Reasons for polypharmacy among psychiatric patients

INTRODUCTION: Increasing attention has recently been focused on polypharmacy, which is often referred to as an indicator of irrational drug consumption. Although polypharmacy is an important risk factor for problems arising from drug therapies, certain health concerns and conditions or patient-specific factors may justify the need for polypharmacy. In recent years there no data have been published regarding polypharmacy in Hungary. OBJECTIVE: The authors examined the frequency of polypharmacy among psychiatric patients. The study also looked at the extent to which comorbidity and demographic characteristics (age, gender) were responsible for the multiple drug use. METHODS: An inpatient database of the year 2001 at the psychiatric department was analysed. Based on the standard definition of polypharmacy the authors enrolled into the polypharmacy group those patients who were on more than five drugs as part of chronic and simultaneous therapy. The data were analysed with the SPSS 9.0 statistics program package. RESULTS: Among the psychiatric patients included in the study (N = 984) the frequency of polypharmacy was 33.6%. Significant correlation was found between the investigated factors (age, gender, comorbidity) and polypharmacy. On the basis of OR-values, comorbidity was the strongest inducer of polypharmacy. CONCLUSION: Polypharmacy cannot be fundamentally regarded as unnecessary drug use. Numerous facts prove that in certain diseases and conditions adequate polypharmacy is necessary.     

Study on drug related hospital admissions in a tertiary care hospital in South India

Background and objectives

Accidental and intentional poisonings or drug overdoses constitute a significant source of aggregate morbidity, mortality, and health care expenditure. Studies evaluating drug related hospitalization have estimated that approximately 5–10% of all hospital admissions are drug related. The present study was carried out to investigate type, nature and incidence of drug related admissions in our hospital settings.

Method

A hospital based retrospective study was conducted in 575 cases of drug related admissions. The case records of patients admitted in various clinical departments of Amrita Institute of Medical Sciences (AIMS) Hospital during last 8 years (January 2002–December 2009) were collected and analyzed.

Results

During the retrospective study, the total number of drug related cases reported were 575. Out of these, 35.5% cases were induced by central nervous system (CNS) drugs, 19.8% were by cardiovascular system (CVS) drugs, 12.3% were by NSAIDs, 11.3% were by antibiotics and 9.9% were by anticoagulants, 11.3% by other drugs which includes hormones, cytotoxic drugs, hypolipidemics, etc. Four hundred and forty cases were admitted to emergency department. Common drug related problems resulting in hospital visits were due to intentional, accidental and overdose. The incidence of drug related hospital admissions was found to be 0.20%.

Conclusion

The most of the accidental and suicidal cases were reported are by CNS drugs. Psychiatric patients intentionally taking medicines as suicidal attempt and as a part of their illness. As drug related problems are so significant, increased awareness and enhanced collaborative efforts among patients, physicians, pharmacists and caregivers within community and hospital have the potential to minimize the impact of this problem.     

老年慢病患者用药相关性问题的识别与分析

探索临床药师对老年慢病患者用药相关性问题的识别与干预。选取我院2017年2~7月老年慢病门诊132例病人,对其用药相关性问题进行回顾性分析。发现132例患者中有药物相关性问题191项,主要集中在“药物疗效不佳（37.2%）”和“无适应证用药（24.1%）”等方面。临床药师分析了191项药物相关性问题的形成原因,并讨论了识别的效果与不足。患者是药物相关性问题的承受者,医药患三方面共同努力可减少多重用药的负面问题,保证用药安全合理。     

Review of prescription medications in home-based older adults with stroke: A pilot study

BackgroundPharmacological intervention for comorbid management and stroke prevention may increase polypharmacy, inappropriately prescribed drugs (IPDs), and potential drug-drug interactions (PDDIs) among older adults with a history of stroke.ObjectiveThe objective of this study was to determine prevalence and incidence of polypharmacy, IPDs, and PDDIs in a cohort of home-based older adults with self-reported stroke living in New York and Florida.MethodsUsing a cross-sectional design, we determined the prevalence of PDDIs in 191 older adults with a history of stroke. We quantified the odds of PDDIs using bivariate logistic regression. Using a 3-year retrospective longitudinal design, we determined the relative risk (RR) of PDDIs in 41 new cases (New York) with polypharmacy and IPD. The independent variables were polypharmacy and IPDs, and the dependent variable was PDDIs.ResultsSubjects from Florida were older, had higher frequencies of some medical conditions, and used more medications, but the prevalence rates of PDDIs showed similar trends for the 2 states: 60% (New York) and 86% (Florida). The 3 strongest predictors of PDDIs in New York were polypharmacy (≥4 drugs) (odds ratio [OR] = 10.3; 95% confidence interval [CI] = 3.8-27.8); IPDs (OR = 8.4; 95% CI = 2.7-25.5); and having a heart condition (OR = 6.0; 95% CI = 1.6-22.8). The logistic model yielded one predictor for PDDIs in Florida: polypharmacy (≥4 drugs) (OR = 9.7; 95% CI = 1.4-65.4). The 3-year RR for PDDIs (New York) was 1.8 (95% CI = 1.2-2.8) from polypharmacy and 2.1 (95% CI = 1.3-3.3) from IPDs.ConclusionsAlthough this research is exploratory and used a small convenience sample, the estimates obtained suggest consideration of prospective hypothesis testing using a larger database and a greater number of subjects using more recent medications. Prospective examination of developing drug-drug interactions in this way will enhance the generalizability of these findings. This study shows similarities in the prevalence rates between 2 historical cohorts in 2 states, thereby suggesting plausibility of findings.     

欧洲医药保健网分类系统在呼吸科老年人多重用药中的应用研究

目的采用欧洲医药保键网(Pharmaceutical care network Europe,PCNE)分类系统对老年多重用药患者的药物相关问题(Drug related problems,DRPs)进行分析和评估,从而为药师对老年患者的药学监护模式提供参考。方法回顾性收集2018-2019年在呼吸科住院且年龄≥65岁,服用5种药物以上的老年患者,对发生的药物相关问题的类型、原因、干预、干预接受程度及DRPs解决状态等方面进行分析。结果共纳入152例患者,发现DRPs共300个。平均年龄77.3岁,每人合并疾病的平均种类数3.4个,其中DRPs发生的次数1.97次/人。治疗安全性是主要问题,表现为药物不良事件,占54%。主要原因为药物相互作用,占39.7%。DRPs的干预类型中,针对医生方面占84%。DRPs问题最终解决65%。结论通过PCNE分类能及时发现和解决DRPs,同时有助于对老年多重用药患者的药学监护记录的标准化和规范化,为患者安全、有效、合理使用药物提供依据。     

Population pharmacokinetics of carbamazepine in Singapore epileptic patients

AIMS: To document the population pharmacokinetics of carbamazepine in patients with epilepsy living in Singapore, the majority of whom are of Chinese origin and others of minority races. METHODS: Steady-state plasma carbamazepine concentration data were gathered during routine care from various hospitals in Singapore for patients with epilepsy. Age, body weight, gender, race, formulation and concurrent medication (for other illnesses) were the fixed effects (covariates) tested simultaneously for their influence on the population mean of carbamazepine clearance, using the nonlinear mixed-effects model, in the NONMEM program. RESULTS: No age, gender, race, or formulation-related effect was found. Body weight (W), age (A) and concurrent medication with phenobarbitone (PB) emerged as the determinants of carbamazepine clearance (CL). The final regression model for carbamazepine clearance found best to describe the data was CL = 40.7 x A(0.494) x W(-1.17) x 1.44PB where CL is in l day(-1) kg(-1), A is in years, W is in kg and PB = 0 for a patient on carbamazepine only and PB = 1 for a patient on concomitant PB. The corresponding interindividual variability (CV%) in CL, described by using an exponential model, was 21.4%, and the residual error, described by using an exponential error model, was 18.2%. Predictive performance of this population covariate model was evaluated by Bayesian forecasting in a similar, but independent cohort of patients. There was no statistically significant bias between predicted and measured plasma carbamazepine concentrations. The population mean value of carbamazepine clearance obtained was similar to that previously reported for patients with a very different ethnic (Caucasians and Blacks) or geographical background (South Africa, Europe and USA). CONCLUSIONS: The derived covariate regression model reasonably predicted concentrations in the separate validation Singapore patient data set. The correlation between carbamazepine clearance and patient-specific characteristics may thus allow dosage adjustment to be made to achieve target steady-state plasma concentrations.     

Project Octo-Pills - A practice model engaging community pharmacists in the care of patients from a tertiary hospital

Even while pharmacy practice evolves to a more patient-centric mode of practice, local hospitals, due to high patient load as well as space and resource constraints, find it challenging to conduct thorough medication review and physical medication reconciliation for all patients. In light of this, optimizing the local current healthcare system to involve community pharmacists in the care of patients from public hospitals could potentially better cater to the healthcare needs of the older population. Due to easy accessibility, community pharmacies are often the first point of contact in the healthcare system. Project Octo-Pills aims to engage community pharmacists in the collaborative care of patients from a tertiary hospital, providing patients with quality medication reconciliation and review services from a more convenient location within their neighborhood. This paper describes the model for this pilot initiative.     

An update on the clinical consequences of polypharmacy in older adults: a narrative review

ABSTRACT

Introduction: Polypharmacy, the use of multiple medications by one individual, is increasingly common among older adults. Caring for the growing number of older people with complex drug regimens and multimorbidity presents an important challenge in the coming years.

Areas covered: This article reviews the international trends in the prevalence of polypharmacy, summarizes the results from previous reviews on polypharmacy and negative health outcomes, and updates a previous review on the clinical consequences of polypharmacy by focusing on studies published after 2013. This narrative review, which is based on a literature search in MEDLINE and EMBASE from January 1990 to June 2018, was undertaken to identify relevant articles. Search terms included variations of polypharmacy and multiple medications.

Expert opinion: The prevalence of polypharmacy is increasing worldwide. More than half of the older population is exposed to polypharmacy in some settings. Polypharmacy is associated with a broad range of clinical consequences. However, methods to assess the dangers of polypharmacy should be refined. In our opinion, the issue of ‘confounding by multimorbidity’ has been underestimated and should be better accounted for in future studies. Moreover, researchers should develop more clinically relevant definitions of polypharmacy, including measures of inappropriate or problematic polypharmacy.     

肿瘤化疗病人癌因性疲乏相关因素的调查研究

目的 总结肿瘤化疗患者癌因性疲乏相关因素,为改善癌因性疲乏提高参考.方法 以2014年6月至2015年5月收治的肿瘤患者共120例为对象,发放一般资料问卷调查表和Piper癌因性疲乏量表收集相关资料,并进行单因素分析.结果 经癌因性疲乏量表测定:整体疲乏得分为(4.83±2.56)分,其中:无疲乏7例(5.83％),轻度疲乏23例(19.17％),中度疲乏38例(31.67％),重度疲乏52例(4333％).癌因性疲乏单因素分析结果表明:文化程度、肿瘤分期、治疗方案、化疗次数、病程、医保情况、化疗副反应是影响肿瘤化疗患者癌因性疲乏的因素(P＜0.05).结论 肿瘤患者化疗后存在不同程度的癌因性疲乏.多数因素可诱发癌因性疲乏.有必要强化肿瘤化疗患者的心理干预和社会支持,控制癌因性疲乏.     

Incidence and costs of polypharmacy: data from a randomized,double-blind,placebo-controlled study of risperidone and quetiapine in patients with schizophrenia or schizoaffective disorder

ABSTRACT

Objective: The use of adjunctive psychotropics and the costs of poly­pharmacy in patients randomized to receive risperidone or quetiapine were compared in a placebo-controlled double-blind study conducted in India, Romania, and the United States.

Methods: The efficacy and safety of risperidone, quetiapine, and placebo were compared in a 14-day monotherapy phase in patients experiencing an acute exacerbation of symptoms of schizophrenia or schizoaffective disorder. This was followed by a 28-day, additive-therapy phase during which addition of antipsychotics or other psychotropic medications was permitted. Risperidone was received by 153 patients in the monotherapy phase and 133 in the additive therapy phase, quetiapine by 156 and 122, respectively, and placebo by 73 and 53. Rates of polypharmacy were examined using the Cochran–Mantel–Haenszel, Kaplan–Meier, and Cox regression methods. Costs of poly­pharmacy were analyzed by non­parametric Wilcoxon 2-sample tests.

Results: Primary study results have been reported elsewhere (Potkin et al., Schizophr Res 2006;85:254-65). Mean (±SD) doses at the additive-therapy baseline were 4.7 ± 0.9?mg/day of risperidone and 579.0 ± 128.9?mg/day of quetiapine. Additional psychotropics were received by 36% of the risperidone group, 58% of the quetiapine group (?p < 0.01), and by 58% of the placebo group. Antipsychotics accounted for > 95% of the added psychotropics, the most common being olanzapine and haloperidol. The relative risk (quetiapine vs. risperidone) for antipsychotic polypharmacy was 1.90 (?p = 0.001; 95% CI 1.29, 2.80). The mean projected cost of additional antipsychotics per randomized patient during the additive-therapy phase was $57.03 in the risperidone group and $101.64 in the quetiapine group (?p < 0.01).

Conclusions: The results confirm earlier reports of higher rates of poly­pharmacy with quetiapine than with risperidone. The findings also reveal substantial between-treatment differences in costs associated with poly­pharmacy. Limitations of the study include that the study was of short duration and that a high proportion of patients were recruited from countries other than the United States.     

Medication errors when transferring elderly patients between primary health care and hospital care

Objective: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care.Method: Elderly primary health care patients (> 65years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital.Main outcome measure: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not.Results: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added.Conclusion: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.     

A prospective study of adverse drug reactions as a cause of admission to a paediatric hospital

1 A total of 512 consecutive paediatric hospital admissions of children 2 years old or less were evaluated to assess the extent and pattern of admission caused by suspected adverse drug reactions (ADRs). The proportion of suspected ADRs related to hospital admissions was 4.3%.
2 The organ-systems most commonly implicated were the central nervous system (40.5%), digestive system (16.7%), and skin and appendages (14.3%). Together, they accounted for 71.5% of admissions attributed to ADRs. The most common clinical manifestations inducing admission were convulsions (4 cases), dizziness (4), vomiting (3), and tremor, fever, itching and apnoea (2 cases each).
3 The four classes of drugs most frequently suspected in admissions due to ADRs were respiratory drugs (35%), anti-infective agents (25%), drugs active on the central nervous system (15%) and drugs used in dermatology (10%). The most common drugs related to ADRs were a combination of chlorpheniramine, diphenhydramine, phenylephrine, guaiphenesin and salicylic acid (4 cases), followed by fenoterol, adrenaline, paracetamol, DTP vaccine and antipolio vaccine (2 cases each).
4 There were no significant differences between children older and younger than 1 year (odds ratio 0.89; 95% CI 0.37–2.17) or between the sexes as regards hospital admittance due to suspected ADRs (odds ratio 1.94; 95% CI 0.72–5.42).
5 The results of this kind of study may be influenced by patterns of drug utilization. Nevertheless, the lack of specific studies of drug effects in young children makes it desirable to carry out pharmacoepidemiological studies in this age group.     

Effects of joint hospital admission and couples treatment for hospitalized alcoholics: a pilot study.

In a pilot study evaluating the effectiveness of joint hospitalization and couples treatment for alcoholics and alcohol abusers, 33 persons hospitalized with alcohol problems and their nonalcoholic spouses were randomly assigned to one of three experimental treatment groups: joint (husband and wife) hospitalization followed by couples and individual outpatient treatment for both spouses: couples and individual outpatient treatment for both without joint admission: or individual inpatient and outpatient treatment for the patient alone. Couples were evaluated at 6–8 weeks and 6–8 months after hospital discharge. All groups showed significant decreases in number of reported marital problems, depression, anxiety, other psychological symptoms and decreased impairment from use of alcohol. Only the joint admission and couples groups showed significant decreases in quantity of alcohol consumed although the individuals group also decreased markedly. There were no other significant differences among the three groups, and no significant differences between the joint admission and combined couples and individual groups. Implications for a marital treatment approach to alcoholism are discussed.     

Serum digoxin and beta-methyldigoxin in elderly patients on hospital admission: correlation with home compliance and clinical variables

Summary Serum digoxin and beta-methyldigoxin (BMD) were measured in 165 elderly patients (age >60 years) admitted to hospital, of whom 109 had been treated at home with digoxin and 56 with BMD.The mean BMD level was significantly lower than that of digoxin (1.1 vs. 1.4 ng/ml). Creatinine clearance and daily dose were the variables most strongly associated with digoxin level, and the prescribed dose and serum albumin were the best predictors of the BMD concentration. Compliance was assessed by a compliance index (CI), namely the ratio of the measured glycoside concentration, corrected for creatinine clearance, over the expected steady-state dose, calculated from a hospitalized reference group. Compliant individuals in both treatment groups, i.e. those with a CI > the median value, were characterized by a lower daily dose and dosage frequency.Toxicity, whether clinical or electrocardiographic, was present in 9% of the patients and was associated only with a significantly higher mean serum level of the drug.     

基层医院急诊患者用药监护需求调查及影响因素分析

目的探讨基层医院急诊患者用药监护需求程度及影响因素,寻找急诊患者用药监护的针对人群及切入点。方法自行设计调查表,使用SPSS11.5软件对数据进行统计学分析,了解急诊患者用药监护需求程度及影响因素。结果急诊患者用药监护需求程度差,主要原因在于患者在院时间短,监护难度大,对于医生治疗的依赖性及信任度明显高于药师用药指导;患者病情严重度及对疾病相关知识的掌握程度,也是影响需求程度的重要原因。结论为以后能顺利开展急诊患者用药监护,要逐渐加强患者安全用药教育宣教,并对临床药师用药监护的意识及能力开展培训。