Intelligent Polypharmacy

8/10/2019 Intelligent Polypharmacy

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Intelligent Polypharmacy

Professor Colin P Bradley

Department of General Practice

University College Cork


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Polypharmacy

No standard definition

2005 review the use of medications

that are not clinically indicated 2010 Swedish study - > 5 medicines

defined as polypharmacy and > 10

excessive polypharmacy


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Problems of polypharmacy

Increased risk & prevalence of drug-drug interactions

Increased risk & prevalence ofadverse effects

Increased risk & prevalence of non-

adherence Increased risk & prevalence of

medication errors

Increased cost


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Risk of type D* interactionsrelated to number of drugs (Astrand et.al., 2007)

* Interactions which may have serious clinical consequences


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Factors determining risk ofadverse effects of medications

Patient age, gender, ethnicity

Renal and hepatic function

Co-morbities which increase ADR riskse.g. peptic ulcer disease or heartdisease and NSAIDs

Therapeutic index of the medicine


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Factors determining risk of non-adherence

Experience of adverse effects

Experience of interactions

Complexity of medication regimen Cognitive function

Drug aversion


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Factors related to risk ofmedication error

Number of medicines prescribed

Complexity of medication regimen

SALADs sound alike, look alike drugse.g. penicillin & penicillamine

Cognitive function of doctor,

pharmacist, patient and/or carers Care setting hospital, home etc.


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Costs of polypharmacy

Costs of medicines

Costs of mechanisms to reduce error

Costs of strategies to compensate forcognitive function decline

Costs of non-adherence (waste)


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Benefits of polypharmacy =benefits of pharmacotherapy

Reduction in adverse events

prophylactic medicines

medicines to counter possible ADRs Improvement in clinical conditions

reduction in complication rates

reduction in symptoms control of disease progression

Savings to health system if usedappropriately


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What isintelligent polypharmacy?

Use of multiple medicines in patients

where the benefits of the medicinestaken still outweigh the risks intrinsicto each medicine plus the risksassociated with the combination ofmedicines.


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An example of intelligentpolypharmacy? the polypill

Proposed originally in 2003 by Wald & Law

Combination of statin, thiazide, beta-

blocker, ACE inhibitor, folic acid and aspirin Estimated to reduce risk of cardiovascular

disease by 80% in unselected population

aged over 55 yearsADR rate estimated at 8-15%

Has been trialed in India


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Other examples

H. Pylori eradication regimens

HAART for HIV infection

Multi-drug regimens for TB treatment Treatment of type 2 diabetes

usually involves metformin, other

glucose lowering drugs plus drugs forhypertension (esp ACEI) and lipidlowering drugs


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Implementing intelligentpolypharmacy in practice

Systematic review of patients on multiplemedicines

Key drugs to review drugs with narrow therapeutic index e.g.

Warfarin, digoxin etc. drugs with known detectable ADRs e.g.

Immunosuppresants watch out for the prescribing cascade (Feely)

Key conditions to review Renal disease hepatic disease

Key patient group - elderly


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SAIL and TIDE

SAIL Simple as possible

Adverse reactions look

out for them Indication to be checked

for each medicine

List all the medicines in

the notes and providecopy to the patient

TIDE Time set aside to review

medicines

Individual responsesneed to gauged

Drug-drug interactionsneed to be checked

Educate the patient abouttheir medicines


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STOPP/ START

ScreeningTool of Older

Peoplespotentially

inappropriatePrescriptions

ScreeningTool to Alert

doctors toRight (i.e.

appropriate,indicated)Treatment


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Which are the problemdrugs?

Cardiovascular

CNS and psychotropics

Gastrointestinal Respiratory

Musculoskeletal

Urogenital Endocrine


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The problem drugs -cardiovascular

Digoxin Loop diuretics Thiazide diuretics Beta-blockers Calcium channel blockersVasodilators

DipyridamoleAspirin Clopidrogrel

Warfarin


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The problem drugs - CNS

Tricyclic anti-depressants

Benzodiazepines

Neuroleptics

Phenothiazines

Anti-cholinergics

SSRIs

First generation anti-histamines

Opiates


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The problem drugs gastro-intestinal

Diphenoxylate

Loperamide

Codeine phosphate Prochlorperazine

PPIs

Anti-cholinergic anti-spasmodics


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The problem drugs respiratorysystem

Theophylline

Systemic corticosteroids

Nebulised ipratropium


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The problem drugs musculoskeletal system

NSAIDs

Corticosteroids

Colchicine


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The problem drugs urogenitalsystem

Bladder anti-muscarinics

Alpha-blockers


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The problem drugs endocrinesystem

Glibenclamide

Chlorpromamide

Oetrogens


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Other issues

Duplicate drugs same class or sametherapeutic effect

Complex regimens more than twice per day or

other special requirements for taking the drug Multiple tablets to be taken simultaneously

Look-alike tablets

Difficult formulations

Slow accumulation of medical problems (and,hence, associated medications)

Prevention v therapy


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Medications sometimes deniedinappropriately

Warfarin

Aspirin

Clopidrogrel

StatinsACE inhibitors

Beta-blockers

Beta-agonists Inhaled

corticosteroids

L-DOPA

Antidepresants

PPIs

Fibre supplements DMARDs

Bisphosphonates

Calcium and vit D Metformin


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Reducing the risk

Avoid prescribing where appropriate

Start low and go slow

Robust repeat prescribing system

Clinical pharmacy ICT solutions

Interaction alerts

Drug disease contraindication alerts

Dosage alerts including paediatric alerts


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Case 1

66 year old man with a history of

hypertension x 10yrs;

angina x 3 yrs and

osteoarthritis x 1 yr

Atenolol 100mg daily x 30

Lisinopril 5mg daily x 30

Imdur (isosorbide mononitrate) 60mg daily x 30 Nuseals aspirin 75mg x 30

Lipostat 20mg nocte x 30

Voltarol 25mg tds x 90


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Case 2

72 year old woman with 12yr history of type II diabetes,

6 yr history of hypertension

history of ankle oedema (of uncertain causeand duration).

Daonil 5mg daily x 30

Frusemide 20mg daily x 30

Tritace 10mg daily x 30 Dalmane 30mg nocte x 30


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Case 3

58 year old woman with a 9 monthhistory of hypertension

Adalat LA 20mg daily x 30

Innovace 10mg daily x 30

Moducren ii daily x 30 (combination

of hydrochlorthiazide 25mg; amiloride2.5mg and timolol maleate 10mg)


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Case 4

64 year old woman with a history of recurrent depression

was found on screening 3 years ago to haveosteoporosis

Fosamax i weekly x 8

Lexapro 10mg daily x 30

Zopiclone 7.5mg nocte x30

Nexium 20mg daily x 30 Ixprim ii prn x 100


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Case 5

62 year old man with a

4 year history of atrial fibrillation

recently presented with a first episode of gout

Digoxin .625mg od x 30

Warfarin 4mg daily (INR check 8 weekly,last reading 6 weeks ago was 2.3)

Centyl K i daily x 30 Indomethacin 50mg tds x 14 days


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Case 6

77 year old woman with 5 year history of angina,

1 year history of polymyalgia rheumatica

recently presented with indigestion

Atenolol 50mg daily x 30

Adalat 10mg three times daily x 90

GTN spray as needed x 1

Syndol i or ii as needed x 50 Prednisolone 5mg daily x 30

Gaviscon Advance 10mls as needed

Pariet 10mg daily x 30


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Intelligent Polypharmacy