A Bag Full of Pills: Polypharmacy in the Elderly Texas Family Medicine Symposium Dale C. Moquist, MD June 8, 2019 1
Speaker Disclosure • Dr. Moquist has disclosed that he has no actual or potential conflict of interest in relation to this topic. 2
Learning Objectives 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. 5
Outline Overview Update on 2019Beers START/STOPP Deprescribing Cases Summary 6
Overview Complexity Challenges Basics of Prescribing 7
Audience Polling 1 What % of prescriptions in U.S. is bought by people >age 65? 1. 10% 2. 20% 3. 33% 4. 40% 5. 50% 8
Importance of Geriatric Pharmacotherapy 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. Slide 9
Polypharmacy 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 10
Drug Treatment More Complex 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 11
Challenges of Geriatric Pharmacotherapy 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 12
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 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 14
The REAL Question What is the APPROPRIATE medication for your patient? 15
Basics of Prescribing for The Elderly 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 16
Prescribing a New Medication 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? 17
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 18
Audience Polling 2 Which of the following cardiac medication is on the Beers’ List? 1. Atenolol 2. Metoprolol 3. Lisinopril 4. Amiodarone 19
Audience Polling 3 Which of the following antihypertensives is on the Beers’ List? 1. Lisinopril 2. Metoprolol 3. Hydrochlorothiazide 4. Valsartan 5. Clonidine 20
Audience Polling 4 Which of the following diabetic drugs is NOT on the Beers’ List? 1. Pioglitazone 2. Insulin Glargine 3. Sliding Scale Insulin 4. Rosiglitazone 21
Audience Polling 5 Which of the following is NOT on the Beers’ List? 1. Temazepam 2. Zolpidem 3. Zaleplon 4. Eszopiclone 5. Trazodone 22
Intent of the AGS 2019 Beers Criteria Goals: • Improve care by ↓ exposure to PIMS • Educational tool • Quality measure • Not meant to be punitive • Research tool 23
Purpose of Beer’s Criteria 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 24
Benefits and Challenges Use of many medications has declined Increased appreciation of special considerations when prescribing for older 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 25
Not Included in Beer’s List 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 26
Previous Drugs to Avoid Dropped from 2012 AGS Beers Criteria Drugs Rationale • Off market Cyclandelate • Off market Guanethidine, Guanadrel • Off market Propoxyphene Stimulant laxative, chronic • New safety info • 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 27
2015 Changes • “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 28
FDA Black Box Warning, April 30, 2019 Serious injuries with insomnia meds Sleep walking Sleep driving Activities while NOT fully awake Eszopiclone Zaleplon Zolpidem 66 complex sleep behaviors – 20 being fatal 29
2019 Beers Changes 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 30
Beer’s Recommendations 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 31
Drugs to Avoid Organ System or Rationale Recommend Quality of Strength of TC or Drug Evidence Recommend Nitrofurantoin Pulmonary tox Avoid long term Moderate Strong Alternatives suppression; avoid if Lack of efficacy <60 CrCl <60 mL/min mL/min Antipsychotics Increase CVA and CV Avoid unless danger Moderate Strong (conventional or mortality in dementia to self/others and atypical) non pharm has failed Insulin, sliding scale Hypoglycemia risk Avoid Moderate Strong Chlorpropamide Hypoglycemia risk Avoid High Strong Glyburide Glimepiride 32
Drugs to Avoid Organ System or Rationale Recommend. Quality of Strength of TC or Drug Evidence Recommend. Benzodiazepines Risk cognitive effects Avoid for treatment High Strong Short and long- and injury (fall/MVA); of insomnia, agitation, acting rare use appropriate or delirium e.g., Benzo withdrawal Megestrol Minimal effect on Avoid Moderate Strong weight; risk of thrombotic events and death Metclopramide EPS and TD Avoid, unless Moderate Strong gastroparesis Non-COX NSAIDs, GI bleeding; Protection Avoid chronic use Moderate Strong oral w/ PPIs or Misoprostol 33
Drugs to Avoid Organ System or Rationale Recommend. Quality of Strength of TC or Drug Evidence Recommend. Non-Benzodiazepines Risk cognitive effects Avoid chronic use, Moderate Strong Hypnotics (“Z” and injury (fall/MVA); >90 days Drugs) same ADE as Benzo’s Estrogens with or Carcinogenic potential, Avoid oral and High Strong w/o progestin lack of efficacy in topical patch. dementia/CV disease Topical cream safe prevention and effective for vaginal symptoms Muscle Relaxants Ineffective at tolerated Avoid Moderate Strong doses, antichol, falls 34
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