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Anticoagulants, Diabetes Meds Cause ADE Hospitalization in Seniors

  • Authors: News Author: Robert Lowes
    CME Author: Désirée Lie, MD, MSEd
  • CME/CE Released: 12/2/2011
  • Valid for credit through: 12/2/2012, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, geriatricians, cardiologists, endocrinologists, hematologists, and other specialists who care for older patients.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the demographics of older patients hospitalized for adverse drug events.
  2. Identify medications associated with adverse drug events in older adults.


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  • Robert Lowes

    Robert Lowes is a journalist for Medscape Medical News. A former senior editor at Medical Economics magazine and contributor to numerous healthcare publications, Robert has covered medicine from almost every conceivable angle — public policy, managed care, education, ethics, medical malpractice, information technology, billing and collections, waiting-room design, and first-degree murder. His articles have won major awards such as first place in the annual journalism competition of the National Institute for Health Care Management, and several have been republished in books. Robert also is an anthologized poet. He can be contacted at [email protected].


    Robert Lowes has disclosed no relevant financial relationships.


  • Brande Nicole Martin, MA

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin, MA, has disclosed no relevant financial relationships.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor; Director of Research and Faculty Development, Department of Family Medicine, University of California, Irvine at Orange


    Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
    Served as a nonproduct speaker for: "Topics in Health" for Merck Speaker Services

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  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

Nurse Planner

  • Laurie E. Scudder, DNP, NP

    Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC


    Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.

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Anticoagulants, Diabetes Meds Cause ADE Hospitalization in Seniors

Authors: News Author: Robert Lowes CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME/CE Released: 12/2/2011

Valid for credit through: 12/2/2012, 11:59 PM EST


Clinical Context

According to the current study by Budnitz and colleagues, the goal of the initiative Partnership for Patients is to reduce preventable rehospitalizations by 20% by the year 2013. Hospitalizations for adverse drug events (ADEs) constitute a high proportion of preventable events. Nearly all published studies of hospitalizations for ADEs in the past 15 years have been conducted outside of the United States.

This database study uses nationally representative public health data to describe emergency hospitalizations for ADEs in persons 65 years or older and assess the contribution of specific drugs to these hospitalizations.

Study Synopsis and Perspective

ADEs cause an estimated 100,000 emergency hospitalizations for seniors each year, yet two thirds involve just a handful of anticoagulants and diabetes medications, according to a study published in the November 24 issue of the New England Journal of Medicine.

The study, by researchers from the US Centers for Disease Control and Prevention (CDC), singles out 4 drugs and drug classes — warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Alone or together, they account for 67% of emergency ADE hospitalizations of adults 65 years and older. Warfarin was implicated in 33%, lead author Daniel Budnitz, MD, MPH, director of the CDC's Medication Safety Program, and coauthors write.

In contrast, medications red-flagged as high risk or inappropriate by health authorities explained only 1.2% and 6.6%, respectively, of such hospital admissions.

For clinicians, the take-home message of the study is clear: Improved management of antithrombotic and antidiabetes drugs can keep thousands of seniors out of the hospital.

"These data suggest that focusing safety initiatives on a few medicines that commonly cause serious, measurable harms can improve care for many older Americans," Dr. Budnitz said in a press release. "Blood thinners and diabetes medicines often require blood testing and dosing changes, but these are critical medicines for older adults with certain medical conditions."

"Doctors and patients should continue to use these medications but remember to work together to safely manage them."

Dr. Budnitz and coauthors analyzed data collected from 2007 to 2009 from 58 hospitals participating in an ADE surveillance project to come up with national estimates for that time frame. Nearly two thirds of the estimated 100,000 emergency ADE hospitalizations of seniors each year stemmed from unintentional overdoses, they write. In 48% of the cases, the patient was 80 years or older.

Hospitalizations arising from ADEs promise to increase "as Americans live longer, have greater numbers of chronic conditions, and take more medications," the authors note. Lowering the number of such hospitalizations, they write, is a major priority of a federal initiative called Partnership for Patients, which was launched in April.

The program aims, among other things, to reduce the number of preventable hospital readmissions by 20% by the end of 2013.

The authors have disclosed no relevant financial relationships.

N Engl J Med. 2011;365:2002-2012. Abstract

Related Link:
The FDA's Adverse Drug Reactions Database allows healthcare professionals to search for reports of adverse drug events for all FDA-approved agents. Additionally, the database allows the user to request an electronic report that summarizes ADEs reported with a particular agent.

Study Highlights

  • The National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance (NEISS-CADES) is an electronic surveillance system using data from 58 nonpediatric hospitals with a minimum of 6 beds and a 24-hour emergency department that contribute nationally representative data.
  • Narrative descriptions of adverse events (clinician diagnoses and manifestations) are coded by the Medical Dictionary for Regulatory Activities, version 9.1.
  • A surveillance case was defined as hospitalization after an emergency department visit by a person 65 years or older during 2007 to 2009 for a condition treated by a clinician specifically identified as being the result of a drug or drug-specific adverse event.
  • Hospitalizations included inpatient admissions, observation admissions, and transfers to another hospital.
  • Adverse events were categorized as allergic reactions, adverse events, or unintentional overdoses.
  • Other effects included adverse effects from drug delivery methods or vaccine reactions.
  • Excluded were intentional self-harm, drug abuse, therapeutic failures, and drug withdrawal.
  • Outpatient visits for adults 65 years and older were identified from public-use data files for 2007 and 2008. Up to 8 prescriptions or over-the-counter medications, vaccines, and dietary supplements that were ordered or continued at each visit were recorded.
  • The primary outcome was hospitalization after an emergency department visit for an ADE.
  • Secondary outcome was hospitalization after an adverse event resulting from a "high-risk" drug, as defined by the 2011 Healthcare Effectiveness Data and Information Set (HEDIS).
  • On the basis of 12,666 cases, an estimated 265,802 emergency department visits for an ADE occurred annually from 2007 through 2009 for adults 65 years and older.
  • 37.5% of these visits required hospitalization, including 34.1% for inpatient admissions, 1.1% for transfers to another hospital, and 2.2% for observation admissions.
  • Nearly half (48.1%) of the ADEs involved adults 80 years or older.
  • The population rate of hospitalizations for ADEs was 3.5 times as high for those 85 years and older as for those 65 to 59 years old (4.6 vs 1.3 hospitalizations per 1000 persons).
  • The risk remained elevated when stratified for the number of medications (0 - 4 vs ≥ 5 concomitant medications).
  • The 5 most common therapeutic categories implicated were hematologic, endocrine, cardiovascular, central nervous system, and anti-infective agents.
  • Most hospitalizations for hematologic agents were for hemorrhagic events (71.3%), and warfarin represented two thirds of hospitalizations.
  • Nearly all hospitalizations for endocrine agents were related to hypoglycemia (94.6%), and two thirds of these hospitalizations involved neurologic symptoms such as loss of consciousness.
  • The 4 most commonly implicated drugs were warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%).
  • Together, these drugs accounted for 67.0% of all hospitalizations and remained most common when stratified by age.
  • Nearly all hospitalizations involving warfarin, insulin, and hypoglycemic agents resulted from unintentional overdoses.
  • Of hospitalizations implicating warfarin, 12.5% involved another drug, most often an antiplatelet agent.
  • Only 1.2% of hospitalizations for ADEs involved a high-risk HEDIS medication, and 6.6% were attributed to Beers-criteria potentially inappropriate agents.
  • The rates of warfarin- and insulin-related hospitalizations were at least 48 times as high as ADEs resulting from HEDIS high-risk medications.
  • The authors concluded that warfarin, insulins, oral antiplatelet agents, and hypoglycemic agents accounted for two thirds of ADEs leading to hospitalizations and that these hospitalizations were more common among older patients.

Clinical Implications

  • ADEs leading to hospitalizations are more common among adults older than 80 years vs adults 65 to 69 years old and are independent of the number of concomitant drugs.
  • The 4 most common drugs causing hospitalization for ADEs are warfarin, insulins, oral antiplatelet agents, and hypoglycemic agents. Only 1.2% of these hospitalizations involve HEDIS high-risk medications.

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