JAGS
OCTOBER 2014–VOL. 62, NO. 10
The current case, in addition to the aforementioned case reports, highlights that physicians should be vigilant about the possibility of hepatic injury after initiation of AChEIs even though this is an uncommon occurrence. When starting AChEIs in elderly adults the potential risk of hepatotoxicity from drug interactions and comorbidities should be taken into account, with dose adjustments and monitoring of liver function in individuals with underlying hepatic impairment or who are concurrently taking SSRIs. Aik Phon Chew, MBBS, MRCP Wee Shiong Lim, MBBS, MRCP, Mmed Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, Singapore Keng Teng Tan, BSc Department of Pharmacy, Tan Tock Seng Hospital, Singapore
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Preparation of manuscript: Chew, Lim. Case management and critical review of manuscript: all authors. Sponsor’s Role: None.
REFERENCES 1. Jackson S. The safety and tolerability of donepezil in patients with Alzheimer’s disease. Br J Clin Pharmacol 2004;58(Suppl 1):1–8. 2. Naranjo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239– 245. 3. Otton SV. Inhibition by fluoxetine of cytochrome P450 2D6 activity. Clin Pharmacol Ther 1993;53:401–409. 4. Alfaro CL. CYP2D6 inhibition by fluoxetine, paroxetine, sertraline, and venlafaxine in a crossover study: Intraindividual variability and plasma concentration correlations. J Clin Pharmacol 2000;40:58–66. 5. Verrico MM. Fulminant chemical hepatitis possibly associated with donepezil and sertraline therapy. J Am Geriatr Soc 2000;48:1659–1663. 6. Marshall K. Toxic interaction between fluoxetine and donepezil: A case of cholinergic toxidrome. J Neuropsychiatry Clin Neurosci 2012;24: E50. 7. Reyes JF. Steady-state pharmacokinetics, pharmacodynamics and tolerability of donepezil hydrochloride in hepatically impaired patients. Br J Clin Pharmacol 2004;58(Suppl 1):9–17. 8. Dierckx RI. Donepezil-related toxic hepatitis. Acta Clin Belg 2008;63:339– 342. 9. Mumoli N. Hepatitis with cholestasis caused by rivastigmine transdermal patch. Am J Gastroenterol 2009;104:2859–2860.
LETTERS TO THE EDITOR
2011
been forced to use a wheelchair to ambulate in the last 1 year and could not perform activities of daily living (ADLs). He did not have any other comorbid medical problems except controlled hypertension. Plain radiographs confirmed Ahlb€ ack grade IV osteoarthritic (OA) changes in both knees (Figure 1). He was offered and underwent simultaneous bilateral total knee arthroplasty (SBTKA) under epidural anesthesia. During surgery, large bone defects were found in the upper medial tibia that required bone grafting and long-stem arthroplasty components. Surgery and the postsurgical period were uneventful. His knee pain was significantly reduced after the surgery, and the deformities of the knee were fully corrected. At 3-year follow-up, he remained pain free and could perform most of his ADLs without much assistance. His Knee Society Score improved from 32 preoperatively to 85 postoperatively.
DISCUSSION Worldwide, the population of elderly adults is increasing because of longer life expectancy. It is estimated that in the United States alone, the population of elderly adults (≥85) will increase 400% by 2050.1 The population of centenarians is also projected to double every decade. This increase will inevitably be associated with a parallel increase in the number of OA knees requiring TKAs. TKA is a well-established and successful procedure for end-stage arthritis of the knees, with good long-term results and outcomes.2 Some studies have reported results of TKA in octogenarians,2 but its use in nonagenarians is not well documented. No published case reports of SBTKA in a nonagenarian were found. Even though comparative studies have shown that there is much more improvement in pain and function in nonagenarians, without higher complication rates, than in younger individuals,2,3 elderly adults are less willing to undergo TKA than their younger counterparts.4 This could be for several reasons, such as ignorance, consideration of their old age, uncertainty about their life expectancy, associated comorbidities, and fear of potential postoperative complications.5
HOW OLD IS OLD FOR A SIMULTANEOUS BILATERAL TOTAL KNEE ARTHROPLASTY? CASE REPORT OF A 93-YEAR-OLD MAN To the Editor: A 93-year-old man, a retired college principal, presented with a history of progressive pain and deformity of both knees for 10 years. His motivation and positive attitude had kept him going with arthritic knees until he had
Figure 1. Anteroposterior radiograph of the knees showing advanced osteoarthritic changes in both knees.
2012
LETTERS TO THE EDITOR
Because elderly adults may have age-related physical and medical problems, more-severe and -complex deformities,2 poorer response to rehabilitation, greater need for postoperative medical assistance, and higher total cost of treatment,2 they present challenges for surgeons, so there is a tendency for family and doctors not to recommend even eligible patients for surgery.6 Nevertheless, with recent advances in the medical field, major surgical procedures such total hip arthroplasty (THA) and TKA can be safely in performed elderly adults.2 From the experience of this case and other similar cases in octogenarians (unpublished data), the advantages of performing SBTKA rather than the two-stage total knee arthroplasty include shorter exposure to anesthesia, less time in the hospital, shorter rehabilitation and physical therapy, fewer wound complications, less surgical stress, convenience for family members, and more cost-effective treatment.6 It has been observed that, after TKA, 76% of individuals aged 85 and older could live independently and approximately one-third could drive a car.7 Hence, the quality of improvement in their lives was significantly greater, and TKA seems a valuable procedure for them. Although SBTKA cannot add years to the lives of these individuals, it can add quality to the remaining years of their lives. When considering elderly adults for SBTKA, various factors such as age, overall health, mental function, and motivation must be considered. Older age alone should not discourage doctors and family from recommending surgery. These elderly adults, who live much longer than their counterparts, have exceptional qualities such as low probability of disease or disability, active engagement with life, and high cognitive and physical function.7
CONCLUSION With predictable benefits of surgery, SBTKA seems a safe, effective, viable procedure for carefully selected elderly adults, provided that doctors, the individuals, and family members accept the risks. These individuals should not be deprived of potential benefits of this surgery. Biological age is more important than the chronological age of these elderly adults when considering them for SBTKA. Raju Vaishya, MBBS Vipul Vijay, MBBS Kapil Mani, MBBS Department of Orthopedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India Abhishek Vaish, MBBS Sancheti Institute of Orthopedics, Pune, India
ACKNOWLEDGMENTS We are extremely grateful to Dr. Amitabh Chakrawarty (the son of our patient), who encouraged his father to undergo surgery on both knees and looked after him. Conflict of Interest: The authors have not received any financial support from any source for this study. The editor in chief has reviewed the conflict of interest check-
OCTOBER 2014–VOL. 62, NO. 10
JAGS
list provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed significantly to study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. Sponsor’s Role: None.
REFERENCES 1. U.S. Census Bureau. Projections of the population by age and sex for the United States: 2010 to 2050; 2009 [on-line]. Available at http://www. census.gov/population/www/projections/2009summarytables.html Accessed November 29, 2011. 2. Brander VA, Malhotra S, Jet J et al. Outcome of hip and knee arthroplasty in persons aged 80 years and older. Clin Orthop 1997;345:67–78. 3. Zicat B, Rorabeck CH, Bourne RB et al. Total knee arthroplasty in the octogenarian. J Arthroplasty 1993;8:395–400. 4. Katz BP, Freund DA, Heck DA et al. Demographic variation in the rate of knee replacement: A multi-year analysis. Health Serv Res 1996;31:125–140. 5. Kreder HJ, Berry GK, McMurtry IA et al. Arthroplasty in the octogenarian: Quantifying the risks. J Arthroplasty 2005;20:289–293. 6. Jankiewicz JJ, Sculco TP, Ranawat CS et al. One stage versus 2-stage bilateral total knee arthroplasty. Clin Orthop 1994;309:94–101. 7. Laskin RS. Total knee replacement in patients older than 85 years. Clin Orthop Relat Res 1999;367:43–49.
SKIN LESIONS AFTER ORAL ACETYLCHOLINESTERASE INHIBITOR THERAPY: A CASE REPORT To the Editor: Rivastigmine is an acetylcholinesterase and butyrylcholinesterase inhibitor used for the symptomatic treatment of mild to moderate Alzheimer’s disease or mild to moderate Parkinson’s dementia and is given in oral or transdermal form.1 Rivastigmine is usually well tolerated and has a favorable safety profile.2 The frequency of side effects does not differ between the oral and transdermal forms.3 Approximately 10% of individuals develop more than mild skin reactions with transdermal rivastigmine therapy. Contact irritation, with mild erythema and pruritus, is most common.2 Allergic dermatitis with transdermal therapy is rare and presents with localized erythema and edema, which might spread beyond the borders of the patch.2 We report a case with recurrent allergic dermatitis with oral galantamine treatment at a site previously sensitized with a rivastigmine patch.4
CASE A 74-year-old man was treated with rivastigmine 4.6 mg per 24-hour patch after the diagnosis of Alzheimer’s dementia with vascular lesions. After 3 months, the treatment was evaluated. He tolerated the treatment well, and he and his brother noted a positive effect, so the dose was increased to 9.5 mg per 24-hour patch. A year later, he visited the outpatient clinic with pruritus and an allergic rash far beyond the patch circumference and not round in shape on the left flank. A side effect of rivastigmine was suspected. To confirm the diagnosis, the rivastigmine treatment was discontinued, and an oral antihistaminic was prescribed. The rash disappeared in a few days. Because of
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
OCTOBER 2014–VOL. 62, NO. 10
The current case, in addition to the aforementioned case reports, highlights that physicians should be vigilant about the possibility of hepatic injury after initiation of AChEIs even though this is an uncommon occurrence. When starting AChEIs in elderly adults the potential risk of hepatotoxicity from drug interactions and comorbidities should be taken into account, with dose adjustments and monitoring of liver function in individuals with underlying hepatic impairment or who are concurrently taking SSRIs. Aik Phon Chew, MBBS, MRCP Wee Shiong Lim, MBBS, MRCP, Mmed Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, Singapore Keng Teng Tan, BSc Department of Pharmacy, Tan Tock Seng Hospital, Singapore
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Preparation of manuscript: Chew, Lim. Case management and critical review of manuscript: all authors. Sponsor’s Role: None.
REFERENCES 1. Jackson S. The safety and tolerability of donepezil in patients with Alzheimer’s disease. Br J Clin Pharmacol 2004;58(Suppl 1):1–8. 2. Naranjo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239– 245. 3. Otton SV. Inhibition by fluoxetine of cytochrome P450 2D6 activity. Clin Pharmacol Ther 1993;53:401–409. 4. Alfaro CL. CYP2D6 inhibition by fluoxetine, paroxetine, sertraline, and venlafaxine in a crossover study: Intraindividual variability and plasma concentration correlations. J Clin Pharmacol 2000;40:58–66. 5. Verrico MM. Fulminant chemical hepatitis possibly associated with donepezil and sertraline therapy. J Am Geriatr Soc 2000;48:1659–1663. 6. Marshall K. Toxic interaction between fluoxetine and donepezil: A case of cholinergic toxidrome. J Neuropsychiatry Clin Neurosci 2012;24: E50. 7. Reyes JF. Steady-state pharmacokinetics, pharmacodynamics and tolerability of donepezil hydrochloride in hepatically impaired patients. Br J Clin Pharmacol 2004;58(Suppl 1):9–17. 8. Dierckx RI. Donepezil-related toxic hepatitis. Acta Clin Belg 2008;63:339– 342. 9. Mumoli N. Hepatitis with cholestasis caused by rivastigmine transdermal patch. Am J Gastroenterol 2009;104:2859–2860.
LETTERS TO THE EDITOR
2011
been forced to use a wheelchair to ambulate in the last 1 year and could not perform activities of daily living (ADLs). He did not have any other comorbid medical problems except controlled hypertension. Plain radiographs confirmed Ahlb€ ack grade IV osteoarthritic (OA) changes in both knees (Figure 1). He was offered and underwent simultaneous bilateral total knee arthroplasty (SBTKA) under epidural anesthesia. During surgery, large bone defects were found in the upper medial tibia that required bone grafting and long-stem arthroplasty components. Surgery and the postsurgical period were uneventful. His knee pain was significantly reduced after the surgery, and the deformities of the knee were fully corrected. At 3-year follow-up, he remained pain free and could perform most of his ADLs without much assistance. His Knee Society Score improved from 32 preoperatively to 85 postoperatively.
DISCUSSION Worldwide, the population of elderly adults is increasing because of longer life expectancy. It is estimated that in the United States alone, the population of elderly adults (≥85) will increase 400% by 2050.1 The population of centenarians is also projected to double every decade. This increase will inevitably be associated with a parallel increase in the number of OA knees requiring TKAs. TKA is a well-established and successful procedure for end-stage arthritis of the knees, with good long-term results and outcomes.2 Some studies have reported results of TKA in octogenarians,2 but its use in nonagenarians is not well documented. No published case reports of SBTKA in a nonagenarian were found. Even though comparative studies have shown that there is much more improvement in pain and function in nonagenarians, without higher complication rates, than in younger individuals,2,3 elderly adults are less willing to undergo TKA than their younger counterparts.4 This could be for several reasons, such as ignorance, consideration of their old age, uncertainty about their life expectancy, associated comorbidities, and fear of potential postoperative complications.5
HOW OLD IS OLD FOR A SIMULTANEOUS BILATERAL TOTAL KNEE ARTHROPLASTY? CASE REPORT OF A 93-YEAR-OLD MAN To the Editor: A 93-year-old man, a retired college principal, presented with a history of progressive pain and deformity of both knees for 10 years. His motivation and positive attitude had kept him going with arthritic knees until he had
Figure 1. Anteroposterior radiograph of the knees showing advanced osteoarthritic changes in both knees.
2012
LETTERS TO THE EDITOR
Because elderly adults may have age-related physical and medical problems, more-severe and -complex deformities,2 poorer response to rehabilitation, greater need for postoperative medical assistance, and higher total cost of treatment,2 they present challenges for surgeons, so there is a tendency for family and doctors not to recommend even eligible patients for surgery.6 Nevertheless, with recent advances in the medical field, major surgical procedures such total hip arthroplasty (THA) and TKA can be safely in performed elderly adults.2 From the experience of this case and other similar cases in octogenarians (unpublished data), the advantages of performing SBTKA rather than the two-stage total knee arthroplasty include shorter exposure to anesthesia, less time in the hospital, shorter rehabilitation and physical therapy, fewer wound complications, less surgical stress, convenience for family members, and more cost-effective treatment.6 It has been observed that, after TKA, 76% of individuals aged 85 and older could live independently and approximately one-third could drive a car.7 Hence, the quality of improvement in their lives was significantly greater, and TKA seems a valuable procedure for them. Although SBTKA cannot add years to the lives of these individuals, it can add quality to the remaining years of their lives. When considering elderly adults for SBTKA, various factors such as age, overall health, mental function, and motivation must be considered. Older age alone should not discourage doctors and family from recommending surgery. These elderly adults, who live much longer than their counterparts, have exceptional qualities such as low probability of disease or disability, active engagement with life, and high cognitive and physical function.7
CONCLUSION With predictable benefits of surgery, SBTKA seems a safe, effective, viable procedure for carefully selected elderly adults, provided that doctors, the individuals, and family members accept the risks. These individuals should not be deprived of potential benefits of this surgery. Biological age is more important than the chronological age of these elderly adults when considering them for SBTKA. Raju Vaishya, MBBS Vipul Vijay, MBBS Kapil Mani, MBBS Department of Orthopedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India Abhishek Vaish, MBBS Sancheti Institute of Orthopedics, Pune, India
ACKNOWLEDGMENTS We are extremely grateful to Dr. Amitabh Chakrawarty (the son of our patient), who encouraged his father to undergo surgery on both knees and looked after him. Conflict of Interest: The authors have not received any financial support from any source for this study. The editor in chief has reviewed the conflict of interest check-
OCTOBER 2014–VOL. 62, NO. 10
JAGS
list provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed significantly to study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. Sponsor’s Role: None.
REFERENCES 1. U.S. Census Bureau. Projections of the population by age and sex for the United States: 2010 to 2050; 2009 [on-line]. Available at http://www. census.gov/population/www/projections/2009summarytables.html Accessed November 29, 2011. 2. Brander VA, Malhotra S, Jet J et al. Outcome of hip and knee arthroplasty in persons aged 80 years and older. Clin Orthop 1997;345:67–78. 3. Zicat B, Rorabeck CH, Bourne RB et al. Total knee arthroplasty in the octogenarian. J Arthroplasty 1993;8:395–400. 4. Katz BP, Freund DA, Heck DA et al. Demographic variation in the rate of knee replacement: A multi-year analysis. Health Serv Res 1996;31:125–140. 5. Kreder HJ, Berry GK, McMurtry IA et al. Arthroplasty in the octogenarian: Quantifying the risks. J Arthroplasty 2005;20:289–293. 6. Jankiewicz JJ, Sculco TP, Ranawat CS et al. One stage versus 2-stage bilateral total knee arthroplasty. Clin Orthop 1994;309:94–101. 7. Laskin RS. Total knee replacement in patients older than 85 years. Clin Orthop Relat Res 1999;367:43–49.
SKIN LESIONS AFTER ORAL ACETYLCHOLINESTERASE INHIBITOR THERAPY: A CASE REPORT To the Editor: Rivastigmine is an acetylcholinesterase and butyrylcholinesterase inhibitor used for the symptomatic treatment of mild to moderate Alzheimer’s disease or mild to moderate Parkinson’s dementia and is given in oral or transdermal form.1 Rivastigmine is usually well tolerated and has a favorable safety profile.2 The frequency of side effects does not differ between the oral and transdermal forms.3 Approximately 10% of individuals develop more than mild skin reactions with transdermal rivastigmine therapy. Contact irritation, with mild erythema and pruritus, is most common.2 Allergic dermatitis with transdermal therapy is rare and presents with localized erythema and edema, which might spread beyond the borders of the patch.2 We report a case with recurrent allergic dermatitis with oral galantamine treatment at a site previously sensitized with a rivastigmine patch.4
CASE A 74-year-old man was treated with rivastigmine 4.6 mg per 24-hour patch after the diagnosis of Alzheimer’s dementia with vascular lesions. After 3 months, the treatment was evaluated. He tolerated the treatment well, and he and his brother noted a positive effect, so the dose was increased to 9.5 mg per 24-hour patch. A year later, he visited the outpatient clinic with pruritus and an allergic rash far beyond the patch circumference and not round in shape on the left flank. A side effect of rivastigmine was suspected. To confirm the diagnosis, the rivastigmine treatment was discontinued, and an oral antihistaminic was prescribed. The rash disappeared in a few days. Because of
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
