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can be safely in performed elderly adults.2 From the experience of this case and other similar cases in octogenarians (unpublished data), the advantages of performing SBTKA rather than the two-stage total knee arthroplasty include shorter exposure to anesthesia, less time in the hospital,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
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OCTOBER 2014–VOL. 62, NO. 10
earlier positive clinical effects of rivastigmine, another oral acetylcholinesterase inhibitor, galantamine, was started after 1 month. Four days after initiation of galantamine treatment, he developed a rash at the previous location. Galantamine treatment was discontinued, and the rash disappeared. After 2 weeks, oral memantine, a N-methyl-Daspartate receptor inhibitor, was initiated as an alternative treatment, and he experienced no adverse drug reactions.
DISCUSSION A suspected side effect with a cross-reaction of acetylcholinesterase inhibitors is described in this case-report. Oral treatment with galantamine caused skin lesions similar to those from the patch with rivastigmine. According to the Naranjo algorithm, the likelihood that the adverse drug reaction was due to the suspected drug was probable.5 Two cases of individuals with allergic dermatitis after administration of rivastigmine patches are previously described. In one, transdermal rivastigmine was replaced with oral rivastigmine, and the rash grew.6 In the other, transdermal rivastigmine treatment was discontinued, and after disappearance of the rash, oral rivastigmine was administered under anesthesiological surveillance. In this case, the skin lesions reappeared at the same location, after which rivastigmine treatment was discontinued in any form.7 Recurrent dermatitis at a previously sensitized site after reexposure at a new site has been reported with nickel, gold, and chromate.8 No case reports were found of recurrent dermatitis after switching to oral therapy of a different acetylcholinesterase inhibitor, such as galantamine in this case. Locally induced T-cells at the site of the allergic dermatitis could have caused the reappearance of the rash at the previously sensitized site with the use of a different oral acetylcholinesterase inhibitor. Allergic dermatitis is a T-cell-mediated delayed type of hypersensitivity, and even with disappearance of the skin lesions, T-cells can be detected at this site for at least 21 days after the skin rash.8,9 In this case, no skin biopsy was performed. To the knowledge of the authors, this is the first reported case in which oral administration of galantamine lead to reappearance of an allergic dermatitis on a site that had previously been sensitized by transdermal rivastigmine. This case shows that, in the case of local side effects, sensitization can occur. Screening for recurrent local effects after switching from a patch to oral therapy of the suspected drug or to a drug from the same therapeutic drug group may be useful. Nienke M. S. Gol€ uke, MSc Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Astrid M. van Strien, MD Paul J. L. Dautzenberg, MD, PhD Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands Naomi Jessurun, PharmD LAREB, Netherlands Pharmacovigilance Centre ‘s-Hertogenbosch, the Netherlands
LETTERS TO THE EDITOR
2013
Carolina J. P. W. Keijsers, MD Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands
ACKNOWLEDGMENTS Conflict of Interest: Paul JL Dautzenberg was on the 2012 advisory boards for Eli Lilly and Novartis, received sponsorship for a memory congress from 2001 to 2013 from Novartis, and participated in Phase III medication trials from MSD, Novartis, and Janssen-Cilag during the conduct of the study. All other authors declare no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work. Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the drafting of the manuscript. Data collection: Dautzenberg, van Strien. Study supervision: Keijsers. All authors approved the final version. Sponsor’s Role: No sponsor.
REFERENCES 1. European Public Assessment Report. Exelon 2013. European Medicine Agency Science Medicines Health [on-line]. Available at http:// www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/ 000169/human_med_000777.jsp&mid=WC0b01ac058001d124 Accessed April 2, 2014. 2. Darreh-Shori T, Jelic V. Safety and tolerability of transdermal and oral rivastigmine in Alzheimer’s disease and Parkinson’s disease dementia. Expert Opin Drug Saf 2010;9:167–176. 3. Wouters CJ, Dautzenberg L, Thissen A et al. Galantamine of rivastigmine pleister. Een beschrijvend onderzoek op een geheugenpolikliniek in Nederland. Tijdschr Gerontol Geriatr 2010;41:146–150 (Dutch). 4. Summary of Product Characteristics. Reminyl Tablets 2013. Electronic Medicines Compendium [on-line]. Available at http://www.medicines.org.uk/emc/ medicine/10335/SPC/Reminyl+Tablets/ Accessed April 2, 2014. 5. Narnajo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30: 239–245. 6. Makris M, Koulouis S, Koti I et al. Maculopapular eruption to rivastigmine’s transdermal patch application and successful oral desensitization. Allergy 2010;65:925–926. 7. Grieco T, Rossi M, Faina V et al. An atypical cutaneous reaction to rivastigmine transdermal patch. J Allergy 2011;2011:752098. 8. Nuare A, Cruz PD. Recall dermatitis at patch test sites in alopecia areata treated with diphencyprone. Dermatitis 2012;23:98–99. 9. Moed H, Boorsma DM, Tensen CP et al. Increased CCL27-CCR10 expression in allergic contact dermatitis: Implications for local skin memory. J Pathol 2004;204:39–46.
CONSTIPATION: AN UNUSUAL PRESENTATION OF ULCERATIVE PANCOLITIS IN AN ELDERLY ADULT To the Editor: Ulcerative colitis (UC), along with Crohn’s disease (CD), is one of the major types of inflammatory bowel disease. UC has a bimodal age distribution; the
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
JAGS
OCTOBER 2014–VOL. 62, NO. 10
earlier positive clinical effects of rivastigmine, another oral acetylcholinesterase inhibitor, galantamine, was started after 1 month. Four days after initiation of galantamine treatment, he developed a rash at the previous location. Galantamine treatment was discontinued, and the rash disappeared. After 2 weeks, oral memantine, a N-methyl-Daspartate receptor inhibitor, was initiated as an alternative treatment, and he experienced no adverse drug reactions.
DISCUSSION A suspected side effect with a cross-reaction of acetylcholinesterase inhibitors is described in this case-report. Oral treatment with galantamine caused skin lesions similar to those from the patch with rivastigmine. According to the Naranjo algorithm, the likelihood that the adverse drug reaction was due to the suspected drug was probable.5 Two cases of individuals with allergic dermatitis after administration of rivastigmine patches are previously described. In one, transdermal rivastigmine was replaced with oral rivastigmine, and the rash grew.6 In the other, transdermal rivastigmine treatment was discontinued, and after disappearance of the rash, oral rivastigmine was administered under anesthesiological surveillance. In this case, the skin lesions reappeared at the same location, after which rivastigmine treatment was discontinued in any form.7 Recurrent dermatitis at a previously sensitized site after reexposure at a new site has been reported with nickel, gold, and chromate.8 No case reports were found of recurrent dermatitis after switching to oral therapy of a different acetylcholinesterase inhibitor, such as galantamine in this case. Locally induced T-cells at the site of the allergic dermatitis could have caused the reappearance of the rash at the previously sensitized site with the use of a different oral acetylcholinesterase inhibitor. Allergic dermatitis is a T-cell-mediated delayed type of hypersensitivity, and even with disappearance of the skin lesions, T-cells can be detected at this site for at least 21 days after the skin rash.8,9 In this case, no skin biopsy was performed. To the knowledge of the authors, this is the first reported case in which oral administration of galantamine lead to reappearance of an allergic dermatitis on a site that had previously been sensitized by transdermal rivastigmine. This case shows that, in the case of local side effects, sensitization can occur. Screening for recurrent local effects after switching from a patch to oral therapy of the suspected drug or to a drug from the same therapeutic drug group may be useful. Nienke M. S. Gol€ uke, MSc Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Astrid M. van Strien, MD Paul J. L. Dautzenberg, MD, PhD Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands Naomi Jessurun, PharmD LAREB, Netherlands Pharmacovigilance Centre ‘s-Hertogenbosch, the Netherlands
LETTERS TO THE EDITOR
2013
Carolina J. P. W. Keijsers, MD Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands
ACKNOWLEDGMENTS Conflict of Interest: Paul JL Dautzenberg was on the 2012 advisory boards for Eli Lilly and Novartis, received sponsorship for a memory congress from 2001 to 2013 from Novartis, and participated in Phase III medication trials from MSD, Novartis, and Janssen-Cilag during the conduct of the study. All other authors declare no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work. Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the drafting of the manuscript. Data collection: Dautzenberg, van Strien. Study supervision: Keijsers. All authors approved the final version. Sponsor’s Role: No sponsor.
REFERENCES 1. European Public Assessment Report. Exelon 2013. European Medicine Agency Science Medicines Health [on-line]. Available at http:// www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/ 000169/human_med_000777.jsp&mid=WC0b01ac058001d124 Accessed April 2, 2014. 2. Darreh-Shori T, Jelic V. Safety and tolerability of transdermal and oral rivastigmine in Alzheimer’s disease and Parkinson’s disease dementia. Expert Opin Drug Saf 2010;9:167–176. 3. Wouters CJ, Dautzenberg L, Thissen A et al. Galantamine of rivastigmine pleister. Een beschrijvend onderzoek op een geheugenpolikliniek in Nederland. Tijdschr Gerontol Geriatr 2010;41:146–150 (Dutch). 4. Summary of Product Characteristics. Reminyl Tablets 2013. Electronic Medicines Compendium [on-line]. Available at http://www.medicines.org.uk/emc/ medicine/10335/SPC/Reminyl+Tablets/ Accessed April 2, 2014. 5. Narnajo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30: 239–245. 6. Makris M, Koulouis S, Koti I et al. Maculopapular eruption to rivastigmine’s transdermal patch application and successful oral desensitization. Allergy 2010;65:925–926. 7. Grieco T, Rossi M, Faina V et al. An atypical cutaneous reaction to rivastigmine transdermal patch. J Allergy 2011;2011:752098. 8. Nuare A, Cruz PD. Recall dermatitis at patch test sites in alopecia areata treated with diphencyprone. Dermatitis 2012;23:98–99. 9. Moed H, Boorsma DM, Tensen CP et al. Increased CCL27-CCR10 expression in allergic contact dermatitis: Implications for local skin memory. J Pathol 2004;204:39–46.
CONSTIPATION: AN UNUSUAL PRESENTATION OF ULCERATIVE PANCOLITIS IN AN ELDERLY ADULT To the Editor: Ulcerative colitis (UC), along with Crohn’s disease (CD), is one of the major types of inflammatory bowel disease. UC has a bimodal age distribution; the
