BLCS 1-Clinical Overview Dr. Chris Rauscher Clinical Lead Shared Care Polypharmacy Risk Reduction Initiative
Fraser Health Guide To Person-Centered Medication Decisions
Factors to Consider When Systematically Reviewing Medications Goals of Care Co-Morbidities, Disease Trajectory, Functional Status, Quality of Life Stats on Benefit and Harm- Event Rates, % and NNT for Benefit, % and NNT for Harm As May Apply to: Drug Initiation Drug Maintenance Drug Discontinuation Adverse Drug Effects Remaining Life Expectancy - Time Until Benefit/Time to Lose Benefit Treatment (Management) Targets 3
RC Med Reviews Opportunities Occasions for Full RC Medication Reviews Scheduled Med Reviews regular, but effective? When first admitted or during admissions process Transitions e.g. from Acute/ED, Special Care Unit Goals of Care (MOST +) Review of standing orders e.g. Gravol 50mg Occasions for Focused RC Medication Reviews Addressing Polypharmacy in the Elderly Episode of decline symptom-directed, e.g. fall, delirium Request by staff e.g. behaviour, med concerns, etc Request by resident/family education opportunity
Medication Review- Evidence of Benefit Case-control study over 1 year, mod-severe demented Israeli facility residents on ~ 7 drugs* (Garfinkel) 2.8 drugs/patient stopped Only 18% drugs / 10% patients had the stopped meds restarted over a year Decr mortality (21 vs 45%) NNT 4.1 Decr acute care transf (12 vs 30%) NNT 5.5 This is when average stay is ~ 1 yr! * IMAJ 2009;9:430-434
So, if common side effects of most medications include. Fatigue, weakness, muscle aches Anorexia, nausea, bloating, cramps, constipation, diarrhea Dizziness, postural instability Headaches 6
Accumulation of minor side effects leads to feeling 7
Tools You Decide sheets www.thennt.com Medstopper (http://medstopper.com) Med review template (Rosenberg) 8
You Decide Sheets On web site (http://www.sharedcarebc.ca/initiatives/polypharmacy): PPIs Statins Antipsychotics In preparation: Antihypertensive medications Osteoporosis medications Depression meds with dementia -?Hypnotics
Potential Adverse Consequences of Medications with Anticholinergic Properties Can t see Can t pee Can t spit Can t sh Can t stand Can t think 11
Using Statistics For Decision-Making Event rates NNT/NNH % benefit and harm 12
13 Statins-You Decide
Statins for Primary Prevention in >65 year olds over 3.5 years Placebo Statin Risk Difference NNT MI 3.9% 2.7% 1.2% 84 Stroke 2.8% 2.1% 0.7% 143 1.2% avoided an MI 0.7% avoided a stroke ~98% had no benefit from the statins they took
Benefits of statin for primary prevention of MI 100 90 80 % who have an MI 70 60 50 40 30 94.1% do not have MI regardless of tx 20 3.9% 10 1.2% do not have MI- due to tx 2.7% 0 Placebo Statin 2.7% have MI regardless of tx
Medstopper: www.medstopper.com 17
May improve symptoms? pain, insomnia, depression May reduce future illness? blood pressure, glucose, lipids May cause harm? relative harm Beers/ STOPP Criteria SUGGESTED TAPER APPROACH If used daily for more than 3-4 weeks. Reduce dose by 50% every 1 to 2 weeks. Once at 25% of the original dose and no withdrawal symptoms have been seen, stop the drug. If any withdrawal symptoms occur, go back to approximately 75% of the previously tolerated dose. WHAT TO WATCH FOR chest pain, pounding heart, heart rate, blood pressure (re-measure for up to 6 months), anxiety, tremor
Deprescribing Network Algorithms Antipsychotics PPIs Benzos Antihyperglycemics https://www.deprescribingnetwork.ca/algorithms http://www.open-pharmacy-research.ca/evidence-based-ppideprescribing-algorithm/
Set the Context in GOC - Symptoms, Function Health Care CG burden Focus on Clinical Issues/Symptoms Agents/Factors (Adapted from Template of Dr. Actions Ted Rosenberg, Victoria, BC) Monitoring Plan/Impact of Change (Adapted from Template of Dr. Ted Rosenberg,
EDNA-GOC Outcomes- Symptoms, Function Health Care CG burden Focus on Clinical Issues/Symptoms Orthostatic Hypotension Agents/Factors Actions Monitoring Plan/Impact of Change AC=Oxybutynin*, Fluoxetine + BP Meds Fall Above meds + Temazepam Reduced mobility Constipation Mild memory loss Simvastatin, Omeprazole, Alendronate Calcium*, AC- Oxybutynin, Fluoxetine CNS (Fluoxetine, Temazepam) + AC drugs: Oxybytinin, Metorpolol STOP-Oxybutynin, HCT TAPER to D/C- Metoprolol (AC), Fluvoxetine +REDUCE- Temazepam STOP- Simvastatin, Alendronate Taper to D/C- Omeprazole STOP-Calcium, Oxybutynin Taper to D/C- Fluoxetine CNS meds and, Metoprolol, Oxybutynin as above No orthostatic BP drop Feels more stable No falls Moving around better Constipation resolved Feels clearer Drug-Drug Interaction Drug cascade Prevention Ibuprofen and BP med Lactulose Aspirin STOP- Ibuprofen REVIEW-Lactulose STOP-Aspirin ---------------------------- ONLY DRUGS LEFT: Vit D, ENALAPRIL, ACETAMINOPHEN, Monitor arthritis pain (Template developed by Dr. Ted Rosenberg, Victoria, BC)
Resources and Links Shared Care Polypharmacy Risk Reduction http://www.sharedcarebc.ca/initiatives/polypharmacy http://www.sharedcarebc.ca/initiatives/polypharmacy/clinical% 20Support Thennt.com Medstopper: http://medstopper.com Anticholinergic Cognitive Burden Scale: www.agingbraincare.org https://www.deprescribingnetwork.ca/algorithms
91 Y.O. WOMAN-MODERATE DEMENTIA: Drug Medications Indications Oxazepam 30mg - Insomnia Galantamine 16mg Dementia Risperidone 0.5mg BID Agitation/Aggression/Paranoia Citalopram 20mg Depression, irritability Felodipine 10mg HTN HCTZ 25mg TN Atorvastatin 20mg Hyperlipidemia (no IHD/CVA) Ecasa-81mg od Primary Prevention stroke and MI Metformin 1000mg BID DM Allopurinol 300mg Gouty arthritis Alendronate, Ca, Vit. D Osteoporosis Other Clinical findings BP -124/64 sitting and 106/60 standing HGB -104 ;Ferritin 30 A1C 5.5 GFR 54 Reconciliation Problems Identified at the Review - Dementia MMSE 11; Functional Review - Engages with family and will speak with some paraphrasia - will do a.m. care with standby - Toilets self - Can find and walk to common area and dining room - Still feeds self Behaviour no reported problems, some anxiety at pill time - Unsteady, Forgets to use walker - Anorexia, Poor intake, Weight loss 5 lbs. - Constipation - Edema - +3 with some stasis dermatitis - Caregiver Stress - husband and daughters exhausted Goals of Care: QofL, maintain function, control symptoms, not survival, expected life expectancy <2 years
GOC Outcomes- Symptoms, Function Health Care CG burden Used with permission from Dr. Ted Rosenberg, Victoria, BC Focus on Clinical Issues/Symptoms Agents/Factors Actions Monitoring Plan/Impact of Change Fall, Orthostatic BP BP meds, CNS meds Stop (taper): Felodipine, HCT; Stop: Naproxen Reduce: Citalopram 10mg OD, Respiridone 0.25mg OD, Oxazepam 7.5mg Edema BP meds Stop (taper): Felodipine, HCT Anorexia, Nausea, Swallowing, Anemia Calcium, Alendronate, Atorvastatin, ASA, Metformin, Allopurinol, Galantamine Stop: Ca, Alendronate, Atorvastatin, ASA Reduce: Metformin, Allopurinol Galantamine re-started Add Fe Gluc. BP: 146/72 Balance better, no falls Mood stable Sleeping OK Edema +1 Appetite and weight up Hb 136 Constipation Calcium Stop Calcium Less laxative Reduced GFR Naproxen Allopurinol Stop Naproxen Reduce Allopurinol Inc. GFR Pill Burden All meds As above Reduced pill burden