From Geriatric Pharmacy intern Jessica Enogieru Pharm (c) University of Florida College of Pharmacy
In April 2005, the FDA released a public health advisory stating that elderly patients treated with atypical antipsychotics for dementia-related psychosis are at an increased risk of death. This was based on the FDA’s analysis of 17 placebo-controlled trials that studied 5377 elderly patients with dementia-related behavioral disorders; it showed an increased risk of death (1.6-1.7) in drug-treated patients versus placebo-treated patients. The majority of deaths were due to cardiovascular (e.g sudden death, heart failure) or infections (e.g pneumonia). The FDA asked manufacturers of atypical antipsychotics to include this information in the Boxed Warning and Warnings section of the drug pamphlet.
Published in 2008, two observational epidemiological studies (Gill et al, Schneeweiss et al) examined the risk of death in patients treated with conventional antipsychotics. Gill et al, a retrospective cohort study, examined the risk of death with atypical antipsychotics versus no antipsychotic and the risk of death with conventional antipsychotics versus atypical antipsychotics. The study revealed that atypical antipsychotics were associated with increased mortality versus no antipsychotic use; this risk was evident as early as 30 days into the trial and persisted until the end of the study at 180 days. Furthermore, it revealed that conventional antipsychotic use had a slightly higher risk of death versus atypical antipsychotic use. Schneeweiss et al, a retrospective cohort study, compared 180-day all cause mortality with conventional antipsychotics versus atypical antipsychotics. The study revealed that the risk of death with conventional antipsychotics was comparable to, or possibly greater than, the risk of death with atypical antipsychotics.
Because of the methodological limitations of epidemiological studies, health professionals and the lay public should not conclude that conventional antipsychotics carry a higher risk of death than atypical antipsychotics. But the FDA has determined that conventional antipsychotics share the increased risk of death in elderly patients with dementia-related psychosis treated with atypical antipsychotics. The FDA has recommended that physicians who prescribe antipsychotics to elderly patients with dementia-related psychosis should discuss the increased risk of mortality with their patients, patient’s families, and caregivers.
To get help with mediocation-related problems, visit the MediSort Medication Consultants website.
Sunday, July 12, 2009
Friday, July 10, 2009
Eyelid considerations in older adults
From Geriatric Pharmacy Intern, Yesenia Martinez PharmD(c),
Nova Southeastern University, College of Pharmacy
The eyelids of older adults can present with a multitude of conditions ranging from mild inflammation that resolves on its own to potentially fatal diseases. The following paragraphs discuss very briefly and in very general terms some of the more common eyelid concerns along with their possible causes and treatment options.
Blepharoptosis, or drooping of the eyelid, can be the result of many things. It is fequently the result of the stretching of the skin due to aging but it could also be a sign of a more serious problem, such as neurological damage. Drooping caused by aging can be corrected with surgery if the problem is severe enough that it causes a significant loss of your visual field. Lid retraction, or the “stare”, often indicates a thyroid problem. In this case, the eyelids are pulled back tightly which may interfere with blinking and cause dry eyes as well as more serious complications. If bothersome, one treatment option for dry eyes is artificial tears or ointment. Blepharospasm, or involuntary eyelid twitching and blinking, can be the result of stress, too much caffeine, or fatigue. However, it may also be caused by a more serious psychological problem. If your primary care physician (PCP) or ophthalmologist determines the spasms to be harmless but the symptoms are too troublesome, they can be temporarily corrected with botulinum toxin injections (better known as Botox).
When it comes to growths on the eyelids, it is helpful to keep several things in mind. Compared to malignant tumors, benign tumors are generally found in multiples, are better circumscribed, and are usually less inflamed. They also tend to grow more slowly, not bleed or ulcerate, and look “stuck on”. With regard to infection and inflammation, symptoms to look out for include redness, crusty eyelashes, itching, irritation, scaling, pain, and blurred vision. Another type of inflammation called seborrheic blepharitis may present with greasy or dry scales on the eyelids and eyelashes. Contact dermatitis is yet another form of inflammation and is caused by an allergen or irritant coming into contact with the very sensitive skin that makes up the eyelid. In most cases, these inflammatory conditions can be treated by your PCP with simple eye washes and/or antibiotics. A hordeolum, more commonly known as a stye, usually appears as a red, swollen lump that is tender and tends to be recurrent. These can be treated with hot compresses at home or, if necessary, your PCP may determine the need for antibiotics.
Eyelids are made up of a complex set of tissues and they serve a very important purpose by lubricating and protecting the eye. In most cases your PCP can easily diagnose and treat your eyelids conditions, but in some cases referral to an ophthalmologist or more specialized physician may be required. In all cases it is wise to always discuss any concerns you may have or sudden changes that you notice with your PCP and allow him or her to perform a thorough examination.
Zucker, Jamie L. The eyelids: Some common disorders seen in everyday practice. Geriatrics. 2009 April; 64(4):14-19,28.
Nova Southeastern University, College of Pharmacy
The eyelids of older adults can present with a multitude of conditions ranging from mild inflammation that resolves on its own to potentially fatal diseases. The following paragraphs discuss very briefly and in very general terms some of the more common eyelid concerns along with their possible causes and treatment options.
Blepharoptosis, or drooping of the eyelid, can be the result of many things. It is fequently the result of the stretching of the skin due to aging but it could also be a sign of a more serious problem, such as neurological damage. Drooping caused by aging can be corrected with surgery if the problem is severe enough that it causes a significant loss of your visual field. Lid retraction, or the “stare”, often indicates a thyroid problem. In this case, the eyelids are pulled back tightly which may interfere with blinking and cause dry eyes as well as more serious complications. If bothersome, one treatment option for dry eyes is artificial tears or ointment. Blepharospasm, or involuntary eyelid twitching and blinking, can be the result of stress, too much caffeine, or fatigue. However, it may also be caused by a more serious psychological problem. If your primary care physician (PCP) or ophthalmologist determines the spasms to be harmless but the symptoms are too troublesome, they can be temporarily corrected with botulinum toxin injections (better known as Botox).
When it comes to growths on the eyelids, it is helpful to keep several things in mind. Compared to malignant tumors, benign tumors are generally found in multiples, are better circumscribed, and are usually less inflamed. They also tend to grow more slowly, not bleed or ulcerate, and look “stuck on”. With regard to infection and inflammation, symptoms to look out for include redness, crusty eyelashes, itching, irritation, scaling, pain, and blurred vision. Another type of inflammation called seborrheic blepharitis may present with greasy or dry scales on the eyelids and eyelashes. Contact dermatitis is yet another form of inflammation and is caused by an allergen or irritant coming into contact with the very sensitive skin that makes up the eyelid. In most cases, these inflammatory conditions can be treated by your PCP with simple eye washes and/or antibiotics. A hordeolum, more commonly known as a stye, usually appears as a red, swollen lump that is tender and tends to be recurrent. These can be treated with hot compresses at home or, if necessary, your PCP may determine the need for antibiotics.
Eyelids are made up of a complex set of tissues and they serve a very important purpose by lubricating and protecting the eye. In most cases your PCP can easily diagnose and treat your eyelids conditions, but in some cases referral to an ophthalmologist or more specialized physician may be required. In all cases it is wise to always discuss any concerns you may have or sudden changes that you notice with your PCP and allow him or her to perform a thorough examination.
Zucker, Jamie L. The eyelids: Some common disorders seen in everyday practice. Geriatrics. 2009 April; 64(4):14-19,28.
Thursday, July 9, 2009
Lantus and Cancer Risk: Should you be concerned?
From Geriatric Pharmacy intern Jessica Enogieru PharmD(c) University of Florida College of Pharmacy
Several studies looking at the association between insulin glargine (Lantus) and cancer risk have shown conflicting results. One study (Hemkens) compared the mitogenic (growth promoting) potencies of several insulin analogues (lispro, aspart, glargine) and human insulin. After adjusting for insulin dose, the study showed a significant, dose dependent increase in the risk of cancer in patients treated with insulin glargine versus human insulin. A second study showed an increasing cancer risk with only one type of cancer (breast cancer). The third study did not find a significant association between insulin glargine and cancer risk, but analysis performed in a subset of patients who received insulin glargine exclusively revealed an increase risk of all cancers and breast cancer. A fourth study found no association between increased cancer risk and insulin glargine. On the surface, these findings seem very alarming. But worried diabetic patients using insulin analogues like glargine should consider these three points.
First the study results are conflicting. In the study done by Hemkens et al in Germany, the unadjusted analysis showed a lower cancer incidence in glargine-treated patients while the adjusted data showed a dose dependent increase in cancer risk with glargine. Another study of 114,841 Swedish diabetic patients suggested an increased risk of breast cancer during exclusive treatment with insulin monotherapy. After adjustment for age and sex, use of insulin glargine doubled the risk of breast cancer. In contrast, a Scottish study of 50,000 patients treated with insulin found no increased cancer risk associated with use of insulin glargine. Overall, patients using insulin glargine had the same incidence of cancers as patients who did not receive glargine. Using 62,809 diabetic patients, British investigators found an increased risk of solid tumors in patients treated with insulin or insulin secretagogues compared with metformin. However, the addition of metformin to insulin eliminated most of the excess risk and analysis of cancer risk by type of insulin used showed no difference in patients treated with human insulin or insulin analogs.
Second all of the studies done were epidemiological studies; they retrospectively looked at large databases to find associations between types of cancer and types of insulin. However that type of study is much less robust than a randomized controlled trial (RCT), which is considered the gold standard. Epidemiological studies come with a lot of pitfalls and their results should be evaluated carefully.
Third experts in diabetes care believe the results are not strong enough to sanction a change in insulin treatment for diabetes. The American Diabetes Association, American Association for Clinical Endocrinologists, and European Association for the Study of Diabetes issued statements saying the evidence was insufficient to warrant changes in a diabetic patient's current insulin regimen. Furthermore, the authors of the studies agreed that their findings did not warrant changes to diabetic insulin regimens.
In essence, the moral of the story is that diabetics should continue to use insulin glargine and other insulin analogues. Until a substantial casual relationship between insulin glargine and cancer risk is found, the benefits of treatment outweigh the risks.
Several studies looking at the association between insulin glargine (Lantus) and cancer risk have shown conflicting results. One study (Hemkens) compared the mitogenic (growth promoting) potencies of several insulin analogues (lispro, aspart, glargine) and human insulin. After adjusting for insulin dose, the study showed a significant, dose dependent increase in the risk of cancer in patients treated with insulin glargine versus human insulin. A second study showed an increasing cancer risk with only one type of cancer (breast cancer). The third study did not find a significant association between insulin glargine and cancer risk, but analysis performed in a subset of patients who received insulin glargine exclusively revealed an increase risk of all cancers and breast cancer. A fourth study found no association between increased cancer risk and insulin glargine. On the surface, these findings seem very alarming. But worried diabetic patients using insulin analogues like glargine should consider these three points.
First the study results are conflicting. In the study done by Hemkens et al in Germany, the unadjusted analysis showed a lower cancer incidence in glargine-treated patients while the adjusted data showed a dose dependent increase in cancer risk with glargine. Another study of 114,841 Swedish diabetic patients suggested an increased risk of breast cancer during exclusive treatment with insulin monotherapy. After adjustment for age and sex, use of insulin glargine doubled the risk of breast cancer. In contrast, a Scottish study of 50,000 patients treated with insulin found no increased cancer risk associated with use of insulin glargine. Overall, patients using insulin glargine had the same incidence of cancers as patients who did not receive glargine. Using 62,809 diabetic patients, British investigators found an increased risk of solid tumors in patients treated with insulin or insulin secretagogues compared with metformin. However, the addition of metformin to insulin eliminated most of the excess risk and analysis of cancer risk by type of insulin used showed no difference in patients treated with human insulin or insulin analogs.
Second all of the studies done were epidemiological studies; they retrospectively looked at large databases to find associations between types of cancer and types of insulin. However that type of study is much less robust than a randomized controlled trial (RCT), which is considered the gold standard. Epidemiological studies come with a lot of pitfalls and their results should be evaluated carefully.
Third experts in diabetes care believe the results are not strong enough to sanction a change in insulin treatment for diabetes. The American Diabetes Association, American Association for Clinical Endocrinologists, and European Association for the Study of Diabetes issued statements saying the evidence was insufficient to warrant changes in a diabetic patient's current insulin regimen. Furthermore, the authors of the studies agreed that their findings did not warrant changes to diabetic insulin regimens.
In essence, the moral of the story is that diabetics should continue to use insulin glargine and other insulin analogues. Until a substantial casual relationship between insulin glargine and cancer risk is found, the benefits of treatment outweigh the risks.
Saturday, July 4, 2009
Preventing Acetaminophen Toxicity In The Elderly
From Geriatrics Pharmacy Intern: Seth Rana, PharmD (c) Palm Beach Atlantic University College of Pharmacy
Acetaminophen is a commonly used over-the-counter (OTC) medication popularly known as Tylenol. According to the Food and Drug Administration (FDA), acetaminophen has been a primary cause of 56,000 emergency room visits each year for liver toxicity. Acetaminophen is used as treatment for fever and minor aches and pains and American College of Rheumatology recommends it as the first-line treatment of pain due to osteoarthritis. Many physicians recommend acetaminophen for pain in the geriatric population because it is generally recognized as safe and its side effects are uncommon as compared to other OTC pain medications such as aspirin, ibuprofen, and naproxen. It is a common active ingredient in many combination OTC and prescription medications, thus making it easier for people to reach unintentional overdose. For this reason, FDA Advisory Committee panelists recommend lowering daily maximum dose to less than 4 grams.
Taking acetaminophen according to the label does not usually cause harm but it can have toxic outcomes on the liver when consumed in excess of 4 grams in 24 hours. Patients having more than 3 alcoholic drinks per day, those with liver disease, and those taking other medications which effect the liver may experience toxicity at an even lower amount of acetaminophen consumption. Some of the medications which may contain acetaminophen include: Excedrin Extra Strength, Nyquil Cold and Flu, Feverall, Midol Menstrual Complete, Alka Seltzer Plus Cold and Sinus, Coricidin, Fioricet, Ultracet, Vicodin, Darvocet, Percocet, Norco, and of course Tylenol. These medications contain various amounts of acetaminophen and are targeted for different uses. For example, someone may be taking Vicodin for knee pain and they may take Excedrin temporarily for headaches or they may take Nyquil for cold and flu. Only take one medication containing acetaminophen due to additive effects on the liver and always consult a physician or a local pharmacist before taking these medications. Acetaminophen is often abbreviated as APAP for N-acetyl-para-aminophenol and may show up as propoxyphene/APAP as a generic for Darvocet on the prescription vial. Travelers should watch for “paracetamol” as it is another generic name referring to acetaminophen outside of the United States.
It is important to always read and follow all of the directions on the label and not be influenced by various marketing approaches. It is not appropriate to consume more than the recommended dosage even if these pills are available in larger than 250 count bottles. Acetaminophen toxicity symptoms may be delayed and can take few days to appear and they are non-specific: nausea, vomiting, poor appetite, and abdominal pain. Immediate medical attention is recommended if acetaminophen toxicity is suspected. Speak to your senior care pharmacist for information regarding how long to wait between doses and how many doses you can take in one day. Acetaminophen has been used for many decades and with proper information and guidance everyone can use acetaminophen safely and effectively.
Acetaminophen is a commonly used over-the-counter (OTC) medication popularly known as Tylenol. According to the Food and Drug Administration (FDA), acetaminophen has been a primary cause of 56,000 emergency room visits each year for liver toxicity. Acetaminophen is used as treatment for fever and minor aches and pains and American College of Rheumatology recommends it as the first-line treatment of pain due to osteoarthritis. Many physicians recommend acetaminophen for pain in the geriatric population because it is generally recognized as safe and its side effects are uncommon as compared to other OTC pain medications such as aspirin, ibuprofen, and naproxen. It is a common active ingredient in many combination OTC and prescription medications, thus making it easier for people to reach unintentional overdose. For this reason, FDA Advisory Committee panelists recommend lowering daily maximum dose to less than 4 grams.
Taking acetaminophen according to the label does not usually cause harm but it can have toxic outcomes on the liver when consumed in excess of 4 grams in 24 hours. Patients having more than 3 alcoholic drinks per day, those with liver disease, and those taking other medications which effect the liver may experience toxicity at an even lower amount of acetaminophen consumption. Some of the medications which may contain acetaminophen include: Excedrin Extra Strength, Nyquil Cold and Flu, Feverall, Midol Menstrual Complete, Alka Seltzer Plus Cold and Sinus, Coricidin, Fioricet, Ultracet, Vicodin, Darvocet, Percocet, Norco, and of course Tylenol. These medications contain various amounts of acetaminophen and are targeted for different uses. For example, someone may be taking Vicodin for knee pain and they may take Excedrin temporarily for headaches or they may take Nyquil for cold and flu. Only take one medication containing acetaminophen due to additive effects on the liver and always consult a physician or a local pharmacist before taking these medications. Acetaminophen is often abbreviated as APAP for N-acetyl-para-aminophenol and may show up as propoxyphene/APAP as a generic for Darvocet on the prescription vial. Travelers should watch for “paracetamol” as it is another generic name referring to acetaminophen outside of the United States.
It is important to always read and follow all of the directions on the label and not be influenced by various marketing approaches. It is not appropriate to consume more than the recommended dosage even if these pills are available in larger than 250 count bottles. Acetaminophen toxicity symptoms may be delayed and can take few days to appear and they are non-specific: nausea, vomiting, poor appetite, and abdominal pain. Immediate medical attention is recommended if acetaminophen toxicity is suspected. Speak to your senior care pharmacist for information regarding how long to wait between doses and how many doses you can take in one day. Acetaminophen has been used for many decades and with proper information and guidance everyone can use acetaminophen safely and effectively.
Monday, June 29, 2009
Medication-Related Problems in Long-Term Care
From Geriatric Pharmacy Intern Angela M Antuna, PharmD(c) Palm Beach Atlantic University Lloyd L. Gregory School of Pharmacy
The American Society of Consultant Pharmacist (ASCP) and the American Medical Directors Association (AMDA) have teamed up to create a list of the top ten drug interactions in long-term care. Their purpose is to make all health professionals join forces to improve prescribing, administering, and monitoring of drug therapy in long-term care. The residents in long-term care facilities are usually on multiple drug regimens. This increases their chances for having a medication-related problem.
The most effective way to prevent a medication-related problem from occurring is by documenting the error. When a medication error is reported it educates others of such error. However, medication errors still occur regardless of the reporting systems. In addition, it is important for all health professionals to be educated on medication errors. Although this list is not all inclusive, it identifies the most commonly seen drug interactions in long-term care facilities.
List of Top Ten Drug Interactions in Long-Term Care
1. Warfarin — NSAIDs*
2. Warfarin — Sulfa drugs
3. Warfarin — Macrolides
4. Warfarin — Quinolones**
5. Warfarin — Phenytoin
6. ACE inhibitors — Potassium supplements
7. ACE inhibitors — Spironolactone
8. Digoxin — Amiodarone
9. Digoxin — Verapamil
10. Theophylline — Quinolones**
* NSAID class does not include COX-2 inhibitors
** Quinolones that interact include: ciprofloxacin, enoxacin, norfloxacin, and ofloxacin The Multidisciplinary Management Project (www.scoup.net/M3Project/topten/index.htm)
The American Society of Consultant Pharmacist (ASCP) and the American Medical Directors Association (AMDA) have teamed up to create a list of the top ten drug interactions in long-term care. Their purpose is to make all health professionals join forces to improve prescribing, administering, and monitoring of drug therapy in long-term care. The residents in long-term care facilities are usually on multiple drug regimens. This increases their chances for having a medication-related problem.
The most effective way to prevent a medication-related problem from occurring is by documenting the error. When a medication error is reported it educates others of such error. However, medication errors still occur regardless of the reporting systems. In addition, it is important for all health professionals to be educated on medication errors. Although this list is not all inclusive, it identifies the most commonly seen drug interactions in long-term care facilities.
List of Top Ten Drug Interactions in Long-Term Care
1. Warfarin — NSAIDs*
2. Warfarin — Sulfa drugs
3. Warfarin — Macrolides
4. Warfarin — Quinolones**
5. Warfarin — Phenytoin
6. ACE inhibitors — Potassium supplements
7. ACE inhibitors — Spironolactone
8. Digoxin — Amiodarone
9. Digoxin — Verapamil
10. Theophylline — Quinolones**
* NSAID class does not include COX-2 inhibitors
** Quinolones that interact include: ciprofloxacin, enoxacin, norfloxacin, and ofloxacin The Multidisciplinary Management Project (www.scoup.net/M3Project/topten/index.htm)
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