Rationalizing Medications. Tan Jianming Senior Pharmacist KTPH

Transcription

1 Rationalizing Medications Tan Jianming Senior Pharmacist KTPH

2 + Older patients are more likely to: 2 Have multiple co-morbid diseases Have age-related physiological changes that result in a reduced tolerance to medication Have problems with polypharmacy (often defined as having 5 or more medications) Be susceptible to inappropriate or unforeseen drug interactions or adverse drug reactions

3 + Deprescribing The missing 3 continuum Deprescribing is the process of tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing polypharmacy and improving outcomes. Indication Prescribing Monitoring Titration Monitoring Deprescribing Thompson W. & Farrell B. Deprescribing: What is it and what does the evidence tell us? CJHP 2013; 66(3):

4 + Outline 4 Criterias for Assessing Quality of Medication Prescribing Beers criteria Mcleod criteria START/STOPP Medication Appropriateness Index The Good Palliative-Geriatric Practice algorithm Deprescribing What has been done in KTPH 5-step Deprescribing Protocol Managing Diabetes Managing Hypertension Conclusion

5 + Criterias for Assessing Quality of 5 Medication Prescribing Many tools have been studied Two main categories: Explicit (Criterion-based) Expert reports & Published Reviews High reliability & reproducibility Specific drugs & disease states Implicit (Judgement-based) Person-specific & Explore patient preferences Rely on evaluator judgement, low reliability However, none of the tools address frailty directly Although some measure surrogates of frailty Poudel A., Hubbard R.E., Nissen L. & Mitchell C. Frailty: a key indicator to minimize inappropriate medications in older people. Q J Med 2013; 106:

6 + Beers criteria 6 First published in US in 1991, then 1997, 2003, 2012, 2015 May be most commonly used and most regularly updated Originally designed for older nursing home residents Later revised for all older patients An example of an Explicit criteria: Lists of potentially inappropriate medications for older patients Does not take into account disease burden or patient preferences Does not address underprescribing, drug duplication and drug-drug interaction American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Available at url: Accessed 13/5/17

7 + McLeod Criteria 7 Developed in Canada in1997 Lists inappropriate prescribing of NSAIDs, CV drugs, psychotropics, analgesics and some miscellaneous drugs Based on risk-benefit ratios Allows assessment of drug-drug and drug-disease interactions Limited use in clinical practice Used for research

8 + START/STOPP 8 Developed in the UK in 2008 Screening Tool to Alert doctors to Right Treatment (START) criteria 22 evidence-based prescribing indicators Highlights potentially serious errors of prescribing omission in older people Screening Tool of Older Person s Prescriptions (STOPP) criteria 65 indicators of inappropriate prescribing Special attention to drug that adversely affect older patients At risk of falls, Drug-drug interaction Drug-disease interaction Drug duplication Very time-consuming, difficult to apply in clinical practice Gallagher P., Ryan C., Byrne S., Kennedy J. & O'Mahony D. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmaco Therap 2008; 46(2): 72-83

9 + Medication Appropriateness Index 9 Refined implicit method Highly dependent on adminstrator Many papers published but highly time-consuming to administer Each medication that the patient is on has to undergo the list of 10 questions Before and after intervention Targets 10 elements of prescribing: 1) Indication 2) Effectiveness 3) Dose 4) Correct directions 5) Practical directions 6) Drug-drug interactions 7) Drug-disease interactions 8) Duplication 9) Duration 10) Cost Hanlon J.T. & Schmader K.E. The Medication Appropriateness Index at 20: Where it started, where it has been, and where it may be going. Drugs Aging 2013; 30:

10 Garfinkel D., Zur-Gil S. & Ben-Israel J. The war against polypharmacy: A New Cost-Effective Geriatric-Palliative Approach for Improving Drug Therapy in Disabled Elderly People. IMAJ 2007; 9: The Good Palliative-Geriatric 10 Practice algorithm Published in Israel in 2007 Intended for nursing home elderly Combination of both explicit and implicit indicators Suggested to be better than using either alone

11 + What is lacking? 11 The tools above Risk being too simplistic (Beers criteria, McLeod criteria) Are too convoluted to use in real world situations (MAI, START/STOPP) All the tools above do not consider patient s preferences

12 + Deprescribing in KTPH 12 - What has been done? Project Cut-a-piller since 2014 The Deprescribing Protocol Prof Ian Scott The 10-step conceptual framework -> 5-step deprescribing protocol Systematic and individualized framework that identifies medications with little or no benefit in older patients and ultimately aids to discontinue them Both Explicit and Implicit Both medication-related and medication management-related aspects of appropriate prescribing are addressed However, not validated in older patients in various settings

13 + 5 step Deprescribing Protocol 13 1) Ascertain all the drugs the patient is currently taking and the reasons for each one 2) Consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention 3) Assess each drug for its eligibility to be discontinued 4) Prioritize drugs for discontinuation 5) Implement and monitor drug discontinuation regimen Scott I.A. et al. Reducing Inappropriate Polypharmacy The process of deprescribing. JAMA Intern Med 2015; 175(5):

14 + Algorithm for Deprescribing 14 Scott I.A. et al. Reducing Inappropriate Polypharmacy The process of deprescribing. JAMA Intern Med 2015; 175(5):

15 + Managing Diabetes 15

16 + Diabetes Medications 16 High Risk for Hyperglycemia Insulin therapy Insulin secretagogues Sulphonylureas Meglitinides Low Risk for Hypoglycemia Metformin DPP4 inhibitors SGLT2 inhibitors Acarbose GLP 1 receptor agonists Thiazolinediones However, these can still potentiate hypoglycemia when used with other oral agents/insulin

17 + Challenges in Treating Diabetes in 17 Elderly People Physical frailty, problems with vision and cognitive function (often progressive) Knowledge of symptoms and treatment of hypoglycemia is limited Non-specific hypoglycemia presentations Renal Impairment Altered homeostasis Social isolation many live alone Dependency on nursing/ social services is common Meals may be variable (fluctuating appetite) and inadequate May have practical difficulty (manual dexterity, vision) with self-administration of insulin and BG testing (insulin therapy will necessitate BG testing)

18 + International Diabetes Foundation 18 Guidelines Functional Status HbA1c Remarks Independent 7-7.5% NA Dependent 7-8% Impairment in basic ADLs Dependent + Frail Up to 8.5% Avoid agents with GI side effects or LOW Dependent + Dementia End of Life Up to 8.5% Avoid complication of hyperglycemia Educate carer on signs of hypoglycemia May withdraw insulin at terminal phase International diabetes Foundation IDF Global Guidelines for Managing Older People with Type 2 Diabetes.

19 + Poor correlation of HbA1c and 19 hypoglycemia Self-reported hypoglycemia was common (10.7% of cohort); insulin0treated patients (19%) Severe hypoglycemia was common across all levels of glycemic control Although adjusted for age, sex, race, comorbs, polypharmacy, prior history of hypo, category of diabetic meds Risk of hypo high with nearnormal HbA1c & very poor glycemic control May need to focus on short term day to day glucose levels to avoid hypoglycemia Lipska K.J.et al. HbA1c and risk of severe hypoglycemia in type 2 diabetes. The Diabetes and Aging Study. Diabetes Care 2013; 36: Abdelhafiz A.H., Rodriguez-Manas L., Morley J.E. & Sinclair A.J. Hypoglycemia in Older People - A Less Well Recognised Risk Factor for Frailty. Aging & Disease 2015; 6(2):

20 + Managing Hypertension 20

21 + Case Example 21 Mr LWE, 90yo Chi M. Past medical history of Diabetes, Hypertension. Otherwise healthy. Socially isolated, lives alone, CFS 5, community ambulant. Currently only on Enalapril 5mg OM, his diabetes is diet controlled with the last HbA1c of 7.5%. He now presents to you with urinary frequency, nocturia, weak urine stream and dribbling after urination. DRE shows an enlarged prostate You diagnose him with BPH, but his resting blood pressure is only 110/50 with HR 50 bpm.

22 + What is the best course of action? 22 A. Add on Tamsulosin 0.4mg ON B. Add on Terazosin 0.5mg ON C. Stop Enalapril 5mg OM and add on Tamsulosin 0.4mg ON

23 + Establishing Priorities 23 The risk for the development of diabetic nephropathy is low in a normoalbuminuric patient with diabetes duration of greater than 30 years. Patients who have no proteinuria after years have a risk of developing overt renal disease of only approximately 1% per year. Anyway his blood pressure is already too low, can stop Enalapril 5mg OM and trial Tamsulosin 0.4mg ON To give him better QoL Warn him of possibility of postural hypotension! Batuman V.et al. Diabetic Nephropathy.Drug & Diseases. Medscape. Updated 21/4/2017 Retrieved from

24 + What bp targets do we use for 24 elderly? Guidelines Population Goal BP, mm Hg Remarks JNC General 60 y <150/90 Diabetes <140/90 CKD <140/90 ESH/ESC 2013 General elderly <80 y General 80 y <150/90 Diabetes <140/85 CKD no proteinuria <140/90 CKD + proteinuria <130/90 CHEP 2013 General 80 y <150/90 Diabetes <130/80 CKD <140/90 NICE 2011 General 80 y <150/90 <150/90 *For fragile elderly, SBP goals should be adapted to individual tolerability Abbreviations: CHEP, Canadian Hypertension Education Program; JNC, Joint National Committee; ESC, European Society of Cardiology; ESH, European Society of Hypertension; NICE, National Institute for Health Clinical Excellence.

25 Cumulative incidence of cardiovascular events + Overtreatment of HTN is linked 25 with higher CVS events N=4961, Median age 80 years receiving anti-hypertensives PLoS ONE. 2014;9(3):e Days since baseline

26 + Antihypertensives & Falls 26 Many papers reporting the risk of falls with antihypertensives Note White Coat Hypertension! What you see may not be what you get! Antihypertensives causing postural hypotension α - blockers Diltiazem Nifedipine Methyldopa Hydralazine Nitrates Diuretics ACE-i

27 + Conclusion 27 Deprescribing should be a part of the prescribing continuum Many tools that can help with appropriate prescribing and deprescribing Proper communication and discussions with patients/family members/caregivers will give you the Green Light required for deprescribing Establish priorities for medication use and establish patient s priorities Document, document, document!

28