La prescrizione appropriata nell’anziano dai

La prescrizione appropriata
nell’anziano:
dai sistemi soft-aid (cpoewis)
alla farmacogenetica
Alberto Pilotto
Dipartimento Cure Geriatriche, OrtoGeriatria e
Riabilitazione
- Livello 3: Area delle Fragilità -
E.O. Ospedali Galliera
Ospedale di Rilievo Nazionale e Alta Specializzazione
Genova, Italy
2011 data from OsMed database on all prescribed drugs reimbursed by the INHS, n= 12,301,537
Onder, J Gerontol A Biol Sci Med Sci 2014;69 (4): 430-7
Hospital admission associated with ADR:
a systematic review of prospective studies
25 studies, 106.586 hospitalized patients, 2143 ADRs
Median Overall Prevalence: 5.3%
15
10,7
6,3
10
4,1
%
5
0
Children
Adults
Elderly
Kongkaew, Ann Pharmacother 2008; 42: 1017-25
Selezione delle “Prescrizioni Inappropriate”: i criteri espliciti
J Am Geriatr Soc, 2012
Key points
The present study describes the updating and revision of STOPP/START criteria, resulting
in a 31% increase of the number of STOPP/START criteria compared with the 2008
version, i.e. 114 criteria.
Age Ageing. 2015 Mar;44(2):213-8.
Interazioni farmacopatologia
(criteri di STOPP)
Interazioni farmacofarmaco
(Micromedex)
Durata-dosaggioindicazioni d’uso
(criteri di STOPP)
Duplicazioni terapeutiche
(criteri di STOPP)
Grion et al. Drugs Aging. 2016 Jan 20. [Epub ahead of print]
REPORT CPOE-WIS
Computer Prescriber Order Entry-Warning Integrated System
8
Disegno dell’ Intervento
ingresso
dimissione
raccolta dati
elaborazione
Discussione Report
(Briefing)
MODIFICA
TERAPIA
Farmacista-Medico
Infermiere
MAI*
dimissione
MAI*
ingresso
differenza MAI*
* Medication Appropriateness Index
Grion et al. Drugs Aging. 2016 Jan 20. [Epub ahead of print]
- 49.0%
-39.7%
-29.5%
-53.4%
-72.9%
Grion et al. Drugs Aging. 2016 Jan 20. [Epub ahead of print]
SC Geriatria E.O. Galliera: Nov-Dic 2015
INTERAZIONI - MICROMEDEX
CRITERI STOPP
p< 0.001
Rossi et al, 2016
Progetto APPROGER: punti di forza
• strumenti validati nella pratica clinica: STOPP e Micromedex DR;
• interazione tra sistema CPOE-WIS e professionisti sanitari;
• interazione multiprofessionale (farmacista-medico-infermiere);
• attivazione di percorsi formativi nell’ambito della de-prescrizione (o
riconciliazione terapeutica) nell’anziano multimorbido e politrattato
• riduzione del rischio clinico in termini di:
- N° totale di prescrizioni;
- N° di ADR
- N° di ricoveri da ADR
Ginsburg, Arch Intern Med 2005; 165: 2331-6
Pharmacogenetics/genomics
are likely to be among the
first clinical applications of the
Human Genome Project
CORRIERE DELLA SERA, 2 SETTEMBRE 2007
Allelic variation of CYP2C9 is
associated with NSAID-related
gastroduodenal bleeding
Cytochrome
P450
2C9
(CYP2C9) is involved in the
metabolism of several NSAIDs.
Two common variants of the
CYP2C9 gene—CYP2C9*2 and
CYP2C9*3—have been shown
to decrease the activity of the
enzyme. Pilotto and colleagues
investigated whether the risk
of….
© 2007 Nature Publishing Group
nature
clinicalpractice
Seripa et al. Exp Opin Drug Metab Toxicol 2015; 11 (7):1-16
Current Drug Metabolism 2011, 12, 621-634
Pharmacogenetics in Geriatric Medicine:
Challenges and Opportunities for Clinical Practice
Alberto Pilotto, Francesco Panza, and Davide Deripa
In clinical practice several factors may explain the variable response to
drug treatments, including functional and cognitive disabilities,
malnutrition, organ-specific failures, concomitant diseases, and
concomitant
therapies.
This
may
seriously
limiting
the
pharmacogenomic approach to drug prescription.
Geriatric patients need a multidimensional approach to optimize their
clinical care including treatments. The introduction in clinical practice of
pharmacogenetics may be useful to improve the “clinical decision
making” in drug treatments.
PHARMACOGENETICS AS A “DOMAIN” OF THE
MULTIDIMENSIONAL ASSESSMENT
Take Home Messages
Pharmacogenetics and Pharmacogenomics
Up to date
1.
Polymorphisms in genes may explain
the variable response to treatments
2.
The SNP and GWAS are
complementary methods for the study
of PGs in clinical practice
3.
4.
Clinical traslation : the successful
histories of warfarin, clopidogrel,
antineoplasms, SSRI, …
Recommendations and Guidelines
from Regulatory International
Agencies (FDA, EMA)
Future directions
1. Need for additional research: RCTs to
evaluate clinical utility and costeffectiveness
2. Need for standardization and reducing
costs of PGx tests
3. Need for clinical practice models that can
apply PGx discoveries to patient care.
4. Need for PGx studies of “critical” drugs
used in old age: psychotropic drugs,
NSAIDs, AD drugs
5. Need for education
Pilotto A. EUGMS 2014 Bruxels
Dipartimento Cure Geriatriche, OrtoGeriatria e Riabilitazione
Livello 3 “Area delle Fragilità”
E.O. Ospedali Galliera
Ospedale di Rilievo Nazionale e Alta Specializzazione
http://www.mpiage.eu
MPI_AGE Project
European Community (CHAFEA) Co-funded
Grazie per l’attenzione