Factors associated to potentially inappropriate prescribing in older patients according to STOPP/START criteria: MoPIM multicentre cohort study

Objectives The objectives of the present analyses are to estimate the frequency of potentially inappropriate prescribing (PIP) at admission according to STOPP/START criteria version 2 in older patients hospitalised due to chronic disease exacerbation as well as to identify risk factors associated to the most frequent active principles as potentially inappropriate medications (PIMs). Methods A multicentre, prospective cohort study including older patients (≥65) hospitalized due to chronic disease exacerbation at the internal medicine or geriatric services of 5 hospitals in Spain between September 2016 and December 2018 was conducted. Demographic and clinical data was collected, and a medication review process using STOPP/START criteria version 2 was performed, considering both PIMs and potential prescribing omissions (PPOs). Primary outcome was defined as the presence of any most frequent principles as PIMs, and secondary outcomes were the frequency of any PIM and PPO. Descriptive and bivariate analyses were conducted on all outcomes and multilevel logistic regression analysis, stratified by participating centre, was performed on the primary outcome. Results A total of 740 patients were included (mean age 84.1, 53.2% females), 93.8% of them presenting polypharmacy, with a median of 10 chronic prescriptions. Among all, 603 (81.5%) patients presented at least one PIP, 542 (73.2%) any PIM and 263 (35.5%) any PPO. Drugs prescribed without an evidence-based clinical indication were the most frequent PIM (33.8% of patients); vitamin D supplement in older people who are housebound or experiencing falls or with osteopenia was the most frequent PPO (10.3%). The most frequent active principles as PIMs were proton pump inhibitors (PPIs) and benzodiazepines (BZDs), present in 345 (46.6%) patients. This outcome was found significantly associated with age, polypharmacy and essential tremor in an explanatory model with 71% AUC. Conclusions PIMs at admission are highly prevalent in these patients, especially those involving PPIs or BZDs, which affected almost half of the patients. Therefore, these drugs may be considered as the starting point for medication review and deprescription. Trial registration number NCT02830425

Polypharmacy: definition, risks, management

A search was performed in the Scopus, Web of Science, MedLine, The Cochrane Library databases. The term “polypharmacy”, in contrast to the term “polypragmasia”, does not always has a negative meaning and is often used to describe the simultaneous use of five or more drugs, and polypharmacy is considered intensive, when the patient takes 10 or more drugs at the same time. One of the main causes of polypharmacy is polymorbidity. Severe condition of the patient, self-medication and inappropriate recommendations can also cause polypharmacy, as well as some demographic factors (age, gender, level of education) and the level of the health care system development. Polypharmacy can be appropriate when the prescription of a large number of drugs is justified, and inappropriate (problematic) when the number of prescribed drugs is incorrect and/or unbalanced. Problematic polypharmacy is a manifestation of polypragmasia, with several drugs prescribed improperly that does not allow realizing the expected advantage of these drugs. The risk of harm from treatment outweighs the benefits due to drug interactions, adverse reactions, increasing economic burden of treatment. Problematic polypharmacy is especially dangerous for critically ill patients. The management of problematic polypharmacy should be based on its transition into an appropriate form. The combination of drugs is substantiated, which allows treating the patient effectively, safely and economically expediently through the prevention of drug interaction and adverse effects. Deprescribing of certain drugs can be used as a therapeutic intervention, it should be performed in each individual patient through the assessment of benefits and risks. Beers criteria, ARMOR, STOPP-START criteria are offered for prevention and correction of problematic polypharmacy in the elderly.

Basic principles of combination therapy: focus on drug-drug interaction

The article is devoted to the issue of drug interactions in the combination regimens. Today, when drug therapy is the first-line approach for patients with noncommunicable diseases, and the world population ageing leads to an increase in the number of patients with severe comorbidity and polypharmacy, the problem of drug-drug interaction is especially relevant. The article discusses the main types of drug interactions — pharmacokinetic (related to absorption, distribution, metabolism and excretion of drugs) and pharmacodynamic ones, leading to synergy or antagonism of the pharmacological effects. The consequences of drug interactions can be desirable and undesirable, while the latter are much more common. Attention should be directed precisely to preventing such interactions. Also, using data from special scales and lists (Beers criteria, STOPP/START criteria), the options for various adverse drugdrug interactions are briefly described. In addition, the article provides a number of Internet resources that allow assessing the drug interaction risk when prescribing combination therapy.

Indications for prescription and deprescription in multimorbid independently living elderly outpatients

Introduction Global trend to population ageing is associated with inevitable increase of polypharmacy in multimorbid elderly population. Purpose To estimate the level and structure of comorbidity and pharmacotherapy in independently living patients of different age groups with high and extreme cardiovascular risk, when observed in outpatient clinics Methods 282 consecutive patients of high cardiovascular risk have been enrolled. Inclusion criteria were: SCORE ≥5%, documented history of acute myocardial infarction (AMI), acute or transient cerebrovascular accident (CVD), coronary artery intervention, acute coronary syndrome (ACS), stable angina, intermittent claudication, type 2 diabetes mellitus (DM2) or type 1 DM with diabetic nephropathy, angiogram or ultrasound proved atherosclerotic plaques, total serum cholesterol level ≥8 mmol/L, blood pressure ≥180/110 mmHg and signed voluntary informed consent form. Current clinical conditions, pharmacologic treatment and indications for prescription and deprescription were studied. STOPP criteria for prescribing potentially non-recommended drugs in people over 65 years of age, START criteria for not prescribing necessary drugs in people over 65 years of age, non-recommended in elderly people over 65 drug list were used to assess polypharmacy. According to the WHO age classification, there were three groups: Group 1 (aged 45 to 59), Group 2 (aged 60 to 74) and Group 3 (aged 75 +). Results There were no differences in the frequency of statins administration (p=0.72) and antiplatelet agents (p=0.49) between 3 groups. Polypragmasia (administration of more than 5 drugs) was registered in 150 patients (53%) and was significantly more common in Group 3 (p=0.001). 48 cases of inadequate prescribing were registered in 46 (28%) elderly patients. 24 cases of prescribing potentially unacceptable medications for the elderly were reported. Conclusion Unavoidable polypragmasia was found in 53% multimorbid elderly patients. Irrational drug treatment was detected in 28% elderly patients STOPP criteria were met in 32.1% and START criteria were met in 30.4% cases. Polypragmasia being inevitable in elderly multimorbid patients, administration of any new medication should be performed after a thorough risk-benefits balance assessment. FUNDunding Acknowledgement Type of funding sources: None.

Polypharmacy in elderly patients with falls

Background: Falls in elderly–a multifactorial syndrome. One of the modifiable factors is polypharmacy. STOPP/START criteria are used for correction of polypharmacy in geriatrics.Aim: Assessment of the prevalence of polypharmacy, analysis and correction of pharmacotherapy using STOPP/START criteria in patients with falls.Materials and methods: The study included 655 patients hospitalized in the geriatric department over 60 years of age, who were divided into two groups. Group 1 (n=332, 50.7%)–patients with 1 or more falls, group 2 (n=323,49.3%)–patients without falls. The analysis of the received therapy before hospitalization was performed. After that, based on the indications, contraindications and STOPP/START criteria, drug therapy was corrected in patients with falls.Results: Patients of group 1 took 4.5±2.18 drugs, group 2–4.3±2.6. Polypharmacy was diagnosed in 150 (45.2%) patients with falls and in 122 (37.8%) patients without falls. Patients with falls were more likely to receive sleeping pills, NSAIDs. Univariate analysis showed that falls were associated with NSAIDs (OR 2.15, 95% CI 1.38–3.35, p=0.001) and sleeping pills (OR 2.03, 95% CI 1.02–4.02, p=0.047). An audit and correction of therapy was performed: in 108 (32.5%) patients the number of prescribed drugs was reduced. Patients with falls were prescribed statins, antidementia drugs, anticonvulsants and antidepressants as components of therapy for chronic pain syndrome, chondroitin sulfate and glucosamine sulfate for the treatment of osteoarthritis, calcium and antiresorbtive therapy, antianemic drugs, vitamin D. Antiplatelet agents, digoxin, sleeping pills and NSAIDs were less frequently prescribed. STOPP/START criteria and their frequency in patients with falls were analyzed. 141 cases of potentially non-recommended but prescribed medications were identified. STOPP criteria were for the administration of NSAIDs (n=53, 37.6%) and acetylsalicylic acid (n=62, 44%). There were 458 cases of potentially recommended but not prescribed medications. The most common START criteria were not for the administration of vitamin D and statins.Conclusion. Half of elderly patients with falls have polypharmacy. These patients are more likely to take sleeping pills and NSAIDs. STOPP criteria most often concerned the appointment of NSAIDs and acetylsalicylic acid, and the START criteria revealed the absence of the appointment of vitamin D and statins.

Early use of cytokine adsorption in treatment of COVID-19 associated respiratory distress syndrome

Introduction. It is the recommendations for treatment of sepsis and septic shock combined with rheumatologists’ recommendations for monoclonal antibodies therapy that guide severe COVID-19 management in ICU. However, those recommendations may not be fully applied to patients with acute respiratory distress-syndrome associated with SARS-CoV-2, as there exists a difference in pathogenesis between sepsis and virus-associated pneumonias. Monoclonal antibodies therapy may contribute to cytokine cascade severity and promote lung injury. Cytokine storm aggravates the course of the disease. At present, there are two groups of methods described in literature for cytokine storm control and therapy: pharmacological and extracorporeal approaches.Materials and methods. We have performed a retrospective analysis of five COVID-19 patients with acute respiratory syndrome. Cytokine adsorption start criteria were respiratory insufficiency and IL-6 levels greater than 500 pg/ml. Adsorption therapy was initiated within 24 hours of ICU admission and continued for 48–120 hours in hemoperfusion mode on Multifiltrate machine (Fresenius Medical Care). The length of a single session of CytoSorb (Cytosorbents Inc.) therapy was 24 hours.Results. All patients demonstrated SpO2/FiO2 ratio growth and IL-6 concentration decrease by the end of hemoadsorption. We noted lymphocyte count rise as well as IgM и IgG SARS-CoV-2 antibodies titer substantial increase.Conclusions. Our observations suggest that the early start of hemoadsorption associates with gas-exchange stabilization and hinders respiratory distress progression. Hemoadsorption allows for pro-inflammatory cytokines concentrations decrease and prevents secondary lung injury. According to our data, hemoadsorption is beneficial to form a coronavirus infection specific immune response. Further research is needed for a detailed study of the results we here describe.

The Prevalence of Potentially Inappropriate Prescribing in the Elderly at the Primary Care Level in Kazakhstan

BACKGROUND: These potentially inappropriate prescribing is associated with the development of undesired medical reactions in elderly patients, and increase the frequency of hospitalizations, the number of aggravations and the cost of treatment. All of these adverse events are preventable. For detection of PIP and to prevent the adverse drug reactions (ADRs) in elderly patients, it is necessary to screen for potentially inappropriate prescribing. AIM: The aim of the study is to study the prevalence of PIP and the factors associated with these prescriptions at the level primary link in Kazakhstan. METHODS: A prospective descriptive study was carried out at the primary care level, in five clinics in Kazakhstan. The study involved 205 patients over 65 years old who received regular outpatient treatment for chronic diseases. Patients’ current diagnoses and prescription medicines were reviewed and the STOPP and START tools applied. RESULT: The prevalence of PIP in terms of STOPP criteria was 54% (114 patients). In general, we have identified 181 cases of PIP. The most commonly prescribed PIP were moxonidine (20%), glimeperide (16.5%), and PPI (20%). The prevalence of prescribing omissions in terms of START criteria was 22% (48 patients). Overall 66 cases of prescribing omissions were identified. The most commonly prescribed omissions were statins (6%) and ACE inhibitors (4%). Comparative analysis revealed a statistically significant effect of polymorbidity on the prevalence of PIP (p < 0.001) and number of prescribed medicines on the prevalence of PIP (p < 0.05). We have found a statistically significant effect of age on the presence of prescribing omissions of patients. (p < 0.001) CONCLUSION: Our results showed a high prevalence of potentially inappropriate prescribing at the primary care level in Kazakhstan. Screening tools should be incorporated into the everyday practice of primary care doctors.

Pharmacoepidemiological Safety of Drugs Used in Geriatrics: A Systematic Review in Madanapalle and Punganur Region of Andhra Pradesh

In this study, we were provided universal considerations for the setting up and carry out of pharmacoepidemiological studies of drug use for disorders like Osteoarthritis, Hypertension, Hyperlipidemia, Hypothyroidism, Depression, and Osteoporosis in geriatric patient. The study method was focused on monitored and categorized the prescriptions of geriatrics from 650 patient in Madapalle and Puganur region of Andhra Pradesh, Identified and prepare the list of drugs, which were inappropriately prescribed and used in geriatrics by using Revised Beers criteria and also assess the Activities of Daily Living (ADL) by using Modified Barthel Index (MBI). Identify any drug-drug interactions among the drugs used in geriatrics. We were reported the adverse drug reactions appeared in geriatrics and the various treatments that the patients are received with different co-morbidity disease with the assessment of drug exposure, and ascertainment of PIM, PPO STOPP, START criteria and MBI outcomes. Characteristic of statistics sources include evaluation of complete history of drug use in elderly patient with co-morbidity condition, allowing approximate of collective exposure. Result data from beers criteria with PIM, modified barthel index are preferable, but elderly patient treatment data from reliable sources, for example, patient or pathology registries, and medical records are also considered. We present report to showed poly-pharmacy effects of drug use on elderly patient improvement and converse the need for employing STOPP and START criteria of PIM and PPO to avoid undesirable drug reaction causation. We emphasize that a study design of beers criteria always be considered and result of Modified barthel index shows the dependency rate in elderly patient. We also underline the need for Comorbidity analyses in geriatric patient and drug usage, as drug utilization in geriatric are prone to dose and number of drugs in treatment dependent. In the main, studies of Prescription analyses like polypharmacy, PIM, PPO in prescription should explore risk Geriatric patient, the present study reveal the PIM and PPO of in prescription from six hundred and fifty geriatric patient. We conclude the pharmacoepidemiological studies of elderly patient are likely to develop significantly in the coming years, due to the rising mortality of long-term drug exposures and less awareness of poly-pharmacy result, the increasing perform of multinational studies, permiting studies of rare and common disease in elderly people, types of medication and procedural development specifically addressing geriatric treatment and long-term outcomes.