Introduction: Proportion of seniors in the world population is growing and substantial attention is given to population aging worldwide. Geriatric patients present very heterogenous group of patients with high interindividual differences. With increasing age number of chronic and degenerative disorders increases, drug consumption raises and consequently also polypharmacy. The more medications a senior consume, the higher probability of prescription of high-risk medications he/she has. With the aim to rationalize drug prescribing in geriatric patients, significant number of explicit criteria of medications/medication procedures potentially inappropriate in older age has been published. The aim of this diploma thesis was to evaluate prevalence of potentially inappropriate prescribing in geriatric population in studies published between 1991 and 2015 years and to further evaluate the most frequently prescribed potentially inappropriate medications (PIMs) in these studies. Methods: Detailed literature search has been conducted with the use of PubMed and Web of Science databases. Studies dealing with potentially inappropriate prescribing that have been published from 1st January 1991 to 31st December 2015 were included. Data from scientific articles were summarized in the first part of the diploma...

Introduction: Older persons represent a quickly growing segment of the population worldwide and more vulnerable population to various adverse drug reactions and adverse outcomes. Many explicit criteria of potentially inappropriate medications (PIMs) have been developed in different countries in order to improve the quality and safety of geriatric prescribing and to reduce the risk of drugs in older adults. The aim of this diploma thesis was to summarize (using narrative literature review) the negative outcomes of potentially inappropriate medications documented in pharmacoepidemological studies published by 2016 year. The outputs of diploma thesis create a part of the effort of the research subgroup "Aging and Changes in the Therapeutic Value of Medications in the Aged" and EU COST Action initiative IS1402 (2015-2018). Methods: The literature review using PubMed and Web of Science datasets during the period 10/2015 - 1/2017 was conducted. 421 studies were identified during the primary literature search and after thorough consideration of abstracts 67 (16%) of studies were selected for works on summary tables (354 of studies were excluded because in these studies only prevalence of PIMs, no negative outcomes were documented, or PIMs were defined based on implicit criteria or full text of articles...

Orientador: Paulo José Fortes Villas Boas / Resumo: Introdução: A prescrição de Medicamentos Potencialmente Inapropriados (MPIs) possuem aspectos relevantes em idosos juntamente com a prevalência de automedicação, interações medicamentosas, reações adversas e polifarmácia, sendo, portanto, necessário utilizar medidas que proporcionem o uso racional destes medicamentos nessa população, além de elaborar medidas que possibilitem a diminuição de custos relacionados à essa prática para as Instituições de Saúde. Objetivo: Analisar os custos diretos das prescrições medicamentosas de idosos internados em enfermaria de Clínica Médica e comparar os custos das prescrições com e sem medicamentos potencialmente inapropriados (MPI) para idosos. Metodologia: Estudo observacional retrospectivo descritivo, realizado em enfermaria de Clínica Médica de hospital universitário público de nível terciário. Foram analisadas as prescrições de 124 idosos com 60 anos ou mais, internados por condições clínicas. Os dados das prescrições foram coletados por meio do sistema de prontuário eletrônico da instituição. Os custos das prescrições foram obtidos junto à Seção Técnica de Farmácia de acordo com a tabela de preço unitário do ano vigente de 2018, sendo realizada a somatória total dos custos de toda internação. Os medicamentos foram considerados MPI segundo critérios de Beers de 2019 da American Geriatrics Society. Resultados: Foram avaliadas prescrições de 124 pacientes com mediana de idade de 74,6 (percentil 25 – 75: 69 – 81) anos, sendo 60,5% do sexo ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Prescription of Potentially Inappropriate Medications (PIMs) have relevant aspects in the elderly along with the prevalence of self-medication, drug interactions, adverse reactions and polypharmacy, therefore, it is necessary to use measures that provide rational use of these drugs in this population, besides to elaborate measures that allow the reduction of costs related to this practice for the Health Institutions. Objective: To analyze the direct costs of the prescriptions of elderly patients hospitalized in a Clinical Medical ward and to compare the costs of prescriptions with and without potentially inappropriate medications (PIM) for the elderly. Methodology: Descriptive retrospective observational study, carried out in a Clinical Medical ward of a tertiary-level public university hospital. The prescriptions of 124 elderly patients 60 years of age or older hospitalized for clinical conditions were analyzed. Prescribing data were collected through the institution's electronic medical record system. Prescription costs were obtained from the Technical Section of Pharmacy according to the unit price table of the current year of 2018, and the total sum of the costs of all hospitalization was made. The drugs were considered PIM according to the 2015 Beers criteria of the American Geriatrics Society. Results: Prescriptions of 124 patients with a median age of 74.6 (25 - 75: 69 - 81 percentile) years were evaluated, with 60.5% being male. The median number of medi... (Complete abstract click electronic access below) / Mestre

Orientador: Paulo José Fortes Villas Boas / Resumo: Introdução: A prescrição de Medicamentos Potencialmente Inapropriados (MPIs) é altamente prevalente em idosos e estes frequentemente estão associados à maior risco de interações medicamentosas, aumento das admissões hospitalares e Reações Adversas à Medicamentos (RAM), podendo ser prejudiciais à saúde do idoso. Objetivo: Analisar a prevalência de MPI em idosos em uma unidade de internação de hospital terciário e associação com a ocorrência de RAM durante a hospitalização. Material e Métodos: Trata-se de um estudo longitudinal, do tipo coorte, realizado em 2015 na Enfermaria da Clínica do HCFMB – UNESP com acompanhamento de 155 pacientes. Foram incluídos pacientes com 60 anos ou mais internados por condição clínica de ambos os sexos, e excluídos pacientes hospitalizados por um período inferior a 72 horas, e com internação prévia há menos de 30 dias. Foi utilizado como instrumento para identificar a associação entre o medicamento e a RAM o algorítimo de Naranjo, e utilizado os Critérios de Beers (2015) para categorizar os medicamentos como MPI. Resultados: Faziam uso contínuo de MPI antes da internação 113 (73,3%) idosos e receberam MPI durante a internação 139 (89,7%). Na análise multivariável observou-se associação de MPI na internação com uso de MPI antes da internação (RR=1,09; IC 95% = 0,00 – 0,57), Doença Arterial Coronariana (DAC) (RR = 1,39; IC 95% = 1,18 – 69,41) com p < 0,05. Identificou-se que 49 (36,1%) apresentam RAM, sendo no total 71 reações. Os principais medica... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Prescription of Potentially Inappropriate Medications (PIMs) is highly prevalent in the elderly, and these are often associated with increased risk of drug interactions, increased hospital admissions, and Adverse Drug Reactions (ADRs), which may be detrimental to the health of the elderly. Objective: To analyze the prevalence of PIM in the elderly in a tertiary hospital admission unit and association with the occurrence of ADR during hospitalization. Material and methods: This is a longitudinal study, cohort type, carried out in 2015 at the HCFMB Clinic Infirmary - UNESP, with follow-up of 155 patients. Patients with 60 years or more hospitalized due to clinical condition of both sexes, excluding patients hospitalized for less than 72 hours, and hospitalized for less than 30 days were included. The Naranjo algorithm was used as an instrument to identify the association between the drug and ADR and the criteria of Beers (2015) were used to categorize the drugs as PIM. Results: PIM were continuously used before hospitalization (73.3%), and received PIM during hospitalization (89.7%). In the multivariate analysis, the association of PIM was observed in the interment with PIM before admission (RR = 1.09, 95% CI = 0.00 - 0.57), Coronary Artery Disease (CAD) (RR = 1.39; 95% CI = 1.18 - 69.41) with p <0.05. It was identified that 49 (36.1%) presented ADR, being in total 71 reactions. The main drugs involved in ADR were furosemide (10), enoxoparin (5) and haloperidol (4... (Complete abstract click electronic access below) / Doutor

BACKGROUND: High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. A better understanding of their co-morbidity status, medication use, and healthcare utilization is needed to improve health interventions and policies. OBJECTIVES: We aimed to: (1) synthesize what is known about HCUs and interventions for managing them, (2) characterize how HCUs differ from non-HCUs, and (3) explore the impact of medications and whether prescribing quality contributes to differences in healthcare costs and HCU status development. METHODS: We synthesized what is known about HCUs and used the GRADE framework to evaluate the evidence for interventions designed to improve their health. We conducted retrospective population-based matched cohort and case-control studies of incident older adult HCUs using health administrative data. We examined prescribing and medication costs over the non-HCU to HCU transition period and compared them to non-HCUs. We conducted logistic regression to evaluate associations between HCU status development and the use of high-cost drugs and potentially inappropriate medications. RESULTS: HCU interventions to date have shown inconsistent effects on clinical outcomes and healthcare costs and the overall quality of evidence supporting their efficacy is low. Compared to non-HCUs, HCUs have higher rates of polypharmacy, hospitalization, and mortality. Medications are the highest healthcare cost category in the pre-HCU year and these costs rise nearly 1.7-fold in the HCU year. High-cost drug use increases significantly during the HCU transition period and 3.6% achieve HCU status based on drug costs alone. Use of several potentially inappropriate medications and high-cost drugs significantly increase the odds of HCU development. CONCLUSIONS: Medications can contribute to high-cost healthcare directly through drug costs alone or indirectly through adverse effects on health. Medication optimization interventions and policies to reduce inappropriate medication use and ensure cost-effective medication use are needed to manage high-cost healthcare and prevent HCU development. / Thesis / Doctor of Philosophy (PhD) / High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. More research is needed to better understand HCUs to design interventions to improve their health outcomes and costs. In this thesis, we evaluated what previous studies have discovered about HCUs and we used Ontario’s health system data to explore whether the quality of prescribing and medication use in older adults influences their risk of becoming a HCU. We found that current interventions for HCUs have had inconsistent effects on improving health outcomes and costs. We also found two medication-related factors contributing to the risk of becoming an older adult HCU: (1) use of very expensive medications, and (2) use of potentially inappropriate medications where the risk of harm may outweigh potential benefits. Interventions and health policies to optimize the appropriate and cost-effective use of medications are needed to manage high-cost healthcare and prevent HCU development.

Introduction During the last decades, proportion of geriatric patients in the world population increases. This phenonemon is caused particularly by advances in medical science, social care and working conditions. However, the problem still lies in a very frequent polypharmacotherapy and polymorbidity in older patients. With the aim to reduce the frequent adverse drug events in seniors, the explicite criteria of PIMs (potentially inappropriate medications) have been created. The aim of this work was to determine the registration rates of PIMs in several Eastern and Central European countries using all until now published 22 explicit criteria of potentially inappropriate medications in older patients that are available in published scientific literature. Methods A set of 345 PIMs gained from all explicit criteria published in peer- reviewed or impact factor journals by 2015 year and summarized in diploma thesis of S . Grešákové, MSc (defended in June 2016) was used in this work. Every drug has been included in the list only once, disregarding the other conditions of inappropriateness (e.g. drug-disease interactions, dosing schedules, etc.). The exception were PIMs available in non-sustained and sustained-release forms, because each of this drug form can be identified under a specific ATC code....

Institution/department: Charles University, Faculty of Pharmacy in Hradec Kralove, Department of Social and Clinical Pharmacy Title of diploma thesis: Evaluation of the rationality of prescribing of selected potentially inappropriate medications in ambulatory geriatric patients Supervisor: Assoc. Prof. Daniela Fialova, PharmDr. Ph.D. Author: Roman Lestina Introduction: Rational therapy in the geriatric population is an essential area due to the ever-increasing percentage of geriatric patients in the population. Due to the frequent polypharmacotherapy in these patients, including possible polypragmatism, it is important to constantly monitor potential drug problems and address potential drug risks in a timely manner. As an auxiliary tool in rational geriatric pharmacotherapy, expert groups have defined many potentially inappropriate medications (PIMs), which often contribute to drug reactions in the elderly, and which should be given more attention in clinical practice. This diploma thesis focused on 10 selected, most frequently used PIMs in the geriatric outpatient clinic of the University Hospital in Hradec Králové, and its aim was to monitor how often these drugs are prescribed in high-risk situations in geriatric patients (i.e., in the presence of symptoms, laboratory results and diseases, which...

Estados e municípios puderam definir seu próprio elenco de medicamentos a ser ofertados aos seus cidadãos com a Política Nacional de Medicamentos (1998), e a consequente descentralização da Assistência Farmacêutica. Percebeu-se a oportunidade de realizar um estudo para analisar peculiaridades de um conjunto de Relações Municipais de Medicamentos Essenciais (Remumes) de municípios paulistas, visando a racionalidade das listas como instrumento norteador da aquisição, distribuição, prescrição e planejamento da AF municipal. Considerou-se as possibilidades de diferentes cenários, dependente da qualidade da gestão, organização e do perfil dos recursos humanos locais e que uma equipe farmacêutica competente e qualificada prove uma melhor gestão da AF. Além disso, considerando os impactos da transição demográfica e epidemiológica da população brasileira em que os idosos utilizam mais medicamentos, gestores e profissionais da saúde precisam selecionar medicamentos criteriosamente para atender necessidades dessa faixa etária. O emprego de medicamentos potencialmente inapropriados (MPI) para idosos requer cuidado e estudos tem procurado lista-los e criar instrumentos de seleção. Aqueles inclusos nos critérios Beers definidos com apoio da Sociedade Americana de Geriatria encontram-se associados a desfechos desfavoráveis de saúde e mortalidade. OBJETIVOS: Analisar Remumes disponibilizadas para este estudo visando alertar profissionais de saúde e gestores sobre MPIs que podem comprometer a segurança dos pacientes no processo de utilização de medicamentos. MÉTODOS: Trata-se de um estudo transversal de análise das Remumes dos municípios sedes dos 17 Departamentos Regionais de Saúde (DRSs) e das Remumes dos 27 municípios do Departamento Regional de Saúde (DRS) XIII enfatizando aqueles MPIs contidos nelas. Obtiveram-se 100% das 17 Remumes dos municípios sedes dos DRSs e 92,3% das 27 Remumes dos municípios do DRS XIII, formando um banco de dados com 9063 medicamentos, discriminados pela classificação ATC e pelos diversos critérios de Beers. RESULTADOS E DISCUSSÃO: Os municípios sedes apresentaram Remumes contendo de 128 (Piracicaba) a 396 (Santos) medicamentos, com média de 272,3 (DP=71,1) medicamentos. As Remume dos municípios da DRS XIII apresentaram entre 32 (Luiz Antônio) e 403 (Cássia dos Coqueiros) medicamentos, com média de 198 (DP=111,4). Predominaram os medicamentos que atuavam no sistema nervoso seguidos pelos cardiovasculares e anti-infecciosos sistêmicos. Quando os medicamentos contidos nas Remumes foram submetidos à aplicação dos critérios de Beers, foram identificados 59,9% de MPIs, sendo que do total de 77 classes terapêuticas 39 (53,6%) classes tinham pelo menos um representante na lista dos Critérios de Beers. Os achados foram discutidos comparando dados dos municípios, outros critérios para medicamentos inapropriados para idosos, à luz de evidências clíncas mais recentes. CONCLUSÃO: As Remumes mostraram elevada variação no número de medicamentos e grupos farmacológicos e elenco considerável de medicamentos dos critérios de Beers. Apontou para necessidade de qualificação da assistência farmacêutica municipal e a elaboração de um guia norteador que contribuam para o fortalecimento da Atenção Básica e da Assistência Farmacêutica. Este aprimoramento da utilização de medicamentos em geral e para idosos, envolvendo a prescrição, dispensação, administração e uso pelo paciente, reduzem morbimortalidade relacionada aos medicamentos. / States and municipalities were able to define their own list of medicines to be offered to their citizens with the National Drug Policy (1998) and the consequent decentralization of Pharmaceutical Assistance (PA). It was noticed the opportunity to carry out a study to analyze the peculiarities of a set of Municipal Lists of Essential Medicines (Remumes) of São Paulo state municipalities, aiming at the rationality of lists as a guiding instrument for the acquisition, distribution, prescription and planning of the municipal PA. Consideration was given to the possibilities of different scenarios, depending on the quality of management, organization and the profile of local human resources, and that a competent and qualified pharmaceutical team provides a better management of PA. In addition, considering the impact of the demographic and epidemiological transition of the Brazilian population in which the elderly use more drugs, managers and health professionals need to select medicines carefully to meet the needs of this age group. The employment of potentially inappropriate medications (PIM) for the elderly require care and studies have sought to list them and develop screening tools . Those included in the Beers criteria, defined with support from the American Society of Geriatrics, are associated with unfavorable health and mortality outcomes. OBJECTIVES: To analyze Remumes made available for this study in order to alert health professionals and managers about MPIs that may compromise patients\' safety in the medication use process. METHODS: This is a cross-sectional study of the Remumes of the municipalities of the 17 Regional Health Departments (DRSs) and of the Remumes of the 27 municipalities of the Regional Health Department (DRS) XIII emphasizing those MPIs contained in them. 100% of the 17 Remumes of the municipalities of the DRSs and 92.3% of the 27 Remumes of the municipalities of the DRS XIII were formed, forming a database with 9063 medicines, discriminated by the ATC classification and by the diverse criteria of Beers. RESULTS AND DISCUSSION: The municipal districts presented Remumes containing from 128 (Piracicaba) to 396 (Santos) medications, with an average of 272.3 (SD = 71.1) medications. Remume of DRS XIII municipalities presented medications between 32 (Luiz Antônio) and 403 (Cássia dos Coqueiros), with a mean of 198 (SD = 111.4). Predominant drugs that worked in the nervous system followed by cardiovascular and systemic anti-infectious. When medicinal products contained in Remumes were submitted to the Beers criteria, 59.9% of PIMs were identified. Of the total of 77 therapeutic classes, 39 (53.6%) classes had at least one representative in the list of Criteria of Beers. The findings were discussed comparing data from the municipalities, other criteria for PIMs for the elderly, in light of more recent clinical evidence. CONCLUSION: Remumes showed high variation in the number of drugs and pharmacological groups and considerable list of drugs of the Beers criteria. He pointed to the need for qualification of municipal pharmaceutical assistance and the elaboration of a guiding guide that contribute to the strengthening of Primary Care and Pharmaceutical Assistance. This improvement in the utilization of medications in general and for the elderly, involving prescription, dispensing, administration and use by the patient, reduces drug-related morbidity and mortality.

Estados e municípios puderam definir seu próprio elenco de medicamentos a ser ofertados aos seus cidadãos com a Política Nacional de Medicamentos (1998), e a consequente descentralização da Assistência Farmacêutica. Percebeu-se a oportunidade de realizar um estudo para analisar peculiaridades de um conjunto de Relações Municipais de Medicamentos Essenciais (Remumes) de municípios paulistas, visando a racionalidade das listas como instrumento norteador da aquisição, distribuição, prescrição e planejamento da AF municipal. Considerou-se as possibilidades de diferentes cenários, dependente da qualidade da gestão, organização e do perfil dos recursos humanos locais e que uma equipe farmacêutica competente e qualificada prove uma melhor gestão da AF. Além disso, considerando os impactos da transição demográfica e epidemiológica da população brasileira em que os idosos utilizam mais medicamentos, gestores e profissionais da saúde precisam selecionar medicamentos criteriosamente para atender necessidades dessa faixa etária. O emprego de medicamentos potencialmente inapropriados (MPI) para idosos requer cuidado e estudos tem procurado lista-los e criar instrumentos de seleção. Aqueles inclusos nos critérios Beers definidos com apoio da Sociedade Americana de Geriatria encontram-se associados a desfechos desfavoráveis de saúde e mortalidade. OBJETIVOS: Analisar Remumes disponibilizadas para este estudo visando alertar profissionais de saúde e gestores sobre MPIs que podem comprometer a segurança dos pacientes no processo de utilização de medicamentos. MÉTODOS: Trata-se de um estudo transversal de análise das Remumes dos municípios sedes dos 17 Departamentos Regionais de Saúde (DRSs) e das Remumes dos 27 municípios do Departamento Regional de Saúde (DRS) XIII enfatizando aqueles MPIs contidos nelas. Obtiveram-se 100% das 17 Remumes dos municípios sedes dos DRSs e 92,3% das 27 Remumes dos municípios do DRS XIII, formando um banco de dados com 9063 medicamentos, discriminados pela classificação ATC e pelos diversos critérios de Beers. RESULTADOS E DISCUSSÃO: Os municípios sedes apresentaram Remumes contendo de 128 (Piracicaba) a 396 (Santos) medicamentos, com média de 272,3 (DP=71,1) medicamentos. As Remume dos municípios da DRS XIII apresentaram entre 32 (Luiz Antônio) e 403 (Cássia dos Coqueiros) medicamentos, com média de 198 (DP=111,4). Predominaram os medicamentos que atuavam no sistema nervoso seguidos pelos cardiovasculares e anti-infecciosos sistêmicos. Quando os medicamentos contidos nas Remumes foram submetidos à aplicação dos critérios de Beers, foram identificados 59,9% de MPIs, sendo que do total de 77 classes terapêuticas 39 (53,6%) classes tinham pelo menos um representante na lista dos Critérios de Beers. Os achados foram discutidos comparando dados dos municípios, outros critérios para medicamentos inapropriados para idosos, à luz de evidências clíncas mais recentes. CONCLUSÃO: As Remumes mostraram elevada variação no número de medicamentos e grupos farmacológicos e elenco considerável de medicamentos dos critérios de Beers. Apontou para necessidade de qualificação da assistência farmacêutica municipal e a elaboração de um guia norteador que contribuam para o fortalecimento da Atenção Básica e da Assistência Farmacêutica. Este aprimoramento da utilização de medicamentos em geral e para idosos, envolvendo a prescrição, dispensação, administração e uso pelo paciente, reduzem morbimortalidade relacionada aos medicamentos. / States and municipalities were able to define their own list of medicines to be offered to their citizens with the National Drug Policy (1998) and the consequent decentralization of Pharmaceutical Assistance (PA). It was noticed the opportunity to carry out a study to analyze the peculiarities of a set of Municipal Lists of Essential Medicines (Remumes) of São Paulo state municipalities, aiming at the rationality of lists as a guiding instrument for the acquisition, distribution, prescription and planning of the municipal PA. Consideration was given to the possibilities of different scenarios, depending on the quality of management, organization and the profile of local human resources, and that a competent and qualified pharmaceutical team provides a better management of PA. In addition, considering the impact of the demographic and epidemiological transition of the Brazilian population in which the elderly use more drugs, managers and health professionals need to select medicines carefully to meet the needs of this age group. The employment of potentially inappropriate medications (PIM) for the elderly require care and studies have sought to list them and develop screening tools . Those included in the Beers criteria, defined with support from the American Society of Geriatrics, are associated with unfavorable health and mortality outcomes. OBJECTIVES: To analyze Remumes made available for this study in order to alert health professionals and managers about MPIs that may compromise patients\' safety in the medication use process. METHODS: This is a cross-sectional study of the Remumes of the municipalities of the 17 Regional Health Departments (DRSs) and of the Remumes of the 27 municipalities of the Regional Health Department (DRS) XIII emphasizing those MPIs contained in them. 100% of the 17 Remumes of the municipalities of the DRSs and 92.3% of the 27 Remumes of the municipalities of the DRS XIII were formed, forming a database with 9063 medicines, discriminated by the ATC classification and by the diverse criteria of Beers. RESULTS AND DISCUSSION: The municipal districts presented Remumes containing from 128 (Piracicaba) to 396 (Santos) medications, with an average of 272.3 (SD = 71.1) medications. Remume of DRS XIII municipalities presented medications between 32 (Luiz Antônio) and 403 (Cássia dos Coqueiros), with a mean of 198 (SD = 111.4). Predominant drugs that worked in the nervous system followed by cardiovascular and systemic anti-infectious. When medicinal products contained in Remumes were submitted to the Beers criteria, 59.9% of PIMs were identified. Of the total of 77 therapeutic classes, 39 (53.6%) classes had at least one representative in the list of Criteria of Beers. The findings were discussed comparing data from the municipalities, other criteria for PIMs for the elderly, in light of more recent clinical evidence. CONCLUSION: Remumes showed high variation in the number of drugs and pharmacological groups and considerable list of drugs of the Beers criteria. He pointed to the need for qualification of municipal pharmaceutical assistance and the elaboration of a guiding guide that contribute to the strengthening of Primary Care and Pharmaceutical Assistance. This improvement in the utilization of medications in general and for the elderly, involving prescription, dispensing, administration and use by the patient, reduces drug-related morbidity and mortality.