Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study

When prescribing medications for the initiation of  a new therapy in patients with multiple chronic diseases, physicians often look to guidelines to determine their recommended treatment option.  While this is considered good practice, it is important to not look at the disease state as a singular entity when choosing a therapy for the patient to follow due to the effects that certain conditions have on one another. This study looked to analyze the association between guideline recommended drugs and death in older adults with multiple chronic disease states. To do this, 8578 adults aged 65 and older were monitored though three years of treatment. Patients involved in the study had a variety of disease states including but not limited to atrial fibrillation, chronic kidney disease, depression, diabetes,  and hyperlipidemia. Results from the study showed that over 50% of the participants received guideline recommended drugs without the consideration of other disease states. Although 15% of the patients died during the course of the study, researchers were able to determine that cardiovascular medications were associated with a decrease in mortality. Other guideline medications analyzed in the study did not show an association with reduced mortality. Overall, it was determined that choosing medication therapy for patients should only be done after fully analyzing the patients other conditions.

I believe this study is important due to the fact that guideline recommended medications are commonly dispensed in the pharmacy setting. It is thus important for us to understand how guideline drugs interact with each other to protect a patient at the point of treatment initiation. By doing this, we will be able to avoid adverse drug effects that can result due to medication interactions. I believe that this is one of the most important roles of a pharmacist because it helps promote patient well-being and increases the likelihood of medication regiment adherence. The goal of our profession is to protect patients and advise them on how to find ways to live a healthy lifestyle. The easiest way to do this is by starting at the roots of the solution.

Tinoetti M, McAvay G, Trentalange M, et al. Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study. BMJ 2015; 351: h4984

Predictive Validity of Beers and STOPP Criteria to Detect Adverse Drug Events in the United States

One of the largest concerns among the geriatric pharmacy community is being able to predict adverse drug events from medications that are inappropriate within the elderly population.  To help with reducing these adverse outcomes and emergency department visits, most geriatric health providers often turn to recommendation resources such as Beers criteria or the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) for guidance on drugs that are potentially inappropriate medications (PIMs).  The issue with these criteria is a lack of research into how sensitive and accurate they are for predicting ADE or ED visits among the elderly who may have indications for the medications.

A recent study by members of the University of Arkansas, College of Pharmacy published in the Journal of American Geriatrics Society that assessed the predictive power of Beers and STOPP criteria for PIM in elderly populations.  The performed an eight-year retrospective cohort study on over 174,000 commercially insured patients over 65 years old, monitoring them for association between ADE and ED visits based on inappropriate medication use based on the criteria of either 2003 beers, 2012 Beers, or STOPP recommendations.  Over the course of the study, 41% of the patient population were exposed to a PIM from at least one of the criteria sets.  The 2012 Beers criteria identified PIMs in 34.1% of patients and STOPP identified in 27.6% of patients.  Observed differences are related to differences in classification of inappropriateness between the two identification systems.  The two criteria sets showed similar sensitivity and specificity, although they varied in predictive ability between drug classes, given variation in recommendations between classes of drugs for the two systems.

Both systems displayed acceptable prognostic power to predict adverse drug events in patients exposed to PIMs based on their individual criteria.  The study found no significant differences between the two systems in discrimination power for ADEs or ED visits, although the researchers did admit that further studies would be required to increase the predictive power of the criteria sets by medication classes.  This is the first study of its kind to look into the predictive ability of the major geriatric medication recommendations, and needs further assessment by other groups to get an accurate look at the medication lists for the elderly population in the United States.  What should pharmacists and other health care professionals be looking at to determine if our current recommendations are sufficient?  Do you have any ideas to help ensure the current system of geriatric cares are appropriate?

Article Link

Brown, J. D., Hutchison, L. C., Li, C., Painter, J. T. and Martin, B. C. Predictive Validity of the Beers and Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) Criteria to Detect Adverse Drug Events, Hospitalizations, and Emergency Department Visits in the United States. Journal of the American Geriatrics Society (2016) 64: 22–30. doi: 10.1111/jgs.13884

Post-surgical Pain Management Guideline

There is a new guideline released by The American Pain Society that addresses practices to improve pain management postoperative. They complied this guideline from reviews of more than 6500 scientific abstracts and clinical studies and is based on that there is often inadequate pain relief leading to larger, prolonged negative outcomes. The panel that wrote the guideline includes 23 members and incorporate anesthesia, pain management, nursing, and surgery specialties. There are 32 recommendations that are rated based on the quality of evidence as strong, moderate, or weak. There are four recommendations graded as strong. The first recommendation is that there should be wider use of a variety of analgesic medications and techniques. Multimodal anesthesia that specifically target different mechanisms of actions in the nervous systems have shown better pain relief than single medications using one technique. The second recommendation is to use acetaminophen and/or NSAIDs as part of the multimodal management post-surgery. The third recommendation is for clinicians to consider peripheral, regional anesthetic techniques at the surgical site. The fourth recommendation is for patients at risk for cardiac and pulmonary complications or prolonged intestinal distress that spinal analgesia is appropriate in major thoracic and abdominal procedures. They authors of the guideline state that the intended audience of their guideline is all clinicians who manage pain after surgery. How does the pharmacist fit into the target audience, and how could they use these guidelines within their field of practice?

J Pain. 2016;17(2):131-157

Improving Heart Failure Patient Care

Heart failure is the condition in which the heart cannot sufficiently pump blood throughout the body creating a lack of oxygen and other nutrients reaching certain parts of the body and thus failing to meet metabolic needs across the body. This condition, even if treated appropriately, still has a high degree of mortality associated with this disease state and often results in frequent hospitalizations before death occurs. However, all hope is not lost as new and improved guidelines are released each and every year to help improve the quality of life for persons affected by this disease state. The  Pharmacist’s Letter/ Prescriber’s Letter as of February 2016, has created a set of practical tips and resources that can be used to help manage patients with heart failure and prevent re-admissions into the hospital.

These recommendations range from changes in drug therapy such as choosing the right medications for patients with this condition such as: a diuretic for fluid retention and the addition of other medications based on race and heart strength as determined by ejection fraction(EF). The article also discusses avoiding certain medications that will worsen the condition such as NSAIDS, verapamil, and dilitiazem. Furthermore, tips are provided on how to adequately provide patient education on their disease state, how to bolster patient adherence as well as tips on what to monitor to ensure their disease state is being adequately managed.

Do you feel that these new and improved guidelines will lead to an improvement in the management of patients with heart failure? Why or Why not? Are new guidelines always better than the old? Will guidelines for different disease states continue to be updated indefinitely as time passes or will we reach a point where the guidelines can no longer be advanced because they are leading to the ultimate management of patient disease state.

Citation:

PL Detail-Document, Improving Heart Failure Care. Pharmacist’s Letter/Prescriber’s Letter. February 2016.

 

USPSTF Recommendation for Screening for Depression in Adults

The USPSTF has updated its recommendation from 2009 on screening adults for depression. The USPSTF is the US Preventive Services Task Force. The recommendation applies to the population over the age of 18 and is for the general population. The update in the recommendation is that there is specific mention of screening of pregnant and postpartum women unlike the 2009 recommendation in which that sub group was not mentioned. The 2009 recommendation also suggested selective screening based on professional judgment and patient preference or when staff-assisted depression care supports are in place. This is omitted in the new recommendation, claiming that the screening no longer needs to be selective, but all inclusive.

Besides suggesting that the general adult population and postpartum women be screened, the recommendation suggests that “screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This a category B recommendation, meaning that it is recommended to offer or provide service and that there is high certainty that the net benefit is moderate.

Depression is the lead cause in disability in those over the age of 15, and with postpartum women, depression can be harmful not only to the woman, but also to the child. Creating effective screening and treatment for depression can have large impacts on health.

The USPSTF acknowledges that they do not consider the cost when making recommendations. How would the cost of screening and treatment of depression that is suggested affect the implementation of this recommendation? In addition, would these costs actually be lower than the costs of untreated depression?

Siu, AL. Screening for Depression in Adults US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380-387. doi:10.1001/jama.2015.18392.