Objectives 10 DRUGS TO STOP GIVING HOSPICE PATIENTS Richard E. Allen MD, MPH Hospice Medical Director Family Medicine Residency Director Salt Lake City, Utah 2 Recognize 10 commonly prescribed medications with little or no benefit in hospice patients Use evidence and finesse to negotiate with patients and caregivers Apply hospice principles of comfort care and dignity in treating patients Case Ruby 1- Warfarin 3 82 debility: weight loss, bedridden, pneumonia, 6/6 ADLs A-fib, GERD, dementia, hypertension, recurrent UTI Rx warfarin, omeprazole, simvastatin, donepezil, nitrofurantoin, tylenol, baby aspirin, vitamins 4 Anticoagulant through Vit K inhibition Atrial fibrillation Thromboembolism (DVT, PE) Valvular heart disease Protime (International Normalized Ratio, INR) 1- Warfarin Warfarin discontinuation 5 Stroke risk on Rx 2% Stroke risk off Rx 4% CHA 2 DS 2 -VASc score Age>75, female, hypertension = 4 points Bleeding risk on Rx 8.4% HEMORR2HAGES index Age>75, hypertension, fall risk= 3 points Major bleed risk (intracranial, GI) increase with aspirin, nsaids, elderly 6 Comfort care principles Dignity in death Complications of monitoring Risk > benefit Too many pills 1
7 2- Statins Inhibit HMG-CoA reductase in cholesterol synthesis Widespread use for preventive and secondary treatment 8 Cholesterol in older adults Plateau after age 50 J-shaped curve cholesterol : death Increased adverse effects Cost of treatment and monitoring Clinical trials are long term (6 years) Association with memory loss? Patients with a limited life span from a concomitant illness are probably not candidates for drug therapy 9 Case Violet 66 lung cancer: cachexia, cough, oxygen, PPS 60% CAD with stent 4 years ago Osteoporosis, hypothyroidism Rx clopidogrel, aspirin, levothyroxine, alendronate, metoprolol, furosemide, lorazepam, atorvastatin, inhalers 10 3- Clopidogrel Anti-platelet therapy Dual antiplatelet therapy (DAPT) with aspirin Post-stent treatment 1-6 months Stable CAD treatment? Stroke prevention? 11 3- Clopidogrel CHARISMA trial 15,000 patients no CAD benefit Doubled GI bleeding with ASA MATCH trial 7500 patients Risk > benefit Stent studies 1-month benefit with metal, 6- month with eluting CAPRIE 19,000 patients NNT 200 over 2 years to prevent 1 stroke 12 Clopidogrel cost Plavix $100-200/month Aspirin cost $11,000 per year of life gained Plavix cost $130,000 per year of life gained 2
13 4- Furosemide Diuresis for fluid overload/retention Loop of Henle 14 4- Furosemide Increase norepinephrine, renin, vasopressin Chronic use resistance, blunted vasodilation Decrease renal blood flow, Cr Orthostasis, electrolyte abnormalities Indications: acute decompensated heart failure, clinical symptomatic fluid overload 15 Case EmmaLou 96 dementia: FAST 7C, PPS 20% Memory-care unit for years Osteoporosis, hypothyroidism, distant history coronary artery disease, diabetes Rx aspirin, levothyroxine, ibandronate, glyburide, memantine, risperidone 16 5- Bisphosphonates Osteoporosis treatment 50% decrease in fracture at 36 months 3-5 years = 10 years protection drug holiday 3-5 years Hypercalcemia tratment 17 5- Bisphosphonates Must be taken fasting with 8 oz. water Must remain standing or upright 30 minutes Not recommended for Cr clearance <35 ml/min 3-5 years = 10 years protection Long-term medication, studies 3-5 years esophagitis 18 6- Cholinesterase inhibitors Treatment of mild to moderate Alzheimers Questionable use in severe dementia Some effect seen in other dementias and brain syndromes Effect is clinically marginal 0.1 SDs on ADL scales 0.09 SDs on instrumental ADL (IADL) scales 3
6- donepezil (dementia treatment) 7- Sulfonylureas 19 20 Diabetes treatment Pancreatic beta-cell secretion of insulin Commonly used well beyond effective time A1c goals < 7% for fit patients with 10-year life expectancy 7 7.9% for patients with cardiovascular disease 8% for frail elderly and/or multiple co-morbidities 21 Hypoglycemia Increased in elderly Short- and long-term cognitive impairment Delirium, weakness, dizziness 22 Case Harold 86 COPD Hypoxia, cachexia Dysphagia, history esophageal stricture Rx multivitamin, fish oil, B12 shot, Vit C, Calcium, Vit D, ramipril, amlodopine, clonidine, atorvastatin, omeprazole, allopurinol, montelukast, mirtazapine, buproprion, lorazepam, 3 inhalers 23 pills per day 23 8- Vitamins 24 9- Anti-hypertensves Trial Subjects Mean age Mean BP Duration SHEP 4376 72 170/77 5 years Syst-Eur 4695 70 174/86 4 years MRC 3496 72 185/91 5.8 years HYVET 3845 84 173/91 2 years 4
9- Anti-hypertensves 10- Antidepressants 25 To treat Target 150/80? Symptoms?? or not to treat Orthostasis falls Fatigue Renal insufficiency Cough Edema 26 Beers list 2012 STOPP screening tool of older persons potentially inappropriate prescriptions START screening tool to alert doctors to right treatment 10- Antidepressants 10 Drugs to Stop on Hospice patients 27 Antipsychotics (> 1 month) Most common potentially inappropriate type of medication used in nursing homes Double risk of death Benzodiazepines Increased confusion and fall risk Selective serotonin reuptake inhibitors Increased fall risk (odds ratio = 1.72) even more than tricyclic antidepressants (odds ratio = 1.51) 28 Warfarin Statins Clopidogrel Furosemide Bisphosphonates Donepezil Sulfonylureas Vitamins Anti-hypertensives Anti-depressants 29 References Gage BF et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151(3):713. Agarwal S et al. Current trial-associated outcomes with warfarin in prevention of stroke in patients with nonvalvular atrial fibrillation: a meta-analysis. Arch Intern Med. 2012;172(8):623. Evans MA. Statin-associated adverse cognitive effects: survey results from 171 patients. Pharmacotherapy. 2009;29(7):800-811. Corti MC et al. Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Intern Med. 1997;126(10):753 Bhatt DL et al CHARISMA Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354(16):1706 Diener HC et al MATCH investigators. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364(9431):331. 30 References CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348(9038):1329 Grinstead WC et al. Discontinuation of chronic diuretic therapy in stable congestive heart failure secondary to coronary artery disease or to idiopathic dilated cardiomyopathy. Am J Cardiol. 1994;73(12):881 Black DM et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. 1996;348(9041):1535 Courtney C et al, AD2000 Collaborative Group. Long-term donepezil treatment in 565 patients with Alzheimer's disease (AD2000): randomised double-blind trial. Lancet. 2004;363(9427):2105. Raina P et al. Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a clinical practice guideline. Ann Intern Med. 2008;148(5):379. 5
References 31 Gerstein HC et al. Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545. Whitmer RA et al. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA. 2009;301(15):1565 Odden MC et al. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty. Arch Intern Med. 2012;172(15):1162. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631. 6