Anemia in nursing homes, proton pump inhibitors and prescribing cascade of antianemic drugs.

PURPOSE: Some medications can cause anemia through their effect on gastrointestinal function, such as proton pump inhibitors and H2-antagonists, and on the risk of bleeding, such as anticoagulants and antiplatelet agents. The main aim of this study is to evaluate how anemia is related with the most commonly used drugs in a large sample of NH residents. METHODS: This retrospective cross-sectional multicenter study was conducted in a sample of Italian long-term care NHs distributed throughout the country. RESULTS: In all, 2602 NH residents recruited from 27 Italian long-term NHs (mean age ± SD: 88.4 ± 8.5) and 441 (16.9%) had a diagnosis of anemia. The unadjusted model showed a significant relation with PPI (OR 1.71, 95% CI 1.39-2.11, p < 0.0001). This relation was maintained in the model adjusted for age, sex, CKD, atrophic gastritis, peptic ulcer and rheumatic disease (OR 1.61, 95% CI 1.31-1.99, p < 0.0001). PPI users were also at higher risk of being treated with antianemic drugs-iron supplements, folate, vitamin B12 and erythropoietin (OR 2.03, 95% CI 1.67-2.48, p < 0.0001)-even if they did not have anemia (OR 1.94, 95% CI 1.55-2.42, p < 0.0001). CONCLUSION: Proton pump inhibitors are associated with anemia in NH residents. PPIs are also related with an increased probability of receiving drugs to treat anemia, such as iron supplements, folate or cyanocobalamin and erythropoietin, as the effect of a prescribing cascade. Optimization of PPI prescription is needed to avoid adverse events and promote rational drug prescription.

Use of preventive drugs during the last year of life in older adults with cancer or chronic progressive diseases.

PURPOSE: To evaluate the prescription of preventive medications with questionable usefulness in community dwelling elderly adults with cancer or chronic progressive diseases during the last year of life. METHODS: Through the utilization of the healthcare databases of the Lombardy region, Italy, we identified two retrospective cohorts of patients aged 65 years or more, who died in 2018 and had a diagnosis of either a solid cancer (N = 19 367) or a chronic progressive disease (N = 27 819). We estimated prescription of eight major classes of preventive drugs 1 year and 1 month before death; continuation or initiation of preventive drug use during the last month of life was also investigated. RESULTS: Over the last year of life, in both oncologic and non-oncologic patients, we observed a modest decrease in the prescription of blood glucose-lowering drugs, anti-hypertensives, lipid-modifying agents, and bisphosphonates, and a slight increase in the prescription of vitamins, minerals, antianemic drugs, and antithrombotic agents (among oncologic patients only). One month before death, the prescription of preventive drugs was still common, particularly for anti-hypertensives, antithrombotics, and antianemics, with more than 60% of patients continuing to be prescribed most preventive drugs and an over 10% starting a therapy with an antithrombotic, an antianemic, or a vitamin or mineral supplement. CONCLUSION: These findings support the need for an appropriate drug review and improvement in the quality of drug prescription for vulnerable populations at the end-of-life.

Strategies to Improve Medication Adherence in Older Persons: Consensus Statement from the Senior Italia Federanziani Advisory Board.

Poor adherence to treatment regimens has long been recognized as a substantial roadblock to achieving better outcomes for patients. Non-adherence to medications affects the quality and length of life and has been associated with negative health outcomes and increasing healthcare costs. The problem of non-adherence is particularly troublesome in older patients who are affected by multiple chronic diseases and for this reason receive multiple treatments. To date, no single intervention strategy has been shown to be effective in improving adherence across all patients, conditions, and settings. Between September and October 2014, a group of experts in geriatrics, pharmacology, epidemiology, and public health applied a modified RAND appropriateness method to reach a consensus on the possible best interventions to improve adherence in older individuals. Seven interventions were identified, classified based on their target (patient, therapy, and public health/society): (1) Comprehensive Geriatric Assessment, (2) patient (and caregiver) education to improve patient empowerment, (3) optimization of treatment, (4) use of adherence aids, (5) physician and other healthcare professionals' education, (6) adherence assessment, (7) facilitating access to medicine by service integration. For each intervention, experts assessed (a) target population, (b) health professionals potentially involved in the intervention, (c) strategies/instruments needed for implementation, and (d) time of the intervention. Interventions that target adherence must combine different approaches targeting the complex aspects of older adults in a holistic approach. Tackling non-adherence, with its complexity, requires a multi-stakeholder patient-centred approach acting in a defined framework of interactions in which the different players may provide different services but are integrated with one another.

The drug prescription network: a system-level view of drug co-prescription in community-dwelling elderly people.

Networks are well suited to display and analyze complex systems that consist of numerous and interlinked elements. This study aimed at: (1) generating a series of drug prescription networks (DPNs) displaying co-prescription in community-dwelling elderly people; (2) analyzing DPN structure and organization; and (3) comparing various DPNs to unveil possible differences in drug co-prescription patterns across time and space. Data were extracted from the administrative prescription database of the Lombardy Region in northern Italy in 2000 and 2010. DPNs were generated, in which each node represents a drug chemical subclass, whereas each edge linking two nodes represents the co-prescription of the corresponding drugs to the same patient. At a global level, the DPN was a very dense and highly clustered network, whereas at the local level it was organized into anatomically homogeneous modules. In addition, the DPN was assortative by class, because similar nodes (representing drugs with the same anatomic, therapeutic, and pharmacologic annotation) connected to each other more frequently than expected, indicating that similar drugs are often co-prescribed. Finally, temporal changes in the co-prescription of specific drug sub-groups (for instance, proton pump inhibitors) translated into topological changes of the DPN and its modules. In conclusion, complementing more traditional pharmaco-epidemiology methods, the DPN-based method allows appreciatiation (and representation) of general trends in the co-prescription of a specific drug (e.g., its emergence as a heavily co-prescribed hub) in comparison with other drugs.

How pre-marketing data can be used for predicting the weight of drug interactions in clinical practice.

Unexpected drug interactions have led to the withdrawal of many drugs, raising concern about the gap between what is known at the time of approval and the risk of serious effects in the longer term, particularly in high-risk populations generally excluded from drug development. This is because the majority of drug interaction studies are done using in vitro methods, or in healthy young volunteers who may not reflect the complexity of patients, and the settings in which the drug will be used in clinical practice. Pre-marketing interaction studies should therefore be designed to make information easily accessible and clinically transferable. They should be adequate in terms of sample size, population, comorbidity, phenotyping and/or genotyping, end-points and outcome measures, and conducted in conditions of dose, route and timing of co-administration that reproduce the proposed therapeutic indications of the new drug. Although young volunteers have the advantage of minimizing some confounding effects introduced by diseases or polypharmacy, patients drawn from populations for whom the drug is intended would be more relevant and accurate, providing the studies are feasible and safe.

Predicting the clinical relevance of drug interactions from pre-approval studies.

Drug interactions (DIs) may result in adverse drug events that could be prevented, but in many cases the available information on potential DIs is not easily transferable to clinical practice. The majority of studies date from preclinical or premarketing phases, using animals or human-derived sources that may not accurately reflect the growing clinical complexity of high-risk populations, such as the elderly, women, children, patients with chronic disease, polytherapy and impaired organ functions. Thus, at the time of approval of a new drug the information in the summary of product characteristics refers to potential DIs, but lacks specific management recommendations and is of limited clinical utility. Therefore, we set out to review in vitro and in vivo methods to predict and quantify potential DIs, to see whether these studies could help the physician tackle daily problems of the assessment and choice of combined drug therapies, and to propose, from a clinical point of view, how premarketing studies could be improved so as to help the physician at the patient's bedside. Preclinical and premarketing study design needs to be improved to make information easily accessible and clinically transferable. Studies should also take into account appropriate sample size, duration, co-morbidity, number of coadministered drugs, within- and between-subject variability, specific at-risk populations and/or drugs with a relatively narrow therapeutic window, and clinical endpoints. After premarketing development in situations where there is potential high risk of serious adverse events, specific phase IV studies (and/or active pharmacovigilance studies) should be required to monitor and quantitatively assess their clinical impact.

Alzheimer special care units compared with traditional nursing home for dementia care: are there differences at admission and in clinical outcomes?

BACKGROUND: Studies comparing Alzheimer Special Care Units (ASCUs) with traditional nursing homes (NHs) have reported conflicting results. OBJECTIVES: To compare the characteristics and the effects on mortality, hospitalization, use of physical restraints, falls, and antipsychotics among patients admitted to ASCUs or to NHs. METHODS: A sequential cohort of patients with dementia was recruited and followed for 18 months in a sample of randomly selected ASCUs and NHs. Data on socio-demographic, cognitive, functional, behavioral, and clinical characteristics, and drug exposure were collected at baseline and at 6-month intervals up to 18 months. RESULTS: A total of 349 patients were enrolled in 35 ASCUs and 81 in 9 NHs. Patients admitted to ASCUs were younger, cognitively and functionally less impaired, but had more behavioral disturbances than those in NH. During follow-up, ASCU patients had a lower risk of hospitalization (odds ratio: 0.67; 95% confidence interval: 0.46-0.99; P=0.04), and use of physical restraints (odds ratio: 0.66; 95% confidence interval: 0.51-0.86; P=0.003), and showed a higher rate of withdrawal of antipsychotics (P=0.003). No difference was found in mortality and falls. Propensity score analysis gives similar results. CONCLUSIONS: This study found that patients with dementia in ASCUs had different baseline clinical and functional characteristics from those in NHs. They had a lower rate of hospitalization and use of physical restraints at 6-month follow-up, and a higher probability of having antipsychotic agents withdrawn.