Acetazolamide for metabolic alkalosis complicating respiratory failure with chronic obstructive pulmonary disease or obesity hypoventilation syndrome: a systematic review.

BACKGROUND: Metabolic alkalosis may lead to respiratory inhibition and increased need for ventilatory support or prolongation of weaning from ventilation for patients with chronic respiratory disease. Acetazolamide can reduce alkalaemia and may reduce respiratory depression. METHODS: We searched Medline, EMBASE and CENTRAL from inception to March 2022 for randomised controlled trials comparing acetazolamide to placebo in patients with chronic obstructive pulmonary disease, obesity hypoventilation syndrome or obstructive sleep apnoea, hospitalised with acute respiratory deterioration complicated by metabolic alkalosis. The primary outcome was mortality and we pooled data using random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 (Risk of Bias 2) tool, heterogeneity was assessed using the I2 value and χ2 test for heterogeneity. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. RESULTS: Four studies with 504 patients were included. 99% of included patients had chronic obstructive pulmonary disease. No trials recruited patients with obstructive sleep apnoea. 50% of trials recruited patients requiring mechanical ventilation. Risk of bias was overall low to some risk. There was no statistically significant difference with acetazolamide in mortality (relative risk 0.98 (95% CI 0.28 to 3.46); p=0.95; 490 participants; three studies; GRADE low certainty) or duration of ventilatory support (mean difference -0.8 days (95% CI -7.2 to 5.6); p=0.36; 427 participants; two studies; GRADE: low certainty). CONCLUSION: Acetazolamide may have little impact on respiratory failure with metabolic alkalosis in patients with chronic respiratory diseases. However, clinically significant benefits or harms are unable to be excluded, and larger trials are required. PROSPERO REGISTRATION NUMBER: CRD42021278757.

The extent of polypharmacy and use of 'fall risk increasing drugs' in the oldest old admitted to a regional New South Wales hospital.

OBJECTIVE(S): Polypharmacy is associated with significant morbidity including cognitive decline and falls. We sought to quantify the extent of polypharmacy and use of medications associated with fall risk in the very old admitted to a regional NSW hospital. METHODS: Cross-sectional study of patients aged over 80 years admitted to a regional NSW hospital from September to October 2019. Demographic data and medication usage on admission were collected. Polypharmacy was defined as regular use of five or more medications. RESULTS: A total of 401 patients were included: mean age was 87.2 (±4.6) years and 56.9% were female. Of the participations, 82.9% experienced polypharmacy, and the mean number of medications was 8.2 (±4.2). Of the patients, 91.6% utilised medications associated with risk of falls. There was no association between age and number of preadmission regular medications. CONCLUSION: Polypharmacy is extremely common prior to acute hospitalisation for regional older individuals. This highlights the importance of medication rationalisation to reduce medication-related harm.