NEJM: Warfarin culprit for most hospitalizations in elderly; management may help
Warfarin, the most commonly prescribed and trickiest to manage anticoagulant, is the key culprit of hospitalizations for the elderly patient population, according to a study published Nov. 24 in the New England Journal of Medicine. Warfarin was followed by insulins and oral-anticoagulants, and the researchers found that nearly two-thirds of hospitalizations were due to unintentional overdoses.
“Hospitalizations for adverse drug events are likely to increase as Americans live longer, have greater numbers of chronic conditions and take more medication," Daniel S. Budnitz, MD, MPH, of the division of healthcare quality promotion at the Centers for Disease Control and Prevention, and colleagues wrote. In fact, 40 percent of patients age 65 years or older are prescribed five to nine medications and 18 percent take 10 or more.
“Age-related physiological changes, a greater degree of frailty, a larger number of coexisting conditions and polypharmacy have been associated with an increased risk of adverse events, and older adults are nearly seven times as likely as younger persons to have adverse drug events that require hospitalization,” according to the authors.
To outline the trends of hospitalizations in this elderly population, Budnitz and colleagues used adverse-event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project to estimate the frequency of readmissions post-emergency department visits for adverse drug events in this population.
To do so, Budnitz et al evaluated 99,628 emergency hospitalizations for adverse drug events in the U.S. between 2007 and 2009, and assessed the medications that contributed to these adverse events. The patients were 65 years of age or older and nearly half of the hospitalizations took place in adults who were 80 years of age or older. Women accounted for 59.5 percent of hospitalizations.
The researchers reported that 65.7 percent of hospitalizations were due to unintentional overdoses and four drug classes were the culprit of 67 percent of these hospitalizations: warfarin (33.3 percent), insulins (13.9 percent), oral antiplatelet agents (13.3 percent) and oral hypoglycemic agents (10.7 percent).
Hospitalizations for adverse drug events were 3.5 times higher among adults age 85 or older compared with those between the ages of 65 to 69 (4.9 hospitalizations per 1,000 patients vs. 1.3 hospitalizations per 1,000 patients).
Warfarin-related hemorrhages accounted for 21,010 hospitalizations, which represented 63.3 percent of all warfarin-related hospitalizations. Likewise, 88.1 percent of antiplatelet-related hospitalizations were for hemorrhages and nearly 95 percent of the hospitalizations related to endocrine agents were related to hypoglycemia.
“Novel oral anticoagulants may be an alternative to warfarin, but until the role of these agents is better defined, and as long as warfarin remains the most common cause of emergency hospitalizations for adverse drug events, safety policies should address these harms,” the authors wrote.
“Some assume that efforts to minimize the risk of adverse events come at the expense of reductions in the benefits of therapy,” the authors wrote. “The risks from some drugs may be mitigated only by eliminating or restricting their use, but in the case of warfarin, anticoagulation management services have been shown to improve anticoagulation control and reduce both thromboembolic and bleeding events.”
By 2013, the goal of the Partnership for Patients initiative is to reduce the number of preventable readmissions by 20 percent. The authors concluded that improving the management of both antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations, which could lead to reduced costs in the older adult population.
“Hospitalizations for adverse drug events are likely to increase as Americans live longer, have greater numbers of chronic conditions and take more medication," Daniel S. Budnitz, MD, MPH, of the division of healthcare quality promotion at the Centers for Disease Control and Prevention, and colleagues wrote. In fact, 40 percent of patients age 65 years or older are prescribed five to nine medications and 18 percent take 10 or more.
“Age-related physiological changes, a greater degree of frailty, a larger number of coexisting conditions and polypharmacy have been associated with an increased risk of adverse events, and older adults are nearly seven times as likely as younger persons to have adverse drug events that require hospitalization,” according to the authors.
To outline the trends of hospitalizations in this elderly population, Budnitz and colleagues used adverse-event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project to estimate the frequency of readmissions post-emergency department visits for adverse drug events in this population.
To do so, Budnitz et al evaluated 99,628 emergency hospitalizations for adverse drug events in the U.S. between 2007 and 2009, and assessed the medications that contributed to these adverse events. The patients were 65 years of age or older and nearly half of the hospitalizations took place in adults who were 80 years of age or older. Women accounted for 59.5 percent of hospitalizations.
The researchers reported that 65.7 percent of hospitalizations were due to unintentional overdoses and four drug classes were the culprit of 67 percent of these hospitalizations: warfarin (33.3 percent), insulins (13.9 percent), oral antiplatelet agents (13.3 percent) and oral hypoglycemic agents (10.7 percent).
Hospitalizations for adverse drug events were 3.5 times higher among adults age 85 or older compared with those between the ages of 65 to 69 (4.9 hospitalizations per 1,000 patients vs. 1.3 hospitalizations per 1,000 patients).
Warfarin-related hemorrhages accounted for 21,010 hospitalizations, which represented 63.3 percent of all warfarin-related hospitalizations. Likewise, 88.1 percent of antiplatelet-related hospitalizations were for hemorrhages and nearly 95 percent of the hospitalizations related to endocrine agents were related to hypoglycemia.
“Novel oral anticoagulants may be an alternative to warfarin, but until the role of these agents is better defined, and as long as warfarin remains the most common cause of emergency hospitalizations for adverse drug events, safety policies should address these harms,” the authors wrote.
“Some assume that efforts to minimize the risk of adverse events come at the expense of reductions in the benefits of therapy,” the authors wrote. “The risks from some drugs may be mitigated only by eliminating or restricting their use, but in the case of warfarin, anticoagulation management services have been shown to improve anticoagulation control and reduce both thromboembolic and bleeding events.”
By 2013, the goal of the Partnership for Patients initiative is to reduce the number of preventable readmissions by 20 percent. The authors concluded that improving the management of both antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations, which could lead to reduced costs in the older adult population.