Polypharmacy The Good, the Bad, and the Ugly

Transcription

1 Poypharmacy The Good, the Bad, and the Ugy Cavin Hirsch, MD Division of Genera Medicine & Geriatrics UC Davis Medica Center

2 Discosures I have no financia conficts of interest.

3 Poypharmacy: The Presence of Mutipe Drug Stores

4 Poypharmacy: Taking Mutipe Medications

5 How Many Medicines Does It Take to Make Poypharmacy? Among 1,705 men over age 69 enroed in the Concord Heath & Aging in Men Project, 5 or more medications predicted: Deveopment of fraity Disabiity Fas Death Five of more routiney taken medications = poypharmacy

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7 Poypharmacy as Harmfu v Poypharmacy as Good Medicine Standard of care for many chronic inesses requires mutipe meds. Poyiness common: Age Group: % with 4 chronic conditions Arch Intern Med. 2002;162:2269

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10 Case Study: Mrs. D 77 year od obese woman with diabetes, high bood pressure, heart faiure, moderatey severe kidney disease, high choestero, heart burn, severe knee arthritis, burning neuropathy in her feet, gaucoma, depression, and insomnia. In addition to her primary doctor, seen by an endocrinoogist, cardioogist, neuroogist, psychiatrist, and ophthamoogist.

11 Mrs. D s Medications Metformin X daiy Gipizide 5 mg daiy Metoproo 50 mg 2 X daiy Lisinopri 40 mg daiy Furosemide 20 mg 2 X daiy Simvastatin 40 md 2 X daiy Amitriptyine 25 mg at bedtime Duoxetine 20 mg daiy Conazepam 0.5 mg 2 X daiy Gabapentin 600 mg 3 X daiy Ranitidine 150 mg 2 X daiy Acetaminophen with hydrocodone (Vicodin )500mg/5mg 4 X daiy as needed Timoo 0.5% 1 drop to both eyes daiy (OTC) Diphenhydramine 25 mg at bedtime (Sominex )

12 Are There Potentiay Inappropriate Medications? Metformin X daiy Gipizide 5 mg daiy Metoproo 50 mg 2 X daiy Lisinopri 40 mg daiy Furosemide 20 mg 2 X daiy Simvastatin 40 md 2 X daiy Amitriptyine 25 mg at bedtime Duoxetine 20 mg daiy Conazepam 0.5 mg 2 X daiy Gabapentin 600 mg 3 X daiy Ranitidine 150 mg 2 X daiy Acetaminophen with hydrocodone (Vicodin )500mg/5mg 4 X daiy as needed Timoo 0.5% 1 drop to both eyes daiy (OTC) Diphenhydramine 25 mg at bedtime (Sominex )

13 Why Potentiay Inappropriate? Amitriptyine Conazepam Ranitidine Diphenhydramine Vicodin Metformin at her dose with moderate-severe kidney faiure Metoproo (for high bood pressure) + timoo (for gaucoma)

14 Why Don t Doctors Pick This Up? Narrow focus on speciaty unaware of best treatment of other medica conditions Poor communication among doctors u Primary doctor may not know about drugs prescribed by speciaist! Not aware of the ageassociated side-effects and drug interactions Primary doctor defers to speciaist

15 DRUGS AND THE AGING PROCESS

16 Age-Dependent Changes in Body Composition

17 Age-Reated Changes in the Metaboism of Medications Due to age-reated changes in body composition and the functioning of body organs. Two types of age-reated changes in the handing of medications: u u PHARMACOKINETIC changes in the time course associated with the absorption, distribution, metaboism, and eimination of the drug. PHARMACODYNAMIC: -- changes in the action of the drug

18 EPIDEMIOLOGY OF POLYPHARMACY IN OLDER ADULTS

19 Number of Meds Used in Last 24h Austraian Nationa Census of Medicines Use (6/09-2/10) Morgan et a., Med J Aust 2012; 196:50

20 Poypharmacy among Oder Patients Admitted to Hospita U.S. veterans study: 678 randomy seected unpanned admissions (out of 2.4 miion) from a 152 VA Medica Centers between 2003 and 2006; mean age = 76.4 * u u 35.4% took 5-8 meds at admission 44.8% took 9 meds * Marcum et a, J Am Geriatr Soc 2012; 60:34

21 Poypharmacy in Nursing Homes Data from 57 nursing homes in 7 European countries coected between 2009 and Tota of 4,023 residents, mean age 83.5 (± 9.4) u < 5 drugs N = 1,044 (26%) u 5-9 drugs N = 2,000 (50%) u 10 drugs N = 979 (24%)

22 Reasons for Poypharmacy: Poyiness Data from 971 participants of the Women s Heath & Aging Study. Mean age = 78.3 (65-100) Number of participants in each category *

23 Other Reasons for Poypharmacy Mutipe drugs for individua conditions. More new drugs and new indications.

24 Adding Drugs to Treat Drug Side-Effects Justifiabe u u E.g., Laxatives for opioid-induced constipation. E.g., Antacid to reduce risk of gastritis during NSAID administration. Probaby not justifiabe u E.g., An anti-psychotic medicine prescribed for haucinations in patient taking ropiniroe (Requip ) for restess eg syndrome. A side-effect of Requip is haucinations. u E.g., The anti-incontinence drug, oxybutynin, prescribed for nighttime incontinence in patient taking a diuretic at bedtime.

25 And There Are Patients Who Ask for Drugs from their Doctors!

26 CONSEQUENCES OF POLYPHARMACY

27 Gossary: Non-Adherence Faiure to foow the directions for a medication (such as not taking, taking differenty from the way prescribed).

28 Non-Adherence Due To Poypharmacy Medication Safety Review Cinic Taiwan Study * u u u u 193 Taiwanese patients (mean age 76) prescribed average of 8.9 meds. Non-adherence = taking < 80% or > 120% of a medication. 34% were non-adherent with 25% of meds. Adherence worse when mutipe daiy dosing. * Tsai et a, Medication adherence among geriatric outpatients prescribed mutipe medications Am J Geriatr Pharmacother. 2012;10: 61 68

29 Non-Adherence Due To Cost % Seniors Reporting Prescription Non-Adherence 2º Cost, 2003 Adapted from: Nationa Survey of Seniors and Prescription Drugs, Heath Affairs Web Excusive 2005; W5:152

30 Poypharmacy and Fas 46,946 diabetics enroed in Kaiser Permanente Northern Caifornia Incident fas identified over 5 y of foow-up Hazard ratios (with 95% confidence intervas) for fas adjusted for patient characteristics, comorbid iness, and prior hospitaizations. Reference (not shown) = no meds. Huang et a, J Gen Intern Med 2010; 25:141 Highight = statisticay significant.

31 Poypharmacy and the Potentia for Bad Things

32 Potentia Drug-Drug Interactions Per Patient Retrospective resuts from 81,650 outpatients at a Taiwanese medica center between January and March, Incuded patients had 2+ prescriptions and had used each drug for at east 14 days. Lin et a., Poypharmacy, aging and potentia drug-drug interactions in outpatients in Taiwan. A retrospective computerized screening study. Drugs Aging 2011; 28:

33 Adverse Drug Reaction & Adverse Drug Event Have sighty different meanings in the iterature, but often used interchangeaby. Incusive definition: Harm resuting from use of the drug taken at norma doses or harm resuting from the way the drug was administered (e.g., wrong dose or omission).

34 Risk of Adverse Drug Events Pharmacokinetics Pharmacodynamics Poypharmacy (drug-drug and drugdisease interactions)

35 Consequences of ADEs and ADRs in Oder Patients An estimated 1.5 miion preventabe ADEs occur annuay in U.S. at cost of > $4 biion(institute of Medicine, 2007). Lazarou et a. 1 estimated the incidence of hospitaizations due to serious and fata ADRs in the U.S. in Tota Patients Studied Estimated incidence of ADRs 95% Confidence Interva of estimate Serious 28,017 1,317 (4.7%) 3.1%-6.2% Fata 17, (0.13%) 0.04%-0.21% 1 Lazarou et a, Incidence of adverse drug reactions in hospitaized patients. A meta-anaysis of prospective studies. JAMA 1998; 279: 1200

36 Prevaence of Unpanned Hospitaizations Caused by Adverse Drug Reactions in Oder Veterans* U.S. veterans study: 678 randomy seected unpanned admissions (out of 2.4 miion) from ; mean age = u 68 (10%) of tota admissions ADR-reated. u 25 (36.8%) of these deemed preventabe. u ADRs significanty associated with # meds: # Meds With ADR (N = 68) Without ADR (N = 610) P-Vaue (7.4%) 129 (21.1%) (33.8%) 217 (35.6%) 9 40 (58.8%) 264 (43.3%) * Marcum et a., J Am Geriatr Soc 2012; 60:34

37 APPROACHES TO POLYPHARMACY IN THE OLDER PATIENT

38 One of the first duties of the physician is to educate the masses not to take medicine. -- Sir Wiiam Oser ( ) Nihiist Approach

39 Carrie Nation Approach

40 Inteigent Design for Physician Prescribing

41 FULLY EVOLVED PRESCRIBING PARADIGM Recognizing and minimizing Potentiay Inappropriate Medications (PIMs)

42 Potentiay Inappropriate Medications (PIMs) Medications that pose more risks than benefits to oder aduts by themseves and considering avaiabiity of aternative treatments.

43 Consequences of PIMs PIMs found in 35% of oder patients admitted to a teaching hospita. Of these 35%, 33% presented with an associated ADE. 1 PIM use associated with a 43% greater risk of an ADE, compared to not taking a PIM. 2 In community-dweing edery, estimated extra cost from PIMs in U.S. in 2001 = $7.2 biion (95% CI $3.4 biion to $15.7 biion). 3 1 Gaagher P, O Mahoney, D Age Ageing 2008; 37:673 2 Lund et a., Ann Pharmacother 2010; 44:957 3 Fu et a., Med Care 2007; 45:472

44 Recognizing PIMs Impossibe to know a harmfu side-effects of every medication! Having a ist of PIMs can be a usefu too for safer prescribing. Doctors shoud have such a ist, but often don t. Patients can have one not to decide what to take, but to hep their doctors make the safest choices.

45 Toos to Identify PIMs Beers Criteria Most widey used source of PIMs. Deveoped in 1991 for SNFs. Expanded to a settings in u Updated in 2003 and PIMs identified by systematic iterature search: u 2012: 25,549 citations 2,267 2, member expert pane: u Geriatricians, Nurses, Pharmacists, Experts in research and quaity measures. Dr. Mark Beers J Am Geriatr Soc 2012; 60:616; E-pub

46 Beers Criteria, cont. Medications categorized by u u Organ system or therapeutic category Disease or syndrome

47 Bottom Line: A PIM Too Can Ony Hep If It s Handy Artices aren t very portabe. u 2012 Beers Criteria 16 pages ong Beers Criteria now avaiabe as part of igeriatrics for iphone and ipad.

48 2012 Beers Criteria Pocket Guide

49 Questions to Ask the Doctor Who Is Prescribing for the Edery MULTIPURPOSE: Can a singe drug safey treat more than one condition or symptom? Does the drug increase the risk of COGNITIVE IMPAIRMENT? u u u New cognitive impairment or confusion Worsened dementia Deirium on top of dementia

50 Does the Drug Increase the Risk of Cognitive Impairment? Antichoinergic drugs that act on the brain u u u Be cautious of: 1st-generation anti-histamines (e.g., diphenhydramine, chorpheniramine, triproidine, hydroxyzine, mecizine used in aergy meds, cod remedies, anti-itch meds, anti-dizziness meds). 2 nd generation better and avaiabe without prescription (e.g., Caritin [oratidine], Zyrtec [cetirizine]) Be cautious of: anti-nausea meds (e.g., scopaamine, dramamine, Compazine, Phenergan) No safer anti-nausea med avaiabe without prescription. Be cautious of: 1st-generation drugs for urinary incontinence (e.g., Ditropan [oxybutynin], toterodine [Detro]) Safer: Enabex (darifenacin), Vesicare (soifenacin)

51 Does the Drug Increase Risk of Cognitive Impairment, cont. Benzodiazepines and reated drugs u u Be cautious of: anti-anxiety drugs (Vaium, Xanax) Be cautious of: seeping pis (e.g., Ambien, Restori, Lunesta) Narcotics (opiates and their derivatives) u Be cautious of: Opioid-containing pain medications (e.g., Vicodin, Percocet)

52 Drugs That Can Increase Risk of Fas Benzodiazepines and reated drugs (Vaium, Ativan, Xanax, Restori, Ambien) Drugs that can make patient cumsy/ataxic (e.g., Diantin) Drugs that can cause the bood pressure to fa when standing up (many bood pressure meds) Drugs that affect baance or cause dizziness (e.g., Neurontin [gabapentin], other anti-seizure meds [some of which given to contro neuropathic pain]) Any drug that causes drowsiness (e.g., diphenhydramine, Ambien, Ativan)

53 Another Reason to Avoid PIMs?

54 Take-Home Messages Poypharmacy is amost inevitabe as we age (uness you re very, very heathy). Poypharmacy increases the risks of adverse drug reactions (ADRs). Poypharmacy aso can be part of the optima treatment of medica conditions. Goa is SMART prescribing.

55 Take-Home Messages: Smart Prescribing Minimize the number of potentiay inappropriate medications (PIMs). If a PIM is recommended, are there safer aternatives? What is the potentia impact of the drug for geriatric syndromes, ike confusion, incontinence, and fas? Can the drug regimen be simpified? The Beers List is a handy reference for PIMs. u Remember: It s a guide, not a ist of never meds.

56 Hep Your Doctor Prescribe Thoughtfuy and Be a Happier Patient! THE END