Over half the patients self-reported non-adherence. The main modifiable barriers leading to non-adherence were forgetfulness and skipped doses. Personalised interventions focused on habit forming may improve adherence in this population.

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This review summarizes how possible age-related changes in tacrolimus and cyclosporine pharmacokinetics and pharmacodynamics may influence drug dosing and monitoring in the elderly, and highlights how micro-sampling may be useful in this cohort in the future. Advancing biological age leads to physiological changes that can affect drug absorption, distribution, metabolism and excretion, as well as immune system responsiveness. Some studies have shown that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors, suggesting that doses may need to be lowered in elderly recipients. Only one study has examined how aging effects drug target enzyme activity and demonstrated that age does not correlate with the calcineurin inhibitor half-maximal inhibitory concentration. Several studies have shown elderly kidney transplant recipients have increased risk of both morbidity and mortality, compared to younger adults due to increased susceptibility to immunosuppressant side effects, particularly cardiovascular disease, infection and malignancy. Current immunosuppressant dosing and monitoring protocols often make no adjustments for age. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established. Blood draw by micro-sampling may be useful for drug monitoring in this cohort in the future, as blood collection is minimally invasive and less painful than venepuncture. Micro-sampling could also make further pharmacokinetic, pharmacodynamics and outcome studies in the elderly more feasible.

Background Today, older adult patients routinely undergo kidney transplantation. To support graft survival, patients must take immunosuppressant medicines for the rest of their lives. The post-transplant medication regimen is complex, and barriers to medication taking are likely confounded by both functional and intrinsic changes associated with advancing age. To develop diverse and innovative approaches to support best health outcomes in this vulnerable age group, it is imperative that the degree to which patients' needs are currently being met, be identified. Aim The aim of this study was to examine medication-taking behaviours of kidney transplant recipients transplanted at 60 years of age or older. Methods This qualitative study used semi-structured patient interviews to explore how kidney transplant recipients currently manage their immunosuppressant regimen and how they cope after transplantation with the complex routine. Data were themed using the principles of Grounded Theory methodology; with interviews conducted until data saturation was reached. Results Quantitative information was collected from 14 participants who ranged in age from 66 to 77 years (at time of interview), and were prescribed a median of 13 (min: 10, max: 26) medicines. The main themes that emerged from the interview were variability in health literacy toward medicines, the importance of support networks, the need to adjust health expectations, factors that were motivators for self-care, different approaches to medication management, and different approaches to medication taking. Overall, it was found that patients prioritised medication taking above all else, and gratitude to their donor was a powerful motivator to adhere. However, strategies to support medication taking were sometimes ineffective when patients' routine changed. Conclusions Future interventions should consider approaches to foster adaptable medication taking behaviours that stand up to changes in the day-to-day routine. Plain Language SummaryMedication taking is complicated in transplant recipients, due to the number of medicines that need to be taken and the complex nature of the treatment regimen. Challenges in older transplant recipients may be more pronounced and varied compared with younger adults. There are multiple factors that may impact medication taking in older adults and each requires consideration, including level of dependence, living arrangements, level of mobility and manual dexterity, vision and memory, and social situation. To better identify the gaps in support, patients' current perspectives around medication taking and how they cope after transplantation must be explored. Therefore, this study aimed to identify how older adult transplant recipients currently manage their anti-rejection medicine regimen. Participants described several strategies around how they manage a complex medication regimen. These included cues such as an alarm and linking the time they should take their

Purpose The COVID-19 pandemic likely impacted cannabis distribution, access and usage worldwide. This study aims to describe self-reported changes in cannabis use and related outcomes following COVID-19-related restrictions among an international sample of people who use drugs. Design/methodology/approach Using data from the Global Drug Survey COVID-19 Special Edition, the authors identified 20,417 respondents from 13 countries who reported whether the number of THC-containing cannabis usage days changed compared with February 2020 (before COVID-19 restrictions). Using descriptive statistics and a multinomial multivariable logistic regression, the authors investigated the impact of changes in cannabis use on respondents’ mental health, physical health, relationships, finances, work/study performance and cannabis-related pleasure/enjoyment. Findings Similar proportions of respondents reported that their cannabis use had stayed the same (38.2%) or increased (38.3%) compared with February 2020, while 21.9% of respondents reported a decrease. The most common reason for increased use was having more time (68.4%), while decreased use was associated with having less contact with people they use cannabis with (58.4%). The likelihood of reporting worse mental and physical health, finances, and work/study performance following COVID-19 restrictions was highest among those who reported increased cannabis use. Research limitations/implications These findings provide a unique understanding of the short-term international impact of initial COVID-19 restrictions on cannabis use, and highlight the need for policy to address the ongoing and improved provision of evidence-based mental health and other support for people who frequently use cannabis. Originality/value To the best of the authors’ knowledge, this is the world’s largest international study exploring the impacts of these changes in cannabis use following initial COVID-19 restrictions on individuals’ mental health, physical health, relationships, finances, work/study performance and cannabis-related pleasure. This study is also unique in comparing these changes across multiple continents.

Background The elderly is the fastest growing kidney transplant recipient group; however, they are more likely to die from immunosuppressant side effects than graft failure. Aim The aim of this study was to explore immunosuppressant prescribing practices in elderly kidney transplant recipients. Method We conducted a retrospective audit of registry data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry between 2000 and 2015, to determine the actual prescribing trends of immunosuppressant drugs in elderly recipients (≥65 years). Drug choice and doses, prescribed initially and at 1‐year, were examined, with a survival analysis conducted to determine if drug regimen influenced graft survival. Results Six hundred and one elderly recipients were included in the analysis. Elderly patients were less likely to be prescribed tacrolimus at 1 year than younger patients, and median doses (149.3 vs 155.6 micrograms/kg; p < 0.05) were significantly lower in elderly patients across the timeframe (initially and at 1‐year post‐transplant). We also observed that elderly recipients prescribed dual immunosuppressant therapy (compared to triple therapy) had an increased risk of graft loss (p < 0.05). Conclusion By examining Registry data across a 15‐year span, we observed differences in both immunosuppressant usage and drug dosing trends in elderly recipients. The implications of these findings may suggest that guidelines need adjustment to reflect this.