Transcript Polypharmacy

Polypharmacy In
Elderly
Dr Faisal Saleh
Al Adan Hospital
MB,BCh, BAO,ABIM,FRCPC
Objective
– Define polypharmacy and ADR
– Size and burden of polypharmacyon elderly
– Unique Pharmacokinetics and pharmacodynamics of the elderly
body
– Polypharmacy and non compliance
– Medication withdrawal
Objective
– The prescribing cascade
– Drug utilization tools
– Risk Reduction strategies
– Prevention of polypharmacy: CARE strategy
Mrs H
78 yrs oldFemale
HTN , DM , MI 15 yrs ago , arthritis, GERD,bladder
irritability ,COPD
Had A visit to her local clinic with Inc SOB.
Prescribed lasix and sent home
followed her visit with sever postural dizziness.
Mrs H
Mrs H
O/E
• BP:80/40 ,P125 regular rhythm
• was severely dehydrated
Chest: bilateral wheeze andfine bibasilar crackle
• Jvp: low
• Cardiac : normal S1-S2,Systolic murmur @ Apex
• Abd: Benign
• LL: PPF, no Oedema
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Medication :
Aspirin 81mg QD
Norvasc 5mg poqday
HCTZ 25mg poQd
Digoxin 0.25mg poqday
Lactulose 10 cc poqhsprn constipation
Gavisconesyr 3 times per day prn GERD
Steroid and ventolin inhalers
3 type of Diabetic med`s
Paracetamol 325mg 2-4 tablets poprn arthritis
KCL 20mEq po bid
Oxybutanin 5mg po TDS
Simvastatin 20 mg qday
Lasix 40 mg BID recently added for increasing SOB .
Initial Lab:
Prerenal acute failure, Normal HGB, and LFT,Cardiac work up
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CXR : hyperinflated, No CHF
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Cardiogenic and septic shock were ruled out.
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Was treated with IV Fluid and oral Moxifloxacilin for 5 days.
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Improved clinical status and renal function.
Mrs H
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Medication :
Aspirin 81mg QD
Norvasc 5mg poqday
HCTZ 25mg poQd
Digoxin 0.25mg poqday
Lactulose 10 cc poqhsprn constipation
Gavisconesyr 3 times per day prn GERD
Steroid and ventolin inhalers
3 type of Diabetic med`s
Paracetamol 325mg 2-4 tablets poprn arthritis
KCL 20mEq po bid
Oxybutanin 5mg po TDS
Simvastatin 20 mg qday
Lasix 40 mg BID recently added for increasing SOB
ACE inhibitor added
Polypharmacy
“If medication related problems were ranked as a disease,
it would be the fifth leading cause of death in the US!”
Beers MH. Arch Internal Med. 2003
Definition of polypharmacy
Bushardt 2008
Challenges in prescribing in elderly
• Heterogeneous group
• Multiple co morbidity
Nearly 92% of older adults have at least one chronic condition, and 77% have at
least two
• Multiple prescription
• Altered pharmacokinetics
(drugabsorbtion,distrebution,metabolism and
elimination)
• Altered pharmacodynamics (physiological effect of
the drugs)
‫‪Growth of Geriatric around the globe‬‬
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‫اليابان‬
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‫إيطاليا‬
‫ألمانيا‬
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‫فرنسا‬
‫المملكة المتحدة‬
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‫الواليات المتحدة‬
‫الصين‬
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‫الدول النامية‬
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DRUG USE IN THE ELDERLY
12% of the population is aged 65+
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DRUG USE IN THE ELDERLY
12% of the population is aged 65+
30% of all prescription drug use is among
those aged 65+
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DRUG USE IN THE ELDERLY
12% of the population is aged
65+
30% of all prescription drug
use is among those aged 65+
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50% of all OTC drug use is
among those aged 65+
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DRUG USE IN THE ELDERLY
• Average use for persons of 65
• 2 to 6 prescription drugs
• 1 to 3.4 over-the-counter medicine
Christilles et al journal of gerontology 1992,47,137-144
• Average American spends $955/year for pharmaceuticals
• In the community population, medication-related problems cost
$177.4 billion a year.
Who is at risk?
Kaufman 2002
Prevalence of polypharmacy
• Steinman 2006
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Evaluated 196 patients taking 1,582 medications
65% of patients were taking one or more inappropriate meds
64% missing beneficial meds
42% taking inappropriate meds AND were missing beneficial
meds
– 13% had appropriate therapy!!
Prevalence of polypharmacy
• Hajjar2005
– 384 frail, elderly patients’ medication regimens evaluated at
hospital discharge
– 44% had at least one unnecessary drug
• Almost 75% of these patients were on this unneeded drug
prior to hospitalization
– 18% had 2 or more inappropriate meds
Unique pharmacokinetics
normal part of aging process
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Absorption
Distribution
Metabolism
Excretion
Unique pharmacokinetics
normal part of aging process
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Absorption :
Age-related GI and skin changes seem to be of minor clinical significance for
medication usage.
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Distribution
Metabolism
Excretion
Unique pharmacokinetics
normal part of aging process
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Absorption
Distribution:
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Decrease in Lean Body Mass and TBW
Increased percentage Body Fat
decrease plasma protein ( Albumin)
Metabolism
Excretion
Unique pharmacokinetics
normal part of aging process
• Increase in volume of distribution for lipophilic drugs, such as
sedatives that penetrate CNS.
• Hydrophilic drugs (Ethanol,Lithium,Digoxine,&acebutalol) may
have reduced VD and consequent increase in plasma
concentration.
• Protein Binding changes
Amer J Of Thersp2007 14,488-498
Unique pharmacokinetics
normal part of aging process
• Absorption
• Distribution
• Metabolism :
• some overall decline in metabolic capacity
Decreased liver mass and hepatic blood flow
• Excretion
Unique pharmacokinetics
normal part of aging process
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Absorption
Distribution
Metabolism
Excretion:
– Age-related decreased renal blood flow an GFR
iswell-established.
Pharmacodynamics and aging
• “What the Drug Does to the Body”
• Generally, lower drug doses are required to achieve
the same effect with advancing age.
• Receptor numbers, affinity, or post-receptor cellular
effects may change.
• Changes in homeostatic mechanisms can increase or
decrease drug sensitivity.
Potential hazard of Polypharmacy
• Adverse drug reaction (ADR)
Non adherence
Increase cost /morbidity / mortality
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Falls/decreased mobility
Cognitive loss/Delirium
Dehydration
Constipation
Depression
hip fractures
loss of functional capacity, poor quality of life
nursing home placement
Potential hazard of Polypharmacy
Adverse Drug Reaction (ADR):
A response to a drug that is: noxious and
Unintended ,occurs in doses normally used for the
treatment, prophylaxis, or diagnosis of disease, or the
modification of physiological function.
(WHO )
Potential hazard of Polypharmacy
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ADRsoccur as a result of
Drug-drug interactions
Drug-disease interactions
Drug-food interactions
1. Drug side effects
2. Drug toxicity
Warfarin/Aspirin
Gout/Lasix
lipitor and grapefruite
Potential hazard of polypharmacy
Estimate of as many as high as 200.000 people die of (ADR) each yr.
in united state
Simonson et al Drug& Aging 2005
In ambulatory elderly:
• 35% of experience ADRs
In nursing facilities:
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2/3 of residents experience ADRs
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1:7 require hospitalization
Up to 30% of elderly hospital admissions involve ADRs
Beers MH. Arch Internal Med. 2003
Potential hazard of polypharmacy
The most consistent risk factor for adverse drug
reactions is:
• number of drugs being taken
Risk rises exponentially as the number of drugs increases.
• 1.2% with 1 drug
• 10% with 9 drugs
• 50% with 10 drugs
Nonadherence
Big deal?
In CHF and DM patient study:
15% when the patient took 1 med
25% when taking 2-3 meds
35% when > 4 meds
Hulka et al J Chronic Dis 2006
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Patient outcomes
Poor quality of life
High rate of symptoms / risk of hospitalization
(Unnecessary) drug expense
Non compliance / Non adherence
Osterberg L, Blaschke T. NEJM. 2005; 353:
487-97.
Non compliance / Non adherence
• Strong Correlation with number of meds, rather than
age.
• The greater the number of meds, the greater the non
adherence.
• Adherence inversely proportional to frequency of
dosing
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Osterberg L, Blaschke T. NEJM. 2005; 353: 487-97.
Non compliance / Non adherence
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Elderly: 26-59% with non
adherence
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33-69% of drug-related
admissions result from non
adherence (for all patients)
OsterbergNJ, Blaschke T. NEJM. 2005
Factor contributing toPolypharmacy
• Health care provider:
• No med review with patient on regular bases/
Automatic refill
• Limited time for discussion
• Presume that patient expect meds
• Not enough/sufficient investigation of the clinical
situation
• Provider unclear, complex or incomplete instruction
about why and how to take the medication
• Lack of knowledge of geriatric clinical pharmacology
• No effort to simplify meds regimen
Factor contributing toPolypharmacy
Patient factor:
• Under / over reporting symptoms
• Underreporting meds.
• Use of multiple providers/pharmacy
• Use of others’ medications.
• The power of inertia
• Change in activities, smoking , food and fluid intake
can affect action of meds.
The prescribing Cascade
– Part of the risk of polypharmacy may be the unintentional
practice of prescribing additional drugs for the adverse effects of
other drugs.
BMJ 1997;315:1096-1099.
The prescribing Cascade
BMJ 1997;315:1096-1099.
Medication Withdrawal
• There is evidence for the benefit of reducing exposure to some
classes of medications in older people
• RCT : withdrawal of psychotropic medications in older subjects
taking, on average, 5–6.5 medications each, it was found that
there was a 76% reduction in falls over 44 weeks
Campbell et al , J. Am. Geriatr. Soc. (1999) 47 850–853
Medication Withdrawal
Another study of 333 elderly (70–84 years)
hypertensive patients found that antihypertensive
therapy could be withdrawn for up to 5 years in 20%
of subjects.
During the state of 'no treatment’ subjects had lower
total mortality risk than the matched treated group
Ekbom et al J. Intern. Med. (1994) 235 581–588.
Drug utilization review tools
• Beers’ List
• Medication Appropriateness Index
• STOPP
– Screening Tool of Older Persons’ potentially
inappropriate Prescriptions
• Hyperpharmacotherapy Assessment Tool
• START
– Screening Tool to Alert doctors to the Right
Treatment
• Assessment of Underutilization Index
• Geriatric Evaluation
Beers Drug Criteria
• Originally compiled by Dr. Mark Beers in 1991for
nursing homes
• Most recently updated in 2012
• a panel of 13 independent experts in geriatrics care
and pharmacology.
Arch Intern Med 2003;163:2716-2724.
Beers’ List
• Lists of medication considered potentially inappropriate
medications in elderly patients
1. Drugs to avoid in elderly
2. Drugs to avoid in elderly with certain disease states
3. Drugs to be used with caution in the elderly
• a guideline only
Fick 2012
Beers Drug Criteria
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Medication that should be avoided or to be used with specific dose and
duration
Beer`s Drug Criteria
• Medication to be avoided with concomitant disease
Beers Drug Criteria
potentially inappropriate medication for certain diagnosis and condition
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Medication to be avoided with concomitant disease
MEASURES TO REDUCE MEDICATION- RELATED
PROBLEMS IN ELDERLY
PATIENTS
• Health systems design
• CARE strategy
Federal Study of Adherence to Medications in the Elderly
(FAME)
• Prospective randomized trial
• June 2004 and August 2006
• Addresses medication adherence in patients aged ≥
65 years
• ≥ 4 chronic medications
• Living independently
• Men & Women
Federal Study of Adherence to Medications in the Elderly
(FAME)
• Patient education
• Regular follow-up
• Customized blister packs for administration of blood
pressure and lipid-lowering regimens
Result:
• Increased adherence over 6 months from 60% to
≥96%
• Resulted in reductions of SBP and LDL-C
The short term effect of interdisciplinary
medication review on function and cost in elderly
patient
• RCT N=140
• an average of 1.5 drugs reduction in intervention group.
• No differences in functioning were observed between
groups.
• Intervention subjects saved an average $26.92 per
month medication costs; control subjects saved $6.75
per month (P<.006).
JAGS. 2004;52:93-98.
The impact of prescribing
safety alert for elderly person in an electronic medical
record
• The objective of this study was to examine the effects of
computerized provider order entry with clinical decision support in
reducing the use of potentially contraindicated agents in elderly
persons.
• 39-month period, HMO in the north west
• The intervention was computerized warning alerts that preferred
alternative to Benzo`s& TCA in elderly persons.
Arch Intern Med 2006;166:1098-1104.
The impact of prescribing
safety alert for elderly person in an electronic medical
record
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Alert :
Arch Intern Med 2006;166:1098-1104.
The impact of prescribing
safety alert for elderly person in an electronic medical
record
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Result:
Arch Intern Med 2006;166:1098-1104.
Effectiveness of telephone counseling by a pharmacist in
reducing mortality in patient receivingPolypharmacy(RCT)
Primary outcome : mortality
Intervention: pharmacist call 10-15 min
NNT=16
BMJ 2006 ;333: 522-527
CARE : strategy to Avoid polypharmacy
Caution and Compliance
• Understand side effect profiles
• Identify risk factors for an ADR
• Consider a risk to benefit ratio
• Keep dosing simple- QD or BID
• Ask about compliance!
• Carful written medication instructions
• Discourage pill-sharing
• Tie to scheduled daily activities, meals, sleep/wake
CARE : strategy to Avoid polypharmacy
• Review Regimen Regularly
• Avoid automatic refills
• Look for other sources of medications- OTC/herbal/Vit`s
• Caution with multiple providers
• Don’t use medications to treat side effects of other meds
• What can you discontinue or substitute for safer med?
CARE : strategy to Avoid
polypharmacy
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Educate
Talk to your patient about potential ADRs
Warn them for potential side effects
Educate the family and caregiver
Ask pharmacist for help identifying interactions
Assist your patient in making and updating a medication
list- personal medical record!
Take Home Messege
• Polypharmacy is common and important
• Can present non specifically.
• There are tools like the Medication Appropriateness
Index and Beers criteria to guide prescribing in the
elderly.
• Beware of the prescribing cascade.
• Electronic Alert on medical record and pharmacist
intervention help reducing polypharmacy.
Thank you
Questions ….???