The median number of medicines prescribed per age category (IQR)

Size: px

Start display at page:

Download "The median number of medicines prescribed per age category (IQR)"

Marilynn Jackson
5 years ago
Views:

Drug Prescribing in the Elderly Panita Limpawattana Geriatric Medicine Unit, Internal Medicine Department, KKU 26 Nov 12 Scopes Pharmaceutical use in the elderly Pharmacologic changes with ageing

1 Drug Prescribing in the Elderly Panita Limpawattana Geriatric Medicine Unit, Internal Medicine Department, KKU 26 Nov 12 Scopes Pharmaceutical use in the elderly Pharmacologic changes with ageing Barriers to drug adherence Geriatric syndrome and medication-related Updated screening tool An approach to reduce polypharmacy Case studies Pharmaceutical use in the elderly 30% of prescription use & 40% of OTC Ageing group Prevalent & increase risk for ADEs, M&M, utilization of health care resources 3,500 community-dwelling adults 29%: > 5 prescription medications 42%: >1 OTC medications 49%: >1 dietary supplements Polypharmacy in the Elderly Polypharmacy = "many drugs. The use of more medication than is clinically indicated, or when a medication regimen contains at least 1 unnecessary drug Alternative definition >5 drugs Therapeutic polypharmacy Medication use in the elderly of Internal Medicine OPD, Srinagarind hospital Demographics 308 The median number of medicines prescribed per age category (IQR) Male 157 (51%) Age (years+sd) 72.8 (6.3) Age range Median no. of prescribing drugs (IQR) 5.6 (3.5,7) Mean CCI (+SD) 4.7 (3.5) Limpawattana P, et al. Unpublished data of PIM in the elderly 2012 Limpawattana P, et al. Unpublished data of PIM in the elderly

2 If medication related problems were ranked as a disease, it would be the fifth leading cause of death in the US! Why is ageing the high risk group? Pharmacokinetics & pharmacodynamic change Reduced body reserve Multiple pathology polypharmacy (drug-drug interaction, drug-disease interaction) Atypical presentation Communication problems Cognitive impairment OTC, herbal medicine use Physician factors Beers MH. Arch Internal Med Pharmacologic changes with ageing Pharmacokinetic change Absorption Distribution Metabolism Elimination Pharmacodynamic change Summary of pharmacokinetic change with ageing Pharmacokinetic process Age-related influence Absorption Distribution Metabolism Elimination Little or no change Increased body fat and decreased body water Phase 1 enzyme activity reduction Phase 2 unchanged Decreased in GFR Pharmacodynamicchanges Altered drug sensitivity Physiologic and homeostatic changes Altered drug sensitivity Increase: BZP, opioids, metoclopamide, levodopa, oral anticoaggulants, neuroleptics, anesthetics Decrease: beta-blocker, beta agonist, furosemide, vaccine 2

Physiologic and homeostatic changes ANS: orthostatic hypotension, bowel-bladder problems Thermoregulation: hypothermia, hyperthermia CNS: confusion, depression Postural instability: falls Glucose

3 Physiologic and homeostatic changes ANS: orthostatic hypotension, bowel-bladder problems Thermoregulation: hypothermia, hyperthermia CNS: confusion, depression Postural instability: falls Glucose intolerance: hyperglycemia Immunosenescence Hormonal changes Barriers to drug adherence Physical illness/disability Medication side effects Cognitive loss Psychological conditions Functional loss Social loss Geriatric syndrome & medication-related Disease Examples Fall sedatives, vasodilators, diuretics Parkinsonism flunarizine, cinnarizine, antipsychotics, metoclopramide Orthostatic TCA, diuretics, antihypertensive agents hypotension esp. α-blockers, sympatholytics, nitrate, bromocriptine, narcotics, sedatives, sildenafil Urinary diuretics, anticholinergics(overflow incontinence), incontinence alcohol, caffeine Urinary retention anticholinergics, antidepressants, antipsychotics, sedatives, narcotics, α-adrenergic agonists, β-adrenergic agonists, calcium-channel blockers Disease Constipation Xerostomia Examples anticholinergics, narcotics, calcium, iron supplement anticholinergicagents eg. disopyramide, clonidine, metoprolol, TCA, selegiline, anti-neoplastic agents (methotrexate),diuretics Sexual dysfunction SSRIs, centrally acting sympatholyticagents, beta-blockers, diuretic, anti-androgen Anorexia, weight loss digitalis, amiodarone, procainamide, quinidine, fluoxetine, most ATB, iron sulfate, anti-neoplastics, NSAIDs, colchicines, theophylline, laxatives, cholestyramine, pseudoephedrine, metformin, cholinesterase inhibitors Depression Delirium Disease Renal failure Rheumatic syndromes - myopathy - gouty attack - drug-induced lupus - drug-induced arthralgia Examples propanolol, clonidine, hydralazine, reserpine, narcotics, digitalis narcotics, anticholinergics, sedatives, anticonvulsants, antiarrhythmics, digitalis, methyldopa, β-blocker NSAIDs, diuretics (volume depletion), aminoglycoside, amphotericin B, contrast media statins(esp. combined with cyclosporine, fibrates, azole antifungals, macrolide ATBs) ethanol, cytotoxicdrugs, warfarin, low dose salicylate, ethambutol, pyrazinamide, diuretics procainamide, hydralazine, methyldopa, quinidine, chlorpromazine statins, fibrates, interferons, quinolones, amphotericin, acyclovir, minocycline, vaccine Screening tools to identify inappropriate prescribing in the elderly Beers criteria Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) Screening Tool to Alert doctors to Right Treatment (START) 3

4 Beers criteria The most widely used consensus data for inappropriate medication use in the elderly Original 1991, revised 1997, 2002, 2003 and 2012 Excellent well researched reference Easily available! Quality and Strength of : ACP Guideline Grading System, GRADE Quality High Moderate Low Strength of recommendation Weak Insufficient Not included in Beer s List Drugs with risks not unique to elderly Purpose is for PIMs specific to elderly Drug-drug interactions Not unique to elderly List of alternatives Too complex, requires patient specific judgment OrganSystem or TC or Drug Non-COX NSAIDs, oral Drugs to Avoid (except if ) Rationale GIB; Protection w/ PPIs or misoprostol Recommend. Quality of Avoidchronic use Moderate Strength of Recommend. Merperidine Neurotoxicity Avoid High Muscle Relaxants Ineffective at tolerated doses, antichol, falls Metclopramide EPS and TD Avoid, unless gastroparesis Insulin,sliding scale Hypoglycemia risk Avoid Moderate Moderate Avoid Moderate Drugs to Avoid (except if ) Drugs to Avoid (except if ) OrganSystem or TC or Drug Anticholinergics (excludes TCAS) Antipsychotics (conventional/ atypical) Benzodiazepines Short and long acting Rationale Dec clearance, tolerance develops, S/E IncreaseCVA &CV mortality in dementia Risk cognitive effects &injury; rare use appropriate eg benzo withdrawal Recommend. Quality of Avoid Avoid unless danger to self/others &non drug failure Avoid for treatment of insomnia, agitation,or delirium Moderate to high Moderate High Strength of Recommend. OrganSystem or TC or Drug Megestrol Digoxin > 0.125mg/d Antiarrhythmic drugs (class Ia,Ic, III) eg. amiodarone Rationale Recommend. Quality of Minimal effecton weight; risk of thrombotic events and death HF:higher dosesno more benefit, inc toxicity Rate control better than rhythm control Avoid Avoid Avoid as 1 st line fro AF Rx Moderate Moderate High Strength of Recommend. 4

5 Drugs to Avoid (except if ) Drug-disease/syndrome Interactions OrganSystem or TC or Drug Non Benzodiazepines Hypnotic s ( z drugs) Estrogens with or w/o progestin Rationale Recommend. Quality of Risk cognitive effects and injury (fall/mva); same ADE as benzo s Carcinogenic potential, lack of efficacy in dementia/cv dz prevention Avoid chronic use, >90 days Avoid oral and topical patch. Topical cream safe and effective for vaginal symptoms Moderate High Strength of Recommend. Diseaseor Syndrome Heart failure Delirium Drug Rationale Recomm Quality of NSAIDs,COX-2 inhibitors, nondihydro CCB (in SHF), pioglit, cilostozol All TCAs, anticholinergic,steroid,h2 block, BZP,sedative/h ypnotics Dementia As delirium Promote fluid retention Inducing/ worsening delirium Adverse CNS S/E Avoid NSAIDS, CCB: mod Pioglit: high Cilostozol:lo w Strengthof Recomm. Avoid Moderate Avoid High Drug-disease/syndrome Interactions Use of Caveats Diseaseor Syndrome Syncope Insomnia Drug Rationale Recomm. Quality of AChEIs Peripheral α- blockers Tert. TCAs Chlorpromazine Thioridazine Olanzapine Oral decongestants Stimulants Theobromines Orthostatic hypotension or bradycardia CNS stimulant effects Avoid α-blockers: High TCAs, AChEIs, antipsych: Moderate Strengthof Recomm. AChEIs, TCAs: α-blockers, antipsych.: Weak Avoid Moderate Z drugs for sleep: avoid chronic use Testosterone: avoid unless indicated for moderate to severe hypogonadism Topical vaginal estrogen: acceptable low dose use for specific conditions Spironolactone: avoid >25 mg/day in ptswith heart failure or CrCl <30 Antipsychotics: avoid unless nonpharmtreatment has failed or threat to self/others Use with Caution Limitations Drug Rationale Recommend Quality of Dabigatran Drugs linked to SIADH/ Hyponatremia(eg SSRI, TCA, CBZ, antipsychotics) Risk of bleeding; lack of evidence if CrCl < 30mL/min May exacerbate or cause SIADH/ hyponatremia; monitor Use with caution if >75 or if CrCl < 30mL/min Use with caution Moderate Weak Strengthof Recommend Moderate base available What s not covered Dose-adjustments for kidney function Drug-drug interactions Therapeutic duplication Special populations within geriatrics Search strategy - missed information 5

FREE Beers Criteria Apps Common drugs with anticholinergicproperties in older adults Drug class/ indication Antidepressants Antiarrhythmics Antiemetics/vertigo/ motion sickness Antihistamines

6 FREE Beers Criteria Apps Common drugs with anticholinergicproperties in older adults Drug class/ indication Antidepressants Antiarrhythmics Antiemetics/vertigo/ motion sickness Antihistamines Antipsychotics, atypical Antipsychotics, typical Bronchodilators Examples Cyclic antidepressants (eg.amitryptyline, imipramine) Quinidine, disopyramide Dimenhydrinate, meclizine,promethazine, prochlorperazine, scopolamine Brompheniramine, chorpheniramine, diphenhydramine, doxylamine, hydroxyzine, meclizine Clozapine, olanzapine, quetiapine Chlorprmazine, thioridazine Ipratropium bromide Hayes BD, et al. ClinGeriatrMed 2007; 23: Common drugs with anticholinergicproperties in older adults Drug class/ indication GI antispasmotics Mydriatics/ cycloplegics Overactivebladder Parkinson s disease Pre-anesthetics Examples Clidiniumbromide, hyoscyamine, methscopolaminebromide, propantheline Atropine, cyclopentolate Oxybutynin, propantheline, tolterodine, trospium Benztropine, biperiden,procyclidine, trihexyphenidyl Atropine Skeletal muscle relaxants Cyclobenzaprine, orphenadrine Hayes BD, et al. ClinGeriatrMed 2007; 23: Class anticonvulsants Atypical antipsychotics Benzodiazepines Musclerelaxants Opioids SSRIs TCAs Commonly used drugs causing sedation in older adults Drugs Gabapentin, phenobarbital, valproic acid Aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone Alprazolam, clonazepam, diazepam, lorazepam, midazolam, oxazepam, temazepam, triazolam Baclofen, carisoprodol, cyclobenzaprine,metaxalone, tizanidine Codeine, hydrocodone, hydromorphone, morphine, fentanyl, methadone, oxycodone Fluoxetine Amitryptyline, clomipramine, desipramine, doxepin, imipramine, nortryptyline, protryptyline Hayes BD, et al. ClinGeriatrMed 2007; 23: Common Herbs and Drug Interactions Herbs Drugs Adverse events ใบแปะก วย (Ginkgo biloba) โสม (Ginseng) กระเท ยม Aspirin Warfarin Thiazide Acetaminophen/ Ergotamine/ Caffeine Warfarin Alcohol Phenelzine (Nadil); monoamine oxidase inhibitor NSAIDS, Warfarin Spontaneous hyphema Intracerebral hemorrhage HT Subdural hematoma Dec. INR Inc. alcohol clearance Headache, Tremor, Mania Inc. anticoagulation effect William CM. Using medications appropriately in older adults. Am FamPhysician 2002; 66:

มะขามแขก (Senna) ชะเอมเทศ (Licorice) Herbs Drugs Adverse events Dec. drug availability Prolonged use loss K digitalis & antiarrhythmic agents intoxication St.

7 มะขามแขก (Senna) ชะเอมเทศ (Licorice) Herbs Drugs Adverse events Dec. drug availability Prolonged use loss K digitalis & antiarrhythmic agents intoxication St. John s wort Possible interference with any intestinally absorbed drugs Thiazides Digitalis Corticosteroids Thiazides Digitalis Corticosteroids SSRIs, Digitalis, Theophylline, Cyclosporin Hypokalemia Inc. digitalis sensitivity Inc. corticosteroids effect Serotonin syndrome Dec. drug bioavailability Risk factors An approach to reduce polypharmacy Patient Physician Health care system Polypharmacy Intervention Rational prescribing Precriber education Patient education Outcomes Dec. ADE Dec. drug interaction Dec. M&M Dec. cost Inc.adherence William CM. Using medications appropriately in older adults. Am FamPhysician 2002; 66: What to do with polypharmacy? Document and determine indication Prioritize Vital vs. optional Cure vs. relieve symptom Discuss with patient, caregiver Plan for medication reduction Vital vs. optional Cure vs. relieve symptom A 70 yr old lady Case I PHx: IHD, DM2, OA, glaucoma, stress incontinence, PUD Meds: ASA, furosemide, digoxin TimololED Metformin Ibuprofen Tramadol prn pain Omeprazole Oxybutynin Diphenhydramine prn insomnia 40 General prescribing considerations Use single daily dose regimens Limit the use of PRN medications Consider all new medicines as a therapeutic trial Discontinue a drug if it is ineffective or intolerable A/E occur Provide legible written instructions Instruct caregivers as needed Attempt to prescribe a drug that will treat more than one existing problem Avoid prescribing cascade Beers Criteria only Part of Quality Prescribing A 68 Year old man with PD Meds Madopar Trihexyphenidyl Lorazepam Chlorpheniramine Amitryptyline Case 2 7

8 Diagnosis How common? Tardive dyskinesia Involuntary movements of tongue, lips, face, trunk & extremities in patients treated with long term dopaminergic antagonist drugs Vulnerable patients Schizophrenia & other neuropsychiatric disorders** Brain disorders Frequency (US) 15-30% of persons with long-term neuroleptics Rx 1-2% of persons with DPM antagonists Rx Parkinsonism are more common Higher in cigarette smokers Race Africans & African Americans Age Advanced age* Elderly female patients Brasic JR, Bronson B. Tardive dyskinesia, 2010 Brasic JR, Bronson B. Tardive dyskinesia, 2010 Differential diagnosis Medications causing TD Drug -induced TD *** CNS disorder: dementia with PD/ PSP Psychiatric condition eg. somatizationdisorder, schizophrenia, malingering Metabolic disorders: hyperthyroidism, hypoparathyroidism, Wilson disease Infection: syphilis CNT disease: SLE Poorly fitting dentures Brasic JR, Bronson B. Tardive dyskinesia, Antipsychotic agents Haloperidol Phenothiazines Chlorpromazine Fluphenazine Perphenazine Thioridazine Atypical antipsychotic agents Olanzapine(Zyprexa) Quetiapine(Seroquel) Risperidone(Risperdal) Brasic JR, Bronson B. Tardive dyskinesia, 2010 Medications causing TD Medication Red Flags Nonneuroleptic medications Anticholinergics Antidepressants Antiemetics Antihistamine Antihistaminic decongestants Antimalarial Antiparkinson agents Antiepileptic drugs Anxiolytics Mood stabilizers Stimulants Avoid drug-induced TD if possible Recognition of nonneuroleptics induced TD Using lowest effective dose of causative agents for the shortest time Reduction & cessation of causative agents can relieve TD Brasic JR, Bronson B. Tardive dyskinesia,

9 Case III A 84 year-old lady with HT, dementia, OP presented with fatigue for 3 days 1. Exelon patch 5mg/d 2. Felodipine5 mg pood 3. HCTZ 25 mg pood 4. Calcitriol 0.25mcg po bid 5. CaCO3 1.25gm pobid 6. Centrum 1 tab pood 7. B tab potid 8. Menatetrenone(Glakay) 15mg po tid 9. Fish oil 1 cap pood Causes! CBC: Hct35%, MCV 80, WC 8500, Plt203,000 BUN/Cr 50/1.8 Na 135, K 2.9, HCO3 26, Cl100 Ca 17, PO4 3, Mg 1.5 Alb 3.2, glob 2.5 Others are unremarkable Hypercalcemia, Hypokalemia, Metabolic alkalosis and prerenal azotemia Other investigations PTH level 2.7 pmol/l ( pmol/l) Body bone scan: no evidence of bone metastases VitD level -? S.protein immunoelectrophoresis: normal 24-h-urine calcium 8.2 mmol/d(<7.0 mmol/d) Ur. phosphorus 19 mmol/day (<50 mmol/day) U/S: no KUB stones or nephrocalcinosis Diagnosis Calcium alkali syndrome Hypercalcemia, metabolic alkalosis & RF secondary to CaCO 3 intake for OP prevention An acute hypercalcemiacrisis, responding rapidly to hydration Phosphorus level: normal to low The 3 rd commonest cause of hospital admissions for hypercalcaemia (9-12%) Medarov BI, Mayo Clin Proc, 2009 Calcium alkali syndrome The diagnosis is based on A history of ingestion of calcium rich compounds Concordant biochemical findings Exclusion of other causes esp. primary hyper PTH & hypercalcemia of malignancy Medarov BI, Mayo Clin Proc, 2009 Who are at risk? All patients who present with hypercalcemia Taking preparations that contain CaCO 3 Simple dyspepsia Renal failure Osteoporosis Rx and prophylaxis Unusual form (Far East) Betel nut chewers + lime paste (calcium oxide & calcium hydroxide) Kaklamanos M. BMJ 2007, Waked A. Access Journal

10 Contributing factors Differences in intestinal absorption of calcium Old age Decreased gastric ph Pre-existing renal failure Daily amount of ingested calcium: ranging from 2-20 gm Total Calcium & Vitamin D Cal mg/d Cal 600mg, VitD 400 IU VitD 20 IU Cal 1000mg Cal 175mg VitD 400 IU HCTZ Kaklamanos M. BMJ 2007 Treatment of this case Withdrawal of calcitriol, centrum, HCTZ Low calcium diet Correction of volume depletion & furosemide Correct hypokalemia Discharged with normal calcium concentration after 6 days of admission During a 2 week follow-up, results of biochemistry tests remained normal Management Withdrawal of offending agent Supportive Rx & hydration Recovery from acute form: 1-2 days & slower in chronic case Furosemide may be used to enhance calciuresis Bisphosphanates: avoided initially Refractory cases: hemodialysis Hypercalcemia: resolves several days-6 months Kaklamanos M. BMJ 2007, Waked A. Access Journal 2009 Medical Red Flag Calcium alkali syndrome: considered in all patients with hypercalcaemia Early Dx& Rx: a favourable outcome A careful Hxof drug use should always be taken Elemental Cal < 2 g is safe but be careful in a person with predisposing factors The public needs to be educated about calcium supplementation & potential A/E TAKE HOME POINTS! Polypharmacy & ADRs have profound medical and economic consequences Elderly have unique pharmacokinetics High risk meds: cardiovascular, analgesic, psychotropics& meds with a low therapeutic index Use the prescribing pearl in prescribing Start improving our patients' QOL! 10

COMMON DRUG RELATED PROBLEMS SEEN IN PACE AND MECHANISMS TO MITIGATE RISK

COMMON DRUG RELATED PROBLEMS SEEN IN PACE AND MECHANISMS TO MITIGATE RISK Robert L Alesiani, PharmD, CGP Chief Pharmacotherapy Officer CareKinesis, Inc. (a Tabula Rasa Healthcare Company) 2 3 4 5 Pharmacogenomics