Transcript
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
