Reduction of Potentially Inappropriate Medication in the Elderly

Abstract

Background: Medications with an unfavorable risk-benefit profile in the elderly, and for which there are safer alternatives, are designated as potentially inappropriate medications (PIM). The RIME trial (Reduction of Potentially Inappropriate Medication in the Elderly) was based on PRISCUS, a list of PIM that was developed in 2010 for the German pharmaceuticals market. In this trial, it was studied whether special training and the PRISCUS card could lessen PIM and undesired drug-drug interactions (DDI) among elderly patients in primary care.

Methods: A three-armed, cluster-randomized, controlled trial was carried out in two regions of Germany. 137 primary care practices were randomized in equal numbers to one of two intervention groups-in which either the primary care physicians alone or the entire practice team received special training-or to a control group with general instructions about medication. The primary endpoint was the percentage of patients with at least one PIM or DDI (PIM/DDI) per practice. The primary hypothesis was that at 1 year this endpoint would be more effectively lowered in the intervention groups compared to the control group.

Results: Among 1138 patients regularly taking more than five drugs, 453 (39.8%) had at least one PIM/DDI at the beginning of the trial. The percent - ages of PIM/DDI at the beginning of the trial and 1 year later were 43.0% and 41.3% in the intervention groups and 37.0% and 37.6% in the control group. The estimated intervention effect of any intervention (69 practices) versus control (68 practices) was 2.3% (p = 0.36), while that of team training (35 practices) versus physician training (34 practices) was 4.3% (p = 0.22).

Conclusion: The interventions in the RIME trial did not significantly lower the percentage of patients with PIM or DDI.

Figure 1

Study flow diagram mITT, modified „intention to treat“

Figure 2

Medication at baseline: most common potentially inappropriate medications (1138 patients)

Figure 3

Number of undesirable drug–drug interaction at timepoints T0 and T1 by type and study arm (in the 969 patients able to be interviewed at the end of 1 year) A2, drug class that includes ACE inhibitors, AT1-antagonists, and renin inhibitors; NSAID, nonsteroidal anti-inflammatory or antiphlogistic drug; OAC, oral anticoagulant; APD, antiplatelet drug

eFigure

Medication at baseline: Occurrence of drug–drug interactions of concern (data from 1138 patients) A2, drug class that includes ACE inhibitors, AT1-antagonists, and renin inhibitors; NSAID, nonsteroidal anti-inflammatory or antiphlogistic drug; OAC, oral anticoagulant; APD, antiplatelet drug