Skip to main content

Adverse drug reactions in elders: looking for flubs in all the wrong places

A great deal of energy – and money - has been spent on preventing adverse drug reactions in elders. Many of these efforts have had limited success. Taking the next step to limit the harmful impacts of adverse drug reactions (ADRs) requires a fresh approach, and should focus on monitoring adverse effects of drugs after they are prescribed rather than preventing problem drugs from being prescribed in the first place.


At first blush, this approach seems counter-intuitive – isn’t it better to prevent a problem rather than trying to catch it once it has already happened? Of course, the answer is yes, but primary prevention of ADRs is often difficult if not impossible. In large part, this is because most ADRs are not due to “bad” drugs, but are unfortunate complications of drugs that have a legitimate place in the therapeutic armamentarium. This was demonstrated in an important national study
that evaluated causes of adverse drug reactions in elders that led to emergency room visits. Less than 4% of these ADRs were attributable to drugs from the Beers criteria, a consensus list of drugs to avoid prescribing to elders. In contrast, almost one-third of all adverse events were due to warfarin and insulin, which each have clear appropriate uses in elders. In another landmark study, Gurwitz and colleagues found that more than half of preventable ADRs in community-dwelling elders were due to failures to appropriately monitor drugs, rather than errors at the time the drug was initially prescribed. For example, 36% of ADRs were caused by a clinician not obtaining follow-up lab tests or inquiring about drug-related side effects. Another 37% of ADRs were caused by a clinician obtaining this information but failing to make an appropriate intervention (e.g., the treating physician did not stop or lower the dose of a drug after receiving lab test results that showed drug toxicity).

A focus on monitoring isn’t perfect, since some elders are going to experience serious adverse events that cannot be reasonably anticipated or prevented. Nonetheless, there is still a lot that we can do to help older patients. Many potential ADRs can be identified before they cause clinical harm to a patient. For example, close home monitoring of blood glucose can identify patients at risk of hypoglycemic episodes before such an episode happens. Other ADRs can be identified and mitigated before they cause substantial harm (a process termed “amelioration” in the ADR literature). For example, early detection of muscle aches and elevated creatinine kinase levels in a patient taking a statin can allow a clinician to stop the drug before the symptoms progress to full-blown rhabdomyolysis.

These monitoring interventions are hardly rocket science, and often are done in clinical practice. However, the lack of systems to support monitoring programs such as these often lead to patients falling through the cracks. The energy and resources of patient safety and ADR prevention programs can be mobilized to help develop these systems. If we are really committed to reducing ADRs and promoting patient safety, targeted interventions to improve monitoring of high-risk medications and conditions are likely to yield greater benefits than the current emphasis on encouraging doctors to avoid prescribing drugs on “drugs-to-avoid” lists.

Comments

Patrice Villars said…
Very interesting post. In GNP school, we reviewed the meds to avoid in the elderly but not their actual relevance in a clinical setting. This is not to say that prescribing meds in the elderly is not both an art and a science, but you make an excellent point to again remember to look at the bigger picture.
ken covinsky said…
This is a really interesting way to think about this problem. This way of thinking about the problem makes a lot of clinical sense--and is more sound than just deeming meds good meds and bad meds. It is kind of interesting that while the approach you outline seems so obvious, there are few systematic approaches in place to do this type of monitoring. This is definitely an idea worth developing further. TP!
Alex Smith said…
Agree this is a more thoughtful approach to these issues than blacklisting medications. Relates well to Partrice's post about hospice care of geriatric patients. In end-of-life settings with older patients, I am concerned that there is not enough monitoring of the drugs that are prescribed in hospice and palliative care, and too many adverse side effects are ascribed to the "dying process."
Anonymous said…
This comment has been removed by a blog administrator.

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …