Polypharmacy: So Many Drugs, So Little Time. Shannon O. Smith, MD General Internal Medicine Conference

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1 Polypharmacy: So Many Drugs, So Little Time Shannon O. Smith, MD General Internal Medicine Conference

2 Objectives 1. Recognize polypharmacy and what it means to your patients 2. Fix it.

3 Patient Susie Q 57 year old Caucasian woman Transferring care from PCP in Chicago Moving to Madison to be closer to family because of her multiple medical problems

4 Patient Susie Q: Problem List Mixed connective tissue disease Breast CA x 2 (with complicated mastectomy & poor wound closure) HTN Diabetes Elevated pulmonary pressures Malabsorption (of unclear etiology) Tremor

5 Patient Susie Q: Problem List Peripheral neuropathy Diastolic dysfunction h/o DVT and PE Osteoporosis Chronic nausea Lower extremity edema NASH

6 Patient Susie Q: Meds Amantadine 100 mg TID Amiloride 5 mg qhs Carvedilol 25 mg BID Cevimeline 30 mg 2 caps BID Vitamin D 1000 units daily Clonidine 0.3 mg BID Domperidone 10 mg 2 tabs qid Vitamin B mcg daily Doxazosin 4 mg qhs Enalapril 20 mg once daily Esomeprazole 40 mg BID Folate 1 mg once daily Furosemide 20 mg once daily Glipizide 10 mg once daily HCTZ 25 mg once daily Hydroxychloroquine 200 mg BID Infliximab 1000 mg IV q6 wks

7 Patient Susie Q: Meds Lactobacillus 1 cap once daily Prednisone 15 mg once daily Lamotrigine 150 mg BID Promethazine 25 mg TID Metformin 850 mg BID Simvastatin 40 mg qhs Methotrexate 2.5 mg 8 tabs Tolterodine 4 mg once daily weekly Coumadin 5 mg qhs Nystatin cream prn Zinc oxide ointment Tincture of opium 0.7 mls TID Reclast 5 mg IV once yearly Pramoxine HC ointment

8 Patient Susie Q: Meds Lactobacillus 1 cap once daily Prednisone 15 mg once daily Lamotrigine 150 mg BID Promethazine 25 mg TID Metformin 850 mg BID Simvastatin 40 mg qhs Methotrexate 2.5 mg 8 tabs Tolterodine 4 mg once daily weekly Coumadin 5 mg qhs Nystatin cream prn Zinc oxide ointment Tincture of opium 0.7 mls TID Reclast 5 mg IV once yearly Pramoxine HC ointment Roughly 60 pills per day!

9 Polypharmacy: Definition No standard definition Some say 2 9 meds Some say any time a patient is taking a medicine that is not indicated

10 Polypharmacy: Prevalence 57% of women >65 take at least 5 meds 12% of women >65 take at least 10 meds Nursing home population: 14 24% >9 meds

11 Polypharmacy: Why Do We Care? Growing population of elderly (72 mil by 2030) Prevalence increases with advancing age People are living longer with chronic diseases There are no natural advocates

12 How Does It Affect Our Patients? Compliance Cost Drug interactions Adverse Drug Reactions (ADRs) Decreased functional status

13 Compliance Number of meds is stronger predictor than age General population compliance: 80% for once daily dosing 50% for QID dosing

14 Bankrupted Susie Q Cost

15 Drug Interactions Risk increases with # of drugs Can approach 100% with 8 or more meds

16 Adverse Drug Reactions (ADRs) Definition: Harm from a medication given at a normal dose and with normal use Polypharmacy increases risk of ADRs: 13% with 2 meds 58% with 5 meds 82% with 7 or more meds Most common drugs: CV drugs, diuretics, anticoagulants, NSAIDs, Abx, hypoglycemics

17 Decreased functional status 1989 study of >600 elderly patients: The more meds, the worse the physical functioning and ability to carry out ADLs 2011 study showed polypharmacy associated with worsening physical & psychological health

18 How to Fix It SAIL and TIDE Borrowed from Werder and Preskorn: Managing Polypharmacy: Walking a Fine Line between Help and Harm. jfponline.com

19 SAIL Simplify use meds that are qd or BID Adverse effects Be familiar with these Indication Make sure each med has an indication and a defined, realistic therapeutic goal List List name and dose of each med, and share it with the patient

20 TIDE Time Allow sufficient time to address & discuss medication issues Individualize Dose adjusting for renal and/or hepatic impairment Start low and go slow Drug interaction Know them! Educate Discuss expected medication effects, potential adverse effects, and monitoring

21 Take Home Points Recognize the problem Be an advocate for your patient Make sure both you & your patient know the indications for each of their medications Keep cost & dosing in mind when prescribing Know potential side effects & drug drug interactions Schedule an appt devoted completely to medication review & management for your polypharmacy patients

22 Polychildrenism

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