Presented by: Ontario s Geriatric Steering Committee

Transcription

1 Polypharmacy: A Medication Management Opportunity Chris Fan-Lun, BScPhm, ACPR, CGP Clinical Practice Leader, Dept. of Pharmacy Services Mount Sinai Hospital, Sinai Health system

2 Learning Objectives Provide insight into polypharmacy and associated adverse drug outcomes Understand principles behind the medication review process Utilize strategies to address and manage polypharmacy 2

3 Key Learnings Polypharmacy: A Medication Management Opportunity

4 Polypharmacy More medication use than clinically indicated Associated with negative outcomes: Treatment non-adherence Adverse drug events Falls Health care utilization Mortality 4

5 Elderly: Adverse Drug Events Age-related physiological changes affect drug pharmacokinetics Tissue composition (affects distribution) Hepatic & renal function (harder to metabolize & excrete) Polymorbidity 5

6 Medication Review and Assessment Gather comprehensive medication list Critical examination with consideration of: Appropriate, effective Treatment adherence Side effects, drug interactions Unmet need 6

7 Medication Management: Optimization and Deprescribing Start low, go slow Stop slow as you go low K.I.S.S. for adherence Communicate & update med lists 7

8 Common Causes Polypharmacy: A Medication Management Opportunity

9 Polypharmacy Research definition: 5+ drugs Clinical Definition: concomitant use of multiple medications than are indicated clinically 9 Steward RB, Cooper JW. Drugs Aging. 1994;4(6):449-61

10 Polypharmacy Impact Drug-drug interactions Adverse drug events (ADEs) Adherence to drug regimens Quality of life, poorer outcomes Health care utilization Prescribing cascade 10

11 Adverse Drug Events in Elderly ~ 15% of hospitalizations are ADE related The more meds, the risk of drug-drug interactions and ADEs ~ 75% of ADEs are dose related 11 Carbonin P et al. J Am Geriatr Soc. 1991;39(11):1093-9

12 12

13 Adverse Drug Events and Age-related Physiological Changes % 30% Fat % 13% Age 25 Age 70 53% 12% Water Cell Solids Bone Mineral 13

14 Drug Metabolism and Elimination Physiological Changes Hepatic liver mass and hepatic blood flow Renal mass and blood flow Clinical Significance Phase 1 rxns altered (Cytochromes P450) Phase 2 rxns - no significant change (UGT enzyme) Renally excreted drugs require dose adjustments 14

15 Polypharmacy Factors Patient expectations Communication gaps Polymorbidity, complexity Clinical Practice Guidelines Prescribing Cascade 15

16 Prescribing Cascade Drug 1 ADE interpreted as new medical condition Drug 2 ADE interpreted as new medical condition Drug 3 16 Rochon PA, Gurwitz JH. BMJ 1997;315:1097.

17 Prescribing Cascade Donepezil Cholinesterase inhibitor Urge Incontinence Tolterodine anticholinergic Delirium Risperidone antipsychotic 17 Gill SS et al. Arch Intern Med 2005;165:

18 Assessment Polypharmacy: A Medication Management Opportunity 18

19 Brown Bag Medication Review All prescriptions, OTCs and supplements Clinical indication Side effects; Avoid prescribing cascade Identify age-related PK/PD that ADE risk Eliminate drugs without benefit or indication Substitute less toxic drugs where able Simplify regimen 19 Carlson JE. Geriatrics 1996;51;26 30,35.

20 NO TEARS Medication Review Need and indication Open questions Tests and monitoring Evidence and guidelines Adverse events Risk reduction or prevention Simplification and switches 20 Lewis T. BMJ 2004; 329:434

21 All medicines have risks as well as benefits 21

22 All medicines have risks as well as benefits 22

23 Screening Tools 23 Fick D et al. J Am Geriatr Soc. 2012;60(4): Gallagher P et al. Age and Ageing 2008;37: Barry PJ et al. Age and Ageing 2007;36:632-8.

24 Emergency Hospitalizations for ADEs 24 Budnitz DS et al. N Engl J Med 2011;365:

25 Management Polypharmacy: A Medication Management Opportunity 25

26 Polypharmacy Strategies Treat conditions in order of priority Use drugs when strictly necessary to reduce risk Ask patients if they are using over the counter medicines or herbal medicines Inform patients what they should avoid Monitor response periodically and appearance of any adverse effects Review treatment periodically 26

27 Deprescribing Process of tapering or stopping medications to reduce: Polypharmacy Adverse drug effects Inappropriate or ineffective medication use 27

28 Compliance Aids 28

29 Implications for Practice Polypharmacy: A Medication Management Opportunity 29

30 Revising the Prescribing Stage 30 Bain KT et al. J Am Geriatr Soc 2008; 56(10):

31 Steps Associated with Discontinuing Medications 31 Bain KT et al. J Am Geriatr Soc 2008; 56(10):

32 Deprescribing Challenges Communication gaps, unaware of changes Fear of stopping Rx started by someone else Going against clinical guidelines Knowledge regarding evidence for treatment targets in the elderly Worry about something bad happening 32

33 Guideline Adaptation for Frail Elderly Frail elderly and > 80yo underrepresented in clinical trials Special population sections (elderly, frail, limited life expectancy) CHEP (Hypertension) CDA (Diabetes) AHA/ACC (Cholesterol) 33

34 Treatment Decisions & Life Expectancy 34 Yourman LC et al. JAMA 2012;307(2):

35 Medications Lists 35

36 Reconcile Medication at Visits & Care Transitions New Medications Pneumococcal vaccine given Sept 1, 2015 Tylenol Extra Strength 1g TID Medication Dose Changes L-thyroxine dose to 50 mcg QHS Medications Stopped NitroDur patch Percocet Nortriptyline 36

37 Adverse Drug Withdrawal Events Clinically significant signs/symptoms due to drug withdrawal Physiological withdrawal reaction eg tachycardia after stopping β-blockerexacerbation of condition eg edema after stopping furosemide for HF New symptoms eg weakness and nausea after stopping steroid Increased risk with: Longer duration, higher doses, short half-life History of dependence/abuse 37 Graves T et al. Arch Intern Med. 1997;157:

38 Deprescribing Monitoring 38 Hardy JE et al. J Pharm Pract Res 2011;41:146-51

39 Questions?

40 Thank you!