Cardiovascular Medicines Research Articles

Adverse drug reactions in adult medical inpatients in a South African hospital serving a community with a high HIV/AIDS prevalence: prospective observational study

What is already known about this subject. Studies conducted primarily in developed countries have shown that adverse drug reactions (ADRs) are a significant cause of hospital admission, prolong hospital stay and consequently increase the cost of disease management in patients. Cardiovascular medicines, hypoglycaemic agents, nonsteroidal anti-inflammatory drugs and antibiotics are the most frequently implicated medicines in these studies. A large proportion of these ADRs have been shown to be preventable through improved drug prescribing, administration and monitoring for adverse effects. What this paper adds. This is the first Sub-Saharan African study in the HIV/AIDS era that describes the contribution of ADRs to patient morbidity, hospitalisation and mortality. Cardiovascular medicines and antiretroviral therapy contributed the most to community-acquired ADRs at the time of hospital admission while medicines used for opportunistic infections (such as antifungals, antibiotics and antituberculosis medicines were most frequently implicated in hospital acquired ADRs. ADRs in HIV-infected patients were less likely to be preventable. To describe the frequency, nature and preventability of community-acquired and hospital-acquired adverse drug reactions (ADRs) in a South African hospital serving a community with a high prevalence of human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome. A 3-month prospective observational study of 665 adults admitted to two medical wards. Forty-one (6.3%) patients were admitted as a result of an ADR and 41 (6.3%) developed an ADR in hospital. Many of the ADRs (46.2%) were considered preventable, although less likely to be preventable in HIV-infected patients than in those with negative or unknown HIV status (community-acquired ADRs 2/24 vs. 35/42; P < 0.0001; hospital-acquired ADRs 3/25 vs. 14/26; P = 0.003). Patients admitted with ADRs were older than patients not admitted with an ADR (median 53 vs. 42 years, P = 0.003), but 60% of community-acquired ADRs at hospital admission were in patients <60 years old. Among patients <60 years old, those HIV infected were more likely to be admitted with an ADR [odds ratio (OR) 2.32, 95% confidence interval (CI) 1.17, 4.61; P = 0.017]. Among HIV-infected patients, those receiving antiretroviral therapy (ART) were more likely to be admitted with an ADR than those not receiving ART (OR 10.34, 95% CI 4.50, 23.77; P < 0.0001). No ART-related ADRs were fatal. Antibiotics and drugs used for opportunistic infections were implicated in two-thirds of hospital-acquired ADRs. ADRs are an important, often preventable cause of hospitalizations and inpatient morbidity in South Africa, particularly among the elderly and HIV-infected. Although ART-related injury contributed to hospital admissions, many HIV-related admissions were among patients not receiving ART, and many ADRs were associated with medicines used for managing opportunistic infections.

Changes in the use of cardiovascular medicines in the elderly aged 75 years or older - a population-based Kuopio 75+ study

The aim of this population-based cohort study was to examine the changes in the regular use of cardiovascular medication among the elderly aged 75 years or more in Finland in 1998 and 2003. The study population (n = 700) was a random sample of all persons aged 75 years or more living in Kuopio, in eastern Finland. Of them, 601 persons participated in 1998. The surviving persons (n = 339) were re-examined in 2003. Of them 85% (n = 289) were home-dwelling and 15% (n = 50) lived in institutional care. Data on their use of medication and their physical and mental health was collected from interviews conducted by trained nurses. From 1998 to 2003 regular use of one or more cardiovascular medicine increased from 80% to 87% among all the survivors (n = 339, P < 0.001). The mean number of regularly used cardiovascular medicines increased from 2.1 (95% CI 1.9-2.3) to 2.7 (95% CI 2.5-2.9, P < 0.001) during the follow-up period. The most commonly used cardiovascular medicines were beta-blocking agents. The proportion of users of beta-blocking agents was in 1998 45% and in 2003 51%. The proportion of users of diuretics increased from 27% to 40% (P < 0.001), users of cardiac therapy from 35% to 43% (P < 0.001), users of ACE inhibitors and AT 1 receptor antagonists from 20% to 30% (P < 0.001) and users of lipid modifying agents from 7% to 12%. The use of cardiovascular medicines was common among elderly persons. The proportion of users increased with age and over time. A large proportion of elderly persons would need medication monitoring focusing on cardiovascular medication.

Exploring patient adherence to cardiovascular medicines

Medicines are the most common evidence-based healthcare intervention. However, low levels of patient adherence to medicines for chronic illnesses mean that some expenditure may be wasted. This article provides a guide for nurses who wish to explore the patient adherence literature and improve clinical practice. The related terms of compliance, adherence and concordance are defined, and differences in interpretation are explained. Broad roles are suggested for nurses who administer or prescribe medicines, and levels of patient adherence to various cardiovascular medicines are discussed. The risks and benefits associated with higher levels of adherence are summarized, and patient views about adherence are illustrated. Finally, some practical strategies for improving patient adherence and engagement in decision making are evaluated.

Trends over 5 years in cardiovascular medicine use in Australian veterans with diabetes

To determine trends over 5 years in cardiovascular medicine use in the Australian veteran population with diabetes. An observational study. All veterans dispensed medicines indicative of diabetes between 2000 and 2005 were identified from the Veterans Affairs pharmacy claims dataset. Concurrent dispensings of angiotensin-converting enzyme inhibitor (ACEI), lipid-lowering medicines and antiplatelets were assessed. ACEI/angiotensin II receptor blocker use has risen from 46% to 67% in the veteran population dispensed medicines indicative of diabetes. Lipid-lowering medicines have increased from 33% to 58% and antiplatelets from 28% to 50%. The increasing use of cardiovascular medicines in the diabetes population is suggestive of improved treatment practices over time, consistent with guidelines and quality use of medicines initiatives.

Cardiovascular drug trials: how to examine interaction, and why so

In practice the benefit of cardiovascular medicines is less consistent than it is in clinical trials. This is due to multiple uncontrolled factors that co-determine the efficacy of the new treatment. In statistical terms, they interact with the new treatment. Interaction effects are rarely assessed in cardiovascular trials. To review (1) important factors that may interact with the treatment efficacy, (2) how to examine such factors, and (3) why so. Important factors include (a) possible risk factors such as specific patient characteristics, and concomitant medications, and (b) study-specific aspects such as heterogeneities of investigators, health centres, and individual patients including patient compliance. Such factors can be assessed by comparing subgroups. A common but incorrect approach is the comparison of the significances of difference between treatment modalities in either subgroup. Instead, a direct comparison of effect sizes relative to the standard errors is adequate. As an alternative, regression modelling is adequate and convenient. Results of interaction assessments are post-hoc and, therefore, of an exploratory and unconfirmed nature. So, why should they be performed? In cardiovascular research the effects of patient characteristics and drug-drug interactions on drug efficacies are numerous. It is valuable to account at least post-hoc for such mechanisms. Second, current cardiovascular trials involve heterogeneous health centres, investigators, and patient groups. Accounting for these heterogeneities can be helpful to better predict individual responses in future patients. Cardiovascular trials enrolling patient groups at risk for heterogeneity should include at least a post-hoc assessment for interaction. Correct and incorrect methods for that purpose are described. Interaction assessments are helpful to better predict the efficacy/safety of new cardiovascular medicines in the future treatment of subgroups of patients. (Neth Heart J 2007;15:61-6.).

MDR- and CYP3A4-Mediated Drug–Drug Interactions

P-glycoprotein (P-gp), multiple drug resistance associated proteins (MRPs), and cytochrome P450 3A4 together constitute a highly efficient barrier for many orally absorbed drugs. Multidrug regimens and corresponding drug-drug interactions are known to cause many adverse drug reactions and treatment failures. Available literature, clinical reports, and in vitro studies from our laboratory indicate that many drugs are substrates for both P-gp and CYP3A4. Our primary hypothesis is that transport and metabolism of protease inhibitors (PIs) and NNRTIs will be altered when administered in combination with azole antifungals, macrolide, fluroquinolone antibiotics, statins, cardiovascular agents, immune modulators, and recreational drugs [benzodiazepines, cocaine, lysergic acid dithylamide (LSD), marijuana, amphetamine (Meth), 3,4-methylenedioxymethamphetamine (MDMA), and opiates] due to efflux, and/or metabolism at cellular targets. Therefore, such drug combinations could be a reason for the unexpected and unexplainable therapeutic outcomes. A number of clinical reports on drug interaction between PIs and other classes (macrolide antibiotics, azole antifungals, cholesterol lowering statins, cardiovascular medicines, and immunomodulators) are discussed in this article. MDCKII-MDR1 was employed as an in vitro model to evaluate the effects of antiretrovirals, azole antifungals, macrolide, and fluroquinolone antibiotics on efflux transporters. Ketoconazole (50 muM) enhanced the intracellular concentration of (3)H ritonavir. The inhibitory effects of ketoconazole and MK 571 on the efflux of (3)H ritonavir were comparable. An additive effect was observed with simultaneous incorporation of ketoconazole and MK 571. Results of (3)H ritonavir uptake studies were confirmed with transcellular transport studies. Several fluroquinolones were also evaluated on P-gp-mediated efflux of (3)H cyclosporin and 14C erythromycin. These in vitro studies indicate that grepafloxacin, levofloxacin, and sparfloxacin are potent inhibitors of P-gp-mediated efflux of 14C erythromycin and (3)H cyclosporin. Simultaneous administration of fluoroquinolones and macrolides could minimize the efflux and metabolism of both of the drugs. Effects of erythromycin and ketoconazole on carbamazepine metabolism were examined. Formation of 10,11-epoxy carbamazepine, a major CBZ metabolite, was significantly inhibited by these agents. Therefore, drug efflux proteins (P-gp, MRPs) and metabolizing enzyme (CYP450) are major factors in drug interactions. Overlapping substrate specificities of these proteins result in complex and sometimes perplexing pharmacokinetic profiles of multidrug regimens. Drug-drug interactions with PIs and other coadministered agents for human immunodeficiency virus (HIV) positive population have been discussed in light of efflux transporters and metabolizing enzymes. This article provides an insight into low and variable oral bioavailability and related complications leading to loss of therapeutic activity of MDR and CYP 450 substrates.

GRK2 Expression in Lymphocytes of Human Patients with Heart Failure-A New Biomarker

Introduction: Despite numerous therapeutic advances recently for heart failure (HF), hospitalizations and deaths are still rising. Thus, new treatments as well as improved biomarkers are critically needed to improve the overall care of HF patients. Recently, we have shown that G-protein Coupled Receptor Kinase-2 (GRK2) expression in peripheral lymphocytes tracks with myocardial levels and higher levels in the blood is associated with more severe HF. Hypothesis and Methods: Our hypothesis is that blood GRK2 is a novel biomarker in HF that may help represent a surrogate marker. In order to solidify our previous results showing that lymphocyte GRK2 is negatively associated with LV function in HF, we need to compare levels in HF patients to normal control subjects without LV dysfunction. We have determined lymphocyte GRK2 protein levels in HF and control subjects in this study. HF subjects were recruited and consented during their hospitalization or their outpatient visit to a HF specialist. Patients with normal LV function and taking no cardiovascular medicines were also recruited. Blood was drawn from these subjects and the white blood cells were isolated using Ficoll gradient centrifugation. Purified lymphocyte protein extracts were used for GRK2 protein immunoblotting and quantification via densitometry and normalization with the housekeeping protein, GAPDH. Results: GRK2 levels expressed as a ratio between GRK2 expression and GAPDH (GRK2/GAPDH) in the normal control group (n = 30) was 0.264 ± 0.068. Importantly, in HF patients (n = 20), we found a significant 3-4 fold increase in GRK2 levels in peripheral blood, 1.00 ± 0.258 GRK2/GAPDH (P<0.05). Moreover, there was a relationship between GRK2 levels and disease severity (HF class) in the HF patients. Conclusions: With a larger number of study subjects, we have confirmed that GRK2 in white blood cells is elevated in human patients with failing hearts when compared to subjects with normal LV function. Future studies will compare GRK2 levels in HF patients treated with standard pharmacologic and device therapy to test our hypothesis that GRK2 can be a surrogate marker for determination of a given patient's response to treatment.

Increasing use of medicines in elderly persons: a five-year follow-up of the Kuopio 75+Study

The aim of this study was to describe the changes in medicine use, polypharmacy and excessive polypharmacy between 1998 and 2003 among a cohort of elderly Finns. For this prospective follow-up study, a random sample of 700 participants aged >or=75 years was drawn from the City of Kuopio, Finland. Of them, 601 participated in the study at baseline in 1998. The changes in medicine use among the survivors (n=339), who were re-examined in 2003, were recorded and are described here. Statistical significance of changes in medicine use was evaluated by Student's paired-samples and independent-samples t-test and Fisher's exact test. From 1998 to 2003, the mean number of medicines in use per individual increased from 6.3 to 7.5 (p<0.001). The prevalence of polypharmacy (>5 medicines in use) increased from 54% to 67% and excessive polypharmacy (>or=10 medicines in use) from 19% to 28%. The increase was due to increased use of regularly taken medicines, whereas the use of medicines taken as needed decreased during the follow-up in both sexes. At the time of follow-up survey, persons in institutional care used significantly more medicines (10.9) than community-dwelling elderly persons (7.0) (p<0.001). Central nervous system medicines and cardiovascular medicines were the most commonly used medicines in both years. The number of medicines and the prevalence of polypharmacy and excessive polypharmacy increases with advancing age. In order to avoid possible harmful effects and to optimize medication it is necessary to assess the medication regimen at regular intervals.

A population-based study on well-being in the very old: the role of cardiovascular diseases and drugs

Cardiovascular diseases constitute the most common health problems in very old people. Consequently, cardiovascular drugs are the medicines that are most frequently used by elderly subjects. Although many studies have examined the physiological effect and adverse reactions of these drugs, knowledge on their effect on emotional well-being is missing. The present study aims to examine the association between cardiovascular diseases and their medical treatment on the emotional well-being of very old people. We investigated a representative group of elderly subjects gathered from a population-based study ( n = 235). Participants were 84 years or older and cognitively intact (mini-mental state examination (MMSE) ≥24 points). Well-being was assessed with the positive and negative affect schedule (PANAS), measuring different mood categories. Cardiovascular diseases were diagnosed following the International Classification of Diseases. In this population the prevalence of cardiovascular diseases was high (62%). Multivariate regression analysis showed that while being affected by a cardiovascular disease did not affect the emotional well-being of the subjects (PANAS-PA, p = 0.171; PANAS-NA, p = 0.209), the use of some cardiovascular drugs showed an association. Cardiac glycosides ( p = 0.006) and nitrates ( p = 0.008) were associated with increased negative feelings. Due to high prevalence of cardiovascular diseases and use of cardiovascular medicines, this finding has relevance on the quality of life of elderly people. However, due to the nature of this study we cannot assess cause–effect relationship of this positive association. Therefore, the present findings suggest that there is a need for clinical studies in this increasing and limited studied age group.

The cost effectiveness of cardiovascular medicines

The cost effectiveness of cardiovascular medicines

Pharmacogenomics in Cardiovascular Medicine

AbstractThe completion of the Human Genome Project (HGP) holds promise for further insight into how genetic differences contribute to an individual's response to a medicine(s). Even before the completion of the HGP, cardiovascular medicine was thrust into the arena of pharmacogenomics by the observation that many drugs, cardiovascular and noncardiovascular, promote cardiac arrhythmias. It is now recognized that these adverse responses as well as beneficial responses to cardiovascular medicines can be influenced by alterations in the genes for metabolizing enzymes, drug transporters, and drug targets. To the present, much basic information regarding gene–drug interactions has accumulated, but translation to clinical care has been slow. It is anticipated that the pace of clinical cardiovascular pharmacogenomics will increase as the result of better‐designed studies and technological advances. The final adoption of this area of investigation into clinical practice will also be influenced by financial, psychosocial, and legal factors. Drug Dev. Res. 62:180–190, 2004. © 2004 Wiley‐Liss, Inc.

Medication-related problems commonly occurring in an Australian community setting.

This study characterised medication-related problems in 1000 Australian patients living in the community, and who were considered at risk of medication misadventure. A review was undertaken of 1000 clinical case notes, developed during the delivery of medication management reviews. Patient demographics, medications used, medical conditions and medication-related problems were categorised according to established classification systems. Descriptive analyses were undertaken. Overall, 2222 problems were identified. Ninety per cent of patients had at least one medication-related problem. One in three people were found to require additional monitoring, one in four required additional medication, one in four were using the wrong or inappropriate medication and one in five were using insufficient medication. Cardiovascular, nervous system, alimentary and respiratory medicines were most commonly implicated, accounting for 69% of the medication-related problems. This analysis reveals the need for ongoing vigilance of, and support for, people at high risk of medication misadventure. This information is also useful for informing the design of public health or health promotion strategies aiming to reduce the prevalence of these problems.

EURO-MED-STAT: monitoring expenditure and utilization of medicinal products in the European Union countries: a Public Health approach

Background: There is uncertainty about the level of utilization and expenditure for medicines in the European Union (EU), making assessment of their impact on public health difficult. Our aim is to develop indicators to monitor price, expenditure and utilization of medicinal products in the EU, so as to facilitate comparisons. Methods: There are four major tasks. Task 1: To catalogue data sources and available data in each EU Member State. Task 2: To assess the reliability and comparability of data among the EU Member States by ATC/DDD on country coverage, reimbursement, prescriptions, price category (e.g. wholesale, hospital, retail) and private versus public spending. Task 3: To develop Standard Operating Procedures for data management and to define clearly the proposed indicators in terms of objective, definition, description, rationale, and data collection. Task 4: To pool, compare and report the validated data according to the established indicators, using cardiovascular medicines as an example. Results: Preliminary results from Tasks 1 and 2 are available and demonstrate the methodological difficulties in comparing data from different countries. Multiple data sources must be used. These cover different populations, and refer to different prices or costs. Nevertheless, useful data can be derived, illustrated by the example of lipid lowering medicines. The data shows that only five products are commonly available in all countries. Even when a medicine is available in all countries, there may be substantial differences in packages, which can hinder comparison. Data on utilization of statins shows high usage in Scandinavian countries and least in Italy. Conclusion: The preliminary results of EURO-MED-STAT show wide differences in availability, and use of medicines across Europe that may have substantial implications for public health.

The association between noise exposure and blood pressure and ischemic heart disease: a meta-analysis.

It has been suggested that noise exposure is associated with blood pressure changes and ischemic heart disease risk, but epidemiologic evidence is still limited. Furthermore, most reviews investigating these relations were not carried out in a systematic way, which makes them more prone to bias. We conducted a meta-analysis of 43 epidemiologic studies published between 1970 and 1999 that investigate the relation between noise exposure (both occupational and community) and blood pressure and/or ischemic heart disease (International Classification of Diseases, Ninth Revision, codes 410-414). We studied a wide range of effects, from blood pressure changes to a myocardial infarction. With respect to the association between noise exposure and blood pressure, small blood pressure differences were evident. Our meta-analysis showed a significant association for both occupational noise exposure and air traffic noise exposure and hypertension: We estimated relative risks per 5 dB(A) noise increase of 1.14 (1.01-1.29) and 1.26 (1.14-1.39), respectively. Air traffic noise exposure was positively associated with the consultation of a general practitioner or specialist, the use of cardiovascular medicines, and angina pectoris. In cross-sectional studies, road traffic noise exposure increases the risk of myocardial infarction and total ischemic heart disease. Although we can conclude that noise exposure can contribute to the prevalence of cardiovascular disease, the evidence for a relation between noise exposure and ischemic heart disease is still inconclusive because of the limitations in exposure characterization, adjustment for important confounders, and the occurrence of publication bias.

Some economic consequences of noncompliance.

The twin problems of poor compliance and poor persistence with prescribed antihypertensive drug regimens appear to be responsible for much of the huge shortfall in the proportion of hypertensives whose treatment brings their blood pressure down to satisfactory levels. A further problem is the confounding of nonresponse and poor compliance in patients with "drug-resistant hypertension," in that about half of such patients are poor compliers, whose response to simple regimens usually proves satisfactory once their compliance with prescribed regimens is corrected. Electronic means for compiling ambulatory patients' drug dosing histories have now made it both technically and economically feasible to distinguish clearly between noncompliers and nonresponders, which clinical judgment cannot do because it is no better at making this crucial distinction than a coin toss. With the advent of reliable, economical measurements of patient compliance with prescribed drug dosing regimens, we can probably eliminate most of the compliance problems. The problem awaiting us after that is poor persistence with prescribed regimens for antihypertensive and other cardiovascular medicines that are meant for long-term or life-long use. A recent study has shown that median persistence with fully reimbursed drugs of the statin class is only 6 months, which is about one fortieth of the length it should be to realize full benefits of such therapy.

Determinants of pharmacists' interventions linked to prescription processing.

The role of pharmacists in today's healthcare is changing rapidly. As they are close to the prescribing process, pharmacists are in the position to identify and adjust prescribing errors before dispensing. The objective of this study was to identify relevant determinants of interventions directly linked to prescription processing in community pharmacy. As part of a yearly continuing education programme, all community pharmacies in the region of 'Zealand' (N = 23) in the south-west of The Netherlands kept detailed records of all interventions directly linked to prescription processing during one week in May 1998. For every patient involved in an intervention, a control-patient was matched on pharmacy practice, date, gender and age. A total of 39,357 prescriptions were evaluated by the 23 pharmacies during the one-week intervention programme. Out of these, one out of 10 resulted into an intervention. Being a first prescription in a new treatment episode was found to be a significant determinant (OR 1.75, 95 CI% 1.18-2.33). Variables reflecting drug therapy complexity (> 3 prescribers, > 15 prescriptions in 3 months before, > 3 different medications) showed all ORs higher than 1.00, but not significant. When looking at the individual drug categories, anti-infectives, respiratory drugs and cardiovascular medicines came out as important drug classes for intervention risk. We could not find any association between the number of signals per pharmacy and the number of interventions. The 'whistle-blower' model of pharmacy based interventions is a valid one but needs a targeted and integral way of implemented thinking and use of information technology. In such an environment, interventions are a logical step of in-process quality control in the drug usage system.

The Po River Delta epidemiological study: use of medicines in a general population sample of north Italy

Purpose—To provide information on the actual use of medicines in a general population sample. Methods—Information was collected in a general population sample of North Italy (1946 subjects; 938 males, 1008 females) by an interviewer-administered questionnaire. Results—Of the subjects 25.9% took habitually at least one medicine, whereas 11.1% used medicaments only occasionally. The use of medicines was significantly higher in females than in males (p < 0.001), but only in 15–44-year-old females, because of the use of oral contraceptives. The use of medicines increased with ageing (OR=1.80, p < 0.001). The highest use of habitual medicaments was found in subjects of 55+ years of both sexes. In both sexes, the medicines classified in the cardiovascular therapeutic group were the most frequently used. The use of gastrointestinal and cardiovascular medicines was significantly higher in males than in females (p < 0.001). In males, the use of habitual medicines was significantly (p < 0.001) higher in current smokers and ex-smokers than in never smokers. Only 23% of allergic subjects used antiallergic medicines, and only 35% of subjects with respiratory symptoms/diseases used medicines classified into the bronchopulmonary therapeutic group. The percentage of subjects who reported cardiovascular symptoms/diseases and used medicines classified in the cardiovascular therapeutic group was greater (62%). Conclusions—We stress the importance of data collection in general population samples by questionnaires to investigate the actual use of medicines. This may give a more accurate estimate of medicine use than is possible from pharmacy sales or hospital records. Copyright © 2000 John Wiley & Sons, Ltd.

The Po River Delta epidemiological study: use of medicines in a general population sample of north Italy

Purpose-To provide information on the actual use of medicines in a general population sample.Methods-Information was collected in a general population sample of North Italy (1946 subjects; 938 males, 1008 females) by an interviewer-administered questionnaire.Results-Of the subjects 25.9% took habitually at least one medicine, whereas 11.1% used medicaments only occasionally. The use of medicines was significantly higher in females than in males (p < 0.001), but only in 15-44-year-old females, because of the use of oral contraceptives. The use of medicines increased with ageing (OR=1.80, p < 0.001). The highest use of habitual medicaments was found in subjects of 55+ years of both sexes. In both sexes, the medicines classified in the cardiovascular therapeutic group were the most frequently used. The use of gastrointestinal and cardiovascular medicines was significantly higher in males than in females (p < 0.001). In males, the use of habitual medicines was significantly (p < 0.001) higher in current smokers and ex-smokers than in never smokers. Only 23% of allergic subjects used antiallergic medicines, and only 35% of subjects with respiratory symptoms/diseases used medicines classified into the bronchopulmonary therapeutic group. The percentage of subjects who reported cardiovascular symptoms/diseases and used medicines classified in the cardiovascular therapeutic group was greater (62%).Conclusions-We stress the importance of data collection in general population samples by questionnaires to investigate the actual use of medicines. This may give a more accurate estimate of medicine use than is possible from pharmacy sales or hospital records. Copyright (c) 2000 John Wiley & Sons, Ltd.

Polypharmacy among older men in South Wales.

To describe the pattern of polypharmacy (PP) among older men and to relate medication use to personal, social and medical information. Information on medication use, both prescribed and 'over the counter' (OTC), was collected from 1906 men, aged 56-75 years, observed on up to four occasions since 1979 in a community survey the Caerphilly prospective study. On each visit, a variety of questionnaires regarding personal, social and medical factors were completed, and a brief medical examination was conducted. Medication use was related to some of the questionnaire information and biological measurements collected in order to identify factors associated with PP. A quarter of the men (475/1906) reported using three or more prescription-only medicines (PoMs), with 9% (163) using five or more (major PP). PP was related to increasing age, lower social class, not being in employment, smoking and obesity (high body mass index). Men with a medical history, especially of high blood pressure, angina, heart attack, or hospital admission in the last 5 years, comprised a large proportion of those on major PP. Higher levels of PoM use by this group had been apparent over the previous 14 years. Men on PP reported lower levels of self-rated health and higher rates of non-PoM use. Cardiovascular and, to a lesser extent, central nervous and respiratory system drugs were the main medicines used by men on major PP. PP is common among men aged 56-75 years in Caerphilly, South Wales. It is related to many personal, social and medical factors, and associated with lower self-rated health status and greater use of non-PoMs. Cardiovascular medicines are the main contributor to major PP. Those on PP require regular review and, where possible, PP should be reduced as it has many potential adverse effects.

Pirkle-Concept Chiral Stationary Phases for the HPLC Separation of Pharmaceutical Racemates

Abstract The enantioselectivity of various Pirkle-concept chiral stationary phases (CSPs) for the direct HPLC separation of chiral drugs is explored and discussed. Seven different CSPs are surveyed for their utility to separate enantiomeric pairs belonging to the following major pharmaceutical classes: cardiovascular medicines (antihypertensives, antiarrhythmics, antianginals, diuretics), adrenergic drugs (vasopressors), antiinflammatory and analgesic compounds, topical anesthetics, antihistaminics, and antimalarial therapeutics.