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PubMed2005

Clinical management of the dental patient taking multiple drugs.

Adverse drug reactions (ADRs) occur often in elders often due to polypharmacy. Those over 65 currently comprise 13% of the population but consume approximately a third of all drugs prescribed. Increased care when prescribing certain drug classes and careful monitoring of the patient can prevent many ADRs. This article examines four questions that should be addressed when providing dental care for an older patient taking multiple medications. These include: (1) what are the medical conditions that necessitate the medications, (2) what impact do these medical conditions have on the provision of care, (3) what are the oral side effects of the medications, and (4) how will the patient's current list of medications alter the dentist's prescribing patterns for drugs used in dentistry?

Adverse Drug Reaction Reporting Systems↗

PubMed2005

[Dealing with adverse drug reactions in dentistry. Procedures on encountering adverse drug reactions and goal of the Swiss Pharmacovigilance system].

Dentists may be confronted with adverse drug reactions (ADRs) in their dental practice, and are--like other health professionals--obliged to report certain ADRs. The aim of this article is to sensitise dentists for this topic, to show how to proceed in case of a supposed ADR, and to emphasise the importance of spontaneous reporting of ADRs. ADRs may not always be clearly distinguished from symptoms of underlying diseases, and in cases of polypharmacy multiple drugs may be responsible for the reaction. It is therefore important to get a detailed medical history, and to establish a temporal relationship between start of a therapy and appearance of the symptom. Information from the medical literature, exclusion of other possible causes, and identification of risk factors help to confirm a causal relationship between a suspected drug and an observed reaction. In Switzerland severe and unexpected ADRs have to be reported to one of the regional Pharmacovigilance centres with the yellow ADR reporting form from Swissmedic. The spontaneous reports of ADRs help to early identify new problems of a drug therapy, and permit to take measures to minimise the risk.

Adverse Drug Reaction Reporting Systems↗

PubMed2005

[Pharmacovigilance as new direction of research].

Pharmacovigilance: permanent collection and assessment of the safety data of the drug, in the interest of precise knowledge of the safety profile of the pharmacon; permanent collection of unexpected adverse drug reactions, effects on special patient populations, drug interactions, adverse drug reactions of long-term treatment, adverse drug reactions of long latency. Our study was performed under the tutelage of the Drug Safety Programme in Psychiatry (AMSP), 2004. We review the side effects occuring in the different organ systems; side effects during the use of antidepressive and antipsychotic therapy. We review how the danger of polypharmacy can be avoided by reducing the dose of the current drug; by using therapeutic drug; or just by monitoring therapeutic and adverse effects.

Adverse Drug Reaction Reporting Systems↗

PubMed2005

[Medication use in older patients with chronic renal failure].

Adverse drug reactions in the elderly are of growing concern because of the increasing elderly population and the increasing numbers of medications prescribed to this group. Ageing and the frequent comorbid diseases in the elderly result in altered drug pharmacokinetics and pharmacodynamics increasing the risk of side effects. The decline in renal function affects the elimination of many drugs. Before prescribing an estimation of the glomerular filtration rate is of the highest importance. All the nomogramms and formulae are approximate in the oldest old. The Cockcroft and Gault formula is frequently used. Pharmacodynamic alterations are particularly important for the centrally active drugs that older people are more vulnerable to, for example increased and prolonged effects of anticholinergic, hypnotic and sedative drugs. Polypharmacy and self-medication is also common in these patients, with increased chance for drug-drug interactions. In France, the recent law on Public Health (August 09, 2004) requires for the next five years to decrease the frequency of inappropiate prescriptions in elderly people and of to decrease the frequency of the drug-induced hospitalisations. Undertreatment of the elderly is not the solution: it's necessary to optimize their medication: to well appreciate before prescription their motor and cognitive deficiencies interfering with compliance, to "start low and go slow" their medications, to review their drug consumption on a regular basis, to educate them and their family for a good observance.

Aged, 80 and over↗

PubMed2006

Prescription pattern at primary health care centres in Lagos State.

Health care received in health facilities depends on adequate consultation, correct prescription and dispensing with relevant information given to the patient. These are some of the indicators for rational drug use. The objective of the study was to determine the pattern of prescription among prescribers in twenty Primary Health Care Centers of Lagos State using some of these indicators used in investigating health facilities by the World Health Organisation and International Network for Rational Use of Drugs. The study was carried out using multi-stage random sampling in selecting the Primary Health Care Centers from each of the twenty Local Government Areas of Lagos State. Both prospective and retrospective data were collected and analysed using Epi-Info version 6. The results showed that there was polypharmacy, misuse of antibiotics and injections. There was no statistically significant difference between the retrospective and prospective indicators of mean drugs prescribed per encounter, percentage antibiotics prescribed and percentage of generic prescription. It was concluded that there was irrational prescription pattern in all the selected health facilities as evidenced by poly-pharmacy, misuse of antibiotics and low generic prescriptions. There is need for educational intervention to improve the prescribing habits of health professionals in these health facilities.

Anti-Bacterial Agents↗

PubMed1996

Xerostomia: prevalence and pharmacotherapy. With special reference to beta-adrenoceptor antagonists.

The main objective of this thesis was to estimate the prevalence of subjectively perceived dry mouth, xerostomia, in a representative general adult population, and the possible co-morbidity between xerostomia and on-going pharmacotherapy. Further, to evaluate the effects of beta-adrenoceptor antagonists on saliva flow rate and composition. The prevalence of xerostomia was evaluated by means of a questionnaire mailed to a random sample of 4.200 adult subjects living in the southern part of the province of Halland, Sweden. Three hundred men and equally many women aged 20, 30, 40, 50, 60, 70 and 80 years were selected from the national census register. From 3311 (81%) evaluable questionnaires was concluded that, in the studied population, 21.3% of the men and 27.3% of the women reported xerostomia. The difference between the sexes was statistically significant, women reporting higher prevalence of dry mouth than men. It was also found that xerostomia was significantly age-related. Further, it was demonstrated that there was a strong co-morbidity between reported prevalence of dry mouth and on-going pharmacotherapy. Generally, no specific drug or drug-group proved to be especially xerogenic, rather, polypharmacy was strongly correlated to reported symptoms of dry mouth, and it was also a significant correlation between increasing xerostomia and the number of medications taken. The effects of beta-adrenoceptor antagonists on saliva flow rate and composition were evaluated both in healthy volunteers and in hypertensive patients. The effects of one week of treatment with the non-selective (propranolol) and the beta 1-selective (atenolol) adrenoceptor antagonists were compared with that of placebo in three different clinical trials, including 38, 11 and 19 healthy volunteers, respectively. Two of these studies were focused on the effects on whole saliva secretion rate and composition and the third study on the secretions from the parotid and the submandibular-sublingual glands. Salivary composition but not saliva flow rates were affected by the beta-adrenoceptor antagonists, and the most pronounced effects were observed for total protein composition and amylase activity, both being significantly decreased during treatment with any of the antagonists, however, more accentuated during treatment with atenolol. Twelve hypertensive patients who were well-controlled in their blood-pressure by means of monotherapy with metoprolol, a beta 1-selective adrenoceptor antagonist, were observed during four weeks of withdrawal and after re-exposure to this antihypertensive treatment. The observed effects on salivary composition were essentially the same as those found in healthy volunteers. In the hypertensive group, however, whole saliva flow rates increased significantly on drug withdrawal and decreased again on re-exposure to metoprolol.

Adrenergic beta-Antagonists↗

PubMed1998

The effects of aging on anesthetic pharmacology.

Aging alters both the pharmacokinetic and the pharmacodynamic aspects of anesthetic requirement. Studies of the relationship between drug concentration and effect in older adults clearly demonstrate a decline in median effective dose requirement for agents that act within the central nervous system, but there appears to be little change in the dose required for peripheral effects such as neuromuscular blockade. Most drugs also undergo somewhat slower biotransformation and demonstrate prolonged clinical effects if they require hepatic or renal degradation, although many newer agents such as remifentanil and cisatracurium have organ-independent pathways that are not affected by age. In some cases, however, the appearance of increased sensitivity to a given dose of anesthetic or opiate may actually reflect higher-than expected plasma concentrations of drug following a rapid intravenous injection. Therefore, it is impossible to completely separate the interactions between pharmacodynamic and pharmacokinetic factors associated with aging. The use of pharmacological sympathectomy with intrathecal agents and with sympatholytic adrenergic agonists may further improve outcome in a patient population at high risk because of reduced functional reserve, increased incidence of polypharmacy, and the consequences of age-related disease.

Adrenergic Agonists↗

PubMed1993

Drug prescribing for the elderly.

Both the geriatric population of the United States and the use of prescription drugs by this age group continue to increase. Cardiovascular medicines, analgesics, anti-inflammatories, and psychotropic medications are used most commonly. Polypharmacy, defined as a condition in which a patient receives too many drugs, drugs for too long, or drugs in exceedingly high doses, often results.

Aged↗

PubMed2000

Discrepancies in the use of medications: their extent and predictors in an outpatient practice.

BACKGROUND: Misuse of medications is a major cause of morbidity and mortality. Few studies have examined the frequency of, and factors associated with, discrepancies between what doctors prescribe and what patients take in actual practice. PATIENTS AND METHODS: Patients' medication bottles and their reported use of medications were compared with physicians' records of outpatients seen between November 1997 and February 1998 in a private practice affiliated with an academic medical center in Boston, Mass. Three hundred twelve patients from the practices of 5 cardiologists and 2 internists who were returning for their routine follow-up visits were included. MAIN OUTCOME MEASURE: The presence of discrepancies based on comparing medication bottles with medical records. RESULTS: Discrepancies were present in 239 patients (76%). The 545 discrepancies in these patients were the result of patients taking medications that were not recorded (n = 278 [51%]); patients not taking a recorded medication (n = 158 [29%]); and differences in dosage (n = 109 [20%]). Overall, discrepancies were randomly distributed among different drugs and discrepancy types with no discernible pattern. On multivariate analysis, patient age and number of recorded medications were the 2 most significant predictors of medication discrepancy. CONCLUSIONS: Discrepancies among recorded and reported medications were common and involved all classes of medications, including cardiac and prescription drugs. Older age and polypharmacy were the most significant correlates of discrepancy. The pervasiveness of discrepancies can have significant health care implications, and action is urgently needed to address their causes. Such action would likely have a positive impact on patient care.

Adult↗

PubMed2002

A community-wide survey of physician practices and attitudes toward cholesterol management in patients with recent acute myocardial infarction.

BACKGROUND: Physicians' current attitudes and practices toward the management of high cholesterol levels in patients with recent acute myocardial infarction are not well defined. OBJECTIVE: To examine threshold levels of serum cholesterol and other factors that influence physicians' decision to prescribe lipid-lowering drugs and initiate dietary therapy in patients with recent acute myocardial infarction. METHODS: Community-wide questionnaire survey of general internists, cardiologists, and family physicians practicing in the Worcester, Mass, metropolitan area. RESULTS: Among the 257 responding physicians, lipid-lowering drug therapy was more likely to be initiated in younger patients at lower total serum and low-density lipoprotein (LDL) cholesterol levels than in older patients (P =.03). Younger physicians were more likely to initiate dietary and lipid-lowering drug therapy at lower total and LDL cholesterol levels than their older counterparts. Younger physicians also considered LDL cholesterol level the most important factor in initiating lipid-lowering drug therapy in contrast to older physicians who favored total cholesterol level (P =.001). General practice physicians were more likely to initiate dietary therapy at lower total cholesterol levels, but tended to initiate lipid-lowering drug therapy at higher total and LDL cholesterol levels compared with internists and cardiologists. Physicians reported that the most important factors that interfere with patients' use of lipid-lowering medication were concerns about medication costs, issues related to polypharmacy, and failure to recognize the importance of lipid-lowering drugs. Several physician-associated factors, including perceived importance of other cardiac drugs and provider responsibility, were associated with the nonuse of lipid-lowering medications. CONCLUSION: Educational and practice-based efforts remain necessary to remove potential barriers to the implementation of effective long-term cholesterol management in patients with recent acute myocardial infarction.

Anticholesteremic Agents↗

PubMed2004

Safety of anticoagulation therapy in well-informed older patients.

BACKGROUND: In older populations, oral anticoagulation therapy (OAT) is underused by physicians, mainly because of fear of bleeding complications. The aim of this study was to determine the incidence of bleeding complications and associated risk factors in a large heterogeneous group of older patients. METHODS: Combined retrospective and prospective cohort study conducted in geriatric and internal medicine departments. All patients 80 years or older discharged with the recommendation of OAT were followed up for a mean +/- SD of 28.8 +/- 36.3 months. The rate of bleeding events and the quality of anticoagulation were compared across a wide range of demographic and clinical variables and cognitive and functional status. In addition, we assessed the quality of education given to the patient or caregiver on the use of OAT. RESULTS: Among 15 387 patients 80 years or older, 323 (2.1%) were discharged with the recommendation of OAT. The rate of major bleedings was 2.4 events per 1000 patient-months. Socioeconomic and cognitive variables and functional impairments were not associated with an increased rate of bleeding. In multivariate analysis, insufficient education on OAT as perceived by the patient or caregiver (odds ratio [OR], 8.83), polypharmacy (OR, 6.14), and international normalized ratio values above the therapeutic range (OR, 1.08) were the only significant predictive factors for bleeding complications. CONCLUSIONS: The rate of bleeding complications, especially major bleedings, was low in this large group of older patients, many with comorbidities and cognitive and functional impairments. Insufficient OAT education was the major factor that predicted bleeding. Therefore, improving and fostering better methods of OAT education may further reduce bleeding complications.

Aged↗

PubMed2005

The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998-2001.

BACKGROUND: Polypharmacy-the concurrent prescription of multiple medications-is a salient consideration in the care of older patients with heart failure. Little is known, however, about the complexity and financial burden of medical therapy in this population. METHODS: This is a study of the chronic medications prescribed at hospital discharge to patients 65 years or older hospitalized for heart failure in 2 cohorts separated by 27 months (April 1998-March 1999, n = 31 602; July 2000-June 2001, n = 30,774). Three utilization measures were assessed: the number of drugs, the estimated number of doses per day, and the estimated annual costs using the same cost standard (2003 average wholesale prices) for both samples. Utilization associated with population characteristics and between time frames was assessed in multivariable models. RESULTS: In 1998-1999, the mean number of drugs was 6.8, representing 10.1 doses daily at a cost of 3142 dollars/y, increasing to 7.5 drugs, 11.1 doses daily and 3823 dollars/y in 2000-2001 (P<.001 for all comparisons). After adjustment, the number of drugs increased by 12% and costs by 24% between samples. Factors associated with greater complexity and cost included diabetes (1.6 additional drugs and 1094 dollars/y additional cost), prior revascularization (1.3 drugs, 1154 dollars/y), and chronic lung disease (1.2 drugs, 814 dollars/y). Younger age and white race were also associated with more drugs and higher costs. CONCLUSIONS: The drug treatment of older patients with heart failure is characterized by rapidly increasing complexity and cost. Efforts should be directed toward optimizing the complex drug regimens of elderly patients with heart failure and multiple comorbidities.

Aged↗

PubMed1980

Automated review system for orders of psychotropic drugs.

A computerized drug-review system both reviews drug orders and notifies clinicians of orders that are considered exceptions to some clinical guidelines. The impact of this system in a psychiatric center in which it has been used since December 1975 is examined in terms of the reduction of the percentage of orders of psychotropic drugs that involve polypharmacy or dose-range exceptions. The results show a substantial reduction in orders in exception since the implementation of the system.

Computers↗

PubMed2005

Potentially inappropriate medication use among elderly home care patients in Europe.

CONTEXT: Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability. OBJECTIVE: To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument. MAIN OUTCOME MEASURES: Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model. RESULTS: Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001). CONCLUSIONS: Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.

Aged↗

PubMed2000

Ciprofloxacin-warfarin coagulopathy: a case series.

Ciprofloxacin, when given to patients previously anticoagulated with warfarin, can occasionally cause an exaggerated hypoprothombinemic response and bleeding diatheses. Two such cases encountered at our institution are presented and data is combined with 64 cases reported to the Food and Drug Administration's (FDA) Spontaneous Reporting System (SRS) database, which included all cases reported from 1987 through 1997. Of 66 total cases the median age was 72 (range 36-94). The mean time to detection of the coagulopathy following the ciprofloxacin challenge was 5.5 days (n = 50). Hospitalization was reported in 15 cases, bleeding in 25 cases, and death in one case. The median prothrombin time (PT) and International Normalized Ratio (INR) was 38.0 (n = 13) and 10.0 (n = 23), respectively. The mean number of medications taken was 6.5 (n = 45). The mean time to correction was significantly shorter between the treated (2.5 days) and the untreated (4.0 days) groups (P < 0. 008). The ciprofloxacin-warfarin coagulopathy occurred most commonly in patients in their seventh decade and in those who require polypharmacy. Active treatment of the coagulopathy results in more rapid resolution than observation alone. Clinicians should be aware of the potential bleeding complications that can occur with the ciprofloxacin-warfarin drug-drug interaction.

Aged↗

PubMed1998

Medication use in nursing homes for elderly people.

Residents of nursing and residential homes are often prescribed medication for physical and mental ill-health with resultant polypharmacy and the possibility of iatrogenic disorders. Sometimes drugs are prescribed inappropriately and a number of studies have highlighted the overuse of psychotropic drugs. Legislation in the USA has been effective in controlling their use in that neuroleptic prescriptions for the treatment of behavioural disturbances have been significantly reduced and non-pharmacists have a role to play in the appropriate management of medicines in elderly residents; they can improve patient care and be cost-effective. Identification of methods by which to improve awareness of inappropriate medication prescription and to avoid certain types of drugs is required. This review critically evaluates medication use in this population with specific reference to psychotropics and aims to raise awareness of the issue.

Aged↗

PubMed1996

A 1-year study of drug prescriptions and adverse drug reactions in psychiatric hospital practice.

Drug prescribing habits and adverse drug reaction occurrence were investigated in a psychiatric hospital ward for chronic resident patients, and the usefulness of a drug prescription and adverse event (AE) routine monitoring programme in this setting was assessed. A computerized data base was established and updated bimonthly with clinical data concerning each patient. In particular, information about drug prescriptions was routinely obtained from the clinical records, stored in the data base and periodically retrieved and analysed. The ward doctors were required to report on a form the AEs, which were subsequently examined by a panel of clinical pharmacologists and hospital consultants, to assess their relationship with drug treatments. Moreover, the data base was periodically scrutinized, to search for further AEs. Drug prescription monitoring, besides providing valuable information about drug utilization, allowed identification of some questionable issues (e.g. polypharmacy, low frequency of treatment revisions). The AE monitoring system proved to be effective and the participation of the ward doctors was satisfactory. It is concluded that in this psychiatric hospital setting a drug prescription and AE routine monitoring programme can provide useful information and promote improvement of the quality of care.

Journal Article↗

PubMed1997

Geriatric prescribing in the medical wards of a teaching hospital in Nepal.

A retrospective study on prescribing patterns for 100 randomly selected geriatric patients admitted over a period of 1 year to the medical wards of the Tribhuvan University Teaching Hospital (TUTH) in Nepal showed that polypharmacy was prevalent. During a hospital stay, 73% patients received more than five, 54% received more than eight, and 24% received more than nine drugs concurrently. Although the average drug exposure per patient during a hospital stay was found to be 11.2, this figure would actually go up to 14.5 if all the active ingredients of the fixed-dose combination products prescribed (15.4% of all drugs) were taken into account. Intravenous fluids were the most commonly prescribed drugs and were given to 91% of the patients. Antibiotics (excluding metronidazole and antituberculous drugs) were given to over three-quarters (77%) of the patients. Ciprofloxacin was the most commonly prescribed antibiotic. Of the 42 patients treated with this drug, 31 (73.8%) received it intravenously, either for a part of or throughout the course. This antibiotic was prescribed concurrently with theophylline in 14 patients without the facility for monitoring plasma-theophylline levels. It was also administered at the same time as antacid in nine patients. Nearly half (46.4%) of the drugs were prescribed by brand or proprietary names. The prescribing error of leaving the prescription card undated or unsigned when prescribing or stopping drugs was found to be high. The results of this survey indicate that there is considerable scope for improving geriatric prescribing practices in the medical wards of TUTH.

Journal Article↗