Deprescribing: An Approach to Reducing Polypharmacy in Nursing Home Residents

There is an urgent need to address the growing problem of polypharmacy in the elderly. Elderly patients are often prescribed multiple medications, some of which are high risk or no longer necessary, which increases the risk for adverse drug reactions and health care costs. Reducing polypharmacy should be a priority for clinicians working in nursing homes. Clinicians should consider care goals, disease trajectory, and life expectancy when discontinuing medications. This article discusses the challenges associated with deprescribing, the ethical and clinical uncertainty that can exist in the indefinite use of some medications, and the guidelines available to help clinicians.     

Maladaptive Opioid Use Behaviors and Psychiatric Illness: What Should We Do with What We Know?

It is well established that opioids are broadly effective for chronic pain. Although there is some agreement that stable, moderate dosing is desirable; longer-term management of patients with chronic pain often confronts clinicians with difficult decisions regarding when to intensify opioid treatment and when to declare failure. Under these circumstances the concern for addiction arises with uncomfortable frequency in specialty settings. An emerging literature has defined a number of plausible markers of risk for aberrant opioid use behaviors in clinical chronic pain populations. Some of these risk factors involve the presence of comorbid psychiatric illnesses, which puts clinicians in the difficult position of deciding whether or not to limit treatment to patients who are more complex. The authors discuss the issues of bad behavioral outcomes in opioid therapy, the implications of this emerging literature for clinicians, and suggest broad areas in which researchers can improve the knowledge base with which clinicians operate.     

临床护理人员用药风险防范认知度调查分析

目的：了解护理人员对用药风险防范的认知和重视程度,加强用药风险管理,保障患者用药安全。方法：对护理人员进行用药风险防范认知度问卷调查,并对调查结果进行分析。结果：有13.04%的护理人员没有认识到防范用药风险的责任;对药品不良反应、用药错误和药品损害三个基本概念的总体认知率分别为39.13%,30.43%和58.69%;对药物不良事件的报告意愿率为67.39%。结论：以药品不良反应、用药错误和药品损害为用药风险的主要来源,采用教育、制度和督查并重的方法,不断强化防范用药风险的责任意识。     

Long QT syndrome and other repolarization-related dysrhythmias

Until recently, sudden cardiac death in a young person often remained an unexplained tragedy. However, in the last decade there have been dramatic advances in medical knowledge regarding inheritable dysrhythmias that increase the risk of SCD in otherwise healthy young individuals. The primary mechanism in this group of dysrhythmias appears to be an alteration of cardiac repolarization. In some diseases, the specific genes affected and even precise cellular mechanisms have been identified. The information about these diseases is often complex and rapidly evolving, challenging both healthcare providers and the families who must make important decisions based on emerging and incomplete information. The purpose of this article is to describe current understanding of the repolarization-related dysrhythmias and discuss the clinical implications for advanced practice nurses.     

Recognizing drug allergy. How to differentiate true allergy from other adverse drug reactions

Proper diagnosis of adverse drug reactions, although often complicated and difficult, is important for the patient and the physician. Often the question of whether it is safe to readminister a medication is an important clinical judgment that needs to be made. Alternative medications may be less effective or have greater toxicities or cost, or both. Areas of ongoing research to improve diagnostic precision for allergic drug reactions include further understanding of the immunochemistry of allergenic medications, improvement of the reproducibility and sensitivity of relevant in vitro assays, and further validation of computer-assisted evaluation of adverse drug events. The positive and negative predictive values for these diagnostic tests need to be better defined whenever possible. At present, the primary diagnostic tool for properly assessing immunologic drug reactions remains a meticulous and detailed history obtained by an astute, knowledgeable, and motivated physician.     

Herb-drug,food-drug,nutrient-drug,and drug-drug interactions: mechanisms involved and their medical implications

Adverse drug reactions (ADRs) and iatrogenic diseases have been identified as significant factors responsible for patient morbidity and mortality. Significant studies on drug metabolism in humans have been published during the last few years, offering a deeper comprehension of the mechanisms underlying adverse drug reactions and interactions. More understanding of these mechanisms, and of recent advances in laboratory technology, can help to evaluate potential drug interactions when drugs are prescribed concurrently. Increasing knowledge of interindividual variation in drug breakdown capacity and recent findings concerning the influence of environment, diet, nutrients, and herbal products can be used to reduce ADRs and iatrogenic diseases. Reviewed data suggest that drug treatment should be increasingly custom tailored to suit the individual patient and that appropriately co-prescribed diet and herbal remedies, could increase drug efficacy and lessen drug toxicity. This review focuses mainly on recently published research material. The cytochrome p450 enzymes, their role in metabolism, and their mechanisms of action are reviewed, and their role in drug-drug interactions are discussed. Drug-food and drug-herb interactions have garnered attention. Interdisciplinary communication among medical herbalists, medical doctors, and dietetic experts needs to be improved and encouraged. Internet resources for obtaining current information regarding drug-drug, drug-herb, and drug-nutrient interactions are provided.     

Adverse psychologic responses of the elderly to critical illness.

Afflicting as many as 80% of critically ill elderly (older than 65 years) patients, adverse psychologic reactions (e.g., acute confusional states) to critical illness and its treatment present a unique challenge to medical and nursing intensive care practitioners. Additionally, the consequences of these adverse psychologic reactions financially strain health-care organizations, placing additional constraints on the delivery of health-care services. This article presents information regarding the origins of these adverse psychologic reactions and nursing strategies for the prevention, identification, and management of these clinical states. With such information, nurses who work in critical care units may be better equipped to identify and care for patients at risk of or experiencing an adverse psychologic reaction to critical illness.     

Neurotoxicity with Antimicrobials in the Elderly: A Review

PurposeMild adverse drug reactions typically associated with antimicrobials are familiar to most clinicians. However, rare phenomena, such as neurotoxicity, are often unpredictable and potentially unexpected. The toxic effects of antimicrobials on the central nervous system are often underreported and the mechanism(s) may be mixed or obscure. Geriatric patients are at increased risk for adverse drug reactions given physiologic alterations affecting pharmacokinetic processes. A dearth of information exists regarding neurotoxic presentations precipitated by antimicrobial use in the geriatric population. The purpose of this review is to present the available literature on neurotoxic effects of antimicrobials in geriatric patients, with an emphasis on manifestations of psychosis or delirium, or both.MethodsA comprehensive literature search of the PubMed, Medline via Ovid, and Embase databases was conducted from 1966 to 2014. It included systematic reviews, randomized controlled trials, observational studies, case series, and case reports that involved neurologic effects, specifically delirium and psychosis associated with antimicrobial use.FindingsVarious antimicrobial classes are implicated with neurotoxicity. The classes with the most reported cases include fluoroquinolones, macrolides, sulfonamides, nitrofurans, and β-lactams. A higher risk of developing various symptoms of neurotoxicity was found in the elderly with use of piperacillin and tazobactam, cephalosporins, carbapenems, aminoglycosides, trimethoprim and sulfamethoxazole, nitrofurantoin, linezolid, and possibly the fluoroquinolones. Potential mechanisms of neurotoxicity differ between the agents. The etiology of neurotoxicity with some agents is not fully elucidated. Incidence may increase with reported risk factors, renal dysfunction, or drug interactions.ImplicationsAwareness of antimicrobials causing or contributing to neurotoxic events may enhance clinical decisions in diagnosis and management when such incidents occur.     

Adverse drug reactions: part II

Pharmacovigilance is the process of identifying, monitoring, and effectively reducing adverse drug reactions. Adverse drug reactions (ADRs) are an important consideration when assessing a patient's health. The proliferation of new pharmaceuticals means that the incidence of ADRs is increasing. The goal for all health care providers must be to minimize the risk of ADRs as much as possible. Steps to achieve this include understanding the pharmacology for all drugs prescribed and proactively assessing and monitoring those patients at greatest risk for developing an ADR. Groups at greatest risk for developing ADRs include the elderly, children, and pregnant patients, as well as others. Pharmacovigilance must be effectively practiced by all health care providers in order to avoid ADRs.     

Antimalarial drug toxicity: a review

Antimalarial drug toxicity is viewed differently depending upon whether the clinical indication is for malaria treatment or prophylaxis. In the treatment of Plasmodium falciparum malaria, which has a high mortality if untreated, a greater risk of adverse reactions to antimalarial drugs is inevitable. As chloroquine resistance has become widespread, alternative agents may be used in treatment regimens, however, the toxicity of these antimalarial agents should be considered. Quinine is the mainstay for treating severe malaria due to its rare cardiovascular or CNS toxicity, but its hypoglycemic effect may be problematic. Mefloquine can cause dose-related serious neuropsychiatric toxicity and pyrimethamine-dapsone is associated with agranulocytosis, especially if the recommended dose is exceeded. Pyrimethamine-sulfadoxine and amodiaquine are associated with a relatively high incidence of potentially fatal reactions, and are no longer recommended for prophylaxis. Atovaquone/proguanil is an antimalarial combination with good efficacy and tolerability as prophylaxis and for treatment. The artemisinin derivatives have remarkable efficacy and an excellent safety record. Prescribing in pregnancy is a particular problem for clinicians because the risk-benefit ratio is often very unclear.     

Coxibs, which real therapeutic advance?: Recent pharmacoepidemiological data

Therapeutic advance is defined by an improvement in effectiveness, safety and/or convenience. In this article, these three criteria were applied to currently marketed coxibs (celecoxib, rofecoxib), using data from clinical trials and pharmacoepidemiological studies. Risk of adverse drug reactions to coxibs, as evaluated by clinical trials, differs from that observed in real medical practice. Rofecoxib and celecoxib exhibit the same profile of adverse drug reactions as the other classical nonsteroidal anti-inflammatory drugs. Coxibs are currently prescribed and too often used outside the studied and approved indications, which clearly increases their cost (already high for society). Currently marketed coxibs do not appear to meet the previously defined criteria for therapeutic advance.     

Ten Common Questions (and Their Answers) on Medical Futility

The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.     

Antidepressant Pharmacotherapy: Considerations for the Pain Clinician

Abstract: Antidepressant pharmacotherapy presents many challenges to clinicians dealing with patients suffering from chronic pain. Co-existent depression and pain continues to present clinicians with a plethora of difficult treatment selections. Treated in isolation, each of these disease states can prove difficult to treat. Collectively, depression and pain often present significantly more difficult challenges to the clinician. Antidepressants may be used as a primary treatment modality for depression in a patient dealing with chronic pain. At other times these agents may be used to treat certain specific chronic pain syndromes, possibly in the face of concomitant depression. Clinicians should be aware of the many peculiarities associated with this broad class of medications. Included in this review are considerations for drug selection, dose escalation, and common drug related problems (eg, adverse drug reactions). In addition, attention is paid to the appropriate selection of an agent for use in either the primary management of pain or depression.     

注射用哌拉西林钠他唑巴坦钠致全身肌肉震颤伴麻木感一例

注射用哌拉西林钠他唑巴坦钠可用于全身和（或）局部感染,包括软组织感染、细菌性败血症、骨关节感染、多重细菌感染,可疑感染部位存在的各种细菌感染,为烧伤与创面治疗常用抗炎药物,其不良反应常见有皮肤反应、胃肠道症状及过敏反应,而出现中枢神经系统症状,如抽搐或麻木等则极为罕见。结合该例病历资料及相关文献进行回顾性分析,对1例注射用哌拉西林钠他唑巴坦钠致全身肌肉震颤伴麻木感的临床诊治进行总结报道,以期引起临床医师的重视,同时提高对该类药物不良反应的重视,减少不良反应的发生。     

The effects of ceftriaxone by intravenous push on adverse drug reactions in the emergency department

ObjectiveAt our hospital, a shortage of sterile saline bags led to changing ceftriaxone from intravenous infusion to intravenous push. We examined if this change led to an increase in adverse reactions.MethodsWe conducted a retrospective chart analysis on patients 18 and older that were administered ceftriaxone in the ED between January to March 2018. Research assistants recorded information about possible adverse reactions. Adverse reactions were defined as any noxious or unintended response to a drug given at therapeutic doses. Potential adverse reactions were independently reviewed by three EM clinicians and confirmed by an adverse drug reaction probability scale. The primary outcome was the rate of adverse reactions for IVP administration of ceftriaxone.Results831 encounters were identified, 77 were excluded due to erroneous or missing data, and a total of 753 were included. Study demographics include an average age of 52.8, a female majority (54.2%) and predominantly black patient population (41.5%). A total of 24 cases were potential adverse reactions. After independent review, only one of the 24 cases was determined to be an adverse reaction to ceftriaxone from IVP. The total adverse event rate observed was 1/753 or 0.13%.ConclusionsOur study demonstrates that the rate of adverse reactions for IVP is lower than previously reported. Given the demonstrated safety of IVP administration, future studies are warranted to determine the implications for ED efficiency and cost benefits from this change in drug delivery.     

Adverse event reporting in randomised controlled trials of neuropathic pain: Considerations for future practice

High-quality information on the potential benefit and harm of a drug is required for patients and clinicians to make informed treatment decisions and to enable cost-effectiveness modeling to be undertaken. This systematic review describes the collection and reporting of adverse event data as presented in published clinical trials of neuropathic pain for the evaluation of antidepressant or antiepileptic drugs. A total of 74 studies in 16,323 patients published between 1965 and 2012 were identified, of which 43 were published from 2004 onwards. The review found that methods used to collect adverse event data, the frequency of collection, and the selection criteria used by authors for reporting adverse events vary substantially, and these events are often inadequately reported. Consequently, a potential synthesis of valuable harm information across trials is hampered. We make recommendations regarding the reporting of methods used to collect, assess, select, and present adverse event data in publications. Through the Core Outcome Measures in Effectiveness Trials (COMET) initiative, core outcome sets (which include effectiveness and harm) are developed by disease condition. To facilitate data synthesis for adverse events of drug therapies, we suggest that core outcome sets for harms could be developed by therapeutic class (ie, individualized for each class of drug). To improve comparability of information across trials collection methods need to be standardized for patient reports (spontaneous or prompted) and active surveillance (clinical examinations and laboratory tests). Uniform methods for presenting summary information regarding recurrent events, duration and timing of events requires further research.     

Secondary causes of osteoporosis

Secondary causes of bone loss are not often considered in patients who are diagnosed as having osteoporosis. In some studies, 20% to 30% of postmenopausal women and more than 50% of men with osteoporosis have a secondary cause. There are numerous causes of secondary bone loss, including adverse effects of drug therapy, endocrine disorders, eating disorders, immobilization, marrow-related disorders, disorders of the gastrointestinal or biliary tract, renal disease, and cancer. Patients who have undergone organ transplantation are also at increased risk for osteoporosis. In many cases, the adverse effects of osteoporosis are reversible with appropriate intervention. Because of the many treatment options that are now available for patients with osteoporosis and the tremendous advances that have been made in understanding the pathogenesis and diagnosis of the condition, it is important that medical disorders are recognized and appropriate interventions are undertaken. This article provides the framework for understanding causes of bone loss and approaches to their management.     

Effect of adverse drug reactions on length of stay in surgical intensive care units

OBJECTIVE: To determine the frequency of adverse drug reactions in surgical intensive care units and evaluate their effect on the length of stay. DESIGN: Prospective cohort study. Between May 1997 and December 1999, while the patients were staying in the surgical intensive care unit, data were gathered regarding suspected adverse drug reactions and on different variables related to the length of stay. SETTING: Surgical intensive care units of our hospital. PATIENTS: A total of 401 patients hospitalized in the surgical intensive care unit. MAIN RESULTS: In 37 of the 401 patients seen (9.2%; 95% confidence interval, 6.6-12.5), 39 different adverse drug reactions were detected. The adverse drug reactions were most frequently caused by the following drugs: morphine hydrochloride (n = 13), meperidine hydrochloride (n = 9), and metamizole (n = 7). Five adverse drug reactions were severe, the suspected medication had to be discontinued in 14 cases, and new drugs were necessary to manage the adverse drug reaction in 28 cases. The crude estimation of the effect of adverse drug reactions performed on the length of stay with a bivariant regression model indicated that each adverse drug reaction was related to an increase of 3.39 days (95% confidence interval, 1.47-5.31) in the length of stay. This estimation was reduced to 2.31 days (95% confidence interval, 0.64-3.99) when considering other variables that might cause confusion for analysis, although it is still important. CONCLUSIONS: Adverse drug reactions are a significant clinical and economic problem in surgical intensive care units.