I would like to thank the authors for addressing this important topic (1). The focus of the article is on drug interactions. Numerous potential interactions are listed suggesting to avoid the drugs involved. It is known from international literature that polypharmacy (of up to five or more long-term medications) entails an enormous number of potential interactions. The category of clinically relevant interactions refers to cases for which the combination must be avoided, a dose adjustment is required, or additional monitoring is necessary—for example, by measuring the drug concentrations. Interactions that lead to manifest damage in the form of adverse drug events, or to an absence of the expected therapeutic effects, are of particular interest. Out of a large volume of data from spontaneous adverse event reports Leone et al. (2) have filtered and quantified those that can be traced back to drug interactions. An empirically supported overview of clinically relevant drug interactions focusing on psychotropic drugs would be helpful.
Avoiding interactions is not straightforward. Accordingly, various checklists and tools are recommended for support. However, their use for making day-to-day prescriptions is only practical if they are integrated into an electronic clinical decision support system. In addition to alerts to interactions (which are graded according to relevance), this system should include for instance indications of dosage errors and necessary dose adjustments in the case of renal insufficiency (3).
The goal of avoiding polypharmacy is briefly mentioned. Due to the specialty of the authors, I had hoped for an appraisal of polypsychopharmacological treatment of older patients, which is often used: in addition to concurrent use of antipsychotics, antidepressants, and / or sedatives, combinations of several antidepressants (such as venlafaxine in the morning, mirtazapine in the evening) or antipsychotics (for example, classic and atypical) are often prescribed in practices. The 2019 version of the Beers Criteria reinforces and accentuates the warning about concurrent use of three or more drugs that act on the CNS in older adults (4).
Dr. med. Rainer Burkhardt
Conflict of interest statement
Dr. Burkhardt has received honoraria for authorship of publications related to the subject from MedLearning AG, Munich.
|1.||Kratz T, Diefenbacher A: Psychopharmacological treatment in older people—avoiding drug interactions and polypharmacy. Dtsch Arztebl Int 2019; 116: 508–18 VOLLTEXT|
|2.||Leone R, Magro L, Moretti U, et al.: Identifying adverse drug reactions associated with drug-drug interactions. Drug Saf 2010; 33: 667–75 CrossRef MEDLINE|
|3.||Zenziper Y, Kurnik D, Markovits N, et al.: Implementation of a clinical decision support system for computerized drug prescription entries in a large tertiary care hospital. Isr Med Ass J 2014; 16: 289–94.|
|4.||The 2019 American Geriatrics Society Beers Criteria Update Expert Panel: American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019; 67: 674–94 CrossRef MEDLINE|