Polypharmacy and Polymorbid Patients: Practical Tips and Tricks November 2, 2013
Faculty/Presenter Disclosure Faculty: Chris Fan-Lun, BScPhm, ACPR, CGP Pharmacist - Geriatric Medicine Clinical Practice Leader - Dept. of Pharmacy Services,Mount Sinai Hospital Relationships with commercial interests: I have NO actual or potential conflicts of interest in relation to this program
Objectives Highlight common polypharmacy issues in patients with multimorbidity Review the physiologic changes of aging and pharmacological basis for these concerns Provide practical tips to address polypharmacy in polymorbid patients
Polypharmacy in the Elderly Polypharmacy means "many drugs 5 or more drugs The use of more medication than is clinically indicated or warranted
Barnett K et al. Lancet 2012; 380 (9836):37 43.
Polypharmacy Consequences Adverse Drug Reactions Nonadherence Drug costs Poor quality of life, outcomes Magaziner J et al. J Aging Health. 1989;1:470-484. Espino DV et al. J Gerontol A Biol Sci Med Sci. 2006;61:170-175.
Percentage of seniors with polypharmacy, by number of chronic conditions and age group Reason B et al. Fam Pract 2012;29(4):427-432.
Percentage of seniors who experienced a side effect requiring medical attention within the past 12 months, by number of prescription medications Reason B et al. Fam Pract 2012;29(4):427-432.
Canadian Impact Seniors with three or more reported chronic conditions accounted for 40% of reported health care use among seniors, even though they comprised only 24% of all seniors Seniors who reported 3chronic conditions were taking an average of 6 Rx meds, twice as many medications as seniors with only 1 chronic condition Seniors taking a high number of prescription medications were at a greater risk of experiencing side effects requiring medical attention, yet fewer than half of seniors with chronic conditions reported having medication reviews Seniors and the Health Care System: What Is the Impact of Multiple Chronic Conditions?. CIHI 2011
Adverse Drug Effects & Prescribing Cascade Drug 1 ADE interpreted as new medical condition Drug 2 ADE interpreted as new medical condition Drug 3 Rochon PA, Gurwitz JH. BMJ 1997;315:1097.
Case: Ms Dale 84 yo woman widowed, living alone severe knee pain limiting mobility 3 falls in last 6 months memory problems PMHx A Fib HTN OA
Case: Ms Dale EC ASA 81 mg daily Ibuprofen 400 mg bid GRAVOL 50 mg qhs Zopiclone 3.75 mg qhs Warfarin as directed Amlodipine 10 mg daily Perindopril 4 mg daily Furosemide 40 mg bid Metoprolol 50mg bid Slow-K 16 meq daily Atorvastatin 40 mg daily Dextromethophan syrup Pantoprazole 40 mg daily Solifenacin 5 mg daily Vitamin B12 1 mg daily Glucosamine 1 cap tid
Ms Dale s Prescribing Cascades ibuprofen perindopril amlodipine ASA dextromethorphan furosemide potassium dimenhydrinate pantoprazole solifenacin Vitamin B12 zopiclone Prescribing Web Allegory Barb Farrell, Pharmacist, Bruyere Geriatric Day Hospital
10 yrs ago Dx Afib- metoprolol & warfarin Widowed- zopiclone 5 yrs ago Knee pain - ibuprofen HTN - perindopril Cough - DM HTN - Amlodipine ASA neighbour said she should take it 1 yr ago Ankle swelling - furosemide Hypokalemia - potassium Nausea - dimenhydrinate; pantoprazole Low Vit B12 - Vit B12 supplement Nocturia - solifenacin Prescribing Web Allegory Barb Farrell, Pharmacist, Bruyere Geriatric Day Hospital
Polypharmacy Risk Factors Age Multimorbidity Acute hospitalization Health care visits Multiple providers Hajjar ER, Am J Geriatr Pharmacother. 2007;5(4):345-51 Betteridge TM, et al. Int Med J 2012;42(2):208-11. Jorgensen T et al. Ann Pharmacother. 2001;35:1004-1009.
Contributing Factors: Age-Related Physiological Changes Drug absorption YOUNG Faster ELDERLY Slower/ decreased Metabolism Faster Slower Excretion Faster Slower Fat : lean body mass Total body water
Contributing Factors:CPGs Guidelines = standardise, reduce unacceptable variation to improve quality of care Treating diseases in isolation burdensome and potentially inappropriate treatment Barnett K et al. Lancet 2012; 380 (9836):37 43.
Contributing Factors:CPGs A hypothetical case elderly woman with COPD, DM II, OP, HTN, and OA If all CPGs are followed 12 medications, costing $406 (US)/month Undesirable effects, drug-disease and drug-drug interactions Limited applicability to elderly with multimorbidity and medications May have sections for special populations Frail elderly and >80yo underrepresented in CPGs and clinical trials Boyd CM et al. JAMA. 2005;294(6):716-24. Cox L. CFP 2011;57(7):e263 e269. Lugtenberg M et al. PLoS One 2011;6:e25987
CPGs and the elderly Age + Polymorbidity + CPGs = Lots of medications
Screening and Assessment Tools
START & STOPP STOPP Screening Tool of Older Person s Prescriptions inappropriate combinations of medicines and disease START Screening Tool to Alert doctors to Right Treatment a set of recommended treatments for given conditions Gallagher P, O'Mahony D. Age and Ageing 2008;37:673-9. Barry PJ, Gallagher P, Ryan C, O'Mahony D. Age and Ageing 2007;36:632-8.
Avoiding Polypharmacy Pitfalls 1. Obtain accurate history 2. Link medications to disease state 3. Identify prescribing cascade 4. Initiate interventions to ensure adherence 5. Reconcile medications upon discharge from acute care or rehabilitation facility 6. Medication review
Reducing Drug-Related Iatrogenesis in the Elderly Start low, go slow Limit medication changes Avoid high risk meds Understand the pharmacokinetics and pharmacodynamics of drugs prescribed renal/hepatic dosing as needed Early recognition of problems as med side effect
Stopping Medications Medication streamlining Deprescribing Pharmaceutical debridement Drugectomy Rocking the Boat
How to Stop? Reduce or stop one medication at a time Start with medications where there is: Risk of harm with no known benefit Little chance drug withdrawal Unclear or no indication Indication but unknown or minimal benefit Benefit but side effect or safety issues
Deprescribing: Monitoring Hardy JE, Hilmer SN. J Pharm Pract Res 2011;41:146-51
Summary Decreasing medication use in elderly can: Adverse events (eg falls, hospitalization) Pill burden and costs Adherence with remaining medications QOL Team approach Take one step at a time Review medications regularly Develop a plan for rationale prescribing/deprescribing
Question 1 Which of the following age-related changes has implications on drug distribution and duration of action? a) Increased hepatic drug metabolism b) Increased percentage of body fat c) Increased amount of total body water d) All of the above
Question 2 An 84 yo woman began showing symptoms of memory problems and was referred to a neurologist. She was diagnosed w/ Alzheimer s disease and initiated on donepezil. Six weeks later, the patient made an appointment with her primary physician to ask for an overactive bladder medicine that she saw advertised on TV. She was then prescribed darifenacin. This may be a case of: a) Drug interaction b) Adverse drug event c) Prescribing cascade d) Geriatric syndrome
Question 3 Which of the following drugs can be stopped without tapering a) Citalopram b) Docusate c) Bisoprolol d) Lorazepam