The evolution of polypharmacy: appropriate and problematic polypharmacy, choosing the right strategy and tactics

The evolution of polypharmacy, which for many years consisted of quantifying concurrently prescribed drugs, has led to an qualitative description: “appropriate polypharmacy”, which may be beneficial for some patients, and “problematic polypharmacy”, which is harmful. The concept of “appropriate polypharmacy” is to prescribe multiple drugs based on the best evidence, taking into account the patient’s clinical condition and potential drug-drug interactions. With age, the prevalence of geriatric syndromes, comorbidity/multimorbidity, and limitation of life expectancy increase, which reduces the positive benefit/risk ratio for most drugs. The problem with polypharmacy is associated with an increased risk of adverse reactions, drug-drug interactions, and decreased patient compliance. To improve polypharmacy, various methodologies are used to optimize drug use for maximum benefit and least harm. Such interventions include professional patient counseling, the use of additional tools (including Bierce’s criteria, STOPP/START, MAI index, etc.), electronic decision-making systems, educational programs. The effectiveness of interventions to reduce polypharmacy has been evaluated in several Cochrane meta-analyzes (2012, 2014, 2018) and showed a decrease in drug misuse and the risk of ADR, but there was no effect on mortality, and few studies found a decrease in the number of hospitalizations. The deprescribing methodology is especially relevant in the context of problematic polypharmacy and is considered an integral component of the continuum of good prescribing practice, promoted as a strategy to reduce polypharmacy and improve patient outcomes. Among other interventions, deprescribing has the most evidence for its utility in preventing drugrelated complications, improving clinical outcomes, and reducing costs. The International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP) in 2018 developed 10 recommendations to reduce polypharmacy and potentially inappropriate drugs. Thus, the concept of “appropriate polypharmacy” is a rational approach to optimizing polypharmacy; it should be promoted to replace existing thresholds.

Managing Polypharmacy and Deprescribing in Elderly

The increase in the number of medications used may result many negative consequences for patients and health system. Elderly patients are more likely to encounter these health problems associated with polypharmacy. Deprescribing, the process of tapering, withdrawing, discontinuing, or stopping medications, is important in reducing polypharmacy, adverse drug effects, inappropriate or ineffective medication use, and costs. Deprescribing in elderly patients in accordance with the evidence based guidelines has many positive outcomes in older people such as decrease in the risk of falls, improvement in cognition, and improvement in patients’ global health status. Therefore, each visit of an elderly patient should be considered as an opportunity to evaluate the unnecessary use or harms of the prescribed or nonprescribed medications. Clinicians should decide to deprescription process by individualized care goals in line with current guidelines. Beers Criteria, STOPP/START and The Medication Appropriateness Index-MAI can be used to assit clinicians to identify unnecessary or potentially inappropriate drugs and reduce the number of medications in older patients. But, a balance is required between over and under prescribing. In conclusion, prevention of polypharmacy and withdrawing unneccesary and inappropriate medications may be the best clinical decision for family physicians who follow the elderly in primary care.

Penggunaan Antibiotik yang Kurang Tepat pada Peternakan Babi di Kota Kupang, Nusa Tenggara Timur

Misuse of antibiotics has the potential to accelerate the emergence of types that are resistant to inappropriate drugs. This study aims to evaluate the inappropriate use of antibiotics in pig farms in the City of Kupang, East Nusa Tenggara. This antibiotic use evaluation study was conducted from March to May 2018. This study was conducted on 100 pig farmers spread across 6 (six) districts in Kupang City. The sampling technique was done by stratified random sampling method based on the characteristics or types of the population. This research used descriptive analysis method from the results of questionnaire data collection that had been filled out by pig farmers in Kupang City. Based on the results obtained that 84% of pig farmers or respondents did not know the function of antibiotics, and 83% of respondents did not know that the administration of antibiotics must be done with the supervision of a veterinarian. The results also showed that 86% of pig farmers buy antibiotics without a veterinarian’s prescription, with the type of antibiotics most often used were the tetracycline and sulfonamide groups. These results conclude that dominant respondents apply antibiotics without veterinary supervision, which can contribute to the spread of resistant bacteria so that it adversely affects human health.

Type 1 medication review based on a pharmacy’s electronic medication records: first steps towards an algorithm to stratify patients for tailored pharmacy services

Algorithms, queries, and knowledge-based systems are among approaches to screen electronic patient records stored in databases and support pharmacist medication reviews. The aim of this study was to perform a type 1 medication review and identify clusters that enable the definition of an algorithm to tailor pharmacy professional interv A retrospective observational study was conducted on a convenience sample of pharmacy records. Records were included if patients had a medication dispensing history between June 2017 - July 2018 and used two or more chronic medications. Statistical analysis used a two-step cluster to identify common characteristics among fifty-five sets of patient records which underwent Type 1 medication review. The median number of drugs used per patient was five [IQR: 3.0 – 7.0]. 18.2% of patients had inappropriate drugs, and 30.9% had moderate or major interaction potential. Four clusters were identified based on the variables of interactions, number of drugs used, contraindications, Beers criteria and measurable biomarkers, allowing to envision possible pharmaceutical interventions, as well as the priority in providing that intervention. The identification of patient clusters via medication review of electronic records of pharmacy patients supports the design of criteria-based algorithms, likely to be automated.

Drug-Induced Delirium among Older People

Although underdiagnosed, delirium is a common and potentially preventable problem in older patients, being associated with morbimortality. Drugs have been associated with the development of delirium in the geriatric population and may be considered the most easily reversible trigger. Polypharmacy, prescription of deliriogenic, anticholinergic and potentially inappropriate drugs are contributing factors for the occurrence of the disturb. Furthermore, changes in pharmacokinetic and pharmacodynamic parameters, which are intrinsic of the aged process, may contribute for cognitive impairment. Identification and reversal of clinical conditions associated with delirium are the first step to treat the disturbance, as well as mitigation of environmental factors and the exposition to deliriogenic drugs. Current evidence does not support the prescription of antipsychotics and benzodiazepines for the treatment of delirium. However, the judicious use of first- or second-generation antipsychotics can be considered in severe cases. Multi-component non-pharmacological, software-based intervention to identify medications that could contribute to delirium, predictive models, tools, training of health professionals and active actions of pharmacovigilance may contribute to the screening, prevention, and management of delirium in older people. Besides, it is also important to improve the report of drug-induced delirium in medical records, to develop properly risk management plans and avoid cascade iatrogenesis.

Standard drug consumption: a study with elderly people in Primary Health Care

ABSTRACT Objective: To identify the pattern of medication consumption among the elderly assisted in Primary Health Care. Methods: Descriptive, quantitative, cross-sectional study, with a sample of 315 elderly people, in a city in rural Rio Grande do Norte. Results: The average age was 72.41 years, with an average consumption of 3.15 medications per day, ranging from 1 to 16 medications daily. There was a prevalence of antihypertensives, antidiabetics, hypolipidemic and psychotropic drugs. 238 different drugs were mentioned, 15 of which were “potentially inappropriate drugs” for the elderly. Most of these patients follow treatment according to medical prescription, with low self-medication. Most elderly people buy their drugs, although many are available for free. Conclusion: The most consumed drugs are consistent with the most reported diseases (hypertension and diabetes). The daily use of inappropriate medications for the elderly is worrying, especially psychotropics, given the risks of dependence or health complications of these users.

Inappropriate Medication Use and Related Factors in the Elderly Living in Northern Iran

Objectives: Older people are more prone to chronic diseases and are being treated than other age groups; as a result, they use more drugs that may be inappropriate and lead to adverse drug reactions. This study aimed to determine the rate of inappropriate drug use using the Beers criterion among the elderly in Amirkola City. Methods & Materials: The current descriptive-analytical study is part of the comprehensive plan "Study of the health status of the elderly in the Amirkola City” AHAP" (No.: 892917) which has been conducted as a Cohort study since 2011 on all people aged 60 and over in the Amirkola City, north of Iran. Necessary information was collected by a trained person using standard questionnaires that included the number, type and duration of drug use. The collected data were analyzed after entering the SPSS statistical software using Chi-square, Fisher's Exact Test, and Logistic Regression to evaluate the status of inappropriate drug. P-value=0.05 was considered as a significant level. Results: The Mean±SD age of the elderly was 69.71±7.47 years. Prevalence of inappropriate drug use and drugs that should use by caution among the elderly was 37.58% and 29.85%, respectively. Glibenclamide (12.7%), Diclofenac (8.8%) and Clidinium C (5.4%) were among the most inappropriate drugs used in this population. The highest drug-drug interaction was related to the simultaneous use of two anticholinergic drugs. There was a statistically significant relationship between inappropriate drug use with gender, age, education level, employment status and marriage status (P<0.05). Conclusion: The rate of inappropriate drug use among the elderly in Amirkola is high compared to many other studies that expose the elderly to adverse drug reactions.