Márcio Galvão Oliveira

A comparison of the Beers and STOPP criteria for identifying the use of potentially inappropriate medications among elderly patients in primary care

RATIONALE, AIMS AND OBJECTIVES Explicit criteria for evaluating the appropriateness of medication use among the elderly have been extensively employed in several countries. The aim of the current study was to assess and characterize the prevalence of potentially inappropriate medications (PIMs) according to the Screening Tool of Older Peoples Prescriptions (STOPP) criteria and compare these data with the 2012 Beers criteria. METHODS A prospective survey of the medications used by elderly patients was performed. A total of 142 participants were randomly selected via systematic sampling. The Beers and STOPP criteria were applied to evaluate the use of PIMs among the sample. All of the medications included in these criteria were assessed for their availability in Brazil. The prevalence of PIMs was chosen as an occurrence measure and compared among the exposure group using the prevalence ratio (PR) as a measure of association. RESULTS The prevalence of PIM use in the sample was 33.8% according to the STOPP criteria and 51.8% using the 2012 Beers criteria. The most prevalent PIMs according to the Beers criteria were short-acting nifedipine (17.4%) and glyburide (11.9%); according to the STOPP criteria, they were acetylsalicylic acid (32.9%), clonazepam (10.1%) and diclofenac (6.3%). The use of four or more drugs (polypharmacy) was associated with a higher prevalence of PIM use (PR = 3.11, 95% CIs = 1.65-5.85). CONCLUSIONS The 2012 Beers criteria identified more PIMs than the STOPP criteria. This difference highlights the need to develop national criteria.

Prevalência de admissão hospitalar por reação adversa a medicamentos em Salvador, BA

OBJECTIVE: To determine the prevalence of hospital admissions due to ADR in Salvador, Bahia and their outcomes. METHODS: All patients admitted in four Sentinel Hospital (ANVISA) in Salvador-Ba were evaluated and followed to determine the prevalence of admissions due to ADR and their outcomes from April to December 2007. Cases were validated by 03 algorithms. The drugs were classified by Anatomical-Therapeutic-Chemical Classification, organs and systems affected by the WHO criteria and severity seconds Pearson et al. Type of ADR was analyzed by Rawlins and Thompson. RESULTS: The prevalence of ADR admission was 0.5% and adjusted for exposed was 2.1%, with 316 cases. Average of hospitalization due to ADR was 12.3 days. Younger and older accounted for 28.8% and 31.1% of patients. Females and blacks were 60% of cases. Main pharmacologic groups were antineoplastics, antibiotics and diuretics, affecting skin, gastrointestinal and hematologic systems. Around 70% of the ADR was validated as defined. ADR of type A was 80% and 90% recovered, and one death (0.5%). CONCLUSION: The prevalence of ADR admission was similar to those described in the literature and only one patient died. As this is the first national study will form the basis for future investigations.

Análise da prescrição de captopril em pacientes hospitalizados

One of the most common complications of Systemic Arterial Hypertension is the hypertensive crisis(1) characterized by a symptomatic elevation of blood pressure (BP) with or without involvement of target organs, which may lead to immediate or potential risk to life. The hypertensive crisis may manifest itself as hypertensive emergency or urgency. In the emergency there is fast deterioration of target organs and immediate risk to life, a situation that does not occur in hypertensive urgency. On the other hand, situations in which the patient presents elevated BP due to an emotionally charged, painful or uncomfortable event, with no evidence of lesion of target organs or immediate risk to life, characterize the hypertensive pseudo-crisis, a condition that does not require the use of emergency antihypertensive therapy. Despite this fact, the practice has become widespread of prescribing antihypertensive medication prior to situations believed to present a risk of abrupt BP elevation, irrespective of the symptoms. This study aims at assessing the frequency of prescription of captopril prior to BP elevation in patients hospitalized in a university hospital. It was also intended to map the places (clinical or surgical wards) where this procedure was more frequent.

Há evidências favorecendo o uso de betabloqueadores e dobutamina na insuficiência cardíaca aguda

Several studies have reported the benefits of beta-blockers (BB) for patients presenting with systolic heart failure. however, many patients hospitalized as a result of acute heart failure are already using BB and require dobutamine for arterial hypotension and low cardiac output. Therefore, a decision must be made regarding whether BB should be maintained or even started in such cases. The aim of this study was to establish whether there is evidence supporting the safety andyeffectiveness of BB together with dobutamine for patients presenting with acute decompensated heart failure (ADHF). We conducted a search of the English-language literature in the databases MEDLINE, ISI Web of Science, Virtual Health Library, Cochrane Library and the CAPES Portal of Scientific Journals to identify related studies. Additional literature was obtained through the review of relevant references in the identified articles. The expected outcomes included information on the prognosis (in-hospital and on follow-up mortality, number of days of hospitalization and readmission),yeffectiveness and safety (worsening of symptoms, shock, intolerance) of the concomitant use of these drugs in hospitalized patients with ADHF and low cardiac output. This review included nine studies. however, no randomized clinical trials on this subject were found. Most studies include a low number of patients, and no studies addressing the safety of the concomitant use of these drugs were found. The resulting data suggest that a careful literature review did not supply evidence for the systematic use of BB in patients with low cardiac output syndrome who require dobutamine for inotropic support.

Prevalence of hospital admission due to adverse drug reaction in Salvador, Bahia

OBJECTIVE To determine the prevalence of hospital admissions due to ADR in Salvador, Bahia and their outcomes. METHODS All patients admitted in four Sentinel Hospital (ANVISA) in Salvador-Ba were evaluated and followed to determine the prevalence of admissions due to ADR and their outcomes from April to December 2007. Cases were validated by 03 algorithms. The drugs were classified by Anatomical-Therapeutic-Chemical Classification, organs and systems affected by the WHO criteria and severity seconds Pearson et al. Type of ADR was analyzed by Rawlins and Thompson. RESULTS The prevalence of ADR admission was 0.5% and adjusted for exposed was 2.1%, with 316 cases. Average of hospitalization due to ADR was 12.3 days. Younger and older accounted for 28.8% and 31.1% of patients. Females and blacks were 60% of cases. Main pharmacologic groups were antineoplastics, antibiotics and diuretics, affecting skin, gastrointestinal and hematologic systems. Around 70% of the ADR was validated as defined. ADR of type A was 80% and 90% recovered, and one death (0.5%). CONCLUSION The prevalence of ADR admission was similar to those described in the literature and only one patient died. As this is the first national study will form the basis for future investigations.

Access of Elderly Adults to Potentially Inappropriate Medications in the Brazilian Health System

clinical trial of plasma transfusion from young donors to individuals with Alzheimer’s disease (AD). An additional hypothesis is proposed to explain this effect: that young plasma reverses age-related memory impairment by enhancing the peripheral amyloid sink and hence decreasing cerebral amyloid beta (Ab). Accumulation of Ab in the brain is the pathological and molecular hallmark of AD, the most common dementia in elderly adults. Age-related increases in brain Ab impair memory by inactivating molecular promoters of memory such as cyclic adenosine monophosphate response element binding protein (CREB) and suppressing synaptic plasticity and neurogenesis. In addition to deposition in the brain, Ab circulates in plasma, cerebrospinal fluid (CSF), and brain interstitial fluid as soluble and insoluble oligomeric forms. There is an intricate interplay between the production of Ab in the brain and its passage into the peripheral circulation; Ab can cross the blood–brain barrier attached to some proteins, which carry it to the liver for clearance, a process known as the “peripheral amyloid sink.” In the peripheral circulation, the majority of Ab is bound to serum low density–related protein 1 (sLRP1), which sequesters 70% to 90% of plasma Ab, and apolipoprotein E (ApoE). Emerging evidence suggests that there is an imbalance between brain production of Ab and its crossing into the peripheral amyloid sink in individuals with AD. sLRP1 levels and its capacity to bind Ab are low in individuals with AD. Similarly, certain isoforms of the serum Ab transporter ApoE, such as E4, are associated with a greater risk of AD. There is evidence that reducing levels of circulating Ab in the periphery, thereby augmenting the peripheral amyloid sink, leads to lower cerebral Ab burden by shifting Ab from the central nervous system to the blood. More recently, it was shown that exchanging blood from mice with AD with blood from normal wild-type mice resulted in reduction of cerebral Ab deposition and improved spatial memory performance. The rejuvenating effect of plasma from young mice in cognitively impaired old mice may be due, at least in part, to a reduction of cerebral Ab through enhancement of the peripheral amyloid sink. The level and amyloid-binding capacity of the major peripheral amyloid sink, sLRP1, decline with aging. Hence, infusion of young plasma would replenish the sLRP1 in the blood, which could then efficiently shift cerebral Ab to blood, decreasing cerebral Ab burden. In future studies, it will be important to investigate whether reduction in the burden of cerebral Ab through augmentation of the peripheral amyloid sink mediates the rejuvenating effect of plasma from young individuals or mice on age-related cognitive impairment. If that is the case, it would suggest a therapeutic trial of plasma pheresis instead of plasma transfusion in individuals with AD, because pheresis might be more suitable for elderly individuals, who may have cardiovascular compromise.

Use of an indicator to evaluate physician adherence to prescription guidelines for the treatment of heart failure

The aim of this study was to use indicators to evaluate physician adherence to prescription guidelines for heart failure treatment in a university hospital. This was a prospective cohort study conducted in a university hospital. The information collected at the time of patient admission, including therapeutic indication, absolute contra indications and intolerance, was utilised for the formulation of a guideline adherence indicator (GAI). This indicator was calculated as follows: (the number of patients who used the medication/the number of eligible patients) x 100. The percentage of eligible patients was calculated using the following formula: (the number of eligible patients/the total number patients) x 100. The GAI was applied to a population of 53 patients. Inhibitors of angiotensin-converting enzyme/angiotensin receptor blocker (ACE-I/ARB) combination therapy were used in the greatest percentage of eligible patients (92.4%) and demonstrated the largest GAI value (73.5%). The percentages of patients who were eligible for beta-blockers, spironolactone and digitalis treatments were 81.1%, 52.8% and 60.4%, respectively. The GAI values for the use of beta-blockers, spironolactone and digitalis were 60.4%, 57.1% and 56.2%, respectively. For the studied patient population, the GAI was consistent with the proportion of patients who were eligible to receive digitalis and spironolactone.

Reviewing the safety of loratadine for elderly adults: a potential shortcoming of the 2012 beers criteria

veillance in long-term care facilities. Am J Infect Control 1991;19:1–7. 8. Juthani-Mehta M, Tinetti M, Perrelli E et al. Interobserver variability in the assessment of clinical criteria for suspected urinary tract infection in nursing home residents. Infect Control Hosp Epidemiol 2008;29:446–449. 9. Went P, Achterberg W, Bruggink R et al. Richtlijn Urineweg-Infecties. [Guideline urinary tract infections]. Utrecht, the Netherlands: Verenso, Dutch Association of Elderly Care Physicians, 2006. 10. High KP, Bradley SF, Gravenstein S et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc 2009;57:375–394. 11. Schmiemann G, Kniehl E, Gebhardt K et al. The diagnosis of urinary tract infection: A systematic review. Dtsch Arztebl Int 2010;107:361–367. 12. van den Hout WB, Caljouw MAA, Putter H et al. Cost-effectiveness of cranberry capsules to prevent urinary tract infections in long-term care facilities: Economic evaluation alongside a randomized controlled trial. J Am Geriatr Soc 2014;62:111–116.

Drugs available through the Farmácia Dose Certa program and Beers criteria: a further analysis

Dear Editor, We read the recently published article by Lucchetti et al.1 and we have an important comment to make on this study. The objective was to assess the drugs in the Farmacia Dose Certa (“Right Dose Pharmacy”) program that were considered to be inappropriate for the elderly. The authors used the criteria developed by Beers and updated by Fick in 2003 to assess the appropriateness of drug use among elderly people.2 As described by the authors, the Beers-Fick criteria are divided as follows: (1) drugs or drug classes that should generally be avoided for people over 65 years of age, because they are ineffective or have a high risk of unnecessary adverse effects when a safer alternative is available; and (2) medications that should not be used for elderly patients with specific known conditions. However, only those medicines listed in the first group of Beers-Fick criteria were compared with the available drugs within the Dose Certa program. This underestimates the quantity of potentially inappropriate medications for older people available through this program. One example of this is that metoclopramide should be avoided among patients with Parkinson’s disease because of its antidopaminergic/cholinergic effects,2 but was not included in the analysis by Lucchetti et al.1 In our view, the main contribution of their study is to disseminate information about the medications that can potentially be considered inappropriate, and serve as a reference in daily clinical practice. In addition, this information may provide support for regional or national pharmacy and therapeutics committees in making choices of therapeutic alternatives that are more cost-effective and safer for the elderly population.