Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes

Different styles of interventions can reduce medication exposure in older adults. However, the evidence for their clinical effectiveness and sustainability is conflicting and lacking. There are some data to guide clinicians on which medicines are more likely to be inappropriate in older people, which medicines are more likely to cause ADWEs, and which medicines should be tapered slowly rather than stopped. To reduce the likelihood of clinically significant adverse events, clinicians should undertake a step-wise approach to discontinuing medications and do so under appropriate supervision. Further research to determine the most effective ways to discontinue medications, and to provide a better understanding of the clinical benefits of various interventions is required. Large RCTs evaluating multidisciplinary interventions and clinical outcomes of changes in medicines regimen across different settings are required to confirm the findings of the studies performed so far.     

Decreased glomerular filtration rate estimated by 2009 CKD-EPI equation predicts mortality in older hip fracture population

ObjectiveWe examined estimated glomerular filtration rate using the Chronic Kidney Disease Epidemiology equation (eGFR_CDK-EPI), removal of urinary catheter during hospitalization and polypharmacy as predictors of mortality in older hip fracture patients.MethodsPopulation-based prospective data were collected on 1425 consecutive hip fracture patients aged ≥65 years. Outcome was mortality at one year. Independent variables were age, sex, body mass index, fracture type, American Society of Anesthesiology score, delay to surgery, urinary catheter removal during acute hospitalization, eGFR_CDK-EPI, number of daily medications, diagnosis of memory disorder, prefracture mobility and living arrangements.ResultsOf the 1425 patients, 567 (40%) had renal dysfunction on admission, 526 (37%) had their urinary catheters removed during hospitalization and 1177 (83%) were taking ≥4 medications regularly before the fracture. In the multivariate analyses with the Cox proportional hazards model adjusted simultaneously for all the independent variables, eGFR_CDK-EPI 30–44 ml/min/1.73 m² (HR 1.91, 95% CI 1.44–2.52) and <30 ml/min/1.73 m² (HR 1.95, 95% CI 1.36–2.78), non-removal of the urinary catheter (HR 1.45, 95% CI 1.12–1.88) and large number of daily medications (4–10 HR 1.81, 95% CI 1.78–2.79, >10 HR 2.21, 95% CI 1.38–3.54) were associated with mortality.ConclusionsIn older hip fracture patients, moderate to severe level renal dysfunction measured by eGFR_CDK-EPI, non-removal of urinary catheter before discharge and polypharmacy increase mortality after hip fracture. Careful assessment of renal function and medications and following the care protocols on urinary catheter removal are essential in the care of geriatric hip fracture patients.     

‘Tablet burden’ in patients with metastatic breast cancer

The implications for patients with cancer, of the ‘tablet burden’ resulting from increasing use of oral anticancer drugs and medication for co-morbidities have not previously been well explored.AimWe sought to (i) quantify tablet burden in women with metastatic breast cancer (MBC), (ii) establish which groups of drug contribute most to this burden and (iii) gain insight into patients' attitudes towards oral anti-cancer treatment.MethodsOne hundred patients with MBC anonymously completed a questionnaire describing their medication histories and attitudes towards their tablets.ResultsThe patients (mean age 60, range 31–95) were all female and taking a median of six tablets (range 0–31) daily; 37 patients were taking >10 tablets. Oral anticancer treatment constituted the category of treatment taken by the highest proportion of patients, followed by symptomatic cancer treatments, proton pump inhibitors and cardiovascular medication. Numerically, however, symptomatic drugs accounted for 44% of all tablets and specific anti-cancer treatment for 15%; medication not directly related to the cancer accounted for the remaining 40% of tablets. A quarter of patients reported inconvenience in taking their tablets, the main reason being tablet size and one third reported forgetting their tablets at least once a week. Nearly two thirds of patients expressing a preference favoured oral anticancer treatment, the commonest reason being greater convenience.ConclusionTablet burden is considerable for many patients with MBC and can be problematic. A significant proportion of tablets represent treatment for co-morbidities, the significance of which may be questionable in women with MBC.     

老年人多重用药安全管理专家共识

我国是世界上老年人口最多的国家,多病共存的老年人多重用药情况不可避免且非常普遍。因此,越来越多的医学和药学专家呼吁广大医务人员关注老年人多重用药的风险,并提出管理措施,以求避免或减少多重用药时药物相互作用带来的损害。为了满足临床实践需求,进一步提高老年人用药安全的水平,我国临床医学和药学专家经过多次研讨,制定了本《老年人多重用药安全管理专家共识》以供临床参考,确保用药安全。     

《澳大利亚与新西兰老年医学会立场声明：老年人处方》解读

老年人对医疗服务的需求较其他人群更高,但为老年人开具处方是一件相当复杂的工作。老年人的器官老化和功能衰退,药物代谢动力学和药物效应动力学发生改变,且容易罹患多系统疾病,多重用药现象普遍,因而在全球老龄化日益加剧的背景下,如何促进老年人群的合理用药是亟待研究的问题。澳大利亚与新西兰老年医学会（ANZSGM）于2018年8月发布关于老年人处方的立场声明,指出了为老年人开具处方的多方面挑战与不合理用药可能导致的不良后果,解释了其中涉及的医学伦理,并提出了提升老年人处方质量的策略。本文在对该立场声明进行归纳分析的基础上,结合我国实际情况,阐述了老年人处方的完善思路,以期为我国解决老年人合理用药问题提供参考。