Deprescribing with Confidence Dr Sanjay Suman MD FRCP

Transcription

1 Deprescribing with Confidence Dr Sanjay Suman MD FRCP Clinical Director Elderly Care and Stroke Medway NHS Foundation Trust Kent

2 45% of all medications prescribed for 65 years 1 1. Wynne et al Maturitas 2010;246-50

3 What is Deprescribing? Process Required for the safe and effective cessation of inappropriate medication Taking into account Patient s physical functioning co-morbidities preferences lifestyle DTB 52:2014

4 Context Polypharmacy Causative factors Adverse outcomes Medication Review Deprescribing / Rational prescribing

5 Context Increasing prevalence of multimorbidity NICE Guidance (ng 56) 2016 >50% of 85 years + 3 Long Term conditions Melzer D et al. Age Ageing 2014;ageing.afu113 Year Lifestyle Diseases commonest in the list of multimorbidities

6 Dementia Public Health England Dementia: Applying All Our Health Updated 23 January 2018

7 Multimorbidity: NICE Guidance (ng 56) 2016 Treatment Burden -Multiple appointments -Polypharmacy Maybe due to Focus on Primary Prevention Single health condition guidelines Based on Trials that recruit individuals Without multimorbidity Who take fewer medications

8 Case Study 85 years old Male PMH Hypertension, OA, T2DM, CKD Complaints Dizziness Diarrhoea Weight loss Episodic confusion Medications Ramipril 5 mg od Atorvastatin 10 mg od Doxazosin 2 mg od Metformin 1 gm bd Gliclazide 80 mg bd Tramadol 25mg PRN

9 Polypharmacy Historical Definition: Prescription 4 / 5 drugs No. of medications Yrs 28.9% 7.4% 80 Yrs 51.8% 18.6% Prevalence of Polypharmacy in a Scottish Primary care Population Payne et al. Eur J Cl Pharmacol 2004;

10 Polypharmacy Current Take on understanding the issue Appropriate Inappropriate Established co-morbidities Risk outweighs benefit Shared Goals Drug class duplication Effective & tolerated Co-prescribing drugs with potential interactions Spinewine A et al. Lancet 2007;370(9582): Hanlon JT et al. JAGS. 2001;49: Fisk D et al. Arch Intern Med. 2003;163: Steinman et al. JAGS. 2006;54: Omission of medications that are -effective -well tolerated -for established indications highly inappropriate

11 Multiple Prescribers / Silo prescribing Single Health Condition: narrow focus

12 Prescribing Cascade Adverse effects of a medication Treated with prescription of another drug Any new symptom maybe adverse drug effect: STOP, THINK

13 Adverse Drug Events (ADE s) Adverse Drug Reactions (ADR s) Noxious Unintended Undesired effects Medication Errors Prescribing Dispensing Administering

14 ADE s: Contributing Factors Drug Related Complex regimes Narrow therapeutic index drugs 60% Patient Related Living alone Cognitive impairment Physical frailty Poor vision/ Dexterity Poor compliance Clinician Related Inappropriate prescribing Failure to: -adjust Dose -monitor - analyse risk V benefit NPS MEDICINEWISE Sep 2013 Based on data: Roughead EE et al 2004; 13:83-7

15 ADE s: Impact Account for 6.5 % of hospital admissions 1 50% of Hospital Admissions due to Adverse Drug Effects are preventable Case fatality for those admitted to hospital: 4.7%² 70% of these are in individuals > 70 years old and on 5 medications Cost to NHS 466 million / annum³ ¹Medicines optimisation: ²Wu et al JR Soc Med. 2010;103(6): ³Pirmohamed et al BMJ 2004; 329: Scottish Government Polypharmacy Model of Care Group. Polypharmacy Guidance, Realistic Prescribing 3rd Edition, Scottish Governmen

16 ADE s: Polypharmacy contributes strongly Drug-Drug interactions Errors in dispensing Non- adherence Risk of overdose Fermer RE, Arenson JK. BMJ 2006; 333:143-5

17

18 Age related changes risk of ADR s ADR s Pharmacokinetics How the body handles drugs Pharmacodynamics How the drug affects the body

19 Effect of ageing on Pharmacokinetics Physiological Change Effect Drugs most affected Absorption ph & motility absorption Iron, Calcium Distribution body fat Body water Elimination half life Serum level Benzodiazepines Morphine Digoxin, Lithium, Theophylline Metabolism hepatic mass, blood flow first pass metabolism Serum level Propranolol, GTN, Lisinopril, Oxycodone, Atorvastatin Renal excretion GFR Serum level Digoxin, Lithium, Gentamicin, ACEi How the body handles drugs

20 Prevalence (%) Prevalence of CKD with age CKD stage Stage 4 Stage 3 Stage 2 Stage Prevalence of CKD by age group How the body handles drugs Anderson S et al. J Am Soc Nephrol. 2009;20:

21 Ageing enhances susceptibility to ADR s Impairment Drug class Adverse outcome Cholinergic activity Drugs acting on *CNS Delirium Cognitive impairment Falls Baroreceptor reflex Vasodilators Postural hypotension Falls How the drug affects the body *CNS: Central Nervous System

22 Common ADR s in frail individuals Falls Hypoglycaemia ADR s Delirium Dehydration Electrolyte imbalance Acute Kidney Injury

23 High risk medications: Falls Sedation/Drowsiness Antidepressants Antipsychotics Hypnotics Antihistamines Opiates Impaired Postural Stability Hypnotics (Z drugs) Benzodiazepines Anti-epileptics Postural Hypotension Diuretics Alpha-blockers Beta blockers Ace-inhibitors Nitrates Parkinson s disease medications

24 Baroreceptor reflex maintains BP Vasoconstriction + Heart rate Blood Pressure Restored Postural Hypotension X X Age related Impaired baroreceptor reflex enhances the ADR s of cardiovascular drugs Vasodilators β blockers

25 Orthostatic Hypotension (OH) OH Definition A drop of 20 mmhg in systolic or 10 mmhg in diastolic after 3 minutes of standing Important Causes Medications Autonomic failure Fluid depletion

26 Management of OH Stop the offending medication Alpha blockers (Doxazosin, Tamsulosin) Diuretics ACE-inhibitors Nitrates General Measures Fluid intake ( L) Increase salt intake (2-10g) if not contraindicated Adopt strategic getting up strategy Lie propped up at night with a head up tilt degrees (pillow height cm) Full length Gr 2-3 compression hosiery, Lower Limbs Pharmacological (usually initiated by specialists) Fludrocortisone microgram / d Midodrine mg tds ESC 2009, Eur Heart J 2009; 30:

27 ADR s: Cognition Benzodiazepine exposure is associated with increased risk of Alzheimer s Greater the length of exposure, stronger the risk

28 Estimating the anticholinergic burden

29 Lists commonly used drugs with anticholinergic properties Grades each drug with a score 1= Possible anticholinergic 2= Definite anticholinergic 3= Definite anticholinergic Each 1 point score risk of Cognitive impairment by 46% (over 6 years) Death by 26%

30 Benzodiazepines and hypnotics safety Kripke DF, Langer RD, Kline LE. BMJ Open. 2012;2:e

31 Benzodiazepines and hypnotics safety Which policies were effective?

32 Opiate potency compared to morphine Highly addictive 1/3 rd of opiate related deaths in US linked to prescribed opiates Common side effects in elderly include falls, constipation, delirium

33 Incident rate ratio Hypoglycaemia risk in elderly Diabetics with Renal impairment 1,2 In elderly people (>70 years) hypoglycaemia occurs more frequently in subjects with CKD stages With CKD Without CKD 1. Haneda M, Morikawa A. Nephrol Dial Transplant. 2009; 24: Adapted from Moen M et al. Clin J Am Soc Nephrol. 2009; 4:

34 CKD Cautions with Diabetes treatment

35 HbA1C Targets according to functional & cognitive status Functional/Cognitive Status HbA1C (%) HbA1C (mmol/mol) Functionally independent Functionally dependent Frail Up-to Dementia Up-to

36 Case Study Mr D, 85 years PMH Hypertension, OA, T2DM, CKD Complaints Dizziness Diarrhoea Weight loss Episodic confusion Medications Ramipril 5 mg od Atorvastatin 10 mg od Doxazosin 2 mg od Metformin 1 gm bd Gliclazide 80 mg bd Tramadol 50mg PRN Examination Weight 48 Kg, BMI 17 BP Lying 110 / 70, standing 80 /60 HR 60 regular, Gait: unsteady Recent Blood tests HbA1C 43, egfr40

37 Case Study Mr D, 85 years old 2 Falls in last 3 months What will you do next? o Stop Doxazosin o Stop Gliclazide o Reduce Metformin dose o Reduce Ramipril dose o All of the above Medications Ramipril 5 mg od Atorvastatin 10 mg od Doxazosin 2 mg od Metformin 1 gm bd Gliclazide 80 mg bd Tramadol 50mg PRN Examination Weight 48 Kg, BMI 17 BP Lying 110 / 70, standing 80 /60 HR 60 regular, Gait: unsteady Recent Blood tests HbA1C 43, egfr40

38 I feel a lot better since I ran out of those pills you gave me

39 Types and Levels of Medication Review Level 3 Clinical Medication Review Level 2 Treatment review Increasing Frailty severity status Multimorbidity Numbers of medications Suspected ADR s Falls Delirium End of Life Level 1 Prescription Review

40 Medication Review Process leading to Deprescribing Assess Monitor Define goal Stop Reduce Replace Drugs: critical analysis Risk Vs benefit for each drug

41 How often should medication review take place? Opportunistically 6 monthly if on 4 drugs Annually for all >75 years old General Practice Contract Requirement 2017/18 MARCH 2017

42 Practice Based Clinical Pharmacists Important Role in managing long term health conditions Inappropriate polypharmacy reduction Medicine Reconciliation

43 Tools for Polypharmacy reduction Beer s Criteria List 53 potentially inappropriate medications Endorsed by American Geriatrics Society 2012 STOPP / START Criteria Validated and relevant for UK population Endorsed by British Geriatrics Society Guidelines.co.uk/NiceMedOpt

44 Case 2: Mrs J, 81 requests appointment (3 rd in 4 months) PMH: Hypertension, Hypothyroidism Present History Previous 2 GP contacts for constipation still a problem + tired all the times, mobility Consent obtained from Patient for picture to be used for educational presentation Medications Co-Codamol 2 tabs qds Atenolol 50 mg od Simvastatin 40 mg od Levothyroxine 100 mcg od Laxido & Senna not helping

45 Case 2: Mrs J, 81 requests appointment (3 rd in 4 months) What will you do next o Try another laxative o Stop Co-Codamol o Check Thyroid Function o Reassure and follow up PMH: Hypertension, Hypothyroidism Present History Previous 2 GP contacts for constipation still a problem + tired all the times, mobility Medications Co-Codamol 2 tabs qds Atenolol 50 mg od Simvastatin 40 mg od Levothyroxine 100 mcg od Laxido & Senna not helping

46 Case 2: Mrs J has not been taking her Thyroxine as prescribed Constipation Tiredness Reduced Mobility TSH 65 mu/l Coarse facial features Receding hairline Loss of outer 1/3 rd of eyebrows

47 Prescribing for elderly: Considerations Any new symptom maybe adverse drug effect: STOP, THINK Non pharmacological measures remain underutilised Start low, go slow but use enough Life expectancy, functional and cognitive status play a role in shared decision making Quality of life matters most to people

48 Prescribing for elderly: Considerations Focus on common medications NSAID Proton Pump Inhibitors Opiates Hypnotics Benzodiazepines Antipsychotics (for behavioural and psychological symptoms in Dementia) Diuretics for leg oedema Antihypertensives Oral Hypoglycaemic agents Are any medications not being prescribed that need to be? Examples: Osteoporosis Anticoagulation in Atrial fibrillation

49 Prescribing for elderly: Considerations

50 Holistic Approach Guideline Medicine Care & Support Planning Single LTC Standardised Care Multimorbidity Frailty Personalised Care

51 Assessment for frailty / individuals approaching end of life Individualised Management plan Personal goals optimisation plans Advance care plan Psychological Social Comprehensive Geriatric Assessment Functional Medical Multimorbidity: NICE Guidance (ng 56) 2016

52 Conclusions Inappropriate prescribing runs risk of adverse effects particularly for frail elderly Establish local systems for regular medication reviews leading to rational prescribing for elderly / people with multimorbidity and frailty

53 Resources for further reading Thank you for listening