Transcript Discontinuing Medications at the End of Life

Jennifer Good MD
Hospice Medical Director, Home Nursing Agency
Altoona, Pennsylvania
Mary Mihalyo BS, PharmD, RPh
Duquesne University
Pittsburgh , Pennsylvania
Objectives
 To understand that many medications that patients
are on for chronic illnesses may not be helpful late in
life.
 To understand that decisions for discontinuation must
be individualized and take into consideration the
patient’s goals of therapy, life expectancy and
risk/benefits of discontinuation (will depend on
comorbidities).
 To understand that there is little experimental data
dictating discontinuing medications in palliative care
patients.
Elizabeth N.
 Elizabeth N. is a 90 y/o woman who has been referred to
hospice following three hospitalizations in the last 2
months for refractory congestive heart failure. She is short
of breath with minimal exertion. She has decided that she
does not want to be readmitted to the hospital.
 Her current medications include furosemide, lisinopril,
carvedilol, spironolactone, warfarin, simvastatin, ASA,
alendronate and morphine sulfate PRN.
 Would it be appropriate to discontinue any of these
medications?
Specific considerations in
discontinuing medications
 Life-expectancy
 What is patient’s life expectancy?
 How long does it take to see a benefit from a given drug?
 Risk/benefit ratios
 For general population
 For given patient
 Patient’s goals of therapy
 Treatment targets (what is the treatment for)
Life-expectancy?
 Palliative Care vs. Hospice Care
 Expected life expectancy in hospice is < 6 months
 Expected life expectancy in palliative patients with
multiple chronic co-morbidities might be 12 months or
more
How long to see effect from
prescribed medication?
 How long does it take for medication to render effect?
 Analgesics—minutes to hours
 Bisphosph0nates for osteoporosis—months to years
 Tight glucose control in DM—years
 Statins?
Risk-benefit ratio?
 Benefits for general population
 NNT
 Benefits for given patient
 Controls symptoms
 Harms for general population
 NNH
 Harms for a given patient
 Adverse drug reactions
 Cost
 Treatment is not in line with overall goals of care
Patient’s goals of therapy?
 Prolong life
 Prevent morbidity
 Slow disease progression
 Prevent decline
 Comfort
Treatment targets?
 Primary prevention
 Secondary prevention
 Control chronic diseases
 Treat acute diseases
 Control symptoms
Medications to consider
discontinuing
 Cholesterol lowering therapy
 Anti-platelet agents
 Anti-coagulants
 Dementia medications
 Osteoporosis medications
Discontinuing statins
 What is risk of ACS or CVA upon discontinuing?
 ACS




Prevent 5 MIs in 100 patients treated for 5 years (secondary
prevention)
Decreased risk of death by 20 – 30% over 5 years
Patients have increased mortality if statin discontinued
during ACS (5% vs. 11%)
Immediate risk reduction—1 less MI in 100 patients treated for
one month after MI.
 CVA
Recommendations for
discontinuing statin
 Continue:
 Recent MI
 Recent CVA
 ? Symptoms of myocardial ischemia
 Discontinue:
 Patients on statin for primary prophylaxis
Anti-platelet Agents
 Aspirin
 Clopidogrel (Plavix ®)/Prasugrel (Effient®)
 ASA/Dipyridamole (Aggrenox ®)
Discontinuing anti-platelet agents
 Continue clopidogrel/ASA if:
 Bare metal stent in last 3 months
 Drug-eluting stent in last 12 months
 Recent TIA/CVA (if occurred while patient on ASA)
 Continue Aggrenox® if:
 Recent TIA/CVA (if occurred while patient on ASA)
 Continue ASA if:
 Used for secondary prevention in patients with h/o ACS or
CVA
 Used for primary prevention in high risk patient
 Recommend 81 mg/d
Anticoagulants
 Warfarin—most common indications:
 Chronic Atrial Fibrillation to prevent thromboembolic
complications
 Mechanical heart valves to prevent valve thrombosis and
thromboembolic complications
 Patients with history of venous thromboemboli (VTE)
 Dabigatran—a new oral direct thrombin inhibitor
 Non-valvular chronic Atrial Fibrillation
 Low molecular weight heparins
 Most commonly used long term in patients with VTE
and concomitant malignancy
Risk of Embolic Events in AF
 Risk is 2 – 18% year
 Risk based on CHAD2
score:
 Low risk = 0
 Moderate = 1
 High risk= ≥ 2
1
Gage BF. JAMA 285(22):2864 – 70.
CHAD2 Score
Stroke Risk %)1
0
1.9
1
2.8
2
4.0
3
5.9
4
8.5
5
12.5
6
18.5
Recommendation for Discontinuing
Warfarin/Dabigatran
 Continue in Atrial Fibrillation if:
 CHADs2 score of 5 – 6
 Prior CVA
 Mechanical valve (particularly if mitral/tricuspid
position)
 Continue in VTE if:
 VTE in last 3 – 6 months
 History of recurrent VTE
 VTE with concomitant malignancy (LMWH is probably
first choice as more efficacious)
Dementia medications
 Cholinesterase inhibitors—indicated for mild to
moderate dementia
 Donepezil (Aricept®)
 Rivastigment (Exelon®)
 Galantamine (Razadyne®)
 NMDA receptor antagonist—indicated for moderate to
severe dementia
 Memantine (Namenda®)
Recommendations for discontinuing
dementia medications
 Patients in hospice have dementia more severe than
what drug therapy is indicated for
 Expensive
 $200 – 300/month
 May be safer to taper
 Can see more agitation when medication discontinued
 Alternative, cheaper agents for agitation exist
Osteoporosis Medications
 Bisphosphonates
 Alendronate (Fosamax ®)
 Risedronate (Actonel®)
 Ibandronate (Boniva®)
 Zoledronic Acid (Reclast®)
 Teriperatide (Forteo®)
 ≈ $1000/month
Recommendations for discontinuing
osteoporosis medications
 Continue bisphosphonates if:
 Known metastatic bone disease
 Breast CA, prostate CA or multiple myeloma
 Paget’s disease of bone (usually high dose)
 Discontinue all other osteoporosis medications:
 Teriperatide
 Denosumab (Prolia®)
 Calcitriol
 Calcitonin?
Drugs to taper if discontinuing
 Anti-epileptic medications
 Opioids
 Anti-depressants
 Benzodiazepines
 Beta blockers
 Clonidine
 Corticosteroids
Barriers to discontinuing
medications
 Psychological attachment
 Concern that discontinuation implies “giving up”
 Uncertain of risks with discontinuation
 Physical dependence
 Clinical inertia
 Poor communication
Elizabeth N.
 Elizabeth N. is a 90 y/o woman who has been referred to
hospice following three hospitalizations in the last 2
months for refractory congestive heart failure. She is short
of breath with minimal exertion. She has decided that she
does not want to be readmitted to the hospital.
 Her current medications include furosemide, lisinopril,
carvedilol, spironolactone, warfarin, simvastatin, ASA,
alendronate and morphine sulfate PRN.
 Would it be appropriate to discontinue any of these
medications?
Elizabeth N.
 Discontinue:
 Warfarin
 Simvastatin
 Alendronate
 Continue:
 Lisinopril
 Carvedilol
 Spironolactone
 ASA
 Morphine sulfate
David E.
 David E. is a 53 y/o referred to hospice with newly
diagnosed metastatic pancreatic cancer. At the time of
presentation his tumor was non-resectable due to
hepatic metastases and a biliary stent was placed
percutaneously because of obstructive jaundice. His
comorbidities include COPD, BPH and a DVT which
occurred during his recent hospitalization.
 His current medications include warfarin, tamsulosin,
ipratropium, salmeterol/fluticasone, saw palmetto,
iron sulfate and oral meperidine for pain.
David E.
 Discontinue
 Saw palmetto
 FeSO4
 Meperidine (substitute alternative opioid)
 Continue
 Tamsulosin
 Ipratropium
 Salmeterol/fluticasone
 Warfarin (consider change to LMWH)
Lola P.
 Lola P. is a 89 y/o woman with endstage dementia who
has been referred to hospice. She is nonambulatory,
nonverbal, is unable to assist in any activities of daily
living. She is incontinent and has contractures of her
hands and knees. Her comorbidities include COPD,
CAD (with prior MI and CHF), HTN and
hypercholesterolemia.
 Her current medications include furosemide,
lisinopril, salmeterol/fluticasone, simvastatin,
alendronate, vitamin D, calcium carbonate,
omeprazole, donepezil, memantine and aspirin
Lola P.
 Discontinue
 Vitamin D
 Calcium carbonate
 Salmeterol/fluticasone (substitute PRN nebulized beta
agonist)
 Donepazil
 Memantine
 Simvastatin
 Alendronate
 Continue
 Furosemide
 Lisinopril
 (? Omeprazole)
Jennifer Good, MD
[email protected]
Mary Mihalyo, BS, PharmD
[email protected]