dr. bill dalziel chief ottawa regional geriatric program polypharmacy

Dr. Bill Dalziel

Chief

Ottawa Regional Geriatric Program

POLYPHARMACY

Question 1

Approximately how much was spent on prescription drugs in Canada in 2003? (total health care costs approximately $110B)

1. $ 5 B (4.5%)

2. $ 8 B (7.3%)

3. $11 B (10%)

4. $15 B (13.6%)

5. $22 B (20%)

10-15% of hospital admissions of the elderly are due to ADRs: Adverse Drug Reactions.

Consequences of ADR

30% of hospital admissions linked to ADR in US ( Hanlon et al. JAGS 1997)

After discharge from TOH, 23% had at least one ADR ( Forster et al. CMAJ 2004)

ADR in the older person linked to depression, constipation, falls, immobility, confusion, and hip fractures… (Bootman et al. AIM 1997)

Question 2

What is the biggest reason why the elderly are at such high risk for ADRs (Adverse Drug Reactions)

1. Polysymptomatology breeding polypharmacy.

2. Homeostenosis.3. Pharmacokinetics. Pharmacodynamics. 4. All those pharmacology lectures in

medical school (sic!).5. Pharmaceutical companies: research

and marketing.

Drugs and The Older PersonStatistics

30% of prescription drug use 40% of non prescription drug use Average use of 4.5 medications

(community) Average use of 9.1 medications

(hospitalized)

Question 3

How much does the creatinine clearance decrease as someone ages from 50 to 80? (even though serum creatinine may not change).

1. 5%2. 15%3. 25%4. 35%5. 45%

Calculation of Creatinine Clearance

Cockcroft / Gault Equation

Crcl= (140 - AGE) x wt (kgm) x 1.23 (x .085 for women)

Serum Creatinine

Changing age from 50 to 80 decreases Crcl by 1/3!

The 10 Do’s and Don’ts

1. Think of every drug prescribed as a clinical trial with N=1.

The 10 Do’s and Don’ts

2. Always think of drugs as the diagnosis of any new symptom.

Drugs - PrescriptionDrugs - OTC/OTF

Drugs - AlcoholDrugs - Herbal

Question 4

The elderly (65+) are 12% of the Canadian population; what % of OTC drugs do they consume?

1. 10%

2. 20%

3. 30%

4. 40%

5. 50%

Over the Counter Medications in the Elderly

• The elderly consume 40% of all OTC.

Top 5AcetaminophenMultivitamins

ASAAluminum Hydroxide

Cough and Cold

Seniors perceive as “safe”, usually don’t tell their doctor about use.

• Toxicity and drug interaction problems.

The 10 Do’s and Don’ts

3. The only rule you learned about the elderly and drugs in medical school, “START LOW GO SLOW” was only ½ correct.

The 10 Do’s and Don’ts

You need to push/titrate the dosage up until:

1. Therapeutic goals are met.

2. Side effects.

3. You have your maximum comfortable dosage.

? How many drugs do you need (pharmacopia) to take care of 90% of your elderly patient’s prescription needs?

1. 10

2. 25

3. 50

4. 75

5. 100

Question 5

The Geriatric Pharmacopoiea

1. Thyroid (2) 2. Tylenol (4) 3. Estrogen (12) 4. COX 2 NSAID

(10,16) 5. PPI (7, 16) 6. ECASA (5) 7. Statin (1) 8. SSRI (8, 9, 14) 9. CCB (19)

10. Antibiotic (broad spectrum)

11. Coumadin 12. ACEI (3, 6) 13. HCTZ (15) 14. Lasix (11) 15. Cholinesterase

Inhibitors 16. Bisphosphonates 17. Atypical Neuroleptic

18. Benzodiazepine (18, 20)

19. Sinemet 20. Oral Hypoglycemic 21. Insulin 22. Morphine 23. Prednisone 24. MOM/Lactulose 25. Respiratory

inhalers (13) (x) = ranking in Canada 2003

Others: Nitates / NTG, Digoxin, Iron/Vitamin B12/Vitamin D/Calcium, Dilantin

The 10 Do’s and Don’ts

4. You only need a small PHARMACOPOEIA. (25)

The 10 Do’s and Don’ts

5. Regularly review drug regimens and risk reducing drugs regularly.

VA Study 74% of selected drugs d/cd

successful.

(? Why do we worry more about stopping drugs than starting drugs?)

6. Avoid the bandwagon of new drugs unless researched in the elderly or extensively used elsewhere. Ask your drug reps about trials and clinical experience involving elderly subjects.

The 10 Do’s and Don’ts

The 10 Do’s and Don’ts

7. KNOWLEDGE is YOUR RESPONSIBILITY.

Trials in the elderly.Absolute/Relative CI.Major and minor adverse effects.Drug/drug and drug/disease interactions.Starting/usual/maximum dosages.Cost.

The 10 Do’s and Don’ts

8. IF YOU’RE GOING TO PRACTISE POLYPHARMACY AT LEAST MAKE IT

EVIDENCE BASED POLYPHARMACY.

OR

“How do you extrapolate research trials to 85 years old patients?

Question 6

In the EBM (evidence based medicine) world, usual RCTs do not include patients over 75. How can you extrapolate from these results to your 85 year old patients in terms of RRR (relative risk reduction) and ARR (absolute risk reduction). Generally with increasing age above 65…

1. RRR decreases, ARR decreases (NNT increases)

2. RRR decreases, ARR stays the same (NNT stays the same)

3. RRR stays the same, ARR increases (NNT decreases)

4. RRR stays the same, ARR stays the same (NNT stays the same)

5. RRR increases, ARR increases (NNT decreases)

In RCTs with Increasing age:

Relative Risk Reduction (RRR) generally remains the same

Absolute risk reduction (ARR) increases

NNT decreases

Question 7

What is your chance of having a patient in which an adverse drug significantly contributed to mortality? Which is true?

Canada (Annual Deaths related to ADR)

Physician Risk

1. 1,000 1 patient per 60 years

2. 5,000 1 patient per 12 years

3. 10,000 1 patient per 6 years

4. 30,000 1 patient per 2 years

5. 200,000 3.3 patients per year

The 10 Do’s and Don’ts

9. The sword is DOUBLE EDGED!Canadian Estimate: 200,000 serious ADRs/year

10,000 deaths/year

But also under-medication.

Question 8

What % of patients on antihypertensives are significantly non-compliant within 1 year of initiating therapy?

1. 10%2. 20%3. 33%4. 50%5. 75%

The 10 Do’s and Don’ts

10. Noncompliance is a HUGE ISSUE (75% antihypertensives at 1 year).KISSNon-childproof containers.Clear, large labels.Patient explanation/education.Pharmacists -- total pharmaceutical care.

The Top 10 Drugs to Use Less

1. Conventional NSAIDS. GI bleeds use without prodromal c/o Na/H2O retention CR. K BP

The Top 10 Drugs to Use Less

2. Benzodiazepines. Falls, falls, falls First time anxiety in the elderly is not

a benzodiazepine deficiency syndrome.

Alternatives for insomnia. R/O causes Non pharmacologic Trazadone (25-50 mgm)

Question 9

What is the rate of tardive dyskinesia within 3 years of starting therapy with conventional neuroleptics in elderly patients (65 +).

1. 5%

2. 25%

3. 40%

4. 70%

5. 100%

The Top 10 Drugs to Use Less

3. Conventional Neuroleptics. 70% Tardive Dyskinesia (3 year) EPS Oversedation 18% efficacy above placebo

40 vs 58%

The Top 10 Drugs to Use Less

4. Beta Blockers. Less effective than HCTZ in BP Useful post MI Very useful in CHF

(NY II – IV ( EF)(Start lower, go slower).

The Top 10 Drugs to Use Less

5. Glyburide– More hypoglycemia.– 16.6 / 1000 patient years

Question 10

How much $ is spent in Canada per year on colace a drug with ABSOLUTELY NO laxative properties?

1. $1 million2. $5 million3. $25 million4. $50 million5. $150 million

The Top 10 Drugs to Use Less

6. Colace/Irritant Laxatives.

Colace is not a laxative but we spend in Canada $50M/yearly

Sennosides ok short term but risk of cathartic colon long term.

7. Elavil/Amitriptyline

Very anticholinergic Other alternatives in chronic

pain – nortryptaline and desipramine.

SSRIs

The Top 10 Drugs to Use Less

The Top 10 Drugs to Use Less

8. Anticholinergic Drugs.

Central = delirium/dementia Peripheral = retention,

constipation.

9. Talwin, Demerol, p.o.

Ineffective, toxic.

The Top 10 Drugs to Use Less

10. Serc/gravol.

Ineffective, toxic.

The Top 10 Drugs to Use Less

The Top 10 Drugs to Use More

1. COX 2 NSAIDS.

Only better than conventional NSAIDs in major GI events.

Cardiovascular toxicity concern.

The Top 10 Drugs to Use More

2. Drugs to treat depression:• SSRI (Celexa), Effexor XR and TCA with low anticholinergic properties (desipramine,’nortryptaline).• > 2 year maintenance

SSRIs have side effects: GI Parkinson’s Anxiety SIADH Seizures Discontinuation syndrome.

The Top 10 Drugs to Use More

3. Drugs to treat dementia: ACHEI(Aricept, Exelon, Reminyl). Standard of care = trial. ¼ super responder. ½ mild responder. ¼ non responder (switch).

(9 weeks of holidays for caregiver)

NNT < 10

Question 11

With respect to Coumadin for atrial fibrillation and the concerns about falls in the elderly, how many falls per year do you need to = the risk of not anticoagulating?

1. 22. 53. 104. 1005. 300

The Top 10 Drugs to Use More

4. Coumadin (for atrial fibrillation). 68% RRR vs 21% ASA. INR must be over 2.0 (2.5). 295 falls/year.

The Top 10 Drugs to Use More

5. Drugs to treat hypertension, especially systolic: (diuretics, CCB/ACEI)/ARB.

CVA, CVS, dementiaSystolic 165 = diastolic 105 Goal = 140/90 (add ASA) Small doses triple Rx

The Top 10 Drugs to Use More

6. Drugs to treat osteoporosis: (calcium, vitamin D, bisphosphonates), raloxifene.

2002 CPG CMAJ Nov. 12/02 All 65 DXA screening Vit D 800 IU/Ca 1500 mgm/exercise Fosamax/Actonel/didrocal hPTH (to come)

The Top 10 Drugs to Use More

7. Drugs to treat diabetes.

Metformin 2nd generation sulfonylurea Glucosidase inhibitors Thiazolidinediones (glitazones)

Question 12

What % of patients cannot metabolize codeine (prodrug with no analgesic effect) into the active metabolite morphine?

1. 0.7%2. 1%3. 2.5%4. 5%5. 10%

The Top 10 Drugs to Use More

8. Anaglesics (regular dosing, not PRN). 10% can’t metabolize codeine New acetaminophen limit 3gm/d SR strong opioids/duragesic

(AGS Guidelines, JAGS June 1 2002, Supplement)

Nocioceptive: TCA (yes) SSRI (no) Neuropathic: TCA (better than SSRI)

The Top 10 Drugs to Use More

9. Statins. A huge lost opportunity! CVS m & m reduction: 1o/2o

Dementia

(www.cvtoolbox.com)