Case-based polymedication challenges

Transcription

1 Case-based plymedicatin challenges Luise Mallet, B.Sc.Pharm., Pharm.D., BCGP, FESCP Prfesseure titulaire de clinique Faculty f Pharmacie, Université de Mntréal Clinical Pharmacist in Geriatrics McGill University Health Center 1

2 Cnflit f interest N cnflict f interest t declare 2

3 Objectives At the end f the presentatin, participants will be able t: Knw sme strategies fr apprpriate prescribing in frail elderly in rder t avid geriatric syndrmes; Knw hw t discntinue medicatins safely (deprescribing) in lder patients using case-based plymedicatin. 3

4 «When an elderly patient presents with a status change, unless prven therwise, it shuld be assumed t be a medicatin related prblem». Jerry Gurwitz,M.D. 4

5 Prblems with drugs in the elderly Evidence-based medecine Time t benefit Life expectancy Adherence t treatment Pharmackinetic changes Pharmacdynamic changes Reduced hmestatic functin Beers criteria STOPP and START Antichlinergic lad Geriatric syndrme Multiple diseases, medicatins Drug interactins Medicatin cascade Medicatins and Functinal/cgnitive status Adverse drug events 5

6 Geriatric syndrmes «Les grands géants» Delirium Falls Urinary incntinence Malnutritin, weight lss Pain Plypharmacy 6

7 Geriatric syndrmes Falls Delirium Anrexia, malnutritin Urinary incntinence Functinal decline Plypharmacy Medicatins > 4 drugs, antipsychtiques, antidépresseurs, benzdiazépines, etc Antichlinergic medicatins Digxin, metrnidazle, enalapril, lithium Diuretics, ACEI, ACHe inhibitrs, sedativehypntics Antipsychtics, antihypertensives, etc etc Mre than 5 medicatins 7

8 Mr. Falls 79 year ld man 3rd visit t ER fr recurrent falls. Lives with his daughter. Medical histry: Diabetes Neurpathy, retinpathy Hypertensin NKDA Weight: 70 kg Height: 1,67 m Cr = 79 uml/l (stable) ClCr = 60 ml/min 8

9 M. Falls Met with the patient fr his medicatin histry Many falls in past mnths Back pain fllwing his falls Medicatins prescribed by 6 different physicians 9

10 Medicatins: M. Falls Metfrmin 50 mg + Sitagliptin 50 mg 2 x/day Gliclazide MR 60 mg 1 x/day Canagliflzin 100 mg 1 x/day Insuline Lantus 30 u sc at bedtime Simvastatin 20 mg 1 x/day Irbesartan 75 mg 1 x/day Tamsulsin 0.4 mg 1 x/day ECASA 80 mg 1 x/day Lax-a-day 17 g daily in mrning Clace 200 mg daily at bedtime Hydrmrphne 0.5 mg p q 4 hrs prn Acetaminphen 500 mg 1-2 tab q 4-6 hr Vltaren emulgel apply 4 times daily prn 10

11 Hw d we begin Dyks D. Apprch t medicatin reviews in lder adults p. Chapter in Medicatin-related falls in lder persn. Springer

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13 Match medical prblems and medicatins Medical prblems Falls 3rd visit at ER Diabetes Hypertensin Chlesterl Medicatins Metfrmin 50 mg + Sitagliptin 50 mg 2 x/day Gliclazide MR 60 mg 1 x/day Canagliflzin 100 mg 1 x/day Insuline Lantus 30 u sc at bedtime Irbesartan 75 mg 1 x/day Tamsulsin 0.4 mg 1 x/day Metfrmin 50 mg + Sitagliptin 50 mg 2 x/day Gliclazide MR 60 mg 1 x/day Canagliflzin 100 mg 1 x/day Insuline Lantus 30 u sc at bedtime Irbesartan 75 mg 1 x/day/ Simvastastin 20 mg 1x/day?? Tamsulsin 0.4 mg 1 x/day 13

14 Match medical prblems and medicatins Medical prblems Pain Cnstipatin Medicatins Hydrmrphne 0.5 mg p q 4 hrs prn Acetaminphen 500 mg 1-2 tab q 4-6 hr Vltaren emulgel Lax-a-day 17 g daily in mrning Clace 200 mg daily at bedtime 14

15 Medicatins: M. Falls/Chrnlgy Metfrmin 50 mg + Sitagliptin 50 mg 2 x/day Gliclazide MR 60 mg 1 x/day Canagliflzin 100 mg 1 x/day (End f Dec 2015) Insuline Lantus 30 u sc at bedtime Simvastatin 20 mg 1 x/day Irbesartan 75 mg 1 x/day Tamsulsin 0.4 mg 1 x/day (Mars 2016) ECASA 80 mg une 1 x/day Hydrmrphne 0.5 mg p q 4 hrs prn (April 2016) Acetaminphen 500 mg 1-2 tab q 4-6 hr Vltaren emulgel apply 4 times daily prn Lax-a-day 17 g 1 x/day Clace 200 mg p 1 x/day at bedtime 15

16 M. Falls Chrnlgy Canagliflzin 100 daily (End December 2015) Tamsulsin 0.4 mg daily (March 2016) Clavulin 875/125 bid x 10 days (March 2016 ) Patient mentins an assciatin between his new prescriptins fr canagliflzin, tamsulsin and his falls Then tw ER visits: (April 2016) Acetaminphen 500 mg 1-2 tab q 4-6 hr (1 st visit) Dilaudid 0.5 mg p q 4 hrs au prn (2 nd visit) Clace 200 mg at bedtime Lax-a-day 17 g une fis par jur Vltaren emulgel 16

17 What is yur evaluatin? 17

18 Medicatins: M. Falls/Chrnlgy Metfrmin 50 mg + Sitagliptin 50 mg 2 x/day Gliclazide MR 60 mg 1 x/day Canagliflzin 100 mg 1 x/day (End f Dec 2015) Insuline Lantus 30 u sc at bedtime Simvastatin 20 mg 1 x/day Irbesartan 75 mg 1 x/day Tamsulsin 0.4 mg 1 x/day (Mars 2016) ECASA 80 mg une 1 x/day Hydrmrphne 0.5 mg p q 4 hrs prn (April 2016) Acetaminphen 500 mg 1-2 tab q 4-6 hr Vltaren emulgel apply 4 times daily prn Lax-a-day 17 g 1 x/day Clace 200 mg p 1 x/day at bedtime 18

19 Prescibing cascademédeicamenteuse Prescriptin f drug n 0 1 Þ Side effect misinterpreted as a new medical prblem Þ Prescriptin f drug n 0 2 Þ Side effect misinterpreted as a new medical prblem Þ and the cascade cntinue Rchn P, et cll. BMJ 1997;315: Annual Refresher Curse McGill 19

20 Chrnlgy f events Drug 1 Side effects Drug 2 Side effects 20

21 Side effects 21

22 Medicatins: M. Falls: yur evaluatin Metfrmin 50 mg + Sitagliptin 50 mg 2 x/day Gliclazide MR 60 mg 1 x/day Canagliflzin 100 mg 1 x/day Insuline Lantus 30 u sc at bedtime Why 4 drugs fr his DM? Simvastatin 20 mg 1 x/day Irbesartan 75 mg 1 x/day Tamsulsin 0.4 mg 1 x/day ECASA 80 mg 1 x/day Lax-a-day 17 g daily in mrning Clace 200 mg daily at bedtime Hydrmrphne 0.5 mg p q 4 hrs prn Acetaminphen 500 mg 1-2 tab q 4-6 hr Vltaren emulgel apply 4 times daily prn 22

23 Fall as a geriatric syndrme Hypglycemia Orthstatic hyptensin Fall Acute Illness Medicatins Neurpathy Annual Refresher Curse McGill 23

24 Amldipine Fursemide Oxybutynin Dnepezil 24

25 Lecuteur D et al. Deprescribing. Australian Prescriber 2011;34:

26 Sctt IA, et al. JAMA 2015:175:

27 Annual Refresher Curse McGill 27

28 90 year-ld wman wh lives with her sn Was asked t review her medicatins He is respnsable t manage the medicatins, ck meals, etc. CLSC every mnth. Medical prblems: Diabetes, hypertensin, steprsis, dementia, CKD Weight: 60 kg Height: 152 cm Créatinine: 165 uml/l Calclated Cl Cr = 15 ml/min Mrs. N 28

29 Medicatins Medicatins: Amldipine 2.5 mg daily Candesartan 16 mg daily Indapamide 2,5 mg daily Omeprazle 20 mg daily Alendrnate 70 mg p every sunday Dmeperidne 10 mg twice daily Metfrmin 850 mg twice daily Saxagliptin 5 mg daily Calcium Vitamin D 400 U bid Atrvastatin 20 mg daily Acetaminphen 500 mg p 3 fis daily prn 29

30 Geriatric principles Des she take her medicatins? Difficult t cmmunicate with the patient Meeting with the sn: respnsible t give the medicatins Says that his mther takes t many medicatins Des nt give meprazle, dmperidne, atrvastatin and acetaminphen 30

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32 Medicatins Medicatins: Amldipine 2.5 mg daily Candesartan 16 mg daily Indapamide 2,5 mg daily Omeprazle 20 mg daily Alendrnate 70 mg p every sunday Dmeperidne 10 mg twice daily Metfrmin 850 mg twice daily Saxagliptin 5 mg daily Calcium Vitamin D 400 U bid Atrvastatin 20 mg daily Acetaminphen 500 mg p 3 fis daily prn 32

33 Medicatins Medicatins: Amldipine 2.5 mg daily Candesartan 16 mg daily Indapamide 2,5 mg daily Alendrnate 70 mg p every Sunday Metfrmin 850 mg twice daily Saxagliptin 5 mg daily Calcium Vitamin D 400 U bid Calculated ClCr : 15 ml/min At hme: glucse level: 9 t 12 mml/l (accrding t his sn) HbA1 C 6,5% (frm DSQ past 2 mnths) 33

34 Match medical prblems and medicatins Medical prblems Diabetes Drugs Metfrmin 850 mg bid Saxagliptin 5 mg daily Therapeutic bjectives HbA1 C <8.5% Glucse: 9 t 12 mml/l Others Metfrmin nt indicated if CrCl <30 ml/min Saxagliptin: CrCl 50 ml/min: 2.5 mg nce daily Osteprse Alendrnate 70 mg p every Sunday Calcium Vit D 400 U bid N fracture Has been taking it fr at least 10 years accrding t her sn Alendrnate: nt indicated if CrCl < 35 ml/min Vitamin D 10,000 u q week Calcium 500 mg daily 34

35 Questin Is this patient fit, vulnerable r frail? 1. Fit 2. Vulnerable 3. Frail 35

36 Definitin f an elderly persn âgée Independent elderly persn, withut c-mrbidity, verall gd health status; (Bnne santé/fit) Partially dependent elderly persn with 1 t 2 c-mrditities; (Vulnérable/vulnerable) Elderly persn with functinal r cgnitive limitatin with many c-mrbidities, presenting with at least ne geriatric syndrme; (Fragile/frail) 36

37 Questin Is this patient fit, vulnerable r frail? 1. Fit 2. Vulnerable 3. Frail 37

38 Questin Which is yur therapeutic bjective fr this 91 year ld patient with hypertensin? 1. < 120 mm Hg systlic BP (as per SPRINT) 2. < 160 mm Hg systlic BP 3. < 150 mm Hg systlic BP(as per HYVET study) age f the patient 38

39 Questin Which is yur therapeutic bjective fr this 91 year ld patient with hypertensin? 1. < 120 mm Hg systlic BP (as per SPRINT) 2. < 160 mm Hg systlic BP withut rthstatic hyptensin 3. < 150 mm Hg systlic BP withut rthstatic hyptensin (as per HYVET study) age f the patient 39

40 Match medical prblems and medicatins Medical prblems Drugs Therapeutic bjectives Others Hypertensin Amldipine 2.5 mg daily Candesartan 16 mg daily Indapamide 2.5 mg daily Bld pressure: <160 mmhg withut rthstatic hyptensin Indapamide: Canadian labeling cntraindicates use in severe impairment (CrCl <30 ml/minute) Candersartan: in patients with severe renal impairment (CrCl <30 ml/minute/1.73 m 2 ) AUC and C max were apprximately dubled after repeated dsing. Amldipine: can increase dse if needed 40

41 Medicatins Medicatins: Amldipine 5 mg daily Saxagliptin 2,5 mg daily Calcium 500 mg daily Vitamin D 10, u p q week 41

42 91 year ld wman admitted fr «failure t thrive». Acute renal insufficency n CKD Creatinine: 189 uml/l Medicaments : Amldipine 5 mg p daily Candesartan 16 mg p daily Indapamide 2.5 mg p daily Pantprazle 40 mg une fis par jur Metfrmin 1 gm + Saxagliptin 2,5 mg twice daily Vitamine D 10,000 un q week Calcium 500 mg daily Lactate: 4,0 (0,6-2,4) 11 mnths later 42

43 Apprpriate prescribing: The Pyramid Mdel Ref: Hlmes, Arch Int Med,

44 79 year-ld wman admitted t ER fr Gen Det Medicatins at hme: Pregabaline 75 mg p 2x/d Venlafaxine XR 75 mg p daily Dmperidne 10 mg p qid Metclpramide 10 mg p bid Clnazepam 0.5 mg p qid Risperidne 0.5 mg p daily Dimenhydrinate 50 mg p q 4 hrs prn (180/mnth) Cumadin 5 mg p daily Janumet mg (metfrmine + sitagliptine) bid Glyburide 5 mg p bid Rsuvastatin 20 mg p daily Ramipril 5 mg p daily Bisprll 5 mg p daily Amldipine 10 mg p daily Pantprazle 40 mg p daily Levthyrxine mg p daily Clace 100 mg p Annual bid Refresher Curse McGill

45 79 year-ld wman admitted t ER fr Gen Det Pregabaline 75 mg p 2x/d Venlafaxine XR 75 mg p daily: was n Citalpram 40 mg p daily d/c april Dmperidne 10 mg p qid Metclpramide 10 mg p bid: EPS Clnazepam 0.5 mg p qid: Benzdiazepine lng t 1/2 Risperidne 0.5 mg p dialy Dimenhydrinate 50 mg p q 4 hrs prn: antichlinergic Cumadin 5 mg p daily Janumet mg (metfrmine + sitagliptine) bid Glyburide 5 mg p bid: Accumulatin lng t 1/2 and active metablite Rsuvastatin 20 mg p daily Ramipril 5 mg p daily Bisprll 5 mg p daily Amldipine 10 mg p daily Pantprazle 40 mg p daily Levthyrxine mg p daily?? Hw des she take her meds Clace 100 mg p bid 45

46 Thank Yu and Healthy Aging