Polypharmacy and Polymorbid

Patients: Practical Tips and Tricks

November 2, 2013

Faculty/Presenter Disclosure

Faculty: Chris Fan-Lun, BScPhm, ACPR, CGP Pharmacist - Geriatric Medicine

Clinical Practice Leader - Dept. of Pharmacy Services,Mount Sinai Hospital

Relationships with commercial interests: I have NO actual or potential conflicts of interest in relation to this

program

Objectives

• Highlight common polypharmacy issues in

patients with multimorbidity

• Review the physiologic changes of aging and

pharmacological basis for these concerns

• Provide practical tips to address polypharmacy

in polymorbid patients

Polypharmacy in the Elderly

Polypharmacy means

"many drugs“ • 5 or more drugs

The use of more

medication than is

clinically indicated

or warranted

Barnett K et al. Lancet 2012; 380 (9836):37 – 43.

Polypharmacy Consequences

Adverse Drug Reactions

Nonadherence

Drug costs

Poor quality of life, outcomes

Magaziner J et al. J Aging Health. 1989;1:470-484.

Espino DV et al. J Gerontol A Biol Sci Med Sci. 2006;61:170-175.

Percentage of seniors with polypharmacy, by number of chronic

conditions and age group

Reason B et al. Fam Pract 2012;29(4):427-432.

Percentage of seniors who experienced a side effect requiring medical

attention within the past 12 months, by number of prescription

medications

Reason B et al. Fam Pract 2012;29(4):427-432.

Canadian Impact

• Seniors with three or more reported chronic conditions accounted

for 40% of reported health care use among seniors, even though

they comprised only 24% of all seniors

• Seniors who reported ≥3chronic conditions were taking an average

of 6 Rx meds, twice as many medications as seniors with only 1

chronic condition

• Seniors taking a high number of prescription medications were at a

greater risk of experiencing side effects requiring medical

attention, yet fewer than half of seniors with chronic conditions

reported having medication reviews

Seniors and the Health Care System: What Is the Impact of Multiple

Chronic Conditions?. CIHI 2011

Adverse Drug Effects &

Prescribing Cascade

Drug 1

ADE interpreted as new

medical condition

Drug 2

ADE interpreted as new

medical condition

Drug 3

Rochon PA, Gurwitz JH. BMJ 1997;315:1097.

Case: Ms Dale

84 yo woman

• widowed, living alone

• severe knee pain

limiting mobility

• 3 falls in last 6

months

• “memory problems”

PMHx

A Fib

HTN

OA

Case: Ms Dale

• EC ASA 81 mg daily

• Ibuprofen 400 mg bid

• GRAVOL 50 mg qhs

• Zopiclone 3.75 mg qhs

• Warfarin as directed

• Amlodipine 10 mg daily

• Perindopril 4 mg daily

• Furosemide 40 mg bid

• Metoprolol 50mg bid

• Slow-K 16 mEq daily

• Atorvastatin 40 mg daily

• Dextromethophan syrup

• Pantoprazole 40 mg daily

• Solifenacin 5 mg daily

• Vitamin B12 1 mg daily

• Glucosamine 1 cap tid

Ms Dale’s Prescribing Cascades

ibuprofen

amlodipine

perindopril

ASA

dimenhydrinate

pantoprazole

furosemide potassium

dextromethorphan

solifenacin

zopiclone

Vitamin B12

Prescribing Web Allegory

Barb Farrell, Pharmacist, Bruyere Geriatric Day Hospital

Prescribing Web Allegory

Barb Farrell, Pharmacist, Bruyere Geriatric Day Hospital

• Dx Afib- metoprolol & warfarin

• Widowed- zopiclone 10 yrs ago

•Knee pain - ibuprofen

•HTN - perindopril

•Cough - DM

•HTN - Amlodipine

•ASA – neighbour said she should take it

5 yrs ago

•Ankle swelling - furosemide

•Hypokalemia - potassium

•Nausea - dimenhydrinate; pantoprazole

•Low Vit B12 - Vit B12 supplement

•Nocturia - solifenacin

1 yr ago

Polypharmacy Risk Factors

• Age

• Multimorbidity

• Acute hospitalization

• Health care visits

• Multiple providers

Hajjar ER, Am J Geriatr Pharmacother. 2007;5(4):345-51 Betteridge TM, et al. Int Med J 2012;42(2):208-11.

Jorgensen T et al. Ann Pharmacother. 2001;35:1004-1009.

Contributing Factors:

Age-Related Physiological Changes

YOUNG ELDERLY

Drug

absorption Faster

Slower/

decreased

Metabolism Faster Slower

Excretion Faster Slower

Fat : lean body

mass

Total body

water

Contributing Factors:CPGs

• Guidelines = standardise, reduce

unacceptable variation to improve quality

of care

• Treating diseases in isolation

– burdensome and potentially inappropriate

treatment

Barnett K et al. Lancet 2012; 380 (9836):37 – 43.

Contributing Factors:CPGs

• A hypothetical case – elderly woman with COPD, DM II, OP, HTN, and OA

• If all CPGs are followed… – 12 medications, costing $406 (US)/month

– Undesirable effects, drug-disease and drug-drug interactions

• Limited applicability to elderly with multimorbidity and medications

• May have sections for special populations

• Frail elderly and >80yo underrepresented in CPGs and clinical trials

Boyd CM et al. JAMA. 2005;294(6):716-24.

Cox L. CFP 2011;57(7):e263 –e269.

Lugtenberg M et al. PLoS One 2011;6:e25987

CPGs and the elderly

Age + Polymorbidity + CPGs

= Lots of medications

Screening and Assessment Tools

START & STOPP

STOPP – Screening Tool of Older Person’s Prescriptions

• inappropriate combinations of medicines and disease

START – Screening Tool to Alert doctors to Right Treatment

• a set of recommended treatments for given conditions

Gallagher P, O'Mahony D. Age and Ageing 2008;37:673-9.

Barry PJ, Gallagher P, Ryan C, O'Mahony D. Age and Ageing 2007;36:632-8.

Avoiding Polypharmacy Pitfalls

1. Obtain accurate history

2. Link medications to disease state

3. Identify prescribing cascade

4. Initiate interventions to ensure adherence

5. Reconcile medications upon discharge from

acute care or rehabilitation facility

6. Medication review

Reducing Drug-Related

Iatrogenesis in the Elderly

• Start low, go slow

• Limit medication changes

• Avoid “high risk” meds

• Understand the pharmacokinetics and pharmacodynamics of drugs prescribed

– renal/hepatic dosing as needed

• Early recognition of problems as med side effect

Stopping Medications

Medication streamlining

Deprescribing

Pharmaceutical debridement

Drugectomy

Rocking the Boat

How to Stop?

Reduce or stop one medication at a time

Start with medications where there is:

• Risk of harm with no known benefit

• Little chance drug withdrawal

• Unclear or no indication

• Indication but unknown or minimal benefit

• Benefit but side effect or safety issues

Deprescribing: Monitoring

Hardy JE, Hilmer SN. J Pharm Pract Res 2011;41:146-51

Summary

Decreasing medication use in elderly can:

– Adverse events (eg falls, hospitalization)

– Pill burden and costs

– Adherence with remaining medications

– QOL

Team approach

Take one step at a time

– Review medications regularly

– Develop a plan for rationale

prescribing/deprescribing

Question 1

Which of the following age-related

changes has implications on drug

distribution and duration of action? a) Increased hepatic drug metabolism

b) Increased percentage of body fat

c) Increased amount of total body water

d) All of the above

Question 2

An 84 yo woman began showing symptoms of memory problems and

was referred to a neurologist. She was diagnosed w/ Alzheimer’s

disease and initiated on donepezil. Six weeks later, the patient made

an appointment with her primary physician to ask for an “overactive

bladder” medicine that she saw advertised on TV. She was then

prescribed darifenacin. This may be a case of:

a) Drug interaction

b) Adverse drug event

c) Prescribing cascade

d) Geriatric syndrome

Question 3

Which of the following drugs can

be stopped without tapering

a) Citalopram

b) Docusate

c) Bisoprolol

d) Lorazepam