Combined use of an ACE-inhibitor and spironolactone in patients with heart insufficiency. / Risikoreiche Kombination oder leitliniengerechte Verordnung? ACE-Hemmer und Spironolacton: Bei Herzinsuffizienz indiziert.

A patient with cardiac insufficiency takes the ACE-Inhibitor Enalapril as well as Spironolactone regularly. In the interaction monographs of the German ABDA-database there is a note that combined use of these substances should be avoided due to an increased risk of hyperkalemia ­ is there a medication related problem? There is evidence from clinical studies, that combined use of ACE-inhibitors and potassium-sparing agents indeed increases the risk of severe hyperkalemia. The risk seems to be related to the dose of the potassium-sparing agent. However, in patients with cardiac insufficiency NYHA-class II-IV and an ejection fraction of ≤ 35%, the addition of spironolactone to an ACE-inhibitor and betablocking agent reduces mortality and hospitalization for cardiovascular problems. Therefore the combination is indicated in these patients. To minimize the risk for severe adverse events close monitoring of serum potassium and renal function is mandatory. Moreover, additional risk factors for hyperkalemia such as intake of potassium supplements or NSAID should be avoided.

Evaluation of a program of integrated care to reduce recurrent osteoporotic fractures.

PURPOSE: To evaluate the outcomes of patients participating in a program of integrated care for osteoporosis in terms of medication supply, fracture incidence and expenses. METHODS: Outcomes were assessed from secondary data provided by the AOK PLUS health insurance for 2455 participants of the program and the same number of matched controls who were also diagnosed with osteoporosis but did not participate in the program. Supply with Calcium and Vitamin D, antiresorptive agents and analgesics was assessed by defined daily doses. Osteoporotic fractures were identified by hospitalization data. Costs for fracture treatment, medication supply and additional expenses of the program were also included in the dataset. RESULTS: Patients enrolled in the program of integrated care received significantly more medication to treat osteoporosis than controls. There was no significant reduction in fracture incidence among participants of integrated care, but a reduced need of analgesics was noted. Additional costs for patients enrolled in the program were caused by a higher number of drug prescriptions, higher costs for stationary treatment and additional expenses for program related care and diagnostics. CONCLUSIONS: The program of integrated care was not found to be effective in reducing recurrent fractures. Cost effectiveness defined as a reduced rate of fractures in integrated care patients could not be shown by the assessed outcome measures. This missing reduction in fracture incidence may be explained by a non-sufficient improvement - compared to a placebo-controlled clinical trial - in medication supply and non-comparability of our real-world patient population with highly controlled clinical trial participants.