Transcript Less is More: Minimizing Inappropriate Medication Use

Jim Hoehns, Pharm.D., BCPS, FCCP
Research Director, Northeast Iowa Medical Education Foundation
Clinical Associate Professor, University of Iowa College of Pharmacy
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Reflect on the risks of prescribing opioid
analgesics for chronic non-cancer pain
Identify risks associated with long-term
therapy from proton-pump inhibitors
Compare the Beer’s and STOPP criteria as
tools to minimize inappropriate prescribing
among the elderly
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Most common agents
 Oxycodone
 Hydrocodone
 Methadone
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Increased prescribing
 4x increase in prescribing
since 1999
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2014: 14,000 deaths from overdoses of
prescription opioids
Iowa deaths
 2013: 275
 2014: 264
Rudd RA et al. MMWR 2016;64(50):1378-82.
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Usage
 1 out of 5 with non-cancer
pain are prescribed opioids
in office-based settings
 Primary care
▪ Half of all opioid
prescriptions
Users
 Age ≥40 > 20-39 yrs
 Women > men
 White=blacks > hispanics
www.cdc.gov/drugoverdose/data/prescribing.html Accessed 10/7/2016
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Avoid use with CNS depressants
 Aug 2016: FDA black-box warning regarding
benzodiazepine + opioid combination
Recommendation
Category
Evidence
1. Nonpharmacologic and nonopioid preferred; consider
opioid only if anticipated benefit>>risk
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2. Establish realistic goals before starting; establish how
opioids will be DC’d if benefits<risks. Continue only if
benefits>risks
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3. Before and during therapy, discuss known risks and
realistic benefits and patient responsibility
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4. When starting for chronic pain, prescribe IR opioids
instead of ER/LA opioids.
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5. Prescribe lowest effective dose; use caution and reassess if
≥50 MME/day; should avoid/carefully justify ≥90 MME/day
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6. Long-term use often begins with treatment of acute pain.
Use lowest dose/short duration. ≤3 days preferred; ≥7 days
rarely needed
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MMWR 2016;65(1):1-49.
Recommendation
Category
Evidence
7. Evaluate benefits/harms within 1 to 4 wks of starting or
dose escalation. Evaluate continued benefits/harms every 3
months or more frequently. Lower dose/taper if
benefits<harms
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8. Before and during evaluate risk-factors for opioid-related
harms. Incorporate strategies in plan to mitigate risk,
including offering naloxone, if risk factors present (hx of OD,
hx of substance abuse, ≥50 MME/day, or concurrent BZD use)
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Sales
 2015: Nexium #4 in branded volume; #7 in branded
sales ($)
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Evidence of overutilization
 Michigan study
▪ 22% of hospitalized non-ICU pts given SUP
▪ 54% of them continued PPIs in outpatient setting (unnecessary)
 Ohio study
▪ 61% of hospitalized patients taking PPI/AST which was not
indicated according to guidelines
SMJ 2015;108(12):732-8.
Am J Gastroenterol 2006;101:2200-05
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Acute interstitial nephritis
 All PPIs have been documented
▪ 10 days – 18 months (mean: 11 weeks)
▪ Cohort study: adjusted OR 3.0 (1.5-6.1)
 Likely most common cause of drug-induced AIN
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Enteric infections
 Clostridium difficile associated diarrhea (CDAD)
▪ Case-control study: OR 2.5 (95% CI 1.5-4.2)
▪ Prospective cohort: RR 2.64 (95% CI 1.71-4.09)
 Campylobacter, Salmonella, Shigella
CMAJ Open 2015;3(2):E166-171.
Ther Adv Gastroenterol 2012;5(4):219-232.
Clinical Nephrology 2007;68:65-72
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Falls/Fracture
 Case-control; falls/fracture: AOR 2.2 (95%CI 1.25-3.77)
 Most studies: no adverse effect on BMD
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Community-Acquired Pneumonia
 Meta-analysis of 26 studies (N=6,351,656)
▪ Pooled-risk: 1.49 (95% CI 1.16-1.92)
▪ Hospitalization for CAP: OR 1.61 (95% CI 1.12-2.31)
PLoS ONE 10(6):e0128004.doi: 10.1371/journal.pone.0128004
Endocrine 2015;49:606-10.
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Nutritional deficiencies
 Hypomagnesemia
▪ Meta-analysis; 9 studies: 1.43 (1.08-1.88)
▪ FDA warning 2011: 25% of cases Mg supplementation
alone did not sufficiently increase serum Mg level
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Chronic kidney disease
 Geisinger cohort (N=248,751)
▪ Adjusted HR 1.5 (95% CI 1.14-1.96)
▪ Twice daily vs. once daily PPI use
▪ Adjusted HR 1.46 vs. 1.15
▪ Conclusion: PPIs associated with incident CKD
JAMA Intern Med 2016;176(2):238-246.
Ren Fail 2015;37(7):1237-41
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Tapering seems better than abrupt discontinuation
Family Practice 2014;31(6):625-30.
STOPP/START
Physiologic, systems-based
screening tool for elderly
 Expert panel consensus
 STOPP
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 List of potentially inappropriate
prescriptions
 Common errors of commission
 Drug-drug & drug-disease
interactions
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START
 Errors of prescribing omission
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Criteria
 STOPP: 65
 START: 22
Int J Clin Pharm Ther 2008;46:72-83.
BEERS CRITERIA
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2015 American Geriatrics
Society
Expert panel concensus
 LOE/SOR
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Lists
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Medications to avoid
Drug/disease interactions
Medications to use with caution
Drug-drug interactions
Drugs to modify with renal
dysfunction
J Am Geriatr Soc 2015;63:2227-46.
STOPP
START
Thiazide with gout
 Diltiazem/verapamil with
HFrEF
 TCAs with dementia
 TCAs with constipation
 PPI for PUD for >8 weeks
 NSAID with hypertension
 NSAID with warfarin
 Anticholinergics with BPH
 Glyburide with type 2 DM
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ACEIs with HFrEF
BP meds for SBP >160
β-blocker for stable angina
Levodopa for Parkinson’s
Bisphosphonates in pts taking
chronic corticosteroids
 ACEI or ARB for type 2 DM with
nephropathy
 β-agonist/LAMA for mildmoderate COPD
 Calcium/Vit D with osteoporosis
STRONG SOR
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Avoid
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Diphenhydramine
Hydroxyzine
Dicyclomine
Nitrofurantoin if Clcr <30
Doxazosin/terazosin/prazosin
Clonidine
Digoxin
Amitriptyline
Benzodiazepines
Antipsychotics
Zolpidem
Insulin sliding scale
Metoclopramide
NSAIDs
DRUG-DISEASE/DRUG-DRUG
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Heart failure
 NSAIDS, TZD’s
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Seizures
 Bupropion, tramadol,
antipsychotics
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Hx of falls/fracture
 Benzodiazepines, TCAs,
antipsychotics
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CKD
 NSAIDs and COX-2 inhibitors
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Parkinson disease
 Metoclopramide,
promethazine
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Minimize opioids for chronic nonmalignant pain
 Avoid concomitant CNS depressants
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PPIs
 Adverse effects
▪ CKD, AIN, CDAD, falls/fracture, pneumonia, hypomagnesemia
 Attempt periodic dose reduction/discontinuation in
eligible patients
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STOPP/START & Beers criteria
 Minimize anticholinergic medication use