The American journal of managed care
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Pharmacokinetic drug-drug interactions (DDIs) involving opioid analgesics can be problematic. Opioids are widely used, have a narrow therapeutic index, and can be associated with severe toxicity. ⋯ Opioids metabolized by the drug metabolizing enzymes of the cytochrome P450 (CYP450) system (codeine, oxycodone, hydrocodone, fentanyl, tramadol, and methadone) are associated with numerous DDIs that can result in either a reduction in opioid effect or excess opioid effects. Conversely, opioids that are not metabolized by that system (morphine, oxymorphone, and hydromorphone) tend to be involved in fewer CYP450-associated pharmacokinetic DDIs.
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To evaluate the effect of medical comanagement on outcomes of hospitalized surgical patients who had postoperative complications. ⋯ Comanagement of patients who had perioperative complications was associated with lower mortality, suggesting that comanagement may facilitate effective rescue among medically complex surgical patients.
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To study risk factors for and likelihood of unplanned hospital admission and readmission in persons aged >65 years in Catalonia, Spain. ⋯ Aged persons and those who used more hospital services in previous years had a higher probability of hospital admission and readmission.
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Patients with moderate to severe pain often require opioid therapy, and many of these patients have multiple comorbid conditions requiring several medications. Guidelines for opioid use do not properly address their use in patients taking multiple medications, as they focus primarily on patient selection, monitoring the patient for drug abuse, and treatment adherence. Moreover, guidelines discuss very little regarding potential drug-drug interactions (DDIs) with opioids. ⋯ In managed care settings, a medication therapy management program is an excellent way to reduce inappropriate polypharmacy, and should result in cost savings. Clinicians should also consider drug-disease interactions and drug-food interactions that may be unique to individual patients. A proper assessment of these interactions may also provide insight into medications that are inappropriate, ineffective, and/or unnecessary in a particular patient.
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Elderly patients and residents in long term care facilities requiring pain medication often have multiple pharmacologic and physiologic factors that can impact the choice of analgesic. One particular problem with prescribing opioids to the elderly and long term care residents is that opioid safety and efficacy have not been well studied in these populations, and it may be difficult to predict how these patients will respond to opioid treatment. As people age, numerous physiological changes occur, which may affect opioid pharmacokinetics and the potential for drug-drug interactions (DDIs). ⋯ Many elderly and long term care patients have cognitive deficits that impede communication about their pain, thus making detection of opioid DDIs more difficult. Knowledge of the patient's medical history and current prescriptions can help guide the pain management team in the selection of treatment, help minimize the risk of DDIs, and provide these patients with the pain relief they require. There are several practice management recommendations for opioid therapy in the elderly and long term care residents, with the goal of optimizing analgesia while avoiding adverse events and drug interactions.