A Bag Full of Pills: Polypharmacy in the Elderly Texas Family - - PowerPoint PPT Presentation

Texas Family Medicine Symposium Dale C. Moquist, MD June 8, 2019

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A Bag Full of Pills: Polypharmacy in the Elderly

Speaker Disclosure

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• Dr. Moquist has disclosed that he has no actual or potential

conflict of interest in relation to this topic.

Learning Objectives

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By the end of this educational activity, the learner should be better able to:

• 1. Describe common polypharmacy issues in the elderly.
• 2. Using the updated 2018 BEERS Criteria, avoid the use of

problematic medications in the elderly and stop certain medications even if prescribed by other physicians.

• 3. Compare the benefits and risks of polypharmacy and educate elderly

patients and/or their caregivers on appropriate adherence to certain medications.

• 4. Utilize practical strategies to attempt to achieve optimal prescribing

patterns for the elderly.

Outline

Overview Update on 2019Beers START/STOPP Deprescribing Cases Summary

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Overview

Complexity Challenges Basics of Prescribing

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Audience Polling 1 What % of prescriptions in U.S. is bought by people >age 65?

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• 1. 10%
• 2. 20%
• 3. 33%
• 4. 40%
• 5. 50%

Importance of Geriatric Pharmacotherapy

Slide 9

Now, people age 65+ are 13% of U.S. population, buy 33% of prescription drugs. By 2040, will be 25% of population, will buy 50% of prescription drugs.

Polypharmacy

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 Use of more meds than clinically indicated  Cut-point is usually 5 or more meds  Prevalence over age 65  13% with 2 meds  58% with 5 meds  82% with 7 or more  Increased risk of adverse events

 The number of drugs that a patient is taking is the single most

important predictor of harm

Drug Treatment More Complex

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

Acute and chronic diseases



Prevention of many diseases



Correct medication



Correct dosage



Correct disease or condition for the correct patient



Other diseases



Other medications



Functional status



Adherence and beliefs



Affordability

Challenges of Geriatric Pharmacotherapy

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 More drugs are available each year  FDA and off-label indications are expanding  “January Effect” – Formularies change frequently  Knowledge of drug-drug interactions advances  Drugs change from prescription to OTC  “Nutraceuticals” are booming – Herbals and nutritional

supplements

Realities of 2019

 Polypharmacy may be indicated  Heart Failure: 3-5 medications  Stringent blood pressure control  Diabetes Mellitus: 3-5 medications  Medication reconciliation  Make list of all Conditions  Match ALL meds to a condition  Check meds after transitions of care  Meds are usually added or stopped  Inadvertently left out

Risk Factors for ADEs

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 6 or more concurrent chronic conditions  12 or more doses of drugs/day  9 or more medications  Prior adverse drug event  Low body weight or low BMI  Age 85 or older  Estimated CrCl < 50 ml/min

The REAL Question

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What is the APPROPRIATE medication for your patient?

Basics of Prescribing for The Elderly

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 Start with a low dose  Titrate upward slowly – as tolerated by the patient  Avoid starting 2 drugs simultaneously  Ask patient to bring in ALL medications – prescribed, OTC,

supplements, herbal

 Look for duplicate therapies  Eliminate unnecessary medications  Simplify dosing regimens

Prescribing a New Medication

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

Is this medication necessary?



What are the therapeutic endpoints?



Do the benefits outweigh the risks?



Is it used to treat effects of another drug?



Could 1 drug be used to treat 2 conditions?



Could it interact with diseases or other drugs?



Patient Education:

 What it’s for?  How to take it?  What ADEs to look for?

Beer's Criteria

Benefits and Challenges Changes for 2015 and 2019 Drugs to Avoid Use With Caution Drug-Disease/Syndrome Interactions Adverse Drug Interactions Optimal Use of Beers Criteria

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Audience Polling 2 Which of the following cardiac medication is on the Beers’ List?

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• 1. Atenolol
• 2. Metoprolol
• 3. Lisinopril
• 4. Amiodarone

Audience Polling 3 Which of the following antihypertensives is on the Beers’ List?

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• 1. Lisinopril
• 2. Metoprolol
• 3. Hydrochlorothiazide
• 4. Valsartan
• 5. Clonidine

Audience Polling 4 Which of the following diabetic drugs is NOT on the Beers’ List?

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• 1. Pioglitazone
• 2. Insulin Glargine
• 3. Sliding Scale Insulin
• 4. Rosiglitazone

Audience Polling 5 Which of the following is NOT on the Beers’ List?

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• 1. Temazepam
• 2. Zolpidem
• 3. Zaleplon
• 4. Eszopiclone
• 5. Trazodone

Intent of the AGS 2019 Beers Criteria

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Goals:

• Improve care by ↓ exposure to PIMS
• Educational tool
• Quality measure
• Not meant to be punitive
• Research tool

Purpose of Beer’s Criteria

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 Identify potentially inappropriate meds that should be avoided in

many older adults

 To reduce adverse drug events and drug-related problems  Improve medication selection and medication use in older adults  Designed for use in any clinical setting and for education, quality,

and research

Benefits and Challenges

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 Use of many medications has declined  Increased appreciation of special considerations when prescribing for

• lder adults

 Mistakenly believe Beer’s Criteria judge ALL uses of the listed meds is

universally inappropriate

 Some quality improvement programs have implicitly considered use of

these meds to be problematic

 Some prior authorization programs have misapplied Beer’s Criteria by

payors and clinicians

Not Included in Beer’s List

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 Drugs with risks not unique to elderly  Purpose is for PIMs specific to elderly  Drug-drug interactions  Not unique to elderly  List of alternatives  Too complex, requires patient-specific judgement

Previous Drugs to Avoid Dropped from 2012 AGS Beers Criteria

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• Off market

Cyclandelate

• Off market

Guanethidine, Guanadrel

• Off market

Propoxyphene

• New safety info

Stimulant laxative, chronic

• Not geriatric specific

FeSo4 325mg daily

• Risk not geriatric specific

Amphetamines/anorexics

• DDI risk not geri. specific

Cimetidine and Fluoxetine

• Weak ototoxicity evidence

Ethacrynic Acid

Drugs Rationale

2015 Changes

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• “Z” drugs for sleep: Avoid chronic use
• Testosterone: Avoid unless indicated for moderate to severe hypogonadism
• Topical vaginal estrogen: Acceptable low dose use for specific conditions
• Spironolactone: Avoid >25 mg/day in pts with heart failure or CrCl

<30

• Antipsychotics: Avoid unless nonpharm treatment has failed or threat to

self/others

• PPIs beyond 8 weeks: Bone loss, fractures, C. difficile, B12

FDA Black Box Warning, April 30, 2019

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 Serious injuries with insomnia meds  Sleep walking  Sleep driving  Activities while NOT fully awake  Eszopiclone  Zaleplon  Zolpidem  66 complex sleep behaviors – 20 being fatal

2019 Beers Changes

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 Medications Removed: Ticlopidine, Pentazocine,Vasodilators  H2-Blockers changed to avoid in delirium and dementia  Tramadol: Hyponatremia  Glimepiride: Prolonged hypoglycemia  SNRIs: Risk of falls  Aspirin: Prevention in age > 70  Rivaroxaban added to Dabigatran  TMP-SMX in reduced kidney function  Pregabalin and Gabapentin: Avoid with opioids

Beer’s Recommendations

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 Evidence-based  6 Categories

• 1. Drugs to avoid
• 2. Drugs to avoid with specific diseases or syndromes
• 3. Drugs to use with caution
• 4. Selected drugs whose dose should be adjusted based on kidney

function

• 5. Selected drug-drug interactions
• 6. Drugs with strong anticholinergic properties

Drugs to Avoid

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Organ System or TC or Drug Rationale Recommend Quality of Evidence Strength of Recommend Nitrofurantoin Pulmonary tox Alternatives Lack of efficacy <60 mL/min Avoid long term suppression; avoid if CrCl <60 mL/min Moderate Strong Antipsychotics (conventional or atypical) Increase CVA and CV mortality in dementia Avoid unless danger to self/others and non pharm has failed Moderate Strong Insulin, sliding scale Hypoglycemia risk Avoid Moderate Strong Chlorpropamide Glyburide Glimepiride Hypoglycemia risk Avoid High Strong

Drugs to Avoid

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Organ System or TC or Drug Rationale Recommend. Quality of Evidence Strength of Recommend. Benzodiazepines Short and long- acting Risk cognitive effects and injury (fall/MVA); rare use appropriate e.g., Benzo withdrawal Avoid for treatment

• f insomnia, agitation,
• r delirium

High Strong Megestrol Minimal effect on weight; risk of thrombotic events and death Avoid Moderate Strong Metclopramide EPS and TD Avoid, unless gastroparesis Moderate Strong Non-COX NSAIDs,

• ral

GI bleeding; Protection w/ PPIs or Misoprostol Avoid chronic use Moderate Strong

Drugs to Avoid

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Organ System or TC or Drug Rationale Recommend. Quality of Evidence Strength of Recommend. Non-Benzodiazepines Hypnotics (“Z” Drugs) Risk cognitive effects and injury (fall/MVA); same ADE as Benzo’s Avoid chronic use, >90 days Moderate Strong Estrogens with or w/o progestin Carcinogenic potential, lack of efficacy in dementia/CV disease prevention Avoid oral and topical patch. Topical cream safe and effective for vaginal symptoms High Strong Muscle Relaxants Ineffective at tolerated doses, antichol, falls Avoid Moderate Strong

Drugs to Avoid

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Organ System or TC or Drug Rationale Recommend. Quality of Evidence Strength of Recommend. Antidepressants, alone or with: Amitriptyline Desipramine Imipramine Doxepin > 6 mgQD Paroxetine Nortriptyline Highly anticholinergic, sedating, and cause

• rthostatic hypotension

Avoid High Strong Protein-pump Inhibitors Risk of C. difficile, bone loss, fractures, B12 Avoid scheduled us for > 8 wks unless for high- risk High Strong Androgens: Methyltestosterone TestosteroneAnd Potential for cardiac problems and do not use in prostate cancer Avoid unless confirmed hypogonadism Moderate Weak

Drugs to Avoid

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Organ System or TC

• r Drug

Rationale Recommend. Quality of Evidence Strength of Recommend. Peripheral Alpha-1 Blockers: Doxazosin, Prazosin, Terazosin High risk of orthostatic hypotension Avoid use as an antihypertensive Moderate Strong Central Alpha Blockers: Clonidine, Methyldopa, Reserpine High risk of adverse CNS effects, Avoid clonidine as first-line antihypertensive Low Strong Amiodarone Effective but is more toxic than other meds Reasonable in HF Avoid as first-line unless HF or LVH High Strong Nifedipine, immediate releasend Potential for hypotension, risk of myocardial ischemia Avoid High Strong

Drugs to Avoid

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Organ System, Category, or Drug Rationale Recommend Quality of Evidence Strength of Recommend. Anticholinergics Confusion, Dry Mouth, Decreased Clearance, Constipation Avoid Moderate Strong Antispasmodics Highly Anticholinergic Uncertain Effectiveness Avoid Moderate Strong Barbiturates High Rate of Physical Dependence, Tolerance Avoid High Strong Digoxin for AF & HF Should Not Be Used as First-line Avoid Low Strong in Dose >0.125 mg/Day

Use With Caution

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Drug Rationale Recommend Quality of Evidence Strength of Recommend Dabigatran Rivaroxaban Risk of Bleeding Lack of Evidence if CrCl>30ml Use With Caution if > 75 CrCl < 30 ml Moderate Weak Drugs Linked to SIADH: SSRI,TCA,CBZ, antipsychotics May exacerbate SIADH Monitor Use with Caution Moderate Strong TMP-SMX Increased > K with ACE/ARB Use with Caution and Decreased CrCl Low Strong Prasugrel Increased Risk of Bleeding Use With Caution > 75 Moderate Strong Dextromethorphan/ Quinidine Limited Efficacy Increase Falls Not PB Affect Use With Caution Moderate Strong

Drug-disease/Syndrome Interactions

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Disease or Syndrome Drug Rationale Recomm. Quality of Evidence Strength of Recomm. Syncope AChEIs Peripheral α- blockers

• Tert. TCAs

Chlorpromazine Thioridazine Olanzapine Orthostatic hypotension or bradycardia Avoid α- blockers: High TCAs, AChEIs, antipsych: Moderate AChEIs,TCAs: Strong α- blockers, antipsych.: Weak Insomnia Oral decongestants Stimulants Theobromines CNS stimulant effects Avoid Moderate Strong

Drug-disease/Syndrome Interactions

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Disease or Syndrome Drug Rationale

• Recomm. Quality of

Evidence Strength of Recomm. Heart Failure NSAIDs & COX-2 Diltiazem Verapamil Thiazolidinediones Cilostazol Dronedarone Promote Fluid Retention and exacerbate HF Avoid NSAIDs: Mod CCBs: Mod Thiazolidinediones: High Cilostazol: Low Dronedarone: High Strong Parkinson’s Disease All antipsychotics Except: Aripiprazole, Quetiapine, Clozapine Antiemetics: Metoclopramide Prochlorperazine Promethazine Dopamine- receptor antagonists with potential to worsen Parkinsonian symptoms Avoid Moderate Strong

Drug Disease/Syndrome Interactions

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Disease or Syndrome Drug Rationale Recommend Quality of Evidence Strength of Recommend Falls/Fractures Antiepileptics Antipsychotics Benzos “Z” Drugs Antidepressant Opioids Ataxia Syncope Impaired Additional Falls Avoid Unless Safer Alternatives not Available Avoid Opioids: Moderate Others: High Strong Delirium Anticholin. Antipsychotics Corticosteroid H2-Receptor Meperidine “Z” Drugs Avoid Avoid Unless Nonpharm Failed Risk of CVA Avoid H2-Receptor Antagonists: Low All Others: Moderate Strong Dementia Anticholin. Benzos “Z” Drugs Adverse CNS Effects Avoid Unless Nonpharm Failed Avoid Moderate Strong

Drug Disease/Syndrome Interactions

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Disease or Syndrome Drug Rationale Recommend Quality of Evidence Strength of Recommend HX Gastric/Duodenal Ulcers Aspirin>325 Nonselective NSAIDS Exacerbate Ulcers or New Ulcers Avoid Unless Other Altern. are not Effective Moderate Strong Chronic Kidney Disease <30 ml/min NSAIDS May Increase Risk Avoid Moderate Strong Urinary Inc. Estrogen Oral & Transdermal Peripheral Alpha-1 Blockers Lack of Efficacy Avoid inWomen Estrogen: High Peripheral alpha-1 Blockers: Moderate Strong for Both Lower UT SX BPH Strong Anticholinergic Drugs Decrease Urinary Flow and Urinary Retention Avoid in Men Moderate Strong

Adverse Drug Interactions that Increase the Risk

• f Harm

Combination Risk ACE-inhibitor + Potassium-sparing Diuretic Hyperkalemia Anticholinergic + Anticholinergic Cognitive decline Calcium Channel Blockers + Erythromycin or Clarithromycin Hypotension and shock Concurrent use of ≥3 CNS active drugs Falls and fractures Digoxin + Erythromycin, Clarithromycin, or Azithromycin Digoxin toxicity Lithium + Loop Diuretics or ACE-inhibitor Lithium toxicity Peripheral Alpha1 Blockers + Loop Diuretics Urinary incontinence in women Phenytoin + SMX/TMP Phenytoin toxicity

Adverse Drug Interactions that Increase the Risk of Harm

Combination Risk Sulfonylureas + SMX/TMP , Ciprofloxacin, Levofloxacin, Erythromycin, Clarithromycin, Azithromycin, and Cephalexin Hypoglycemia Tamoxifen + Paroxetine (other CYP2D6 inhibitors) Prevention of converting tamoxifen to its active moiety, resulting in increased breast cancer-related deaths Theophylline + Ciprofloxacin Theophylline toxicity Trimethoprim (alone or as SMX/TMP) + ACE- inhibitor or ARB or Spironolactone Hyperkalemia Warfarin + SMX/TMP , Ciprofloxacin, Levofloxacin, Gatifloxacin, Fluconazole, Amoxicillin, Cephalexin, and Amiodarone Bleeding Warfarin + NSAIDs GI bleeding

Optimal Use of Beers Criteria

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• 1. Medications are potentially inappropriate not definitely inappropriate
• 2. Read the rationale and recommendations for each criteria
• 3. Understand why meds are included on the Beers List
• 4. Identify potentially inappropriate meds and offering safe

nonpharmacologic and pharmacologic

• 5. Beers is a starting point for a comprehensive process
• 6. Access to meds on the Beers List should not be excessively restricted

by prior authorization or health plan coverage policies

• 7. Beers Criteria are not equally applicable to all countries

Beers Criteria Apps

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STOPP/START

History START Criteria Commonly Underprescribed Medications STOPP Criteria Commonly Overprescribed Medications

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History

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 Version 1 released in 2008  Updated in 2014 as Version 2  STOPP meds are associated with adverse drug events  STOPP/START applied at a single time point during hospitalization for

acute illness improved appropriateness

 STOPP/START as an intervention applied within 72 hours of admission

reduce ADRs and average length of stay

 Absolute risk reduction 9.3% (NNT=11)  31% increase in STOPP/START criteria in Version 2

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 Screening tool to alert doctors to right treatment (START)  Individualize therapy  Not appropriate for every patient  May not provide medical benefit  Systems-based Tool: Errors of omission  STOPP (Screening Tool of Older People’s Potentially Inappropriate

Prescriptions)

 Similar to Beers  Different Approach: Drug-drug and Drug-disease

Helpful Approaches

START Criteria

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

Cardiovascular

 Warfarin or NOACs for chronic Atrial Fibrillation  Aspirin for Atrial Fibrillation with Warfarin/NOACS contraindication  Antiplatelet RX for CAD, CVD, and PVD  Antihypertensive rx for Systolic BP >160 and Diastolic >90  Statins for secondary prevention (CAD, CVD, and PVD)  ACE for Heart Failure or after MI  Beta-Blocker for chronic stable angina and systolic Heart Failure 

Endocrine

 Metformin for Type 2 Diabetes  ACE/ARB for Diabetes and Nephropathy  Antiplatelet and Statin for Diabetes and CVD

…START Criteria

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

Gastrointestinal

 PPI for severe GERD or esophageal stricture  Fiber supplement for chronic symptomatic diverticular 

Musculoskeletal

 DMARD for moderate and severe Rheumatoid Arthritis  Bisphosphonates and Vitamin D for chronic oral steroids  Calcium and Vitamin D for Osteoporosis and T-Score >-2.5  Bone antiresorptive or anabolic rx for Osteoporosis  Vitamin D in housebound or experiencing falls or Osteopenia  Xanthine-oxidase Inhibitors for recurrent gout  Folic Acid supplementation in patients taking Methotrexate

More on START

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 Nervous System

 Levodopa for Parkinson’s Disease with functional impairment  Non-TCA antidepressant for persistent Major Depression symptoms  Acetyl Cholinesterase Inhibitor for mild-moderate Alzheimer’s  Topical Prostaglandin or Beta-Blocker for open-angle Glaucoma  SSRI or SNRI for persistent Anxiety interfering with function  Dopamine-Agonist for Restless Legs Syndrome

 Respiratory

 Daily inhaled Beta-Agonist or Antimuscarinic for mild-moderate Asthma or COPD  Daily Inhaled Steroid for Asthma or COPD with FEV1<50% of predicted value and

repeated requiring oral corticosteroids

 Continuous home oxygen for chronic hypoxemic respiratory failure: pO2 < 60 mm

Hg

Final START

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

Urogenital System

 Alpha-1 Receptor Blocker with symptomatic prostatism  5-Alpha Reductase Inhibitor with symptomatic prostatism  Topical Vaginal Estrogen for symptomatic atrophic vaginitis 

Analgesics

 High-potency opioids in moderate-severe pain where Acetaminophen,

NSAIDS, or low-potency not effective

 Laxatives in patients receiving opioids regularly 

Vaccines

 Seasonal Trivalent Influenza Vaccine annually  Pneumococcal Vaccine at least once after age 65

Commonly Under Prescribed Drugs

 ACE-inhibitors for patients with diabetes and proteinuria  Angiotensin-receptor blockers  Anticoagulants  Antihypertensives and diuretics for uncontrolled hypertension  B-blockers for patients after MI or with heart failure  Bronchodilators  Proton-pump inhibitors or misoprostol for GI protection from NSAIDs  Statins  Vitamin D and Calcium for patients with or at risk of osteoporosis

STOPP

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 More flexible  Designed to be used with START  Indication of medication  Any drug without an evidence-based clinical indication  Any drug prescribed beyond the recommended duration  Any duplicate drug class prescription (2 NSAIDS)  Highlights of some clinical situations  Amiodarone may be only effective drug for arrhythmia  Doxazosin in resistant hypertension  Nitrofurantoin may be only drug sensitive to pathogen

Cardiovascular System

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

Digoxin for heart failure with normal systolic ventricular function



Loop Diuretic: Ankle edema and hypertension with UI



Thiazide with hypokalemia and gout



B-Blocker with bradycardia



Verapamil/Diltiazem in Class III or IV heart failure



Amiodarone as first-line in SVT



B-Blocker with Verapamil/Diltiazem



Central-acting antihypertensives unless clear intolerance with other meds



ACE-inhibitors or ARBs in hyperkalemia



Aldosterone Antagonists with concurrent Potassium-conserving drugs



Phosphodiesterase Type-5 Inhibitors in heart failure with hypotension or concurrent use of nitrate rx

Antiplatelet/Anticoagulation

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 Long-term ASA >160 mg  ASA in PUD without PPI  ASA, Clopidogrel, NOACs

Dipyridamole, Vit K Antagonists with significant bleeding risk

 ASA + Clopidogrel as

secondary Stroke prevention

 ASA with Warfarin or NOACs

in chronic Atrial Fibrillation

 Clopidogrel with Vit K or NOACs with

CAD/PVD

 Ticlid in any circumstances  Vit K or NOACs for DVT without risk

factors > 6 mos.

 Vit K or NOACS for 1st PE without risk

factors > 12 M

 Combination of NSAID, Vit K, and

NOACs

 NSAID with antiplatelet without PPI

prophylaxis

CNS and Psychotropic

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

TCAs in dementia, glaucoma, cardiac conduction abnormalities, prostatism, and history of urinary retention



TCAs for first-line Antidepressant rx



Long-acting Benzos >1 month



Anticholinergics/Antimuscarinic in delirium, dementia, prostatism, UR



ACE-Inhibitors with syncope, bradycardia, diltiazem, digoxin verapamil



Long-term neuroleptics in Parkinsonism



Anticholinergic rx EPS of neuroleptics



SSRIs in history hyponatremia



First generation antihistamines



Phenothiazines as first-line



Neuroleptics >1 month as a hypnotic



Levodopa/dopamine agonists for benign essential tremor



Neuroleptic antipsychotic for dementia behavior unless severe

More on STOPP

Ur Urogenital

• genital

Endocrine Endocrine

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 Antimuscarinic: Dementia  Antimuscarinic: Glaucoma  Antimuscarinic: Prostatism  Alpha Blockers: Symptomatic

• rthostatic hypotension or

micturition syncope

 Long-acting sulfonylureas  Thiazolidenediones in heart failure  Beta Blockers in DM and frequent

hypoglycemia

 Estrogens: History of breast cancer

• r DVT

 Estrogens without Progesterone with

intact uterus

 Androgens in absence of primary or

secondary Hypogonadism

STOPP on Systems

Gastr Gastroint

• intestinal

estinal Respirat espiratory

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

Drugs likely cause constipation in chronic constipation



Prochlorperazine or metoclopramide in Parkinsonism



Full dose PPI >8 weeks



Oral elemental iron doses > 200 mg daily



Theophylline monotherapy for COPD



Systemic steroids instead of inhaled steroids for maintenance in moderate- severe COPD



Nebulized ipratropium in glaucoma or bladder outflow obstruction



Nonselective B-Blocker in Asthma



Benzos with Acute Respiratory Failure

Musculoskeletal System

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 NSAIDs: PUD or GI Bleed  NSAIDs: Severe Hypertension or

Heart Failure

 NSAIDs >3 months for mild joint

pain without acetaminophen

 Corticosteroids for osteoarthritis  Cox-2 selective NSAIDs with

concurrent CV

 NSAIDs with corticosteroids

without PPI

 Long-term corticosteroids >3

months for monotherapy for Rheumatoid Arthritis

 Long-term NSAID/Colchicine for

chronic rx of gout with NO contraindication to Allopurinol

 Oral Bisphosphonates with current

• r recent history of UGI Disease

Renal System

62

 Digoxin at a long-term dose >1.25 mg Q daily if eGFR <30 ml/min  Dabigatran if eGFR <30 ml/min  Factor Xa Inhibitors (Rivaroxaban, Apixaban) if eGFR <15 ml/min  NSAIDs if eGFR <50 ml/min  Colchicine if eGFR <10 ml/min  Metformin if eGFR <30 ml/min

More STOPP Conditions

Pr Prone t

• ne to F

Falls lls Analgesic Drugs Analgesic Drugs

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 Benzodiazepines  Neuroleptic drugs  Vasodilator drugs: Postural

hypotension

 Hypnotic “Z” Drugs: Prolonged

sedation and ataxia

 Long-term opiates as first-line rx

in mild-moderate

 Regular opiates without

concomitant laxative

 Long-acting opiates without

short-acting opioids for breakthrough pain

Commonly Over Prescribed and Inappropriately Used Drugs

• Androgens/testosterone
• Anti-infective agents
• Anticholinergic agents
• Urinary and GI antispasmodics
• Antipsychotics
• Benzodiazepines
• Nonbenzodiazepine hypnotics
• Digoxin as first-line for Afib or

heart failure

• Dipyridamole
• H2 receptor antagonists
• Insulin, sliding scale
• NSAIDs
• Proton-pump inhibitors
• Sedating antihistamines
• Skeletal muscle relaxants
• Tricyclic antidepressants

Deprescribing

Systemic Process Brown Bag Test Describe 5 Step Process: Harms vs. Benefits Explain and Agree with Management Plan

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Definition

66

 Systemic Process of identifying and discontinuing drugs in instances in

which existing or potential harms outweigh existing or potential benefits within the

 Context of an individual patient’s care goals  Current level of functioning  Life expectancy  Values  Preferences  Not about denying effective treatment to eligible patients  Review demonstrated safety of withdrawing antipsychotics in dementia in

>80%

5 Step Protocol

67

• 1. Ascertain all drugs the patient is currently taking
• 2. Consider overall risk of drug-induced harm
• 3. Assess each drug for discontinuation
• 4. Prioritize drugs for discontinuation
• 5. Implement and monitor drug discontinuation

STEP 1

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 Ask patient to bring ALL drugs  Prescribed, complimentary, and alternative  Bring drug delivery aids  Do not forget OTC, supplements, and herbals

 Brown Bag Test

 Ask about prescribed drugs not being taken  Ask reason for each drug

Step 2

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 Ascertain and assess risk  Number of drugs (single most important predictor)  High-risk drugs  Past or current toxicity  Patient factors  Age >80  Cognitive impairment  Multiple comorbidities  Substance abuse  Multiple prescribers  Past or current nonadherence

Step 3

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 Assess each drug for its eligibility to be discontinued  No valid indication  Part of a prescribing cascade  Potential harm of drug clearly outweighs benefit  Disease/symptom control drug is ineffective, or symptoms have

completely resolved

 Preventive drug is not beneficial over patient’s lifespan  Drugs are imposing unacceptable treatment burden  “Since you started this medicine, has it made such a difference to how

you feel that you would prefer to stay on it?”

Step 4

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 Deciding the order of discontinuation of drug may depend on three

pragmatic criteria

• 1. Those with the greatest harm and least benefit
• 2. Those easiest to discontinue, lowest likelihood of withdrawal

reactions or disease rebound

• 3. Those the patient is most willing to discontinue first

 Rank drugs from high harm/low benefit to low harm/high benefit

Step 5

72

 Implement/monitor drug discontinuation regimen  Explain and agree with patient on management plan  Stop 1 drug at a time so that harms and benefits can be attributed to

specific drugs and rectified

 Wean patients off drugs more likely to cause adverse withdrawal

effects

 Communicate plan to all health professionals and family  Fully document the reasons of describing

Strategies Assisting in Prescribing

73

 What are the treatment options (including nondrug options) for my

condition?

 What are possible benefits and harms of each treatment?  What might be reasonable grounds for discontinuing use of a drug?  Are you experiencing any adverse effects?

Cases

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Case 1

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 Husband of an 82-year-old woman calls because his wife’s behavior has

changed over the last few days. She is confused and becomes agitated when he assists with ADLs. She will not eat because she thinks she is being poisoned.

 History of hypertension, depression, osteoarthritis, Alzheimer’s, and

urinary incontinence. SLUMS score was 22/30 2 months ago.

 Meds: Acetaminophen 325 QID, Donepezil 5 mg QD, Memantine ER

14 mg, HCTZ 25 mg QD, Lisinopril 10 mg QD, Citalopram 20 mg QD, and Tolterodine 2 mg BID

 Tolterodine was increased 1 week ago

Case 1, Continued

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 A visiting nurse obtains laboratory samples later that day  Lab values are:  BUN = 18  Serum creatinine = 1.1  Sodium = 138  Glucose = 81  Urinalysis: 0-5 WBCs, negative for bacteria and leukocyte

esterase

Audience Polling 6 What is most appropriate currently?

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• 1. Discontinue Tolterodine
• 2. Increases Memantine ER to 28 mg QD
• 3. Start Lorazepam 0.5 mg BID
• 4. Start Risperidone 0.25 mg

Case 2

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 80-year-old woman fell and underwent repair of hip fracture 3 days ago.

She now reports dizziness and has excessive daytime drowsiness.

 History: Hypertension, frequent falls, post-herpetic neuralgia  Pre-admission Meds: HCTZ 12.5 mg QD, Metoprolol 50 mg QD,

Amlodipine 10 mg QD, Gabapentin 600 mg TID, Calcium Carbonate 500 mg TID

 Meds started after surgery: Enoxaparin 30 mg QD, Docusate 250 mg

BID, Senna 8.6 mg BID, Oxycodone 5-15 mg every 4 hours, she has received two 10 mgm doses in last 24 hours

Case 2, Continued

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 Weight 45 kg (99 lb.)  Blood Pressure 144/76  No orthostatic changes  Estimated Creatinine clearance is 30 ml/min  Two months ago estimate GFR was 60 ml/min

Audience Polling 7 What is the best next step now?

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• 1. Discontinue Oxycodone
• 2. Increase Enoxaparin to 30 mgm BID
• 3. Reduce Gabapentin to 600 mg BID
• 4. Start Alendronate 70 mg once weekly

Case 3

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 79-year-old woman comes to ER with a history of anxiety of 2-3 weeks.

Family reports worsening confusion and disorientation along with behavior problems. Her symptoms were initially attributed to her dementia but then accelerated. History includes dementia and hypertension.

 On exam, she is combative and disoriented. Lab reveals low sodium.

Urine sodium level and osmolarity are increased.

Audience Polling 8 Which of the following meds is most likely cause of her hyponatremia?

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• 1. Donepezil
• 2. Paroxetine
• 3. Memantine
• 4. Lisinopril

Case 4

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 80-year-old man had repair of hip fracture a day ago. History of

hypertension, Type 2 Diabetes, and CKD. Findings on exam are normal including a negative CAM screen for delirium. Weight is 132 lb. Creatinine is 2 mg/dl and GFR is 25ml/min.

Audience Polling 9 What is the most appropriate prophylaxis for DVT?

84

• 1. Enoxaparin 30 mgm SQ BID
• 2. Enoxaparin 30 mgm SQ daily
• 3. Aspirin 160 mgm daily
• 4. Intermittent pneumatic compression device

SUMMARY

Warning Light Engage The Whole Patient

85

Warning Light

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 Beers and STOPP is a warning light  Warning light should make you stop and think  Why is the patient taking the drug?  Are there safer and/or more effective alternatives?  Does my patient have characteristics that increase or mitigate risk of

this medication?

 Keep in mind there are situations in which use of Beers STOPP meds

are justified and appropriate

Engage

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 Actively inquire about symptoms that could be adverse drug effects  Do not automatically defer to colleagues  Just because another clinician prescribed a Beers/STOPP med

doesn’t mean it is safe and/or effective

 Use the opportunity to discuss with colleagues whether that

medication is right for the patient

 Deprescribing unnecessary medications: A four-part process. FPM.

May/June 2019, pp 28-32.

The Whole Patient

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 Don’t let Beers/STOPP distract you from closely attending to other

elements of prescribing that are not addressed by the criteria

 Issues  Other high-risk meds  Medication adherence  Unnecessary med use  Underuse of medications

One Final Thought

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Use Clinical Common Sense

Resources

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 Pharmacotherapy. Geriatrics Review Syllabus 10th Edition. 2019  Pharmacotherapy. Geriatrics Review Syllabus Teaching Slides. 2019  American Geriatrics Society, 2015 Updated Beers Criteria for

Potentially Inappropriate Medication Use in Older Adults. JAGS. DOI: 10.111/jgs13702.

 O’Mahoney. STOPP/START Criteria for Potentially Inappropriate

Prescribing in Older People: Version 2. Age and Ageing. 2015; 44:213- 218.

Resources

92

 Pretorius. Reducing the Risk of Adverse Drug Events in Older Adults. Am

Fam Phy. March 1, 2013; 87: 331-36.

 Appropriate Use of Polypharmacy for Older Patients. Cochran for Clinicians.

Am Fam Phy. April 1, 2013; 87: 483-4.

 American Geriatrics Society 2019 Updated AGS Beers Criteria for

Potentially Inappropriate Medication Use in Older Adults. JAGS. 00:1-21, 2019.

 Using Wisely: A Reminder on the Proper Use of the American Geriatrics

Society Beers Criteria. JAGS. 00:1-3, 2019

 Scott Ian. Reducing Inappropriate Polypharmacy: The Process of Describing.

JAMA Internal Medicine. Published online March 23, 2015.

Case 5

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 76-year-old man presents with constant itching all over his body for last

6 months. Itching is worse on back and extremities. OTC moisturizers provide moderate relief. He can identify no alleviating or exacerbating factors.

 He is not distressed. Sclera are anicteric. Linear erosions on the back

with sparing of areas that the patient cannot reach. Dryness and xerotic scale are diffuse. No evidence of a primary eruption.

Audience Polling 10 Which one of the following meds is the likely cause

• f this sebostatic and xerotic pruritus?

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• 1. Atenolol
• 2. Acetaminophen
• 3. Tramadol
• 4. Trimethoprim-Sulfamethoxazole

Case 6

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 82-year-old woman comes for her annual visit. She asks is she could stop

taking any of her meds. History of heart failure, CAD, hyperlipidemia, hypertension, and osteoporosis. Meds are Amlodipine 5 mg/d, Enalapril 5 mgm BID, Furosemide 10 mg/d, Vitamin D 2000 IU/d, Levothyroxine 100 mcg/d, Metoprolol 50 mg/d, and Rosuvastatin 10 mg/d.

 Pulse is 72 sitting and 74 standing. BP is 112/70 sitting and 109/65

• standing. Over last 6 months, systolic BP has ranged from 105 to 113

while diastolic BP has ranged from 68 to 72. GFR is 50ml/min.

Audience Polling 11 Which one of the following meds can be safely discontinued at this time?

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• 1. Amlodipine
• 2. Metoprolol
• 3. Enalapril
• 4. Furosemide

Case 7

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 The daughter of 79-year-old woman calls the clinic because her mother

has been more confused and agitated for the past 3 days. She refused dinner last night because of fear of being poisoned. History includes hypertension, depression, Alzheimer’s, and urinary incontinence. Her meds are Donepezil 10 mg/d, HCTZ 12.5 mg/d, Lisinopril 10 mg/d, Mirabegron 50 mg/d, and Citalopram 20 mg/d. She has had URI congestion for a week and has taken Ibuprofen PM 1 prn for cold symptoms.

 GFR is 36 ml/min.

Audience Polling 12 Which one of the following is the most appropriate intervention to address the new symptoms?

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• 1. Increase Citalopram to 30 mg/d
• 2. Discontinue Mirabegron
• 3. Discontinue Ibuprofen PM
• 4. Start Risperidone 0.25 mg/d