Prescribing in the Elderly: Ins and Outs of PIMs. April 8, 2016 Ronan Factora, MD Center for Geriatric Medicine

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1 Prescribing in the Elderly: Ins and Outs of PIMs April 8, 2016 Ronan Factora, MD Center for Geriatric Medicine

2 Learning Objectives Recognize effects on aging on pharmacokinetic/pharmacodynamics of medications Identify potentially inappropriate medications Conduct a medication review to optimize pharmacological therapies

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6 The desire to take medicine is perhaps the greatest feature which distinguishes man from animals - William Osler

7 Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing - Voltaire

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9 BENEFIT RISK

10 HOW MANY DRUGS IS TO MUCH?

11 RISKS AGE > 85 MEDS > 5 5% 2 drugs 5 DRUGS 8 DRUGS 50% 100% >= 6 concurrent chronic diagnoses >=12 doses of medications per day Kaufman DW, et al. JAMA 2002 Hoffman JAMA 1996 Wolff Ach Int Med 2002 Prior adverse drug reaction Low body weight/bmi Est. CrCl < 50mL/min

12 November 2, 1966 January 19, 1947 EASY TO GET TO THE MINIMUM

13 EFFECTS OF AGING

14 TBW V D (hydrophilic) serum levels Reduce loading dose ATENOLOL THEOPHYLLINE ANTIBIOTICS SEDATIVES TBF V D (lipophilic) t 1/2 Avoid lipophilic drugs with long half life HALOPERIDOL DIAZEPAM DIGOXIN AMIODARONE t 1/2 = X V D clearance Hepatic Function Albumin serum levels Reduce doses Renal Function } clearance t 1/2 Avoid albumin binding drugs Avoid CYP450 inhibitors Caution with CYP450 inducers Estimate Cr Clearance PHENYTOIN DIAZEPAM WARFARIN INDOMETHECIN FUROSEMIDE

15 The Beer s List

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17 AGS 2015 Beers Criteria Table 2: Potentially Inappropriate Medications Table 3: Medication-disease interactions Table 4: Medications to be used with caution Table 5: non anti-infective drug-drug interactions Table 6: non-anti-infective drugs to avoid, adjust due to renal dysfunction

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29 STOPP

30 Conducting and Medication Review

31 The 10 Step Process Ascertain all drugs. Identify patients at high risk of or experiencing ADRs. Estimate life expectancy. Define care goals in reference to life expectancy, level of functional incapacity, quality of life, and patient/caregiver priorities. Scott et al. Am J Med. 2012

32 The 10 Step Process Define and confirm existent indications for ongoing treatment with reference to defined care goals. Determine time until benefit for preventive disease-specific medications. Determine disease-specific benefit harm thresholds that may support treatment discontinuation. Scott et al. Am J Med. 2012

33 The 10 Step Process Review the relative utility of individual drugs. Identify drugs that may be discontinued or have their dosing modified. Implement and monitor revised therapeutic plan with ongoing reappraisal of drug utility and patient adherence. Scott et al. Am J Med. 2012

34 GUESS THE PROBLEM

35 Pain and Muscle Spasm in a Depressed Patient Paxil Xanax Percocet Flexeril

36 The 87 yo Heart Failure Patient Captopril Metoprolol ASA Simvastatin Digoxin Spironolactone Furosemide K-Dur

37 Stuffy Head, Coughing, Aching, Sneezing, So You Can Rest Glucophage Glipizide Gabapentin Terazosin Proscar Tylenol Cold

38 Donepezil Memantine Plavix ASA Ziprasidone Citalopram Flecainide Lisinopril HCTZ Explosive Temper

39 Key Points Side effects are common Benefit should outweigh risk Avoid PIMs Most patients appreciate good medication reconciliation

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41 Recommended Readings Scott IA, Gray LC, Martin JH, Mitchell CA. Minimizing inappropriate medications in older populations: a 10- step conceptual framework. Am J Med Jun;125(6): American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. J Am Geriatr Soc Nov;63(11): O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing Mar;44(2):213-8.