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      Analgesic drug use in elderly persons: A population-based study in Southern Italy

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          Abstract

          Introduction

          Analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs), weak and strong opioids are commonly used among elderly persons. The aim of this study was to describe the demographic and clinical characteristics of elderly analgesic users and to measure the frequency of analgesic use, including the frequency of potentially inappropriate analgesic use.

          Methods

          The Arianna database was used to carry out this study. This database contains prescription data with associated indication of use for 1,076,486 inhabitants registered with their general practitioners (GPs) in the Caserta Local Health Unit (Caserta district, Campania region in Italy). A cohort of persons aged ≥65 years old with >1 year of database history having at least one analgesic drug (NSAIDs, strong or weak opioids) between 2010 and 2014 were identified. The date of the first analgesic prescription in the study period was considered the index date (ID).

          Results

          From a source population of 1,076,486 persons, 116,486 elderly persons were identified. Of these, 94,820 elderly persons received at least one analgesic drug: 36.6% were incident NSAID users (N = 36,629), while 13.2% were incident weak opioid users (N = 12,485) and 8.1% were incident strong opioid users (N = 7,658). In terms of inappropriate analgesic use, 9.2% (N = 10,763) of all elderly users were prescribed ketorolac/indomethacin inappropriately, since these drugs should not be prescribed to elderly persons. Furthermore, at least half all elderly persons with chronic kidney disease or congestive heart failure were prescribed NSAIDs, while these drugs should be avoided.

          Conclusion

          Analgesics are commonly used inappropriately among elderly persons, suggesting that prescribing practice in the catchment area may yet be improved.

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          Most cited references22

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          STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

          Purpose: screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria were first published in 2008. Due to an expanding therapeutics evidence base, updating of the criteria was required. Methods: we reviewed the 2008 STOPP/START criteria to add new evidence-based criteria and remove any obsolete criteria. A thorough literature review was performed to reassess the evidence base of the 2008 criteria and the proposed new criteria. Nineteen experts from 13 European countries reviewed a new draft of STOPP & START criteria including proposed new criteria. These experts were also asked to propose additional criteria they considered important to include in the revised STOPP & START criteria and to highlight any criteria from the 2008 list they considered less important or lacking an evidence base. The revised list of criteria was then validated using the Delphi consensus methodology. Results: the expert panel agreed a final list of 114 criteria after two Delphi validation rounds, i.e. 80 STOPP criteria and 34 START criteria. This represents an overall 31% increase in STOPP/START criteria compared with version 1. Several new STOPP categories were created in version 2, namely antiplatelet/anticoagulant drugs, drugs affecting, or affected by, renal function and drugs that increase anticholinergic burden; new START categories include urogenital system drugs, analgesics and vaccines. Conclusion: STOPP/START version 2 criteria have been expanded and updated for the purpose of minimizing inappropriate prescribing in older people. These criteria are based on an up-to-date literature review and consensus validation among a European panel of experts.
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            Individual non-steroidal anti-inflammatory drugs and risk of acute kidney injury: A systematic review and meta-analysis of observational studies.

            The association between acute kidney injury (AKI) and use of non-steroidal anti-inflammatory drugs (NSAIDs) is well established. However, little is known about the comparative risk of individual NSAIDs, including specific COX-2 inhibitors.
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              The Opioid Epidemic: Crisis and Solutions

              The widespread abuse of prescription opioids and a dramatic increase in the availability of illicit opioids have created what is commonly referred to as the opioid epidemic. The magnitude of this epidemic is startling: About 4% of the adult US population misuses prescription opioids, and in 2015, more than 33,000 deaths were attributable to overdose with licit and illicit opioids. Increasing the availability of medication-assisted treatments (such as buprenorphine and naltrexone), the use of abuse-deterrent formulations, and the adoption of US Centers for Disease Control and Prevention prescribing guidelines all constitute short-term approaches to quell this epidemic. However, with more than 125 million Americans suffering from either acute or chronic pain, the development of effective alternatives to opioids, enabled at least in part by a fuller understanding of the neurobiological bases of pain, offers the best long-term solution for controlling and ultimately eradicating this epidemic.
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                Author and article information

                Contributors
                Role: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Writing – original draftRole: Writing – review & editing
                Role: Writing – review & editing
                Role: Data curationRole: Resources
                Role: Data curationRole: Resources
                Role: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                19 September 2019
                2019
                : 14
                : 9
                : e0222836
                Affiliations
                [1 ] Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
                [2 ] Unit of Clinical Pharmacology A.O.U. ‘G. Martino’ Hospital’, Messina, Italy
                [3 ] CIRFF, Center of Pharmacoeconomics, University of Naples Federico II, Naples, Italy
                [4 ] HSR Pisana IRCCS, Rome, Italy
                [5 ] Local Health Unit of Caserta, Caserta, Italy
                [6 ] Department of Medical Informatics, Erasmus Medical Center, Rotterdam, the Netherlands
                University of Catanzaro, ITALY
                Author notes

                Competing Interests: YI, JS, FG, EM, AS, MT, DUT, GB and GT have no conflict of interest related to the study. GT has attended advisory boards on topics not related to this paper in the last 10 years, organized by Sandoz, Hospira, Sanofi, Biogen, Ibsen, Shire, and is consultant for Otsuka. He is the principal investigator of observational studies funded by several pharmaceutical companies (e.g. Amgen, AstraZeneca, Daiichi Sankyo, IBSA) to University of Messina as well as scientific coordinator of the Master program “Pharmacovigilance, pharmacoepidemiology and pharmacoeconomics: real-world data evaluations” at University of Messina which is partly funded by several pharmaceutical companies.

                ‡ YI and JS are joint first authors on this work. FG, EM, AS, MT, DUT, GB, and GT also contributed equally to this work.

                Author information
                http://orcid.org/0000-0001-9622-169X
                Article
                PONE-D-18-30863
                10.1371/journal.pone.0222836
                6752879
                31536588
                b1419506-7652-47d2-a0fd-93ee7ae4865b
                © 2019 Ingrasciotta et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 25 October 2018
                : 8 September 2019
                Page count
                Figures: 2, Tables: 4, Pages: 15
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Analgesics
                Medicine and Health Sciences
                Pain Management
                Analgesics
                Medicine and Health Sciences
                Geriatrics
                People and Places
                Population Groupings
                Age Groups
                Elderly
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pain Management
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Opioids
                Medicine and health sciences
                Pharmacology
                Drugs
                Analgesics
                NSAIDs
                Medicine and health sciences
                Pain management
                Analgesics
                NSAIDs
                Medicine and Health Sciences
                Pharmaceutics
                Drug Therapy
                Antiplatelet Therapy
                People and Places
                Population Groupings
                Ethnicities
                European People
                Italian People
                Biology and Life Sciences
                Neuroscience
                Cognitive Science
                Cognitive Neuroscience
                Cognitive Neurology
                Cognitive Impairment
                Biology and Life Sciences
                Neuroscience
                Cognitive Neuroscience
                Cognitive Neurology
                Cognitive Impairment
                Medicine and Health Sciences
                Neurology
                Cognitive Neurology
                Cognitive Impairment
                Custom metadata
                Data cannot be shared publicly because of an agreement signed between the authors and the data providers which precludes sharing of patient-level data to third parties. Data are available from the the Director General of the Caserta Local Health Unit, Dr. Mario de Biasio, at direzionegenerale@ 123456pec.aslcaserta.it for researchers who meet the criteria for access to confidential data. The authors confirm they had no special access or privileges that other researchers would not have.

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