Medication Assessment and Quality Parameters. Norma J. Owens, PharmD, FCCP Professor of Pharmacy University of Rhode Island

Transcription

1 Medication Assessment and Quality Parameters Norma J. Owens, PharmD, FCCP Professor of Pharmacy University of Rhode Island

2 Financial Disclosure None of the planners, speakers, and/or members of the CME committee have any relevant financial relationships to disclose

3 Disclosures RIGEC is fully supported by the US Department of Health and Human Services, Health Resources and Services Administration through Grant #U1QHP Geriatric Workforce Enhancement Program. There is no commercial support associated with this CE activity. This educational activity does not include any content that relates to the products and/or services of a commercial interest that would create a conflict of interest.

4 Continuing Education Credit Continuing Education Credit is available for: Medicine (1.0 contact hour) Nursing (1.0 contact hour) Social Work (1.0 contact hour) Pharmacy (1.0 contact hour) Please complete the survey at the end of the presentation in order to receive continuing education credit. See special instructions for CE, CME and CPE credits at the end of this presentation.

5 Goals and objectives today Review the three most common tools for assessing medication regimens 2015 Beer s Criteria STOPP START Medication Assessment Instrument (MAI) Discuss how various groups use medication measures as a quality measure Apply the Beer s measures to a patient case

6 Introduction Medications can be used to treat and cure disease To treat symptoms of chronic disease To treat or manage complications of chronic disease Older people are prescribed multiple medications and also frequently take over-the-counter and dietary supplements Medications are frequently beneficial for the management of chronic diseases

7 Introduction, continued Drug-related problems occur frequently in older people May be related to changes in pharmacokinetics and or pharmacodynamics Sub-optimal medication use Too much Too little Wrong medication Adverse drug events Undesirable health outcomes associated with drug therapy Inappropriate medication use

8 Inappropriate Medications In 1991, Mark Beers MD developed a set of criteria designating certain medications as potentially inappropriate using consensus criteria Since that time, the Beers list of potentially inappropriate medications have been updated 3 times Some of the original inappropriate medications have been listed as high risk medications in the elderly and are included in the NCQA HEDIS measures For instance, potentially harmful drug-disease interactions for fall include benzodiazepines, z drug hypnotics, etc.

9 A Brief History 1991 medications to avoid in frail long-term care residents 2003 added medication classes to be avoided for efficacy reasons and certain medications to be avoided in elders with certain medical conditions 2012 evidence based 2015 evidence based, added new sections on renal elimination, drug-drug interactions and oral anticoagulants (JAGS 2015;63: )

10 Inappropriate Medications It s important to always emphasize that these medications are potentially inappropriate Use of the Beer s potentially inappropriate medications as a drug screen, or as a measure of quality, is common because it s easy to identify the presence or absence of these medications in various computerized pharmacy data bases, particularly claims data bases This is controversial because it s difficult to assess patient-specific information that may warrant the use of a potentially inappropriate medication Best approached as a starting point for improving patient safety

11 Beer s Potentially Inappropriate Medications On the next several slides, I will review the most recent Beer s list of potentially inappropriate medications highlighting the recent changes We have included a pdf file of the pocket guideline for this list One of the benefits to going through and thinking about the Beer s list is that you learn a lot about the advantages and disadvantages of some commonly used medications There is a companion article published with the 2015 Beer s list that suggests appropriate alternative medications to use. (JAGS 2015 Dec 63(12):e8-e18)

12 Beer s Criteria Table 1. Therapeutic Category of Drug Anticholinergics Older antihistamines Hydroxyzine Meclizine Promethazine Anti-Infectives nitrofurantoin Recommendation Avoid Highly anticholinergic and needing good renal function associated with an increase in confusion, etc. Quality Evidence is moderate, SR is strong Avoid in those with cr clearance <30 ml/min due to an increase in side effects. Quality Evidence is low, SR is strong

13 Anticholinergic effects Medications that block cholinergic receptors (usually muscarinic) deplete acetylcholine in the brain and nervous system This depletion leads to profound effects that include confusion, memory loss, blurry vision, urinary retention, dry mouth, constipation, etc. Think: Dry as a bone, red as a beet, blind as a bat, and mad as a hatter

14 Beer s Criteria Table 1. Therapeutic Category of Drug Cardiovascular α-1 blockers (prazosin, terazosin, doxazosin) digoxin CNS Benzodiazepines Recommendation Avoid use as an antihypertensive High risk of orthostatic hypotension Quality Evidence is moderate, SR is strong Avoid as 1 st line therapy for a. fib or CHF. If used for a. fib, avoid doses > mg daily QE strong, SR strong Avoid due to increased sensitivity leading to falls, cog impairment, delirium QE moderate, SR strong

15 Beer s Criteria Table 2. Potentially Inappropriate due to drug disease interactions Cardiovascular CNS Condition and Medication Heart failure - NSAIDS Syncope Cholinesterase Inhibitors (such as donepezil) Delirium all anticholinergics Recommendation Avoid due to fluid retention Quality Evidence is moderate, SR is strong Avoid Increased risk of OH and bradycardia QE moderate, SR weak Avoid due to increased likelihood of confusion QE moderate, SR strong

16 Beer s Criteria Table 2. Potentially Inappropriate due to drug disease interactions Condition and Medication CNS Parkinson s disease typical antipsychotics Gastrointestinal H/O gastric or duodenal ulcers NSAIDS and aspirin > 325 mg/d Recommendation Avoid will worsen Parkinsonism symptoms QE moderate, SR strong Avoid will worsen gastric symptoms unless gastroprotective agents are also used QE moderate, SR strong

17 Beer s Criteria Table 3. Potentially Inappropriate Drugs to be Used with Caution Medication Aspirin for primary prevention Dabigatran Carbamazepine, mirtazapine, SSRIs, SNRIs,. Recommendation Use with caution for those >80 years due to less evidence of benefit vs risk. QE low, SR strong Use with caution in those >75 years and with cr cl < 30 ml/min, QE moderate, SR strong Use with caution, may cause SIADH or hyponatremia, monitor sodium levels QE moderate, ST strong

18 Beer s Criteria Table 4. Clinically important drug-drug interactions (excluding antiinfectives) Medication ACEIs with amiloride or triamterene Anticholinergics with anticholinergics Benzodiazepines with 2 CNS active drugs Lithium with ACEIs Recommendation Increase risk of hyperkalemia QE moderate, SR strong Minimize the number of anticholinergic medications due to increased confusion/cog imp QE moderate, SR strong Minimize the number of CNS drugs due to an increase in falls. QE high, SR strong Increased risk of lithium toxicity QE moderate, SR strong

19 Apixaban Rivaroxaban Beer s Criteria Table 5. Clinically important renally eliminated medications (excluding anti-infectives) Medication Recommendation Avoid with cr cl < 25 ml/min; increase in bleeding Avoid with cr cl < 30; reduce dose with cr cl ml/min Edoxaban Avoid with cr cl < 30; reduce the dose cr cl Enoxaparin Reduce the dose with cr cl < 30 Gapapentin Reduce the dose with cr cl < 60 levetiracetam Reduce the dose with cr cl < 80 tramadol Reduce the dose with cr cl < 30; avoid extended release formulation

20 Conclusions about the Beer s Criteria In general, we should avoid using Beer s medications in frail older patients However, data that evaluates the medication related causes that lead hospitalization show that other, more commonly prescribed medications, are linked to hospitalizations. Study conducted over two years using a national drug surveillance system Identified over 5,000 cases representing 100,000 hospital admissions 2/3 rd were unintended over-dosages Nearly half occurred in patients over 80 years of age

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22 STOPP/START STOPP: Screening Tool of Older Persons Prescriptions START: Screening Tool to Alert to Right Treatment

23 STOPP/START Criteria version 1 (2008) Created by European panel of experts to address limitations of 2003 Beers Criteria Highlights Potentially Inappropriate Medications (PIMs) that should be stopped Prevents Potential Prescribing Omissions (PPOs) by including medications that may need to be started

24 Version 1 (continued) Screening tool shown to significantly improve appropriateness of inpatient medications Reduces adverse drug events (ARR 9.3%) when used within 72 hours of admission Reduces average length of stay by three days for older adults hospitalized for acute illness High inter-rater reliability between physicians and between pharmacists

25 STOPP/START Criteria version 2 (2014) Panel reviewed 2008 version to add new evidence-based information and remove recommendations that are no longer relevant Version 2 has total of 80 STOPP criteria and 34 START criteria (31% increase) Current STOPP includes antiplatelet/anticoagulants, medications affected by renal impairment, medications that increase anticholinergic burden Current START includes urogenital medications, analgesics, immunizations

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27 START continued

28 START continued

29 Summary STOPP/START Criteria can be used to identify potential inappropriate medications that should be stopped and medications that may be missing for older adults. Use of the criteria may result in a reduction in medication-related adverse events and length of inpatient stay. The criteria may change over time due to availability of new medications and discovery of increased adverse events in older adults associated with currently approved medications.

30 Brand Generic Dosing Indication Toprol-XL metoprolol succinate 50MG ER 1 tab daily CHF/HTN Aspir-Low aspirin 81MG DR 1 tab daily Secondary prevention Lipitor atorvastatin 20MG 1 tab daily ASCVD Celexa citalopram 30MG 1 tab daily MDD Diovan valsartan 160MG 1 tab daily CHF/HTN Xarelto rivaroxaban 20MG 1 tab daily with dinner Atrial fibrillation Zeasorb topical powder Antivert miconazole meclizine 12.5MG Apply once daily to groin, underarms, & feet 1 tab oral three times a day PRN (last fill 7/25/16) Tinea pedis, cruris Dizziness Mylanta Aluminum hydroxide/magnesium hydroxide/simethicon e oral suspension 2 tablespoons (30 ml) three times a day PRN (last fill 5/3/16) Indigestion/Reflux

31 Beer s Criteria medications: Medication Recommendation Justification PPT comments Citalopram (SSRI) Use with caution May exacerbate or cause SIADH or hyponatremia Last sodium on 3/30/16 was within normal limits; continue to monitor Avoid in history of falls or fracture May cause ataxia, psychomotor dysfunction, syncope May trial dose reduction to 10 mg daily and monitor GDS Meclizine Avoid in elderly Potential for anticholinergic adverse effects risk of confusion, dry mouth, constipation Rivaroxaban Reduce dose if CrCl ml/min Avoid CrCl < 30 ml/min PPT only using as needed and not filled recently Increased risk of bleeding PPT s estimated CrCl is > 90 ml/min; continue to monitor SCr/renal function.

32 Medication Appropriateness Index A methodical evaluation of each drug in a patient s medication list Indication? Effectiveness? Dose Correct directions Drug-drug interactions Drug disease interactions al? Practical directions? Duplication of therapy? Duration of therapy? Cost?

33 Brand Generic Dosing Indication Toprol-XL metoprolol succinate 50MG ER 1 tab daily CHF/HTN Aspir-Low aspirin 81MG DR 1 tab daily Secondary prevention Lipitor atorvastatin 20MG 1 tab daily ASCVD Celexa citalopram 30MG 1 tab daily MDD Diovan valsartan 160MG 1 tab daily CHF/HTN Xarelto rivaroxaban 20MG 1 tab daily with dinner Atrial fibrillation Zeasorb topical powder Antivert miconazole meclizine 12.5MG Apply once daily to groin, underarms, & feet 1 tab oral three times a day PRN (last fill 7/25/16) Tinea pedis, cruris Dizziness Mylanta Aluminum hydroxide/magnesium hydroxide/simethicon e oral suspension 2 tablespoons (30 ml) three times a day PRN (last fill 5/3/16) Indigestion/Reflux

34 MAI Toprol-XL, metoprolol succinate 50MG ER, 1 tab daily, CHF/HTN Is there a diagnosis yes, CHF Is this medication effective for the dx yes; using the succinate form Is the dose/directions correct yes Drug-drug interactions probably not, always look up Drug disease interactions probably not,?bradycardia Duplication no, should be used with an ACEI/ARB in chronic CHF Duration appropriate life long therapy Cost yes, appropriate

35 Advantages/Disadvantages Beer s yes no scoring ability; used by government agencies as quality indicator; doesn t really assess a patient s complete medication list STOPP/START similar to Beer s with suggestions to use medications for common diagnoses that are c/w current practice; still doesn t really assess a patient s complete medication list MAI more complete, time consuming, requires a fair amount of knowledge about drugs, includes cost, helps train your mind to systematically evaluate an entire regimen; drug focused

36 Conclusions There are 3 recognized methods of medication assessment Each have their distinct advantages and disadvantages Always be mindful that, even if there are no Beer s drugs in a patient s medication regimen, Mistakes and errors can still happen Adverse drug events can still happen Must always continue to carefully monitor every patient

37 Geriatric Education Series Series aims to enhance geriatric competencies of healthcare providers and professionals serving older populations, particularly those with complex care needs, and includes five, topic-focused courses offered annually. 1. Palliative Care and Hospice Currently available on line 2. Optimal Pharmacotherapy Currently available on line 3. Standing Together To Stop Falls Coming soon! 4. Cognitive Dysfunction June/July Mental, Social and Behavioral Health August/September 2017 For more information:

38 Reminders After you close out of this webinar, please complete the evaluation by going to the link on the next slide in order to receive continuing education credit. For Pharmacy (CPE) information, please Faith Helm at for the CPE code and instructions for completing a separate program evaluation and reporting CPE data in the URI CPD evaluation system for pharmacists. RIGEC will nursing and social work certificates on Mondays. Healthcentric Advisors will CME certificates on Mondays. For questions about CME certificates, please Susan Midwood at smidwood@healthcentricadvisors.org Thank you!!

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