The epidemiology of polypharmacy

Transcription

1 The epidemiology of polypharmacy Dr Rupert Payne University of Cambridge

2 The ageing population ONS, 2010

3 The burden of multimorbidity Barnett K, Lancet 2012

4 The burden of multimorbidity Barnett K, Lancet 2012

5 Guidelines everywhere Prostate cancer Osteoarthritis Surgical management of OME Irritable bowel syndrome Antenatal care Diabetes in pregnancy Prophylaxis against infective endocarditis Perioperative hypothermia (inadvertent) Type 2 diabetes Lipid modification Stroke Respiratory tract infections Induction of labour Familial hypercholesterolaemia Attention deficit hyperactivity disorder (ADHD) Chronic kidney disease Surgical site infection Metastatic spinal cord compression Medicines adherence Antisocial personality disorder Borderline personality disorder (BPD) Rheumatoid arthritis Breast cancer (early & locally advanced) Breast cancer (advanced) Schizophrenia Critical illness rehabilitation Diarrhoea and vomiting in children under 5 Glaucoma Coeliac disease Type 2 Diabetes - newer agents Low back pain When to suspect child maltreatment Depression in adults Depression with a chronic physical health problem Venous thromboembolism - reducing the risk Donor breast milk banks Unstable angina and NSTEMI Chest pain of recent onset Neuropathic pain - pharmacological management Lower urinary tract symptoms Neonatal jaundice Constipation in children and young people Alcohol-use disorders: physical complications Chronic obstructive pulmonary disease Bacterial meningitis and meningococcal septicaemia Delirium Metastatic malignant disease of unknown primary origin Motor neurone disease - noninvasive ventilation Barrett's oesophagus - ablative therapy Hypertension in pregnancy Chronic heart failure Transient loss of consciousness in adults and young people Pregnancy and complex social factors Nocturnal enuresis - the management of bedwetting in children and young people Sedation in children and young people Anxiety Anaemia management in people with CKD Alcohol dependence and harmful alcohol use Food allergy in children and young people Tuberculosis Colonoscopic surveillance for prevention of colorectal cancer Diabetic foot problems - inpatient management Psychosis with coexisting substance misuse Lung cancer Ovarian cancer Common mental health disorders Hip fracture Peritoneal dialysis Stable angina Hypertension Autism in children and young people Multiple pregnancy Hyperglycaemia in acute coronary syndromes Colorectal cancer Caesarean section Self-harm (longer term management) Anaphylaxis Organ donation Service user experience in adult mental health Epilepsy Patient experience in adult NHS services Infection control Opioids in palliative care Acute upper GI bleeding Autism in adults Sickle cell acute painful episode Venous thromboembolic diseases Spasticity in children and young people Osteoporosis fragility fracture Lower limb peripheral arterial disease Urinary incontinence in neurological disease Antibiotics for early-onset neonatal infection Headaches Neutropenic sepsis Crohn s disease Psoriasis Ectopic pregnancy and miscarriage

6 Guidelines everywhere Years since randomisation NICE, CG127, Hypertension UKPDS38, BMJ 1998

7 Guidelines everywhere Nephropathy Erectile dysfunction Gastroparesis Metformin Sulphonylurea Gliptins Glitazones Exenatide Insulin Dyslipidaemia Antithrombotic Neuropathic pain NICE, CG87, Type 2 diabetes

8 Guidelines everywhere Guidelines generally fail to make it clear when or how to stop drugs

9 Guidelines everywhere

10 age + multimorbidity + guidelines = lots of medicines

11 Prevalence of use of multiple medicines Analysis of 180,815 adult patient (age >20 years) 40 representative GP surgeries across Scotland Primary care data (demographics, prescribing, 40 long-term diagnoses) Linked secondary care admission data

12 Prevalence of use of multiple medicines Payne RA, unpublished data

13 Prescribing is increasing Prescribing Cost Analysis, England

14 Prescribing is increasing Prescribing Cost Analysis, England

15 Prescribing is increasing Guthrie B, SAPC 2012

16 Factors associated with polypharmacy Payne RA, unpublished data

17 Factors associated with polypharmacy Payne RA, unpublished data

18 Factors associated with polypharmacy Payne RA, unpublished data

19 Factors associated with polypharmacy Payne RA, unpublished data

20 Factors associated with polypharmacy Payne RA, unpublished data

21 Factors associated with polypharmacy Payne RA, unpublished data

22 Factors associated with polypharmacy Payne RA, unpublished data

23 Factors associated with polypharmacy Betteridge TM, Int Med J 2011

24 So what?

25 Drug interactions Pharmacodynamic Common effects Common receptors Indirect effects Pharmacokinetic Absorption (chelation, gut motility, gastric ph) Distribution (plasma protein binding competition) Metabolism (cytochrome P450 induction/inhibition) Excretion (renal, bile) Guthrie B, SAPC 2012

26 Adverse drug reactions Hospitalisation for ADRs in UK 6.5% of admissions Mean stay 8 days 466 million Most are avoidable Calderón-Larrañaga A, BJGP 2012

27 Medication errors Adjusted OR 95% CI Female Number of drugs Age 0 to to to Practice Dispensing Non-training Rural (cf. urban) List size < Ref > Medication errors in UK primary care 1 in 8 patients 1 in 20 prescription items Most mild-moderate severity Type of perscribing error % of all errors Incomplete information 30 Dose/strength 17.8 Timing 10.5 Frequency 8.1 Omission of concomitant Rx 7.7 Other 25.9 Avery AJ, The PRACtICe Study, 2012

28 High-risk prescribing Guthrie B, BMJ 2011

29 Medication adherence Gellad WF, Am J Geriatr Pharmacother 2011

30 The elderly Altered pharmacokinetics Altered absorption Changes in fat distribution Altered sensitivity to adverse reactions Impaired gait/balance Cognitive impairment Impaired renal function Impaired liver function

31 Polypharmacy is sometimes bad

32 Polypharmacy is sometimes not bad Payne RA, unpublished data

33 Polypharmacy is sometimes not bad Ref Emergency admission p<0.001 Potentially preventable emergency admission p=0.79 None Number of cardiovascular medicines Appleton S, unpublished data

34 Revisiting the definition of polypharmacy Consider polypharmacy as a continuum Consider polypharmacy in context Appropriate polypharmacy Prescribing for an individual for multiple/complex conditions in circumstances where medicines use can be optimised and the medicines are prescribed according to best evidence. The intent should be maintaining quality of life or improving longevity, whilst minimising harm Problematic polypharmacy Prescribing of multiple medications inappropriately, or where the intended benefit of the medication is not realised

35 Summary Our population is ageing and multimorbidity is the norm, and polypharmacy is increasingly common Polypharmacy is driven by various patient factors, as well as evidencebased clinical guidance Polypharmacy is associated with various adverse outcomes, such as prescribing errors, ADRs and non-adherence Polypharmacy can be both appropriate and problematic, and this should be considered when defining it