Medications and Polypharmacy in LTC

Transcription

1 Medication-Related Problems Medications and Polypharmacy in LTC Dec 14 th 2010 Dr. John Puxty "Any symptom in an elderly patient should be considered a drug side effect until proved otherwise." J Gurwitz, M Monane, S Monane, J Avorn Brown University Long-term Care Quality Letter 1995 Outline Outline challenge of applying clinical practice guidelines for drug use to LTC residents Discuss tensions between avoiding harmful drugs vs. optimizing effective drugs Avoiding harmful drugs: errors of commission Optimizing effective drugs: errors of omission Discuss practical approaches to optimizing medication use for residents in LTC with multiple comorbid illnesses Specific Issues: Hypertension, Anti-psychotics, Diabetes Mellitus, Osteoporosis, Use of anticoagulants Seven Categories of Medication-Related Problems 1. Medical condition that requires new or additional drug therapy. 2. Patient taking unnecessary drug given present condition. 3. Incorrect drug for patient s medical condition. 4. Correct drug, dose too low. 5. Correct drug, dose too high. 6. Adverse drug reaction. 7. Patient not taking drug correctly. Demographics and Disease Rapidly rising population of elderly LTC residents with multiple co-morbid illnesses Rising prevalence rates for many chronic diseases: Diabetes mellitus Coronary artery disease Congestive heart failure Osteoporosis Alzheimer s disease and related dementias, etc Many of these conditions typically require multi-drug regimens Recognition of Drug-Induced Reactions Be mindful of new symptoms that might be an ADE. Review the medications. Examine temporal relationships between new meds or increased/decreased dosage or discontinuation and onset of symptoms. Hyperactive state suspect cholinergic toxicity, alcohol intoxication, stimulant intoxication, serotonin syndrome, alcohol or benzodiazepine withdrawal. Hypoactive state suspect sedative or narcotic intoxication, alcohol or benzodiazepine intoxication. Always, Always, Always consider medications with acute confusion.

2 Prescribing Continuum Polypharmacy (errors of commission) OPTIMAL PRESCRIBING Under-treatment (errors of omission) The Prescribing Cascade A common but under-recognized mechanism by which errors of commission may develop Examples: NSAID HTN antihypertensive therapy Antipsychotic Parkinsonism Sinemet Metoclopromide Parkinsonism Sinemet Antipsychotic akithesia (restlessness) more antipsychotic Cholinesterase inhibitor (e.g. donepezil, galantamine) urinary urgency, incontinence anticholinergic (e.g. oxybutynin) Errors of Commission: Study of 1999 prescribing patterns in >750,000 US subjects > 65 yrs old 21% filled prescription for a drug deemed to be potentially inappropriate by expert panel 51% = drugs with potentially severe adverse effects 23% = amitriptyline, doxepin 15% filled prescriptions for 2 drugs of concern, 4% filled prescriptions for > 2 drugs of concern Similar studies date back at least 10 years with similar results, and little or nothing has been done to address the problem Curtis LH, et al. Arch Intern Med, 2004 Errors of Commission: Several lists of inappropriate prescribing have been published (Beers MH, et al. Arch Intern Med, 1991 and McLeod PJ, et al. CMAJ, 1997) Beers criteria updated (Fick DM, et al. Arch Intern Med, 2003) These criteria have helped define rates of inappropriate prescribing in variety of settings However: They are arbitrary, consensus-based criteria (strength of evidence re: harm with these drugs?) These criteria only cover errors of commission : what about errors of omission? Errors of Commission: Drugs/doses to avoid in most cases: Meperidine (Demerol) Strongly anticholinergic tricyclic antidepressants: amitriptyline, doxepin, imipramine Other anticholinergic medications: e.g. diphenhydramine (Benadryl) Long-acting benzodiazepines such as diazepam Long-acting NSAIDs (piroxicam) High-dose thiazide diuretics (> 25 mg HCTZ) Iron (325 mg once daily is usually enough) Errors of Omission: Study of pharmacologic quality indicators using prescribing data Used different list of inappropriate prescribing practices vs. study by Curtis et al. Found that relatively few patients were being given inappropriate drugs, but many were NOT prescribed medications for which they had indications (Higashi T et al. Ann Intern Med, 2004)

3 Errors of Omission: Under-treatment is common among elderly: Coronary artery disease ( risk treatment paradox ) ASA (primary and secondary prevention) Beta-blockers (post-mi) Anticoagulation in atrial fibrillation Hypertension, especially isolated systolic HTN Osteoporosis Calcium, vitamin D, +/ bisphosphonates/raloxifene Pain Unwarranted fear of narcotic use by patient/physician Long-term adherence (May be less problematic in LTC vs community setting) Holmes HM, et al. Arch Intern Med, 2006 Reconsidering Medication Appropriateness for Patients in Late Life Providing guideline-adherent care for many conditions increasingly means the addition of more drugs to reach disease-specific targets When might it be best to withhold or discontinue medications that are otherwise appropriate on the basis of guidelines? Authors propose practical 4-step model for appropriate prescribing for patients late in life (Holmes HM, et al. Arch Intern Med, 2006) Holmes HM, et al. Arch Intern Med, 2006 Reconsidering Medication Appropriateness for Patients in Late Life Remaining Life Expectancy Time Until Benefit Goals of Care Treatment Targets Medication Review (3D CARE) Is the Drug indicated and best choice (Beers list Fick et al, 2003)? Is the Dosage and Duration correct? Are there Compliance issues? Are there Adverse Reactions as result of: Drug-drug interactions? Drug-disease/condition interactions? Is this drug the least Expensive alternative compared to others of equal utility?

4 Summary / Return to Outline Outline challenge of applying clinical practice guidelines for drug use to LTC residents Discuss tensions between avoiding harmful drugs vs. optimizing effective drugs Avoiding harmful drugs: errors of commission Optimizing effective drugs: errors of omission Discuss practical approaches to optimizing medication use for residents in LTC with multiple comorbid illnesses Benefits of Treatment Treatment reduces overall mortality, CVD events, heart failure, and stroke Treatment effect is greatest in men, patients older than 70 years, and patients with greater pulse pressure Treatment effect is delayed about 5 years, so drug therapy may not be advisable for very elderly people Specific Issues Hypertension Anti-psychotics Diabetes Mellitus Osteoporosis Use of anticoagulants Treatment Choice Angiotensin converting enzyme (ACE) inhibitors, newer calcium channel blockers, and thiazide diuretics are the first and second- line drugs of choice for mortality reduction Wright JM and Musini VM, Cochrane Database Syst Rev 2009 CD Treatment Goals for Hypertension in Elderly To achieve maximum mortality reduction in hypertensive persons over 75, the goal of therapy is typically a standing systolic pressure between 130 and 140, and no lower. (Oates, DJ et al, Journal of the American Geriatrics Society, 2007;55: ) 4,000 persons 80 and over with hypertension followed over 5 years. Lowest mortality if all diastolic pressures 80 to 89, and all systolic pressures 130 to 139. (J-shaped curve) Any diastolic <80, or systolic <130 associated with significant increase in mortality at 5 year follow-up Newer Generation Ca Channel Blockers Amlodipine plus benazepril caused more edema (31 vs 13) than hydrochlorthiazide plus benazepril. But reduced cardiac events and deaths more (11.9 vs 9.6) in 11,000 pts over 3 yrs. (Jamerson K, et al, N Eng J Med 2008:359: ) Amlodipine/felodipine are good for urge incontinence (1/3 of all persons 75 and over), whereas HCTZ/chlorthalidone/indapamide tend to make it worse

5 Centrally acting ACEI* Reduce risk of cognitive decline (Sink KM et Al Arch Int Med 2009:169: ) Reduce risk of mobility decline (Sumukadas D, et al, Effect of Perindopril on physical function in elderly people with functional impairment: a randomized controlled trial. CMAJ 2007; 177: ) HTN in Long Term Care HTN affects about 33% to 66% of residents of long-term care (LTC) facilities Postural hypotension Affects about 33% of residents Independent risk factor for falls, syncope, stroke, mortality * (captopril,fosinopril, lisinopril, perindopril, ramipril, and trandolapril) Role of Beta-Blockers? atenolol is a cardioselective beta-blocker that doesn't reduce mortality (Psaty BM,JAMA;2006;295:1704-6) Unless a person over 75 has CAD (Ml within 5 years) or CHF, use of other beta-blockers proven to reduce mortality for CAD (timolol, propranolol, metaprolol) or CHF (metaprolol, bisoprolol, carvedilol) won't lower mortality due to hypertension (Wiysonge CS, et al, Cochrane Database Syst Rev 2007 CD002003) If a person over 75 has had an Ml within 5 years, or has systolic CHF (EF <45), then an appropriate beta-blocker is MORE effective than other meds for hypertension at reducing mortality (Law MR, BMJ 2009;338:b1665). Dose needed to reduce resting heart rate by 10 beats per minute is probably sufficient Management of HTN in LTC No well-designed trials have studied antihypertensive treatment in the LTC setting Risk-benefit ratio of treatment is unclear in: Patients older than 80 years Patients with multiple comorbidities, taking multiple medications Antihypertensive medications are a risk factor for falls, so assess postural BP Costs Anti-Psychotic Drugs and LTC Metaprolol SR 100 mg = 14 cents Chlorthalidone 12.5 mg (1/4 pill)=3 cents HCTZ 12.5 mg (1/2 pill) = 2 cents Indapamide 1.25 mg = 15 cents All ACE inhibitors are between 27 cents (lisinopril) and 50 cents (ramipril) a day regardless of dose Felodipine (23-69 cents/day), arnlodipine (33-99 cents/day), depending on dose All of the above costs are for generic version. All ARBs/DRIs are $1.15/day or higher In 2010, 39.4% or residents with cognitive impairment were given antipsychotic medications. AS OF % of residents took an antipsychotic medication at some point in their stay. Less than ¼ have a psychosis-linked diagnosis

6 Side-effects of anti-psychotics in Dementia Diabetes Mellitus IN LTC Residents Triple the risk of stroke Increased risk of heart attack Increased mortality rate Diabetes Lethargy and tardive dyskinesia (uncontrolled tremors) Seizures While on antipsychotics, residents often lose the ability to bathe, dress, eat, toilet, ambulate and engage in social interaction Diabetes Mellitus IN LTC Residents Diabetes Mellitus IN LTC Residents Hypoglycemia may be difficult to recognize Attenuated symptoms Less awareness High # s with Dementia Increased risk of confusion and falls Severe hypoglycemia may precipitate CVS event Frequency and impacts of ADR higher Diabetic Guideline for Elderly Residents in LTC (DCP of Nova Scotia) No evidence for tight control (fasting BS 4-7 mmol/l) for frail elderly LTC population Goals should be avoid complication of poor glycemic control including hypo- and hyperglycemia Diabetes Mellitus IN LTC Residents

7 Osteoporosis in Long-Term Care Up to 95% of women and 51% of men Only 12% of residents are being treated The majority of residents are severely Vitamin D deficient Bone Health Protection Strategies Promoting the use of Hip Protectors Hip protectors are padded undergarments designed to decrease the impact of a fall on the hip by either absorbing or shunting energy away from the hip, thus decreasing the risk of hip fracture. Who should wear Hip Protectors? Most promising studies indicate that for high risk LTC resident with a history of hip fracture, using hard-shelled hip protectors seems to reduce the number of fractures. Studies looking at the community are not as successful, mainly due to compliance with wearing them. Osteoporosis Canada, 2009 (Brown et al, 2008; Sawka et al. 2007; Sawka et al., 2005) 40 Osteoporosis in LTC Treat options Calcium and Vitamin D supplements Vitamin D: reduces FALLS by 26% reduces FRACTURES by 22% bisphosphonates Bone Health Protection Strategies Promoting Exercises: Resistance exercises improve mobility, balance and strength. Gait training, stairs, muscle strengthening, coordination and postural training, parallel bar exercise, walking. Wheelchair dependent older adults can use free weights. 41 Drug for Osteoporosis in LTC INR in LTC and risk of stroke or bleed Recommend total intake of approximately 1500 mg elemental calcium daily in patients with Osteopenia or Osteoporosis. Vitamin D IU daily or Vitamin D2 50,000 IU once weekly safe for most patients. Calcitonin: Nasal Salmon Calcitonin 200 IU=1 spray/d IM/SC Salmon Calcitonin 100 IU/d Biphosphonates Alendronate 10 mg PO OD or 70 mg once weekly Risedronate 5 mg PO OD or 35 mg once weekly Etidronate 400 mg PO OD x 2 weeks every three (3) months NOT approved for Osteoporosis Therapy: Pamidronate IV every three (3) months Zoledronic Acid 4 mg IV once p.a. Selective Estrogen Receptor Modulators (SERM) Approved for Osteoporosis therapy: Raloxifene 60 mg PO OD Newly approved for severe Osteoporosis therapy: Teriparatide 20 mcg SC OD x two (2) years Combined risk of stroke/clot & bleeding: When maintained at 2-3: the risk per year is 4.3% When maintained at less than 2: risk per year jumps to 10.6% When maintained at 3-5: risk is 7% If greater than 5: the risk jumps to 52% Conclusion: Keep the resident in INR range of 2-3. Running low INRs (below 2) triples the risk for stroke or bleed. Clearly, avoid INRs greater than 5. (Oake et al.,2008)

8 Therapeutic INR in LTC Residents PTH - Teriparatide Studies have found that residents INR were within, below and above INR therapeutic range: 54%, 35% and 11% of the time. They also found that 20% of the time, the INR was not measured within 7 days after starting or a change in medication dose. Man-Son-Hing, M and Laupacis, A. (2003). Arch Intern Med, 163, Biosynthetic human parathyroid hormone(1-34). NEJM study of PMP women with prior vertebral fracture showed 65% reduction in new vertebral fractures, and 35% reduction in new non-vertebral fractures. Combination therapy with HRT improves BMD compared to HRT alone, whereas comcomitant alendronate delays or attenuates anabolic effect of teriparatide. Side effects: Dizziness, headaches, leg cramps, nausea, hyperca; Osteosarcoma in rats given much higher life-long doses. Reserved for severe Osteoporosis because of high cost and undetermined long-term side effects. Questions? SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMs) - Raloxifene Estrogen agonist activity on bones (antiresorptive) and lipids. Estrogen antagonist activity on breasts and uterus. MORE study: 30% to 50% reduction in vertebral fractures in osteoporotic women treated with Raloxifene for three years. Pooled data from Raloxifene trials indicate 54% reduction in new primary breast cancer. Probable benefits to brain and heart. Side effects: VTE, hot flashes.