ROAD TO UNDERSTANDING POLYPHARMACY. Lt Col PHIL L. SAMPLES BS Phr, Pharm. D., BCNSP

Transcription

1 ROAD TO UNDERSTANDING POLYPHARMACY Lt Col PHIL L. SAMPLES BS Phr, Pharm. D., BCNSP

2 Definition occurs when: 1. a medical regimen includes at least one unnecessary medication 2. Medications have not been optimized for desired therapeutic goal implies the prescribing of too many medication for an individual patient with the associated higher risk of adverse reactions and interactions

3 Scope of the Problem At one large AF Medical Center - greater than 3,200 patients had 15 active prescriptions In one study - 40% of pts received Rx from provider other than PCM A study of elderly patients showed - drug related problems was the major OR contributing reason for hospital admission in 31% of cases

4 Many Causes of the Problem Prescriber-related - pressed for time, prescribe for every symptom, market pressure System-related - lack of central PCM, lack of incentives to reduce Patient-related - belief every symptom requires new Rx, search for miraculous cure, direct to consumer market pressure

5 Factors Contributing to Polypharmacy Increasing age Multiple symptoms Multiple medical problems Copious prescribing Multiple providers Lack of a PCM to coordinate therapy Use of multiple pharmacies Hoarding medications Self treatment

6 Complications of Polypharmacy Increased side effects Adverse drug reactions Drug-drug interaction Noncompliance with the medication regimen Increased Cost Directly due to medication Indirectly due to hospitalization or other treatment of adverse effects

7 Case Studies

8 Case I 81 yo wf with HTN and angina (stable). Pt is limited in ability to ambulate. Wt 105 lbs. HTN has been well controlled and need for SL NTG has been less than once in 4 months. Meds: NTG 1/150 SL prn long acting nifedipine (Adalat CC) 30mg qd HCTZ 25 mg qd Recently pt presented to PCM with the complaint of heartburn for which the provider prescribed rantidine 300mg hs. Four days later patient was admitted to the hospital for severe chest pain (not relieve with NTG).

9 Case I (Cont.) Discussion Questions - 1. What labs would you like on admission? 2. Any test you would perform? 3. What steps would you take to prevent this from happening?

10 Case II 62 yo wf, HTN, NIDDM, hypothyroid (thyroid ablation - 20 years ago), current weight = 171 lbs, 5 3, BG in the 200 +/- range, BP 145/85, last T4 high nl 4 years ago. Meds: propranolol 80mg qd HCTZ 50mg qd levothyroxine 0.1mg qd Glypizide 20mg bid (recent increase - 2 months earlier - no decrease in BG) various OTC medications for seasonal allergies and cough/cold Questions - 1. what should you do to bring this patients BG under control? 2. what changes in therapy would you recommend? Why?

11 Case III 58 yo wf, with depression, primary osteoporosis, mild HTN, mild RA, and GERD admitted to the hospital with severe mental confusion/agitation. Medications - fluoxetine 20 mg qd Calcium 500 mg qd Vitamin D 150 mcg qd enalapril 10 mg qd piroxicam 20 mg qd cimetadine 600 mg bid

12 Case III (Cont.) Discussion Questions - 1. What labs would you want on admission? 2. Are there any other test you would request? Free Ca++ was 9.1mg/dl 3. Manic phase of bipolar disorder? (orig thought of intern)

13 Case IV 26 yo male patient admitted to the ER and subsequently to the ICU for esophageal bleed. Pt was healthy and had no record of medications used. Pt required transfusion with two units of whole blood on the first night and aggressive pressor agents and balloon taponade finally stopped the bleeding.

14 Case IV (Cont.) Discussion Pt was not HTN, was not intoxicated, was in good health. Prior to admission he had been out working on some land he had purchased and was clearing the lot for a house trailer. His only complaint to his wife was very sore muscles. Any questions?

15 Case V 10 yo wm with dx of ADD, mother presents with a request to the new physician for the same meds the child had been on at a previous station Dexidrine 10mg spansule in AM Dexidrine 5mg spansule at noon Nortriptyline 25mg hs

16 Case V (Cont.) Discussion Do we need split dosing of dexidrine? What is the purpose of the nortriptyline? Could this regimen be simplified?

17 Case VI S: 52 yo BF referred for uncontrolled DM II, htn, medication intolerance O: HgA1C 11.6 (9/00) BS range in upper 200 to 300 range AST/ALT 93/93 (11/00) Chol 215, HDL 64, LDL 133, TG 89 (10/00) + proteinuria BP 162/102 (4/00) and 137/89 at home after addition of Plendil wt 213 lbs Allergies codeine patient denies any hypoglycemic episodes

18 Case VI (cont) O: (continued) Current MEDS: Avandia 8mg qd Glucotrol 10mg bid Altace 10 mg bid ECASA 325 qd Plendil 10 mg qd Benadryl 50-mg hs Metamucil QAM numerous medication not tolerated including: Elavil, Reglan, Metformin, Hytrin, Catapres and Tiazac What do you want to know at this point? DISCUSSION

19 Case VI (cont) A/P: 1. Possible absorption issue with metamucil taken with other meds 2. HTN (with comobidity DMII) max ACE, plendil appears to have been effective, recommend add HCTZ 12.5 qd to maximize ACE effect. 3. DM II If LFTs permit continue Avandia for 6 wk trial suggest re-challenge with Metformin IF SrCr < 1.3 initial trial was too aggressive on starting dose. D/C glucotrol if starting metformin consider insulin if above not successful 4. Hyperlipidemia defer until other changes are stable goal is LDL < 100 due to comorbidities

20 Simplifying Regimens Eliminate pharmacologic duplication Avoid combinations that augment side effects tricyclic antidepressant and diphenhydramine for sleep Avoid combinations that duplicate therapy sucralfate plus H2 antagonist Use single medications to manage multiple diseases ACE inhibitor for HTN and CHF, B-blocker for HTN and angina Avoid drugs that can exacerbate the patient s other medical conditions B-blocker used for HTN in a patient with asthma

21 Simplifying Regimens (Cont.) Decrease dosing frequency Best medication for the patient with the least frequent dosing interval (NOTE: QD verses BID - no statistical difference in compliance) Consider sustained-release dosage forms (cost could be a factor here)

22 Simplifying Regimens (Cont.) Regular review of drug regimen Is the patient compliant? Are all agents still needed? Can the regimen be simplified? Brown Bag session Inquire about OTC medication use Inquire about herbal remedies

23 Other Considerations Include other members of the health-care team Pharmacy consultation on high yield areas - inhalation therapy, multiple medication patients, diabetic teaching, etc. Nursing - disease targeted patient education - diabetic care classes for all new diag. diabetics, discharge counseling with primary family members Physical Therapy - increase patients own expectations Health Promotion - have patient share responsibility for their situation

24 THANK YOU

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