quoted South Park in a talk

Transcription

1 So Many Drugs: Using the Updated Beers' List to Address Polypharmacy MONA Annual Meeting April 22, 2016 Just so I can tell my Teenage Boy I quoted South Park in a talk 1

2 Objectives: To discuss the potential dangers of polypharmacy To present a framework for approaching the patient with polypharmacy To highlight the Beers criteria as a way to analyze potentially inappropriate medications in the older adult 2

3 JUST IN CASE I NEED TO MAKE THE CASE FOR: SO MANY DRUGS. 3

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5 What about the polyspecialist 3 drugs per specialist 4 specialists How many drugs? Sixteen meds 5

6 Sixteen meds 4 specialists x 3 drugs per specialist = 12 Sixteen meds 4 specialists x 3 drugs per specialist = 12????? Can t You do math Tatum????? 6

7 Sixteen meds 4 specialists x 3 drugs per specialist = meds from the ER to treat the med side effects Sixteen meds 4 specialists x 3 drugs per specialist = meds from the ER to treat the med side effects 16 7

8 WHY THIS REALLY MATTERS 8

9 Adverse Drug Effects (ADEs) Incidence of ADEs in hospitals: 26/1000 beds (2.6%) ADEs occur in 35% of community dwelling older adults ADEs are responsible for 5% to 28% of acute geriatric hospital admissions MEDICATIONS MOST COMMONLY INVOLVED IN ADEs Cardiovascular drugs, diuretics, NSAIDs, hypoglycemics, antipsychotics, and anticoagulants Medications with a narrow margin of safety (synthroid, phenytoin, lithium, valproic acid, aminoglycosides, anticoagulants, digoxin, hypoglycemic agents, etc) opioids/benzodiazepines Geriatrics Review Syllabus, Pharmacotherapy, Semla et al Adverse Drug Events After Hospital Discharge in Older Adults: Types, Severity, and Involvement of Beers Criteria Medications J Am Geriatr Soc. 2013; 61:

10 RISK FACTORS FOR ADEs Age 85 or older Female Low body weight or low BMI Estimated CrCl < 50 ml/min 5 9 or more medications 12 or more doses of drugs/day 6 or more concurrent chronic conditions Prior adverse drug event ADE PRESCRIBING CASCADE Drug 1 Adverse drug effect - misinterpreted as a new medical condition Drug 2 Adverse drug effect misinterpreted as a new medical condition 10

11 And some other potential harms of polypharmacy (in case you aren t convinced?) Interactions and increased harm End of life issues Care transitions and readmissions Did you know that in the SNF: Monthly QI measure for polypharmacy has merit 9 or more medications 2.33 times more likely to have an Adverse Drug Reaction (p<0.001) Nguyen, Fouts, Kotabe, Lo. Am J of Geri. Pharmacotherapy

12 End of life is an opportunity for MORE polypharmacy Secondary analysis of a Large Randomized controlled trial of health service delivery in palliative care 460 patients Palliative Care led to: Increase in the number of meds Few reductions in medications Absolute number of medications in this study did not peak until week before death. Currow, Stevenson, Abernathy, et. al. JAGS 2007 The IMPACT of meds on care transitions? Nearly 1/5 Medicare patients discharged from hospital readmitted within 30 days. Readmissions affect 2.6 million patients at a cost of $26 billion every year 12

13 Approximately 20% of persons discharged from hospital to home have an adverse event. Two-thirds of these were because of inappropriate drugs being taken on returning home. (Forster AJ, Murff HJ, Peterson JF, et al 2003) characteristics of adverse drug events after hospital discharge in the elderly Nearly 20% of elderly patients discharged back to the community had at least one adverse drug event (ADE) 1/3 were preventable only 16% involved medications on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Kanaan AO, Donovan JL, Duchin NP, J Am Geriatr Soc

14 And the cost? Medicare reimbursement penalties part of the ACA s effort to save costs and improve care by reducing the number of patients who check back into a hospital after treatment. The 2,610 penalized hospitals will lose a total of $428 million in payments 2014 The number of readmitted Medicare patients, or about 2 million people, cost the Federal government about $26 billion each year. How do we track medications as the cause of Readmissions??? 14

15 Successful Post Discharge Calls (Non ED (Inpatient/Observation) vs. ED) Goal Non ED ED 100% 81% 81% 80% 75% 66% 60% 54% 52% 50% 33% 25% 15% 6% 2% 1% 0% '10 '11 Q1 (N=5223; 9922) '10 '11 Q2 (N=4751; 9257) '10 '11 Q3 (N=4678; 8436) '10 '11 Q4 (N=4827; 7811) Discharge Quarter (Denominators Non ED; ED) '11 '12 Q1 (N=4724; 8245) '11 '12 Q2 (N=4653; 7278) 300 Reasons for Follow up September 2010 December 2011 N = 731 Patients Requesting Follow up (938 Area Issues due to multiple areas per patient) Follow up Counts Pre Recent Quarter # of Follow ups

16 All transitions should be accompanied by a legible list of medications and dosages and the indication for the medicine. This simple strategy of a medication list is one of the most powerful tools to decrease errors during transitions. (LaMantia MA, Scheunemann LP, Viera AJ, et al. 2010) Don t be shy, give less meds a try! Why don t we reduce medications on our patients?? And what is a framework to do it? 16

17 A case 88 yo new patient CC dizzy HPI: frequent falls, no vertigo, no clear orthostasis, no cva hx or sx no vision changes, no hearing changes DM2 with neuropathy, Lichen simplex chronicans, DJD knee, Complete rotator tears Lasix 20 mg daily Levo thyroxine 50 µg daily Lyrica 75 mg 1 tablet AM 2 tablets at night Cymbalta 60 mg daily Januvia OCCUvite daily Zyrtec daily Betamethasone 1% cream Ambien 5 mg at night Amlodipine 5 mg Aciphex when necessary GERD KCL 17

18 Step 1: Chief complaint: A case 83 yo new patient CC dizzy HPI: frequent falls, no vertigo, no clear orthostasis, no cva hx or sx no vision changes, no hearing changes 18

19 Lasix 20 mg daily Levo thyroxine 50 µg daily Lyrica 75 mg 1 tablet AM 2 tablets at night Cymbalta 60 mg daily Januvia OCCUvite daily Zyrtec daily Betamethasone 1% cream Ambien 5 mg at night Amlodipine 5 mg Aciphex when necessary GERD KCL Lasix 20 mg daily Levo thyroxine 50 µg daily Lyrica 75 mg 1 tablet AM 2 tablets at night Cymbalta 60 mg daily Januvia OCCUvite daily Zyrtec daily Betamethasone 1% cream Ambien 5 mg at night Amlodipine 5 mg Aciphex when necessary GERD KCL 19

20 Step 1: Chief complaint: Assume the CC is associated with the med list Go to med list and ask which meds cause the cc Step 2 Screen 20

21 Step 2 Screen Annual NH review Annual wellness Are you taking too many meds? Which ones do you think we can get off of? Would you like my advice about reducing meds? Step 3 What is the indication for the medication? 21

22 Another case 89 yo DM2, Severe AS with CHF sp TARP, improving, hx gastroparesis mild, Major depression severe, in remission. DJD. Afib with anticoagulation. CC: nausea Good performance status. Mild cog impairment 22

23 Step 4: Eliminate duplicate medications where able? Step 5: Assess for inappropriate medications BEERS lists Disease specific drug issues INTERACTIONS!!! 23

24 Step 6: special attention to the high risk medications A framework for medication reduction Analyze risks and benefits Stop medications for prevention when no longer able to help (coumadin/aspirin/plavix, statins for prevention, vitamins, etc) Stop medications that have more potential for harm now or less benefit (cholinesterase inhibitors in non ambulatory dementia, alpha blocker in male with catheter) 24

25 Stop when medication didn t have the intended response Medication Appropriateness Index Is there an indication for the drug? Is the medication effective for the condition? Is the dosage correct? Are the directions correct? Are the directions practical? Are there clinically significant drug drug interactions? Are there clinically significant drug disease interactions? Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable? Is this the least expensive alternative? 25

26 NO TEARS Need and indication Open questions Tests and monitoring Evidence and guidelines Adverse events Risk reduction or prevention Simplification and switches Beer s list 26

27 So what are Beer s list meds? An expert panel A list of meds that should Potentially be avoided 27

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30 DRUG DISEASE OR DRUG SYNDROME INTERACTIONS 30

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35 Total anticholinergic load Lots of medications have anticholinergic impact but not recognized Patient with high anticholinergic load: Diminished performance status by 15% Reduction in global quality of life Increased difficulty concentrating Preventing polypharmacy 35

36 Rationale Polypharmacy Decisions at end of life are Goal Driven Is the goal of the patient (or surrogate) Life prolonging? (and is that consistent with prognosis?) prevention meds still appropriate Functional? Continue medications that help maintain the primary functions of life the patient enjoys Comfort? Stop medications that are not specifically relieving a symptom or directly improving quality of life 36

37 Patient characteristics Dying patient Dying, versus unstable, vs. stable what is prognosis? Active vs. Inactive Wt loss and it s impact on meds (insulin) Medication characteristics Change in absorption (dysphagia), volume of distribution (cachexia), metabolism/excretion (worse renal/hepatic function) Is there withdrawal associated with medication 37