DEPRESCRIBING. Phil St John CSIM Workshop

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1 DEPRESCRIBING Phil St John CSIM Workshop

2 Conflict of Interest Disclosure Consultant for: none Speaker for: none Received grant/research support from: CIHR, MHRC, Riverview Foundation Received honoraria from: Co-chair Longterm care formulary, Winnipeg Regional Health Authority

3 JAMA Editorial, March 19, 1910

4 JAMA, 1937

6 KEY POINTS Life is complicated Need to enumerate problems, set goals of treatments, set acceptable trade offs and target therapy Need to understand the patient and family goals

7 Functional status and frailty should be considered in treatment decisions Start low, go slow, and be patient Can dither and change course in some cases, not in others

8 OLDER PEOPLE Are very heterogeneous Highly unpredictable drug effects On average, have more things wrong with them Have more doctors On average, have higher fat/water ratios Generally, longer half-life of lipophilic drugs On average, have lower renal function Generally value functional status more than life extension Have been on medications for longer On average, live less long

9 ALL PEOPLE Generally don t like side-effects Generally like symptomatic benefits Don t adhere to their medications Adhere better to simple regimens Don t always tell the complete truth Have friends and families Read the newspapers and/or internet Should know what we are thinking

10 DEFINITIONS Polypharmacy depends on setting initially four or more Risk Factors Polyproblems Polydoctors Age Gender Low Social Position

11 deprescribing is the cessation of long-term therapy, supervised by a clinician.

12 Clin Geriatr Med 28 (2012)

13 A GENERAL APPROACH Enumerate the problems in all domains Set goals and a plan for them Prioritize and balance Understand patient and family goals Determine the Global approach

14 Get an accurate and up to date medication list Find out how they got there Determine if and how they are taking them Determine risks and benefits Set up a treatment plan May involve starting new meds May involve stopping and or/tapering Should know the guidelines, but not always follow them all the time in all people

15 Should look things up Should take our time Tapering off (Start low, go slow in reverse) A process not an event Collaborative approach Family Friends Pharmacists Nursing Other physicians But should know who is in charge

17 Mrs S 93 year old Assisted Living resident Previous IADL and some ADL dependence Past History of falls, fractured hip, macular degeneration, cataracts, IHD (CABG), CVA, falls, atrial fibrillation, hypertension, CHF (normal systolic fcn), renal insufficiency, osteoporosis, vascular dementia, urinary incontinence Fall with hip fracture Transferred for rehab

18 MEDS Metoprolol 75 mg BID Ramipril 5 mg BID ISDN 15 mg TID ASA 325 mg daily Plavix 75 mg daily Lasix 80 mg daily Amlodipine 5 mg daily Donepezil 10 mg daily Ciprofloxacin 500 mg po daily Omeprazole 20 mg daily Tylenol 3 PRN Morphine prn Fentanyl patch 50 mcg daily Gabapentin 100 mg tid Oyxbutinin 5 mg bid Risperidone 1 mg BID Alendronate 70 mg weekly Vitamin D 400 units daily Zoplicone 7.5 mg QHS LMWH should she go back on warfarin?

19 CAN WE FIX THIS? Which medications are inappropriate? Which medications can be stopped? Which medications must be tapered? Which medications directly antagonize each other? Should she be on any other medications? Are the doses correct?

24 QUESTIONS Did she have a UTI? What happened two days after she was admitted to non-teaching medicine? When did her peripheral oedema start? Why? Why was she itchy? How would you go about medication reduction?

25 What is a prescribing cascade?

26 PRESCRIBING CASCADE DRUG 1 Adverse drug effect - misinterpreted as a new medical condition DRUG 2 Adverse drug effect misinterpreted as a new medical condition Slide 26

27 COMMON CASCADES Anticholinergics and cholinergics NSAIDS and antihypertensives Ca antagonists and diuretics Antipsychotics and antiparkinson agents

29 CASE 3 90 year old man Retired bombardier Living independently in a house in the community Previous history hypertension, osteoarthritis and poor sleep Fell and complained of pain in his back Admitted to family medicine

30 Meds HCT 12.5 mg daily Tylenol plain prn Diazepam 10 mg at HS

31 Admitted to family medicine with L1 fracture Started on heparin S/Q, Vitamin D, Calcium, Calcitonin, Tylenol 975 mg po tid, and Morphine 2.5 mg Q1H for breakthrough Attempted to taper his Valium to 7.5 mg every night

32 Paged at 10, 11, 12 and 1h Started back on original dose Fell and fractured hip three days later Transferred to teaching hospital with ortho

33 Added zopliclone Is this safer?

34 Transferred to Geriatrics Osteoporosis work-up unremarkable What would you do?

35 Agreed to taper zopiclone Attempted diazepam does reduction to 7.5 mg daily Paged hourly from 10 to 1 Restarted

36 Fell 8 days later and fractured two ribs

37 Bush Vows To Wipe Out Prescription- Drug Addiction Among Seniors

38 Pooled odds ratios in relation to not using benzodiazepines in studies aimed at withdrawal from these drugs at post-intervention.a. Gould R L et al. BJP 2014;204: by The Royal College of Psychiatrists

39 Conclusions Supervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.

40 From: Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons Arch Intern Med. 2009;169(21): doi: /archinternmed Figure Legend: Medications and falls: meta analysis results. Odds ratios and 95% credible intervals or 95% confidence intervals on a logarithmic scale for individual or pooled study data for each class of medication. Outcome is occurrence of at least 1 fall. NSAIDs indicates nonsteroidal anti-inflammatory drugs. Date of download: 9/24/2014 Copyright 2014 American Medical Association. All rights reserved.

47 Undercover Cop Never Knew Selling Drugs Was Such Hard Work MARCH 5, 2003 ISSUE 39 08

48 Mr O 87 year old man, living in nursing home Relocated to rehab unit when NH evacuated Previous history HBP DM2 IHD stents and CABG CHF class III - IV Arrest with ICD PVD

49 Falls OA Osteoporosis Prostate Cancer with retention and foley Macular Degeneration CRF Vascular Dementia Dependent in BADLs Aggressive and violent behaviour Atrial fibrillation

50 MEDS Metoprolol 50 mg po BID Warfarin Clopidogrel 75 mg daily ASA 81 mg daily Glyburide 5 mg daily ISDN 15 mg tid Tylenol prn Finasteride Ditropan 5 mg bid Flomax 0.4 mg daily Lasix 80 mg po BID Donepezil 5 mg daily Risperidone 5 mg BID

51 What medications are working in the opposite direction? Would you streamline meds? How would you go about this?

52 COMMON DRUG-DRUG INTERACTIONS Combination ACE inhibitor + diuretic ACE inhibitor + potassium Antiarrhythmic + diuretic Benzodiazepine + antidepressant, antipsychotic, or benzodiazepine Calcium channel blocker + diuretic or nitrate Risk Hypotension, hyperkalemia Hyperkalemia Electrolyte imbalance, arrhythmias Confusion, sedation, falls Hypotension Digitalis + diuretic Arrhythmias Slide 52

53 Selected High-Risk Drugs Copyright restrictions may apply. Steinman, M. A. et al. JAMA 2010;304:

54 COMMON DRUG-DISEASE INTERACTIONS Obesity alters VD of lipophilic drugs Ascites alters VD of hydrophilic drugs Dementia may sensitivity, induce paradoxical reactions to drugs with CNS or anticholinergic activity Renal or hepatic impairment may impair detoxification and excretion of drugs

55 BEFORE PRESCRIBING A NEW DRUG, CONSIDER: Is this medication necessary? What are the therapeutic end points? Do the benefits outweigh the risks? Is it used to treat effects of another drug? Could 1 drug be used to treat 2 conditions? Could it interact with diseases, other drugs? Does patient know what it s for, how to take it, and what ADEs to look for? Slide 55

56 PRINCIPLES OF DRUG REVIEW Ask patient to bring in all medications (prescribed, OTC, supplements) for review LOOK AT THEIR MEDS LOOK AT AIDES DPIN Ask about side effects and screen for drug and disease interactions Look for duplicate therapies or pharmacologic effect Eliminate unnecessary medications and simplify dosing regimens Get collateral family, other doctors, pharmacist

57 NONADHERENCE May be as high as 50% among older patients May result from clinician s failure to consider patient s financial, cognitive, functional status May result from patient s beliefs and understanding of drugs and diseases Slide 57

58 CONCLUSIONS This is a complicated area Need to think less about polypharmacy and more about appropriateness

Deconstructing Polypharmacy. Alan B. Douglass, M.D. Director

Deconstructing Polypharmacy. Alan B. Douglass, M.D. Director Deconstructing Polypharmacy Alan B. Douglass, M.D. Director Recognize this patient? Mrs. Brown- 82 years young Active Medical Problems Hypertension Hyperlipidemia Type 2 Diabetes Peripheral edema Osteoarthritis