Proton Pump Inhibitors and Hypomagnesemia in Older Inpatients: An Observational Study.

Purpose Proton pump inhibitors (PPIs) are prescribed frequently and can cause potentially severe hypomagnesemia. Researchers assessed the prevalence of hypomagnesemia and the association between PPI use and hypomagnesemia in hospitalized older patients. Methods Researchers conducted a single-center, observational, retrospective cohort study with patients admitted to a geriatric ward at the Jeroen Bosch Hospital in the period between June 24, 2016, and August 30, 2020. Patients were included if they were 65 years of age or older, had a serum magnesium measurement, and a complete overview of patient's current medication was present at the day of admission. The primary outcome was the occurrence of hypomagnesemia at hospital admission. Exposure to PPIs was the primary determinant investigated. Covariates were studied to identify risk factors and to adjust for potential confounding. The strength of the association between PPI and hypomagnesemia was evaluated with unconditional logistic regression, expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Results The prevalence of hypomagnesemia was 21.9% in PPI users and 15.8% in non-PPI users. Overall, the use of PPIs was associated with hypomagnesemia (ORadj = 1.38, 95% CI 1.09-1.76). A trend for this association was most pronounced in male patients (ORadj = 1.88, 95% CI 1.27-2.79), smokers (ORadj = 3.95, 95% CI 1.52-10.28), and in patients using > 7 units alcohol a week (ORadj = 4.44, 95% CI 1.40-14.12). Conclusion Older patients who are taking a PPI have a higher risk of developing hypomagnesemia than nonusers; additional factors can contribute to the risk. Physicians should be aware of PPI-induced hypomagnesemia and routinely monitor serum magnesium levels in older patients.

Evidence- and consensus-based guidelines for drug-drug interactions with anticancer drugs; A practical and universal tool for management.

Drug-drug interactions (DDIs) with anticancer drugs are common and can significantly affect efficacy and toxicity of treatment. Therefore, a Dutch Multidisciplinary Expert group is assessing the clinical significance of DDIs in oncology and provides recommendations for the management of these DDIs. We present an overview of methodology and outcome of an evidence- and consensus-based assessment of DDIs between anticancer drugs and non-anticancer drugs. A literature search was performed through PubMed and EMA and FDA assessment reports, to identify potential DDI's involving anticancer drugs. For each potential DDI a concept report for risk analysis and practical advice for management was created. Subsequently, this risk analysis and the corresponding advice were assessed and weighed. A total of 290 potential DDIs have been identified in the literature thus far. Of these 290 potential DDIs, the Expert Group has identified 94 (32%) DDIs as clinically relevant, with a need for an automated alert and a suggested intervention. Furthermore, 110 DDIs have been identified as clinically not relevant. For 86 potential DDIs evidence supporting a relevant DDI was insufficient and in these cases neither an alert nor advice regarding a suggested intervention were formulated. A transparent risk analysis is presented for identification of clinically relevant DDIs with anticancer drugs. Integration of DDI guidelines into the national electronic prescribing system is essential to achieve optimal efficacy and minimal toxicity in patients receiving anticancer therapy. A clear overview of clinically relevant DDIs with anticancer therapy provides clinicians with a structured, evidence-based and consensus-built tool for anticancer therapy surveillance.

Conversion of STOPP/START version 2 into coded algorithms for software implementation: A multidisciplinary consensus procedure.

BACKGROUND: The rapid digitalization of medical practice has attracted growing interest in developing software applications for clinical guidelines and explicit screening tools to detect potentially inappropriate prescribing, such as STOPP/START criteria. The aim of the current study was to develop and provide logically unambiguous algorithms of STOPP/START criteria version 2, encoded with international disease and medication classification codes, to facilitate the development of software applications for multiple purposes. METHODS: A four round multidisciplinary consensus and validation procedure was conducted to develop implementable coded algorithms for software applications of STOPP/START criteria version 2, based on ICD, ICPC, LOINC and ATC classification databases. RESULTS: Consensus was reached for all 34 START criteria and 76 out of 80 STOPP criteria. The resulting 110 algorithms, modeled as inference rules in decision tables, are provided as supplementary data. CONCLUSION: This is the first study providing implementable algorithms for software applications based on STOPP/START version 2, validated in a computer decision support system. These algorithms could serve as a template for applying STOPP/START criteria version 2 to any software application, allowing for adaptations of the included ICD, ICPC and ATC codes and changing the cut-off levels for laboratory measurements to match local guidelines or clinical expertise.

Deprescribing in Newly Admitted Psychogeriatric Nursing Facility Patients.

OBJECTIVE: To determine whether advised changes as a result of structured medication reviews in psychogeriatric patients were implemented and if the implemented changes were maintained. DESIGN: Prospective cohort study. SETTING: Three nursing facilities in The Netherlands. PATIENTS, PARTICIPANTS: Newly admitted psychogeriatric residents. INTERVENTION: After admission, a structured medication review was performed by a pharmacist and physician resulting in a treatment plan that was approved by the patient's legal representative and implemented. MAIN OUTCOME MEASURE(S): The percentage of advised changes approved (= approval rate) and the percentage of implemented medication changes still present 90 days after approval (= 90-day implementation rate). RESULTS: A total of 45 patients were included who used a total number of 333 drugs (mean ± standard deviation 7.4 ± 3.3 drugs). Changes were advised to 159 medications used by 42 patients. Of these changes, 150 were approved (approval rate 94.3%). Finally, 105 were implemented, and 89 were still implemented after 90 days (90-day implementation rate 84.8%). Overall, 59.7% of the advised changes concerned deprescribing (stopping or dose reduction). The proportion of advised changes implemented was similar for symptommodifying and risk-modifying drugs, namely, almost 85%. Overall, 55.3% of the recommended changes to deprescribe concerned 10 drug groups. CONCLUSION: Medication could be successfully deprescribed from psychogeriatric patients after structured medication reviews performed by pharmacists and nursing facility physicians. More than 50% of the advised changes to deprescribe involved 10 drug groups, which raises the question whether the structured medication review can be performed more efficiently by focusing on the most common problems.

Specifying ICD9, ICPC and ATC codes for the STOPP/START criteria: a multidisciplinary consensus panel.

BACKGROUND: the STOPP/START criteria are a promising framework to increase appropriate prescribing in the elderly in clinical practice. However, the current definitions of the STOPP/START criteria are rather non-specific, allowing undesirable variations in interpretation and thus application. The aim of this study was to design specifications of the STOPP/START criteria into international disease and medication codes to facilitate computerised extraction from medical records and databases. METHODS: a three round consensus procedure with a multidisciplinary expert panel was organised to prepare, judge and agree on the design of the STOPP/START criteria specifications in corresponding international disease codes (ICD9 and ICPC) and medication codes (ATC). RESULTS: after two rounds consensus was reached for 74% of the STOPP criteria and for 73% of the START criteria. After three rounds full consensus was reached resulting in a specification of 61 out of 62 STOPP criteria and 26 START criteria with their corresponding codes. One criterion could not be specified and for some criteria corresponding disease codes were lacking or imperfect. CONCLUSION: this study showed the necessity of a consensus procedure as even experts frequently differed on how to specify the STOPP/START criteria. This specification enables next steps such as prognostic validation of these criteria on adverse outcomes and studying the impact of improving appropriate prescribing in the elderly.

[Detection of inappropriate medication use in the elderly; will the STOPP and START criteria become the new Dutch standards?]. / Detectie van ongeschikt medicatiegebruik bij ouderen: worden de STOPP- en START-criteria de nieuwe standaard?

Many drugs that can be prescribed safely and effectively to younger patients are potentially inappropriate for the elderly as a result of physiological changes and increased comorbidity. A screening tool can be useful for detecting potentially inappropriate medication use in the elderly. When analysing medication use in the elderly, both overtreatment and undertreatment should be assessed. In Ireland, a screening method called the STOPP and START criteria has been developed; these provide 'handles' for the detection of potential overtreatment and undertreatment. The STOPP and START criteria, therefore, seem to be more fitting to the Dutch situation than the widely used Beers' criteria. In the new Dutch multidisciplinary guideline, 'Polypharmacy in the elderly' the use of the STOPP and START criteria is advised. In this article, we present a translation of the STOPP and START criteria which has been adapted for Dutch practice.

Consensus-based evaluation of clinical significance and management of anticancer drug interactions.

BACKGROUND: Anticancer drug interactions can affect the efficacy and toxicity of anticancer treatment and that of the interacting drugs. However, information on the significance, prevention, and management of these interactions is currently lacking. OBJECTIVE: The purpose of this study was to assess the clinical significance of interaction among anticancer agents and comedications and to provide recommendations for the management of clinically significant interactions. METHODS: Members of a multidisciplinary expert group of hospital and community pharmacists, medical oncologists, internists, and clinical pharmacologists were selected by their professional organizations, which participated in this consensus project. Literature was extensively searched for any drug interactions with anticancer agents using registration files, reference books, handbooks, and electronic databases. Interactions between anticancer agents were not considered. Interactions were classified by level of best available evidence for the interaction and by severity of the clinical effect, according to a structured assessment procedure. This assessment distinguished 5 levels for the amount and quality of evidence available and 6 severity levels for classification of potential drug-to-drug interactions. RESULTS: A total of 88 drug interactions with anticancer agents were identified from 146 combinations of drugs with anticancer agents found in literature. For 58 combinations, there was insufficient evidence of an interaction. Of the identified interactions, 38 were classified as clinically significant, defined as necessitating an alert or intervention, such as dose adaptation, comedication, discontinuation of treatment, or additional monitoring of treatment. Recommendations were made for management of these interactions. CONCLUSION: Numerous interactions with anticancer agents are clinically significant and should be considered by pharmacists and doctors in daily oncology practice.

Time-dependent drug-drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

Time-dependent drug-drug interactions (TDDIs) are drug combinations that result in a decreased drug effect due to coadministration of a second drug. Such interactions can be prevented by separately administering the drugs. This study attempted to reduce drug administration errors due to overridden TDDIs in a care provider order entry (CPOE) system. In four periods divided over two studies, logged TDDIs were investigated by reviewing the time intervals prescribed in the CPOE and recorded on the patient chart. The first study showed significant drug administration error reduction from 56.4 to 36.2% (p<0.05), whereas the second study was not successful (46.7 and 45.2%; p>0.05). Despite interventions, drug administration errors still occurred in more than one third of cases and prescribing errors in 79-87%. Probably the low alert specificity, the unclear alert information content, and the inability of the software to support safe and efficient TDDI alert handling all diminished correct prescribing, and consequently, insufficiently reduced drug administration errors.