polypharmacy: optimizing medication use through deprescribing
TRANSCRIPT
Polypharmacy:OptimizingMedicationUsethrough
DeprescribingDr.LalithaRaman-Wilms,BScPhm,PharmD,FCSHP
CollegeofPharmacy,UniversityofManitobaMarch9,2018
PresenterDisclosure• LalithaRaman-Wilms
• Relationshipswithcommercialinterests:None– CurrentGrants/ResearchSupport:
– MinistryofHealthandLong-TermCare(MOHLTC),Ontario– CanadianFoundationforPharmacy– InnovationFund
MitigatingPotentialBias• NotApplicable
LearningObjectives• Describetheclinicalimplicationsofpolypharmacyin
geriatriccancerpatients,includingadversedrugreactionsanddruginteractions.
• Describetoolsandstrategiestoscreenolderadultsforpolypharmacy.
• Discussstrategiestooptimizemedicationuseintheelderly.• Discusseducationalstrategiesforsafemedicationuse in
olderadults.
“Thestatisticsarestaggering. Fortypercentofthoseover85inCanadaaretakingatleast10medications.Two-thirdsofthoseover65aretakingatleastfive medications.”
Dr.CaraTannenbaum,aScientificDirectorwiththeCanadianInstitutesofHealthResearch,andtheDirectorofthe CanadianDeprescribingNetwork,andhercolleagueshavebeenworkingtoraisetheprofileoftheoverprescribingproblem.
Terminology• Polypharmacy• MedicationOptimization• PotentiallyInappropriatemedications(PIM)– associatedwithnonadherence,adversedrugreactions(includingdruginteractions),riskforfalls,medicationerrors,hospitalizationandmortality
DRUGTHERAPYCONSIDERATIONSINTHEELDERLY
• Reducedkidneyfunction– greatertoxicitywithrenallyexcreteddrug(e.g.digoxin)
• Changesinliverfunction– longerhalf-lifefordrugsmetabolizedbycytochromeenzymes(e.g.flurazepam)
• GreatersensitivitytoCNS;greateradditiveeffects(e.g.antidepressants)
• Increaseinfat:musclemass(e.g.diazepam)
Clin Geriatr Med 2012;28: 273–286.Drugs Aging 2009;26(12):1039-48.
Clinicalimplicationsofpolypharmacyinolderpatientswithcancer…
• Associatedwith:– Post-operativecomplications(deGlasetal.2013)– Increasedlengthofstay(abdSx)(Badgwelletal.2013)– Grade3-4Chemotherapy-relatedtoxicity(Hamakeretal.2014)
– Loweroverallsurvival(Freyeretal.2005)
• Almost50%ofptsmod-severepotentialdrugissuespriortostartofcancerTx(CanCancerCentre- Quebec)
• Druginteractions:pre-existingmedsandcancerTxin1/3pts;newmedsusedforsupportivecare
Polypharmacyandpotentiallyinappropriatemedicationuseingeriatriconcology.JGeriatrOncol.2016;7(5):346-353Thelancet.com/oncology;2011;v12:1249-1257
DrugInteractions• Pharmaceutical – onedrugmayphysicallybindwithanotherdrugwhentakentogether
• Pharmacokinetic – onedrugaffectstheabsorption,distribution,metabolismorexcretionofanother
• Pharmacodynamic – interactionatsiteofaction– areceptororphysiologicsystem
ExamplesofDrugInteractions– Tamoxifen-fluoxetine/paroxetine– reducedconversionoftamoxifentoactivemetabolite
– Paclitaxel-warfarin– increasedanticoagulanteffect– Cisplatin-phenytoin– decreasedphenytoinconc
Ø Clinicalsignificance&managementØGreater#ofdrugs,higherrisk
AdverseDrugReactions(ADRs)• Adversedrugreaction– aresponsetoadrugwhichisnoxious
andunintendedandwhichoccursatdosesnormallyused(WHO2005)
• ADRinadults:corticosteroids,antibiotics,anticoagulants,antineoplasticandimmuno-suppressivedrugs,CVdrugs,NSAIDs,andopiates
• usuallyrelatedtothecardiovascular,renalorCNSsystems• Commondrug-relatedissuesintheelderly:cognitivechanges,
falls,urinaryincontinence,constipation
https://www.accp.com/docs/bookstore/psap/2015B2.SampleChapter.pdf
Continuingmedications
BENEFIT RISK
- PotentialADR- Frail,elderly- #ofmedications(Rx,
OTC,vitamins)- Adherenceissues
- ClearIndication- Evidencefor
effectiveness
Considerabalancebetweenbenefitsandharmsofmedications,takingintoaccountpatient’svaluesandgoals:
Deprescribing”Medicationsthatweregoodthen,mightnotbethebestchoicenow.Deprescribingispartofgoodprescribing– backingoffwhendosesaretoohigh,orstoppingmedicationsthatarenolongerneeded.”
“Deprescribingistheplannedandsupervisedprocessofdosereductionorstoppingofmedicationthatmaybecausingharmornolongerbeprovidingbenefit.”
https://deprescribing.org/what-is-deprescribing/
Deprescribingdecisions
BENEFITSPOTENTIALHARMS
• Adversewithdrawalreactions
• Worseningofunderlyingcondition
• Patient-familyanxiety
- Decreaseinfalls- Improvementin
cognition- Improvementin
psychomotorfunct- ERvisits,#drugs- Adherence,QoL
• Considerabalancebetweenbenefitsandpotentialharmsofdeprescribingmedications,takingintoaccountpatient’svaluesandgoals:
Medicationsthatmayrequiretapering• Antidepressants
(e.g.citalopram,venlafaxine)• Anticonvulsants(antiseizure
meds)• Antipsychotics• Baclofen• Benzodiazepines&Zdrugs• opioids
• Beta-blockers(e.g.metoprolol)
• CalciumChannelblockers(ifforangina)(e.g.verapamil)
• Cholinesteraseinhibitors(e.g.donepezil)
• Corticosteroids
AdverseDrugWithdrawalEvents
Ref:ThewaragainstPolypharmacy:ANewCost-EffectiveGeriatric-PalliativeApproachforImprovingDrugTherapyinDisabledElderlyPeople.DoronGarfinkel,SarahZur-GilandJoshuaBen-Israel.IMAJ2007;9:430–434
StrategiesforDeprescribing
Apracticalguidetostoppingmedicinesinolderpeople
Factorstoconsider:• Patientwishes• Clinicalindicationandbenefit• Appropriateness• Durationofuse• Adherence• Prescribingcascade
FourStepProcess1. Recognizetheneedtostop2. Reduceorstoponemedicineat
atime3. Considerifcanbestopped
abruptlyorshouldbetapered4. Checkforbenefitorharmafter
eachmedicinestopped
BestPractJ2010;27:10-23.https://bpac.org.nz/BPJ/2010/April/stopguide.aspx
Hardy&Hilmerfile:///Users/lraman/Downloads/Hardy_et_al-2011-Journal_of_Pharmacy_Practice_and_Research.pdf
Deprescribinginthelastyearoflife
5- stepDeprescribingProtocol(Scott2015)1. Comprehensivemedicationlist2. Assessmentofpatient’sclinicalstatus3. Assesseachdrugforeligibilitytobediscontinued
– isitindicated?– Considercurrent/futurebenefitsvsharms– patientgoalsandpreferences
4. Prioritizedrugsfordiscontinuation5. Monitoringandfollow-up
JAMA Intern Med 2015. doi:10.1001/jamainternmed.2015.0324
Elementsofadeprescribingprocess• Collectacompleteandcomprehensivemedicationhistory• Assessoverallriskofharmandbenefitandindividualpatientfactors
whichmayaffectdeprescribing• Identifypotentiallyinappropriatemedications• Decide onmedicationwithdrawal(shared-decisionmaking)• Plantaperingorwithdrawalprocessandmonitoringanddocumentation
and communicationtoallpersonsrelevanttocare• Conductmonitoringandsupport• Documentation
ReeveEetal.EurJIntMed;2017.http://www.ejinme.com/article/S0953-6205(16)30450-2/pdf
ToolstoidentifyPIMs• BeersCriteria– AmGerSoccriteriaforPIMuseinolderadults
• START- ScreeningToolofOlderPersonsPrescriptions/STOPP- ScreeningTooltoAlerttoRightTreatment
• OncPaldeprescribingguideline(palliativecarepatients)• AnticholinergicRiskScalehttps://www.ncbi.nlm.nih.gov/pubmed/26446832https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/SupportCareCancer(2015)23:71-78
Deprescribing.org
Patientinvolvement“Morethan90%ofpatientsarewillingtostopamedicationiftheirdoctorsaysitispossible”(JAGS)
• Patienteducation• Informed-decisionmaking
Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,VéroniqueFrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)
Medicationreview• Reducedcognition
– MaybecontributedtobyanticholinergicloadandCNSdepressants(diltiazem,furosemide,amitriptyline,cyclobenzaprine,carbamazepine,morphine,oxazepam)
– Maynotrequiretreatmentwithgalantamineoncemedicationcontributorstapered
• Lowbloodpressureandorthostatichypotension(andfrequentfalls)– Maybecontributedtobycardiovascularmedications:Nitroglycerinpatch,Furosemide,
Amlodipine,Acebutolol,Quinapril,Diltiazem
Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,VéroniqueFrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)
Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,VéroniqueFrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)
ConsiderationsindeprescribingBarriers
• Patientcomplexity(polypharmacy,multiplecomorbidities)
• Prescribercomplexity(multipleprescribers)
• HCPperceptionofpatient/care-giverattitudes
• Safetyconcerns:adversedrugwithdrawal,returnofmedicalcondition,preventativemedicines,
Enablers• Self-efficacy– useofguidelines• Teamapproach• Collaboration– MD-Phm• Easytousetools/algorithms• Patientengagement• Effectivecommunication
DrugTherapyReview• ArethepatientsmedicationsINDICATED?• IsitEFFECTIVE?Considerdose,route,formulation,duration
• IsitSAFE forthepatient?Considercontraindications,druginteractions,potentialadversedrugeffects
• CanpatientADHEREtotherapy?Sizeofthemedication;frequency;cost
Keypoints• Carryoutregularmedicationreviews• Indicationfordrugtherapy• Toensuresafe&effectivedeprescribing:– Patientinvolvementindecisionmakingandinmonitoring– Collaborativeteamapproach
• Considerwhenandhowmedicationsshouldbetapered
• Discussoptionsfordrugbeingwithdrawn;considernon-pharmapproaches
References• Deprescribing resources:https://deprescribing.org/
• CanadianDeprescribing Network:https://deprescribing.org/caden/
References• Pharmacokineticsandpharmacodynamicchangesassociatedwithagingandimplicationsfordrugtherapy LCSera,ML
McPherson.Clin Geriatr Med 2012;28: 273–286.• Drugs Aging 2009;26(12):1039-48.• Polypharmacyandpotentiallyinappropriatemedicationuseingeriatriconcology.JGeriatrOncol.2016;7(5):346-353• Thelancet.com/oncology;2011;v12:1249-1257• ReeveEetal.EurJIntMed;2017.http://www.ejinme.com/article/S0953-6205(16)30450-2/pdf• https://www.ncbi.nlm.nih.gov/pubmed/26446832• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/• SupportCareCancer(2015)23:71-78• JAMA Intern Med 2015. doi:10.1001/jamainternmed.2015.0324• DeprescribingforolderpatientsChristopherFrankMD,EricaWeirMDMSc.CMAJ,December9,2014,186(18)• ThewaragainstPolypharmacy:ANewCost-EffectiveGeriatric-PalliativeApproachforImprovingDrugTherapyinDisabled
ElderlyPeopleDoronGarfinkel,SarahZur-GilandJoshuaBen-Israel.IMAJ2007;9:430–434• Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,Véronique
FrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)
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