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Drug Safety Matters
Drug Safety Matters brings you the best stories from the world of pharmacovigilance. Through in-depth interviews with our guests, we cover new research and trends, and explore the most pressing issues in medicines safety today. Produced by Uppsala Monitoring Centre, the WHO Collaborating Centre for International Drug Monitoring.
Drug Safety Matters
#32 Pharmacovigilance in older adults – Giovanni Furlan
Medication-related-harm (MRH) is especially prevalent in older adults due to changing physiology as the body ages, increased frailty, and the incidence of polypharmacy in this patient group. Giovanni Furlan, Worldwide Safety Site Lead for Thessaloniki of Pfizer discusses what makes this patient group so vulnerable to adverse drug reactions, how poor representation and using age alone to define older adults exacerbates this problem, and suggests ways forward in monitoring drug safety in older patients.
Tune in to find out:
- What makes older adults especially at risk of experiencing adverse drug reactions and medication errors
- Why frailty is far more useful than age in predicting adverse drug reaction risk
- How pharmacovigilance in older patients may be improved through pharmaceutical practice and better representation in clinical trials.
Want to know more?
This interview all started with Giovanni's Uppsala Reports article on how age is insufficient a measure of adverse event risk. Read it here.
For a summary of the key points discussed in this interview, read Giovanni’s paper on the status of drug safety in geriatric patients.
If our discussion of frailty piqued your interest, read this paper on the biology of frailty and how this impacts clinical pharmacology, this multi-centre cohort study that shows frailty is significantly correlated with MRH, and this commentary advocating for consideration of MRH as a geriatric syndrome, which needs to be managed as such.
As Giovanni mentioned in the interview, Harlan Krumholz was the first to describe post-hospital syndrome. Learn more about this syndrome by reading his paper.
For more on prescribing cascades, their prevention, detection, and reversal, read this paper by Brath and colleagues.
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As our bodies age, we experience a number of physiological changes that affect how we respond to medicines. As older adults, we are also the most likely to be taking multiple medications at once. These and other factors increase the risk of us experiencing adverse drug reactions. How, then, do pharmacovigilance scientists do their due diligence in monitoring medicine safety in this patient group? My name is Alexandra Coutinho, and this is Drug Safety Matters, a podcast by Uppsala Monitoring Centre, where we explore current issues in pharmacovigilance and patient safety. Joining me today is Giovanni Furlan, worldwide Safety Site Lead and Safety Risk Lead at Pfizer. This interview goes deep in explaining what differentiates older patients from other patient groups, why age alone is not enough to define them and what can be done to improve pharmacovigilance in a population group that is most likely to suffer from side effects to medicines. I hope you enjoy listening. Hi, Giovanni, and welcome to Drug Safety Matters. How are you doing today?
Giovanni Furlan:Fine, I am very well. Nice to talk to you today, Alexandra.
Alexandra Coutinho:Likewise, Giovanni. So we first became acquainted through Uppsala Reports, where you wrote a really interesting article on adverse reaction risk in older patients. To kick things off, could you tell our listeners a bit about your background and how you became interested in this topic?
Giovanni Furlan:Yes, so I am a pharmacist. I have been working in pharmacovigilance for 25 years, and what I realised working in pharmacovigilance is that the adverse reactions and the risks of experiencing them are not the same in all patient populations. And I am also becoming older, and so I asked myself "let us see if in the older patients, the risk of experiencing adverse reactions is the same as in the general population". And, as you have read from my articles, I realised that there are specific aspects to be taken into account in the older patients that are not applicable to the general population.
Alexandra Coutinho:So why are older adults especially at risk of experiencing adverse drug reactions and why should we regard them as a special patient group in terms of pharmacovigilance?
Giovanni Furlan:So there are a number of factors that affect the safety of the medications that are taken by older patients. These are physiological, biological changes, the increased number of pathologies that the elderly tend to concomitantly suffer from, and this leads them to taking many medicinal products at the same time. And the more medicinal products you take, the more likely it is that there will be medication errors. Let us see these factors one by one a little bit more in depth. Now we know that as we age, our metabolism changes. For example, there is a reduction of the liver mass and of the blood flow to the liver, and this can increase the bioavailability of certain medications, such as the opioids, but it can also reduce the bioavailability of other medications, the so-called prodrugs. These are the medications that are activated by the liver, such as enalapril or perin dopril. Another example is the renal functionality that also decreases with age, and this has an important clinical consequence for the drugs that have a narrow therapeutic index that are cleared by the kidneys, such as, for example, digoxin or aminoglycoside antibiotics. Therefore, if we don't take into account that the altered renal function in the elderly might cause an over-accumulation of these medications in the body, there might be adverse reaction. But with aging also, how we respond to a medication can change. T his is the so-called pharmacodynamics, and, to go a little bit more into technical detail, the pharmacodynamics changes because the number of the receptor in the body can change, the affinity of the receptor changes, the second messenger response or the cellular response can change. I understand these are rather technical aspects, so I will try to make some practical examples. Some older adults can have an increased response to certain antihypertensive medications, and this can cause an exaggerated antihypertensive effect. A similar observation applies to the medications that are used to treat certain central nervous system disorders such as insomnia, anxiety or agitation, and the increased sedative effect of these medications in the older patients can increase the risk of falls or of hip fractures, and the same applies to the exaggerated antihypertensive effect that can also increase the risk of falls.
Giovanni Furlan:Now, apart from the physiological or the biological changes that we have just seen, the older adults are often characterised by a number of different pathologies, and this can make it rather challenging to prescribe the appropriate medication, because a medication that is of use to treat a certain pathology might be associated with an adverse reaction that aggravates another coexisting medical condition.
Giovanni Furlan:I am particularly referring to the so-called geriatric conditions that characterise the older patients, such as delirium, falls, sarcopenia, urinary incontinence, and several studies have shown that the medication with anticholinergic effect can aggravate some of these diseases. If you take multiple medications, the so-called polypharmacy, because you suffer from many pathologies at the same time, there is an increased likelihood that a medication might interact with another one that is taken at the same time. The interaction can cause a reduction of the effect of a medication or it can increase the risk of a patient experiencing an adverse reaction. And finally, I mentioned before the medication errors. We can easily understand that the more drugs we take, the more likely it is that the compliance with taking the drugs as they are prescribed will be low, and the poor adherence to medical regiments can lead to a substantial worsening of the disease, to increase health care costs and in some extreme instances it can also be fatal. So, from this point of view, looking for ways to increase compliance in older adults may lead to an extension of their healthy and active years of life.
Alexandra Coutinho:And we will get a little bit more into that as we go through the interview. So it does seem to my mind that older patients really have the odds stacked against them when it comes to medicine safety. Let's take one of the problems that you mentioned polypharmacy. One of the papers you sent me to read states that 55% of the elderly take between five and nine drugs per day, with the risk of ADRs almost doubling when five medications are taken and increasing to 95% when eight or more medications are taken. That's huge. Why is this the case?
Giovanni Furlan:Yes, you're absolutely right. So there are various factors that we need to take into account. So each medication is absorbed by the body, distributed, metabolised, and eliminated. This is called the pharmacokinetics of a medication. In simple terms, we can say that the journey of a medication in the body is not only determined by the characteristics of the medication, but also how it interacts with the body. So, to simplify it to the maximum, we can say that a medication is absorbed and it is distributed in the body thanks to its binding with carriers and pumps, it passes through many channels or it binds to the proteins that carry it in the blood. Albumin is an example of a protein with which a medication can bind, and albumin will carry the medication throughout the whole body through the cardiovascular system.
Giovanni Furlan:A medication is also metabolised by a number of enzymes, such as the cytochrome, and a drug can interfere with how another drug interacts with these proteins and enzymes, thereby altering its bioavailability and the plasmatic concentration. This can cause an increase of the concentration of the medication or of its active metabolites, and if there is an increase in the concentration of the medication, there can be an increased risk of adverse reaction. If, instead, we see a decrease of the concentration of the medication or of its active metabolites, there is an impairment of the drug therapeutic effect, and a similar concept applies to a drug's mechanism of action. A medication is able to alter the biochemical pathways of the body, and if more than one medication is taken at the same time, they might interact with the same bio-pathway, thereby altering each other's effects.
Alexandra Coutinho:Right. Polypharmacy aside, you mentioned that the biological changes that occur as we age contribute to this increased risk of experiencing an adverse reaction. In your article for Uppsala Reports, however, you do argue that using age to define and describe this patient group does not adequately reflect who is most at risk of experiencing adverse drug reactions. For those who have not read the article, can you explain why age alone shouldn't be used as the main characteristic for pharmacovigilance in older patients?
Giovanni Furlan:Absolutely. I think that how we age is probably one of the most fascinating and challenging aspects. We don't all age with the same speed and in the same way. Let us consider, for example, the world record for running the marathon. A marathon is of 42.2 kilometres. The world record for those who are more than 80 years of age is of 3 hours and 15 minutes. That is much, much faster than what the vast majority of the 20-year-old adults will ever be able to accomplish. Therefore, how do you classify the physiological age of the 80-year-old athlete who has run the marathon in this time?
Giovanni Furlan:According to the current guidelines, if this person were ever to take part in a clinical study, he would be included in the age category from 75 to 85 years of age.
Giovanni Furlan:Now the question is would he be comparable to other subjects of the same age who maybe have multiple comorbidities and they may be confined in a chair or in a bed? You can very well understand that we are talking about an extremely heterogeneous population. The aging in fact reflects the complex and cumulative interplay between the genes, the lifestyle, what we eat, the psychological, the social circumstances, the environment, and chance. Therefore, the chronological age is not, per se, the most important factor. It is rather the functional age, and frailty is probably the most well-known method to measure the biological age, and it is used to characterise the patients based on their functional age. The frailty is defined and you can find it in every textbook as the increased stressors to due to a decline in the physiological reserves and to the severe dysregulation in the physiological system. So, to talk in more plain terms, frailty tells us how well the body is able to adapt to changing circumstances, and it may be much more relevant than age per se.
Alexandra Coutinho:And for those of you who want to know more about frailty and how it may be used in pharmacovigilance practice to measure adverse reaction risk in this patient group, feel free to read Giovanni Uppsala Reports, article which I linked in the show notes. Apart from this issue, there is also the problem of lack of representation of elderly patients in clinical studies, which adds to this risk of medical harm. Why are the elderly underrepresented in clinical studies, and how does this affect pharmacovigilance?
Giovanni Furlan:There are many reasons why the older adults, but especially the frail older adults, are underrepresented in the clinical study. Broadly, we can categorise these reasons in three main categories, that are, the patient-related, the investigator-related, and the trial-related reasons. Let us go to the patient-related reasons. The elderly patients might perceive the clinical trial will not be of benefit because the study endpoints are not relevant to the condition they suffer from. And if we think about an elderly who cannot take public transportation or who can't drive a car, they might not be able to reach the clinical trial centre.
Giovanni Furlan:When it comes to the investigator-related reasons, the investigator might be reluctant to enrol the elderly patients because they might fear they are at increased risk of experiencing adverse reaction. And if we think about an elderly patient who might have a cognitive impairment, a visual impairment or other impairments, investigators might be afraid that it will take too much time to explain to them what the clinical trial is about, or it might take too much time to visit the patient. Then we have the clinical trial-related barriers, and these are mainly caused by the protocol exclusion criteria. These can say, for example, that the patients who suffer from multiple comorbidities have physical disabilities or cognitive impairment, they cannot be enrolled in a study. Therefore, the older adults who are also frail, such as those who are not capable of conducting an independent life, are particularly underrepresented in the clinical studies.
Alexandra Coutinho:And I guess this underrepresentation must then make it that much harder to be able to measure adverse reaction risk in this patient group right to be able to measure adverse reaction risk in this patient group right? However, we do seem to have some idea of how older patients may react to certain types of medication. That being said, are there specific medications older patients should take with particular care, and is there any advice on how to reduce their risk of experiencing adverse reactions to these medications?
Giovanni Furlan:So, as you all know, I am an employee of a pharma company, so I have first of all to disclose this conflict of interest, since I might be perceived as being biased. Having said that, I have already mentioned before the risk of medications that have an anticholinergic effect, since, especially in the older patients, they are associated with dry mouth, constipation, confusion, increased risk of falls. Now, for a more comprehensive and objective list on which medication to use with increased caution in the older patients, I would suggest you refer to international guidelines, such as the Beers criteria that are regularly updated by the American Geriatric Society. There are also other guidelines, such as the START and STOP criteria, that are thought and they are designed to facilitate the review of the medicines that are taken by the patients, and they are designed to find not only the potentially inappropriate medications, but also the omission of a treatment that can be useful to a patient. I would like to underline the word potentially, since all of these criteria are only a suggestion that has to be adapted to the clinical characteristics of each patient. In fact, even a potentially inappropriate medication might be the correct one for specific patients. We mentioned before anticholinergic medications. We know that they can cause a urinary retention as an adverse reaction, but if the patient suffers from a urinary incontinence, it will not be a problem at all.
Giovanni Furlan:Anoth er main issue that we need to take into account is that the prescribers need to recognise adverse reaction and they should not confuse them with symptoms of other pathologies. This is challenging in older patients who suffer from multiple pathologies and take multiple medications. If an adverse reaction is not recognised as such, then the patient might be administered with another medication to treat the adverse reaction, and the other medication can cause other adverse reactions, and this can go on indefinitely, and it is called the prescribing cascade. So as an example because I always like to make practical examples, we can make the example of an elderly patient who is taking non-steroidal anti-inflammatory medications to treat some kind of pain. But we know that the non-steroidal anti-inflammatory medication can cause heartburn or they can cause hypertension, and if these conditions are not correctly recognised as adverse reactions, the patient might take the proton pump inhibitor or antihypertensive medications that, in turn, can cause other adverse reactions.
Giovanni Furlan:It is therefore of extreme importance that whenever a patient suffers from a new medical condition, the treating physician reviews all of the medication the patient is taking, including over-the-counter herbal drugs and whatever else, can have an effect on the treatment of a certain pathology. And if the medical condition is thought to be caused by a medicine, the question then is if we really need the patient to take the medication, if it should be stopped, or if it should be changed with another drug. It is also very important not to misjudge a new pathology as caused by a medication when it is not, since this might cause the interruption of a medication that the patient actually has to take and that is benefiting the patient. It is therefore very important that the physicians are well trained to recognise adverse reactions.
Alexandra Coutinho:Yes, indeed, I think we need education for all sorts of different pharmacovigilance issues. You also mentioned medication errors before, so let's look a bit more into medication errors in this patient group. There is research on the risk of medication errors occurring during transition of care, especially when patients are discharged from hospital. Officially, the name for it is post-hospital syndrome. Can you speak to this and why elderly patients are more at risk of developing this syndrome?
Giovanni Furlan:Yes, we mentioned it at the beginning of the interview and this is an extremely important aspect to take into account. In general, compliance with the treatment as prescribed and the medication error are an important cause of harm to the elderly. One reason can be that the elderly patients with multiple comorbidities might visit many doctors from a variety of specialties and one doctor might not be aware of the complete medical history of the patient or of all the medications they are taking, and this can lead to a non-appropriate prescribing. So for this reason, it is very important that all of the medications taken by an elderly patient are reviewed and they are also reconciled. If a patient is at a hospital, they might be prescribed with certain medications and they continue to take them once they are at home, but the MD who is looking after the patients when they are at home might not be aware of the additional medications the patient is taking, and he could provide the patients with other medications to treat the same pathology for which the patient is already being treated. Therefore, there can be a redundancy in the medications that the patient is taking. Or another instance is that the patients might not continue to take the therapy they have been given at the hospital as they have been prescribed. Now, this can be understood if we take into account the characteristics of the patients. For example, a patient who is taking multiple medications and is cognitively impaired might forget to take the medication, or he might take it at a wrong dose, or he could confuse a medication with another. This can also be the case of the patients who have a visual impairment. They can also confuse a medication with another or they can take a wrong quantity of a medication, especially if it is a liquid pharmaceutical form. The patients that have impaired hand dexterity might not be able to open a bottle or to use an inhaler. An elderly patient who does not produce enough saliva that is called xerostomia or has issues with ingesting, might not be able to ingest a tablet, or to ingest it, they might break a tablet that is not designed to be broken, and maybe it is a slow release tablet. So what I'm trying to say is that when a patient is discharged from hospital, the therapy needs also to be adapted to the impairments, to the characteristics of the patient and to the level of assistance they have at home once they are discharged. But to provide a more complete answer, we have to remember that the concept of the post-hospital syndrome has been described by Dr Krumholtz, who found that the majority of the 30-day readmissions are not associated to the original illness for which the patient has been hospitalised.
Giovanni Furlan:Now, if we think about it, when a patient is taken from home to the hospital, at hospital they don't have the same environment as they have at home. For example, the environment at the hospital can be a rather noisy environment as compared to when they are at home. So the patients that are hospitalised might have issues with sleeping and this can affect their metabolism, the cognitive performance, or their coordination. It might be decided at a hospital that they should not take anything by mouth. As we know, when you are in a hospital, you are in bed, you don't go around, you don't move, and this can cause a loss of the muscle strength and a loss of coordination.
Giovanni Furlan:All of these issues can affect a frail, older patient with a greater severity and frequency. As we might remember, frailty is the reduced capability of adapting to a stressor, and the stressor can also be the hospitalisation. Therefore, if frail older adults go home after having been hospitalised, but in the hospital they have not slept, they have been malnourished or they are particularly weak, they might not be able to take the medication as they have been prescribed unless they are adequately helped, and they might also be at risk of suffering from additional pathologies.
Alexandra Coutinho:Yeah, and there again, it becomes important to have more information on the frailty of older patients to be able to provide adequate support following hospital discharge should they need it.
Giovanni Furlan:Exactly.
Alexandra Coutinho:That being said, what is currently being done in terms of practice and research regarding pharmacovigilance in elderly patients? For example, are more and more hospitals and organisations using frailty to conduct pharmacovigilance in this patient group?
Giovanni Furlan:So, if we look from a regulatory point of view, in the last few years there has been a big push to consider the characteristic of the elderly patients in all of the phases of a medicine, from when it is given for the first time to human beings, throughout post-marketing. For example, the regulatory guidelines state that the medically complex patients should be enrolled in the clinical studies whenever it is safe to do so. The guidelines on the diversity of the patients included in clinical trials state that the phase 3 clinical trials have to enrol the patients that reflect as much as possible those who will take the drug in the post-approval phase. For the non-technical people who are listening to the podcast, the phase 3 studies are those that provide the evidence of the safety and of the efficacy of the medicine, and they provide the evidence of its value in clinical practice. The guidelines state that the clinical studies should be made less burdensome for the participant and they should use real-world data to facilitate enrolment.
Giovanni Furlan:There are also specific guidelines on the inclusions of older adults in the cancer clinical studies, and these guidelines state that the spectrum of older adults that are included in these studies should be representative of the intended population, including those with frailty and organ impairment. There are also regulations saying what kind of information specifically for the elderly has to be included in the label. So, for example, on the label we have to say if the safety and the efficacy in the elderly is the same as compared to the general population or if it is divergent from the general population. And there are also guidelines that specify how to identify the most appropriate pharmaceutical forms for older patients who have impairments and functional limitations. Now, from the perspective of frailty, we are starting to see the first studies that investigate the efficacy of medicinal products in frail older patients. There are also initiatives to include the patient's frailty status in their medical records and the NHS is using the electronic frailty index to identify patients with moderate and severe frailty.
Alexandra Coutinho:What other examples exist of pharmaceutical practice being specifically tailored to elderly patients?
Giovanni Furlan:So we have mentioned before the pharmaceutical forms and the packaging, but I would suggest that we expand on the concept. So the older patients, as we have said, might have impairments that affect their ability to take the medications. For example, they might not see well, they might have issues with swallowing, hyposalivation, reduced hand and eye movement coordinations. These are all examples that can make it challenging for an older patient to take a medication. Let us think about a patient with a reduced hand dexterity who might find it not easy to handle an inhaler, whereas those with hyposalivation might not find it easy to ingest the tablet, and this can be even more challenging if they have to take many tablets at the same time. So, if this is the issue with a patient, they might find it easier to take a liquid pharmaceutical form instead of a solid pharmaceutical form pharmaceutical form, but if the patient is visually impaired, they might not be able to measure the quantity of the liquid that they have to take. Another issue is that of the polypharmacy and of the complex medication schedules, and they can be challenging for the elderly, who tend to forget things. So for this reason, the elderly might use a multi-compartment compliance aid. This is a box that is divided in smaller compartments, and each compartment clearly states the name of the day and the time when the medication in the specific compartment needs to be taken. So each compartment is filled with all of the solid preparation that the patient has to take at the same time. However, there are also risks when you use the multi-compartment compliance aids. This is the case when a medication has to be stored at a low temperature, while in the multi-compartment aid it might stay at a much higher temperature for a longer period of time, and this can lead to stability issues.
Giovanni Furlan:So what I'm trying to point out is that there is not one size fits all for all of the older patients.
Giovanni Furlan:W e have to have in mind what are the characteristics of each and every patient, who will take the medication, what are their impairments, and how we can design the pharmaceutical form that is most appropriate for the impairments that these patients have. There has been a very interesting development in the field, especially for the patient who take multiple medication, and this is the case of the polypill that is prepared with the use of a 3D extrusion based printer. So the polypill is made of multiple modular units and they are assembled in the same pill that contains many active ingredients. So ideally, the 3D printer should be available in all of the pharmacies so that personalised polypills with the correct quantity of active ingredients can be prepared for each patient. Unluckily, we are not yet there, because this has a cost. There are the formulation challenges and we need to comply with all of the good manufacturing practices, and it might not be easy to comply with these good manufacturing practices in each and every pharmacy.
Alexandra Coutinho:Wow, that was so interesting. I've never heard of was it polypills? Is that what you said?
Giovanni Furlan:Yes, the polypills. So a polypill is one single that contains active ingredients. So instead of taking one tablet for each active ingredient, you only take on tablet that contains all of the active ingredients that you have to take at the same time.
Alexandra Coutinho:It reminds me a bit of this argument that I've been hearing over the years for personalised medicine being the future of care and of ideal care. This is like a great step towards it, if we can finally progress with that.
Giovanni Furlan:Exactly.
Alexandra Coutinho:Well, it does seem that, regardless of how far we still have yet to go, we are certainly well on the way to making medicines safer in this patient population. What more can be done to improve pharmacovigilance in frail elderly patients and minimise their risk of medical harm?
Giovanni Furlan:So, in my opinion, the first step is to develop an internationally agreed standard on how to identify and categorise frailty severity, because today there are various ways to measure the frailty and there are a number of parameters to measure it, such as, for example, the patient's pathologies, their ability to independently perform the activities of daily life, their physical capabilities, such as the gait speed or the time that is required to stand up from when you sit in a chair. So the lack of an internationally agreed standard on which parameters to use, and on what weight each parameter has on the overall frailty index, can make it challenging to compare the results of studies that use different frailty indexes. So once an international standard has been agreed upon, the frailty should be included in patient medical records and, in all adverse events, individual case reports. This would be the basis to perform an adequate analysis on how frailty influences the risk of experiencing adverse reactions for each medicine.
Giovanni Furlan:As for the studies that we mentioned before, it is important not only to include the elderly, but especially the frail elderly, and it is of particular importance if the medication that is investigated will be taken by the frail elderly patients.
Giovanni Furlan:Fo r this reason, the exclusion criteria in the clinical trial should be kept to the minimum, and, this is very important, we should consider if the frail older patient and the non-frail older patient have the same preferences as to what they want to achieve with the medication that they take.
Giovanni Furlan:For example, a frail, older patient with multiple pathologies who is having a treatment for cancer might not be interested in having a limited increase in life expectancy if this is at the cost of experiencing adverse reaction that might impair their independence or their social interaction.
Giovanni Furlan:They might be more interested in taking the medication that will help them to maintain a good quality of life. The same might not be the same for older patients who are not frail, because these patients might benefit from a longer increase in the life expectancy thanks to the cancer medication that is being investigated. Therefore, prior to conducting a study, we should ask frail older patients what they want to achieve with the medication, and there could be clinical trial endpoints that are not the same for the frail and the non-frail older patients. And to conclude, there is still a lot to be understood on the evolution of the frailty and how mild, moderate or severe frailty can influence the risk of experiencing adverse reactions. This is because there is an evolution in the severity of frailty. So the question is how does each stage of frailty impact the risk of experiencing adverse reactions?
Alexandra Coutinho:Yeah, and that seems to be the logical next step in improving pharmacovigilance in older patients, is further research into frailty. It seems that these divisions in frailty kind of also form separate patient groups, depending on how frail they are, right?
Giovanni Furlan:Exactly, this is, I think, the proposal that I have. We are now starting, only now, to looking into frailty, but we are not giving a look at the various severities.
Alexandra Coutinho:Well, I mean it's great that there, as you mentioned before, for example with the NHS, that they are including at least measures of frailty already in routine sort of studies, and so we're taking these first steps into looking more into frailty. Hopefully that will then in due course also come to research more into severity of frailty.
Giovanni Furlan:Yes indeed.
Alexandra Coutinho:Well, Giovanni, thank you. This was a very, very interesting interview into what I feel is a very important aspect of pharmacovigilance that I don't feel is spoken about enough. So thank you very much for your time and for making yourself available for this interview.
Giovanni Furlan:I thank you very much and thank you for being interested in the topic.
Alexandra Coutinho:That's all for now, but we'll be back soon with more conversations on medicine safety. If you would like to know more about pharmacovigilance in older patient groups, check out the episode show notes for useful links. If you like our podcast, subscribe to it in your favourite player so you won't miss an episode, and spread the word on social media so other listeners can find us. Apart from these in-depth conversations with experts, we host a series called Uppsala Reports Long Reads, a selection of audio stories from UMC's pharmacovigilance news site, so do check that out too. Uppsala Monitoring Centre is on Facebook, Linkedin, and X, and we'd love to hear from you. Send us comments or suggestions for the show or send in questions for our guests next time we open up for that. For Drug Safety Matters, I'm Alexandra Coutinho. I'd like to thank Giovanni Furlan for his time, Frederick Bronéus and Matthew Barwick for post-production support and, of course, you for tuning in. Till next time.