Prevalence of drug-herb and drug-supplement interactions in older adults : A cross-sectional survey

© British Journal of General PracticeBackground Polypharmacy is common among older adults, with increasing numbers also using prescription drugs with herbal medicinal products (HMPs) and dietary supplements. There is no reliable evidence from the UK on concurrent use of HMPs and dietary supplements with prescription drugs in older adults. Aim To establish prevalence of concurrent prescription drugs, HMPs, and dietary supplements among UK community-dwelling older adults and identify potential interactions. Design and setting Cross-sectional survey of older adults registered at two general practices in South East England. Method A questionnaire asking about prescription medications, HMPs, and sociodemographic information was posted to 400 older adults aged ≥65 years, identified as taking ≥1 prescription drug. Results In total 155 questionnaires were returned (response rate = 38.8%) and the prevalence of concurrent HMPs and dietary supplements with prescriptions was 33.6%. Females were more likely than males to be concurrent users (43.4% versus 22.5%; P = 0.009). The number of HMPs and dietary supplements ranged from 1 to 8, (mean = 3, median = 1; standard deviation = 1.65). The majority of concurrent users (78.0%) used dietary supplements with prescription drugs. The most commonly used dietary supplements were cod liver oil, glucosamine, multivitamins, and Vitamin D. Others (20.0%) used only HMPs with prescription drugs. Common HMPs were evening primrose oil, valerian, and Nytol Herbal® (a combination of hops, gentian, and passion flower). Sixteen participants (32.6%) were at risk of potential adverse drug interactions. Conclusion GPs should routinely ask questions regarding herbal and supplement use, to identify and manage older adults at potential risk of adverse drug interactions.Peer reviewe

Delineating the Role of Various Factors in Renal Disposition of Digoxin through Application of Physiologically Based Kidney Model to Renal Impairment Populations

Development of sub-models of organs within physiologically-based pharmacokinetic (PBPK) principles and beyond simple perfusion limitations may be challenging because of underdeveloped in vitro-in vivo extrapolation approaches or lack of suitable clinical data for model refinement. However, the advantage of such models in predicting clinical observations in divergent patient groups is now commonly acknowledged. Mechanistic understanding of altered renal secretion in renal impairment is one area that may benefit from such models, despite knowledge gaps in renal pathophysiology (Rowland Yeo et al., 2011; Sayama et al., 2014). In the current study a PBPK kidney model was developed for digoxin, accounting for the roles of organic anion transporting peptide 4C1 (OATP4C1) and P-glycoprotein (P-gp) in its tubular secretion, with the aim to investigate the impact of age and renal impairment (moderate to severe) on renal drug disposition. Initial PBPK simulations based on changes in glomerular filtration rate (GFR) underestimated the observed reduction in digoxin renal excretion clearance (CLR) in subjects with moderately impaired renal function relative to healthy. Reduction in either proximal tubule cell number or the OATP4C1 abundance in the mechanistic kidney model successfully predicted 59% decrease in digoxin CLR, in particular when these changes were proportional to reduction in GFR. In contrast, predicted proximal tubule concentration of digoxin was only sensitive to changes in the transporter expression/ million proximal tubule cells. Based on the mechanistic modelling, reduced proximal tubule cellularity and OATP4C1 abundance, and inhibition of OATP4C1-mediated transport, are proposed as possible causes of reduced digoxin renal secretion in renally impaired patients

Concurrent use of prescription drugs and herbal medicinal products in older adults: A systematic review

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.The use of herbal medicinal products (HMPs) is common among older adults. However, little is known about concurrent use with prescription drugs as well as the potential interactions associated with such combinations. Objective Identify and evaluate the literature on concurrent prescription and HMPs use among older adults to assess prevalence, patterns, potential interactions and factors associated with this use. Methods Systematic searches in MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, Web of Science and Cochrane from inception to May 2017 for studies reporting concurrent use of prescription medicines with HMPs in adults (≥65 years). Quality was assessed using the Joanna Briggs Institute checklists. The Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) three stage approach to mixed method research was used to synthesise data. Results Twenty-two studies were included. A definition of HMPs or what was considered HMP was frequently missing. Prevalence of concurrent use by older adults varied widely between 5.3% and 88.3%. Prescription medicines most combined with HMPs were antihypertensive drugs, beta blockers, diuretics, antihyperlipidemic agents, anticoagulants, analgesics, antihistamines, antidiabetics, antidepressants and statins. The HMPs most frequently used were: ginkgo, garlic, ginseng, St John’s wort, Echinacea, saw palmetto, evening primrose oil and ginger. Potential risks of bleeding due to use of ginkgo, garlic or ginseng with aspirin or warfarin was the most reported herb-drug interaction. Some data suggests being female, a lower household income and less than high school education were associated with concurrent use. Conclusion Prevalence of concurrent prescription drugs and HMPs use among older adults is substantial and potential interactions have been reported. Knowledge of the extent and manner in which older adults combine prescription drugs will aid healthcare professionals can appropriately identify and manage patients at risk.Peer reviewedFinal Published versio

Co-Use of Drugs and Herbal Remedies in General Practice and In Vitro Inhibition of CYP3A4, CYP2D6 and P-Glycoprotein by the Common Herb Aloe Vera.

There is a widespread use of complementary and alternative medicine (CAM) and herbal remedies in particular in different patients groups, but very few are published about co-use among patients in general practice (GP) and herb-drug combinations at risk. Co-use of herbal remedies and drugs can result in none or server adverse effects. Of this reason, knowledge about the GP patients co-use and research on mechanisms of such interactions is needed. The aims of this thesis were divided; 1) To register the co-use of drugs and herbs among GP patients in Norway and the patients communication of such use with health care professionals; 2) To evaluate the interaction potential of one of the commonly used herbs in GPs office, Aloe vera (Aloe barbadensis), on the P-glycoprotein (P-gp) and the cytochrome P-450 (CYP) enzymes, CYP3A4 and CYP2D6. Among the 381 patients answering the questionnaire in the GP office, 44% used herbs. The most common herbs were bilberry (41%), green tea (31%), garlic (27%), Aloe vera (26%) and purple coneflower (18%). Almost every third (29%) patient co-used drugs and herbs. They combined 255 different drug-groups and herbs whereas 18 of these were considered to have a clinically relevant interaction potential. Close to 40% of patients on anticoagulants co-used herbs, reporting garlic and bilberry most frequently. Co-users had significantly (p<0.05) increased odds to be female, elderly, use herbs to treat an illness, use two or more herbs and experienced adverse effects of herbal use compared to other GP patients. Co-use was also associated with use of analgesics or dermatological drugs. Only 23% of the GP patients discussed their herb use with a health care professional. Even though Aloe vera is a well-known, old medicine plant used both in cosmetics and as therapeutics, few or no earlier systematic research on its interaction potential has been investigated when co-used with drugs in vitro. Overall three enzymes accounts for the majority of the pharmacokinetics on the drugs in the market: the efflux-protein P-gp transporting the medicinal drug out of the cell and CYP3A4 and CYP2D6, metabolizing the medicinal drugs to less active components. These enzymes can be influenced by other substances (inhibited or induced) and is therefore important regarding herb-drug interactions. Aloe vera juice (AVJ) did not inhibit P-gp mediated digoxin efflux for the investigated AVJ concentrations in vitro. However, it was shown that both AVJ (10.0 mg/ml) and digoxin (≥3µM) was cytotoxic in large concentrations. Two different AVJs were used in the CYP3A4 and CYP2D6 assays. Both juices inhibited CYP3A4 and CYP2D6 irreversible in vitro, having significant different IC50 values. This can come from different concentrations of active components in the juices. Both IC50 values seems, however, to be too high to be clinical relevant alone. Precautions should although, be made with excessive consumption of AVJ, with poor CYP2D6 activity ("poor metabolisers") or with use of drugs having a narrow therapeutic window. It can be concluded that GP patients co-using drugs and herbs and that this use can give clinical relevant interactions (e.g. excessive haemorrhage when co-using garlic and warfarin). Elderly patients are most vulnerable for co-use. One of the common used herbs among GP patients, Aloe vera, was investigated for in vitro pharmacokinetic interactions on the enzymes P-gp, CYP3A4, CYP2D6. Although it was concluded with low possibility of clinical relevant pharmacokinetic interactions co-using Aloe vera and drugs, patients with poor CYP2D6 activity might risk interactions when co-using large quantities of Aloe vera with conventional drugs which is metabolized of CYP2D6 (e.g. codeine). Clinical in vivo studies are needed to reveal any interactions in humans for Aloe vera and other herbs at risk of herb-drug interactions. Until then, the GPs and other health care professionals are advised to ask all patients about herbal use

Den kompetente klasseleder? : En studie knyttet til ungdomsskolelærerens egenvurderte kompetanse innen sentrale områder i klasseledelse.

Sammendrag Tittel: Den kompetente klasseleder? En studie knyttet til ungdomskolelærerens egenvurderte kompetanse innen sentrale områder i klasseledelse. Bakgrunn og formål: Forskning (Nordenbo m.fl.2008, Hattie 2009, Nordahl, Maursethagen & Kolstø, 2009) viser at læreren er en sentral faktor og har stor betydning for læringsmiljø og alle elevers læringsutbytte. Stortingsmelding nr. 22, har et spesielt fokus på ungdomsskolen. Klasseledelse trekkes i denne meldingen fram som et sentralt punkt der en ser behov for kompetanseheving på ungdomstrinnet. I vår undersøkelse er formålet å finne ut hvordan lærere på ungdomsskolen vurderer sin kompetanse innfor sentrale områder i klasseledelse. Dette er interessant for oss med tanke på satsingen myndighetene har på klasseledelse. Problemstilling: ”I hvilken grad vurderer lærere på ungdomsskoletrinnet egen kompetanse innenfor klasseledelse?” Problemstillingen besvares gjennom følgende underproblemstillinger: 1. Hvordan vurderer lærere egen kompetanse innenfor utvalgte områder i klasseledelse? 2. Hvilken sammenheng er det mellom kompetansen de vurderer å ha og opplevd mestring i klasseledelse? 3. Hvilken sammenheng er det mellom vurdert kompetanse i klasseledelse og hvordan lærere opplever å mestre både forebygging og mestring av problematferd? 4. Hvilken sammenheng er det mellom antall år i skolen og egen vurdering av kompetanse i klasseledelse? Metode: For å besvare oppgavens problemstilling har vi benyttet et selvrapporterende Survey-design. Spørreskjema med faste svaralternativer er utgangspunktet for datainnsamlingen. Utvalget består av 189 informanter fra 7 ulike ungdomsskoler. Svarprosenten er på 59,2 %. Spørreskjemaet har tatt utgangspunktet i sentrale områder innefor proaktiv klasseledelse som kommunikasjon, relasjon, rutiner, regelledelse og beskjeder. I tilegg har vi i slutten av spørreskjemaet formulert noen overordende spørsmål knyttet til lærers vurdering av egen mestring i klasseledelse. Dataanalyse: I behandling og analyse av datamaterialet har vi benyttet Statistical Packages for Social Sciences (SPSS 19.0). I analysen har vi anvendt hovedsakelig frekvenstabeller, bivariate korrelasjonsanalyser og Cronbachs Alpha. Resultater og konklusjoner: Undersøkelsen viser at lærerne i ungdomsskolen vurderer sin kompetanse i klasseledelse jevnt over i høy grad. Det er få variasjoner å spore innenfor de målte områdene som vi har definert innenfor klasseledelse; kommunikasjon, relasjon, rutiner, regelledelse og beskjeder. I tilegg til å ha spørsmål innenfor disse områdene hadde vi noen spørsmål generelt på slutten som tar opp opplevd mestring i forhold til å opprettholde arbeidsro, opplevd mestring i forhold til forebygging og håndtering av problematferd. Det eneste området som tenderer til å bli vurdert lavere i vår undersøkelse er kompetanse innenfor rutiner. Her finner vi litt lave resultater når det gjelder å presisere mål og læringsaktivitet, evaluering av timen sammen med elevene samt å repetere klasseregler. Vi ser også enkeltspørsmål innenfor regelledelse som tar for seg informasjon og gjennomføring av konsekvenser, er lavt vurdert kompetanse hos ungdomsskolelærerne. I tillegg er spørsmålet under området beskjeder som går på å lære elevene å følge en beskjed gjennom rollespill, et spørsmål som blir helt klart vurdert lavest i vår undersøkelse. Resultatet i vår undersøkelse indikerer at lærerne som har deltatt i vår undersøkelse kanskje ikke har behov for den kompetansehevingen slik det blir antydet i Stortingsmelding nr. 22. Resultatene i vår undersøkelsen er ikke i samsvar med nasjonale føringer som omhandler behovet for kompetanseheving innen klasseledelse. Oppsummert kan vi si at mulige grunner til at ungdomsskolelærerne vurderer seg generelt høyt i klasseledelse, kan være at de innehar generelt god kompetanse. En annen mulig årsak kan være manglede begrepsforståelse i forhold til det faglige innholdet vi legger til grunn. Vi er likevel overrasket over at spørsmål som tar for seg didaktiske elementer som presisering av mål og evaluering, kommer ut med relativt lave resultater i sammenligning med øvrige områder de har vurdert sin kompetanse i forhold til

The co-use of conventional drugs and herbs among patients in Norwegian general practice: a cross-sectional study

Background Different patient groups are known to use herbal remedies and conventional drugs concomitantly (co-use). This poses a potential risk of herb-drug interaction through altering the drug’s pharmacokinetics or pharmacodynamics. Little is known about co-use among patients in general practice. The primary aim of this study was to compare patients in general practice that co-use herbal remedies and conventional drugs with those who do not. The secondary aim was to register the herb-drug combinations with potential clinical relevant interactions among the co-users. Method A questionnaire based cross-sectional study conducted in the autumn 2011 in a general practice office with four general practitioners (GPs) and one intern in Western Norway. Adults >18 years who came for an office visit were invited. The questionnaire asked about demographics, herbal use, conventional drug use and communication about herbal use. Multivariable logistic regression was used to compare co-users to the other patients. Results Of the 381 patients who completed the questionnaire, the prevalence of herbal use was 44%, with bilberry (41%), green tea (31%), garlic (27%), Aloe vera (26%) and echinacea (18%) as the most frequently used. Among those using conventional drugs regularly, 108 (45%) co-used herbs. Close to 40% of patients on anticoagulants co-used herbs, with garlic and bilberry as the most frequent herbs. Compared to all other patients, co-users had significantly (p < 0.05) increased odds to be female (adjOR 2.0), age above 70 years (adjOR 3.3), use herbs to treat an illness (adjOR 4.2), use two or more herbs (polyherbacy, adjOR 12.1) and having experienced adverse effects of herbal use (adjOR 37.5). Co-use was also associated with use of analgesics or dermatological drugs (adjOR 5.1 and 7.9 respectively). Three out of four patients did not discuss herbal use with any health care professional. Conclusion A sizable proportion of the GP patients co-used herbs with conventional drugs, also combinations with reported interaction potential or additive effects like anticoagulants and garlic. The low disclosure of herbal use to their GP, polyherbacy and the risk of interactions in vulnerable groups like elderly and chronically ill patients, warrant increased awareness among GPs

The co-use of conventional drugs and herbs among patients in Norwegian general practice: a cross-sectional study

Background Different patient groups are known to use herbal remedies and conventional drugs concomitantly (co-use). This poses a potential risk of herb-drug interaction through altering the drug’s pharmacokinetics or pharmacodynamics. Little is known about co-use among patients in general practice. The primary aim of this study was to compare patients in general practice that co-use herbal remedies and conventional drugs with those who do not. The secondary aim was to register the herb-drug combinations with potential clinical relevant interactions among the co-users. Method A questionnaire based cross-sectional study conducted in the autumn 2011 in a general practice office with four general practitioners (GPs) and one intern in Western Norway. Adults >18 years who came for an office visit were invited. The questionnaire asked about demographics, herbal use, conventional drug use and communication about herbal use. Multivariable logistic regression was used to compare co-users to the other patients. Results Of the 381 patients who completed the questionnaire, the prevalence of herbal use was 44%, with bilberry (41%), green tea (31%), garlic (27%), Aloe vera (26%) and echinacea (18%) as the most frequently used. Among those using conventional drugs regularly, 108 (45%) co-used herbs. Close to 40% of patients on anticoagulants co-used herbs, with garlic and bilberry as the most frequent herbs. Compared to all other patients, co-users had significantly (p < 0.05) increased odds to be female (adjOR 2.0), age above 70 years (adjOR 3.3), use herbs to treat an illness (adjOR 4.2), use two or more herbs (polyherbacy, adjOR 12.1) and having experienced adverse effects of herbal use (adjOR 37.5). Co-use was also associated with use of analgesics or dermatological drugs (adjOR 5.1 and 7.9 respectively). Three out of four patients did not discuss herbal use with any health care professional. Conclusion A sizable proportion of the GP patients co-used herbs with conventional drugs, also combinations with reported interaction potential or additive effects like anticoagulants and garlic. The low disclosure of herbal use to their GP, polyherbacy and the risk of interactions in vulnerable groups like elderly and chronically ill patients, warrant increased awareness among GPs

Excellent PROM results after fast-track hip and knee arthroplasty with no postoperative restrictions: a cohort study validation of fast-track surgery without postoperative restrictions

Background Fast-track hip and knee arthroplasty (HA and KA) has been increasingly common over the last decade. In the same time period, there was a strong trend toward less restrictive mobilization. However, few reports have been published on combining these novel programs while measuring the postoperative results by patient-reported outcome measures (PROMs). Descriptions of fast-track surgery programs and their results are warranted. Methods The aim of this retrospective cohort study was to examine if it is possible to achieve excellent PROM results for hip and knee arthroplasty patients in a fast-track pathway without postoperative restrictions. During 2014–2017, the stepwise introduction of a PROM program was implemented at Stavanger University Hospital for all scheduled HA and KA patients, with preoperative assessments and postoperative follow-ups at the outpatient clinic. Standardized information with a focus on early mobilization and no postoperative restrictions was also initiated for the same patients. The generic EuroQol questionnaire (EQ-5D) and either the Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS or KOOS) were used. Results PROM response rates varied from 80 to 99%. The median (interquartile range) change from preoperative to one-year postoperative results were as follows for HA and KA patients, respectively: pain, 55 (43–68) and 47 (31–61); other symptoms, 50 (40–65) and 36 (19–50); function in daily living, 54 (41–65) and 44 (31–55); function in sports and recreation, 56 (38–75) and 40 (15–64); joint-related quality of life, 69 (50–81) and 56 (38–75). The length of stay (LOS) was reduced by 1.9 days (mean), corresponding to a 40% reduction for HA patients and a 37% reduction for KA patients.publishedVersio

Improving the quality of the fracture liaison service through the implementation of a structured health record

Objective According to the best practice framework for secondary fracture prevention, all patients aged ≥50 years with a fracture should be assessed for osteoporosis within the fracture liaison service (FLS). The framework includes an FLS quality registry database to ensure quality. The input of data into our FLS registry was time-consuming and required entering data twice: into both the journal record and the registry. A ‘3-in-1’ solution was required: (1) developing a structured health record (SHR) to provide decision-support to FLS nurses during patient consultations; (2) making a structured journal record from the SHR and (3) exporting data to the quality registry database. The SHR needed to be web based, secure and available for use all over the world. Design One provider at Stavanger University Hospital met all the criteria for further development of the record (CheckWare). An interdisciplinary working group was established, following the Plan–Do–Study–Act working model. Depending on the answers given, the FLS nurses were provided decision-making support. A significant loss of height (≥4 cm) was highlighted as one of the process quality indicators. All clinically relevant data were summarised in a report, which was exported to the health record software. Data were exported to the FLS quality registry. Results All fracture patients in need of a dual-energy X-ray absorptiometry scan received an appointment at the FLS outpatient clinic and 96% attended. The minimum standard was met for the three quality indicators 1–3). In particular, the use of SHRs increased the number of patients investigated for vertebral fractures with a height loss ≥4 cm from 67% to 93%. Conclusion The SHR was successful in regard to the ‘3-in-1’ solution: providing decision support to FLS nurses, developing structured journal records and exporting data to the FLS quality registry. After implementation, all FLS registry quality indicators improved.publishedVersio