New approaches to Polypharmacy: Oligopharmacy and Deprescribing

Transcription

1 East & outh East England pecialist harmacy ervices East of England, London, outh Central & outh East Coast Medicines Use and afety New approaches to olypharmacy: Oligopharmacy and Deprescribing Nina Barnett, Consultant harmacist, Care of Older eople North West London Hospitals NH Trust NH East & outh East pecialist harmacy ervices Lelly Oboh, Consultant harmacist, Care of Older eople GTT NH Trust and NH East & outh East pecialist harmacy ervices East & outh East England pecialist harmacy ervices MU Team: Winner: R harmaceutical Care award 2013; Finalist: HJ atient safety in primary care award 2013; Winner: UKCA/Guild Conference Best oster award 2013; Winner: UKCA ain award 2012; Winner: UKCA Respiratory award 2012

2 Medicines Use and afety olypharmacy itself should be conceptually perceived as a disease with potentially more serious complications than those of the diseases these different drugs have been prescribed for Doron Garfinkel 2010

3 Medicines Use and afety Who is at risk?- Frail older people What is frailty? Aged over 75, often over 85, with multiple diseases, which may include dementia. (BG definition) Reduced functional reserve more vulnerable to developing complications while in hospital Less resilient to external stressors and take more time to recover Often present to hospital with geriatric syndromes such as falls, immobility and confusion

4 Medicines Use and afety Oligopharmacy Deliberate avoidance of polypharmacy i.e. less than 5 prescription drugs daily (O Mahoney) Deprescribing The complex process required for the safe and effective cessation (withdrawal) of inappropriate medications Takes into account the patient s physical functioning, co-morbidities, preferences and lifestyle.

5 Medicines Use and afety Deprescribing:getting the right balance Life expectancy, comorbidity burden, care goals patient preferences, benefits of medicines ADRs, risks and harms of medicines

6 Medicines Use and afety How to identify frailty? Morley JE et al. J Am Med Dir Assoc ; 2013 Jan 1;14(6):392 7

7 What the literature show 1-3 Medicines Use and afety No long term outcome data...but, reduces drug usage/costs & unlikely to cause harm Must involve patients, carers & multidisciplinary working There s enough evidence to stop certain drugs Many challenges and barriers Clinical and communication skills are important Must be done sequentially, slowly over a period of time Time consuming & dynamic process requiring extensive communication, frequent monitoring and review, tructured approach needed (7 steps)

8 What the literature show 1-3 Medicines Use and afety 7 key steps 1. Assess patient 2. Define overall patient goals 3. Identify inappropriate drugs from an accurate list of medication 4. Assess each drug for specific risks vs benefits in context 5. Decide to stop or reduce dose 6. Communicate with G/prescriber 7. Monitor regularly and adjust accordingly

9 Medicines Use and afety Garfinkel et al 2010 Feasibility study of a systematic approach for discontinuation of multiple medication in older adults 70 community dwelling older adults (Feb 05-Jun 08) Follow up every 3-6 months Algorithm based on evidence for drug indication Algorithm identified 311drugs (in 64 pts) to stop 256 drugs considered after family discussion 81% discontinued 2% restarted 88% reported global improvements in health. 100% success for benzodiazepines

10 The Good alliative Geriatric ractice algorithm Medicines Use and afety

11 Medicines Use and afety O Mahoney et al (of TO/TART fame ) Review of principles for best practice in oligopharmacy Focus is End-of-life or pre-terminal phase Differentiates btwn starting new drugs vs stopping existing drugs uggests using TO tool to identify drugs for stopping Considers suitability/need for drug classes rather than indication for prescribing (cf Garfinkel) Drugs for primary and life extension Drugs for secondary prevention except benefits Aim for <5 medicines, minimise tablet count and doses per day Optimise formulation and administration methods (liaise with community pharmacist) & refer for MUR where appropriate

12 Medicines Use and afety Hilmer 2012 Evidence based discussion for appropriate prescribing and deprescribing Differentiates between robust vs frail older people Considers appropriateness based on current poor evidence for commonly prescribed medicines in older people Drug assessment based on adherence, ADRs, indications and interactions Considers ethical principles Multidisciplinary support required for G to deprescribe safely

13 Key steps in optimising an older patient's medical therapy

14 ummarising the literature Medicines Use and afety Key steps Garfinkel O Mahoney Hilmer 1. Assess patient 2. Define overall patient goals 3. Identify inappropriate drugs from accurate list of medication G-G Algorithm TO tool EBM/ethics 4. Assess each drug for specific risks vs. benefits in context G-G Algorithm Life extending 1 0 /2 0 prevention drugs ADR, adherence, indication, interactions 5. Decide to stop or reduce dose 6. Communicate with G 7. Monitor regularly and adjust accordingly

15 A structured approach to reducing polypharmacy: Key stages Medicines Use and afety Monitor regularly & adjust Communicate with G Decide to stop or reduce dose Assess each drug for specific risks & benefits in the context of individual patient Identify inappropriate drugs from accurate medicines list Define overall treatment goals Assess patient

16 Assess patient Medicines Use and afety With patient and carers Medical history Functional history Estimate frailty, life expectancy (NH highland tool 4 ) & trajectory decline

17 Define overall goal Medicines Use and afety In frail older patients, the main priorities are ymptom control Maintaining function Addressing end-of-life issues Maintaining dignity

18 Medicines Medicines Use and Use afety and afety Identify inappropriate drugs from an Tools accurate list of medication Evidence/consensus guidance to support its use in older people Estimates of risks/benefits 4 TO tool 5 G-G algorithm MAI tool 6 Clinical judgement and experience Does each drug have a matching indication, is indication still valid? Does the drug produce limited benefit for that indication Is it a high risk drug? Are the benefits overweighed by unfavourable ADRs in O

19 Medicines Use and afety Inability to apply existing knowledge to a new and complex situation contributes more often to the occurrence of adverse events in older than younger patients Merten Het al. cale, nature, preventability and causes of adverse events in hospitalised older patients. Age Ageing 2012;

20 Medicines Use and afety Assess each drug for specific risks & benefits in the context of patient circumstance EACH medicine is tailored to the patient s Defined overall goal Circumstances Clinical reality and social situation Morbidities Experience, preferences and ability to comply Life expectancy

21 Medicines Use and afety If shortened life expectancy, query... Drugs for primary prevention No place Drugs for secondary prevention ONLY if time to benefit exceeds life expectancy Lipid lowering drugs revention of fragility # ACEI, ARB, BB to prevent diabetic neuropathy/hf mortality Memantine for improved cognition

22 Medicines Use and afety Decide to stop or reduce dose Discontinue top one at a time Gradually Consider rebound Enlist help of peers or specialists Continue Optimise therapy Reduce dose/frequency/ prn ubstitute with a safer drug, formulation, schedule Wait and see

23 Medicines Use and afety Communication with G rioritise repare a range of options for each drug resent in a simple format Face to face with prescriber is best Follow up with written summary, highlighting Evidence base/rationale Agreed action for each drug and monitoring

24 Medicines Use and afety

25 Medicines Use and afety Barriers to change re-empt resistance, easier to maintain the status quo! Easy to start drugs but difficult to stop Little evidence/guidance on how to deprescribe safely medico legal considerations Withdrawal in older people can be unpredictable/risky Time consuming re changing, monitoring/follow up G reluctance to stop drugs tarted by specialists Where there is a +ve guideline recommendation Consent and capacity issues in older people

26 Medicines Use and afety Regular monitoring & adjust Be clear about what monitoring is needed and ensure its in place Look out for ADRs, toxicity, benefits Look out for non specific ADRs- geriatric syndromes Review as needed or at least 3-6 months Communicate with others about changes

27 Medicines Use and afety ummary: Oligopharmacy and Deprescribing is everybody s business tructured approach integrated with clinical judgement is required. Acknowledgment that some meds may be restarted it s a trial Full engagement of patient, family, carers is imperative and honesty all round harmacists can lead the process but must work with MDT hare the workload with specialists atients, relatives, carers, community pharmacists, OTs, nurses etc can monitor drug effects and feedback Focus on patients with the highest medication related risks and morbidities For individual patients, focus on the drugs with the highest risks or highest benefits

28 Medicines Use and afety References 1. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch. Intern Med 2012;170: O Mahony, O Connor. harmacotherapy at the end-of-life. Age and ageing 2011;40; Hilmer N, Gnjidic D and Le Couteur D.Thinking through the medication list. Australian Family hysician 2012 Vol 41 no 12, p NH Highland. olypharmacy: Guidance for prescribing in frail elderly Gallagher et al. creening tool of older people s potentially inappropriate prescriptions. Int J Clin harmacol Ther 2008;46: Hanlon J et al. Medication Appropriateness Index- MAI. J Clin Epidemiol 1992;45: Further reading 1. teinman M, Hanlon J. Managing medications in complex elders: There s got to be a happy medium. JAMA 2010;304(14): Gnjidic et al, Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Clin Geriatr Med 2012 May;28(2): Ian A cott et al. Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evidence-Based Medicine 2012