M E D I C A T I O N S & Sean M. Jeffery

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1 M E D I C A T I O N S & Sean M. Jeffery

2 Subtitle Could my medications be causing me to fall? A discussion on medication safety and falls prevention.

3 Contact Information & Disclosure Sean M. Jeffery, PharmD, CGP, FASCP, FNAP, AGSF Clinical Professor, Department of Pharmacy Practice University of Connecticut School of Pharmacy & Director, Clinical Pharmacy Services Integrated Care Partners Hartford Healthcare Group Consultant CVS/Caremark National Pharmacy and Therapeutics Committee

4 Awesome Session Educational Objectives Identify medication risk factors associated with falling Discuss strategies to minimize fall risk from medications

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9 A minority of patients account for the majority of morbidity and cost Percent of total expenditure 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 97% 80% 64% 49% 22% 3% Top 1% Top 5% Top 10% Top 20% Top 50% Bottom 50% Percent of population Conwell, Cohen, Characteristics of people with high medical expenses in the USA civilian non-institutiona lized population AHRQ March 2005

10 Opportunity to Drive Change

11 The move to alternative payment models requires a fundamental change in how we organize healthcare Traditional FFS Sick Care / Hospital Care Alternative Payment Value- Based Care Population Health + Sick Care / Hospitals Episodic care Longitudinal care Individuals practicing in silos Variations in care Team-based, coordinated, integrated care Evidence-based standards

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14 TWO-THIRDS OF ADVERSE EVENTS POST-DISCHARGE ARE RELATED TO MEDICATIONS MORE THAN 80% PATIENTS HAVE AT LEAST ONE MEDICATION ISSUE 30% OF READMISSIONS ARE MEDICATION RELATED Omission 45% Duplicate 16%

15 Too many medications + Too complicated + Too Costly + Not aligned with patient s goals of care = hot mess Drugs don t work in people who don t take them. C. Everett Koop, MD

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17 I am having accidents Who: an 85 year old female living alone in her house PMHx: HF w/ 1+ peripheral edema HTN GERD Chronic Pain from OA, spinal stenosis Urinary Incontinence Issue: Patient wants to change diuretics. Is having difficulty getting to the bathroom on time. Transitional Care Case Manager is concerned about medications. Comprehensive medication management consult performed with patient, pharmacist and TCCM nurse.

18 Current Medications 1. Lorazepam1 mg po BID for anxiety 2. Amitriptyline 100 mg po qhs 3. Oxybutynin ER 10 mg po once daily 4. Omeprazole 40 mg po BID 5. OxyContin 20 mg po BID 6. Gabapentin 300 mg po QID 7. Ipratropium Bromide 0.06% nasal solution 8. Claritin 10 mg po once daily 9. Verapamil HCl ER 240 mg po qhs 10. Potassium Cl 20 meq po once daily 11. Metolazone 2.5 mg 1 tab po QOD 12. Bumetanide 4 mg po once daily 13. Furosemide 60 mg po once daily 14. Spironolactone 50 mg po once daily

19 OTC Meds 13. Glucosamine Chondroitin Complex 1 tab po daily 14. Calcium Vit. D 2 tablets po once daily 15. Vit. D 2000 Units 16. Multivitamins 17. Vit. B complex 18. Vit. E 400 Units 19. Co Q Fish oil 21. Folic acid 22. Ginkgo Bilobacaps 23. Melatonin 24. Acidophilus caps 25. Metamucil 26. PEG 3350 Oral powder 27. Sennokot 8.6mg

20 Reconciled Medications 1. Lorazepam 1 mg po BID for anxiety 2. Amitriptyline 100 mg po qhs 3. Oxybutynin ER 10 mg po once daily 4. Omeprazole 40 mg po BID 5. OxyContin 20 mg po BID 6. Gabapentin 300 mg po QID 7. Ipratropium Bromide 0.06% nasal soln 8. Claritin 10 mg po once daily 9. Verapamil HCl ER 240 mg po qhs 10. Potassium Cl 20 meq po once daily 11. Metolazone 2.5 mg 1 tab po QOD 12. Bumetanide 4 mg po once daily 13. Furosemide 60 mg po once daily 14. Spironolactone 50 mg po once daily 13. Glucosamine Chondroitin 1 tab po daily 14. Calcium Vit. D 2 tabs po once daily 15. Vit. D 2000 IU 16. Multivitamins 17. Vit. B complex 18. Vit. E 400 IU 19. Co Q Fish oil 21. Folic acid 22. Ginkgo Biloba caps 23. Melatonin 24. Acidophilus caps 25. Metamucil 26. PEG 3350 Oral powder 27. Sennokot 8.6mg

21 Courtesy Troy Trygstad, PharmD, PhD: CCNC

22 System Hurdles Data? Interoperability/Availability? No standard process

23 Provider Hurdles No standard process Time Consuming Knowledge and skills Patient Expectations

24 Patient Hurdles

25 Reconciled Medications 1. Lorazepam 1 mg po BID for anxiety 2. Amitriptyline 100 mg po qhs 3. Oxybutynin ER 10 mg po once daily 4. Omeprazole 40 mg po BID 5. OxyContin 20 mg po BID 6. Gabapentin 300 mg po QID 7. Ipratropium Bromide 0.06% nasal soln 8. Claritin 10 mg po once daily 9. Verapamil HCl ER 240 mg po qhs 10. Potassium Cl 20 meq po once daily 11. Metolazone 2.5 mg 1 tab po QOD 12. Bumetanide 4 mg po once daily 13. Furosemide 60 mg po once daily 14. Spironolactone 50 mg po once daily 13. Glucosamine Chondroitin 1 tab po daily 14. Calcium Vit. D 2 tabs po once daily 15. Vit. D 2000IU 16. Multivitamins 17. Vit. B complex 18. Vit. E 400 IU 19. Co Q Fish oil 21. Folic acid 22. Ginkgo Biloba caps 23. Melatonin 24. Acidophilus caps 25. Metamucil 26. PEG 3350 Oral powder 27. Sennokot 8.6mg

26 How could we, as healthcare providers, be better stewards of patient medications?

27 MEDICATIONS AS A RISK FACTOR FOR FALLS Data mainly from observational studies Falls typically not included in adverse event reporting Cause of falls usually multifactorial Review of medications is a primary National Patient Safety Goal Suggested to review medication and alcohol use as part of falls evaluation TJC 2011 LTC/Home Care Patient Safety Goals

28 Drugs with High Risk for Serious Adverse Effects Warfarin Hypoglycemics Digoxin 1/3 of all ED visits in Older adults

29 Polypharmacy or Polymedicine?

30 Where do you draw the line? DK

31 NUMBER OF MEDICATIONS AND RISK Study published in 2005 via questionnaire Looked at 6928 adults over the age of 55 years Polypharmacy was risk factor for falls when patient was taking one high risk medication Polypharmacy = 3 to 4 medications High risk medications: Hypnotics Benzodiazepines Anxiolytics Diuretics Br J Clin Pharmacol Feb.

32 POLYPHARMACY AS A RISK FACTOR FOR FALLS Br J Clin Pharmacol Feb.

33 MEDICATION CLASSES IMPLICATED IN FALLS Sedatives Hypnotics Antidepressants Benzodiazepines Analgesics Anticonvulsants Antihistamines Diuretics Beta Blockers Anticoagulants Antihypertensive Agents Hypoglycemic Medications Anticholinergic Agents

34 Discuss Medication Adverse Effects That Contribute to Falls

35 PSYCHOTROPIC MEDICATIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS Medication Pooled Odds Ratio 95% Confidence Interval Any psychotropic Neuroleptics Sedatives/hypnotics Any antidepressant Tricyclic antidepressants Benzodiazepines JAGS 1999; 47: 30-9

36 ANTIPSYCHOTICS Conventional Atypical Adverse Effects Chlorpromazine Aripiprazole Sedation Haloperidol Clozapine Extrapyramidal symptoms (EPS) Perphenazine Olanzapine Anticholinergic Promazine Quetiapine effects Thioridazine Risperidone Orthostatic hypotension Thiothixene Ziprasidone Less Anticholinergic: aripiprazole, haloperidol, quetiapine, and risperidone J Am Geriatc Soc Apr;60(4):

37 NON-BENZODIAZEPINE HYPNOTICS AND SEDATIVES Hypnotics/Sedatives Zolpidem Zaleplon Ezopiclone Chloral hydrate Meprobamate Adverse Effects Dizziness Somnolence Drowsiness Balance disorder Confusion Sleep-walking Performing activities while sleeping Avoid Use: similar effects as benzodiazepines - delirium, falls, fracture risk, hangover feeling J Am Geriatc Soc Apr;60(4):

38 ANTIDEPRESSANTS Tricyclic Antidepressants Nortriptyline Amitriptyline Desipramine Doxepin Adverse Effects Anticholinergic side effects: blurred vision, confusion, drowsiness **On Beer s List due to these adverse effects Orthostatic hypotension Drowsiness EKG abnormalities Imipramine Lexi-Comp DI Handbook

39 ANTIDEPRESSANTS Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs): Citalopram Fluoxetine Paroxetine Fluvoxamine Escitalopram Other: Bupropion Duloxetine Mirtazapine Trazodone Adverse Effects Drowsiness Orthostatic hypotension EKG abnormalities Anticholinergic effects Lexi-Comp DI Handbook

40 ANTICHOLINERGIC MEDICATIONS Anticholinergic Medications Antihistamines: Diphenhydramine, Chlorpheniramine, Brompheniramine Ranitidine Oxybutynin Tolterodine Meclizine Scopolamine Benztropine Amantadine Adverse Effects Dizziness Drowsiness Blurred vision Urinary retention Mental status changes Lexi-Comp DI Handbook

41 ANTICHOLINERGICS: HIDDEN SOURCES OVER THE COUNTER

42 BENZODIAZEPINES Benzodiazepine Short and Intermediate Acting: Alprazolam Lorazepam Oxazepam Temazepam Long Acting: Chlordiazepoxide Clonazepam Diazepam Flurazepam Adverse Effects Dizziness Sedation Confusion Delirium Hypotension Unsteadiness

43 ANTICONVULSANTS Anticonvulsants Older Agents: Carbamazepine Phenytoin Phenobarbital Primidone Ethosuximide Valproic Acid Newer Agents: Topiramate Zonisamide Lamotrigine Levetiracetam Gabapentin Adverse Effects Ataxia Confusion Dizziness Sedation Somnolence Hypotension Impaired coordination Visual disturbance

44 CARDIOVASCULAR MEDICATIONS Cardiovascular Agent Beta Blockers ACE Inhibitors/ ARBs Calcium channel blockers Diuretics Centrally acting agents Alpha blockers Vasodilators Nitrates Adverse Effects Orthostatic hypotension Bradycardia Dizziness Increased urination à increased ambulation Drowsiness Fatigue Confusion

45 ANTICOAGULANTS Anticoagulant Warfarin Heparin Enoxaparin Fondaparinux Novel anticoagulants: Dabigatran Rivaroxaban Apixaban Edoxaban Adverse Effects Bleeding

46 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) NSAID Non-selective: Aspirin > 325mg/day Ibuprofen Naproxen Meloxicam Piroxicam Diclofenac Etodolac Ketorolac Indomethacin COX-selective: Celecoxib Adverse Effects Bleeding Dizziness Drowsiness Lightheadedness Visual disturbances

47 NARCOTICS Narcotic Analgesic Morphine Oxycodone Hydromorphone Fentanyl Methadone Codeine Hydrocodone Butorphanol Opium Tramadol Adverse Effects Sedation Drowsiness Dizziness Confusion Mental status changes Hypotension Constipation

48 INJECTABLE HYPOGLYCEMICS Hypoglycemic Insulin: Aspart Lispro Glulisine Regular NPH Glargine Detemir Other Injectables: Exenatide Pramlintide Adverse Effects Hypoglycemia Dizziness Somnolence Blurred vision

49 ORAL HYPOGLYCEMICS Hypoglycemic Sulfonylureas: Glipizide Glyburide Glimepiride Alpha-glucosidase inhibitors: Acarbose Miglitol Meglitindes: Nateglinide Repaglinide Thiazolidines: Pioglitazone Biguanides: Metformin Adverse Effects Hypoglycemia Dizziness Somnolence Blurred vision Diarrhea

50 Strategies to Reducing Risk of Medication-Related Falls

51 THE ROLE OF THE PHARMACIST Drug information resource Medication review Prior to and following a fall Educate patients and caregivers Anticipate adverse effects Recommend alternate regimen Considerations for special populations

52 SAFER MEDICATION USE IN HIGH RISK PATIENTS Keep up-to-date medication list All patients should carry on their person Include over-the-counter medications Consider one drug for multiple indications Consider overall benefit vs. risk when prescribing Closely monitor for adverse effects Consider all new symptoms as possibly drug-related Perform medication review and reduction

53 MINIMIZE MEDICATIONS Use minimum effective dosing of fewest medications Change to safer medication Withdrawal of unnecessary medications Taper or gradual dose reduction if necessary i.e. Psychotropic medication withdrawal Non-pharmacologic measures in place of medications

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55 MANAGE ORTHOSTATIC HYPOTENSION Non-pharmacologic measures Sit for 2 to 3 minutes before standing Clench hands or pump ankles before standing Compression stockings Liberalize salt intake if appropriate Add post-prandial caffeinated coffee á¹€edications to increase blood pressure: Midodrine Fludrocortisone 2.5 to 10 mg three times daily 0.1 mg one to three times daily

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