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Polypharmacy and the Elderly:Drugs to Avoid and Use with Caution
in Heart Failure
Robert L Page II, Pharm.D., MSPH, FHFSA, FCCP, FAHA, BCPS, BCGP
Professor of Clinical Pharmacy
Clinical Specialist, Division of Cardiology
Section of Advanced Heart Failure/Transplant
University of Colorado Schools of Pharmacy and Medicine
Presenter Disclosure
Financial Disclosure: There are no financial or other relationships to disclose related to this presentation
Unlabeled/Unapproved Uses Disclosure: None
Objectives• Given an older adult with heart failure, delineate specific tools to
evaluate drug complexity in order to minimize polypharmacy.
• Given an older adult with heart failure, evaluate the patient’s medication regimen and identify which medications could cause or exacerbate heart failure symptoms.
• Discuss best practices to avoid polypharmacy in the older adult with heart failure.
• Provide patient education regarding OTC and herbal supplements to avoid in the patients has heart failure.
Polypharmacy: Definition
“As older patients move through time, often from physician
to physician, they are at increasing risk of acclamation layer
upon layer of drug therapy, as a reef accumulates layer upon
layer of coral”….
Jerry Avorn, MD, 2004
Professor
Harvard Schools of Medicine and Public Health
Chief, Division of Pharmacoepidemiology
Brigham and Women's Hospital
Comorbidity ConundrumA
GIN
G
Curr Cardiol Rep. 2012;14(3):276-84.
Polypharmacy: Comorbidities
http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Health_Status.pdf
10 average meds
7 average meds
11 average meds6 average meds
Health Resource Utilization
Circulation 2008;118:S_1030.
Polypharmacy: Other Reasons
Age & Ageing 2008; 37(2):138-41.
The Impact on Medications
0%
10%
20%
30%
40%
50%
60%
70%
1988-1994 1999-2002 2003-2008
0-1 2 3 4 5+
1
2
3
4
5
6
7Number of Comorbidities
0
Me
an N
um
be
r of P
rescrip
tion
Me
dicatio
ns
Pe
rce
nt
of
Pat
ien
ts w
ith
Co
mo
rbid
itie
s
Time Periods
Mean Number of Rx Medications
Circulation 2016 20;134(12):e261.
Circulation. 2016;134:32-69
MAGNITUDE DEFINITION
Major
Effects that are life-threatening or effects that lead to
hospitalization or emergency room visit.
Moderate
Effects that can lead to an additional clinic visit, change in
NYHA functional class, change in cardiac function, or
worsening cardiovascular disease (eg, hypertension,
dyslipidemia, and metabolic syndrome) or effects that lead to
symptoms that warrant a permanent change in the long-term
medication regimen.
Minor
Effects that lead to a transient increase in patient
assessment/surveillance or effects that lead to symptoms
that warrant a transient medication change.
LEVEL of EVIDENCE DEFINITION
Level A
Multiple populations evaluated. Data derived from
multiple randomized, controlled trials or meta-analyses.
Level B
Limited populations evaluated. Data derived from a
single randomized, controlled trial or nonrandomized
studies.
Level C
Very limited populations evaluated. Data have been
reported in case reports, case studies, expert opinion,
and consensus opinion.
ONSET DEFINITION
Immediate Effect is demonstrated within 1 week of drug
administration.
Intermediate Effect is demonstrated within weeks to months of drug
administration.
Delayed Effect is demonstrated within ≥1 y of drug administration.
NSAIDS
Circulation 2016 20;134(12):e261.
NSAIDS: Mechansim
Eur Heart J 2016; 37 (13): 1015-1023.
NSAIDS: Incident Heart Failure
Clin Cardiol 2016; 39 (2): 111-118
NSAIDS: The Coxibs
Lancet 2013;382:769–79.
Diabetes Management
Diabetes Care. 2017; 40(suppl 1): S1-S130.
GLP-1 Receptor Agonists
Diabetes Care. 2017; 40(suppl 1): S1-S130.
Exenatide
Liraglutide
Lixisenatide
Dulaglutide
Albiglutide
DDP4-Inhibitors
Diabetes Care. 2017; 40(suppl 1): S1-S130.
Sitagliptin
Vildagliptin
Saxagliptin
Alogliptin
SGLT2-inhibitors
Diabetes Care 2017; 40(suppl 1): S1-S130.
Dapagliflozin
Epaglifozin
Canagliflozin
Diabetes Medications
Eur J Heart Fail 2016; 19: 43-53.
In patients with type 2 DM,
with stable HF, metformin may
be used if eGFR> 30ml/min
but avoided in unstable or
hospitalized patients with HFIn patients with symptomatic
heart failure, TZDs should
NOT be used
Dipeptidyl-Peptidase 4 Inhibtiors
Dipeptidyl-Peptidase 4 Inhibitors
Diabetes Care 2016 39(Supple 2): S210-S218.
TECOS-HF
JAMA Cardiol 2016; 1(2): 126-135.
Other Drugs to Consider
Alternative Medicines
Circulation 2016;134:32-69.
Alternative Medicines
Circulation 2016;134:32-69.
Medications with High Sodium
Circulation 2016;134:32-69.
Drug Evaluation Tools
Explicit
The Beers’ Criteria
IPET
STOPP
Implicit
MAI
IPET: Improved Prescribing in the Elderly Tool
STOPP: Screening Tool of Older Persons
MAI: Medication Appropriateness Index
Lancet 2007; 370(9582): 173-84
Beers Criteria 2015
J Am Geriatric Soc 2015; 63(11): 2227-2246.
Evaluates 10 validated measures:
1. Indication
2. Effectiveness
3. Dose
4. Correct Direction
5. Practical Directions
6. Drug-drug interactions
7. Drug-disease interactions
8. Duplication
9. Duration
10. CostJ Clin Epidemiol 1992; 45(10): 1045-1051.
The Alternative---MAI
WHY…….
http://www.sciencehumor.org/wp-content/uploads/2008/06/sign_brain.jpg
Rules of ThumbConduct comprehensive medication reconciliation at each clinical visit
and with each admission. Patients should be specifically asked about
drug, dose, and frequency of all their medications, including OTC
medications and CAMs. (Class IIa; Level of Evidence C)
Evaluating the potential risks and benefits of each medication should
be considered before initiation. Medications should be categorized as
either essential to desired outcomes or optional, with an attempt made
to reduce or eliminate optional medications. (Class I; Level of
Evidence C)
It is reasonable to consider avoiding prescribing new medications to treat
side effects of other medications. The use of as-needed medications
should be limited to only those that are absolutely necessary. (Class IIa;
Level of Evidence C).
Circulation 2016;134:32-69.
Final Thoughts to Consider