Michael J. Koronkowski

Adverse drug events in high risk older outpatients.

OBJECTIVE: To describe the prevalence, types, and consequences of adverse drug events (ADEs) in older outpatients with polypharmacy.

A prescription for improving drug formulary decision making.

Gordon Schiff and colleagues present a new tool and checklist to help formularies make decisions about drug inclusion and to guide rational drug use.

Relation of prescription nonsteroidal antiinflammatory drug use to cognitive function among community-dwelling elderly☆☆☆

PURPOSE To evaluate the relationship of nonsteroidal antiinflammatory drug (NSAID) use to level of cognitive function in community-dwelling elderly persons. METHODS The prospective cohort study included 2765 nonproxy subjects from the Duke University Established Populations for Epidemiologic Studies of the Elderly who were cognitively intact at baseline (1986-1987) and alive at follow-up three year later. Cognitive function was assessed by the Short Portable Mental Status Questionnaire (i.e., intact vs. impaired and change in score) and by the individual domains of the Orientation-Memory-Concentration Test (i.e., number of errors). NSAID use, determined from in-home interviews, was coded for chronicity, dose, frequency of use, and prescription status. RESULTS After controlling for demographic factors as well as health status and behavior, continuous, regularly-scheduled, prescription use of NSAID was associated with preservation of one aspect of cognitive functioning: concentration (beta coefficient, 0.29; 95% confidence interval [CI] -0.54 to -0.04, indicating fewer errors). However, no consistent dose-response relationship was found. Current and prior NSAID use was unrelated to level of cognitive functioning across all five measures; among current users, those taking moderate or high doses (beta coefficient, 0.41; 95% CI, 0.08 to 0.74) made more errors on the memory test compared with those taking low doses (beta coefficient 0.03; 95% CI, -.85 to 0.91). CONCLUSIONS These results suggest no substantial or consistent protective effect of prescription NSAID use on cognitive function in community-dwelling elderly. However, recent use at higher doses may be associated with memory deterioration in this population.

Finasteride: The First 5α‐Reductase Inhibitor

Finasteride is a synthetic 4‐azasteroid that is a specific competitive inhibitor of 5α‐reductase, an intracellular enzyme that converts testosterone to dihydrotestosterone (DHT). It has no binding affinity for androgen receptor sites and itself possesses no androgenic, antiandrogenic, or other steroid hormone‐related properties. It is well absorbed after oral administration, with absolute bioavailability in humans of 63% (range 34–108%). The mean time to maximum concentration is 1–2 hours, and it is approximately 90% plasma protein bound. The elimination half‐life averages 6–8 hours. The agent is metabolized to a series of five metabolites, of which two are active and possess less than 20% of the 5α‐reductase activity of finasteride. Little is known about potential drug interactions, although they appear to be minimal and not clinically relevant. The drug is indicated for the treatment of symptomatic benign prostatic hyperplasia. Its efficacy in regression of prostate gland enlargement is rapid and predictable, although correlation with subsequent improvement in urinary flow and symptoms is highly variable. Dosages of 0.5–100 mg/day regress prostate enlargement; the recommended dosage is 5 mg once/day. Finasteride may hold promise for other DHT‐mediated disorders such as acne, facial hirsutism, frontal lobe alopecia, and prostate cancer, but its use in these conditions remains investigational. The frequency of adverse drug events is low, with the most common side effects being impotence, decreased libido, and decreased volume of ejaculate. No reports of intentional overdose have been reported, and dosages of up to 80 mg/day for 3 months have been taken without adverse effect.

Recent Literature Update on Medication Risk in Older Adults, 2015–2016

Medications can pose considerable risk in older adults. This article annotates four articles addressing this concern from 2016. The first provides national data on the use of specific prescription, over‐the‐counter and dietary supplements in older adults and their change over time. The second discusses the opportunity of deprescribing ineffective/unnecessary stool softeners (i.e., docusate) routinely given to older hospital patients. The third national study examines common adverse drug events in older emergency room patients. Finally, a study published demonstrating a potential association between melatonin and fractures is discussed. This manuscript is intended to provide a narrative review of key publications in medication safety for clinicians and researchers committed to improving medication safety in older adults.