Transcript When to Spare Some Pharmaceutical Care

When to Spare Some
Pharmaceutical Care
Jovino Hernandez PharmD
Clinical Manager
Winter Haven Hospital Pharmacy
Services
Goals
Recognize the incidence of polypharmacy
Identify The Risk Associated with
Polypharmacy
Classify Agents that Pose the Most Risk to
the Elderly Population
Develop Strategies to Decrease
Polypharmacy
Introduction
All drugs can be considered “poisons”
The more we ingest, the more apt we are
to have issues
Clinical guidelines often call for multiple
medications
Appropriate medication use beneficial to
patients
Challenge is not to tip the scale toward
adverse events
What is Polypharmacy?
Usually described numerically as five or
more prescribed medications at any time
European Project AgeD in Home Care
(ADHOC) uses 9 or more medications
or
Administration of more medications than
clinically indicated
Our Aging Population
Chronic Diseases are on the rise
Multiple Medications are often used to
treat chronic illness
Sharp rise in aging population
300% Rise in elderly disabled in North
America by 2050
Average North American over the age of
60 years has 2.2 chronic diseases
Our Aging Population
Statistics
Statistics
Statistics
Average elderly patient in community
consumes 4 medications daily
Average elderly patient in a nursing home
consumes 7 medications on average
Risk Factors
 Advanced Age
 13% of US population
 Account for 33% of prescription and 40% on nonprescription use
 Female
 57% of women greater than 65 years take at least 5 medications
 12% take at least 10
 Low Education Level
 Multiple Morbidities
 Average adult over 60 years has 2.2 chronic conditions
 Often based off of evidence based medicine
 Core Measures
 Depression
 Multiple Prescribers
 Frailty
Risk Factors (Prescriber)
Practice Environment
Low number of listed patients
High Workload
Low rate of admission to hospital
High practice prescribing rate
High average number of prescribed
medications
Lower prevalence in female prescribers
No association with age or duration of practice
Risk Factors (Prescriber)
Medical Guidelines
Intended to support physicians in their drug
choice
Usually focus on one disease state
Tend generate more drug therapy especially
when compounded
Examples: CHF, AMI, COPD
Risk Factors (Prescriber)
Prescribing Habits
Dominate perception that diseases should be
treated with drugs
A visit to a provider should end with a
prescription
Can lead to a medical cascade of prescribing
Risk Factors (Prescriber)
Physician Behavior
Failure to make a proper medical review
Poor communication amongst prescribers
Mistrust of guidelines that decrease
medications use (Antibiotics)
Risk Factors (Patient to Prescriber)
Good interaction essential
Reviews of entire medication list with
provider is essential
Personnel continuity
Multiple providers and pharmacies increase the
risk of polypharmacy
Risk
Polypharmacy Associated With
Poor Adherence
Inappropriate Prescribing
Adverse Drug Reactions
Drug Interactions
Geriatric Syndromes
Morbidity/Mortality
Poor Adherence
Nonfulfillment
Prescribed but never filled
Nonpersistence
Patients decides to stop taking without being
advised be health professional
Nonconforming
Incorrect Dosing
Skipping Doses
Incorrect times
Inappropriate Prescribing
 The use of medications that introduce a greater
risk of adverse drug-related events where a
safer, as-effective, alternative therapy is
available to treat the same condition.
 Includes
Use of medicines at a higher frequency
Longer then clinically necessary
Drug-Drug Interactions
Underuse of clinically relevant medications
Adverse Reactions
An unfavorable medical event related to
medication misuse or
Noxious or unintended response t
medication despite appropriate drug
dosage or prophylaxis, diagnosis or
therapy of medical conditions
Adverse Reactions
4.3 million ADR related health care visits
in 2005
Occur in up to 35% of elderly patients in
outpatient setting
Account for 10% of ER visits
Adverse Reactions
Higher amount of meds, higher rate of
ADRS
2 Meds 13%
5 Meds 58%
7 or more Meds 82%
Adverse Reactions
Most Common Classes
Cardiovascular
Diuretics
Anticoagulants
NSAIDs
Antibiotics
Hypoglycemic
Drug Interactions
Elderly at risk
Comorbidities
Nutritional Status
Number of drug interactions increase as
number of morbidities and medications
increase
Often more medications are added to treat
these issues that further complicate
problems
Geriatric Syndromes
Cognitive Impairments
Medications implicated in up to 39% of cases
Four or more medications added the day before
a delirium episode is a risk factor
Finnish Study on Cognitive Impairment
No Polypharmacy – 22% risk
Polypharmacy – 33% Risk
Excessive Polypharmacy – 54% Risk
Geriatric Syndromes
Cognitive Impairments (cont)
Delerium
Opiods
Benzodiazepines
Anticholinergics
Dementia
Benzodiazepine
Anticonvulsants
Anticholinergics
Tricyclic Antidepressants
Geriatric Syndromes
Falls
Increase morbidity and mortality
Cardiovascular, Psychotropic
Urinary Incontinence
Diuretics
Psychotropics
Opioids
Sedatives
Geriatric Syndromes
Nutrition
Associated with poorer nutritional status
Decreased intake of soluble and nonsoluble
fiber, fat soluble vitamins, B vitamins and
minerals
Increased intake of cholesterol, glucose and
sodium
Medications (Beers)
 Updated in 2012
 Goal
The goal of the 2012 AGS Beers Criteria is to improve
care of older adults by reducing their exposure to
potentially inappropriate medications (PIMs)
 Improving selection of drugs
 Evaluating patterns of drug use within population
 Educating on proper drug use
 Evaluating health-outcome, quality care, cost, and use
data
Medications (Beers)
Three Categories
Potentially inappropriate medications and
classes to avoid in older patients
potentially inappropriate medications and
classes to avoid in older adults with certain
diseases and syndromes
medications to be used with caution in
older adults
Beers Criteria for Potentially Inappropriate Use in Older Adults
Medication/Class
Rationale
Anticholinergics(diphenhydramine, hydroxyzine, promethazine
Clearance reduced, confusion, dry mouth, constipation.
Diphenhydramine ok for acute allergic reaction
Alpha1 blockers (doxazosin, prazosin, terazosin)
High risk of orthostatic
hypotension, alternative agents have superior risk/benefit
profile
Antiarrhythmic drugs (Class Ia, Ic,
III) (amiodarone, dronaderone, sotalol)
Rate control yields better balance of benefits than rhythm for
most older pts
Tricyclic Antidepressants (TCAs) (amitriptyline, doxepin >6mg/d,
imipramine
Sedation, orthostatic hypotension
Antipsychotics, first (conventional)and second (atypical) generation
(haloperidol, aripiprazole, olanzapine, risperidone, ziprasidone)
Increased risk of cerebrovascular
accident (stroke) and mortality in
persons with dementia
Benzodiazepines (alprazolam, lorazepam, temazepam, clorazepate,
chlordiazepoxide, diazepam, zolpidem (not quite a
benzodiazepine)
Increased sensitivity, delirium, cognitive impairment, falls.
May still be appropriate for some in
Beers Criteria for Potentially Inappropriate Use in Older Adults
Medication/Class
Rationale
Insulin, Sliding Scale
Higher risk of hypoglycemia without improvement in
hyperglycemia management regardless of care setting
Megestrol
Minimal effect on weight; increases risk of thrombotic events
and possibly death in older adults
Glyburide
Greater risk of hypoglycemia in older patients
Metoclopramide
Avoid, unless for gastroparesis
Meperidine
Not an effective oral analgesic in dosages commonly used;
may cause neurotoxicity; safer alternatives available
Indomethacin, Ketorolac
Increase risk of GI bleeding and PUD
Carisoprodol, Cyclobenzaprine
Poorly tolerated, sedation, questionable efficacy
Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May
Exacerbate the Disease or Syndrome
Disease or Syndrome
Drug
Rationale
Heart Failure
NSAIDs, COX-2 Inhibitors,
Diltiazam, Verapramil, Pioglitazone,
Rosiglitazone, Dronedarone
Potential to promote fluid retention and
exacerbate heart
failure
Syncope
Doxazosin, Prazosin, Terazosin
Increases risk of
orthostatic hypotension
Chronic seizures
or epilepsy
Bupropion, Olanzapine, Tramadol
Lowers seizure threshold
Delirium
TCAs, Anticholinergics,
Benzodiazepines, corticosteroids,
meperidine,
Avoid in patients with or at high risk for
delirium
Dementia and
cognitive
impairment
Anticholinergis, Benzodiazipines,
Zolpidem, Antipsychotics
CNS effects. Anitpsychotics -Increase
in stroke and mortality in persons with
dementia
History of falls or
fractures
Anticonvulsants,Antipsychotics
Benzodiazepines, Zolpidem,
TCAs and SSRIs
Ability to produce ataxia, impaired
psychomotor function,
syncope, and additional falls;
Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions
That May Exacerbate the Disease or Syndrome
Disease or
Syndrome
Drug
Rationale
Parkinson’s
disease
All antipsychotics except for
Quetiapine and Clozapine)
Antiemetics-Metoclopramide
Prochlorperazine, Promethazine
Dopamine receptor antagonists with
potential to worsen
parkinsonian symptoms.
History of gastric
or duodenal ulcers
Aspirin (>325 mg/d) Non–COX-2
selective NSAIDs May exacerbate
existing
May exacerbate existing ulcers or
cause new or additional ulcers
Urinary incontinence
(all types) in women
Estrogen oral and transdermal
(excludes intravaginal estrogen)
Aggravation of incontinence
Lower urinary
tract symptoms,
benign prostatic
hyperplasia
Ipratropium, Tiotropium,
Anticholinergics (except
antimuscarinics for urinary
incontinence)
May decrease urinary
flow and cause
urinary retention
Stress or mixed
urinary incontinence
Doxazosin, Prazosin, Terazosin
Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome
Interactions That May Exacerbate the Disease or Syndrome
Drug
Rationale
Recommendation
Dabigatran
Greater risk of bleeding than
with warfarin in adults 75 or
greater; lack o evidence for
efficacy and safety in
individuals with CrCl < 30
mL/min
Use with caution in adults
aged _75 or if CrCl < 30 mL/
min
Antipsychotics,
Carbamazepine,
Mirtazapine,
SSRIs, TCAs
May exacerbate or cause
syndrome of inappropriate
antidiuretic hormone
secretion (SIADH) or
hyponatremia; need to
monitor sodium level closely
when starting or changing
dosages in older adults due to
increased risk
Use with caution
Preventions
Barriers
Clinician uncomfortable with changing or
discontinuing
Particularly medication prescribed by another
clinician
Little evidence based support on discontinuing
medications
Patients psychologically or physical dependant
on medication
Discontinuing medication perceived as
inadequate care
Prevention
Barriers (cont)
Potential harms such as adverse drug
withdrawal events (ADWEs)
Clinically significant symptoms or signs likely caused
by medication cessation
Cardiovascular and CNS classes most common
Prevention
Considerations
Duration of each medication
Is there still an indication for each medication
Are indications consistent with current
guidelines
Adherence
If patient well without taking, pointless to continue
prescribing
Prevention
Prescribing cascade
Discontinuing medication may reveal adverse
effects of other therapies
Very little evidence to guide withdrawal
process for polypharmacy
A gradual tapering is often recommended
Prevention
Clinical Controlled Trials
Medication Reviews by pharmacist
Prescriber Education Programs
Academic detailing
Comprehensive geriatric assessments
Multidisciplinary interventions engaging
prescribers and pharmacists
Prevention
Nurses Role
Information
Instruction
Organization
Prevention
Information –Discuss with patients
Keep an accurate list of medications
Keep complete list of medical providers and
contact information
Post the name and telephone number of local
pharmacy
Prevention
Instruction: Teach patients about
Each medication, including name, appearance,
purpose and effects
Potential adverse effects and interactions of
each medication
Importance of contacting healthcare provider
with concerns and questions
Potential drug –related problems that warrant
emergency care
Prevention
Instructions (continued)
Importance of taking medications exactly as
directed
Importance of using only one pharmacy to
obtain drugs
Prevention
Organization: To help manage drugs
Avoid sharing medications
Store medication in secure dry area away from
sunlight
Refrigerate if necessary
Dispose of old medications properly
Prevention
No single approach extensively studied
Prescribing and impact on outcomes
inconsitent throughout studies
Best approach is probable a combined
approach
Patient needs to be involved in the
process
Where Are We Now?
Quebec 2004
March 2003 a rise of severe CDAD in
Montreal and regions in Quebec1
12 Hospitals studied over 6 months in
2004
1719 cases reviewed
Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associate
diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9
Quebec 2004
Age
Age (yrs)
Cases
No of Cases
per 1000
admissions
% Attributable
30-Day
Mortality Rate
<40
41-50
51-60
61-70
71-80
81-90
>90
76
85
181
272
523
458
114
3.5
11.2
20.0
24.4
38.3
54.4
74.4
2.6
1.2
3.2
5.1
6.2
10.2
14.0
Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of
Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med
2005;353:2442-9
Quebec 2004
Antibiotics
Antibiotic
Odds Ratio
Any Cephalosporin
3.8
1st Generation
2.4
2nd Generation
6.0
3rd Generation
3.0
Any Fluoroquinolone
3.9
Ciprofloxacin
3.1
Gatifloxacin/Moxifloxacin
3.4
Levofloxacin
0.6
Clindamycin
1.6
Macrolides
1.3
Penicillin w/β-Lactamase Inh
1.2
Carbapenems
1.4
Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of
Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med
2005;353:2442-9
Quebec 2004
 Attributed Mortality 6.9%
A previous Canadian study 6 years prior had 1.5%
mortality rate1
 All hospitals had the similar dominant strain (129
of 157 isolates or 82%)
 Among the 38 patients who acquired CDAD in
the community, 37% had NAP1/027
 Isolates of dominant strain resistant to all
quinolones but susceptible to clindamycin
Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of
Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med
2005;353:2442-9
NAP1/027 Strain
 Linked to several outbreaks in Canada, Britain,
US, and Netherlands.
 Has been around since 1984
Has become fluoroquinolone resistant since then
 Can produce 16 times more toxin A and 23
times more toxin B than standard strain
 Produces an extreme amount of spores
 Higher mortality and colectomies
 Has in many area become the dominate strain
Possibly due to severe diarrhea
Antibiotic trends
Florida
1998-20031
Codes as C. diff on discharge
34/100,000 to 70.2/100,000
• Biggest change from 2000-2001 (35.0 to 46.9)
Death among patients coded with C. Diff
94.8/1000 to 106.7/1000
• More than 80% of deaths were 75 or older
Authors felt the NAP1/027 was a contributing
factor
Sanderson, R A, Bendixsen O, Increasing Clostridium difficile morbidity and mortality, Florida hospitals, 1998-2003, Abstract 2006
Conference on Antimicrobial Resistance
Community-Acquired
 Definition controversial
Many have been in a health care facility recently
Local study showed that 79% of CDAD patients in
hospital acquired if considering 30 day readmission
criteria
 Young patients without a history of antibiotic use
becoming more common
Many have close contact with diarrheal CDAD1
 NAP1/027 is out in the community
1Centers
for Disease Control and Prevention. Severe Clostridium difficile-associated disease in populations previously at low risk—Four
States, 2005. MMWR Morb Mortal Wkly Rep 2005;54:1201-5
Risk Factors
(Hospitalized Patients)
 Increasing Age (excluding infancy)
Younger population is becoming more at risk
 Severity of Underlying Disease
 Non-surgical gastrointestinal procedures
 Presence of nasograstric tubes
 Anti-ulcer medications
 ICU Stay
 Length of Hospital Stay
 Antibiotics
Length of therapy
Multiple Antibiotics
Antibiotics
Fluoroquinolones
Originally considered a low risk
Readily available, particularly ciprofloxacin
Eliminates gram negative and anaerobic
Full resistance to the newer NAP1/027 strain
Appropriate use
 Use narrower spectrum where possible
 Minimize usage of “double coverage” Streamline
antibiotics as soon as possible
 Minimize the use of agents that are largely excreted in
the gut to minimize the selection of resistant gram
negatives and destroy gut flora
 Minimize use of agents that have significant
antianaerobic activity-spare gut anaerobes
 Shorten the length of therapy