MEDICARE CARE DELIVERY Polypharmacy and Deprescribing in Older Adults Oregon Geriatrics Society October 9, 2016 Arthur Hayward, MD, MBA Internist and Geriatrician, Kaiser Permanente Northwest Session Objectives 1. Identify examples of polypharmacy 2. Recognize the particular risks of polypharmacy in the elderly 3. Apply deprescribing algorithms 2 October 10, 2016 1
Case Histories 1. 45 yo on opioids for chronic pancreatitis reports his wife died unexpectedly. 2. 80 yo retired math teacher with dementia has become a zombie after entering a nursing home. 3. 74 yo diabetic in ED for falls has HGBA1C of 6%. 4. Wife says her 79 yo mate won t take all his medicines. 3 October 10, 2016 MEDICARE CARE DELIVERY Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs. The desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures. William Osler, 1849-1919 2
Brief History of Polypharmacy Drugs perform miracles Drugs are widely prescribed Drugs are too widely prescribed Harms result Deprescribing reduces polypharmacy 5 October 10, 2016 Outline 1. Signs of polypharmacy 2. Altered risk/benefit in older adults 3. Solution: Deprescribe? 4. Signs of the deprescribing era 5. Benefits of deprescribing 6 October 10, 2016 3
1. Signs of polypharmacy Reflex prescribing Pharmaceutical hype Increased volume, costs, ADEs Backlash 7 October 10, 2016 Reflex Prescribing Failure to consider alternatives Misapplying guidelines Mistaking ADEs for new conditions Huseyin Naci, John P A Ioannidis. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5577 8 October 10, 2016 4
Non-pharma treatment alternatives For A. Not B. But Back pain NSAIDs Cold and hot compresses Insomnia Zolpidem Sleep hygiene Urinary urgency Ditropan Pelvic floor exercises Depression SSRI s Cognitive behavioral Rx Dementia behaviors Antipsychotics Environmental change Anxiety Benzo s Stress reduction activity Adapted from KP Colorado Clinical Practice Guideline Polypharmacy in the Elderly Statin use in adults older than 79 August 24, 2015. doi:10.1001/jamainternmed.2015.4302 10 October 10, 2016 5
The Drug Cascade A vicious Drug-ADE Cycle Start here Hip pain Hip fracture Fall Ibuprofen HTN Orthostasis HCTZ Terazosin Oxybutynin Urinary Retention Rochon P, GurwitzJ. Optimising drug treatment for elderly people: the prescribing cascade. BMJ, 1997; 315:1096-9 6
Pharmaceutical hype Product promotion Choice of product Narcotic epidemic Who is responsible for the pain pill epidemic? in The New Yorker 11/8/2013. 13 October 10, 2016 Inducements 14 October 10, 2011 Kaiser Foundation Health Plan, 7
From: Pharmaceutical Industry Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries Target branded drugs as a percentage of all filled prescriptions in the drug class. JAMA Intern Med. 2016;176(8):1114-10. doi:10.1001/jamainternmed.2016.2765 Date of download: 8/2/2016 Copyright 2016 American Medical Association. All rights reserved. Opioid (over)use 16 October 10, 2016 8
Narcotic drugs more lethal than autos New York Times, December 18, 2015 Pharma Promotion of Opioid Use Opioids have been aggressively and misleadingly marketed to physicians 1 Federal bodies and state medical boards received funds to promote pain relief 2 Experts with pharma connections have rallied to criticize CDC proposed guidelines 3 1 Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health 2009;99:221-227 2 Who is responsible for the pain pill epidemic? in The New Yorker 11/8/2013. 3 AP wire services 1/31/2016 report on Interagency Pain Research Coordinating Committee 18 October 10, 2016 9
CDC assessment of opioid use Deaths from prescription drug overdose have quadrupled since 2000. Opioids can worsen pain and functioning. Risks increase with dose increases. Use of heroin and illicitly produced Fentanyl has increased. CDC recommends non-pharmacologic approaches. CDC Guideline with comment NEJM March 15, 2016 DOI: 10.1056/NEJMp1515917 CDC guideline for prescribing opioids for chronic pain United States, 2016. MMWR Recomm Rep 2016;65(RR-1:1-49 19 October 10, 2016 Volume Increased numbers of prescriptions (4 B/y) Increased ADEs Increased drug costs ($259B) ($329.1B) IMS Health Inc. data cited by Henry Kaiser Family Foundation Drugmakers article. Wall Street Journal. Oct 3, 2016 20 October 10, 2016 10
% of US adults reporting use of any and of > 5 drugs per day during preceding 30 days by age NHANES data reported by Kantor, E, et al. JAMA November 3, 2015 Volume 314, Number 17 21 October 10, 2011 Kaiser Foundation Health Plan, National Social Life, Health and Aging Project Changes in Use of Drugs, OTCs, and Supplements 2005 to 2011 Findings: Use of any med 84.1 87.7% Use of >/= 5 meds 30.6 35.8% Use of dietary supplements 51.8 63.7% Risk of potential major drug-drug interaction 8.4 15.1% Data from the National Social Life, Health and Aging Project. College of Pharmacy, U of Chicago. JAMA Intern Med. doi:10.1001/jamainternmed.2015.8581 Published online March 21, 2016. 22 October 10, 2011 Kaiser Foundation Health Plan, 11
10/10/2016 Robin Hood Profiteering The New Yorker January 4, 2016 How does epinephrine become a $1B drug? Sunday Business Section New York Times September 4, 2016 Heather Bresch, Chief Executive, Mylan Pharmaceuticals 24 October 10, 2016 2011 Kaiser Foundation Health Plan, Inc. For internal use only. 12
The Other Drug Problem The Oregonian LIVING HEALTH Friday, Sept. 9, 2016 25 October 10, 2016 Signs of polypharmacy Consumer mistrust and backlash 26 October 10, 2016 13
2. Risk/Benefit increases in adults >/= 65 Changes in metabolism and pharmacokinetics/dynamics More conditions/ more guidelines/ more prescribers More side effects 1 / drug cascade to treat side effects Less time to benefit Expense of polypharmacy (estimated ~ $50B/y in US) 2 Multiple meds: inconvenience, burden, misery 1. Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014;10:CD008165. 2. CMMS estimate cited in Lyles A, Culver N, Ivester J, Potter T. effects of health literacy and polypharmacy on medication adherence. Consult Pharm. 2013;28:793-799. 27 October 10, 2016 3. Solution: Deprescribe? Deprescribingis the process of tapering or stopping drugs, aimed at minimizing polypharmacyand improving patient outcomes. 1 Pharmacists play a leading role. Deprescribing algorithms exist 1,2,3 --Ian Scott, et al, Brisbane, Australia 1. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324 Published online March 23, 2015. 2. Garfinkle. Arch Intern Med. 2010;170(18):1648-1654. 3. Frankenthal, et al. (STOPP/START) J Am Geriatr Soc 62:1658 1665, 2014. 28 October 10, 2016 14
Barriers to Deprescribing Survey results of PCPs: Lack of knowledge (39% not aware tight glucose control harms older adults) Fear of bad report card (42%) Fear of legal liability (25%) Not enough time to discuss (30%) JAMA Intern Med. 2015;175(12):1994-1996. doi:10.1001/jamainternmed.2015.5950 LESS IS MORE Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults Garfinkel D, Mangin D Arch Intern Med. 2010;170(18):1648-1654 Protocol- indicated stop of 311 meds in 64 of 70 patients included Result Failure (re-started for original indication) 2% Success (consented and not re-started) 81% Compared to matched cohort Global improvement in health 88% Mortality benefit 14% 15
Improving drug therapy in elderly patients--the Good Palliative-Geriatric Practice algorithm Garfinkel D, Mangin D. Arch Intern Med 2010;170:1648-1654. 31 October 10, 2016 Deprescribing simplified 1. Stop Drugs that are unnecessary Duplicates 2. Shift Safer for riskier Less costly alternative Non-drug treatment 3. Simplify Dosing schedule Substitute one drug for two 32 October 10, 2016 16
Simplified Geriatric Dosing From The New Yorker, November, 2015 33 October 10, 2016 2011 Kaiser Foundation Health Plan, Inc. For internal use only. Med Reconciliation and Polypharmacy Omissions OTCs/ Herbals Side Effects Duplication Correct Dose Cost Effective Renal Dose Adjustments Med Rec Drugs to Avoid in the Elderly Drug-Drug Interactions Is drug still appropriate? Correct Directions Unclear Orders Drug-Disease Interactions Indication Adherence Hajjar ER, Calfiero AC, Hanlon JT. Polypharmacy in Elderly Patients. Am J of Geriatric Pharmacother 2007; 5(4); 345-51 Kaiser Permanente 2010-2011. All Rights Reserved. 34 October 10, 2016 17
Inside KP Inside KP KPCO publishes polypharmacy intranet page KPGA addresses too-low HGBA1C and non-benzo sedatives KPNW s med rec aims to reduce polypharmacy DUM (Drug Utilization Management) program reverses trend in opioid prescribing MTM (Medication Therapy Management) stops unnecessary meds 35 October 10, 2016 MTM and Comprehensive Medication Review at KP Associated with - Lowered mortality - Less hospitalization Rita L. Hui, PharmD, MS; Brian D. Yamada, PharmD; Michele M. Spence, PhD; Erwin W. Jeong, PharmD; and James Chan, PharmD, PhD. Impact of a Medicare MTM Program: Evaluating Clinical and Economic Outcomes. Am J Manag Care. 2014;20(2):e43-e51 18
4. Signs of the deprescribing era Beers list, Choosing Wisely, Direct-to-consumer media efforts More published medical literature, algorithms CMMS incentives A cultural shift O Mahony D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44:213-218. JethaS. Polypharmacy, the Elderly, and Deprescribing. The Consultant Pharmacist. September, 2015;30(9):527-32. 37 October 10, 2016 2015 Beers List Criteria Update 1991 Criteria originated by Mark Beers 2011 AGS (Am Geriatrics Society) charged with review and updates 2015 Revision 1 Alternatives proposed 2 Serious Drug-Drug interactions itemized Drugs requiring renal failure dosing are listed Shifts in emphasis result from literature review 1 DOI: 10.1111/jgs.13702 JAGS, October 2015 2 DOI: 10.1111/jgs.13807 38 October 10, 2016 19
Polypharmacy in preventive cardiology 1 Problem: Millions on CVD drugs* though proof of benefit lacking. Short-term study results are extrapolated over decades. Results from young-old subjects are extrapolated to old-old. We have scant evidence on outcomes of drug withdrawals. Modern clinical practice differs from that when trials were conducted.. Projections of benefits assume hazards are constant over time. Old-old adults may prefer different outcomes. * Aspirin, beta-blockers, statins, ACE inhibitors How long should these drugs be continued? 1 J Am Coll Cardiol 2015;66:1273 85. 39 October 10, 2016 5. Benefits of Deprescribing Simplify care Reduce ADEs Reduce hospitalization Improve adherence Reduce costs Save lives 40 October 10, 2016 20
Declining opioid use in KP 12/13 to 6/15 Case History Discussion 1. 45 yo on opioids for chronic pancreatitis reports unexpected death of his spouse. 2. 80 yo retired math teacher with dementia becomes a zombie after entering a NH. 3. 74 yo female diabetic in ED for falls has HGBA1C of 6%. 4. Wife says her 79 yo won t take all his medicines. 42 October 10, 2016 21
Bibliography InsidePatientCare.com Empowering Community Pharmacists as Health Consultants: Polypharmacyby Rebecca J. Mahan, PHARMD, CGP Brisbane, et al. Reducing Inappropriate Polypharmacy. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324 Tjia, et al. Use of Medications of Questionable Benefit JAMA Intern Med. 2014;174(11):1763-1771. doi:10.1001/ jamainternmed.2014.4103 GarfinkleD, ManginD. Feasibility of a systemic approach Arch Intern Med. 2010;170(18):1648-1654 BMJ 2012:345:e6617 Overtreatment Is the USA s problem ours too? BMJ 2012;345:e668 Overtreamentover here. Lam MP1, Cheung BM. The use of STOPP/START criteria as a screening tool for assessing the appropriateness of medications in the elderly population. Expert Rev Clin Pharmacol2012;5:187 197. (STOPP/START criteria) PL Detail-Document, STARTingand STOPPingMedications in the Elderly. Pharmacist s Letter/Prescriber s Letter. September 2011. (STOPP/START criteria) Frankenthal, et al. Intervention with the Screening Tool of Older Persons Potentially Inappropriate Prescriptions/Screening Tool to Alert Doctors to Right Treatment Criteria in Elderly Residents of a Chronic Geriatric Facility: A Randomized Clinical Trial. J Am Geriatr Soc 62:1658 1665, 2014. Grounder, Celiine. Who is responsible for the pain-pill epidemic? The New Yorker, November 8, 2013. MoonenJ et al. Effect of Discontinuing JAMA Intern Med. doi:10.1001/jamainternmed.2015.4103 Published online August 24, 2015. OddenMC. (Editorial) JAMA Intern Med. Published online August 24, 2015. doi:10.1001/jamainternmed.2015.4309 2015 Beers Criteria Update: DOI: 10.1111/jgs.13702 and alternatives: DOI: 10.1111/jgs.13807 Jetha S. Polypharmacy, the Elderly, and Deprescribing. The Consultant Pharmacist. September, 2015;30(9):527-32. RochonP, GurwitzJ. Optimisingdrug treatment for elderly people: the prescribing cascade. BMJ, 1997; 315:1096-9 QatoDM, et al. Changes in Prescription and Over-the-Counter Medication 2005 2011. JAMA Intern Med. Published online March 21, 2016. doi:10.1001/jamainternmed.2015.8581 BemdenMN.Deprescribing: An Application to Medication Management in Older Adults. Pharmacotherapy 2016;36(7):774 780) doi: 10.1002/phar.1776 Tools and collaborators http://www.medstopper.com http://www.open-pharmacy-research.ca/research-projects/emerging-services/deprescribing-guidelines https://clm.kp.org/wps/portal/cl/co/result?url=/pkc/co/cpg/cpg/polypharmacy.html&category=geriatrics&doctype=guideli nes&sdtype=clinical&location=adultcare&memberage=adult%20care&cntname=polypharmacy%20in%20the%20elderly How to deprescribe (1) ascertain all drugs the patient is currently taking and the reasons for each one (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribingintervention (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324 22