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Stephanie Nichols, Pharm.D., BCPS, BCPPAssociate Professor – Husson University School of PharmacyClinical Pharmacist – Psychiatry & Adult Inpatient [email protected]
American College of Physicians - Maine ChapterAutumn Meeting in Bar Harbor
September, 2014
Define polypharmacy and recall it's prevalence
Illustrate why recognition and management of polypharmacy is important
Demonstrate strategies to avoid polypharmacy
Assess high risk polypharmacy situations and formulate a plan to initiate pharmacological debridement
Employ strategies to improve medication adherence in patients with a high pill burden
X+ chronic daily medications?› OTCs/Herbals› Ex. HF or COPD
“High Risk Polypharmacy”› Ex. 2+ narcotics, 2+ benzos, 3+ oral
hypoglycemics 2+ drugs in the same class?
More drugs prescribed than warranted clinically ?
› “Prescribing cascade”
Kaufman, Kelly, Rosenberg, Anderson, Mitchell. JAMA 2002;287:337-44.
Mean number of meds per patient = 13.5
Nearly a quarter had >16 meds
OR 4.75 (95% CI: 1.0 – 11.2) for polypharmacy with 2+ high risk diagnoses› COPD, CA, DM, CHF, CAD
Rohrer JE et al. J Prim Care Community Health. 2013 Apr 1;4(2):101-5.
Gamble JM et al. Therapeutics and Clinical Risk Management 2014:10 189–196
Slabaugh, Maio, Templin, Abouzaid. Drugs & Aging. 2010; 27(12):1019-1028.
Viktil GK, Blix HS, Moger TA, Reikvam A. Brit J of Clin Pharmacol 2006;63(2):187-95.
Low Adherence Falls and Fractures ED visits and admissions Increased healthcare costs Reduced quality of life Increased mortality
Lyles, Culver, Ivester, Potter. Consult Pharm. 2013 Dec;28(12):793-9.Lai, Liao, Liao, Muo, Liu, Sung. Medicine (Baltimore) 2010;89(5):295.
Circulation. 2010; 122:A14790
4.2% of admissions due to ADRs
Pedros C et al. Eur J Clin Pharmacol. 2014 Mar;70(3):361-7.
Number of Drugs
Odds Ratio of ADR
Admission
95% CI
≤ 2 1.0 (Reference)
3 - 5 5.07 2.71 – 9.59
6 – 9 5.9 3.16 – 11.0
10 + 8.94 4.73 – 16.89
Pedros C et al. Eur J Clin Pharmacol. 2014 Mar;70(3):361-7.
Safety Tolerability Effectiveness Price Simplicity
Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.
Pocket Card› http://www.americangeriatrics.org/files/doc
uments/beers/PrintableBeersPocketCard.pdf
AGS iGeriatrics App - $2.99
2003
STOPP - Screening Tool of Older People’s potentially inappropriate Prescriptions› 65 recommendations
START - Screening Tool to Alert doctors to the Right Treatment› 22 recommendations
http://www.ngna.org/_resources/documentation/chapter/carolina_mountain/STARTandSTOPP.pdfGallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Int J Clin Pharmacol
Ther. 2008 Feb;46(2):72-83.
• Rudolph, Salow, Angelini, McGlinchey. Arch Intern Med. 2008;168(5):508.• Carnahan, Lund, Perry, Pollock, Culp. J Clin Pharmacol 2006;46:1481-6.• Boustani, Campbell, Munger, Maidment, Fox. Aging Health 2008;4:311-20.• http://www.indydiscoverynetwork.org/resources/antichol_burden_scale.pdf
Find an indication for each drug› Goal of therapy?
Are we using the best drug for each problem/disease/disorder in this patient?› Eg. HTN and beta blockers
Schedule a “brown bag” appointment periodically
When switching from one agent to another, or stopping an agent completely…
…ask the community pharmacy to d/c the old prescription
Periodically compare medication lists with the pharmacist/pharmacy
When new symptoms emerge, particularly in geriatric patients, think about medication AEs
http://www.acpm.org/?MedAdherTT_ClinRefhttp://www.iarx.org/documents/PrinciplesOfHealthcare2010.pdf
S implify regimen I mpart knowledgeM odify patient beliefs and human behavior P rovide communication and trust L eave the biasE valuate adherence
Atreja A, Bellam N, Levy S. Medacapt Gen Med. 2005:7(1): 4.
Daily or BID dosing› One-a-day formulations (incl. patches)› Match to ADLs (ex. breakfast)
Combination products › Caution: loss of dosing flexibility
Treat multiple conditions with one agent› Caution: commonly 2 agents are safer
d/c extraneous or unnecessary medications
Focus on shared decision making Discuss purposes and side effects of
medications Use the teach-back method Employ verbal and written instructions Give contact information for further
questions
REALM Assessment› http://www.adultmeducation.com/
downloads/REALMR_INSTR.pdf
“As Needed for Water Retention” “Take two every day”
Presentation of the advantages and disadvantages of each medication in a way that is understandable to your patient
Discuss # of missed doses at each visit, non-punitively
Telephone counselling
Empathy, supporting self-efficacy, avoiding argumentation, rolling with resistance, and developing discrepancy
PSAPs VII; Book 8. Motivational Interviewing. Kavookjian J.
Empower patients to self-manageAsk about specific needs, fears, and concernsIdentify perceived barriers (ex. financial)Ensure knowledge of the actual risks of missing medications
Confirm your patient’s message and paraphrase it
Provide empathy and give feedback Involve your patient in decision making Use plain language and confirm
understanding
Take the time to overcome cultural barriers
Tailor education to the appropriate level of complexity for your patient’s optimal understanding
Ask direct questions and ask them often› Every visit
Identify adherence barriers Recognize lack of perceived benefit
30 day fills on Jan 1st, Feb 7th, Mar 18th, Apr 26th, & June 1st 5 fills * 30d each = 150 days supplyJan 1st – Jun 1st = 151 days + 30 days supply = 181 days150/181 = 83% MPR
Wallet cards – medication lists Pill containers and counting Blister packs Pre-packed kits (ex. Medrol) Textured covers with vision impairment Alarms
› On the bottle› Via email
Team based care!
Consider Long-Acting Injectable Antipsychotics
Engage the patient in the treatment decision when able, particularly regarding AEs
Ask the pharmacist to partner with the treatment team to alert of non-timely filling
Depressed patients are 3x more likely to be non-adherent with medical treatment regimens (non psychotropic)
DiMatteo MR, Lepper HS, Croghan TW. Arch Int Med. 2000;160(14):2101.
Polypharmacy is prevalent, particularly in those 65+
Polypharmacy increases morbidity, mortality, & healthcare costs, and decreases quality of life
Perform ongoing medication assessment with tools, like STEPS, to avoid polypharmacy
Use scores, scales, and lists to optimize medication regimens, avoid unnecessary medications, and/or reduce medication burden
To improve medication adherence in polypharmacy, simplify the medication regimen and have ongoing dialogue with your patient about risks and benefits of each drug being used
Stephanie Nichols, Pharm.D., BCPS, BCPPAssociate Professor, Husson University School of PharmacyClinical Psychiatric Pharmacist, Maine Medical [email protected]
Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.