Jim Kling

May 20, 2013

DALLAS, Texas — An increasing number of senior citizens are being harmed by their prescription medications, investigators warned here at the American Geriatrics Society 2013 Annual Scientific Meeting.

More than one third of older adults were taking at least 1 guideline-recommended medication that had the potential to worsen another chronic condition, presenter Jonathan Lorgunpai, a medical student from Yale University in New Haven, Connecticut, told Medscape Medical News.

"Right now, the guidelines are made for specific conditions, but only 19% of older adults have 1 chronic condition at a time. The majority of them will have multiple chronic conditions," he noted. "Clinicians should weigh the effects of medications on each of the patient's conditions, not just the condition for which the medications are recommended."

Lorgunpai and his team sought to determine the prevalence of therapeutic competition among the most common pairs of coexisting chronic conditions. They then examined medicine use in patients with and without comorbid conditions that could be exacerbated by a competing therapy.

The researchers identified close to 6850 subjects from the Medicare Current Beneficiary Survey cohort, which collects medication data from in-person interviews.

They reviewed Medicare claims to identify the 13 chronic conditions that have an incidence of at least 5% and are treated with oral or inhaled prescription medication.

The researchers then looked at national disease guidelines and identified the classes of drug recommended for each condition, focusing on those used by at least 2% of participants.

Of the 26 medication classes that fit the criteria, 84.6% had the potential to adversely affect another of the chronic conditions being studied. Of the 70 most common pairs of chronic conditions, 50% had at least 1 therapeutic competition.

Inappropriate Prescriptions

Of the 6844 study participants, 35.6% were using at least 1 medication that could have worsened a coexisting condition.

For one set of competing conditions — hypertension and chronic obstructive pulmonary disease (COPD) — 6% of patients were taking nonselective beta blockers, 9% were taking alpha beta blockers, and 38% were taking beta agonists.

Beta blockers are prescribed for hypertension, but they can worsen COPD by causing bronchial constriction. Although beta agonists are indicated for COPD, they can exacerbate hypertension. "That's 1 of the 35 examples of therapeutic competition that we found," said Lorgunpai.

The researchers suggest that the net benefits and harms of medications across conditions should be studied, and clinical guideline developers should consider commonly coexisting conditions when making recommendations.

In the second study, presented by Nerissa Duchin, BS, from the University of Massachusetts Medical School in Worcester, investigators looked at the 2012 Beers criteria for potentially inappropriate medication use in older adults.

This evidence-based guideline lists 53 medications or medication classes that should be avoided in older adults. The degree to which drugs in this list are associated with adverse events after hospital discharge has not been determined.

Incomplete Drug List

Duchin and colleagues studied 1000 consecutive hospital discharges of senior health-plan members at a large multispecialty group practice.

Comprehensive medical record reviews identified 245 adverse drug events. Beers criteria medications were involved in 18.4% of adverse events (95% confidence interval [CI], 13.6% - 23.3%).

Most adverse drug events involved medications not found on the Beers list (81.6%; 95% CI, 76.8% - 86.5%).

This study confirms "that we need to be vigilant across a greater spectrum of medicine classes than just the Beers list," session moderator Cathleen Colón-Emeric, MD, from the Duke University School of Medicine in Durham, North Carolina, told Medscape Medical News.

"Cardiovascular medications are of particular concern," she said. "We need to monitor our patients carefully when we're starting them or changing the medication."

Dr. Colón-Emeric added that the therapeutic competition study highlights the fact that "the potential drug–disease interactions that geriatricians are already concerned with are probably more prevalent that we expected."

"The crucial next step is figuring out which of those are clinically the most significant so that we can focus on interventions, such as electronic medical record reminders, to help clinicians avoid those problems," she said.

The therapeutic competition trial was supported by National Institute on Aging grants, the Yale Pepper Center, and the Yale School of Medicine Medical Student Research Fellowship. The Beers list study was supported by American Federation for Aging Research, Agency for Healthcare Research and Quality. Mr. Lorgunpai, Ms. Duchin, and Dr. Colón-Emeric have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2013 Annual Scientific Meeting: Abstracts P34 and P37. Presented May 5, 2013.

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