Elsevier

Primary Care Diabetes

Volume 14, Issue 5, October 2020, Pages 529-537
Primary Care Diabetes

Original research
Potentially inappropriate medications in older individuals with diabetes: A population-based study in Quebec, Canada

https://doi.org/10.1016/j.pcd.2020.03.003Get rights and content

Highlights

Abstract

Aim

To study the population-based prevalence of potentially inappropriate medication (PIM) among older individuals with diabetes, and to identify factors associated with their use.

Methods

We used the Quebec Integrated Chronic Disease Surveillance System (QICDSS) database to conduct a population-based cohort study of individuals with diabetes ≥66 years between April 1st, 2014 and March 31st, 2015. PIMs were defined according to the 2015 Beers Criteria. Factors associated with PIM use were identified using robust Poisson regression models. Risk ratios (RR) and 99% confidence intervals (99%CI) were calculated.

Results

More than half (56%) of the 286,962 older individuals with diabetes used at least one PIM over a year. Benzodiazepines (41%), proton pump inhibitors (27%) and endocrine medication (mainly glibenclamide) (25%) were the most common PIMs used. Factors associated with PIM use included female sex (RR: 1.17; 99%CI: 1.16–1.18), and comorbidities such as schizophrenia (1.48; 1.45–1.51), anxiety disorders (1.34; 1.33–1.35) and Alzheimer's disease (1.14; 1.13–1.25). Risks of using PIMs increased both with increasing comorbidities and number of medications.

Conclusion

PIM use is highly prevalent among older individuals with diabetes. Interventions to promote optimal medication use should particularly target individuals with comorbidities and polypharmacy who are most vulnerable to adverse drug events.

Introduction

Older individuals with diabetes have an average of five comorbidities [1], which inevitably increases the burden of medications they face. Diabetes is indeed associated with a higher risk of polypharmacy [2]. As large numbers of medications increase the risk of using potentially inappropriate medications (PIMs) [3], older individuals with diabetes are susceptible to PIM exposure [3], [4], [5].

PIMs include drugs that have been shown to induce adverse effects, to be ineffective or for which safer alternatives exist [6], [7]. PIMs are associated with increased rates of hospitalizations and mortality [8], [9], [10]. Their use leads to increased health care costs, both in terms of drug costs and costs incurred for managing drug-related adverse outcomes [11]. The use of ten or more medications and the use of PIMs are both associated with functional decline, geriatric syndrome and frailty among older individuals [4], [5].

As diabetes is also associated with these adverse outcomes of functional decline, geriatric syndrome and frailty [12], [13], the consequences of polypharmacy and PIMs may be amplified in the older individuals with diabetes. Therefore, it is paramount to ensure that iatrogenic risks are reduced among this population. However, recent data on the actual use of PIMs among older individuals with diabetes remains limited. Identifying factors associated with PIMs use would help better target interventions to tackle the problem, if needed.

The objectives of this study consist in determining the proportion of older individuals with diabetes exposed to PIMs, reporting PIMs most frequently used among this population, and identifying factors associated with the use of PIMs.

Section snippets

Data source

We used data from the Quebec Integrated Chronic Disease Surveillance System (QICDSS) of the Institut national de santé publique du Québec (INSPQ). The QICDSS is intended for chronic disease surveillance and is composed of five health administrative databases. The data stems from the public health system that covers the entire population in the province of Quebec, Canada. The QICDSS includes: the health insurance registry, the hospital discharge database (MED-ECHO), the death registry, the

Results

A total of 286,962 individuals with diabetes were included in the cohort, among which 51% were men (Table 1). Mean age was 76.4 years (SD 7.1), with age ranging from 66 to ≥100 years. Most individuals (78.3%) lived in urban area, and 70.6% had at least one of the eight comorbidities (coronary diseases, stroke, COPD, asthma, anxio-depressive disorders, schizophrenia, Alzheimer's disease and related dementias, and osteoporosis). Coronary disease (43.8%), COPD (25.7%) and osteoporosis (22.9%) were

Discussion

Of the 286,962 individuals with diabetes, more than half used at least one PIM. Benzodiazepines, PPIs, and endocrine medications (especially, glyburide [glibenclamide]) were the most commonly used PIMs. Factors associated with PIM use included female sex, higher number of comorbidities (especially psychiatric disorders and Alzheimer's disease), and a larger number of medications.

Our results compare with those of a study conducted in Spain, where 54.5% of hospitalized individuals aged 75 years

Conclusion

With more than one individual with diabetes out of two using PIMs, there is an urgent need to focus on PIMs deprescribing and to provide guidance on how to avoid the use of PIMs in these patients. Considering PIMs are associated with negative health outcomes, it appears crucial to ensure the iatrogenic risks remain minimal for this population who is already vulnerable to these outcomes. This study provides useful information to develop interventions aiming at decreasing the use of PIMs among

Conflict of interest

None.

Financial disclosure

Marie-Eve Gagnon is the recipient of a scholarship from the Fonds de recherche du Québec – Santé (FRQS) in partnership with Unité Soutien from the Strategy for patient-oriented research (SPOR) and was the recipient of a scholarship from the Canadian Institute for Health Research. Caroline Sirois receives a Research Scholarship Junior 1 from the FRQS and a starting grant from the Centre de recherche sur les soins et les services de première ligne de l’Université Laval and the Chaire de recherche

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