There are numerous definitions of polypharmacy to describe the use of many medications among older adults, but there is a need to clarify if they are purposive and meaningful. By means of a systematic review, we identified definitions of polypharmacy used in multimorbid older adults (≥65 years). We evaluated if the definitions align among the domains of research, clinical practice, and public health and appraised whether concepts of polypharmacy are based on strong foundations. More than 46 definitions of polypharmacy were retrieved from 348 publications (research: n = 243; clinical practice: n = 88; public health: n = 17). Several thresholds based on the number of medications were mentioned. The majority of the publications (n = 202, 58%) used a minimal threshold of five medications. Heterogeneous qualitative definitions were identified, mostly stating that polypharmacy is “more drugs than needed”. There was no significant divergence between domains as to the type of definitions used, although qualitative definitions were more common in clinical practice. Nearly half (n = 156, 47%) of the publications provided no justification for the polypharmacy definition used. The wide variety of definitions for polypharmacy precludes comparisons, appropriate identification and management of polypharmacy in multimorbid older adults. Standardized definitions would allow more coherent judgments regarding the individual and collective stakes of polypharmacy.

Objective: Cannabis is increasingly used for medical purposes, particularly in countries like Canada where cannabis was recently legalized for recreational use. We aimed to assess self-medication with cannabis post-cannabis legalization among adults in the Canadian province of Quebec. Methods: This is a cross-sectional online survey of a self-selected convenience sample conducted in Quebec, Canada, from November 2020 to January 2021. Individuals aged ≥ 21 years who endorsed using cannabis bought in legal recreational cannabis stores to self-medicate a health condition were included. Data were analyzed using descriptive statistics and stratified according to sex, age, and the type of cannabis use (exclusively medical versus medical and recreational use). Results: Four hundred eighty-nine participants were included. The median age was 34 years, and 48% were women. About 25% reported exclusive medical use of cannabis. Treated conditions included anxiety (70%), insomnia (56%), pain (53%), depression (37%), and many others. Reasons for not consulting in cannabis clinics included lack of information (52%), the complexity of the process (39%), accessibility of cannabis clinics (23%), and others. Tetrahydrocannabinol (THC) dosage > 20% was reported by 32%. Smoking was the main route of use (81%). Possession of prescribed drugs was reported by 56%. Professionals consulted for information on cannabis included recreational cannabis store agents (36%), physicians (29%), and others. Overall, significant differences were observed for many of the comparisons according to sex, age, and the type of cannabis use. Conclusions: Many conditions are self-medicated with cannabis. The use of high doses of cannabis, smoking as a preferred method of use, and concurrent use of other medications may pose some risks to individuals. Addressing the reported barriers to medical access to cannabis is urgently needed.

Background: Cannabis is increasingly used for therapeutic purpose. However, its safety profile is not well known. This study assessed the risk of cardiovascular-related emergency department (ED) visit and hospitalization in adult patients authorized to use medical cannabis in Ontario, Canada from 2014 to 2017. Methods: This is a longitudinal cohort study of patients who received medical cannabis authorization and followed-up in cannabis clinics, matched to population-based controls. The primary outcome was an ED visit or hospitalization for acute coronary syndrome (ACS) or stroke; and secondary outcome was for any cardiovascular event. Conditional Cox proportional hazards regression was used to assess the association between cannabis authorization and risk. Results: 18,653 cannabis patients were matched to 51,243 controls. During a median follow-up of 242 days, the incidence rates for ACS or stroke were 7.19/1000 person-years and 5.67/1000 person-years in the cannabis and controls group, respectively- adjusted hazard ratio (aHR) of 1.44 (95% CI 1.08–1.93). When stratified by sex, the association was only statistically significant among males: aHR 1.77 (1.23–2.56). For the secondary outcome (any CV events), the aHR was 1.47 (1.26–1.72). The aHR among males and females were 1.52 (1.24–1.86) and 1.41 (1.11–1.79), respectively. Tested interaction between cannabis authorization and sex was not significant (p > 0.05). Conclusions: Medical cannabis authorization was associated with an increased risk of ED visits or hospitalization for CV events including stroke and ACS.

Background: Poor adherence to cardioprotective drugs remains a concern among patients for secondary prevention. A better understanding of adherence fluctuations before and after critical health events may inform approaches for addressing or preventing poor adherence. Therefore, we assessed trajectories of adherence to lipid‐lowering drugs before and after acute coronary syndrome ( ACS ) or stroke and identified post‐ ACS /stroke trajectories’ predictors. Methods and Results: We conducted a cohort study of patients hospitalized for ACS or stroke in Alberta, Canada, using administrative health data between 2009 and 2015. Patients using lipid‐lowering drugs in the 2 years pre‐hospitalization and had post‐discharge follow‐up ≥365 days were included. We used group‐based trajectory modeling to assess adherence trajectories and multinomial logistic regression to assess trajectories’ predictors. In total, 10 623 patients were included. The average age was 69 years, and 65% were men. Five trajectories were identified in both periods: nearly perfect, gradual increase, gradual decline, rapid decline, and poor adherence throughout. Of patients who were poor adherers, rapidly or gradually declining pre‐hospitalization, 2395/3588 (66.8%) switched to gradual increase or perfect adherence post discharge. Conversely, of patients gradually increasing or nearly perfect before, only 4822/7035 (68.5%) were nearly perfect adherers after. Main predictors of poor post‐ ACS /stroke trajectories included older age, female sex, lack of immediate post discharge follow‐up, and prior trajectories. Conclusions: This study suggests that adherence post‐ ACS /stroke is highly variable and emphasizes the importance for clinicians to recognize that post‐discharge adherence will likely change negatively for prior good adherers. Adherence‐enhancing interventions should occur both early and late following discharge.

Thresholds defining medication adherence are rarely evidence-based. A threshold of 0.8 is typically presumed to achieve improved outcomes. We aimed to assess the optimal threshold of adherence to lipid-lowering drugs (LLD) in predicting cardiovascular-related (CV) outcomes in patients with hypertension. Cohort study of new users of LLDs. Comprehensive healthcare administrative databases of the province of Alberta (Canada) from 2008 to 2016. Patients with hypertension, who were new users of LLDs. Patients who had the outcomes prior to the initiation of LLD were excluded. Hospitalization for acute coronary syndrome (ACS)/stroke, CV-related mortality and all-cause mortality. Adherence to LLDs was assessed as the proportion of days covered (PDC) by any LLD, from drug initiation to censoring, outcome, or study end. Three methods were used to assess the threshold: Contal and O'Quigley method, minimum distance method, and Youden's J index. Cox regressions were used to assess the risk associated with each method-specific threshold and Akaike information criteria were used to retain the optimal threshold after adjustment. 52229 patients were included; 4.0% were hospitalized for ACS/stroke, 3.4% died, and 1.3% died from CV-related cause. In predicting ACS/stroke, CV-related and all-cause mortality, the optimal adherence threshold was 0.52 (range: 0.51–0.54), 0.79 (0.45–0.87), and 0.84 (0.79–0.89), respectively. These results were consistent among patients aged ≥ 65 years (n = 19804). However, the results varied among those aged < 65 years, where the incidence rates of outcomes were low. In new-users of LLDs with hypertension, approximately 50% days covered by LLDs may be enough to prevent long-term occurrence of ACS, or stroke. However, a threshold near 0.80 may be needed to prevent or reduce the risk of all-cause or CV-related mortality.

Aims: To assess post‐initiation predictors of discontinuation of sodium‐glucose cotransporter‐2 (SGLT2) inhibitors compared to dipeptidyl‐peptidase‐4 (DPP‐4) inhibitors in the United Kingdom. Materials and Methods: We conducted a comparative population‐based retrospective cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) with linked data to hospital and death records. We included new metformin users who initiated either SGLT2 inhibitors or DPP‐4 inhibitors between January 2013 and October 2019. The main outcome was treatment discontinuation, defined as the first 90‐day gap after the estimated treatment end date. We used a series of extended Cox models to assess which time‐dependent predictors were associated with treatment discontinuation. To test if the hazard ratio of discontinuation for each predictor was statistically different between SGLT2 and DPP‐4 inhibitors, an exposure‐predictor interaction term was added to each model. Results: There were 2550 new users of SGLT2 inhibitors and 8195 new users of DPP‐4 inhibitors. Approximately 69% of SGLT2 inhibitor and 74% of DPP‐4 inhibitor users had discontinued treatment by the end of follow‐up. Occurrence of fractures after treatment initiation was a significant predictor of discontinuation of SGLT2 inhibitors (hazard ratio [HR] 4.13, 95% confidence interval [CI] 2.12‐8.06) but not DPP‐4 inhibitors (HR 0.93, 95% CI 0.79‐1.11). The rate of treatment discontinuation was significantly higher for those with low estimated glomerular filtration rate and minimal contact with the healthcare system. Efficacy endpoints, such as heart failure and glycated haemoglobin level, were not associated with treatment discontinuation. Conclusions: Our findings reflect some discrepancy between the available evidence and prescribing behaviour for SGLT2 inhibitors.