interventions may reduce polypharmacy and the use of potentially inappropriate medications (PIMs); however, few studies have been large enough to evaluate the impact that deprescribing may have on adverse drug events (ADEs).OBJECTIVE To evaluate the effect of an electronic deprescribing decision support tool on ADEs after hospital discharge among older adults with polypharmacy.DESIGN, SETTING, AND PARTICIPANTS This was a cluster randomized clinical trial of older (Ն65 years) hospitalized patients with an expected survival of more than 3 months who were

OBJECTIVES Polypharmacy is common, costly, and harmful for hospitalized older adults. Scalable strategies to reduce the burden of potentially inappropriate medications (PIMs) are needed. We sought to leverage medication reconciliation in hospitalized older adults by pairing with MedSafer, an electronic decision support tool for deprescribing. DESIGN This was a nonrandomized controlled before‐and‐after study. SETTING The study took place on four internal medicine clinical teaching units. PARTICIPANTS Subjects were aged 65 years and older, had an expected prognosis of 3 or more months, and were taking five or more usual home medications. INTERVENTION In the baseline phase, patients received usual care that was medication reconciliation. Patients in the intervention arm also had a “deprescribing opportunity report” generated by MedSafer and provided to their in‐hospital treating team. MEASUREMENTS The primary outcome was ascertained at the time of hospital discharge and was the proportion of patients who had one or more PIMs deprescribed. RESULTS A total of 1066 patients were enrolled, and deprescribing opportunities were present for 873 (82%; 418 during the control and 455 during the intervention phases, respectively). The proportion of patients with one or more PIMs deprescribed at discharge increased from 46.9% in the control period to 54.7% in the intervention period with an adjusted absolute risk difference of 8.3% (2.9%‐13.9%). Not all classes of drugs in the intervention arm were associated with an increase in deprescribing, and new PIM starts were equally common in both arms of the study. CONCLUSION Using an electronic decision support tool for deprescribing, we increased the proportion of patients with one or more PIMs deprescribed at hospital discharge as compared with usual care. Although this type of intervention may help address medication overload in hospitalized patients, it also underscores the importance of powering future trials for a reduction in adverse drug events. Trial registration: NCT02918058. J Am Geriatr Soc 67:1843–1850, 2019

Traumatic brain injury (TBI) patients are known to be at high risk for venous thromboembolic events (VTEs). The Brain Trauma Foundation Guidelines (2007) state that low-molecular-weight heparin or unfractionated heparin should be used to prevent VTE complications, but suggest that there is an increased risk of expansion of intracranial hemorrhages (ICH) with VTE prophylaxis. In addition, it is unclear which treatment regimen (i.e., medication, dose, and timing) provides the best risk:benefit ratio in TBI patients. We reviewed all moderate-to-severe TBI patients admitted over a 5-year period to: (1) examine the occurrence of VTEs and their timing; (2) examine the symptomatic expansion of ICH while on VTE prophylaxis; and (3) compare the efficacy of two prophylactic agents: enoxaparin and dalteparin. Two-hundred eighty-seven patients were included. VTE prophylaxis was started 48-72 h post-trauma in all individuals who had no confounding coagulopathy, when two consecutive computed tomography (CT) scans revealed hemorrhage stability. VTEs occurred in 7.3% of treated patients, mostly within 2 weeks after trauma. Proximal VTEs occurred in 3.1% of treated patients. No significant difference in VTE rates was seen between enoxaparin (7.0%) and dalteparin (7.5%; p = 0.868). Moreover, the group treated with dalteparin was more severely injured (higher Injury Severity Score [p = 0.002]), had lower Glasgow Coma Scale (GCS) scores (p = 0.003), and had more inferior vena cava (IVC) filters placed (p = 0.007). The two groups did not show significant differences in the development of VTE when controlled for ISS and IVC filters (p = 0.819). Importantly, only one patient suffered a symptomatic expansion of ICH while on VTE prophylaxis, at 15 days post-trauma. These results suggest that current regimens of VTE prophylaxis used in our TBI population provide a relatively high level of protection against VTEs, and an extremely low risk of expanding ICH. They also suggest that there was no difference in VTE between dalteparin- and enoxaparin-treated patients.

BACKGROUND/OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes high morbidity and mortality in older adults with chronic illnesses. Several trials are currently underway evaluating the antimalarial drug hydroxychloroquine as a potential treatment for acute infection. However, polypharmacy predisposes patients to increased risk of drug-drug interactions with hydroxychloroquine and may render many in this population ineligible to participate in trials. We aimed to quantify the degree of polypharmacy and burden of potentially inappropriate medications (PIMs) that older hospitalized adults are taking that would interact with hydroxychloroquine. METHODS:We reanalyzed data from the cohort of patients 65 years and older enrolled in the MedSafer pilot study. We first identified patients taking medications with potentially harmful drug-drug interactions with hydroxychloroquine that might exclude them from participation in a typical 2019 coronavirus disease (COVID-19) therapeutic trial. Next, we identified medications that were flagged by MedSafer as potentially inappropriate and crafted guidance around medication management if contemplating the use of hydroxychloroquine. RESULTS: The cohort contained a total of 1,001 unique patients with complete data on their home medications at admission. Of these 1,001 patients, 590 (58.9%) were receiving one or more home medications that could potentially interact with hydroxychloroquine, and of these, 255 (43.2%) were flagged as potentially inappropriate by the MedSafer tool. Common classes of PIMs observed were antipsychotics, cardiac medications, and antidiabetic agents. CONCLUSION: The COVID-19 pandemic highlights the importance of medication optimization and deprescribing PIMs in older adults. By acting now to reduce polypharmacy and use of PIMs, we can better prepare this vulnerable population for inclusion in trials and, if substantiated, pharmacologic treatment or prevention of COVID-19.