Drug-Related Problems in Elderly Patients

Treatment of behavioral and psychological symptoms of dementia (BPSD) and comorbidities often necessitates the concomitant use of antipsychotics and non-antipsychotic drugs, thereby potentiating the risk for drug–drug interactions (DDIs). The primary objective of our study was to identify potentially clinically relevant cytochrome P450 (CYP)-mediated DDIs involving antipsychotics among participants enrolled in the Program of All-Inclusive Care for the Elderly (PACE) with BPSD. Additionally, we wanted to determine the prevalence of antipsychotic use in this population. The study included 10,001 PACE participants. The practice setting used a proprietary clinical decision support system (CDSS) to analyze simultaneous multidrug interactions. A retrospective analysis of pharmacy claims data was conducted to identify DDIs involving antipsychotics prescribed for BPSD, using snapshots of medication profiles paired with the CDSS. Of the participants who met inclusion criteria, 1190 (11.9%) were prescribed an antipsychotic; of those, 1071 (90.0%) were prescribed an atypical antipsychotic. Aripiprazole commonly caused (being a perpetrator drug 94.6% of the time) potential DDIs with antidepressants (e.g., duloxetine, venlafaxine, mirtazapine), opioids (e.g., hydrocodone, oxycodone, tramadol) and metoprolol via the CYP2D6 isoform. Risperidone commonly caused (85.7%) potential DDIs with donepezil, lamotrigine and trazodone via the CYP3A4 isoform. Quetiapine exclusively suffered (100%) from potential DDIs with amlodipine, buspirone, omeprazole or topiramate via the CYP3A4 isoform. Antipsychotics are commonly prescribed to PACE participants for BPSD treatment and they may interact with other drugs used to treat comorbidities. A thorough review of concomitant medications will help mitigate the likelihood of potentially dangerous CYP-mediated DDIs involving antipsychotics. Full article

Co-prescribing of opioids and benzodiazepines can lead to overdoses and mortality. This retrospective study analyzed prescription claims data collected in 2016. A national medication therapy management (MTM) program conducted prescriber-based outreach interventions for patients with concurrent opioid and benzodiazepine prescriptions. The pharmacist’s direct-to-prescriber intervention was conducted following a targeted medication review. The pharmacist initiated interventions with the prescriber via facsimile to recommend discontinuation of concurrent use of these drugs. This study included 57,748 subjects who were predominantly female (67.83%) and aged ≥ 65 years (66.90%). Prescribers were most commonly located in the southern United States (46.88%). The top prescribed opioid medications were hydrocodone-acetaminophen (33.60%), tramadol (17.50%), and oxycodone-acetaminophen (15.66%). The top benzodiazepines prescribed concurrently with opioids were alprazolam (35.11%), clonazepam (21.16%), and lorazepam (20.09%). Based on the pharmacists’ recommendations, 37,990 (65.79%) resulted in a medication discontinuation (benzodiazepines 40.23%; opioids 59.77%) by the provider. There were significant differences in the proportion of opioids discontinued by subject age (p < 0.001) and prescriber geographical region (p = 0.0148). The top medications discontinued by the prescriber were hydrocodone-acetaminophen (18.86%), alprazolam (14.19%), and tramadol HCl (13.51%). This study provides initial evidence for pharmacist-supported, direct-to-prescriber programs as an effective medication safety strategy. Full article

Background: The provision of responsible medication therapy to old nursing home residents with comorbidities is a difficult task and requires extensive knowledge about optimal pharmacotherapy for different conditions. We describe a stepwise pharmacist-led medication review service in combination with an interdisciplinary team collaboration in order to identify, resolve, and prevent medication related problems (MRPs). Methods: The service included residents from four rural Norwegian nursing homes during August 2016–January 2017. All residents were eligible if they (or next of kin) supplied oral consent. The interdisciplinary medication review service comprised four steps: (1) patient and medication history taking; (2) systematic medication review; (3) interdisciplinary case conference; and (4) follow-up of pharmaceutical care plan. The pharmacist collected information about previous and present medication use, and clinical and laboratory values necessary for the medication review. The nurses collected information about possible symptoms related to adverse drug reactions. The pharmacist conducted the medication reviews, identified medication-related problems (MRPs) which were discussed at case conferences with the responsible physician and the responsible nurses. The main outcome measures were number and types of MRPs, percentage agreement between pharmacists and physicians and factors associated with MRPs. Results: The service was delivered for 151 (94%) nursing home residents. The pharmacist identified 675 MRPs in 146 (97%) medication lists (mean 4.0, SD 2.6, range 0–13). The MRPs most frequently identified concerned ‘unnecessary drug’ (22%), ‘too high dosage’ (17%) and ‘drug interactions’ (16%). The physicians agreed upon 64% of the pharmacist recommendations, and action was taken immediately for 32% of these. We identified no association between the number of MRPs and sex (p = 0.485), but between the number of MRPs, and the number of medications and the individual nursing homes. Conclusion: The pharmacist-led medication review service in the nursing homes was highly successfully piloted with many solved and prevented MRPs in interdisciplinary collaboration between the pharmacist, physicians, and nurses. Implementation of this service as a standard in all four nursing homes seems necessary and feasible. If such a service is implemented, effects related to patient outcomes, interdisciplinary collaboration, and health economy should be studied. Full article