Small intestinal biopsy findings consistent with celiac disease in patients with idiopathic inflammatory myopathy: Review of existing literature.

BACKGROUND: Case reports have described patients with idiopathic inflammatory myopathies (IIM) and a concurrent diagnosis of celiac disease (CeD) for whom the muscle inflammation (myositis) component of IIM improves after the patients start standard treatment with gluten-free diet (GFD). A connection between IIM and CeD is not commonly recognized. AIM: In this first systematic review of the topic, we aimed to explore all peer-reviewed publications of IIM cases and concomitant small intestinal biopsy findings consistent with CeD, published after 1975. METHODS: Systematic literature searches were performed in MEDLINE, PubMed, and EMBASE, supplemented by screening of references and non-systematic searches via Google and Google Scholar. RESULTS: Altogether 30 cases published between 1976 and 2017 were uncovered. Information about gastrointestinal symptoms prior to CeD diagnosis was available for 19 patients, with 6/19 (32%) reporting no GI symptoms. CeD-related serological data were available in 23/30 patients. Endomysial antibodies were present in 10/18 (56%), while only 2/9 (22%) had antibodies against tissue transglutaminase. Serum antibodies to native gliadin were present in 16/18 (89%). Clinical effects of a GFD on the IIM were reported for 24 patients, with signs of improvement in 14/24 (58%), including three patients with otherwise therapy-resistant inclusion body myositis. Longitudinal follow-up data available from the published studies indicated that 7/24 (29%) remained in clinical IIM remission with GFD as the sole therapeutic intervention. CONCLUSION: In the IIM cases presented here, duodenal biopsy findings consistent with celiac disease was sometimes present without classical CeD symptoms or positive traditional CeD serology, and in the majority of cases, the IIM improved after introduction of a gluten-free diet. While extra vigilance towards CeD in IIM patients seems warranted, there is need for more research to clarify if GFD has effects on organ systems other than the small intestine in patients with IIM and small intestinal biopsy findings consistent with CeD.

Potentially inappropriate medication use in nursing homes: an observational study using the NORGEP-NH criteria.

BACKGROUND: Frail residents in the nursing home sector call for extra care in prescribing. The Norwegian General Practice Nursing Home (NORGEP-NH) list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed explicitly for this population. The aim of this study was to employ the NORGEP-NH Criteria to study the extent of potentially inappropriate medication use among nursing home residents and explore possible associated factors. METHODS: Cross-sectional observational pharmacoepidemiological study from residents in nursing homes in the county of Vestfold, Norway. Data collected 2009-11 included residents' demographic and clinical status and all medications, regular and on demand. RESULTS: 881 patients from 30 institutions (mean 85.9 years, 68.6% female), were included. According to NORGEP-NH, 43.8% were prescribed at least one potentially inappropriate regular medication, and 9.9% regularly received three or more potentially inappropriate medications. When also including a) the NORGEP-NH Deprescribing Criteria and b) including drugs prescribed for use as needed, 92.7% of all residents received medication that needs particular surveillance according to the NORGEP-NH. 69.7% of the nursing home residents used at least one psychotropic drug regularly. Female residents received more often than males at least one potentially inappropriate regular medication (OR 1.60, p=0.007). Regarding the prescription of three or more concomitant psychotropic medications, odds ratio for females was 1.79 (p=0.03) compared to males. Residents with the best performance in activities of daily living, and residents residing in long-term wards, had higher risk of using three or more psychotropic drugs. Use of multiple psychoactive drugs increased the risk of falls in the course of an acute episode of infection or dehydration (odds ratio 1.70, p=0.009). CONCLUSIONS: Prevalence of potentially inappropriate medications in nursing homes according to the NORGEP-NH was extensive, and especially the use of multiple psychotropic drugs. The high prevalence found in this study shows that there is a need for higher awareness of medication use and side effects in the elderly population. TRIAL REGISTRATION: Retrospectively registered. Data obtained from clinical trial NCT01023763 registered with ClinicalTrials.gov 12/01/2009.

The Norwegian General Practice--Nursing Home criteria (NORGEP-NH) for potentially inappropriate medication use: A web-based Delphi study.

OBJECTIVE: To develop a set of explicit criteria for pharmacologically inappropriate medication use in nursing homes. DESIGN: In an expert panel, a three-round Delphi consensus process was conducted via survey software. SETTING: Norway. SUBJECTS: Altogether 80 participants - specialists in geriatrics or clinical pharmacology, physicians in nursing homes and experienced pharmacists - agreed to participate in the survey. Of these, 62 completed the first round, and 49 panellists completed all three rounds (75.4% of those ultimately entering the survey). MAIN OUTCOME MEASURES: The authors developed a list of 27 criteria based on the Norwegian General Practice (NORGEP) criteria, literature, and clinical experience. The main outcome measure was the panellists' evaluation of the clinical relevance of each suggested criterion on a digital Likert scale from 1 (no clinical relevance) to 10. In the first round panellists could also suggest new criteria to be included in the process. For each criterion, degree of consensus was based on the average Likert score and corresponding standard deviation (SD). RESULTS: A list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed through a three-round web-based Delphi consensus process. Degree of consensus increased with each round. No criterion was voted out. Suggestions from the panel led to the inclusion of seven additional criteria in round two. IMPLICATIONS: The NORGEP-NH list may serve as a tool in the prescribing process and in medication list reviews and may also be used in quality assessment and for research purposes.

Inappropriate prescribing for the elderly--a modern epidemic?

PURPOSE: The elderly often use several drugs on a regular basis and are especially at risk for drug-related harm from side effects and interactions. The aim of this study was to explore the overall prevalence of and predictors for potentially inappropriate medication use among Norwegian elderly outpatients. METHODS: A pharmaco-epidemiological retrospective cross-sectional survey was undertaken based on data from the Norwegian Prescription Database. Prescriptions from all doctors in Norway, dispensed by pharmacies to home-dwelling elderly ≥ 70 years in 2008, were included for a total of 11,491,065 prescriptions from 24,540 prescribers to 445,900 individuals (88.3% of the Norwegian population in this age group, 58.9% females). We applied a list of criteria for pharmacological inappropriateness for elderly people (the NORGEP criteria) to determine the prevalence of potentially inappropriate medications (PIMs) and applied a multiple logistic regression model to identify predictors. RESULTS: According to our criteria, 34.8% of the study population (28.5% of the men, 39.3% of the women) was exposed to at least one PIM. Of these, 59.9% represented psychoactive substances. The odds of receiving potentially harmful prescriptions increased with the number of prescribers (OR 3.52, 99% CI 3.44-3.60 for those with ≥ 5 compared to those with 1 or 2 prescribers). Twenty percent were prescribed more than 10 medications; among these two-thirds had at least one PIM. Adjusted for differences in age distribution and the number of prescribers involved, women were more frequently exposed to PIMs than men, with an odds ratio of 1.60 (99% CI 1.58-1.64). CONCLUSIONS: About one-third of the elderly Norwegian population is exposed to potentially inappropriate medications, and elderly females are at particular risk.