Medicines save lives

Transcription

1 Optimizing Aging Collaborative Disclosures Too much of a good thing: No financial interests to disclose John Newman, MD, PhD Assistant Professor Division of Geriatrics, UCSF Kirby Lee, PharmD, MAS Associate Professor School of Pharmacy, UCSF The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP Medications and you Medications save lives What is polypharmacy Principles of medications in older adults What you can do Medicines save lives [We ll talk principles, not specific medical advice] 3 4

2 Treating high blood pressure saves lives HYVET: A randomized trial in adults over 85 years old Treating high blood pressure saves lives SPRINT: A randomized trials of intensive blood pressure lowering Treating high blood pressure reduced deaths by 20%! Aiming for a lower blood pressure goal reduced deaths by more than 20%! (Especially in adults over 75) 5 NEJM 2008, 358:1887 NEJM 2015, 373: Treating high blood pressure keeps us healthy HYVET: Fewer strokes, less heart failure Treating high blood pressure dramatically reduced how many people developed heart failure over time Too much of anything can harm NEJM 2008, 358:

3 We can t survive without water But you can drown in too much of it Polypharmacy *Balance between avoiding excessive or unnecessary use of medications and providing beneficial therapies 9 10 Problems caused by polypharmacy Duplicate or unnecessary medications Side effects and other adverse drug events Interactions with other medications Difficult to take them all as intended Prescribing cascades Expensive Medicalizing life How to Identify Duplicate Therapy Generic medication names with similar endings are usually in the same class and could be duplicate therapy. Question need and discontinue therapy as appropriate. Statin Drugs (Cholesterol) - Atorvastatin, Lipitor - Lovastatin, Mevacor - Pravastatin, Pravachol - Rosuvastatin, Crestor - Simvastatin, Zocor Gastric Acid Reducers (PPIs) - Omeprazole, Prilosec - Esomeprazole, Nexxium - Lansoprazole, Prevacid - Pantoprazole, Protonix - Rabeprazole, Aciphex Benzodiazepines (Anxiety/Sleep) - Alprazolam, Xanax - Clonazepam, Klonopin - Diazepam, Valium - Lorazepam, Ativan - Temazepam, Restoril Antidepressants (SSRIs) - Fluoxetine, Prozac - Paroxetine, Paxil - Sertraline, Zoloft - Citalopram, Celexa - Escitalopram, Lexapro 11 12

4 Causes of Polypharmacy Aging population (chronic conditions) Complex drug therapies Multiple prescribers Multiple pharmacies Adverse drug reactions (prescribing cascade) Complex Drug Therapies Diabetes Drugs commonly Blood Pressure used for patients Lipids with diabetes Thrombosis Sulphonylureas Diuretics Statins Aspirin Metformin Beta-blockers Ezetimibe Clopidogrel Glitazones ACEI Bile-acid sequestrants Insulin ARB Nicotinic acid Prandial glucose regulators Gliptins (DPP-4) inhibitors Calcium blockers Alpha blockers Fibrates Multiple Prescribers How many medications do we take? 15 Multiple providers prescribe medications for patients with chronic disease Poor communication between patient and all providers Stronger tendency for drugs to be added than discontinued Drug regimens are not regularly monitored for potential problems Medications with no apparent indication Duplicate therapy Drug interactions Inappropriately high or low doses 16 Community-dwelling older adults: 28% take 5 or more medications Nursing home residents: Up to 74% take 9 or more medications Jokanovic JAMDA 2015; Beloosesky Clin Interv Aging 2013

5 Many of these may not be helpful How to Reduce Polypharmacy: More medications often means more inappropriate medications: Potentially unsafe, ineffective, unnecessary, or duplicative 17 Steinman et al., JAGS 2008 Minimize medication use (drugs are not always needed) Medications in older adults should be carefully chosen and dosed appropriately Periodic review of all of your medications More medications = more risks Each new medication increases the risk of an adverse drug event (ADE) each year Taking six or more medications substantially increases the risk of an ADE 18 Each medication adds a smaller benefit Principle: Diminishing benefits and increasing harms Effect size Diminishing marginal benefit The first medication you take for diabetes, blood pressure, etc. has the biggest clinical benefit. Each additional medication may still help, but not as much. Number of meds 19 20

6 and an increasing risk of harm Choose wisely! Effect size Diminishing marginal benefit Increasing marginal risks Falls Cognitive decline Delirium Hospitalization Med interactions Side effects Incorrect use Etc etc Effect size Diminishing marginal benefit Increasing marginal risks Falls Cognitive decline Delirium Hospitalization Med interactions Side effects Incorrect use Etc etc More good than harm! Where you and your doctor should be. Choose wisely! Number of meds Number of meds Treatments should be just right Principle: Goldilocks Older adults often benefit enormously from treating diseases like high blood pressure or heart disease These diseases and their dreaded effects, like strokes or heart attacks, are more common in older adults But older adults can also be harmed by over-treatment, which at extremes can be as dangerous as the disease being treated 23 24

7 Goldilocks: U-shaped curves Goldilocks: U-shaped curves Risk or Outcome (e.g. death) Not enough treatment Just right! Too much treatment Risk or Outcome (e.g. death) Blood pressure too high = Strokes Heart attacks Just right! Blood pressure too low = Falls Strokes Intensity of treatment Intensity of treatment Example: Blood pressure and kidney disease Study of 650,000 older veterans with high blood pressure and kidney disease How did their treated blood pressure affect their risk of dying? Principle: Everyone gets side effects, but older adults get them worse Kovedsy et al., Annals IM

8 29 Older adults have more, serious, side effects JAMA 2006, 296:1858 Emergency Department visits for adverse drug events by age 30 Why are side effects worse in older adults? Slower to metabolize/clear medications from the body Reduced kidney function Reduced liver function Change/decrease in volume of distribution More adipose tissue, less total body water More interactions Polypharmacy is common More diseases Side effects more likely to be significant Less overall physiological resilience More sensitive to drug effects Young adult feels a bit dizzy, older adult falls Why are side effects worse in older adults? Physiological changes make the elderly less able to cope with perturbations caused by drugs (or anything else) Range of OK Vascular: Reduced arterial compliance Cardiac: Reduced maximum heart rate, sick sinus/bradycardia How does a side effect (dizziness from low blood pressure) interact with changes from age to cause a fall? Age This is called homeostenosis, or a narrowing (stenosis) of the conditions in which the body can keep working normally (homeostasis) Renal: Less able to concentrate urine, prone to dehydration Muscles: Reduced muscle mass and strength, unable to recover from near-fall Vascular: Immobile, blood pools in venous insufficient legs during prolonged seated period 31 32

9 Watch out for the prescribing cascade Corollary: A new symptom is a medication side effect until proven otherwise High blood pressure prescribe amlodipine Next visit: leg swelling prescribe furosemide for heart failure Next visit: urinary incontinence prescribe oxybutinin Next visit: confusion dementia? Three new diagnoses, three new medications Boy, Dad is not doing so well Watch out for the prescribing cascade High blood pressure prescribe amlodipine Next visit: leg swelling prescribe furosemide for heart failure What can you do? Next visit: urinary incontinence prescribe oxybutinin Next visit: confusion dementia? All side effects! The first step should be to stop/change amlodipine 35 36

10 Why do we take medications? Why am I taking this? Disease! Why do we take medications? Why do we take medications? Disease Disease Risks Symptoms Risks Symptoms What is most important to you? 39 40

11 Why do we take medications? Beware zombie medications Disease Bad: I have X, therefore I must take Y No one knows where it came from No one knows what it s for Is anyone brave enough to stop it? 41 Risks Good: Prevent strokes What is most important to you? Symptoms Good: Treat tremor Is it worth possible side effects? How do I weigh it against other medications? 42 Zombie medications are especially common after ER visits or hospitalization. Often they were never meant to be continued long-term. Beware zombie medications Some common examples of zombie medications: Sleep medicines Allergy medicines Acid reflux medicines Pain medicines (NSAIDs) Constipation medicines Is this the right medicine? 43 44

12 Ask your doctor about the Beers Criteria 2015 Beers: Ten groups of medicines Beers Criteria is from the American Geriatrics Society List of medications that should be used with caution specifically in older adults Updated every few years by national experts Non-steroidal anti-inflammatory drugs (NSAIDs) Digoxin (Lanoxin) Certain diabetes drugs Muscle relaxants Certain anxiety and insomnia drugs Certain anticholinergic drugs Meperidine (Demerol) Certain antihistamines like diphenhydramine Antipsychotics Estrogen pills and patches Ask your doctor about the Beers Criteria Most serious problems are from a few meds Blood thinners - bleeding Diabetes medicines low blood sugar Inherent in how the medicines work Sudden and serious 47 Budnitz et al., NEJM

13 With great power Powerful medicines save lives Poweful medicines carry powerful risks Know how you affect how the medicine works Diet, monitoring, timing, etc. Know how to identify serious side effects early Is this the right medicine for me? Tell your doctor everything about these medicines Ask for help Precision medicine: Is it right for you? Do any of my other medical problems affect this? What about my kidneys? Your medical history Your priorities Your other medicines Will this interact with my warfarin? How will this work with the other medicine I take for that? How do I weigh the expected benefit vs the possible risks? How would the common side effects affect me? Is this my most important medicine, or the 10 th most important? 52 For every new medicine, and at least once a year for all medicines: Why am I taking this? Do I still need it? Is it still the best choice?

14 Keep all of your doctors in the know Safe prescribing requires knowing everything you take Make sure all of your doctors know everything you take Avoid duplication, interactions, etc. Bring your medications (or an updated list) to every appointment Tell each doctor about any recent changes Ideally, pick one doctor do all the prescribing Tell you doctors about any problems! Principles of medications for older adults Trouble with insurance or the pharmacy Medicines save lives Trouble with affording medications Diminishing benefits and increasing harms Need help organizing or taking medications? Both under-treatment and over-treatment can cause harm Possible side effects Side effects are often worse in older adults If for a symptom, does the medicine help? A new symptom is a medication side effect until proven otherwise If you don t tell them, they ll never know! 55 56

15 What you can do For every new medication, and at least once a year for all medications: Why am I taking this? To prevent something bad, or to help me feel better? Less is often more! Do I still need to take this? Is it important enough to take? Is this the right medication? American Geriatrics Society Beers Criteria Have I changed? Make sure all of your doctors know everything you take Tell your doctors of any problems with your medications Thank you! Optimizing Aging Collaborative at UCSF For more information contact: OAC@ucsf.edu The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP geriatrics.ucsf.edu healthinaging.org