Perspectives on prescribing in nursing homes in Helsinki

Prescribing for older patients is challenging. The prevalence of diseases increases with advancing age and causes extensive drug use. Impairments in cognitive, sensory, social and physical functioning, multimorbidity and comorbidities, as well as age-related changes in pharmacokinetics and pharmacodynamics all add to the complexity of prescribing. This study is a cross-sectional assessment of all long-term residents aged ≥ 65 years in all nursing homes in Helsinki, Finland. The residents’ health status was assessed and data on their demographic factors, health and medications were collected from their medical records in February 2003. This study assesses some essential issues in prescribing for older people: psychotropic drugs (Paper I), laxatives (Paper II), vitamin D and calcium supplements (Paper III), potentially inappropriate drugs for older adults (PIDs) and drug-drug interactions (DDIs)(Paper IV), as well as prescribing in public and private nursing homes. A resident was classified as a medication user if his or her medication record indicated a regular sequence for its dosage. Others were classified as non-users. Mini Nutritional Assessment (MNA) was used to assess residents’ nutritional status, Beers 2003 criteria to assess the use of PIDs, and the Swedish, Finnish, INteraction X-referencing database (SFINX) to evaluate their exposure to DDIs. Of all nursing home residents in Helsinki, 82% (n=1987) participated in studies I, II, and IV and 87% (n=2114) participated in the study III. The residents’ mean age was 84 years, 81% were female, and 70% were diagnosed with dementia. The mean number of drugs was 7.9 per resident; 40% of the residents used ≥ 9 drugs per day, and were thus exposed to polypharmacy. Eighty percent of the residents received psychotropics; 43% received antipsychotics, and 45% used antidepressants. Anxiolytics were prescribed to 26%, and hypnotics to 28% of the residents. Of those residents diagnosed with dementia, 11% received antidementia drugs. Fifty five percent of the residents used laxatives regularly. In multivariate analysis, those factors associated with regular laxative use were advanced age, immobility, poor nutritional status, chewing problems, Parkinson’s disease, and a high number of drugs. Eating snacks between meals was associated with lower risk for laxative use. Of all participants, 33% received vitamin D supplementation, 28% received calcium supplementation, and 20% received both vitamin D and calcium. The dosage of vitamin D was rather low: 21% received vitamin D 400 IU (10 µg) or more, and only 4% received 800 IU (20 µg) or more. In multivariate analysis, residents who received vitamin D supplementation enjoyed better nutritional status, ate snacks between meals, suffered no constipation, and received regular weight monitoring. Those residents receiving PIDs (34% of all residents) more often used psychotropic medication and were more often exposed to polypharmacy than residents receiving no PIDs. Residents receiving PIDs were less often diagnosed with dementia than were residents receiving no PIDs. The three most prevalent PIDs were short-acting benzodiazepine in greater dosages than recommended, hydroxyzine, and nitrofurantoin. These three drugs accounted for nearly 77% of all PID use. Of all residents, less than 5% were susceptible to a clinically significant DDI. The most common DDIs were related to the use of potassium-sparing diuretics, carbamazepine, and codeine. Residents exposed to potential DDIs were younger, had more often suffered a previous stroke, more often used psychotropics, and were more often exposed to PIDs and polypharmacy than were residents not exposed to DDIs. Residents in private nursing homes were less often exposed to polypharmacy than were residents in public nursing homes. Long-term residents in nursing homes in Helsinki use, on average, nearly eight drugs daily. The use of psychotropic drugs in our study was notably more common than in international studies. The prevalence of laxatives equaled other prior international studies. Regardless of the known benefit and recommendation of vitamin D supplementation for elderly residing mostly indoors, the proportion of nursing home residents receiving vitamin D and calcium was surprisingly low. The use of PIDs was common among nursing home residents. PIDs increased the likelihood of DDIs. However, DDIs did not seem a major concern among the nursing home population. Monitoring PIDs and potential drug interactions could improve the quality of prescribing.

Medetomidiinin glukuronidaation inhibitio

Lääkeainemetabolialla tarkoitetaan entsymaattisia reaktioita, jotka muuttavat lääkeaineita paremmin elimistöstä poistuvaan muotoon. Lääkeaineet voivat vaikuttaa toistensa metaboliaan inhiboimalla tai indusoimalla metaboloivia entsyymejä. Tällaisten interaktioiden seurauksena lääkeaineen pitoisuus elimistössä voi kasvaa jopa toksiseksi tai vähentyä merkittävästi. Tämä on erityisesti ongelmana silloin, kun käytössä on useita lääkkeitä samanaikaisesti. Lääketutkimuksessa onkin keskitytty tällaisten interaktioiden ennustamiseen ja niitä yritetään välttää tai ainakin vähentää. Työssä tutkittiin medetomidiinia, jonka on äskettäin havaittu metaboloituvan UDP-glukuronosyylitransferaasien (UGT) välityksellä. Työn tarkoituksena oli löytää medetomidiinin glukuronidaatiota inhiboivia yhdisteitä. Lisäksi haluttiin selvittää mahdollisen inhibition mekanismeja. On yleistä tutkia tietyn entsyymin substraatin interaktioita muiden saman perheen entsyymien kanssa. On kuitenkin harvinaisempaa tutkia tällaisia interaktioita kahden eri entsyymiperheen välillä. Tässä työssä tutkittiin inhiboivatko mahdolliset sytokromi P450 -entsyymiä (CYP) inhiboivat yhdisteet myös medetomidiinia glukuronoivia UDP-glukuronosyylitransferaaseja. Glukuronidaation inhibitiota tutkittiin HPLC-menetelmällä, joka on kehitetty aiemmin medetomidiinin glukuronidaation tutkimiseen. Aluksi glukuronidaatiota tutkittiin ilman inhibiittoreita. Tämän jälkeen tutkittiin kolmen mahdollisen inhibiittoriyhdisteen vaikutuksia medetomidiinin glukuronidaatioon ja tuloksia verrattiin ilman inhibiittoria saatuihin tuloksiin. Kolmen tutkitun yhdisteen havaittiin inhiboivan medetomidiinin glukuronidaatiota. Tutkimuksessa havaittiin myös mielenkiintoinen ilmiö, jossa inhibiittoriyhdisteen sitoutuminen aiheutti entsyymikineettisiä muutoksia UDP-glukuronosyylitransferaasin toiminnassa. On mielenkiintoista, että samat yhdisteet inhiboivat sekä CYP- että UGT-metaboliaa. Tulosten perusteella voidaan päätellä, että jos CYP ja UGT metaboloivat samaa yhdistettä, on mahdollista että yhdisteen rakenteelliset analogit aiheuttavat interaktioita molempien entsyymien kanssa. Uusia lääkeaineita kehitettäessä onkin otettava huomioon yleisesti tunnettujen CYP-entsyymien lisäksi myös UGT:t ja niiden mahdolliset yhteisvaikutukset.