TOP 5 DRUGS.. TO AVOID IN THE ELDERLY Debbie Kwan, BScPhm., MSc., FCSHP Canadian Geriatrics Society, April 20, 2013
Disclosure of Potential for Conflict of Interest: Financial Disclosure: None
Mar 26, 2013
Seniors and Polypharmacy: 63% - claims for 5 drug classes 23% - claims for 10 drug classes Ontario (2007): Cost of ADR-related emergency department visits/hospitalizations: $35 m CIHI 2009 Wu et al., Drug Saf 2012; 35(9): 769-81
Why are the elderly at risk: Age-related changes: Pharmacokinetic Pharmacodynamic Lack of guidelines: Elderly underrepresented Time to benefit
Medications and the Elderly BEERS 2012 update START/STOPP O Mahoney et al., 2010 McLeod et al., 1997
Drug-related Emergency Room visits: Common culprits Insulin Opioids Anticoagulants Digoxin Antihistamine/cold products Many are preventable Top 3? Budnitz et al., JAMA 2006 Zed et al, CMAJ 2008; 178: 1568-9
Selecting the Top 5 Q: How many prescriptions were dispensed in Canada in 2012? >550 million! Commonly used Not absolutely contraindicated Consider using LESS often Reasonable alternatives available Open dialogue
1. NSAIDS
Case 1 - Arlene 68 yr old TIA ASA 325 mg Hypertension lisinopril, hydrochlorothiazide Osteoarthritis celecoxib, naproxen (OTC) BP 175/95
NSAIDs / COX-2 inhibitors Widely available (Rx and OTC) Risks: GI bleed, peptic ulcer disease Exacerbation of: hypertension heart failure Deterioration in renal function Many adverse effects are dose related and reversible
?? High risk: NSAIDs & GI toxicity 1. Previously complicated ulcer 2. Multiple (> 2) risk factors Moderate risk (1-2 risk factors) 1. Age > 65 yr 2. High dose NSAID therapy 3. Previous history of uncomplicated ulcer 4. Concurrent use of ASA (incl. low dose), corticosteroids or anticoagulants Low risk: 1. No risk factors Lanza et al, Am J Gastroenterol 2009; 104: 728-38 H. pylori: independent and additive risk factor Ulcer prophylaxis? 1. Misoprostol ( 200 ug TID) 2. PPI
Impaired Glomerular Autoregulation NSAIDS / COX-2 inhibitors ACEI/ARB Na, BP diuretics plasma volume & renal perfusion
Alternatives for OA pain: Acetaminophen Non-pharm (weight loss, pool therapy, appropriate joint protection, aids) Minimize systemic NSAID exposure Decrease ASA: 81 mg/d Topicals: diclofenac, methylsalicylate Gastroprotection: not H2RA or diclofenac/misoprostol BID (e.g. Arthrotec ) PPI ACR 2012 guidelines
2. GLYBURIDE
Case 2 Joe 83 yr old T2 DM - AIC 8.0% Lives alone Glyburide 7.5 mg bid Metformin 500 mg bid ER x 2 -> confusion ; disruptive behavior -> hypoglycemia
Glyburide Sulfonylurea Top 100 Rank? Concerns: #65 Hypoglycemia 21% per year (UKPDS) Elderly: lack of recognition / asymptomatic consequences: falls, fractures, seizures Mechanism: Active metabolite: accumulates in renal (and hepatic) dysfunction Long duration of action (24 + hr)
CDA 2013 guidelines How low should we go? 8.0%
Safer alternatives for Joe Hypoglycemic risk Dosing Use in renal insufficiency Glimepiride Low Daily X Gliclazide Lowest Daily DPP-4 inhibitor None Daily Adjust dose ODB A1C 8% - continue Metformin alone?
3. GABAPENTIN #51
Case 3 Mildred 79 yr Chronic pain (fibromyalgia) Gabapentin 600 mg TID
Gabapentin: Indication: anticonvulsant 80% sales off-label use (e.g. neuropathic pain, migraine, mood stabilizer) Aggressive marketing Publication bias towards benefit: Published trials: 1 in 3 patients will benefit vs. Unpublished + published trials: 1 in 8 patients Harms: 1 in 8 patient s will suffer adverse event Efficacy (< 900 mg/d) vs. harm with dose N Engl J Med. 2009 Jan 8;360(2):103-6.; http://www.ti.ubc.ca/pdf/75.pdf;. http://www.pharmalot.com/2010/03/pfizer-must-pay-141m-for-neurontin-marketing/
Gabapentin 100% renal excretion (not metabolized) Adjust dose in renal impairment Side effects (> 10%) Somnolence, Fatigue, Ataxia, Dizziness Caution in patients at risk of: Cognitive impairment Balance disturbance Falls Peripheral vascular disease Elderly
Alternatives for Mildred Pregabalin better? Similar side effect profile Renal excretion Duloxetine? Non-Pharm strategies?
4. DES ES Try this instead!
Enantiomers ( Des Es ) Examples Esomeprazole (Nexium ) Escitalopram (Cipralex ) Desvenlafaxine (Pristiq ) Desloratidine (Aerius ) Are they more efficacious? Cost implications
5. DOCUSATE
Docusate #21 / Top 100!? Effectiveness in chronic constipation Implications: pill burden -> adherence, cost Choosing more appropriate laxatives opioid therapy stimulants chronic constipation - lactulose, PEG, bulk-forming Clinical Evidence: Constipation in adults
Medication Non-Adherence 50% prevalence in the elderly Adherence as # of medications Barriers: Too many pills Complex schedules Cost Intentional non-adherence Hajjar ER, Am J Ger Pharm 2007; 5(4): 345-51
Improving Medication Adherence: Multi factorial Reduce pill burden Combination products Engage in deprescribing When to taper vs. stop Simplify medication schedules (timing, tablet splitting, alternate strengths)
Objectives/Summary: Can you? 1. Recognize drugs that should be used less often in the elderly. 2. Describe the potential adverse effects that can occur as a result of using these drugs in the elderly population. 3. Prescribe safer therapeutic alternatives.
Free online resources: Drug interactions: www.medscape.com Clinical search engine: www.tripdatabase.com Drugs and the elderly: BEERS: www.americangeriatrics.org Academic detailing Dalhousie University http://cme.medicine.dal.ca/ads.htm Therapeutics Initiative UBC www.ti.ubc.ca Rx Files (selected info free): www.rxfiles.ca
THANK YOU! DEBBIE.KWAN@UHN.CA Acknowledgement: Derek Jorgenson, Pharm.D, University of Saskatchewan