Both angiotensin converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs can lead to functional renal insufficiency. In an observational study we assessed the frequency of this adverse effect in patients aged over 75 years receiving these drugs in combination. In one year, out of 1500 patients whose records were screened, 12 were prescribed this combination. 2 developed acute renal failure, of whom one died and the other recovered after discontinuation of both drugs. 4 patients showed deterioration in renal function, which returned to normal after one of the drugs was stopped. Renal function remained stable in 6 patients: patients with deterioration in renal function were older and more likely to be on diuretics. This drug combination is commonly nephrotoxic in the elderly and should be avoided, especially in those taking diuretics.

Objective To evaluate drug survival with monotherapy compared with combination therapy with MTX in RA older adults. Methods Patients from the British Society for Rheumatology Biologics Register, a prospective observational cohort, who were biologic naïve and commencing their first TNF inhibitors (TNFi) were included. The cohort was stratified according to age: <75 and ≥75. Cox-proportional hazards models compared the risk of TNFi discontinuation from (i) any-cause, (ii) inefficacy and (iii) adverse events, between patients prescribed TNFi-monotherapy compared with TNFi MTX combination. Results The analysis included 15 700 patients. Ninety-five percent were <75 years old. Comorbidity burden and disease activity were higher in the ≥75 cohort. Fifty-two percent of patients discontinued TNFi therapy during the follow-up period. Persistence with therapy was higher in the <75 cohort. Patients receiving TNFi monotherapy were more likely to discontinue compared with patients receiving concomitant MTX [hazard rate 1.12 (1.06–1.18) P <0.001]. This finding only held true in patients <75 [hazard rate (HR) 1.11 (1.05–1.17) vs ≥75 [HR 1.13 (0.90–1.41)]. Examining TNFi discontinuation by cause revealed patients ≥75 receiving TNFi monotherapy were less likely to discontinue TNFi due to inefficacy [HR 0.66 (0.43–0.99) P=0.04] and more likely to discontinue therapy from adverse events [HR 1.41(1.02–1.96) P =0.04]. These results were supported by the multivariate adjustment in complete case and imputed analyses. Conclusion TNFi monotherapy is associated with increased treatment failure. In older adults, the disadvantage of TNFi monotherapy on drug survival is no longer seen. Patients ≥75 have fewer discontinuations due to inefficacy than adverse events compared with younger patients. This likely reflects greater disposition to toxicity but perhaps also a decline in immunogenicity associated with immunosenescence.

Most patients with atrial fibrillation should be considered for antithrombotic therapy. In a retrospective survey we investigated practice in two hospitals. For patients at high risk, established guidelines recommend warfarin, or aspirin if anticoagulants are contraindicated; for those at medium risk, either may be used. Of 156 with atrial fibrillation (acute, chronic or paroxysmal), 119 were at high risk, mean age 79 years. According to the guidelines, 89 of these were suitable for anticoagulation but only 49 (55%) received warfarin; 27 received aspirin and 13 neither. Of 27 patients at medium risk (mean age 70 years), 6 were not prescribed any antithrombotic therapy. This survey indicates that guidelines on antithrombotic therapy are commonly disregarded and that, in particular, warfarin is underutilized in the group for whom it is most indicated.

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SUMMARYTo discover whether general practitioners are correctly notified of a patient's final diagnosis following hospital discharge, an observational study was undertaken in a district general hospital. The final diagnosis was compared with the diagnosis documented in the discharge summary and the take‐home prescription. Two hundred discharges were studied. Only 163 (81%) discharge summaries and 138 (69%) take‐home prescriptions had the correct diagnosis; 24 (12%) take‐home prescriptions did not have any diagnosis at all. In some cases the diagnosis differed between the discharge summaries and the take‐home prescriptions. Only in 122 (61%) cases was the final diagnosis correctly documented in both instances. Communication regarding diagnosis in discharge letters is less than adequate. Every effort should be made to improve this.