Transcript A Plethora of Pills - American College of Physicians

American College of Physicians - Maine Chapter
Autumn Meeting in Bar Harbor
September, 2014
Stephanie Nichols, Pharm.D., BCPS, BCPP
Associate Professor – Husson University School of Pharmacy
Clinical Pharmacist – Psychiatry & Adult Inpatient Medicine
[email protected]
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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
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X+ chronic daily medications?
› OTCs/Herbals
› Ex. HF or COPD
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“High Risk Polypharmacy”
› Ex. 2+ narcotics, 2+ benzos, 3+ oral
hypoglycemics
2+ drugs in the same class?
 More drugs prescribed than warranted
clinically ?
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› “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
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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.
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Errors
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› Prescribing
› Dispensing
› Administration
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Adverse Reactions
Interactions
› Drug-Drug
 Dynamic
 Kinetic
› Drug-Disease
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Order clarification
necessary
Duplicate
medication/class
Medication omission
Lack of dose
adjustment with AKI or
liver failure
Low Adherence
 Falls and Fractures
Circulation. 2010; 122:A14790
 ED visits and admissions
 Increased healthcare costs
 Reduced quality of life
 Increased mortality
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Lyles, Culver, Ivester, Potter. Consult Pharm. 2013 Dec;28(12):793-9.
Lai, Liao, Liao, Muo, Liu, Sung. Medicine (Baltimore) 2010;89(5):295.
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4.2% of admissions due to ADRs
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.
Pedros C et al. Eur J Clin Pharmacol. 2014 Mar;70(3):361-7.
Safety
 Tolerability
 Effectiveness
 Price
 Simplicity
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Actual
assessment
Probabilistic
of benefits
assessment and harms in
Only
benefit
assessed
of risk vs
benefit on
initial Rx
an ongoing
fashion
Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.
2003
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Pocket Card
› http://www.americangeriatrics.org/files/doc
uments/beers/PrintableBeersPocketCard.pdf
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AGS iGeriatrics App - $2.99
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STOPP - Screening Tool of Older People’s
potentially inappropriate Prescriptions
› 65 recommendations
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START - Screening Tool to Alert doctors to
the Right Treatment
› 22 recommendations
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http://www.ngna.org/_resources/documentation/
chapter/carolina_mountain/STARTandSTOPP.pdf
Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Int J Clin Pharmacol
Ther. 2008 Feb;46(2):72-83.
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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
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Find an indication for each drug
› Goal of therapy?
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Are we using the best drug for each
problem/disease/disorder in this patient?
› Eg. HTN and beta blockers
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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
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Periodically compare medication lists
with the pharmacist/pharmacy
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When new symptoms emerge,
particularly in geriatric patients, think
about medication AEs
http://www.acpm.org/?MedAdherTT_ClinRef
http://www.iarx.org/documents/PrinciplesOfHealthcare2010.pdf
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S implify regimen
I mpart knowledge
M odify patient beliefs and human
behavior
P rovide communication and trust
L eave the bias
E valuate adherence
Atreja A, Bellam N, Levy S. Medacapt Gen Med. 2005:7(1): 4.
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Daily or BID dosing
› One-a-day formulations (incl. patches)
› Match to ADLs (ex. breakfast)
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Combination products
› Caution: loss of dosing flexibility
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Treat multiple conditions with one agent
› Caution: commonly 2 agents are safer
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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
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REALM Assessment
› http://www.adultmeducation.com/downloa
ds/REALMR_INSTR.pdf
“As Needed for Water Retention”
 “Take two every day”
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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
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 Empathy,
supporting self-efficacy,
avoiding argumentation, rolling with
resistance, and developing
discrepancy
PSAPs VII; Book 8. Motivational Interviewing. Kavookjian J.
Empower patients to self-manage
 Ask about specific needs, fears, and
concerns
 Identify perceived barriers (ex. financial)
 Ensure knowledge of the actual risks of
missing medications
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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
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Take the time to overcome cultural
barriers
 Tailor education to the appropriate level
of complexity for your patient’s optimal
understanding
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Ask direct questions and ask them often
› Every visit
Identify adherence barriers
 Recognize lack of perceived benefit
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30 day fills on Jan 1st, Feb 7th, Mar 18th, Apr 26th, & June
1st
 5 fills * 30d each = 150 days supply
 Jan 1st – Jun 1st = 151 days + 30 days supply = 181
days
 150/181 = 83% MPR
Wallet cards – medication lists
 Pill containers and counting
 Blister packs
 Pre-packed kits (ex. Medrol)
 Textured covers with vision impairment
 Alarms
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› On the bottle
› Via email
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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
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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.
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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, BCPP
Associate Professor, Husson University School of Pharmacy
Clinical Psychiatric Pharmacist, Maine Medical Center
[email protected]
Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.