Medication Debridement: A 10 Step Approach to Polypharmacy

Medication Debridement: A 10 Step Approach to Polypharmacy Texas Health Resources Geriatrics Symposium November 3, 2018 Amit Shah, MD, FACP, AGSF Associate Dean for Faculty Affairs, Mayo Clinic School of Medicine Assistant Professor, Division of Community Internal Medicine, Mayo Clinic Shah.Amit@mayo.edu 2015 MFMER slide-1

Disclosure of Financial Relationships Amit Shah, MD Has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. 2015 MFMER slide-2

As a geriatrician: I have cured more diseases by stopping medications than by starting them (okay maybe a bit of an overstatement) 2015 MFMER slide-3

Goals: By the end of this talk you too can: Cure Parkinson s Disease Reverse Dementia Eliminate Gout Gain Your Patient s Trust and Affection Save Your Patient Money 2015 MFMER slide-4

Objectives: Describe the importance of (true) medication reconciliation in the care of the older patient with polypharmacy Identify the roles and responsibilities of each member of the interdisciplinary team in medication reconciliation. Describe a 10 step approach to reducing polypharmacy and discontinuing medications in elderly patients Name at least three medications commonly prescribed to elderly patients which can be discontinued and list some medication sparing treatments List at least three common medications where the risk benefit ratio changes markedly with aging 2015 MFMER slide-5

Disclosures and Caveats I have no conflicts of interest I am not anti-medication Underprescribing can be as much of a problem as overprescribing in the geriatric population (not the focus of this talk) There will be some discussion in this talk about off-label medications (mainly about giving offlabel medication use close scrutiny) 2015 MFMER slide-6

Wound Debridement Medication Debridement Images from http://www.worldwidewounds.com 2015 MFMER slide-7

Why is it so hard to stop a medication? Prescribing Inertia EMR/EHRs make it easy to continue things Assumption that there must be a thoughtful provider behind the prescription Not wanting to step on toes of the original prescribing provider Patient/provider worries about rocking the boat / if it ain t broke. But I ve always done fine on Valium 2015 MFMER slide-8

10 Steps for Successful Medication Debridement 2015 MFMER slide-9

1) Do I Know All of the Medications? Image credits: https://www.flickr.com/photos/dvortygirl/2661856343 CC BY-SA 2.0 Image By ParentingPatch (Own work) [CC BY-SA 3.0 via Wikimedia Commons. 2015 MFMER slide-10

1) Do I Know All of the Medications? Medication Reconciliation Obtaining an accurate medication list is challenging! (even if you are in the patient s home ) In one study, 70% of hospital discharge med rec had at least one error, with 30% of these being potentially serious Wong JD, Bajcar JM, Wong GG, Alibhai SM, Huh JH, Cesta A, Pond GR, Fernandes OA. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008 Oct;42(10):1373-9. doi: 10.1345/aph.1L190. PubMed PMID: 18780806. Photo: http://blog.nj.com/njv_editorial_page/2009/02/house_calls.html 2015 MFMER slide-11

CMS Meaningful Use Stage 2 Objective 7: Medication Reconciliation Must have >50% medication reconciliation for any transition of care (movement of a patient from one setting of care to another) https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/downloads/7_Medication_Reconciliation.pdf 2015 MFMER slide-12

Meaningful Med Rec vs. Meaningful Use Med Rec 2015 MFMER slide-13

Meaningful Med Rec vs. Meaningful Use Med Rec 2015 MFMER slide-14

Meaningful Med Rec vs. Meaningful Use Med Rec 2015 MFMER slide-15

1) Do I Know All of the Medications? Polypharmacy: Typically 4 medications Medication use in the geriatric population (age 65) ~50% on 5 medications (including OTCs) ~37% on 5 prescription medications ~12% on 10 medications Some of our patients don t have enough time in the day to take all of their medications Qato et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008 Dec 24;300(24):2867-78. doi: 10.1001/jama.2008.892. PubMed PMID: 19109115; PubMed Central PMCID: PMC2702513 2015 MFMER slide-16

Transitions of Care Things get messy and mixed up quickly! Great danger of errors during transitions of care 1 in 9 medical patients experienced an ADE during inpatient to outpatient transitions ~1/3 preventable (errors) 1 in 7 of these rated life-threatening >10 medications high risk Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K. and Bates, D. W. (2005), Adverse Drug Events Occurring Following Hospital Discharge. Journal of General Internal Medicine, 20: 317 323. doi: 10.1111/j.1525-1497.2005.30390.x 2015 MFMER slide-17

Why to care about polypharmacy? Polypharmacy increases the risk for Adverse Drug Reactions, in one study: 4% of individuals potentially at risk of having a major drug-drug interaction 10% in age group 75-84 ~50% of these involved the use of nonprescription medications >175,000 ED visits annually Anticoagulants (warfarin, NOACs, clopidogrel, etc.) Hypoglycemics (especially insulins, sulfonylureas) Digoxin (careful in doses >0.125mg daily) Qato et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008 Dec 24;300(24):2867-78. doi: 10.1001/jama.2008.892. PubMed PMID: 19109115; PubMed Central PMCID: PMC2702513. Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007 Dec 4;147(11):755-65. PubMed PMID: 18056659. 2015 MFMER slide-18

1) Do I Know All of the Medications? Only foolproof way: Make a housecall Next best alternatives: Specific orders to home health nurse for medication review (all meds in the home) Create a habit with in your patients so they bring in all of their medications Pre-visit phone calls from pharmacy technician 2015 MFMER slide-19

10 Steps for Successful Medication Debridement 1. Do I know all the medications? 2.Is this Medication Harmful? 2015 MFMER slide-20

2) Is this Medication Harmful? (necrotic tissue, has to go!) There are many published lists of medications that are potentially harmful in older patients Drugs for which there are safer alternatives Example: Avoid long-acting sulfonylureas such as chlorpropamide, glyburide, glimepiride (instead use glipizide) In one study, oral hypoglycemics accounted for 10% of hospitalizations for ADEs in older patients Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011 Nov 24;365(21):2002-12. doi: 10.1056/NEJMsa1103053. PubMed PMID: 22111719. 2015 MFMER slide-21

The Beers List Formally: The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Original List published in 1991 Updated in 1997, 2003, 2012, and 10/8/2015 2018 update coming soon! Dr. Mark Beers 1954-2009 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702. PubMed PMID: 26446832. 2015 MFMER slide-22

American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Based on expert review of primary literature: Drugs to Avoid/ Think twice about (not a blacklist!) Drug-Disease/Drug-Syndrome (e.g. CHF and TZDs or dementia and anticholinergics) Drug-Drug interactions (common in older persons) Common drugs to avoid or reduce dose with renal insufficiency (e.g. colchicine) 2015 MFMER slide-23

STOPP / START (Ireland/UK) (more explicit than Beer s Criteria) STOPP: Screening Tool of Older Person s Prescriptions (80 of these) PIMs: potentially inappropriate medications START: Screening Tool to Alert doctors to the Right Treatment (30 of these) PPOs: potential prescribing omissions SENATOR (Software ENgine for the Assessment and optimization of drug and nondrug Therapy in Older persons) O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015 Mar;44(2):213-8. doi: 10.1093/ageing/afu145. Epub 2014 Oct 16. PubMed PMID: 25324330; PubMed Central PMCID: PMC4339726. 2015 MFMER slide-24

How do you actually stop things (and get patients to do it? Algorithms for stopping: PPI Sulfnoylurea Antipsychotic Benzodiazepene receptor agonist (e.g. Ambien) Cholenesterase/Memantine Pamphelts Infographics Patient guides Tapering guidelines! https://www.deprescribingnetwork.ca/ 2015 MFMER slide-25

10 Steps for Successful Medication Debridement 1. Do I know all the medications? 2. Is this Medication Harmful? 3.Is This Drug Indicated? 2015 MFMER slide-26

3) Is This Drug Indicated? Beware of off-label prescribing ~20% of all prescribing! Higher in with psychiatric drugs (~40%) An example: gabapentin (Neurontin) If there is a nerve involved, think Neurontin At that time, the largest fine in FDA history: $430 million (Pfizer/Warner-Lambert) >90% off label prescribing Side effects: dizziness, drowsiness, and loss of balance or coordination (especially at effective/therapeutic doses) Radley DC, Finkelstein SN, Stafford RS. Off-label prescribing among office-based physicians. Arch Intern Med. 2006 May 8;166(9):1021-6. PubMed PMID: 16682577. 2015 MFMER slide-27

10 Steps for Successful Medication Debridement 1. Do I know all the medications? 2. Is this Medication Harmful? 3. Is This Drug Indicated? 4.Has This Drug Outlived its Utility? 2015 MFMER slide-28

4) Has This Drug Outlived its Utility? Jumping Cactus (Jumping Cholla) 2015 MFMER slide-29

4) Has This Drug Outlived its Utility? Proton Pump Inhibitors continued posthospitalization Antidepressant medications continued indefinitely without a trial of discontinuation 2015 MFMER slide-30

10 Steps for Successful Medication Debridement 1. Do I know all the medications? 2. Is this Medication Harmful? 3. Is This Drug Indicated? 4. Has This Drug Outlived its Utility? 5.Do the side effects outweigh the potential benefits of this drug? 2015 MFMER slide-31

5) Do the side effects outweigh the potential benefits of this drug? Avoid prescribing drugs with highly statistically significant, but clinically meaningless results 2015 MFMER slide-32

5) Do the side effects outweigh the potential benefits of this drug? e.g. Anticholinergics for urge urinary incontinence From the package insert for VESIcare (solifenacin): 1.3 fewer micturitions per 24 hours (2.4 vs. 1.7 less) 0.7 fewer incontinent episodes per 24 hours (1.8 vs. 1.1) (mean incontinent episodes on treatment=~1/day) ~20-30 ml more urine voided p <0.001 for all of these 23% more dry mouth; ~11% more constipation 3% blurry vision, 2% more UTIs COST: >$300/month!!! 2015 MFMER slide-33

5) Do the side effects outweigh the potential benefits of this drug? Cholinesterase Inhibitors such as Aricept (donepezil) Improve on the ADAS-cog by ~3 points But the scale is 0-70 points 0.8 points on the MMSE (30 points) The drug does not affect the underlying course of disease ; no decline in institutionalization or progression of disability at 3 years GI side effects in 20% Bradycardia with increased in rate of syncope hospitalization by 3.2/100 patient-years New onset urinary incontinence and increased risk of anticholinergic bladder medication (1.55 times higher) Gill SS, Mamdani M, Naglie G, Streiner DL, Bronskill SE, Kopp A, Shulman KI, Lee PE, Rochon PA. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med. 2005 Apr 11;165(7):808-13. PubMed PMID: 15824303. 2015 MFMER slide-34

Aricept 23mg vs 10mg Severe Impairment Battery (0-100) Cost: >$300/month (vs. as low as $8/month generic 10mg tablets) 2015 MFMER slide-35

10 Steps for Successful Medication Debridement 1. Do I know all the medications? 2. Is this Medication Harmful? 3. Is This Drug Indicated? 4. Has This Drug Outlived its Utility? 5. Do the side effects outweigh the potential benefits of this drug? 6.Are there any drug-drug or drug-disease interactions? 2015 MFMER slide-36

6) Are there any drug-drug or drug-disease interactions? Impossible to remember all of the drug-drug reactions Beware of click-through and alert fatigue Utilize Epocrates Multicheck or Medscape interaction checker or similar apps 2015 MFMER slide-37

6) Are there any drug-drug or drug-disease interactions? Drug-Disease interactions Anticholinergic medications in a patient with BPH (benign prostatic hyperplasia) Thiazolidinediones (TZDs) in patients with comorbid congestive heart failure 2015 MFMER slide-38

10 Steps for Successful Medication Debridement 6. Are there any drug-drug or drug-disease interactions? 7.What about the over-thecounter and supplements/herbal medications? 2015 MFMER slide-39

7) What about the over-the-counter and supplements/herbal medications? Any interactions? Calcium supplements decrease absorption of: Levothyroxine Fluoroquinolone antibiotics Tetracycline antibiotics 2015 MFMER slide-40

10 Steps for Successful Medication Debridement 6. Are there any drug-drug or drug-disease interactions? 7. What about the over-the-counter and supplements/herbal medications? 8.Is this drug being used to treat the side effects of another drug? 2015 MFMER slide-41

8) Is this drug being used to treat the side effects of another drug? Prescribing Cascade Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ : British Medical Journal. 1997;315(7115):1096-1099. Figure adapted from: https://dundeemedstudentnotes.wordpress.com/2014/08/26/prescribing-in-older-people/ 2015 MFMER slide-42

8) Is this drug being used to treat the side effects of another drug? Thiazide Diuretics Allopurinol for Gout ~2 times the risk for HCTZ dose 25mg When I cured Parkinson s Disease Patient with nausea/vomiting and Diabetes Metoclopramide 10mg QID scheduled started Parkinsonian features neurologist levodopa treatment with Sinemet ~3-5 times more likely to be started on levodopa in a study of NJ Medicaid patients Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ : British Medical Journal. 1997;315(7115):1096-1099. 2015 MFMER slide-43

10 Steps for Successful Medication Debridement 6. Are there any drug-drug or drug-disease interactions? 7. What about the over-the-counter and supplements/herbal medications? 8. Is this drug being used to treat the side effects of another drug? 9.Is there a non-pharmacologic approach I can try instead of a drug? 2015 MFMER slide-44

9) Is there a non-pharmacologic approach I can try instead of a drug? Urinary Incontinence Kegel/pelvic floor strengthening Exercises Scheduled Voiding Sleep problems Counseling about the normal changes in sleep with aging Sleep Hygiene Relaxation techniques Addressing the underlying issue (e.g. pain) 2015 MFMER slide-45

10 Steps for Successful Medication Debridement 6. Are there any drug-drug or drug-disease interactions? 7. What about the over-the-counter and supplements/herbal medications? 8. Is this drug being used to treat the side effects of another drug? 9. Is there a non-pharmacologic approach I can try instead of a drug? 10.Will my patient live long enough to gain potential benefit from the drug? 2015 MFMER slide-46

10) Will my patient live long enough to gain potential benefit from the drug? 102 year old put on statin for primary prevention Risk/Benefit in the old-old? Bisphosphonates in patients >85 years old Prognostication is difficult: 2015 MFMER slide-47

10 Steps for Successful Medication Debridement 1. Do I know all the medications? 2. Is this medication harmful? 3. Is this drug indicated? 4. Has this drug outlived its utility? 5. Do the side effects outweigh the potential benefits? 6. Any drug-drug or drug-disease interactions? 2015 MFMER slide-48

10 Steps for Successful Medication Debridement 7. What about the over-the-counter and supplements/herbal medications? 8. Is this drug being used to treat the side effects of another drug? 9. Is there a non-pharmacologic approach I can try instead of a drug? 10.Will my patient live long enough to gain potential benefit from the drug? 2015 MFMER slide-49

Let s Do Meaningful Medication Reconciliation, which means debriding that medication list! 2015 MFMER slide-50

Thank You! Questions/Discussion 2015 MFMER slide-51