Teaching transgender patient care to student pharmacists.

INTRODUCTION: This study describes content on transgender care taught in a doctor of pharmacy (PharmD) course and evaluates students' confidence and knowledge of providing care for transgender people. It also examines what pharmacy students want to learn about providing care to transgender people. METHODS: Three hours of transgender patient care content was integrated into a pharmacy course that focused on therapeutics of special populations. Students completed an electronic survey before and after the class sessions to identify changes in their confidence in caring for transgender patients. The pre-class survey inquired about what the students were hoping to learn. The post-class survey asked students what was missing from this session that they would have liked to learn. Knowledge regarding transgender care was assessed through a multiple-choice examination. RESULTS: Students reported interest in improving communication skills, learning terminology/vocabulary preferred by transgender people, and understanding population-specific challenges faced by transgender patients. Students reported they would have liked additional information about the transition, being transgender, and local resources available. Student confidence in asking about patient pronouns and counseling on effects of medications for gender transition were both significantly increased from the pre-class survey to post-class survey. Students demonstrated proficiency toward the learning objectives, with a 92.4% average on the examination questions on transgender care. CONCLUSIONS: Student pharmacists are interested in learning skills to provide care to transgender patients. A learning session on transgender patient care integrated into a PharmD curriculum increased student knowledge and confidence in caring for transgender patients.

Medication use, renin-angiotensin system inhibitors, and acute care utilization after hospitalization in patients with chronic kidney disease.

OBJECTIVES: The aims of this secondary analysis were to: (a) characterize medication use following hospital discharge for patients with chronic kidney disease (CKD), and (b) investigate relationships of medication use with the primary composite outcome of acute care utilization 90 days after hospitalization. METHODS: The CKD-Medication Intervention Trial (CKD-MIT) enrolled acutely ill hospitalized patients with CKD stages 3-5 not dialyzed (CKD 3-5 ND). In this post hoc analysis, data for medication use were characterized, and the relationship of medication use with the primary outcome was evaluated using Cox proportional hazards models. RESULTS: Participants were taking a mean of 12.6 (standard deviation=5.1) medications, including medications from a wide variety of medication classes. Nearly half of study participants were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB). ACE inhibitor/ARB use was associated with decreased risk of the primary outcome (hazard ratio=0.51; 95% confidence interval 0.28-0.95; p=0.03) after adjustment for baseline estimated glomerular filtration rate, age, sex, race, blood pressure, albuminuria, and potential nephrotoxin use. CONCLUSIONS: A large number, variety, and complexity of medications were used by hospitalized patients with CKD 3-5 ND. ACE inhibitor or ARB use at hospital discharge was associated with a decreased risk of 90-day acute care utilization.

Newly Approved Novel Dosage Forms of Glucagon for Management of Severe Hypoglycemia.

The prevalence and clinical impact of diabetes mellitus (DM) continues to increase in the United States and throughout the world. Older adults are at increased risk for adverse outcomes associated with hypoglycemia, particularly in situations where a lack of awareness may arise because typical symptoms are not necessarily present, serve to prompt medical intervention with oral glucose. Glucagon emergency kits that have been available to date require multiple-step reconstitution that may compromise timely and appropriate administration of lifesaving glucagon treatment during episodes of severe hypoglycemia. In settings such as long-term care facilities, trained medical professionals may not be readily available, meaning that glucagon must be administered by laypersons. Novel dosage forms of glucagon that have recently been approved for marketing in the United States allow glucagon to be delivered more easily, which may positively impact effective treatment of severe hypoglycemia among older people. Nasal glucagon and glucagon autoinjection "pens" are as effective as glucagon kits and increase the likelihood glucagon will be appropriately used by patient caregivers. The safety, efficacy, and convenience of these new devices may improve outcomes and reduce health care costs of older people with diabetes.

Medication Regimen Complexity in Patients Receiving Consultant Pharmacy Services in Home Health Care.

An interprofessional, team-based approach has become common in a variety of settings. However, consultant pharmacist participation in home health care (HHC) has been limited. To evaluate a potential need for pharmacists in HHC, the objective of this project was to document the medication complexity of patients seen by an established HHC consultant pharmacist service. This retrospective review reports on medication regimen complexity in 79 patients receiving this service using the Patient-Level Medication Regimen Complexity Index (MRCI) tool. The average MRCI score was 30 (± 15 standard deviation), suggesting a high level of medication regimen complexity in this population. High scores have been correlated with increased potential adverse drug events, 30-day hospital readmissions, and reduced adherence. Further research is needed for both the utilization of consultant pharmacists in HHC and the use of MRCI in identifying HHC patients needing pharmacist services.

Analysis of a Long-Standing Consultant Pharmacy Service in Home Health Care.

OBJECTIVE: To analyze the long-term utilization of an on-site consultant pharmacist referral service at a home health care (HHC) agency (HHA) and the medication-related problems in the homebound patients served.
DESIGN: A retrospective, descriptive study reporting the pharmacist's role in providing pharmaceutical care to patients referred by HHC clinicians from 2009 through 2015.
SETTING: A nonprofit HHA in Spokane, Washington, that has utilized a consultant pharmacist service for more than 20 years as part of an academic partnership with Washington State University.
PARTICIPANTS: All patients referred to the pharmacy team were eligible for inclusion in the data analysis.
INTERVENTIONS: Pharmacists provided comprehensive medication management via telephone calls, home visits, and communication with HHA clinicians to resolve clinician-referred problems.
MAIN OUTCOMES: Reason for referral, modality of resolution, number and type of medication-related problems, prescriber response rate.
RESULTS: Of 1,263 referrals, the pharmacy team resolved the case by visiting 421 patients, calling 261 patients, and collaborating with the clinician team for 323 patients; 258 patients declined or were lost to follow-up. The most common problems were the need for education (37%), adverse drug effect (18.8%), and nonadherence (18.4%). The pharmacy team contacted the prescriber 209 times with a 58.4% rate of partial or full acceptance of pharmacy recommendations (nonresponses were counted as not accepted). An additional 265 prescriber contacts were planned to be done by either the patient or HHC clinician.
CONCLUSION: Consultant pharmacists can play an integral role as part of an interdisciplinary HHC team to resolve medication-related problems.

Potential Adverse Drug Events and Associated Costs During Transition from Hospital to Home.

OBJECTIVE: The purpose of this study was to evaluate differences in medication discrepancy identification between pharmacists and nurses for patients 50 years of age and older receiving home health services following discharge from an inpatient hospital. It also evaluates the potential cost savings to the health care system as a result of avoiding adverse drug events (ADEs). Medication discrepancies were documented within seven days following hospital discharge.
DESIGN: The study was a secondary analysis of existing data from a completed randomized clinical trial.
SETTING: Home health care following transition from inpatient hospital care.
PARTICIPANTS: Hospitalized patients (N = 101) 50 years of age or older referred for home care services following discharge.
INTERVENTION: Existing data on medication discrepancy identification by pharmacists and nurses and potential costs of ADEs that could result were evaluated. Anticipated costs of ADEs unrecognized by nurses were estimated using Centers for Medicare & Medicaid Services claims data.
MAIN OUTCOME MEASURES: Number and severity of medication discrepancies identified by pharmacists and nurses, potential consequences for patient health and health care utilization, and anticipated costs to the health care system.
RESULTS: Pharmacists identified 677 medication discrepancies, of which 271 (40%) were considered likely to result in an ADE. Nurses identified 202 (30%) of the 677 medication discrepancies identified by pharmacists. It was estimated that approximately $9,670 in additional health care expenses could have been prevented within the cohort by pharmacist intervention.
CONCLUSION: Pharmacists identified more medication discrepancies during transition from hospital to home when compared with nurses, with the potential benefit of preventing more ADEs and saving associated health care costs during such care transitions.

Medication Therapy Management after Hospitalization in CKD: A Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: CKD is characterized by remarkably high hospitalization and readmission rates. Our study aim was to test a medication therapy management intervention to reduce subsequent acute care utilization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The CKD Medication Intervention Trial was a single-blind (investigators), randomized clinical trial conducted at Providence Health Care in Spokane, Washington. Patients with CKD stages 3-5 not treated by dialysis who were hospitalized for acute illness were recruited. The intervention was designed to improve posthospitalization care by medication therapy management. A pharmacist delivered the intervention as a single home visit within 7 days of discharge. The intervention included these fundamental elements: comprehensive medication review, medication action plan, and a personal medication list. The primary outcome was a composite of acute care utilization (hospital readmissions and emergency department and urgent care visits) for 90 days after hospitalization. RESULTS: Baseline characteristics of participants (n=141) included the following: age, 69±11 (mean±SD) years old; women, 48% (67 of 141); diabetes, 56% (79 of 141); hypertension, 83% (117 of 141); eGFR, 41±14 ml/min per 1.73 m2 (serum creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation); and urine albumin-to-creatinine ratio median, 43 mg/g (interquartile range, 8-528) creatinine. The most common primary diagnoses for hospitalization were the following: cardiovascular events, 36% (51 of 141); infections, 18% (26 of 141); and kidney diseases, 12% (17 of 141). The primary outcome occurred in 32 of 72 (44%) of the medication intervention group and 28 of 69 (41%) of those in usual care (log rank P=0.72). For only hospital readmission, the rate was 19 of 72 (26%) in the medication intervention group and 18 of 69 (26%) in the usual care group (log rank P=0.95). There was no between-group difference in achievement of guideline-based goals for use of renin-angiotensin system inhibition or for BP, hemoglobin, phosphorus, or parathyroid hormone. CONCLUSIONS: Acute care utilization after hospitalization was not reduced by a pharmacist-led medication therapy management intervention at the transition from hospital to home.

Development of a Tool to Identify Problems Related to Medication Adherence in Home Healthcare Patients.

In the home healthcare setting, clinicians are required to evaluate patient's medication therapy, including adherence. To facilitate this conversation, a pilot question list to help uncover potential medication nonadherence was created after completing a review of the literature and ascertaining the common themes as to why patients were nonadherent to their medication therapies. Pharmacy personnel who provide onsite consultations in a home healthcare setting used the question list to identify medication-related problems that could contribute to nonadherence and to document potential solutions. Through pharmacist-patient interactions, which occurred after admission to the home healthcare agency, pharmacy personnel found on average 2.3 issues per patient, which could affect medication adherence. Side effects were the most common problem identified. After this tool was tested with 65 patient interviews, the questions were analyzed and condensed into a shorter list more specific to the identification of medication-related problems for use by home care clinicians.

Preserving Self: Medication-Taking Practices and Preferences of Older Adults With Multiple Chronic Medical Conditions.

PURPOSE: To examine the experiences of older adults with multiple chronic medical conditions when a new medication was added to their existing multiple medication regimen. DESIGN: A multimethod qualitative design was used. Thirty adults 60 years of age with (a) at least three chronic medical diagnoses, (b) at least five medications at baseline, and (c) a new medication prescription were enrolled in a prospective study of 30 days duration, participating from their homes. METHODS: In-depth hermeneutic interviews (2 per 15 participants) and self-assessment diaries recorded on electronic tablets (daily per 30 participants) were completed. Transcribed interviews and self-recorded survey data were analyzed using hermeneutical analysis and ecological momentary assessment and content analysis, respectively. FINDINGS: Common reasons participants did not take medications as prescribed included tolerability, transportation, access to medications, and forgetting. The overarching pattern, "preserving self," was supported by two patterns that subsumed several themes: (a) engaging the powerful hold of my illness, and (b) engaging providers in visioning health. CONCLUSIONS: A deeper understanding of the impact of receiving a new prescription and of managing medication reveals the challenges patients experience in preserving a sense of self. Healthcare providers of all disciplines should understand the meaning of medication prescribing and medication taking to ameliorate medication-taking difficulties. CLINICAL RELEVANCE: The provider-patient relationship is often cited as an area that needs to be addressed in healthcare practice. Our study emphasized the patients' voices and their profound needs around medication management. The emphasis on preservation of self is an important finding that focalizes the concern.

Medication Intervention for Chronic Kidney Disease Patients Transitioning from Hospital to Home: Study Design and Baseline Characteristics.

BACKGROUND: The hospital readmission rate in the population with chronic kidney disease (CKD) is high and strategies to reduce this risk are urgently needed. METHODS: The CKD-Medication Intervention Trial (CKD-MIT; www.clinicaltrials.gov; NCTO1459770) is a single-blind (investigators), randomized, clinical trial conducted at Providence Health Care in Spokane, Washington. Study participants are hospitalized patients with CKD stages 3-5 (not treated with kidney replacement therapy) and acute illness. The study intervention is a pharmacist-led, home-based, medication management intervention delivered within 7 days after hospital discharge. The primary outcome is a composite of hospital readmissions and visits to emergency departments and urgent care centers for 90 days following hospital discharge. Secondary outcomes are achievements of guideline-based targets for CKD risk factors and complications. RESULTS: Enrollment began in February 2012 and ended in May 2015. At baseline, the age of participants was 69 ± 11 years (mean ± SD), 50% (77 of 155) were women, 83% (117 of 141) had hypertension and 56% (79 of 141) had diabetes. At baseline, the estimated glomerular filtration rate was 41 ± 14 ml/min/1.73 m2 and urine albumin-to-creatinine ratio was 43 mg/g (interquartile range 8-528 mg/g). The most frequent diagnosis category for the index hospital admission was cardiovascular diseases at 34% (53 of 155), but the most common single diagnosis for admission was community-acquired acute kidney injury at 10% (16 of 155). CONCLUSION: Participants in CKD-MIT are typical of acutely ill hospitalized patients with CKD. A medication management intervention after hospital discharge is under study to reduce post-hospitalization acute care utilization and to improve CKD management.

Assessed Value of Consultant Pharmacist Services in a Home Health Care Agency.

OBJECTIVE: To report results of a survey administered to clinicians in a home health care agency regarding reasons for them to initiate consultation with a pharmacist working onsite at the agency and the perceived value of the interaction. DESIGN: The survey listed 16 reasons why an agency clinician commonly makes referrals and 9 questions assessing the perceived value of these services provided by the onsite consultant pharmacist. Responses were reported on a five-point Likert scale where 1 = Almost always/strongly agree and 5 = Almost never/strongly disagree. SETTING: Home health care agency in Spokane, Washington, with onsite and in-home consultant pharmacy services for 20 years via a partnership with Washington State University. PARTICIPANTS: All clinicians employed by the home health care agency. RESULTS: Twenty-eight of 101 part-time and full-time clinicians responded to the survey. Eighty-nine percent of respondents strongly agreed that it is valuable to have a consultant pharmacist onsite and pharmacy personnel serve as a helpful source of information. The most common reasons for referral were pain management, drug side effects, and drug interactions. CONCLUSION: Clinicians indicated consultant pharmacist services are beneficial and they used the consultant pharmacist primarily for pain management, drug side effects, and drug interactions, but made referrals for a wide range of reasons. This indicates that an onsite consultant pharmacist is valuable to home care providers. Further research regarding the benefit of an onsite consultant pharmacist in the home care setting is warranted.

Cognitive and literacy screening as predictors of ability to fill a pillbox using two pillbox assessment scoring methods.

OBJECTIVE: To compare patient cognition measured by Medi-Cog, a tool to assess cognitive literacy and pillbox skills, with pillbox concordance using two scoring methods, Pillbox Fill (PBF) and Prospective Pill Count (PPC). DESIGN: Prospective, descriptive, cross-sectional study. SETTING: Primary care. PARTICIPANTS: Multiethnic participants with type 2 diabetes with sufficient vision and dexterity to load a pillbox. INTERVENTION: Medi-Cog scores were correlated with ability to fill a pillbox based on both the PPC and the PBF scoring methods. Variables were analyzed by multivariate linear and logistic regression. MAIN OUTCOME MEASURES: To determine whether there is a difference between PBF and PPC scoring methods relative to Medi-Cog prediction of pillbox concordance. RESULTS: Sixty-four participants loaded an average of 5.2 medications. Mean Medi-Cog score for five patients who failed PBF but passed PPC were lower than the entire cohort (5.6 compared with 6.2). Correlation between PBF and PPC methods was 0.978; P = 0.01. Regression values for Medi-Cog's ability to predict PBF and PPC scores were r = 0.668 and r2 = 0.446, and r = 0.660 and r2 = 0.436; P < 0.01 for all. CONCLUSION: Compared with PPC, PBF proved to be a more conservative scoring method and captured an additional five patients who scored less-well on the Medi-Cog. Future studies are needed to explore the value of using pillbox assessments as well as cognitive screening prior to recommending pillbox use.

Physiological Changes in Older Adults and Their Effect on Diabetes Treatment.

In Brief Physiological changes associated with aging have the potential to affect the treatment of diabetes. However, evidence regarding treatment of diabetes in geriatric patients has been limited, especially for "oldest-old" patients. Recent research has provided greater insight into the risks and benefits of treatment, and new guidelines provide more specific information regarding treatment goals in older people with diabetes and encourage greater individualization of treatment.

Risedronate's Role in Reducing Hip Fracture in Postmenopausal Women with Established Osteoporosis.

UNLABELLED: Osteoporosis is a significant concern for postmenopausal women and is a critical factor in hip fracture. Examining evidence for osteoporosis medications in hip fracture is important for optimizing treatment. PURPOSE: Review risedronate's role for hip fracture in postmenopausal women. METHODS: A literature search was conducted using Medline and Web of Science. The search was limited using the terms "risedronate" and "hip fracture," and to studies that included women. Similar articles linked to the search and pertinent articles in bibliographies were also examined. RESULTS: Risedronate has demonstrated efficacy and cost effectiveness for hip fracture, but may not be beneficial for patients with low fracture risk. Risedronate is generally well tolerated, but may cause side effects in some patient populations. CONCLUSION: Risedronate has benefit for hip fracture, but patients should be carefully screened to determine the appropriateness of risedronate before starting treatment.

Management of osteoporosis in elderly men.

Osteoporosis is a common condition associated with aging but has been considered to primarily affect women because of the substantial effect of menopause on osteoporosis. Bone density can decrease with aging in men but occurs more gradually than in postmenopausal women. With improvements in healthcare and extended life expectancy, it is becoming more apparent that osteoporosis affects men and can have serious consequences. Recently, a greater number of osteoporosis studies are either including men or focusing specifically on them. The majority of medication trials in men, however, used bone density as the primary outcome rather than fractures. Therefore, treatment data for men is still rather limited, and there is also very little information in the oldest subset of this population. The more recent guidelines for treating osteoporosis now include men, but the recommendations for screening and treatment are not necessarily gender specific. Despite the limited data, some osteoporosis treatments have received approval to treat or prevent osteoporosis specifically in men. Future studies must provide greater information on fracture prevention in men and also must include a greater population of the oldest geriatric patients, who are typically not well represented in osteoporosis trials, to evaluate any differences in both efficacy and side effects. The oldest group is important because they are at the highest risk for both osteoporosis-related complications and treatment-related adverse events.

Diabetes mellitus, inflammation, obesity: proposed treatment pathways for current and future therapies.

OBJECTIVE: To review the pathophysiology, pharmacology, and current or future therapies under study for use in treating diabetes mellitus, inflammation associated with diabetes mellitus, and/or obesity related to diabetes mellitus, through 1 of 4 investigational pathways: adiponectin, ghrelin, resveratrol, or leptin. DATA SOURCES: A literature search using MEDLINE (1966-December 12, 2009), PubMed (1950-December 12, 2009), Science Direct (1994-December 12, 2009), and International Pharmaceutical Abstracts (1970-December 12, 2009) was performed using the terms adiponectin, ghrelin, resveratrol, leptin, inflammation, obesity, and diabetes mellitus. English-language, original research, and review articles were examined, and citations from these articles were assessed as well. STUDY SELECTION AND DATA EXTRACTION: Clinical studies and in vitro studies were included in addition to any Phase 1, 2, or 3 clinical trials. DATA SYNTHESIS: Mechanistic pathways regarding adiponectin, ghrelin, resveratrol, and leptin are of interest as future treatment options for diabetes mellitus. Each of these pathways has produced significant in vitro and in vivo clinical data warranting further research as a possible treatment pathway for diabetes-related inflammation and/or obesity reduction. While research is still underway to determine the exact effects these pathways have on metabolic function, current data suggest that each of these compounds may be of interest for future therapies. CONCLUSIONS: While several pathways under investigation may offer additional benefits in the treatment of diabetes mellitus and associated impairments, further investigation is necessary for both investigational and approved therapies to ensure that the impact in new pathways does not increase risks to patient safety and outcomes.

Effectiveness of a pharmacist-nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

PURPOSE: The effectiveness of a collaborative pharmacist-nurse intervention on resolving detected medication discrepancies as patients transitioned from hospital to home health care was evaluated. METHODS: Patients age 50 years or older who were transitioning from hospital to home health care with qualifying diagnoses were eligible for study inclusion. Patients were assigned to a control or intervention group based on the geographic location of the patients' home. For the intervention group, the study coordinator initiated consultation with the nurse case manager to facilitate discrepancy resolution. Patients in the control group received usual care after the initial home visit by the study coordinator. Rehospitalization rates and the number of planned and unplanned physician visits were analyzed. Descriptive statistics were used to characterize and contrast patients in each study group. Equivalency testing was conducted to evaluate group comparability for demographic and health status variables and the use of health care services. RESULTS: A total of 490 medication discrepancies were identified. The discrepancy resolution rates in the intervention and control groups were 67.0% and 54.6%, respectively. Assignment to the intervention group was associated with enhanced medication discrepancy resolution (r = 0.539, p = 0.001). There was a trend toward more planned and unplanned physician visits, and a trend toward a greater number of rehospitalization days. CONCLUSION: A pharmacist-nurse collaboration designed to identify and resolve medication-related discrepancies in patients transitioning from the hospital to home health care led to significant improvement in medication discrepancy resolution.

Colesevelam hydrochloride for the treatment of type 2 diabetes mellitus.

BACKGROUND: Colesevelam hydrochloride is a bile acid sequestrant approved in January 2008 by the US Food and Drug Administration (FDA) for the treatment of adult patients with type 2 diabetes mellitus (DM) in combination with a sulfonylurea, metformin, and/or insulin therapy. OBJECTIVE: The purpose of this article was to review the pharmacology, pharmacokinetics, efficacy, adverse effects and tolerability, drug-drug interactions, contraindications/precautions, dosage and administration, pharmacoeconomics, and the overall role of colesevelam in the management of adult patients with type 2 DM. METHODS: A literature search using MEDLINE (1966-October 27, 2008), PubMed (1950-October 27, 2008), Science Direct (1994-October 27, 2008), Web of Science (1980-October 27, 2008), American Diabetes Association Scientific Abstracts (2004-2008), and International Pharmaceutical Abstracts (1970-October 27, 2008) was performed using the term colesevelam. English-language, original research and review articles were examined, and citations from these articles were assessed. Manufacturer prescribing information and the FDA review of the new drug application for colesevelam were also examined. RESULTS: Colesevelam is a hydrophilic, water-insoluble polymer, with negligible absorption and systemic distribution, that is excreted primarily in the feces. Through a mechanism still under investigation, colesevelam effectively lowers glycosylated hemoglobin (HbA(1c)) when used in combination with a sulfonylurea, metformin, and/or insulin therapy. Three completed, published Phase III clinical trials investigating colesevelam for the treatment of type 2 DM were evaluated for information, data, and conclusions. At dosing of 1.875 g BID or 3.75 g once daily in combination with one of the aforementioned agents versus placebo, reductions in HbA(1c) in all 3 Phase III clinical trials of colesevelam ranged from 0.5% to 0.7% (P < 0.02). In clinical trials, colesevelam was well tolerated, with hypoglycemia occurring in approximately 3% of studied patients. CONCLUSIONS: When used in combination with a sulfonylurea, metformin, and/or insulin therapy, colesevelam has been reported to significantly reduce HbA(1c) in adult patients with type 2 DM. Colesevelam's role in the management of type 2 DM remains undefined, however; further investigation into its mechanism of action and long-term efficacy and safety should be performed.

Pharmacological management of glycemic control in the geriatric patient with type 2 diabetes mellitus.

OBJECTIVE: Discuss geriatric considerations in the treatment of diabetes mellitus and review the advantages and disadvantages of the various pharmacologic agents, including oral medications and insulin, currently available for the treatment of type 2 diabetes mellitus (T2DM). DATA SOURCES: Literature identified within MEDLINE and PubMED, with an emphasis on material published since 2000, were reviewed. STUDY SELECTION: Overall, 67 primary study manuscripts, clinical reviews, and dosing guidelines were identified and reviewed based on their clinical relevance to the geriatric population. DATA EXTRACTION: Literature searches were performed for studies and reviews that included information on the use of antidiabetic medications in the geriatric population. Information was gathered from the available literature base for each medication class included in the review. DATA SYNTHESIS: The literature identified provided guidelines and considerations for the treatment of the older patient with diabetes mellitus to optimize patient outcomes while minimizing the risk for adverse events. This review provides a systematic outline of these considerations and suggests treatment pearls. CONCLUSION: The approach to managing T2DM in the elderly should be conservative and methodical in nature, with careful consideration of side effects, drug-disease and drug-drug interactions, and the risk of inducing hypoglycemia in this at-risk population.

Review of osteoporosis pharmacotherapy for geriatric patients.

BACKGROUND: Fractures are a significant problem in geriatric patients, and understanding the evidence for benefit and possible harm of osteoporosis treatments is critical to appropriate management of this patient population. OBJECTIVE: The purpose of this article was to review the evidence and treatment considerations related to use of the approved osteoporosis treatments in the United States across the continuum of ages in the geriatric population. METHODS: MEDLINE and the Web of Science were searched to find English-language articles published from 2000 through July 2009. Search terms included: practice guideline, osteoporosis, calcium, vitamin D, pharmacoeconomics, ethnicity, and treatment. The generic names of each of the osteoporosis treatments approved in the United States were searched to find relevant clinical trials and randomized controlled trials (RCTs). Pivotal trials that included fracture data or focused specifically on elderly patients (> or = 60 years of age) were selected. Bibliographies in the identified articles were searched for additional articles, and the prescribing information for each of the approved treatments was reviewed. RESULTS: Many osteoporosis studies have a mean patient age >60 years, but data for older patients are limited. Subanalyses of older patient groups have found risedronate to be beneficial for vertebral fractures in patients aged 70 to 79 years (absolute risk reduction [ARR], 8.4%; P < 0.001) and teriparatide to be beneficial for both vertebral (ARR, 6.4%; P < 0.05) and new nonvertebral fragility fractures (ARR, 9.9%; P < 0.05) in women aged > or = 75 years. However, no RCTs of geriatric patients who were either nonambulatory or had multiple comorbidities were identified in the literature. CONCLUSIONS: Evidence indicates that the osteoporosis treatments currently available in the United States are beneficial for treating osteoporosis in geriatric patients. However, data are limited for the oldest patients (> or = 80 years) and those with significant comorbidities. Because of the limited availability of data for geriatric patients with significant comorbidities, the properties of the various agents, including efficacy, tolerability, and potential contraindications, should be considered carefully for each geriatric patient.