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PubMed2005

A propensity score analysis of the impact of angiotensin-converting enzyme inhibitors on long-term survival of older adults with heart failure and perceived contraindications.

OBJECTIVES: The purpose of this study is to determine the association between discharge use of angiotensin-converting enzyme (ACE) inhibitors in patients with perceived contraindications to these drugs and 4-year post-discharge survival among hospitalized older adults discharged alive with a primary discharge diagnosis of systolic heart failure. BACKGROUND: Perceived contraindications to the use of ACE inhibitors are often associated with underuse of these life-saving drugs. METHODS: Chronic renal insufficiency, hypotension, hyperkalemia, and severe aortic stenosis were conditions perceived as contraindications. Using a multivariable logistic regression model, we at first determined propensity scores for receipt of ACE inhibitors for each patient. Bivariate and multivariable Cox proportional hazard analyses were used to determine crude and adjusted risks of 4-year mortality compared with patients without perceived contraindications who were discharged on an ACE inhibitor (referent group). RESULTS: Compared with the referent group, patients with perceived contraindications who were not discharged on an ACE inhibitor had a significant 2-fold increase in the risk of 4-year mortality (adjusted hazard ratio [HR] = 2.33, 95% CI = 1.30-4.19). Patients with perceived contraindications who were discharged on ACE inhibitors had a non significant 23% higher risk of 4-year mortality (versus the referent group) (adjusted HR = 1.23, 95% CI = 0.71-2.13). CONCLUSION: Discharge use of ACE inhibitors was associated with significant long-term survival benefit in patients considered to have contraindication to these drugs.

Aged↗
PubMed1991

Verapamil administration to patients with contraindications: is it associated with adverse outcomes?

STUDY OBJECTIVES: To determine if the use of verapamil in patients with contraindications is associated with adverse sequelae, thereby assessing whether process measures of the quality of care are correlated with patient outcomes. DESIGN: Retrospective chart review comparing the incidence of adverse outcomes and drug failure in patients with and without contraindications to verapamil administration. SETTING: University hospital emergency department. PARTICIPANTS: All patients more than 12 years old who received IV verapamil during the study period. MEASUREMENTS: The presence or absence of contraindications to verapamil, the occurrence of complications, and the frequency of drug failure were determined by chart review. MAIN RESULTS: Patients with contraindications to verapamil experienced a significantly higher incidence of adverse outcomes and drug failures than those without contraindications. The presence of contraindicated rhythms, low pretreatment blood pressure, and signs of congestive heart failure were each specifically associated with an increased risk of adverse sequelae. CONCLUSION: Verapamil should not be administered to patients with contraindications to its use. In this instance, quality assurance process measures correlate with patient outcomes.

Adult↗
PubMed2002

Survival benefits of angiotensin-converting enzyme inhibitors in older heart failure patients with perceived contraindications.

OBJECTIVES: To determine the association between angiotensin-converting enzyme (ACE) inhibitor therapy and survival of older heart failure patients with conditions perceived by physicians as contraindications to ACE inhibitors. SETTING: Hospital. DESIGN: Retrospective follow-up study. PARTICIPANTS: Hospitalized older heart failure patients with systolic blood pressure of 90 mmHg or less, serum creatinine of 2.5 mg/dL or more, serum potassium of 5.5 mmol/L or more, or severe aortic stenosis. MEASUREMENTS: One-year postdischarge mortality (with and without adjustment for various patient and care characteristics). Logistic regression analyses were used to estimate the effect of the perceived contraindications on subsequent use of ACE inhibitors. Using Cox proportional hazards models, crude and adjusted hazard ratios (HRs) of 1-year mortality with 95% confidence intervals (CIs) were estimated for patients discharged on ACE inhibitors and compared with those without. HRs were estimated for all patients and were repeated after stratifying patients based on the presence of perceived contraindications to ACE inhibitor use. RESULTS: Of the 295 subjects, 52 (18%) had conditions perceived as contraindications, 186 (63%) received ACE inhibitors, and 107 (40%) died within 1 year of discharge. Presence of a perceived contraindication was independently associated with underutilization of ACE inhibitors on discharge (adjusted OR = 0.35, 95% CI = 0.17-0.71). ACE inhibitor prescription at discharge was associated with lower 1-year mortality overall (HR = 0.58, 95% CI = 0.40-0.85) and for the groups of patients with (HR = 0.34, 95% CI = 0.14-0.81) and without (HR = 0.66, 95% CI = 0.42-1.02) perceived contraindications. CONCLUSIONS: ACE inhibitor use was associated with a significant survival benefit in this cohort of hospitalized older heart failure patients with perceived contraindications.

Aged↗
PubMed2005

Effect of prescriber education on the use of medications contraindicated in older adults in a managed medicare population.

OBJECTIVE: To measure the effect of pharmacy intervention programs on the percentage of older adult members filling prescriptions for one or more contraindicated medications in a managed Medicare population. METHODS: Prescribers of potentially inappropriate (i.e., contraindicated) medications in a managed Medicare + Choice (now known as Medicare Advantage) health maintenance organization (HMO) were identified from drug claims each calendar quarter for letter and telephone contact. The initial study population was composed of members in the Medicare + Choice HMO who were aged 65 years or older and who utilized their managed care pharmacy benefit during the 4-year measurement period from 1999 fourth quarter (Q4) through 2003 Q4. The study population was expanded in 2003 Q1 to include all patients aged 65 years or older, including commercial HMO members and Medicare + Choice members. The prescribers of target (contraindicated) drugs were contacted by a letter that described the program and included a prescriber-specific list of patients who had received a potentially inappropriate drug. Each prescriber was requested to review the report and change the contraindicated drug to a more appropriate agent, lower the medication dose, or carefully monitor those patients who could not discontinue the drug. A clinical pharmacist contacted high-volume prescribers of target drugs (4 or more patients in a given quarter) by telephone to discuss the identified patients. RESULTS: The incidence of inappropriate use of the target medications in older adults declined by 19%, from an absolute 5.3% of prescriptions in the base period (1999 Q4) to 4.3% at the end of the first 2-year period, in 2001 Q4. A change in the target drugs in 2002 Q1 from a list based upon the Beers' criteria to a list based in part on the Zhan et al. criteria was associated with a 45% reduction in the percentage (2.4%) of older adult members who received target drugs; this proportion remained essentially unchanged at 2.2% through 2003 Q4, the end of the second half of the 4-year intervention period. CONCLUSIONS: A clinical intervention program targeting prescribers of drugs judged to be contraindicated in older adults was associated with a decline in the percentage of HMO members receiving one or more target contraindicated drugs. After a 4-year intervention period, 2.2% of older adult HMO members continued to receive one or more target contraindicated drugs.

Aged↗
PubMed2001

Coprescribing and codispensing of cisapride and contraindicated drugs.

CONTEXT: Cisapride, an oral prokinetic drug indicated for the symptomatic treatment of nocturnal heartburn due to gastroesophageal reflux disease, was approved by the US Food and Drug Administration in July 1993. After reports of serious cardiac arrhythmias and deaths during administration of cisapride, most involving concomitant exposure to another drug, a series of label changes and warnings were issued in February 1995, October 1995, June 1998, and June 1999. Cisapride was removed from general distribution in July 2000. OBJECTIVE: To determine the frequency of contraindicted coprescribing and codispensings, in which cisapride and a contraindicated drug were prescribed or dispensed to the same patient for overlapping periods, and the proportion of contraindicated coprescribing by the same physicians and codispensing by the same pharmacies. DESIGN AND SETTING: Retrospective study of prescription claims from a managed care organization database for all patients with cisapride prescriptions between July 1993 and December 1998. PARTICIPANTS: A total of 38 757 adult and pediatric patients who had a cisapride prescription immediately preceded by at least 60 days of insurance eligibility. MAIN OUTCOME MEASURE: Proportion of cisapride prescriptions or dispensing occurring during the same treatment period as a drug contraindicated at that time prescribed by the same physicians or dispensed by the same pharmacies. RESULTS: Of 131 485 cisapride prescriptions dispensed after the warnings began, 4414 (3.4%) overlapped with at least 1 drug contraindicated in the labeling at the time of the prescription. Of all overlapping prescription pairs, 2190 (50%) were by the same physicians, 3908 (89%) were by the same pharmacies, and 765 (17%) were dispensed on the same day. CONCLUSION: Prescriptions dispensed by the same pharmacies accounted for a far higher proportion of contraindicated medication pairs than prescriptions from the same physicians. The pharmacy may be an important and underutilized intervention point to prevent contraindicated drugs from being used together.

Adolescent↗
PubMed2001

Contraindicated medications dispensed with cisapride: temporal trends in relation to the sending of 'Dear Doctor' letters.

PURPOSE: 'Dear Doctor' letters alert the prescribing community of drug labeling changes that contain new contraindications, warnings, adverse reactions, and precautions. There has been little assessment of the impact of these letters. We quantified the impact of two 'Dear Doctor' letters concerning interactions between cisapride and a series of drugs. A letter in 1995 described a risk of prolonged QT intervals and serious ventricular arrhythmia in patients who received macrolide antibiotics and imidazole antifungals in conjunction with cisapride. A June 1998 letter that expanded the list of contraindicated comedications had wider distribution than an earlier one, was accompanied by substantial Internet and media coverage, and was complemented by an effort to inform large pharmacy dispensing information organizations of the warnings against concurrent use of the named drugs. METHODS: Health plan members with one or more outpatient pharmacy claims for cisapride during the period 1 January 1995 through 31 May 1999 were identified among members of a large New England health insurer. A retrospective review of concurrent and nearly concurrent dispensings of cisapride and contraindicated comedications was undertaken in the automated pharmacy claims data using both graphical and statistical time-series analysis. We tabulated by month the fraction of cisapride dispensings that occurred in close temporal relation to dispensings of contraindicated comedications. Codispensings that occurred on the same day were taken as the most direct measure of prescriber responsiveness to the letters. Codispensings that occurred in windows of plus or minus 2 weeks (29 day window) and plus or minus 4 weeks (57 day window) were taken as measures of possible simultaneous consumption. Among overlapping dispensings, we counted the proportion dispensed by the same pharmacy. Time series regression analysis of secular, seasonal, and step-effects was conducted. RESULTS: There was a steady decline in codispensing of cisapride and contraindicated medicines, and a pronounced seasonal effect, arising principally from the seasonal use of macrolide antibiotics. Against this background, the isolated Dear Doctor letter of October 1995 had no discernible effect on prescribing practices. The 1998 letter and surrounding activity, by contrast, were followed by a 66% decline in same-day dispensings and a smaller, but still pronounced decline in dispensings in the wider time windows. For most codispensings of contraindicated medications with cisapride, both medications came from the same pharmacy. CONCLUSIONS: Publicity and direct intervention with dispensing pharmacies may be an important supplement to Dear Doctor letters when the goal is to eliminate the codispensing of drugs that should not be taken together.

Adolescent↗
PubMedDate not supplied

Incidence of contraindications to total disc arthroplasty: a retrospective review of 100 consecutive fusion patients with a specific analysis of facet arthrosis.

BACKGROUND CONTEXT: The role of total disc arthroplasty (TDA) in the treatment of spinal pathology is unclear. TDA has been touted as an alternative to fusion. However, not all back pain is purely discogenic in origin. Contraindications to TDA exist. At Spine Week in Porto, Portugal, Cammisa's group from the Hospital for Special Surgery in New York presented a series of 56 fusions where 100% of patients had one or more of 10 contraindications to TDA. En face, this appears to be an extremely large number. PURPOSE: The purpose of the study was to repeat the Hospital for Special Surgery study in another cohort of fusion patients. STUDY DESIGN/SETTING: This study was an independent, retrospective record review of 100 consecutive lumbar spinal fusions performed at a tertiary care private medical center. PATIENT SAMPLE: All adult patients having primary1-3 level lumbar spinal fusions from January 2003 to May 2004 were assessed. OUTCOME MEASURES: Physiologic measures included imaging, range of motion, and response to facet blocks. METHODS: A retrospective chart review was performed of 100 consecutive patients having primary 1-3 level lumbar fusion by all five active staff spinal surgeons (3 orthopedic and 2 neurosurgeons). The review was performed independently by the doctorate level physiotherapist who serves as the medical center's research coordinator, reporting to the chairman of the Hospital institutional review board. The same 10 contraindications from Cammisa's study were noted. Additional facet arthrosis data were collected, including mention on imaging reports or operating room notes. Clinical notes were reviewed for documentation of range of lumbar motion (ROM) and whether there was restricted or painful extension ROM. Note was made if patients had facet blocks as another clinical indicator of facet arthrosis. RESULTS: All 100 patients had at least one contraindication to TDA. The average was 3.69 (range 1-7). Only one patient had facet arthrosis as their only contraindication. Facet arthrosis was documented on imaging reports or operating room notes in 97/100. Reduced extension was present in 71/75 charts that documented ROM. Facet blocks were performed in 12/100 and gave greater than 50% relief in nine. CONCLUSIONS: Both our study and Cammisa's indicate that all lumbar fusion patients in our two institutions have at least one contraindication to TDA. The average fusion patient does not appear to have isolated discogenic pain. A large proportion of the patients appeared to have facet arthritis. The point where facet arthrosis definitely constitutes a contradiction to TDA will require analysis during long-term arthroplasty follow-up studies. Suitable patients for TDA may not represent a significant cohort presently undergoing lumbar fusion.

Adult↗
PubMed1998

Medical contraindications are not a major factor in the underutilization of breast conserving therapy.

BACKGROUND: Multiple randomized trials have demonstrated that survival after breast conserving therapy (BCT) is equal to survival after mastectomy, but large population-based studies indicate that > 50% of patients with early stage breast cancer continue to undergo mastectomy. This study was undertaken to determine whether medical contraindications to BCT or patient choice are responsible for high mastectomy rates. STUDY DESIGN: Four hundred thirty-two patients with stage 0, I, or II breast carcinoma were prospectively evaluated by a multidisciplinary team for eligibility for BCT. Standard criteria developed by a joint committee of the American College of Surgeons, American College of Radiologists, College of American Pathologists, and Society of Surgical Oncology were used. Eligible patients were offered a choice among BCT, mastectomy, or mastectomy and immediate reconstruction. RESULTS: Only 97 of the 432 patients had contraindications to BCT. The incidence of contraindications varied by stage: 10% for stage I, 28% for stage II, and 33% for stage 0 (p < 0.01). The type of contraindications also varied with stage. Age, histologic tumor type, and axillary node status (when controlled for tumor size) did not influence rates of BCT. Of eligible patients, 81% chose BCT, independent of age or race. CONCLUSIONS: Medical contraindications to BCT are not major factors resulting in high mastectomy rates. Strategies like neoadjuvant chemotherapy, which addresses medical contraindications, are unlikely to have a major impact on national rates of BCT.

Adult↗
PubMed1990

Measles/mumps/rubella vaccine (MMR): an audit of Leeds health professionals' knowledge of contraindications and intention to vaccinate assessed by postal questionnaire.

An audit of Leeds health professionals' knowledge of valid contraindications to measles/mumps/rubella (MMR) vaccine was undertaken by postal questionnaire, three months after its introduction. The health professional groups were health visitors, clinical medical officers, general practice trainers and general practice vocational trainees. The results indicate that some health professionals would give MMR vaccine to children when it was contraindicated (e.g. to a child receiving chemotherapy or radiotherapy). However, a much greater problem was the number of health professionals stating that they would not vaccinate children with MMR vaccine in clinical situations where there were no valid contraindications to its use. Some health professionals were also applying contraindications to the use of pertussis vaccine to the use of MMR vaccine. The information contained in the Joint Committee on Vaccination and Immunisation handbook Immunisation against infectious disease on contraindications to MMR vaccine use is also reviewed. It is important that false contraindications are not used by health professionals to wrongly deny children the protection provided by MMR vaccine.

Allied Health Personnel↗
PubMed2005

When should vaccination be contraindicated in children?

No child should be denied immunisation without serious consideration given to the consequences. In the past, many contraindications to vaccination were based on theoretical concerns. These concerns often assumed an immunoallergic mechanism for adverse reactions, whereas many such events are often due to other causes. Other contraindications were based on evidence of excess risk, but this risk was not always balanced against the higher risk of disease. Therefore, contraindications often varied between countries and over time. In recent years, the widespread availability of less reactogenic vaccines and the common use of combined preparations have prompted a review of contraindications in many countries. Accumulated experience worldwide has allowed the list of conditions that contraindicate vaccination to be reduced. The international consensus now is that there are very few situations in which a child should not be immunised and the only true contraindication applicable to all vaccines is a history of anaphylaxis to a vaccine component or following a previous dose of the vaccine. Health professionals should feel confident in accepting national recommendations and, if in doubt, should refer children for an expert opinion, rather than deny a child protection against a serious infection.

Anaphylaxis↗
PubMed2005

Percutaneous vertebroplasty and kyphoplasty performed at a cancer center: refuting proposed contraindications.

OBJECT: The purpose of this study was to examine a group of patients with cancer who underwent a vertebroplasty or a kyphoplasty for a vertebral body (VB) fracture, even though the procedure may have been considered contraindicated based on previous reports in the literature. METHODS: The electronic database maintained by the Departments of Neurosurgery and Anesthesiology-Pain Management at the University of Texas M. D. Anderson Cancer Center was searched for patients who underwent vertebroplasty or kyphoplasty between January 2001 and July 2003. The criteria defining a contraindicated procedure were based on a review of the literature. Group I consisted of patients who did not undergo a contraindicated vertebroplasty or kyphoplasty, whereas Group II consisted of patients who underwent one of these procedures even though it may have been considered contraindicated. There were 53 patients with fractures at 132 levels who met the criteria for the study. Of these, 17 patients with fractures at 18 levels (14% of total) were considered to have undergone a contraindicated vertebroplasty or kyphoplasty (Group II). There were 12 complications (11%) in the 114 levels in Group I and seven complications (39%) in the 18 levels in Group II (p = 0.03). The most common complication was cement extrusion from the anterior VB that did not involve the venous system. No patient required an open surgical procedure to remove extruded cement. CONCLUSIONS: Vertebroplasty and kyphoplasty appear to be safe and effective in the setting of severe back pain caused by VB fracture that is unresponsive to other therapies, even in the presence of relative contraindications to the procedures.

Adult↗
PubMed1992

[Plastic surgery and breast cancer. Are there contraindications for plastic surgery?].

Plastic surgery has acquired an important place in primary breast cancer treatment (conservative or radical) and in the treatment of sequelae. The authors have tried to define, based on their experience, the contraindications for breast reconstruction. They are rare from a technical point of view. The carcinologic contraindications are relative: highly aggressive cancers, locally advanced cancers, cancers with metastases or recurrences. Radionecrosis and radio-induced sarcomas, treatment sequelae are also contraindications for breast reconstruction. General contraindications are relative (major obesity, smoking, diabetes, general weakness). Psychological contraindications must be taken into consideration. The authors conclude that contraindications for breast reconstruction are mainly carcinologic and the decision for reconstruction is usually taken by the patient after complete medical information.

Breast Neoplasms↗
PubMed2005

Contraindications can damage your health--is metformin a case in point?

Metformin is an effective anti-hyperglycaemic and cardioprotective agent, but a long list of contraindications precludes millions of patients with type 2 diabetes from using it. This is largely due to the historical experience of lactic acidosis with phenformin, despite the fact that metformin does not predispose to this when compared with other therapies. Contraindications such as old age, renal impairment and cardiac insufficiency are increasingly disregarded in clinical practice, yet there is no evidence that the incidence of lactic acidosis has changed. Metformin has been shown to improve metabolic control without causing lactic acidosis in elderly patients with multiple comorbidities, including explicit contraindications, and its use in patients with type 2 diabetes over the age of 70 with mild renal impairment did not produce a clinically relevant increase in plasma lactate. There is no correlation between levels of metformin and lactate in patients with lactic acidosis, and its prognosis is mainly related to the causal hypoxic underlying disease and comorbidities. These findings raise doubts about the pathogenetic significance of metformin in lactic acidosis. We propose that advanced age per se, mild renal impairment and compensated heart failure can no longer be upheld as contraindications for metformin. A clear re-definition of contraindications to metformin will enable more physicians to prescribe within guidelines.

Acidosis, Lactic↗
PubMed2003

Absolute contraindications in relation to potential drug interactions in outpatient prescriptions: analysis of the first five million prescriptions in 1999.

OBJECTIVES: Adverse drug interactions increase morbidity and mortality. To prevent these, situations leading to adverse prescriptions must be clarified. This study quantifies and analyses prescriptions with potential adverse drug interactions in primary health care in the North of France over a 3-month period. METHODS: All prescriptions administered between 1 January 1999 and 31 March 1999 were analysed to identify potential interactions amongst drugs appearing on the same prescription sheet. The regional French healthcare database was compiled to further classify contraindications. RESULTS: There were 5,358,374 prescriptions administered to 44% of the overall population of the Nord-Pas de Calais area (1,754,372 patients per 3,990,167 general population). There were 14,390 prescriptions classified as either absolute (26%) or relative contraindications (74%). Nine drug categories accounted for most of the absolute contraindications: dopaminergic antiparkinsonians, neuroleptic agents, migraine treatments (such as ergot alkaloids, sumatriptan and other triptan derivatives), prokinetic drugs (cisapride), antibacterial drugs (macrolides), antifungals (imidazoles), antiarrhythmics, beta-blockers and analgesics (opioids and floctafenine). In 54% of patients exposed, the incurred risk was either QT prolongation/Torsade de Pointes or antagonism of dopaminergic antiparkinson agents with dopamine receptor antagonists prescribed as antipsychotic agents. CONCLUSIONS: Among a non-selected population of ambulatory outpatients, the number of quarterly prescriptions with contraindications with potentially harmful drug interactions is 27 in 10,000 prescriptions. This would extrapolate to nearly 200,000 contraindications on same-prescription sheets in France in the first quarter of 1999.

Adolescent↗
PubMed2004

Contraindications for superficial heat and therapeutic ultrasound: do sources agree?

OBJECTIVES: To determine the amount of agreement among general rehabilitation sources for both superficial heating and therapeutic ultrasound contraindications. DATA SOURCES: English-language textbook and peer-reviewed journal sources, from January 1992 to July 2002. Searches of computerized databases (HealthSTAR, CINAHL, MEDLINE, Embase) as well as Library of Congress Online Catalogs, Books in Print, and AcqWeb's Directory of Publishers and Venders. DATA SELECTION: Sources were excluded if they (1) were published before 1992, (2) failed to address general rehabilitation audiences, or (3) were identified as a researcher's related publication with similar information on the topic. DATA EXTRACTION: Type and number of contraindications, type of audience, year of publication, number of references, rationales, and alternative treatment strategies. DATA SYNTHESIS: Eighteen superficial heat and 20 ultrasound sources identified anywhere from 5 to 22 and 9 to 36 contraindications/precautions, respectively. Agreement among sources was generally high but ranged from 11% to 95%, with lower agreement noted for pregnancy, metal implants, edema, skin integrity, and cognitive/communicative concerns. Seventy-two percent of superficial heat sources and 25% of ultrasound sources failed to reference at least 1 contraindication claim. CONCLUSIONS: Agreement among contraindication sources was generally good for both superficial heat and therapeutic ultrasound. Sources varied with regard to the number of contraindications, references, and rationales cited. Greater reliance on objective data and standardized classification systems may serve to develop more uniform guidelines for superficial heat and therapeutic ultrasound.

Contraindications↗
PubMed2002

Contraindicated NSAIDs are frequently prescribed to elderly patients with peptic ulcer disease.

AIMS: To establish the frequency with which NSAIDs were prescribed to elderly patients after admission to hospital for serious gastrointestinal complications and to study which factors are determinants of the prescription of these contraindicated drugs. METHODS: A retrospective cohort study of patients from The Rotterdam Elderly Study, a prospective population-based cohort study of people older than 55 years of age was carried out. Elderly patients with a hospital admission for serious gastrointestinal complications were followed until prescription of an NSAID, death, removal to another area or end of the study period, whichever came first. The following baseline determinants for receiving a contraindicated prescription were studied: gender, age, presence of rheumatoid arthritis or osteoarthritis, presence of cardiovascular risk factors, number of GP visits, number of visits to a medical specialist, cognitive function and the prescriber being a GP or a medical specialist. RESULTS: Prescriptions of an NSAID after discharge from hospital, were identified in 73 patients (73%). Fifty-one percent were prescribed aspirin of whom the large majority used it as an antithrombotic agent, and 49% were prescribed a nonaspirin NSAID after discharge from hospital. Twenty percent of the patients used more than one NSAID on one or more occasions after discharge. For patients who were prescribed NSAIDs before admission as well as after discharge, the proportion of contraindicated prescriptions with concomitant use of antiulcer drugs rose significantly from 0.19 before discharge to 0.60 after discharge for aspirin and from 0.11 to 0.61 for nonaspirin NSAIDs. In the multivariate analysis the only remaining factor with prognostic influence on prescription of NSAIDs was a history of NSAID use before cohort enrollment. A history of rheumatoid arthritis or osteoarthritis was not associated with NSAID prescription after discharge. CONCLUSIONS: Contraindicated NSAIDs are prescribed to a great extent in elderly patients, despite their greater vulnerability for life-threatening gastrointestinal blood loss. It is remarkable that a history of rheumatoid arthritis or osteoarthritis is no significant determinant for receiving a contraindicated prescription, which suggests that these drugs are mainly prescribed for uncomplicated arthralgia.

Aged↗
PubMed2006

[Traditional contraindications to the use of metformin -- more harmful than beneficial?].

For fear of lactic acidosis the currently listed contraindications to the use of metformin exclude a large number of people with type 2 diabetes from efficacious anti-hyperglycemic and cardioprotective treatment. Yet recent data call the traditional contraindications to metformin into question. As the incidence of lactic acidosis in patients with type 2 diabetes is the same with or without metformin therapy (about 9 per 100,000 patient years) there is no evidence that metformin therapy is associated with an increased risk of lactic acidosis. Similarly, despite disregard internationally of major metformin contraindications, there has been no corresponding increase in the incidence of lactic acidosis. Metformin treatment of elderly diabetics with multiple comorbidities and explicit contraindications has led to significantly better clinical parameters in them than in the control group without metformin; and there were no cases of lactic acidosis. The two groups did not differ with regard to progression of renal failure, patient-oriented endpoints or overall mortality. Compared with its predecessors phenformin and buformin, metformin is considerably less lipophilic and has a shorter plasma half-life; it is eliminated renally in unchanged form. In type 2 diabetics treated with metformin -- even those over 70 years of age and those in mild renal failure -- no relevant increases in lactate levels were found. In patients with lactic acidosis there was no correlation between the levels of metformin and lactate. The prognosis of lactic acidosis is determined less by the serum concentrations of metformin and lactate than by the hypoxia caused by the underlying disease and comorbidities. These findings raise doubts about the significance of metformin in the pathogenesis of lactic acidosis. On the basis of the current data, advanced age per se, mild renal impairment and stable heart failure can no longer be upheld as contraindications to the use of metformin. It should be safe to withdraw metformin the evening before radiological examinations with intravenous contrast media or surgical procedures under general anaesthesia in diabetics with normal renal function.

Acidosis, Lactic↗
PubMed1993

[Indications and contraindications for implantation of bifocal intraocular lenses].

BACKGROUND: Bifocal intraocular lenses (BIOLs) performed satisfactorily in a certain number of patients only. This paper therefore provides an overview of the indications and contraindications of BIOLs. CONCLUSIONS INDICATIONS: BIOLs are indicated in younger and active patients without ocular pathologies. BIOLs should be implanted bilaterally, corneal astigmatism should be less than 1 dpt, emmetropia should be the target refraction, pupil size and responsiveness must be normal, and IOL decentration should be avoided. CONTRAINDICATIONS: Corneal astigmatism in excess of 1 dpt, very small or atonic pupils, ocular pathologies, and a monofocal fellow eye are definite contraindications. In addition, BIOLs are contraindicated in patients who require maximum resolution at low contrast. Relative contraindications include very old patients, eyes with an axial length of more than 24.5 mm or less than 22 mm, and patients who may not tolerate the visual side effects (halos, glare).

Aged↗