculoskeletal Adaptations to Exercise Training in Older Adults. Bone Rep 2015; 1:1-8. [PMID: 25642444 PMCID: PMC4310009 DOI: 10.1016/j.bonr.2014.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prostaglandins (PGs) increase in bone in response to mechanical loading and stimulate bone formation. Inhibition of cyclooxygenase (COX), the enzyme responsible for PG synthesis, by non-steroidal anti-inflammatory drugs (NSAIDs) impairs the bone formation response to loading in animals when administered before, but not after, loading. The aim was to determine whether the timing of ibuprofen use (400 mg before versus after exercise sessions) is a significant determinant of the adaptive response of BMD to exercise training in older adults. We hypothesized that taking ibuprofen before exercise would attenuate the improvements in total hip and lumbar spine BMD in response to 36 weeks of training when compared with placebo or with ibuprofen use after exercise. Untrained women and men (N = 189) aged 60 to 75 years were randomly assigned to 1 of 3 treatment arms: placebo before and after exercise (PP); ibuprofen before and placebo after exercise (IP); and placebo before and ibuprofen after exercise (PI). The difference between groups in the change in BMD was not significant when IP was compared with either PP (hip, − 0.5% (− 1.4, 0.4); spine, 0.1% (− 0.9, 1.2)) or PI (hip, 0.3% (− 0.6, 1.2); spine, 0.5% (− 0.5, 1.5)). Ibuprofen use appeared to have more adverse effects on BMD in women than men. The study demonstrated that ibuprofen use did not significantly alter the BMD adaptations to exercise in older adults, but this finding should be interpreted cautiously. It had been expected that the inhibition of bone formation by ibuprofen would be more robust in men than in women, but this did not appear to be the case and may have limited the power to detect the effects of ibuprofen. Further research is needed to understand whether NSAID use counteracts, in part, the beneficial effects of exercise on bone. The purpose was to determine whether musculoskeletal adaptations to exercise training in older adults are influenced by NSAID use. Ibuprofen use did not significantly alter changes in BMD or fat-free mass, but the study may have been inadequately powered. Study attrition was significantly lower in the group that took NSAIDs before exercise suggesting improved tolerance of vigorous bone-loading exercise. This was the first randomized, double-blinded placebo- controlled study of ibuprofen effects on BMD from exercise in an older population.
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Affiliation(s)
- Catherine M. Jankowski
- College of Nursing, University of Colorado Anschutz Medical Campus, USA
- Department of Medicine, Division of Geriatric Medicine, University of Colorado, Anschutz Medical Campus, USA
- Corresponding author at: Mail Stop C288-19, 13120 East 19th Avenue, Aurora, CO 80045, USA.
| | - Karen Shea
- Department of Medicine, Division of Geriatric Medicine, University of Colorado, Anschutz Medical Campus, USA
| | - Daniel W. Barry
- Department of Medicine, General Internal Medicine, University of Colorado Anschutz Medical Campus, USA
| | - Sunny A. Linnebur
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, USA
| | - Pamela Wolfe
- Department of Preventive Medicine and Biometrics, University of Colorado Anschutz Medical Campus, USA
| | - John Kittelson
- Department of Preventive Medicine and Biometrics, University of Colorado Anschutz Medical Campus, USA
| | - Robert S. Schwartz
- Department of Medicine, Division of Geriatric Medicine, University of Colorado, Anschutz Medical Campus, USA
| | - Wendy M. Kohrt
- Department of Medicine, Division of Geriatric Medicine, University of Colorado, Anschutz Medical Campus, USA
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Linnebur SA, Vande Griend JP, Metz KR, Hosokawa PW, Hirsch JD, Libby AM. Patient-level medication regimen complexity in older adults with depression. Clin Ther 2014; 36:1538-1546.e1. [PMID: 25456562 DOI: 10.1016/j.clinthera.2014.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [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: 07/29/2014] [Revised: 10/06/2014] [Accepted: 10/06/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE Polypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity. METHODS A sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained. FINDINGS The cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7-8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing. IMPLICATIONS As expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient's entire regimen for opportunities to reduce complexity and improve ease of self-care.
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Affiliation(s)
- Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado.
| | - Joseph P Vande Griend
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Kelli R Metz
- Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Patrick W Hosokawa
- Colorado Health Outcomes Program, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jan D Hirsch
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California; Veterans Affairs of San Diego Healthcare System, San Diego, California
| | - Anne M Libby
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado; Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
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Thompson AM, Linnebur SA, Vande Griend JP, Saseen JJ. Glycemic targets and medication limitations for type 2 diabetes mellitus in the older adult. ACTA ACUST UNITED AC 2014; 29:110-23. [PMID: 24513421 DOI: 10.4140/tcp.n.2014.110] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the optimal management of type 2 diabetes mellitus (T2DM) in the older adult. DATA SOURCES A PubMed search was completed to identify publications in the English language from 1947 to 2013 using combinations of the search terms: geriatrics, aged, diabetes mellitus, and type 2 diabetes mellitus. References of articles were also reviewed for inclusion if not identified in the PubMed search. STUDY SELECTION AND DATA EXTRACTION Original studies, clinical reviews, and guidelines were identified and evaluated for clinical relevance. DATA SYNTHESIS Although the number of older adults with T2DM is growing, evidence for the treatment of T2DM in this population is lacking. Barriers such as polypharmacy, comorbid conditions, economic limitations, cognitive impairment, and increased risk of hypoglycemia may limit optimal glycemic control in older adults. Several organizations provide recommendations for glycemic targets and recommend using standard glycemic goals in most healthy older adults. However, less stringent goals are necessary in certain older populations such as those patients with limited life expectancy and severe hypoglycemia. In general, glycemic goals should be individualized in older patients. Age-related pharmacokinetic and pharmacodynamic changes, comorbid conditions, adverse drug reactions, ease of medication administration, and cost of medications necessitate the need to individualize pharmacologic therapy. CONCLUSION Glycemic targets and medication use for T2DM should be individualized in older adults.
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Affiliation(s)
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Joseph P Vande Griend
- Departments of Clinical Pharmacy and Family Medicine, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
| | - Joseph J Saseen
- Departments of Clinical Pharmacy and Family Medicine, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
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Trujillo JM, Saseen JJ, Linnebur SA, Borgelt LM, Hemstreet BA, Fish DN. Impact of student- versus instructor-directed case discussions on student performance in a pharmacotherapy capstone course. Am J Pharm Educ 2014; 78:56. [PMID: 24761017 PMCID: PMC3996388 DOI: 10.5688/ajpe78356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 10/22/2013] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To evaluate the impact of incorporating student-directed (SD) vs instructor-directed (ID) active learning on student performance in a pharmacotherapy capstone course. DESIGN This 9-credit course was redesigned from exclusively ID case discussions to a format in which half were SD and half were ID. Student performance on evaluation questions derived from SD sessions was compared with that from ID sessions. ASSESSMENT Overall, students (n=299) performed better on ID-session questions than on SD-session questions (78.7% vs 75.3%, correctly answered, respectively; p<0.001). For written evaluations, students performed better on ID-session questions than on SD-session questions (79.8% vs 73.9%, respectively; p<0.001). For verbal evaluations, students performed better on SD-session questions than on ID-session questions (79.5% vs 74.5%, respectively; p<0.001). After the course revision, student confidence regarding their ability to think critically, solve problems, make decisions, and pursue lifelong learning was high, and student and faculty feedback was positive. CONCLUSION Student performance in a pharmacotherapy capstone course remained acceptable when a combination of SD and ID active learning was used, but the addition of SD learning did not translate to better performance on course evaluations.
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Affiliation(s)
- Jennifer M. Trujillo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Joseph J. Saseen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
- University of Colorado School of Medicine, University of Colorado, Aurora, Colorado
| | - Sunny A. Linnebur
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Laura M. Borgelt
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
- University of Colorado School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Douglas N. Fish
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
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Hammond KP, Nielsen C, Linnebur SA, Langness JA, Ray G, Maroni P, Kiser JJ. Priapism induced by boceprevir-CYP3A4 inhibition and α-adrenergic blockade: case report. Clin Infect Dis 2013; 58:e35-8. [PMID: 24092799 DOI: 10.1093/cid/cit673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 44-year-old white man presented to the emergency department with a 3-day history of priapism requiring a surgically performed distal penile shunt. A drug-drug interaction is the suspected cause whereby CYP3A4 inhibition by boceprevir led to increased exposures of doxazosin, tamsulosin, and/or quetiapine, resulting in additional α-adrenergic blockade.
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Thompson A, Vande Griend JP, Linnebur SA, Saseen JJ. Evaluation of type 2 diabetes mellitus medication management and control in older adults. ACTA ACUST UNITED AC 2013; 28:296-306. [PMID: 23649678 DOI: 10.4140/tcp.n.2013.296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The primary aims of this study were to characterize glycemic control and pharmacologic management in older patients and to compare glycemic control and pharmacological management in patients 65 to 79 years of age ("young-old") with those 80 to 89 years of age ("old-old"). We hypothesized that patients 80 to 89 years of age would be prescribed fewer medications and would have higher A1c values compared with younger patients. DESIGN Retrospective medical record review. SETTING This study was conducted in outpatient clinics within a university hospital setting. PATIENTS, PARTICIPANTS This study included 400 adults 65 to 89 years of age with a diagnosis of type 2 diabetes mellitus and at least one A1c measurement over 12 months. MAIN OUTCOME MEASURES A1c measurements and diabetes mellitus medications were assessed in these patients. RESULTS The overall mean A1c was similar in the young-old compared with the old-old (7.1 ± 1.1% vs. 7.0 ± 1.1%; P = NS). There was no difference between groups for any of the A1c ranges studied. Fewer diabetes medications were prescribed in the old-old compared with the young-old (P = 0.003). In the young-old compared with the old-old, metformin (51.0% vs. 33.0%; P < 0.01), glucagon-like peptide-1 agonists (6.7% vs. 0%; P < 0.01), insulin glargine/detemir (24.7% vs. 13.0%; P < 0.05), and short-acting insulin (15.0% vs. 7.0%; P < 0.05) were more frequently prescribed. CONCLUSION Our results indicate that glycemic control was similar between the young-old and old-old. However, the old-old required fewer diabetic medications for this same level of glycemic control.
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Affiliation(s)
- Angela Thompson
- Department of Clinical Pharmacy, University of Colorado, Aurora, CO, USA
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Libby AM, Fish DN, Hosokawa PW, Linnebur SA, Metz KR, Nair KV, Saseen JJ, Vande Griend JP, Vu SP, Hirsch JD. Patient-Level Medication Regimen Complexity Across Populations With Chronic Disease. Clin Ther 2013; 35:385-398.e1. [PMID: 23541707 DOI: 10.1016/j.clinthera.2013.02.019] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/19/2013] [Accepted: 02/21/2013] [Indexed: 01/01/2023]
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Abstract
A 91-year-old woman living independently in the community presented along with her son for a medication therapy management (MTM) appointment with the clinical pharmacist at the University of Colorado Hospital Seniors Clinic. The purpose of the visit was to review the patient's medications, perform medication reconciliation, and identify ways to increase proper medication management. As requested for the MTM appointment, the patient and her son brought in several large bags of her over-the-counter (OTC) and prescription medications from her home, including those that she was not currently taking. The clinical pharmacist reviewed the medications and found multiple instances of duplicate therapies, nonadherence, discrepancies in her medication regimen, cost concerns, and other drug-therapy problems. In addition, the pharmacist's evaluation showed that the patient had been hoarding more than 100 medications, which increased her risk for drug-related problems. Most of the OTC and some prescription medications were voluntarily removed from the patient's possession to reduce the likelihood of potential overuse of medications.The pharmacist educated the patient and her son regarding her updated medication list and how to properly manage her medications. Finally, the patient's son volunteered to help his mother with medication management or hire someone to assist her. This case demonstrates the usefulness of requesting all medications-including OTC and prescription, active and inactive medications-be brought to the MTM appointment.The case also supports the need for family support for older adults struggling with managing polypharmacy.
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Affiliation(s)
- Melanie L Martinez
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado 80045, USA
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Vande Griend JP, McQueen RB, Linnebur SA, Vondracek SF. Prescription ergocalciferol dosing for vitamin D repletion: a retrospective evaluation. Pharmacotherapy 2012; 32:135-41. [PMID: 22392422 DOI: 10.1002/phar.1052] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVES To determine the efficacy and safety of vitamin D repletion with prescription ergocalciferol and to determine patient-specific factors that may influence the amount of ergocalciferol needed to attain vitamin D sufficiency. DESIGN Retrospective medical record review. SETTING University-affiliated outpatient health system. PATIENTS A total of 1446 patients aged 18-89 years who had a prescription for ergocalciferol 50,000 IU between January 1, 2007, and December 31, 2008, were identified; of these patients, 582 patients had a vitamin D concentration measured 120 days before their first prescription (baseline) and had another concentration measured 60-180 days after this prescription (follow-up) and were deemed "first-time users" of ergocalciferol. MEASUREMENTS AND MAIN RESULTS Vitamin D sufficiency was defined as a 25-hydroxyvitamin D (vitamin D) concentration of 30 ng/ml or higher. Twenty-nine different ergocalciferol prescribing regimens were identified in the 1446 patients. For the 582 first-time users of ergocalciferol, vitamin D concentrations increased from a mean ± SE of 17.7 ± 0.32 ng/ml at baseline to 32.9 ± 0.73 ng/ml at first follow-up concentration, with a mean ± SE prescribed ergocalciferol dose of 63,876 ± 1973 IU given over an average of 17 weeks. Overall, 326 (56%) of the 582 first-time users attained sufficiency with their prescribed regimen. With use of a logistic regression model to control for variables that could influence a patient's response to vitamin D, patients prescribed 50,000-100,000 IU/week were significantly more likely to attain vitamin D sufficiency compared with those prescribed less than 50,000 IU/week (OR 2.61, 95% CI 1.37-4.99). Body mass index of 30 kg/m(2) or higher decreased the odds of attaining vitamin D sufficiency, whereas use of a loading dose did not increase the odds of attaining sufficiency. CONCLUSION Many different ergocalciferol regimens were used to replace vitamin D, and overall attainment of vitamin D sufficiency appeared to be moderate. Based on our findings, an ergocalciferol regimen of 50,000-100,000 IU/week with no loading dose could be considered as a starting point for vitamin D repletion.
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Affiliation(s)
- Joseph P Vande Griend
- Department of Clinical Pharmacy, Universityof Colorado Skaggs School of Pharmacy and PharmaceuticalSciences, Aurora, Colorado 80045, USA.
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Vande Griend JP, Linnebur SA. Inhaled anticholinergic agents and acute urinary retention in men with lower urinary tract symptoms or benign prostatic hyperplasia. Ann Pharmacother 2012; 46:1245-9. [PMID: 22851743 DOI: 10.1345/aph.1r282] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the risk of acute urinary retention with the use of inhaled anticholinergic agents in men with lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH). DATA SOURCES A literature search was performed with MEDLINE via PubMed from 1967 through May 2012 using the terms inhaled anticholinergics, urinary retention, benign prostatic hyperplasia, lower urinary tract symptoms, tiotropium, and ipratropium. In addition, references from reviewed publications were identified and official labeling was obtained from the manufacturers' Web sites. STUDY SELECTION AND DATA EXTRACTION Only English-language publications were included. Randomized controlled trial data, observational studies, case reports, package labeling, and commentaries regarding men with BPH/LUTS using inhaled anticholinergic agents and the associated development of urinary retention were reviewed. DATA SYNTHESIS Two case reports; 1 prospective, open-label, single-arm study; and 2 nested case-control studies evaluated or described the use of inhaled anticholinergic agents and the development of acute urinary retention in men with BPH/LUTS. Taken together, the available data demonstrate that treatment with inhaled anticholinergic agents is associated with acute urinary retention in men with preexisting LUTS or BPH. CONCLUSIONS Men with LUTS or BPH who are treated with inhaled anticholinergic agents may develop acute urinary retention, but this cannot be quantified based on the limited information available. Inhaled anticholinergic agents should be used when indicated in men with LUTS or BPH, but close monitoring and patient education should be implemented.
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Affiliation(s)
- Joseph P Vande Griend
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA.
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Marcum ZA, Vande Griend JP, Linnebur SA. FDA drug safety communications: a narrative review and clinical considerations for older adults. ACTA ACUST UNITED AC 2012; 10:264-71. [PMID: 22683398 DOI: 10.1016/j.amjopharm.2012.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [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] [Received: 05/14/2012] [Accepted: 05/18/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND The US Food and Drug Administration (FDA) has new regulatory authorities intended to enhance drug safety monitoring in the postmarketing period. This has resulted in an increase in communication from the FDA in recent years about the safety profile of certain drugs. It is important to stay abreast of the current literature on drug risks to effectively communicate these risks to patients, other health care providers, and the general public. OBJECTIVE To summarize 4 new FDA drug safety communications by describing the evidence supporting the risks and the clinical implications for older adults. METHODS The FDA Web site was reviewed for new drug safety communications from May 2011 to April 2012 that would be relevant to older adults. Approved labeling for each drug or class was obtained from the manufacturer, and PubMed was searched for primary literature that supported the drug safety concern. RESULTS FDA drug safety communications for 4 drugs were chosen because of the potential clinical importance in older adults. A warning for citalopram was made because of potential problems with QT prolongation in patients taking less than 40 mg per day. The evidence suggests minor changes in QT interval. Given the flat dose-response curve in treating depression with citalopram, the new 20-mg/d maximum dose in older adults is sensible. Another warning was made for proton pump inhibitors (PPIs) and an increased risk of Clostridium difficile infection. A dose-response relationship was found for this drug risk. With C. difficile infections on the rise in older adults, along with other safety risks of PPI therapy, PPIs should only be used in older adults indicated for therapy for the shortest duration possible. In addition, a warning about dabigatran was made. There is strong evidence from a large clinical trial, as well as case reports, of increased bleeding risk in older adults taking dabigatran, especially in older adults with decreased renal function. This medication should be used with caution in older adults. Finally, several warnings were made about statins. Routine periodic monitoring of liver enzymes does not appear to be effective in detecting or preventing serious liver injury from statin use; thus, liver enzymes are no longer recommended to be routinely monitored. Statin-induced cognitive changes are rare, and insufficient evidence is currently available to establish causality. Statins appear to moderately increase the risk of developing diabetes (versus placebo), and regular screening for diabetes should be considered, especially for patients taking high-dose statins and patients with multiple risk factors for diabetes. CONCLUSION FDA drug safety communications incorporate complex methodologies that investigate the risks (and relative benefits) of medication therapy. Clinicians caring for older adults need to be aware of the most current evidence behind these drug risks to effectively communicate with and care for their patients.
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Affiliation(s)
- Zachary A Marcum
- Department of Medicine, Division of Geriatric Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA.
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O'Bryant CL, Linnebur SA, Yamashita TE, Kutner JS. Inconsistencies in opioid equianalgesic ratios: clinical and research implications. J Pain Palliat Care Pharmacother 2012; 22:282-90. [PMID: 21923312 DOI: 10.1080/15360280802537241] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cancer pain is common, occurring in up to 60% of patients and opioid conversion may be required for effective pain management. Conversion from one opioid to another can be problematic due to differences in equianalgesic ratios found in established resources. This study explores the implications of using various published equianalgesic ratios when converting to a common opioid unit. This secondary analysis includes 105 advanced cancer patients who reported use of transdermal fentanyl, long-acting oxycodone, or oral methadone. Common clinically used equianalgesic ratios were identified and utilized to calculate a parenteral morphine equivalent for each of the selected agents. When the equianalgesic ratios were applied to each drug, there were substantial differences in the calculated morphine equivalent for transdermal fentanyl (2-fold difference) and methadone (100-fold difference). The calculated difference for oxycodone was lower, with a 1.5-fold difference. This study demonstrates large variability in opioid conversions based on the use of common equianalgesic ratios for transdermal fentanyl, long-acting oxycodone, and methadone. These findings have important clinical and research implications. First, this study substantiates the use of these ratios as only guidelines for treatment. Second, it supports the need for well-designed, rigorous studies to evaluate opioid conversions. Third, this study demonstrates the need for a standard reporting system of opioid equianalgesic ratios employed in clinical trials.
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Affiliation(s)
- Cindy L O'Bryant
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Denver, Aurora, Colorado, USA
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Linnebur SA, Fish DN, Ruscin JM, Radcliff TA, Oman KS, Fink R, Van Dorsten B, Liebrecht D, Fish R, McNulty M, Hutt E. Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia. ACTA ACUST UNITED AC 2011; 9:442-450.e1. [PMID: 22055208 DOI: 10.1016/j.amjopharm.2011.09.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines. OBJECTIVE The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home-acquired pneumonia (NHAP) guidelines related to use of antibiotics. METHODS This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline. RESULTS A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use. CONCLUSIONS The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.
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Haverhals LM, Lee CA, Siek KA, Darr CA, Linnebur SA, Ruscin JM, Ross SE. Older adults with multi-morbidity: medication management processes and design implications for personal health applications. J Med Internet Res 2011; 13:e44. [PMID: 21715286 PMCID: PMC3221383 DOI: 10.2196/jmir.1813] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 04/27/2011] [Accepted: 05/11/2011] [Indexed: 11/13/2022] Open
Abstract
Background Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults’ needs, preferences, and practices. Objective The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA. Methods We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling. Results We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers. Conclusions This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.
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Affiliation(s)
- Leah M Haverhals
- Colorado REAP (Research Enhancement Award Program) to Improve Care Coordination, Veterans Affairs Medical Center, Denver, CO, USA
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Linnebur SA, Rapacchietta OC, Vejar M. Hepatotoxicity associated with chinese skullcap contained in Move Free Advanced dietary supplement: two case reports and review of the literature. Pharmacotherapy 2010; 30:750, 258e-262e. [PMID: 20586134 DOI: 10.1592/phco.30.7.750] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Move Free Advanced is a widely available dietary supplement in the United States, marketed to comfort sore joints and improve flexibility and mobility. This product contains glucosamine, chondroitin, hyaluronic acid, and Uniflex proprietary extract, which is a combination of Chinese skullcap and black catechu. We describe two patients who developed hepatotoxicity after ingesting a Move Free Advanced product. In both patients, the hepatotoxicity resolved after discontinuation of the supplement. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6 for both patients) between the patients' development of hepatotoxicity and the Move Free Advanced supplement. Based on a review of the literature, the herbal extract Chinese skullcap is the most likely cause of the hepatotoxicity. To our knowledge, these two cases are the first to be published regarding possible hepatotoxicity associated with Move Free Advanced. Patients seeking dietary supplements for osteoarthritis may want to avoid glucosaminechondroitin products such as Move Free Advanced that also contain Chinese skullcap.
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Affiliation(s)
- Sunny A Linnebur
- School of Pharmacy, University of Colorado Denver, Aurora, Colorado 80045, USA.
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