Ronald L. Castelino

Targeting Suboptimal Prescribing in the Elderly: A Review of the Impact of Pharmacy Services

Objective To review the currently available literature on the impact of interventions by pharmacists on suboptimal prescribing in the elderly. Data Sources MEDLINE, EMBASE, and International Pharmaceutical Abstracts databases were searched for studies published between January 1992 and December 2008. Key words included medication review, drug regimen review, pharmaceutical services, pharmaceutical care, pharmacists, medications, appropriateness, suboptimal, underuse, aged, elderly, randomized controlled trial, inappropriate, prescribing, and intervention. Study Selection And Data Extraction To be included in the review, studies must have been conducted in patients 65 years or older, published in English, randomized and controlled, and must have included an intervention delivered by a pharmacist or had a pharmacist as a member of the intervention team. From each relevant study, the following data were extracted: study duration, country, number of patients, year of publication, objective, type and impact of the intervention, method used to assess suboptimal prescribing, and data concerning the quality of the study. Data Synthesis A total of 38 articles were identified, of which 12 matched our inclusion criteria. Seven articles included interventions initiated by pharmacists, and the remaining 5 described interventions in which the pharmacist was a part of the multidisciplinary team. A broad range of tools was used to measure prescribing appropriateness; we found that a consensus on the best approach has not been reached. Most of the studies involving pharmacists showed significant improvement in suboptimal prescribing at one or more time points. However, most of these interventions were directed toward reducing the overuse or misuse of medications. Conclusions Pharmacy services to reduce suboptimal prescribing have shown promising and noteworthy improvements. More research is needed to address the underutilization of medications in the elderly and healthcare impact of reducing suboptimal prescribing.

Drug Burden Index and Potentially Inappropriate Medications in Community-Dwelling Older People The Impact of Home Medicines Review

BackgroundA significant problem in older people (aged ≥65 years) is the use of potentially inappropriate medications (PIMs), including those with sedative and anticholinergic properties. However, effective intervention strategies have yet to be identified. The Drug Burden Index (DBI) is an evidence-based tool that measures a person’s total exposure to medications with sedative and anticholinergic properties and has been shown to be independently associated with impairment in cognitive and physical function.ObjectiveThe main aim of the study was to investigate whether Home Medicines Review (HMR) services by pharmacists for community-dwelling older people would lead to an improvement in the use of medications, as measured by a decrease in the DBI score. The study also aimed to investigate the (i) distribution of DBI scores and PIMs among older people living in the community, and (ii) impact of pharmacists’ recommendations on DBI scores and PIMs.MethodsA retrospective analysis of medication reviews was performed for 372 community-dwelling older people (aged ≥65 years) who received an HMR service from the pharmacist. The main outcome measure was the total DBI score at baseline and post-HMR. The data were also examined to determine the extent of PIM use (2003 Beers’ criteria), and the number and nature of pharmacists’ recommendations.ResultsOverall, medications contributing to the DBI (i.e. medications with sedative or anticholinergic properties) and PIMs were identified in 60.5% (n = 225) and 39.8% (n=148) of the patients, respectively. Following pharmacist recommendations during the HMR service, medications contributing to the DBI were identified in 51.6% (n = 192) of the patients. A statistically significant reduction in the sum total of DBI scores for all patients was observed following pharmacists’ recommendations during the HMR service (206.9 vs 157.3, p < 0.001). Pharmacists’ recommendations also led to a decrease in the use of PIMs, which were identified in 28.2% (n= 105) of the patients following the HMR service.ConclusionWhen the DBI is used for evaluation, pharmacists’ recommendations during HMR services, if acted upon, may effect changes in the prescribing of sedative and anticholinergic medications, thereby substantially reducing the patient’s drug burden. Future studies should focus on whether such a decrease may translate into functional improvements. The study also showed a positive influence of HMR services on the prescribing of PIMs.

Nonadherence to Medication Therapy in Haemodialysis Patients: A Systematic Review

Background End-stage kidney disease (ESKD) patients are often prescribed multiple medications. Together with a demanding weekly schedule of dialysis sessions, increased number of medicines and associated regimen complexity pre-dispose them at high risk of medication nonadherence. This review summarizes existing literature on nonadherence and identifies factors associated with nonadherence to medication therapy in patients undergoing haemodialysis. Methods A comprehensive search of PubMed, Embase, CINAHL, PsycInfo, and Cochrane Database of Systematic Reviews covering the period from 1970 through November 2014 was performed following a predefined inclusion and exclusion criteria. Reference lists from relevant materials were reviewed. Data on study characteristics, measures of nonadherence, prevalence rates and factors associated with nonadherence were collected. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was followed in conducting this systematic review. Results Of 920 relevant publications, 44 were included. The prevalence of medication nonadherence varied from 12.5% to 98.6%, with widespread heterogeneity in measures and definitions employed. Most common patient-related factors significantly associated with nonadherence were younger age, non-Caucasian ethnicity, illness interfering family life, being a smoker, and living single and being divorced or widowed. Similarly, disease-related factors include longevity of haemodialysis, recurrent hospitalization, depressive symptoms and having concomitant illness like diabetes and hypertension. Medication-related factors such as daily tablet count, total pill burden, number of phosphate binders prescribed and complexity of medication regimen were also associated with poor adherence. Conclusions A number of patient-, disease-, and medication-related factors are associated with medication nonadherence in haemodialysis patients. Clinicians should be aware of such factors so that adherence to medications can be optimised in haemodialysis patients. Future research should be directed towards well-designed prospective longitudinal studies developing standard definitions and validating available measurement tools, while focusing on the role of additional factors such as psychosocial and behavioural factors in predicting nonadherence to medications.

Dose adjustment guidelines for medications in patients with renal impairment: how consistent are drug information sources?

It is known that patients with renal disease are often administered inappropriate dosages of drugs. A lack of quantitative data in the available drug information sources and inconsistency in dosing information may augment the problem of dosing error.

Hospitalization in older patients due to adverse drug reactions -the need for a prediction tool.

Adverse drug reactions (ADRs) represent a major burden on society, resulting in significant morbidity, mortality, and health care costs. Older patients living in the community are particularly susceptible to ADRs, and are at an increased risk of ADR-related hospitalization. This review summarizes the available evidence on ADR-related hospital admission in older patients living in the community, with a particular focus on risk factors for ADRs leading to hospital admission and the need for a prediction tool for risk of ADR-related hospitalization in these individuals. The reported proportion of hospital admissions due to ADRs has ranged from 6% to 12% of all admissions in older patients. The main risk factors or predictors for ADR-related admissions were advanced age, polypharmacy, comorbidity, and potentially inappropriate medications. There is a clear need to design intervention strategies to prevent ADR-related hospitalization in older patients. To ensure the cost-effectiveness of such strategies, it would be necessary to target them to those older individuals who are at highest risk of ADR-related hospitalization. Currently, there are no validated tools to assess the risk of ADRs in primary care. There is a clear need to investigate the utility of tools to identify high-risk patients to target appropriate interventions toward prevention of ADR-related hospital admissions.

Use of evidence-based therapy for the prevention of cardiovascular events among older people.

Evidence-based therapies (EBTs) for the prevention of cardiovascular disease (CVD) are reportedly underutilized in older people. The primary purpose of this study was to evaluate the use of EBTs for the prevention of CVD events in older people and secondarily whether a Home Medicines Review (HMR) service by pharmacists’ predicts the use of these medicines. A retrospective cross-sectional audit of HMR reports pertaining to 608 community-dwelling older people (≥65 years) was conducted. EBTs considered for this audit included four guideline-recommended therapies for CVD: antithrombotic therapy (warfarin ± antiplatelet therapy), β-blockers, statins, and angiotensin agents (angiotensin-converting enzyme inhibitors [ACEI] ± angiotensin II receptor blockers [ARBs]). The prevalence of EBT use among the older people, mean age (SD) 75.6 (7.5) years, was: 73% for antithrombotic therapy, 75% for statins, 74% for angiotensin therapy, and 35% for β-blockers. CVD risk factors warranting treatment with these EBTs were frequently associated with use of EBTs. EBTs were least likely to be used in those with coronary interventions like coronary artery bypass grafting (CABG)/stent insertion (all EBTs except angiotensin agents) and angiotensin agents in those with a history of myocardial infarction or chronic heart failure. A pharmacist-led HMR service was significantly associated with the prescribing of all 4 EBTs. The results from this study show good adherence to evidence-based guidelines in general, although there is still room for improvement to further optimize clinical outcomes in these complex patients. The study also adds to the available literature on the effectiveness of pharmacists’ collaborative contribution to the care of these high-risk patients.

Metformin usage in type 2 diabetes mellitus: are safety guidelines adhered to?

To (i) evaluate the prescribing patterns of metformin in patients with type 2 diabetes mellitus (T2DM) and determine the prevalence of contraindications to its use, especially renal impairment, and (ii) identify potential cases of lactic acidosis (LA) related to metformin usage.

Prediction of Hospitalization due to Adverse Drug Reactions in Elderly Community-Dwelling Patients (The PADR-EC Score).

Background Adverse drug reactions (ADRs) are the major cause of medication-related hospital admissions in older patients living in the community. This study aimed to develop and validate a score to predict ADR-related hospitalization in people aged ≥65 years. Methods ADR-related hospitalization and its risk factors were determined using a prospective, cross-sectional study in patients aged ≥65 years admitted to two hospitals. A predictive model was developed in the derivation cohort (n = 768) and the model was applied in the validation cohort (n = 240). ADR-related hospital admission was determined through expert consensus from comprehensive reviews of medical records and patient interviews. The causality and preventability of the ADR were assessed based on the Naranjo algorithm and modified Schumock and Thornton criteria, respectively. Results In the derivation sample (mean [±SD] age, 80.1±7.7 years), 115 (15%) patients were admitted due to a definite or probable ADR; 92.2% of these admissions were deemed preventable. The number of antihypertensives was the strongest predictor of an ADR followed by presence of dementia, renal failure, drug changes in the preceding 3 months and use of anticholinergic medications; these variables were used to derive the ADR prediction score. The predictive ability of the score, assessed from calculation of the area under the receiver operator characteristic (ROC) curve, was 0.70 (95% confidence interval (CI) 0.65–0.75). In the validation sample (mean [±SD] age, 79.6±7.6 years), 30 (12.5%) patients’ admissions were related to definite or probable ADRs; 80% of these admissions were deemed preventable. The area under the ROC curve in this sample was 0.67 (95% CI 0.56–0.78). Conclusions This study proposes a practical and simple tool to identify elderly patients who are at an increased risk of preventable ADR-related hospital admission. Further refinement and testing of this tool is necessary to implement the score in clinical practice.

Prevalence of medication-related problems among patients with renal compromise in an Indian hospital.

What is known and Objective:  Patients suffering from renal dysfunction often have multiple medical conditions either as a cause or as a consequence of their renal disease. These patients receive an average of 10–12 medications daily leading to complex dosing schedules and are more likely to develop medication‐related problems (MRPs). The objectives of this study were to determine the nature and extent of MRPs in renally compromised patients and to explore the potential clinical significance of the MRPs. The potential for a clinical pharmacist to contribute towards resolving or preventing some of these MRPs was also explored.

Retrospective evaluation of potentially inappropriate prescribing in hospitalized patients with renal impairment

Abstract Background/aims: Patients with chronic kidney disease require appropriate adjustment of nephrotoxic and renally cleared medications to ensure safe and effective pharmacotherapy. It is currently unclear how often appropriate medication selection and dosage adjustment occurs in practice. Therefore, this study aimed to evaluate the extent of potentially inappropriate prescribing (PIP) (the use of a contraindicated medication or inappropriately high dose according to the renal function) in patients with renal impairment from admission through to discharge from the Royal Hobart Hospital (RHH), Tasmania, Australia; to evaluate the medications most commonly implicated in PIP; and the factors associated with PIP in renal impairment. Methods: Medical records of 251 patients consecutively admitted to the RHH aged 40 years and above, with a creatinine clearance of ≤60 mL/min, and hypertension and/or diabetes mellitus in their medical history, were reviewed. PIP was assessed using the Australian Medicines Handbook and/or product information. Results: Of the 251 patients, 81 (32.3%) were receiving a total of 116 potentially inappropriate medications (PIMs) at the time of admission. The number of patients receiving PIMs (81 vs. 44, p < 0.001 chi-square test) as well as the total number of PIMs (116 vs. 63, p < 0.001 Wilcoxon signed rank test) were significantly decreased at discharge. Metformin was the most common PIM at admission. However, PIP of metformin was reduced by approximately 50% by discharge. Logistic regression analysis revealed two significant independent risk factors for PIP: a higher number of medications at admission increased risk of PIP (OR 1.1, 95% CI 1.02–1.18, p = 0.010), and higher initial estimated glomerular filtration rate (eGFR) decreased the risk of PIP (OR 0.9, 95% CI 0.96–0.99, p = 0.011). Conclusions: Despite the limitations of lack of body weight documentation and lack of clear guidelines for dosage adjustment based on the eGFR, PIP in patients with renal impairment is common and admission to the hospital was associated with a significant reduction in PIP. More recognition of chronic kidney disease in the community and strategies to alert clinicians of the need for dosage adjustment in renal impairment are warranted.